311 ship between trauma exposure and onset of other psychiatric disorders, there are several mechanisms that can be considered, and these arguably function in an interactive manner. One key potential mechanism is the impact of PTSD on the capacity to down-regulate emotional distress. It is well documented that PTSD involves impaired emotion regulation, and it is possible that this impairment predisposes people to develop new psychiatric disorders or worsens others. The capacity to regulate emotions in PTSD can be related to the well-documented deficits in executive functioning. Deficient working memory and attentional capacity can limit the extent to which one can regulate emotions, which can result in greater risk for mental health problems. Moreover, avoidance is a key symptom of PTSD, and this can trigger a cascade of strategies that can be maladaptive. Avoidance can involve situations or thoughts and memories related to the traumatic experience. This tendency can generalize to more pervasive avoidance of social networks, emotional states, and activities that promote good mental health. This can lead to a worsening of depression, anxiety and other psychiatric conditions. Another common form of avoidance for people with PTSD is self-medicating with prescription or non-prescription substances to numb the distress that is experienced along with traumatic memories. This behaviour can not only lead to substance abuse, which has been documented in longitudinal studies of PTSD, but also facilitate other psychiatric problems, because issues may not be addressed in a constructive manner. Avoidance tendencies can also result in not seeking help from mental health services, which can impede early intervention or adequate treatment for other psychiatric disorders. The DSM-5 explicitly recognizes the presence of harmful behaviors in PTSD, including such risk-taking behaviors as dangerous driving, severe alcohol use, and self-harm. These reactions are conceptualized as a result of the extreme arousal and the difficulties in impulse control that can be experienced by people with PTSD. These behaviors can lead to a range of events and habits triggering repetitive cycles of exposure to trauma. This can compound the sensitization that has been reported in PTSD, in which the condition results in neural sensitivity to threats and stressors in one’s environment, such that the person is more reactive to these events. One of the strongest transdiagnostic predictors of risk for mental health problems is represented by maladaptive or catastrophic appraisals about oneself or the environment. A key feature of PTSD is the tendency to engage in catastrophic appraisals after the traumatic experience, and these appraisals can generalize to many aspects of a person’s life, such as one’s selfesteem, trust in others, fears of negative evaluations, germs, or self-blame. These cognitive tendencies are major risk factors for an array of psychiatric conditions, including anxiety,
{"title":"Intimate partner violence and mental health: lessons from the COVID‐19 pandemic","authors":"L. Howard, Claire A. Wilson, P. Chandra","doi":"10.1002/wps.20976","DOIUrl":"https://doi.org/10.1002/wps.20976","url":null,"abstract":"311 ship between trauma exposure and onset of other psychiatric disorders, there are several mechanisms that can be considered, and these arguably function in an interactive manner. One key potential mechanism is the impact of PTSD on the capacity to down-regulate emotional distress. It is well documented that PTSD involves impaired emotion regulation, and it is possible that this impairment predisposes people to develop new psychiatric disorders or worsens others. The capacity to regulate emotions in PTSD can be related to the well-documented deficits in executive functioning. Deficient working memory and attentional capacity can limit the extent to which one can regulate emotions, which can result in greater risk for mental health problems. Moreover, avoidance is a key symptom of PTSD, and this can trigger a cascade of strategies that can be maladaptive. Avoidance can involve situations or thoughts and memories related to the traumatic experience. This tendency can generalize to more pervasive avoidance of social networks, emotional states, and activities that promote good mental health. This can lead to a worsening of depression, anxiety and other psychiatric conditions. Another common form of avoidance for people with PTSD is self-medicating with prescription or non-prescription substances to numb the distress that is experienced along with traumatic memories. This behaviour can not only lead to substance abuse, which has been documented in longitudinal studies of PTSD, but also facilitate other psychiatric problems, because issues may not be addressed in a constructive manner. Avoidance tendencies can also result in not seeking help from mental health services, which can impede early intervention or adequate treatment for other psychiatric disorders. The DSM-5 explicitly recognizes the presence of harmful behaviors in PTSD, including such risk-taking behaviors as dangerous driving, severe alcohol use, and self-harm. These reactions are conceptualized as a result of the extreme arousal and the difficulties in impulse control that can be experienced by people with PTSD. These behaviors can lead to a range of events and habits triggering repetitive cycles of exposure to trauma. This can compound the sensitization that has been reported in PTSD, in which the condition results in neural sensitivity to threats and stressors in one’s environment, such that the person is more reactive to these events. One of the strongest transdiagnostic predictors of risk for mental health problems is represented by maladaptive or catastrophic appraisals about oneself or the environment. A key feature of PTSD is the tendency to engage in catastrophic appraisals after the traumatic experience, and these appraisals can generalize to many aspects of a person’s life, such as one’s selfesteem, trust in others, fears of negative evaluations, germs, or self-blame. These cognitive tendencies are major risk factors for an array of psychiatric conditions, including anxiety, ","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"31 10","pages":"311 - 313"},"PeriodicalIF":73.3,"publicationDate":"2022-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41331499","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}
The year 2021 has been another tough one for us all. Uncertainty about the COVID situation, restrictions about travel, and difficulties in getting connected have been the major issues that have affected our professional work and personal lives during that year. The WPA has also struggled coping with these limitations. However, that period has given us some motivation and new insight to work under difficult circumstances and to continue with the implementation of our Action Plan 20202023. The WPA Executive Committee and Standing Committees, along with the Secretariat staff, remained committed to fulfil their responsibilities. The WPA’s drive to encourage and inspire learning among colleagues and trainees around the world led to offering more online educational activities during 2021. We were delighted to organize, support and promote several new educational modules, courses, teaching sessions and online programmes. The accelerated development of the WPA education portal and learning management system (LMS) has promoted the launch of new education and training modules to support our young professionals, especially for the emergency response measures during the pandemic period. The first of these modules supports psychiatrists in using e-mental health tools. The portal also gives ready access to WPA’s existing training materials available in several languages. Available programmes also include ICD-11 and Yoga courses, free webinars on Early Intervention in Psychosis, updates in Psychopharmacology and courses on Telepsychiatry, Psychotherapy and Child and Adolescent Psychiatry. We continued with our projects outlined in the Action Plan. Various Working Groups offered a number of activities in ar eas of training, research and clinical updates. The Working Groups on Co-morbidity in Mental Illnesses, Early Intervention in Psychosis, Public Mental Health, and Promotion of Psychiatry among Medical Students highlighted their contributions in various activities. I am pleased that we also completed some unfinished projects started in the previous triennium. The WPA Scientific Sections likewise supported the scientific work of the Association in an inspiring way. Since the start of the network of WPA Collaborating Centres in 2016, these centres are providing practical advice on teaching, policy, research and clinical activities in psychiatry worldwide. During 2021, the network, now including eight sites, supported the implementation of the WPA’s strategic plan to build a global alliance for better mental health. In addition to the pandemic, unfortunately, we saw many adversities in 2021 in several parts of the world. Following WPA’s mission to help and support our membership during disasters, we established an Advisory Committee for Responses to Emergencies (ACRE), that brought together the leaders of the larger Member Societies to facilitate practical and concrete aid to Member Societies in need. This work continued mobilizing and fostering education, in for
{"title":"Implementation of the WPA Action Plan 2020‐2023: an update","authors":"A. Javed","doi":"10.1002/wps.20978","DOIUrl":"https://doi.org/10.1002/wps.20978","url":null,"abstract":"The year 2021 has been another tough one for us all. Uncertainty about the COVID situation, restrictions about travel, and difficulties in getting connected have been the major issues that have affected our professional work and personal lives during that year. The WPA has also struggled coping with these limitations. However, that period has given us some motivation and new insight to work under difficult circumstances and to continue with the implementation of our Action Plan 20202023. The WPA Executive Committee and Standing Committees, along with the Secretariat staff, remained committed to fulfil their responsibilities. The WPA’s drive to encourage and inspire learning among colleagues and trainees around the world led to offering more online educational activities during 2021. We were delighted to organize, support and promote several new educational modules, courses, teaching sessions and online programmes. The accelerated development of the WPA education portal and learning management system (LMS) has promoted the launch of new education and training modules to support our young professionals, especially for the emergency response measures during the pandemic period. The first of these modules supports psychiatrists in using e-mental health tools. The portal also gives ready access to WPA’s existing training materials available in several languages. Available programmes also include ICD-11 and Yoga courses, free webinars on Early Intervention in Psychosis, updates in Psychopharmacology and courses on Telepsychiatry, Psychotherapy and Child and Adolescent Psychiatry. We continued with our projects outlined in the Action Plan. Various Working Groups offered a number of activities in ar eas of training, research and clinical updates. The Working Groups on Co-morbidity in Mental Illnesses, Early Intervention in Psychosis, Public Mental Health, and Promotion of Psychiatry among Medical Students highlighted their contributions in various activities. I am pleased that we also completed some unfinished projects started in the previous triennium. The WPA Scientific Sections likewise supported the scientific work of the Association in an inspiring way. Since the start of the network of WPA Collaborating Centres in 2016, these centres are providing practical advice on teaching, policy, research and clinical activities in psychiatry worldwide. During 2021, the network, now including eight sites, supported the implementation of the WPA’s strategic plan to build a global alliance for better mental health. In addition to the pandemic, unfortunately, we saw many adversities in 2021 in several parts of the world. Following WPA’s mission to help and support our membership during disasters, we established an Advisory Committee for Responses to Emergencies (ACRE), that brought together the leaders of the larger Member Societies to facilitate practical and concrete aid to Member Societies in need. This work continued mobilizing and fostering education, in for","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"21 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2022-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41392342","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}
truths – truths perhaps accessible only to forms of self-conscious or hyperreflexive awareness unavailable to most of us. In closing, one must acknowledge some gaps in our grasp of subjectivity and its significance for psychiatry. It may be obvious to common sense that the exercise of free will, together with a person’s experience of meaning or significance, do play a role in human behavior and thereby affect the material plane of brain functioning (if I choose to close my eyes, in prayer, patterns in visual cortex are altered). But it is also true that we have difficulty incorporating the domains of conscious life and its physical substrate within a single explanatory account (the mind/body problem). In particular, we have difficulty integrating “act” with “affliction” aspects of psychological existence – that is, appreciating the subtle but decisive ways in which defensive or other goal-directed forms of thought or behavior can interact with aspects of mental life over which the person has little or no control. Even more basic is the challenge of observing and describing consciousness itself, whose ever-changing, all-encompassing flow we, as human beings and language speakers, are constantly tempted to misperceive or misdescribe. We succumb to this temptation by using words that stress the substantive over the transitory aspects of experience, or by focusing on particular objects of awareness while ignoring subtle alterations in, for example, the experience of space, time, or the overall atmosphere of reality. In fact, no approach can be fully “bottom-up” in the sense of being purely empirical or a-theoretical: when it comes to describing experience, patients as well as professionals are burdened (though also blessed) with the objectifying prejudices of their language and their worldview. The study of “lived experience” may then be impossible as a foolproof, quasi-empiricist venture. It is, however, also indispensable – and to both the ethical and the scientific enterprise of psychiatry.
{"title":"What is good acute psychiatric care (and how would you know)?","authors":"D. Tracy, Dina M. Phillips","doi":"10.1002/wps.20958","DOIUrl":"https://doi.org/10.1002/wps.20958","url":null,"abstract":"truths – truths perhaps accessible only to forms of self-conscious or hyperreflexive awareness unavailable to most of us. In closing, one must acknowledge some gaps in our grasp of subjectivity and its significance for psychiatry. It may be obvious to common sense that the exercise of free will, together with a person’s experience of meaning or significance, do play a role in human behavior and thereby affect the material plane of brain functioning (if I choose to close my eyes, in prayer, patterns in visual cortex are altered). But it is also true that we have difficulty incorporating the domains of conscious life and its physical substrate within a single explanatory account (the mind/body problem). In particular, we have difficulty integrating “act” with “affliction” aspects of psychological existence – that is, appreciating the subtle but decisive ways in which defensive or other goal-directed forms of thought or behavior can interact with aspects of mental life over which the person has little or no control. Even more basic is the challenge of observing and describing consciousness itself, whose ever-changing, all-encompassing flow we, as human beings and language speakers, are constantly tempted to misperceive or misdescribe. We succumb to this temptation by using words that stress the substantive over the transitory aspects of experience, or by focusing on particular objects of awareness while ignoring subtle alterations in, for example, the experience of space, time, or the overall atmosphere of reality. In fact, no approach can be fully “bottom-up” in the sense of being purely empirical or a-theoretical: when it comes to describing experience, patients as well as professionals are burdened (though also blessed) with the objectifying prejudices of their language and their worldview. The study of “lived experience” may then be impossible as a foolproof, quasi-empiricist venture. It is, however, also indispensable – and to both the ethical and the scientific enterprise of psychiatry.","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":" ","pages":""},"PeriodicalIF":73.3,"publicationDate":"2022-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44024230","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}
315 With the pandemic continuing to evolve, it will be critical to keep on answering key questions about the role of SSRIs in the treatment of acute COVID-19 illness. What is the best dose and timing of fluvoxamine, and how effective is it in combination with other treatments against COVID-19 (such as monoclonal antibodies)? Is fluoxetine, which has lower S1R affinity compared to fluvoxamine but has shown promise in preclinical and observational studies, also an effective treatment, considering that it is more widely available and easier to use? And what are the best treatments for neuropsychiatric manifestations of long COVID, and in which patients? Given that many psychotropics are now appreciated to have widespread molecular, cellular and physiological effects, including anti-inflammatory, neuroprotective and cardioprotective, and antiproliferative, we can expect that lessons learned in testing these medications for COVID-19 will be important for other drug repurposing efforts, ranging from infectious and inflammatory diseases, to neurodegenerative diseases such as Alzheimer’s disease, and cancer. Eric J. Lenze, Angela M. Reiersen, Paramala J. Santosh Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA; Department of Child and Adolescent Psychiatry, King’s College London, London, UK
{"title":"Empirical severity benchmarks for obsessive‐compulsive disorder across the lifespan","authors":"M. Cervin, D. Mataix-Cols","doi":"10.1002/wps.20984","DOIUrl":"https://doi.org/10.1002/wps.20984","url":null,"abstract":"315 With the pandemic continuing to evolve, it will be critical to keep on answering key questions about the role of SSRIs in the treatment of acute COVID-19 illness. What is the best dose and timing of fluvoxamine, and how effective is it in combination with other treatments against COVID-19 (such as monoclonal antibodies)? Is fluoxetine, which has lower S1R affinity compared to fluvoxamine but has shown promise in preclinical and observational studies, also an effective treatment, considering that it is more widely available and easier to use? And what are the best treatments for neuropsychiatric manifestations of long COVID, and in which patients? Given that many psychotropics are now appreciated to have widespread molecular, cellular and physiological effects, including anti-inflammatory, neuroprotective and cardioprotective, and antiproliferative, we can expect that lessons learned in testing these medications for COVID-19 will be important for other drug repurposing efforts, ranging from infectious and inflammatory diseases, to neurodegenerative diseases such as Alzheimer’s disease, and cancer. Eric J. Lenze, Angela M. Reiersen, Paramala J. Santosh Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA; Department of Child and Adolescent Psychiatry, King’s College London, London, UK","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":" ","pages":""},"PeriodicalIF":73.3,"publicationDate":"2022-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41798495","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}
The experience and presentations of mental disorders are affected by culture and the social milieu, not only of patients and families, but also of the individuals and health systems providing care. These cultural views impact what is considered normal or pathological. The salience of cultural considerations has therefore been increasingly reflected in modern classifica tion systems. The two dominant classification systems in psychiatry, in their earlier editions, took somewhat different approaches to reflecting cultural influences on diagnosis. The Clinical De scriptions and Diagnostic Guidelines (CDDG) for ICD10 Men tal and Behavioural Disorders did not include a classification of culturespecific disorders, but rather noted the presence of cultural variations in expression under broad disorder group ings (e.g., somatoform disorder) and in helpseeking and ill nessrelated behaviour. However, consideration of culture was not systematically incorporated in the manual. In contrast, the DSMIV incorporated brief descriptions of cultural features under specific disorders, outlined components of a cultural formulation approach, and listed twentyfive “culturebound syndromes”. The development of the ICD11 has emphasized the prin ciple of global applicability, i.e., the need for the diagnostic guide lines to function well across global regions, countries and lan guages. Reflecting the cultural context in which clinical encoun ters take place is likely to enhance this goal. However, there is an inev itable tension between the incorporation of lo cally relevant material and the essential purpose of an interna tional classi fication system, which is to reliably convey clinical information across diverse boundaries. Responding to this chal lenge requires a pragmatic balance that involves recognizing cultural differenc es where these are clinically im portant with out allowing them to detract from the goal of a common global diagnostic language. As a way of including meaningful consideration of culture in the diagnostic process, the World Health Organization (WHO) Department of Mental Health and Substance Abuse constituted a Working Group to develop guidance on cultural considera tions for the ICD11 CDDG, based on the current state of clini cally applicable information for individual disorders and/or disorder groupings. The focus was on providing pragmatic, actionable material to assist clinicians in their evaluation of patients using the ICD11 guidelines and reduce bias in clinical decisionmaking by facili tating diagnostic assessment in a culturally informed manner. Thus, for example, while recognizing that specific idioms relat ing to mental illness are always influenced by culture, what the guidance describes are emotions, cognitions or behaviours that are broadly universal and therefore not “culturebound” in the sense of being unique. The Working Group developed the following set of questions to guide the generation of the material
{"title":"Systematic inclusion of culture‐related information in ICD‐11","authors":"O. Gureje, R. Lewis-Fernández, B. Hall, G. Reed","doi":"10.1002/wps.20676","DOIUrl":"https://doi.org/10.1002/wps.20676","url":null,"abstract":"The experience and presentations of mental disorders are affected by culture and the social milieu, not only of patients and families, but also of the individuals and health systems providing care. These cultural views impact what is considered normal or pathological. The salience of cultural considerations has therefore been increasingly reflected in modern classifica tion systems. The two dominant classification systems in psychiatry, in their earlier editions, took somewhat different approaches to reflecting cultural influences on diagnosis. The Clinical De scriptions and Diagnostic Guidelines (CDDG) for ICD10 Men tal and Behavioural Disorders did not include a classification of culturespecific disorders, but rather noted the presence of cultural variations in expression under broad disorder group ings (e.g., somatoform disorder) and in helpseeking and ill nessrelated behaviour. However, consideration of culture was not systematically incorporated in the manual. In contrast, the DSMIV incorporated brief descriptions of cultural features under specific disorders, outlined components of a cultural formulation approach, and listed twentyfive “culturebound syndromes”. The development of the ICD11 has emphasized the prin ciple of global applicability, i.e., the need for the diagnostic guide lines to function well across global regions, countries and lan guages. Reflecting the cultural context in which clinical encoun ters take place is likely to enhance this goal. However, there is an inev itable tension between the incorporation of lo cally relevant material and the essential purpose of an interna tional classi fication system, which is to reliably convey clinical information across diverse boundaries. Responding to this chal lenge requires a pragmatic balance that involves recognizing cultural differenc es where these are clinically im portant with out allowing them to detract from the goal of a common global diagnostic language. As a way of including meaningful consideration of culture in the diagnostic process, the World Health Organization (WHO) Department of Mental Health and Substance Abuse constituted a Working Group to develop guidance on cultural considera tions for the ICD11 CDDG, based on the current state of clini cally applicable information for individual disorders and/or disorder groupings. The focus was on providing pragmatic, actionable material to assist clinicians in their evaluation of patients using the ICD11 guidelines and reduce bias in clinical decisionmaking by facili tating diagnostic assessment in a culturally informed manner. Thus, for example, while recognizing that specific idioms relat ing to mental illness are always influenced by culture, what the guidance describes are emotions, cognitions or behaviours that are broadly universal and therefore not “culturebound” in the sense of being unique. The Working Group developed the following set of questions to guide the generation of the material","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":" ","pages":""},"PeriodicalIF":73.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20676","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42958207","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}
289 of spontaneous remission, about half was due to nonspecific factors that would occur in any given treatment, and only about a sixth was due to the specific effects of presumably “active” treatments. Because all of the studies that he included in his meta-analysis were randomized controlled trials, he could legitimately draw a causal inference with respect to the nonspecific factors. After decades of process research that sought to determine how treatments work, but could not answer the question as to whether they actually do work (have a causal effect), Cuijpers has provided a most compelling answer and a very clever roadmap for others to follow. I do think, however, that it is premature for Cuijpers to conclude that there is no evidence that CBT works through cognitive change to produce change in depression. As he points out, the problem is that it is easier to detect an effect than it is to explain it, largely because we can use powerful experimental methods to test for causal effects of treatment on both the purported mediator and the outcome, but are left to rely on purely correlational methods to try to draw a causal inference regarding the link between me diator and outcome. That being said, I think he is wrong when he asserts that the absence of specificity denotes an absence of causal effect. If cognition did not change over the course of CBT then it could not be a mediator, but the fact that it shows comparable change in ADM does not rule such a causal process out. The problem is that a given process can be both a cause and a consequence of change. In an earlier trial we found that change in depression-relevant cognition predicted subsequent change in depressive symptoms with CBT but not with ADM, which likely worked through other causal mechanisms. The issue is one of moderated mediation in which the treatment affects the nature of the relation between the purported mech anisms and the outcome. While CBT produces change in cognition that leads to (mediated) subsequent change in depression, ADM produces change in depression through other mechanisms that lead to subsequent change in cognition. Absolute change in cognition was comparable between the two treatment modalities, but the causal paths that led to that change were likely quite distinct. Whereas moderated mediation as a consequence of differential treatment tends to obscure mediational effects that might be present, because it alters the apparent relation between the mediator and the outcome, moderated mediation as a function of individual differences among patients can be used to amplify that signal. As Kazdin first pointed out, any instance of moderation suggests that different causal mechanisms may be at work in different patients. This means that tests of mediation can be made more precise (and therefore more powerful) if we include patient by treatment interactions in those analyses. I agree with Cuijpers that mediation is difficult to detect, but a more sophisticated app
{"title":"Building resilience through psychotherapy.","authors":"Charles F Reynolds","doi":"10.1002/wps.20663","DOIUrl":"https://doi.org/10.1002/wps.20663","url":null,"abstract":"289 of spontaneous remission, about half was due to nonspecific factors that would occur in any given treatment, and only about a sixth was due to the specific effects of presumably “active” treatments. Because all of the studies that he included in his meta-analysis were randomized controlled trials, he could legitimately draw a causal inference with respect to the nonspecific factors. After decades of process research that sought to determine how treatments work, but could not answer the question as to whether they actually do work (have a causal effect), Cuijpers has provided a most compelling answer and a very clever roadmap for others to follow. I do think, however, that it is premature for Cuijpers to conclude that there is no evidence that CBT works through cognitive change to produce change in depression. As he points out, the problem is that it is easier to detect an effect than it is to explain it, largely because we can use powerful experimental methods to test for causal effects of treatment on both the purported mediator and the outcome, but are left to rely on purely correlational methods to try to draw a causal inference regarding the link between me diator and outcome. That being said, I think he is wrong when he asserts that the absence of specificity denotes an absence of causal effect. If cognition did not change over the course of CBT then it could not be a mediator, but the fact that it shows comparable change in ADM does not rule such a causal process out. The problem is that a given process can be both a cause and a consequence of change. In an earlier trial we found that change in depression-relevant cognition predicted subsequent change in depressive symptoms with CBT but not with ADM, which likely worked through other causal mechanisms. The issue is one of moderated mediation in which the treatment affects the nature of the relation between the purported mech anisms and the outcome. While CBT produces change in cognition that leads to (mediated) subsequent change in depression, ADM produces change in depression through other mechanisms that lead to subsequent change in cognition. Absolute change in cognition was comparable between the two treatment modalities, but the causal paths that led to that change were likely quite distinct. Whereas moderated mediation as a consequence of differential treatment tends to obscure mediational effects that might be present, because it alters the apparent relation between the mediator and the outcome, moderated mediation as a function of individual differences among patients can be used to amplify that signal. As Kazdin first pointed out, any instance of moderation suggests that different causal mechanisms may be at work in different patients. This means that tests of mediation can be made more precise (and therefore more powerful) if we include patient by treatment interactions in those analyses. I agree with Cuijpers that mediation is difficult to detect, but a more sophisticated app","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"18 3","pages":"289-291"},"PeriodicalIF":73.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20663","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41217715","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}
World Psychiatry 18:3 October 2019 adults, because it is the only measure of functioning that: a) has population norms and validation data across different countries; b) is well-understood both internationally and – through its inclusion in the DSM-5 – in the country that produces the most psychological treatment outcome data (i.e., the US); c) is already been used successfully in a range of major international studies; d) provides data that can be easily analyzed for cost-effectiveness studies, including possible conversion into population-level outcomes such as quality adjusted life years (QALYs), which is important for policy making; and e) is used in research across different areas of health, making improvements in its scores interpretable by an audience beyond mental health experts. Cuijpers also emphasizes the need to col lect data on the perspectives of those who are meant to be helped by the intervention, the so-called patients, clients, service users, consumers, or people with lived experience. Though WHO guidelines take the perspectives of these and other key stakeholders into consideration, so far the WHO GDGs have not listed person-defined outcomes as outcomes in PICO questions, likely because of the absence of a strong research tradition to collect such data. It is hoped that this may change in the future. Indeed, at the WHO we are promoting the use of person-defined outcomes through their routine inclusion in our own RCTs of psychological interventions among communities affected by adversity. Again, the consistent use of the same outcome measure will be important. At the WHO we currently use the Psychological Outcome Profiles (PSYCHLOPS) in many of our trials, and the experiences thus far are positive. Showing effects on a person-defined outcome measure is helpful to convince skeptics of etic approaches, who in some countries may include local policy makers, that a suggested psychological intervention is locally meaningful.
{"title":"The all-encompassing perspective of the mental health care patient.","authors":"Bart Groeneweg","doi":"10.1002/wps.20670","DOIUrl":"https://doi.org/10.1002/wps.20670","url":null,"abstract":"World Psychiatry 18:3 October 2019 adults, because it is the only measure of functioning that: a) has population norms and validation data across different countries; b) is well-understood both internationally and – through its inclusion in the DSM-5 – in the country that produces the most psychological treatment outcome data (i.e., the US); c) is already been used successfully in a range of major international studies; d) provides data that can be easily analyzed for cost-effectiveness studies, including possible conversion into population-level outcomes such as quality adjusted life years (QALYs), which is important for policy making; and e) is used in research across different areas of health, making improvements in its scores interpretable by an audience beyond mental health experts. Cuijpers also emphasizes the need to col lect data on the perspectives of those who are meant to be helped by the intervention, the so-called patients, clients, service users, consumers, or people with lived experience. Though WHO guidelines take the perspectives of these and other key stakeholders into consideration, so far the WHO GDGs have not listed person-defined outcomes as outcomes in PICO questions, likely because of the absence of a strong research tradition to collect such data. It is hoped that this may change in the future. Indeed, at the WHO we are promoting the use of person-defined outcomes through their routine inclusion in our own RCTs of psychological interventions among communities affected by adversity. Again, the consistent use of the same outcome measure will be important. At the WHO we currently use the Psychological Outcome Profiles (PSYCHLOPS) in many of our trials, and the experiences thus far are positive. Showing effects on a person-defined outcome measure is helpful to convince skeptics of etic approaches, who in some countries may include local policy makers, that a suggested psychological intervention is locally meaningful.","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"18 3","pages":"296-297"},"PeriodicalIF":73.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20670","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41217723","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}
361 the gold standard of treatment evaluation. However, on their own, they do not provide evidence that a psychological therapy works through the mechanisms that it claims. The effect could result from the expectation of the therapy working (placebo effect), or through simply talking to a professional. Again, if we follow the successful examples of other sciences, such as chemistry, physics and engineering, the most robust test of a theory is to build and assess a working model of a process. This tradition started with Galileo, continued with prototyping in machine design, and today is typically carried out within computer simulations. If the model behaves the same way as the real system under natural conditions, then the theory informing the model must be correct. There is no a priori reason why this should not apply as well to human behaviour as it does to the theory of aerodynamics informing airplane design, for example. Our clinical research team uses Method of Levels (MOL) as a transdiagnostic intervention which we disseminate widely. This therapy is based on perceptual control theory, a general theory of behaviour drawn from control engineering. Its key principles of control, conflict and reorganization have been assessed through testing computational models against behavioural data. In sum, transdiagnostic psychiatry is well established, but to understand its transformative potential requires adopting the appropriate scientific approach. Future reviews need to evaluate a broad literature including general psychopathology and shared neuropsychological pathways, and to separate the evaluation of treatment and process studies. Treatment research needs to consider the multiple perspectives of different stakeholders when determining how to index evidence for the potential benefits of a transdiagnostic approach. Process research, on the other hand, needs to be theory driven, hypothesis-led, and ideally emulate the model-testing paradigms of other sciences. A transdiagnostic approach of this kind has the potential to generate a genuine, interdisciplinary, paradigm shift in psychiatry and mental health.
{"title":"TRANSD recommendations: improving transdiagnostic research in psychiatry.","authors":"Paolo Fusar-Poli","doi":"10.1002/wps.20681","DOIUrl":"https://doi.org/10.1002/wps.20681","url":null,"abstract":"361 the gold standard of treatment evaluation. However, on their own, they do not provide evidence that a psychological therapy works through the mechanisms that it claims. The effect could result from the expectation of the therapy working (placebo effect), or through simply talking to a professional. Again, if we follow the successful examples of other sciences, such as chemistry, physics and engineering, the most robust test of a theory is to build and assess a working model of a process. This tradition started with Galileo, continued with prototyping in machine design, and today is typically carried out within computer simulations. If the model behaves the same way as the real system under natural conditions, then the theory informing the model must be correct. There is no a priori reason why this should not apply as well to human behaviour as it does to the theory of aerodynamics informing airplane design, for example. Our clinical research team uses Method of Levels (MOL) as a transdiagnostic intervention which we disseminate widely. This therapy is based on perceptual control theory, a general theory of behaviour drawn from control engineering. Its key principles of control, conflict and reorganization have been assessed through testing computational models against behavioural data. In sum, transdiagnostic psychiatry is well established, but to understand its transformative potential requires adopting the appropriate scientific approach. Future reviews need to evaluate a broad literature including general psychopathology and shared neuropsychological pathways, and to separate the evaluation of treatment and process studies. Treatment research needs to consider the multiple perspectives of different stakeholders when determining how to index evidence for the potential benefits of a transdiagnostic approach. Process research, on the other hand, needs to be theory driven, hypothesis-led, and ideally emulate the model-testing paradigms of other sciences. A transdiagnostic approach of this kind has the potential to generate a genuine, interdisciplinary, paradigm shift in psychiatry and mental health.","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"18 3","pages":"361-362"},"PeriodicalIF":73.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20681","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41217726","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}
{"title":"Embodiment and the Other's look in feeding and eating disorders","authors":"G. Stanghellini","doi":"10.1002/wps.20683","DOIUrl":"https://doi.org/10.1002/wps.20683","url":null,"abstract":"","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":" ","pages":""},"PeriodicalIF":73.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20683","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44318591","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}
World Psychiatry 18:3 October 2019 Similarly, processes of change supposedly need to be treatment program specific. This idea emerges from a protocol focus – defending that a method engages unique processes of change – but it takes on a different hue when treatment is processbased. If processes of change are central, why is it lethal if various technologies alter them? Treatment generality might in principle make change processes more important, not less. Processes of change ultimately must be theory based and testable, but techniques under various banners and brand names may alter overlapping and broadly applicable processes of change. From the practitioners’ point of view, so much the better. That fact empowers prac titioners to broaden the range of methods they use in order to target an important change process. Longitudinal evidence, basic research evidence, and component study evidence suggest that some processes of change are more important than others. For example, it would be strange if processes of change had no linkage to variation, selection, retention, and context sensitivity processes that are to be key to the evolution of complex systems in every other area of life. Indeed, it is worth noting that some of the patient-supplied outcomes described by Cuijpers – such as interpersonal effectiveness, social support, the capacity for problem solving, accepting and valuing oneself, awareness, or self-understand ing – have been examined in other con texts under the rubric of processes of change. This suggests that patients themselves intuitively care about processes of change even when traditional intervention science has not focused effectively on them. Departing from a nomothetic latent disease model and embracing the idiographic complexity of human suffering could free the field to pursue a more processbased approach. Focusing on therapeutic change processes should not be a side note but should take center-stage if we want clinical science to move forward.
{"title":"Moderation, mediation, and moderated mediation.","authors":"Steven D Hollon","doi":"10.1002/wps.20665","DOIUrl":"https://doi.org/10.1002/wps.20665","url":null,"abstract":"World Psychiatry 18:3 October 2019 Similarly, processes of change supposedly need to be treatment program specific. This idea emerges from a protocol focus – defending that a method engages unique processes of change – but it takes on a different hue when treatment is processbased. If processes of change are central, why is it lethal if various technologies alter them? Treatment generality might in principle make change processes more important, not less. Processes of change ultimately must be theory based and testable, but techniques under various banners and brand names may alter overlapping and broadly applicable processes of change. From the practitioners’ point of view, so much the better. That fact empowers prac titioners to broaden the range of methods they use in order to target an important change process. Longitudinal evidence, basic research evidence, and component study evidence suggest that some processes of change are more important than others. For example, it would be strange if processes of change had no linkage to variation, selection, retention, and context sensitivity processes that are to be key to the evolution of complex systems in every other area of life. Indeed, it is worth noting that some of the patient-supplied outcomes described by Cuijpers – such as interpersonal effectiveness, social support, the capacity for problem solving, accepting and valuing oneself, awareness, or self-understand ing – have been examined in other con texts under the rubric of processes of change. This suggests that patients themselves intuitively care about processes of change even when traditional intervention science has not focused effectively on them. Departing from a nomothetic latent disease model and embracing the idiographic complexity of human suffering could free the field to pursue a more processbased approach. Focusing on therapeutic change processes should not be a side note but should take center-stage if we want clinical science to move forward.","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"18 3","pages":"288-289"},"PeriodicalIF":73.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20665","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41217718","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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