G. Shields, R. Ng, A. Ventriglio, J. Castaldelli-Maia, J. Torales, D. Bhugra
The problem of recruitment in psychiatry is universal. There are very few countries where this problem does not exist. Variations have to be seen in the context of health care systems, training options and educational systems. The World Health Organization has set a target of one psychiatrist per 10,000 population globally. While this target is met in most European countries, North America and Japan, just under half of the world population live in countries with less than one psychiatrist/100,000 population. The rates are extremely low throughout Africa, and low in South America, Southeast Asia and Subcontinental Asia, with high urbanrural disparity. Despite the relatively high numbers of psychiatrists, many high-income countries are suffering from a perceived “recruitment crisis”. In many countries vacancy rates in training posts remain over 10%. To complicate matters further, often international medical graduates who may see psychiatry as popular take up much of the slack, contributing to “brain drain” from their countries of origin. Who chooses psychiatry, and what influences their choice? Many students choose medicine for the specific purpose of doing psychiatry, but some change their mind during their training. Others see the process through. Some students fall into psychiatry either passively or choose it actively. The reasons are often complex. Most of the studies have focused on understanding issues in Europe and the US. As duration of undergraduate training in psychiatry varies from 2 to 8 weeks, it is important to explore and understand these variations. WPA studies have shown that female doctors are slightly more likely to choose psychiatry. A personal or family history of mental illness increases the likelihood of choosing psychiatry. Medical students with undergraduate exposure to psychology or social sciences are more likely to choose psychiatry. Having a positive experience of psychiatry teaching and placement with clinical activities and exposure to psychotherapy during medical school, and/or additional exposure through clinical electives, also influence the choice of psychiatry. What factors negatively influence recruitment? A fall in levels of interest in psychiatry during undergraduate training can be attributed to poor exposure to teaching, a lack of psychiatric facilities and limited clinical exposure. Furthermore, the quality of mental healthcare in many parts of the world is extremely poor, and largely inpatient, with little opportunity for exposure to community-based psychiatry or other specialities. As such, students may be turned off psychiatry by what they witness during placements. The relative lack of financial reward can also affect career choice. Other factors are stigma against the psychiatric profession and against mental illness in general, resulting in perception of psychiatry as unscientific, ineffective, or apart from mainstream medicine. There is a perceived lack of respect from colleagues in other specialiti
{"title":"WPA Position Statement on Recruitment in Psychiatry","authors":"G. Shields, R. Ng, A. Ventriglio, J. Castaldelli-Maia, J. Torales, D. Bhugra","doi":"10.1002/wps.20392","DOIUrl":"https://doi.org/10.1002/wps.20392","url":null,"abstract":"The problem of recruitment in psychiatry is universal. There are very few countries where this problem does not exist. Variations have to be seen in the context of health care systems, training options and educational systems. The World Health Organization has set a target of one psychiatrist per 10,000 population globally. While this target is met in most European countries, North America and Japan, just under half of the world population live in countries with less than one psychiatrist/100,000 population. The rates are extremely low throughout Africa, and low in South America, Southeast Asia and Subcontinental Asia, with high urbanrural disparity. Despite the relatively high numbers of psychiatrists, many high-income countries are suffering from a perceived “recruitment crisis”. In many countries vacancy rates in training posts remain over 10%. To complicate matters further, often international medical graduates who may see psychiatry as popular take up much of the slack, contributing to “brain drain” from their countries of origin. Who chooses psychiatry, and what influences their choice? Many students choose medicine for the specific purpose of doing psychiatry, but some change their mind during their training. Others see the process through. Some students fall into psychiatry either passively or choose it actively. The reasons are often complex. Most of the studies have focused on understanding issues in Europe and the US. As duration of undergraduate training in psychiatry varies from 2 to 8 weeks, it is important to explore and understand these variations. WPA studies have shown that female doctors are slightly more likely to choose psychiatry. A personal or family history of mental illness increases the likelihood of choosing psychiatry. Medical students with undergraduate exposure to psychology or social sciences are more likely to choose psychiatry. Having a positive experience of psychiatry teaching and placement with clinical activities and exposure to psychotherapy during medical school, and/or additional exposure through clinical electives, also influence the choice of psychiatry. What factors negatively influence recruitment? A fall in levels of interest in psychiatry during undergraduate training can be attributed to poor exposure to teaching, a lack of psychiatric facilities and limited clinical exposure. Furthermore, the quality of mental healthcare in many parts of the world is extremely poor, and largely inpatient, with little opportunity for exposure to community-based psychiatry or other specialities. As such, students may be turned off psychiatry by what they witness during placements. The relative lack of financial reward can also affect career choice. Other factors are stigma against the psychiatric profession and against mental illness in general, resulting in perception of psychiatry as unscientific, ineffective, or apart from mainstream medicine. There is a perceived lack of respect from colleagues in other specialiti","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":" ","pages":""},"PeriodicalIF":73.3,"publicationDate":"2017-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20392","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41647583","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}
Laws to protect the public from mentally ill people who have committed a violent offence date from the attempted assassination of King George III by a disturbed ex-soldier in 1800. In the last 50 years, the assumption that mental illness is both a cause and a predictor of violence has led to changes in mental health laws that limit involuntary treatment to those considered to be dangerous and to research into how to assess the risk of violence. The most common form of violence risk assessment is still a judgment made by a clinician. However, this form of assessment lacks transparency, is vulnerable to cognitive biases and relies on the experience and expertise of the clinician. Actuarial assessments based on a score from of a list of identified risk factors have made violence risk assessment more objective, reliable and probably more accurate. More than 200 actuarial violence risk instruments have been described. Despite their advantages over unaided clinical judgment, there are both scientific and ethical problems with the use of these instruments in clinical practice. The scientific concerns are about the strength of the statistical separation of high-risk and lower-risk groups, the overreliance on measures of discrimination (such as the area under the curve or odds ratios) rather than measures of prediction (such as the positive predictive value), the applicability of instruments to different groups, and the extent to which aggregate risk data apply to individuals. The ethical concerns include the potential for risk assessment to add to the stigma and discrimination experienced by the mentally ill, unfair restrictions after false positive predictions, and denial of care to those assessed to be lower-risk. With these concerns in mind, any evaluation of the current state of violence risk assessment must answer two important questions: Does violence risk assessment produce valid information? And is this information clinically useful? The first question has been answered by a recent metaanalysis of 92 studies that independently replicated the results of nine popular violence risk instruments. The pooled estimate of the diagnostic odds of violence among high-risk patients was 3.08 (95% CI: 2.45-3.88), indicating that the rate of severe violence can be expected to be about three times higher in high-risk groups than lower-risk ones. An odds ratio of three indicates that risk assessment produces valid information with a modestly strong effect size – a degree of separation between high-risk and lower-risk groups similar to the risk of suicide associated with male gender. To answer the second question about the usefulness of the information generated by a violence risk assessment, we need to consider whether there are treatments or interventions that can be reasonably allocated to high-risk patients but denied to lower-risk patients, and whether the transfer of treatment resources from lower-risk to high-risk groups actually reduces the overall rate of
{"title":"The limitations and future of violence risk assessment","authors":"M. Large, O. Nielssen","doi":"10.1002/wps.20394","DOIUrl":"https://doi.org/10.1002/wps.20394","url":null,"abstract":"Laws to protect the public from mentally ill people who have committed a violent offence date from the attempted assassination of King George III by a disturbed ex-soldier in 1800. In the last 50 years, the assumption that mental illness is both a cause and a predictor of violence has led to changes in mental health laws that limit involuntary treatment to those considered to be dangerous and to research into how to assess the risk of violence. The most common form of violence risk assessment is still a judgment made by a clinician. However, this form of assessment lacks transparency, is vulnerable to cognitive biases and relies on the experience and expertise of the clinician. Actuarial assessments based on a score from of a list of identified risk factors have made violence risk assessment more objective, reliable and probably more accurate. More than 200 actuarial violence risk instruments have been described. Despite their advantages over unaided clinical judgment, there are both scientific and ethical problems with the use of these instruments in clinical practice. The scientific concerns are about the strength of the statistical separation of high-risk and lower-risk groups, the overreliance on measures of discrimination (such as the area under the curve or odds ratios) rather than measures of prediction (such as the positive predictive value), the applicability of instruments to different groups, and the extent to which aggregate risk data apply to individuals. The ethical concerns include the potential for risk assessment to add to the stigma and discrimination experienced by the mentally ill, unfair restrictions after false positive predictions, and denial of care to those assessed to be lower-risk. With these concerns in mind, any evaluation of the current state of violence risk assessment must answer two important questions: Does violence risk assessment produce valid information? And is this information clinically useful? The first question has been answered by a recent metaanalysis of 92 studies that independently replicated the results of nine popular violence risk instruments. The pooled estimate of the diagnostic odds of violence among high-risk patients was 3.08 (95% CI: 2.45-3.88), indicating that the rate of severe violence can be expected to be about three times higher in high-risk groups than lower-risk ones. An odds ratio of three indicates that risk assessment produces valid information with a modestly strong effect size – a degree of separation between high-risk and lower-risk groups similar to the risk of suicide associated with male gender. To answer the second question about the usefulness of the information generated by a violence risk assessment, we need to consider whether there are treatments or interventions that can be reasonably allocated to high-risk patients but denied to lower-risk patients, and whether the transfer of treatment resources from lower-risk to high-risk groups actually reduces the overall rate of","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":" ","pages":""},"PeriodicalIF":73.3,"publicationDate":"2017-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20394","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41988416","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}
{"title":"ICD‐11 draft diagnostic guidelines open to input by mental health professionals","authors":"P. Bucci","doi":"10.1002/wps.20402","DOIUrl":"https://doi.org/10.1002/wps.20402","url":null,"abstract":"","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":" ","pages":""},"PeriodicalIF":73.3,"publicationDate":"2017-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20402","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48919506","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}
G. Reed, J. Drescher, R. Krueger, Elham Atalla, S. Cochran, M. First, P. Cohen-Kettenis, Iván Arango-de Montis, S. Parish, S. Cottler, P. Briken, S. Saxena
In the World Health Organization's forthcoming eleventh revision of the International Classification of Diseases and Related Health Problems (ICD‐11), substantial changes have been proposed to the ICD‐10 classification of mental and behavioural disorders related to sexuality and gender identity. These concern the following ICD‐10 disorder groupings: F52 Sexual dysfunctions, not caused by organic disorder or disease; F64 Gender identity disorders; F65 Disorders of sexual preference; and F66 Psychological and behavioural disorders associated with sexual development and orientation. Changes have been proposed based on advances in research and clinical practice, and major shifts in social attitudes and in relevant policies, laws, and human rights standards. This paper describes the main recommended changes, the rationale and evidence considered, and important differences from the DSM‐5. An integrated classification of sexual dysfunctions has been proposed for a new chapter on Conditions Related to Sexual Health, overcoming the mind/body separation that is inherent in ICD‐10. Gender identity disorders in ICD‐10 have been reconceptualized as Gender incongruence, and also proposed to be moved to the new chapter on sexual health. The proposed classification of Paraphilic disorders distinguishes between conditions that are relevant to public health and clinical psychopathology and those that merely reflect private behaviour. ICD‐10 categories related to sexual orientation have been recommended for deletion from the ICD‐11.
{"title":"Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current scientific evidence, best clinical practices, and human rights considerations","authors":"G. Reed, J. Drescher, R. Krueger, Elham Atalla, S. Cochran, M. First, P. Cohen-Kettenis, Iván Arango-de Montis, S. Parish, S. Cottler, P. Briken, S. Saxena","doi":"10.1002/wps.20354","DOIUrl":"https://doi.org/10.1002/wps.20354","url":null,"abstract":"In the World Health Organization's forthcoming eleventh revision of the International Classification of Diseases and Related Health Problems (ICD‐11), substantial changes have been proposed to the ICD‐10 classification of mental and behavioural disorders related to sexuality and gender identity. These concern the following ICD‐10 disorder groupings: F52 Sexual dysfunctions, not caused by organic disorder or disease; F64 Gender identity disorders; F65 Disorders of sexual preference; and F66 Psychological and behavioural disorders associated with sexual development and orientation. Changes have been proposed based on advances in research and clinical practice, and major shifts in social attitudes and in relevant policies, laws, and human rights standards. This paper describes the main recommended changes, the rationale and evidence considered, and important differences from the DSM‐5. An integrated classification of sexual dysfunctions has been proposed for a new chapter on Conditions Related to Sexual Health, overcoming the mind/body separation that is inherent in ICD‐10. Gender identity disorders in ICD‐10 have been reconceptualized as Gender incongruence, and also proposed to be moved to the new chapter on sexual health. The proposed classification of Paraphilic disorders distinguishes between conditions that are relevant to public health and clinical psychopathology and those that merely reflect private behaviour. ICD‐10 categories related to sexual orientation have been recommended for deletion from the ICD‐11.","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"77 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2016-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20354","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"51239295","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}
tic clinical utility. The recent emergence of low-cost pharmacogenomic techniques has sparked new interests in combinatorial use of allelic variations in drug transporters or metabolic genes as biomarkers that might predict drug response. An initial generation of research identified a number of candidate genes with apparent validity as predictors of treatment efficacy and treatment-related side effects. These candidates include genes implicated in serotonergic function, the ABC family of xenobiotic transporters located in the blood-brain barrier, and the cytochrome P450 detoxification enzymes. However, to date, there are no effective biological methods to objectively assess depression endophenotypes, severity, or treatment response. Previous efforts to achieve better treatment outcomes in psychiatry have led to the introduction of pharmacogenomics based decision-support tools, to help identify which patients are more or less likely to have a favorable outcome with specific pharmacotherapies, based on single nucleotide polymorphisms (SNPs) and gene variants in transporters and metabolizing enzymes. Genome-wide association studies have revealed that common genetic variations are unlikely to explain sufficient variance in treatment response to guide selection of treatment for individual patients. Rare gene variants have greater explanatory power than common variants, but such individual markers would likely apply to relatively few patients. Thus, if neither common nor rare gene variants are likely to have widespread predictive value as “stand alone” predictors of treatment response in typical clinical trials, a new strategy is needed, one that integrates several types of clinical and neurobiological markers to guide clinical decision making for depressive disorders. Since it is unlikely that a single biological alteration will have a one-to-one mapping with a DSM-defined or RDoCspecified mental phenomenon, a viable alternative to the single-biomarker approach is the development of biosignatures that aim to profile a diverse array of peripheral/serum growth factors, cytokines, hormones and metabolic markers. Additionally, integration with neurological, cognitive and psychological assessments will provide coverage of multiple abnormalities that contribute to the heterogeneity of depressive disorders. Such a biosignature will not only improve our ability to identify specific subtypes of depressive disorders, but will also assist with the selection of treatments that are likely to be more clinically useful. Based on this, some of the most promising variables to evaluate include: comprehensive clinical phenotype; magnetic resonance imaging using measures of cortical structure; diffusion tensor imaging to assess cortical white matter tract integrity; functional magnetic resonance imaging assessing brain activation patterns to both emotional conflict and reward-dependent learning tasks; quantitative electroencephalography (EEG) to assess cortical and subco
{"title":"Person‐centered measurement‐based care for depression","authors":"R. Uher","doi":"10.1002/wps.20363","DOIUrl":"https://doi.org/10.1002/wps.20363","url":null,"abstract":"tic clinical utility. The recent emergence of low-cost pharmacogenomic techniques has sparked new interests in combinatorial use of allelic variations in drug transporters or metabolic genes as biomarkers that might predict drug response. An initial generation of research identified a number of candidate genes with apparent validity as predictors of treatment efficacy and treatment-related side effects. These candidates include genes implicated in serotonergic function, the ABC family of xenobiotic transporters located in the blood-brain barrier, and the cytochrome P450 detoxification enzymes. However, to date, there are no effective biological methods to objectively assess depression endophenotypes, severity, or treatment response. Previous efforts to achieve better treatment outcomes in psychiatry have led to the introduction of pharmacogenomics based decision-support tools, to help identify which patients are more or less likely to have a favorable outcome with specific pharmacotherapies, based on single nucleotide polymorphisms (SNPs) and gene variants in transporters and metabolizing enzymes. Genome-wide association studies have revealed that common genetic variations are unlikely to explain sufficient variance in treatment response to guide selection of treatment for individual patients. Rare gene variants have greater explanatory power than common variants, but such individual markers would likely apply to relatively few patients. Thus, if neither common nor rare gene variants are likely to have widespread predictive value as “stand alone” predictors of treatment response in typical clinical trials, a new strategy is needed, one that integrates several types of clinical and neurobiological markers to guide clinical decision making for depressive disorders. Since it is unlikely that a single biological alteration will have a one-to-one mapping with a DSM-defined or RDoCspecified mental phenomenon, a viable alternative to the single-biomarker approach is the development of biosignatures that aim to profile a diverse array of peripheral/serum growth factors, cytokines, hormones and metabolic markers. Additionally, integration with neurological, cognitive and psychological assessments will provide coverage of multiple abnormalities that contribute to the heterogeneity of depressive disorders. Such a biosignature will not only improve our ability to identify specific subtypes of depressive disorders, but will also assist with the selection of treatments that are likely to be more clinically useful. Based on this, some of the most promising variables to evaluate include: comprehensive clinical phenotype; magnetic resonance imaging using measures of cortical structure; diffusion tensor imaging to assess cortical white matter tract integrity; functional magnetic resonance imaging assessing brain activation patterns to both emotional conflict and reward-dependent learning tasks; quantitative electroencephalography (EEG) to assess cortical and subco","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"15 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2016-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20363","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"51240114","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}
Maude Schneider, M. Armando, M. Pontillo, S. Vicari, M. Debbané, F. Schultze-Lutter, S. Eliez
The 22q11.2 deletion syndrome (22q11DS) is characterized by high rates of psychotic symptoms and schizophrenia, making this condition a promising human model for studying risk factors for psychosis. We explored the predictive value of ultra high risk (UHR) criteria in a sample of patients with 22q11DS. We also examined the additional contribution of socio‐demographic, clinical and cognitive variables to predict transition to psychosis within a mean interval of 32.5 ± 17.6 months after initial assessment. Eighty‐nine participants with 22q11DS (age range: 8‐30 years; mean 16.1 ± 4.7) were assessed using the Structured Interview for Psychosis‐Risk Syndromes. Information on Axis I diagnoses, internalizing and externalizing symptoms, level of functioning and IQ was also collected. At baseline, 22 (24.7%) participants met UHR criteria. Compared to those without a UHR condition, they had a significantly lower functioning, more frequent anxiety disorders, and more severe psychopathology. Transition rate to psychosis was 27.3% in UHR and 4.5% in non‐UHR participants. Cox regression analyses revealed that UHR status significantly predicted conversion to psychosis. Baseline level of functioning was the only other additional predictor. This is the first study investigating the predictive value of UHR criteria in 22q11DS. It indicates that the clinical path leading to psychosis is broadly comparable to that observed in other clinical high‐risk samples. Nevertheless, the relatively high transition rate in non‐UHR individuals suggests that other risk markers should be explored in this population. The role of low functioning as a predictor of transition to psychosis should also be investigated more in depth.
{"title":"Ultra high risk status and transition to psychosis in 22q11.2 deletion syndrome","authors":"Maude Schneider, M. Armando, M. Pontillo, S. Vicari, M. Debbané, F. Schultze-Lutter, S. Eliez","doi":"10.1002/wps.20347","DOIUrl":"https://doi.org/10.1002/wps.20347","url":null,"abstract":"The 22q11.2 deletion syndrome (22q11DS) is characterized by high rates of psychotic symptoms and schizophrenia, making this condition a promising human model for studying risk factors for psychosis. We explored the predictive value of ultra high risk (UHR) criteria in a sample of patients with 22q11DS. We also examined the additional contribution of socio‐demographic, clinical and cognitive variables to predict transition to psychosis within a mean interval of 32.5 ± 17.6 months after initial assessment. Eighty‐nine participants with 22q11DS (age range: 8‐30 years; mean 16.1 ± 4.7) were assessed using the Structured Interview for Psychosis‐Risk Syndromes. Information on Axis I diagnoses, internalizing and externalizing symptoms, level of functioning and IQ was also collected. At baseline, 22 (24.7%) participants met UHR criteria. Compared to those without a UHR condition, they had a significantly lower functioning, more frequent anxiety disorders, and more severe psychopathology. Transition rate to psychosis was 27.3% in UHR and 4.5% in non‐UHR participants. Cox regression analyses revealed that UHR status significantly predicted conversion to psychosis. Baseline level of functioning was the only other additional predictor. This is the first study investigating the predictive value of UHR criteria in 22q11DS. It indicates that the clinical path leading to psychosis is broadly comparable to that observed in other clinical high‐risk samples. Nevertheless, the relatively high transition rate in non‐UHR individuals suggests that other risk markers should be explored in this population. The role of low functioning as a predictor of transition to psychosis should also be investigated more in depth.","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"15 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2016-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20347","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"51239129","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}
This paper aims to give an overview of the key issues facing those who are in a position to influence the planning and provision of mental health systems, and who need to address questions of which staff, services and sectors to invest in, and for which patients. The paper considers in turn: a) definitions of community mental health care; b) a conceptual framework to use when evaluating the need for hospital and community mental health care; c) the potential for wider platforms, outside the health service, for mental health improvement, including schools and the workplace; d) data on how far community mental health services have been developed across different regions of the world; e) the need to develop in more detail models of community mental health services for low- and middle-income countries which are directly based upon evidence for those countries; f) how to incorporate mental health practice within integrated models to identify and treat people with comorbid long-term conditions; g) possible adverse effects of deinstitutionalization. We then present a series of ten recommendations for the future strengthening of health systems to support and treat people with mental illness.
{"title":"Community mental health care worldwide: current status and further developments.","authors":"Graham Thornicroft, Tanya Deb, Claire Henderson","doi":"10.1002/wps.20349","DOIUrl":"10.1002/wps.20349","url":null,"abstract":"<p><p>This paper aims to give an overview of the key issues facing those who are in a position to influence the planning and provision of mental health systems, and who need to address questions of which staff, services and sectors to invest in, and for which patients. The paper considers in turn: a) definitions of community mental health care; b) a conceptual framework to use when evaluating the need for hospital and community mental health care; c) the potential for wider platforms, outside the health service, for mental health improvement, including schools and the workplace; d) data on how far community mental health services have been developed across different regions of the world; e) the need to develop in more detail models of community mental health services for low- and middle-income countries which are directly based upon evidence for those countries; f) how to incorporate mental health practice within integrated models to identify and treat people with comorbid long-term conditions; g) possible adverse effects of deinstitutionalization. We then present a series of ten recommendations for the future strengthening of health systems to support and treat people with mental illness.</p>","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"15 1","pages":"276-286"},"PeriodicalIF":73.3,"publicationDate":"2016-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20349","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"51238789","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}
Most countries in the modern world have a formal system of medicines regulation. Medicinal drugs, or more specifically their formulation and dosage, are licensed or “labelled” for certain specific indications in which their use has been shown to be broadly safe and beneficial. Prescribers can, as a consequence, have confidence in the assumption that a drug licensed for a particular precisely defined ailment is likely to be effective in that condition. Outside this regulatory framework is a body of literature which may relate to other, unlicensed or “off‐label” uses. Sometimes the extra‐regulatory evidence base amounts to no more than a handful of case reports, but often there are published and successful randomized controlled trials. The licensed uses of a medicine are thus merely those for which formal approval has been sought and obtained by the manufacturer. Other beneficial uses are certainly not precluded by a drug's label.
{"title":"Prescribing according to diagnosis: how psychiatry is different","authors":"David Taylor","doi":"10.1002/wps.20343","DOIUrl":"https://doi.org/10.1002/wps.20343","url":null,"abstract":"Most countries in the modern world have a formal system of medicines regulation. Medicinal drugs, or more specifically their formulation and dosage, are licensed or “labelled” for certain specific indications in which their use has been shown to be broadly safe and beneficial. Prescribers can, as a consequence, have confidence in the assumption that a drug licensed for a particular precisely defined ailment is likely to be effective in that condition. Outside this regulatory framework is a body of literature which may relate to other, unlicensed or “off‐label” uses. Sometimes the extra‐regulatory evidence base amounts to no more than a handful of case reports, but often there are published and successful randomized controlled trials. The licensed uses of a medicine are thus merely those for which formal approval has been sought and obtained by the manufacturer. Other beneficial uses are certainly not precluded by a drug's label.","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"15 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2016-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20343","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"51238476","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}
Obsessive-compulsive disorder (OCD) is a chronic disabling disorder characterized by recurrent obsessions and uncontrolled compulsions. Recent research suggests that OCD is more common than assumed before. Cognitive-behavioral therapy and selective serotonin reuptake inhibitors have been shown to be equally efficacious in OCD, but with rates between 50% and 60% for response and 25% or below for remission. Thus, further development of efficacious treatments is required. Despite the long clinical tradition of describing and treating OCD from a psychodynamic perspective, no evidence-based psychodynamic treatment exists. Recent research on anxiety disorders, however, suggests that manual-guided short-term psychodynamic therapy (STPP) may be a promising approach. Building on STPP for anxiety disorders, a model of STPP for OCD was developed which is based on Luborsky’s supportiveexpressive therapy. The treatment consists of twelve modules which include both the characteristic elements of supportiveexpressive therapy (i.e., focus on the core conflictual relationship theme, CCRT, and on the helping alliance) and additional disorder-specific treatment elements. In the following the treatment is briefly described. At the beginning of treatment, the CCRT associated with the symptoms of OCD is assessed. A CCRT encompasses three components: a wish (W, e.g. aggressive or sexual impulses), a response from others (RO, e.g. to be condemned), and a response of the self (RS, e.g. obsessions and/or compulsions). Focusing on the CCRT, the therapist relates the patient’s OCD symptoms (RS) to his or her wishes (or impulses and affects, W) and to the (expected) responses by others (RO). The CCRT is presented to the patient as his or her “OCD formula”. This formula allows patients to understand their pattern of anxiety and OCD reactions. It translates the patient’s symptoms into (internal and external) interpersonal relationships. Enhancing the patient’s cognitive and emotional understanding of his or her symptoms and of the underlying CCRT represents the expressive (interpretive) element of SE therapy. An expressive intervention addressing the CCRT for Shakespeare’s Lady Macbeth’s compulsive washing may be: “As we have seen your compulsive washing (RS) is related to your aggression, the murder of Duncan (W), and to your feelings of guilt (internalized RO). By your compulsive washing rituals, you are trying to make your deed undone and to get relief from your guilt feelings. . . By washing your hands again and again, you are replacing moral purity by physical cleanness”. During treatment, the CCRT and its components are worked through in present and past relationships, including the “here and now” relationship with the therapist. Consistent with available evidence, working through the CCRT can be expected to improve the patients’ understanding of their conflicts, to reduce their OCD symptoms and to help them in developing more adaptive behaviors (RS). Both within and bet
{"title":"Psychodynamic therapy of obsessive‐compulsive disorder: principles of a manual‐guided approach","authors":"F. Leichsenring, Christiane Steinert","doi":"10.1002/wps.20339","DOIUrl":"https://doi.org/10.1002/wps.20339","url":null,"abstract":"Obsessive-compulsive disorder (OCD) is a chronic disabling disorder characterized by recurrent obsessions and uncontrolled compulsions. Recent research suggests that OCD is more common than assumed before. Cognitive-behavioral therapy and selective serotonin reuptake inhibitors have been shown to be equally efficacious in OCD, but with rates between 50% and 60% for response and 25% or below for remission. Thus, further development of efficacious treatments is required. Despite the long clinical tradition of describing and treating OCD from a psychodynamic perspective, no evidence-based psychodynamic treatment exists. Recent research on anxiety disorders, however, suggests that manual-guided short-term psychodynamic therapy (STPP) may be a promising approach. Building on STPP for anxiety disorders, a model of STPP for OCD was developed which is based on Luborsky’s supportiveexpressive therapy. The treatment consists of twelve modules which include both the characteristic elements of supportiveexpressive therapy (i.e., focus on the core conflictual relationship theme, CCRT, and on the helping alliance) and additional disorder-specific treatment elements. In the following the treatment is briefly described. At the beginning of treatment, the CCRT associated with the symptoms of OCD is assessed. A CCRT encompasses three components: a wish (W, e.g. aggressive or sexual impulses), a response from others (RO, e.g. to be condemned), and a response of the self (RS, e.g. obsessions and/or compulsions). Focusing on the CCRT, the therapist relates the patient’s OCD symptoms (RS) to his or her wishes (or impulses and affects, W) and to the (expected) responses by others (RO). The CCRT is presented to the patient as his or her “OCD formula”. This formula allows patients to understand their pattern of anxiety and OCD reactions. It translates the patient’s symptoms into (internal and external) interpersonal relationships. Enhancing the patient’s cognitive and emotional understanding of his or her symptoms and of the underlying CCRT represents the expressive (interpretive) element of SE therapy. An expressive intervention addressing the CCRT for Shakespeare’s Lady Macbeth’s compulsive washing may be: “As we have seen your compulsive washing (RS) is related to your aggression, the murder of Duncan (W), and to your feelings of guilt (internalized RO). By your compulsive washing rituals, you are trying to make your deed undone and to get relief from your guilt feelings. . . By washing your hands again and again, you are replacing moral purity by physical cleanness”. During treatment, the CCRT and its components are worked through in present and past relationships, including the “here and now” relationship with the therapist. Consistent with available evidence, working through the CCRT can be expected to improve the patients’ understanding of their conflicts, to reduce their OCD symptoms and to help them in developing more adaptive behaviors (RS). Both within and bet","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"15 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2016-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20339","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"51238248","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}
I first recognized what R. Perlis1 calls “artisanal practice” as a medical student in Liberia. Witch doctors – basically the local primary and psychiatric care providers at the time – regularly engaged in “throwing the bones”. Chicken bones, often in a bag but sometimes in hand, were shaken and thrown on the ground, resulting in a unique pattern which served as the basis for recommendation(s) offered to each “patient”. “Throwing the bones” was common and well accepted. So much so that it was rare to have dehydrated neonates arrive at the hospital without dung spread over their depressed fontanelles, courtesy of the “doctor”. Personalized care – maybe; precision medicine – not so much.
{"title":"Toward precision medicine for depression: admitting ignorance and focusing on failures","authors":"Gavin Andrews, M. Hobbs","doi":"10.1002/wps.20365","DOIUrl":"https://doi.org/10.1002/wps.20365","url":null,"abstract":"I first recognized what R. Perlis1 calls “artisanal practice” as a medical student in Liberia. Witch doctors – basically the local primary and psychiatric care providers at the time – regularly engaged in “throwing the bones”. Chicken bones, often in a bag but sometimes in hand, were shaken and thrown on the ground, resulting in a unique pattern which served as the basis for recommendation(s) offered to each “patient”. “Throwing the bones” was common and well accepted. So much so that it was rare to have dehydrated neonates arrive at the hospital without dung spread over their depressed fontanelles, courtesy of the “doctor”. Personalized care – maybe; precision medicine – not so much.","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"15 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2016-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20365","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"51239751","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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