<p>As a medical student in the 1970s, my deep concern about the civil rights of the mentally ill was one of the main reasons for my interest in psychiatry and which ultimately inspired me to enter the field. These were “negative rights” which needed to be addressed and still do.</p> <p>Galderisi et al<span><sup>1</sup></span> devote most of their paper to the protection of these civil rights. Less extensively addressed are the “positive rights”, that is the economic, social and cultural rights of the mentally ill. This includes the structural neglect of the mentally ill within the health care and medical research systems across all societies, including high-income countries<span><sup>2</sup></span>.</p> <p>A global average of just around 2% of the health care budget is spent on the care of the mentally ill. Even in WEIRD (Western, Educated, Industrialized, Rich and Democratic) countries of the Global North, access to and quality of care are dramatically lower than for physical illness, such as cancer and cardiovascular diseases.</p> <p>This gross global neglect is a major driver of coercive cultures of care, which in turn are an inevitable result of late intervention, with treatment only being offered as a last resort. Neglect also contributes to high rates of premature death from suicide and preventable and treatable medical causes, marginalization and immiseration.</p> <p>In 2023, the World Mental Health Day celebrated mental health as a universal human right. However, the meaning of this – as eloquently argued by Patel<span><sup>3</sup></span> – is ideologically loaded. He points out that the population has the right to be protected from “known harms to mental health”. Such harms result from government policies and new megatrends that have created powerful structural forces which undermine mental health and produce higher levels of mental ill-health. They do so through creating increased poverty and marginalization, disproportionate exposure to violence and displacement, and surging wealth inequality.</p> <p>The paradigm shift that began in the early 1990s to make early intervention a belated addition to the spectrum of treatment and care in psychiatry should be seen as part of the response to the above gross global neglect. Early intervention began within the field of schizophrenia and psychotic disorders and profoundly challenged and ultimately transformed this field. Subsequently it spread as a principle and goal across the full spectrum of mental disorders.</p> <p>With K. Schaffner, I co-edited a special issue of <i>Schizophrenia Research</i> in 2001 on the ethics of early detection and intervention in schizophrenia. The main topic clearly is the balance between non-maleficence and beneficence, or risks versus benefits. Galderisi et al focus on the clinical high risk (CHR) for psychosis field in discussing the relevant issues. Ultra high risk (UHR) – or, in the US, CHR – is a concept that my colleagues and I introduced and operationally de
{"title":"Human rights and early intervention: ethics as a positive force","authors":"Patrick D. McGorry","doi":"10.1002/wps.21236","DOIUrl":"https://doi.org/10.1002/wps.21236","url":null,"abstract":"<p>As a medical student in the 1970s, my deep concern about the civil rights of the mentally ill was one of the main reasons for my interest in psychiatry and which ultimately inspired me to enter the field. These were “negative rights” which needed to be addressed and still do.</p>\u0000<p>Galderisi et al<span><sup>1</sup></span> devote most of their paper to the protection of these civil rights. Less extensively addressed are the “positive rights”, that is the economic, social and cultural rights of the mentally ill. This includes the structural neglect of the mentally ill within the health care and medical research systems across all societies, including high-income countries<span><sup>2</sup></span>.</p>\u0000<p>A global average of just around 2% of the health care budget is spent on the care of the mentally ill. Even in WEIRD (Western, Educated, Industrialized, Rich and Democratic) countries of the Global North, access to and quality of care are dramatically lower than for physical illness, such as cancer and cardiovascular diseases.</p>\u0000<p>This gross global neglect is a major driver of coercive cultures of care, which in turn are an inevitable result of late intervention, with treatment only being offered as a last resort. Neglect also contributes to high rates of premature death from suicide and preventable and treatable medical causes, marginalization and immiseration.</p>\u0000<p>In 2023, the World Mental Health Day celebrated mental health as a universal human right. However, the meaning of this – as eloquently argued by Patel<span><sup>3</sup></span> – is ideologically loaded. He points out that the population has the right to be protected from “known harms to mental health”. Such harms result from government policies and new megatrends that have created powerful structural forces which undermine mental health and produce higher levels of mental ill-health. They do so through creating increased poverty and marginalization, disproportionate exposure to violence and displacement, and surging wealth inequality.</p>\u0000<p>The paradigm shift that began in the early 1990s to make early intervention a belated addition to the spectrum of treatment and care in psychiatry should be seen as part of the response to the above gross global neglect. Early intervention began within the field of schizophrenia and psychotic disorders and profoundly challenged and ultimately transformed this field. Subsequently it spread as a principle and goal across the full spectrum of mental disorders.</p>\u0000<p>With K. Schaffner, I co-edited a special issue of <i>Schizophrenia Research</i> in 2001 on the ethics of early detection and intervention in schizophrenia. The main topic clearly is the balance between non-maleficence and beneficence, or risks versus benefits. Galderisi et al focus on the clinical high risk (CHR) for psychosis field in discussing the relevant issues. Ultra high risk (UHR) – or, in the US, CHR – is a concept that my colleagues and I introduced and operationally de","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"194 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248368","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}
Colm Healy, Ulla Lång, Kirstie O’Hare, Juha Veijola, Karen O'Connor, Marius Lahti-Pulkkinen, Eero Kajantie, Ian Kelleher
Children who have a parent with a psychotic disorder present an increased risk of developing psychosis. It is unclear to date, however, what proportion of all psychosis cases in the population are captured by a familial high-risk for psychosis (FHR-P) approach. This is essential information for prevention research and health service planning, as it tells us the total proportion of psychosis cases that this high-risk approach would prevent if an effective intervention were developed. Through a prospective cohort study including all individuals born in Finland between January 1, 1987 and December 31, 1992, we examined the absolute risk and total proportion of psychosis cases captured by FHR-P and by a transdiagnostic familial risk approach (TDFR-P) based on parental inpatient hospitalization for any mental disorder. Outcomes of non-affective psychosis (ICD-10: F20-F29) and schizophrenia (ICD-10: F20) were identified in the index children up to December 31, 2016. Of the index children (N=368,937), 1.5% (N=5,544) met FHR-P criteria and 10.3% (N=38,040) met TDFR-P criteria. By the study endpoint, 1.9% (N=6,966) of the index children had been diagnosed with non-affective psychosis and 0.5% (N=1,846) with schizophrenia. In terms of sensitivity, of all non-affective psychosis cases in the index children, 5.2% (N=355) were captured by FHR-P and 20.6% (N=1,413) by TDFR-P approaches. The absolute risk of non-affective psychosis was 6.4% in those with FHR-P, and 3.7% in those with TDFR-P. There was notable variation in the sensitivity and total proportion of FHR-P and TDFR-P cases captured based on the age at which FHR-P/TDFR-P were determined. The absolute risk for psychosis, however, was relatively time invariant. These metrics are essential to inform intervention strategies for psychosis risk requiring pragmatic decision-making.
{"title":"Sensitivity of the familial high-risk approach for the prediction of future psychosis: a total population study","authors":"Colm Healy, Ulla Lång, Kirstie O’Hare, Juha Veijola, Karen O'Connor, Marius Lahti-Pulkkinen, Eero Kajantie, Ian Kelleher","doi":"10.1002/wps.21243","DOIUrl":"https://doi.org/10.1002/wps.21243","url":null,"abstract":"Children who have a parent with a psychotic disorder present an increased risk of developing psychosis. It is unclear to date, however, what proportion of all psychosis cases in the population are captured by a familial high-risk for psychosis (FHR-P) approach. This is essential information for prevention research and health service planning, as it tells us the total proportion of psychosis cases that this high-risk approach would prevent if an effective intervention were developed. Through a prospective cohort study including all individuals born in Finland between January 1, 1987 and December 31, 1992, we examined the absolute risk and total proportion of psychosis cases captured by FHR-P and by a transdiagnostic familial risk approach (TDFR-P) based on parental inpatient hospitalization for any mental disorder. Outcomes of non-affective psychosis (ICD-10: F20-F29) and schizophrenia (ICD-10: F20) were identified in the index children up to December 31, 2016. Of the index children (N=368,937), 1.5% (N=5,544) met FHR-P criteria and 10.3% (N=38,040) met TDFR-P criteria. By the study endpoint, 1.9% (N=6,966) of the index children had been diagnosed with non-affective psychosis and 0.5% (N=1,846) with schizophrenia. In terms of sensitivity, of all non-affective psychosis cases in the index children, 5.2% (N=355) were captured by FHR-P and 20.6% (N=1,413) by TDFR-P approaches. The absolute risk of non-affective psychosis was 6.4% in those with FHR-P, and 3.7% in those with TDFR-P. There was notable variation in the sensitivity and total proportion of FHR-P and TDFR-P cases captured based on the age at which FHR-P/TDFR-P were determined. The absolute risk for psychosis, however, was relatively time invariant. These metrics are essential to inform intervention strategies for psychosis risk requiring pragmatic decision-making.","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"5 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248373","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}
Simon Hartmann, Dominic Dwyer, Blake Cavve, Enda M. Byrne, Isabelle Scott, Caroline Gao, Cassandra Wannan, Hok Pan Yuen, Jessica Hartmann, Ashleigh Lin, Stephen J. Wood, Johanna T.W. Wigman, Christel M. Middeldorp, Andrew Thompson, Paul Amminger, Monika Schlögelhofer, Anita Riecher-Rössler, Eric Y.H. Chen, Ian B. Hickie, Lisa J. Phillips, Miriam R. Schäfer, Nilufar Mossaheb, Stefan Smesny, Gregor Berger, Lieuwe de Haan, Merete Nordentoft, Swapna Verma, Dorien H. Nieman, Patrick D. McGorry, Alison R. Yung, Scott R. Clark, Barnaby Nelson
The concept of ultra-high risk for psychosis (UHR) has been at the forefront of psychiatric research for several decades, with the ultimate goal of preventing the onset of psychotic disorder in high-risk individuals. Orygen (Melbourne, Australia) has led a range of observational and intervention studies in this clinical population. These datasets have now been integrated into the UHR 1000+ cohort, consisting of a sample of 1,245 UHR individuals with a follow-up period ranging from 1 to 16.7 years. This paper describes the cohort, presents a clinical prediction model of transition to psychosis in this cohort, and examines how predictive performance is affected by changes in UHR samples over time. We analyzed transition to psychosis using a Cox proportional hazards model. Clinical predictors for transition to psychosis were investigated in the entire cohort using multiple imputation and Rubin's rule. To assess performance drift over time, data from 1995-2016 were used for initial model fitting, and models were subsequently validated on data from 2017-2020. Over the follow-up period, 220 cases (17.7%) developed a psychotic disorder. Pooled hazard ratio (HR) estimates showed that the Comprehensive Assessment of At-Risk Mental States (CAARMS) Disorganized Speech subscale severity score (HR=1.12, 95% CI: 1.02-1.24, p=0.024), the CAARMS Unusual Thought Content subscale severity score (HR=1.13, 95% CI: 1.03-1.24, p=0.009), the Scale for the Assessment of Negative Symptoms (SANS) total score (HR=1.02, 95% CI: 1.00-1.03, p=0.022), the Social and Occupational Functioning Assessment Scale (SOFAS) score (HR=0.98, 95% CI: 0.97-1.00, p=0.036), and time between onset of symptoms and entry to UHR service (log transformed) (HR=1.10, 95% CI: 1.02-1.19, p=0.013) were predictive of transition to psychosis. UHR individuals who met the brief limited intermittent psychotic symptoms (BLIPS) criteria had a higher probability of transitioning to psychosis than those who met the attenuated psychotic symptoms (APS) criteria (HR=0.48, 95% CI: 0.32-0.73, p=0.001) and those who met the Trait risk criteria (a first-degree relative with a psychotic disorder or a schizotypal personality disorder plus a significant decrease in functioning during the previous year) (HR=0.43, 95% CI: 0.22-0.83, p=0.013). Models based on data from 1995-2016 displayed good calibration at initial model fitting, but showed a drift of 20.2-35.4% in calibration when validated on data from 2017-2020. Large-scale longitudinal data such as those from the UHR 1000+ cohort are required to develop accurate psychosis prediction models. It is critical to assess existing and future risk calculators for temporal drift, that may reduce their utility in clinical practice over time.
{"title":"Development and temporal validation of a clinical prediction model of transition to psychosis in individuals at ultra-high risk in the UHR 1000+ cohort","authors":"Simon Hartmann, Dominic Dwyer, Blake Cavve, Enda M. Byrne, Isabelle Scott, Caroline Gao, Cassandra Wannan, Hok Pan Yuen, Jessica Hartmann, Ashleigh Lin, Stephen J. Wood, Johanna T.W. Wigman, Christel M. Middeldorp, Andrew Thompson, Paul Amminger, Monika Schlögelhofer, Anita Riecher-Rössler, Eric Y.H. Chen, Ian B. Hickie, Lisa J. Phillips, Miriam R. Schäfer, Nilufar Mossaheb, Stefan Smesny, Gregor Berger, Lieuwe de Haan, Merete Nordentoft, Swapna Verma, Dorien H. Nieman, Patrick D. McGorry, Alison R. Yung, Scott R. Clark, Barnaby Nelson","doi":"10.1002/wps.21240","DOIUrl":"https://doi.org/10.1002/wps.21240","url":null,"abstract":"The concept of ultra-high risk for psychosis (UHR) has been at the forefront of psychiatric research for several decades, with the ultimate goal of preventing the onset of psychotic disorder in high-risk individuals. Orygen (Melbourne, Australia) has led a range of observational and intervention studies in this clinical population. These datasets have now been integrated into the UHR 1000+ cohort, consisting of a sample of 1,245 UHR individuals with a follow-up period ranging from 1 to 16.7 years. This paper describes the cohort, presents a clinical prediction model of transition to psychosis in this cohort, and examines how predictive performance is affected by changes in UHR samples over time. We analyzed transition to psychosis using a Cox proportional hazards model. Clinical predictors for transition to psychosis were investigated in the entire cohort using multiple imputation and Rubin's rule. To assess performance drift over time, data from 1995-2016 were used for initial model fitting, and models were subsequently validated on data from 2017-2020. Over the follow-up period, 220 cases (17.7%) developed a psychotic disorder. Pooled hazard ratio (HR) estimates showed that the Comprehensive Assessment of At-Risk Mental States (CAARMS) Disorganized Speech subscale severity score (HR=1.12, 95% CI: 1.02-1.24, p=0.024), the CAARMS Unusual Thought Content subscale severity score (HR=1.13, 95% CI: 1.03-1.24, p=0.009), the Scale for the Assessment of Negative Symptoms (SANS) total score (HR=1.02, 95% CI: 1.00-1.03, p=0.022), the Social and Occupational Functioning Assessment Scale (SOFAS) score (HR=0.98, 95% CI: 0.97-1.00, p=0.036), and time between onset of symptoms and entry to UHR service (log transformed) (HR=1.10, 95% CI: 1.02-1.19, p=0.013) were predictive of transition to psychosis. UHR individuals who met the brief limited intermittent psychotic symptoms (BLIPS) criteria had a higher probability of transitioning to psychosis than those who met the attenuated psychotic symptoms (APS) criteria (HR=0.48, 95% CI: 0.32-0.73, p=0.001) and those who met the Trait risk criteria (a first-degree relative with a psychotic disorder or a schizotypal personality disorder plus a significant decrease in functioning during the previous year) (HR=0.43, 95% CI: 0.22-0.83, p=0.013). Models based on data from 1995-2016 displayed good calibration at initial model fitting, but showed a drift of 20.2-35.4% in calibration when validated on data from 2017-2020. Large-scale longitudinal data such as those from the UHR 1000+ cohort are required to develop accurate psychosis prediction models. It is critical to assess existing and future risk calculators for temporal drift, that may reduce their utility in clinical practice over time.","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"13 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248372","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}
Silvana Galderisi, Paul S. Appelbaum, Neeraj Gill, Piers Gooding, Helen Herrman, Antonio Melillo, Keris Myrick, Soumitra Pathare, Martha Savage, George Szmukler, John Torous
Psychiatry shares most ethical issues with other branches of medicine, but also faces special challenges. The Code of Ethics of the World Psychiatric Association offers guidance, but many mental health care professionals are unaware of it and the principles it supports. Furthermore, following codes of ethics is not always sufficient to address ethical dilemmas arising from possible clashes among their principles, and from continuing changes in knowledge, culture, attitudes, and socio-economic context. In this paper, we identify topics that pose difficult ethical challenges in contemporary psychiatry; that may have a significant impact on clinical practice, education and research activities; and that may require revision of the profession's codes of ethics. These include: the relationships between human rights and mental health care, research and training; human rights and mental health legislation; digital psychiatry; early intervention in psychiatry; end-of-life decisions by people with mental health conditions; conflicts of interests in clinical practice, training and research; and the role of people with lived experience and family/informal supporters in shaping the agenda of mental health care, policy, research and training. For each topic, we highlight the ethical concerns, suggest strategies to address them, call attention to the risks that these strategies entail, and highlight the gaps to be narrowed by further research. We conclude that, in order to effectively address current ethical challenges in psychiatry, we need to rethink policies, services, training, attitudes, research methods and codes of ethics, with the concurrent input of a range of stakeholders, open minded discussions, new models of care, and an adequate organizational capacity to roll-out the implementation across routine clinical care contexts, training and research.
{"title":"Ethical challenges in contemporary psychiatry: an overview and an appraisal of possible strategies and research needs","authors":"Silvana Galderisi, Paul S. Appelbaum, Neeraj Gill, Piers Gooding, Helen Herrman, Antonio Melillo, Keris Myrick, Soumitra Pathare, Martha Savage, George Szmukler, John Torous","doi":"10.1002/wps.21230","DOIUrl":"https://doi.org/10.1002/wps.21230","url":null,"abstract":"Psychiatry shares most ethical issues with other branches of medicine, but also faces special challenges. The Code of Ethics of the World Psychiatric Association offers guidance, but many mental health care professionals are unaware of it and the principles it supports. Furthermore, following codes of ethics is not always sufficient to address ethical dilemmas arising from possible clashes among their principles, and from continuing changes in knowledge, culture, attitudes, and socio-economic context. In this paper, we identify topics that pose difficult ethical challenges in contemporary psychiatry; that may have a significant impact on clinical practice, education and research activities; and that may require revision of the profession's codes of ethics. These include: the relationships between human rights and mental health care, research and training; human rights and mental health legislation; digital psychiatry; early intervention in psychiatry; end-of-life decisions by people with mental health conditions; conflicts of interests in clinical practice, training and research; and the role of people with lived experience and family/informal supporters in shaping the agenda of mental health care, policy, research and training. For each topic, we highlight the ethical concerns, suggest strategies to address them, call attention to the risks that these strategies entail, and highlight the gaps to be narrowed by further research. We conclude that, in order to effectively address current ethical challenges in psychiatry, we need to rethink policies, services, training, attitudes, research methods and codes of ethics, with the concurrent input of a range of stakeholders, open minded discussions, new models of care, and an adequate organizational capacity to roll-out the implementation across routine clinical care contexts, training and research.","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"46 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248365","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}
<p>Galderisi et al<span><sup>1</sup></span> provide an insightful overview of current ethical challenges in psychiatry, including those presented by digital psychiatry, as well as recommendations for addressing these challenges. As they discuss, “digital psychiatry” encompasses an array of different digital tools, including mental health apps, chatbots, telehealth platforms, and artificial intelligence (AI). These tools hold promise for improving diagnosis and care, and could facilitate access to mental health services by marginalized populations. In particular, digital mental health tools can assist in expanding mental health support in lower-to-middle income countries.</p> <p>Many of the ethical challenges identified by the authors in the use of digital tools reflect inequities and challenges within broader society. For example, in the US, lack of mental health insurance and insufficient representation of racialized minorities in medical research contribute to the difficulties with access and fairness in digital psychiatry. In many ways, the ethical challenges presented by digital psychiatry reflect long-standing concerns about who benefits, and who does not, from psychiatry. The array of forward-looking recommendations advanced by Galderisi et al show that these ethical challenges can also be seen as opportunities for moving towards greater equity and inclusion in psychiatry.</p> <p>Discussions of the ethics of digital health benefit from broadening the scope of issues to include social context. Galderisi et al refer to inequities in how mental health care is researched, developed and accessed, and to historical power imbalances in psychiatry due to which patient voices are undervalued and overlooked. A broader approach to ethical challenges related to digital health technologies recognizes that issues affecting these technologies often emerge due to their interactions with the social institutions in which they are developed and applied<span><sup>2</sup></span>. For example, privacy and safety of digital psychiatry tools must be understood within the context of the specific regulatory environment and infrastructure (e.g., broadband, hardware) in which they are being used.</p> <p>Digital health tools and medical AI are often promoted for improving cost-effectiveness, but this business-oriented emphasis can obscure discussion of what trade-offs in costs are considered acceptable, such as whether lesser-quality services are deemed acceptable for low-income groups. Institutions that regulate medical devices often struggle when they have to deal with softwares or AI. Consumers and patients too often find it difficult to obtain information that can help them decide which digital psychiatry tools are appropriate and effective for their needs.</p> <p>There have been pioneering efforts to assist with evaluating effective digital mental health tools, such as American Psychiatric Association's mental health app evaluator<span><sup>3</sup></span>. However
{"title":"A broader approach to ethical challenges in digital mental health","authors":"Nicole Martinez-Martin","doi":"10.1002/wps.21237","DOIUrl":"https://doi.org/10.1002/wps.21237","url":null,"abstract":"<p>Galderisi et al<span><sup>1</sup></span> provide an insightful overview of current ethical challenges in psychiatry, including those presented by digital psychiatry, as well as recommendations for addressing these challenges. As they discuss, “digital psychiatry” encompasses an array of different digital tools, including mental health apps, chatbots, telehealth platforms, and artificial intelligence (AI). These tools hold promise for improving diagnosis and care, and could facilitate access to mental health services by marginalized populations. In particular, digital mental health tools can assist in expanding mental health support in lower-to-middle income countries.</p>\u0000<p>Many of the ethical challenges identified by the authors in the use of digital tools reflect inequities and challenges within broader society. For example, in the US, lack of mental health insurance and insufficient representation of racialized minorities in medical research contribute to the difficulties with access and fairness in digital psychiatry. In many ways, the ethical challenges presented by digital psychiatry reflect long-standing concerns about who benefits, and who does not, from psychiatry. The array of forward-looking recommendations advanced by Galderisi et al show that these ethical challenges can also be seen as opportunities for moving towards greater equity and inclusion in psychiatry.</p>\u0000<p>Discussions of the ethics of digital health benefit from broadening the scope of issues to include social context. Galderisi et al refer to inequities in how mental health care is researched, developed and accessed, and to historical power imbalances in psychiatry due to which patient voices are undervalued and overlooked. A broader approach to ethical challenges related to digital health technologies recognizes that issues affecting these technologies often emerge due to their interactions with the social institutions in which they are developed and applied<span><sup>2</sup></span>. For example, privacy and safety of digital psychiatry tools must be understood within the context of the specific regulatory environment and infrastructure (e.g., broadband, hardware) in which they are being used.</p>\u0000<p>Digital health tools and medical AI are often promoted for improving cost-effectiveness, but this business-oriented emphasis can obscure discussion of what trade-offs in costs are considered acceptable, such as whether lesser-quality services are deemed acceptable for low-income groups. Institutions that regulate medical devices often struggle when they have to deal with softwares or AI. Consumers and patients too often find it difficult to obtain information that can help them decide which digital psychiatry tools are appropriate and effective for their needs.</p>\u0000<p>There have been pioneering efforts to assist with evaluating effective digital mental health tools, such as American Psychiatric Association's mental health app evaluator<span><sup>3</sup></span>. However","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"1 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248370","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}
<p>Adolescence is a time of dramatic change in physical, behavioral, emotional, cognitive and social domains, and the context in which one matures plays a crucial role. The early 2020s provided a unique context for adolescent development, filled with unprecedented events across multiple levels of life. These contextual forces potentially impacted what we know from previously studied developmental trajectories during adolescence.</p> <p>Here we briefly highlight recent research on adolescent anxiety associated with social media use and the COVID-19 pandemic, and focus on the latest trends and advances in cognitive-behavioral therapy (CBT) for treating anxiety in youth. We emphasize the importance of behavioral exposure tasks and the necessity of “flexibility within fidelity”<span><sup>1</sup></span> in manual-based CBT interventions. Lastly, we identify future research directions for evaluating the development, maintenance and treatment of anxiety in adolescents.</p> <p>Rates of anxiety among youth – as well as depression, suicidality, and other mental health conditions – have increased in recent years. Specifically, anxiety symptoms increased during the COVID-19 pandemic, with 20% of surveyed youth experiencing these symptoms, compared to 11% before the pandemic<span><sup>2</sup></span>. Further, across all socioeconomic levels, about 70% of adolescents reported believing that anxiety and depression are major problems among people of their age in their community<span><sup>3</sup></span>. Widening disparities in anxiety prevalence have been noted among girls relative to boys, and among sexual minority youth compared to heterosexual ones<span><sup>2, 4</sup></span>.</p> <p>Adolescents currently face stressors that may contribute to increases in anxiety. The COVID-19 pandemic took a toll on youth psychological well-being, including disrupted milestones, loss of peer interactions, and social isolation<span><sup>2</sup></span>. Adolescents are heavy consumers of digital technology and social media: this has the potential to provide benefits to youth through opportunities to strengthen social relationships. However, social media may also lead to an increase in anxiety symptoms. In a longitudinal study of adolescents aged 12-15, those spending more than three hours per day on social media were prospectively more likely to experience internalizing problems (i.e., anxiety and depression<span><sup>5</sup></span>). It is not a stretch to see the double-edged features of heavy adolescent social media use.</p> <p>Recent research continues to bolster the large body of existing evidence demonstrating the efficacy<span><sup>6</sup></span> and effectiveness<span><sup>7</sup></span> of CBT in treating adolescent anxiety, with the latest studies parsing treatment effects according to intervention modality and emphasis on key components (e.g., psychoeducation, cognitive restructuring, exposure tasks). When comparing CBT modalities to waitlist controls based on anxie
{"title":"Trends, advances and directions in cognitive-behavioral therapy for adolescent anxiety","authors":"Philip C. Kendall, Marisa Meyer, Julia S. Ney","doi":"10.1002/wps.21247","DOIUrl":"https://doi.org/10.1002/wps.21247","url":null,"abstract":"<p>Adolescence is a time of dramatic change in physical, behavioral, emotional, cognitive and social domains, and the context in which one matures plays a crucial role. The early 2020s provided a unique context for adolescent development, filled with unprecedented events across multiple levels of life. These contextual forces potentially impacted what we know from previously studied developmental trajectories during adolescence.</p>\u0000<p>Here we briefly highlight recent research on adolescent anxiety associated with social media use and the COVID-19 pandemic, and focus on the latest trends and advances in cognitive-behavioral therapy (CBT) for treating anxiety in youth. We emphasize the importance of behavioral exposure tasks and the necessity of “flexibility within fidelity”<span><sup>1</sup></span> in manual-based CBT interventions. Lastly, we identify future research directions for evaluating the development, maintenance and treatment of anxiety in adolescents.</p>\u0000<p>Rates of anxiety among youth – as well as depression, suicidality, and other mental health conditions – have increased in recent years. Specifically, anxiety symptoms increased during the COVID-19 pandemic, with 20% of surveyed youth experiencing these symptoms, compared to 11% before the pandemic<span><sup>2</sup></span>. Further, across all socioeconomic levels, about 70% of adolescents reported believing that anxiety and depression are major problems among people of their age in their community<span><sup>3</sup></span>. Widening disparities in anxiety prevalence have been noted among girls relative to boys, and among sexual minority youth compared to heterosexual ones<span><sup>2, 4</sup></span>.</p>\u0000<p>Adolescents currently face stressors that may contribute to increases in anxiety. The COVID-19 pandemic took a toll on youth psychological well-being, including disrupted milestones, loss of peer interactions, and social isolation<span><sup>2</sup></span>. Adolescents are heavy consumers of digital technology and social media: this has the potential to provide benefits to youth through opportunities to strengthen social relationships. However, social media may also lead to an increase in anxiety symptoms. In a longitudinal study of adolescents aged 12-15, those spending more than three hours per day on social media were prospectively more likely to experience internalizing problems (i.e., anxiety and depression<span><sup>5</sup></span>). It is not a stretch to see the double-edged features of heavy adolescent social media use.</p>\u0000<p>Recent research continues to bolster the large body of existing evidence demonstrating the efficacy<span><sup>6</sup></span> and effectiveness<span><sup>7</sup></span> of CBT in treating adolescent anxiety, with the latest studies parsing treatment effects according to intervention modality and emphasis on key components (e.g., psychoeducation, cognitive restructuring, exposure tasks). When comparing CBT modalities to waitlist controls based on anxie","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"194 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248417","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}
<p>In the late 1980s, the ICD-10 Working Party on Personality Disorders had little evidence on which to base its decisions and, understandably, followed the lead of the DSM, with its well-funded and popular third and subsequent editions.</p> <p>When the Working Party came to the sensitive subject of individual personality disorders, it found that the evidence for “borderline personality disorder” was insufficient for it to be included. But a lobby of supporters did not allow this, and eventually two extra personality disorder groupings were included under the heading of “emotionally unstable personality disorder” (F60.3) – an “impulsive type” (F60.30), characterized by a “tendency to act unexpectedly” and to show “quarrelsome behaviour” and an “unstable and capricious mood”; and a “borderline type” (F60.31), characterized by uncertain self-image, unstable relationships, efforts to avoid abandonment, and recurrent self-harm.</p> <p>We have yet to see much evidence that the impulsive type (F60.30) has been used in practice. On the contrary, the borderline type is by far the most commonly used personality disorder diagnosis, so much so that the original splitting of the “emotionally unstable personality disorder” into two groups has been forgotten entirely.</p> <p>In the ICD-11 revision group, more than two decades later, the same conclusion was reached: borderline personality disorder was not considered to be a suitable diagnosis for inclusion and was ignored, as indeed were all other categories of personality disorder in the new dimensional system<span><sup>1</sup></span>. But, as with the ICD-10, the borderline diagnosis was not to be spurned by others. There was general dissatisfaction with its omission<span><sup>2</sup></span>, and a strong appeal for it to be included in some form. Thus, the “borderline pattern specifier” was added as a compromise<span><sup>3</sup></span>.</p> <p>How do we explain that, after two revision groups decided to exclude this condition as unsatisfactory, borderline personality disorder continues to be supported as a diagnosis? The standard explanations are that it is useful in clinical practice, is widely used, and gives options for treatment, unlike other personality disorders. However, the same could be said, almost exactly, of the diagnosis of neurasthenia between 1870 and 1990 (it appeared apologetically in the ICD-10), which has now been recognized to be redundant, as it was vaguely defined, was so prevalent that it lacked discrimination, and became toxic through criticism and stigma.</p> <p>These same concerns apply to borderline personality disorder. It is like a large bubble wrap over all personality disorders, easily recognized on the surface but obscuring the disorders that lie beneath. Personality abnormality is identifiable through traits that are persistent, exactly as normal personality traits. The features of borderline personality disorder are not traits, but symptoms and fluctuating behaviours<span><
{"title":"The problem with borderline personality disorder","authors":"Peter J. Tyrer, Roger T. Mulder","doi":"10.1002/wps.21249","DOIUrl":"https://doi.org/10.1002/wps.21249","url":null,"abstract":"<p>In the late 1980s, the ICD-10 Working Party on Personality Disorders had little evidence on which to base its decisions and, understandably, followed the lead of the DSM, with its well-funded and popular third and subsequent editions.</p>\u0000<p>When the Working Party came to the sensitive subject of individual personality disorders, it found that the evidence for “borderline personality disorder” was insufficient for it to be included. But a lobby of supporters did not allow this, and eventually two extra personality disorder groupings were included under the heading of “emotionally unstable personality disorder” (F60.3) – an “impulsive type” (F60.30), characterized by a “tendency to act unexpectedly” and to show “quarrelsome behaviour” and an “unstable and capricious mood”; and a “borderline type” (F60.31), characterized by uncertain self-image, unstable relationships, efforts to avoid abandonment, and recurrent self-harm.</p>\u0000<p>We have yet to see much evidence that the impulsive type (F60.30) has been used in practice. On the contrary, the borderline type is by far the most commonly used personality disorder diagnosis, so much so that the original splitting of the “emotionally unstable personality disorder” into two groups has been forgotten entirely.</p>\u0000<p>In the ICD-11 revision group, more than two decades later, the same conclusion was reached: borderline personality disorder was not considered to be a suitable diagnosis for inclusion and was ignored, as indeed were all other categories of personality disorder in the new dimensional system<span><sup>1</sup></span>. But, as with the ICD-10, the borderline diagnosis was not to be spurned by others. There was general dissatisfaction with its omission<span><sup>2</sup></span>, and a strong appeal for it to be included in some form. Thus, the “borderline pattern specifier” was added as a compromise<span><sup>3</sup></span>.</p>\u0000<p>How do we explain that, after two revision groups decided to exclude this condition as unsatisfactory, borderline personality disorder continues to be supported as a diagnosis? The standard explanations are that it is useful in clinical practice, is widely used, and gives options for treatment, unlike other personality disorders. However, the same could be said, almost exactly, of the diagnosis of neurasthenia between 1870 and 1990 (it appeared apologetically in the ICD-10), which has now been recognized to be redundant, as it was vaguely defined, was so prevalent that it lacked discrimination, and became toxic through criticism and stigma.</p>\u0000<p>These same concerns apply to borderline personality disorder. It is like a large bubble wrap over all personality disorders, easily recognized on the surface but obscuring the disorders that lie beneath. Personality abnormality is identifiable through traits that are persistent, exactly as normal personality traits. The features of borderline personality disorder are not traits, but symptoms and fluctuating behaviours<span><","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"14 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248416","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}
Nitsa Nacasch, Tal Malka, Joseph Zohar, Yarden V. Dejorno, Gal Levi, Raz Gross, Mark Weiser, Hagit Cohen
<p>On October 7, 2023, about 4,000 civilians attending the Nova open-air music festival in southern Israel were the victims of a sudden terrorist attack. They had to swiftly react to the attack by running and hiding for extended periods of time to protect their lives.</p> <p>At the time of the attack, a significant proportion of these people were under the influence of various recreational drugs. We hypothesized that the pre-trauma use of psychostimulants or hallucinogens would be significantly associated with the severity of peri-traumatic dissociation, anxiety, depression, and acute stress disorder (ASD) symptoms in survivors of the attack.</p> <p>Two hundred thirty-two survivors sought assistance at the Chaim Sheba Medical Center and underwent clinical evaluation. They were considered for this study if they had no severe physical injuries; no first-degree family member killed during the attack; and no history of mental disorders, including post-traumatic stress disorder (PTSD).</p> <p>Of the 232 survivors screened for the study, 126 met the above criteria and provided informed consent to participate. However, two of them who reported using hallucinogenic mushrooms, and one who reported using ketamine prior to the traumatic event, were excluded from the analysis, due to the small sample size for these drugs, leaving a sample of 123 participants. Their mean age (±SE) was 28.4±0.7 years; 75 of them (60.9%) were male; 68.9% were never married, and 68.2% were holding a high-school degree or equivalent.</p> <p>Seventy-one of them (57.7%) reported using psychoactive drugs at the festival – 12 only alcohol, nine only lysergic acid (LSD), seven only 3,4-methylenedioxymethamphetamine (MDMA), six only cannabis, three only methylmethcathinone (MMC), 15 various drug combinations including alcohol, and 19 various drug combinations excluding alcohol.</p> <p>All participants completed several questionnaires, assessing peri-traumatic dissociation (Peritraumatic Dissociative Experiences Questionnaire, PDEQ), post-traumatic anxiety (Generalized Anxiety Disorder-7, GAD-7; and Visual Analog Scale for Anxiety, VAS-A), depression (Patient Health Questionnaire-9, PHQ-9), and ASD symptoms (Posttraumatic Diagnostic Scale, PDS-5).</p> <p>Both the GAD-7 scores and the PDS-5 hyperarousal scores were significantly higher in the drug-user than in the drug-free group (p<0.05 and p<0.008, respectively). The scores of most participants were above the clinical threshold for these instruments (>10 for GAD-7 in 70.4%, and >28 for PDS-5 in 81.3% of the participants), indicating a very high level of anxiety- and hyperarousal-related symptoms in both groups. Both the PDEQ and PHQ-9 scores were higher in the drug-user than in the drug-free group, but the differences were not significant. No significant differences were found between the groups in the VAS-A, total PDS-5, and PDS-5 subscales. The VAS-A scores of 51.9% of the participants were higher than 6, which is the cli
{"title":"Impact of pre-trauma recreational drug use on mental health outcomes among survivors of the Israeli Nova Festival terrorist attack","authors":"Nitsa Nacasch, Tal Malka, Joseph Zohar, Yarden V. Dejorno, Gal Levi, Raz Gross, Mark Weiser, Hagit Cohen","doi":"10.1002/wps.21254","DOIUrl":"https://doi.org/10.1002/wps.21254","url":null,"abstract":"<p>On October 7, 2023, about 4,000 civilians attending the Nova open-air music festival in southern Israel were the victims of a sudden terrorist attack. They had to swiftly react to the attack by running and hiding for extended periods of time to protect their lives.</p>\u0000<p>At the time of the attack, a significant proportion of these people were under the influence of various recreational drugs. We hypothesized that the pre-trauma use of psychostimulants or hallucinogens would be significantly associated with the severity of peri-traumatic dissociation, anxiety, depression, and acute stress disorder (ASD) symptoms in survivors of the attack.</p>\u0000<p>Two hundred thirty-two survivors sought assistance at the Chaim Sheba Medical Center and underwent clinical evaluation. They were considered for this study if they had no severe physical injuries; no first-degree family member killed during the attack; and no history of mental disorders, including post-traumatic stress disorder (PTSD).</p>\u0000<p>Of the 232 survivors screened for the study, 126 met the above criteria and provided informed consent to participate. However, two of them who reported using hallucinogenic mushrooms, and one who reported using ketamine prior to the traumatic event, were excluded from the analysis, due to the small sample size for these drugs, leaving a sample of 123 participants. Their mean age (±SE) was 28.4±0.7 years; 75 of them (60.9%) were male; 68.9% were never married, and 68.2% were holding a high-school degree or equivalent.</p>\u0000<p>Seventy-one of them (57.7%) reported using psychoactive drugs at the festival – 12 only alcohol, nine only lysergic acid (LSD), seven only 3,4-methylenedioxymethamphetamine (MDMA), six only cannabis, three only methylmethcathinone (MMC), 15 various drug combinations including alcohol, and 19 various drug combinations excluding alcohol.</p>\u0000<p>All participants completed several questionnaires, assessing peri-traumatic dissociation (Peritraumatic Dissociative Experiences Questionnaire, PDEQ), post-traumatic anxiety (Generalized Anxiety Disorder-7, GAD-7; and Visual Analog Scale for Anxiety, VAS-A), depression (Patient Health Questionnaire-9, PHQ-9), and ASD symptoms (Posttraumatic Diagnostic Scale, PDS-5).</p>\u0000<p>Both the GAD-7 scores and the PDS-5 hyperarousal scores were significantly higher in the drug-user than in the drug-free group (p<0.05 and p<0.008, respectively). The scores of most participants were above the clinical threshold for these instruments (>10 for GAD-7 in 70.4%, and >28 for PDS-5 in 81.3% of the participants), indicating a very high level of anxiety- and hyperarousal-related symptoms in both groups. Both the PDEQ and PHQ-9 scores were higher in the drug-user than in the drug-free group, but the differences were not significant. No significant differences were found between the groups in the VAS-A, total PDS-5, and PDS-5 subscales. The VAS-A scores of 51.9% of the participants were higher than 6, which is the cli","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"36 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248419","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}
Rising concerns about social isolation and loneliness globally have highlighted the need for a greater understanding of their mental and physical health implications. Robust evidence documents social connection factors as independent predictors of mental and physical health, with some of the strongest evidence on mortality. Although most data are observational, evidence points to directionality of effects, plausible pathways, and in some cases a causal link between social connection and later health outcomes. Societal trends across several indicators reveal increasing rates of those who lack social connection, and a significant portion of the population reporting loneliness. The scientific study on social isolation and loneliness has substantially extended over the past two decades, particularly since 2020; however, its relevance to health and mortality remains underappreciated by the public. Despite the breadth of evidence, several challenges remain, including the need for a common language to reconcile the diverse relevant terms across scientific disciplines, consistent multi-factorial measurement to assess risk, and effective solutions to prevent and mitigate risk. The urgency for future health is underscored by the potentially longer-term consequences of the COVID-19 pandemic, and the role of digital technologies in societal shifts, that could contribute to further declines in social, mental and physical health. To reverse these trends and meet these challenges, recommendations are offered to more comprehensively address gaps in our understanding, and to foster social connection and address social isolation and loneliness.
{"title":"Social connection as a critical factor for mental and physical health: evidence, trends, challenges, and future implications","authors":"Julianne Holt-Lunstad","doi":"10.1002/wps.21224","DOIUrl":"https://doi.org/10.1002/wps.21224","url":null,"abstract":"Rising concerns about social isolation and loneliness globally have highlighted the need for a greater understanding of their mental and physical health implications. Robust evidence documents social connection factors as independent predictors of mental and physical health, with some of the strongest evidence on mortality. Although most data are observational, evidence points to directionality of effects, plausible pathways, and in some cases a causal link between social connection and later health outcomes. Societal trends across several indicators reveal increasing rates of those who lack social connection, and a significant portion of the population reporting loneliness. The scientific study on social isolation and loneliness has substantially extended over the past two decades, particularly since 2020; however, its relevance to health and mortality remains underappreciated by the public. Despite the breadth of evidence, several challenges remain, including the need for a common language to reconcile the diverse relevant terms across scientific disciplines, consistent multi-factorial measurement to assess risk, and effective solutions to prevent and mitigate risk. The urgency for future health is underscored by the potentially longer-term consequences of the COVID-19 pandemic, and the role of digital technologies in societal shifts, that could contribute to further declines in social, mental and physical health. To reverse these trends and meet these challenges, recommendations are offered to more comprehensively address gaps in our understanding, and to foster social connection and address social isolation and loneliness.","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"8 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248363","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}
Roger S McIntyre, Mohammad Alsuwaidan, Bernhard T Baune, Michael Berk, Koen Demyttenaere, Joseph F Goldberg, Philip Gorwood, Roger Ho, Siegfried Kasper, Sidney H Kennedy, Josefina Ly-Uson, Rodrigo B Mansur, R Hamish McAllister-Williams, James W Murrough, Charles B Nemeroff, Andrew A Nierenberg, Joshua D Rosenblat, Gerard Sanacora, Alan F Schatzberg, Richard Shelton, Stephen M Stahl, Madhukar H Trivedi, Eduard Vieta, Maj Vinberg, Nolan Williams, Allan H Young, Mario Maj
Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.
{"title":"Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions.","authors":"Roger S McIntyre, Mohammad Alsuwaidan, Bernhard T Baune, Michael Berk, Koen Demyttenaere, Joseph F Goldberg, Philip Gorwood, Roger Ho, Siegfried Kasper, Sidney H Kennedy, Josefina Ly-Uson, Rodrigo B Mansur, R Hamish McAllister-Williams, James W Murrough, Charles B Nemeroff, Andrew A Nierenberg, Joshua D Rosenblat, Gerard Sanacora, Alan F Schatzberg, Richard Shelton, Stephen M Stahl, Madhukar H Trivedi, Eduard Vieta, Maj Vinberg, Nolan Williams, Allan H Young, Mario Maj","doi":"10.1002/wps.21120","DOIUrl":"10.1002/wps.21120","url":null,"abstract":"<p><p>Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.</p>","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"22 3","pages":"394-412"},"PeriodicalIF":73.3,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10503923/pdf/WPS-22-394.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10359288","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}
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