Psychiatric Advance Directives and Artificial Intelligence: A Conceptual Framework for Theoretical and Ethical Principles.

The patient's decision-making abilities are often altered in psychiatric disorders. The legal framework of psychiatric advance directives (PADs) has been made to provide care to patients in these situations while respecting their free and informed consent. The implementation of artificial intelligence (AI) within Clinical Decision Support Systems (CDSS) may result in improvements for complex decisions that are often made in situations covered by PADs. Still, it raises theoretical and ethical issues this paper aims to address. First, it goes through every level of possible intervention of AI in the PAD drafting process, beginning with what data sources it could access and if its data processing competencies should be limited, then treating of the opportune moments it should be used and its place in the contractual relationship between each party (patient, caregivers, and trusted person). Second, it focuses on ethical principles and how these principles, whether they are medical principles (autonomy, beneficence, non-maleficence, justice) applied to AI or AI principles (loyalty and vigilance) applied to medicine, should be taken into account in the future of the PAD drafting process. Some general guidelines are proposed in conclusion: AI must remain a decision support system as a partner of each party of the PAD contract; patients should be able to choose a personalized type of AI intervention or no AI intervention at all; they should stay informed, i.e., understand the functioning and relevance of AI thanks to educational programs; finally, a committee should be created for ensuring the principle of vigilance by auditing these new tools in terms of successes, failures, security, and relevance.

How New Technologies Can Improve Prediction, Assessment, and Intervention in Obsessive-Compulsive Disorder (e-OCD): Review.

BACKGROUND: New technologies are set to profoundly change the way we understand and manage psychiatric disorders, including obsessive-compulsive disorder (OCD). Developments in imaging and biomarkers, along with medical informatics, may well allow for better assessments and interventions in the future. Recent advances in the concept of digital phenotype, which involves using computerized measurement tools to capture the characteristics of a given psychiatric disorder, is one paradigmatic example. OBJECTIVE: The impact of new technologies on health professionals' practice in OCD care remains to be determined. Recent developments could disrupt not just their clinical practices, but also their beliefs, ethics, and representations, even going so far as to question their professional culture. This study aimed to conduct an extensive review of new technologies in OCD. METHODS: We conducted the review by looking for titles in the PubMed database up to December 2017 that contained the following terms: [Obsessive] AND [Smartphone] OR [phone] OR [Internet] OR [Device] OR [Wearable] OR [Mobile] OR [Machine learning] OR [Artificial] OR [Biofeedback] OR [Neurofeedback] OR [Momentary] OR [Computerized] OR [Heart rate variability] OR [actigraphy] OR [actimetry] OR [digital] OR [virtual reality] OR [Tele] OR [video]. RESULTS: We analyzed 364 articles, of which 62 were included. Our review was divided into 3 parts: prediction, assessment (including diagnosis, screening, and monitoring), and intervention. CONCLUSIONS: The review showed that the place of connected objects, machine learning, and remote monitoring has yet to be defined in OCD. Smartphone assessment apps and the Web Screening Questionnaire demonstrated good sensitivity and adequate specificity for detecting OCD symptoms when compared with a full-length structured clinical interview. The ecological momentary assessment procedure may also represent a worthy addition to the current suite of assessment tools. In the field of intervention, CBT supported by smartphone, internet, or computer may not be more effective than that delivered by a qualified practitioner, but it is easy to use, well accepted by patients, reproducible, and cost-effective. Finally, new technologies are enabling the development of new therapies, including biofeedback and virtual reality, which focus on the learning of coping skills. For them to be used, these tools must be properly explained and tailored to individual physician and patient profiles.

Virtual Reality (VR) in Assessment and Treatment of Addictive Disorders: A Systematic Review.

Background: Substance Use Disorder (SUD) and behavioral addictions are common and require a multidisciplinary approach. New technologies like Virtual Reality could have the potential to improve assessment and treatment of these disorders. Objective: In the present paper, we therefore present an overview of Virtual Reality (Head Mounted Devices) in the field of addiction medicine for craving assessment and treatment. Method: We conducted a systematic review by querying PubMed database for the titles of articles published up to March 2019 with the terms [virtual] AND [addictive] OR [addiction] OR [substance] OR [alcohol] OR [cocaine] OR [cannabis] OR [opioid] OR [tobacco] OR [nicotine] OR [methamphetamine] OR [gaming] OR [gambling]. Results: We screened 319 abstracts and analyzed 37 articles, dividing them into two categories, the first for assessment of cue reactivity (craving, psychophysiological response and attention to cue) and the second for intervention, each drug (nicotine, cocaine, alcohol, cannabis, gambling) being detailed within each category. Conclusions: This overview suggest that VR provide benefits in the assessment and treatment of substance use disorders and behavior addictions and achieve high levels of ecological validity. While, craving provocation in VR is effective across addiction disorders, treatments based exclusively on virtual exposure to drug related cues as shown heterogenous results.

Psychiatrists' Attitudes Toward Disruptive New Technologies: Mixed-Methods Study.

BACKGROUND: Recent discoveries in the fields of machine learning (ML), Ecological Momentary Assessment (EMA), computerized adaptive testing (CAT), digital phenotype, imaging, and biomarkers have brought about a new paradigm shift in medicine. OBJECTIVE: The aim of this study was to explore psychiatrists' perspectives on this paradigm through the prism of new clinical decision support systems (CDSSs). Our primary objective was to assess the acceptability of these new technologies. Our secondary objective was to characterize the factors affecting their acceptability. METHODS: A sample of psychiatrists was recruited through a mailing list. Respondents completed a Web-based survey. A quantitative study with an original form of assessment involving the screenplay method was implemented involving 3 scenarios, each featuring 1 of the 3 support systems, namely, EMA and CAT, biosensors comprising a connected wristband-based digital phenotype, and an ML-based blood test or magnetic resonance imaging (MRI). We investigated 4 acceptability domains based on International Organization for Standardization and Nielsen models (usefulness, usability, reliability, and risk). RESULTS: We recorded 515 observations. Regarding our primary objective, overall acceptability was moderate. MRI coupled with ML was considered to be the most useful system, and the connected wristband was considered the least. All the systems were described as risky (410/515, 79.6%). Regarding our secondary objective, acceptability was strongly influenced by socioepidemiological variables (professional culture), such as gender, age, and theoretical approach. CONCLUSIONS: This is the first study to assess psychiatrists' views on new CDSSs. Data revealed moderate acceptability, but our analysis shows that this is more the result of the lack of knowledge about these new technologies rather than a strong rejection. Furthermore, we found strong correspondences between acceptability profiles and professional culture profiles. Many medical, forensics, and ethical issues were raised, including therapeutic relationship, data security, data storage, and privacy risk. It is essential for psychiatrists to receive training and become involved in the development of new technologies.

Acute Frontal Lobe Dysfunction Following Prefrontal Low-Frequency Repetitive Transcranial Magnetic Stimulation in a Patient with Treatment-Resistant Depression.

The potential of repetitive transcranial magnetic stimulation (rTMS) to treat numerous neurological and psychiatric disorders has been thoroughly studied for the last two decades. Here, we report for the first time, the case of a 65-year-old woman suffering from treatment-resistant depression who developed an acute frontal lobe syndrome following eight sessions of low-frequency rTMS (LF-rTMS) to the right dorsolateral prefrontal cortex while also treated with sertraline and mianserin. The pathophysiological mechanisms underlying such an unexpected acute frontal lobe dysfunction are discussed in relation to the therapeutic use of LF-rTMS in combination with pharmacotherapy in depressed patients.

Antipsychotic-Induced Dopamine Supersensitivity Psychosis: Pharmacology, Criteria, and Therapy.

The first-line treatment for psychotic disorders remains antipsychotic drugs with receptor antagonist properties at D2-like dopamine receptors. However, long-term administration of antipsychotics can upregulate D2 receptors and produce receptor supersensitivity manifested by behavioral supersensitivity to dopamine stimulation in animals, and movement disorders and supersensitivity psychosis (SP) in patients. Antipsychotic-induced SP was first described as the emergence of psychotic symptoms with tardive dyskinesia (TD) and a fall in prolactin levels following drug discontinuation. In the era of first-generation antipsychotics, 4 clinical features characterized drug-induced SP: rapid relapse after drug discontinuation/dose reduction/switch of antipsychotics, tolerance to previously observed therapeutic effects, co-occurring TD, and psychotic exacerbation by life stressors. We review 3 recent studies on the prevalence rates of SP, and the link to treatment resistance and psychotic relapse in the era of second-generation antipsychotics (risperidone, paliperidone, perospirone, and long-acting injectable risperidone, olanzapine, quetiapine, and aripiprazole). These studies show that the prevalence rates of SP remain high in schizophrenia (30%) and higher (70%) in treatment-resistant schizophrenia. We then present neurobehavioral findings on antipsychotic-induced supersensitivity to dopamine from animal studies. Next, we propose criteria for SP, which describe psychotic symptoms and co-occurring movement disorders more precisely. Detection of mild/borderline drug-induced movement disorders permits early recognition of overblockade of D2 receptors, responsible for SP and TD. Finally, we describe 3 antipsychotic withdrawal syndromes, similar to those seen with other CNS drugs, and we propose approaches to treat, potentially prevent, or temporarily manage SP.

Cognitive impairment in systemic lupus erythematosus women with elevated autoantibodies and normal single photon emission computerized tomography.

BACKGROUND: Systemic lupus erythematosus (SLE) is known to induce psychiatric disorders, from psychoses to maladaptive coping. Brain autoantibodies were proposed to explain SLE neuropsychiatric disorders and found to be elevated before the onset of clinical symptoms. We assessed cognition in Caucasian SLE women with elevated autoantibodies without overt neuropsychiatric syndromes, in conjunction with single photon emission computerized tomography (SPECT). METHODS: 31 women meeting SLE criteria of the American College of Rheumatology (ACR) were included. Patients who met the ACR neuropsychiatric definition were excluded. Matched controls were 23 healthy women from the Champagne-Ardenne region, France. Participants completed neuropsychological and autoantibodies measurements, and 19 completed SPECT. RESULTS: 61% (19/31) of women with SLE and 53% (9/17) of those with normal SPECT had significant global cognitive impairment defined as 4 T-scores <40 in cognitive tests, compared to 0% (0/23) of controls. SLE women also had significantly greater cognitive dysfunction (mean T-score) on the Wechsler Adult Intelligence Scale (WAIS) visual backspan, Trail Making Test A and B, WAIS Digit Symbol Substitution Test and Stroop Interference, compared to controls. Elevated antinuclear antibody correlated with impairment in the WAIS visual span, WAIS visual backspan, and cancellation task; elevated anti-double-stranded DNA antibody and anticardiolipin correlated respectively with impairment in the Trail Making Test A and WAIS auditive backspan. Two SLE women had abnormal SPECT. CONCLUSIONS: A high prevalence of cognitive deficits was found in Caucasian SLE women compared to normal women, which included impairment in cognitive domains important for daily activities. Elevated autoantibodies tended to correlate with cognitive dysfunction.

Current research on cognitive aspects of anxiety disorders.

PURPOSE OF REVIEW: Cognitive dysfunction is frequently reported in anxiety disorders. Our aim is to describe recent advances concerning these cognitive aspects. RECENT FINDINGS: Cognitive dysfunction in anxiety disorders can be classified into four domains. The first concerns executive functions, mainly attentional processes. The second concerns memory, including deficits in working, episodic, and autobiographical memory. The third encompasses maladaptive cognitions, or thoughts and beliefs. Finally, a burgeoning area of research (mainly in obsessive-compulsive disorder and posttraumatic stress disorder) concerns metacognitions, or thoughts and beliefs about one's own thoughts and beliefs. All of these dysfunctions may contribute to maintain or aggravate anxiety disorders. When developing and implementing interventions, researchers and clinicians alike must consider these cognitive aspects, and may need to tailor their approaches accordingly. SUMMARY: Advances have clearly been made in the elucidation of the cognitive functioning associated with anxiety disorders. It remains unclear if particular cognitive profiles can help to distinguish anxiety disorders from one another, although emerging evidence suggests this may be the case. Further clarification will add to our understanding of the development and maintenance of these disorders, and may provide targets for future therapy and endophenotypes.

Management of post traumatic stress disorder after childbirth: a review.

Prevalence and risk factors for the development of post traumatic stress disorder (PTSD) after childbirth is well described in the literature. However, its management and treatment has only begun to be investigated. The aim of this article is to describe the studies that examine the effects of interventions on PTSD after childbirth. MedLine, PILOTS, CINAHL and ISI Web of Science databases were systematically searched for randomised controlled trials, pilot studies and case studies using key words related to PTSD, childbirth, treatment and intervention. The reference lists of the retrieved articles were also used to supplement the search. A total of nine studies were retrieved. Seven studies that examined debriefing or counselling were identified; six randomised controlled trials and one pilot study. Also found were one case report describing the effects of cognitive behavioural therapy (CBT) on two women, and one pilot study of eye movement desensitisation and reprocessing (EMDR). Overall, there is limited evidence concerning the management of women with PTSD after childbirth. The results agree with the findings from the non-childbirth related literature: debriefing and counselling are inconclusively effective while CBT and EMDR may improve PTSD status but require investigation in controlled trials before conclusions could be drawn.

Normal and pathological aging of attention in presymptomatic Huntington's, Huntington's and Alzheimer's Disease, and nondemented elderly subjects.

BACKGROUND: Attention models view attention as having at least two components: endogenous attention defined as executive and directed by voluntary acts, and exogenous attention defined as automatic and directed by external stimulation. METHODS: Three studies (2 of our own) were designed to evaluate the decline of these two components of attention in normal aging and two neurodegenerative diseases. Standardized tests derived from Posner's model of visuospatial attention were administered to normal healthy elderly participants (n = 13), patients suffering from Huntington's disease (HD; n = 17) and Alzheimer's disease (n = 15), and matched control subjects (n = 57). Outcome measures were reaction time (RT) and RT difference score (defined as invalid RT minus valid RT). RESULTS: In healthy elderly participants, the decline was more pronounced for endogenous attention in situations of perceptual conflict. In Alzheimer's disease, there was a significant decline in both attention components, while in HD, voluntary attention was markedly impaired and automatic attention preserved. CONCLUSIONS: Normal aging and HD are characterized by decreased endogenous attention in situations of perceptual conflict. Our data support previous findings that older people display impairment of attention in complex perceptual situations. We propose a model which allows for the separation of attention pathologies, thus improving therapeutic strategies for patients and elderly.

Two-year study of relapse prevention by a new education program in schizophrenic patients treated with the same antipsychotic drug.

It is not clear whether patient's psycho-education enhances compliance to antipsychotic treatments and reduces the number of relapses. Here we investigated the impact of a new psycho-educational program (SOLEDUC) on the one- and two-years rate of relapse (primary outcome measure) and a number of clinical assessments (secondary outcome measures). This was a multicentric French clinical trial (51 centers) of Phase IV, open, controlled, randomized, consisting in two parallel groups: the Soleduc group (N=111) and the control group (N=109). All subjects received a variable dose over the 2-year period of the same antipsychotic drug (amisulpride). Soleduc consisted of a 7-session program (1h per session), presented three times (at baseline, 6-months and 12-months). Patients in the control group received a non-specific psychosocial training for an equivalent period of time. The models of Andersen-Gill (AG) and Prentice, Williams and Peterson (PWP) were used to analyze relapses. Patients in the Soleduc group attended 14.8+/-6.1 sessions (mean+/-SD), including 17 patients who never attended a session. Intent to treat analysis showed less patients relapsing in the Soleduc group as compared to the control group (21.6% versus 28.4% after 1 year and 84.4% versus 90.8% after 2years), but the differences were not statistically significant. Relapse risk was significantly reduced for patients who followed at least 7 modules (p=0.015 AG-test; p<0.001 PWP-test). In conclusion, no significant differences in relapse rates were found between patients attending the Soleduc program and the control group. Attendance of at least 7 out of 21 program sessions was required to see a modest, but significant two-year relapse prevention in schizophrenia. Other well designed studies are required to evaluate the medical impact of patient's education programs.

Effects of the dopamine agonist piribedil on prefrontal temporal cortical network function in normal aging as assessed by verbal fluency.

Normal aging has been associated with impaired performance in verbal fluency suggesting a prefrontal temporal cortical network (PFTCN) deficiency. In this study, we investigated the effects of a 2-month treatment period with a dopaminergic agonist (DA) on PFTCN function. Forty healthy, elderly volunteers were assessed on semantic and phonemic verbal fluency after two months of a placebo or a DA treatment (i.e. piribedil 50 mg/day) in a double-blind crossover design. Protocols were scored considering clustering, (i.e. production of words within semantic or phonemic categories, depending on the integrity of temporal lobe), and switching (i.e. the ability to shift between clusters, depending on frontal lobe functioning). Results revealed no significant main effect of the DA treatment on either verbal fluency variables but showed a significant interaction with working memory capacities, with high-capacity span subjects improving phonemic switching on DA whereas low-capacity span subjects performed more poorly on the drug than off. These data are consistent with the literature and confirm the crucial link between working memory capacities and dopamine agonist effects. The present study also provides evidence that pharmacological remediation of age-related cognitive decline has to be taken into consideration.

Conscious recollection in autobiographical memory: an investigation in schizophrenia.

Whether or not conscious recollection in autobiographical memory is affected in schizophrenia is unknown. The aim of this study was to address this issue using an experiential approach. An autobiographical memory enquiry was used in combination with the Remember/Know procedure. Twenty-two patients with schizophrenia and 22 normal subjects were asked to recall specific autobiographical memories from four lifetime periods and to indicate the subjective states of awareness associated with the recall of what happened, when and where. They gave Remember, Know or Guess responses according to whether they recalled these aspects of the event on the basis of conscious recollection, simply knowing, or guessing. Results showed that the frequency and consistency of Remember responses was significantly lower in patients than in comparison subjects. In contrast, the frequency of Know responses was not significantly different, whereas the frequency of patients' Guess responses was significantly enhanced. It is concluded that the frequency and consistency of conscious recollection in autobiographical memory is reduced in patients with schizophrenia.

Reduced levels of specific autobiographical memories in schizophrenia.

Autobiographical memory is intrinsically related to the self and personal identity. This study investigated whether both personal episodic memory and semantic memory are impaired in schizophrenia, a disease characterized by an abnormal personal identity. Personal episodic memory and personal semantic memory were investigated in 24 patients with schizophrenia and 24 normal subjects using an autobiographical fluency task and an autobiographical memory inquiry. Autobiographical memory scores and the proportion of specific memories were lower in patients with schizophrenia than in normal subjects. The deficit of personal episodic and semantic memory, as assessed by the autobiographical memory inquiry and the autobiographical fluency task, respectively, was most apparent after the onset of clinical symptoms. Schizophrenia is associated with an impairment of both personal episodic and semantic memory and with a reduction of specific autobiographical memories. Those impairments are consistent with the existence of an abnormal personal identity in patients with schizophrenia.

Cognitive skill learning and aging: a component process analysis.

The ability to acquire a cognitive and motor skill was investigated in 20 older and 20 younger participants using repeated testing on the Tower of Toronto (TT) puzzle, a variant of the Tower of Hanoi. Explicit memory, perceptual priming, and sustained attention were also assessed. Older subjects exhibited a defective cognitive skill performance despite the fact that cognitive skill learning suffered little or no impairment. Poor problem-solving ability, diminished attention, fatigue, defective explicit memory, and meta-cognitive processes were likely to play a limiting role. Factors interfering with the generation of reliable goal structures are likely to prevent cognitive skill learning, giving important cues for future cognitive remediation.