Suicidal behavior-advances in clinical and neurobiological research and improvement of prevention strategies

Suicide is the 14^th leading cause of death worldwide. It is responsible for 1%-5% of all mortality. This article highlights the latest developments in universal, selective, and indicated prevention strategies. Concerning universal suicide prevention, current research has shown that strategies such as restricting access to lethal means (e.g., control of analgesics and hot-spots for suicide by jumping) and school-based awareness programs are most efficacious. Regarding selective prevention, substantial progress can be expected in psychological screening methods for suicidal behavior. The measurement of implicit cognition proved to be more valid in predicting future suicide attempts than classic clinical assessment. Latest developments are smartphone-based interventions and real-time monitoring of suicidal behavior. Great effort has been made to establish valid neurobiological screening methods (e.g., genetic and epigenetic risk factors for suicide, hypothalamic-pituitary-adrenal axis) without yielding a major bre-akthrough. Potentially, multiple biomarkers rather than a single one are necessary to identify individuals at risk. With regard to indicated prevention in form of psychopharmacological treatment, recent pharmacoepidemiological studies and meta-analyses have supported a protective role of antidepressants, lithium, and clozapine. However, the data concerning a specific anti-suicidal effect of these drugs are currently not consistent. Promising results exist for ketamine in reducing suicidal ideation, independently of its antidepressant effect. Concerning psychotherapy, recent findings suggest that psychotherapeutic interventions specifically designed to prevent suicide re-attempts are most efficacious. Specifically, cognitive behavioral therapy and psychodynamic therapy approaches proved to decrease the number of suicide re-attempts significantly.     

Psychological therapies in bipolar disorder: the effect of illness history on relapse prevention – a systematic review

Objectives:  Despite some encouraging outcomes and shared components of psychological therapies specific to bipolar disorders, not all studies found conclusively that the addition of a psychosocial intervention to pharmacological interventions improves outcomes. There was some tentative evidence from post hoc analyses that patients with more than 12 previous episodes did not benefit from psychoeducation or cognitive therapy. This paper presents a systematic review and meta-analysis which examines the overall efficacy of bipolar disorder-specific psychological therapies and the impact of the number of previous episodes on the efficacy of psychological therapies in relapse prevention.
Methods:  Systematic literature searches of electronic databases and reference lists of existing reviews were carried out. The number of participants experiencing relapse in randomized, controlled studies was combined in a meta-analysis to determine the overall treatment effect in relapse prevention. Metaregression modeling was used to examine whether the number of previous episodes confounded the number of relapses experienced by participants by the end of treatment.
Results:  Meta-analysis of relapse calculated an overall relative risk of 0.74 [95% confidence interval (CI): 0.64–0.85] with some heterogeneity present (I² = 43.3%). Metaregression of six studies showed no relationship between number of episodes and number of relapses by endpoint.
Conclusion:  Psychological therapy specifically designed for bipolar disorder is effective in preventing or delaying relapses in bipolar disorders, and there is no clear evidence that the number of previous episodes moderated the effect.     

Cognitive Behavioral Therapy (Brief vs Standard Duration) for Schizophrenia

There is some evidence from research that suggests that cognitive behavioral therapy for psychosis (CBTp) might offer some advantage if offered in combination with pharmacological treatments for people with schizophrenia. There are, however, limitations in its provision due to available resource and training issues. Brief forms of CBTp might be an alternative in settings with limited resources. Brief therapies have shown to be as effective as standard therapies for some nonpsychotic disorders. There is some evidence in favor of brief CBTp. We wanted to review the effects of brief CBTp for people with schizophrenia compared with standard CBTp. We searched the Cochrane Schizophrenia Group’s Trials Register for randomized controlled trials (RCTs) involving adults with schizophrenia or related disorders, comparing brief cognitive behavioral therapy for people with psychosis vs standard CBTp. We found only 7 studies which used a brief version of CBTp, but no study compared brief CBTp with CBTp of standard duration. There is a need for RCTs which compare brief with standard CBTp. This review also highlighted the need for setting standard criteria for CBTp dose. For this review, we considered brief CBTp to be delivered within 4 months and using 6–10 sessions.Key words: brief, cognitive therapy, schizophrenia, psychosis     

Behavior therapy: a clinical update

Through refinements from research and judicious combination with other therapies, behavior therapy has become increasingly relevant in the treatment of psychiatric disorders. After outlining the four models that serve as a framework for behavior therapy (classical conditioning, operant conditioning, social learning theory, and cognitive behavior modification), the authors provide an update for clinicians on developments in the behavioral treatment of anxiety disorders, sexual disorders, depression, and schizophrenia. Most advances have been made in the treatment of anxiety disorders, including definition of variables for successful use of exposure to phobic stimuli in the treatment of phobic disorders and the use of flooding for post-traumatic stress disorder. By becoming better acquainted with cognitive and behavioral therapies, clinicians may be able to offer their patients more effective treatment options.     

COVID-19 survivors: Multi-disciplinary efforts in psychiatry and medical humanities for long-term realignment

The coronavirus disease 2019 pandemic represents an enduring transformation in health care and education with the advancement of smart universities, telehealth, adaptive research protocols, personalized medicine, and self-controlled or artificial intelligence-controlled learning. These changes, of course, also cover mental health and long-term realignment of coronavirus disease 2019 survivors. Fatigue or anxiety, as the most prominent psychiatric “long coronavirus disease 2019” symptoms, need a theory-based and empirically-sound procedure that would help us grasp the complexity of the condition in research and treatment. Considering the systemic character of the condition, such strategies have to take the whole individual and their sociocultural context into consideration. Still, at the moment, attempts to build an integrative framework for providing meaning and understanding for the patients of how to cope with anxiety when they are confronted with empirically reduced parameters (e.g., severe acute respiratory syndrome coronavirus type 2) or biomarkers (e.g., the FK506 binding protein 5) are rare. In this context, multidisciplinary efforts are necessary. We therefore join in a plea for an establishment of ‘translational medical humanities’ that would allow a more straightforward intervention of humanities (e.g., the importance of the therapist variable, continuity, the social environment, etc) into the disciplinary, medial, political, and popular cultural debates around health, health-care provision, research (e.g., computer scientists for simulation studies), and wellbeing.     

Sensory impairments, intellectual disability and psychiatry

The present review looks at: (1) prevalence studies of sensory impairments in people with intellectual disability (ID); (2) studies looking at psychological and psychiatric disorders in people with sensory impairments; and (3) studies that have examined the association of sensory impairments with autism. Research has indicated that sensory impairments are more common in people with ID. Psychiatric disorders are believed to be more common in children with visual impairment (VI) when associated with other handicaps. Some authors believe that hearing impairment (HI) can result in personality disorders. Studies have also shown a higher prevalence of psychiatric disorders in children with HI and a higher incidence of deaf people in psychiatric hospitals than in the general population. Psychiatric disorders in children with HI are particularly associated with low IQ and low communication ability, especially in those with multiple handicaps. There is little evidence for a higher incidence of schizophrenia in people with HI. Blind people demonstrate many autistic‐like features and there has been discussion in the literature as to their cause. Deaf people also demonstrate some similar features to those in autism, but an association with autism has not been conclusively made. Deaf‐blind people commonly demonstrate problem behaviour (e.g. self‐injury). Usher syndrome, which is the most common cause of deaf‐blindness, is associated with psychiatric disorders, particularly psychosis. The need for assessment of sensory functioning in people with ID, the difficulties inherent in this and the need for specialist services is stressed.     

Cognitive phenotype and psychiatric disorder in 22q11.2 deletion syndrome: A review

The behavioural phenotype of 22q11.2 deletion syndrome syndrome (22q11DS), one of the most common human multiple anomaly syndromes, frequently includes intellectual disability (ID) together with high risk of diagnosis of psychotic disorders including schizophrenia. Candidate cognitive endophenotypes include problems with retrieval of contextual information from memory and in executive control and focussing of attention. 22q11DS may offer a model of the relationship between ID and risk of psychiatric disorder. This paper reviews research on the relationship between the cognitive phenotype and the development of psychiatric disorders in 22q11DS.Aspects of cognitive function including verbal I.Q., visual memory, and executive function, are associated with mental health outcome in people with 22q11DS. This relationship may result from a common neurobiological basis for the cognitive difficulties and psychiatric disorders. Some of the cognitive difficulties experienced by people with 22q11DS, especially in attention, memory retrieval, and face processing, may, however, in themselves constitute risk factors for development of hallucinations and paranoid delusions.Future research into factors leading to psychiatric disorder in people with 22q11DS should include assessment of social and psychological factors including life events, symptoms associated with trauma, attachment, and self-esteem, which together with cognitive risk factors may mediate mental health outcome.     

Behavior therapy: an overview

The authors examine the broad field of behavior therapy, the theories underlying its development, and the techniques that are used to change behavior. They review recent developments in behavior therapy as they relate to behavioral medicine and to treatment of psychiatric disorders, and briefly describe the use of cognitive behavior therapy in the treatment of depression and other problems. They discuss methods of behavioral assessment and the application of behavior therapy in large populations, as well as new uses of behavioral techniques in business and industry, gerontology, and marital therapy.     

Psychiatric diagnoses in relation to severity of intellectual disability and challenging behaviors: a register study among older people

ABSTRACT

Objective: To investigate the possible association between severity of intellectual disability (ID) and presence of challenging behavior, respectively, on diagnoses of psychiatric disorders among older people with ID.

Methods: People with a diagnosis of ID in inpatient or specialist outpatient care in 2002–2012 were identified (n = 2147; 611 with mild ID, 285 with moderate ID, 255 with severe or profound ID, and 996 with other/unspecified ID). Moreover, using impairment of behavior as a proxy for challenging behavior, 627 people with, and 1514 without such behavior were identified.

Results: Severe/profound ID was associated with lower odds of diagnoses of psychotic, affective, and anxiety disorders than was mild/moderate ID. People with moderate ID had higher odds than those with mild ID of having diagnoses of affective disorders. Diagnoses of psychotic, affective, and anxiety disorders, and dementia were more common among people with challenging behavior than among those without.

Conclusions: People with severe/profound ID had lower odds of receiving psychiatric diagnoses than those with mild and moderate ID. Whether this is a result of differences in prevalence of disorders or diagnostic difficulties is unknown. Further, challenging behaviors were associated with diagnoses of psychiatric disorders. However, the nature of this association remains unclear.     

Current status of research on cognitive therapy/cognitive behavior therapy in Japan

Cognitive therapy/cognitive behavior therapy was introduced into the field of psychiatry in the late 1980s in Japan, and the Japanese Association for Cognitive Therapy (JACT), founded in 2004, now has more than 1500 members. Along with such progress, awareness of the effectiveness of cognitive therapy/cognitive behavioral therapy has spread, not only among professionals and academics but also to the public. The Study Group of the Procedures and Effectiveness of Psychotherapy, funded by the Ministry of Health, Labor and Welfare, has conducted a series of studies on the effectiveness of cognitive therapy/cognitive behavior therapy since 2006 and shown that it is feasible for Japanese patients. As a result, in April 2010 cognitive therapy/cognitive behavior therapy for mood disorders was added to the national health insurance scheme in Japan. This marked a milestone in Japan's psychiatric care, where pharmacotherapy has historically been more common. In this article the authors review research on cognitive therapy/cognitive behavior therapy in Japan.     

The potential of psychological interventions to improve quality of life and mood in muscle disorders

Quality of life (QoL) and mood are reduced in many patients with muscle disorders. Psychological variables appear to be contributors to both QoL and mood, suggesting that psychological interventions could improve these outcomes, yet research in this area is sparse. We review the roles of psychological variables, plus context and disease severity, in explaining QoL. A cognitive‐behavioral model of disease self‐management, with acceptance as the central component, is discussed. This model is then used to describe how psychological interventions derived from cognitive behavioral therapy (CBT), in particular Acceptance and Commitment Therapy (ACT), might be applied to address the issues of distress, nonadherence to treatments, pain, and fatigue in people with muscle disorders. Muscle Nerve 52 : 131–136, 2015     

An update on adjunctive treatment options for bipolar disorder

Objectives

Bipolar disorder is a complex illness often requiring combinations of therapies to successfully treat symptoms. In recent years, there have been significant advancements in a number of therapies for bipolar disorder. It is therefore timely to provide an overview of current adjunctive therapeutic options to help treating clinicians to inform their patients and work towards optimal outcomes.

Methods

Publications were identified from PubMed searches on bipolar disorder and pharmacotherapy, nutraceuticals, hormone therapy, psychoeducation, interpersonal and social rhythm therapy, cognitive remediation, mindfulness, e‐Health and brain stimulation techniques. Relevant articles in these areas were selected for further review. This paper provides a narrative review of adjunctive treatment options and is not a systematic review of the literature.

Results

A number of pharmacotherapeutic, psychological and neuromodulation treatment options are available. These have varying efficacy but all have shown benefit to people with bipolar disorder. Due to the complex nature of treating the disorder, combination treatments are often required. Adjunctive treatments to traditional pharmacological and psychological therapies are proving useful in closing the gap between initial symptom remission and full functional recovery.

Conclusions

Given that response to monotherapy is often inadequate, combination regimens for bipolar disorder are typical. Correspondingly, psychiatric research is working towards a better understanding of the disorder's underlying biology. Therefore, treatment options are changing and adjunctive therapies are being increasingly recognized as providing significant tools to improve patient outcomes. Towards this end, this paper provides an overview of novel treatments that may improve clinical outcomes for people with bipolar disorder.     

Prevalence of Psychiatric Diagnoses and Challenging Behaviors in a Community-Based Population of Adults With Intellectual Disability

Previous research has suggested substantial variation in prevalence rates of psychiatric disorders in individuals with intellectual disability (ID) and also differential patterns of associations between psychiatric disorders and challenging behaviors in people with ID. The aim of this study was to determine the prevalence rate of specific psychiatric disorders and challenging behaviors and the relationship between them in a community-based sample of individuals with ID. A community-based sample of 159 adults primarily with mild and moderate ID was surveyed for the presence of psychiatric disorders and challenging behaviors using the Behavior Problem Inventory and the Psychiatric Assessment Schedule (PAS-ADD). Individuals who met threshold on the PAS-ADD were subsequently evaluated using the Mini PAS-ADD Interview. Screening for psychiatric disorders using the PAS-ADD indicated a prevalence rate of 10%. There was a large discrepancy between the overall rate of challenging behaviors (45%) and the rate of psychiatric disorders identified by the Mini PAS-ADD Interview (6%). However, the rate of more severe behavior problems (8%) was closer to the rate of psychiatric disorders (6%). Thirty-one percent of people with severe challenging behaviors also were rated as having psychiatric disorders and odd ratio analysis indicates that individuals with severe challenging behaviors are substantially more likely to present with a psychiatric disorder. However, the relationship between different topographies of challenging behaviors and discrete diagnostic categories of psychiatric disorders appears to be unclear. This study reports a low prevalence of psychiatric disorders in a community-based population. The presence of severe challenging behaviors appears to have some association with psychiatric disorders but does not appear specific to discrete diagnostic categories. Clinicians and researchers need to debate the validity of considering challenging behaviors atypical manifestations of psychiatric disorders.     

A systematic review of neuropsychiatric comorbidities in patients with both epilepsy and intellectual disability

Epilepsy is a neurological condition that is particularly common in people with intellectual disability (ID). The care for people with both epilepsy and ID is often complicated by the presence of neuropsychiatric disorders, defined as psychiatric symptoms, psychiatric disorders, and behavioral problems. The aim of this study was to investigate associations between epilepsy or epilepsy-related factors and neuropsychiatric comorbidities in patients with ID and between ID and neuropsychiatric comorbidities in patients with epilepsy. We performed a systematic review of the literature, published between January 1995 and January 2015 and retrieved from PubMed/Medline, PsycINFO, and ERIC and assessed the risk of bias using the SIGN-50 methodology. Forty-two studies were identified, fifteen of which were assessed as having a low or acceptable risk-of-bias evaluation. Neuropsychiatric comorbidities were examined in relation to epilepsy in nine studies; in relation to epilepsy-related factors, such as seizure activity, seizure type, and medication in four studies; and in relation to the presence and degree of ID in five studies. We conclude that the presence of epilepsy only was not a clear determinant of neuropsychiatric comorbidity in patients with ID, although a tendency towards negative mood symptoms was identified. Epilepsy-related factors indicating a more severe form of epilepsy were associated with neuropsychiatric comorbidity as was the presence of ID as compared to those without ID in patients with epilepsy, although this should be validated in future research. A large proportion of the studies in this area is associated with a substantial risk of bias. There is a need for high quality studies using standardized methods to enable clear conclusions to be drawn that might assist in improving the quality of care for this population.     

Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review

Background: Acute stress disorder (ASD) predicts the development of posttraumatic stress disorder (PTSD), which in some sufferers can persist for years and lead to significant disability. We carried out a review of randomized controlled trials to give an update on which psychological treatments are empirically supported for these disorders, and used the criteria set out by Chambless and Hollon [1998: J Consult Clin Psychol 66:7–18] to draw conclusions about efficacy, first irrespective of trauma type and second with regard to particular populations. Methods: The PsycINFO and PubMed databases were searched electronically to identify suitable articles published up to the end of 2008. Fifty‐seven studies satisfied our inclusion criteria. Results: Looking at the literature undifferentiated by trauma type, there was evidence that trauma‐focused cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) are efficacious and specific for PTSD, stress inoculation training, hypnotherapy, interpersonal psychotherapy, and psychodynamic therapy are possibly efficacious for PTSD and trauma‐focused CBT is possibly efficacious for ASD. Not one of these treatments has been tested with the full range of trauma groups, though there is evidence that trauma‐focused CBT is established in efficacy for assault‐ and road traffic accident‐related PTSD. Conclusions: Trauma‐focused CBT and to a lesser extent EMDR (due to fewer studies having been conducted and many having had a mixed trauma sample) are the psychological treatments of choice for PTSD, but further research of these and other therapies with different populations is needed. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Implementation of psychological clinical trials in epilepsy: Review and guide

The International League Against Epilepsy (ILAE) Neuropsychiatry commission and United States Institute of Medicine report both identified cognitive and psychological comorbidities as a significant issue for individuals with epilepsy, with rates as high as 60%. However, there is a paucity of evidence-based treatments for many psychological conditions (e.g., learning disorders, cognitive disorders, behavioral disorders). Because of inherent challenges in the implementation of psychological therapy trials and specific considerations for the population with epilepsy, the focus of the current review was to provide guidance and recommendations to conduct psychological trials for individuals with epilepsy. Several key areas will be discussed, including selection of patients, trial design, psychological intervention considerations, outcomes and evaluation of results, publication of trial results, and special issues related to pediatric clinical trials. Rigorously designed psychological therapy trials will set the stage for evidence-based practice in the care of individuals with epilepsy, with the goal of improving seizures, side effects, and HRQOL.     

Non-Pharmacological Treatment of Insomnia

Insomnia is one of the most common sleep disorders, which is characterized by nocturnal symptoms of difficulties initiating and/or maintaining sleep, and by daytime symptoms that impair occupational, social, or other areas of functioning. Insomnia disorder can exist alone or in conjunction with comorbid medical and/or psychiatric conditions. The incidence of insomnia is higher in women and can increase during certain junctures of a woman??s life (e.g., pregnancy, postpartum, and menopause). This article will focus on an overview of cognitive behavioral therapy for insomnia, evidence of effectiveness for this treatment when insomnia disorder is experienced alone or in parallel with a comorbidity, and a review with promising data on the use of cognitive behavioral therapy for insomnia when present during postpartum and menopause.     

The prevalence of people with intellectual disability admitted to general hospital psychiatric units: level of handicap, psychiatric diagnoses and care utilization

Previous studies have stated that people with intellectual disability (ID) are more often afflicted by psychiatric disorders than the general population. In spite of the high prevalence of psychiatric disorders among people with ID, it is not known how many actually receive psychiatric in-patient care and treatment by the mental health services. In the present study, the number of people with mild and severe ID admitted to in-patient psychiatric care were compared with corresponding figures in the general population in Sweden. The results show a low frequency of psychiatric care utilization among people with ID and coexisting psychiatric disorders in comparison to the proportion of psychiatric care utilization among people with psychiatric disorders in the general population. The results are discussed in terms of how the level of ID might influence referral or diagnoses, the length of admissions, and the support provided within the special services to people with ID and psychiatric disorders.     

Behavioral and psychological symptoms of dementia in relation to level of cognitive impairment

BACKGROUND: Many people with dementia exhibit some behavioral or psychological symptoms, e.g. aggressive or aberrant motor behavior, depression or hallucinations, at some time during the course of the disorder. The aim of the present study was to describe the probability of the occurrence of these symptoms of dementia in relation to the level of cognitive impairment. METHODS: 3404 people with cognitive impairment were selected from two large cross-sectional surveys of those in geriatric care settings, conducted in 1982 and 2000 in the county of V?sterbotten, Sweden. Symptoms were assessed using the Multi-Dimensional Dementia Assessment Scale (MDDAS), subsumed with a rotated factor analysis, and investigated in relation to level of cognitive impairment, measured using the Gottfries cognitive scale. RESULTS: The passiveness factor had an almost linear correlation to the level of cognitive impairment (r2 = 0.237). Non-linear correlations, with highest prevalences in middle-stage cognitive impairment, were found for aggressive behavior (r2 = 0.057), wandering behavior (r2 = 0.065), restless behavior (r2 = 0.143), verbally disruptive/attention-seeking behavior (r2 = 0.099), regressive/inappropriate behavior (r2 = 0.058), hallucinatory symptoms (r2 = 0.021) and depressive symptoms (r2 = 0.029). CONCLUSION: The relations between the behavioral and psychological symptoms of dementia and level of cognitive impairment were non-linear, with higher prevalence rates in the middle stages of dementia, apart from the symptom of passiveness, which increased almost linearly with the severity of cognitive impairment.     

L’approche psychologique des troubles anxieux : information, soutien et psychothérapies

Anxiety disorders (panic disorder, generalized anxiety disorders, phobia) are very prevalent and have frequently serious consequences on social, familial and professional adaptation. Their treatments are in some cases based on pharmacotherapy, but in most cases on psychological approaches. In particular, cognitive-behavioral therapies have for a long time demonstrated their efficacy. The behavioral techniques consist on relaxation learning and on exposition to feared stimuli. The cognitive treatments aim to identify the dysfunctional process of thinking and to modify anxiogenic cognitive schemes. Social phobia are frequently treated with group therapy, including social skills training, exposure techniques and cognitive restructuration. These methods have to be applied by trained clinicians, but non-specialized physicians could play three key roles in the treatment process: diagnostic recognition, patients information and orientation towards specific psychological treatment.