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}
287 “diagnosis” relying on current classification systems. We still need to figure out what constitutes a meaningful change in scores and we might have to stick with relatively arbitrary clinical indices such as response (for example, the 50% reduction in scores often used in depression trials) which are also used for other dimensional health conditions (such as hypertension), or we could calibrate a meaningful change in scores against patient-defined global ratings to generate a “minimal clinically important difference”. Outcomes may, in turn, vary across the severity dimension of the psychopathology; for example, the primary domain of concern may be symptom experience at one stage, but may shift to social functioning at another. Another implication of adopting dimensional approaches is that new kinds of outcomes, amenable to remote monitoring, may become a reality, for example real-time passive assessment of digital behavioural markers. In this context, outcome assessments are not only useful as end-points to evaluate the effectiveness of psychotherapy, but also as dynamic decision points for guiding treatment choices which can allocate more intensive interventions as per patient trajectories, for example to distiguish early responders to low-intensity interventions from those who need more intensive treatments. In short, reimagining outcomes and targets must require a reimagining of the nature of mental health conditions. We must invest in clinical research paradigms which adopt novel, dimensional, approaches to characterizing these conditions, offering new approaches to defining targets and outcomes. The current system which has been the foundation of psychiatric research, and which historically was envisioned to lead to an elucidation of etiology, mechanisms and therapeutics, has brought us to a dead-end.
{"title":"Therapeutic change processes link and clarify targets and outcomes.","authors":"Stefan G Hofmann, Steven C Hayes","doi":"10.1002/wps.20664","DOIUrl":"https://doi.org/10.1002/wps.20664","url":null,"abstract":"287 “diagnosis” relying on current classification systems. We still need to figure out what constitutes a meaningful change in scores and we might have to stick with relatively arbitrary clinical indices such as response (for example, the 50% reduction in scores often used in depression trials) which are also used for other dimensional health conditions (such as hypertension), or we could calibrate a meaningful change in scores against patient-defined global ratings to generate a “minimal clinically important difference”. Outcomes may, in turn, vary across the severity dimension of the psychopathology; for example, the primary domain of concern may be symptom experience at one stage, but may shift to social functioning at another. Another implication of adopting dimensional approaches is that new kinds of outcomes, amenable to remote monitoring, may become a reality, for example real-time passive assessment of digital behavioural markers. In this context, outcome assessments are not only useful as end-points to evaluate the effectiveness of psychotherapy, but also as dynamic decision points for guiding treatment choices which can allocate more intensive interventions as per patient trajectories, for example to distiguish early responders to low-intensity interventions from those who need more intensive treatments. In short, reimagining outcomes and targets must require a reimagining of the nature of mental health conditions. We must invest in clinical research paradigms which adopt novel, dimensional, approaches to characterizing these conditions, offering new approaches to defining targets and outcomes. The current system which has been the foundation of psychiatric research, and which historically was envisioned to lead to an elucidation of etiology, mechanisms and therapeutics, has brought us to a dead-end.","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"18 3","pages":"287-288"},"PeriodicalIF":73.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20664","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41217724","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}
Cuijpers highlights that, in spite of major progress in mental health research, there are still many important unanswered questions regarding psychotherapies. He emphasizes the significance of looking beyond symptomatic reduction and studying a range of treatment outcomes. He suggests (and we agree) that symptom reduction does not necessarily reflect many crucial and sustainable aspects of therapeutic change. One of the reasons why change in symptoms is the most widely studied outcome is that researchers conducting rando mized controlled trials (RCTs) are required to define their primary outcome a priori. Defining multiple primary outcomes results in an increase of the number of individuals to be included in a study to satisfy statistical power requirements. Thus, selecting a broader more representative range of outcomes becomes expensive, impractical and strategically problematic within the current major funding mechanisms. Additionally, reports of con flicting findings when similar research questions are examined using different measures make it difficult to determine which measures are to be prioritized conceptually and psychometrically. It is indeed crucial to conceptualize and measure outcomes from the patient’s perspective. Even patients who experience reductions in symptoms and meet remission criteria may still struggle in major domains such as navigating relationships, regulating emotions, maintaining consistent employment, and coping with stress. Other aspects of outcome, such as patients’ capacity to cope with stressors and to use strategies learned in therapy in the face of adversity, should also be evaluated. Another understudied outcome is patients’ gained subjective sense of freedom – one’s ability to confront and resolve conflicting demands that arise from perceptions of the outer and inner worlds and make “choices” that are not determined by unconscious forces. A patient-centered approach suggests that the treatment course should be guided by patients’ specific needs, preferences, and perspectives on their own therapeutic change. Many medical specialties are now shifting towards a “precision medicine” model – tailoring treatment to the individual patient. In psychotherapy, this model requires a comprehensive assessment of the individual patient’s functioning across multiple domains in order to develop a personalized treatment plan. Some progress has been made in the development of computerized algorithms, with preliminary evidence for efficacy of matching patients with the optimal treatment package. However, implementing these algorithms requires the availability of skilled therapists who can deliver the selected “optimal” complex treatment modality. Treatment packages involve extensive clinical training and supervision, which limits their feasibility and applicability, especially for large populations of patients who reside in areas with limited access to experienced mental health professionals. Thus, in addition to focusing on m
{"title":"Toward a personalized approach to psychotherapy outcome and the study of therapeutic change.","authors":"Jacques P Barber, Nili Solomonov","doi":"10.1002/wps.20666","DOIUrl":"https://doi.org/10.1002/wps.20666","url":null,"abstract":"Cuijpers highlights that, in spite of major progress in mental health research, there are still many important unanswered questions regarding psychotherapies. He emphasizes the significance of looking beyond symptomatic reduction and studying a range of treatment outcomes. He suggests (and we agree) that symptom reduction does not necessarily reflect many crucial and sustainable aspects of therapeutic change. One of the reasons why change in symptoms is the most widely studied outcome is that researchers conducting rando mized controlled trials (RCTs) are required to define their primary outcome a priori. Defining multiple primary outcomes results in an increase of the number of individuals to be included in a study to satisfy statistical power requirements. Thus, selecting a broader more representative range of outcomes becomes expensive, impractical and strategically problematic within the current major funding mechanisms. Additionally, reports of con flicting findings when similar research questions are examined using different measures make it difficult to determine which measures are to be prioritized conceptually and psychometrically. It is indeed crucial to conceptualize and measure outcomes from the patient’s perspective. Even patients who experience reductions in symptoms and meet remission criteria may still struggle in major domains such as navigating relationships, regulating emotions, maintaining consistent employment, and coping with stress. Other aspects of outcome, such as patients’ capacity to cope with stressors and to use strategies learned in therapy in the face of adversity, should also be evaluated. Another understudied outcome is patients’ gained subjective sense of freedom – one’s ability to confront and resolve conflicting demands that arise from perceptions of the outer and inner worlds and make “choices” that are not determined by unconscious forces. A patient-centered approach suggests that the treatment course should be guided by patients’ specific needs, preferences, and perspectives on their own therapeutic change. Many medical specialties are now shifting towards a “precision medicine” model – tailoring treatment to the individual patient. In psychotherapy, this model requires a comprehensive assessment of the individual patient’s functioning across multiple domains in order to develop a personalized treatment plan. Some progress has been made in the development of computerized algorithms, with preliminary evidence for efficacy of matching patients with the optimal treatment package. However, implementing these algorithms requires the availability of skilled therapists who can deliver the selected “optimal” complex treatment modality. Treatment packages involve extensive clinical training and supervision, which limits their feasibility and applicability, especially for large populations of patients who reside in areas with limited access to experienced mental health professionals. Thus, in addition to focusing on m","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"18 3","pages":"291-292"},"PeriodicalIF":73.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20666","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41217725","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}
Alessio M Monteleone, Fernando Fernandez-Aranda, Ulrich Voderholzer
369 leadership for a significant improvement in practice on the subject; b) through supporting and building a network of practitioners and those with lived experience of mental ill health and their supporters, in effect a movement for better practice to minimize coercion; c) by developing new materials, testing them and learning from their use in a way that strengthens knowledge on human rights and mental health more broadly, of which minimizing coercion is a central element. Ultimately, the impact we seek is that an understanding of ways to minimize coercion is developed by mental health professionals internationally, in collaboration with civil society, and that better practices are adopted. As a result, the dangers of coercive practices will also be minimized, and the supports available to people experiencing mental health problems and their families will increase significantly over time. There are people and groups across countries working actively to promote these and other initiatives that contribute to the common goal of the advancement of psychiatry and mental health for all people. All of us in the WPA leadership welcome comments and engage ment from readers and colleagues. Helen Herrman President, World Psychiatric Association
{"title":"Evidence and perspectives in eating disorders: a paradigm for a multidisciplinary approach.","authors":"Alessio M Monteleone, Fernando Fernandez-Aranda, Ulrich Voderholzer","doi":"10.1002/wps.20687","DOIUrl":"https://doi.org/10.1002/wps.20687","url":null,"abstract":"369 leadership for a significant improvement in practice on the subject; b) through supporting and building a network of practitioners and those with lived experience of mental ill health and their supporters, in effect a movement for better practice to minimize coercion; c) by developing new materials, testing them and learning from their use in a way that strengthens knowledge on human rights and mental health more broadly, of which minimizing coercion is a central element. Ultimately, the impact we seek is that an understanding of ways to minimize coercion is developed by mental health professionals internationally, in collaboration with civil society, and that better practices are adopted. As a result, the dangers of coercive practices will also be minimized, and the supports available to people experiencing mental health problems and their families will increase significantly over time. There are people and groups across countries working actively to promote these and other initiatives that contribute to the common goal of the advancement of psychiatry and mental health for all people. All of us in the WPA leadership welcome comments and engage ment from readers and colleagues. Helen Herrman President, World Psychiatric Association","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"18 3","pages":"369-370"},"PeriodicalIF":73.3,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/wps.20687","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41217716","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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