Preventing psychosis in patients at clinical high risk may be a promising avenue for pre‐emptively ameliorating outcomes of the most severe psychiatric disorder. However, information on how each ...preventive intervention fares against other currently available treatment options remains unavailable. The aim of the current study was to quantify the consistency and magnitude of effects of specific preventive interventions for psychosis, comparing different treatments in a network meta‐analysis. PsycINFO, Web of Science, Cochrane Central Register of Controlled Trials, and unpublished/grey literature were searched up to July 18, 2017, to identify randomized controlled trials conducted in individuals at clinical high risk for psychosis, comparing different types of intervention and reporting transition to psychosis. Two reviewers independently extracted data. Data were synthesized using network meta‐analyses. The primary outcome was transition to psychosis at different time points and the secondary outcome was treatment acceptability (dropout due to any cause). Effect sizes were reported as odds ratios and 95% confidence intervals (CIs). Sixteen studies (2,035 patients, 57% male, mean age 20.1 years) reported on risk of transition. The treatments tested were needs‐based interventions (NBI); omega‐3 + NBI; ziprasidone + NBI; olanzapine + NBI; aripiprazole + NBI; integrated psychological interventions; family therapy + NBI; D‐serine + NBI; cognitive behavioural therapy, French & Morrison protocol (CBT‐F) + NBI; CBT‐F + risperidone + NBI; and cognitive behavioural therapy, van der Gaag protocol (CBT‐V) + CBT‐F + NBI. The network meta‐analysis showed no evidence of significantly superior efficacy of any one intervention over the others at 6 and 12 months (insufficient data were available after 12 months). Similarly, there was no evidence for intervention differences in acceptability at either time point. Tests for inconsistency were non‐significant and sensitivity analyses controlling for different clustering of interventions and biases did not materially affect the interpretation of the results. In summary, this study indicates that, to date, there is no evidence that any specific intervention is particularly effective over the others in preventing transition to psychosis. Further experimental research is needed.
ABSTRACT
Several lines of evidence suggest that the normal integration of cerebral communication may be compromised in schizophrenia, with white matter (WM) abnormalities being integral to these ...functional deficits. Diffusion tensor imaging (DTI) is a neuroimaging technique which has increasingly been used to study WM through quantitative indices of its structural and orientational characteristics. Identifying the WM differences early in the course of schizophrenia may assist in prevention, early diagnosis and identification of treatment targets. In that respect, the aims of the present study were to (a) systematically review WM integrity in the early stages of schizophrenia as inferred by DTI and (b) specifically examine parameters that may affect WM: age, duration of illness and treatment. In summary, DTI studies in early schizophrenia suggest that structural dysconnectivity may be already present in recent‐onset and drug‐naïve patients, as well as in individuals clinically at high risk for developing schizophrenia. Although the pattern of WM differences is not totally consistent frontal, fronto‐temporal and fronto‐limbic connections, with tracts including the superior longitudinal fasciculus, cingulum bundle, uncinate fasciculus and corpus callosum seem to be affected. These differences may depend on the developmental stage of the subjects, the duration of illness and exposure to antipsychotic medication.
Top‐tier evidence on the safety/tolerability of 80 medications in children/adolescents with mental disorders has recently been reviewed in this journal. To guide clinical practice, such data must be ...combined with evidence on efficacy and acceptability. Besides medications, psychosocial interventions and brain stimulation techniques are treatment options for children/adolescents with mental disorders. For this umbrella review, we systematically searched network meta‐analyses (NMAs) and meta‐analyses (MAs) of randomized controlled trials (RCTs) evaluating 48 medications, 20 psychosocial interventions, and four brain stimulation techniques in children/adolescents with 52 different mental disorders or groups of mental disorders, reporting on 20 different efficacy/acceptability outcomes. Co‐primary outcomes were disease‐specific symptom reduction and all‐cause discontinuation (“acceptability”). We included 14 NMAs and 90 MAs, reporting on 15 mental disorders or groups of mental disorders. Overall, 21 medications outperformed placebo regarding the co‐primary outcomes, and three psychosocial interventions did so (while seven outperformed waiting list/no treatment). Based on the meta‐analytic evidence, the most convincing efficacy profile emerged for amphetamines, methylphenidate and, to a smaller extent, behavioral therapy in attention‐deficit/hyperactivity disorder; aripiprazole, risperidone and several psychosocial interventions in autism; risperidone and behavioral interventions in disruptive behavior disorders; several antipsychotics in schizophrenia spectrum disorders; fluoxetine, the combination of fluoxetine and cognitive behavioral therapy (CBT), and interpersonal therapy in depression; aripiprazole in mania; fluoxetine and group CBT in anxiety disorders; fluoxetine/selective serotonin reuptake inhibitors, CBT, and behavioral therapy with exposure and response prevention in obsessive‐compulsive disorder; CBT in post‐traumatic stress disorder; imipramine and alarm behavioral intervention in enuresis; behavioral therapy in encopresis; and family therapy in anorexia nervosa. Results from this umbrella review of interventions for mental disorders in children/adolescents provide evidence‐based information for clinical decision making.
The impact of air pollution and climate change on mental health has recently raised strong concerns. However, a comprehensive overview analyzing the existing evidence while addressing relevant biases ...is lacking. This umbrella review systematically searched the PubMed/Medline, Scopus and PsycINFO databases (up to June 26, 2023) for any systematic review with meta‐analysis investigating the association of air pollution or climate change with mental health outcomes. We used the R metaumbrella package to calculate and stratify the credibility of the evidence according to criteria (i.e., convincing, highly suggestive, suggestive, or weak) that address several biases, complemented by sensitivity analyses. We included 32 systematic reviews with meta‐analysis that examined 284 individual studies and 237 associations of exposures to air pollution or climate change hazards and mental health outcomes. Most associations (n=195, 82.3%) involved air pollution, while the rest (n=42, 17.7%) regarded climate change hazards (mostly focusing on temperature: n=35, 14.8%). Mental health outcomes in most associations (n=185, 78.1%) involved mental disorders, followed by suicidal behavior (n=29, 12.4%), access to mental health care services (n=9, 3.7%), mental disorders‐related symptomatology (n=8, 3.3%), and multiple categories together (n=6, 2.5%). Twelve associations (5.0%) achieved convincing (class I) or highly suggestive (class II) evidence. Regarding exposures to air pollution, there was convincing (class I) evidence for the association between long‐term exposure to solvents and a higher incidence of dementia or cognitive impairment (odds ratio, OR=1.139), and highly suggestive (class II) evidence for the association between long‐term exposure to some pollutants and higher risk for cognitive disorders (higher incidence of dementia with high vs. low levels of carbon monoxide, CO: OR=1.587; higher incidence of vascular dementia per 1 μg/m3 increase of nitrogen oxides, NOx: hazard ratio, HR=1.004). There was also highly suggestive (class II) evidence for the association between exposure to airborne particulate matter with diameter ≤10 μm (PM10) during the second trimester of pregnancy and the incidence of post‐partum depression (OR=1.023 per 1 μg/m3 increase); and for the association between short‐term exposure to sulfur dioxide (SO2) and schizophrenia relapse (risk ratio, RR=1.005 and 1.004 per 1 μg/m3 increase, respectively 5 and 7 days after exposure). Regarding climate change hazards, there was highly suggestive (class II) evidence for the association between short‐term exposure to increased temperature and suicide‐ or mental disorders‐related mortality (RR=1.024), suicidal behavior (RR=1.012), and hospital access (i.e., hospitalization or emergency department visits) due to suicidal behavior or mental disorders (RR=1.011) or mental disorders only (RR=1.009) (RR values per 1°C increase). There was also highly suggestive (class II) evidence for the association between short‐term exposure to increased apparent temperature (i.e., the temperature equivalent perceived by humans) and suicidal behavior (RR=1.01 per 1°C increase). Finally, there was highly suggestive (class II) evidence for the association between the temporal proximity of cyclone exposure and severity of symptoms of post‐traumatic stress disorder (r=0.275). Although most of the above associations were small in magnitude, they extend to the entire world population, and are therefore likely to have a substantial impact. This umbrella review classifies and quantifies for the first time the global negative impacts that air pollution and climate change can exert on mental health, identifying evidence‐based targets that can inform future research and population health actions.
The developmental period from 0 to 25 years is a vulnerable time during which children and young people experience many psychosocial and neurobiological changes and an increased incidence of mental ...illness. New clinical services for children and young people aged 0 to 25 years may represent a radical transformation of mental healthcare.
Critical, non-systematic review of the PubMed literature up to 3rd January 2019.
: the youngest age group has an increased risk of developing mental disorders and 75% of mental disorders begin by the age of 24 and prodromal features may start even earlier. Most of the risk factors for mental disorders exert their role before the age of 25, profound maturational brain changes occur from mid-childhood through puberty to the mid-20s, and mental disorders that persist in adulthood have poor long-term outcomes. The optimal window of opportunity to improve the outcomes of mental disorders is the prevention or early treatment in individuals aged 0 to 25 within a clinical staging model framework.
: children and young people face barriers to primary and secondary care access, delays in receiving appropriate treatments, poor engagement, cracks between child and adult mental health services, poor involvement in the design of mental health services, and lack of evidence-based treatments.
: the most established paradigm for reforming youth mental services focuses on people aged 12-25 who experienced early stages of psychosis. Future advancements may include early stages of depression and bipolar disorders. Broader youth mental health services have been implemented worldwide, but no single example constitutes best practice. These services seem to improve access, symptomatic and functional outcomes, and satisfaction of children and young people aged 12-25. However, there are no robust controlled trials demonstrating their impact. Very limited evidence is available for integrated mental health services that focus on people aged 0-12.
Children and young people aged 12-25 need youth-friendly mental health services that are sensitive to their unique stage of clinical, neurobiological, and psychosocial development. Early intervention for psychosis services may represent the starting platform to refine the next generation of integrated youth mental health services.
Psychosis is the most ineffable experience of mental disorder. We provide here the first co‐written bottom‐up review of the lived experience of psychosis, whereby experts by experience primarily ...selected the subjective themes, that were subsequently enriched by phenomenologically‐informed perspectives. First‐person accounts within and outside the medical field were screened and discussed in collaborative workshops involving numerous individuals with lived experience of psychosis as well as family members and carers, representing a global network of organizations. The material was complemented by semantic analyses and shared across all collaborators in a cloud‐based system. The early phases of psychosis (i.e., premorbid and prodromal stages) were found to be characterized by core existential themes including loss of common sense, perplexity and lack of immersion in the world with compromised vital contact with reality, heightened salience and a feeling that something important is about to happen, perturbation of the sense of self, and need to hide the tumultuous inner experiences. The first episode stage was found to be denoted by some transitory relief associated with the onset of delusions, intense self‐referentiality and permeated self‐world boundaries, tumultuous internal noise, and dissolution of the sense of self with social withdrawal. Core lived experiences of the later stages (i.e., relapsing and chronic) involved grieving personal losses, feeling split, and struggling to accept the constant inner chaos, the new self, the diagnosis and an uncertain future. The experience of receiving psychiatric treatments, such as inpatient and outpatient care, social interventions, psychological treatments and medications, included both positive and negative aspects, and was determined by the hope of achieving recovery, understood as an enduring journey of reconstructing the sense of personhood and re‐establishing the lost bonds with others towards meaningful goals. These findings can inform clinical practice, research and education. Psychosis is one of the most painful and upsetting existential experiences, so dizzyingly alien to our usual patterns of life and so unspeakably enigmatic and human.
Background
Clinical research into the Clinical High Risk state for Psychosis (CHR‐P) has allowed primary indicated prevention in psychiatry to improve outcomes of psychotic disorders. The strategic ...component of this approach is the implementation of clinical services to detect and take care of CHR‐P individuals, which are recommended by several guidelines. The actual level of implementation of CHR‐P services worldwide is not completely clear.
Aim
To assess the global geographical distribution, core characteristics relating to the level of implementation of CHR‐P services; to overview of the main barriers that limit their implementation at scale.
Methods
CHR‐P services worldwide were invited to complete an online survey. The survey addressed the geographical distribution, general implementation characteristics and implementation barriers.
Results
The survey was completed by 47 CHR‐P services offering care to 22 248 CHR‐P individuals: Western Europe (51.1%), North America (17.0%), East Asia (17.0%), Australia (6.4%), South America (6.4%) and Africa (2.1%). Their implementation characteristics included heterogeneous clinical settings, assessment instruments and length of care offered. Most CHR‐P patients were recruited through mental or physical health services. Preventive interventions included clinical monitoring and crisis management (80.1%), supportive therapy (70.2%) or structured psychotherapy (61.7%), in combination with pharmacological treatment (in 74.5%). Core implementation barriers were staffing and financial constraints, and the recruitment of CHR‐P individuals. The dynamic map of CHR‐P services has been implemented on the IEPA website: https://iepa.org.au/list‐a‐service/.
Conclusions
Worldwide primary indicated prevention of psychosis in CHR‐P individuals is possible, but the implementation of CHR‐P services is heterogeneous and constrained by pragmatic challenges.
Aims
To test how attentional bias and explicit liking are influenced by delta‐9‐tetrahydrocannabinol (THC) and whether these effects are moderated by cannabidiol (CBD).
Design
Double‐blind, ...randomised, within‐subjects cross‐over study.
Setting
NIHR Wellcome Trust Clinical Research Facility at King's College Hospital, London, United Kingdom.
Participants/Cases
Forty‐six infrequent cannabis users (cannabis use <1 per week).
Intervention(s)
Across four sessions, participants inhaled vaporised cannabis containing 10 mg of THC and either 0 mg (0:1 CBD:THC), 10 mg (1:1), 20 mg (2:1) or 30 mg (3:1) of CBD, administered in a randomised order and counter‐balanced across participants (a total of 24 order groups).
Measurements
Participants completed two tasks: (1) Attentional Bias (AB), comparing reaction times toward visual probes presented behind 28 target stimuli (cannabis/food) compared with probes behind corresponding non‐target (neutral) stimuli. Participants responding more quickly to probes behind target than non‐target stimuli would indicate greater attentional bias to cannabis/food; (2) Picture Rating (PR), where all AB stimuli were rated on a 7‐point pleasantness scale, measuring explicit liking.
Findings
During the AB task, participants were more biased toward cannabis stimuli in the 0:1 condition compared with baseline (mean difference = 12.2, 95% confidence intervals CIs = 1.20–23.3, d = 0.41, P = 0.03). No other significant AB or PR differences were found between cannabis and food stimuli between baseline and 0:1 condition (P > 0.05). No significant CBD effect was found on AB or PR task performance at any dose (P > 0.05). There was additionally no cumulative effect of THC exposure on AB or PR outcomes (P > 0.05).
Conclusions
A double‐blind, randomised, cross‐over study among infrequent cannabis users found that inhaled delta‐9‐tetrahydrocannabinol increased attentional bias toward cannabis in the absence of explicit liking, a marker of liability toward cannabis use disorder. At the concentrations normally found in legal and illegal cannabis, cannabidiol had no influence on this effect.
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