Geoffrey M. Reed, Karen T. Maré, Michael B. First, T.S. Jaisoorya, Girish N. Rao, John-Joe Dawson-Squibb, Christine Lochner, Mark van Ommeren, Dan J. Stein
<p>The movement to a descriptive, symptom-based diagnostic system that started with the DSM-III was in part a response to widespread concerns and criticisms regarding the reliability of psychiatric diagnoses. This fueled an emphasis on increasingly precise operationalization of diagnostic constructs and criteria, based on the assumption that this would produce successive improvements in reliability.</p> <p>Clinician-administered structured diagnostic interviews were subsequently developed. For example, the Research Diagnostic Criteria were used to develop a Schedule for Affective Disorders and Schizophrenia<span><sup>1</sup></span>, while the DSM-III criteria were incorporated into the Structured Clinical Interview for DSM (SCID)<span><sup>2</sup></span>. In addition, the Diagnostic Interview Schedule<span><sup>3</sup></span> was developed for use by non-clinician interviewers in epidemiological surveys of mental disorders. These instruments have been widely used in research on mental disorders.</p> <p>Structured diagnostic interviews have subsequently been developed or adapted for successive revisions of the DSM and the ICD. The SCID, a semi-structured interview – meaning that the interviewer probes unclear responses and makes certain clinical judgments – has been updated with each edition of the DSM<span><sup>4</sup></span>. The briefer and fully structured Mini International Neuropsychiatric Interview (MINI)<span><sup>5</sup></span> has also been widely employed. The Composite International Diagnostic Interview (CIDI)<span><sup>6</sup></span> incorporated both DSM and ICD diagnostic requirements and was used in the National Comorbidity Survey and the World Mental Health Surveys. Similarly, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), based on the Present State Examination, assessed for both DSM and ICD requirements<span><sup>7</sup></span>. Structured diagnostic interviews for children have also been developed, as have a range of more focused interviews that cover specific conditions or diagnostic groupings.</p> <p>Based on an extensive program of field testing, the reliability of the diagnostic guidance provided in the Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR)<span><sup>8</sup></span> was found to be higher than that of other mental disorder classification systems, ranging from moderate to almost perfect according to the specific category. This finding was perhaps counterintuitive, insofar as the CDDR avoid highly prescriptive symptom counts and duration requirements, unless these are specifically supported scientifically, in order to facilitate clinical use.</p> <p>These results, therefore, challenge the assumed relationship between operational precision and diagnostic reliability. They also suggest that the diagnoses based on the CDDR would be sufficiently reliable for certain types of research projects (e.g., studies focusing on diagnostic gr
{"title":"The WHO Flexible Interview for ICD-11 (FLII-11)","authors":"Geoffrey M. Reed, Karen T. Maré, Michael B. First, T.S. Jaisoorya, Girish N. Rao, John-Joe Dawson-Squibb, Christine Lochner, Mark van Ommeren, Dan J. Stein","doi":"10.1002/wps.21227","DOIUrl":"https://doi.org/10.1002/wps.21227","url":null,"abstract":"<p>The movement to a descriptive, symptom-based diagnostic system that started with the DSM-III was in part a response to widespread concerns and criticisms regarding the reliability of psychiatric diagnoses. This fueled an emphasis on increasingly precise operationalization of diagnostic constructs and criteria, based on the assumption that this would produce successive improvements in reliability.</p>\u0000<p>Clinician-administered structured diagnostic interviews were subsequently developed. For example, the Research Diagnostic Criteria were used to develop a Schedule for Affective Disorders and Schizophrenia<span><sup>1</sup></span>, while the DSM-III criteria were incorporated into the Structured Clinical Interview for DSM (SCID)<span><sup>2</sup></span>. In addition, the Diagnostic Interview Schedule<span><sup>3</sup></span> was developed for use by non-clinician interviewers in epidemiological surveys of mental disorders. These instruments have been widely used in research on mental disorders.</p>\u0000<p>Structured diagnostic interviews have subsequently been developed or adapted for successive revisions of the DSM and the ICD. The SCID, a semi-structured interview – meaning that the interviewer probes unclear responses and makes certain clinical judgments – has been updated with each edition of the DSM<span><sup>4</sup></span>. The briefer and fully structured Mini International Neuropsychiatric Interview (MINI)<span><sup>5</sup></span> has also been widely employed. The Composite International Diagnostic Interview (CIDI)<span><sup>6</sup></span> incorporated both DSM and ICD diagnostic requirements and was used in the National Comorbidity Survey and the World Mental Health Surveys. Similarly, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), based on the Present State Examination, assessed for both DSM and ICD requirements<span><sup>7</sup></span>. Structured diagnostic interviews for children have also been developed, as have a range of more focused interviews that cover specific conditions or diagnostic groupings.</p>\u0000<p>Based on an extensive program of field testing, the reliability of the diagnostic guidance provided in the Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR)<span><sup>8</sup></span> was found to be higher than that of other mental disorder classification systems, ranging from moderate to almost perfect according to the specific category. This finding was perhaps counterintuitive, insofar as the CDDR avoid highly prescriptive symptom counts and duration requirements, unless these are specifically supported scientifically, in order to facilitate clinical use.</p>\u0000<p>These results, therefore, challenge the assumed relationship between operational precision and diagnostic reliability. They also suggest that the diagnoses based on the CDDR would be sufficiently reliable for certain types of research projects (e.g., studies focusing on diagnostic gr","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"3 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248366","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>The use of psychoactive substances is highly prevalent and contributes substantially to risk behaviours, morbidity and mortality. The United Nations Office on Drugs and Crime World Drug Report<span><sup>1</sup></span> estimated that, in 2021, one in every 17 people aged 15-64 in the world had used an illicit drug in the year before. Users increased from 240 million in 2011 to 296 million in 2021, substantially more than accounted for by population growth.</p> <p>Cannabis continued to be the most used illicit drug (219 million users, 4.3% of the global adult population); 36 million people had used amphetamines, 22 million cocaine, and 20 million methylenedioxymethamphetamine (MDMA or “ecstasy”) or related drugs in the previous year. An estimated 60 million people engaged in non-medical opioid use, 31.5 million of whom used opiates (i.e., non-synthetic opioids; mainly heroin).</p> <p>Globally, there is very limited implementation of efficient and effective prevention strategies for substance use<span><sup>2</sup></span>, and there is a substantial treatment gap for disorders due to this use<span><sup>3</sup></span>. Global evidence has called attention to the need for a new and comprehensive conceptualization of substance use disorders that incorporates the full range of relevant conditions, from risky consumption to mental disorders linked to harmful drug use<span><sup>4</sup></span>.</p> <p>In response to these challenges, the World Health Organization (WHO) adopted a public health approach to the development of the classification of disorders due to substance use in the ICD-11. By public health approach, we refer to a broader perspective that integrates health and social aspects, aiming to benefit affected individuals and their community, and focusing on population well-being<span><sup>5</sup></span>.</p> <p>From a public health perspective, it is essential to identify persons who exhibit a hazardous use of substances that increases the risk of harmful psychological or medical consequences, but whose symptoms do not meet the diagnostic requirements for substance use disorders. These individuals can benefit from education, prevention, and community interventions. People with diagnosable disorders need harm reduction and treatment services of differing intensities and settings, depending on the nature of their condition and the substance involved. Those who suffer physical or psychological harm due to others’ substance use should also be identified and may require services<span><sup>6</sup></span>.</p> <p>In line with this perspective, the range of psychoactive substances classified in the ICD-11 section on disorders due to substance use has been expanded, reflecting changes in the substances associated with public health impact in different parts of the world. An extended set of substance classes will help track patterns more accurately, in order to formulate appropriate clinical and social policy responses nationally and globally. For example
{"title":"How the ICD-11 and the CDDR address the public health dimensions of substance use","authors":"María Elena Medina-Mora, Rebeca Robles","doi":"10.1002/wps.21252","DOIUrl":"https://doi.org/10.1002/wps.21252","url":null,"abstract":"<p>The use of psychoactive substances is highly prevalent and contributes substantially to risk behaviours, morbidity and mortality. The United Nations Office on Drugs and Crime World Drug Report<span><sup>1</sup></span> estimated that, in 2021, one in every 17 people aged 15-64 in the world had used an illicit drug in the year before. Users increased from 240 million in 2011 to 296 million in 2021, substantially more than accounted for by population growth.</p>\u0000<p>Cannabis continued to be the most used illicit drug (219 million users, 4.3% of the global adult population); 36 million people had used amphetamines, 22 million cocaine, and 20 million methylenedioxymethamphetamine (MDMA or “ecstasy”) or related drugs in the previous year. An estimated 60 million people engaged in non-medical opioid use, 31.5 million of whom used opiates (i.e., non-synthetic opioids; mainly heroin).</p>\u0000<p>Globally, there is very limited implementation of efficient and effective prevention strategies for substance use<span><sup>2</sup></span>, and there is a substantial treatment gap for disorders due to this use<span><sup>3</sup></span>. Global evidence has called attention to the need for a new and comprehensive conceptualization of substance use disorders that incorporates the full range of relevant conditions, from risky consumption to mental disorders linked to harmful drug use<span><sup>4</sup></span>.</p>\u0000<p>In response to these challenges, the World Health Organization (WHO) adopted a public health approach to the development of the classification of disorders due to substance use in the ICD-11. By public health approach, we refer to a broader perspective that integrates health and social aspects, aiming to benefit affected individuals and their community, and focusing on population well-being<span><sup>5</sup></span>.</p>\u0000<p>From a public health perspective, it is essential to identify persons who exhibit a hazardous use of substances that increases the risk of harmful psychological or medical consequences, but whose symptoms do not meet the diagnostic requirements for substance use disorders. These individuals can benefit from education, prevention, and community interventions. People with diagnosable disorders need harm reduction and treatment services of differing intensities and settings, depending on the nature of their condition and the substance involved. Those who suffer physical or psychological harm due to others’ substance use should also be identified and may require services<span><sup>6</sup></span>.</p>\u0000<p>In line with this perspective, the range of psychoactive substances classified in the ICD-11 section on disorders due to substance use has been expanded, reflecting changes in the substances associated with public health impact in different parts of the world. An extended set of substance classes will help track patterns more accurately, in order to formulate appropriate clinical and social policy responses nationally and globally. For example","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":"142248486","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>The process of scientific validation of the ICD-11 Clinical Descriptions and Diagnostic Requirements (CDDR) for Mental Disorders has spanned more than 10 years, being remarkably comprehensive and inclusive as well as truly international, with the involvement of many hundreds of clinicians and researchers from all regions of the world.</p> <p>The field trials of the ICD-11 CDDR – contrary to those of the ICD-10 Clinical Descriptions and Diagnostic Guidelines (CDDG) and the DSM-5 diagnostic criteria – have been genuinely “developmental” (as opposed to “summative” or “evaluative”) in their nature<span><sup>1</sup></span>. That is, they have been conducted <i>before</i> the finalization of the relevant sets of criteria or guidelines – thus allowing the identification of conceptual or terminological problems in the proposed texts, the correction of those texts, and the further testing of the revised versions – rather than being conducted or concluded <i>after</i> the finalization of the relevant sets of criteria or guidelines, thus just providing information to clinicians about what they could expect from those products. As we will see, several amendments to the CDDR were actually implemented as a consequence of this design.</p> <p>The CDDR field trials can be subdivided into two main groups: a) Internet-based trials, implemented through the Global Clinical Practice Network (involving, at the time when the trials were conducted, more than 15,000 mental health and primary health care professionals from more than 150 countries), which used a case vignette methodology to assess the effects of specific differences between the CDDR and the ICD-10 CDDG on the participants’ clinical decision making; b) clinic-based (or ecological) trials, assessing the reliability and clinical utility of the CDDR in real clinical contexts. The clinic-based trials differed from the DSM-5 field trials in that they used a joint-rater design (with two clinicians jointly interviewing each patient) rather than a test-retest design (with two clinicians separately interviewing each patient at different time points), thus controlling for information variance and more specifically testing the reliability of the proposed guidelines (rather than testing more generally the reliability of the relevant psychiatric diagnoses)<span><sup>2</sup></span>.</p> <p>Among the Internet-based CDDR field trials, of special interest have been those focusing on disorders specifically associated with stress<span><sup>3</sup></span>, and on feeding and eating disorders<span><sup>4</sup></span>. A case-control field trial on the former grouping of disorders<span><sup>3</sup></span>, conducted with 1,738 mental health professionals from 76 countries, found that several changes introduced in the ICD-11 – including the addition of complex post-traumatic stress disorder (complex PTSD) and prolonged grief disorder – resulted in significantly improved diagnostic decisions. However, the trial also identified s
{"title":"Scientific validation of the ICD-11 CDDR","authors":"Mario Maj","doi":"10.1002/wps.21226","DOIUrl":"https://doi.org/10.1002/wps.21226","url":null,"abstract":"<p>The process of scientific validation of the ICD-11 Clinical Descriptions and Diagnostic Requirements (CDDR) for Mental Disorders has spanned more than 10 years, being remarkably comprehensive and inclusive as well as truly international, with the involvement of many hundreds of clinicians and researchers from all regions of the world.</p>\u0000<p>The field trials of the ICD-11 CDDR – contrary to those of the ICD-10 Clinical Descriptions and Diagnostic Guidelines (CDDG) and the DSM-5 diagnostic criteria – have been genuinely “developmental” (as opposed to “summative” or “evaluative”) in their nature<span><sup>1</sup></span>. That is, they have been conducted <i>before</i> the finalization of the relevant sets of criteria or guidelines – thus allowing the identification of conceptual or terminological problems in the proposed texts, the correction of those texts, and the further testing of the revised versions – rather than being conducted or concluded <i>after</i> the finalization of the relevant sets of criteria or guidelines, thus just providing information to clinicians about what they could expect from those products. As we will see, several amendments to the CDDR were actually implemented as a consequence of this design.</p>\u0000<p>The CDDR field trials can be subdivided into two main groups: a) Internet-based trials, implemented through the Global Clinical Practice Network (involving, at the time when the trials were conducted, more than 15,000 mental health and primary health care professionals from more than 150 countries), which used a case vignette methodology to assess the effects of specific differences between the CDDR and the ICD-10 CDDG on the participants’ clinical decision making; b) clinic-based (or ecological) trials, assessing the reliability and clinical utility of the CDDR in real clinical contexts. The clinic-based trials differed from the DSM-5 field trials in that they used a joint-rater design (with two clinicians jointly interviewing each patient) rather than a test-retest design (with two clinicians separately interviewing each patient at different time points), thus controlling for information variance and more specifically testing the reliability of the proposed guidelines (rather than testing more generally the reliability of the relevant psychiatric diagnoses)<span><sup>2</sup></span>.</p>\u0000<p>Among the Internet-based CDDR field trials, of special interest have been those focusing on disorders specifically associated with stress<span><sup>3</sup></span>, and on feeding and eating disorders<span><sup>4</sup></span>. A case-control field trial on the former grouping of disorders<span><sup>3</sup></span>, conducted with 1,738 mental health professionals from 76 countries, found that several changes introduced in the ICD-11 – including the addition of complex post-traumatic stress disorder (complex PTSD) and prolonged grief disorder – resulted in significantly improved diagnostic decisions. However, the trial also identified s","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":"142248364","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>From a historical perspective, Engel<span><sup>1</sup></span> conceptualized psychopathology as resulting from an interaction of three orders of factors: biological, psychological and social. The first half of the 20th century has been mostly devoted to conceptualizing the psychological component of mental disorders, the second half to the understanding of the biological component. We are now, in the 21st century, busy at better understanding the role of social processes that impact treatment approaches to psychopathology as well as the psychiatrist-patient relationship.</p> <p>Even more than other medical disciplines, psychiatry is influenced by external events that plague society, such as epidemics, natural disasters and wars. These events often require the involvement of ethics committees that will determine the duties and rights of the physician in potentially conflictual ethical contexts, such as triage situations (i.e., choosing whom to treat first). The COVID-19 pandemic has shown how deeply interwoven the epidemiology of mental disorders and the access to mental health services are with both social factors and somatic health. Grief, isolation, loss of income and fear exacerbate existing mental health problems or create new ones. The pandemic has demonstrated that the biological and social dimensions of medicine and public health are inextricably linked<span><sup>2</sup></span>.</p> <p>Profound changes in social values and norms, such as the legitimization of medical procedures for transgender individuals, or the availability of euthanasia in some countries, require a redefinition of the psychiatrist's role within the medical staff, and the development of ethical guidelines that take into account a variety of emotional, religious and ideological aspects pertaining to both the patient and the physician.</p> <p>This changing scenario is extensively reflected in Galderisi et al's paper<span><sup>3</sup></span>. I will focus here on three of the issues discussed by the authors. The first is stigma related to mental disorders in society in general, and particularly in the medical world. Studies documenting the importance of social/environmental components in the development of psychopathology<span><sup>4</sup></span>, as well as those showing the close relationship between physical illness and emotional states, have contributed to reduce that stigma. The inclusion of psychiatric wards within general hospitals has been both a consequence and a further determinant of this evolution. Likewise, the importance of the psychiatrist's presence in transdisciplinary medical teams, as well as in hospital ethics committees, has become more obvious than in the past. It is also increasingly clear that codes of ethics of physical medicine and psychiatry overlap to a large extent, especially with regard to the therapist-patient relationship.</p> <p>The second topic I wish to emphasize is the changing relationship between psychiatrists and representatives of
{"title":"Ethics from the lens of the social dimension of psychiatry","authors":"Sam Tyano","doi":"10.1002/wps.21238","DOIUrl":"https://doi.org/10.1002/wps.21238","url":null,"abstract":"<p>From a historical perspective, Engel<span><sup>1</sup></span> conceptualized psychopathology as resulting from an interaction of three orders of factors: biological, psychological and social. The first half of the 20th century has been mostly devoted to conceptualizing the psychological component of mental disorders, the second half to the understanding of the biological component. We are now, in the 21st century, busy at better understanding the role of social processes that impact treatment approaches to psychopathology as well as the psychiatrist-patient relationship.</p>\u0000<p>Even more than other medical disciplines, psychiatry is influenced by external events that plague society, such as epidemics, natural disasters and wars. These events often require the involvement of ethics committees that will determine the duties and rights of the physician in potentially conflictual ethical contexts, such as triage situations (i.e., choosing whom to treat first). The COVID-19 pandemic has shown how deeply interwoven the epidemiology of mental disorders and the access to mental health services are with both social factors and somatic health. Grief, isolation, loss of income and fear exacerbate existing mental health problems or create new ones. The pandemic has demonstrated that the biological and social dimensions of medicine and public health are inextricably linked<span><sup>2</sup></span>.</p>\u0000<p>Profound changes in social values and norms, such as the legitimization of medical procedures for transgender individuals, or the availability of euthanasia in some countries, require a redefinition of the psychiatrist's role within the medical staff, and the development of ethical guidelines that take into account a variety of emotional, religious and ideological aspects pertaining to both the patient and the physician.</p>\u0000<p>This changing scenario is extensively reflected in Galderisi et al's paper<span><sup>3</sup></span>. I will focus here on three of the issues discussed by the authors. The first is stigma related to mental disorders in society in general, and particularly in the medical world. Studies documenting the importance of social/environmental components in the development of psychopathology<span><sup>4</sup></span>, as well as those showing the close relationship between physical illness and emotional states, have contributed to reduce that stigma. The inclusion of psychiatric wards within general hospitals has been both a consequence and a further determinant of this evolution. Likewise, the importance of the psychiatrist's presence in transdisciplinary medical teams, as well as in hospital ethics committees, has become more obvious than in the past. It is also increasingly clear that codes of ethics of physical medicine and psychiatry overlap to a large extent, especially with regard to the therapist-patient relationship.</p>\u0000<p>The second topic I wish to emphasize is the changing relationship between psychiatrists and representatives of","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"3 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248371","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}
Natalie C. Momen, Søren Dinesen Østergaard, Uffe Heide-Jorgensen, Henrik Toft Sørensen, John J. McGrath, Oleguer Plana-Ripoll
People with physical diseases are reported to be at elevated risk of subsequent mental disorders. However, previous studies have considered only a few pairs of conditions, or have reported only relative risks. This study aimed to systematically explore the associations between physical diseases and subsequent mental disorders. It examined a population-based cohort of 7,673,978 people living in Denmark between 2000 and 2021, and followed them for a total of 119.3 million person-years. The study assessed nine broad categories of physical diseases (cardiovascular, endocrine, respiratory, gastrointestinal, urogenital, musculoskeletal, hematological and neurological diseases, and cancers), encompassing 31 specific diseases, and the subsequent risk of mental disorder diagnoses, encompassing the ten ICD-10 groupings (organic, including symptomatic, mental disorders; mental disorders due to psychoactive substance use; schizophrenia and related disorders; mood disorders; neurotic, stress-related and somatoform disorders; eating disorders; personality disorders; intellectual disabilities; pervasive developmental disorders; and behavioral and emotional disorders with onset usually occurring in childhood and adolescence). Using Poisson regression, the overall and time-dependent incidence rate ratios (IRRs) for pairs of physical diseases and mental disorders were calculated, adjusting for age, sex and calendar time. Absolute risks were estimated with the Aalen-Johansen estimator. In total, 646,171 people (8.4%) were identified as having any mental disorder during follow-up. All physical diseases except cancers were associated with an elevated risk of any mental disorder. For the nine broad pairs of physical diseases and mental disorders, the median point estimate of IRR was 1.51 (range: 0.99-1.84; interquartile range: 1.29-1.59). The IRRs ranged from 0.99 (95% CI: 0.98-1.01) after cancers to 1.84 (95% CI: 1.83-1.85) after musculoskeletal diseases. Risks varied over time after the diagnosis of physical diseases. The cumulative mental disorder incidence within 15 years after diagnosis of a physical disease varied from 3.73% (95% CI: 3.67-3.80) for cancers to 10.19% (95% CI: 10.13-10.25) for respiratory diseases. These data document that most physical diseases are associated with an elevated risk of subsequent mental disorders. Clinicians treating physical diseases should constantly be alert to the possible development of secondary mental disorders.
{"title":"Associations between physical diseases and subsequent mental disorders: a longitudinal study in a population-based cohort","authors":"Natalie C. Momen, Søren Dinesen Østergaard, Uffe Heide-Jorgensen, Henrik Toft Sørensen, John J. McGrath, Oleguer Plana-Ripoll","doi":"10.1002/wps.21242","DOIUrl":"https://doi.org/10.1002/wps.21242","url":null,"abstract":"People with physical diseases are reported to be at elevated risk of subsequent mental disorders. However, previous studies have considered only a few pairs of conditions, or have reported only relative risks. This study aimed to systematically explore the associations between physical diseases and subsequent mental disorders. It examined a population-based cohort of 7,673,978 people living in Denmark between 2000 and 2021, and followed them for a total of 119.3 million person-years. The study assessed nine broad categories of physical diseases (cardiovascular, endocrine, respiratory, gastrointestinal, urogenital, musculoskeletal, hematological and neurological diseases, and cancers), encompassing 31 specific diseases, and the subsequent risk of mental disorder diagnoses, encompassing the ten ICD-10 groupings (organic, including symptomatic, mental disorders; mental disorders due to psychoactive substance use; schizophrenia and related disorders; mood disorders; neurotic, stress-related and somatoform disorders; eating disorders; personality disorders; intellectual disabilities; pervasive developmental disorders; and behavioral and emotional disorders with onset usually occurring in childhood and adolescence). Using Poisson regression, the overall and time-dependent incidence rate ratios (IRRs) for pairs of physical diseases and mental disorders were calculated, adjusting for age, sex and calendar time. Absolute risks were estimated with the Aalen-Johansen estimator. In total, 646,171 people (8.4%) were identified as having any mental disorder during follow-up. All physical diseases except cancers were associated with an elevated risk of any mental disorder. For the nine broad pairs of physical diseases and mental disorders, the median point estimate of IRR was 1.51 (range: 0.99-1.84; interquartile range: 1.29-1.59). The IRRs ranged from 0.99 (95% CI: 0.98-1.01) after cancers to 1.84 (95% CI: 1.83-1.85) after musculoskeletal diseases. Risks varied over time after the diagnosis of physical diseases. The cumulative mental disorder incidence within 15 years after diagnosis of a physical disease varied from 3.73% (95% CI: 3.67-3.80) for cancers to 10.19% (95% CI: 10.13-10.25) for respiratory diseases. These data document that most physical diseases are associated with an elevated risk of subsequent mental disorders. Clinicians treating physical diseases should constantly be alert to the possible development of secondary mental disorders.","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"24 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248414","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>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}
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