Slade's paper1 usefully articulates the clinical and ethical arguments in support of shared decision making (SDM); emphasizes that, despite widespread superficial agreement that SDM is important, there is significant potential for contradiction between these arguments; and puts forward a number of approaches which may inform responses to the shift in the mental health system brought about by more empowered patients. Here I briefly comment on each of these components of Slade's review. While I admire his elegant synthesis of the literature and concur with the thrust of many of his arguments, I do also wish to express some cautions. First, Slade notes that – while there is a clinical argument that patients who are active decision makers will be more engaged, with consequent improved decision making, increased adherence, and superior outcomes – there are in fact limited data to support this view. One potentially important consideration is that, in psychiatry, the link between scientific knowledge and patient outcomes is not always as tight as we would ideally like; so that clinical decision making, whether shared or not, is unable to predict fully which individual will respond to which intervention. Furthermore, the data included in the Cochrane review of the clinical value of SDM for people with psychiatric disorders2 are from work done in Germany. It is theoretically possible that in other settings, where patients may have different expectations of the clinical encounter, the data may be even less supportive of the clinical argument for SDM. Second, Slade notes that, despite the ethical argument that SDM is a human right, clinical practice occurs in a range of different contexts, and it is less clear that SDM is the best approach to decision making in non-capacitous patients. Indeed, a potentially important issue is that, in medical and psychiatric practice, disorders range from more typical conditions (where, say, the disorder can be conceptualized as caused by an external agent that both clinician and patient are committed to eradicating) to more atypical ones (where, for example, it is harder to differentiate the self from the illness, which may itself impact negatively on decision making)3. It is also noteworthy that the desire to participate in SDM appears higher in some patient groups. Good ethical arguments can be put forward to support different sorts of decision-making models for different sorts of patients and different sorts of disorders. Third, Slade emphasizes that, although SDM is widely endorsed in official policies and by active clinicians, in theory it entails potential contradictions (for example, there is a potential for empowered patients to choose to be less adherent to treatment recommendations), and that in practice SDM is in fact often not implemented. Slade argues that data from the “Clinical decision making and outcome in routine care for people with severe mental illness” (CEDAR) study4 show that both patient outcomes and experiences are improved by SDM, so that there is an alignment between clinical and ethical justifications. However, although the CEDAR study is multi-national, it is based on a relatively restricted population (outpatients in Europe), and the statistical analysis cited by Slade does not focus on clinical symptoms (but rather on patient-rated unmet needs). Finally, Slade suggests that social marketing and the hospital industry provide potentially useful approaches for addressing the shift in the mental health system that will be brought about by more empowered patients. Metaphors play a crucial role in framing our views of physical and mental disorders, and of the clinician-patient relationship5. A collaborative model of the clinician-patient relationship has been particularly useful in cognitive behavioural therapy, for example. And viewing the patient as a consumer does have some advantages, perhaps particularly in the context of empowerment or activism6. However, we should be careful not to entirely jettison metaphors of the doctor-patient relationship that emphasize caring (rather than only collaborating or consuming). Caring is a core aspect of the work of mental health professionals, and one that is deserving of particular emphasis and pride. Dan J. Stein Department of Psychiatry and Mental Health, University of Cape Town and Medical Research Council Unit on Anxiety and Stress Disorders, Cape Town, South Africa
ABSTRACT Prenatal exposure to maternal stress and depression has been identified as a risk factor for adverse behavioral and neurodevelopmental outcomes in early childhood. However, the molecular mechanisms through which maternal psychopathology shapes offspring development remain poorly understood. We applied transcriptome-wide screens to 149 umbilical cord blood samples from neonates born to mothers with posttraumatic stress disorder (PTSD; n =20), depression ( n =31) and PTSD with comorbid depression ( n =13), compared to carefully matched trauma exposed controls ( n =23) and healthy mothers ( n =62). Analyses by maternal diagnoses revealed a clear pattern of gene expression signatures distinguishing neonates born to mothers with a history of psychopathology from those without. Co-expression network analysis identified distinct gene expression perturbations across maternal diagnoses, including two depression-related modules implicated in axon-guidance and mRNA stability, as well as two PTSD-related modules implicated in TNF signaling and cellular response to stress. Notably, these disease-related modules were enriched with brain-expressed genes and genetic risk loci for autism spectrum disorder and schizophrenia, which may imply a causal role for impaired developmental outcomes. These molecular alterations preceded changes in clinical measures at twenty-four months, including reductions in cognitive and socio-emotional outcomes in affected infants. Collectively, these findings indicate that prenatal exposure to maternal psychological distress induces neuronal, immunological and behavioral abnormalities in affected offspring and support the search for early biomarkers of exposures to adverse in utero environments and the classification of children at risk for impaired development.
Birthweight was an important predictor of growth trajectory during infancy. Birthweight and growth were influenced by several important modifiable factors.
A summary is not available for this content. As you have access to this content, full HTML content is provided on this page. A PDF of this content is also available in through the ‘Save PDF’ action button.
Trichotillomania is a prevalent but often hidden psychiatric condition, characterized by repetitive hair pulling. The aim of this study was to confirm or refute structural brain abnormalities in trichotillomania by pooling all available global data. De-identified MRI scans were pooled by contacting authors of previous studies. Cortical thickness and sub-cortical volumes were compared between patients and controls. Patients (n = 76) and controls (n = 41) were well-matched in terms of demographic characteristics. Trichotillomania patients showed excess cortical thickness in a cluster maximal at right inferior frontal gyrus, unrelated to symptom severity. No significant sub-cortical volume differences were detected in the regions of interest. Morphometric changes in the right inferior frontal gyrus appear to play a central role in the pathophysiology of trichotillomania, and to be trait in nature. The findings are distinct from other impulsive-compulsive disorders (OCD, ADHD, gambling disorder), which have typically been associated with reduced, rather than increased, cortical thickness. Future work should examine sub-cortical and cerebellar morphology using analytic approaches designed for this purpose, and should also characterize grey matter densities/volumes.
Read moreAlthough anxiety has long held a central place in theories of psychopathology, it has only recently been appreciated that the anxiety disorders are the most prevalent category of mental illness in the United States (Kessler et al. 2010) and that they account for approximately a third of the country’s total mental health costs (Lepine 2002). Furthermore, although it has long been recognized that specific neurological lesions may lead to anxiety symptoms (Von Economo 1931), only in recent decades have advances in research allowed specific neuroanatomical hypotheses to be proposed for each of the anxiety disorders. DSM-III (American Psychiatric Association 1980) provided significant impetus to research on anxiety disorders by replacing the category of “anxiety neurosis” with several different conditions and by providing each with operational diagnostic criteria. DSM-IV-TR (American Psychiatric Association 2000) anxiety disorders include panic disorder with and without agoraphobia, social phobia (social anxiety disorder), generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), substance-induced anxiety disorder, and anxiety disorder due to a general medical condition. The DSM-5 (American Psychiatric Association 2013) section on anxiety disorders no longer includes PTSD (which is found in the section on trauma- and stressor-related disorders) or OCD (which is included within the section on obsessive-compulsive and related disorders). For the purposes of this volume, we use the current DSM-5 classification and also retain inclusion of PTSD. In each of the anxiety disorders, it is possible to discern a component comprising anxiety symptoms and a component comprising avoidance symptoms. In GAD, patients have anxiety about the future, and worry may serve as an avoidance behavior. In panic disorder, the anxiety symptoms are those of the panic attack , a discrete period of anxiety that develops rapidly, often spontaneously. The individual also may develop agoraphobia symptoms, or avoidance of those stimuli that appear to promote panic attacks. In social anxiety disorder, panic attacks develop only in the context of performance or other social situations in which the person fears embarrassment or humiliation. As a result of these fears, the person may avoid these situations. In PTSD, in the aftermath of a traumatic event, the person has intrusive experiences, hyperarousal symptoms, negative alterations in cognition and mood, and a range of avoidance and numbing symptoms. In this chapter, we review these developments in our understanding of the anxiety disorders from a neuropsychiatric perspective. The neurochemistry and neuroanatomy of each of the main anxiety disorders and PTSD are considered first. Neurological disorders that may manifest with anxiety symptoms are then discussed, and future directions in the neuropsychiatry of anxiety disorders are considered briefly.
Read moreAbstract Seemingly paradoxical characteristics of psychiatric disorders, including moderate to high prevalence, reduced fecundity, and high heritability have motivated explanations for the persistence of common risk alleles for severe psychiatric phenotypes throughout human evolution. Proposed mechanisms include balancing selection, drift, and weak polygenic adaptation acting either directly, or indirectly through selection on correlated traits. While many mechanisms have been proposed, few have been empirically tested. Leveraging publicly available data of unprecedented sample size, we studied twenty-five traits (i.e., ten neuropsychiatric disorders, three personality traits, total intracranial volume, seven subcortical brain structure volume traits, and four complex traits without neuropsychiatric associations) for evidence of several different signatures of selection over a range of evolutionary time scales. Consistent with the largely polygenic architecture of neuropsychiatric traits, we found no enrichment of trait-associated single-nucleotide polymorphisms (SNPs) in regions of the genome that underwent classical selective sweeps (i.e., events which would have driven selected alleles to near fixation). However, we discovered that SNPs associated with some, but not all, behaviors and brain structure volumes are enriched in genomic regions under selection since divergence from Neanderthals ~600,000 years ago, and show further evidence for signatures of ancient and recent polygenic adaptation. Individual subcortical brain structure volumes demonstrate genome-wide evidence in support of a mosaic theory of brain evolution while total intracranial volume and height appear to share evolutionary constraints consistent with concerted evolution. We further characterized the biological processes potentially targeted by selection, through expression Quantitative Trait Locus (eQTL) and Gene Ontology (GO) enrichment analyses and found evidence for the role of regulatory functions among selected SNPs in immune and brain tissues. Taken together, our results suggest that alleles associated with neuropsychiatric, behavioral, and brain volume phenotypes have experienced both ancient and recent polygenic adaptation in human evolution, acting through neurodevelopmental and immune-mediated pathways.
Read moreDepression contributes significantly to the global burden of disease in low- and middle-income countries. In South Africa, individuals may be at elevated risk for depression due to HIV and AIDS, violence, and poverty. For adolescents, resilience-focused prevention strategies have the potential to reduce onset of depression. Involving families in promoting adolescent mental health is developmentally appropriate, but few existing interventions take a family approach to prevention of adolescent depression. We conducted a qualitative investigation from 2013-2015 to inform the development of a family intervention to prevent adolescent depression in South Africa among families infected or at risk for HIV. Using focus groups with adolescents and parents (eight groups, n = 57), and interviews (n = 25) with clinicians, researchers, and others providing mental health and related services, we identified context-specific factors related to risk for family depression, and explored family interactions around mental health more broadly as well as depression specifically. Findings indicate that HIV and poverty are important risk factors for depression. Future interventions must address linguistic complexities in describing and discussing depression, and engage with the social interpretations and meanings placed upon depression in the South African context, including bewitchment and deviations from prescribed social roles. Participants identified family meetings as a context-appropriate prevention strategy. Family meetings offer opportunities to practice family problem solving, involve other family members in communal parenting during periods of parental depression, and serve as forums for building Xhosa-specific interpretations of resilience. This study will guide the development of Our Family Our Future, a resilience-focused family intervention to prevent adolescent depression (ClinicalTrials.gov #NCT02432352).
Read moreThese data suggest that OCPD symptoms, defined in terms of at least 4 of 8 DSM criteria being met, are common in Internet users. OCPD symptoms were associated with considerably higher levels of psychopathology relating to both impulsive (ADHD) and compulsive (OCD-related and problematic Internet use) disorders. These data merit replication and extension using standard in-person clinical assessments, because the current study relied on self-report over the Internet.
Read moreBackground: Primary Sclerosing Cholangitis (PSC) patients with refractory inflammatory bowel disease (IBD) after liver transplantation (LT) pose a dilemma for treating physicians, as little is known about the risk of serious infection when combining anti-TNF therapy with immunosuppression for prevention of rejection. Our aim was to investigate the infection risk in this patient group by systematic review and meta-analysis of the available data. Methods: A literature search was conducted for full papers and conference proceedings through September 2015 regarding liver transplant recipients and anti-TNF therapy. All studies were appraised using the adapted Newcastle-Ottawa Scale (NOS), which contains 9 criteria for cohort studies and is adapted to 6 criteria for case series and case reports. Two reviewers (MWvM and PWJM) independently extracted study and control-patient data (age, duration of follow up, number of all infections, number of serious infections, time since transplant). As additional control population, PSC-IBD patients from the LUMC LT cohort were used. Poisson regression was used to compare serious infections (according to ICH-definition) per patient year follow up between the anti-TNF and control group, correcting for mean time since transplant. Results: Initially, 465 articles and abstracts were identified, of which 8 were included. These 8 studies contained 53 post-LT patients on anti-TNF therapy and 23 post-LT control patients not on anti-TNF therapy. None of the studies scored less than 75% of the NOS quality criteria. From the LUMC LT cohort, 41 PSC-patients with PSC-IBD but without anti-TNF therapy were included as control population. Serious infection rates differed from 0 to 0.38 serious infections per patient year in the anti-TNF therapy group, and 0.04 to 0.24 in the control group. The overall infection rate for TNF-exposed patients was 0.12, compared to 0.15 in the control patients, resulting in a rate ratio of 0.80 (95% CI: 0.17–3.97, p=0.80). Age at time of transplant was not associated with the rate ratio for serious infections, whereas the time since transplantation was. Although correcting for time since transplant causes the infection rates in the anti-TNF-group to be higher than in the control group (0.13 vs 0.12 serious infections per patient year) the rate ratio remained non-significant (1.1, p=0.82). Conclusions: No significant increase in the serious infection rate was observed in LT-recipients with PSC-IBD during exposure to anti-TNF therapy. However, the wide confidence intervals of these results show that more data is needed to provide a definitive conclusion on the safety of anti-TNF therapy in these patients.
Read more83 Background: In January 2016, we opened a novel, multidisciplinary ambulatory surgical center dedicated to perform complex cancer surgeries on an Ambulatory Extended Recovery (AXR) pathway specifically aimed at a 1-night or less hospital stay. This is a standalone facility separate from the inpatient hospital. The aim of this study is to evaluate the 30-day post-operative follow-up of Minimally Invasive Radical Prostatectomy (MIRP) performed in an ambulatory care setting. Methods: Between January 2016 – September 2016, we performed 424 MIRP in the AXR dedicated surgical center. The baseline demographics, cancer characteristics, surgical information and follow-up data were prospectively collected. We evaluated the 30-day complications, rate of falling-off the AXR pathway, rate of transfer to our inpatient hospital, number urgent care visits and need for re-admission. Results: MIRP was performed as robot assisted (85%) and laparoscopic (15%) procedures. The median (range) overall length of hospital stay was 27.1 (11.4 – 35.2) hours with a total operative time of 4.8 (3.1 – 9.3) hours with an estimated blood loss of 175 (20 - 800) ml. Nine patients (2.1%) fell off the AXR pathway and were transferred to the main hospital for further care. In the 30-day post-surgery period, complications were noted in 6.4% patients (Grade 1 -38%, 2 - 34% 3 – 27%), while urgent care visits and re-admission rates were 10.7% and 2.6% respectively. The median (range) time from surgery to re-admission was 16 (2 - 43) days. Conclusions: A multidisciplinary ambulatory surgical center with a dedicated AXR pathway represents a significant advancement in MIRP surgical care, providing a 1-night hospital stay in an ambulatory setting with acceptably low rates of complications, urgency care visits and re-admissions.
Read moreIn this paper we report the clinical utility of the diagnostic guidelines for ICD-11 mental, behavioural and neurodevelopmental disorders as assessed by 339 clinicians in 1,806 patients in 28 mental health settings in 13 countries. Clinician raters applied the guidelines for schizophrenia and other primary psychotic disorders, mood disorders (depressive and bipolar disorders), anxiety and fear-related disorders, and disorders specifically associated with stress. Clinician ratings of the clinical utility of the proposed ICD-11 diagnostic guidelines were very positive overall. The guidelines were perceived as easy to use, corresponding accurately to patients' presentations (i.e., goodness of fit), clear and understandable, providing an appropriate level of detail, taking about the same or less time than clinicians' usual practice, and providing useful guidance about distinguishing disorder from normality and from other disorders. Clinicians evaluated the guidelines as less useful for treatment selection and assessing prognosis than for communicating with other health professionals, though the former ratings were still positive overall. Field studies that assess perceived clinical utility of the proposed ICD-11 diagnostic guidelines among their intended users have very important implications. Classification is the interface between health encounters and health information; if clinicians do not find that a new diagnostic system provides clinically useful information, they are unlikely to apply it consistently and faithfully. This would have a major impact on the validity of aggregated health encounter data used for health policy and decision making. Overall, the results of this study provide considerable reason to be optimistic about the perceived clinical utility of the ICD-11 among global clinicians.
Read moreThe Eastern Mediterranean Region (EMR) is witnessing an increase in chronic disorders, including mental illness. With ongoing unrest, this is expected to rise. This is the first study to quantify the burden of mental disorders in the EMR. We used data from the Global Burden of Disease study (GBD) 2013. DALYs (disability-adjusted life years) allow assessment of both premature mortality (years of life lost-YLLs) and nonfatal outcomes (years lived with disability-YLDs). DALYs are computed by adding YLLs and YLDs for each age-sex-country group. In 2013, mental disorders contributed to 5.6% of the total disease burden in the EMR (1894 DALYS/100,000 population): 2519 DALYS/100,000 (2590/100,000 males, 2426/100,000 females) in high-income countries, 1884 DALYS/100,000 (1618/100,000 males, 2157/100,000 females) in middle-income countries, 1607 DALYS/100,000 (1500/100,000 males, 1717/100,000 females) in low-income countries. Females had a greater proportion of burden due to mental disorders than did males of equivalent ages, except for those under 15 years of age. The highest proportion of DALYs occurred in the 25-49 age group, with a peak in the 35-39 years age group (5344 DALYs/100,000). The burden of mental disorders in EMR increased from 1726 DALYs/100,000 in 1990 to 1912 DALYs/100,000 in 2013 (10.8% increase). Within the mental disorders group in EMR, depressive disorders accounted for most DALYs, followed by anxiety disorders. Among EMR countries, Palestine had the largest burden of mental disorders. Nearly all EMR countries had a higher mental disorder burden compared to the global level. Our findings call for EMR ministries of health to increase provision of mental health services and to address the stigma of mental illness. Moreover, our results showing the accelerating burden of mental health are alarming as the region is seeing an increased level of instability. Indeed, mental health problems, if not properly addressed, will lead to an increased burden of diseases in the region.
Read moreIn search of the holy grail: can unconditional cash transfers graduate households
Read more
