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}
World Psychiatry 18:3 October 2019 precision of the licensing of medications and other therapies replaced by a more flexible and accurate evidence-based approach as in mainstream health care. The potential value of such an approach for the redesign of mental health care cannot be overestimated, as we struggle to replace 50-year-old mindsets and work practices with a modern, dynamic 21st century approach.
{"title":"Transdiagnostic psychiatry goes above and beyond classification","authors":"W. Mansell","doi":"10.1002/wps.20680","DOIUrl":"https://doi.org/10.1002/wps.20680","url":null,"abstract":"World Psychiatry 18:3 October 2019 precision of the licensing of medications and other therapies replaced by a more flexible and accurate evidence-based approach as in mainstream health care. The potential value of such an approach for the redesign of mental health care cannot be overestimated, as we struggle to replace 50-year-old mindsets and work practices with a modern, dynamic 21st century approach.","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.20680","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41605541","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"What is \"evidence\" in psychotherapies?","authors":"Scott O Lilienfeld","doi":"10.1002/wps.20654","DOIUrl":"10.1002/wps.20654","url":null,"abstract":"","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"18 3","pages":"245-246"},"PeriodicalIF":60.5,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732681/pdf/WPS-18-245.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41217727","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}
Anne Margriet Pot, Dolores Gallagher-Thompson, Lily D Xiao, Bernadette M Willemse, Iris Rosier, Kala M Mehta, Diana Zandi, Tarun Dua
{"title":"iSupport: a WHO global online intervention for informal caregivers of people with dementia.","authors":"Anne Margriet Pot, Dolores Gallagher-Thompson, Lily D Xiao, Bernadette M Willemse, Iris Rosier, Kala M Mehta, Diana Zandi, Tarun Dua","doi":"10.1002/wps.20684","DOIUrl":"10.1002/wps.20684","url":null,"abstract":"","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":" ","pages":"365-366"},"PeriodicalIF":60.5,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732694/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42440297","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":"Outcomes help map out evidence in an uncertain terrain, but they are relative.","authors":"Tim Kendall","doi":"10.1002/wps.20668","DOIUrl":"10.1002/wps.20668","url":null,"abstract":"","PeriodicalId":49357,"journal":{"name":"World Psychiatry","volume":"18 3","pages":"293-295"},"PeriodicalIF":60.5,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732678/pdf/WPS-18-293.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41217719","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":"Cognitive remediation for severe mental illness: state of the field and future directions","authors":"C. Bowie","doi":"10.1002/wps.20660","DOIUrl":"https://doi.org/10.1002/wps.20660","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.20660","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49216864","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}
Post‐traumatic stress disorder (PTSD) is arguably the most common psychiatric disorder to arise after exposure to a traumatic event. Since its formal introduction in the DSM‐III in 1980, knowledge has grown significantly regarding its causes, maintaining mechanisms and treatments. Despite this increased understanding, however, the actual definition of the disorder remains controversial. The DSM‐5 and ICD‐11 define the disorder differently, reflecting disagreements in the field about whether the construct of PTSD should encompass a broad array of psychological manifestations that arise after trauma or should be focused more specifically on trauma memory phenomena. This controversy over clarifying the phenotype of PTSD has limited the capacity to identify biomarkers and specific mechanisms of traumatic stress. This review provides an up‐to‐date outline of the current definitions of PTSD, its known prevalence and risk factors, the main models to explain the disorder, and evidence‐supported treatments. A major conclusion is that, although trauma‐focused cognitive behavior therapy is the best‐validated treatment for PTSD, it has stagnated over recent decades, and only two‐thirds of PTSD patients respond adequately to this intervention. Moreover, most people with PTSD do not access evidence‐based treatment, and this situation is much worse in low‐ and middle‐income countries. Identifying processes that can overcome these major barriers to better management of people with PTSD remains an outstanding challenge.
{"title":"Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges","authors":"R. Bryant","doi":"10.1002/wps.20656","DOIUrl":"https://doi.org/10.1002/wps.20656","url":null,"abstract":"Post‐traumatic stress disorder (PTSD) is arguably the most common psychiatric disorder to arise after exposure to a traumatic event. Since its formal introduction in the DSM‐III in 1980, knowledge has grown significantly regarding its causes, maintaining mechanisms and treatments. Despite this increased understanding, however, the actual definition of the disorder remains controversial. The DSM‐5 and ICD‐11 define the disorder differently, reflecting disagreements in the field about whether the construct of PTSD should encompass a broad array of psychological manifestations that arise after trauma or should be focused more specifically on trauma memory phenomena. This controversy over clarifying the phenotype of PTSD has limited the capacity to identify biomarkers and specific mechanisms of traumatic stress. This review provides an up‐to‐date outline of the current definitions of PTSD, its known prevalence and risk factors, the main models to explain the disorder, and evidence‐supported treatments. A major conclusion is that, although trauma‐focused cognitive behavior therapy is the best‐validated treatment for PTSD, it has stagnated over recent decades, and only two‐thirds of PTSD patients respond adequately to this intervention. Moreover, most people with PTSD do not access evidence‐based treatment, and this situation is much worse in low‐ and middle‐income countries. Identifying processes that can overcome these major barriers to better management of people with PTSD remains an outstanding challenge.","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.20656","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43152609","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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