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To explore current and potential upcoming legal provisions concerning advance healthcare directives in psychiatry in Ireland, with particular focus on clinical challenges and ethical issues (e.g., self-harm, suicide).
Methods:
Review and analysis of selected relevant sections of the Assisted Decision-Making (Capacity) Act 2015, Assisted Decision-Making (Capacity) (Amendment) Act 2022, Mental Health Act 2001, Mental Health Bill 2024, and Criminal Law (Suicide) Act 1993, and relevant publications from Ireland’s Medical Council and Decision Support Service.
Results:
The Assisted Decision-Making (Capacity) Act 2015 outlined new procedures for advance healthcare directives. The Assisted Decision-Making (Capacity) (Amendment) Act 2022 specified that advance healthcare directives relating to mental health are binding for involuntary patients unless involuntary status is based on Section 3(1)(a) of the Mental Health Act 2001 (i.e., the ‘risk’ criteria). The Mental Health Bill 2024 proposes making advance healthcare directives binding for all involuntary patients. In relation to suicide and self-harm, the Criminal Law (Suicide) Act 1993 states that ‘a person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be guilty of an offence’, and the Decision Support Service advises that healthcare professionals are exempted from criminal liability if complying with a valid and applicable advance healthcare directive that refuses life-sustaining treatment, even where the directive-maker has attempted suicide.
Conclusions:
Considerable public and professional education are needed if advance healthcare directives are to be widely used. The ethical dimensions of certain advance directives require additional thought and, ideally, professional ethical guidance.
This study described the development and assessment of the psychometric properties of the Dissociation-Integration of Self-States Scale (D-ISS). This is a new scale to assess dissociation at the ‘between modes’ or self-state (personality) level. The D-ISS is rooted in cognitive behavioural theory and designed to measure between-mode dissociation (dissociation between self-states) in clinical practice and research.
Method:
Study 1: D-ISS scale items were generated and then answered by 344 young adults (16–25 years) who reported experiencing stressful times. An exploratory factor analysis (EFA) was conducted and the results were used to refine the scale to 25 items.
Study 2: The final 25-item D-ISS was completed by 383 adults (18–65 years) who reported experiencing mental health difficulties. A confirmatory factor analysis (CFA) was conducted using the second dataset. Internal consistency, test–retest reliability, convergent validity and divergent validity of the final D-ISS was assessed.
Results:
Study 1: The EFA showed a clear 5-factor solution, which was used to refine the D-ISS to a total of 25 items with five items in each factor.
Study 2: The 5-factor solution from Study 1 was confirmed as a good fit by the CFA using the data collected in Study 2. The D-ISS demonstrated good internal reliability and test–retest reliability. The D-ISS showed no correlations with divergent scales. For convergent validity, the D-ISS showed moderate correlations with the Dissociative Experiences Scale (DES-II).
Conclusions:
The new D-ISS measure of between-mode dissociation is reliable and valid for the population represented by our sample. Further research into its use in clinical populations is required.
Key learning aims
(1) To understand and be able to use a new measure of dissociation at the personality or self-states level.
(2) To understand the cognitive behavioural model of dissociation.
(3) To understand the theoretical underpinnings of the scale, in terms of the effects of childhood and adult adversity and other factors on psychological development.
(4) To consider the potential clinical and research applications of the scale.
(5) To appreciate the limitations of the research so far and the nature of future research required.
The prevalence of alcohol use disorder among older adults is increasing, with this population being particularly vulnerable to alcohol’s detrimental effects. While knowledge of preventative factors is scarce, physical activity has emerged as a potential modifiable protective factor. This study aimed to examine associations between alcohol consumption and physical activity in a large-scale, multi-national prospective study of the older adult population.
Methods
Longitudinal data from the SHARE study on physical activity, alcohol consumption, demographic, socioeconomic, and health variables, were analyzed in older adults. Individual-level data were examined using logistic regression models. Both cross-sectional and longitudinal models were calculated to account for potential latency in the association between physical activity and alcohol consumption.
Results
The study included 3133 participants from 13 countries. Higher physical activity levels were significantly associated with higher alcohol consumption in cross-sectional (p = 0.0004) and longitudinal analyses (p = 0.0045) over a median follow-up of 6 years. While the presence of depressive symptoms and higher educational attainment were associated with higher alcohol consumption, female sex and persons with lower perceived health showed lower frequency of alcohol consumption. Additionally, the country of residence also proved to be a relevant factor for alcohol consumption.
Conclusions
Higher levels of physical activity showed an association with higher alcohol consumption in older adults. Future research should investigate whether this association is causal and underpinned by neurobiological, social, or methodological factors.
The literature on cortical excitability, inhibitory and facilitatory properties of the brain in patients with primary dystonia is not well elucidated. We aimed to study the changes in these neurophysiological parameters in patients with dystonia using transcranial magnetic stimulation (TMS).
Methods:
Patients with primary dystonia of presumed genetic etiology (n = 36) and an equal number of healthy controls (HC) (n = 36) were recruited from May 2021 to September 2022. TMS was done using single and paired pulse paradigms. The left motor cortex was stimulated, and responses were recorded from the contralateral first dorsal interosseus muscle. Resting motor threshold (RMT), central motor conduction time, contralateral silent period (cSP), ipsilateral silent period (iSP), short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF) were recorded. All patients underwent whole exome sequencing.
Results:
The mean age of patients was 36.6 ± 13.5 years. There was a significant reduction of cSP (79.5 ± 33.8 vs 97.5 ± 25.4, p = 0.02) and iSP (42.3 ± 13.5 vs 53.8 ± 20.8, p = 0.003) in patients compared to HC. SICI was significantly enhanced in patients (0.38 ± 0.23) compared to HC (0.51 ± 0.24, p = 0.006). RMT was higher (42.1 ± 7.9 vs 37.1 ± 6.4%, p = 0.032) with enhanced SICI (0.36 ± 0.21 vs 0.56 ± 0.25, p = 0.004) in patients with generalized dystonia (n = 20) compared to HC. The genetically determined subgroup (n = 13) had significantly enhanced SICI compared to HC (0.23 ± 0.15 vs 0.51 ± 0.23, p = 0.001).
Conclusions:
Patients with primary dystonia have altered cortical excitability and inhibition with significantly reduced silent period and enhanced intracortical inhibition suggestive of impaired GABAergic neurotransmission.
Childhood obsessive-compulsive disorder (OCD) stems from a bunch of restricted and repetitive behaviors, which are part of normal behavioral repertoire up to the age of 7. The persistence of compulsive-like behaviors after that age is often associated with unique comorbidity patterns, which are age-at-onset dependent and reflect different developmental stages. In particular, OCD synchronically co-occurs with a broad constellation of neurodevelopmental disorders, whereas diachronically it is related to an increased risk of major adult psychoses. Moreover, OCD is associated with trait-like sensory phenomena, suggesting a common disrupted sensorimotor grounding.
The present study is aimed at exploring the hypothesis that this specific temporal and comorbidity OCD profile may be due to a developmental heterochronic mechanism of delay in attenuation of ontogenetically early behavioral patterns. The developmental shift of highly evolutionarily conserved behavioral phenotypes might be regulated by epigenetic changes induced by different conditions of sensory unbalance. This evolutionary and developmental model allows capturing childhood OCD in light of the ultimate causes of ritual behavior throughout phylogeny, namely its “homeostatic” function over conditions of unpredictability. Moreover, it may have important clinical implications, as OCD symptoms could represent putative biomarkers of early divergent developmental trajectories, with a pathoplastic effect on course and outcome.
The study assessed the interactions and the impact of specialist mobile community care teams (assertive outreach teams or AOTs) implemented in the mental health (MH) system of Bizkaia (Spain) using a methodology derived from an ecosystem perspective.
Methods
First, the experts assessed the system’s services and codified them according to an international classification system. Second, following an iterative methodology for expert-knowledge elicitation, a clients’ flow diagram showing the inter-dependencies of the system’s components was developed. It included variables and their relationships represented in a causal model. Third, the system elements where the AOTs had a major impact (stress nodes) were identified. Fourth, three scenarios (variable combinations representing the ‘stress points’ of the system) were modelled to assess its relative technical efficiency (technical performance indicator).
Results
The classification system identified the lack of fidelity of the AOTs to the original assertive community treatment model, categorizing them as non-acute low-intensity mobile care. The causal model identified the following elements of the system as ‘stress nodes’ in relation to AOT: users’ families; social services (outside of the healthcare system); acute hospitals; non-acute residential facilities and, to a lesser extent, acute hospital day care services. When the stress nodes inside the healthcare system were modelled separately, acute and non-acute hospital care services resulted in a large deterioration in the system performance, while acute day hospital care had only a small impact.
Conclusions
The development of the expert-knowledge-based causal model from an ecosystem perspective was helpful in combining information from different levels, from nano to macro, to identify the components in the system likely to be most affected by a potential policy intervention, such as the closure of AOTs. It was also able to illustrate the interaction between the MH system components over time and the impact of the potential changes on the technical performance of the system. Such approaches have potential future application in assisting with service planning and decision-making in other health systems and socio-economic contexts.
Mild behavioural impairment (MBI) is a neurobehavioral prodrome to dementia with multiple phenotypic characteristics. To investigate the complex neurobiological substrate underlying MBI, we evaluated its association with a composite magnetic resonance imaging (MRI)-based measure of concomitant cerebrovascular disease (CeVD) and neurodegeneration; and the interaction effects of MBI and MRI scores on cognitive and clinical trajectory.
Methods:
253 dementia-free participants (mean age = 71.9, follow-up period = 49.89 months) from 2 memory clinics were included in this study. 37 (14.6%) participants met clinical diagnostic criteria for MBI, ascertained by repeated neuropsychiatric inventory assessments. MRI scores were computed using a validated weighted sum of white matter hyperintensities volume, presence of infarct, hippocampal volume, and cortical thickness of known Alzheimer’s disease-associated regions. Clinical and cognitive outcomes were evaluated annually using the Clinical Dementia Rating sum-of-boxes (CDR-SB) and standardised global cognitive scores of a comprehensive neuropsychological battery respectively.
Results:
Lower MRI scores, indicating greater burden of comorbid CeVD and neurodegeneration, yielded a 3.8-fold likelihood of MBI compared to 1.5-fold with larger WMH volume or lower cortical thickness individually. Interaction analyses showed that MBI participants with low MRI scores had greater increase in CDR-SB (B = 0.05, SE = 0.01, p < 0.001) over time. All models involving the composite MRI measure yielded a better fit compared to reduced models with either pathology alone.
Conclusion:
MBI is associated with a composite MRI measure that reflects mixed pathologies of dementia and their co-evaluation may improve risk profiling and identification of memory clinic patients without dementia who are at the highest risk of experiencing clinical decline.
One of the most effective treatments for social anxiety disorder (SAD) is cognitive behavioural therapy (CBT). Prior research indicates group cohesion is connected to treatment success in group CBT for SAD (CBGT). Videoconference CBGT delivery is now common following the COVID-19 pandemic; however, research investigating treatment outcomes and group cohesion in videoconference CBGT for SAD is limited.
Aims:
The present study aimed to compare group cohesion in videoconference CBGT for SAD to group cohesion in both in-person CBGT for SAD and videoconference CBGT for other anxiety and related disorders. A secondary aim was to compare symptom reduction across all three groups.
Method:
Patients completed a 12-week CBGT program for SAD in-person (n=28), SAD via videoconference (n=46), or for another anxiety or related disorder via videoconference (n=100). At mid- and post-treatment patients completed the Group Cohesion Scale Revised (GCS-R), and at pre- and post-treatment patients completed the Social Phobia Inventory (SPIN, only in the SAD groups) and the Depression Anxiety Stress Scales (DASS-21).
Results:
Over the course of treatment, all three groups showed a significant increase in cohesion and a significant decrease in symptoms (ηp2 ranged from .156 to .562, all p<.001). Furthermore, analyses revealed no significant difference in cohesion scores between groups at both mid- and post-treatment.
Conclusions:
These results suggest that videoconference CBGT for SAD is similarly effective in facilitating cohesion and reducing symptoms compared with in-person delivery. Limitations of the study and implications for treatment are discussed.
The notion of cognitive detachment (i.e. the capacity to treat thoughts as just thoughts, with no greater significance or importance) is introduced in this paper. Its link to similar established terminologies (e.g. distancing, decentering, defusion/deliteralisation, detached mindfulness), importance within cognitive behaviour therapies and place within an adapted cognitive-behavioural framework is highlighted. The use of metaphor to facilitate cognitive detachment is then the primary focus of the paper. An overview of how metaphor has typically been used within psychotherapy is presented and reflects mostly the use of therapist-generated metaphor for psychoeducational purposes. While the use of metaphor in serving a therapeutic cognitive detachment function is not new, developing idiosyncratic client-generated metaphors in this regard has been largely neglected, despite the widely held view that client-generated metaphors are more potent. Practical guidance on how clinicians can collaboratively assist clients to intentionally generate their own personalised cognitive detachment metaphor is provided, and specific ways to elaborate metaphors during therapy to enhance metaphor application and hence effectiveness in enabling cognitive detachment is considered. Finally, clinical examples are provided to illustrate the varied, creative and rich metaphors that can emerge from this process.
Key learning aims
(1) To introduce the term cognitive detachment and understand this important therapy target within an adapted cognitive-behavioural framework.
(2) To appreciate the broader use of metaphors in therapy and frame metaphor as one method for facilitating cognitive detachment.
(3) To motivate therapists to pursue idiosyncratic client-generated metaphor.
(4) To provide an instructional script to support therapists to help clients develop a personalised cognitive detachment metaphor.
(5) To provide specific guidance to therapists regarding methods for metaphor elaboration.
Depression affects twice as many women as men. Risk factors for depression certainly impact this difference, but their strong interconnectedness challenges the assessment of standalone contributions. Network models allow the identification of systematic independent relationships between individual symptoms and risk factors. This study aimed to evaluate whether the extended networks of depressive symptoms, cognitive functions, and leisure activities in like-sex twins differ depending on gender or zygosity.
Methods
Twins, including 2,040 women (918 monozygotic and 1,122 dizygotic) and 1,712 men (730 monozygotic and 982 dizygotic), were selected from the Danish Twin Registry for having, along with their like-sex co-twin, completed measures of depressive symptoms, cognition, and leisure activities (physical, intellectual, and social). Network models were estimated and compared at three levels: co-twins to each other within groups defined by gender and zygosity; monozygotic to dizygotic twins within the same gender, and between genders.
Results
No significant differences were observed when co-twins were compared to each other, regardless of the pair’s zygosity or gender, nor when monozygotic twins were compared to dizygotic twins within gender. However, the gendered networks differed significantly in global strength, structure, and partial correlations between specific depressive symptoms and risk factors, all indicating stronger connectedness in women relative to men.
Conclusions
Environmental factors appear to best explain between-gender network differences. Women’s networks showed significantly stronger associations both among depressive symptoms and between depressive symptoms and risk factors (i.e., decreased cognition and leisure activities). Longitudinal research is needed to determine the causality and directionality of these relationships.
The COVID-19 pandemic has had a negative impact on the population’s mental health, particularly for individuals with health anxiety (HA) and obsessive compulsive disorder (OCD). This is in conjunction with a significant change in accessibility of face-to-face psychological services which have had to rapidly adapt to the remote delivery of therapy.
Aims:
Using a single-arm open trial design, the study aimed to evaluate the effectiveness of evidence-based CBT interventions for HA and OCD delivered via a blend of online therapist consultations interspersed with self-study reading materials. A secondary aim was to evaluate remote training workshops provided to therapists.
Method:
Therapists attended three half-day remote workshops after which consecutive participants with HA or OCD were assigned to therapists for treatment. Monthly expert supervision was provided. Patients completed routine outcome measures at each session and an idiosyncratic measure of pre-occupation with COVID-19 at pre- and post-treatment.
Results:
Significant and comparable improvements were observed on measures of anxiety, depression and social adjustment from pre- to post-treatment in both the HA (n=14) and OCD (n=20) groups. Disorder-specific measures also showed significant improvements after treatment. The HA group showed greater levels of change on the COVID-19-specific questionnaire. The training workshops were well received by therapists, who valued the monthly supervision sessions.
Conclusions:
The study provides support for the effectiveness of the online delivery of CBT for HA and OCD supported by the inclusion of additional self-study booklets.
Selective serotonin reuptake inhibitors (SSRIs) have been associated with increased risk of osteoporosis, and sertraline may be more potent than citalopram in this regard. Here, target trial emulation was used to investigate whether sertraline, citalopram and escitalopram (the S-enantiomer of citalopram) differentially affect the risk of osteoporosis. Subsequently, it was examined whether SSRIs increase the risk of osteoporosis in a dose-response-like manner.
Methods:
Danish nationwide registers were used to identify all individuals that initiated treatment for depression with sertraline, citalopram, or escitalopram between January 1, 2007, and March 1, 2019. These individuals were followed until development of osteoporosis, death, or end of follow-up. Cox proportional hazards regression was used to adjust for relevant baseline covariates to emulate randomised treatment allocation to compare the rate of osteoporosis for individuals treated with sertraline, citalopram or escitalopram. Subsequently, the cumulative dose of sertraline, citalopram, and escitalopram was calculated, and Cox proportional hazards regression was used to assess dose-response-like relationships with osteoporosis.
Results:
We identified 27,280, 65,529, and 17,703 individuals initiating treatment with sertraline, citalopram, and escitalopram, respectively. There was no material or statistically significant differential risk of osteoporosis between these groups (adjusted hazard rate ratio, aHRR = 0.98 for citalopram versus sertraline and aHRR = 0.94 for escitalopram versus sertraline). The results were not indicative of the SSRIs having a dose-response-like effect on osteoporosis risk.
Conclusions:
Sertraline, citalopram and escitalopram do not appear to differentially affect the risk of osteoporosis. The lack of clear dose-response-like relationships suggest that they do not have a causal effect on osteoporosis risk.
This article introduces a novel methodology to model the hierarchical dependence structure of manifest variables (MVs). This is done by reconstructing their correlation matrix considering a hierarchy of latent factors which forms an ultrametric correlation matrix. The proposed ultrametric factor analysis model will be shown to obtain reliable, unidimensional, and unique hierarchical factors. This approach addresses the limitations of traditional factor analysis methods that often oversimplify the multidimensional and complex relationships among MVs. The article provides an in-depth mathematical description of the proposed model, as well as an algorithm for parameter estimation. An extensive simulation study with $3,000$ generated samples validates the proposal across twelve different scenarios. Finally, we demonstrate the potential of the proposed model using a real data set that is a benchmark in psychological research.
The goodness of fit of categorical models of psychological processes is often assessed with the log-likelihood ratio statistic (G2), but its underlying asymptotic theory is known to have limited empirical validity. We use examples from the scenario of fitting psychometric functions to psychophysical discrimination data to show that two factors are responsible for occasional discrepancies between actual and asymptotic distributions of G2. One of them is the eventuality of very small expected counts, by which the number of degrees of freedom should be computed as (J−1) × I−P−K0.06, where J is the number of response categories in the task, I is the number of comparison levels, P is the number of free parameters in the fitted model, and K0.06 is the number of cells in the implied I × J table in which expected counts do not exceed 0.06. The second factor is the administration of small numbers ni of trials at each comparison level xi (1 ≤ i ≤ I). These numbers should not be ridiculously small (i.e., lower than 10) but they need not be identical across comparison levels. In practice, when ni varies across levels, it suffices that the overall number N of trials exceeds 40 × I if J = 2 or 50 × I if J = 3, with no ni lower than 10. Correcting the degrees of freedom and using large ni are easy to implement in practice. These precautions ensure the validity of goodness-of-fit tests based on G2.
Conditional dependence (CD) reflects potential interactions between persons and items in measurement, offering valuable information for deriving personalized diagnoses, evaluations, and feedback. The recent integration of psychometric models with latent space provides an effective way to visualize and quantify person–item interactions unexplained by latent variables and item parameters. In such applications, it is important to recognize the relative nature of CD, as models with different structures and complexities (e.g., due to factor dimensionality and item parameters) produce varying systematic explanations of person and item effects, leading to differing residual variations in both quantitative and qualitative sense. To demonstrate this relativity, we extend the previously developed unidimensional Rasch-based latent space item response model by incorporating between-item multidimensionality and item discrimination parameters. The resulting model can be reduced to simpler models with appropriate constraints, allowing us to explore the relativity in CD by comparing them. Simulation studies demonstrate that (1) the most complex proposed model properly recovers its parameters, (2) it outperforms the traditional IRT models by accounting for CD, and (3) the models in comparison exhibit distinctive extents of CD. The study continues with empirical examples that further illustrate relative changes in the extent and configurations of CD with practical implications.
This study examines the mediating role of horizontal trust and collective resilience in the relationship between organizational justice and job performance at the team level based on the HEalthy & Resilient Organizations Model (HERO) (Salanova et al., 2012). The sample consisted of 927 workers grouped into 100 work teams belonging to seven healthcare centers in Spain. The relationships among organizational justice, horizontal trust, collective resilience, and perceived job performance of work teams were analyzed using structural equation modeling (SEM). The results revealed that the perceptions of justice and organizational trust positively impact job performance at the team level. Furthermore, the predictive role of horizontal trust in collective resilience was evidenced, with both variables mediating the relationship between the perception of justice and job performance of work teams. These findings underscore the significance of cultivating both horizontal trust and resilience in work teams, offering valuable insights for healthcare management and organizational psychology in highly complex environments such as healthcare organizations.