Neuropsychological Impact of Trauma-Related Mental Illnesses: A Systematic Review of Clinically Meaningful Results

Gender differences in the associations of psychosocial trauma and acute medical stressors with immune system activation and dementia risk

Objective: The purpose of this article is to provide a narrative review synthesizing the literature on differences between women and men in relationships among certain stressors associated with immune system activation and their relationship to cognitive dysfunction and dementia. Method: We review the cycle of stress leading to neuroinflammation via cortisol and neurochemical alterations, cell-mediated immune system activation, and pro-inflammatory cytokines, and how this is implicated in the development of dementia. We follow this by discussing sex differences in stress physiology and immune function. We then review the work on early life adversity (ELA) and adverse childhood experiences (ACEs), post-traumatic stress disorder, acute medical stressors, and their associations with cognitive dysfunction and dementia. Throughout, we emphasize women's presentations and issues unique to women (e.g. trauma disorder prevalence). Conclusions: There is a need for more mechanistic and longitudinal studies that consider trauma accumulation, both physical and emotional, as well as a greater focus on traumas more likely to occur in women (e.g. sexual abuse), and their relationship to early cognitive decline and dementia.

Forensic mental health: envisioning a more empirical future

Forensic mental health services provide crucial interventions for society. Such services provide care for people with mental disorders who commit violent and other serious crimes, and they have a key role in the protection of the public. To achieve these goals, these services are necessarily expensive, but they have been criticised for a high-cost, low-volume approach, for lacking consistent standards of care, and for neglecting human rights and other ethical considerations. A key concern is an insufficient evidence base to justify common practices, such as restricting leave from hospital and detaining patients for long periods. There is also insufficient quality evidence for core interventions, including psychological therapies, pharmacotherapy, and seclusion and restraint. The causes for this evidence deficit are complex but include insufficient investment in research infrastructure and fragmentation and isolationism of services, both nationally and internationally. In this Personal View, we highlight some of the major gaps in the forensic mental health evidence base and the challenges in addressing these gaps. We suggest solutions with implications at clinical, societal, and public health policy levels.

Violence risk assessment instruments in forensic psychiatric populations: a systematic review and meta-analysis

BACKGROUND

Although structured tools have been widely used to predict violence risk in specialist mental health settings, there is uncertainty about the extent and quality of evidence of their predictive performance. We aimed to systematically review the predictive performance of tools used to assess violence risk in forensic mental health, where they are routinely administered.

METHODS

In our systematic review and meta-analysis, we followed PRISMA guidelines and searched four databases (PsycINFO, Embase, Medline, and Global Health) from database inception to Nov 1, 2022, to identify studies examining the predictive performance of risk assessment tools in people discharged from forensic (secure) mental health hospitals. Systematic and narrative reviews were excluded from the review. Performance measures and descriptive statistics were extracted from published reports. A quality assessment was performed for each study using the Prediction Model Risk of Bias Assessment Tool. Meta-analysis was conducted on the performance of instruments that were independently externally validated with a sample size greater than 100. The study was registered with PROSPERO, CRD42022304716.

FINDINGS

We conducted a systematic review of 50 eligible publications, assessing the predictive performance of 36 tools, providing data for 10 460 participants (88% men, 12% women; median age [from 47 studies] was 35 years, IQR 33-38) from 12 different countries. Post-discharge interpersonal violence and crime was most often measured by new criminal offences or recidivism (47 [94%] of 50 studies); only three studies used informant or self-report data on physical aggression or violent behaviour. Overall, the predictive performance of risk assessment tools was mixed. Most studies reported one discrimination metric, the area under the receiver operating characteristic curve (AUC); other key performance measures such as calibration, sensitivity, and specificity were not presented. Most studies had a high risk of bias (49 [98%] of 50), partly due to poor analytical approaches. A meta-analysis was conducted for violent recidivism on 29 independent external validations from 19 studies with at least 100 patients. Pooled AUCs for predicting violent outcomes ranged from 0·72 (0·65-0·79; I2=0%) for H10, to 0·69 for the Historical Clinical Risk Management-20 version 2 (95% CI 0·65-0·72; I2=0%) and Violence Risk Appraisal Guide (0·63-0·75; I2=0%), to 0·64 for the Static-99 (0·53-0·73; I2=45%).

INTERPRETATION

Current violence risk assessment tools in forensic mental health have mixed evidence of predictive performance. Forensic mental health services should review their use of current risk assessment tools and consider implementing those with higher-quality evidence in support.

FUNDING

Wellcome Trust.

Eye movement desensitization and reprocessing for post-stroke post-traumatic stress disorder: Case report using the three-phase approach

Medically-induced post-traumatic stress disorder (PTSD) is substantially more prevalent than PTSD in the general population. In people with stroke, it can impact as many as 23% of patients, with negative effects on mental health as well as stroke-related disability. Medically-induced PTSD may have unique features compared to other forms of PTSD, and therefore there is a pressing need to evaluate existing treatments for PTSD in this context. The current study reports on the feasibility, safety, and efficacy of Eye Movement Desensitization and Reprocessing (EMDR) for PTSD subsequent to a pontine stroke. Using a quasi-experimental case design, a 44-year-old Caucasian woman received EMDR delivered via telehealth. Self-report measures were obtained at baseline, pre-EMDR, and post-EMDR, with brief neuropsychological testing pre/post-EMDR. After 3 sessions of EMDR, the patient no longer met criteria for PTSD, and showed clinically significant reductions in depressive and generalized anxiety symptoms. With proper safety provisions, it is feasible to deliver EMDR via telehealth to alleviate post-stroke PTSD. Reduced linguistic demands of EMDR may be particularly appealing for persons with neurological disorders as compared to other trauma therapies. Further work is also needed to understand the parameters of baseline neuropsychological function that could impact response to intervention.

Differences in Neuropsychological Performance between Refugee and Non-Refugee Children in Palestine

Neuropsychological studies on refugee children are scarce, but there are even less in the case of Palestinian children. This work aims to study the neuropsychological performance of Palestinian refugee children in Palestine compared to other Palestinian children living outside refugee camps. A comprehensive Neuropsychological battery was administrated to 584 Palestinian school children (464 refugees and 120 non-refugees) aged 6, 7, and 8 years old. Results showed that non-refugee children outperformed refugee children in sustained attention, verbal comprehension, verbal memory, and visual memory. This study is the first to have performed a comprehensive neuropsychological assessment, based on a standardized and validated battery with the Palestinian refugee children. It supports professionals in their evaluation of neurodevelopment and neuropsychological alterations in refugee and non-refugee children in Palestine.