Beyond diagnosis in psychiatric practice

Allocation of Users of Mental Health Services to Needs-Based Care Clusters: An Italian Pilot Study

In Italy, despite strong community-based mental health services, needs assessment is unsatisfactory. Using the Mental Health Clustering Tool (MHCT) we adopted a multidimensional and non-diagnosis dependent approach to assign mental health services users with similar needs to groups corresponding to resources required for effective care. We tested the MHCT in nine Departments of Mental Health in four Italian regions. After a brief training, 318 professionals assessed 12,938 cases with a diagnosis of schizophrenia, depression, bipolar disorder and personality disorder through the MHCT. 53% of cases were 40-59 years, half were females, 51% had a diagnosis of schizophrenia, 48% of cases were clinically severe. Clusters included different levels of clinical severity and diagnostic groups. The largest cluster was 11 (ongoing recurrent psychosis), with 18.9% of the sample, followed by cluster 3 (non-psychotic disorders of moderate severity). The MHCT could capture a variety of problems of people with mental disorders beyond the traditional psychiatric assessment, therefore depicting service population from a different standpoint. Following a brief training, MHCT assessment proved to be feasible. The automatic allocation of cases made the attribution to clusters easy and acceptable by professionals. To what extent clustering provide a sound base for care planning will be the matter of further research.

On mental pain and suicide risk in modern psychiatry

Facing suicide risk is probably the most difficult task for clinicians when dealing with patients in crisis. It requires professional, intellectual, and emotional efforts. Suicide risk assessment can sometimes be distressing for clinicians, and such a state may favour the avoidance of an in-depth exploration of suicidal thoughts and behaviour. Patients often feel subjected to interpersonal assessments with little opportunity to explore their perspectives. The "One size fits all" approach tends to create distance and paradoxically contributes to an increase in the risk of suicide. Traditional clinical factors may be of limited value if a shared understanding of the patient's suicide risk is missed. To understand the suicidal mind, it is necessary to take the point of view of the subject in crisis. In this essay, the "operational model of mental pain as a main ingredient of suicide" provided by Edwin Shneidman' is overviewed with the aim of a better empathic understanding of patients' sufferance. With a phenomenological approach, the suicidal crisis appears as a complex, pervasive state rather than as a symptom of a mental disorder, as the new paradigm also suggests. In this regard, the "mentalistic" aspects of suicide propose a broader insight into the suicidal scenario far beyond the diagnosis of psychiatric disorders. In this article, the perspective of individuals who deem their mental pain to be intolerable is described to make sense of their ambivalence between the wish to die and the wish to live that can prevail if relief is provided.

Conceptualizing a less paranoid schizophrenia

Schizophrenia stands as one of the most studied and storied disorders in the history of clinical psychology; however, it remains a nexus of conflicting and competing conceptualizations. Patients endure great stigma, poor treatment outcomes, and condemnatory prognosis. Current conceptualizations suffer from unstable categorical borders, heterogeneity in presentation, outcome and etiology, and holes in etiological models. Taken in aggregate, research and clinical experience indicate that the class of psychopathologies oriented toward schizophrenia are best understood as spectra of phenomenological, cognitive, and behavioral modalities. These apparently taxonomic expressions are rooted in normal human personality traits as described in both psychodynamic and Five Factor personality models, and more accurately represent explicable distress reactions to biopsychosocial stress and trauma. Current categorical approaches are internally hampered by axiomatic bias and systemic inertia rooted in the foundational history of psychological inquiry; however, when such axioms are schematically decentralized, convergent cross-disciplinary evidence outlines a more robust explanatory construct. By reconceptualizing these disorders under a dimensional and cybernetic model, the aforementioned issues of instability and inaccuracy may be resolved, while simultaneously opening avenues for both early detection and intervention, as well as for more targeted and effective treatment approaches.

Using big data and Population Health Management to assess care and costs for patients with severe mental disorders and move toward a value-based payment system

BACKGROUND

Mental health (MH) care often exhibits uneven quality and poor coordination of physical and MH needs, especially for patients with severe mental disorders. This study tests a Population Health Management (PHM) approach to identify patients with severe mental disorders using administrative health databases in Italy and evaluate, manage and monitor care pathways and costs. A second objective explores the feasibility of changing the payment system from fee-for-service to a value-based system (e.g., increased care integration, bundled payments) to introduce performance measures and guide improvement in outcomes.

METHODS

Since diagnosis alone may poorly predict condition severity and needs, we conducted a retrospective observational study on a 9,019-patient cohort assessed in 2018 (30.5% of 29,570 patients with SMDs from three Italian regions) using the Mental Health Clustering Tool (MHCT), developed in the United Kingdom, to stratify patients according to severity and needs, providing a basis for payment for episode of care. Patients were linked (blinded) with retrospective (2014-2017) physical and MH databases to map resource use, care pathways, and assess costs globally and by cluster. Two regions (3,525 patients) provided data for generalized linear model regression to explore determinants of cost variation among clusters and regions.

RESULTS

Substantial heterogeneity was observed in care organization, resource use and costs across and within 3 Italian regions and 20 clusters. Annual mean costs per patient across regions was €3,925, ranging from €3,101 to €6,501 in the three regions. Some 70% of total costs were for MH services and medications, 37% incurred in dedicated mental health facilities, 33% for MH services and medications noted in physical healthcare databases, and 30% for other conditions. Regression analysis showed comorbidities, resident psychiatric services, and consumption noted in physical health databases have considerable impact on total costs.

CONCLUSIONS

The current MH care system in Italy lacks evidence of coordination of physical and mental health and matching services to patient needs, with high variation between regions. Using available assessment tools and administrative data, implementation of an episodic approach to funding MH could account for differences in disease phase and physical health for patients with SMDs and introduce performance measurement to improve outcomes and provide oversight.

Integrating neuroscience in psychiatry: a cultural-ecosocial systemic approach

Psychiatry has increasingly adopted explanations for psychopathology that are based on neurobiological reductionism. With the recognition of health disparities and the realisation that someone's postcode can be a better predictor of health outcomes than their genetic code, there are increasing efforts to ensure cultural and social-structural competence in psychiatric practice. Although neuroscientific and social-cultural approaches in psychiatry remain largely separate, they can be brought together in a multilevel explanatory framework to advance psychiatric theory, research, and practice. In this Personal View, we outline how a cultural-ecosocial systems approach to integrating neuroscience in psychiatry can promote social-contextual and systemic thinking for more clinically useful formulations and person-centred care.

Context v. algorithm: evidence that a transdiagnostic framework of contextual clinical characterization is of more clinical value than categorical diagnosis

BACKGROUND

A transdiagnostic and contextual framework of 'clinical characterization', combining clinical, psychopathological, sociodemographic, etiological, and other personal contextual data, may add clinical value over and above categorical algorithm-based diagnosis.

METHODS

Prediction of need for care and health care outcomes was examined prospectively as a function of the contextual clinical characterization diagnostic framework in a prospective general population cohort (n = 6646 at baseline), interviewed four times between 2007 and 2018 (NEMESIS-2). Measures of need, service use, and use of medication were predicted as a function of any of 13 DSM-IV diagnoses, both separately and in combination with clinical characterization across multiple domains: social circumstances/demographics, symptom dimensions, physical health, clinical/etiological factors, staging, and polygenic risk scores (PRS). Effect sizes were expressed as population attributable fractions.

RESULTS

Any prediction of DSM-diagnosis in relation to need and outcome in separate models was entirely reducible to components of contextual clinical characterization in joint models, particularly the component of transdiagnostic symptom dimensions (a simple score of the number of anxiety, depression, mania, and psychosis symptoms) and staging (subthreshold, incidence, persistence), and to a lesser degree clinical factors (early adversity, family history, suicidality, slowness at interview, neuroticism, and extraversion), and sociodemographic factors. Clinical characterization components in combination predicted more than any component in isolation. PRS did not meaningfully contribute to any clinical characterization model.

CONCLUSION

A transdiagnostic framework of contextual clinical characterization is of more value to patients than a categorical system of algorithmic ordering of psychopathology.

Current Evidence and Theories in Understanding the Relationship between Cognition and Depression in Childhood and Adolescence: A Narrative Review

The present narrative review has covered the current evidence regarding the role of cognitive impairments during the early phase of major depressive disorder (MDD), attempting to describe the cognitive features in childhood, adolescence and in at-risk individuals. These issues were analyzed considering the trait, scar and state hypotheses of MDD by examining the cold and hot dimensions, the latter explained in relation to the current psychological theoretical models of MDD. This search was performed on several electronic databases up to August 2022. Although the present review is the first to have analyzed both cold and hot cognitive impairments considering the trait, scar and state hypotheses, we found that current evidence did not allow to exclusively confirm the validity of one specific hypothesis since several equivocal and discordant results have been proposed in childhood and adolescence samples. Further studies are needed to better characterize possible cognitive dysfunctions assessing more systematically the impairments of cold, hot and social cognition domains and their possible interaction in a developmental perspective. An increased knowledge on these topics will improve the definition of clinical endophenotypes of enhanced risk to progression to MDD and, to hypothesize preventive and therapeutic strategies to reduce negative influences on psychosocial functioning and well-being.

Utility and validity of the Brief Psychiatric Rating Scale (BPRS) as a transdiagnostic scale

The Brief Psychiatric Rating Scale (BPRS) was originally conceived to assess psychopathology in several psychiatric disorders, making it an appropriate candidate to be used as a transdiagnostic instrument. We analyzed the utility and validity of the BPRS in a diagnostically heterogeneous sample of 600 psychiatric inpatients. As a comparator, we chose the mini-ICF-APP, a scale used to measure functioning and impairment across the diagnostic spectrum. Both scales had good internal consistency. The BPRS and the mini-ICF-APP showed a moderate correlation, with good levels of agreement. We were able to identify general symptoms present across the diagnostic spectrum, influencing severity and a cluster of symptoms specific for each diagnosis. Our results show the utility and validity of the BPRS as a transdiagnostic assessment tool that could easily be introduced in routine clinical work.

The Dialectics of Altered Experience: How to Validly Construct a Phenomenologically Based Diagnosis in Psychiatry

In this paper, we present how a dialectical perspective on phenomenological psychopathology, called Dialectical Phenomenology (DPh), can contribute to current needs of psychiatric diagnosis. We propose a three-stage diagnostic methodology: first- and second-person stages, and synthetic hermeneutics stage. The first two stages are divided into a pre-dialectical and a dialectical phase. The diagnostic process progresses in a trajectory of increasing complexity, in which knowledge obtained at one level is dialectically absorbed and intertwined into the next levels. Throughout the article, we offer some examples of each step. In overall, the method starts off from the patient's own narrative, proceeds to two stages of phenomenological reduction designed to guarantee the scientific validity of the object, and concludes with a hermeneutical narrative synthesis that is dialectically composed of the patient's and psychopathologist's shared narratives. At the end of this process, the initial first-person narrative is transformed into a specific scientific object, a full dialectical phenomenological psychiatric diagnosis. This form of diagnosis constitutes a comprehensive alternative for an integral assessment of the complexities of human psychological alteration, bringing together both the interpretation of the suffering person and the scientific categories of psychiatry.

We Should Improve Personalization of Management in Patients with a Diagnosis of Schizophrenia

The current management of patients with schizophrenia is marked by a lack of personalization. After the diagnosis is made, a second-generation antipsychotic is usually prescribed based on the current clinician’s preferences, sometimes accompanied by a psychosocial intervention which is typically not evidence-based and not targeted to the specific needs of the individual patient. In this opinion paper, some steps are outlined that could be taken in order to address this lack of personalization. A special emphasis is laid on the clinical characterization of the patient who has received a diagnosis of schizophrenia. Considerations are put forward concerning the assessment of the negative dimension in ordinary clinical practice, which is often neglected; the evaluation of cognitive functioning using a simple test battery which requires limited professional training and takes no more than 15 min to administer; the evaluation of social functioning using a validated instrument focusing on personal care skills, interpersonal relationships, social acceptability, activities, and work skills; and the assessment of the unmet needs of the person (including practical, social, and emotional needs, and existential or personal recovery). The implications of the assessment of these domains for the formulation of the management plan are discussed.

The Etiologic, Theory-Based, Ontogenetic Hierarchical Framework of Alcohol Use Disorder: A Translational Systematic Review of Reviews

Modern nosologies (e.g., ICD-11, DSM-5) for alcohol use disorder (AUD) and dependence prioritize reliability and clinical presentation over etiology, resulting in a diagnosis that is not always strongly grounded in basic theory and research. Within these nosologies, DSM-5 AUD is treated as a discrete, largely categorical, but graded, phenomenon, which results in additional challenges (e.g., significant phenotypic heterogeneity). Efforts to increase the compatibility between AUD diagnosis and modern conceptualizations of alcohol dependence, which describe it as dimensional and partially overlapping with other psychopathology (e.g., other substance use disorders) will inspire a stronger scientific framework and strengthen AUD's validity. We conducted a systematic review of 144 reviews to integrate addiction constructs and theories into a comprehensive framework with the aim of identifying fundamental mechanisms implicated in AUD. The product of this effort was the Etiologic, Theory-Based, Ontogenetic Hierarchical Framework (ETOH Framework) of AUD mechanisms, which outlines superdomains of cognitive control, reward, as well as negative valence and emotionality, each of which subsume narrower, hierarchically-organized components. We also outline opponent processes and self-awareness as key moderators of AUD mechanisms. In contrast with other frameworks, we recommend an increased conceptual role for negative valence and compulsion in AUD. The ETOH framework serves as a critical step towards conceptualizations of AUD as dimensional and heterogeneous. It has the potential to improve AUD assessment and aid in the development of evidence-based diagnostic measures that focus on key mechanisms in AUD, consequently facilitating treatment matching.

Predominant Polarity and Polarity Index of Maintenance Treatments for Bipolar Disorder: A Validation Study in a Large Naturalistic Sample in Italy

Background and Objectives: Predominant polarity (PP) may be a useful course specifier in at least a significant proportion of patients with Bipolar Disorder (BD), being associated with several clinically relevant correlates. Emerging evidence suggests that the concept of PP might influence the selection of maintenance treatments, based on a drug polarity index (PI) which measures the greater antidepressive vs. antimanic preventive efficacy of mood stabilizers over long-term maintenance treatment. In this study, we aimed to validate the PI in a large sample of Italian BD patients with accurate longitudinal characterization of the clinical course, which ensured a robust definition of the PP. Materials and Methods: Our sample is comprised of 653 patients with BD, divided into groups based on the predominant polarity (manic/hypomanic predominant polarity—MPP, depressive predominant polarity—DPP and no predominant polarity). Subsequently we calculated the mean total polarity index for each group, and we compared the groups. Results: When we examined the mean PI of treatments prescribed to individuals with DPP, MPP and no predominant polarity, calculated using two different methods, we failed to find significant differences, with the exception of the PI calculated with the Popovic method and using the less stringent criterion for predominant polarity (PP_50%). Conclusions: Future prospective studies are needed in order to determine whether the predominant polarity is indeed one clinical factor that might guide the clinician in choosing the right mood stabilizer for BD maintenance treatment.

Integrating clinical staging and phenomenological psychopathology to add depth, nuance, and utility to clinical phenotyping: a heuristic challenge

Psychiatry has witnessed a new wave of approaches to clinical phenotyping and the study of psychopathology, including the US National Institute of Mental Health's Research Domain Criteria, clinical staging, network approaches, the Hierarchical Taxonomy of Psychopathology, the general psychopathology factor, and a revival of interest in phenomenological psychopathology. The question naturally emerges about what the relationship between these new approaches is. Are they mutually exclusive and competing approaches, or can they be integrated in some way and be used to enrich each other? In this Personal View, we propose a possible integration between clinical staging and phenomenological psychopathology. Domains identified in phenomenological psychopathology (eg, selfhood, embodiment, and affectivity) can be overlaid on clinical stages to enrich and deepen the phenotypes captured in clinical staging (creating high-resolution clinical phenotypes). This approach might be useful both ideographically and nomothetically, to complement diagnosis, enrich clinical formulation, inform treatment of individual patients, and help to guide aetiology research, prediction of clinical trajectory and treatment. Overlaying phenomenological domains on clinical stages might require reformulating these domains in dimensional rather than categorial terms. This integrative project requires assessment tools (some of which are already available) that are sufficiently sensitive and thorough to pick up on the range of relevant psychopathology. The proposed approach offers opportunities for mutual enrichment: clinical staging might be enriched by introducing greater depth to phenotypes; phenomenological psychopathology might be enriched by introducing stages of severity and disorder progression to phenomenological analysis.

Social Cognition in a Research Domain Criteria Perspective: A Bridge Between Schizophrenia and Autism Spectra Disorders

Schizophrenia and autism spectra disorders are currently conceptualized as distinct clinical categories. However, the relationship between these two nosological entities has been revisited in recent years due to the evidence that they share some important clinical and neurobiological features, putting into question the nature and the extent of their commonalities and differences. In this respect, some core symptoms that are present in both disorders, such as social cognitive deficits, could be a primary target of investigation. This review briefly summarizes the commonalities and overlapping features between schizophrenia and autism spectra disorders in social cognitive functions, considering this construct in a Research Domain Criteria perspective. The clinical manifestation of deficits in social cognition are similar in schizophrenia spectrum disorders and autism spectrum disorders, and brain areas that appear to be altered in relation to these impairments are largely shared; however, the results of various studies suggest that, in some cases, the qualitative nature of these alterations may be different in the two spectra. Moreover, relevant differences could be present at the level of brain networks and connections. More research is required in this field, regarding molecular and genetic aspects of both spectra, to better define the neurobiological mechanisms involved in social cognition deficits, with the objective of developing specific and targeted treatments.