Should our major classifications of mental disorders be revised?

Flourishing, Mental Health Professionals and the Role of Normative Dialogue

This paper explores the dilemma faced by mental healthcare professionals in balancing treatment of mental disorders with promoting patient well-being and flourishing. With growing calls for a more explicit focus on patient flourishing in mental healthcare, we address two inter-related challenges: the lack of consensus on defining positive mental health and flourishing, and how professionals should respond to patients with controversial views on what is good for them. We discuss the relationship dynamics between healthcare providers and patients, proposing that 'liberal' approaches can provide a pragmatic framework to address disagreements about well-being in the context of flourishing-oriented mental healthcare. We acknowledge the criticisms of these approaches, including the potential for unintended paternalism and distrust. To mitigate these risks, we conclude by suggesting a mechanism to minimize the likelihood of unintended paternalism and foster patient trust.

Mortality rates for mental disorders by gender in urban and rural areas in China from 2006 to 2020: An age-period-cohort analysis

This study was to explore the trends of mortality rates for mental disorders by gender in urban and rural areas in China (2006-2020) and estimate the independent effects of age, period, and cohort on the mortality of mental disorders. This study employs data from the China Health Statistical Yearbook. The data were analysed using joinpoint regression analysis as well as age-period-cohort analysis. Results revealed the age-standardized mortality rates of mental disorders in China showed a downward trend, and women had a faster rate of decline than men over the years 2006-2020. Age, period, and birth cohort effects were statistically significant in the trend analysis of mental disorder mortality, and compared with period and cohort effects, age effects were the leading correlate of mental disorder mortality. The risk of death increased with advancing age. Our findings suggest that the mortality of mental disorders showed a downward trend, but some effective measures, especially regarding mental disorders, need to be taken to protect people with these disorders and prevent their occurrence in the setting of an ageing population.

Realising stratified psychiatry using multidimensional signatures and trajectories

Background

Stratified or personalised medicine targets treatments for groups of individuals with a disorder based on individual heterogeneity and shared factors that influence the likelihood of response. Psychiatry has traditionally defined diagnoses by constellations of co-occurring signs and symptoms that are assigned a categorical label (e.g. schizophrenia). Trial methodology in psychiatry has evaluated interventions targeted at these categorical entities, with diagnoses being equated to disorders. Recent insights into both the nosology and neurobiology of psychiatric disorder reveal that traditional categorical diagnoses cannot be equated with disorders. We argue that current quantitative methodology (1) inherits these categorical assumptions, (2) allows only for the discovery of average treatment response, (3) relies on composite outcome measures and (4) sacrifices valuable predictive information for stratified and personalised treatment in psychiatry.

Methods and findings

To achieve a truly ‘stratified psychiatry’ we propose and then operationalise two necessary steps: first, a formal multi-dimensional representation of disorder definition and clinical state, and second, the similar redefinition of outcomes as multidimensional constructs that can expose within- and between-patient differences in response. We use the categorical diagnosis of schizophrenia—conceptualised as a label for heterogeneous disorders—as a means of introducing operational definitions of stratified psychiatry using principles from multivariate analysis. We demonstrate this framework by application to the Clinical Antipsychotic Trials of Intervention Effectiveness dataset, showing heterogeneity in both patient clinical states and their trajectories after treatment that are lost in the traditional categorical approach with composite outcomes. We then systematically review a decade of registered clinical trials for cognitive deficits in schizophrenia highlighting existing assumptions of categorical diagnoses and aggregate outcomes while identifying a small number of trials that could be reanalysed using our proposal.

Conclusion

We describe quantitative methods for the development of a multi-dimensional model of clinical state, disorders and trajectories which practically realises stratified psychiatry. We highlight the potential for recovering existing trial data, the implications for stratified psychiatry in trial design and clinical treatment and finally, describe different kinds of probabilistic reasoning tools necessary to implement stratification.

Disorder-specific versus transdiagnostic and clinician-guided versus self-guided internet-delivered treatment for panic disorder and comorbid disorders: A randomized controlled trial

Transdiagnostic cognitive behaviour therapy (TD-CBT) aims to target the symptoms of multiple disorders whereas disorder-specific CBT (DS-CBT) targets the symptoms of principal disorders. This study compared the relative benefits of internet-delivered TD-CBT and DS-CBT when provided in clinician-guided (CG-CBT) and self-guided (SG-CBT) formats for people with a principal diagnosis of Panic Disorder (PD). Participants (n=145) were randomly allocated to receive TD-CBT or DS-CBT and CG-CBT or SG-CBT. Large reductions in symptoms of PD (Cohen's d ≥ 0.71; avg. reduction ≥ 36%) and moderate-to-large reductions in symptoms of comorbid depression (Cohen's d ≥ 0.71; avg. reduction ≥ 33%), generalised anxiety disorder (Cohen's d ≥ 0.91; avg. reduction ≥ 34%) and social anxiety disorder (Cohen's d ≥ 0.50; avg. reduction ≥ 15%) were found over the 24-month follow-up period. Highlighting their efficacy and acceptability, no marked and consistent differences were observed between TD-CBT and DS-CBT or CG-CBT and DS-CBT.

Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for generalized anxiety disorder and comorbid disorders: A randomized controlled trial

Generalized anxiety disorder (GAD) can be treated effectively with either disorder-specific cognitive behavior therapy (DS-CBT) or transdiagnostic CBT (TD-CBT). The relative benefits of DS-CBT and TD-CBT for GAD and the relative benefits of delivering treatment in clinician guided (CG-CBT) and self-guided (SG-CBT) formats have not been examined. Participants with GAD (n=338) were randomly allocated to receive an internet-delivered TD-CBT or DS-CBT intervention delivered in either CG-CBT or SG-CBT formats. Large reductions in symptoms of GAD (Cohen's d ≥ 1.48; avg. reduction ≥ 50%) and comorbid major depressive disorder (Cohen's d ≥ 1.64; avg. reduction ≥ 45%), social anxiety disorder (Cohen's d ≥ 0.80; avg. reduction ≥ 29%) and panic disorder (Cohen's d ≥ 0.55; avg. reduction ≥ 33%) were found across the conditions. No substantive differences were observed between DS-CBT and TD-CBT or CG-CBT and SG-CBT, highlighting the public health potential of carefully developed TD-CBT and SG-CBT.

Predictors of inpatient psychiatric admission in patients presenting to the emergency department: the role of dimensional assessment

OBJECTIVE

To identify which patient factors predict psychiatric hospitalization in patients presenting to the emergency department and to examine the role of the dimensional approach to psychopathology in predicting hospitalization.

METHODS

We consecutively recruited 312 patients undergoing psychiatric evaluation in the emergency room of a hospital in Rome over a 6-month period. Patients were rated on the SVARAD (Scala per la Valutazione Rapida Dimensionale), a scale designed for the rapid assessment of the main psychopathological dimensions. Information about patient history, as well as sociodemographic and clinical variables, was also collected. Univariate analysis was performed to detect the variables associated with recommendation of psychiatric hospitalization. Multiple logistic regression analysis was used to identify independent predictors of hospitalization and compare their strength. A replication study was performed in another hospital on a random sample of 118 patients.

RESULTS

In both studies, patients who were recommended for psychiatric hospitalization showed significantly higher levels of anger/aggressiveness, apathy, impulsivity, reality distortion, thought disorganization and activation. Multivariate analysis identified psychopathological dimensions (reality distortion, impulsivity, apathy), diagnosis of psychotic or mood disorders and proposal for compulsory admission as independent predictors of psychiatric hospitalization. Hierarchical regression analysis revealed that the dimensional evaluation was the strongest predictor.

CONCLUSIONS

Our findings suggest that, in emergency setting, a systematic dimensional assessment may usefully complement the categorical assessment. Future research should aim at developing an operational assessment model, including both categorical and dimensional approaches to psychopathology.

Disorder-specific versus transdiagnostic and clinician-guided versus self-guided treatment for major depressive disorder and comorbid anxiety disorders: A randomized controlled trial

Disorder-specific cognitive behavior therapy (DS-CBT) is effective at treating major depressive disorder (MDD) while transdiagnostic CBT (TD-CBT) addresses both principal and comorbid disorders by targeting underlying and common symptoms. The relative benefits of these two models of therapy have not been determined. Participants with MDD (n=290) were randomly allocated to receive an internet delivered TD-CBT or DS-CBT intervention delivered in either clinician-guided (CG-CBT) or self-guided (SG-CBT) formats. Large reductions in symptoms of MDD (Cohen's d≥1.44; avg. reduction≥45%) and moderate-to-large reductions in symptoms of comorbid generalised anxiety disorder (Cohen's d≥1.08; avg. reduction≥43%), social anxiety disorder (Cohen's d≥0.65; avg. reduction≥29%) and panic disorder (Cohen's d≥0.45; avg. reduction≥31%) were found. No marked or consistent differences were observed across the four conditions, highlighting the efficacy of different forms of CBT at treating MDD and comorbid disorders.

Management of medically unexplained symptoms: outcomes of a specialist liaison clinic

Aims and method Service utilisation and clinical outcomes of a newly developed specialist primary-secondary care liaison clinic for patients with medically unexplained symptoms (MUS) were evaluated in a cross-sectional and feasibility pilot study. The impact of body-oriented psychological therapy (BOPT) was explored in a small cohort of patients with an identified somatoform disorder.

Results Of 147 consecutive referrals, 113 patients engaged with the assessment process. Of patients with MUS, 42% (n = 45) had a primary diagnosis of somatoform disorder, 36% (n = 38) depressive disorder, and depressive symptoms (even subsyndromal) mediated the effect of somatic symptoms. A marked variation of presenting complaints and service utilisation across ethnic groups was noted. A significant reduction in somatic symptom levels and service utilisation was achieved for patients undergoing BOPT.

Clinical implications A high proportion of patients with MUS have undiagnosed and therefore untreated mental disorders. New and locally derived collaborative care models of active engagement in primary care settings are required. Patients with somatoform disorder may benefit from BOPT; this requires further evaluation in adequately powered clinical trials.

The DSM-5 personality disorder proposal and future directions in the diagnostic classification of personality disorder

BACKGROUND

The compilation of DSM-5 presented a substantial opportunity to develop a coherent, evidence-based classification of personality disorder. The irremediable problems with DSM-IV are widely recognized, the field seemed ready for change, and the data and methods for constructing a scientific classification are readily available. Rather than seize this opportunity, DSM-5 advanced an incoherent proposal lacking in evidential support and too poorly organized for clinical use.

METHODS

This article examines the problems with the proposal based on a consideration of the basic requirements of a satisfactory classification. It is suggested that an adequate system should have an explicit and coherent conceptual structure, be based on the best available scientific evidence, possess clinical utility, and be as parsimonious as possible.

RESULTS

The DSM-5 proposal fails to meet these criteria. Problems with the product and process suggest the need for a radical reconsideration of how personality disorders are classified and how classifications are compiled.

CONCLUSIONS

The article proposes that greater emphasis be placed on developing a classification that provides the diagnostic information clinicians need to treat personality disorder and that future classifications should be constructed through an explicit process that is open to public scrutiny.

Predictors of recurrent sickness absence due to depressive disorders--a Delphi approach involving scientists and physicians

BACKGROUND

Depression is a common and highly recurrent mental disorder that is accompanied by poor functioning at home and at work. Not all depressed employees report sick and little is known about variables associated with sickness absence (SA) due to depression. Recurrent SA due to depression tends to marginalize employees from the workforce and exclude them from social participation. Therefore, this study sought group consensus on factors predicting recurrent SA due to depression.

METHODOLOGY/PRINCIPAL FINDINGS

23 scientists in the field of work and mental health and 23 physicians with expertise in assessing work disability were invited for a Delphi study. Sixty-seven factors retrieved from the literature were scored for their impact on the recurrence of SA due to depression, range 1 (no impact) to 10 (very high impact) in two Delphi rounds. The third Delphi round addressed the assessability and modifiability of elected predictors. Group consensus was defined as 75% agreement. In the first round (response 78%), group consensus was reached on a high impact of 13 factors on recurrent SA due to depression. The second round (response 79%) added another 8 factors with high impact on recurrent SA due to depression. The panelists were of the opinion that stressful life and work events, age at first diagnosis, duration of the last depressive episode, anxiety, lifetime number of depressive episodes, and psychological work demands were readily assessable in consultation with patients. Furthermore, work factors, particularly decision latitude, psychological job demands, and commitment to work, were recognized as modifiable.

CONCLUSIONS/SIGNIFICANCE

Although results have to be validated with further quantitative research, physicians may identify employees at risk of recurrent SA due to depression and may support them to adjust their work aimed at increasing commitment to work and preventing future SA due to depression.

Comorbid anxiety and depression: bête noire or quick fix?

The common territory shared by anxiety and depression has always been a contentious subject. Research in favour of anxious depression as a potentially treatment-relevant subtype has been limited by diagnostic dilemmas and crude measurement. The most recent evidence from genetics, neuropeptide systems and functional neuroimaging suggests a valid diagnostic construct.

Latent class analysis of co-morbidity in the Adult Psychiatric Morbidity Survey in England 2007: implications for DSM-5 and ICD-11

BACKGROUND

Psychiatric co-morbidity is complex and ubiquitous. Our aim was to describe the extent, nature and patterning of psychiatric co-morbidity within a representative sample of the adult population of England, using latent class analysis.

METHOD

Data were used from the 2007 Adult Psychiatric Morbidity Survey, a two-phase national household survey undertaken in 2007 comprising 7325 participants aged 16 years and older living in private households in England. The presence of 15 common mental health and behavioural problems was ascertained using standardized clinical and validated self-report measures, including three anxiety disorders, depressive episode, mixed anxiety depressive disorder, psychosis, antisocial and borderline personality disorders, eating disorders, post-traumatic stress disorder, attention deficit disorder, alcohol and drug dependencies, problem gambling and attempted suicide.

RESULTS

A four-class model provided the most parsimonious and informative explanation of the data. Most participants (81.6%) were assigned to a non-symptomatic or 'Unaffected' class. The remainder were classified into three qualitatively different symptomatic classes: 'Co-thymia' (12.4%), 'Highly Co-morbid' (5.0%) and 'Addictions' (1.0%). Classes differed in mean numbers of conditions and impairments in social functioning, and these dimensions were correlated.

CONCLUSIONS

Our findings confirm that mental disorders typically co-occur and are concentrated in a relatively small number of individuals. Conditions associated with the highest levels of disability, mortality and cost--psychosis, suicidality and personality disorders--are often co-morbid with more common conditions. This needs to be recognized when planning services and when considering aetiology.

Neurodevelopmental hypothesis of schizophrenia

The neurodevelopmental hypothesis of schizophrenia provided a valuable framework that allowed a condition that usually presents with frank disorder in adolescence or early adulthood to be understood at least in part as a consequence of events occurring early in development. However, the implications of the neurodevelopmental hypothesis for nosological conceptions of the disorder can only now be fully appreciated. Recent research indicates genetic overlap between schizophrenia and syndromes in which psychopathology is manifest in childhood and that are often grouped together as 'neurodevelopmental disorders' such as autism-spectrum disorders, intellectual disability and attention-deficit hyperactivity disorder. These findings challenge the aetiological basis of current diagnostic categories and, together with evidence for frequent comorbidity, suggest that we should view the functional psychoses as members of a group of related and overlapping syndromes that result in part from a combination of genetic and environmental effects on brain development and that are associated with specific and general impairments of cognitive function. This has important implications for future research and for the configuration of psychiatric services.

Memoir and the Diagnosis of Schizophrenia: Reflections on The Center Cannot Hold, Me, Myself, and Them, and the 'Crumbling Twin Pillars' of Kraepelinian Psychiatry

In 1896 Emil Kraepelin revolutionised the classification of psychosis by identifying what he argued were two natural disease entities: manic-depressive psychosis (bipolar disorder) and dementia praecox (schizophrenia). Kraepelin's twin pillars have governed psychiatric thinking, practice and research for over a century. However, a growing number of researchers, clinicians, and mental health service users argue contest the claim that there are fundamental differences between schizophrenia and bipolar disorder, and call for a symptom-led approach which prioritises subjective experience over diagnostic category. How can the published first-person accounts of experts by experience contribute to this debate? This short paper looks at the representation of psychiatric diagnosis in two much-lauded autobiographies: Kurt Snyder's Me, Myself, and Them: A Firsthand Account of One Young Person's Experience with Schizophrenia (2007) and Elyn Saks' The Center Cannot Hold: My Journey Through Madness (2007). As well as providing a prognosis and a plan for treatment, the psychiatric diagnosis of schizophrenia, for both these writers, gives shape and meaning to the illness experience and ultimately becomes the pivot or platform from which identity and memoir unfold. Saks and Snyder do not claim to speak for all people who receive a diagnosis of schizophrenia and it would be a mistake to read their texts in this way even if they did. But if the debate about the future of psychiatric nosology is going to respect subjective experience, the insights they and others offer in to the multiple meanings and effects of psychiatric diagnosis more than compel our attention.