Neuroscience and the future for mental health?

Mental health meets computational neuroscience: A predictive Bayesian account of the relationship between interoception and multisensory bodily illusions in anorexia nervosa

Mental health disorders pose a significant challenge to society. The Bayesian perspective on the mind offers unique insights and tools that may help address a variety of mental health conditions. Psychopathological dysfunctions are often connected to altered predictive and active inference processes, in which cognitive and physiological pathogenic beliefs shape the clinical condition and its symptoms. However, there is a lack of general empirical models that integrate cognitive beliefs, physiological experience, and symptoms in healthy and clinical populations. In this study, we examined the relationship between altered predictive mechanisms, interoception, and pathological bodily distortions in healty individuals and in individuals suffering from anorexia nervosa (AN). AN patients (N=15) completed a Virtual Reality Full-Body Illusion along with interoceptive tasks twice: at hospital admission during an acute symptomatological phase (Time 1) and after a 12-week outpatient clinical weight-restoring rehabilitative program (Time 2). Results were compared to a healthy control group. Our findings indicated that higher levels of interoceptive metacognitive awareness were associated with a greater embodiment. However, unlike in healthy participants, AN patients' interoceptive metacognition was linked to embodiment even in multisensory mismatching (asynchronous) conditions. In addition, unlike in healthy participants, higher interoceptive metacognition in AN patients was related to prior abnormal bodily distortions during the acute symptomatology phase. Prediction errors in bodily estimates predicted posterior bodily estimate distortions after the illusion, but while this relationship was only significant in the synchronous condition in healthy participants, there was no significant difference between synchronous and asynchronous conditions in AN patients. Despite the success of the rehabilitation program in restoring some dysfunctional patterns in the AN group, prediction errors and posterior estimate distortions were present at hospital discharge. Our findings suggest that individuals with AN prioritize interoceptive metacognitive processes (i.e., confidence in their own perceived sensations rather than their actual perceptions), disregarding bottom-up bodily inputs in favour of their prior altered top-down beliefs. Moreover, even if the rehabilitative program partially mitigated these alterations, the pathological condition impaired the patients' ability to coherently update their prior erroneous expectations with real-time multisensory bottom-up bodily information, possibly locking the patients in the experience of a distorted prior top-down belief. These results suggest new therapeutic perspectives and introduce the framework of regenerative virtual therapy (RVT), which aims at utilizing technology-based somatic modification techniques to restructure the maladaptive priors underlying a pathological condition.

Evidence, ethics and the promise of artificial intelligence in psychiatry

Researchers are studying how artificial intelligence (AI) can be used to better detect, prognosticate and subgroup diseases. The idea that AI might advance medicine's understanding of biological categories of psychiatric disorders, as well as provide better treatments, is appealing given the historical challenges with prediction, diagnosis and treatment in psychiatry. Given the power of AI to analyse vast amounts of information, some clinicians may feel obligated to align their clinical judgements with the outputs of the AI system. However, a potential epistemic privileging of AI in clinical judgements may lead to unintended consequences that could negatively affect patient treatment, well-being and rights. The implications are also relevant to precision medicine, digital twin technologies and predictive analytics generally. We propose that a commitment to epistemic humility can help promote judicious clinical decision-making at the interface of big data and AI in psychiatry.

Is 'another' psychiatry possible?

In this paper, we examine a number of approaches that propose new models for psychiatric theory and practices: in the way that they incorporate 'social' dimensions, in the way they involve 'communities' in treatment, in the ways that they engage mental health service users, and in the ways that they try to shift the power relations within the psychiatric encounter. We examine the extent to which 'alternatives' - including 'Postpsychiatry', 'Open Dialogue', the 'Power, Threat and Meaning Framework' and Service User Involvement in Research - really do depart from mainstream models in terms of theory, practice and empirical research and identify some shortcomings in each. We propose an approach which seeks more firmly to ground mental distress within the lifeworld of those who experience it, with a particular focus on the biopsychosocial niches within which we make our lives, and the impact of systematic disadvantage, structural violence and other toxic exposures within the spaces and places that constitute and constrain many everyday lives. Further, we argue that a truly alternative psychiatry requires psychiatric professionals to go beyond simply listening to the voices of service users: to overcome epistemic injustice requires professionals to recognise that those who have experience of mental health services have their own expertise in accounting for their distress and in evaluating alternative forms of treatment. Finally we suggest that, if 'another psychiatry' is possible, this requires a radical reimagination of the role and responsibilities of the medically trained psychiatrist within and outside the clinical encounter.

Communalistic use of psychoactive plants as a bridge between traditional healing practices and Western medicine: A new path for the Global Mental Health movement

The Global Mental Health (GMH) movement aims to provide urgently needed treatment to those with mental illness, especially in low- and middle-income countries. Due to the complexity of providing mental health services to people from various cultures, there is much debate among GMH advocates regarding the best way to proceed. While biomedical interventions offer some degree of help, complementary approaches should focus on the social/community aspects. Many cultures conduct traditional rituals involving the communal use of psychoactive plants. We propose that these practices should be respected, protected, and promoted as valuable tools with regard to mental health care at the community level. The traditional use of psychoactive plants promotes community engagement and participation, and they are relatively affordable. Furthermore, the worldviews and meaning-making systems of local population are respected. The medical systems surrounding the use of psychoactive plants can be explained in biomedical terms, and many recently published clinical trials have demonstrated their therapeutic potential. Psychoactive plants and associated rituals offer potential benefits as complementary aspects of mental health services. They should be considered as such by international practitioners and advocates of the GMH movement.

What kind of science for dual diagnosis? A pragmatic examination of the enactive approach to psychiatry

The recommended treatment for dual diagnosis - the co-occurrence of substance use and another mental disorder - requires seamless integration of the involved disciplines and services. However, no integrative framework exists for communicating about dual diagnosis cases across disciplinary or sectoral boundaries. We examine if Enactive Psychiatry may bridge this theoretical gap. We evaluate the enactive approach through a two-step pragmatic lens: Firstly, by taking a historical perspective to describe more accurately how the theoretical gap within the field of dual diagnosis initially developed. Secondly, by applying the Enactive Psychiatry approach to data from a longitudinal study on the trajectory of cannabis use in psychosis disorders. By applying the theory rather than simply presenting it, we position ourselves better to evaluate whether it may assist the purpose of achieving a more expedient pragmatic “grip” on the field of dual diagnosis. In our discussion, we suggest that this may very well be the case. Finally, we consider the enactive approach as one of a small handful of new theories of mental disorders that draw on systems thinking and ecological psychology, and discuss whether they have the potential for a wider progressive problemshift within psychiatry. The case in favor of such potential, we argue, is less strong unless the role of complexity, similar to that seen within the dual diagnosis field, may be demonstrated for other fields of clinical practice.

Reporting Grantee Demographics for Diversity, Equity, and Inclusion in Neuroscience

Professional neuroscience organizations have recently pledged their commitments to diversity, equity, and inclusion in examining institutional discrimination; to raise questions about how to train underrepresented scientists; and to recruit underrepresented subjects for a more equitable scientific enterprise in the 21st century. Studies have illuminated racial disparities in funding, likely because of implicit bias in the review process and differential access to resources. We propose that one concrete way to monitor and redress these disparities is to collect and publicize data on grantees by gender, race, ethnicity, and location from neuroscience funding agencies. Beyond remedying historical disadvantages, disseminating funding more equitably across recipients would be an empirical solution that can improve the very quality of neuroscience.

Experiences and implications of smartphone apps for depression and anxiety

Apps on smartphones are increasingly used for self-care for depression and anxiety, yet how and why they are accessed, and their social effects, remain under-investigated. Sociologists have begun to theorise how these technologies affect and relate; crucial questions for a contemporary sociology of health. This study seeks to contribute to our conceptualisation of how digital health technologies are implicated in health by investigating the motivations, experiences and relations of people using mobile apps for depression or anxiety. We interviewed 14 individuals living in England with a diagnosis of depression or an anxiety disorder, who used smartphone apps as part of self-care. Analysis followed a thematic approach. Three themes were identified. Apps exist within relational contexts - alongside smartphones, beliefs about mental health and other support - which shape app use and lead to an imprecise, casual approach. People engage with apps in a straightforward and uncomplicated manner, leading to immediate symptomatic alleviation, but to limited longer term benefit. The contradiction between the apps' promise as tools of individual empowerment, with their ability to promote responsibilising frameworks that restrain users' reflexivity, is central to their implications. Apps can thus contribute to isolation from interpersonal support and promote reductionist biomedical conceptualisations of mental ill health.

Urban environment and psychiatric disorders: a review of the neuroscience and biology

Most of the world's population now lives in cities. While living in cities have both health risks and benefits, mental health has been usually considered to be negatively affected by urbanicity. While mental health disorders have complex etiology and multiple causes, it has been shown in multiple observational studies that mood and anxiety disorders are more prevalent in urban centers and incidence has been increasing. In addition, the incidence of schizophrenia is strongly increased in people born and raised in cities. Studies on the effects of urbanicity on the brain, however, are more challenging to conduct, since individual and environmental factors are hard to distinguish. The main objective of this article is to review studies on how specific neural processes mediate those associations between urbanicity and psychiatric disorders and how environmental factors affect genetic regulation (epigenetics). Neuroimaging studies have shown how urban stressors might affect the brain by conducting experiments using functional magnetic resonance imaging (fMRI). There have been demonstrations that urban upbringing and city living have dissociable impacts on social evaluative stress processing in humans. City living was associated with increased amygdala activity and the urban upbringing has been shown to affect the perigenual anterior cingulate cortex, a key region for regulation of amygdala activity, negative affect and stress. In addition, studies on epigenetics have shown associations between exposure to features of the environment and methylation patterns. The goal of understanding how urban environments act as a risk factor for mental disorders may be pursued on several levels. It can be approached by measuring the effects of economic factors (unemployment, socioeconomic status), social condition (social network support), environmental exposures (toxins, air pollution, noise, light), that must be weighed to identify how it contributes to mental disorders.

Digitising psychiatry? Sociotechnical expectations, performative nominalism and biomedical virtue in (digital) psychiatric praxis

Digital artefacts and infrastructures have been presented as ever more urgent and necessary for mental health research and practice. Telepsychiatry, mHealth, and now digital psychiatry have been promoted in this regard, among other endeavours. Smartphone apps have formed a particular focus of promissory statements regarding the improvement of epistemic and clinical work in psychiatry. This article contextualises and historicises some of these developments. In doing so, I show how purportedly novel fields have been constituted in part through practices of 'performative nominalism' (whereby articulations of a neologism in relation to established and recent developments participate in producing the referent of the new term). Central to this has been implicit and explicit extolment of what I term biomedical virtues in public-facing and professionally orientated discourse. I document how emphases on various virtues have shifted with the attention of psychiatry to different digital modalities, culminating with knowledge-production in mental health as one significant focus.

Psychedelic-Assisted Psychotherapy: A Paradigm Shift in Psychiatric Research and Development

Mental disorders are rising while development of novel psychiatric medications is declining. This stall in innovation has also been linked with intense debates on the current diagnostics and explanations for mental disorders, together constituting a paradigmatic crisis. A radical innovation is psychedelic-assisted psychotherapy (PAP): professionally supervised use of ketamine, MDMA, psilocybin, LSD and ibogaine as part of elaborated psychotherapy programs. Clinical results so far have shown safety and efficacy, even for “treatment resistant” conditions, and thus deserve increasing attention from medical, psychological and psychiatric professionals. But more than novel treatments, the PAP model also has important consequences for the diagnostics and explanation axis of the psychiatric crisis, challenging the discrete nosological entities and advancing novel explanations for mental disorders and their treatment, in a model considerate of social and cultural factors, including adversities, trauma, and the therapeutic potential of some non-ordinary states of consciousness.

Gender-related dimensions of childhood adversities in the general population

Objective:

Childhood adversities (CAs) comprise a group of negative experiences individuals may suffer in their lifetimes. The goal of the present study was to investigate the cluster discrimination of CAs through psychometric determination of the common attributes of such experiences for men and women.

Methods:

Parental mental illness, substance misuse, criminality, death, divorce, other parental loss, family violence, physical abuse, sexual abuse, neglect, physical illness, and economic adversity were assessed in a general-population sample (n=5,037). Exploratory and confirmatory factor analysis determined gender-related dimensions of CA. The contribution of each individual adversity was explored through Rasch analysis.

Results:

Adversities were reported by 53.6% of the sample. A three-factor model of CA dimensions fit the data better for men, and a two-factor model for women. For both genders, the dimension of family maladjustment – encompassing physical abuse, neglect, parental mental disorders, and family violence – was the core cluster of CAs. Women endorsed more CAs than men. Rasch analysis found that sexual abuse, physical illness, parental criminal behavior, parental divorce, and economic adversity were difficult to report in face-to-face interviews.

Conclusion:

CAs embrace sensitive personal information, clustering of which differed by gender. Acknowledging CAs may have an impact on medical and psychiatric outcomes in adulthood.

How do antidepressants work? New perspectives for refining future treatment approaches

Most currently available antidepressants target monoamine neurotransmitter function. However, a purely neurotransmitter-based explanation for antidepressant drug action is challenged by the delayed clinical onset of most agents and the need to explain how neurochemical changes reverse the many different symptoms of depression. Novel approaches to understanding of antidepressant drug action include a focus on early changes in emotional and social processing and the role of neural plasticity. In this Review, we discuss the ways in which these two different theories reflect different or complementary approaches, and how they might be integrated to offer novel solutions for people with depression. We consider the predictions made by these mechanistic approaches for the stratification and development of new therapeutics for depression, and the next steps that need to be made to facilitate this translation of science to the clinic.

Psychiatric Genomics and Mental Health Treatment: Setting the Ethical Agenda

Realizing the benefits of translating psychiatric genomics research into mental health care is not straightforward. The translation process gives rise to ethical challenges that are distinctive from challenges posed within psychiatric genomics research itself, or that form part of the delivery of clinical psychiatric genetics services. This article outlines and considers three distinct ethical concerns posed by the process of translating genomic research into frontline psychiatric practice and policy making. First, the genetic essentialism that is commonly associated with the genomics revolution in health care might inadvertently exacerbate stigma towards people with mental disorders. Secondly, the promises of genomic medicine advance a narrative of individual empowerment. This narrative could promote a fatalism towards patients' biology in ways that function in practice to undermine patients' agency and autonomy, or, alternatively, a heightened sense of subjective genetic responsibility could become embedded within mental health services that leads to psychosocial therapeutic approaches and the clinician-patient therapeutic alliance being undermined. Finally, adopting a genomics-focused approach to public mental health risks shifting attention away from the complex causal relationships between inequitable socio-economic, political, and cultural structures and negative mental health outcomes. The article concludes by outlining a number of potential pathways for future ethics research that emphasizes the importance of examining appropriate translation mechanisms, the complementarity between genetic and psychosocial models of mental disorder, the implications of genomic information for the clinician-patient relationship, and funding priorities and resource allocation decision making in mental health.