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Diagnosis in psychiatry faces familiar challenges. Validity and utility remain elusive, and confusion regarding the fluid and arbitrary border between mental health and illness is increasing. The mainstream strategy has been conservative and iterative, retaining current nosology until something better emerges. However, this has led to stagnation. New conceptual frameworks are urgently required to catalyze a genuine paradigm shift.
Methods
We outline candidate strategies that could pave the way for such a paradigm shift. These include the Research Domain Criteria (RDoC), the Hierarchical Taxonomy of Psychopathology (HiTOP), and Clinical Staging, which all promote a blend of dimensional and categorical approaches.
Results
These alternative still heuristic transdiagnostic models provide varying levels of clinical and research utility. RDoC was intended to provide a framework to reorient research beyond the constraints of DSM. HiTOP began as a nosology derived from statistical methods and is now pursuing clinical utility. Clinical Staging aims to both expand the scope and refine the utility of diagnosis by the inclusion of the dimension of timing. None is yet fit for purpose. Yet they are relatively complementary, and it may be possible for them to operate as an ecosystem. Time will tell whether they have the capacity singly or jointly to deliver a paradigm shift.
Conclusions
Several heuristic models have been developed that separately or synergistically build infrastructure to enable new transdiagnostic research to define the structure, development, and mechanisms of mental disorders, to guide treatment and better meet the needs of patients, policymakers, and society.
Negative symptoms are a key feature of several psychiatric disorders. Difficulty identifying common neurobiological mechanisms that cut across diagnostic boundaries might result from equifinality (i.e., multiple mechanistic pathways to the same clinical profile), both within and across disorders. This study used a data-driven approach to identify unique subgroups of participants with distinct reward processing profiles to determine which profiles predicted negative symptoms.
Methods
Participants were a transdiagnostic sample of youth from a multisite study of psychosis risk, including 110 individuals at clinical high-risk for psychosis (CHR; meeting psychosis-risk syndrome criteria), 88 help-seeking participants who failed to meet CHR criteria and/or who presented with other psychiatric diagnoses, and a reference group of 66 healthy controls. Participants completed clinical interviews and behavioral tasks assessing four reward processing constructs indexed by the RDoC Positive Valence Systems: hedonic reactivity, reinforcement learning, value representation, and effort–cost computation.
Results
k-means cluster analysis of clinical participants identified three subgroups with distinct reward processing profiles, primarily characterized by: a value representation deficit (54%), a generalized reward processing deficit (17%), and a hedonic reactivity deficit (29%). Clusters did not differ in rates of clinical group membership or psychiatric diagnoses. Elevated negative symptoms were only present in the generalized deficit cluster, which also displayed greater functional impairment and higher psychosis conversion probability scores.
Conclusions
Contrary to the equifinality hypothesis, results suggested one global reward processing deficit pathway to negative symptoms independent of diagnostic classification. Assessment of reward processing profiles may have utility for individualized clinical prediction and treatment.
John Locke defined political power·in part as “a Right of making Laws with Penalties of Death, and consequently all less Penalties ... ”. Capital punishment, and a wide range of barbaric penalties, are no longer with us. Of the forms of punishment that remain, imprisonment is generally recognized as the most serious. Although generally overlooked deportation must rank not far behind. Like imprisonment, deportation can result in considerable hardship and suffering, not only to the person subjected to the measure, but to his or her family and friends. Losing the right to live in what one regards as one’s homeland can be seen as even more serious a deprivation than losing one’s liberty.
Given the significance of the measure, it is necessary to consider not just the specific conditions under which the state is entitled to deport someone, but more fundamentally, who it is entitled to deport. As a constitutional issue, debate in Australia has centred on the question of how the Commonwealth’s immigration power is to be interpreted.
How are we to explain the High Court's reluctance to move into stronger forms of rights protection, as evinced by the disparity between its federalism and rights-based judicial review practices? It has been suggested that the federal and ‘rights’ provisions of the Constitution are equally indeterminate, calling into question the notion that the legal materials themselves compel a preference for one or another type of review. And the Court's record of rendering politically consequential decisions in its federalism jurisdiction suggests that political-institutional constraints may not preclude it from expanding its rights review powers. This article contends that the disparity in the Court's review practices can be explained only by way of a theory of judicial politics that is sensitive to notions of cultural as well as political constraint. It traces the historical emergence of an Australian politico-legal culture, before examining its role in restraining the further protection of constitutional rights.
On 5 October 2000, the High Court handed down its latest decision on the scope of s 80 of the Commonwealth Constitution. This note provides an overview of the decision and its importance, and offers a critique of the reasoning employed in the majority judgments.
Section 80, variously described but commonly referred to as the trial by jury provision, “has led to some of the sharpest divisions of opinion in the history of this Court”. Whilst the decision in Cheng v The Queen (hereafter Cheng) confirms the interpretation given to s 80 in Kingswell v The Queen—which involved a challenge to the same provisions of the Customs Act 1901 (Cth)—some of the judges making up the majority in Cheng admitted to reservations about that interpretation. In addition, Kirby J and Gaudron J were vociferous in their disagreement with much of the majority's reasoning, which suggests that fundamental differences over the meaning of s 80 will continue to plague the Court into the future.
If being asked to give to charity stimulates an emotional response, like empathy, that makes giving difficult to resist, a natural self-control mechanism might be to avoid being asked in the first place. We replicate a result from a field experiment that points to the role of empathy in giving. We conduct an experiment in a large superstore in which we solicit donations to charity and randomly allow shoppers the opportunity to avoid solicitation by using the other door. We find the rate of avoidance by store entrants to be 8.9 %. However, we also find that the avoidance effect disappears in very cold weather, suggesting that avoidance behavior is sensitive to its cost.
Clastic sedimentary systems and their characteristics are assumed not to have been modified by carbonate bioclastic grains until the Phanerozoic. Here, we show that the presence of carbonate bioclasts produced by disintegrated biomineralizing metazoans modified fine-grained siliciclastic facies in the Late Ediacaran Tamengo Formation, Brazil, ca. 555–542 Ma. The analysis of both polished sections and thin sections shows that sand-sized carbonate bioclasts (< 2 mm) derived from the Ediacaran metazoan Corumbella created diverse sedimentary features later found in the Phanerozoic record, such as bioclastic-rich horizontal and low-angle cross-laminations, erosive pods and lenses, bioclastic syneresis cracks, ripples preserved by bioclastic caps, microbial lamination eroded and filled with bioclasts, and entrapped bioclasts within microbial mats. These sedimentary features would have hardly been recorded in fine siliciclastic facies without the sand-sized bioclasts. Based on these features, together with other sedimentary evidence, Corumbella depositional settings in the Tamengo Fm. are reinterpreted as mid-ramp, subtidal settings. The multi-component organization of the skeleton of Corumbella favoured disarticulation to yield a sand-sized bioclast, so in turn creating a new complexity to shallow marine clastic settings typical of Phanerozoic marine depositional systems.
This study sought to assess undergraduate students’ knowledge and attitudes surrounding perceived self-efficacy and threats in various common emergencies in communities of higher education.
Methods
Self-reported perceptions of knowledge and skills, as well as attitudes and beliefs regarding education and training, obligation to respond, safety, psychological readiness, efficacy, personal preparedness, and willingness to respond were investigated through 3 representative scenarios via a web-based survey.
Results
Among 970 respondents, approximately 60% reported their university had adequately prepared them for various emergencies while 84% reported the university should provide such training. Respondents with high self-efficacy were significantly more likely than those with low self-efficacy to be willing to respond in whatever capacity needed across all scenarios.
Conclusions
There is a gap between perceived student preparedness for emergencies and training received. Students with high self-efficacy were the most likely to be willing to respond, which may be useful for future training initiatives.
The number of women on high courts across the globe has been steadily increasing. Recent estimates found that women now make up 61% of the judiciary in European countries (Organisation for Economic Co-operation and Development 2019). The large number of women now serving in judicial positions has resulted in a changing demographic makeup of courts. While the majority might think this is a step forward for diverse representation, there is ultimately a dichotomy between judicial accountability that comes as a result of increased diversity in descriptive representation and judicial independence. Given this dichotomy, along with the increase in women on courts, it follows that the public’s perceptions of courts’ independence has the potential to change. We explore this phenomenon by asking the following question: How does the presence of women on high courts impact perceptions of judicial independence among the public? Using survey data gathered from respondents in twenty-seven European countries from 2016 to 2022, we examine how the dynamics of an increasing number of women on high courts alters the public’s perceptions on the level of independence of the court in their country. We draw from literature on judicial independence as well as women political elites and corruption. Importantly, we document that increasing the percentage of women on courts results in higher perceptions of judicial independence for women. Overall, our findings highlight important trends regarding gender diversity in political institutions and how changes in descriptive characteristics shape perceptions of judicial independence.
Health inequalities can be described as avoidable, systematic, and unjust differences in health between different groups within society. This research described and evaluated potential methods to measure the effects of health inequalities that could be used in health technology assessment (HTA) in the UK. The research included recommendations for current and future policy objectives relating to incorporating health inequalities.
Methods
A targeted literature review was conducted to identify methodological approaches used to incorporate health inequalities in HTA. Stakeholder interviews and a workshop were conducted with a range of stakeholders in the UK. This engagement aimed to discuss any gaps in the literature and to assess whether attitudes, methods, and policies were evolving at the same rate as the literature. Other aims of the engagement included obtaining stakeholder views on health inequalities and a better understanding of the perspectives of decision-makers.
Results
Five potential methods were identified to account for health inequalities, with equity-based weighting and distributional cost-effectiveness analysis considered to be the most feasible quantification methods. Stakeholders reiterated that a deliberative process should remain the center of HTA. Stakeholders also raised issues such as the burden on committees, trade-offs between complexity and accessibility, and the importance of measuring the size and direction of inequality impacts. Recommendations were then produced based on these findings to better account for inequalities in HTA, highlighting the importance of combining a range of approaches.
Conclusions
Both companies and HTA agencies should be more proactive in accounting for health inequalities. Companies should be encouraged to provide quantitative analysis on health inequalities, while decision-makers should be trained in new methods. Despite the recent rise in quantitative methods, qualitative methods remain extremely important for a layered approach to considering health inequalities.
Medicines routinely funded for use in Wales undergo health technology appraisal by the All Wales Medicines Strategy Group (AWMSG) or the National Institute for Health and Care Excellence (NICE). This includes pediatric license extensions (PLE) notwithstanding any existing advice in adults. A review of the PLE process was conducted with the aim of providing faster access to children’s medicines in Wales.
Methods
Data were collected for PLE appraisals of medicines previously approved for adults by the AWMSG or NICE that subsequently went through the original PLE process between January 2010 and December 2020, or a simplified PLE process between January 2021 and March 2023. Data were analyzed using descriptive statistics and a two-tailed t-test (unequal variance) to test the null hypothesis that the difference between the two means was zero. An alpha of less than 0.05 was considered significant. Feedback was obtained from relevant stakeholders including the Association of the British Pharmaceutical Industry (Wales) and the Royal College of Paediatrics and Child Health.
Results
The AWMSG issued positive recommendations for all PLE appraisals included in the data collected, and these were endorsed by the Welsh Government. Appraisals that went through the original PLE process (n=56) took a mean 229.8 days (standard deviation 55.6), whereas those that went through the simplified PLE process (n=15) took a mean 102.6 days (standard deviation 48.1; p < 0.0001). The rapid access to children’s medicines was welcomed by the Association of the British Pharmaceutical Industry and the Royal College of Paediatrics and Child Health.
Conclusions
Review of the 2020 and 2023 PLE processes facilitated faster access to clinically effective and cost-effective medicines for children in Wales. In March 2023, the AWMSG and the Welsh Government reviewed these results and agreed that because all PLE medicines were approved for use within Wales irrespective of the process used, the AWMSG would no longer be required to routinely appraise PLEs.
Patients with hematological malignancies are at high risk of infections due to both the disease and the associated treatments. The use of immunoglobulin (Ig) to prevent infections is increasing in this population, but its cost effectiveness is unknown. This trial-based economic evaluation aimed to compare the cost effectiveness of prophylactic Ig with prophylactic antibiotics in patients with hematological malignancies.
Methods
The economic evaluation used individual patient data from the RATIONAL feasibility trial, which randomly assigned 63 adults with chronic lymphocytic leukemia, multiple myeloma, or lymphoma to prophylactic Ig or prophylactic antibiotics. The following two analyses were conducted to estimate the cost effectiveness of the two treatments over the 12-month trial period from the perspective of the Australian health system:
(i) a cost-utility analysis (CUA) to assess the incremental cost per quality-adjusted life-year (QALY) gained using data collected with the EuroQol 5D-5L questionnaire; and
(ii) a cost-effectiveness analysis (CEA) to assess the incremental cost per serious infection prevented (grade ≥3) and per infection prevented (any grade).
Results
The total cost per patient was significantly higher in the Ig arm than in the antibiotic arm (difference AUD29,140 [USD19,000]). There were non-significant differences in health outcomes between the treatment arms: patients treated with Ig had fewer QALYs (difference −0.072) and serious infections (difference −0.26) than those given antibiotics, but more overall infections (difference 0.76). The incremental cost-effectiveness from the CUA indicated that Ig was more costly than antibiotics and associated with fewer QALYs. In the CEA, Ig costed an additional AUD111,262 (USD73,000) per serious infection prevented, but it was more costly than antibiotics and associated with more infections when all infections were included.
Conclusions
These results indicate that, on average, Ig prophylactic treatment may not be cost effective compared with prophylactic antibiotics for the group of patients with hematological malignancies recruited to the RATIONAL feasibility trial. Further research is needed to confirm these findings in a larger population and over the longer term.
The purpose of this paper is to introduce a new method for fitting item response theory models with the latent population distribution estimated from the data using splines. A spline-based density estimation system provides a flexible alternative to existing procedures that use a normal distribution, or a different functional form, for the population distribution. A simulation study shows that the new procedure is feasible in practice, and that when the latent distribution is not well approximated as normal, two-parameter logistic (2PL) item parameter estimates and expected a posteriori scores (EAPs) can be improved over what they would be with the normal model. An example with real data compares the new method and the extant empirical histogram approach.
Stigma of mental health conditions hinders recovery and well-being. The Honest, Open, Proud (HOP) program shows promise in reducing stigma but there is uncertainty about the feasibility of a randomized trial to evaluate a peer-delivered, individual adaptation of HOP for psychosis (Let's Talk).
Methods
A multi-site, Prospective Randomized Open Blinded Evaluation (PROBE) design, feasibility randomised controlled trial (RCT) comparing the peer-delivered intervention (Let's Talk) to treatment as usual (TAU). Follow-up was 2.5 and 6 months. Randomization was via a web-based system, with permuted blocks of random size. Up to 10 sessions of the intervention over 10 weeks were offered. The primary outcome was feasibility data (recruitment, retention, intervention attendance). Primary outcomes were analyzed by intention to treat. Safety outcomes were reported by as treated status. The study was prospectively registered: https://doi.org/10.1186/ISRCTN17197043.
Results
149 patients were referred to the study and 70 were recruited. 35 were randomly assigned to intervention + TAU and 35 to TAU. Recruitment was 93% of the target sample size. Retention rate was high (81% at 2.5 months primary endpoint), and intervention attendance rate was high (83%). 21% of 33 patients in Let's talk + TAU had an adverse event and 16% of 37 patients in TAU. One serious adverse event (pre-randomization) was partially related and expected.
Conclusions
This is the first trial to show that it is feasible and safe to conduct a RCT of HOP adapted for people with psychosis and individual delivery. An adequately powered trial is required to provide robust evidence.
History of prior mental disorder, particularly post-traumatic stress disorder (PTSD), increases risk for PTSD following subsequent trauma exposure. However, limited research has examined differences associated with specific prior mental disorders among people with PTSD.
Aims
The current study examined whether different prior mental disorders were associated with meaningful differences among individuals presenting to a specialist service for severe earthquake-related distress following the Canterbury earthquakes (N = 177).
Method
Two sets of comparisons were made: between participants with no history of prior disorder and participants with history of any prior disorder; and between participants with history of prior PTSD and those with history of other prior disorders. Comparisons were made in relation to sociodemographic factors, earthquake exposure, peri-traumatic distress, life events and current psychological functioning.
Results
Participants with any prior mental disorder had more current disorders than those with no prior disorder. Among participants with history of any prior disorder, those with prior PTSD reported more life events in the past 5 years than those with other prior disorders.
Conclusions
Findings suggest a history of any prior mental disorder contributes to increased clinical complexity, but not increased PTSD severity, among people with PTSD seeking treatment. Although post-disaster screening efforts should include those with prior mental disorders, it should also be recognised that those with no prior disorders are also at risk of developing equally severe PTSD.