{"title":"Physical health of people with severe mental disorders: leave no one behind.","authors":"Shekhar Saxena, Mario Maj","doi":"10.1002/wps.20403","DOIUrl":"10.1002/wps.20403","url":null,"abstract":"","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":" ","pages":"1-2"},"PeriodicalIF":60.5,"publicationDate":"2017-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5269495/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49047440","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}
Nancy H Liu, Gail L Daumit, Tarun Dua, Ralph Aquila, Fiona Charlson, Pim Cuijpers, Benjamin Druss, Kenn Dudek, Melvyn Freeman, Chiyo Fujii, Wolfgang Gaebel, Ulrich Hegerl, Itzhak Levav, Thomas Munk Laursen, Hong Ma, Mario Maj, Maria Elena Medina-Mora, Merete Nordentoft, Dorairaj Prabhakaran, Karen Pratt, Martin Prince, Thara Rangaswamy, David Shiers, Ezra Susser, Graham Thornicroft, Kristian Wahlbeck, Abe Fekadu Wassie, Harvey Whiteford, Shekhar Saxena
Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio-environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual-focused, health system-focused, and community level and policy-focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas.
{"title":"Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas.","authors":"Nancy H Liu, Gail L Daumit, Tarun Dua, Ralph Aquila, Fiona Charlson, Pim Cuijpers, Benjamin Druss, Kenn Dudek, Melvyn Freeman, Chiyo Fujii, Wolfgang Gaebel, Ulrich Hegerl, Itzhak Levav, Thomas Munk Laursen, Hong Ma, Mario Maj, Maria Elena Medina-Mora, Merete Nordentoft, Dorairaj Prabhakaran, Karen Pratt, Martin Prince, Thara Rangaswamy, David Shiers, Ezra Susser, Graham Thornicroft, Kristian Wahlbeck, Abe Fekadu Wassie, Harvey Whiteford, Shekhar Saxena","doi":"10.1002/wps.20384","DOIUrl":"10.1002/wps.20384","url":null,"abstract":"<p><p>Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio-environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual-focused, health system-focused, and community level and policy-focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas.</p>","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":" ","pages":"30-40"},"PeriodicalIF":60.5,"publicationDate":"2017-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5269481/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46665407","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}
design and delivery seem to be – at least in our experience – different, for example at the primary care level. Furthermore, when talking about the integration of mental health into primary care, it might be beneficial to allocate some attention to the way it is being done. Although implementation research is still ongoing, the Mental Health Gap Action Programme (mhGAP) Intervention Guide has been useful in training and supervising the primary care staff. However, to ensure the effective and sustainable integration of mental health within health systems, tools for the implementation and incorporation of the mhGAP within existing health systems are much needed. Such tools would help in the allocation of tasks/roles among different professionals at the primary care level, in the care packages and pathways for different disorders, in the health information system, and in the links of the primary care with specialized services. A lot of attention is also needed for human resources. The tipping point in positive attitude change towards persons with mental disorders for many primary health care staff is often seen after they disclose a personal experience with mental health concerning themselves or a member of their family to an mhGAP supervisor and feel that the supervisor is able to listen and support. Addressing the mental health of the staff is a key action for integrating mental health into primary care and as such deserves closer attention. A further factor to consider in order to enhance the integration of mental health into primary care is the use of innovations in domains such as management and information technology that have the potential to decrease cost and increase efficiency. The third point highlights the importance of the context where persons with severe mental disorders live. Two main examples are prisons and humanitarian crisis. It might be a good idea if the framework delineated by Liu et al could include an item to highlight persons with severe mental disorders living in prisons as a vulnerable group in need of specific interventions. The same applies to persons with severe mental disorders living in humanitarian settings, where they are often either locked in big institutions or very disadvantaged in reaching the needed services, which in both cases will put them at a higher risk for premature death. In summary, details pertaining to the implementation of the framework and to how it links to other mental health priorities are needed. This being said, this framework adds to the available tools and usefully highlights the importance of addressing the excess mortality in persons with severe mental disorders. In lowresource contexts – where mental health systems are under development with competing priorities – mental health disorder management, physical health treatment, screening for medical conditions, and stigma reduction interventions seem to be the components of the framework that would be easier and most important to consider,
{"title":"A service user's perspective","authors":"C. Sunkel","doi":"10.1002/wps.20378","DOIUrl":"https://doi.org/10.1002/wps.20378","url":null,"abstract":"design and delivery seem to be – at least in our experience – different, for example at the primary care level. Furthermore, when talking about the integration of mental health into primary care, it might be beneficial to allocate some attention to the way it is being done. Although implementation research is still ongoing, the Mental Health Gap Action Programme (mhGAP) Intervention Guide has been useful in training and supervising the primary care staff. However, to ensure the effective and sustainable integration of mental health within health systems, tools for the implementation and incorporation of the mhGAP within existing health systems are much needed. Such tools would help in the allocation of tasks/roles among different professionals at the primary care level, in the care packages and pathways for different disorders, in the health information system, and in the links of the primary care with specialized services. A lot of attention is also needed for human resources. The tipping point in positive attitude change towards persons with mental disorders for many primary health care staff is often seen after they disclose a personal experience with mental health concerning themselves or a member of their family to an mhGAP supervisor and feel that the supervisor is able to listen and support. Addressing the mental health of the staff is a key action for integrating mental health into primary care and as such deserves closer attention. A further factor to consider in order to enhance the integration of mental health into primary care is the use of innovations in domains such as management and information technology that have the potential to decrease cost and increase efficiency. The third point highlights the importance of the context where persons with severe mental disorders live. Two main examples are prisons and humanitarian crisis. It might be a good idea if the framework delineated by Liu et al could include an item to highlight persons with severe mental disorders living in prisons as a vulnerable group in need of specific interventions. The same applies to persons with severe mental disorders living in humanitarian settings, where they are often either locked in big institutions or very disadvantaged in reaching the needed services, which in both cases will put them at a higher risk for premature death. In summary, details pertaining to the implementation of the framework and to how it links to other mental health priorities are needed. This being said, this framework adds to the available tools and usefully highlights the importance of addressing the excess mortality in persons with severe mental disorders. In lowresource contexts – where mental health systems are under development with competing priorities – mental health disorder management, physical health treatment, screening for medical conditions, and stigma reduction interventions seem to be the components of the framework that would be easier and most important to consider,","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.20378","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43435716","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}
they may be helpful for DMDD. Data support the use of atypical antipsychotic medication in youth with autism and irritability, and in youth with aggression. However, recent increases in antipsychotic prescriptions may have resulted in part from attempts to treat pediatric irritability, perhaps without adequate exploration of alternative pharmacologic and psychotherapeutic approaches. Selective serotonin reuptake inhibitors (SSRIs) may treat irritability in adults; such an approach in children is supported by the high comorbidity and longitudinal associations among irritability, anxiety and depression. SSRIs are now being tested in youth with DMDD. Psychotherapeutic approaches are likely to be important in the treatment of irritability. Parent training can decrease a child’s aggression and might also decrease irritability. Cognitive behavioral approaches are being tested, as is implicit training designed to alter irritable children’s tendency to view ambiguous faces as angry. In conclusion, the recent focus on irritability has yielded considerable knowledge about its longitudinal course and associations with psychopathology. Ongoing work is aimed at identifying the brain mechanisms mediating irritability and at using that knowledge to inform novel treatment approaches.
{"title":"Are there new advances in the pharmacotherapy of autism spectrum disorders?","authors":"E. Hollander, G. Uzunova","doi":"10.1002/wps.20398","DOIUrl":"https://doi.org/10.1002/wps.20398","url":null,"abstract":"they may be helpful for DMDD. Data support the use of atypical antipsychotic medication in youth with autism and irritability, and in youth with aggression. However, recent increases in antipsychotic prescriptions may have resulted in part from attempts to treat pediatric irritability, perhaps without adequate exploration of alternative pharmacologic and psychotherapeutic approaches. Selective serotonin reuptake inhibitors (SSRIs) may treat irritability in adults; such an approach in children is supported by the high comorbidity and longitudinal associations among irritability, anxiety and depression. SSRIs are now being tested in youth with DMDD. Psychotherapeutic approaches are likely to be important in the treatment of irritability. Parent training can decrease a child’s aggression and might also decrease irritability. Cognitive behavioral approaches are being tested, as is implicit training designed to alter irritable children’s tendency to view ambiguous faces as angry. In conclusion, the recent focus on irritability has yielded considerable knowledge about its longitudinal course and associations with psychopathology. Ongoing work is aimed at identifying the brain mechanisms mediating irritability and at using that knowledge to inform novel treatment approaches.","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.20398","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45200646","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}
onists have been tested in ASD associated with fragile X syndrome, and showed promise in a subgroup of patients. GABAergic agents, such as the GABA-B receptor agonist arbaclofen (STX209), have shown some effect on irritability and social withdrawal in ASD children. The peptide hormone oxytocin is important in social cognition and behavior. In ASD adults, acute intravenous administration of oxytocin reduced repetitive behaviors and improved accuracy of recognizing emotions in speech over time. Intranasal administration improved social cognition in children, adolescents and adults with ASD. A vasopressin 1a receptor antagonist had some effect on speech recognition of emotions such as fear and lust in high-functioning ASD adults. Insulin-like growth factor 1 (IGF-1) is important in central nervous system maturation, development and connectivity, that are perturbed in ASD. Studies in Shank-3 deficient mice that model Phelan-McDermid syndrome (PMS), which may be associated with some cases of ASD, indicated that IGF-1 may reverse structural changes in ionotropic glutamate receptors, functional synaptic plasticity changes, and excitation/inhibition imbalance. A clinical trial with recombinant human IGF-1 in PMS children showed improvement in social impairment and restricted behaviors. Agents modulating the immune system have been tested in ASD. The immune response induced by the whipworm Trichuris suis ova has shown benefit on the repetitive behavior domain in adult ASD. Immunosuppressive and protein synthesis inhibiting drugs such as the mTOR inhibitor rapamycin have been shown to improve social deficits in some forms of ASD. The alpha-7 nicotinic acetylcholine receptor (nACR) gene is associated with autism and ADHD. nACR drugs tested in clinical trials include mecamylamine, transdermally administered nicotine, and donepezil. Some alpha-7 nACR antagonists such as galantamine have shown promise in animal models and clinical trials. Drugs modulating the cannabinoid system, such as cannabidiol, have been found effective in childhood epilepsy, and may be worth studying in ASD due to their anti-anxiety, antiepileptic, immunomodulating and cognitive-enhancing effects and good safety. Interestingly, social reward and oxytocin induce release of endocannabinoids in nucleus accumbens. In ASD animal models, cannabidiol has some impact on social deficits, repetitive behaviors and irritability. Complementary and alternative medicine (CAM) treatments have been tested in ASD. However, they are not strictly regulated and have not been studied in large-scale clinical trials. Therefore, their safety and efficacy is not well determined. CAM treatments may complement rather than replace proven therapies for ASD. Melatonin may be used for sleep disorders, omega-3 fatty acids for reducing repetitive behaviors and improving sociability. Vitamin B12 supplements are believed to protect against the oxidative damage in ASD. Curcumin, an active ingredient of turmeric, may be bene
{"title":"Nonmedical use of prescription drugs in adolescents and young adults: not just a Western phenomenon","authors":"S. Martins, L. Ghandour","doi":"10.1002/wps.20350","DOIUrl":"https://doi.org/10.1002/wps.20350","url":null,"abstract":"onists have been tested in ASD associated with fragile X syndrome, and showed promise in a subgroup of patients. GABAergic agents, such as the GABA-B receptor agonist arbaclofen (STX209), have shown some effect on irritability and social withdrawal in ASD children. The peptide hormone oxytocin is important in social cognition and behavior. In ASD adults, acute intravenous administration of oxytocin reduced repetitive behaviors and improved accuracy of recognizing emotions in speech over time. Intranasal administration improved social cognition in children, adolescents and adults with ASD. A vasopressin 1a receptor antagonist had some effect on speech recognition of emotions such as fear and lust in high-functioning ASD adults. Insulin-like growth factor 1 (IGF-1) is important in central nervous system maturation, development and connectivity, that are perturbed in ASD. Studies in Shank-3 deficient mice that model Phelan-McDermid syndrome (PMS), which may be associated with some cases of ASD, indicated that IGF-1 may reverse structural changes in ionotropic glutamate receptors, functional synaptic plasticity changes, and excitation/inhibition imbalance. A clinical trial with recombinant human IGF-1 in PMS children showed improvement in social impairment and restricted behaviors. Agents modulating the immune system have been tested in ASD. The immune response induced by the whipworm Trichuris suis ova has shown benefit on the repetitive behavior domain in adult ASD. Immunosuppressive and protein synthesis inhibiting drugs such as the mTOR inhibitor rapamycin have been shown to improve social deficits in some forms of ASD. The alpha-7 nicotinic acetylcholine receptor (nACR) gene is associated with autism and ADHD. nACR drugs tested in clinical trials include mecamylamine, transdermally administered nicotine, and donepezil. Some alpha-7 nACR antagonists such as galantamine have shown promise in animal models and clinical trials. Drugs modulating the cannabinoid system, such as cannabidiol, have been found effective in childhood epilepsy, and may be worth studying in ASD due to their anti-anxiety, antiepileptic, immunomodulating and cognitive-enhancing effects and good safety. Interestingly, social reward and oxytocin induce release of endocannabinoids in nucleus accumbens. In ASD animal models, cannabidiol has some impact on social deficits, repetitive behaviors and irritability. Complementary and alternative medicine (CAM) treatments have been tested in ASD. However, they are not strictly regulated and have not been studied in large-scale clinical trials. Therefore, their safety and efficacy is not well determined. CAM treatments may complement rather than replace proven therapies for ASD. Melatonin may be used for sleep disorders, omega-3 fatty acids for reducing repetitive behaviors and improving sociability. Vitamin B12 supplements are believed to protect against the oxidative damage in ASD. Curcumin, an active ingredient of turmeric, may be bene","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.20350","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45719520","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. 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}
{"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}
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}
Geoffrey M Reed, Jack Drescher, Richard B Krueger, Elham Atalla, Susan D Cochran, Michael B First, Peggy T Cohen-Kettenis, Iván Arango-de Montis, Sharon J Parish, Sara Cottler, Peer Briken, Shekhar 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.
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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}
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