The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta-analytic evaluation of recent meta-analyses

No Magic Pill: A Systematic Review of the Pharmacological Treatments for Compulsive Sexual Behavior Disorder

Compulsive sexual behavior disorder (CSBD) is a burgeoning diagnostic construct. No systematic reviews of CSBD pharmacotherapy interventions have been conducted. We addressed this gap using a three-aim approach. We reviewed researchers' theoretical arguments for various pharmacotherapies, outcomes from pharmacotherapy trials, and the generalizability of the extant findings. Our review included k = 13 studies, with n = 141 participants. An opioid model of reward seeking was the most popular framework, though inconsistently specified. A serotonin model was also documented, though with few details. Naltrexone was the most prominently examined pharmacotherapy and the only medication that reliably demonstrated a therapeutic effect for some (but not all) indicators compared to placebo. Paroxetine and citalopram were also documented in placebo-controlled trials, though their incremental benefit compared to placebo is suspect. Several additional pharmacotherapies have been documented in case series contexts. Across studies, only one female participant was identified. All trials were conducted in developed nations, and race was rarely assessed. We conclude that the case for pharmacotherapy for CSBD is limited and should preferably not occur outside of clinical trial contexts. Naltrexone offers the best evidence for a potential research program, though new theoretically informed approaches are welcome. Finally, we call for additional pharmacotherapy research in women and non-White populations.

Effectiveness and predictors of psychotherapy in eating disorders: state-of-the-art and future directions

PURPOSE OF REVIEW

Psychotherapy is the cornerstone of the multidisciplinary treatment approach for eating disorders. This review examines recent evidence regarding effectiveness, predictors, and mechanisms of change of psychotherapy in eating disorders, providing a road map for clinicians and researchers.

RECENT FINDINGS

Family-based treatments (FBT) are effective in adolescents with anorexia nervosa and bulimia nervosa. Evidence-based psychotherapies for anorexia nervosa have no evidence of superiority compared with treatment as usual (TAU) in adults with anorexia nervosa. Cognitive-behavioural therapy (CBT) is the first-choice psychotherapy recommended for adults with bulimia nervosa and binge-eating disorder (BED). Self-help interventions have some evidence of effectiveness in nonunderweight individuals with eating disorders. Early symptom improvement and adolescent age predict more favourable outcomes.

SUMMARY

Evidence-based psychotherapies can be suggested for eating disorders, although follow-up data are needed. Beyond anorexia nervosa, bulimia nervosa, and BED, there is no evidence of psychotherapy effectiveness in other eating disorders. The effectiveness of novel (e.g. 'third-wave') psychotherapies, treatment delivery modality (e.g. internet-delivered), and adjunctive interventions (e.g. virtual reality) needs to be further explored. A broader definition of recovery is recommended, including behavioural, physical, and psychological criteria. Predictors and mechanisms of changes have not been studied enough: quantitative and qualitative studies are needed to promote more tailored and individualized psychotherapy interventions.

Coercive Measures in Psychiatry Can Hardly Be Justified in Principle Any Longer-Ethico-Legal Requirements Versus Empirical Research Data and Conceptual Issues

AIM

To review the scientific and empirical evidence that is usually accepted for the ethical and legal justification of coercion in psychiatry.

METHOD

Five key criteria are examined as follows: (1) the demonstrable existence of a mental disorder; (2) the effectiveness of psychiatric measures; (3) the use of coercion as last resort and as least possible restriction; (4) the benefit of the person affected by the coercive measure and (5) the restoration of the affected person's autonomy.

RESULTS

(1) The existence of a demarcation between a mentally ill and a mentally healthy state cannot be confirmed; (2) Pharmacological and psychotherapeutic interventions in psychiatry are not even moderately effective; (3) Coercive measures are usually not used as last resort and as least restrictive measure; (4) Most people affected by psychiatric coercion do not benefit from the measures; (5) It is at least unclear whether autonomy is affected by a mental illness and whether it can be restored through a coercive psychiatric measure.

DISCUSSION

None of the central ethical and legal criteria for the use of coercion in psychiatry are clearly and unambiguously fulfilled according to current research.

IMPLICATIONS

Psychiatric coercion can hardly be justified any longer.

Anxious/depressed individuals exhibit disrupted frontotemporal synchrony during cognitive conflict encoding

Anxiety and depressive disorders are associated with cognitive control deficits, yet their underlying neural mechanisms remain poorly understood. Here, we used high-resolution stereotactic EEG (sEEG) to determine how anxiety and/or depression modulates neural and behavioral responses when cognitive control is engaged in individuals with medically refractory epilepsy undergoing sEEG monitoring for surgical evaluation. We analyzed sEEG data recorded from frontotemporal regions of 29 participants (age range: 19-55, mean age: 35.5, female: 16/29) while they performed a Multi-Source Interference Task (MSIT) designed to elicit cognitive conflict. Neurobehavioral interviews, symptom rating scales, and clinical documentation were used to categorize participants as demonstrating anxiety and/or depression symptoms (A/D, n=13) or as epilepsy controls (EC, n=16). Generalized linear mixed-effects (GLME) models were used to analyze behavioral and neural data. Models of oscillatory power were used to identify brain regions within conflict-encoding networks in which coherence and phase locking values (PLV) were examined in A/D and EC. A/D participants demonstrated a greater conflict effect (response time slowing with higher cognitive load), without impairment in response time (RT) or accuracy compared to EC. A/D participants also showed significantly enhanced conflict-evoked theta (4-8Hz) and alpha (8-15Hz) power in the dorsolateral prefrontal cortex (dlPFC) and amygdala as well as widespread broadband activity in the lateral temporal lobe (LTL) compared to EC. Additionally, theta coherence and PLV between dlPFC-LTL and dlPFC-amygdala were reduced by conflict in A/D. Our findings suggest individuals with anxiety/depression symptoms exhibit heightened frontotemporal oscillatory activity and disrupted frontotemporal synchrony during cognitive conflict encoding, which may indicate a greater need for cognitive resources due to ineffective cognitive processing. These results highlight a potential role of frontotemporal circuits in conflict encoding that are altered in anxiety/depression, and may further inform future therapeutic interventions aimed at enhancing cognitive control in these populations.

Acculturation stress and mental health outcomes in a sample of migrant inpatients: Findings from a naturalistic study

INTRODUCTION

Migrants face numerous risk factors for mental disorders, including stressors and traumatic events during the pre-, peri-, and post-migratory phases. Acculturation stress, a significant post-migratory stressor, can adversely affect mental health during the cultural adaptation process. This study aims to assess the clinical implications of acculturation stress in migrants admitted to a psychiatric intensive care unit, with a focus on identifying predictors of acculturative stress and their impact on clinical outcomes.

METHODS

We conducted a retrospective study of 268 immigrant patients hospitalized between 2004 and 2019 at the psychiatric inpatient unit of the University of Foggia. We collected socio-demographic and clinical data using ad hoc schedules and validated assessment instruments, including the Brief Psychiatric Rating Scale (BPRS), the Global Assessment of Functioning (GAF), and the Clinical Global Impression (CGI). Diagnoses were based on DSM-IV-TR/DSM-5 criteria. We analyzed associations between demographic and clinical characteristics of patients reporting acculturative stress and those not reporting it, using appropriate statistical methods.

RESULTS

The majority of patients were diagnosed with affective (45.1%) or psychotic disorders (31.7%), with 57.1% experiencing their first psychiatric episode. Acculturation stress was reported by 51.9% of patients (N = 139), predominantly among males (71.9%), single individuals (80.9%), and those of Islamic faith (56.8%). Patients experiencing acculturation stress were more likely to be unemployed (57.6%) and without a residence permit (63.3%). This stress was particularly prevalent among patients with psychotic disorders (25.9%) and first-episode psychiatric cases (64.7%). At discharge, patients with acculturation stress showed less improvement on CGI, GAF, and BPRS scores compared to those without such stress.

CONCLUSIONS

Acculturation stress is influenced by several socio-demographic factors and is crucial for the full symptomatic remission of migrant patients. Culturally-oriented mental health services, including language and cultural integration programs, are essential in reducing acculturative stress and improving the overall well-being of immigrants.

A Cellulose-Rich Diet Disrupts Gut Homeostasis and Leads to Anxiety through the Gut-Brain Axis

It is widely said that a healthy intestinal environment plays an essential role in better mental condition. One known dietary nutrient that maintains the intestinal environment is dietary fiber. A recent study showed that maintaining the intestinal environment with dietary fiber alleviated symptoms of psychiatric disorders in animals. However, such effects have only been reported with soluble fiber, which is highly fermentable and promotes short-chain fatty acid (SCFA) production, and not with insoluble fiber. Therefore, we aimed to verify whether insoluble fiber, such as cellulose, can alter emotion via changes in the gut. We divided mice into two groups and fed either a standard diet (SD, which contains both insoluble and soluble dietary fibers) or a cellulose-rich diet (CRD, which contains cellulose alone as the dietary fibers). We found that CRD-fed mice display increased anxiety-like behavior. CRD-fed animals also showed decreased intestinal SCFA levels along with increased intestinal permeability, dysmotility, and hypersensitivity. This behavioral and physiological effect of CRD has been completely abolished in vagotomized mice, indicating the direct link between intestinal environment exacerbation to the emotion through the gut-brain axis. Additionally, we found that amygdalar dopamine signaling has been modified in CRD-fed animals, and the opioid antagonist abolished this dopaminergic modification as well as CRD-induced anxiety. Altogether, our findings indicate that consumption of cellulose alone as the dietary fiber may evoke intestinal abnormalities, which fire the vagus nerve, then the opioidergic system, and amygdalar dopamine upregulation, resulting in the enhancement of anxiety.

First impressions count: Therapists' impression on patients' motivation and helping alliance predicts psychotherapy dropout

OBJECTIVE

With meta-analytically estimated rates of about 25%, dropout in psychotherapies is a major concern for individuals, clinicians, and the healthcare system at large. To be able to counteract dropout in psychotherapy, accurate insights about its predictors are needed.

METHOD

We compared logistic regression models with two machine learning algorithms (elastic net regressions and gradient boosting machines) in the prediction of therapy dropout in two large inpatient samples (N = 1,691 and N = 12,473) using baseline and initial process variables reported by patients and therapists.

RESULTS

Predictive accuracies of the two machine learning algorithms were similar and higher than for logistic regressions: Therapy dropout could be predicted with an AUC of .73 and .83 for Sample 1 and 2, respectively. The initial evaluation of patients' motivation and the therapeutic alliance rated by the respective therapist were the most important predictors of dropout.

CONCLUSIONS

Therapy dropout in naturalistic inpatient settings can be predicted to a considerable degree by using baseline indicators and therapists' first impressions. Feature selection via regularization leads to higher predictive performances whereas non-linear or interaction effects are dispensable. The most promising point of intervention to reduce therapy dropouts seems to be patients' motivation and the therapeutic alliance.

Impact of emotional abuse on eating disorder psychopathology: A multiple mediation analysis

INTRODUCTION

Childhood maltreatment, particularly emotional abuse (EA), has been identified as a significant risk factor for the development of eating disorders (EDs). This study investigated the association between EA and ED symptoms while considering multiple potential mediators.

METHODS

Participants included 151 individuals with Anorexia Nervosa (AN), 115 with Bulimia Nervosa (BN), and 108 healthy controls. The Childhood trauma questionnaire, the Toronto Alexithymia scale, the Behavioral inhibition System, and the Eating Disorder Inventory 2 scale were completed before treatment. A mediator path model was conducted in each group: EA was set as independent variable, eating symptoms as dependent variables and ineffectiveness, sensitivity to punishment, alexithymia, and impulsivity as mediators.

RESULTS

In individuals with AN, impulsivity emerged as a significant mediator between EA and desire for thinness and bulimic behaviors. Conversely, in individuals with BN, sensitivity to punishment was found to mediate the association between EA and dissatisfaction with one's body. Ineffectiveness and difficulty identifying emotions were identified as transdiagnostic mediators in both clinical groups. No mediation effect was found in healthy individuals.

DISCUSSION

The simultaneous assessment of multiple mediators in a unique model outlines the complex interplay between childhood EA and ED psychopathology. Improving ineffectiveness, emotion identification, sensitivity to punishment and impulsivity and exploring their relations with early emotional abuse may represent treatment targets in individuals with EDs and childhood trauma.

The relationship between self-reported antipsychotics side effects and depression in Saudi Arabia

Background

The utilization rate of antipsychotics to treat different mental disorders is rising. However, little is known about their side effects' impact on depression levels. Therefore, the objective of this study was to examine the association between antipsychotic side effects and depression among psychiatric patients treated with antipsychotics.

Methods

This is a prospective, single-center, interview-based, cross-sectional study that examined the association between antipsychotic side effects and depression among adult patients (e.g., ≥18 yrs.) with psychiatric illnesses (e.g., depression, schizophrenia, bipolar disorder) visiting outpatient clinics in a university-affiliated tertiary care center. Antipsychotic side effects were assessed using the Arabic version of the Glasgow Antipsychotic Side-effect Scale (GASS), while depression was assessed using the Arabic version of the 9-item Patient Health Questionnaire (PHQ-9). Univariate and multiple linear regressions were conducted to examine the association between the PHQ-9 and GASS scores.

Results

One hundred patients met the inclusion criteria and consented to participate. Most of the patients were females (72 %) with a mean age of 38 years. Schizophrenia (37 %) and bipolar disorder (54 %) were the most common mental disorders among the recruited patients. The majority of patients were treated with atypical (e.g., second-generation) antipsychotics (88 %) for at least six months (74 %). Controlling for age, gender, annual family income, education, employment status, marital status, number of comorbidities, duration of treatment with antipsychotics, the type of antipsychotic, and psychiatric illness, higher GASS scores, which indicate more severe antipsychotic side effects, predicted higher PHQ-9 score (e.g., higher levels of depression) (β = 0.419, 95 % CI=[0.307-0.532], p-value < 0.0001).

Conclusion

Early identification and management of antipsychotic side effects among psychiatric patients should enhance patient adherence and improve treatment outcomes. Future studies should verify the findings of this study using more robust study designs.

Predicting the outcome of psychotherapy for chronic depression by person-specific symptom networks

Psychotherapies are efficacious in the treatment of depression, albeit only with a moderate effect size. It is hoped that personalization of treatment can lead to better outcomes. The network theory of psychopathology offers a novel approach suggesting that symptom interactions as displayed in person-specific symptom networks could guide treatment planning for an individual patient. In a sample of 254 patients with chronic depression treated with either disorder-specific or non-specific psychotherapy for 48 weeks, we investigated if person-specific symptom networks predicted observer-rated depression severity at the end of treatment and one and two years after treatment termination. Person-specific symptom networks were constructed based on a time-varying multilevel vector autoregressive model of patient-rated symptom data. We used statistical parameters that describe the structure of these person-specific networks to predict therapy outcome. First, we used symptom centrality measures as predictors. Second, we used a machine learning approach to select parameters that describe the strength of pairwise symptom associations. We found that information on person-specific symptom networks strongly improved the accuracy of the prediction of observer-rated depression severity at treatment termination compared to common covariates recorded at baseline. This was also shown for predicting observer-rated depression severity at one- and two-year follow-up. Pairwise symptom associations were better predictors than symptom centrality parameters for depression severity at the end of therapy and one year later. Replication and external validation of our findings, methodological developments, and work on possible ways of implementation are needed before person-specific networks can be reliably used in clinical practice. Nevertheless, our results indicate that the structure of person-specific symptom networks can provide valuable information for the personalization of treatment for chronic depression.

Traditional healing practices, factors influencing to access the practices and its complementary effect on mental health in sub-Saharan Africa: a systematic review

OBJECTIVES

In areas with limited and unaffordable biomedical mental health services, such as sub-Saharan Africa (SSA), traditional healers are an incredibly well-used source of mental healthcare. This systematic review synthesises the available evidence on traditional healing practices, factors to access it and its effectiveness in improving people's mental health in SSA.

DESIGN

Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach.

DATA SOURCES

PubMed, MEDLINE, CINAHL and Scopus studies published before 1 December 2022.

ELIGIBILITY CRITERIA

Qualitative and quantitative studies reported traditional healing practices to treat mental health problems in SSA countries published in English before 1 December 2022.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using Covidence software, thematically analysed and reported using tables and narrative reports. The methodological quality of the included papers was evaluated using Joanna Briggs Institute quality appraisal tools.

RESULTS

In total, 51 studies were included for analysis. Traditional healing practices included faith-based (spiritual or religious) healing, diviner healing practices and herbal therapies as complementary to other traditional healing types. Objectively measured studies stated that people's mental health improved through collaborative care of traditional healing and biomedical care services. In addition, other subjectively measured studies revealed the effect of traditional healing in improving the mental health status of people. Human rights abuses occur as a result of some traditional practices, including physical abuse, chaining of the patient and restriction of food or fasting or starving patients. Individual, social, traditional healers, biomedical healthcare providers and health system-related factors were identified to accessing traditional healing services.

CONCLUSION

Although there is no conclusive, high-level evidence to support the effectiveness of traditional healing alone in improving mental health status. Moreover, the included studies in this review indicated that traditional healing and biomedical services collaborative care improve people's mental health.

PROSPERO REGISTRATION NUMBER

CRD42023392905.

Model of integrated mental health video consultations for people with depression or anxiety in primary care (PROVIDE-C): assessor masked, multicentre, randomised controlled trial

OBJECTIVE

To evaluate whether an integrated mental health video consultation approach (PROVIDE model) can improve symptoms compared with usual care in adults with depression and anxiety disorders attending primary care.

DESIGN

Assessor masked, multicentre, randomised controlled trial (PROVIDE-C).

SETTING

In 29 primary care practices in Germany, working remotely online from one trial hub.

PARTICIPANTS

376 adults (18-81 years) who presented to their general practitioner (GP) with depression or anxiety, or both.

INTERVENTION

Participants were randomised (1:1) to receive the PROVIDE model (n=187) or usual care (n=189). Usual care was provided by GPs through interventions such as brief counselling and psychotropic medication prescriptions and may or may not have included referrals to mental health specialists. The PROVIDE model comprised transdiagnostic treatment provided through five real-time video sessions between the patient at the primary care practice and a mental health specialist at an offsite location.

MAIN OUTCOME MEASURES

The primary outcome was the absolute change in the mean severity of depressive and anxiety symptoms measured using the patient health questionnaire anxiety and depression scale (PHQ-ADS) at six months, in the intention-to-treat population. Secondary outcomes, measured at six and 12 months, included PHQ-ADS subscores, psychological distress related to somatic symptoms, recovery, health related quality of life, quality and patient centredness of chronic illness care, and adverse events.

RESULTS

Between 24 March 2020 and 23 November 2021, 376 patients were randomised into treatment groups. Mean age was 45 years (standard deviation (SD) 14), 63% of the participants were female, and mean PHQ-ADS-score was 26 points (SD 7.6). Compared with usual care, the PROVIDE intervention led to improvements in severity of depressive and anxiety symptom (adjusted mean change difference in the PHQ-ADS score -2.4 points (95% confidence interval -4.5 to -0.4), P=0.02) at six months. The effects were sustained at 12 months (-2.9 (-5.0 to -0.7), P<0.01). No serious adverse events were reported in either group.

CONCLUSIONS

Through relatively low intensity treatment, the PROVIDE model led to a decrease in depressive and anxiety symptoms with small effects in the short and long term. Depression and anxiety disorders are prevalent and therefore the small effect might cumulatively impact on population health in this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04316572.

Mostly harmless? Clinical practice guidelines need further consideration of psychotherapy adverse effects

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines on mood disorders recommend psychotherapy as foundational care for patients with acute depression with minimal discussion of any potential adverse effects. Randomised controlled trial evidence on psychotherapy adverse effects is limited. This is problematic because clinicians must balance the benefits of treatment against the harms, and clinical decisions become skewed without data on adverse effects. We suggest that clinical practice guidelines should be more guarded about recommending psychotherapy and add consensus statements on adverse effects for informed consent and clinical decision-making.

Reflection on the RANZCP position on the adverse effects of psychotherapy

OBJECTIVE

In this perspective, we investigate how the Royal Australian and New Zealand College of Psychiatrists' (RANZCP) position statement on psychotherapy takes the potential for adverse effects into account.

CONCLUSIONS

Psychotherapy has two critical outcomes - efficacy and adverse effects. Evidence-based psychotherapy is significantly more effective than care-as-usual for about one in 10 psychotherapy patients. However, a similar proportion also reports adverse effects. Despite this, the RANZCP position statement on psychotherapy focuses on efficacy with minimal discussion of the adverse effects. This is an oversight because psychiatrists have legal and ethical obligations to consider the adverse effects as well as the benefits of any treatment. We therefore reflect on the RANZCP's six recommendations in light of the adverse effects of psychotherapy.

The Role of Therapists' Attachment and Introject in Their Treatment Process and Outcome: A Systematic Review

Previous reviews have examined empirical evidence of the relationship between therapists' internalized relational models, including therapists' attachment styles and Sullivan's notion of introject, and the therapeutic relationship. This review expands upon previous reviews by examining the effect of therapists' internalized relational models on the treatment process (e.g., therapeutic alliance and countertransference) and treatment outcomes (e.g., symptoms and functioning) more broadly. Our systematic search identified 42 empirical studies measuring therapist's internalized relational models, defined as therapist attachment style (i.e., the way the therapist relates to others) and/or introject (i.e., the way the therapist relates to themselves), in relation to therapy process and outcome, including 35 studies on attachment, nine studies on introject and two that examined both constructs. A rigorous quality assessment was conducted; two studies were rated as 'moderate', and 40 were rated as 'weak' in quality. Based on the study findings, it appears that more securely attached therapists may have stronger working alliances and more positive therapeutic processes with their patients. Contrary to expectations, therapist attachment security does not appear to impact treatment outcomes. Therapists who relate to themselves in a more affirming way may have stronger working alliances and better treatment outcomes, but very few studies have addressed this question thus far. More rigorous research, especially on the effect of therapists' introject, is needed. Therapists may consider the potential impact of their internalized relational models on the working alliance and other treatment processes that influence therapeutic outcomes.

Childhood Trauma Questionnaire-based child maltreatment profiles to predict efficacy of the Cognitive Behavioral Analysis System of Psychotherapy versus non-specific psychotherapy in adults with early-onset chronic depression: cluster analysis of data from a randomised controlled trial

BACKGROUND

Child maltreatment is a broadly confirmed risk factor for mental and physical illness. Some psychological treatments specifically target mental health conditions associated with child maltreatment. For example, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) focuses on maladaptive interpersonal behaviours in chronic depression. However, how the assessment of child maltreatment could inform personalised treatment is unclear. We used data from a previously published clinical trial to investigate whether a pre-established child maltreatment clustering approach predicts differential outcomes after CBASP versus non-specific supportive psychotherapy in patients with early-onset chronic depression.

METHODS

We did a cluster analysis of data from a previous randomised controlled trial of unmedicated adult outpatients with early-onset chronic depression who were treated at eight university clinics and psychological institutes in Germany with 32 sessions of CBASP or non-specific supportive psychotherapy. Participants were eligible for the original trial if they were aged 18-65 years; had major depressive disorder (MDD) with an early onset and duration of at least 2 years, current MDD superimposed on a pre-existing dysthymic disorder, or recurrent MDD with incomplete remission between episodes as defined by DSM-IV; and had a score of at least 20 points on the 24-item Hamilton Rating Scale for Depression (HRSD-24). Participants were included in the current study if they had completed the short form of the Childhood Trauma Questionnaire (CTQ) at trial baseline. We used an agglomerative hierarchical clustering approach to derive child maltreatment clusters from individual patterns across the five domains of the CTQ. We used linear mixed models to investigate whether clustering could predict differential clinical outcomes (change in symptom severity on the HRSD-24) up to 2 years after treatment onset. People with lived experience were involved in the current study.

FINDINGS

253 patients (129 [51%] treated with CBASP and 124 [49%] with supportive psychotherapy) had complete CTQ records and were included in the analysis. 169 (67%) participants were women, 84 (33%) were men, and the mean age was 45·9 years (SD 11·7). We identified seven child maltreatment clusters and found significant differences in treatment effects of CBASP and supportive psychotherapy between the clusters (F(6,948·76)=2·47; p=0·023); differences were maintained over the 2-year follow-up. CBASP was superior in distinct clusters of co-occurring child maltreatment: predominant emotional neglect (change in β -6·02 [95% CI -11·9 to -0·13]; Cohen's d=-0·98 [95% CI -1·94 to -0·02]; p=0·045), predominant emotional neglect and abuse (-6·39 [-10·22 to -2·56]; -1·04 [-1·67 to -0·42]; p=0·0011), and emotional neglect and emotional and physical abuse (-9·41 [-15·91 to -2·91]; -1·54 [-2·6 to -0·47]; p=0·0046).

INTERPRETATION

CTQ-based cluster analysis can facilitate identification of patients with early-onset chronic depression who would specifically benefit from CBASP. Child maltreatment clusters could be implemented in clinical assessments and serve to develop and personalise trauma-informed care in mental health.

FUNDING

The German Research Foundation and the German Federal Ministry of Education and Research.

Drug development in psychopharmacology: Insights from evolutionary psychiatry

In the last decade, no other branch of clinical pharmacology has been subject to as much criticism of failed innovation and unsatisfactory effectiveness as psychopharmacology. Evolutionary psychiatry can offer original insights on the problems that complicate pharmacological research. Considering that invalid phenotyping is a major obstacle to drug development, an evolutionary perspective suggests targeting clinical phenotypes related to evolved behavior systems because they are more likely to map onto the underlying biology than constructs based on predetermined diagnostic criteria. Because of their emphasis on symptom remission, pharmacological studies of psychiatric populations rarely include functional capacities as the primary outcome measure and neglect the impact of social context on the effects of psychiatric drugs. Evolutionary psychiatry explains why it is appropriate to replace symptoms with functional capacities as the primary target of psychiatric therapies and why social context should be a major focus of studies assessing the effectiveness of drugs currently used and new drugs under development. When the focus of research shifts to those questions that go beyond the "disease-based" concept of drug action, evolutionary psychiatry clearly emerges as a reference framework to assess drug effectiveness and to optimize clinicians' decisions about prescribing, deprescribing, and non-prescribing.

A consulting room with a view: Psychotherapy and the ecological context

BACKGROUND

The field of psychotherapy is witnessing a lively debate today. The literature on the efficacy of psychological interventions has grown exponentially, but the assumptions of the prevailing research paradigms have been criticised from many points of view. One of the main concerns is that of a too often simplistic conception of psychotherapy, viewed as a set of specific methods for the treatment of point-like problems or symptoms.

LITERATURE REVIEW ON MENTAL HEALTH AND THE ECOLOGICAL CONTEXT

Instead, emerging perspectives are trying to promote a more complex view on psychotherapy, as a process based on the therapeutic potential of relationships, which takes place in relevant social and cultural contexts. Even the ecological context is taken in greater consideration, as growing evidence exists about the detrimental effects of ecological threats-such as climate change and other environmental challenges-on mental health.

CONCLUSIONS

Psychotherapists and psychotherapy associations are now paying due attention to such issues, as well as to social justice and other dimensions that no longer can be thought of as mere elements of the scenario in which psychotherapy is practiced. Rather they are dimensions that exert a strong influence on psychological well-being, and thus must be properly acknowledged and assessed to connect clinical work with the communities and ecological contexts in which people live.

Facing the Next "Geriatric Giant"-A Systematic Literature Review and Meta-Analysis of Interventions Tackling Loneliness and Social Isolation Among Older Adults

OBJECTIVES

Loneliness and social isolation are associated with adverse health outcomes, especially within the older adult population, underlining the need for effective interventions. This systematic review and meta-analysis aims to summarize all available evidence regarding the effectiveness of interventions for loneliness and social isolation, to map out their working mechanisms, and to give implications for policy and practice.

DESIGN

Systematic literature review and meta-analysis.

SETTING AND PARTICIPANTS

Older adults (≥65 years).

METHODS

A systematic search was conducted in MEDLINE, PsycINFO, and CINAHL for studies quantitively or qualitatively assessing effects of interventions for loneliness and social isolation in older adults, following predefined selection criteria. Risk of bias as well as small study effects were assessed and, wherever appropriate, information about effect sizes of individual studies pooled using random-effects meta-analyses. Sources for between-study heterogeneity were explored using meta-regression.

RESULTS

Of n = 2223 identified articles, n = 67 were eventually included for narrative synthesis. Significant intervention effects were reported for a proportion of studies (55.9% and 50.0% for loneliness and social isolation, respectively) and 57.6% of studies including a follow-up measure (n = 29) reported sustained intervention effects. Meta-analysis of n = 27 studies, representing n = 1756 participants, suggested a medium overall effect of loneliness interventions (d = -0.47; 95% CI, -0.62 to -0.32). Between-study heterogeneity was substantial and could not be explained by differences in study design, year of publication, outcome measures, intervention length, participant demographics, setting, baseline level of loneliness, or geographic location. However, non-technology-based interventions reported larger effect sizes on average (Δd = -0.35; 95% CI, -0.66 to -0.04; P = .029) and were more often significant. Qualitative assessment of potential intervention mechanisms resulted in 3 clusters of effective components: "promoting social contact," "transferring knowledge and skills," and "addressing social cognition".

CONCLUSIONS AND IMPLICATIONS

Interventions for loneliness and social isolation can generally be effective, although some unexplained between-study heterogeneity remains. Further research is needed regarding the applicability of interventions across different settings and countries, also considering their cost-effectiveness.

10-year outcome trajectories of people with mental illness and their families who receive services from multidisciplinary case management and outreach teams: protocol of a multisite longitudinal study

INTRODUCTION

Individuals with mental illness and their families often undergo their recovery process in their communities. This study explored the long-term outcome trajectories of individuals and families who received case management services provided by multidisciplinary outreach teams in a community setting. The primary objective of this study was to determine whether trajectories of subjective quality of life (QoL) related to personal recovery were linked to those clinical and societal outcomes and changes in outreach service frequency.

METHODS AND ANALYSIS

The protocol of this 10-year multisite cohort study was collaboratively developed with individuals with lived experience of psychiatric disorders who had received services from participating outreach teams, and with family members in Japanese family associations. The participants in the study include patients and their key family members who receive services from 23 participating multidisciplinary outreach teams. The participant recruitment period is set from 1 October 2023 to 30 September 2025. If necessary, the recruitment period may be extended and the number of participating teams may be increased. The study will annually evaluate the following outcomes after participants' initial utilisation of services from each team: QoL related to personal recovery, personal agency, feelings of loneliness, well-being and symptom and functional assessments. The family outcomes encompass QoL, well-being, care burden and family relationships. Several meetings will be held to monitor progress and manage issues during the study. Multivariate analyses with repeated measures will be performed to investigate factors influencing changes in the patients' QoL scores as the dependent variable.

ETHICS AND DISSEMINATION

The study protocol was approved by the ethical committee of the National Center of Neurology and Psychiatry (no. A2023-065). The study findings will be reported in peer-reviewed publications and presented at relevant scientific conferences.

TRIAL REGISTRATION NUMBER

UMIN-CTR, No. UMIN000052275.

Individualized EEG-Based Neurofeedback Targeting Auditory Steady-State Responses: A Proof-of-Concept Study

Gamma-band (> 30 Hz) brain oscillatory activity is linked with sensory and cognitive processes and exhibits abnormalities in neuropsychiatric disorders. Therefore, neuromodulation techniques targeting gamma activity are being developed. One promising approach is neurofeedback (NFB) which is based on the alteration of brain responses via online feedback. However, the existing gamma-based NFB systems lack individualized approach. In the present work, we developed and tested an individualized EEG-NFB system. 46 healthy volunteers participated in three sessions on separate days. Before NFB training, individual gamma frequency (IGF) was estimated using chirp-modulated auditory stimulation (30-60 Hz). Participants were subjected to IGF-increase (if IGF was ≤ 45 Hz) or IGF-decrease conditions (if IGF was > 45 Hz). Gamma-band responses were targeted during NFB training, in which participants received auditory steady-state stimulation at frequency slightly above or below IGF and were instructed to try to increase their response while receiving real-time visual feedback. Each time a pre-defined response goal was reached, stimulation frequency was either increased or decreased. After training, IGF was reassessed. Experimental group participants were divided into equal groups based on the median success rate during NFB training. The results showed that high-responders had a significantly higher IGF modulation compared to control group, while low-responders did not differ from controls. No differences in IGF modulation were found between sessions and between NFB repetitions in all participant groups. The initial evaluation of the proposed EEG-NFB system showed potential to modulate IGF. Future studies could investigate longer-lasting electrophysiological and behavioural effects of the application of ASSR/IGF-based NFB system in clinical populations.

Status and trends of TMS research in depressive disorder: a bibliometric and visual analysis

Background

Depression is a chronic psychiatric condition that places significant burdens on individuals, families, and societies. The rapid evolution of non-invasive brain stimulation techniques has facilitated the extensive clinical use of Transcranial Magnetic Stimulation (TMS) for depression treatment. In light of the substantial recent increase in related research, this study aims to employ bibliometric methods to systematically review the global research status and trends of TMS in depression, providing a reference and guiding future studies in this field.

Methods

We retrieved literature on TMS and depression published between 1999 and 2023 from the Science Citation Index Expanded (SCIE) and Social Science Citation Index (SSCI) databases within the Web of Science Core Collection (WoSCC). Bibliometric analysis was performed using VOSviewer and CiteSpace software to analyze data on countries, institutions, authors, journals, keywords, citations, and to generate visual maps.

Results

A total of 5,046 publications were extracted covering the period from 1999 to 2023 in the field of TMS and depression. The publication output exhibited an overall exponential growth trend. These articles were published across 804 different journals, BRAIN STIMULATION is the platform that receives the most articles in this area. The literature involved contributions from over 16,000 authors affiliated with 4,573 institutions across 77 countries. The United States contributed the largest number of publications, with the University of Toronto and Daskalakis ZJ leading as the most prolific institution and author, respectively. Keywords such as "Default Mode Network," "Functional Connectivity," and "Theta Burst" have recently garnered significant attention. Research in this field primarily focuses on TMS stimulation patterns, their therapeutic efficacy and safety, brain region and network mechanisms under combined brain imaging technologies, and the modulation effects of TMS on brain-derived neurotrophic factor (BDNF) and neurotransmitter levels.

Conclusion

In recent years, TMS therapy has demonstrated extensive potential applications and significant implications for the treatment of depression. Research in the field of TMS for depression has achieved notable progress. Particularly, the development of novel TMS stimulation patterns and the integration of TMS therapy with multimodal techniques and machine learning algorithms for precision treatment and investigation of brain network mechanisms have emerged as current research hotspots.

Prevalence of anxiety, depression, sleeping problems, cognitive impairment, and suicidal ideation in people with autoimmune skin diseases

BACKGROUND

Autoimmune skin diseases (ASDs) such as psoriasis and vitiligo, in addition to causing visible skin symptoms, are closely associated with psychological health issues. However, a comprehensive understanding of the prevalence of these psychological comorbidities in affected individuals is lacking. This study aims to identify the prevalence of anxiety, depression, sleeping problems, cognitive impairment, and suicidal ideation in people with ASDs.

METHOD

PubMed, MEDLINE, Web of Science, and Cochrane Library searches were conducted from 1993 to May 2024. Observational studies reporting prevalence data for anxiety, depression, sleeping problems, cognitive impairment, and suicidal ideation among people with ASDs were included in the analysis. The Newcastle-Ottawa scale was used to evaluate the quality of studies.

RESULTS

The study included 114 studies from 37 countries including 823,975 participants. The estimated pooled prevalence of anxiety in patients with ASDs was 33.3% (95% CI: 27.3-29.3%). The estimated pooled prevalence of depression was 33.7% (95% CI: 29.2-38.1%). The estimated pooled prevalence of sleeping problems was 45.0% (95% CI:31.6-58.4%). The estimated pooled prevalence of cognitive impairment and suicidal ideation was 30.8% (95% CI:15.0-46.7%) and 21.6% (95% CI:13.4-29.8%), respectively. The most common mental disorder in patients with systemic lupus erythematosus and psoriasis was sleeping problems at 55.9% (95% CI: 35.6-76.1%, I2 = 97%) and 39.0% (95% CI: 21.1-56.9%, I2 = 99%).

CONCLUSION

Among patients with ASDs, anxiety, depression, sleeping problems, cognitive impairment, and suicidal ideation were common. The most prevalent mental disorder among patients with systemic lupus erythematosus and psoriasis was sleeping problems. Those with ASDs may experience considerable psychological burdens, and integrated mental health support is necessary for their treatment.

Nominating novel proteins for anxiety via integrating human brain proteomes and genome-wide association study

BACKGROUND

The underlying pathogenesis of anxiety remain elusive, making the pinpointing of potential therapeutic and diagnostic biomarkers for anxiety paramount to its efficient treatment.

METHODS

We undertook a proteome-wide association study (PWAS), fusing human brain proteomes from both discovery (ROS/MAP; N = 376) and validation cohorts (Banner; N = 152) with anxiety genome-wide association study (GWAS) summary statistics. Complementing this, we executed transcriptome-wide association studies (TWAS) leveraging human brain transcriptomic data from the Common Mind Consortium (CMC) to discern the confluence of genetic influences spanning both proteomic and transcriptomic levels. We further scrutinized significant genes through a suite of methodologies.

RESULTS

We discerned 14 genes instrumental in the genesis of anxiety through their specific cis-regulated brain protein abundance. Out of these, 6 were corroborated in the confirmatory PWAS, with 4 also showing associations with anxiety via their cis-regulated brain mRNA levels. A heightened confidence level was attributed to 5 genes (RAB27B, CCDC92, BTN2A1, TMEM106B, and DOC2A), taking into account corroborative evidence from both the confirmatory PWAS and TWAS, coupled with insights from mendelian randomization analysis and colocalization evaluations. A majority of the identified genes manifest in brain regions intricately linked to anxiety and predominantly partake in lysosomal metabolic processes.

LIMITATIONS

The limited scope of the brain proteome reference datasets, stemming from a relatively modest sample size, potentially curtails our grasp on the entire gamut of genetic effects.

CONCLUSION

The genes pinpointed in our research present a promising groundwork for crafting therapeutic interventions and diagnostic tools for anxiety.

The absurdity of the latent disease model in mental health: 10,130,814 ways to have a DSM-5-TR psychological disorder

BACKGROUND

Latent disease classification is currently the accepted approach to mental illness diagnosis. In the United States, this takes the form of the Diagnostic and Statistical Manual of Mental Disorders-5-Text Revision (DSM-5-TR). Latent disease classification has been criticized for reliability and validity problems, particularly regarding diagnostic heterogeneity. No authors have calculated the scope of the heterogeneity problem of the entire DSM-5-TR.

AIMS

We addressed this issue by calculating the unique diagnostic profiles that exist for every DSM-5-TR diagnosis.

METHODS

We did this by applying formulas previously used in smaller heterogeneity analyses to all diagnoses within the DSM-5-TR.

RESULTS

We found that there are 10,130,814 ways to be diagnosed with a mental illness using DSM-5-TR criteria. When specifiers are considered, this number balloons to over 161 septillion unique diagnostic presentations (driven mainly by bipolar II disorder). Additionally, there are 1,951,065 ways to present with psychiatric symptoms, yet not meet diagnostic criteria.

CONCLUSIONS

Latent disease classification leads to considerable heterogeneity in possible presentations. We provide examples of how latent disease classification harms research and treatment programs. We echo recommendations for the dismissal of latent disease classification as a mental illness diagnostic program.

Assessing the effectiveness of internet-based interventions for mental health outcomes: an umbrella review

Internet-based interventions (IBIs) for behavioural health have been prevalent for over two decades, and a growing proportion of individuals with mental health concerns prefer these emerging digital alternatives. However, the effectiveness and acceptability of IBIs for various mental health disorders continue to be subject to scholarly debate. We performed an umbrella review of meta-analyses (MAs), conducting literature searches in PubMed, Web of Science, Embase, Cochrane and Ovid Medline from their inception to 17 January 2023. A total of 87 MAs, reporting on 1683 randomised controlled trials and 295 589 patients, were included. The results indicated that IBIs had a moderate effect on anxiety disorder (standardised mean difference (SMD)=0.53, 95% CI 0.44 to 0.62) and post-traumatic stress disorder (PTSD) (SMD=0.63, 95% CI 0.38 to 0.89). In contrast, the efficacy on depression (SMD=0.45, 95% CI 0.39 to 0.52), addiction (SMD=0.23, 95% CI 0.16 to 0.31), suicidal ideation (SMD=0.23, 95% CI 0.16 to 0.30), stress (SMD=0.41, 95% CI 0.33 to 0.48) and obsessive-compulsive disorder (SMD=0.47, 95% CI 0.22 to 0.73) was relatively small. However, no significant effects were observed for personality disorders (SMD=0.07, 95% CI -0.13 to 0.26). Our findings suggest a significant association between IBIs and improved mental health outcomes, with particular effectiveness noted in treating anxiety disorders and PTSD. However, it is noteworthy that the effectiveness of IBIs was impacted by high dropout rates during treatment. Furthermore, our results indicated that guided IBIs proved to be more effective than unguided ones, playing a positive role in reducing dropout rates and enhancing patient adherence rates. PROSPERO registration number: CRD42023417366.

Application of GWAS summary data and drug-induced gene expression profiles of neural progenitor cells in psychiatric drug prioritization analysis

Common psychiatric disorders constitute one of the most substantial healthcare burdens worldwide. However, drug development in psychiatry remains hampered partially due to the lack of approaches to estimating drugs that can simultaneously modulate the expression of a nontrivial fraction of disease susceptibility genes. We proposed a new drug prioritization strategy under the framework of our previously proposed phenotype-associated tissues estimation approach (DESE) by investigating the drugs' selective perturbation effect on disease susceptibility genes. Based on the genome-wide association study summary data and drug-induced gene expression profiles of neural progenitor cells, we applied this strategy to prioritize candidate drugs for schizophrenia, depression and bipolar I disorder and identified several known therapeutic drugs among the top-ranked drug candidates. Also, our results revealed that the disease susceptibility genes involved in the selective gene perturbation analysis were enriched with many biologically sensible function terms and interacted with known therapeutic drugs. Our results suggested that selective gene perturbation analysis could be a promising starting point to prioritize biologically sensible drug candidates under the "one drug, multiple targets" paradigm for the drug development of common psychiatric disorders.

The Mental Health Outcomes and Cost Estimates of Korean Medicine for Anxiety Disorder Patients

Korean medicine (KM) is used to treat anxiety disorders, but there is limited research on its effects. This study aimed to examine the associations between improved QoL and reduced clinical symptoms and KM in patients with anxiety disorders. The medical records of patients with anxiety who were treated with KM (acupuncture, psychotherapy, Chuna therapy, aromatherapy, or herbal medicine) for at least 4 weeks were retrospectively analyzed. Clinical, QoL, and cost outcomes were measured at baseline and at weeks 4 and 12 (Anxiety: State-Trait Anxiety Inventory [STAI X-1 (state), X-2 (trait)], Beck Anxiety Inventory [BAI]; anger: State-Trait Anger Expression Inventory State [STAXI-S (state), T (trait)], Anger Expression Inventory [AXI-K-I (anger-in), AXI-K-O (anger-out), AXI-K-C (anger-control); depression: Beck Depression Inventory-II [BDI II], QoL: QoL-related instruments Euro Quality of Life 5 Dimensions utility score [EQ-5D], Euro QoL Visual Analog Scale [EQ-VAS]). The total costs for each item were calculated in terms of NHIS-covered costs and patients' out-of-pocket costs from the perspective of the healthcare system. The medical records of 67 patients were evaluated. The KM treatments were found to be associated with decreased anxiety (STAI X-1; STAI X-2; BAI, p < 0.0001), depression (BDI-II, p < 0.0001), and anger (AKI-K-I; AKI-K-O, p < 0.05) and increased QoL (EQ-5D; EQ-VAS, p < 0.0001). An average of USD 1360 was paid for the KM treatments for 4 weeks. The study findings suggested that KM may improve clinical symptoms and QoL outcomes in patients with anxiety disorders.

Electrophysiological Correlates of Reward Anticipation in Subjects with Schizophrenia: An ERP Microstate Study

The current study aimed to investigate alterations of event-related potentials (ERPs) microstate during reward anticipation in subjects with schizophrenia (SCZ), and their association with hedonic experience and negative symptoms. EEG data were recorded in thirty SCZ and twenty-three healthy controls (HC) during the monetary incentive delay task in which reward, loss and neutral cues were presented. Microstate analysis and standardized low-resolution electromagnetic tomography (sLORETA) were applied to EEG data. Furthermore, analyses correlating a topographic index (the ERPs score), calculated to quantify brain activation in relationship to the microstate maps, and scales assessing hedonic experience and negative symptoms were performed. Alterations in the first (125.0-187.5 ms) and second (261.7-414.1 ms) anticipatory cue-related microstate classes were observed. In SCZ, reward cues were associated to shorter duration and earlier offset of the first microstate class as compared to the neutral condition. In the second microstate class, the area under the curve was smaller for both reward and loss anticipation cues in SCZ as compared to HC. Furthermore, significant correlations between ERPs scores and the anticipation of pleasure scores were detected, while no significant association was found with negative symptoms. sLORETA analysis showed that hypo-activation of the cingulate cortex, insula, orbitofrontal and parietal cortex was detected in SCZ as compared to HC. Abnormalities in ERPs could be traced already during the early stages of reward processing and were associated with the anticipation of pleasure, suggesting that these dysfunctions might impair effective evaluation of incoming pleasant experiences. Negative symptoms and anhedonia are partially independent results.

Prevalence and 20-year trends in meditation, yoga, guided imagery and progressive relaxation use among US adults from 2002 to 2022

Meditation, yoga, guided imagery, and progressive relaxation are promoted as complementary approaches for health and wellbeing in the United States, but their uptake by different sociodemographic groups is unclear. This study assessed the prevalence and 20 year trends in the use of these practices in US adults between 2002-2022. We examined practice use and associations with sociodemographic and health factors in a population-weighted analysis of n = 134,959 participants across 5 cycles of the National Health Interview Survey. The overall use of meditation (18.3%, 60.53 million), yoga (16.8%, 55.78 million) and guided imagery/progressive relaxation (6.7%, 22.22 million) increased significantly from 2002 to 2022. Growth was consistent across most sociodemographic and health strata, however users of 'Other' race (comprising 54% Indigenous Americans, Odds Ratios; ORs = 1.28-1.70) and users with moderate (ORs = 1.19-1.29) psychological distress were overrepresented across all practices, and those with severe psychological distress were overrepresented in meditation (OR = 1.33) and guided imagery/progressive relaxation (OR = 1.42). Meditation use has accelerated over time for 65 + year olds (OR = 4.22), people not accessing mental health care (OR = 1.39), and less educated (OR = 4.02) groups, potentially reflecting unmet health needs. Health professionals should consider the extensive use of complementary practices in service and treatment planning and consider their risks and benefits.

Attitudes and gaps in knowledge of the diagnosis, treatment, and psychopathology of eating disorders among different health professionals

BACKGROUND

Health professionals from different specialties in medical and psychological areas play an important role in diagnosis and treatment of eating disorders (EDs). This study aimed to identify gaps in knowledge about the diagnosis, etiology, and management of EDs and to assess health professionals' attitudes towards these illnesses.

METHODS

A new questionnaire was developed and validated. Residents and consultants working in disciplines involved in the management of EDs (namely, internal medicine, general practitioners, psychiatric area, psychological area, and surgical area) completed the questionnaire. Knowledge and attitudes were compared among the study groups through one-way ANCOVA and chi-square tests.

RESULTS

The final version of the questionnaire consisted of 54 items assessing the following areas: stigma, treatment, physical complications, diagnosis, and aetiopathogenesis of EDs. For all health professionals the area of most deficiency was the aetiopathogenesis, while the best one was the management of physical complications. All medical professionals showed less knowledge than psychiatrists in terms of etiology, diagnosis, and treatment of EDs. A lack of knowledge about evidence-based psychotherapies, general psychopathology, and family members' role in the management of EDs emerged among all health professionals. Stigma was found among non-mental health professionals who considered these patients to be different from others and responsible for their abnormal eating behaviors.

CONCLUSIONS

Clarifying the health professionals' specific gaps occurring in the knowledge of EDs and in the attitudes towards these individuals may inform educational programs to improve early detection and management of EDs.

Mediation role of interpersonal problems between insecure attachment and eating disorder psychopathology

PURPOSE

Although insecure attachment and interpersonal problems have been acknowledged as risk and maintaining factors of eating disorders (EDs), the mediating role of interpersonal problems between attachment style and ED psychopathology has been poorly explored. The purpose of this study was to investigate the mediating role of interpersonal problems between insecure attachment and ED psychopathology.

METHODS

One-hundred-nine women with anorexia nervosa and 157 women with bulimia nervosa filled in the Eating Disorder Inventory-2 (EDI-2) and the Experiences in Close Relationships (ECR) revised scale to assess ED core symptoms and attachment styles, respectively. Interpersonal difficulties were evaluated by the Inventory of Interpersonal Problems (IIP-32). A mediator's path model was conducted with anxious and avoidant attachment subscores as independent variables, ED core symptoms as dependent variables and interpersonal difficulties as mediators. The diagnosis was entered in the model as a confounding factor.

RESULTS

The socially inhibited/avoidant interpersonal dimension was a mediator between avoidant attachment and the drive to thinness as well as between avoidant attachment and body dissatisfaction. An indirect connection was found between attachment-related anxiety and bulimic symptoms through the mediation of intrusive/needy score.

CONCLUSIONS

Social avoidance and intrusiveness mediate the relationships between avoidant and anxious attachment styles and ED psychopathology. These interpersonal problems may represent specific targets for psychotherapeutic treatments in individuals with EDs and insecure attachment.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Ten years of maintenance treatment of severe melancholic depression in an adult woman including discontinuation experiences

BACKGROUND

There are only few publications on long-term treatments for major depressive disorder (MDD) lasting 5 years or longer. Most clinical controlled trials lasted no longer than 2 years and some recent studies suggested an advantage of cognitive behavioral therapy (CBT) over antidepressants in relapse prevention of MDD.

METHODS

Exclusively outpatient "real world" treatment of severe melancholia, prospectively documented over 10 years with different serial treatment strategies, discontinuation phenomena and complications.

METHODS

Compared to CBT, agomelatine, mirtazapine, bupropion and high-dose milnacipran, high-dose venlafaxine (extended-release form, XR) was effective, even sustainably. Asymptomatic premature ventricular contractions (PVCs) were found at the beginning of the treatment of the MDD, which initially led to the discontinuation of high-dose venlafaxine (300 mg daily). Even the various treatment strategies mentioned above were unable to compensate for or prevent the subsequent severe deterioration in MDD (2 rebounds, 1 recurrence). Only the renewed use of high-dose venlafaxine was successful. PVC no longer occurred and the treatment was also well tolerated over the years, with venlafaxine serum levels at times exceeding 5 times the recommended upper therapeutic reference level (known bupropion-venlafaxine interaction, otherwise 2.5 to 3-fold increase with high-dose venlafaxine alone). During dose reduction or after gradual discontinuation of high-dose venlafaxine, rather mild withdrawal symptoms occurred, but as described above, also two severe rebounds and one severe recurrence happened.

DISCUSSION

This long-term observation supports critical reflections on the discontinuation of successful long-term treatment with antidepressants in severe MDD, even if it should be under "the protection" of CBT. The PVC seemed to be more related to the duration of the severe major depressive episode than to the venlafaxine treatment itself. A particular prospective observation of this longitudinal case study is that relapses (in the sense of rebounds) during or after previous venlafaxine tapering seemed to herald the recurrence after complete recovery. Remarkably, neither relapses nor recurrence could be prevented by CBT.

CONCLUSION

In this case, high-dose venlafaxine has a particular relapse-preventive (and "recurrence-preventive") effect with good long-term tolerability.

Understanding the experiences of ketogenic metabolic therapy for people living with varying levels of depressive symptoms: a thematic analysis

Background

Evidence suggests that a ketogenic diet (KD) may help to alleviate psychiatric symptoms, including depression and anxiety. Positive changes have been reported such as improvements in cognition, concentration, and sleep, a reduction in hunger, and an increase in well-being, energy, confidence, and resilience. This research aims to understand the impact of a non-calorie-restricted KD on depression and aspects of psychological well-being in those with varying degrees of depressive symptoms. Though there are a few studies directly exploring the experiences of those following a KD, this will be the first study to explore the narrative from a mental health and psychological well-being viewpoint.

Method

A sample of nine participants who had followed a non-calorie restricted KD intervention of 50 g of carbohydrates or less per day for at least 12 weeks were recruited. Participants were split into 'healthy adults' group who had no to low depressive symptoms and 'depressive symptoms' group who had mild to moderate depressive symptoms. A reflexive thematic analysis was considered suitable for this study.

Findings

Five core themes and 24 subthemes were created. These were, (1) Poor health prior to program; (2) Hunger and cravings-the food and mood connection; (3) Psychological well-being improvements; (4) It becomes a lifestyle; and (5) Implementation difficulties. Participants experienced mental health improvements such as increased self-esteem, confidence, motivation, and achievement. Some experienced more control in life and a greater sense of reward. Those with depressive symptoms who initially reported low self-worth and hopelessness later reported increased self-esteem and renewed meaning and purpose in life. The findings from this study reflect the previous reports that the diet implementation can be difficult initially, but soon becomes easy to follow and turns into a lifestyle.

Conclusion

In the literature, there are very few qualitative studies that explore the accounts and lived experiences of those following a KD. From the participants' accounts in this study, it appears that the benefits and positive outcomes of this diet outweigh any negative side-effects experienced. This is encouraging for those who are looking for adjunctive therapies to address and improve their depressive symptoms and overall mental health.

Lost diagnoses? A multi-year trajectory of patients with childhood ADHD in the criminal justice system in Switzerland

Background

Attention-deficit/hyperactivity disorder (ADHD) is prevalent amongst offenders, increasing risks for aggressive and delinquent behaviors. Since ADHD and its symptoms can persist into adulthood, accurately diagnosing and maintaining diagnoses in offenders is crucial to ensure appropriate treatment and reduce recidivism.

Methods

This study employed a retrospective longitudinal design to investigate ADHD amongst adult offenders with a confirmed diagnosis of ADHD during childhood or adolescence at a Swiss forensic outpatient clinic between 2008 and 2021. N = 181 patient files were reviewed, including forensic expert witness assessments and treatment reports. We charted the adulthood trajectory of patients with a confirmed childhood/adolescence ADHD diagnosis, examining the course of their diagnoses.

Results

Of 181 patients, evidence indicated that 12 (7%) had an ADHD diagnosis in childhood/adolescence. In 1 (8%) of these 12 cases, the diagnosis was maintained throughout the observation period. For 4 patients (33%), a diagnosis was given in the first forensic psychiatric expert witness assessment in adulthood but subsequently dropped. In another 4 cases (33%), the diagnosis was dropped in adulthood but later re-assigned, whereas in 3 cases (25%), the diagnosis was discontinued throughout the observation period. In 50% of cases with a diagnostic change, the discontinuation of an adult ADHD diagnosis coincided with a newly diagnosed personality disorder (or vice versa).

Conclusions

Our findings highlighted considerable inconsistencies in the assignment of adult ADHD diagnoses amongst offenders. Whilst ADHD remission in adulthood occurs, the diagnostic variability in our results warrants detailed scrutiny. One possibility is that ADHD has similar fluctuations to conditions like depression, as argued elsewhere. Equally, diagnoses may become "lost", meaning they are not given even when applicable and replaced by other diagnoses. Additionally, residual symptoms may remain but beyond the diagnostic threshold. This is significant because untreated ADHD can increase re-offending risks and adverse health outcomes.

Algorithm-based modular psychotherapy vs. cognitive-behavioral therapy for patients with depression, psychiatric comorbidities and early trauma: a proof-of-concept randomized controlled trial

Effect sizes of psychotherapies currently stagnate at a low-to-moderate level. Personalizing psychotherapy by algorithm-based modular procedures promises improved outcomes, greater flexibility, and a better fit between research and practice. However, evidence for the feasibility and efficacy of modular-based psychotherapy, using a personalized treatment algorithm, is lacking. This proof-of-concept randomized controlled trial was conducted in 70 adult outpatients with a primary DSM-5 diagnosis of major depressive disorder, a score higher than 18 on the 24-item Hamilton Rating Scale for Depression (HRSD-24), at least one comorbid psychiatric diagnosis according to the Structured Clinical Interview for DSM-5 (SCID-5), a history of at least "moderate to severe" childhood maltreatment on at least one domain of the Childhood Trauma Questionnaire (CTQ), and exceeding the cut-off value on at least one of three measures of early trauma-related transdiagnostic mechanisms: the Rejection Sensitivity Questionnaire (RSQ), the Interpersonal Reactivity Index (IRI), and the Difficulties in Emotion Regulation Scale-16 (DERS-16). Patients were randomized to 20 sessions of either standard cognitive-behavioral therapy alone (CBT) or CBT plus transdiagnostic modules according to a mechanism-based treatment algorithm (MoBa), over 16 weeks. We aimed to assess the feasibility of MoBa, and to compare MoBa vs. CBT with respect to participants' and therapists' overall satisfaction and ratings of therapeutic alliance (using the Working Alliance Inventory - Short Revised, WAI-SR), efficacy, impact on early trauma-related transdiagnostic mechanisms, and safety. The primary outcome for efficacy was the HRSD-24 score at post-treatment. Secondary outcomes included, among others, the rate of response (defined as a reduction of the HRSD-24 score by at least 50% from baseline and a score <16 at post-treatment), the rate of remission (defined as a HRSD-24 score ≤8 at post-treatment), and improvements in early trauma-related mechanisms of social threat response, hyperarousal, and social processes/empathy. We found no difficulties in the selection of the transdiagnostic modules in the individual patients, applying the above-mentioned cut-offs, and in the implementation of MoBa. Both participants and therapists reported higher overall satisfaction and had higher WAI-SR ratings with MoBa than CBT. Both approaches led to major reductions of depressive symptoms at post-treatment, with a non-significant superiority of MoBa over CBT. Patients randomized to MoBa were nearly three times as likely to experience remission at the end of therapy (29.4% vs. 11.4%; odds ratio, OR = 3.2, 95% CI: 0.9-11.6). Among mechanism-based outcomes, MoBa patients showed a significantly higher post-treatment effect on social processes/empathy (p<0.05) compared to CBT patients, who presented an exacerbation on this domain at post-treatment. Substantially less adverse events were reported for MoBa compared to CBT. These results suggest the feasibility and acceptability of an algorithm-based modular psychotherapy complementing CBT in depressed patients with psychiatric comorbidities and early trauma. While initial evidence of efficacy was observed, potential clinical advantages and interindividual heterogeneity in treatment outcomes will have to be investigated in fully powered confirmation trials.

In the new era of psychedelic assisted therapy: A systematic review of study methodology in randomized controlled trials

Recent years have seen a resurgence in randomized, placebo controlled trials (RCTs) utilizing non-classical psychedelics (e.g. 3,4-methyl enedioxy methamphetamine [MDMA]), and classical psychedelics (e.g. psilocybin, lysergic acid diethylamide [LSD], and N,N-dimethyltryptamine [DMT/ayahuasca]) in conjunction with assisted therapy (AT) for psychiatric disorders. A notable methodological challenge in psychedelic AT, however, is the complexity of blinding procedures. The lack of efficacious blinding can introduce considerable response bias, reduce internal validity, and compromise participant retention. This systematic review examines design and blinding techniques in RCTs utilizing psychedelics and placebo for the treatment of psychiatric disorders. The aim of this work is to identify factors that may inform future RTC design for conducting psychedelics research. We conducted a systematic review of PubMed, MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Psycinfo, Embase, and Web of Science Core Collection to examine: (1) placebo selection, (2) study design, and (3) integrity of blinding measures. Sixteen publications were identified as meeting the criteria for a systematic review. Our findings suggest that traditional placebo administration is insufficient to control for expectancy confounds. Consequently, experimental methodology that limits personnel unblinding and the use of an active placebo are important considerations when designing prospective clinical studies involving psychedelics.

A transdiagnostic group exercise intervention for mental health outpatients in Germany (ImPuls): results of a pragmatic, multisite, block-randomised, phase 3 controlled trial

BACKGROUND

Globally, mental health conditions pose a substantial burden of disease. Despite the availability of evidence-based pharmacological and psychological treatments, the symptoms of a substantial subgroup of patients do not respond to these interventions, and only a minority of patients have access to them. This study aimed to assess the efficacy of ImPuls, a 6-month transdiagnostic group exercise intervention, plus treatment-as-usual, compared with treatment-as-usual alone in outpatients with various mental disorders.

METHODS

In this pragmatic, two-arm, multisite, randomised controlled trial in Germany, ten outpatient rehabilitative and medical care facilities were involved as study sites. Participants were outpatients diagnosed according to ICD-10 with one or more of the following disorders based on structured clinical interviews: moderate or severe depression, primary insomnia, post-traumatic stress disorder (PTSD), panic disorder, or agoraphobia. Participants were required to be aged between 18 years and 65 years, insured by the health insurers Allgemeine Ortskrankenkasse Baden-Württemberg or Techniker Krankenkasse, fluent in German, and without medical contraindications for exercise. Blocks of six participants were randomly allocated to ImPuls plus treatment-as-usual or treatment-as-usual alone (allocation ratio: 1:1), stratified by study site. The randomisation sequence was generated by an external data manager. The team responsible for data collection and management was masked to the randomisation sequence. The ImPuls intervention comprised evidence-based outdoor exercises lasting 30 min, and aimed at achieving at least moderate intensity. It also incorporated behavioural change techniques targeting motivational and volitional determinants of exercise behaviour. Treatment-as-usual was representative of typical outpatient health care in Germany, allowing patients access to any standard treatments. The primary outcome was global symptom severity at 6 months after randomisation, measured using self-report on the Brief Symptom Inventory (BSI-18) and analysed in the intention-to-treat sample. No individuals with lived experience of mental illness were involved in conducting the study or writing the final publication. Safety was assessed in all participants. The trial was registered with the German Clinical Trials Register (DRKS00024152) with a completion date of June 30, 2024.

FINDINGS

600 patients provided informed consent, were recruited to the study, and underwent a diagnostic interview between Jan 1, 2021, and May 31, 2022. Following this, 199 were excluded on the basis of inclusion and exclusion criteria and one withdrew consent during the baseline assessment. Of the 400 eligible participants, 284 (71%) self-identified as female, 106 (27%) self-identified as male, and nine (2%) self-identified as other. The mean age was 42·20 years (SD 13·23; range 19-65). Ethnicity data were not assessed. 287 (72%) participants met the criteria for moderate or severe depression, 81 (20%) for primary insomnia, 37 (9%) for agoraphobia, 46 (12%) for panic disorder, and 72 (18%) for PTSD. 199 participants were allocated to the intervention group of ImPuls plus treatment-as-usual and 201 to the control group of treatment-as-usual alone. 38 (19%) participants did not receive the minimum ImPuls intervention dose. ImPuls plus treatment-as-usual demonstrated superior efficacy to treatment-as-usual alone in reducing global symptom severity, with an adjusted difference on BSI-18 of 4·11 (95% CI 1·74-6·48; d=0·35 [95% CI 0·14-0·56]; p=0·0007) at 6 months. There were no significant differences in the total number of adverse events or serious adverse events between the two groups. There was one serious adverse event (male, torn ligament) related to the intervention.

INTERPRETATION

ImPuls is an efficacious transdiagnostic adjunctive treatment in outpatient mental health care. Our findings suggest that exercise therapy should be implemented in outpatient mental health care as an adjunctive transdiagnostic treatment for mental disorders such as depression, insomnia, panic disorder, agoraphobia, and PTSD. Transdiagnostic group exercise interventions might ameliorate the existing disparity in care provision between the many individuals in need of evidence-based treatment and the few who are receiving it.

FUNDING

The German Innovation Fund of the Federal Joint Committee of Germany.

Identifying predictors of a favourable outcome for outpatients with a persistent depressive disorder treated with Cognitive Behavioural Analysis System of Psychotherapy: A prospective cohort study

OBJECTIVES

Cognitive Behavioural Analysis System of Psychotherapy (CBASP) is the first therapy specifically developed for persistent depressive disorder (PDD). This study aimed to identify predictors of favourable treatment outcome after group CBASP and assess change in depression severity over 24 weeks.

DESIGN

A prospective cohort study was conducted in patients with PDD treated with group-CBASP.

METHODS

Outcomes were depression severity measured by the Inventory of Depression Severity-self-report (IDS-SR) after 6 and 12 months. Potential predictors investigated were baseline depression severity, prior antidepressant use, age, family status, income source, age of onset and childhood trauma. Multivariate logistic regression was performed to assess their effects with a ≥25% IDS-SR score decrease as the dependent variable.

RESULTS

The IDS-SR score (range 0-84) significantly decreased from 37.78 at start to 33.45 at 6 months, an improvement which was maintained at 12 months. Having paid work and no axis I comorbidity significantly predicted favourable response. In the groups without a favourable outcome predictor a substantial percentage still showed at least partial response (16.7% and 19.2%).

CONCLUSIONS

Source of income and axis I comorbidity were predictors of response to group-CBASP. Within the group without favourable outcome predictors, a subgroup showed at least partial response. These results suggest that group-CBASP has promise for patients who do not respond to standard treatments. Future studies should include outcome measures that take into account comorbidity and other clinically relevant changes, such as social functioning.

Absolute and relative outcomes of psychotherapies for eight mental disorders: a systematic review and meta-analysis

Psychotherapies are first-line treatments for most mental disorders, but their absolute outcomes (i.e., response and remission rates) are not well studied, despite the relevance of such information for health care users, providers and policy makers. We aimed to examine absolute and relative outcomes of psychotherapies across eight mental disorders: major depressive disorder (MDD), social anxiety disorder, panic disorder, generalized anxiety disorder (GAD), specific phobia, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and borderline personality disorder (BPD). We used a series of living systematic reviews included in the Metapsy initiative (www.metapsy.org), with a common strategy for literature search, inclusion of studies and extraction of data, and a common format for the analyses. Literature search was conducted in major bibliographical databases (PubMed, PsycINFO, Embase, and the Cochrane Register of Controlled Trials) up to January 1, 2023. We included randomized controlled trials comparing psychotherapies for any of the eight mental disorders, established by a diagnostic interview, with a control group (waitlist, care-as-usual, or pill placebo). We conducted random-effects model pairwise meta-analyses. The main outcome was the absolute rate of response (at least 50% symptom reduction between baseline and post-test) in the treatment and control conditions. Secondary outcomes included the relative risk (RR) of response, and the number needed to treat (NNT). Random-effects meta-analyses of the included 441 trials (33,881 patients) indicated modest response rates for psychotherapies: 0.42 (95% CI: 0.39-0.45) for MDD; 0.38 (95% CI: 0.33-0.43) for PTSD; 0.38 (95% CI: 0.30-0.47) for OCD; 0.38 (95% CI: 0.33-0.43) for panic disorder; 0.36 (95% CI: 0.30-0.42) for GAD; 0.32 (95% CI: 0.29-0.37) for social anxiety disorder; 0.32 (95% CI: 0.23-0.42) for specific phobia; and 0.24 (95% CI: 0.15-0.36) for BPD. Most sensitivity analyses broadly supported these findings. The RRs were significant for all disorders, except BPD. Our conclusion is that most psychotherapies for the eight mental disorders are effective compared with control conditions, but absolute response rates are modest. More effective treatments and interventions for those not responding to a first-line treatment are needed.

Originalbeiträge (Originals). Network meta-analysis: science or alchemy? –What works best in generalized anxiety disorder?

Recently Papola et al. (2023) published a network meta-analysis (NMA) on psychotherapy of generalized anxiety disorder (GAD) and concluded that cognitive-behavioral therapy (CBT) should be considered the first-line treatment for GAD. However, there are several concerns with regard to the procedures and the conclusions of this NMA and of NMA in general. We show that these concerns question the conclusions by Papola et al. Furthermore, we place concerns about thisNMAin a broader context and question whether existing evidence is consistent with the notion that one form of psychotherapy can be regarded as the gold standard for mental disorders and for all patients and therapists.

Physiological synchronization and innovative moments in psychotherapy: A single-case study of micro-process

OBJECTIVE

Interpersonal synchronization is increasingly studied as a biomarker of empathy, therapeutic alliance, and treatment outcome. However, most studies average data over sessions, leaving associations between synchrony and actual interactions largely unexplored. We aim to showcase a novel approach examining synchronization during specific micro-processes: Innovative Moments (IM) as markers of exceptions to clients' problematic patterns of meaning.

METHODS

Electrodermal activity was recorded over 15 sessions of a psychodynamic psychotherapy single case. Moment-to-moment patient-therapist synchrony was calculated using the Adaptive Matching Interpolated Correlations (AMICo) algorithm. The Innovative Moments Coding System was utilized to identify IMs within session transcripts with precise timing. Monte-Carlo permutation tests were conducted to examine the association between physiological synchrony and IM Levels of increasing complexity (Levels 1-3).

RESULTS

Higher-than-random synchronization emerged during Level 3 IMs (p = 0.046; d = 0.21) but not in lower Levels. Post-hoc qualitative analyses linked high synchrony to sub-processes of Level 3 IMs, such as positive contrasts and attributions for change.

CONCLUSION

Our findings show it is possible to link moment-by-moment physiological co-regulation to theoretically identified meaning-making processes. While generalization of these observations is undue, this work demonstrates a robust and promising application of a multimodal approach to investigating psychotherapy, providing insights into both the clinical case and the theoretical model adopted.

Diet quality and anxiety: a critical overview with focus on the gut microbiome

Anxiety disorders disproportionally affect females and are frequently comorbid with eating disorders. With the emerging field of nutritional psychiatry, focus has been put on the impact of diet quality in anxiety pathophysiology and gut microbiome underlying mechanisms. While the relationship between diet and anxiety is bidirectional, improving dietary habits could better facilitate the actions of pharmacological and psychological therapies, or prevent their use. A better understanding of how gut bacteria mediate and moderate such relationship could further contribute to develop personalized programs and inform probiotics and prebiotics manufacturing. To date, studies that look simultaneously at diet, the gut microbiome, and anxiety are missing as only pairwise relationships among them have been investigated. Therefore, this study aims at summarizing and integrating the existing knowledge on the dietary effects on anxiety with focus on gut microbiome. Findings on the effects of diet on anxiety are critically summarized and reinterpreted in relation to findings on (i) the effects of diet on the gut microbiome composition, and (ii) the associations between the abundance of certain gut bacteria and anxiety. This novel interpretation suggests a theoretical model where the relationship between diet and anxiety is mediated and/or modulated by the gut microbiome through multiple mechanisms. In parallel, this study critically evaluates methodologies employed in the nutritional field to investigate the effects of diet on anxiety highlighting a lack of systematic operationalization and assessment strategies. Therefore, it ultimately proposes a novel evidence-based approach that can enhance studies validity, reliability, systematicity, and translation to clinical and community settings.

The Economics of Treatment for Depression

The global prevalence of depression has risen over the past three decades across all socioeconomic groups and geographic regions, with a particularly rapid increase in prevalence among adolescents (aged 12-17 years) in the United States. Depression imposes large health, economic, and societal costs, including reduced life span and quality of life, medical costs, and reduced educational attainment and workplace productivity. A wide range of treatment modalities for depression are available, but socioeconomic disparities in treatment access are driven by treatment costs, lack of culturally tailored options, stigma, and provider shortages, among other barriers. This review highlights the need for comparative research to better understand treatments' relative efficacy, cost-effectiveness, scalability, and potential heterogeneity in efficacy across socioeconomic groups and country and cultural contexts. To address the growing burden of depression, mental health policy could consider reducing restrictions on the supply of providers, implementing digital interventions, reducing stigma, and promoting healthy lifestyles.

Ethological Problems with the Interpersonal Theory of Suicide

Joiner and colleagues' Interpersonal Theory of Suicide (IPTS), a prominent "desire-capability" model of suicide-based on the common-sense idea that people take their own lives because they want to, and can-is critiqued from a biological perspective. Tinbergen's ethological "four questions" guide the analysis: evolution, survival value, ontogeny, and proximate causation, each addressing a different aspect of biological understanding. Problems for IPTS emerge with all four. As a parsimonious solution, the desire-capability hypothesis is reconceived as an ultimate, instead of proximate, mode of explanation. By this light, desire and capability for suicide combined in our species' ancestral past, thus making suicide a recurrent survival threat, and driving the evolution of special-purpose defensive adaptations. This stance tallies with the pain-brain theory of the evolution of suicide, and with Joiner and colleagues' own investigation into organismic anti-suicide defenses, which appears to conflict conceptually with IPTS. These defenses' evolved algorithm may make suicide an intrinsically aleatory phenomenon, opaque to usefully accurate prediction. Positive implications for prevention and research are proposed.

Cannabidiol and its Potential Evidence-Based Psychiatric Benefits - A Critical Review

The endocannabinoid system shows promise as a novel target for treating psychiatric conditions. Cannabidiol (CBD), a naturally occurring cannabinoid, has been investigated in several psychiatric conditions, with diverse effects and an excellent safety profile compared to standard treatments. Even though the body of evidence from randomised clinical trials is growing, it remains relatively limited in most indications. This review comprises a comprehensive literature search to identify clinical studies on the effects of CBD in psychiatric conditions. The literature search included case studies, case reports, observational studies, and RCTs published in English before July 27, 2023, excluding studies involving nabiximols or cannabis extracts containing CBD and ∆9-tetrahydrocannabinol. Completed studies were considered, and all authors independently assessed relevant publications.Of the 150 articles identified, 54 publications were included, covering the effects of CBD on healthy subjects and various psychiatric conditions, such as schizophrenia, substance use disorders (SUDs), anxiety, post-traumatic stress disorder (PTSD), and autism spectrum disorders. No clinical studies have been published for other potential indications, such as alcohol use disorder, borderline personality disorder, depression, dementia, and attention-deficit/hyperactivity disorder. This critical review highlights that CBD can potentially ameliorate certain psychiatric conditions, including schizophrenia, SUDs, and PTSD. However, more controlled studies and clinical trials, particularly investigating the mid- to long-term use of CBD, are required to conclusively establish its efficacy and safety in treating these conditions. The complex effects of CBD on neural activity patterns, likely by impacting the endocannabinoid system, warrant further research to reveal its therapeutic potential in psychiatry.

Healthy lifestyle and the risk of depression recurrence requiring hospitalisation and mortality among adults with pre-existing depression: a prospective cohort study

BACKGROUND

Although lifestyle-based treatment approaches are recommended as important aspects of depression care, the quantitative influence of aggregated healthy lifestyles on depression recurrence and mortality remains unknown.

OBJECTIVE

To investigate the association between healthy lifestyle and the risks of first-time hospitalisation for recurrent depression and mortality.

METHODS

26 164 adults with depression (mean (SD) age, 56.0 (7.9) years) were included from UK Biobank between 2006 and 2010 and followed up until 2022. Depression was defined as a physician's diagnosis in hospital admissions or the use of prescribed antidepressant medication. A weighted healthy lifestyle score (HLS) was calculated based on smoking, alcohol consumption, diet, sleep pattern, physical activity, social health, employment status and greenspace interaction.

FINDINGS

Over a 13.3-year follow-up, 9740 cases of first-time hospitalisation due to depression recurrence and 1527 deaths were documented. Compared with the lowest HLS tertile, the highest tertile was associated with a 27% lower risk (HR=0.73, 95% CI 0.69 to 0.77) of first-time hospitalisation for depression recurrence and a 22% (HR=0.78, 95% CI 0.68 to 0.91) lower risk of mortality among adults with depression. Lower risks of first-time hospitalisation for depression recurrence were observed among those who smoked less, drank more alcohol, followed healthier diets and sleep patterns, spent more time employed in current job or had greater exposure to greenspace.

CONCLUSION AND IMPLICATIONS

Greater adherence to healthy lifestyle was associated with a lower risk of hospitalisation and mortality among adults with pre-existing depression. Incorporating behaviour modification as an essential part of clinical practice for depressed patients could complement medication-based therapies.

Large language models could change the future of behavioral healthcare: a proposal for responsible development and evaluation

Large language models (LLMs) such as Open AI's GPT-4 (which power ChatGPT) and Google's Gemini, built on artificial intelligence, hold immense potential to support, augment, or even eventually automate psychotherapy. Enthusiasm about such applications is mounting in the field as well as industry. These developments promise to address insufficient mental healthcare system capacity and scale individual access to personalized treatments. However, clinical psychology is an uncommonly high stakes application domain for AI systems, as responsible and evidence-based therapy requires nuanced expertise. This paper provides a roadmap for the ambitious yet responsible application of clinical LLMs in psychotherapy. First, a technical overview of clinical LLMs is presented. Second, the stages of integration of LLMs into psychotherapy are discussed while highlighting parallels to the development of autonomous vehicle technology. Third, potential applications of LLMs in clinical care, training, and research are discussed, highlighting areas of risk given the complex nature of psychotherapy. Fourth, recommendations for the responsible development and evaluation of clinical LLMs are provided, which include centering clinical science, involving robust interdisciplinary collaboration, and attending to issues like assessment, risk detection, transparency, and bias. Lastly, a vision is outlined for how LLMs might enable a new generation of studies of evidence-based interventions at scale, and how these studies may challenge assumptions about psychotherapy.