The clinician's illusion

The effectiveness of character strength intervention on severe mental illness in Hong Kong

The Character Strength Intervention is designed to cultivate and enhance positive traits and virtues in individuals. We sought to explore whether severely mentally ill adult participants who attended sixteen 40-min sessions of the intervention and treatment as usual (TAU) would report higher purpose in life, life satisfaction, recovery, and happiness composite scores than participants in TAU only. Thirty-nine participants received Intervention + TAU, and 50 received TAU-only. The participants filled in the evaluations at baseline, two mid-point assessments during the intervention, and one after the intervention. The ANCOVA models show a significant intervention effect on recovery and happiness at T3 but diminished at T4 after the intervention wrapped up. The intervention group has significantly less deterioration in recovery than the control group. No significant intervention effect emerged in purpose in life and life satisfaction. It should be noted that the intervention outcome is also negatively impacted by the baseline condition. The slope analysis indicates that for intervention recipients whose happiness scores are lower than 14.16, the predicted intervention outcome is even lower than that of the control group. Future severe mental illness interventions could consider incorporating CSI to enhance recovery and happiness while also being mindful of the baseline conditions to enhance intervention efficacy.

Mental illness and personal recovery: A narrative identity framework

This article presents a metamorphic model to describe the manifold role of narrative identity, a person's internal life story, across the course of mental illness and personal recovery. First, early adversity and negative co-authoring may contribute to the development of a fragile life story, which itself may combine with life stressors to increase the likelihood of mental illness. Second, mental illness may negatively impact the development of narrative identity, which in turn may exacerbate the devastating effects of mental illness on daily functioning. Finally, positive changes in narrative identity, as they are influenced by recovery stories of peers and the supportive co-authorship provided by mental health professionals, may contribute in powerful ways to the process of personal recovery. In sum, the metamorphic model demonstrates how narrative identity, as it is implicated in a variety of social spheres, shapes and is shaped by the course of mental illness and recovery. We also show how the model differs from other personality-oriented theories of psychopathology and how it may guide future research and interventions.

Attitudes of ambulance service staff towards people with mental illness: A cross-sectional survey in the Verona province, Italy

Healthcare professionals can be sources of stigma for people with mental illness. Ambulance personnel are often the first healthcare providers that people with mental illness encounter during physical and mental health crises and their attitudes may be influenced by misconceptions and stereotyping views. This study aimed to assess the attitudes of ambulance personnel toward people with mental illness using the Opening Minds Stigma Scale for Health Care Providers (OMS-HC) and to evaluate its psychometric properties. The study involved 510 ambulance staff members from a non-profit organization. The original factor structure of the OMS-HC, comprising three subscales was confirmed. The internal consistency for the OMS-HC total score was good (α=0.75) and acceptable for the subscales (Social Distance α=0.66; Attitudes α=0.59; Disclosure/Help-Seeking α=0.61). One-third of respondents displayed stigmatizing attitudes on half of the OMS-HC items. Higher scores were associated with being male, having lower levels of education, and working as both rescuers and ambulance drivers and with feeling uncomfortable when dealing with patients with mental illness. Overall, stigmatizing attitudes towards individuals with mental illness are prevalent among ambulance staff. The Italian version of the OMS-HC for ambulance personnel demonstrated satisfactory psychometric properties and is recommended for evaluating training programs targeting this population.

Co-occurrence between mental disorders and physical diseases: a study of nationwide primary-care medical records

BACKGROUND

Mental disorders and physical-health conditions frequently co-occur, impacting treatment outcomes. While most prior research has focused on single pairs of mental disorders and physical-health conditions, this study explores broader associations between multiple mental disorders and physical-health conditions.

METHODS

Using the Norwegian primary-care register, this population-based cohort study encompassed all 2 203 553 patients born in Norway from January 1945 through December 1984, who were full-time residents from January 2006 until December 2019 (14 years; 363 million person-months). Associations between seven mental disorders (sleep disturbance, anxiety, depression, acute stress reaction, substance-use disorders, phobia/compulsive disorder, psychosis) and 16 physical-health conditions were examined, diagnosed according to the International Classification of Primary Care.

RESULTS

Of 112 mental-disorder/physical-health condition pairs, 96% of associations yielded positive and significant ORs, averaging 1.41 and ranging from 1.05 (99.99% CI 1.00-1.09) to 2.38 (99.99% CI 2.30-2.46). Across 14 years, every mental disorder was associated with multiple different physical-health conditions. Across 363 million person-months, having any mental disorder was associated with increased subsequent risk of all physical-health conditions (HRs:1.40 [99.99% CI 1.35-1.45] to 2.85 [99.99% CI 2.81-2.89]) and vice versa (HRs:1.56 [99.99% CI 1.54-1.59] to 3.56 [99.99% CI 3.54-3.58]). Associations were observed in both sexes, across age groups, and among patients with and without university education.

CONCLUSIONS

The breadth of associations between virtually every mental disorder and physical-health condition among patients treated in primary care underscores a need for integrated mental and physical healthcare policy and practice. This remarkable breadth also calls for research into etiological factors and underlying mechanisms that can explain it.

Comparing stigma between French people experiencing schizophrenia versus bipolar disorders

BACKGROUND

Among the multiple challenges that people experiencing mental illness in general, and schizophrenia or bipolar disorders in particular, have to face, stigma appears to be one of the most difficult to tackle. In France, the body of research about stigma regarding people experiencing schizophrenia or bipolar disorders is growing, but not as much as in other western countries.

AIMS

In this context, our study aims to explore and compare stigma in French people experiencing schizophrenia or bipolar disorders, along with their respective mental healthcare system experience, in order to better address them within public health policies.

METHODS

20 French mental health service users experiencing schizophrenia and 20 experiencing bipolar disorders answered the Stigma Scale, which assesses three dimensions of stigma (discrimination, difficulties of divulgation and lack of positive aspects). A semi-structured interview was used to collect information about the experience of the mental healthcare system (level of information, access to diagnosis, treatment, access to psychoeducation, etc.).

RESULTS

People experiencing schizophrenia and people experiencing bipolar disorders are different populations in terms of social impairment. However, they share a comparable negative experience of the mental healthcare system and a comparable level of information about their illness, to the exception of diagnosis divulgation, as people experiencing bipolar disorders have a better access to their diagnosis. People experiencing schizophrenia perceive a higher actual discrimination than people experiencing bipolar disorders.

CONCLUSIONS

Public health policies should take into account the strong perception of actual discrimination of people experiencing schizophrenia, with capitalizing on what seems beneficial for people experiencing bipolar disorders.

10 Lessons Learned in Launching a Division-Wide Measurement-Based Care Initiative

Mental health problems are a major source of morbidity and mortality for children and adolescents, affecting 15% to 20% of those under 18 years of age in the US.1 Half of all mental health conditions start by age 14 years, although most cases remain undetected and untreated.2 Despite knowing much about mental health conditions affecting children, many speculate that the lack of standardized approaches to patient care contribute to poor outcomes, including substantial diagnostic variation, few remissions, risk for relapse or recidivism, and, ultimately, greater mortality due to an inability to accurately predict who will make a suicide attempt.3-5 Studies support this over-reliance on the "art of medicine" (ie, subjective judgment without use of standardized measures), finding that only 17.9% of psychiatrists and 11.1% of psychologists in the US routinely administer symptom rating scales to their patients, despite studies suggesting that when using clinical judgment alone, mental health providers detect deterioration for only 21.4% of patients.4.

Child abuse and neglect and mental health outcomes in adulthood by ethnicity: Findings from a 40-year longitudinal study in New Zealand/Aotearoa

BACKGROUND

Longitudinal studies consistently report adverse long-term outcomes of childhood maltreatment. Little is known about the impact of childhood maltreatment on mental health among a marginalized population (New Zealand Māori); therefore, we cannot assume the effects of maltreatment are the same across the population.

OBJECTIVE

Associations were examined between childhood sexual abuse (CSA), childhood physical punishment (CPP) and childhood neglect (CN) (<16 years) and mental health outcomes 18-40 years, by ethnicity (Māori/non-Māori).

PARTICIPANTS AND SETTING

Data from the Christchurch Health and Development Study, a study of a birth cohort of 1265 children born in Christchurch in 1977. By age 40, 17.8 % (n = 191) reported New Zealand Māori ethnic identity; 82.2 % (n = 883) were non-Māori.

METHODS

CSA, CPP (<16 years) were measured at 18, 21 years; CN was measured at 40 years. Major depression, anxiety disorder, suicidal ideation, alcohol abuse/dependence and cannabis abuse/dependence were measured at ages 21, 25, 30, 35 and 40 years. Childhood confounding variables controlled. Analyses were extended to include Māori ethnicity.

RESULTS

After statistical adjustment, experience of severe childhood maltreatment increased odds of mental health problems 1.8-2.6×, compared to no maltreatment; the effects of maltreatment were similar for males and females. For Māori, some higher rates of mental health problems were seen among those maltreated, no statistically significant associations were detected after Bonferroni correction (among severe maltreatment vs. no maltreatment). Limitations should be considered when interpreting results.

CONCLUSIONS

Exposure to childhood maltreatment has long-term effects into middle-age. Further research employing culturally-sensitive approaches may help clarify Māori childhood maltreatment outcomes.

A Clinical Psychologist Who Studies Alcohol

In this article, I describe why I believe the study of alcohol use and its consequences is a rich and rewarding area of scholarly activity that touches on multiple disciplines in the life sciences, the behavioral sciences, and the humanities. I then detail the circuitous path I took to become an alcohol researcher and the various challenges I encountered when starting up my research program at the University of Missouri. A major theme of my journey has been my good fortune encountering generous, brilliant scholars who took an interest in me and my career and who helped guide and assist me over the course of my career. I also highlight selected, other professional activities I've been involved in, focusing on editorial work, quality assurance, and governance of professional societies. While the focus is on my training and work as a psychologist, the overarching theme is the interpersonal context that nurtures careers.

Anxiety, mood, and substance use disorders in adult men and women with and without Attention-Deficit/Hyperactivity Disorder: a substantive and methodological overview

Knowledge on psychiatric comorbidity in adult ADHD is essential for prevention, detection, and treatment of these conditions. This review (1) focuses on large studies (n> 10,000; surveys, claims data, population registries) to identify (a) overall, (b) sex- and (c) age-specific patterns of comorbidity of anxiety disorders (ADs), major depressive disorder (MDD), bipolar disorder (BD) and substance use disorders (SUDs) in adults with ADHD relative to adults without ADHD; and (2) describes methodological challenges relating to establishing comorbidity in ADHD in adults as well as priorities for future research. Meta-analyses (ADHD: n=550,748; no ADHD n=14,546,814) yielded pooled odds ratios of 5.0(CI:3.29-7.46) for AD, 4.5(CI:2.44-8.34) for MDD, 8.7(CI:5.47-13.89) for BD and 4.6(CI:2.72-7.80) for SUDs, indicating strong differences in adults with compared to adults without ADHD. Moderation by sex was not found: high comorbidity held for both men and women with sex-specific patterns as in the general population: higher prevalences of ADs, MDD and BD in women and a higher prevalence of SUDs in men. Insufficient data on different phases of the adult lifespan prevented conclusions on developmental changes in comorbidity. We discuss methodological challenges, knowledge gaps, and future research priorities.

Frontal alpha asymmetry in anxious school-aged children during completion of a threat identification task

Asymmetry of EEG alpha power in the frontal lobe has been extensively studied over the past 30 years as a potential marker of emotion and motivational state. However, most studies rely on time consuming manipulations in which participants are placed in anxiety-provoking situations. Relatively fewer studies have examined alpha asymmetry in response to briefly presented emotionally evocative stimuli. If alpha asymmetry can be evoked in those situations, it would open up greater methodological possibilities for examining task-driven changes in neural activation. Seventy-seven children, aged 8-12 years old (36 of whom were high anxious), completed three different threat identification tasks (faces, images, and words) while EEG signal was recorded. Alpha power was segmented and compared across trials in which participants viewed threatening vs. neutral stimuli. Threatening images and faces, but not words, induced lower right vs. left alpha power (greater right asymmetry) that was not present when viewing neutral images or faces. Mixed results are reported for the effect of anxiety symptomatology on asymmetry. In a similar manner to studies of state- and trait-level withdrawal in adults, frontal neural asymmetry can be induced in school-aged children using presentation of brief emotional stimuli.

Polygenic analyses show important differences between MDD symptoms collected using PHQ9 and CIDI-SF

Symptoms of Major Depressive Disorder (MDD) are commonly assessed using self-rating instruments like the Patient Health Questionnaire 9 (PHQ9, for current symptoms), and the Composite International Diagnostic Interview Short-Form (CIDI-SF, for lifetime worst-episode symptoms). Using data from the UKBiobank, we show that corresponding symptoms endorsed through PHQ9 and CIDI-SF have low to moderate genetic correlations (rG=0.43-0.87), and this cannot be fully attributed to different severity thresholds or the use of a skip-structure in CIDI-SF. Through a combination of Mendelian Randomization (MR) and polygenic prediction analyses, we find that PHQ9 symptoms are more associated with traits which reflect general dysphoria, while the skip-structure in CIDI-SF allows for the identification of heterogeneity among likely MDD cases. This has important implications on factor analyses performed on their respective genetic covariance matrices for the purpose of identification of genetic factors behind MDD symptom dimensions and heterogeneity.

Commentary: Commentary on the Twitter comments evoked by the May 2022 debate on diagnosing personality disorders in adolescents

The debate about the value and utility of personality disorder (PD) diagnosis in adolescence published in the May 2022 issue of CAMH generated fervent Twitter discussion. This commentary addresses some points raised in the Twitter discussion that represent important social and/or cultural beliefs that are often presented in day-to-day practice but are rarely tested in the context of scientific evidence. This includes, in particular, the assertion that symptoms used to diagnose personality disorder are better described as sequelae of trauma, and the assertion that effective treatment for PD is possible without a diagnosis. The call for a fundamental transformation of mental health services that currently do not meet the needs of people with PD and for the involvement of people with lived experience as equal partner in this process is supported by evidence and might represent common ground among those clinician-scientist advocating for early intervention for PD and those expressing their concerns about this issue.

Clinical Course in Patients With Melancholic and Nonmelancholic Bipolar Depression

The aim of the current study was to compare the longitudinal clinical course of patients with a history of melancholic and nonmelancholic bipolar depression. Seventy-seven euthymic outpatients with bipolar disorder were categorized as melancholic or nonmelancholic through the clinician-rated Sydney Melancholia Prototype Index. Clinical course was assessed for a period longer than 48 months by time spent ill, density of affective episodes, severity and duration of depressive episodes, and time to depressive recurrence. The mean follow-up time was 69.05 months. Patients with melancholic depressions had more severe and longer depressive episodes during follow-up, whereas patients with nonmelancholic depressions had a shorter time to depressive recurrence and more subsyndromal depressive symptoms and affective instability. These findings highlight the heterogeneity inherent to the current construct of bipolar depression and position melancholia as an interesting target for comparison with nonmelancholic depressions in other external validators in the field of bipolar disorder.

The attitudes of mental health professionals on the employability of people with mental illness: A different view limiting employment rehabilitation

OBJECTIVES

Mental health professionals are becoming increasingly involved in the process of employment rehabilitation of persons with psychiatric disabilities. However, few studies address the attitudes of these professionals toward the employability of those with mental illness. The aim of this research was to identify differences in the attitudes of medical and non-medical mental health professionals, as well as to detect any association between attitude scores and the type of professional.

METHODS

A sample of 140 employees from public and third sector mental health organizations answered a questionnaire using a scale measuring their attitudes and views on the employability of people with psychiatric disabilities. The psychometric characteristics of the scale are provided together with the variations detected in the professionals' attitudes.

RESULTS

This research shows that significant differences in the attitudes between medical and non-medical mental health employees exist and that there is a need for the implementation of educational programs that may help to improve the attitudes of medical professionals toward the employability of people with mental illness.

CONCLUSION

This research indicates the importance of improving the professionals' attitudes to support people attempting to return to work.

The characteristics of people who inject drugs in the United Kingdom: changes in age, duration, and incidence of injecting, 1980-2019, using evidence from repeated cross-sectional surveys

BACKGROUND AND AIMS

Mortality and drug treatment data suggest that the median age of people who inject drugs is increasing. We aimed to describe changes in the characteristics of people injecting drugs in the United Kingdom (UK).

DESIGN

Repeat cross-sectional surveys and modelling.

SETTING

Low-threshold services in the United Kingdom such as needle and syringe programmes.

PARTICIPANTS

A total of 79 900 people who recently injected psychoactive drugs in the United Kingdom, recruited as part of the Unlinked Anonymous Monitoring Survey (England, Wales, Northern Ireland, 1990-2019) and Needle Exchange Surveillance Initiative (Scotland, 2008-2019).

MEASUREMENTS

Age of people currently injecting, age at first injection, duration of injecting (each 1990-2019) and estimates of new people who started injecting (1980-2019).

FINDINGS

In England, Wales and Northern Ireland between 1990 and 2019, the median age of people injecting increased from 27 (interquartile range [IQR], 24-31) to 40 (IQR, 34-46); median age at first injection increased from 22 (IQR, 19-25) to 33 (IQR, 28-39); and median years of injecting increased from 7 (IQR, 3-11) to 18 (IQR, 9-23). Values in Scotland and England were similar after 2008. The estimated number that started injecting annually in England increased from 5470 (95% prediction interval [PrI] 3120-6940) in 1980 to a peak of 10 270 (95% PrI, 8980-12 780) in 1998, and then decreased to 2420 (95% PrI, 1320-5580) in 2019. The number in Scotland followed a similar pattern, increasing from 1220 (95% PrI, 740-2430) in 1980 to a peak of 3080 (95% PrI, 2160-3350) in 1998, then decreased to a 270 (95% PrI, 130-600) in 2018. The timing of the peak differed between regions, with earlier peaks in London and the North West of England.

CONCLUSIONS

In the United Kingdom, large cohorts started injecting psychoactive drugs in the 1980s and 1990s and many still inject today. Relatively few people started in more recent years. This has led to changes in the population injecting drugs, including an older average age and longer injecting histories.

"These are people just like us who can work": Overcoming clinical resistance and shifting views in the implementation of Individual Placement and Support (IPS)

Purpose

Individual Placement and Support (IPS) is a recovery-based approach to support people with mental health difficulties back into employment. Embedding of IPS within the mental health Multi-Disciplinary Team (MDT) is a key component of IPS fidelity; however, few studies have examined how those involved with IPS implementation navigate this process. This article explores how IPS Employment Specialists (ES) and Occupational Therapist (OT) Managers integrated and embedded IPS within traditionally-oriented MDTs as part of a national reform program in the Republic of Ireland.

Methods

The study design was qualitative, descriptive with data collected through three focus groups with 17 IPS ESs and 11 OT Managers. Data were analyzed using thematic synthesis.

Results

Three key themes emerged from analysis. The first characterizes the context into which IPS landed, described as one marked by clinical resistance, doubt, and fear of risk. The second explores the strategies and factors that helped with the introduction of IPS into Irish mental health services. These included strategies, such as providing education and information about IPS and reassuring the MDT about IPS governance and IPS ES’ competencies. The evidenced-based nature of IPS and its attached accountabilities through IPS fidelity measures were perceived to be an important factor in its acceptance. The final theme encapsulates perceptions of how IPS impacted on the MDTs’ views of people with mental health difficulties. Findings suggest a shift in the ways in which MDTs view their clients. Initial fears about work capacity and risk shifted towards seeing people beyond the label of ‘service user’ and their diagnosis.

Conclusions

It is contended that IPS is an approach that allows practitioners to engage with real recovery-practice and may be one key to unlocking how a recovery approach can truly trickle down and embed itself within mental health service provision and support mental health system reform.

Neurodegenerative model of schizophrenia: Growing evidence to support a revisit

Multidimensional progressive declines in the absence of standard biomarkers for neurodegeneration are observed commonly in the development of schizophrenia, and are accepted as consistent with neurodevelopmental etiological hypotheses to explain the origins of the disorder. Far less accepted is the possibility that neurodegenerative processes are involved as well, or even that key dimensions of function, such as cognition and aspects of biological integrity, such as white matter function, decline in chronic schizophrenia beyond levels associated with normal aging. We propose that recent research germane to these issues warrants a current look at the question of neurodegeneration. We propose the view that a neurodegenerative hypothesis provides a better explanation of some features of chronic schizophrenia, including accelerated aging, than is provided by neurodevelopmental hypotheses. Moreover, we suggest that neurodevelopmental influences in early life, including those that may extend to later life, do not preclude the development of neurodegenerative processes in later life, including some declines in cognitive and biological integrity. We evaluate these views by integrating recent findings in representative domains such as cognition and white and gray matter integrity with results from studies on accelerated aging, together with functional implications of neurodegeneration for our understanding of chronic schizophrenia.

The Time is Ripe for a Consensus Definition of Clinical Recovery in First-episode Psychosis: Suggestions Based on a 10-Year Follow-up Study

OBJECTIVES

A consensus definition of clinical recovery in first-episode psychosis (FEP) is required to improve knowledge about recovery rates in this population. To propose criteria for a future consensus definition, this study aims to investigate rates of clinical recovery when using a standard definition (full psychotic symptom remission and adequate functioning for minimum one year) across both affective and nonaffective FEP groups (bipolar spectrum and schizophrenia spectrum disorders). Second, we aim to explore changes in rates when altering the standard definition criteria. Third, to examine the extent to which healthy controls meet the functioning criteria.

STUDY DESIGN

In total, 142 FEP participants and 117 healthy controls preselected with strict criteria, were re-assessed with structured clinical interviews at 10-year follow-up.

STUDY RESULTS

A total of 31.7% were in clinical recovery according to the standard definition, with significantly higher recovery rates in bipolar (50.0%) than in schizophrenia spectrum disorders (22.9%). Both groups' recovery rates decreased equally when extending duration and adding affective symptom remission criteria and increased with looser functioning criteria. In healthy controls, 18.8% did not meet the standard criteria for adequate functioning, decreasing to 4.3% with looser criteria.

CONCLUSIONS

Findings suggest that clinical recovery is common in FEP, although more in bipolar than in schizophrenia spectrum disorders, also when altering the recovery criteria. We call for a future consensus definition of clinical recovery for FEP, and suggest it should include affective symptom remission and more reasonable criteria for functioning that are more in line with the general population.

The Lost Social Context of Recovery Psychiatrization of a Social Process

From being a concept questioning the core of psychiatric knowledge and practice, recovery has been adopted as a guiding vison for mental health policy and practice by different local, national, and international organizations. The aim of this article is to contextualize the different understandings of recovery and its psychiatrization through the emergence of an individualizing and de-contextualized definition which have gained a dominant position. It ends with an attempt to formulate a new definition of recovery which integrates people in their social context. Research results from various follow-up studies showing the possibility of recovery from severe mental distress have stressed the importance of societal, social and relational factors as well of the person's own agency when facing their distress and reactions from their environment. These researches were published in the 1970s and 80s; a period of struggle for liberation from colonialism, of struggle by women and black people for their civil rights, and a time of de-institutionalization of services directed toward the poor, elderly, handicapped, prisoners, and people with mental health problems. Recovery research pointed at the central role of individuals in their recovery journey and it was understood as a personal process in a social context. However, with neo-liberal political agenda, the personal role of individuals and their own responsibility for their well-being was stressed, and contextual understandings and the role of social, material and cultural changes to promote recovery faded away. Thus, during recent decades recovery has been mostly defined as an individualistic journey of changing the persons and their perception of their situation, but not of changing this situation. Contextual aspects are almost absent. The most quoted definition accepts the limits posed by an illness-based model. This kind of definition might be a reason for the wide acceptance of a phenomenon that was initially experienced as a break with the bio-medical paradigm. Recently, this dominant individualized understanding of recovery has been criticized by service users, clinicians and researchers, making possible a redefinition of recovery as a social process in material and cultural contexts.

Major Depression and Its Recurrences: Life Course Matters

Major depression is one of the most prevalent and debilitating personal and public health conditions worldwide. Less appreciated is that depression's tremendous burdens are not shared equally among all who become depressed. Some will suffer recurrences over the rest of their lives, whereas half or more will never have a recurrence. Based on these two distinctive life course prototypes, we propose a subtype distinction for research on the origins and lifetime course of major depression. A pressing goal is to determine at the time of depression's first onset who will follow which clinical trajectory. The lack of recognition of this distinction has resulted in many obstacles, including conceptual biases, methodological oversights, and definitional dead ends. Current theories are reviewed and compared. The implications for contemporary diagnostic controversies, reevaluating research on treatment and prevention, and enhancing the predictive strength of traditionally weak indicators of recurrences and recurrent depression are discussed. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Childhood Maltreatment and Eating Disorders: A Prospective Investigation

OBJECTIVES

To determine whether childhood maltreatment is a risk factor for two eating disorders (anorexia nervosa and bulimia nervosa) using objective and subjective case definitions.

METHODS

Using a prospective cohorts design, children with documented cases of physical abuse, sexual abuse, and neglect (ages 0-11) from 1967 to 1971 in a Midwestern metropolitan county area were matched on age, race, sex, and approximate family socioeconomic status with non-maltreated children. Both groups were followed up. Retrospective self-reports about childhood maltreatment were collected at age 29. DSM-IV anorexia nervosa (AN) and bulimia nervosa (BN) disorders were assessed at age 41 (N = 807). Logistic and linear regression results are reported.

RESULTS

Using documented cases, childhood maltreatment was not a significant risk factor for AN or BN diagnoses or symptoms in adulthood. However, adults who retrospectively reported any maltreatment and physical and sexual abuse reported significantly more symptoms of AN than those who did not.

CONCLUSIONS

The prediction that childhood maltreatment is a risk factor for anorexia nervosa and bulimia nervosa was partially supported in this longitudinal study. While misattribution of cases might have occurred, these results suggest that researchers and clinicians should use caution in drawing inferences about these relationships and designing interventions.

l'Optimisme and youth mental health: has it attained Voltaire's 'best of all possible worlds'?

OBJECTIVE

Youth mental health has been politicised by high-profile health advocates, and often leads the Australian national policy agenda. The ensuing debate is being conducted at multiple levels: scientific, clinical, economic and political. These levels interact, and we explore how scholars' experiences with early intervention (EI) shape their roles as health advocates and political lobbyists.

CONCLUSIONS

Health advocacy influences major government decisions. EI researchers have been successful as health advocates in Australia, attracting substantial government funding for selected youth mental health programmes. Positive experiences with the short-term gains of EI might encourage the necessary optimism amongst researchers for successful health advocacy. However, as medical experts, clinicians are aware that most patients and carers face a huge burden from schizophrenia, even after high-quality EI. These patients require fully integrated and well-funded mental healthcare across the lifespan.

Evaluating the Effects of Experiencing Virtual Reality Simulation of Psychosis on Mental Illness Stigma, Empathy, and Knowledge in Medical Students

OBJECTIVES

Applying technologies such as virtual reality (VR) in education has gained popularity especially in comprehending abstract and subjective phenomena. Previous studies have shown that applying a virtual reality simulation of psychosis (VRSP) is useful in increasing knowledge and empathy toward patients. Here, the efficacy of using VRSP in altering stigma, empathy and knowledge as well as side effects have been assessed in medical students in comparison with the routine education (visiting the patients).

METHOD

After attending one session of lecture about positive psychotic symptoms, medical students were allocated to two groups: experiencing one session of VRSP or visiting patients under supervision as routine practice in the ward. Before and after the first session and after the second one, questionnaires of knowledge, empathy and stigma were filled by students. Finally, the results were compared in two groups.

RESULTS

Both interventions were effective in reducing stigma as well as increasing knowledge and empathy toward patients with psychotic experiences. VRSP could significantly reduce stigma and increase knowledge and empathy compared with the traditional visiting patients under supervision. The side effects were minimal and ameliorated right after the experience.

CONCLUSION

VRSP is an effective tool in decreasing stigma and increasing empathy and knowledge of the students and can be incorporated in psychiatric education with minimal side effects.

Seeing the complete picture: A systematic review of mental health consumer and health professional experiences of diagnostic overshadowing

AIM

To systematically identify, explore and synthesise qualitative data related to mental health consumer and health professional experiences of diagnostic overshadowing.

BACKGROUND

Mental health consumers experience significantly high rates of physical illness, poorer health outcomes and are more likely to die prematurely of physical illnesses than the general population. Diagnostic overshadowing is a complex and life-threatening phenomenon that occurs when physical symptoms reported by mental health consumers are misattributed to mental disorders by health professionals. This typically occurs in general healthcare settings.

METHODS

Drawing on JBI methodology for systematic reviews, four scholarly databases and grey literature was searched, followed by eligibility screening and quality assessment using JBI QARI frameworks, resulting in six studies for inclusion. Findings were synthesised using meta-aggregation. The PRISMA checklist was adhered to throughout this process.

FINDINGS

Five synthesised findings emerged. Three from the health professional experience: working in ill-suited healthcare systems, missing the complete diagnostic picture, and misunderstanding the lived experience of mental illness. Two from the mental health consumer experience: not knowing if the cause is physical or mental, and surviving and ill-suited health care system.

CONCLUSIONS

Diagnostic overshadowing is a multidimensional experience of interconnecting factors including systematic healthcare system issues, health professionals limited mental health knowledge and skills, stigmatic attitudes and mental health consumers miscommunicating their physical healthcare needs. Further research is needed to make diagnostic overshadowing visible and mitigate against this phenomenon that deprives mental health consumers of equitable access to quality healthcare.

RELEVANCE TO CLINICAL PRACTICE

Those who govern healthcare systems have an obligation to recognise and address the unique needs of mental health consumers who seek help for physical illnesses to ensure they receive quality and safe care. Forming collaborative partnerships with mental health consumers in the development of knowledge translation initiatives targeting healthcare policy, practice and education are urgently required.

Changing Attitudes Towards Voice Hearers: A Literature Review

Auditory verbal hallucinations, or voice hearing, is increasingly understood as a common experience. Despite this, voice hearers still experience a great deal of stigma, which can have serious negative impacts on the person's experience of their voices, and their recovery. Research has demonstrated that healthcare professionals may be a major source of the stigma surrounding voice hearing, with service-level implications for the development and delivery of evidence-based interventions. Therefore, reducing this stigma is a critical intervention target. The purpose of this narrative review is to examine evidence for interventions aimed at reducing stigma towards people who hear voices, in populations of healthcare professionals, students, and the general public. The available evidence supports the use of anti-stigma interventions based around direct contact with voice hearers and education about voice hearing. However, further research is necessary in this area to confirm these findings.

Evidence-based medicine's curious path: From clinical epidemiology to patient-centered care through decision analysis

Evidence-based medicine (EBM), one of the most important movements in health care, has been a lightning rod for controversy. Conflicts about the meaning and value of EBM are owing in part to lack of clarity about basic questions regarding its development, the importance of expertise and intuition, and the role of evidence in clinical decision making. These issues have persisted in part because of unclarity at the outset, but also because of how EBM evolved, why it was introduced when it was, and how it was modified following its introduction. This paper traces the evolution of EBM from clinical epidemiology (CE) and the internal dispute that precipitated the developers to establish EBM as a distinct approach to clinical practice. The paper proposes that health care industrialization also had a significant role in EBM's emergence and that industrialization influenced the decision to merge EBM with the method of normative decision making known as decision analysis (DA). The paper discusses the impact of this merger, in particular how it led to EBM's identification with managed care and has added momentum to the effort at forging a connection between a normative decision model and clinical judgement. This effort would turn clinical decision making into a conduit for bringing administrative rules and regulations into the consulting room and would result in expertise becoming a surplus skill. The paper closes by discussing a challenge yet unmet by EBM's advocates and critics-to chronicle the dangers that EBM in the framework of DA during the current era of industrialization poses to health and health care, and discover ways of unhinging the relationship between model and judgement.

Naturalistic outcome of medication-naïve obsessive compulsive disorder treated with serotonin reuptake inhibitors

OBJECTIVE

The data on the course of obsessive compulsive disorder (OCD) is mostly derived from studying chronic, severely ill patients with varying degree of treatment resistance. We studied the course and outcome of OCD patients who were medication-naïve at initial assessment compared to those who were medicated.

MATERIAL AND METHODS

We analyzed the clinical chart data of all patients with a primary diagnosis of OCD attending a speciality OCD clinic in India during a specified period and compared outcome between medication-naïve (n = 75) and medicated (n = 117) patients.

RESULTS

The mean time to remission was shorter in the medication-naïve [18.99 months (95 % CI: 14.61-23.37)] compared to medicated [33.91 months (95 % CI: 27.55-40.28)] patients. The survival distribution of the two groups was significantly different as per the log-rank test (χ2 = 5.76, p = 0.02). In the Cox proportional hazards regression, medication-naïve status predicted time to remission. Overall, the rate of remission was the same in both groups (57 %).

CONCLUSIONS

Medication-naïve OCD patients seem to remit faster than the previously treated patients. Future prospective naturalistic studies can compare the outcome of medication naïve OCD patients treated with medications and CBT.

Where are all the psychologists? A review of factors impacting the underrepresentation of psychology in work with serious mental illness

Over the last few decades, clinical psychologists have played a key role in the development of empirically-validated psychosocial interventions for those with serious mental illness (SMI). However, in contrast to these substantial contributions, clinical psychologists in the United States are grossly underrepresented in treatment provision with this population (Roe, Yanos, & Lysaker, 2006; Rollins & Bond, 2001). This review aims to highlight various factors contributing to the establishment and perpetuation of this underrepresentation. First, we highlight systemic factors (e.g., the emergence of managed care) through an examination of the evolving role of the clinical psychologist. Next, we review training-based factors (e.g., limitations to SMI specific training) through a review of training in clinical psychology. Through an examination of training factors, the role of mental health stigma amongst clinicians toward individuals with SMI is identified as a potential perpetuating factor of this underrepresentation. Factors associated with clinician stigma are then reviewed and the relationship between clinical training and clinician stigma is considered. Lastly, important future directions to further investigate and address this underrepresentation are suggested - namely, investigating factors (training and individual) that may impact clinical psychology doctoral students' attitudes toward those with SMI.

Cannabis Use, Cannabis Use Disorder, and Comorbid Psychiatric Illness: A Narrative Review

BACKGROUND

The landscape of attitudes, legal status and patterns of use of cannabis is rapidly changing in the United States and elsewhere. Therefore, the primary aim of this narrative review is to provide a concise overview of the literature on the comorbidity of cannabis use and cannabis use disorder (CUD) with other substance use and psychiatric disorders, and to use this information to accurately guide future directions for the field.

METHODS

A literature review of PubMed was conducted for studies relating to cannabis use, CUD, and a co-occurring psychiatric disorder. To provide an overview of representative data, the literature review focused on national-level, population-based work from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and National Survey on Drug Use and Health (NSDUH) surveys. Considering rapidly changing cannabis laws, recent (past five-year) studies were addressed.

RESULTS

A strong body of literature shows associations between cannabis use and CUD with other drug use, psychosis, mood disorders, anxiety disorders, and personality disorders. The strongest evidence of a potential causal relationship exists between cannabis use and psychotic disorders. While some evidence shows potential directionality between cannabis use and mood and anxiety disorders, results are inconsistent. Studies have established higher rates of CUD among those with personality disorders, but little about the specifics of this relationship is understood.

CONCLUSIONS

Although the general population in the United States increasingly perceives cannabis to be a harmless substance, empirical evidence shows that cannabis use is associated both with CUD and comorbid psychiatric illness. However, there is mixed evidence regarding the role of cannabis in the etiology, course, and prognosis of a co-occurring disorder across all categories of psychiatric disorders. Future research should expand on the existing body of literature with representative, longitudinal data, in order to better understand the acute and long-term effects of cannabis on comorbid psychiatric illness.

Implementing a transdiagnostic sleep and circadian intervention in a community mental health setting: A qualitative process evaluation with community stakeholders

The implementation of evidence-based psychological treatments (EBPTs) may be particularly challenging to accomplish in community mental health settings for individuals with severe mental illness (SMI). Transdiagnostic treatments, or treatments that target a mechanism that underpins multiple mental health problems, may be particularly well-suited to community mental health settings. This study examines community stakeholder perspectives (N = 22) of the Transdiagnostic Sleep and Circadian Intervention (TranS-C) implemented in a community mental health setting in the context of a randomized controlled trial of TranS-C for SMI. The present study aimed to identify barriers and facilitators to the implementation of TranS-C for SMI in a community mental health setting using (1) a deductive theory-based process based on the Framework for Dissemination in Health Services Intervention Research and (2) an inductive thematic analysis process. All deductive themes were identified as both barriers and facilitators to the implementation of EBPTs and TranS-C in this community mental health setting. Seven additional themes were identified through the inductive thematic analysis. A discussion of how the findings are related to prior research, other EBPT implementation, and future TranS-C implementation are included.

Opportunities, Enablers, and Barriers to the Use of Recorded Recovery Narratives in Clinical Settings

Background: Recorded Recovery Narratives (RRNs) describing first-person lived experience accounts of recovery from mental health problems are becoming more available. Little is known about how RRNs can be used in clinical practice and clinical education. Aims: The aim of this paper is to enable implementation planning for RRN interventions by identifying determinants of uptake. The objective was to identify opportunities, barriers, and enablers to the uptake of RRN interventions in clinical practice and education. Method: Three phases of focus groups were conducted with multi-professional mental health clinicians. Phase 1 (4 groups, n = 25) investigated current and possible uses of RRNs, Phase 2 (2 groups, n = 15) investigated a specific intervention delivering recovery narratives. Phase 3 (2 groups, n = 12) investigated clinical education uses. Thematic analysis was conducted. Results: RRNs can reinforce the effectiveness of existing clinical practices, by reducing communication barriers and normalizing mental health problems. They can also extend clinical practice (increase hope and connection, help when stuck). Clinical considerations are the relationship with care pathways, choice of staff and stage of recovery. In educational use there were opportunities to access lived experience perspectives, train non-clinical staff and facilitate attitudinal change. Barriers and enablers related to design (ability to use online resources, accessibility of language, ability to individualize choice of narrative), risk (triggering content, staff skills to respond to negative effects), trust in online resource (evidence base, maintenance), and technology (cost of use, technology requirements). Conclusions: RRNs can both improve and extend existing clinical practice and be an important educational resource. RRNs can improve engagement and hope, and address internalized stigma. Beneficially incorporating RRNs into clinical practice and education may require new staff skills and improved technological resources in healthcare settings. Future work could focus on the use of peer support workers views on RRN use and how to avoid unnecessary and unhelpful distress. Trial Registration Number: Work in this paper has informed three clinical trials: ISRCTN11152837; ISRCTN63197153; ISRCTN76355273.

Factors Affecting Mental Health Professionals' Sharing of Their Lived Experience in the Workplace: A Scoping Review

OBJECTIVE

Research has suggested that some mental health professionals (MHPs) continue to hold stigmatized beliefs about persons with emotional distress. These beliefs may be amenable to contact-based interventions with similar peers. To inform future interventions, policy, and research, this scoping review examined existing literature to identify factors that affect disclosure of lived experience by MHPs to colleagues and supervisors.

METHODS

A systematic search was conducted of four online databases, gray literature, and the reference lists of included articles. Primary research studies of any design conducted with MHPs with lived experience of emotional distress and their colleagues were included. The findings of included studies were inductively coded within the themes of enabling, constraining, and intrapersonal factors influencing disclosure.

RESULTS

A total of 23 studies were included in data extraction and synthesis. Factors that influenced MHPs' sharing of their lived experience in the workplace were categorized into five overarching themes: the "impaired professional," the "us and them" divide, the "wounded healer," belief in the continuum of emotional distress, and negotiating hybrid identities. MHPs with lived experience described feeling conflict between professional and service user identities that affected the integration and use of their clinical and experiential knowledge. Enabling factors reflected best-practice human resource management, such as organizational leadership, access to supervision and training, inclusive recruitment practices, and the provision of reasonable accommodations.

CONCLUSIONS

Findings of this scoping review suggest that organizational interventions to support MHPs in order to share their lived experience may improve workplace diversity and well-being, with implications for service users' experience.

Schizophrenia stigma in mental health professionals and associated factors: A systematic review

BACKGROUND

The consequences of schizophrenia stigma are numerous and highly damaging to individuals, their families, the health care system and society. Mental health professionals (MHP) are considered to be one of the main sources of stigmatization.

OBJECTIVES

To identify the characteristics of MHP stigma in schizophrenia in comparison with other psychiatric disorders, the specificities of MHP compared with other social groups, and associated factors.

METHODS

Following PRISMA guidelines, we systematically searched multiple electronic databases for articles: (i) reporting original data published in English in peer-reviewed journals, (ii) reporting quantitative data with statistical analysis, (iii) assessing stigma in a broad sense, and (iv) including samples composed only of MHP.

RESULTS

A total of 38 articles published from 1999 to 2019 and involving 10,926 MHP fulfilled our inclusion criteria. Studies showed that schizophrenia is the most stigmatized mental illnesses in MHP, despite recent results suggesting that borderline personality disorder and substance abuse may be more stigmatized. In comparison with other social groups, MHP reported less dangerousness beliefs and more positive beliefs regarding pharmacological treatment. Nevertheless, results were less consistent regarding prognosis and desire for social distance. Age, education level, type of mental health profession, or length of practice were associated factors that showed inconsistent relations with stigma. Work setting and biological causal beliefs were more clearly associated with MHP stigma.

CONCLUSION

These findings provide strong support for the need to conduct specific research on schizophrenia stigma in MHP and the importance of controlling for several variables to identify predictors of stigma.

Incident psychiatric comorbidity following stress disorder diagnoses in Danish school-aged children: prospective population-based study

BACKGROUND

Prospective population-based studies of psychiatric comorbidity following trauma and severe stress exposure in children are limited.

AIMS

To examine incident psychiatric comorbidity following stress disorder diagnoses in Danish school-aged children using Danish national healthcare system registries.

METHOD

Children (6-15 years of age) with a severe stress or adjustment disorder (ICD-10) between 1995 and 2011 (n = 11 292) were followed prospectively for an average of 5.8 years. Incident depressive, anxiety and behavioural disorder diagnoses were examined relative to an age- and gender-matched comparison cohort (n = 56 460) using Cox proportional hazards regression models. Effect modification by gender was examined through stratified analyses.

RESULTS

All severe stress and adjustment disorder diagnoses were associated with increased rates for all incident outcome disorders relative to the comparison cohort. For instance, adjustment disorders were associated with higher rates of incident depressive (rate ratio RR = 6.8; 95% CI 6.0-7.7), anxiety (RR = 5.3; 95% CI 4.5-6.4), and behavioural disorders (RR = 7.9; 95% CI 6.6-9.3). Similarly, PTSD was also associated with higher rates of depressive (RR = 7.4; 95% CI 4.2-13), anxiety (RR = 7.1; 95% CI 3.5-14) and behavioural disorder (RR = 4.9; 95% CI 2.3-11) diagnoses. There was no evidence of gender-related differences.

CONCLUSIONS

Stress disorders varying in symptom constellation and severity are associated with a range of incident psychiatric disorders in children. Transdiagnostic assessments within a longitudinal framework are needed to characterise the course of post-trauma or severe stressor psychopathology.

Why do psychiatrists doubt the value of early intervention? The power of illusion

OBJECTIVE

Face validity and the best available evidence strongly support the value of early intervention (EI) for psychotic disorders, and increasingly for other mental illnesses. Yet its value continues to be intensely criticised by some academics and doubted by many psychiatrists. This disconnect is examined through the lens of the 'clinician's illusion'.

CONCLUSIONS

A number of sources fuel resistance to EI; however, the cumulative exposure to persistent and disabling illness that dominates the day-to-day experience of psychiatrists may be a key influence. This experience forms the basis of the clinician's illusion, a hidden bias health professionals develop as a natural consequence of their clinical experiences, which shapes belief and perception of prognosis, and breeds therapeutic nihilism. This bias has been reinforced by grossly under-resourced systems of mental health care, undermining morale and adding a sense of learned helplessness to our mindset.

A diffusion model analysis of sustained attention in children with attention deficit hyperactivity disorder

OBJECTIVE

Whether children with attention deficit hyperactivity disorder (ADHD) have deficits in sustained attention remains unresolved due to the ongoing use of cognitive paradigms that are not optimized for studying vigilance and the fact that relatively few studies report performance over time.

METHOD

In three independent samples of school-age children with (total N = 128) and without ADHD (total N = 59), we manipulated event rate, difficulty of discrimination, and use signal detection (SDT) and diffusion models (DM) to evaluate the cause of the vigilance decrement during a continuous performance task.

RESULTS

For both groups of children, a bias toward "no-go" over time (as indexed by the SDT parameter B″ and the DM parameter z/a) was responsible for generating the vigilance decrement. However, among children with ADHD, the rate at which information accumulated to make a no-go decision (vNoGo) also increased with time on task, representing a possible secondary mechanism that biases children against engagement. At all time points, children with ADHD demonstrated reduced sensitivity to discriminate targets from nontargets.

CONCLUSION

Children with ADHD are particularly sensitive to the cost of task engagement, but nonspecific slower drift rate may ultimately provide a better conceptualization of the cognitive atypicalities commonly observed in that group. Results are interpreted in the context of updated conceptualizations of sustained attention and vigilance. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Longitudinal Assessment of Mental Health Disorders and Comorbidities Across 4 Decades Among Participants in the Dunedin Birth Cohort Study

IMPORTANCE

Mental health professionals typically encounter patients at 1 point in patients' lives. This cross-sectional window understandably fosters focus on the current presenting diagnosis. Research programs, treatment protocols, specialist clinics, and specialist journals are oriented to presenting diagnoses, on the assumption that diagnosis informs about causes and prognosis. This study tests an alternative hypothesis: people with mental disorders experience many different kinds of disorders across diagnostic families, when followed for 4 decades.

OBJECTIVE

To describe mental disorder life histories across the first half of the life course.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study involved participants born in New Zealand from 1972 to 1973 who were enrolled in the population-representative Dunedin Study. Participants were observed from birth to age 45 years (until April 2019). Data were analyzed from May 2019 to January 2020.

MAIN OUTCOMES AND MEASURES

Diagnosed impairing disorders were assessed 9 times from ages 11 to 45 years. Brain function was assessed through neurocognitive examinations conducted at age 3 years, neuropsychological testing during childhood and adulthood, and midlife neuroimaging-based brain age.

RESULTS

Of 1037 original participants (535 male [51.6%]), 1013 had mental health data available. The proportions of participants meeting the criteria for a mental disorder were as follows: 35% (346 of 975) at ages 11 to 15 years, 50% (473 of 941) at age 18 years, 51% (489 of 961) at age 21 years, 48% (472 of 977) at age 26 years, 46% (444 of 969) at age 32 years, 45% (429 of 955) at age 38 years, and 44% (407 of 927) at age 45 years. The onset of the disorder occurred by adolescence for 59% of participants (600 of 1013), eventually affecting 86% of the cohort (869 of 1013) by midlife. By age 45 years, 85% of participants (737 of 869) with a disorder had accumulated comorbid diagnoses. Participants with adolescent-onset disorders subsequently presented with disorders at more past-year assessments (r = 0.71; 95% CI, 0.68 to 0.74; P < .001) and met the criteria for more diverse disorders (r = 0.64; 95% CI, 0.60 to 0.67; P < .001). Confirmatory factor analysis summarizing mental disorder life histories across 4 decades identified a general factor of psychopathology, the p-factor. Longitudinal analyses showed that high p-factor scores (indicating extensive mental disorder life histories) were antedated by poor neurocognitive functioning at age 3 years (r = -0.18; 95% CI, -0.24 to -0.12; P < .001), were accompanied by childhood-to-adulthood cognitive decline (r = -0.11; 95% CI, -0.17 to -0.04; P < .001), and were associated with older brain age at midlife (r = 0.14; 95% CI, 0.07 to 0.20; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that mental disorder life histories shift among different successive disorders. Data from the present study, alongside nationwide data from Danish health registers, inform a life-course perspective on mental disorders. This perspective cautions against overreliance on diagnosis-specific research and clinical protocols.

A real-world study on clinical predictors of relapse after hospitalized detoxification in a Chinese cohort with alcohol dependence

BACKGROUND

The relapse rate of alcohol dependence (AD) after detoxification is high, but few studies have investigated the clinical predictors of relapse after hospitalized detoxification in real-world clinical practice, especially among Chinese patients.

METHODS

This longitudinal cohort study followed up 122 AD patients who were discharged from January 1, 2016 to January 30, 2018 from their most recent hospitalization for detoxification. These patients were interviewed by telephone from May 20, 2017, to June 30, 2018, at least 6 months after discharge. During the interview, the relapse were assessed by using a revised Chinese version of the Alcohol Use Disorder Identification Test. Candidate predictors, such as therapeutic modalities during hospitalization and at discharge, medical history data related to alcohol use, and demographic information, were obtained from the medical records in the hospital information system.

RESULTS

During the 6-24 months (with a median of 9 months) follow-up period, the relapse rate was 53.3%. Individuals with a college education level and those who had not been treated with the brief comprehensive cognitive-motivational-behavioural intervention (CCMBI) were more likely than their counterparts to relapse after hospitalized detoxification, and their adjusted HRs (95% CIs) were 1.85 (1.09, 3.16) and 2.00 (1.16, 3.46), respectively. The CCMBI use predicted a reduction in the relapse rate by approximately one-fifth.

CONCLUSION

Undergoing the CCMBI during detoxification hospitalization and having less than a college-level education could predict a reduced risk of AD relapse. These findings provide useful information both for further clinical research and for real-world practice.

The Prevalence of "Late-Onset" ADHD in a Clinically Referred Adult Sample

OBJECTIVE

Three recent prospective longitudinal studies of population cohorts reported nontrivial rates of "adult-onset" ADHD. Given that this result is at odds with the neurodevelopmental conceptualization of ADHD, as well as with general clinical experience, we obtained report of onset of symptoms in a clinical sample of adults diagnosed with ADHD.

METHOD

One hundred four adults diagnosed with ADHD completed retrospective ratings of DSM-IV/DSM-5 ADHD symptoms between the ages of 5 and 12 years.

RESULTS

Fifty percent of the sample met full retrospective child diagnostic symptom criteria of six ADHD symptoms in either the inattentive or hyperactive-impulsive domains. Seventy-five percent met a less stringent criterion of four symptoms in either domain.

DISCUSSION

These results are interpreted in light of a dimensional model of ADHD that posits emergence of ADHD symptoms and corresponding impairment as a function of increasing performance demands and/or decreasing environmental supports during the course of development.

Association of Polygenic Liabilities for Major Depression, Bipolar Disorder, and Schizophrenia With Risk for Depression in the Danish Population

IMPORTANCE

Although the usefulness of polygenic risk scores as a measure of genetic liability for major depression (MD) has been established, their association with depression in the general population remains relatively unexplored.

OBJECTIVE

To evaluate whether polygenic risk scores for MD, bipolar disorder (BD), and schizophrenia (SZ) are associated with depression in the general population and explore whether these polygenic liabilities are associated with heterogeneity in terms of age at onset and severity at the initial depression diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

Participants were drawn from the Danish iPSYCH2012 case-cohort study, a representative sample drawn from the population of Denmark born between May 1, 1981, and December 31, 2005. The hazard of depression was estimated using Cox regressions modified to accommodate the case-cohort design. Case-only analyses were conducted using linear and multinomial regressions. The data analysis was conducted from February 2017 to June 2018.

EXPOSURES

Polygenic risk scores for MD, BD, and SZ trained using the most recent genome-wide association study results from the Psychiatric Genomics Consortium.

MAIN OUTCOMES AND MEASURES

The main outcome was first depressive episode (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] code F32) treated in hospital-based psychiatric care. Severity at the initial diagnosis was measured using the ICD-10 code severity specifications (mild, moderate, severe without psychosis, and severe with psychosis) and treatment setting (inpatient, outpatient, and emergency).

RESULTS

Of 34 573 participants aged 10 to 31 years at censoring, 68% of those with depression were female compared with 48.9% of participants without depression. Each SD increase in polygenic liability for MD, BD, and SZ was associated with 30% (hazard ratio [HR], 1.30; 95% CI, 1.27-1.33), 5% (HR, 1.05; 95% CI, 1.02-1.07), and 12% (HR, 1.12; 95% CI, 1.09-1.15) increases in the hazard of depression, respectively. Among cases, a higher polygenic liability for BD was associated with earlier depression onset (β = -.07; SE = .02; P = .002).

CONCLUSIONS AND RELEVANCE

Polygenic liability for MD is associated with first depression in the general population, which supports the idea that these scores tap into an underlying liability for developing the disorder. The fact that polygenic risk for BD and polygenic risk for SZ also were associated with depression is consistent with prior evidence that these disorders share some common genetic overlap. Variations in polygenic liability may contribute slightly to heterogeneity in clinical presentation, but these associations appear minimal.

"You have to believe in something": Risk of psychosis and psychiatrists' beliefs in the self-fulfilling prophecy

BACKGROUND

Psychiatric care is a fruitful setting for exploring the rise of surveillance medicine, which shapes gray zones of uncertainty between health and illness. Predicting psychosis has become a priority in the international mental health field, but French psychiatrists appear reluctant to refer their young patients for standardized assessments or disclose their risks to them.

AIM

This research addressed French psychiatrists' attitudes towards risk disclosure about psychosis to adolescents presenting symptoms that might reflect either typical teenager unease or the first signs of psychosis onset.

METHODS

A mixed-method design included 12 in-depth qualitative interviews followed by an online survey with responses from 487 psychiatrists.

RESULTS

French psychiatrists' reluctance to engage in risk disclosure emerges from a professional norm: a belief in the self-fulfilling prophecy. They - especially those with a background in social science and psychology - believe in the optimistic self-fulfilling prophecy. They fear the consequences of pessimistic predictions, struggle to maintain functional optimism, favor long-term inconspicuous medical watchfulness, and systematically understand favorable outcomes as a consequence of medical care, independent of the accuracy of risk detection.

A genome-wide association study of shared risk across psychiatric disorders implicates gene regulation during fetal neurodevelopment

There is mounting evidence that seemingly diverse psychiatric disorders share genetic etiology, but the biological substrates mediating this overlap are not well characterized. Here we leverage the unique Integrative Psychiatric Research Consortium (iPSYCH) study, a nationally representative cohort ascertained through clinical psychiatric diagnoses indicated in Danish national health registers. We confirm previous reports of individual and cross-disorder single-nucleotide polymorphism heritability for major psychiatric disorders and perform a cross-disorder genome-wide association study. We identify four novel genome-wide significant loci encompassing variants predicted to regulate genes expressed in radial glia and interneurons in the developing neocortex during mid-gestation. This epoch is supported by partitioning cross-disorder single-nucleotide polymorphism heritability, which is enriched at regulatory chromatin active during fetal neurodevelopment. These findings suggest that dysregulation of genes that direct neurodevelopment by common genetic variants may result in general liability for many later psychiatric outcomes.

How does familiarity impact the stigma of mental illness?

This paper reviews studies on familiarity of mental illness to determine the relationships that familiarity has with public stigma. We propose a U-shaped relationship between familiarity and stigma that includes the expected inverse distribution (greater familiarity leads to less public stigma) and a provocative, positive relationship (familiarity in some groups leads to worse public stigma). Note that despite many studies in this arena, the U-shaped curve is not definitively supported by existing research. We believe its value, however, lies as a heuristic for hypotheses development to better understand the relationship between familiarity and public stigma. After reviewing research, we focus on two roles that comprise the surprising positive relationship: nuclear family members and mental health service providers like clinical psychologists. We then review research that suggests burden and associative stigma might account for the positive relationship between these groups and stigma. We end by using these findings to propose directions for future research, including on the development and evaluation of anti-stigma approaches.

Reproductive Outcomes Among Women with Eating Disorders or Disordered Eating Behavior: Does Methodological Approach Shape Research Findings?

BACKGROUND

There is a well-documented link between eating disorders (EDs) and adverse health outcomes, including fertility difficulties. These findings stem largely from clinical data or samples using a clinical measure (e.g., diagnosis) of EDs, which may limit our understanding of how EDs or disordered eating behaviors (DEBs) shape female fertility.

METHODS

We compared reproductive outcomes from two longitudinal data sources, clinical and population-based data from the Utah Population Database (UPDB) (N = 6,046), and nonclinical community-based data from the National Longitudinal Study of Adolescent to Young Adult Health (Add Health) (N = 5,951). We examined age at first birth using Cox regression and parity using negative binomial regression.

RESULTS

Using the UPDB data, women with diagnosed ED experienced later ages of first birth (hazard rate ratio [HRR] = 0.38; p < 0.01) and lower parity (incidence rate ratio [IRR] = 0.38; p < 0.01) relative to women without EDs. Using the Add Health sample, women who self-reported DEB experienced earlier age of first birth (HRR = 1.16; p < 0.05) and higher parity (IRR = 1.17; p < 0.01) relative to women without DEB.

CONCLUSIONS

Conflicting results suggest two sets of mechanisms, physical/biological (sex specific) and social/behavioral (gender specific), may be simultaneously shaping the reproductive outcomes of women with histories of EDs or DEB. Discipline-specific methodology likely shapes Women's Health research outcomes.