Transdiagnostic approaches to mental health problems: Current status and future directions

Schizophrenia polygenic risk scores in youth mental health: preliminary associations with diagnosis, clinical stage and functioning

BACKGROUND

The schizophrenia polygenic risk score (SCZ-PRS) is an emerging tool in psychiatry.

AIMS

We aimed to evaluate the utility of SCZ-PRS in a young, transdiagnostic, clinical cohort.

METHOD

SCZ-PRSs were calculated for young people who presented to early-intervention youth mental health clinics, including 158 patients of European ancestry, 113 of whom had longitudinal outcome data. We examined associations between SCZ-PRS and diagnosis, clinical stage and functioning at initial assessment, and new-onset psychotic disorder, clinical stage transition and functional course over time in contact with services.

RESULTS

Compared with a control group, patients had elevated PRSs for schizophrenia, bipolar disorder and depression, but not for any non-psychiatric phenotype (for example cardiovascular disease). Higher SCZ-PRSs were elevated in participants with psychotic, bipolar, depressive, anxiety and other disorders. At initial assessment, overall SCZ-PRSs were associated with psychotic disorder (odds ratio (OR) per s.d. increase in SCZ-PRS was 1.68, 95% CI 1.08-2.59, P = 0.020), but not assignment as clinical stage 2+ (i.e. discrete, persistent or recurrent disorder) (OR = 0.90, 95% CI 0.64-1.26, P = 0.53) or functioning (R = 0.03, P = 0.76). Longitudinally, overall SCZ-PRSs were not significantly associated with new-onset psychotic disorder (OR = 0.84, 95% CI 0.34-2.03, P = 0.69), clinical stage transition (OR = 1.02, 95% CI 0.70-1.48, P = 0.92) or persistent functional impairment (OR = 0.84, 95% CI 0.52-1.38, P = 0.50).

CONCLUSIONS

In this preliminary study, SCZ-PRSs were associated with psychotic disorder at initial assessment in a young, transdiagnostic, clinical cohort accessing early-intervention services. Larger clinical studies are needed to further evaluate the clinical utility of SCZ-PRSs, especially among individuals with high SCZ-PRS burden.

The perceptual control model of psychopathology

Perceptual control theory states that behaviour controls perception; we act against disturbances in the environment to align hierarchically organised perceived aspects of the self and the world with neurally specified reference values. The diverse symptoms of psychopathology are each examples of loss of control, which are maintained by conflicting control systems, and effective interventions shift and sustain awareness to the source of the conflict to allow trial-and-error changes (reorganisation) in the parameters of the superordinate system to the conflict, until control is restored. Experimental, phenomenological, therapeutic and computational research has examined its mechanisms, and its mode of delivery has extended it from a client-led psychotherapy (method of levels) to brief training, group interventions and computerised modalities.

Evaluation of a mental health drop-in centre offering brief transdiagnostic psychological assessment and treatment for children and adolescents with long-term physical conditions and their families: a single-arm, open, non-randomised trial

BACKGROUND

Children and young people with long-term physical conditions have significantly elevated mental health needs. Transdiagnostic, brief psychological interventions have the potential to increase access to evidence-based psychological treatments for patients who attend health services primarily for physical health needs.

OBJECTIVE

A non-randomised study was conducted to assess the impact of brief, transdiagnostic psychological interventions in children and young people presenting at a drop-in mental health centre in the reception area of a paediatric hospital.

METHODS

186 participants attending a transdiagnostic mental health drop-in centre were allocated to assessment and psychological intervention based on a clinical decision-making algorithm. Interventions included signposting, guided self-help based on a modular psychological treatment and referral to the hospital's paediatric psychology service. The primary transdiagnostic mental health outcome measure was the parent-reported Strengths and Difficulties Questionnaire (SDQ), which was given at baseline and 6 months post-baseline.

FINDINGS

There was a significant positive impact of attending the drop-in mental health centre on the SDQ (Cohen's d=0.22) and on the secondary outcome measure of Paediatric Quality of life (Cohen's d=0.55).

CONCLUSIONS

A mental health drop-in centre offering brief, transdiagnostic assessment and treatment may reduce emotional and behavioural symptoms and improve quality of life in children and young people with mental health needs in the context of long-term physical conditions. A randomised controlled trial to investigate the specificity of any effects is warranted.

CLINICAL IMPLICATIONS

Drop-in centres for mental health needs may increase access and have beneficial effects for children and young people with physical conditions.

Is "Self-Experience" Really a Transdiagnostic Concept? Preliminary Evidence in Favor of the Transdiagnostic Conception of Functional Analytic Psychotherapy

Functional Analytic Psychotherapy (FAP) offers a radically behavioral and transdiagnostic conception of the formation of the "self" and the appearance of a diversity of psychological problems. This study examined the extent to which a wide variety of psychological disorders (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility/aggressiveness, phobic anxiety, paranoid ideation, and psychoticism) and a global index of psychopathological severity may in fact be linked to problems of the "self" according to the FAP conception. Two questionnaires, one related to self-experience according to FAP and the other to find the scores on several different psychopathology scales, were administered to 280 adult Spaniards for this purpose. The results confirmed the transdiagnostic nature of the "self"-experience. There are significant and strong correlations between all the psychopathology scales studied and self-experience. Linear regression analyses also show that, along with age and gender, in some cases, the score on self-experience predicts each and every one of the psychopathological variables studied, in addition to the Global Severity Index. These results are discussed and related to the transdiagnostic approach to psychopathology.

Using Digital Technologies to Facilitate Care Coordination Between Youth Mental Health Services: A Guide for Implementation

Enhanced care coordination is essential to improving access to and navigation between youth mental health services. By facilitating better communication and coordination within and between youth mental health services, the goal is to guide young people quickly to the level of care they need and reduce instances of those receiving inappropriate care (too much or too little), or no care at all. Yet, it is often unclear how this goal can be achieved in a scalable way in local regions. We recommend using technology-enabled care coordination to facilitate streamlined transitions for young people across primary, secondary, more specialised or hospital-based care. First, we describe how technology-enabled care coordination could be achieved through two fundamental shifts in current service provisions; a model of care which puts the person at the centre of their care; and a technology infrastructure that facilitates this model. Second, we detail how dynamic simulation modelling can be used to rapidly test the operational features of implementation and the likely impacts of technology-enabled care coordination in a local service environment. Combined with traditional implementation research, dynamic simulation modelling can facilitate the transformation of real-world services. This work demonstrates the benefits of creating a smart health service infrastructure with embedded dynamic simulation modelling to improve operational efficiency and clinical outcomes through participatory and data driven health service planning.

Recognition and Justice? Conceptualizing Support for Women Whose Children Are in Care or Adopted

This paper examines the views of mothers who have experienced (or are judged to be at risk of) recurrent removal of children into care or adoption. Drawing on their accounts of working with an intensive 18 month support program called Pause, we argue for the relevance of conceptualizing policy and practice with reference to Honneth’s theory of recognition and Fraser’s arguments about the need to address misrecognition through redistribution, attending to gendered political and economic injustice. The analysis draws on qualitative longitudinal interviews with 49 women, conducted as part of a national UK Department for Education (DfE)-funded evaluation of Pause. Each woman was interviewed up to four times over a period of up to 20 months, both during and after the Pause intervention. Case-based longitudinal analysis illuminates how stigma can obscure women’s rights and needs—including welfare entitlements and health, as well as rights to family life—and shows how support can act to enable both redistribution, advocating to ensure women’s rights in a context of diminishing public welfare, and recognition, challenging stigmatization through recognition of women’s motherhood, and of their rights to care, solidarity, respect and fun.

CBT at the Crossroads: The Rise of Transdiagnostic Treatments

Transdiagnostic treatments span a heterogeneous group of interventions that target a wider range of disorders and can be applied to treat several disorders simultaneously. Several meta-analyses have highlighted the evidence base of these novel therapies. However, these meta-analyses adopt different definitions of transdiagnostic treatments, and the growing field of transdiagnostic therapies has become increasingly difficult to grasp. The current narrative review proposes a distinction of “one size fits all” unified and “my size fits me” individualized approaches within transdiagnostic therapies. Unified treatments are applied as “broadband” interventions to a range of disorders without tailoring to the individual, while individualized treatments are tailored to the specific problem presentation of the individual, e.g., by selecting modules within modular treatments. The underlying theoretical foundation and relevant empirical evidence for these different transdiagnostic approaches are examined. Advantages and limitations of the transdiagnostic treatments as well as future developments are discussed.

A Low-Intensity Internet-Based Intervention Focused on the Promotion of Positive Affect for the Treatment of Depression in Spanish Primary Care: Secondary Analysis of a Randomized Controlled Trial

Background: A large number of low-intensity Internet-based interventions (IBIs) for the treatment of depression have emerged in Primary Care; most of them focused on decreasing negative emotions. However, recent studies have highlighted the importance of addressing positive affect (PA) as well. This study is a secondary analysis of a randomized control trial. We examine the role of an IBI focused on promoting PA in patients with depression in Primary Care (PC). The specific objectives were to explore the profile of the patients who benefit the most and to analyze the change mechanisms that predict a significantly greater improvement in positive functioning measures. Methods: 56 patients were included. Measures of depression, affect, well-being, health-related quality of life, and health status were administered. Results: Participants who benefited the most were those who had lower incomes and education levels and worse mental health scores and well-being at baseline (7.9%-39.5% of explained variance). Improvements in depression severity and PA were significant predictors of long-term change in well-being, F (3,55) = 17.78, p < 0.001, R² = 47.8%. Conclusions: This study highlights the importance of implementing IBIs in PC and the relevance of PA as a key target in Major Depressive Disorder treatment.

The Relationship between Suicide and Oxidative Stress in a Group of Psychiatric Inpatients

Diagnosis of suicide risk is a clinical challenge requiring an interdisciplinary therapeutic approach. Except for psychological explanation of the suicidal mechanism, there is evidence that it is associated with brain chemistry disturbances as oxidative stress. The objective of this study was to explore the role of oxidative stress components in suicidality comparing subjects at different stages of suicide. The study included psychiatric inpatients aged 18–64 (n = 48) with different psychiatric diagnoses. Blood specimens were collected from subjects and tested for oxidative stress biomarkers: superoxide dismutase (SOD), dityrozine (DT), oxidative stress index (OSI), glutathione peroxidase (GPx), total antioxidant capacity (TAC trolox), ferric reducing ability of plasma (FRAP), total oxidant status (TOS), catalase (CAT), advanced glycoxidation end products (AGE), NADPH oxidase (NOX), and advanced oxidation protein products (AOPP). The Columbia Severity Suicide Scale (C-SSRS) was used for suicidality assessment. Subjects with a history of suicide ideations over the last three months had significantly higher levels of NOX, AOPP, and OSI. There was no significant relationship to any oxidative stress component levels either with a history of suicide behaviors or with suicide attempts over the last three months. The levels of NOX and AOPP were both positively correlated to the intensity of suicidal thoughts. Moreover, there was a positive correlation between a number of suicide attempts during a lifetime with AGE and DT and negative with CAT. Similarly, the subjects with a history of suicide attempts had significantly higher AGE and DT levels and lower CAT values. The study confirmed that oxidative stress plays an important role in the pathophysiology of suicide and specific oxidative stress measures vary in suicidal and non-suicidal psychiatric inpatients.

Concluding commentary: Treating perfectionism transdiagnostically with an eye on the future

The current piece of work is a commentary section for the special issue regarding the treatment of perfectionism. It discusses analytically the similarities and the differences between the six clinical case formulations included in the special issue to emphasize that there are different routes to beneficial outcomes. All the psychotherapeutic approaches included here are either transdiagnostic or have transdiagnostic applications. As such, the second part of the commentary focuses on the transdiagnostic future of the treatment of perfectionism. Concluding remarks evidence a collection of clinical case studies covering multiple forms of psychotherapy and an integrating overview of the literature from which practitioners can extract best practices examples. Though there is still a lot to be done with and for interventions on perfectionism, the current collection of case studies is a good starting point.

Adaptation of the WHO group interpersonal therapy for people living with HIV/AIDS in Northwest Ethiopia: A qualitative study

BACKGROUND

Psychological treatments improve depressive symptoms in people living with HIV/AIDS (PLWHA). Adaptation of treatments should be based on explanatory models of depression and other elements within the given context.

AIM

This study aimed to examine explanatory models of depression and acceptable approaches for implementation of group IPT in Northwest Ethiopia.

METHODS

Qualitative data were collected from April to May 2019 from case managers, adherence supporters and service users using focus group discussion and analysed thematically.

RESULTS

PLWHA attributed depression to psychosocial problems, spiritual factors and biological factors. Depression had several impacts at individual and family level. Group-based interpersonal therapy (IPT) was acceptable if provided by trained peer counselors.

CONCLUSION

The current study findings informed how to conduct feasibility and acceptability trials of group IPT in the HIV population in Ethiopia.

Transdiagnostic Risk and Protective Factors for Psychopathology in Young People: Systematic Review Protocol

Background

Mental and substance use disorders are among the leading causes of burden of disease worldwide, with risk of onset peaking between the ages of 13 and 24 years. Comorbidity is also common among young people and complicates research, diagnosis and assessment, and clinical decision making. There is increasing support for empirically derived models of psychopathology that overcome issues of comorbidity and provide a transdiagnostic framework for investigating the specificity and generality of risk and protective factors for psychopathology.

Objective

This systematic review aims to identify transdiagnostic risk and protective factors for psychopathology in young people by synthesizing and evaluating findings from research investigating empirically based models of psychopathology.

Methods

Searches will be conducted in Medline, EMBASE, and PsycINFO databases. Reference lists of selected articles will also be hand searched for other relevant publications. All studies will be screened against eligibility criteria designed to identify studies that examined empirical models of psychopathology in relation to risk and/or protective factors in young people with a mean age between 10 and 24 years. Study quality will be assessed using the Joanna Briggs Institute Critical Appraisal Checklists for Cohort Studies and Analytical Cross-Sectional Studies. Findings will be summarized in a narrative synthesis, and a meta-analysis will be conducted if sufficient data are available.

Results

This review is ongoing. At the time of submission, full-text screening was completed, and hand searching of selected articles was underway. Results are expected to be completed by the end of 2020.

Conclusions

This protocol is for a systematic review of evidence for transdiagnostic risk and protective factors associated with empirically based models of psychopathology in young people. To our knowledge, the critical synthesis of this evidence will be the first to date and will provide a better understanding of the factors that contribute to the onset and maintenance of psychopathology in young people. Insights drawn from the review will provide critical new knowledge to improve the targeting of interventions to prevent or reduce mental health problems.

Trial Registration

This systematic review is registered with PROSPERO (CRD42020161368) and is available via Open Science Framework.

International Registered Report Identifier (IRRID)

DERR1-10.2196/19779