[Complex dynamical systems in psychiatry: an integrative approach]. / Psychopathologie als zelforganisatie van complexe dynamische systemen.

BACKGROUND: Psychiatry may currently hold unprecedented knowledge in the diagnosis and treatment of psychiatric conditions. Yet, there is a widely held belief that this knowledge is not adequately integrated, nor does it fully account for the complexity of the phenomena under study. OBJECTIVE: To assess the effectiveness of a system-oriented and network-focused approach in capturing and integrating the complexity of psychiatric disorders. Next, to explore the epistemological implications of such an approach. METHOD: Narrative literature review. RESULTS: Psychiatric research is still too often characterized by reductionism, linear-causal pathogenesis, and traditional nosology. There appears to be a need for a different metatheoretical model in psychiatry. CONCLUSION: The development from General System Theory to complex dynamic systems thinking and network theory holds significant epistemological implications for the future of the field, how we conduct science, and the way we frame and structure our care systems.

Beyond Step Count: Are We Ready to Use Digital Phenotyping to Make Actionable Individual Predictions in Psychiatry?

Some models for mental disorders or behaviors (eg, suicide) have been successfully developed, allowing predictions at the population level. However, current demographic and clinical variables are neither sensitive nor specific enough for making individual actionable clinical predictions. A major hope of the "Decade of the Brain" was that biological measures (biomarkers) would solve these issues and lead to precision psychiatry. However, as models are based on sociodemographic and clinical data, even when these biomarkers differ significantly between groups of patients and control participants, they are still neither sensitive nor specific enough to be applied to individual patients. Technological advances over the past decade offer a promising approach based on new measures that may be essential for understanding mental disorders and predicting their trajectories. Several new tools allow us to continuously monitor objective behavioral measures (eg, hours of sleep) and densely sample subjective measures (eg, mood). The promise of this approach, referred to as digital phenotyping, was recognized almost a decade ago, with its potential impact on psychiatry being compared to the impact of the microscope on biological sciences. However, despite the intuitive belief that collecting densely sampled data (big data) improves clinical outcomes, recent clinical trials have not shown that incorporating digital phenotyping improves clinical outcomes. This viewpoint provides a stepwise development and implementation approach, similar to the one that has been successful in the prediction and prevention of cardiovascular disease, to achieve clinically actionable predictions in psychiatry.

Drug development in psychopharmacology: Insights from evolutionary psychiatry.

In the last decade, no other branch of clinical pharmacology has been subject to as much criticism of failed innovation and unsatisfactory effectiveness as psychopharmacology. Evolutionary psychiatry can offer original insights on the problems that complicate pharmacological research. Considering that invalid phenotyping is a major obstacle to drug development, an evolutionary perspective suggests targeting clinical phenotypes related to evolved behavior systems because they are more likely to map onto the underlying biology than constructs based on predetermined diagnostic criteria. Because of their emphasis on symptom remission, pharmacological studies of psychiatric populations rarely include functional capacities as the primary outcome measure and neglect the impact of social context on the effects of psychiatric drugs. Evolutionary psychiatry explains why it is appropriate to replace symptoms with functional capacities as the primary target of psychiatric therapies and why social context should be a major focus of studies assessing the effectiveness of drugs currently used and new drugs under development. When the focus of research shifts to those questions that go beyond the "disease-based" concept of drug action, evolutionary psychiatry clearly emerges as a reference framework to assess drug effectiveness and to optimize clinicians' decisions about prescribing, deprescribing, and non-prescribing.

The Use of Telepsychiatry Services in Emergency Settings: Scoping Review.

BACKGROUND: Telepsychiatry (TP), a live video meeting, has been implemented in many contexts and settings. It has a distinct advantage in the psychiatric emergency department (ED) setting, as it expedites expert assessments for psychiatric patients. However, limited knowledge exits for TP's effectiveness in the ED setting, as well as the process of implementing TP in this setting. OBJECTIVE: This scoping review aimed to review the existing evidence for the administrative and clinical outcomes for TP in the ED setting and to identify the barriers and facilitators to implementing TP in this setting. METHODS: The scoping review was conducted according to the guidelines for the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Three electronic databases were examined: PubMed, Embase, and Web of Science. The databases were searched from January 2013 to April 2023 for papers and their bibliography. A total of 2816 potentially relevant papers were retrieved from the initial search. Studies were screened and selected independently by 2 authors. RESULTS: A total of 11 articles were included. Ten papers reported on administrative and clinical outcomes of TP use in the ED setting and 1 on the barriers and facilitators of its implementation. TP is used in urban and rural areas and for settings with and with no on-site psychiatric services. Evidence shows that TP reduced waiting time for psychiatric evaluation, but in some studies, it was associated with prolonged total length of stay in the ED compared with in-person evaluation. Findings indicate lower admission rates in patients assessed with TP in the ED. Limited data were reported for TP costs, its use for involuntary commitment evaluations, and its use for particular subgroups of patients (eg, those with a particular diagnosis). A single paper examined TP implementation process in the ED, which explored the barriers and facilitators for implementation among patients and staff in a rural setting. CONCLUSIONS: Based on the extant studies, TP seems to be generally feasible and acceptable to key stakeholders. However, this review detected a gap in the literature regarding TP's effectiveness and implementation process in the ED setting. Specific attention should be paid to the examination of this service for specific groups of patients, as well as its use to enable assessments for possible involuntary commitment.

[Electroencephalography: features of the obtained data and its applicability in psychiatry]. / Elektroentsefalografiya: osobennosti poluchaemykh dannykh i ikh primenimost' v psikhiatrii.

Presently, there is an increased interest in expanding the range of diagnostic and scientific applications of electroencephalography (EEG). The method is attractive due to non-invasiveness, availability of equipment with a wide range of modifications for various purposes, and the ability to track the dynamics of brain electrical activity directly and with high temporal resolution. Spectral, coherency and other types of analysis provide volumetric information about its power, frequency distribution, spatial organization of signal and its self-similarity in dynamics or in different sections at a time. The development of computing technologies provides processing of volumetric data obtained using EEG and a qualitatively new level of their analysis using various mathematical models. This review discusses benefits and limitations of using the EEG in scientific research, currently known interpretation of the obtained data and its physiological and pathological correlates. It is expected to determine the complex relationship between the parameters of brain electrical activity and various functional and pathological conditions. The possibility of using EEG characteristics as biomarkers of various physiological and pathological conditions is being considered. Electronic databases, including MEDLINE (on PubMed), Google Scholar and Russian Scientific Citation Index (RSCI, on elibrary.ru), scientific journals and books were searched to find relevant studies.

Large language models in psychiatry: Opportunities and challenges.

The ability of Large Language Models (LLMs) to analyze and respond to freely written text is causing increasing excitement in the field of psychiatry; the application of such models presents unique opportunities and challenges for psychiatric applications. This review article seeks to offer a comprehensive overview of LLMs in psychiatry, their model architecture, potential use cases, and clinical considerations. LLM frameworks such as ChatGPT/GPT-4 are trained on huge amounts of text data that are sometimes fine-tuned for specific tasks. This opens up a wide range of possible psychiatric applications, such as accurately predicting individual patient risk factors for specific disorders, engaging in therapeutic intervention, and analyzing therapeutic material, to name a few. However, adoption in the psychiatric setting presents many challenges, including inherent limitations and biases in LLMs, concerns about explainability and privacy, and the potential damage resulting from produced misinformation. This review covers potential opportunities and limitations and highlights potential considerations when these models are applied in a real-world psychiatric context.

Generative AI for precision neuroimaging biomarker development in psychiatry.

The explosion of generative AI offers promise for neuroimaging biomarker development in psychiatry, but effective adoption of AI methods requires clarity with respect to specific applications and challenges. These center on dataset sizes required to robustly train AI models along with feature selection that capture neural signals relevant to symptom and treatment targets. Here we discuss areas where generative AI could improve quantification of robust and reproducible brain-to-symptom associations to inform precision psychiatry applications, especially in the context of drug discovery. Finally, this communication discusses some challenges that need solutions for generative AI models to advance neuroimaging biomarkers in psychiatry.

Exploring the potential of representation and transfer learning for anatomical neuroimaging: Application to psychiatry.

The perspective of personalized medicine for brain disorders requires efficient learning models for anatomical neuroimaging-based prediction of clinical conditions. There is now a consensus on the benefit of deep learning (DL) in addressing many medical imaging tasks, such as image segmentation. However, for single-subject prediction problems, recent studies yielded contradictory results when comparing DL with Standard Machine Learning (SML) on top of classical feature extraction. Most existing comparative studies were limited in predicting phenotypes of little clinical interest, such as sex and age, and using a single dataset. Moreover, they conducted a limited analysis of the employed image pre-processing and feature selection strategies. This paper extensively compares DL and SML prediction capacity on five multi-site problems, including three increasingly complex clinical applications in psychiatry namely schizophrenia, bipolar disorder, and Autism Spectrum Disorder (ASD) diagnosis. To compensate for the relative scarcity of neuroimaging data on these clinical datasets, we also evaluate three pre-training strategies for transfer learning from brain imaging of the general healthy population: self-supervised learning, generative modeling and supervised learning with age. Overall, we find similar performance between randomly initialized DL and SML for the three clinical tasks and a similar scaling trend for sex prediction. This was replicated on an external dataset. We also show highly correlated discriminative brain regions between DL and linear ML models in all problems. Nonetheless, we demonstrate that self-supervised pre-training on large-scale healthy population imaging datasets (N≈10k), along with Deep Ensemble, allows DL to learn robust and transferable representations to smaller-scale clinical datasets (N≤1k). It largely outperforms SML on 2 out of 3 clinical tasks both in internal and external test sets. These findings suggest that the improvement of DL over SML in anatomical neuroimaging mainly comes from its capacity to learn meaningful and useful abstract representations of the brain anatomy, and it sheds light on the potential of transfer learning for personalized medicine in psychiatry.

[Transidentites : the relevance of involving psychiatrists]. / Transidentités : pertinence de l'implication des psychiatres.

Psychiatrists play a crucial role in evaluating requests and treatment indications for individuals experiencing gender incongruence, while also providing support throughout the transition process. Their work involves addressing both the psychological and somatic aspects of this journey, facilitating the profound identity changes it entails.

Les psychiatres psychothérapeutes jouent un rôle essentiel pour évaluer les demandes et les indications au traitement des personnes souffrant d'incongruence de genre, et les accompagner dans leur parcours de transition. Leur travail permet d'intégrer les enjeux psychologiques et somatiques de ce cheminement et de soutenir les remaniements identitaires profonds qu'il implique.

The blind spots of psychiatric reform in Greece.

According to international experience, the conditions for the successful outcome of a psychiatric reform are the following: (a) Existence of political will (supporting a national plan with assessment, monitoring, and corrective intervention procedures for structural dysfunctions, etc.). (b) Strong mental health leadership (executive expertise and skills that advance the public health agenda). (c) Challenging the dominance of the biomedical model in therapeutic practice through the promotion of holistic care practices, evidence-based innovative actions, collaborative care, the promotion of recovery culture, and the and the use of innovative digital tools. (d) Ensuring necessary resources over time, so that resources from the transition of the asylum model to a model of sectorial community mental health services "follow" the patient. (e) Strengthening the participation of service recipients and their families in decision-making processes and evaluation of care quality. (f) Practices based on ethical principles (value-based practice) and not only on the always necessary documentation (evidence-based practice).1- 4 Convergent evidence from the "ex post" evaluation of the implementation of the national plan Psychargos 2000-20095 and from the recent rapid assessment of the psychiatric reform by the Ministry of Health and the WHO Athens office (SWOT analysis)6 indicates "serious fragmentation of services, an uncoordinated system that often results in inappropriate service provision, a lack of epidemiological studies and studies concerning the local needs of specific populations, uneven development of services between different regions of the country, a large number of specialized professionals with significant deficits in community psychiatry expertise, a lack of personnel in supportive roles, significant gaps in specialized services (for individuals with autism spectrum disorders, intellectual disabilities, eating disorders, old and new addictions, and community forensic psychiatry services)". We would also like to highlight lack of coordination and collaboration among different mental health service systems (public primary and secondary service providers, NGOs, municipal services, mental health services of the armed forces, private sector), complete absence of systematic evaluation and monitoring (lack of quality of care indicators, clinical outcomes, epidemiological profile of each service), lack of quality assurance mechanisms and clinical management systems, insufficient number of beds mainly for acute cases, unclear protocols for discharge issuance and ensuring continuity of care, deficient budget for Mental Health in relation to the overall healthcare expenditure (currently 3.3%), and finally, one of the highest rates of involuntary hospitalizations in Europe, which is linked to serious issues concerning the protection of the rights of service users. After the pandemic and the emergence of the silent but expected mental health pandemic, WHO, EU, and the Greek Ministry of Health emphasized the need to adopt a public mental health agenda with an emphasis on community psychiatry in order to address both the old structural dysfunctions and inadequacies of psychiatric reform (regulation 815/1984, Leros I-Leros II plan, Psychargos A & B, incomplete implementation of laws 2071/1992 & 2716/1999, incomplete deinstitutionalization of the remaining psychiatric hospitals). However, it is time to reflect that it is not possible to talk today about the need to update and implement a new national plan to upgrade mental health in the country without answering basic questions, both old and new, about the wider context of its implementation. The transformation of the deficient psychiatric care in the country cannot be completed without the urgent restructuring of the National Health System7 and the reform of the Greek welfare state itself, which is also characterized by irrationality, inequalities, bureaucratic inefficiency, and fragmentation.8 As we should have learned from the bankruptcy and the prolonged economic, social, and cultural crisis in our country, reforms usually pay off in the long term, while the time horizon of the applied policies is narrow and usually reaching the next election. The fact is that in any reform effort, including psychiatry, the political system does not demonstrate the ability to promote transparency, evaluation, stable rules of regulation, reference to a universally applicable legal and institutional framework, the limitation of clientelism and guild resistances. From this point of view, it is necessary to give meaning in the context of Greek psychiatric reform to the professional burnout of the National Health System workers, the lack of motivation and vision, the intrusion into the NGO space by new entities without any connection to the culture of psychiatry reform, the guild resistances of all relevant specialties, the selective use of psychotherapeutic techniques, as trends of discrediting the relief of social and psychological suffering in the field of public mental health. There is an urgent need to understand new pathologies (narcissistic disorders, new forms of addiction, eating disorders, "pathology of emptiness", adolescent delinquency and suicide, psychosomatic manifestations due to high stress, pathology of fluid social ties, deficient socialization of young people "outside of their algorithms") through a solid and coherent analysis of the toxic postmodernity culture. In addition to the social determinants of mental health,9 it is necessary in clinical work to also assess the psychological factors, such as uncertainty, conflict, loss of control, and incomplete information, that burden human health.10 In order to reduce the gap between declarations and real life, there is an urgent need to overcome the blind spots of psychiatric reform in the country by establishing internal and external evaluation processes, training young professionals in holistic care and community networking and communication skills, retraining leaders for organizational change, and strengthening the participation of service users in the context of deepening democracy in mental health. As mental health professionals, the object of our work in the community should be the reconstruction of meaning and the fragile or non-existent social bond in subjects who have been cut off from any possible production of meaning and participation in their history. Why should our therapeutic responses be stereotypically repetitive in the face of these complex, radical changes in the meta-context and the new demands of our patients? After all, as the philosopher Ernst Bloch puts it, utopia is "that which does not exist yet.".

Innovation at the Intersection: Emerging Translational Research in Neurology and Psychiatry.

Translational research in neurological and psychiatric diseases is a rapidly advancing field that promises to redefine our approach to these complex conditions [...].

The clinical utility and relevance in clinical practice of DSM-5 specifiers for major depressive disorder: A Delphi expert consensus study.

Major depressive disorder (MDD) is a heterogeneous syndrome, associated with different levels of severity and impairment on the personal functioning for each patient. Classification systems in psychiatry, including ICD-11 and DSM-5, are used by clinicians in order to simplify the complexity of clinical manifestations. In particular, the DSM-5 introduced specifiers, subtypes, severity ratings, and cross-cutting symptom assessments allowing clinicians to better describe the specific clinical features of each patient. However, the use of DSM-5 specifiers for major depressive disorder in ordinary clinical practice is quite heterogeneous. The present study, using a Delphi method, aims to evaluate the consensus of a representative group of expert psychiatrists on a series of statements regarding the clinical utility and relevance of DSM-5 specifiers for major depressive disorder in ordinary clinical practice. Experts reached an almost perfect agreement on statements related to the use and clinical utility of DSM-5 specifiers in ordinary clinical practice. In particular, a complete consensus was found regarding the clinical utility for ordinary clinical practice of using DSM-5 specifiers. The use of specifiers is considered a first step toward a "dimensional" approach to the diagnosis of mental disorders.

Ethological computational psychiatry: Challenges and opportunities.

Studying the intricacies of individual subjects' moods and cognitive processing over extended periods of time presents a formidable challenge in medicine. While much of systems neuroscience appropriately focuses on the link between neural circuit functions and well-constrained behaviors over short timescales (e.g., trials, hours), many mental health conditions involve complex interactions of mood and cognition that are non-stationary across behavioral contexts and evolve over extended timescales. Here, we discuss opportunities, challenges, and possible future directions in computational psychiatry to quantify non-stationary continuously monitored behaviors. We suggest that this exploratory effort may contribute to a more precision-based approach to treating mental disorders and facilitate a more robust reverse translation across animal species. We conclude with ethical considerations for any field that aims to bridge artificial intelligence and patient monitoring.

Barriers to long-acting injectable atypical antipsychotic use in Japan: Insights from a comparative psychiatrist survey.

AIMS: To investigate the negative attitudes of Japanese psychiatrists toward atypical long-acting injectable (LAI) antipsychotics, which are the current mainstream LAIs in Japan. METHODS: We surveyed 69 Japanese psychiatrists using a 5-point Likert scale to assess their attitudes toward atypical LAI antipsychotics. Our assessment referenced concerns identified in a study conducted in Japan a decade ago, which found significant differences when compared with a survey of German psychiatrists. We also identified the factors influencing these negative attitudes. Additionally, the results were compared with those of previous Japanese and German studies. RESULTS: More than 50% of Japanese psychiatrists expressed negative attitudes toward atypical LAI antipsychotics in various areas. These concerns included apprehensions about cost, reluctance to recommend them initially, pain from injections, complexity of switching to LAI, usage in first-episode cases, and sufficient medication adherence with oral drugs. In all three studies, cost and adequate adherence to oral medication were concerns that exceeded the average of the three negative comments. Age and experience in psychiatry influenced the psychiatrists' attitudes toward using these drugs in first-episode cases. CONCLUSIONS: These findings shed light on the reasons for the underutilization of atypical LAI antipsychotics and suggest opportunities to enhance their appropriate use in clinical settings.