WPA

World Psychiatry

OFFICIAL JOURNAL OF THE WORLD PSYCHIATRIC ASSOCIATION (WPA)
Volume 18, Number 1

February 2019

EDITORIAL

Saving the UN Convention on the Rights of
Persons with Disabilities – from itself
P.S. APPELBAUM

1

SPECIAL ARTICLESInnovations and changes in the ICD-11 classification 3of mental, behavioural and neurodevelopmental
disordersG.M. REED, M.B. FIRST, C.S. KOGAN ET AL
Internet-delivered psychological treatments: from 20
innovation to implementation
G. ANDERSSON, N. TITOV, B.F. DEAR ET ALPERSPECTIVES
Personal growth in psychosis
M. SLADE, L. BLACKIE, E. LONGDEN
Assessment and determinants of patient satisfaction
with mental health care
S. PRIEBE, E. MIGLIETTA
Community alternatives to inpatient admissions in
psychiatry
B. LLOYD-EVANS, S. JOHNSON
Drop-outs in psychotherapy: a change of perspective
F. LEICHSENRING, L. SARRAR, C. STEINERT

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30
31
32

FORUM – SUBSTITUTE DECISION-MAKING
IN PSYCHIATRY: STATEMENTS BY UN BODIESAND THEIR PRACTICAL IMPLICATIONS“Capacity”, “best interests”, “will and preferences”
and the UN Convention on the Rights of Persons
with Disabilities
G. SZMUKLER

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50

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RESEARCH REPORTS
The impact of pharmacological andnon-pharmacological interventions to improvephysical health outcomes in people withschizophrenia: a meta-review of meta-analysesof randomized controlled trials
D. VANCAMPFORT, J. FIRTH, C.U. CORRELL ET AL
Transdiagnostic dimensions of psychosis in the
Bipolar-Schizophrenia Network on Intermediate
Phenotypes (B-SNIP)
U. REININGHAUS, J.R. BÖHNKE, U. CHAVEZ-BALDINI

53

67

ET AL

Estimating the risk of PTSD in recent trauma
77
survivors: results of the International Consortium
to Predict PTSD (ICPP)
A.Y. SHALEV, M. GEVONDEN, A. RATANATHARATHORN ET AL

REAPPRAISAL34

The evidence-based group-level symptomreduction model as the organizing principle
for mental health care: time for change?
J. VAN OS, S. GULOKSUZ, T.W. VIJN ET AL

88

INSIGHTS

Commentaries
Mental health and human rights in the 21st century
D. PŪRAS, P. GOODING
Practical strategies to end coercive practices inmental health services
M. FUNK, N. DREWThe UN Committee’s interpretation of “will andpreferences” can violate human rights
T. STEINERTThe CRPD Article 12, the limits of reductionist
approaches to complex issues and the necessary
search for compromise
J.M. CALDAS DE ALMEIDAThe UN Convention on the Rights of Persons with
Disabilities: great opportunities and dangerous
interpretations
S. GALDERISIWill and preferences in the overall CRPD project
P. BARTLETT
The rejection of capacity assessments in favor ofrespect for will and preferences: the radical
promise of the UN Convention on the Rights
of Persons with Disabilities
E. FLYNN
The UN Convention: a service user perspective
C. SUNKEL

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45
46

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Towards a consensus around standards for
smartphone apps and digital mental healthJ. TOROUS, G. ANDERSSON, A. BERTAGNOLI ET AL
AVATAR therapy: a promising new approachfor persistent distressing voices
T.K.J. CRAIG
Parental divorce or separation and children’s
mental health
B. D’ONOFRIO, R. EMERYResilience from a developmental systems
perspective
A.S. MASTEN

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LETTERS TO THE EDITOR

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WPA NEWS

113

IMPACT FACTOR: 30.000

ISSN 1723-8617

The World Psychiatric Association (WPA)World Psychiatry

The WPA is an association of national psychiatric societies
aimed to increase knowledge and skills necessary for work in
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It has produced several educational programmes and seriesof books. It has developed ethical guidelines for psychiatricpractice, including the Madrid Declaration (1996).
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World Psychiatry is the official journal of the World Psychiatric Association. It is published in three issues per year and issent free of charge to psychiatrists whose names and addresses
are provided by WPA member societies and sections.
Research Reports containing unpublished data are welcome for submission to the journal. They should be subdivided
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References should be numbered consecutively in the text andlisted at the end according to the following style:
1. Cuijpers P, Sijbrandij M, Koole SL et al. Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. World Psychiatry 2014;13:
56-67.
2. McRae TW. The impact of computers on accounting. London: Wiley, 1964.
3. Fraeijs de Veubeke B. Displacement and equilibrium models in the finite element method. In: Zienkiewicz OC,
Hollister GS (eds). Stress analysis. London: Wiley, 1965:14597.
All submissions should be sent to the office of the Editor.

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EDITORIAL

Saving the UN Convention on the Rights of Persons with
Disabilities – from itself
The United Nations (UN) Convention on the Rights of Per­
sons with Disabilities (CRPD) is a problem child of interna­
tional human rights law. Like the girl with a little curl right inthe middle of her forehead, immortalized in rhyme by H.W.
Longfellow, when it’s good, it’s very, very good, and when it’sbad it’s horrid1. In embodying the rights of people with dis­abilities to accessibility, education, health, privacy, and otherconditions likely to encourage their flourishing, the CRPD of­fers hope to people around the world whose disabilities havebeen the basis for their exclusion from the usual aspirations oflife. However, in promoting restrictions in Article 12 on govern­­ments’ abilities to intervene to protect the interests and rights
of disabled persons, the CRPD – at least as interpreted by the
UN Committee on the Rights of Persons with Disabilities (theCommittee), set up to oversee its implementation2 – may end up
hurting the very people it purports to help.
As Szmukler notes in his thoughtful essay in this issue ofthe journal3, the CRPD is being interpreted by the Committee
as precluding any involuntary intervention targeted at people
with disabilities. Thus, under this view of the CRPD, elderly per­sons with dementia, no longer able to care for their own needs
but unwilling to accept management of their finances, health,or living situations by a guardian, could not be compelled to
do so. People intending to end their lives as a result of major
depression could not be hospitalized against their will, nor
could persons suffering from psychosis who are refusing to eat
because they believe their food is poisoned. Someone in the
manic stage of bipolar disorder would be free to dissipate hisfamily’s savings or wreck her business. In the name of protect­ing all these people from discrimination, they would be free todestroy their own lives and ruin the lives of their loved ones.
I have considered elsewhere how we arrived at this state4. In
short, blame is due to a drafting process that was captured bysome of the most radical elements of the patients’ rights move­
ment, which are willing to sacrifice the well-being of persons
with disabilities to achieve what they see as their long-term
political goals. It falls as well on the many governments aroundthe world that thoughtlessly ratified the CRPD without consid­
ering its implications. Here, though, I want to focus on strate­
gies for addressing the problems raised by the CRPD going
forward. As best I can tell, there are three alternatives: ignore
the CRPD, reinterpret it, or amend it.
Ignoring the CRPD, or at least those portions of it that are
particularly problematic, might not seem like a viable alterna­
tive, given that the overwhelming majority of countries in theworld – 177 at last count5, with the US a major exception – have
ratified the document. In practice, however, that may not be thecase. Szmukler cites a recent decision of the European Courtof Human Rights which he characterizes as reinterpreting the
CRPD, but which could equally well be considered simply toWorld Psychiatry 18:1 - February 2019

have ignored Article 12 and its limitations. The court held that
“The [appointment of a substitute decision maker for a personwith intellectual disabilities] was proportional and tailored tothe applicant’s circumstances, and was subject to review bycompetent, independent and impartial domestic courts. The
measure taken was also consonant with the legitimate aimof protecting the applicant’s health, in a broader sense of his
well-being”6. Along similar lines, as Dawson7 notes, several
countries ratified the Convention with reservations that would
negate the more restrictive aspects of Article 12, or in theirbiennial reports have simply asserted that they were in compli­
ance when they clearly were not.
Reinterpreting the CRPD in ways that differ from the approachtaken by the Committee is another way of dealing with the prob­
lems. Those efforts have included arguments that protecting
vulnerable people does not constitute discrimination – indeed,
ignoring their vulnerability may be discriminatory4,7; that whenrights protected by the CRPD are in conflict, e.g., preservationof life vs. exercise of legal capacity, the more important rightshould take precedence8; and that even the language of Article
12 itself appears to recognize that limitations on a person’s
decision-making power may be necessary7. Szmukler’s analysisof the ways in which “will” and “preferences” – key terms in the
CRPD – may be in conflict, and the logic in privileging sustained
will over short-term preferences, falls into this category as well.
In my view, all of these critiques of Article 12, which is a deep­
ly flawed and internally inconsistent provision, are cogent.
However, given the low probability that the Committee will be
led by these critiques to change its interpretation, the argu­
ments’ efficacy will likely depend either on persuading states toignore the counterproductive aspects of the CRPD or to pursue
a more radical remedy, namely amendment of the CRPD.
Amending the CRPD may be the most effective long-termso­lution to the problems that so many governments and com­mentators have identified. It will not be an easy process. Draft­
ing the CRPD required a roughly five-year effort, involving
scores of non-governmental organizations and hundreds ofindividuals9. However, the CRPD itself (Article 47) envisions
a less arduous process by which amendments can be made,allowing any state that is a party to the CRPD to propose anamendment, which can be considered with the support of onethird of states and adopted by a vote of two-thirds. Resistancecan be anticipated from the Committee and the more radical
parts of the disability rights movement that succeeded initiallyin capturing the drafting process; hence, success will dependon mobilization of governmental agencies, professional organi­zations, academics, family organizations, and disabled persons
themselves to lobby their governments regarding the needfor change. Only amending Article 12 can definitively reverse
the extreme interpretation of the Committee and remove the1specter of international condemnation of any country that fails
to comply with its approach.
Until that occurs, we can anticipate that governments andothers responsible for the welfare of people rendered vulnerable
by their disabilities will – and I would suggest should – ignore
the Convention when it would interfere with a commonsense
approach to protecting citizens who in one way or another areincapable of protecting themselves. For the future, the lesson to
be learned is the critical importance of involvement of state rep­resentatives, professional organizations, and individual experts
representing mainstream positions in the process of drafting
crucial international documents.

1.
2.
3.
4.
5.
6.
7.
8.
9.

Longfellow HW. There was a little girl. https://www.poetryfoundation.org/
poems/44650/there-was-a-little-girl.
Committee on the Rights of Persons with Disabilities. General Comment
No. 1 on Article 12: Equal recognition before the law. CRPD/C/GC/1. 2014.
Szmukler G. World Psychiatry 2019;18:34-41.
Appelbaum PS. Psychiatr Serv 2016;67:366-8.
Office of the High Commissioner for Human Rights, United Nations. Statusof ratification interactive dashboard. http://indicators.ohchr.org/.
European Court on Human Rights. AM-V v Finland ECHR 273, 2017.
Dawson J. Int J Law Psychiatry 2015;40:70-9.
Freeman MC, Kolappa K, Caldas de Almeida JM et al. Lancet Psychiatry
2015;2:844-50.
Sabatello M, Schulze M (eds). Human rights and disability advocacy.
Philadelphia: University of Pennsylvania Press, 2014.

DOI:10.1002/wps.20583

Paul S. Appelbaum
Department of Psychiatry, Columbia University, and New York State Psychiatric Insti­tute, New York, NY, USA

2

World Psychiatry 18:1 - February 2019

SPECIAL ARTICLE

Innovations and changes in the ICD-11 classification of mental,
behavioural and neurodevelopmental disorders
Geoffrey M. Reed1,2, Michael B. First2,3, Cary S. Kogan4, Steven E. Hyman5, Oye Gureje6, Wolfgang Gaebel7, Mario Maj8, Dan J. Stein9,
Andreas Maercker10, Peter Tyrer11, Angelica Claudino12, Elena Garralda11, Luis Salvador-Carulla13, Rajat Ray14, John B. Saunders15,
Tarun Dua1, Vladimir Poznyak1, María Elena Medina-Mora16, Kathleen M. Pike2, José L. Ayuso-Mateos17, Shigenobu Kanba18,
Jared W. Keeley19, Brigitte Khoury20, Valery N. Krasnov21, Maya Kulygina21, Anne M. Lovell22, Jair de Jesus Mari12, Toshimasa Maruta23,
Chihiro Matsumoto24, Tahilia J. Rebello2,3, Michael C. Roberts25, Rebeca Robles16, Pratap Sharan26, Min Zhao27, Assen Jablensky28,
Pichet Udomratn29, Afarin Rahimi-Movaghar30, Per-Anders Rydelius31, Sabine Bährer-Kohler32, Ann D. Watts33, Shekhar Saxena34
1

Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland; 2Department of Psychiatry, Columbia University Medical Center, New
York, NY, USA; 3New York State Psychiatric Institute, New York, NY, USA; 4School of Psychology, University of Ottawa, Ottawa, ON, Canada; 5Stanley Center for PsychiatricResearch, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA, USA; 6Department of Psychiatry, University of Ibadan, Ibadan, Nigeria;
7
Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany; 8Department of Psychiatry, University of Campania “L.
Vanvitelli”, Naples, Italy; 9Department of Psychiatry, University of Cape Town, and South African Medical Research Council Unit on Risk and Resilience in Mental Disorders,Cape Town, South Africa; 10Department of Psychology, University of Zurich, Zurich, Switzerland; 11Centre for Mental Health, Imperial College, London, UK; 12Department of
Psychiatry, Universidade Federal de São Paulo (UNIFESP/EPM), São Paulo, Brazil; 13Research School of Population Health, Australian National University, Canberra, ACT,
Australia; 14National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India; 15Centre for Youth Substance Abuse Research, Universityof Queensland, Brisbane, QLD, Australia; 16National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico; 17Department of Psychiatry, Universidad
Autonoma de Madrid; Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM); Instituto de Investigación Sanitaria La Princesa,
Madrid, Spain; 18Department of Neuropsychiatry, Kyushu University, Fukuoka, Japan; 19Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA;
20
Department of Psychiatry, American University of Beirut Medical Center, Beirut, Lebanon; 21Moscow Research Institute of Psychiatry, National Medical Research Centre for
Psychiatry and Narcology, Moscow, Russian Federation; 22Institut National de la Santé et de la Recherche Médicale U988, Paris, France; 23Health Management Center, Seitoku
University, Matsudo, Japan; 24Japanese Society of Psychiatry and Neurology, Tokyo, Japan; 25Office of Graduate Studies and Clinical Child Psychol­ogy Program, University of
Kansas, Lawrence, KS, USA; 26Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India; 27Shanghai Mental Health Center and Department of
Psychiatry, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China; 28Centre for Clinical Research in Neuropsychiatry, University of Western
Australia, Perth, WA, Australia; 29Department of Psychiatry, Prince of Songkla University, Hat Yai, Thailand; 30Iranian National Center for Addiction Studies, Tehran University of
Medical Sciences, Tehran, Iran; 31Department of Child and Adolescent Psychiatry, Karolinska Institute, Stockholm, Sweden; 32International Federation of Social Workers, Basel,
Switzerland; 33Entabeni Hospital, Durban, South Africa; 34Harvard T.H. Chan School of Public Health, Boston, MA, USA

Following approval of the ICD-11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transi­tion from the ICD-10 to the ICD-11, with reporting of health statistics based on the new system to begin on January 1, 2022. The WHO
Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD-11 Mental,
Behavioural and Neurodevelopmental Disorders following ICD-11’s approval. The development of the ICD-11 CDDG over the past decade,based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary
and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD-11 include the provision of
consistent and systematically characterized information, the adoption of a lifespan approach, and culture-related guidance for each disorder.
Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders,in ways that are consistent with current evidence, are more compatible with recovery-based approaches, eliminate artificial comorbidity, andmore effectively capture changes over time. Here we describe major changes to the structure of the ICD-11 classification of mental disorders
as compared to the ICD-10, and the development of two new ICD-11 chapters relevant to mental health practice. We illustrate a set of new
categories that have been added to the ICD-11 and present the rationale for their inclusion. Finally, we provide a description of the importantchanges that have been made in each ICD-11 disorder grouping. This information is intended to be useful for both clinicians and researchers
in orienting themselves to the ICD-11 and in preparing for implementation in their own professional contexts.
Key words: International Classification of Diseases, ICD-11, diagnosis, mental disorders, clinical utility, dimensional approaches, culturerelated guidance(World Psychiatry 2019;18:3–19)

In June 2018, the World Health Organization (WHO) released
a pre-final version of the 11th revision of the International Clas­
sification of Diseases and Related Health Problems (ICD-11) for
mortality and morbidity statistics to its 194 member states, forreview and preparation for implementation1. The World Health
Assembly, comprising the ministers of health of all member
states, is expected to approve the ICD-11 at its next meeting,in May 2019. Following approval, member states will begin apro­cess of transitioning from the ICD-10 to the ICD-11, with re­
porting of health statistics to the WHO using the ICD-11 to begin
on January 1, 20222.

World Psychiatry 18:1 - February 2019

The WHO Department of Mental Health and Substance
Abuse has been responsible for coordinating the developmentof four ICD-11 chapters: mental, behavioural and neurodeve­l­opmental disorders; sleep-wake disorders; diseases of the nerv­
ous system; and conditions related to sexual health (jointly with
the WHO Department of Reproductive Health and Re­search).
The mental disorders chapter of the ICD-10, the current
version of the ICD, is by far the most widely used classificationof mental disorders around the world3. During the development of the ICD-10, the WHO Department of Mental Healthand Substance Abuse considered that different versions of the3classification had to be produced in order to meet the needs of
its various users. The version of the ICD-10 for statistical reporting contains short glossary-like definitions for each disorder
category, but this was considered to be insufficient for use bymental health professionals in clinical settings4.
For mental health professionals, the Department developed
the Clinical Descriptions and Diagnostic Guidelines (CDDG) for
ICD-10 Mental and Behavioural Disorders4, informally known
as the “blue book”, intended for general clinical, educationaland service use. For each disorder, a description of the main
clinical and associated features was provided, followed by more
operationalized diagnostic guidelines that were designed to assist mental health clinicians in making a confident diagnosis.
Information from a recent survey5 suggests that clinicians regularly use the material in the CDDG and often review it systematically when making an initial diagnosis, which is counter to thewidespread belief that clinicians only use the classification forthe purpose of obtaining diagnostic codes for administrativeand billing purposes. The Department will publish an equivalent CDDG version of ICD-11 as soon as possible following
approval of the overall system by the World Health Assembly.
More than a decade of intensive work has gone into the development of the ICD-11 CDDG. It has involved hundreds ofcontent experts as members of Advisory and Working Groups
and as consultants, as well as an extensive collaboration withWHO member states, funding agencies, and professional andscientific societies. The development of the ICD-11 CDDG has
been the most global, multilingual, multidisciplinary and participative revision process ever implemented for a classificationof mental disorders.

GENERATING THE ICD-11 CDDG: PROCESSAND PRIORITIESWe have previously described the importance of clinicalutility as an organizing principle in developing the ICD-11
CDDG6,7. Health classifications represent the interface between health encounters and health information. A system that
does not provide clinically useful information at the level of thehealth encounter will not be faithfully implemented by clinicians and therefore cannot provide a valid basis for summary
health encounter data used for decision making at the healthsystem, national and global level.
Clinical utility was, therefore, strongly emphasized in thein­structions provided to a series of Working Groups, generally or­ganized by disorder grouping, appointed by the WHO
Department of Mental Health and Substance Abuse to makerecommendations regarding the structure and content of the
ICD-11 CDDG.
Of course, in addition to being clinically useful and globally
applicable, the ICD-11 must be scientifically valid. Accordingly,
Working Groups were also asked to review the available scientific evidence relevant to their areas of work as a basis for de­veloping their proposals for ICD-11.

4

The importance of global applicability6 was also strongly
emphasized to Working Groups. All groups included representatives from all WHO global regions – Africa, the Americas,
Europe, Eastern Mediterranean, Southeast Asia, and Western
Pacific – and a substantial proportion of individuals from lowand middle-income countries, which account for more than
80% of the world’s population8.
A shortcoming of the ICD-10 CDDG was the lack of consistency in the material provided across disorder groupings9. For
the ICD-11 CDDG, Working Groups were asked to deliver theirrecommendations as “content forms”, including consistent andsystematic information for each disorder that provided the basis for the diagnostic guidelines.
We have previously published a detailed description of thework process and the structure of the ICD-11 diagnostic guidelines9. The development of the ICD-11 CDDG occurred during
a period that overlapped substantially with the production of
the DSM-5 by the American Psychiatric Association, and many
ICD-11 Working Groups included overlapping membershipwith corresponding groups working on the DSM-5. ICD-11
Working Groups were asked to consider the clinical utility andglobal applicability of material being developed for the DSM-5.
A goal was to minimize random or arbitrary differences between the ICD-11 and the DSM-5, although justified conceptual differences were permitted.

INNOVATIONS IN THE ICD-11 CDDG
A particularly important feature of the ICD-11 CDDG is theirapproach to describing the essential features of each disorder, which represent those symptoms or characteristics thata clinician could reasonably expect to find in all cases of thedisorder. While the lists of essential features in the guidelines
superficially resemble diagnostic criteria, arbitrary cutoffs andprecise requirements related to symptom counts and duration are generally avoided, unless these have been empiricallyestablished across countries and cultures or there is anothercompelling reason to include them.
This approach is intended to conform to the way clinicians
actually make diagnoses, with the flexible exercise of clinicaljudgment, and to increase clinical utility by allowing for culturalvariations in presentation as well as contextual and health-system factors that may affect diagnostic practice. This flexible approach is consistent with results of surveys of psychiatrists andpsychologists undertaken early in the ICD-11 development process regarding the desirable characteristics of a mental disorders classification system3,10. Field studies in clinical settings in
13 countries have confirmed that clinicians consider the clinicalutility of this approach to be high11. Importantly, the diagnostic
reliability of the ICD-11 guidelines appears to be at least as highas that obtained using a strict criteria-based approach12.
A number of other innovations in the ICD-11 CDDG werealso introduced by means of the template provided to Working
Groups for making their recommendations (that is, the “con-World Psychiatry 18:1 - February 2019

tent form”). As a part of the standardization of information provided in the guidelines, attention was devoted for each disorderto the systematic characterization of the boundary with normal
variation and to the expansion of the information provided onboundaries with other disorders (differential diagnosis).
The lifespan approach adopted for the ICD-11 meant thatthe separate grouping of behavioural and emotional disorders
with onset usually occurring in childhood and adolescence waseliminated, and these disorders distributed to other groupings
with which they share symptoms. For example, separation
anxiety disorder was moved to the anxiety and fear-related disorders grouping. Moreover, the ICD-11 CDDG provide information for each disorder and/or grouping where data were available describing variations in the presentation of the disorderamong children and adolescents as well as among older adults.
Culture-related information was systematically incorporated
based on a review of the literature on cultural influences on
psychopathology and its expression for each ICD-11 diagnostic
grouping as well as a detailed review of culture-related material
in the ICD-10 CDDG and the DSM-5. The cultural guidance forpanic disorder is provided in Table 1 as an example.
Another major innovation in the ICD-11 classification has
been the incorporation of dimensional approaches within thecontext of an explicitly categorical system with specific taxonomic constraints. This effort was stimulated by the evidence
that most mental disorders can be best described along a number of interacting symptom dimensions rather than as discrete

categories13-15, and has been facilitated by innovations in thecoding structure for the ICD-11. The dimensional potential of
the ICD-11 is most clearly realized in the classification of personality disorders16,17.
For non-specialist settings, the dimensional rating of sever­
ity for ICD-11 personality disorders offers greater simplicity
and clinical utility than the ICD-10 classification of specificpersonality disorders, improved differentiation of patients whoneed complex as compared to simpler treatments, and a bettermechanism for tracking changes over time. In more specialized settings, the constellation of individual personality traits
can inform specific intervention strategies. The dimensional
system eliminates both the artificial comorbidity of personality
disorders and the unspecified personality disorder diagnoses,
as well as providing a basis for research into underlying dimensions and interventions across various personality disorder man­ifestations.
A set of dimensional qualifiers has also been introduced todescribe the symptomatic manifestations of schizophrenia andother primary psychotic disorders18. Rather than focusing on
diagnostic subtypes, the dimensional classification focuses on
relevant aspects of the current clinical presentation in waysthat are much more consistent with recovery-based psychiatricrehabilitation approaches.
The dimensional approaches to personality disorders andsymptomatic manifestations of primary psychotic disorders
are described in more detail in the respective sections later inthis paper.

Table 1 Cultural considerations for panic disorder•• The symptom presentation of panic attacks may vary acrosscultures, influenced by cultural attributions about their origin or
pathophysiology. For example, individuals of Cambodian origin
may emphasize panic symptoms attributed to dysregulation ofkhyâl, a wind-like substance in traditional Cambodian ethnophysiology (e.g., dizziness, tinnitus, neck soreness).
•• There are several notable cultural concepts of distress related topanic ­disorder, which link panic, fear, or anxiety to etiological attributions regarding specific social and environmental influences.
Examples include attributions related to interpersonal conflict(e.g., ataque de nervios among Latin American people), exertion
or orthostasis (khyâl cap among Cambodians), and atmosphericwind (trúng gió among Vietnamese i­ndividuals). These culturallabels may be applied to s­ ymptom p­ resentations other than panic(e.g., anger paroxysms, in the case of ataque de nervios) but theyoften constitute panic episodes or presentations with partial
phenomenological overlap with panic attacks.
•• Clarifying cultural attributions and the context of the experience of­symptoms can inform whether panic attacks should be considered
expected or unexpected, as would be the case in panic disorder. For
example, panic attacks may involve specific foci of apprehensionthat are better explained by another disorder (e.g., social situations
in social anxiety disorder). Moreover, the cultural linkage of theapprehension focus with specific exposures (e.g., wind or cold andtrúng gió panic attacks) may suggest that acute anxiety is expected
when considered within the individual’s cultural framework.

World Psychiatry 18:1 - February 2019

ICD-11 FIELD STUDIESThe ICD-11 field studies program also represents an areaof major innovation. This program of work has included theuse of novel methodologies for studying the clinical utility ofthe draft diagnostic guidelines, including their accuracy andconsistency of application by clinicians as compared to ICD-10
as well as the specific elements responsible for any observed
confusion19. A key strength of the research program has beenthat most studies have been conducted in a time frame allowing their results to provide a basis for revision of the guidelines
to address any observed weaknesses20.
Global participation has also been a defining characteristicof the ICD-11 CDDG field studies program. The Global Clini­
cal Practice Network (GCPN) was established to allow mental
health and primary care professionals from all over the world
to participate directly in the development of the ICD-11 CDDG
through Internet-based field studies.
Over time, the GCPN has expanded to include nearly 15,000
clinicians from 155 countries. All WHO global regions are represented in proportions that largely track the availability ofmental health professionals by region, with the largest proportions coming from Asia, Europe and the Americas (approximately equally divided between the US and Canada on the one
hand and Latin America on the other). More than half of GCPN

5

members are physicians, predominantly psychiatrists, and 30%
are psychologists.
Approximately a dozen GCPN studies have been completed
to date, most focusing on comparisons of the proposed ICD11 diagnostic guidelines with ICD-10 guidelines in terms ofaccuracy and consistency of clinicians’ diagnostic formulations, using standardized case material manipulated to test
key differences19,21. Other studies have examined scaling for
diagnostic qualifiers22 and how clinicians actually use classifications5. GCPN studies have been conducted in Chinese,
French, Japanese, Russian and Spanish, in addition to English,
and have included an examination of results by region andlanguage to identify potential difficulties in global or cultural
applicability as well as problems in translation.
Clinic-based studies have also been conducted through a
network of international field study centers to evaluate theclinical utility and usability of the proposed ICD-11 diagnostic
guidelines in natural conditions, in the settings in which they
are intended to be used11. These studies also evaluated thereliability of diagnoses that account for the greatest proportion of disease burden and mental health services utilization12.
International field studies were located in 14 countries across
all WHO global regions, and patient interviews for the studies
were conducted in the local language of each country.

originally used in Kraepelin’s Textbook of Psychiatry, whichbegan with organic disorders, followed by psychoses, neuroticdis­orders, and personality disorders25. Principles guiding the
ICD-11 organization included trying to order the diagnostic
groupings following a developmental perspective (hence, neurodevelopmental disorders appear first and neurocognitive
disorders last in the classification) and grouping disorders together based on putative shared etiological and pathophysiological factors (e.g., disorders specifically associated withstress) as well as shared phenomenology (e.g., dissociative
disorders). Table 2 provides a listing of the diagnostic groupingsin the ICD-11 chapter on mental, behavioural and neurodevelopmental disorders.
The classification of sleep disorders in the ICD-10 relied on
the now obsolete separation between organic and non-organic
disorders, resulting in the “non-organic” sleep disorders being
included in the chapter on mental and behavioural disordersof the ICD-10, and the “organic” sleep disorders being included
in other chapters (i.e., diseases of the nervous system, diseases of the respiratory system, and endocrine, nutritional andmetabolic disorders). In ICD-11, a separate chapter has beencreated for sleep-wake disorders that encompasses all relevant
sleep-related diagnoses.
Table 2 Disorder groupings in the ICD-11 chapter on mental, behavioural and neurodevelopmental disorders

OVERALL STRUCTURE OF THE ICD-11
CHAPTER ON MENTAL, BEHAVIOURAL AND
NEURODEVELOPMENTAL DISORDERS
In the ICD-10, the number of groupings of disorders was artificially constrained by the decimal coding system used in theclassification, such that it was only possible to have a maximumof ten major groupings of disorders within the chapter on mental and behavioural disorders. As a result, diagnostic groupings
were created that were not based on clinical utility or scientificevidence (e.g., anxiety disorders being included as part of theheterogeneous grouping of neurotic, stress-related, and somatoform disorders). ICD-11’s use of a flexible alphanumeric coding structure allowed for a much larger number of groupings,
making it possible to develop diagnostic groupings based moreclosely on scientific evidence and the needs of clinical practice.
In order to provide data to assist in developing an organizational structure that would be more clinically useful, twoformative field studies were conducted23,24 to examine the conceptualizations held by mental health professionals aroundthe world regarding the relationships among mental disorders.
These data informed decisions about the optimal structure of
the classification. The ICD-11 organizational structure was also
influenced by efforts by the WHO and the American Psychiatric
Association to harmonize the overall structure of the ICD-11
chapter on mental and behavioural disorders with the structureof the DSM-5.
The organization of the ICD-10 chapter on mental and behavioural disorders largely reflected the chapter organization

6

Neurodevelopmental disorders
Schizophrenia and other primary psychotic disorders
Catatonia
Mood disorders
Anxiety and fear-related disorders
Obsessive-compulsive and related disorders
Disorders specifically associated with stress
Dissociative disorders
Feeding and eating disorders
Elimination disorders
Disorders of bodily distress and bodily experience
Disorders due to substance use and addictive behaviours
Impulse control disorders
Disruptive behaviour and dissocial disorders
Personality disorders
Paraphilic disorders
Factitious disorders
Neurocognitive disorders
Mental and behavioural disorders associated with pregnancy, childbirth andthe puerperium
Psychological and behavioural factors affecting disorders or diseases­classified elsewhere
Secondary mental or behavioural syndromes associated with disorders or
diseases classified elsewhere

World Psychiatry 18:1 - February 2019

The ICD-10 also embodied a dichotomy between organicand non-organic in the realm of sexual dysfunctions, with “nonorganic” sexual dysfunctions included in the chapter on mental
and behavioural disorders, and “organic” sexual dysfunctions
for the most part listed in the chapter on diseases of the genitourinary system. A new integrated chapter for conditions related tosexual health has been added to the ICD-11 to house a unifiedclassification of sexual dysfunctions and sexual pain disorders26
as well as changes in male and female anatomy. Moreover, ICD10 gender identity disorders have been renamed as “genderincongruence” in the ICD-11 and moved from the mental disorders chapter to the new sexual health chapter26, meaning thata transgender identity is no longer to be considered a mental
disorder. Gender incongruence is not proposed for eliminationin the ICD-11 because in many countries access to relevant
health services is contingent on a qualifying diagnosis. The ICD11 guidelines explicitly state that gender variant behaviour andpreferences alone are not sufficient for making a diagnosis.

NEW MENTAL, BEHAVIOURAL AND
NEURODEVELOPMENTAL DISORDERS IN THE
ICD-11
Based on a review of the available evidence on scientificvalidity, and a consideration of clinical utility and global applicability, a number of new disorders have been added to the
ICD-11 chapter on mental, behavioural and neurodevelopmental disorders. A description of these disorders as definedin the ICD-11 diagnostic guidelines and the rationale for their
inclusion are provided below.

Catatonia
In the ICD-10, catatonia was included as one of the subtypesof schizophrenia (i.e., catatonic schizophrenia) and as one ofthe organic disorders (i.e., organic catatonic disorder). In recognition of the fact that the syndrome of catatonia can occur
in association with a variety of mental disorders27, a new diagnostic grouping for catatonia (at the same hierarchical level asmood disorders, anxiety and fear-related disorders, etc.) has
been added in the ICD-11.
Catatonia is characterized by the occurrence of several
symptoms such as stupor, catalepsy, waxy flexibility, mutism,
negativism, posturing, mannerisms, stereotypies, psychomotor
agitation, grimacing, echolalia and echopraxia. Three conditions are included in the new diagnostic grouping: a) catatonia associated with another mental disorder (such as a mooddisorder, schizophrenia or other primary psychotic disorder,
or autism spectrum disorder); b) catatonia induced by psychoactive substances, including medications (e.g., antipsychotic
medications, amphetamines, phencyclidine); and c) secondary
catatonia (i.e., caused by a medical condition, such as diabetic
ketoacidosis, hypercalcemia, hepatic encephalopathy, homo-

World Psychiatry 18:1 - February 2019

cystinuria, neoplasm, head trauma, cerebrovascular disease,or encephalitis).

Bipolar type II disorder
The DSM-IV introduced two types of bipolar disorder. Bi­
polar type I disorder applies to presentations characterized
by at least one manic episode, whereas bipolar type II disorder re­quires at least one hypomanic episode plus at least one
major de­pressive episode, in the absence of a history of manic
episodes. Evidence supporting the validity of the distinction
between these two types includes differences in antidepressantmonotherapy response28, neurocognitive measures28,29, genetic
effects28,30, and neuroimaging findings28,31,32.
Given this evidence, and the clinical utility of differentiating
between these two types33, bipolar disorder in ICD-11 has also
been subdivided into type I and type II bipolar disorder.

Body dysmorphic disorder
Individuals with body dysmorphic disorder are persistently
preoccupied with one or more defects or flaws in their bodily
appearance that are either unnoticeable or only slightly noticeable to others34. The preoccupation is accompanied by repetitive and excessive behaviours, including repeated examinationof the appearance or severity of the perceived defect or flaw, excessive attempts to camouflage or alter the perceived defect, or
marked avoidance of social situations or triggers that increase
distress about the perceived defect or flaw.
Originally called “dysmorphophobia” , this condition was
first included in the DSM-III-R. It appeared in the ICD-10 as
an embedded but incongruous inclusion term under hypochondriasis, but clinicians were instructed to diagnose it asdelusional disorder in cases in which associated beliefs wereconsidered delusional. This created a potential for the same
disorder to be assigned different diagnoses without recognizing
the full spectrum of severity of the disorder, which can include
beliefs that appear delusional due to the degree of conviction
or fixity with which they are held.
In recognition of its distinct symptomatology, prevalence inthe general population and similarities to obsessive-compulsive and related disorders (OCRD), body dysmorphic disorderhas been included in this latter grouping in the ICD-1135.

Olfactory reference disorderThis condition is characterized by a persistent preoccupation
with the belief that one is emitting a perceived foul or offensive
body odour or breath, that is either unnoticeable or only slightly
noticeable to others34.
In response to their preoccupation, individuals engage inrepetitive and excessive behaviours such as repeatedly checking

7for body odour or checking the perceived source of the smell;
repeatedly seeking reassurance; excessive attempts to camouflage, alter or prevent the perceived odour; or marked avoidanceof social situations or triggers that increase distress about theperceived foul or offensive odour. Affected individuals typicallyfear or are convinced that others noticing the smell will rejector humiliate them36.
Olfactory reference disorder is included in the ICD-11 OCRD
grouping, as it shares phenomenological similarities with otherdisorders in this grouping with respect to the presence of per­sistent intrusive preoccupations and associated repetitive be­haviours35.

Hoarding disorder
Hoarding disorder is characterized by the accumulation ofpossessions, due to their excessive acquisition or to difficulty
discarding them, regardless of their actual value35,37. Excessive
acquisition is characterized by repetitive urges or behaviours
related to amassing or buying items. Difficulty discarding ischaracterized by a perceived need to save items and a distressassociated with discarding them. The accumulation of possessions results in living spaces becoming cluttered to the pointthat their use or safety is compromised.
Although hoarding behaviours may be exhibited as a part ofa broad range of mental and behavioural disorders and otherconditions – including obsessive-compulsive disorder, depres­sive disorders, schizophrenia, dementia, autism spectrum dis­orders and Prader-Willi syndrome – there is sufficient evidence
supporting hoarding disorder as a separate and unique disorder38.
Individuals affected by hoarding disorder are underrecognized and undertreated, which argues from a public health per­spective for its inclusion in the ICD-1139.

Excoriation disorder
A new diagnostic subgrouping, body-focused repetitive behaviour disorders, has been added to the OCRD grouping. It
includes trichotillomania (which was included in the groupingof habit and impulse disorders in ICD-10) and a new condition,
excoriation disorder (also known as skin-picking disorder).
Excoriation disorder is characterized by recurrent picking of
one’s own skin, leading to skin lesions, accompanied by unsuccessful attempts to decrease or stop the behaviour. The skinpicking must be severe enough to result in significant distressor impairment in functioning. Excoriation disorder (and trichotillomania) are distinct from other OCRDs in that the behaviour
is rarely preceded by cognitive phenomena such as intrusive
thoughts, obsessions or preoccupations, but instead may be
preceded by sensory experiences.
Their inclusion in the OCRD grouping is based on sharedphenomenology, patterns of familial aggregation, and puta­tive

8

etiological mechanisms with other disorders in this group­
ing35,40.

Complex post-traumatic stress disorder
Complex post-traumatic stress disorder (complex PTSD)41
most typically follows severe stressors of a prolonged nature,or multiple or repeated adverse events from which escape isdifficult or impossible, such as torture, slavery, genocide campaigns, prolonged domestic violence, or repeated childhood
sexual or physical abuse.
The symptom profile is marked by the three core fea­tures of
PTSD (i.e., re-experiencing the traumatic event or events in thepresent in the form of vivid intrusive memories, flashbacks ornightmares; avoidance of thoughts and memories of the event or
activities, situations or people reminiscent of the event; per­sist­ent perceptions of heightened current threat), which are ac­com­panied by additional persistent, pervasive and enduring distur­banc­es in affect regulation, self-concept and relational functioning.
The addition of complex PTSD to the ICD-11 is justified on
the basis of the evidence that individuals with the disorder
have a poorer prognosis and benefit from different treatments
as compared to individuals with PTSD42. Complex PTSD replaces the overlapping ICD-10 category of enduring personalitychange after catastrophic experience41.

Prolonged grief disorder
Prolonged grief disorder describes abnormally persistentand disabling responses to bereavement41. Following the deathof a partner, parent, child or other person close to the bereaved,
there is a persistent and pervasive grief response characterized by longing for the deceased or persistent preoccupation
with the deceased, accompanied by intense emotional pain.
Symptoms may include sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling that the individual has losta part of one’s self, an inability to experience positive mood,emotional numbness, and difficulty in engaging with social orother activities. The grief response must persist for an atypicallylong period of time following the loss (more than six months)
and clearly exceed expected social, cultural or religious norms
for the individual’s culture and context.
Although most people report at least partial remission fromthe pain of acute grief by around six months following bereavement, those who continue experiencing severe grief reactions
are more likely to experience significant impairment in theirfunctioning. The inclusion of prolonged grief disorder in the
ICD-11 is a response to the increasing evidence of a distinct
and debilitating condition that is not adequately described bycurrent ICD-10 diagnoses43. Its inclusion and differentiationfrom culturally normative bereavement and depressive episodeis important, because of the different treatment selection implications and prognoses of these latter disorders44.

World Psychiatry 18:1 - February 2019

Binge eating disorder
Binge eating disorder is characterized by frequent, recurrent
episodes of binge eating (e.g., once a week or more over a periodof several months). A binge eating episode is a distinct periodof time during which the individual experiences a subjective
loss of control over eating, eats notably more or differently thanusual, and feels unable to stop eating or limit the type or amountof food eaten.
Binge eating is experienced as very distressing and is often
accompanied by negative emotions such as guilt or disgust.
However, unlike in bulimia nervosa, binge eating episodes
are not regularly followed by inappropriate compensatory behaviours aimed at preventing weight gain (e.g., self-induced
vomiting, misuse of laxatives or enemas, strenuous exercise).
Although binge eating disorder is often associated with weightgain and obesity, these features are not a requirement and thedisorder can be present in normal weight individuals.
The addition of binge eating disorder in the ICD-11 is basedon extensive research that has emerged during the last 20 years
supporting its validity and clinical utility45,46. Individuals whoreport episodes of binge eating without inappropriate compensatory behaviours represent the most common group among
those who receive ICD-10 diagnoses of other specified or unspecified eating disorder, so that it is expected that the inclusion of binge eating disorder will reduce these diagnoses47.

Avoidant/restrictive food intake disorder
Avoidant/restrictive food intake disorder (ARFID) is characterized by abnormal eating or feeding behaviours that resultin the intake of an insufficient quantity or variety of food tomeet adequate energy or nutritional requirements. This resultsin significant weight loss, failure to gain weight as expectedin childhood or pregnancy, clinically significant nutritional
deficiencies, dependence on oral nutritional supplements or
tube feeding, or otherwise negatively affects the health of theindividual or results in significant functional impairment.
ARFID is distinguished from anorexia nervosa by the absence of concerns about body weight or shape. Its inclu­sion in
the ICD-11 can be considered to be an expansion of the ICD-10
category “feeding disorder of infancy and childhood”, and islikely to improve clinical utility across the lifespan (i.e., unlike its ICD-10 counterpart, ARFID applies to children, adolescents and adults) as well as maintaining consistency with
DSM-545,47.

Body integrity dysphoria
Body integrity dysphoria is a rare disorder characterized by
the persistent desire to have a specific physical disability (e.g.,
amputation, paraplegia, blindness, deafness) beginning inchildhood or early adolescence48. The desire can be manifested

World Psychiatry 18:1 - February 2019

in a number of ways, including fantasizing about having thedesired physical disability, engaging in “pretending” behaviour(e.g., spending hours in a wheelchair or using leg braces tosimulate having leg weakness), and spending time searching
for ways to achieve the desired disability.
The preoccupation with the desire to have the physical disability (including time spent pretending) significantly interfereswith productivity, leisure activities, or social functioning (e.g.,
the person is unwilling to have close relationships because it
would make it difficult to pretend). Moreover, for a significant
minority of individuals with this desire, their preoccupation
goes beyond fantasy, and they pursue actualization of the desire
through surgical means (i.e., by procuring an elective amputationof an otherwise healthy limb) or by self-damaging a limb to adegree in which amputation is the only therapeutic option (e.g.,freezing a limb in dry ice).

Gaming disorder
As online gaming has greatly increased in popularity in recent years, problems have been observed related to excessive
involvement in gaming. Gaming disorder has been included
in a newly added diagnostic grouping called “disorders due to
addictive behaviours” (which also contains gambling disorder)
in response to global concerns about the impact of problematic
gaming, especially the online form49.
Gaming disorder is characterized by a pattern of persistentor recurrent Internet-based or offline gaming behaviour (“digit­
al gaming” or “video-gaming”) that is manifested by impaired
control over the behaviour (e.g., inability to limit the amountof time spent gaming), giving increasing priority to gaming to
the extent that it takes precedence over other life interests anddaily activities; and continuing or escalating gaming despite its
negative consequences (e.g., being repeatedly fired from jobs
because of excessive absences due to gaming). It is differentiated from non-pathological gaming behaviour by the clinicallysignificant distress or impairment in functioning it produces.

Compulsive sexual behaviour disorder
Compulsive sexual behaviour disorder is characterized bya persistent pattern of failure to control intense repetitive sexual impulses or urges, resulting in repetitive sexual behaviour
over an extended period (e.g., six months or more) that causes
marked distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.
Possible manifestations of the persistent pattern include:
repetitive sexual activities becoming a central focus of the individual’s life to the point of neglecting health and personal careor other interests, activities and responsibilities; the individual
making numerous unsuccessful efforts to control or significantly
reduce the repetitive sexual behaviour; the individual continuing to engage in repetitive sexual behaviour despite adverse

9consequences such as repeated relationship disruption; andthe individual continuing to engage in repetitive sexual behaviour even when he or she no longer derives any satisfaction
from it.
Although this category phenomenologically resembles substance dependence, it is included in the ICD-11 impulse control disorders section in recognition of the lack of definitive
information on whether the processes involved in the development and maintenance of the disorder are equivalent to thoseobserved in substance use disorders and behavioural addictions. Its inclusion in the ICD-11 will help to address unmet
needs of treatment seeking patients as well as possibly reducing
shame and guilt associated with help seeking among distressedindividuals50.

Intermittent explosive disorderIntermittent explosive disorder is characterized by repeatedbrief episodes of verbal or physical aggression or destruction ofproperty that represent a failure to control aggressive impulses,
with the intensity of the outburst or degree of aggressivenessbeing grossly out of proportion to the provocation or precipitating psychosocial stressors.
Because such episodes can occur in a variety of other conditions (e.g., oppositional defiant disorder, conduct disorder,
bipolar disorder), the diagnosis is not given if the episodes are
better explained by another mental, behavioural or neurodevelopmental disorder.
Although intermittent explosive disorder was introduced in
the DSM-III-R, it appeared in the ICD-10 only as an inclusion
term under “other habit and impulse disorders”. It is includedin the ICD-11 impulse control disorders section in recognitionof the substantial evidence of its validity and utility in clinicalsettings51.

Premenstrual dysphoric disorder
Premenstrual dysphoric disorder (PMDD) is characterized
by a variety of severe mood, somatic or cognitive symptoms
that begin several days before the onset of menses, start to improve within a few days, and become minimal or absent withinapproximately one week following the onset of menses.
More specifically, the diagnosis requires a pattern of mood
symptoms (depressed mood, irritability), somatic symptoms(lethargy, joint pain, overeating), or cognitive symptoms (concentration difficulties, forgetfulness) that have occurred during a majority of menstrual cycles within the past year. The
symptoms are severe enough to cause significant distress or
significant impairment in personal, family, social, educational,
occupational or other important areas of functioning, and do
not represent the exacerbation of another mental disorder.
In the ICD-11, PMDD is differentiated from the far more com­mon premenstrual tension syndrome by the severity of the10

symptoms and the requirement that they cause significant distress or impairment52. The inclusion of PMDD in the research
appendices of the DSM-III-R and DSM-IV stimulated a great
deal of research that has established its validity and reliability52,53, leading to its inclusion in both the ICD-11 and DSM-5.
Although its primary location in the ICD-11 is in the chapter
on diseases of the genitourinary system, PMDD is cross-listed in
the subgrouping of depressive disorders due to the prominenceof mood symptomatology.

SUMMARY OF CHANGES BY ICD-11 DISORDERGROUPING
The following sections summarize the changes introduced ineach of the main disorder groupings of the ICD-11 chapter onmental, behavioural and neurodevelopmental disorders in addition to the new categories described in the previous section.
These changes have been made on the basis of a review ofavailable scientific evidence by ICD-11 Working Groups andexpert consultants, consideration of clinical utility and global
applicability, and, where possible, the results of field testing.

Neurodevelopmental disorders
Neurodevelopmental disorders are those that involve significant difficulties in the acquisition and execution of specificintellectual, motor, language or social functions with onset during the developmental period. ICD-11 neurodevelopmental
disorders encompass the ICD-10 groupings of mental retardation and disorders of psychological development, with theaddition of attention deficit hyperactivity disorder (ADHD).
Major changes in the ICD-11 include the renaming of disorders of intellectual development from ICD-10 mental retardation, which was an obsolete and stigmatizing term that did notadequately capture the range of forms and etiologies associatedwith this condition54. Disorders of intellectual development
continue to be defined on the basis of significant limitations in
intellectual functioning and adaptive behaviour, ideally determined by standardized, appropriately normed and individuallyadministered measures. In recognition of the lack of access tolocally appropriate standardized measures or trained personnel to administer them in many parts of the world, and becauseof the importance of determining severity for treatment planning, the ICD-11 CDDG also provide a comprehensive set of
behavioural indicator tables55.
Separate tables for intellectual functioning and adaptive
behaviour functioning domains (conceptual, social, practical)
are organized according to three age groups (early childhood,childhood/adolescence and adulthood) and four levels of severity (mild, moderate, severe, profound). Behavioural indicators describe those skills and abilities that would be typicallyobserved within each of these categories and are expected to
improve the reliability of the characterization of severity and toWorld Psychiatry 18:1 - February 2019

improve public health data related to the burden of disorders ofintellectual development.
Autism spectrum disorder in the ICD-11 incorporates bothchildhood autism and Asperger’s syndrome from the ICD-10
under a single category characterized by social communication
deficits and restricted, repetitive and inflexible patterns of behaviour, interests or activities. Guidelines for autism spectrum
disorder have been substantially updated to reflect the current
literature, including presentations throughout the lifespan.
Qualifiers are provided for the extent of impairment in intellectual functioning and functional language abilities to capture
the full range of presentations of autism spectrum disorder in amore dimensional manner.
ADHD has replaced ICD-10 hyperkinetic disorders and has
been moved to the grouping of neurodevelopmental disorders
because of its developmental onset, characteristic disturbances
in intellectual, motor and social functions, and common co-­occurrence with other neurodevelopmental disorders. This
move also addresses the conceptual weakness of viewing ADHD
as more closely related to disruptive behaviour and dissocial
disorders, given that individuals with ADHD are typically notintentionally disruptive.
ADHD can be characterized in the ICD-11 using qualifiers
for predominantly inattentive, predominantly hyperactive-­
impulsive, or combined type, and is described across the lifespan.
Finally, chronic tic disorders, including Tourette syndrome,are classified in the ICD-11 chapter on diseases of the nervous
system, but are cross-listed in the grouping of neurodevelopmental disorders because of their high co-occurrence (e.g., withADHD) and typical onset during the developmental period.

Schizophrenia and other primary psychotic disorders
The ICD-11 grouping of schizophrenia and other primary
psychotic disorders replaces the ICD-10 grouping of schizophrenia, schizotypal and delusional disorders. The term “primary” indicates that psychotic processes are a core feature, incontrast to psychotic symptoms that may occur as an aspect ofother forms of psychopathology (e.g., mood disorders)18.
In the ICD-11, schizophrenia symptoms have largely remained unchanged from the ICD-10, though the importanceof Schneiderian first-rank symptoms has been de-emphasized.
The most significant change is the elimination of all subtypes ofschizophrenia (e.g., paranoid, hebephrenic, catatonic), due totheir lack of predictive validity or utility in treatment selection.
In lieu of the subtypes, a set of dimensional descriptors has
been introduced18. These include: positive symptoms (delusions, hallucinations, disorganized thinking and behaviour,
experiences of passivity and control); negative symptoms (constricted, blunted or flat affect, alogia or paucity of speech, avolition, anhedonia); depressive mood symptoms; manic mood
symptoms; psychomotor symptoms (psychomotor agitation,
psychomotor retardation, catatonic symptoms); and cognitive symptoms (particularly deficits in speed of processing,World Psychiatry 18:1 - February 2019

attention/concentration, orientation, judgment, abstraction,verbal or visual learning, and working memory). These same
symptom ratings can also be applied to other categories in thegrouping (schizoaffective disorder, acute and transient psychotic disorder, delusional disorder).
ICD-11 schizoaffective disorder still requires the near simultaneous presence of both the schizophrenia syndrome and amood episode. The diagnosis is meant to reflect the current episode of illness and is not conceptualized as longitudinally stable.
ICD-11 acute and transient psychotic disorder is characterized by a sudden onset of positive psychotic symptoms thatfluctuate rapidly in nature and intensity over a short period oftime and persist no longer than three months. This corresponds
only to the “polymorphic” form of acute psychotic disorder in
the ICD-10, which is the most common presentation and onethat is not indicative of schizophrenia56,57. Non-polymorphic
subtypes of acute psychotic disorder in the ICD-10 have been
eliminated and would instead be classified in the ICD-11 as“other primary psychotic disorder”.
As in the ICD-10, schizotypal disorder is classified in thisgrouping and is not considered a personality disorder.

Mood disorders
Unlike in the ICD-10, ICD-11 mood episodes are not independently diagnosable conditions, but rather their pattern overtime is used as a basis for determining which mood disorder
best fits the clinical presentation.
Mood disorders are subdivided into depressive disorders(which include single episode depressive disorder, recurrent
depressive disorder, dysthymic disorder, and mixed depressive
and anxiety disorder) and bipolar disorders (which include bipolar type I disorder, bipolar type II disorder, and cyclothymia).
The ICD-11 subdivides ICD-10 bipolar affective disorder into
bipolar type I and type II disorders. The separate ICD-10 subgrouping of persistent mood disorders, consisting of dysthymia
and cyclothymia, has been eliminated58.
The diagnostic guidelines for depressive episode are one of
the few places in the ICD-11 where a minimal symptom countis required. This is due to the longstanding research and clinicaltradition of conceptualizing depression in this manner. A minimum of five of ten symptoms is required rather than the fourof nine possible symptoms stipulated in ICD-10, thus increasing consistency with the DSM-5. The ICD-11 CDDG organize
depressive symptoms into three clusters – affective, cognitive
and neurovegetative – to assist clinicians in conceptualizing
and recalling the full spectrum of depressive symptomatology.
Fatigue is part of the neurovegetative symptom cluster but is nolonger considered sufficient as an entry-level symptom; rather,either almost daily depressed mood or diminished interest in
activities lasting at least two weeks is required. Hopelessness
has been added as an additional cognitive symptom because ofstrong evidence of its predictive value for diagnoses of depressive disorders59. The ICD-11 CDDG provide clear guidance on

11the differentiation between culturally normative grief reactions
and symptoms that warrant consideration as a depressive episode in the context of bereavement60.
For manic episodes, the ICD-11 requires the presence of theentry level symptom of increased activity or subjective experience of increased energy, in addition to euphoria, irritability
or expansiveness. This is meant to guard against false positive
cases that might be better characterized as normative fluctuations in mood. ICD-11 hypomanic episodes are conceptualized
as an attenuated form of manic episodes in the absence ofsignificant functional impairment.
Mixed episodes are defined in the ICD-11 in a way that isconceptually equivalent to the ICD-10, based on evidence forthe validity of this approach61. Guidance is provided regarding
the typical contrapolar symptoms observed when either manicor depressive symptoms predominate. The presence of a mixed
episode indicates a bipolar type I diagnosis.
The ICD-11 provides various qualifiers to describe the current mood episode or remission status (i.e., in partial or infull remission). Depressive, manic and mixed episodes can be
described as with or without psychotic symptoms. Current depressive episodes in the context of depressive or bipolar disorders can be further characterized by severity (mild, moderate orsevere); by a melancholic features qualifier that bears a direct
relationship with the concept of the somatic syndrome in ICD10; and by a qualifier to identify persistent episodes of morethan two years’ duration. All mood episodes in the context ofdepressive or bipolar disorders can be further described using
a prominent anxiety symptoms qualifier; a qualifier indicating
the presence of panic attacks; and a qualifier to identify seasonal pattern. A qualifier for rapid cycling is also available forbipolar disorder diagnoses.
The ICD-11 includes the category of mixed depressive andanxiety disorder because of its importance in primary care settings62,63. This category has been moved from anxiety disorders
in the ICD-10 to depressive disorders in the ICD-11 because ofevidence of its overlap with mood symptomatology64.

In the ICD-11, GAD has a more elaborated set of essential
features, reflecting advances in the understanding of its unique
phenomenology; in particular, worry is added to general apprehension as a core feature of the disorder. Contrary to ICD-10,
the ICD-11 CDDG specify that GAD can co-occur with depressive disorders as long as symptoms are present independent ofmood episodes. Similarly, other ICD-10 hierarchical exclusion
rules (e.g., GAD cannot be diagnosed together with phobic
anxiety disorder or obsessive-compulsive disorder) are also
eliminated, due to the better delineation of disorder phenomenology in the ICD-11 and the evidence that those rules interferewith detection and treatment of conditions requiring separate
specific clinical attention.
In the ICD-11, agoraphobia is conceptualized as marked
and excessive fear or anxiety that occurs in, or in anticipationof, multiple situations where escape might be difficult or help
not available. The focus of apprehension is fear of specific negative outcomes that would be incapacitating or embarrassingin those situations, which is distinct from the narrower concept
in the ICD-10 of fear of open spaces and related situations,such as crowds, where an escape to a safe place may be diffi­
cult.
Panic disorder is defined in the ICD-11 by recurrent unexpected panic attacks that are not restricted to particular stimuli
or situations. The ICD-11 CDDG indicate that panic attacks
which occur entirely in response to exposure or anticipation of
the feared stimulus in a given disorder (e.g., public speaking insocial anxiety disorder) do not warrant an additional diagnosisof panic disorder. Rather, a “with panic attacks” qualifier can beapplied to the other anxiety disorder diagnosis. The “with panic
attacks” qualifier can also be applied in the context of otherdisorders where anxiety is a prominent though not defining
feature (e.g., in some individuals during a depressive episode).
ICD-11 social anxiety disorder, defined on the basis of fear ofnegative evaluation by others, replaces ICD-10 social phobias.
The ICD-11 CDDG specifically describe separation anxiety
disorder in adults, where it is most commonly focused on aromantic partner or a child.

Anxiety and fear-related disorders
Obsessive-compulsive and related disorders
The ICD-11 brings together disorders with anxiety or fear as
the primary clinical feature in this new grouping65. Consistent
with ICD-11’s lifespan approach, this grouping also includes
separation anxiety disorder and selective mutism, which wereplaced among the childhood disorders in the ICD-10. The ICD10 distinction between phobic anxiety disorders and otheranxiety disorders has been eliminated in the ICD-11 in favorof the more clinically useful method of characterizing eachanxiety and fear-related disorder according to its focus of apprehension66; that is, the stimulus reported by the individualas triggering his or her anxiety, excessive physiological arousal
and maladaptive behavioural responses. Generalized anxiety
disorder (GAD) is characterized by general apprehensivenessor worry that is not restricted to any particular stimulus.

12

The introduction of the OCRD grouping in the ICD-11 represents a significant departure from the ICD-10. The rationale for creating an OCRD grouping distinct from anxiety andfear-related disorders, despite phenomenological overlap, isbased on the clinical utility of collating disorders with shared
symptoms of repetitive unwanted thoughts and related repetitive behaviours as the primary clinical feature. The diagnostic
coherence of this grouping comes from emerging evidence ofthe shared validators among included disorders from imaging,
genetic and neurochemical studies35.
ICD-11 OCRD include obsessive-compulsive disorder,
body dysmorphic disorder, olfactory reference disorder, hypochondriasis (illness anxiety disorder) and hoarding disorder.

World Psychiatry 18:1 - February 2019

Equivalent categories that exist in the ICD-10 are located indisparate groupings. Also included in OCRD is a subgrouping of body-focused repetitive behaviour disorders that includes trichotillomania (hair-pulling disorder) and excoriation(skin-picking) disorder, both sharing the core feature of repetitive behaviour without the cognitive aspect of other OCRDs.
Tourette syndrome, a disease of the nervous system in ICD-11,
is cross-listed in the OCRD grouping because of its frequentco-occurrence with obsessive-compulsive disorder.
The ICD-11 retains the core features of ICD-10 obsessivecompulsive disorder, that is, persistent obsessions and/or
compulsions, but with some important revisions. The ICD-11
broadens the concept of obsessions beyond intrusive thoughts
to include unwanted images and urges/impulses. Moreover,the concept of compulsions is expanded to include covert (e.g.,
repeated counting) as well as overt repetitive behaviours.
Although anxiety is the most common affective experience
associated with obsessions, the ICD-11 explicitly mentions
other phenomena reported by patients, such as disgust, shame,a sense of “incompleteness”, or uneasiness that things do notlook or feel “right”. ICD-10 subtypes of OCD are eliminated,because the majority of patients report both obsessions andcompulsions, and because they lack predictive validity fortreatment response. The ICD-10 prohibition against diagnosing
obsessive-compulsive disorder along with depressive disorders
is removed in the ICD-11, reflecting the high rate of co-occurrence of these disorders and the need for distinct treatments.
Hypochondriasis (health anxiety disorder) is placed in OCRD
rather than among anxiety and fear-related disorders, eventhough health preoccupations are often associated with anxiety
and fear, because of shared phenomenology and patterns offamilial aggregation with OCRD67. However, hypochondriasis(health anxiety disorder) is cross-listed in the anxiety and fearrelated disorders grouping, in recognition of some phenomenological overlap.
Body dysmorphic disorder, olfactory reference disorder, andhoarding disorder are new categories in ICD-11 that have been
included in the OCRD grouping.
In OCRDs that have a cognitive component, beliefs may beheld with such intensity or fixity that they appear to be delusional. When these fixed beliefs are entirely consistent with thephenomenology of the OCRD, in the absence of other psychotic symptoms, the qualifier “with poor to absent insight” should
be used, and a diagnosis of delusional disorder should not be
assigned. This is intended to help guard against inappropriate
treatment for psychosis among individuals with OCRDs35.

Disorders specifically associated with stress
The ICD-11 grouping of disorders specifically associatedwith stress replaces ICD-10 reactions to severe stress and adjustment disorders, to emphasize that these disorders share
the necessary (but not sufficient) etiologic requirement for
exposure to a stressful event, as well as to distinguish included

World Psychiatry 18:1 - February 2019

disorders from the various other mental disorders that arise
as a reaction to stressors (e.g., depressive disorders)41. ICD-10
reactive attachment disorder of childhood and disinhibited attachment disorder of childhood are reclassified to this grouping
owing to the lifespan approach of the ICD-11 and in recognitionof the specific attachment-related stressors inherent to these
disorders. The ICD-11 includes several important conceptual
updates to the ICD-10 as well as the introduction of complex
PTSD and prolonged grief disorder, which have no equivalent
in the ICD-10.
PTSD is defined by three features that should be present
in all cases and must cause significant impairment. They are:re-experiencing the traumatic event in the present; deliberate
avoidance of reminders likely to produce re-experiencing; andpersistent perceptions of heightened current threat. The inclusion of the requirement for re-experiencing the cognitive, affective or physiological aspects of the trauma in the here and now
rather than just remembering the event is expected to address
the low diagnostic threshold for PTSD in ICD-1042.
Adjustment disorder in the ICD-11 is defined on the basis of
the core feature of preoccupation with a life stressor or its consequences, while in the ICD-10 the disorder was diagnosed if
symptoms occurring in response to a life stressor did not meet
definitional requirements of another disorder.
Finally, acute stress reaction is no longer considered to be amental disorder in the ICD-11, but instead is understood to bea normal reaction to an extreme stressor. Thus, it is classified
in the ICD-11 chapter on “factors influencing health status orcontact with health services”, but cross-listed in the groupingof disorders specifically associated with stress to assist withdifferential diagnosis.

Dissociative disorders
The ICD-11 dissociative disorders grouping corresponds
to ICD-10 dissociative (conversion) disorders, but has beensignificantly reorganized and simplified, to reflect recent empirical findings and to enhance clinical utility. Reference to theterm “conversion” is eliminated from the grouping title68. ICD11 dissociative neurological symptom disorder is conceptuallyconsistent with ICD-10 dissociative disorders of movement
and sensation, but is presented as a single disorder with twelve
subtypes defined on the basis of the predominant neurological symptom (e.g., visual disturbance, non-epileptic seizures,speech disturbance, paralysis or weakness). ICD-11 dissociative amnesia includes a qualifier to indicate whether dissociative fugue is present, a phenomenon that is classified as aseparate disorder in ICD-10.
The ICD-11 divides ICD-10 possession trance disorder into
the separate diagnoses of trance disorder and possession trance
disorder. The separation reflects the distinctive feature in possession trance disorder wherein the customary sense of personal
identity is replaced by an external “possessing” identity attributed to the influence of a spirit, power, deity or other spiritual13entity. In addition, a greater range of more complex behaviours
may be exhibited in possession trance disorder, while trance
disorder typically involves the repetition of a small repertoire of
simpler behaviours.
ICD-11 dissociative identity disorder corresponds to the concept of ICD-10 multiple personality disorder and is renamed tobe consistent with currently used nomenclature in clinical andresearch contexts. The ICD-11 also introduces partial dissociative identity disorder, reflecting the fact that the preponderanceof ICD-10 unspecified dissociative disorders is accounted for bypresentations in which non-dominant personality states do notrecurrently take executive control of the individual’s consciousness and functioning.
Depersonalization and derealization disorder, located in theother neurotic disorders grouping in the ICD-10, is moved tothe dissociative disorders grouping in the ICD-11.

Feeding and eating disorders
The ICD-11 grouping of feeding and eating disorders integrates ICD-10 eating disorders and feeding disorders of childhood, in recognition of the interconnectedness of these disorders
across the lifespan, as well as reflecting the evidence that these
disorders can apply to individuals across a broader range ofages45,47.
The ICD-11 provides updated conceptualizations of anorexia nervosa and bulimia nervosa to incorporate recent evidence,
which eliminates the need for ICD-10 “atypical” categories. It
also includes the new entities of binge eating disorder, whichis introduced based on empirical support for its validity andclinical utility, and ARFID, which expands upon ICD-10 feeding disorder of infancy and childhood.
Anorexia nervosa in the ICD-11 eliminates the ICD-10 requirement for the presence of a widespread endocrine disorder, because evidence suggests that this does not occur in allcases and, even when present, is a consequence of low bodyweight rather than a distinct defining feature of the disorder.
Furthermore, cases without endocrine disorder were largely
responsible for atypical anorexia diagnoses. The threshold for
low body weight in ICD-11 is raised from 17.5 kg/m2 to 18 kg/
m2, but the guidelines accommodate situations in which the
body mass index may not adequately reflect a worsening clinical picture (e.g., precipitous weight loss in the context of otherfeatures of the disorder). Anorexia nervosa does not require“fat phobia” as in the ICD-10, to allow for the full spectrum ofculturally diverse rationales for food refusal and expressions ofbody preoccupation.
Qualifiers are provided to characterize the severity of underweight status, given that extremely low body mass index isassociated with greater risk of morbidity and mortality. A qualifier describing the pattern of associated behaviours is included(i.e., restricting pattern, binge-purge pattern).
Bulimia nervosa in the ICD-11 can be diagnosed regardless of the current weight of the individual, as long as the body14mass index is not so low as to meet definitional requirements
for anorexia nervosa. In lieu of specific minimal binge frequencies that are, in fact, not supported by evidence, the ICD-11
provides more flexible guidance. A bulimia nervosa diagnosis
does not require “objective” binges and can be diagnosed on
the basis of “subjective” binges, in which the individual eats
more or differently than usual and experiences a loss of control
over eating accompanied by distress, regardless of the amountof food actually eaten. This change is expected to reduce thenumber of unspecified feeding and eating disorder diagnoses.

Elimination disorders
The term “non-organic” is removed from the ICD-11 elimination disorders, which include enuresis and encopresis. These
disorders are differentiated from those that can be better accounted for by another health condition or the physiologicaleffects of a substance.

Disorders of bodily distress and bodily experience
ICD-11 disorders of bodily distress and bodily experience en­compass two disorders: bodily distress disorder and body integrity dysphoria. ICD-11 bodily distress disorder replaces ICD-10
somatoform disorders and also includes the concept of ICD-10
neurasthenia. ICD-10 hypochondriasis is not included and in­stead is reassigned to the OCRD grouping.
Bodily distress disorder is characterized by the presence of
bodily symptoms that are distressing to the individual and an excessive attention directed toward the symptoms, which may be
manifest by repeated contact with health care providers69. The
disorder is conceptualized as existing on a continuum of severity and can be qualified accordingly (mild, moderate or severe)depending on the impact on functioning. Importantly, bodily
distress disorder is defined according to the presence of essential
features, such as distress and excessive thoughts and behaviours,
rather than on the basis of absent medical explanations for bothersome symptoms, as in ICD-10 somatoform disorders.
ICD-11 body integrity dysphoria is a newly introduced diagnosis that is incorporated into this grouping48.

Disorders due to substance use and addictive behaviours
The ICD-11 grouping of disorders due to substance use andaddictive behaviours encompasses disorders that develop as aresult of the use of psychoactive substances, including medications, and disorders due to addictive behaviours that develop as a result of specific repetitive rewarding and reinforcing
behaviours.
The organization of ICD-11 disorders due to substance use
is consistent with the approach in the ICD-10, whereby clinical syndromes are classified according to substance classes70.

World Psychiatry 18:1 - February 2019

However, the list of substances in the ICD-11 is expanded toreflect current availability and contemporary use patterns of
substances. Each substance or substance class can be associated with mutually exclusive primary clinical syndromes:
single episode of harmful substance use or harmful pattern of
substance use, which represents a refinement of ICD-10 harmful use; and substance dependence. Substance intoxication andsubstance withdrawal can be diagnosed either together withprimary clinical syndromes or independently as a reason fordelivery of health services when the pattern of use or possibilityof dependence is unknown.
Given the extremely high global disease burden of disorders due to substance use, the grouping has been revised to
optimally enable the capture of health information that will be
useful in multiple contexts, support accurate monitoring andreporting, and inform both prevention and treatment70. The
addition of ICD-11 single episode of harmful substance use
provides an opportunity for early intervention and preventionof escalation of use and harm, whereas the diagnoses of harmful pattern of substance use and substance dependence suggest
the need for increasingly intensive interventions.
The ICD-11 expands the concept of harm to health due tosubstance use to comprise harm to the health of other people,
which can include either physical harm (e.g., due to driving
while intoxicated) or psychological harm (e.g., development of
PTSD following an automobile accident).
The ICD-11 includes substance-induced mental disorders
as syndromes characterized by clinically significant mental or
behavioural symptoms that are similar to those of other mental disorders but that develop due to psychoactive substanceuse. Substance-induced disorders can be related to substanceintoxication or substance withdrawal, but the intensity or duration of symptoms are substantially in excess of those characteristic of intoxication or withdrawal due to the specified
substances.
The ICD-11 also includes categories of hazardous substanceuse, which are not classified as mental disorders but rather are
situated in the chapter on “factors influencing health status orcontact with health services”. These categories may be used
when a pattern of substance use increases the risk of harmful
physical or mental health consequences to the user or to others to an extent that warrants attention and advice from healthprofessionals, but no overt harm has yet occurred. They aremeant to signal opportunities for early and brief interventions,particularly in primary care settings.
ICD-11 disorders due to addictive behaviours include two
diagnostic categories: gambling disorder (pathological gambling in ICD-10) and gaming disorder, which is newly introduced49. In ICD-10, pathological gambling was classified as ahabit and impulse disorder. However, recent evidence points
to important phenomenological similarities between disorders due to addictive behaviours and substance use disorders,
including their higher co-occurrence as well as the common
feature of being initially pleasurable followed by progression
to loss of hedonic value and need for increased use. Moreover,World Psychiatry 18:1 - February 2019

disorders due to substance use and disorders due to addictive
behaviours appear to share similar neurobiology, especially
activation and neuroadaptation within the reward and motivation neural circuits71.

Impulse control disorders
ICD-11 impulse control disorders are characterized by therepeated failure to resist a strong impulse, drive or urge to perform an act that is rewarding to the person, at least in the shortterm, despite longer-term harm either to the individual or to oth­ers.
This grouping includes pyromania and kleptomania, which
are classified in the ICD-10 under habit and impulse disorders.
The ICD-11 introduces intermittent explosive disorder andreclassifies ICD-10 excessive sexual drive to this grouping as
ICD-11 compulsive sexual behaviour disorder50,72,73.

Disruptive behaviour and dissocial disorders
The ICD-11 grouping of disruptive behaviour and dissocial
disorders replaces ICD-10 conduct disorders. The new term
better reflects the full range of severity of behaviours and phenomenology observed in the two conditions included in thisgrouping: oppositional defiant disorder and conduct-dissocial
disorder. An important change introduced in the ICD-11 is thatboth disorders can be diagnosed across the lifespan, whereas the
ICD-10 construes them as disorders of childhood. Additionally,
the ICD-11 introduces qualifiers that characterize subtypes of
disruptive behaviour and dissocial disorders intended to improve clinical utility (e.g., prognostically).
ICD-11 oppositional defiant disorder is conceptually similar to its ICD-10 equivalent category. However, a “with chronic
irritability and anger” qualifier is provided to characterize
those presentations of the disorder with prevailing, persistentirritable mood or anger. This presentation is recognized tosignificantly increase the risk for subsequent depression andanxiety. The ICD-11 conceptualization of this presentation
as a form of oppositional defiant disorder is concordant withcurrent evidence and diverges from the DSM-5 approach of
introducing a new disorder, disruptive mood dysregulation
disorder74-76.
ICD-11 conduct disorder consolidates the three separate
conduct disorder diagnoses classified in ICD-10 (i.e., confinedto the family context, unsocialized, socialized). The ICD-11 acknowledges that disruptive behaviour and dissocial disorders
are frequently associated with problematic psychosocial environments and psychosocial risk factors, such as peer rejection,
deviant peer group influences, and parental mental disorder.
A clinically meaningful distinction between childhood andadolescent onset of the disorder can be indicated with a qualifier, based on the evidence that earlier onset is associated withmore severe pathology and a poorer course of the disorder.

15

A qualifier to indicate limited prosocial emotions can be
assigned to both disruptive behaviour and dissocial dis­orders.
In the context of an oppositional defiant disorder diagnosis,
this presentation is associated with a more stable and extreme
pattern of oppositional behaviours. In the context of conductdissocial disorder, it is associated with a tendency towards
a more severe, aggressive and stable pattern of antisocial behaviour.

Personality disorders
Problems with the ICD-10 classification of ten specific personality disorders included substantial underdiagnosis relative to their prevalence among individuals with other mental
disorders, the fact that only two of the specific personality disorders (emotionally unstable personality disorder, borderline
type, and dissocial personality disorder) were recorded withany frequency in publicly available databases, and that rates
of co-occurrence were extremely high, with most individuals
with severe disorders meeting the requirements for multiple
personality disorders16,17.
The ICD-11 CDDG ask the clinician to first determine whether the individual’s clinical presentation meets the general diagnostic requirements for personality disorder. The clinician thendetermines whether a diagnosis of mild, moderate or severe
personality disorder is appropriate, based on: a) the degreeand pervasiveness of disturbances in functioning of aspectsof the self (e.g., stability and coherence of identity, self-worth,accuracy of self-view, capacity for self-direction); b) the degreeand pervasiveness of interpersonal dysfunction (e.g., understanding others’ perspectives, developing and maintaining
close relationships, managing conflict) across various contexts
and relationships; c) the pervasiveness, severity and chronicity
of emotional, cognitive and behavioural manifestations of personality dysfunction; and d) the extent to which these patterns
are associated with distress or psychosocial impairment.
Personality disorders are then further described by indicating the presence of characteristic maladaptive personality
traits. Five trait domains are included: negative affectivity (thetendency to experience a broad range of negative emotions);
detachment (the tendency to maintain social and interpersonal
distance from others); dissociality (disregard for the rights andfeelings of others, encompassing both self-centeredness andlack of empathy); disinhibition (the tendency to act impulsively
in response to immediate internal or environmental stimuli
without consideration of longer-term consequences); andanankastia (a narrow focus on one’s rigid standard of perfection and of right and wrong and on controlling one’s own andothers’ behaviour to ensure conformity to those standards).
As many of these trait domains may be assigned as part of thediagnosis as are judged to be prominent and contributing to thepersonality disorder and its severity.
In addition, an optional qualifier is provided for “borderline pattern”. This qualifier is intended to ensure continuity of16

care during the transition from the ICD-10 to the ICD-11 andmay enhance clinical utility by facilitating the identificationof individuals who may respond to certain psychotherapeutic
treatments. Additional research will be needed to determine
whether it provides information that is distinct from that provided by the trait domains.
The ICD-11 also includes a category for personality difficulty, which is not considered a mental disorder, but rather islisted in the grouping of problems associated with interpersonal interactions in the chapter on “factors influencing healthstatus or contact with health services” . Personality difficultyrefers to pronounced personality characteristics that may affecttreatment or provision of health services but do not rise to thelevel of severity to warrant a diagnosis of personality disorder.

Paraphilic disorders
The ICD-11 grouping of paraphilic disorders replaces the ICD10 grouping of disorders of sexual preference, consistent with
contemporary terminology used in research and clinical contexts. The core feature of paraphilic disorders is that they involve
sexual arousal patterns that focus on non-consenting others77.
ICD-11 paraphilic disorders include exhibitionistic disorder,
voy­euristic disorder, and pedophilic disorder. Newly introduced
categories are coercive sexual sadism disorder, frot­teuristic disorder, and other paraphilic disorder involving non-consenting
individuals. A new category of other paraphilic disorder in­volving solitary behaviour or consenting individuals is also included, which can be assigned when sexual thoughts, fantasies,
urges or behaviours are associated with substantial distress(but not as a consequence of rejection or feared rejection of thearousal pattern by others) or confer direct risk of injury or death(e.g., asphyxophilia).
The ICD-11 distinguishes between conditions that are relevant to public health and clinical psychopathology and thosethat merely reflect private behaviour, and for this reason the
ICD-10 categories of sadomasochism, fetishism, and fetishistictransvestism have been eliminated26.

Factitious disorders
The ICD-11 introduces a new grouping of factitious disorders that includes factitious disorder imposed on the self andfactitious disorder imposed on another. This grouping is conceptually equivalent to the ICD-10 diagnosis of intentional production or feigning of symptoms or disabilities, either physicalor psychological (factitious disorder), but extended to include
the clinical situation where an individual feigns, falsifies, orintentionally induces or aggravates medical, psychological or
behavioural signs and symptoms in another individual (usually a child).
The behaviours are not solely motivated by obvious external
rewards or incentives, and are distinguished on this basis fromWorld Psychiatry 18:1 - February 2019

malingering, which is not classified as a mental, behavioural orneurodevelopmental disorder, but rather appears in the chap­ter on “factors influencing health status or contact with healthservices”.

Neurocognitive disorders
ICD-11 neurocognitive disorders are acquired conditions
characterized by primary clinical deficits in cognitive functioning, and include most conditions that are classified among
ICD-10 organic, including symptomatic, mental disorders.
Thus, the grouping includes delirium, mild neurocognitive
disorder (called mild cognitive disorder in ICD-10), amnestic
disorder, and dementia. Delirium and amnestic disorder can
be classified as due to a medical condition classified elsewhere,
due to a substance or a medication, or due to multiple etiological factors. Dementia may be classified as mild, moderate orsevere.
The syndromal characteristics of dementia associated withdifferent etiologies (e.g., dementia due to Alzheimer disease,dementia due to human immunodeficiency virus) are classified and described within the chapter on mental, behaviouraland neurodevelopmental disorders, whereas the underlying
etiologies are classified using categories from the chapter ondis­eases of the nervous system or other sections of the ICD,
as appropriate78. Mild neurocognitive disorder can also be
identified in conjunction with an etiological diagnosis, reflecting improved detection methods for early cognitive decline,
which represents an opportunity to provide treatment in orderto delay disease progression. The ICD-11 therefore clearly recognizes the cognitive, behavioural and emotional components
of neurocognitive disorders as well as their underlying causes.

CONCLUSIONS
The development of the ICD-11 CDDG for mental, behavioural and neurodevelopmental disorders and their underlying
statistical classification represents the first major revision of theworld’s foremost classification of mental disorders in nearly
30 years. It has involved an unprecedented level and range ofglobal, multilingual and multidisciplinary participation. Sub­stantial changes have been made to increase scientific validity
in the light of current evidence and to enhance clinical utility
and global applicability based on a systematic program of fieldtesting.
Now, both the version of the ICD-11 chapter to be used by
WHO member states for health statistics and the CDDG for use inclinical settings by mental health professionals are substantively
complete. In order for the ICD-11 to achieve its potential in theworld, the WHO’s focus will shift to working with member states
and with health professionals on implementation and training.
The implementation of a new classification system involves
the interaction of the classification with each country’s laws,

World Psychiatry 18:1 - February 2019

policies, health systems and information infrastructure. Multi­
ple modalities must be developed for training a vast array ofinternational health professionals. We look forward to continu­
ing our very productive collaboration with the WPA and to
working with member states, academic centers, professionaland scientific organizations and with civil societies in this next
phase of work.
ACKNOWLEDGEMENTS
The authors alone are responsible for the views expressed in this paper and they
do not necessarily represent the decisions, policy or views of the WHO. The
authors express their gratitude to the following individuals who con­trib­uted
substantially to the development of the ICD-11 classification of mental, behav­
ioural and neurodevelopmental disorders: G. Baird, J. Lochman, L.A. Clark, S.
Evans, B.J. Hall, R. Lewis-Fernández, E. Nijenhuis, R.B. Krueger, M.D. Feldman,
J.L. Levenson, D. Skuse, M.J. Tassé, P. Caramelli, H.G. Shah, D.P. Goldberg, G.
Andrews, N. Sartorius, K. Ritchie, M. Rutter, R. Thara, Y. Xin, G. Mellsop, J. Mez­zich, D. Kupfer, D. Regier, K. Saeed, M. van Ommeren and B. Saraceno. They also
thank the additional members of ICD-11 Working Groups and consultants, too
numerous to name here (please see http://www.who.it/mental_health/evidence/
ICD_11_contributors for a more complete listing).

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DOI:10.1002/wps.20611

19

SPECIAL ARTICLE

Internet-delivered psychological treatments: from innovation to
implementation
Gerhard Andersson1,2, Nickolai Titov3,4, Blake F. Dear3,4, Alexander Rozental2,5, Per Carlbring6,71

Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; 2Department of Clinical Neuroscience, Division of Psychiatry, Karolinska
Institutet, Stockholm, Sweden; 3MindSpot Clinic, Macquarie University, Sydney, Australia; 4eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia;
5Institute of Child Health, University College London, London, UK; 6Department of Psychology, Stockholm University, Stockholm, Sweden; 7Department of Psychology,
University of South­ern Denmark, Odense, Denmark

Internet interventions, and in particular Internet-delivered cognitive behaviour therapy (ICBT), have existed for at least 20 years. Here we
review the treatment approach and the evidence base, arguing that ICBT can be viewed as a vehicle for innovation. ICBT has been developed
and tested for several psychiatric and somatic conditions, and direct comparative studies suggest that therapist-guided ICBT is more effective
than a waiting list for anxiety disorders and depression, and tends to be as effective as face-to-face CBT. Studies on the possible harmful effects
of ICBT are also reviewed: a significant minority of people do experience negative effects, although rates of deterioration appear similar to thosereported for face-to-face treatments and lower than for control conditions. We further review studies on change mechanisms and conclude
that few, if any, consistent moderators and mediators of change have been identified. A recent trend to focus on knowledge acquisition isconsidered, and a discussion on the possibilities and hurdles of implementing ICBT is presented. The latter includes findings suggesting that
attitudes toward ICBT may not be as positive as when using modern information technology as an adjunct to face-to-face therapy (i.e., blended
treatment). Finally, we discuss future directions, including the role played by technology and machine learning, blended treatment, adaptationof treatment for minorities and non-Western settings, other therapeutic approaches than ICBT (including Internet-delivered psychodynamic
and interpersonal psychotherapy as well as acceptance and commitment therapy), emerging regulations, and the importance of reporting
failed trials.
Key words: Internet interventions, cognitive behaviour therapy, innovation, anxiety disorders, depression, moderators and mediators, nega­tive effects, blended treatment, implementation(World Psychiatry 2019;18:20–28)

Modern information technology has changed the world andthe way we interact with one another1. Computers were utilized
early in psychotherapy research2 and, with the advent of the Inter­
net, use of computers in research and practice increased rapidly3.
Clinical psychology and psychiatry have been influenced bythese technological advances. Not only have Internet interven­tions become available, but so have websites providing informa­tion about psychiatric conditions4, assessment procedures5, andsocial forums related to psychiatric diagnoses6. More recently,
modern mobile phones (smartphones) have facilitated data col­lection7, increasing the reach and dissemination of therapeu­
tic help. There are now literally thousands of smartphone apps
­dealing with mental health concerns, such as depression andstress8,9.
The focus of this review is on Internet-delivered psycholog­
ical treatments10,11. The first of these treatments were developed,
evaluated and delivered as part of routine care in the mid-1990s12.
Subsequently, the number of controlled trials of Internet-delivered
psychological treatments has grown at a much faster rate than tri­
als of psychotherapy in general. Most of the programs and re­searchon Internet-delivered treatments have involved different formsof cognitive behaviour therapy (CBT), often referred to as ICBT13.

TREATMENT APPROACH
There are numerous different versions of ICBT, but all re­quire a treatment software platform to deliver and manage theintervention. This platform presents assessment instruments,
20

treatment materials, and technology to facilitate interactions
between a clinician and a client14. Treatment programs can de­liver content in the form of text, video or audio, which are pre­sented in the platform together with homework assignments,
and interactions with a clinician and/or automated support
functions (especially in the case of self-guided treatments). The
layout of pages in the platform can be fully responsive, adapting
to screen size and ensuring a fully-functional user experience
regardless of whether the platform is accessed using a desktop
computer, a mobile phone (smartphone) or a tablet14.
Other important features of treatment software platforms
include that they need to be able to regularly administer symp­
tom questionnaires, which can be used to monitor progress, se­verity of symptoms, and possibly risk of self-harm15. Security ofdata is also crucial16, in particular when there is an interaction
between a client and a therapist via text or video chat and sen­sitive information is exchanged, and to record clinical notes.
The legal requirements for management of privacy of healthrelated data are rapidly evolving, but security requirements are
generally similar to those for industries that involve electronictransmission of sensitive data, such as Internet banking (e.g.,when bills are paid online), including encryption of data traffic
and a double-authentication procedure at login14.
Many programs include all components of an evidencebased psychological intervention17: for example, exposure in­structions in the case of anxiety disorders and behaviouralactivation in the case of depression. Thus, some programs can
include the equivalent of 150 pages of text, even if the material
is presented online and with interactive features such as a quiz.
World Psychiatry 18:1 - February 2019

It has been possible to transfer a large proportion of common
CBT techniques to the Internet format, with early programs
sharing close similarities with bibliotherapy18, and current ones
being more easily readable on the screen or in the form of slide
shows that present the principles of CBT via text and images19.
While CBT has been the dominant model of therapy used inInternet interventions so far, different models have been andare being explored, including acceptance and commitment
therapy20, psychodynamic approaches21, interpersonal psy­
chotherapy22, physical activity23, mindfulness24, and programs
based on attention bias modification training25.
A large proportion of studies and several implementations
involve a clinician who guides the client through the program,provides feedback on homework assignments and also general
support and answers to questions from the client17. The role ofthe clinician in ICBT has been investigated in many studies:
overall, guided ICBT programs tend to be more effective thanself-guided ICBT26, even if some studies in which administra­
tive contact is included tend to show that self-guided treat­ments can also produce clinically significant improvements27,28.
While there are still few studies, there are indications thata practical and technical support may be sufficient29, and that
novice clinicians can be as effective as clinicians who havemore experience with ICBT30. On the other hand, studies also
show that what the therapist does is not irrelevant31, and that alenient therapist response to uncompleted homework assign­ments can be associated with less improvement in ICBT for
generalized anxiety disorder32. Moreover, affirming responses
to client e-mails can be associated with better outcomes in
ICBT for depression, and the same seems to happen if the ther­
apist is self-disclosing33, just to give two examples. To increase
fidelity and therapist efficacy, guidelines can be developed andfollowed which facilitate both research and clinical training34.
Several studies have investigated the role of therapeutic alli­ance in ICBT35, with a focus on agreement with regard to tasks
and goals as well as the bond between the therapist and the cli­
ent36. While some studies show a small but statistically signifi­
cant association between early alliance ratings and outcome
in ICBT37, other studies fail to find this38. Overall, high allianceratings have been reported, suggesting that clients do develop
a relationship with their online therapist. However, there areproblems with this research, in that it is likely that alliance israted in relation to the whole program and not just to the rela­
tively minor interactions between the client and the therapist39.
Further, with the exception of a study on blended face-to-faceand ICBT40, studies have not involved observer-rated alliance.

INNOVATION
One aspect of Internet-delivered interventions, including
ICBT, is the possibility of rapid clinical innovation, a hallmark
of science as there is often room for improvement in treatment
research41. Psychotherapy research has most likely sufferedfrom the high costs involved with running controlled trials, andWorld Psychiatry 18:1 - February 2019

one advantage of conducting studies online is lower costs andshorter study periods.
First, recruitment is usually much faster than in ordinary
clinical trials, in part because it is not geographically confined.
Second, diagnostic procedures are often performed from a
distance, with structured telephone interviews complementing
the self-reported data gathered through the use of validated
online questionnaires42. Third, by using online materials thatprovide a significant proportion of the therapeutic content, theactual time devoted to each client is much less than in face-toface treatment research, with an average of 10 min per client
and week versus the traditional 45 min weekly sessions. Thereis no need for a therapy room, and clients do not need to wait to
the same extent as in a face-to-face study. Further advantages
are the possibility to repeat a lesson/module and the faster ac­
cess to support if needed.
Researchers in this field often start by conducting a ran­domized controlled trial (RCT), sometimes referred to as a “pilot
RCT”43, but not necessarily having smaller samples than inolder psychotherapy trials, which were often underpowered44.
Some researchers perform open pilot studies before running acontrolled trial45, but, as a controlled trial is more likely to give
clearer answers regarding effects, and still does not cost morethan a pilot trial, there is a tendency to skip this open testing
once a treatment has been developed.
Phase IV open studies with no control groups have an impor­tant role to play in clinical effectiveness research46, when it is not
feasible or even possible to randomize clients. Investigationsof Internet interventions can also use qualitative methods,
including interviews of individuals who have completed thetreatment47. Such studies are on the increase. What is lack­ing, however, are detailed case descriptions and, to the bestof our knowledge, there are very few case studies on Internet
interventions48.
Given the large sample sizes that can be obtained in Internet
interventions research, the possibility has emerged to conduct
factorial design trials instead of the ordinary treatment ver­sus control trials. In factorial research designs, it is possible toanswer more than one question, as two or more independent
variables (or factors) are tested within the same study, leading
to two or more main effects and possible interaction effects
between conditions. At a minimum, this leads to a design withfour experimental conditions (or groups). For example, two dif­ferent forms of ICBT for depression (behavioural activation vs.
cognitive therapy) could be compared as well as two different
ways to provide support (scheduled vs. on request).
There are various versions of factorial designs49, and several
such studies are in progress50,51. The use of factorial designs
is likely to speed up the development of new interventions
and treatment components. However, even current Internet
interventions research can be viewed as an engine for innova­
tion, with treatments being developed and tested directly forInternet delivery instead of first being tested as a face-to-facetreatment. One such example is a recently developed treatment
for procrastination52.

21

The possibility to recruit patients without geographical bar­riers also presents opportunities for testing psychotherapy forpeople with conditions and problems (e.g., spinal cord injury,
epilepsy) that can be highly disabling while also having a rela­
tively low prevalence, making them very difficult to study fea­
sibly in face-to-face trials53.

EVIDENCE BASE TO DATEThe evidence base for ICBT, and for Internet interventions
in general, has increased rapidly, making separate systematic
reviews for different conditions necessary. There are now as
many as 300 controlled trials of Internet interventions (includ­ing unpublished studies), for different disorders and target
populations, and the number continues to increase.
Early reviews tended to focus more broadly on the effects of
ICBT54, or on computerized interventions in general55. It is stillcommon to mix different technologies in reviews, which canbe problematic, as there are differences between computer­
ized treatments delivered in a clinic and ICBT involving contactfrom a distance.
Some contemporary reviews focus on the effects of Internet
interventions for specific disorders or conditions, different tar­get populations, and on specific forms of psychological treat­ments, such as, for example, acceptance and commitment ther­
apy56. Another recent trend is to conduct individual participantdata meta-analyses, by pooling the raw data from different
research groups, which facilitates moderator analyses57.
A common problem when reviewing the literature on Inter­
net interventions, including ICBT, is the use of different terms
to describe the interventions, for example digital therapy,
Internet interventions, and computerized psychotherapy.
Other terms, such as web-based psychotherapy and online
psychotherapy, are also commonly used. This has been referred
to as “terminology chaos”58, and there are no signs that it will
be solved since, for example, smartphone delivery and virtual
reality are now sometimes being seamlessly combined with themore standard Internet format59.
Concerning anxiety disorders, several systematic reviews
and meta-analyses are available, with a Cochrane review ontherapist-delivered ICBT being one of the most recently up­
dated60. This included randomized controlled trials of therapistsupported ICBT compared to a waiting list, attention, informa­tion or online discussion group; unguided CBT; or face-to-face
CBT. Studies on adults with panic disorder, agoraphobia, social
phobia, post-traumatic stress disorder (PTSD), acute stress dis­order, generalized anxiety disorder, obsessive-compulsive dis­order, or specific phobia, defined according to DSM-III/III-R/
IV/IV-TR or ICD-9/10, were included. The standardized meandifference (SMD) for disorder-specific anxiety symptoms (22studies, 1,573 participants) and general anxiety symptoms (14studies, 1,004 participants) at post-treatment favored therapistsupported ICBT over waiting list, attention, information, or
online discussion group only (respectively, SMD=−1.12, 95%

22

CI: −1.39 to −0.85 for disorder-specific anxiety symptoms; andSMD=−0.79, 95% CI: −1.10 to −0.48 for general anxiety symp­toms). The quality of the evidence, however, was rated as low.
There was no significant difference between therapist-support­
ed ICBT and face-to-face CBT for either disorder-specific anxi­
ety symptoms (6 studies, 424 participants, SMD=0.09, 95% CI:−0.26 to 0.43) or general anxiety symptoms (5 studies, 317 par­ticipants, SMD=0.17, 95% CI: −0.35 to 0.69) at post-treatment.
Again, the quality of the evidence was rated as low.
This is in line with a more recent review by Andrews et al61,
in which the Hedges’ g for ICBT or computerized CBT (cCBT)
compared to care as usual, waiting list, information control,
psychological placebo or pill placebo was 1.31 (95% CI: 0.85 to
1.76; 12 studies) for panic disorder, 0.92 (95% CI: 0.76 to 1.08;
11 studies) for social anxiety disorder, and 0.70 (95% CI: 0.39 to
1.01; 9 studies) for generalized anxiety disorder. Nine studies
compared ICBT to face-to-face CBT (568 subjects in total), andthe difference was found to be not significant (g=0.14 in favor
of face-to-face CBT, 95% CI: −0.04 to 0.32).
Overall, these data seem to suggest that therapist-supported
ICBT is more efficacious than control conditions for anxiety
disorders, and not significantly different from face-to-face CBT,
although further evidence of a better quality is needed.
Several separate reviews have been published on, for ex­
ample, PTSD62, in which the pooled between-group effect sizewith treatment against waiting list control was g=0.71, based on
10 studies and 1,139 participants. There is also a recent review
on the effects of ICBT for children and adolescents63, which
included 24 studies and found a moderate effect size against
control conditions (g=0.62).
Concerning depression, Andrews et al61 found an Hedges’ g
for ICBT or cCBT compared to care as usual, waiting list, infor­
mation control, psychological placebo or pill placebo of 0.67
(95% CI: 0.51 to 0.81), based on 32 studies. Josephine et al64, in asystematic review and meta-analysis focusing on Internet- andmobile-based interventions in adults with diagnosed depres­sion, compared with waiting list or attention placebo, foundthat only 19 studies were eligible for inclusion (i.e., included
patients with diagnosed major depression). Internet- and mo­bile-based interventions had a significantly greater impact on
depression severity compared to waiting list at the end of treat­ment (g=−0.90, 95% CI: −1.07 to −0.73).
A recent meta-analysis of individual participant data65 man­aged to get the raw data from 13 randomized controlled trials(3,876 participants) in which self-guided ICBT was comparedwith a control condition (usual care, waiting list or attention
control) in individuals with symptoms of depression. Selfguided ICBT was significantly more effective than control con­ditions on depressive symptoms severity (g=0.27) and treat­ment response (odds ratio=1.95, 95% CI: 1.52 to 2.50). These
effect sizes seem to confirm the results of older reviews sug­gesting that self-guided ICBT tends to be less effective thantherapist-guided ICBT66.
One approach to ICBT is to tailor the intervention accord­
ing to the patient profile, which is a way to handle comorbidity

World Psychiatry 18:1 - February 2019

between disorders. An alternative is to use a transdiagnostic
approach targeting the underlying mechanisms of several dis­orders (e.g., avoidance). Both approaches have been tested in
ICBT research, and a meta-analysis of studies dealing with anxi­
ety and depression, including 19 controlled trials and 2,952 par­ticipants, found an average effect size against control conditionsof g=0.82 (95% CI: 0.58 to 1.05) for anxiety and g=0.79 (95% CI:
0.59 to 1.00) for depression. There were no substantial differenc­
es between transdiagnostic and disorder-specific treatments67.
In addition to studies on psychiatric conditions, there is alarge literature on various health problems, such as chronic
pain68, insomnia69, tinnitus70, and stress71, just to mention a few
examples. There are also studies on addictions72.
Many studies point in the direction of equivalent effects ofguided Internet interventions and face-to-face treatments, but
this question can only be addressed by direct comparisons. In
an updated meta-analysis of a previous review73, 20 studies
in which participants had been randomly assigned to guided
ICBT for psychiatric and somatic conditions or to face-to-face
CBT were included74. The pooled between-group effect size at
post-treatment was g=0.05, suggesting that ICBT and face-toface treatment produce equivalent effects.
While early studies of unguided ICBT suffered from high drop­out rates (a weighted average of 31% of the participants dropped
out of treatment in 19 studies of Internet-based treatment pro­grams for psychological disorders)75, a recent meta-analysis of
ICBT for adult depression76, including 24 studies, found thatparticipants in guided ICBT completed on average 80.8% of theirtreatment, which did not differ significantly from participants in
face-to-face CBT (83.9%, p=0.59). However, the percentage ofcompleters (total intervention) was significantly higher in faceto-face CBT (84.7%) than in guided ICBT (65.1%, p<0.001).
There are also studies in which the long-term effects of ICBT
have been investigated. A recent review included 14 trials inwhich data had been collected for a follow-up period of two
years or longer after completion of treatment. The included
studies had an average follow-up period of three years77. There
were long-term outcome studies on panic disorder, social anxi­
ety disorder, generalized anxiety disorder, depression, mixed
anxiety and depression, obsessive-compulsive disorder, patho­
logical gambling, stress, and chronic fatigue. The pre- to followup effect size was g=1.52.
In sum, the literature on Internet interventions and ICBT isgrowing, guided ICBT tends to be as effective as face-to-face
CBT, and the effects are likely to be sustained over time.

HARMFUL EFFECTS
While hardly being noticed (and perhaps even dismissed
for a long time), the possibility of negative effects during andfollowing psychotherapy has more recently been investigatedin relation to ICBT78. Negative effects are increasingly docu­
mented in association with controlled trials of ICBT, but there
are also separate reports of negative effects.

World Psychiatry 18:1 - February 2019

One example is a patient-level meta-analysis79, which includ­
ed 2,866 patients from 29 clinical trials of ICBT. Using the Reliable
Change Index, the deterioration rate was 5.8% in the treatment
and 17.4% in the control conditions (odds ratio=3.10, 95% CI: 2.21
to 4.34). Being in a relationship, being older and having at least auniversity degree were associated with lower odds of deteriora­tion, but only in patients assigned to the treatment condition.
Another patient-level meta-analysis focused on self-guided
Internet treatments for depression80, and found that, of the
3,805 participants analyzed, 5.8% in the treatment groups and9.1% in the control groups had deteriorated (odds ratio=0.62,
p<0.001). No examined moderators were significantly associ­ated with the deterioration rate.
In a similar patient-level analysis on guided ICBT81 (18 stud­ies, 2,079 participants), the deterioration rate was 3.36% in thetreatment groups and 7.60% in the control groups (relativerisk=0.47, 95% CI: 0.29 to 0.75). Patients with lower education
presented a higher risk for deterioration than those with higher
education.
Overall, these rates of deterioration appear similar to thosereported in face-to-face treatments78. However, it is important
to note that our methods for exploring negative effects arestill limited and, for example, relatively little is known about
the causes (e.g., the intervention itself, factors outside of theintervention) of the negative effects observed during Internet
interventions. Negative effects other than symptom deteriora­tion may also occur in ICBT and should be documented, for ex­
ample by using open-ended questions or self-report measurescovering adverse and unwanted events79.

MECHANISMS OF CHANGE AND PREDICTORSOF OUTCOME
As would be expected from the literature on face-to-face
psychotherapies82, there are no consistent predictors or changemechanisms reported in Internet interventions research. We
have reviewed above the literature on therapeutic alliance, inwhich the results have been inconsistent. In addition, studies
have been conducted on genetic variables, but findings havenot been promising83.
One study84 hypothesized that a greater cognitive flexibility
would provide a better foundation for learning and implement­
ing the cognitive restructuring techniques used in ICBT, lead­ing to better treatment outcomes. Data from three samples
including patients with depression, social anxiety disorderand tinnitus were used. The 64-card Wisconsin Card Sorting
Test (WCST) was administered prior to treatment. There wasno significant association between perseverative errors on the
WCST and treatment gains in any group.
However, another study85, conducted on 66 older adults
with mixed anxiety depression randomized to ICBT or control
conditions, who were administered the WCST (perseverative
errors) and the Cognitive Failures Questionnaire before treat­ment, reported a moderate between-group effect on the main23

outcome measure, the Beck Anxiety Inventory (d=0.50), favor­
ing the treatment group. The authors concluded that the role ofcognitive functioning in the outcome of ICBT should be further
investigated.
Perhaps more promising, but still very preliminary, are stud­ies on brain imaging. One study86 showed that the long-term
outcome of ICBT for social anxiety disorder could be predictedby blood oxygen level-dependent (BOLD) responses to selfreferential criticism in the fear-expressing dorsal anterior cin­
gulate cortex and amygdala regions at pre-treatment, analyzed
using a support vector machine learning approach. Anotherstudy87 found that larger pre-treatment right rostral anterior
cingulate cortex volume was a significant predictor of greater
depressive symptom improvement on ICBT, even after control­ling for demographic and clinical variables previously linked totreatment response.
Various demographic characteristics have been investigatedas well, with mixed findings. It is common to find that variables
such as age, gender, marital status, computer skills, educational
level, and having children have no significant predictive value88.
There are other possible mediators of outcome more directly
related to the actual treatment process, and factors that are like­ly to influence uptake and adherence to treatment. For instance,
it has been reported that Internet therapy is more effective when
the treatment is user friendly and not overly technically ad­vanced, and a clear deadline is provided for the duration of thetreatment89. Furthermore, sudden gains (i.e., large and stable
improvements occurring between two consecutive treatment
sessions) have been found to predict larger improvements at
both post-treatment and one-year follow-up in patients receiv­
ing ICBT for severe health anxiety90. Design features of ICBT
could also be important: a systematic review91 found that “per­suasive technology” elements (such as more extensive employ­ment of dialogue support) significantly predicted better adher­
ence to treatment.
ICBT has been also conceptualized as a form of patient ed­
ucation. Studies have investigated whether ICBT influences
knowledge acquisition in social anxiety disorder30, eating dis­orders92 and, most recently, adolescents with depression93. The
studies show that improvements in knowledge occur following
ICBT. More research is needed in this domain, for example, to test
if knowledge acquisition can be influenced directly in treatment(by using methods from educational science).
Another recent and related body of work indicates that cli­
ent’s use of CBT skills may predict change in symptoms and sat­
isfaction with life94. This promising direction of work indicatesthat practice of such skills may be an important mechanism ofchange, but requires large scale replication.
In sum, while there are observational studies on mechanismsof change in ICBT, there are few consistent findings regarding
both moderators and mediators. Theory-driven and experimen­
tal research with repeated measure of process variables might
help to identify what to look for, as much research has been
informed by traditional psychotherapy research rather than theunique aspects of ICBT.

24

IMPLEMENTATIONICBT and Internet interventions at large have been aroundfor about 20 years3, but implementation efforts have had mixed
success. Moreover, these efforts have rarely been well docu­
mented from an implementation science perspective.
However, several effectiveness studies, with data from rou­tine clinical practice settings, have been published for a num­
ber of disorders and conditions95. One early application in
general health care was the tinnitus clinic in Uppsala, Sweden,
which began delivering CBT for tinnitus via the Internet by
the end of 1999, and published effectiveness data early on96.
Another early example was the Interapy program from theNetherlands, which started in the 1990s and subsequently pub­lished effectiveness data on adult patients with symptoms ofdepression, panic disorder, PTSD or burnout97. The publicly
available Moodgym from Australia is another early example
with published data from community users98.
Two contemporary examples of effectiveness reports comefrom the MindSpot Clinic in Australia19 and the Internet psychi­
atry unit in Sweden46,99. Both groups have published data fromtheir routine clinical practice, indicating that ICBT works when
delivered as a regular intervention with ordinary clients. A re­cent study described the implementation of ICBT in five coun­tries: Australia, Canada, Norway, Sweden and Denmark100. The
authors also included references to published effectivenessstudies of outcomes from their clinics, which all demonstrated
large clinical improvement, low rates of deterioration, and highlevels of patient satisfaction.
While still being at an early stage, published data clearly sug­gest that ICBT can work in regular settings, even as a steppedcare approach101. However, in most cases, the implementation
has been handled by specialist and centralized clinics as op­
posed to wide-scale dissemination across a whole country withseveral clinics involved.
One potential obstacle when implementing Internet inter­
ventions and ICBT is negative attitudes among clients, cliniciansand other stakeholders (such as insurance companies). One
stakeholder survey was conducted in eight European countries
with 175 organizations participating102. Results showed greater
acceptability of blended treatment (the integration of face-toface and Internet sessions within the same treatment protocol)
compared to stand-alone Internet treatments. For example,
for mild depression, 46.5% would recommend ICBT only and69.8% blended treatment, but for moderate depression the cor­
responding figures were 15.7% and 57.2%, a marked difference.
The same discrepancy was found for severe depression, with
1.9% recommending ICBT and 27% blended treatments. Thus,
stakeholders are still hesitant to recommend ICBT as a standalone intervention, in particular for more severe depression.
Another example is a study from the US conducted in a primarycare setting, which showed that patients were less interested intaking part in ICBT than face-to-face treatment103.
This literature should be interpreted with some caution, as
there are likely differences both between and within countries

World Psychiatry 18:1 - February 2019and settings. Given the observation that clinicians may notknow what ICBT is, there is also a role for education in order tofacilitate dissemination104. Nevertheless, the benefit of Internet
interventions is likely to be that they provide an opportunity tocare for people who cannot or do not want to access face-toface care, rather than for people presenting for and wanting
face-to-face care.

FUTURE DIRECTIONS
It is hard to predict how technology will develop, and also if
new technology will be adapted for clinical use. One example
is the use of sensors to measure physiological activity and be­
haviours such as sleep through smartphones8. Such technology
already exists, but there is a need to investigate if it can advancetreatment in any way. Another example is serious gaming andother delivery formats than just text and pictures105. Virtual
reality is another technique that has become less expensive
and can be integrated with ICBT106. Finally, in light of the ability
to generate large amounts of data, the role of machine learn­
ing can possibly increase, with one initial study suggestingthat prediction of treatment outcome may benefit from thisapproach107.
A second possible future direction of research is to expand
the reach of ICBT to other languages and cultures than areusually targeted in psychotherapy research (for example, im­migrants). As an example of this, controlled studies have been
conducted in the Arabic language108 as well as in Chinese109.
One project aimed at disseminating treatment across lan­
guages and cultures involved translation of a Swedish ICBT
pro­gram for social anxiety disorder into Romanian110.
A third development, already mentioned earlier, is the de­velopment and testing of Internet-delivered psychotherapies
other than CBT. Examples include psychodynamic therapy21,
interpersonal therapy111, and treatment programs involving
attention training112. This is likely to increase, along with thepossible integration of therapeutic techniques. We also expect
more research into models of blended care, as described earlier.
A fourth development has to do with research designs andpublication bias. With regards to research designs, we be­lieve that the standard treatment versus control design may
be less needed as compared to more sophisticated factorial
designs testing several research questions simultaneously51.
Publication bias is a problem in both basic and applied re­search, but we believe that change will happen. “Failed” trials
of ICBT are already being reported113, as well as trials withnegative findings25.
A fifth likely development is the creation of regulations andstandards governing the delivery of ICBT in routine care. We
recognize that health services delivered via the Internet shouldmeet the same safety and quality standards as traditional mod­els, but must also meet appropriate standards for the safety andsecurity of sensitive health-related data. As a consequence ofincreasing interest in ICBT by health funders and regulators, weWorld Psychiatry 18:1 - February 2019

expect considerable future debate about how best to regulate
such services, what standards they should meet, and how theyshould be accredited114,115.

CONCLUSIONSICBT and other forms of Internet interventions hold promise
as a way to increase access to evidence-based psychologicaltreatment. They can also serve as vehicles for innovation, which
may subsequently inform face-to-face treatments.
Even if ICBT is gradually being implemented, the process
is slow and needs to be better documented. While the inter­
vention has proved to be cost-effective116, there are several
professional challenges when moving from traditional service
models. Most likely, blended approaches, which retain advan­
tages from both face-to-face and technology-driven methods,
will gain more popularity in the future.
ACKNOWLEDGEMENTS
G. Andersson is grateful to Linköping University, the Swedish Council for Work­ing and Life Research, and the Swedish Foundation for Humanities and Social
Sciences for financial support to his research.

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105. Sardi L, Idri A, Fernandez-Aleman JL. A systematic review of gamificationin e-Health. J Biomed Inform 2017;71:31-48.
106. Lindner P, Miloff A, Hamilton W et al. Creating state of the art, next-­
generation Virtual Reality exposure therapies for anxiety disorders using
consumer hardware platforms: design considerations and future direc­
tion. Cogn Behav Ther 2017;46:404-20.
107. Lenhard F, Sauer S, Andersson E et al. Prediction of outcome in internetdelivered cognitive behaviour therapy for paediatric obsessive-compul­
sive disorder: a machine learning approach. Int J Methods Psychiatr Res
2018;27:e1576.
108. Knaevelsrud C, Brand J, Lange A et al. Web-based psychotherapy for post­traumatic stress disorder in war-traumatized Arab patients: randomized
controlled trial. J Med Internet Res 2015;17:e71.

27

109. Choi I, Zou J, Titov N et al. Culturally attuned Internet treatment for de­pression amongst Chinese Australians: a randomised controlled trial. J
Affect Disord 2012;136:459-68.
110. Tulbure BT, Szentagotai A, David O et al. Internet-delivered cognitivebehavioral therapy for social anxiety disorder in Romania: a randomized
controlled trial. PLoS One 2015;10:e0123997.
111. Donker T, Bennett K, Bennett A et al. Internet-delivered interpersonal
psychotherapy versus internet-delivered cognitive behavioral therapy for
adults with depressive symptoms: randomized controlled noninferiority
trial. J Med Internet Res 2013;15:e82.
112. Boettcher J, Berger T, Renneberg B. Internet-based attention trainingfor ­social anxiety: a randomized controlled trial. Cogn Ther Res 2012;36:552-36.

28

113. Lindh-Åstrand L, Spetz Holm A-C, Sydsjö G et al. Internet-delivered ap­
plied relaxation for vasomotor symptoms in postmenopausal women:
lessons from a failed trial. Maturitas 2015;80:432-4.
114. Borgueta AM, Purvis CK, Newman MG. Navigating the ethics of Internetguided self-help interventions. Clin Psychol Sci Pract 2018;25:e12235.
115. Dever Fitzgerald T, Hunter PV, Hadjistavropoulos T et al. Ethical and le­gal considerations for internet-based psychotherapy. Cogn Behav Ther
2010;39:173-87.
116. Donker T, Blankers M, Hedman E et al. Economic evaluations of Internet
interventions for mental health: a systematic review. Psychol Med 2015;45:3357-76.
DOI:10.1002/wps.20610

World Psychiatry 18:1 - February 2019

PERSPECTIVES

Personal growth in psychosis
Recovery is a new paradigm for mental health systems glob­­ally. One implication is a greater emphasis on subjective ex­perience – what is it like to live with schizophrenia and otherpsychoses?
A systematic review of the experience of recovery found thatthe impact of psychosis is more mixed than traditional illness
models would imply1. The process of recovery was charac­terized as an active and life-changing experience, involving
struggle and occurring both with and without professional
intervention. However, clinical practice often remains focussed
on deficit amelioration through treatment, rather than on sup­porting these active processes of change which are involved indeveloping an identity as a “person in recovery”.
Trauma is both a cause2 and effect of psychosis, and trauma
research has identified a range of post-traumatic growth andadaptation processes which are relevant to people living withpsychosis. Post-traumatic growth research focuses on the ex­tent to which the struggle to overcome trauma can act as acatalyst for personal growth and development.
In the process of adapting to distressing experiences, in­cluding making sense of and attributing meaning to theseexperiences, individuals may challenge and change some of
their pre-trauma beliefs. For example, aspects of personality,
relationships with others and beliefs about the world can allchange in a manner that the individual views as positive andreflective of personal growth.
The profile of these positive changes varies across individu­
als, but a consensus has emerged about five post-traumatic
growth domains in which these changes typically occur: height­
ened feelings of personal strength; more intimate relationships
with loved ones; recognition of new possibilities or directions
in one’s life purpose; greater appreciation of life; and engage­
ment with spiritual and existential questions about the natureand meaning of life3.
Post-traumatic growth has clinical relevance. A meta-­analysisof populations experiencing a diverse range of traumatic events
found that engaging in post-traumatic growth was an adaptive
and clinically beneficial process4. Higher post-traumatic growth
was associated with lower levels of depression and higher levels
of well-being. Post-traumatic growth can, therefore, be consid­
ered as a process that aids recovery by enabling the individual
to find meaning from a painful struggle and to recalibrate his/
her identity and purpose in life in light of his/her experiences.
Post-traumatic growth in psychosis is both possible andsupportive of recovery. A scoping review of evidence relat­
ing to first-episode psychosis identified several forms of posttraumatic growth: developing positive character traits, making
positive lifestyle changes, developing stronger relationships,
greater appreciation of life and spirituality, and integrating
one’s experience of first-episode psychosis into one’s identity5.
Predictors of post-traumatic growth in psychosis are emerg­
ing. A study of 34 first-episode psychosis participants in England

World Psychiatry 18:1 - February 2019

found that higher levels of post-traumatic growth were pre­dicted by lower levels of post-traumatic stress disorder symp­
toms, greater levels of self-disclosure behaviour, and higher
self-reported recovery6. Similarly, a study of 121 community
rehabilitation service users with psychosis in Israel found that
post-traumatic growth is mediated by coping self-efficacy ap­
praisal and meaning-making7.
In relation to meaning-making, an important aspect of posttraumatic growth in psychosis is the opportunity for validationand collective identity offered by peer-support networks. For
example, the International Hearing Voices Movement (HVM)
has worked in partnership with academics and clinicians forthe past 30 years to promote more accepting and empowering
perspectives on what has traditionally been an extremely stig­
matized and marginalized experience.
One aspect of this approach is helping members to devel­
op a positive identity as someone who hears voices. A central
philosophy of the HVM has been that the ownership and in­terpretation of one’s voices always belongs to the individual
voice hearer. Correspondingly, a great emphasis is placed on
personal testimony and meaning-making, in which distressedindividuals are supported to find explanatory frameworks thatare subjectively useful and significant. Thus, while psychosocial
models have been strongly promoted within the HVM, includ­ing the links between trauma and voice hearing8, they are notprivileged; alternative explanatory frameworks, such as spir­
itual or cultural, are seen as equally valid.
The HVM perspective is that even the most devastating peri­
ods of mental ill-health can ultimately be a source of personal
development. Many narratives from HVM members show how
psychiatric crisis has prompted, for example, a greater capacity
for political activism, emotional insight, creativity, courage, andcompassion for self and others.
The idea of relocating voice hearing from being a meaning­
less disease symptom to a personally significant event that
can inform and guide one’s recovery journey has resonatedwith many mental health service users. There has been a rapid
expansion of HVM networks across Europe, Australasia andNorth America, with initiatives currently emerging in Asia,
Africa and South America: “the HVM appear[s] to offer an at­
tractive alternative for voice-hearers who have not been fully
helped by traditional approaches, who are searching for greater
understanding and acceptance of their experiences, or who
feel that their stories have not been heard or acknowledged”9.
We identify three clinical implications. First, clinical assess­ment should include trauma and its effects. An insight offeredby the HVM is that it may be as useful to find out “What’s hap­
pened to you?” as opposed to “What’s wrong with you?”. Second,
promoting post-traumatic growth is an approach to supporting
recovery. The five established domains of strengths, relation­
ships, life possibilities, appreciation and ­spirituality provide anassessment framework which may have ­clinical utility, both for29encouraging therapeutic optimism that a more positive future
is possible and for identifying points of intervention.
Finally, supporting people who live with psychosis to makepersonally-meaningful sense of their experiences is a different
skill to promoting insight, and may require new clinical ap­
proaches which avoid imposing explanatory clinical models.
The expertise of organizations such as the HVM may be neededin the mental health system.

1.
2.
3.
4.
5.
6.
7.
8.
9.

Mike Slade1, Laura Blackie2, Eleanor Longden3

DOI:10.1002/wps.20585

Leamy M, Bird V, Le Boutillier C et al. Br J Psychiatry 2011;199:445-52.
Radua J, Ramella-Cravaro V, Ioannidis J et al. World Psychiatry 2018;17:49-66.
Jayawickreme E, Blackie L. Eur J Personality 2014;28:312-31.
Helgeson V, Reynolds K, Tomich P. J Consult Clin Psychol 2006;74:797-816.
Jordan G, Pope M, Lambrou A et al. Early Interv Psychiatry 2017;11:187-99.
Pietruch M, Jobson L. Psychosis 2012;4:213-23.
Mazor Y, Gelkopf M, Mueser K et al. Front Psychiatry 2016;7:202.
Pilton M, Varese F, Berry K et al. Clin Psychol Rev 2015;40:138-55.
Corstens D, Longden E, McCarthy-Jones S et al. Schizophr Bull 2014;40(Suppl. 4):S285-94.

1School of Health Sciences, Institute of Mental Health, University of Nottingham, Not­
tingham, UK; 2School of Psychology, University of Nottingham, Nottingham, UK;3
Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust,
Manchester, UK

Assessment and determinants of patient satisfaction with mental
health care
How satisfied patients are with the care they are receiving is
widely regarded as an important process variable and quality
indicator in mental health care.
It is a process variable, as it predicts to what extent the aim ofcare, i.e. the alleviation or overcoming of mental distress, may
be achieved. Various studies have shown that more satisfied pa­
tients are more adherent to treatment and – even if there is no dif­ference in adherence – benefit more from care than less satisfied
patients. Furthermore, patient satisfaction predicts outcomesright from the initial stages of treatment, e.g. when assessed with­in the first two days of hospital care1. It is also a quality indicator,
because all treatments should be as patient friendly as possible,
independently of any impact on health and social outcomes.
Since the 1960s, numerous scales have been used to mea­
sure patient satisfaction with mental health care, also termed
treatment satisfaction, service satisfaction or consumer satis­
faction. A recent systematic review indicates that scales varysignificantly in their structure, length, focus and quality2. Thereis no consensus on how exactly patient satisfaction should bemeasured and, across scales, patients are asked to rate theirsatisfaction with 19 different aspects of care. Despite an ex­
tensive literature, the review identified only four scales thathave been used in more than 15 studies and may therefore be
regarded as more established.
The Client Satisfaction Questionnaire3 for outpatient treat­ment and the Client Assessment of Treatment Scale4 for in­patient treatment are brief scales of 8 and 7 items respectively
and provide global scores. The Verona Service Satisfaction
Scale5 and the Self-Rating Patient Satisfaction Questionnaire6
are much longer and have subscales on different care aspects
in addition to a global score.
Satisfaction with care, as measured on such scales, can be
influenced by characteristics of the patients and by aspects ofthe care they are receiving7.
A number of socio-demographic characteristics such as
gender, ethnicity, socio-economic and marital status have been30suggested as determinants of satisfaction with care, but theassociations are usually weak and the findings across studies
are inconsistent. The only socio-demographic feature that is
consistently linked with higher patient satisfaction with care isolder age, which however is also associated with higher satis­
faction with life in general.
More substantial correlations have been found with clinicalcharacteristics and patient reported outcomes, such as subjec­
tive quality of life. Patients with higher symptom levels, espe­
cially more depressive symptoms, with personality disorders
and with lower subjective quality of life tend to express lesssatisfaction with their care8.
Only a few aspects of care have consistently been foundto impact on patient satisfaction. Coercive treatment and the­perception of a negative therapeutic relationship are strong­ly associated with lower satisfaction with care, which might­however be regarded as highly expected findings. There also
seems to be a tendency for patients to be more satisfied withtreatment in the community than in hospitals9.
When satisfaction scores are obtained for the evaluationof different treatments and services, one should consider theabove determinants – e.g., age, the legal status of the treatment,
and severity of illness or symptoms, in particular depressive
symptoms – as potential confounders. Adjusting scores forthese confounders minimizes the risk that positive or negative
ratings get falsely attributed to a specific form of care when
in fact they reflect general tendencies of a patient group withspecific characteristics. For instance, patients with marked
depressive mood are more likely to express lower satisfaction
with any form of care.
Adjusting for age and the legal status of treatment should
usually be feasible in mental health services, as such data are
available in most routine data documentation systems. In many
research studies, one can also obtain observer or self ratings ofsymptoms, including depressive symptoms. When patients rate
their satisfaction in routine care, however, it is often not possible

World Psychiatry 18:1 - February 2019to assess their symptom levels at the same time. Still, consider­ing some global rating of symptom severity would be helpful.
How patient satisfaction with mental health care should beassessed in research and practice depends mainly on the scopeand purpose of the assessment. Quantitative scores as provided
by the established scales can be helpful, if an adjustment for
confounders is possible. Some scales are short and simple touse, and provide helpful scores for research studies and broad­er evaluations of services or treatments. When using the scales,
one might, however, also want to be aware of their limitations.
When satisfaction scores are obtained to evaluate services,
substantial differences of such scores between services or sig­
nificant changes over time are unlikely, when all confounders
are considered. Frequent measurement of satisfaction scoresmay, therefore, not be very informative. Also, differences on
quantitative scores alone will not be a precise guide for whichaspects of care should be improved to raise the satisfaction ofpatients. For this, one may want to analyze subscales or single
items of scales. Even these scores, however, have limitations, as
no scale covers all aspects of care, and low satisfaction scores
do not necessarily indicate what exactly should be done to
make patients more satisfied.
Better than quantitative scales, open questions on what
specifically patients are satisfied or dissatisfied with can elicit
information on a wide range of aspects of care that may be rel­evant in a given context and that professionals can potentiallyact on. For example, if patients express dissatisfaction with the

behaviour of one particular staff member or with the timing ofhome visits or with the dose of their medication, clinicians maychange these aspects of care and thus directly improve patientsatisfaction.
Finally, no scale or survey can replace the most important pro­cedure to assess patient satisfaction with care in practice, which
is a direct and open communication between patients and cli­
nicians about patients’ experiences, appraisals and wishes. Thiscan facilitate ongoing consideration of these experiences andviews in shared treatment planning and service development.
Stefan Priebe1, Elisabetta Miglietta2
1

Unit for Social and Community Psychiatry, Queen Mary University of London, Lon­don, UK; 2Section of Psychiatry, Department of Neuroscience, Biomedicine andMovement Science, University of Verona, Verona, Italy
1.
2.
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Priebe S, Barnicot K, McCabe R et al. Eur Psychiatry 2011;26:408-13.
Miglietta E, Belessiotis-Richards C, Ruggeri M et al. J Psychiatr Res 2018;100:33-46.
Larsen DL, Attkisson CC, Hargreaves WA et al. Eval Progr Plann 1979;2:
197-207.
Richardson M, Katsakou C, Torres-González F et al. Psychiatry Res 2011;118:
156-60.
Ruggeri M, Lasalvia A, Dall’Agnola R et al. Br J Psychiatry 2000;177(Suppl.
39):s41-8.
Hansson L, Höglund E. Nord J Psychiatry 1995;49:257-62.
Woodward S, Berry K, Bucci S. J Psychiatr Res 2017;92:81-93.
Reininghaus U, Priebe S. Br J Psychiatry 2012;201:262-7.
Ruggeri M, Lasalvia A, Bisoffi G et al. Schizophr Bull 2003;29:229-45.

DOI:10.1002/wps.20586

Community alternatives to inpatient admissions in psychiatry
The aim of treating people experiencing a mental health cri­
sis in settings other than hospital inpatient wards is not new1.
A ­system of family foster care for people with mental healthproblems at times of need was established in Geel, Belgium,
700 years ago. In the 1930s, A. Querido set up a home treatment
admission-diversion system in Amsterdam, The Netherlands. In
the 1970s, P. Polak developed in Colorado a network of crisis ser­vices including family placements, crisis beds, an acute day unit
and treatment by mobile mental health teams. The first recog­
nizable modern multi-disciplinary crisis resolution home treat­ment team was founded by L. Stein in Colorado in the 1970s.
The attractions of averting hospital admission where possi­
ble are obvious. Inpatient care is very costly. Potential harms topatients from hospital admission include: institutionalizationand dependency; distress from enforced social proximity toothers, or from separation from friends and family; harm fromother patients or staff; loss of employment or housing tenure;the development of unhelpful coping strategies; stigma2. Someof these harms may be mitigated by alternative residential crisis
provision. Treatment at home during a crisis offers positive op­
portunities: to identify and modify social and environmental
precipitants of crisis, enlist family support, develop coping
skills applicable to people’s normal social context, and offer aWorld Psychiatry 18:1 - February 2019

more equal basis for collaborative relationships between staff
and patients.
Patients tend to strongly advocate alternatives to admission
being available. The provision of a range of crisis services, fromwhich patients and staff could collaboratively choose the best
option, appears evidently desirable. A number of community
service models now have trial evidence as viable alternatives
to inpatient admission for many patients. Acute day hospitals
may be able to treat as many as one in five patients who would
otherwise be admitted to acute wards, with comparable out­
comes3. Crisis resolution teams can reduce inpatient admis­
sions and increase satisfaction with acute care4. Residential cri­sis houses may have greater patient satisfaction and lower costs
than inpatient admission, with comparable effectiveness5.
Despite this promising evidence, community crisis alterna­
tives have struggled to become fully embedded in national
acute care systems. Crisis resolution teams are probably themost widely adopted model, but have only been implemented
nationally in England and Norway. Community crisis models,even where they do act effectively as an alternative to admis­
sion, risk being labeled as a luxury and vulnerable to cuts.
Community alternatives are unlikely ever to replace psychi­
atric hospitals completely: some patients may always be un­31willing to accept treatment, or pose such a high risk that secureaccommodation is required. No crisis alternative has demon­
strated any impact on rates of compulsory hospital admission.
Four challenges can be identified for community crisis alter­
natives to thrive in modern mental health systems, as detailed
below.
Rapid response. In many countries, lack of bed availability
can lead to delays in admissions, or patients being admitted
far from home. In principle, though, referral routes to inpatient
wards are clear and new patients can be accepted rapidly at any
time. Community alternatives, in order to provide a genuine
crisis service, must seek to match this. Yet in England, for ex­
ample, crisis resolution teams’ response time targets for initialassessment of patients referred in crisis vary from one hour to
one week6.
Managing acuity. While community alternatives must set
responsible limits on levels of risk which can be safely man­aged, an ability to accept acutely ill and distressed patients,
even where some risks are present, is essential. Referral pro­
cesses, staffing levels and skill mix, the physical environment,
and organizational culture have been identified as modifiablebarriers to successful management of acuity in community cri­
sis services7.
Role clarity. Community alternatives may offer either com­parable treatment to inpatient wards in an alternative setting,or distinctly different care from psychiatric hospital. Crisis reso­
lution teams typically emphasize the former, providing clinicaltreatment from a multi-disciplinary team to all those for whom
hospital admission might be averted. Residential crisis houses
may seek a more niche role, to provide different, innovative andpotentially more appropriate care for a specific demographic
or clinical group. The Soteria model of crisis houses provides
the best known example of this. Developed in California in
the 1970s, Soteria houses offer a minimum medication-use,
non-hierarchical residential treatment setting for people with
first-onset psychosis in crisis8. Being perceived by local com­missioners and service planners as having a clearly definedrole is a key factor influencing the sustainability and survivalof crisis alternatives7.
Implementation. Community crisis alternatives face the com­
mon challenge of replicating the benefits observed from early
adopters and initial evaluations, when scaled up. The English

experience of implementing crisis resolution teams nationallyexemplifies this. Reductions in inpatient admissions antici­
pated from trials have not been consistently reproduced9 andimplementation of national policy guidelines has only been
partial6. High model specification, rigorous assessment of ad­
herence, and programmes to support implementation may berequired to maximize the benefits of crisis alternatives.
Potential unintended consequences of crisis alternatives
should also be considered. Outcomes for rare adverse events,
such as suicides, are poorly evaluated by individual studies.
Community alternatives may attract skilled staff away from in­patient wards and, by accepting the more compliant, less highrisk patients, may raise the overall levels of disturbance andacuity on acute wards. Increasing the complexity of local acutecare systems presents challenges to maintaining continuity ofcare. Overall length of stay in acute care could be increased, if
crisis alternatives were commonly used as a “step down” provi­sion from inpatient wards.
Community crisis alternatives, which offer a cheaper al­
ternative to inpatient admission, as well as a potentially lessfrightening, stigmatizing and socially dislocating experience,
have a positive role to play in sustaining deinstitutionalization.
Yet, there is little consensus within or across countries about
optimal acute service configurations. The next challenge forresearchers is to move beyond evaluating individual service
models to system level evaluation, which can identify service
components and configurations which provide the best out­
comes for patients within mental health acute care systems.
Brynmor Lloyd-Evans, Sonia Johnson
Division of Psychiatry, University College London, London, UK
1.
2.
3.
4.
5.
6.
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Johnson S. Adv Psychiatr Treat 2013;19:115-23.
Bowers L, Chaplin R, Quirk A et al. J Ment Health 2009;18:316-25.
Marshall M, Crowther R, Sledge W et al. Cochrane Database Syst Rev 2011;
12:CD004026.
Murphy S, Irving C, Adams C et al. Cochrane Database Syst Rev 2015;12:
CD001087.
Lloyd-Evans B, Slade M, Jagielska D et al. Br J Psychiatry 2009;195:109-17.
Lloyd-Evans B, Lamb D, Barnby J et al. BJPsych Bull 2018;42:146-51.
Morant N, Lloyd-Evans B, Gilburt H et al. Epidemiol Psychiatr Sci 2012;21:
175-85.
Bola JR, Mosher LR. J Nerv Ment Dis 2003;191:219-29.
Jacobs R, Barrenho E. J Ment Health Pol Econom 2011;14:S13.

DOI:10.1002/wps.20587

Drop-outs in psychotherapy: a change of perspective
Research including almost 84,000 adult psychotherapy pa­
tients from 669 randomized controlled and uncontrolled tri­
als shows that almost 20% of patients prematurely terminate
psychotherapeutic treatments, with no differences in drop-out
rates among the different approaches (e.g., cognitive-behavioral,humanistic or psychodynamic)1.
No differences between diagnostic groups seem to exist,
except for personality and eating disorders showing higher
drop-out rates. Rates were also found to be higher in patients32

not receiving their preferred treatment, in treatments that are
not time-limited or manualized, in psychotherapy performedby trainees, in effectiveness studies (as opposed to efficacy
studies) and in younger patients1. A recent meta-analysis foundthat almost 29% of children and adolescents dropped out from
cognitive-behavioral therapy2.
There are different ways to operationalize and measuredrop-out1. In randomized controlled trials, for example, pa­tients who unilaterally do not finish the prescribed treatment
World Psychiatry 18:1 - February 2019

protocol are usually considered as drop-outs. More generally,premature termination or drop-out occurs when a patient de­cides to discontinue treatment before reaching a sufficient
reduction of the problems that initially led him/her to seeking
therapy1,3.
When compared with completers, patients who drop out of
psychotherapy show poorer treatment outcomes4. Thus, it is im­
portant to address this phenomenon.
Taking research findings into account1,3,5, several strategies
may be helpful to address the issue of drop-outs. Most of thesestrategies not only apply to psychotherapy, but to pharmaco­
therapy as well. A first group of strategies includes measures
which psychotherapists can already apply at present. A second
group encompasses issues to be addressed in future research.
First of all, dropping out of treatment is related to problems
in patient expectations and the therapeutic alliance5. Thus, bet­
ter preparing the patient for psychotherapy may help to reduce
drop-out rates. In a socialization interview, for example, patientsshould be informed about the disorder and the treatment, in­cluding the roles of patient and therapist. These are impor­tant steps for establishing and fostering a therapeutic alliance.
Shared decision making also contributes to fostering the alli­ance. Ruptures in the alliance need to be adequately addressed6.
Several additional strategies fostering the therapeutic alliance
may help to prevent dropping out of treatment, such as convey­
ing a sense of understanding, acceptance and respect, setting
goals, conveying realistic hope, reviewing what has already beenachieved, recognizing that the patient has made some progress
towards the jointly set goals, or that he/she is becoming more
and more able to use the “tools” of the treatment (e.g., challeng­
ing cognitions in cognitive-behavior therapy or core conflictual
relationship themes in psychodynamic therapy)7.
Addressing ambivalence, doubts and resistance towards
therapy early in treatment is another promising strategy, anapproach consistent with motivational interviewing. In addi­tion, patient preferences for treatments need to be taken into
account5. Risk for non-response and drop-out may also be
reduced by continuous feedback on patient progress5.
All of these strategies may be particularly important foryounger patients, trainees, and patients with personality or
eating disorders. In the psychotherapeutic work with children
and adolescents, it is essential to take the concept of the dual
working relationship (i.e., the relationship of the therapist withthe patients as well as their parents) into account, to prevent
inappropriate expectations from parents as well as a conflictof loyalties for the patients, factors that may increase drop-out
from psychotherapy.
For younger patients, it is also important to take into accountthe adaptability and competence of parents to support the child’sdevelopment during psychotherapeutic treatment – parents may
justify a drop-out by arguing that it is a “good decision” and “inWorld Psychiatry 18:1 - February 2019

favor” of the family even though the consequences for the patient
may be negative. Thus, addressing potential fears, ambivalence
and resistance of parents is an important aspect of psychother­
apy with younger patients. In the case of adolescent patients,
wishes for increasing autonomy may also be a reason for drop­
ping out.
Further research is needed in this area. The reasons for drop­
ping out need to be further explored, and patient charac­ter­
istics associated with dropping out need to be more compre­
hensively identified. For this purpose, qualitative interviews
may be useful. Furthermore, up to date, it is unknown what hap­pens to patients who drop out of treatment, as they are usually
lost from follow-up assessments. Future trials may be designed­offering alternative treatments (so-called switch trials) to par­ticipants not responding to treatments or at risk of dropping
out8,9.
Up to now, dropping out of treatment has had a negative
connotation. A shift in perspective may be helpful: in research,
unexpected results are sometimes of particular interest. Dropouts both inspire and force us to develop treatments that work
for a broader range of patients. Further, as only about 50% of
patients respond to psychotherapy and even less patients showa remission, at least some patients may have made a good de­cision when discontinuing a treatment that does not seem tobe helpful to them. In addition, examining the relationshipbetween drop-outs and side effects can be useful – the latter
represent another neglected issue in psychotherapy.
Drop-outs represent a challenge for psychotherapy (andpharmacotherapy). Seen from a different perspective, they pro­vide a chance to learn more about our treatments, for whomthey work and for whom they do not, why and how they work
and why not. They can inform us about limitations and noncurative factors of psychotherapy. For these reasons, a paradigm
shift may be needed, regarding drop-outs (and non-responders)
as important informants.
Falk Leichsenring1, Lea Sarrar2,3, Christiane Steinert1,2
1

Department of Psychosomatics and Psychotherapy, Justus-Liebig-University, Giessen,
Germany; 2Department of Psychology, Medical School Berlin, Berlin, Germany;
3
Department of Audiology and Phoniatrics, Charité-University Medicine Berlin, Berlin,
Germany
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Swift JK, Greenberg RP, Tompkins KA et al. Psychotherapy 2017;54:47-57.
Cahill J, Barkham M, Hardy G et al. Br J Clin Psychol 2003;42:133-43.
Swift JK, Greenberg RP, Whipple JL et al. Prof Psychol Res Pr 2012;43:79-87.
Muran JC, Safran JD, Gorman BS et al. Psychotherapy 2009;46:233-48.
Luborsky L. Principles of psychoanalytic psychotherapy: a manual for sup­portive-expressive treatment. New York: Basic Books, 1984.
Markowitz JC, Milrod BL. Lancet Psychiatry 2015;2:186-90.
Steinert C, Kruse J, Leichsenring F. Psychother Psychosom 2016;85:235-7.

DOI:10.1002/wps.20588

33

FORUM  –  SUBSTITUTE DECISION-MAKING IN PSYCHIATRY: STATEMENTS BY UN BODIESAND THEIR PRACTICAL IMPLICATIONS“Capacity”, “best interests”, “will and preferences” and the UN
Convention on the Rights of Persons with Disabilities
George Szmukler
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

The United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD) is the most up-to-date international legal instrument
concerning the rights of persons with disabilities. Such persons are taken to include those with serious mental disorders. According to an authoritative interpretation of a crucial Article (Article 12 - Equal recognition before the law) by the UN CRPD Committee, involuntary detention and treatment of people with mental health disabilities are prohibited under the Convention. Both conventional mental health law and“capacity-based” law are deemed to violate the Convention. However, some other UN bodies are not in full agreement (for example, the UN
Human Rights Committee and the Subcommittee on Prevention of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment),
while others are less explicitly absolutist (for example, the Human Rights Council). Furthermore, strong criticisms of the position of the CRPD
Committee have been mounted from a number of academic quarters. These criticisms center on whether the role of a person’s ability to makea decision can be ignored, no matter the circumstances. Much of the above debate turns on the concept of “legal capacity” and the now oftenrepeated precept that one must always respect the “will and preferences” of the person with a disability. However, “will and preferences” remains
undefined. In this paper, I offer an analysis of “will and preferences” that can clarify interventions that may be acceptable or non-acceptable
under the terms of the UN Convention.
Key words: UN Convention, human rights, persons with disability, UN CRPD Committee, mental disorders, involuntary treatment, mental
health law, legal capacity, mental capacity, will, preferences, best interests, substitute decision-making(World Psychiatry 2019;18:34–41)

The United Nations (UN) Convention
on the Rights of Persons with Disabilities(CRPD)1 is the most up-to-date international legal instrument specifically tailored to stipulate the rights of persons
with disabilities. Such persons are taken
to include those with serious mental disorders.
Recent authoritative interpretations is­sued by the UN Committee set up tomonitor the implementation of the Con­vention (CRPD Committee) lead to an in­sistence that involuntary detention andtreatment of people with mental health(or “psychosocial”) disabilities are prohibited.
For example, the Committee’s General
Comment No. 1 on Article 12 (Equal recognition before the law) of the Convention2
includes the following statements:

making by supported decision-making,which respects the person’s autonomy,
will and preferences.” (para. 26)

or health diagnosis is contrary to the rightto liberty, and amounts to arbitrary deprivation of liberty. ” (para. 13)“The denial of the legal capacity of persons with disabilities and their detention
in institutions against their will, either
without their consent or with the consent
of a substitute decision-maker… constitutes arbitrary deprivation of liber­ty and violates articles 12 and 14 of theConvention.” (para. 40)

These challenging assertions follow
from the Committee’s position that Article
12 of the Convention entails that all persons, regardless of their decision-making
capabilities, must enjoy “legal capacity”
on an “equal basis with others”. Legal capacity involves the right to be recognized
as a person before the law, as well as theright to legal agency, that is, to have one’s
decisions – for example, concerning healthor social care, where and how to live, finances – legally recognized. “Legal capac­ity” is considered fundamental to personhood, equal human dignity, and full citizenship4,5.
The Committee’s interpretation2 statesthat “legal capacity” and “mental capac­ity”
are distinct: the former is a legal concept,
the latter a psychological one. Contrary to
the virtually universal provisions in mental health law and capacity-based law,
the Committee maintains that the existence of a disability (based on a physical,
mental, sensory or psychosocial impairment) must never be grounds for denying legal capacity and the imposition of“substitute decision-making” – that is, aFurthermore, the Committee’s State­ment on Article 14 (Liberty and securityof person) of the Convention3 argues that:“Support in the exercise of legal ca­pacity
must respect the rights, will and preferences of persons with disabilities andshould never amount to substitute decision-making.” (para. 17)“The Committee has called on States parties to protect the security and personal
integrity of persons with disabilities who
are deprived of their liberty, including
by eliminating the use of forced treatment, seclusion and various methodsof restraint in medical facilities, includ­ing physical, chemical and mechanic re­straints. ” (para. 12)“States parties must review the laws allow­
ing for guardianship and trusteeship, andtake action to develop laws and policies
to replace regimes of substitute decision-“The involuntary detention of persons
with disabilities based on risk or danger­
ousness, alleged need of care or treatment or other reasons tied to impairment

34

World Psychiatry 18:1 - February 2019

decision made by another person in theplace of the person with a disability (notappointed by the person, done against
his or her will, and not based on his or
her own “will and preferences”).
The Committee insists that the preser­
vation of “legal capacity” means that we“must respect the rights, will and preferences of persons with disabilities”. With
the appropriate support (strictly speaking for the exercise of “legal capacity”,
and that the State is obligated to provide),
people with disabilities will be able to express their “will and preferences”. Wherea person has difficulty in communicating
this directly, the Committee states thatone should achieve a “best interpretation” of the person’s “will and preferences”, involving those who know the person.
Article 14 of the CRPD states that “theexistence of a disability shall in no casejustify a deprivation of liberty”1. On theCommittee’s interpretation2, even where
there is a risk to the person or to othersin association with a disability, involuntary measures are nevertheless in breachof the Convention. Thus, convention­almental health law, based on a diagnosis
of some form of “mental disorder” plus
risk to self or others, is clearly ruled out.
This interpretation of Article 12 (to­gether with that of Article 13 - Access tojustice) has also important implications
for forensic practice, including a possible pro­hibition of the “mental condition”
defenses – “unfitness to stand trial” and“not guilty by reason of insanity” – on the
grounds that defenses must be “disabili­
ty-neutral”6-9.
An important background factor in theemphasis on legal capacity in the CRPD is
the widespread abuse of the rights of persons with disabilities. In many places thishas amounted to a loss of nearly all civilrights, sometimes termed a “civil death”.

WHY IS THE CONVENTIONIMPORTANT?
The Convention, adopted in 2006,
came into force in 2008. Although it does
not create rights not already existing inuniversal human rights treaties, it specifies how the principles of human dignity,

World Psychiatry 18:1 - February 2019equality, non-discrimination, autonomy
and full social participation and inclusion
apply in the case of persons with disabilities. It aims to ensure that such persons
are treated on an equal basis with others.
The Convention can be regarded as
rep­resenting a “paradigm shift” in thelegal concept of “disability”10,11. Persons
with disabilities are characterized as “in­cluding those who have long-term physi­cal, mental, intellectual or sensory im­pair­ments which in interaction with var­ious barriers may hinder their full andeffective participation in society on an
equal basis with others”. This is not an­exhaustive definition. Most authorities(but not all service users) accept that per­sons with a mental disorder treated within the mental health system are included.
The Convention puts forward a “social
model” of disability: it is the level of accommodations made by a society that
determines the degree to which a person’s impairment becomes a disability. It
is in this sense that “supported decisionmaking” may be necessary for a personwith a mental health disability to facilitate the person’s expression of his or her“will and preferences”.
At the time of this writing, 177 States
have ratified the Convention. Ratification
signals the willingness of a State to foster the specified legal rights and obligations. Depending on the jurisdiction, theConvention may or may not be automat­
ically incorporated into national law uponratification. In many common law countries (like the UK), it is incorporated into
national law only when directly legislated.

OTHER UN INTERPRETATIONSThe UN currently has ten “treaty-based”
bodies set up to monitor specific humanrights legal instruments such as the CRPD.
There is also the UN “charter-based” Hu­
man Rights Council, with its various “special procedures”, such as reports by “special rapporteurs”, “independent experts”,
and working groups. A “flat” overall structure means that there may be significant
differences in the interpretation of similar issues across these essentially independent bodies.

The CRPD Committee’s absolute pro­hibition on involuntary detention andtreat­ment is supported by the Special
Rapporteur on Disability12, the first Spe­cial Rapporteur on the Rights of Persons
with Disabilities13, the UN Working Groupon Arbitrary Detention 14, and the UN
High Commissioner on Human Rights15.
However, there are statements fromother UN bodies that do not support theCommittee’s interpretation, at least in its
absolutist form.
Some positions are clearly at variance.
In 2014, the Human Rights Committee
published a General Comment (No. 35) on
Article 9 of the International Cove­nant on
Civil and Political Rights, which states16:“The existence of a disability shall not in
itself justify a deprivation of liberty but
rather any deprivation of liberty must
be necessary and proportionate, for the
purpose of protecting the individual inquestion from serious harm or preventing injury to others. It must be applied
only as a measure of last resort and forthe shortest appropriate period of time,and must be accompanied by adequate
procedural and substantive safeguards established by law. The procedures should
ensure respect for the views of the individual and ensure that any representative
genuinely represents and defends thewishes and interests of the individual.”
A similar position has been taken by
the Subcommittee on Prevention of Tor­
ture and Other Cruel, Inhuman or De­
grading Treatment or Punishment17.
Other UN bodies’ positions are less ex­
plicit about an absolute prohibition on
involuntary interventions, but are framedin terms that support a central role for“will and preferences”. They call for an
urgent need to develop alternatives tocoercive interventions.
An important Resolution on Mental
Health and Human Rights from the UN
Hu­man Rights Council18 calls upon Statesto “abandon all practices that fail to respect the rights, will and preferences of all
persons, on an equal basis” and to “provide mental health services for persons
with mental health conditions or psychosocial disabilities on the same basis as to35

those without disabilities, including on
the basis of free and informed consent”.
A report of the UN Special Rapporteuron the right of everyone to the enjoyment of the highest attainable standardof physical and mental health19 notes thelack of consensus on compulsion within
the UN bodies. The Rapporteur offers
to work with others to achieve one. He
notes that discrimination is still evident
in mental health services, for example,
in depriving users of the rights to refuse
treatment, to legal capacity and to privacy, as well as other civil and politicalrights. He insists that action is required
to radically reduce coercion and to facilitate a move towards an eventual end to
all forced psychiatric treatment.
A report from the UN Special Rappor­
teur on torture and other cruel, inhumanor degrading treatment or punishment20
seems ambiguous on whether involuntary measures can ever be justified.
Worth noting at this point is a recent
decision by the European Court of Human
Rights21 which, whilst addressing Article
12 of the CRPD, concluded that it was
justified not to accede to the expressed“preference” of a man with an intellectual
disability concerning where he should
live, since “the disability was of a kind
that, in terms of its effects on the applicant’s cognitive skills, rendered the applicant unable to adequately understandthe significance and the implications of
the specific decision he wished to take”,
and that, therefore, “the applicant’s wellbeing and interests require that the mentor [in effect, a substitute decision-maker]
arrangement be maintained”. Thus, theCourt’s interpretation of Article 12 did notconcur with that of the CRPD Committee.

CRITICISMS OF THE CRPDCOMMITTEE’S INTERPRETATIONOF ARTICLE 12
It is no surprise that the absolutist po­sition of the CRPD Committee, so dramatically at odds with centuries of legal
acceptance of involuntary detention andtreatment, should receive harsh criticism.
An international group of clinicians22
argues that the Committee’s interpreta-36

tion threatens to undermine hard-won,critical rights of people with mental
health disabilities – the right to the highest attainable standard of health, to life,or access to justice. Furthermore, theyfear that the rights of others, the family
and the public, are similarly threatened,with a consequent increase in mental illness stigma. A central necessary role fora person’s decision-making capacity is
described (though, of course, in the majority of jurisdictions, capacity plays noformal role in civil commitment regimes).
The authors bemoan the Committee’s ap­
parent limited expertise in relation tomental illness, the lack of clinician input,
and the Committee’s failure to consider
the views of a broad population of service
users, a significant proportion of whom
support involuntary treatment, at least
as a last resort.
Dawson23, from a legal perspective,
criticizes the Committee’s interpretation
for failing to offer adequate guidance on
how, when situations arise where rights
articulated in the CRPD are in conflict,this can be resolved. This is especially im­
portant since the relevant text of the CRPD,
he maintains, is ambiguous. A key concept
in many legal systems, in settling the balance between competing imperatives, is afunctional test of decision-making capacity. This points to whether – in a particularinstance – autonomy, on the one hand, or
protection of the interests of a vulnerable
person, on the other, should prevail.
Furthermore, Dawson notes that thelaw in general is riddled with mental concepts, deprecated by the Committee as
not objective, like intention, understanding or foresight. A denial of legal capacity
in a specific domain, he argues, is not necessarily a denial of intrinsic human rights.
Blind persons are not allowed to drive;
the key consideration is whether the person has an impairment of the relevant
functions, physical or mental, necessary
to act safely in that domain. Dawson criticizes the Committee’s understanding of
the meaning of “discrimination”, arguingthat it is not necessarily improper to treat
people differently if relevant differences
exist between their situations even after
adequate support has been provided andreasonable accommodations made.

Scholten and Gather24 argue that theCommittee’s standpoint, if accepted,
would result in a number of serious adverse consequences for persons with men­tal health disabilities. Important would
be a serious effect on “autonomy” andwell-being. By “autonomy” they mean“the ability to live one’s life according to
one’s own conception of the good”. They
state: “When a person’s decision-making
competence is substantially impaired,
the person is often not in the best position to assess which treatment option
will be most conducive to her well-being
and consistent with her conception of thegood. In such cases, the practice of informed consent loses its point”.
They further argue that the Com­mit­
tee’s proposals would make it difficult todetermine whether “undue influence”
had been exerted by a supporter of thedisabled person: “It will be more difficult for the medical staff to monitor theactions of support persons because thedistinction between the interests of thepatient and those of the support person becomes diffuse”. Related to thisproblem, they maintain, would be theformal allocation of responsibility for adeci­sion exclusively to the person witha mental disability. Support persons arepresumably to be left without any formal
accountability.
All three critiques above have in common a key objection. They ask whether
the role of a person’s ability to make a de­cision can be ignored, no matter the circumstances. If all efforts at support havefailed, or if the person refuses support,
but there is still an inability to under­
stand the facts pertinent to the decisionin question, or to appreciate their rele­vance, or to use, weigh, or reason with that
information in terms of what is importantto that person, to his or her beliefs andvalues, to his or her personal life goals or
personal conception of the good, is his or
her choice to be nevertheless accepted?
Decision-making ability is currently
widely constructed as the crux aroundwhich justifications are sought for interfering in a person’s life in the interests ofrestoring that person’s ability to decide
and thus his or her well-being. Or, as
Daw­son proposes, the basis on which we

World Psychiatry 18:1 - February 2019

work to resolve serious situations where
rights contradict each other – for example
the right to self-determination versus theright to life, or to the highest standard ofhealth care, or to be free of violence andex­ploitation.
All three critiques also raise the related question of how we are to understand“advance directives”. At Time 1, a personwith unquestioned decision-making ability may predict that, because of an anticipated future episode involving what that
person recognizes as an impairment inthat ability (Time 2), he or she will express a different, contradictory preference, which the person states is not to be
regarded as what he or she truly or “autonomously” desires. If the feared episodeoccurs, which preference should be respected? The CRPD Committee provides
no explicit guid­ance on this question. Is
it the Time 2 preference, disavowed atTime 1, that is to be followed? If so, whatis the point of such an advance directive?
Since significant criticisms of the Com­mittee’s interpretation turn on the notionof decision-making ability, I suggest thatan examination of how this concept might
relate to the CRPD’s “respect for rights,
will and preferences” may be fruitful. Sucha discussion will have a strong bearing on
two key principles underlying the CRPD:
support for autonomy and the eliminationof discrimination.

DECISION-MAKING ABILITY, A
DISABILITY-NEUTRAL LAW, ANDDISCRIMINATION
Before the CRPD Committee had issued its interpretation, colleagues and I
presented an argument that a “disabilityneutral” law could be formulated thatwas non-discriminatory towards people
with mental health disabilities25,26. Such alaw would permit involuntary treatment
when all attempts at support had failed
in helping the person to make a decisionthat could be considered autonomous.
Such a law, we proposed – as do thecrit­ics discussed above – would be square­
ly based on decision-making ability. This
is not a “blanket” inability but is specificto a particular treatment decision at a par-World Psychiatry 18:1 - February 2019

ticular time. People with mental illness do
not have an impairment of such an ability
for most, or indeed all decisions, and formost or all of the time. If there was a significant impairment of this ability, involuntary treatment would only be justified
if it were in the person’s “best interests”.
We qualified the term “best interests” as“sub­jective” best interests – that is, onethat gives paramount importance to theper­son’s deep beliefs and values, or whatmight be termed the person’s “will andpreferences”.
We also suggested that decision-mak­ing ability itself might be construed interms of a person’s beliefs and values.
An assessment of the person’s decisionmaking ability would go beyond the moreconventional, so-called “cognitive” elements, by examining the coherence of aperson’s treatment decision with his or
her relevant deep beliefs, values, andcommitments. A similarity was noted to
Bach and Kerzner’s influential accountof how “will and preferences” could beassessed in the light of a person’s ability to express an intention (or will) andits coherence with a sense of a personal
identity through time27,28.
Further, we argued it was essentialthat the law be “generic”. To avoid discri­
mination, it had to apply to all persons
on an equal basis, no matter the cause of
the impairment of their decision-making ability, whether it was a “mental” or“physical” disorder, nor whether they
had a “disability” or not. Decision-mak­ing ability, we argued, is conceptually dis­tinct from a “disability” and may occur inpeople with or without a disability.
Dawson and I had earlier proposedsuch a generic law, which we termed a“fusion law”, as a riposte to conventional
mental health legislation. We argued
that conventional law was unfairly discriminatory against people with a mental
illness, in that their autonomy or rightto self-determination was not accorded
the same respect as given to all other patients in general medicine or surgery.
Some, including the CRPD Commit­
tee, criticize capacity-based law – evena generic law applicable to all – as discriminatory, because a disproportionate
number of people with mental health dis-abilities would be judged to lack decisionmaking capability, even if such a lack is
specific to a time and decision. Certainly,
this would constitute a “disproportionate
effect”. However, a disproportionate ef­
fect does not automatically entail discri­
mination – in such cases, “indirect discrimination”. For example, a person withan intellectual disability is rarely accepted for training as a doctor. As entry qualifications do not explicitly exclude people
with an intellectual disability, there isno “direct discrimination”. However, theentry criteria, usually requiring top classexamination results in academic subjects, do have a disproportionate impact
on people with an intellectual disability.
Yet, we do not claim these criteria discriminate unfairly against people with an
intellectual disability.
This is because it is accepted, certainly
in international law, that a disproportionate effect does not amount to indirect discrimination provided its basis
has three attributes: a) it has a legitimate
aim, b) the criteria leading to the effectare objective, and c) the criteria are reasonable in the light of that aim29.
The “aim”, in the instances that interest us, should be seen in the terms of thefundamental principles of the CRPD: respect for the “inherent dignity of the person, and individual autonomy, including
the freedom to make one’s own choices”.
The aim is essentially to ensure that people experiencing a serious difficulty inmaking an important decision are supported in acting autonomously (according to their deeply held personal beliefs
and values, their personal conception of
the “good”, or “will and preferences’”),and that those values are given effectthrough facilitation from others until the
person’s autonomy is restored.
A substantial body of research on thestan­dard criteria for “decision-making capacity” – as defined, for example, in thework of Grisso and Appelbaum30 – show alevel of agreement between independent
assessors, a strong index of “objectivity”,
that is very high31.
“Reasonableness” turns on whether
the basis of the differential treatment advances the legitimate aim. Is it a reasonable and proportionate means to achieve37

that aim? A person’s “autonomy” – in thesense above – is necessarily related tosome kind of decision-making ability. If
a person is unable to make a decision re­flecting or furthering his or her conception of the good, despite all measures of
support, this pos­es an obstacle to acting
autonomously.
Under what circumstances might a­per­son have difficulties in making a treatment decision that is coherent with his or
her individual conception of the good, or
his or her deep beliefs and values? What
the CRPD Committee has not directly considered is a common situation for people
with a serious mental illness, such as a
psychosis: that is, a significant, often dramatic, change in the person’s preferences.
Indeed, the same may occur in people
without a mental illness, for example,
with an organic brain syndrome caused
by a brain injury or adverse drug reaction.
An examination of the terms “will andpreferences” can perhaps help to clarify
the elements entering into such situations; and how we might respond to themin a manner arguably consistent with the
CRPD, yet sometimes allowing for an “involuntary” intervention.

THE MEANING OF “WILL AND
PREFERENCES”: “WILL” VERSUS“PREFERENCE”
According to the CRPD Article 12,­ l­ause 4, “States Parties shall ensure thatC
all measures that relate to the exercise
of legal capacity provide for appropriate
and effective safeguards to prevent abusein accordance with international humanrights law. Such safeguards shall ensurethat measures relating to the exercise oflegal capacity respect the rights, will andpreferences of the person, are free of conflict of interest and undue influence, areproportional and tailored to the person’s
circumstances, apply for the shortest
time possible and are subject to regularreview by a competent, independent andimpartial authority or judicial body. ”
There appears to be ambiguity in thistext, born of compromise. Some author­
ities have interpreted this clause as per­mit­ting substitute decision-making, but only38with the safeguards stated11. However, as
we have seen, the CRPD Com­mittee maintains that the exercise of legal capacity
prohibits substitute decision-making andinsists that we must at all times “respect
the rights, will and preferences” of persons with disabilities (as we presumably
do for everyone else)2. The expression “willand preferences”, as noted earlier, appears
in many UN bodies’ statements, even in
those that do not explicitly prohibit substitute decision-making.
Though the expression “will and pref­­­
erences” is frequently repeated, no authority has provided a definition of its
meaning. I have not found one in the“travaux préparatoires”. Why were these
two words, “will” and “preference”, cho­sen? “Preference” has a relatively straight­
forward meaning: the Oxford English
Dictionary defines it as “a greater liking
for one alternative over another”. On theother hand, the meaning of “will” moves
us into a much more difficult ­territory.
In ordinary language, “will” has astronger sense of force or resolve to act
in a particular way than does a “preference”. Fur­thermore, the “will” has a long
history in the philosophy of mind. It is
no surprise that the views expressed byphilosophers concerning its meaning reveal significant differences. Indeed, in a
recent volume dealing with the subject,
the author describes the “incomplete demise” of the “modern theory of the will”
that held sway from Descartes to the 19th
century and came under fierce attack inthe 20th century32.
A 17th century account might see the“will” as occupying a kind of causal role
between the desire and the act aimed
at fulfilling the desire. A distinction between the “will” and a desire (or wish or“preference”) is generally drawn in thephilosophical literature. Influential has
been Kant’s concept of the “will”, helpfully summarized as: “The will, then, as
distinct from the ability to choose, is thecapacity to transform felt urges or desires
with causal force into motivating reasonsfor action with justifying validity. To possess a will is therefore also to be able totest desires to see whether or not they canbe validated as reasons”33. Kant’s “will”
forms part of a larger account including

the choice of “ends”, but this is not relevant for our purposes.
Pertinent to this discussion, and shar­ed with a number of recent accounts, isthe idea of the “will” as a kind of higher-or­
der motivating structure that determines
which desires are to be translated into
acts. It may be seen as having a special“reason-giving force”34, or as a higherorder self-governing mechanism, one inwhich “values” play a key role and where
desires are subject to forms of deliberation
within higher-order “policies” extending
over time and expressing commitments
towards ends that embody values35.
Consistent with this framework, we
can develop an account of “will” and“preference” that proves helpful in understanding when we may become con­cerned that a person’s decision-making
is undermined36. A distinction may be
drawn between the “will” – as a higher-order, self-governing function – as op­posed
to desires or inclinations or “preferences”,
expressed in the present. The “will”, on
this view, is a manifestation of a person’s
deeply held, reasonably stable and coherent personal beliefs, values, commitments and conception of the good. It iswhat we may understand as characterizing personal “autonomy”. In this sense,
it is not the same as a desire, inclination,
or a currently held “preference”, even astrongly expressed one.
Normally, “will” and “preferences”, byand large, run together. It is when the“will” and a “preference” diverge or arecontradictory, and a person needs to makea serious decision, that a problem mayarise.

WHERE A “PREFERENCE” IS
INCONSISTENT WITH THE“WILL”: ALL PREFERENCES ARENOT CREATED EQUAL
For an instructive model we can returnto “advance directives”, cited as prob­
lematic in the critiques of the CRPD Committee’s interpretation of Article 12. Noting the difference between the “will” of theperson (and its associated preferences) at
Time 1, as against the “preferences” thatthe person anticipates will be expressed at

World Psychiatry 18:1 - February 2019

Time 2 – and which the person asks to beignored – it is explained why we generally
respect the person’s Time 1 “will” and not
the Time 2 “preference”. If the person were
to “will” at Time 1 that treatment on an involuntary basis in the face of a predicted
persistent refusal at Time 2 (as a last resort,
all attempts at support having failed), theargument is strong that the Time 2 refusal
should be overridden. We favor the Time 1
instruction as it reflects the person’s “will”– his or her relatively stable, deeply held
beliefs and values, and personal conception of the good.
To honor the preference at Time 2 is toundermine the “will” or, in essence, the“autonomy”, of the person. It is hard to see
how this would be consistent with the first“General Principle” of the CRPD: “Respect
for [the] inherent dignity, individual autonomy including the freedom to makeone’s own choices, and independ­ence of
persons”.
If this analysis is accepted, it would
follow that we would act similarly if theperson had not made a written advancedirective, but had expressed, throughvarious statements and life choices, thesame values (or “will”) and associated“preferences”, as evidenced by people
who know the person well, for example,
relatives and friends. Even if the person
had not previously expressed clear treatment wishes, his or her previously manifest “will”, as evident from his or her valuecommitments, life choices and goals,
would have to count heavily in deciding whether or not to respect a present“preference”.
Consistent with the spirit of the CRPD
would be – despite an involuntary intervention – the necessity of developing a
relationship aimed at facilitating the person’s expression of his or her will as soon
as possible27.
This analysis of “will and preferences”
adds a further dimension in the conceptualization of “decision-making capacity” and “best interests”, if not a major re­formulation. Treatment decision-mak­ing
capacity is undermined when there is aserious divergence between the person’s“will” and a currently expressed treatment “preference”; while a person’s “bestin­terests” are served by acting so as toWorld Psychiatry 18:1 - February 2019

give ef­fect to the person’s “will”. An advance directive offers the clearest model.
The case for an involuntary intervention
is stronger, the greater the threat to theperson’s “will” that would result from theperson enacting a contradicting “preference”.
How well are we able to determine
what are a person’s deep beliefs, values
or personal conception of the good? The
tool we use is called, by philosophers,“interpretation”37-39, not to be confusedwith the psychoanalytic version. Inter­
pretation involves a form of “folk” or“com­mon-sense” psychology we use tounderstand and predict others’ behaviour in everyday terms of mental statessuch as beliefs and desires. Dennett 40
characterized this ability as follows: “Forall of its blemishes, warts and perplexities, folk psychology is an extraordinarily
powerful source of prediction. It is notjust prodigiously powerful but remarkably easy for human beings to use. We
are virtuoso exploiters of not so much atheory as a craft”. When employed collaboratively with the patient, and withpeople who know the patient well, one
would expect an appropriate degree of“objectivity” in the assessment.
No doubt the reader will have seensome potential difficulties in this “will andpreferences” approach. Here, I point tosome briefly.
Can a person’s “will” (and associatedpreferences) change without it being asign of that “will” being undermined? Al­
though there are accounts of a sudden,“quantum” change in a person’s deep be­liefs and values, these appear to be rare41.
They are usually in the nature of spiritualrevelations, and the result of the change
appears to be an overall largely coherent
conception of the “good”, often of a religious nature. More commonly, a change
in the “will” is gradual and understandable, usually involving a working throughof value conflicts: “coherence” in an interpretive sense is maintained. Another instance where a new “will” may be seen as“authentic” may occur in a person with along-standing psychosis, where the person
has changed significantly, but where there
is a sufficient degree of stability and coherence in the person’s new beliefs, values,and conception of the good, with a reasonable correspondence with the real world.
Should one always privilege the “will”
over a conflicting “preference”? When the
impairment of decision-making is due toa reversible cause, it is usually straightforwardly so. However, when irreversible,
for example in dementia, it is arguablethat the person now is not the “same person” having the previous “will”. Whether
that “will” should be respected rather
than a strongly held but divergent “preference” in the present, I suggest, should
be determined on a case-by-case basis,
involving those with a close interest in thewell-being of the person39.
There are situations where it may be
impossible to know what a person’s “will”
might be – for example, a person who is
unconscious or is in an organic confusional state where no-one is available
who knows the person; or a person with asevere intellectual disability who may nothave been able to clearly express a coherent “will” (though there may be fragmentsof observed behaviour and utterances
pointing to what has been important to
the person that offer an indication). In
such cases, it has been proposed that thedefault position might be to consider thehuman rights relevant to the situation as
the guide for the decision to be made42.

RESPECT FOR “RIGHTS”
AS WELL AS “WILL” AND“PREFERENCES”?
Just as “will” and “preferences” maypoint in different directions, so may “will”
and “rights”. When a “right” should override a clearly formulated “will” constitutes
a predicament more familiar to us, usuallyframed as “protection” versus “autonomy”.
An example is whether a right to enjoy
freedom from exploitation should override a person’s “will” to live alone in a situation where such a right is threatened.
Its resolution might depend on a “bestin­terpretation” of whether the person’s“will” to live independently – as judged
on the basis of his or her beliefs, values andconception of the good – would be consistent with accepting the level of risk towhich the person would be exposed (af­39ter appropriate support services were pro­­vided).
From the previous discussion, it will
be evident that the word “respect” in thephrase “one must respect the rights, will
and preferences” of the person cannot
mean that one must comply or accede
to all those three elements. If they point
in different directions, that is logically
impossible.

CONCLUSIONSThe UN CRPD is an important legal
instrument clearly specifying the rightsof persons with disabilities. If given effectby ratifying States, it will dramaticallytransform the standing in society of such
persons. This is to be strongly welcome.
However, the CRPD Committee’s in­
terpretation of Article 12 prohibiting“substitute decision-making”, while supported in some quarters, has not been
fully endorsed in statements from someother UN bodies, and has drawn strong
criticism from legal and clinical scholars.
An absolute prohibition on involuntary treatment is, at least at present, notcredible. Nevertheless, States parties areconstantly reminded of the Committee’s
position in its Concluding Observations,published following regular examinations of each State’s progress in implementing the Convention43. Almost in­variably, States are asked to replace
regimes of “substitute decision-making”
with regimes of “supported decisionmaking”.
While it is probable that service innovations aiming to reduce coercive mea­sures can substantially reduce theirfrequency, there will always be cases –for example, due to organic confusional
states or neurodegenerative disorders– where ethically persuasive justifications can be made for such measures, atthe very least in circumstances carrying
grave consequences. Furthermore, surveys reveal that a significant proportionof people who have been involuntarily treated for a mental illness state thatsuch a measure can be appropriate asa last resort44-46. This indicates that law
reform must involve those most directly40

affected and take into account the diversity of views in this group47.
It would be an unhappy state of affairs
if regard for the CRPD were under­minedby the Committee’s interpretation. Itshould be noted that, while this interpre­ta­tion is “authoritative”, it is neverthelessnot “legally binding” in international
law29.
Despite these concerns, the Commit­
tee’s role in drawing attention to involuntary detention and treatment is welcome.
Sadly, this has been a neglected area inmental health care. We prefer not to linger on what can be a profoundly distress­
ing and humiliating experience for patients (and a disturbing one for clinicians). The discrimination against people with a mental illness in conventional
mental health law is being increasingly
recognized, raising fundamental questions about justifications for compulsion.
The Committee’s objective to eliminate
the obvious discrimination against persons with mental health disabilities and topay special or paramount regard to such
persons’ deeply held beliefs and values (orpersonal conception of the good, or “will”
and “preferences”) is to be highly commended. However, by failing to analyze
the meaning of the regularly endorsed
phrase “respect for will and preferences”,
especially in cases where there is a radical change in a person’s “preferences”, theCommittee’s interpretation is incomplete.

ACKNOWLEDGEMENTS
The author thanks G. Richardson for her commentson the manuscript, and S. Gurbai and W. Martin for
their help with tracking the UN bodies’ statements.

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DOI:10.1002/wps.20584

41

COMMENTARIES

Mental health and human rights in the 21st century
Mental health is emerging from theshadows. Human rights are on the agenda, and advocates are increasingly callingfor parity with general health funding anda reduction of the treatment gap for people
in crisis, particularly in low- and middle-­
income countries. There is high-level agree­
ment on key components of good mental
health policy, from promotion to prevention, treatment and re­habilitation.
However, important disagreements re­main about how to invest resources. An
impasse has emerged, and it risks hardening into a dispute. The controversy relates to complex connections between
mental health and human rights, andco­alesces around a single question: do
involuntary psychiatric interventions vio­late international human rights law?
Coercion in psychiatry and broader
mental health services is rising worldwide. This fact demands not merely discussion but action. The Convention on
the Rights of Persons with Disabilities(CRPD) offers a chance for all stakeholders to rethink conventional wisdoms, address long-standing power imbalances
and implement innovative practices.
Anxieties about the change must not
obstruct dialog or political action. The
CRPD provides a unique opportunity toliberate not just users of mental healthservices but the entire field of mental
health from a legacy of stigma, hopelessness and discrimination. The directiveof the CRPD to embrace a social or “human rights” model of disability and moveaway from a “medical model” of disability
has strategic advantages, including shining a light on the many social, politicaland economic factors that create grave
disparities for people with mental healthconditions or psychosocial disability.
It may be tempting to focus on the most
exceptional cases, which seem unmanageable without coercion. More important, however, is the need to substantiallyreduce coercion by implementing alternative, human rights compliant ways of providing support. Psychiatry can and mustbe among the leaders in this direction, notjust among those resisting change.

42

Human rights violations in the mental health context remain significant
throughout the world, including in high-,
middle- and low-income countries. The
prevalence of rights abuse cannot be explained by a mere lack of resources. In therelatively wealthy European region, forexample, funds continue to be invested
in the renovation and expansion of large
scale residential and psychiatric institutions1,2. These sites perpetuate a vicious
cycle of exclusion and despair. The riseelsewhere of involuntary psychiatric intervention in hospitals and homes alsosuggests that something is wrong.
We recognize the serious arguments ofprofessionals who warn against a prohi­
bition of forced treatment. They insist on
retaining legal permission to treat individuals with serious mental health con­di­tions
involuntarily in exceptional cir­cumstancesin ways that preserve dig­nity and autonomy, even the right to life. Those against
argue that the non-consensual impositionof mind- and body-altering drugs basedon narrow conceptions of impairment,
poorly evidenced claims about “risk” and“necessity” , and a limited range of alternatives, is incompatible with dignity andautonomy.
Scholars in diverse fields, including
philosophy, neuroscience, psychology
and economics, are increasingly challenging the grounds for the “exceptions”
that legitimize coercion in mental healthcare. The CRPD has elevated this challenge to the level of international humanrights law. Indeed, the CRPD challenges
centuries of legally sanctioned prejudice.
However, “exceptions” remain at the domestic level, in law, policy and practice,and they filter into the norm, fostering
power asymmetries, the overuse of biomedical interventions, and the disempowerment of an already marginalized
population. Systemic violations follow.
This status quo, which can be observed
on a global scale, is no longer acceptable.
For psychiatrists and all healing professions, a pivot toward human rights
would require setting aside “substitutedecision-making” and offering support

according to a person’s “will and preferences”, and where unknown, the “best interpretation” of her/his will, preferences
and rights.
Szmukler’s paper3 makes a substantial
contribution to this effort. He elucidates
some of the practical and conceptual requirements involved in a move towarda “will and preferences framework” andasks seriously what the CRPD means forthe future of psychiatry, and for global
health governance more generally.
One of his claims, however, raises someconcerns: namely, the proposal to assess
decision-making inability in the form offunctional assessments of mental capacity when a person’s will and preferences
are unclear or appear to be in conflict.
On this point, caution is warranted.
Szmukler mentions the many critics offunctional assessments of mental capacity,
to whom the authors of the World HealthOrganization’s QualityRights Frame­work4
could be added. Yet, his ef­forts to assure
against discrimination or a replication of
long-standing power im­bal­anc­es will fail
to convince many (in­­cluding ourselves).
He is right, however, in­so­far as emergen­cy responses are need­­­ed and the dialog
must continue to find grounds for intervening in ways that are just.
This Forum in World Psychiatry, and
the WHO QualityRights Framework, areexemplary of this ongoing search. Creative
responses are needed that foster therapeutic relationships based on trust andempowerment, in ways that avoid the pitfalls of the past. Moving in this direction
opens space and creates urgency to develop innovative practices, some of which
emerge organically when involuntary interventions are suspended or greatly restricted (as appears to have occurred inGermany, for example)5.
Academic psychiatry – as Szmukler’s
own work makes eminently clear – will beessential to this shift. Clinical researchers
can continue this effort by calling for thereinvestment of the vast resources currently spent on narrow biomedical research, shifting funds instead to social,clinical and community studies within

World Psychiatry 18:1 - February 2019a humanistic frame6. Ties between psychiatry, public health and social sciences
need to be strengthened.
There are no simple solutions. Debates
may be uncomfortable, but they could
open new opportunities and roles forpsychiatry. The shift would diminish the“formal power” currently afforded to psychiatrists. Yet, there could be multiple
benefits in shifting the profession froma tutelary to a facilitative role, including
unlocking funds currently used for coercion and addressing important issuesof image and reputation. It should be in
the interests of psychiatry as a medical
profession to substantially reduce its reliance on coercion, and to spread such a
message to its members worldwide.

A rights-based approach can provide
a pathway to the future of mental healthcare we want for all. The CRPD can beused to promote the investment of human and financial resources into a broad
spectrum of support to drastically reduce
non-consensual measures with a view totheir elimination. It offers a framework toachieve social justice, attain the highest
standard of health care, and strengthen
governance of health and social services.
Dainius Puˉras1,2, Piers Gooding3
1

United Nations Special Rapporteur on the Right to Phys­
ical and Mental Health; 2Clinic of Psychiatry, Fac­ul­ty of
Medicine, Vilnius University, Vilnius, Lithuania; 3Melbourne
Social Equity Institute, University of Melbourne, Mel­bourne, VIC, Australia

1.

2.
3.
4.

5.
6.

World Health Organization. Mental health, human rights and standards of care. Assessmentof the quality of institutional care for adults
with psychosocial and intellectual disabilities
in the WHO European Region. Geneva: World
Health Organization, 2018.
Winkler P, Krupchanka D, Roberts T et al. Lan­cet Psychiatry 2017;4:634-42.
Szmukler G. World Psychiatry 2019;18:34-41.
World Health Organization. Protecting the rightto legal capacity in mental health and related
services (pilot version). Geneva: World HealthOrganization, 2018.
Zinkler M. Laws 2016;5:15.
Kleinman A. Br J Psychiatry 2012;201:421-2.

DOI:10.1002/wps.20599

Practical strategies to end coercive practices in mental healthservices
Mental health has become a global im­perative. Increasing coverage of treatment
options and support services is crucial.
However, without deep reflection andchange in paradigm about the types ofservices being provided, we risk reproducing some of the poor outcomes anddissatisfaction that we see in high-income
countries, stemming from overmedicalization, overuse and inappropriate useof medications (and their negative impacts, for example, in terms of metabolic
disturbance, sexual dysfunction, premature mortality) and human rights violations associated with involuntary admission, forced treatment, seclusion andre­straint1-3.
Promoting human rights in mental
health must go hand-in-hand with efforts to scale-up services in countries, andmental health strategies and interventions must be firmly grounded in a humanrights approach4.
The Convention on the Rights of Per­
sons with Disabilities (CRPD) sets out key
obligations on countries to end practices
based on force, coercion and substitutedecision making in mental health, andinstead requires that practices be basedon people’s will and preferences or on

World Psychiatry 18:1 - February 2019the best interpretation of their will andpreferences5,6.
Coercive practices are particularly chal­lenging to change, since they are com­monly accepted in society, seen as necessary to protect persons from harm, andare firmly cemented and sanctioned inlaw and policy across all countries. This
despite the absence of evidence for theireffectiveness, and the available evidence
demonstrating that practices such as seclusion and restraint actively cause harmto physical and mental health, and canlead to death7.
G. Szmukler8 argues that there are ex­
ceptions where, in the interest of promot­
ing people’s autonomy, it becomes neces­sary to utilize involuntary interventions,and that a person’s ability to make a de­cision should be a decisive factor in de­termining whether forced admission andtreatment is a legitimate response. Below,
we set out our disagreement with this po­
sition and also address some specificpoints raised by the author.
First, denying a person who is blind theright to drive is not the same as denying aperson, whose decision making capacity
is impaired, the right to decide on his/her admission and treatment. A person

who is blind is objectively so, and cannot
drive a car. On the other hand, determining that a person’s decision making is impaired is subjective. Furthermore, there
is no objective way that a health or otherprofessional can know what is best for the
person, because preferences are themselves subjective. The professional does
not have the same history, experienceor knowledge as the person concerned
about what he/she finds helpful in his/her recovery.
The underlying issue in the scenario
outlined by Szmukler is not the denial of
the right to drive, but rather understanding that the function of driving is first andforemost the possibility to get from A to
B. A person who is blind will be primarily
interested in the freedom of movementthat driving affords, rather than the act ofdriving itself. Thus, while the act of driving
may not be a guaranteed right, creating
the necessary accommodations to enable
him/her to get from A to B, on an equalbasis with others, is an obligation underinternational human rights law.
Similarly, in the case of someone whose
decision making is affected, the obligation is to support him/her to make his/her own decisions on an equal basis with43

others. This support may mean help­ing
the person to access relevant information, understand and weigh up the benefits and negative effects of treatment,
and support him/her to assert and communicate his/her decisions and choices.
If a person is unable to communicate
his/her decisions directly, these should
be based on the best interpretation of his/her will and preferences. Best interpretation can be determined, for example, bydrawing upon a trusted support personor network to help interpret what the person would want in the current situation,
based on what is already known about
him/her (e.g., his/her views, beliefs, values in life)9.
Alternatively, one can refer to a person’s
advance directive, containing information
about his/her will and preferences should
he/she be unable to communicate decisions sometime in the future. However,there are cases in which a person, who
expressed a particular wish at Time 1, expresses a contrary will and preference at
a later time. In such scenarios, Szmukler
questions which preference should be respected. In fact, advance directives can include an “Ulysses clause”, which enables
people to state that any objections they
may express “in the moment” should beoverruled in favor of the written directive.
This also allows options for people using
services who report that they are in favorof involuntary treatment. However, evenwith a Ulysses clause, it is important to
consult a support network to validate thefinal decision where discrepancies havearisen.
In situations where there are no support
persons or advance directive available (orwhen an advance directive is not clear),sufficient time should be allowed for a
person to make his/her decision in a safe,
non-coercive environment. If there is nolife threatening urgency to the situation,then decisions can be deferred to such atime that the person is able to express his/her will and preference. And even if there
is urgency, one is still obliged to interpret
what the person’s will and preference
might be, based on information that one
has at hand.
In these situations it is possible thaterrors are made, and that decisions based44

on the best interpretation turn out not to
be in line with a person’s will and pref­
erences. In these situations it is essentialthat the experience serves as a learning
opportunity to gain a deeper understanding of the person’s wishes, how best to
support him/her moving forward, andto prevent such incidents from re-occurring. In the aftermath of such situations,
it is useful to encourage the person to develop or update advance directives andto help him/her to identify trusted persons/networks to support him/her by interpreting his/her will and preferences in
the future if necessary.
In addition to achieve long-term sustainable change, policy and law will needto reflect the practice changes describedabove. Many recently formulated laws
around mental health contain substantial provisions about “managing” the “exceptional” use of involuntary admission
and treatment, as well as seclusion andrestraint. However, the system of exceptions has not worked even when there
have been stringent rules and restrictions
about their use. Furthermore, the endlessdebate about what is “exceptional” hasserved to hinder progress and productive
dialogue both at national and international levels. Energies should instead beconcentrated on looking at a way forward
and at strategies and solutions to promote
the right of people to receive quality careand support in line with the CRPD.
Change will be required at multiple lev­
els, including knowledge, attitudes andpractices of professionals, families andothers towards supporting people in theirdecision making, providing services that
operate without force, that promote rights,
recovery, and people centered care andsupport, and redefining policy and law
so that these move beyond a narrowly
focused biomedical approach in order tofully embrace a human rights approachthat addresses the social determinants ofmental health, and emphasizes support
instead of coercion.
WHO QualityRights has developed
training and guidance tools to enable
national stakeholders to integrate CRPD
rights into their practices10. The initiativeis also developing best practice guidance
identifying and providing the evidence

for community based services that operate without coercion, respond to people’s
needs, support recovery, and promoteautonomy and inclusion. The initiativeis also at the early stages of discussing
new guidance for human rights oriented
policy and law in line with the CRPD.
Michelle Funk, Natalie Drew
Department of Mental Health and Substance Abuse,
World Health Organization, Geneva, Switzerland
The authors are staff members of the WHO. They
alone are responsible for the views expressed in thiscommentary and they do not necessarily represent
the decisions, policy or views of the WHO.

1.

United Nations High Commissioner for Human
Rights. Mental health and human rights. Reportof the United Nations High Commissioner for
Human Rights. A/HRC/34/32. 2017.
2. Maslej MM, Bolker BM, Russell MJ et al. Psy­
chother Psychosom 2017;86:268-82.
3. Young SL, Taylor M, Lawrie SM. J Psychophar­macol 2015;29:353-62.
4. UN Human Rights Council. Resolution on Men­tal Health and Human Rights. A/HRC/36/L.25.
2017.
5. Committee on the Rights of Persons with Dis­abilities. General Comment No. 1 on Article 12:
Equal recognition before the law. CRPD/C/GC/1.
2014.
6. Committee on the Rights of Persons with Dis­abilities. Guidelines on Article 14 of the Conven­tion on the Rights of Persons with Disabilities:
the right to liberty and security of persons withdisabilities. Adopted during the Committee’s
14th session, September 2015.
7. US Substance Abuse and Mental Health Servic­
es Administration. The business case for preventing and reducing restraint and seclusionuse. Rockville: US Substance Abuse and Mental
Health Services Administration, 2011.
8. Szmukler G. World Psychiatry 2019;18:34-41.
9. World Health Organization. Realising support­
ed decision making and advance planning –WHO QualityRights training to act, unite andempower for mental health (pilot version). Ge­
neva: World Health Organization, 2017.
10. World Health Organization. QualityRights guid­ance and training tools (pilot versions). Geneva:
World Health Organization, 2017.

DOI:10.1002/wps.20600

World Psychiatry 18:1 - February 2019

The UN Committee’s interpretation of “will and preferences”
can violate human rights
In the controversies with the United
Nations (UN) Committee for the imple­
mentation of the Convention on the Rights
of Persons with Disability (CRPD), G.
Szmukler1 highlights an important pointin focusing on what the manifold cited
notion of a person’s “will and preferences”
actually means.
He sets forth that the “will” should beconsidered as “some kind of higher-­or­der motivating structure that determines
which desires are to be translated intoacts”, reflecting the person’s “deeply held
beliefs” , while “preferences” should becon­sidered as more superficial, momentary wishes which can undergo rapidchange, e.g. by mental illness. Corre­
spond­ingly, the “will” as stated in an ad­vance directive should be overriding lat­er
ex­pressed “preferences” , because other­wise advance directives would not makesense.
I am not really convinced that this interpretation adds “a further dimension
in the conceptualization of decisionmaking capacity and best interests”, as hestates. I doubt that “will” and “preferences” can be differentiated without using
either psychiatric or normative ­concepts,
both of which would be rejected from theCommittee’s radical perspective as discriminatory.
I have tried to reconcile psychiatricethics with the UN CRPD2. However, I
think that to find a common ground with
the Committee’s radical interpretation is
not possible, since the clinical and legal
consequences are irreconcilable.
Let us consider two clinical examples.
The first is the case of a patient with delusional depression and a strong suicidal
intention; the second the case of a patientwith severe anorexia nervosa and a lifethreatening body mass index. The first patient wants to commit suicide because heis deeply convinced to be the devil himself
and to be able to save the world only by his
death. The other patient has demonstrated over years that her highest value seems
to be eating as little as possible, even at theprice of her death.

World Psychiatry 18:1 - February 2019

How can we affirm that these wishes
are only “preferences” and not the patients’ “real” will? Either by pointing outthat we know a significant number ofpeo­ple with similar conditions who hadchanged their intentions completely after
psychiatric treatment, maybe with some
initial coercion, and continued to live
for decades even without treatment andwithout any intention to die. This is the“mental illness” concept. If one denies
this concept and wants to deter thesepeople from dying nonetheless, he has
to suppose that their “real” will is to live,
shar­ing the wishes of most people – living
in good mental and physical health, under good conditions and with good relations to the people next to them. In otherwords, it means to enjoy their humanrights. However, this is normative andvery closely related to the “best interest”
concept.
According to the Committee’s position,
both the above concepts are misleading.
The Committee invokes a new legislation
which for these two patients would resultin the consequence of death. This would
certainly violate some of their most important human rights: the right to life (UNCRPD, para. 10), and the right of health(UN CRPD, para. 25).
Similar to ethical principles, humanrights are individually not absolute, but
their degree of fulfillment is subject totheir compatibility with other humanrights. A typical example is circumcisionof new-born boys, inducing a conflict between (the parents’) freedom of religionand (the baby’s) right to physical integrity.
Similar deliberations are necessary in ourcases. For example, in cases of patientswith psychotic disorders who can live inthe community with medication but end
up in a seclusion room or a forensic hospital without medication, it seems shortsighted to focus only on para. 12 of the UN
CRPD (equal recognition before the law),
without taking into account para. 19 (living independently and being included in
the community), which is likewise important for such extremely vulnerable people.

In my country (Germany), we do nothave common law but a constitution,with the Federal Constitutional Court(FCC) as the highest and widely respected institution. This has the advantage thata renowned legal authority is available
that is competent to clarify controversial
legal issues as last instance. In 2011, theFCC published two seminal decisions
on the issue of involuntary treatment3.
According to the FCC, treatment withuse of coercion is only admissible undervery restrictive conditions. However, theFCC pointed out that, in case of lack of
capacity, involuntary treatment can beeven required to protect the patient’s
right to freedom. In this context, theFCC made clear distinctions between
the “free will” (corresponding to “will”
in Szmukler’s paper) and the “naturalwill” (correspond­ing to “preference” in
Szmukler’s paper).
Moreover, the FCC dealt in detail with
the question whether the concept of involuntary treatment is in accordance with
the UN CRPD, and confirmed that it is. In
addition, the FCC made in 2017 a decisionin the case of a woman with breast cancer
and a psychotic disorder who had refused
the necessary operation because she denied being ill. Since involuntary treatment was only legal in combination withinvoluntary detention in a psychiatrichospital, her decision to stay voluntarily
entailed that she could not be treated, andshe con­sequently died. Retrospectively,
the FCC decided that the state had a “dutyto protect” in such cases and required thelaw to be changed, allowing treatment
against a patient’s will also in general hospitals. This is a careful deliberation of conflicting human rights and is completely inline with medical ethics2.
Human rights belong to the most universal and precious ideas of mankind. If
the UN CRPD Committee says they are
unique advocates of the human rights
perspective and all of us psychiatric professionals together with our domestic
laws should, at least morally, stand in thedock because of torture, this is not only45

an “incomplete” view, as Szmukler says,
but it is shocking and inacceptable.
We should dare to express that. Exag­­
gerations may be sometimes necessary toachieve political goals, but exaggerations
in morality and medicine can have deadly consequences. Nonetheless, the UN

CRPD itself, as Szmukler emphasized, ishighly welcome, and deserves high efforts
to be realized in a reasonable manner.
Tilman Steinert
Clinic for Psychiatry and Psychotherapy I, Ulm University,
Centers for Psychiatry Suedwuerttemberg, Ravensburg,
Germany

1.
2.
3.

Szmukler G. World Psychiatry 2019;18:34-41.
Steinert T. Psychiatr Serv 2017;68:291-4.
German Constitutional Court. http://www.bverfg.de/entscheidungen/rs20110323_2bvr088209.
html.

DOI:10.1002/wps.20601

The CRPD Article 12, the limits of reductionist approaches tocomplex issues and the necessary search for compromise
The United Nations (UN) Convention
on the Rights of Persons with Disabilities(CRPD)1 was received with high expectations by all those concerned with theprotection of the human rights of people
with mental disorders and psychosocial
disabilities. For most sectors of the mental health community, it appeared to be aunique opportunity to take a leap forwardin the development of laws promoting therights of this group of people and facilitating the development of communitybased and human rights-oriented mental health care.
Is it possible that the UN Committee’s
General Comment No. 1 on Article 12of the Convention2 has created a situation in which all these expectations arein danger? Unfortunately, the danger isreal. A large number of States Parties thathave ratified the Convention have also
expressed their disagreement with theCommittee’s interpretation, in particularregarding the absolute prohibition of substitute decision-making. An increasing
number of human rights experts, scholars
and clinicians have stated their conviction that this interpretation, if accepted,
would result in serious adverse consequences for people with mental healthdisorders and psychosocial disabilities, and would undermine some of thehard-won critical rights of these people3.
Although many mental health service users’ organizations support the prohibition of involuntary admission and treatment, there are indicators showing that
this view is not shared by all people withmental disorders nor by the majority offamily members. In this context, we haveto conclude that the possibility that gov-

46ernments will change their mental healthlaws in accordance with the directives of
the Committee seems rather remote.
How did we get into this situation? The
limited involvement of some relevant
sectors (e.g., clinicians) in the drafting of
the Committee’s Comment, and an insufficient debate about the implications andthe implementation of the CRPD, were
important factors. However, in my opinion, the ambiguity of the text of clause 4of Article 12, pointed out by Szmukler4,
has certainly had a very strong influencein this process. It was this ambiguity, inwhich it is difficult not to see an imperfect compromise between conflicting approaches, that the Committee has tried
to overcome, alas, at the cost of a radical and reductionist interpretation, thatis not compatible with the complexity of
the issue at stake.
According to the Committee’s interpretation, any form of substitute decisionmaking is considered a violation of theConvention’s guarantee of legal capacity
on an equal basis. This means that, facedwith a person with a mental disorder who
does not accept a treatment considered
indispensable and has a severe lack of decision-making skills, a psychiatrist would
not be allowed to resort to involuntarytreatment in any circumstance. Because,in order to preserve legal capacity, it isnecessary to respect the person’s rights,
will and preferences, in such a situation
the psychiatrist would have to rely solely
on the support that the State is obliged toprovide for the person to become able toexpress his/her will and preferences.
This approach suffers from several fragilities and contradictions. One of thesehas to do with the arguments used by
the Committee to justify why the lack ofdecision-making skills cannot be the basis for any form of substitute decision. In
fact, one of these arguments – that the as­
sessment of these skills would be impossible – is not confirmed by the available
evidence5, while the other – that its determination would be discriminatory – hasbeen refuted by several experts, who haveargued that the assessment of decisionmaking capacity does not need to be discriminatory in nature and can be applied
to all people equally4,6.
Another example is the idea according to which, with the appropriate support, most persons with disabilities will
be able to express their will and preferences, a presumption which ignores thefact that, in many situations, it is not possible to guarantee this support, while inmany other situations this support will
not be effective. Finally, denying persons
with severe mental disorders the treatment they need, in cases where it has
been proved that they lack the ability tomake decisions regarding their treatment
needs, and doing so in the name of “thefreedom to take risks”, is, in my opinion,highly debatable from the ethical pointof view.
Despite all the objections that may beleveled against the Committee’s Com­­ment, we should not forget, as Szmukler4
rightly underlines, that the publicationof this Comment has had several important merits. It has stimulated a debate,although this has been manifestly insufficient so far. It has called attention to thefact that, for many people with mental
disorders and psychosocial disabilities,

World Psychiatry 18:1 - February 2019

involuntary admission and treatment
may be a very painful and traumatic experience. Finally, it has represented astrong challenge to be met by the development of new contributions that may
help to build a much-needed consensus.
The proposal of Szmukler and Daw­
son4,7 goes in that direction and provesthat it is possible to formulate a law thatis generic, non-discriminatory towards
people with mental health disabilities,
based on decision-making ability in relation to a particular treatment decision
at a particular time, and that permits involuntary treatment when all attempts at
support have failed in helping the person
to make a decision that could be considered autonomous.
The proposal of a more subjective approach to both the concept of best interests and the assessment of the person’s
decision-making ability could also help
to ensure that the deep beliefs and values (in other words, the will and preferences) of the person are taken into consideration4. Although differing from thisapproach in several specific aspects, theproposals put forward by Freeman et al3

and Scholten and Gather8 share some ofits principles.
Important differences remain between
these proposals and the Committee’sview. However, they all represent valuable contributions to the construction of
a formulation that will take into accountthe complexity of what is at stake andwill have real chances of being incorporated into the mental health laws of mostcountries.
For this to happen, several things arenecessary: a) to promote all forms of debate that may help to build a new consensus; b) to ensure the participation in
the discussion of a much broader rangeof stakeholders (e.g., different groups ofpeople with mental disabilities, family
members, mental health professionals
with clinical experience, and experts inmental health legislation and policy); c) toclarify the definition of and the relations
between relevant concepts (e.g., mental
disorders, disabilities, psychosocial disabilities); d) to admit that, rather thanconcentrating our efforts on “an absoluteprohibition on involuntary treatment(that) is, at least at present, not credible”4,

we should “devote more time to thinking
about how to make the essential practiceof substitute decision-making as respectful as possible”9; and e) to invest moreon the reform of services and practices,
without which no meaningful change inprotection of the human rights of people
with mental disorders will ever occur.
José Miguel Caldas de Almeida
Lisbon Institute of Global Mental Health, Chronic Dis­eases Research Center, Nova Medical School/Nova Uni­
versity of Lisbon, Lisbon, Portugal
1.
2.

3.
4.
5.
6.
7.
8.
9.

United Nations. Convention on the rights of persons with disabilities. New York: United Nations,
2006.
Committee on the Rights of Persons with Dis­abilities. General Comment No. 1 on Article
12: Equal recognition before the law. CRPD/C/
GC/1. 2014.
Freeman MC, Kolappa K, Caldas de Almeida
JM et al. Lancet Psychiatry 2015;2:844-50.
Szmukler G. World Psychiatry 2019;18:34-41.
Appelbaum PS. N Engl J Med 2007;357:1834-40.
Szmukler G, Daw R, Callard F. Int J Law Psy­
chiatry 2014;37:245-52.
Dawson J, Szmukler G. Br J Psychiatry 2006;188:504-9.
Scholten M, Gather J. J Med Ethics 2018;44:22633.
Burch M. J Appl Philos 2017;34:389-402.

DOI:10.1002/wps.20602

The UN Convention on the Rights of Persons with Disabilities: great
opportunities and dangerous interpretations
G. Szmukler’s paper1 provides an indepth analysis of some critical aspects of
the United Nations (UN) Convention on
the Rights of Persons with Disabilities(CRPD) that make its implementationprob­lematic in mental health care laws
and provisions.
Out of 177 States Parties that ratified theConvention, only 92 signed the Optional
Protocol, and several of them expressed
reservations on the Convention or expli­
citly put forward their interpretation ofsome articles2.
Actually, as correctly pointed out in
Szmukler’s paper1, the most critical aspects do not stem directly from the textof the Convention, but from the interpretations provided by the UN Committee
set up to monitor the implementationof the Convention (CRPD Committee)3.

World Psychiatry 18:1 - February 2019

Articles 12 and 14 represent the best
examples. The text of these articles requires appropriate measures by States
Parties to guarantee persons with disabilities the support they may require in
exercising their legal capacity. However,in the interpretation provided by theCommittee, these articles would preclude all non-consensual treatment andsubstitute decision making on behalf ofpersons with mental disorders.
Szmukler focuses on three concepts
likely to underlie misinterpretations ofseveral articles of the Convention andgenerate problems in its implementation
in mental health laws: legal capacity, will
and preferences.
The position taken by the Committee
on the issue of legal capacity is a challenge for common sense. It is based on

the assumption that mental capacity andlegal capacity are independent from eachother, though both of them (in particular,
legal capacity in terms of legal agency)
involve decision making processes. As aresult, a person may lack the capability ofmaking decisions, but will be consideredable to do so from a legal point of view, inorder to avoid discrimination and denialof human rights.
This assumption entails multiple risks
for multiple entities. The recognition offull legal capacity would deprive the person with mental disorder of any right tobenefit from the acknowledgement of amental condition as a source of defense.
In the absence of decisional capacity,a person with a severe mental disorder(e.g., psychotic disorder or dementia)
may be unable to protect her/his own in-47

terests, and may be victim of exploitation
by others. Those who care for people withmental disorders know that this happens
and, unfortunately, it is not a rare event.
It is also worth reminding all of us thatseveral people are willing to take theirown life when deeply depressed. However,when recovered from depression, the same
people are very thankful to doctors whotreated them (even under a coercive treatment regimen) for being still alive.
Of course, the need to support people
in being actively involved in decisions relevant to their treatments, housing or finances is not questioned, and efforts aimed at
identifying and disseminating the best
relevant practices should be encouraged.
Indeed, the shift from a classical welfare
approach to one focusing on autonomy
and full inclusion in the society of people
with disabilities is more than welcome,as demonstrated by the ratification of theConvention by so many States Parties.
However, a rigid approach, as the one
advocated by the Committee’s General
Comment No. 1 on Article 12, would notprovide any safeguard in case support
fails to enable the person’s active andinformed participation in the decisional
process, and would leave room for ex­
ploitation and extreme irreversible decisions. As highlighted in Szmukler’s paper,
rigid interpretations of the Convention
may result in a paradoxical situation inwhich both the person with mental dis­ability and her/his unofficial carers may
ex­perience more disadvantages than ad­vantages.
The reliance on will and preferences ofthe person in ensuring the exercise of le­gal capacity suggests a lack of clinicalexpertise and input in the writing of theConvention. In several neurological, psychiatric and internal medicine condi­tions,such as those involving quantitative andqualitative alterations of consciousness,the possibility to assess the person’s will
and preferences “coherent with a sense of
personal identity”1 is very limited. During
a manic episode, for instance, a person
may prefer to behave in ways that, outsidethat episode, would make her/him deeply ashamed, or concerned, or even guilty.
When recovered, the person might ask
those around her/him why no one did
anything to prevent her/him from causing so many troubles. When acutely delusional, a person might wish to donate
all her/his goods to someone else, andlater on, when no more delusional, feeldesperate for having ruined her/himself
and the whole family. Conflicts between
different wills in different moments, andeven among different rights, are clearlypresent here: in these cases, should, as
noted by Szmukler, the right to enjoy
freedom from exploitation override theright to act according to one’s own current preferences?
In spite of the drawbacks underlinedby Szmukler, advance directives might
be an important resource. However, anin-depth discussion among all stakeholders is needed in order to identify thebest relevant procedures and validatethem in different cultural contexts.
In the light of the potentially harmful
consequences of rigid interpretations, it is
not surprising that several States Parties,
while ratifying the UN Convention, expressed reservations on some of its articles (in particular on Articles 12, 14 and19) and did not sign the Optional Protocol.
It is also not surprising that, as highlighted
by Szmukler, other UN bodies do not support the interpretations provided by the
CPRD Committee4. The issue of mental
disabilities is very complex, and requires
high ethical standards, appropriate training, as well as mental health care services

with adequate structural and human re­sources.
In spite of the critical aspects highlight­
ed in Szmukler’s paper, the Conven­tion has
fueled a lively debate on inappropriately
neglected hot topics which, at odds withthe tendency to shortcuts and oversimplifications characteristic of the CPRD
Committee and Special Rapporteur’s report, seem to require accurate testing ofdifferent models and a neutral evaluationof their outcomes.
For the time being, a general agreement could and should be reached on thefollowing aspects: a) the determination ofincapacity should never be based upon
diagnosis alone, as no mental disorder
impairs the capability of making decisions by definition; b) in each State Party,
procedures for advance directives should
be identified and included in mental
health laws after adequate validation;c) a careful documentation of attempts
made to establish a therapeutic allianceand to support the patient in the processof making decisions relevant to her/his
treatment, housing, finances, etc., should
be provided in patients’ clinical records.
Silvana Galderisi
Department of Psychiatry, University of Campania L.
Vanvitelli, Naples, Italy
1.
2.

3.
4.

Szmukler G. World Psychiatry 2019;18:34-41.
United Nations. Treaty Series 2515:3. https://treaties.un.org/Pages/ViewDetails.aspx?src=
TREATY&mtdsg_no=IV-15&chapter=4&lang=_
en&clang=_en.
Committee on the Rights of Persons with Disabili­ties. General Comment No. 1 on Article 12: Equal
recognition before the law. CRPD/C/GC/1. 2014.
United Nations High Commissioner for Human
Rights. Mental health and human rights. Reportof the United Nations High Commissioner for
Human Rights. A/HRC/34/32. 2017.

DOI:10.1002/wps.20603

Will and preferences in the overall CRPD project
G. Szmukler’s paper1 needs to be understood in the context of the Convention
on the Rights of Persons with Disabilities(CRPD) as a whole, and what the CRPD
endeavors to achieve.

48

The motivation for the CRPD was an
acknowledgement that existing legal andpolicy approaches, both at the international and the national levels, were notdelivering human rights for people withdisabilities2. As that relates to people withmental disabilities, that is unlikely to becontested by the readers of this jour­nal.
We are all aware of institutional systems
in which people with mental disabil­

World Psychiatry 18:1 - February 2019

ities may spend most of their lives in
conditions that are frankly deplorable.
Countries of the global North sometimes
portray themselves as somehow above
this, but a perusal of the reports of theEuropean Committee for the Preventionof Torture suggests that none of us has
much to crow about3.
Life in the community is often notmuch better. Poverty is endemic, no doubt
in part reflecting the risible employment
rates of people with mental disabilities.
Community housing is often substan­
dard. There is little evidence of meaningfulsocial integration, but certainly evidenceof being the victims of violence, exploitation and abuse4. These problems areinternational: we all have to own them as
they relate to our own countries, wherever we are.
In that sense, the CRPD is an attempt
to hit the reset button. It tries to create afresh start in international human rights
law, envisaging a world where people
with disabilities do get to enjoy the rights
and the meaningful lives that the rest of
us take for granted2. When commentators
speak of the CRPD introducing a “newparadigm”, that is what is meant: it is an
acknowledgement that the way we haveapproached human rights of people withdisabilities since the Second World War(and perhaps for centuries before) needs
a fundamental rethink.
Fundamental to that is a challenge torethink the role of the state, and its relationship to people with disabilities.
Traditionally, the role of the state has
been one of control. Mental disabilities
provide a particularly clear example ofthis: we have locked up people with mental disabilities because of perceived dangerousness, or “for their own good” , orto remove them from the public gaze, or
to allow their family carers to work. When
we have established community programmes for them, social workers andsimilar professionals have been expect­
ed to keep a close eye on their lives. Usu­
ally this has been done with good intentions; but it has created a second class­cit­izenship, where rights are contingent
in a way not experienced by the rest ofsociety.

World Psychiatry 18:1 - February 2019

The CRPD is not anti-state or libertarian. Instead, it re-casts the state, not as amanager of people with disabilities, but
in a support role. If people with disabilities are to enjoy the meaningful lives therest of us expect, supports have to be put
in place to bring this about, and that requires either service provision by states,or services provided under state regulation. The services do need to be what people with disabilities want, however: thesepeople should not be required as a matterof state policy to take what is on offer, any
more than any other citizen should. The
CRPD envisages a world where people
with disabilities get to make the same
choices as the rest of us.
Szmukler is correct that a number ofinternational human rights bodies havebeen slow to pick this up, but that is appropriately a criticism of those bodies. It
is difficult to see how the existing humanrights systems that those bodies perpetuate can provide the legal, cultural, policy
and ideological shifts that are required tomake human rights real for people withdisabilities. The failure of these existing systems for people with disabilities
was, after all, the reason why the CRPD
was perceived as needed, and the international human rights bodies noted by
Szmukler need to own that truth.
That is not necessarily to say that theposition of the CRPD Committee is to betaken uncritically or as unassailable. It is
to say that the problems the CRPD is intended to address are real, and critics of
the CRPD position should be challenged
to provide positive alternatives, rather
than to trot out the approaches of thepast that have proven insufficient.
What does all this mean for Szmukler’s
analysis? Three points are of particular
relevance.
The first is that in Szmukler’s analysis,
as elsewhere in the literature, the debates
about capacity, supported vs. best in­ter­ests decision-making, and the CRPD
Com­mittee’s General Comment No. 15
take place in isolation from the bigger pic­­tures of what needs to change for people
with disabilities. Unsurprisingly, physicians view these issues through the lensof medicine and the effects on their prac-

tice. Almost certainly, this will only be asmall piece of what is required.
Further, decision-making is only relevant if there are options to choose between. The changes needed to realize the
CRPD ambition will no doubt include
provision of the best available standardsof health, but provisions for example concerning the structures of social care andbenefits, housing, and community integration will also be pivotal. We should
all be working with people with disabilities to articulate those broader changes
in ways relevant to our own countries.
The discussion of how decisions should
be taken in “hard cases” needs to occur
in that broader set of contexts, not justwithin clinical treatment.
The second issue is how far Szmukler’s
analysis actually diverges from the CRPD
Committee’s approach in General Com­
ment No. 1. He does seem to suggest thatthe influence of the will and preferencesof a person with disability in determining
a decision should be directly proportional to the clarity and reliability of those will
and preferences. That already seems to
be moving a considerable distance fromthe hard capacity/incapacity divide ofcurrent law.
Szmukler might well be agreeable toproper support being offered to the person with disability in reaching and articulating views. While he does not use
the phrase, his view would appear to bethat, in hard cases, decisions should betaken based on the “best approximation”
of the person’s will and preferences – the
CRPD Committee’s approach. There isadmittedly some divergence on what
constitute hard cases, but the similarity of Szmukler’s position to that of theCommittee is notable. Certainly, versionsof Szmukler’s approach could mean a con­siderable move from the managerial ethosof the current system – and that is verymuch consistent with the CRPD.
Finally, there is the question of who
should support the person with disability in articulating his/her will and preferences, and deciding what weight should
be given to divergent views expressed by
the person. Psychiatrists, like many othercare professionals, have for generations

49

been at the centre of the culture that people with disabilities are to be managed by
the state – the old paradigm. If a will andpreferences approach is to be provided
by psychiatrists in a non-managerial way,
and if psychiatrists are to have the trust ofpeople with disabilities in providing the
support in articulating will and preferences, psychiatry will have to break fromthe old, controlling paradigm. It is notclear whether psychiatry as a profession
is ready to make that break.
Peter Bartlett
School of Law and Institute of Mental Health, Universityof Nottingham, Nottingham, UK
1.
2.

Szmukler G. World Psychiatry 2019;18:34-41.
MacKay D, Syracuse J. Int’l L & Com 2006-7;
34:323-31.

3.
4.
5.

European Committee for the Prevention of Tor­
ture. https://www.coe.int/en/web/cpt/states.
Bartlett P, Schulze M. Int J Law Psychiatry 2017;
53:2-14.
Committee on the Rights of Persons with Dis­abili­ties. General Comment No. 1 on Article 12: Equal
recognition before the law. CRPD/C/GC/1. 2014.

DOI:10.1002/wps.20604

The rejection of capacity assessments in favor of respect for will
and preferences: the radical promise of the UN Convention on the
Rights of Persons with Disabilities
G. Szmukler1 argues for an interpretation of “will and preferences” that allows
for determinations of decision-making
abi­lity, in the form of functional assessments of mental capacity, to be used to interpret the decisions of those who ap­pear
to display conflicting will and pref­erences.
In this commentary, I will focus on
three core issues which arise from Szmuk­
ler’s approach: the issue of indirect discrimination in functional assessments ofmental capacity, the dilemma of advancedecisions, and the need for a humanrights compliant response in a situation
where the individual’s preference(s) appears to conflict with his/her will.
Concerning the first issue, Szmukler
argues that the application of functional
assessments of decision-making ability
should not be regarded as unlawful discrimination, because these serve a legitimate aim, the assessments are objective
in nature, and meet the criteria of reasonableness and proportionality in pursuit of
their legitimate aim.
Even if the notion of a legitimate aim– protecting the totality of the person’s
human rights – is accepted, it is far lesscertain whether functional assessmentsof capacity can be considered objective
in nature, or a reasonable and proportionate response to resolving a perceived
conflict of rights. Szmukler cites Grisso
and Appelbaum’s review of measuresused to assess competence2 in support of
the argument for objectivity, but this is by
no means an uncontested position in theliterature.

50

For example, Morgan and Veitch3 criticize the purported objectivity of mental
capacity assessments. They argue that“the real point of legal tests for mental
capacity seems not to be to assess someprojected future or, indeed, past ability
to make a choice… but to assess whether
the person making that decision canconstruct a convincing case why he or
she reaches the standard of the ‘ability’that law expects in such circumstances”.
In support of this argument, Haidt4
and Iyengar and Lepper 5 showed that
individuals only conjure up reasons fortheir decisions when called upon to doso, and these reasons rarely correlate with
their actual decision-making process at
the time of the original decision, but rath­er reflect the most persuasive explana­tion the person can find for his/her decision.
These studies suggest that the processof assessing an individual’s mental capacity, even on a functional basis, is an
inherently subjective and value-laden
one. Therefore, the use of such assessments to restrict or deny legal capacity
violates the requirement of objectivity demanded by human rights norms in order
to avoid the categorization of disabilitybased discrimination.
It is also clear that the use of functional
assessments of mental capacity to reconcile perceived conflicts of rights, will andpreferences does not meet the criteria of
reasonableness and proportionality. With
increasing evidence of the effectivenessof alternatives to substitute decision-

making6, a reliance on mental capacity
assessments as a trigger for (potentially
coercive) interventions seems less andless reasonable. As long as alternative,
less intrusive measures exist which could
be used to reconcile perceived conflicting will and preferences, it cannot be
proportionate to impose substitute decision-making based on an external decision-maker’s functional assessment of
an individual’s mental capacity to make aparticular decision.
The second issue I wish to address relates to advance directives. Such directives – which are listed in the Committee
on the Rights of Persons with Disabilities’
General Comment No. 17 as an important example of support to exercise legal
capacity – can easily be reframed awayfrom the capacity/incapacity paradigm,
to give the directive-maker much greater
flexibility to determine when the directive becomes operational. In other words,
the perceived absence of functional mental capacity should not be the automatic
legal trigger for a directive entering into
force. Instead, the directive-maker should
specify the circumstances in which he/she wishes his/her directive to take effect.
A directive-maker could, for example,
specify that the directive should be activated once he/she starts exhibiting certain
behaviors, or when he/she is admitted tohospital, or when a number of trusted
supporters named in the directive all
agree that he/she is now in crisis or unable to communicate. This ensures that thepower remains with the d­ irective-makerWorld Psychiatry 18:1 - February 2019to set the conditions under which the directive will take legal effect.
As for the thorny question of Ulysses
clauses, in my view it should be possible for individuals to include these indirectives if they so choose. In practice,
I anticipate that the use of such clauses
would be very rare, as most people will
not want to bind their future selves toa situation that they would not then beable to reverse. But, as this is an important support option which some individuals wish to have, it should be available
to persons with disabilities on an equalbasis with others.
The final issue I wish to address is how
a human rights compliant response canbe developed where we perceive an individual’s will and preferences to be in conflict and incapable of reconciliation. As I
have previously argued8, where will andpreferences conflict, a number of strategies can be employed. First of all, what
an outsider might perceive as a conflict
between will and preferences may not
be perceived by the individual decisionmaker as problematic – it might reflect achange of approach from past decisions
based on experience, a new perspective,
or simply the fact that the person haschanged his/her mind.
A human rights compliant approachto resolving these perceived conflicts involves engaging in all forms of commu-

nication with the person, and speaking
with those the person indicates are trust­ed supporters to inform the interpretation of his/her will and preferences inthis specific situation. It may happen
during this process that the will and preferences of the person become clear. If
the will and preferences of the person
remain unclear following all efforts, anda decision still needs to be made, theinterpreter will have to make a decision
informed by the “best interpretation” ofthe person’s will and preferences he/she
arrives at, given all the information available about the person’s wishes.
Others have suggested that a “best interpretation” means “the interpretation ofan adult’s behaviour and/or communication that seems most reasonably justified
in the circumstances”, and that “decisionmaking supporters must be able to provide a reasonable account of how this interpretation was arrived at”9.
The process of arriving at a “best interpretation” of will and preferences isinevitably challenging and fraught withuncertainty, but, if the new paradigm heralded by the Convention on the Rights
of Persons with Disability (CRPD) is tomean anything, it must be understoodthat this process is radically different
from how determinations of decisionmak­ing ability have been undertaken in
the past.

Therefore, contrary to what Szmukler
proposes, it is my contention – in keeping with the jurisprudence of the CRPD
Committee – that functional assessmentsof mental capacity cannot be used to determine whether a particular preference
should take precedence over what others perceive to be the individual’s will, or
whether third parties’ interpretation of aperson’s will can justify ignoring the individual’s clearly expressed preference.
Eilionóir Flynn
Centre for Disability Law and Policy, National Universityof Ireland Galway, Galway, Ireland
1.
2.

3.
4.
5.
6.
7.
8.
9.

Szmukler G. World Psychiatry 2019;18:34-41.
Grisso T, Appelbaum PS. Assessing competence
to consent to treatment: a guide for physiciansand other health professionals. New York:
Oxford University Press, 1998.
Morgan D, Veitch K. Sydney Law Rev 2004;26:
107-30.
Haidt J. Psychol Rev 2001;108:814-34.
Iyengar SS, Lepper MR. J Pers Soc Psychol 2000;
79:995-1006.
Davidson G, Brophy L, Campbell J et al. Int J
Law Psychiatry 2012;44:30-40.
Committee on the Rights of Persons with Disabili­ties. General Comment No. 1 on Article 12: Equal
recognition before the law. CRPD/C/GC/1. 2014.
Arstein-Kerslake A, Flynn E. Int J Human Rights
2016;20:471-90.
Canadian Association of Community Living. A
statutory framework for the right to legal capacity and supported decision making. Oshawa:
Canadian Association of Community Living,2012.

DOI:10.1002/wps.20605

The UN Convention: a service user perspective
The United Nations (UN) Convention
on the Rights of Persons with Disabilities(CRPD)1 has sparked quite a global debate
around Articles 12 (Equal recognition before the law) and 14 (Liberty and securityof the person), and their relation to involuntary hospitalization and treatment.
In light of this controversy, the South
African Federation for Mental Health(SAFMH) has conducted an engagement
exercise with mental health care users
who had experienced involuntary hospitalization. Seventy-one percent of participants indicated that they were in favor of
involuntary treatment, and specified that
their preference was due to acknowledg-

World Psychiatry 18:1 - February 2019

ing that there had been intervals during a
relapse where they were unable to act intheir own best interest.
The participants felt that the practice of
involuntary treatment “protected” themfrom their own behaviour at a time of relapse where they may not have control
over their actions, and which may consequently result in personal harm or harm
to others (harm not specifically defined asphysical harm but including psychological harm).
Participants, however, emphasized thatthey had more often not been involved indecision-making when it came to treatment options. They noted that their expe-

riences with involuntary hospitalization
had happened without consultation, andthat they became aware of what was going on only when the ambulance and/or
police arrived. They further noted that involuntary hospitalization would in most
instances not have been necessary should
they have been consulted and would haveagreed to voluntarily go to hospital fortreat­­ment.
Paternalism has a long history in psychiatry2, sometimes with the best of intentions, but it is a disempowering component of the mental health care system,
where others instinctively tend to takeon a decision-making role. Paternalism51­ enies the opportunity to make an ind
formed decision through a consultative
process (or through a supported decisionmaking process when necessary) to allow for the will and preferences of mental
health care users to be acknowledged, respected and executed.
Assumptions are often made instinctively as to the decision-making capacityof a mental health care user, without any
determination on whether the person isin fact unable/able to make an informed
decision or needs support to make a decision. Moreover, paternalistic decisionmaking may reinforce self-stigma andlead to poorer health outcomes3.
Mental health care systems need totake bold steps and strategically redesign
the way in which services are provided, toensure alignment with international hu­
man rights standards and evidence-ba­sedinterventions, with an emphasis on em­
powerment, recovery and mental healthcare user involvement in the evaluation of
the system. An example of a mental healthcare system that achieved considerable
transformation is the “Open Door – No Re­
straint” system in Italy4, focusing on re­­covery and citizenship, where mental
health care users are at the centre of service delivery.
Apart from reverting away from abruptly dismissing the will and preferences ofservice users when it comes to treatment
options, the change should pay serious­attention to the environment in which
services are delivered. Psychiatric facili­ties often look and function more like prisons than places of care and recovery. The
dilapidated state of such facilities impacts
on bioethical principles that should promote respect for autonomy, non-maleficence, beneficence, and justice.
Psychiatric facilities and mental healthservices have been noted as environ­ments
in which human rights violations are most
likely to take place5, and where service­users’ voices are often silenced. It is, there­
fore, a logical expectation that a person
will refuse admission to such psychiatricfacilities if the environment which should
help and care for him/her exposes him/
her to degrading and undignified treatment, adding to the psychological dis­52

tress that he/she may experience at thetime.
In South Africa, persons refusing hos­pital treatment may be resistant not be­cause of diminished legal or mental capacity (however perceived), but becauseof the knowledge of what happens in
those facilities.
In the engagement exercise conductedby SAFMH, the word “dignity” came up
several times where participants explained
how the mental health care system had
violated their rights. Words describing
their experiences included “devastated” ,“frightened” , “confused” , “undignified” ,“violated”, “criminalized”, “treated as lessthan human”, “Nazi concentration camp”,“tied down like a dog”.
My own experience of involuntary
hospitalization was more traumatic thanthe devastating symptoms I experienced
with my diagnosed schizophrenia. I refused voluntary hospitalization basedon past experience of unconducive andabusive conditions within the hospital.
Even though my will and preference wasaimed at obtaining treatment, just not insuch an environment, yet I was considered to have diminished decision-making
capacity and to be unable to acknowledge
what was in my own best interest.
On the other hand, the CRPD Commit­
tee’s interpretation of the Convention’s
Articles 12 and 13, which would meanthat the “insanity plea” would be scrapped
as far as “unfitness to stand trial” and“not guilty by reason of insanity” are concerned, may have consequences that impact on a person with a mental disorder
who enters the justice system. A casestudy in South Africa that I have dealt
with in my advocacy work gives insight
into this.
A person with a diagnosis of schizophrenia who in a psychotic state caused
damage to property, in response to voicesthat instructed him to do so, was arrested
and stood trial without his diagnosis at
any point being introduced as a defense.
Consequently, he was found guilty andserved a prison sentence. Upon release,he failed to obtain employment merely
because of his criminal record. In the alternative scenario where he could havebeen found “not guilty by reason of insanity”, he would not have had a criminal record that now prevents him fromobtaining employment and ultimately
independence. The question is: was it afair trial if the circumstances surrounding
his actions on the day of the damage toproperty were not considered?
Prison systems may often not be equip­
ped or sufficiently resourced to care forand protect people with mental disorders
from victimization and abuse, or may not
be able to provide an adequate standardof mental health care and services to thispopulation. Even in a more resourced
country like the US, prisoners with mental disorders are “more likely than otherprisoners to be held in solitary confinement, be financially exploited, physicallyand sexually assaulted, commit suicide,or be intentionally self-destructive”6.
Any person, whether he/she has a men­tal disorder, a disability or not, may atsome point be unable to make an informed
decision (for whatever reason) and, where
will and preference are in contradiction,
there must be a mechanism that protects
the individual.
To avoid stigmatization and discrimination, I support Szmukler’s suggestion7of a law that is solely based on decisionmaking ability, with a clear definition ofwill and preference, human rights andbest interest processes to be consideredon an individual case basis, opposed to alaw that is specifically aimed at persons
with mental disorders.
Charlene Sunkel
South African Federation for Mental Health, Global Men­tal Health Peer Network, Randburg West, South Africa
1.
2.
3.
4.
5.
6.
7.

United Nations. Convention on the rights of persons with disabilities. New York: United Nations,
2006.
Pelto-Piri V, Engström K, Engström I. BMC Med
Ethics 2013;14:49.
Hamann J, Buhner M, Rusch N. Psychiatr Serv
2017;68:783-8.
Mezzina R. J Nerv Ment Dis 2014;202:440-5.
Drew N, Funk M, Tang S et al. Lancet 2011;378:
1664-75.
Pittaro M. The challenges of incarcerating mentally ill inmates. In Public Safety, December 7,
2015.
Szmukler G. World Psychiatry 2019;18:34-41.

DOI:10.1002/wps.20606

World Psychiatry 18:1 - February 2019

RESEARCH REPORTThe impact of pharmacological and non-pharmacologicalinterventions to improve physical health outcomes in people withschizophrenia: a meta-review of meta-analyses of randomized
controlled trials
Davy Vancampfort1,2, Joseph Firth3-5, Christoph U. Correll6-8, Marco Solmi9, Dan Siskind10,11, Marc De Hert2,12, Rebekah Carney4,
Ai Koyanagi13,14, André F. Carvalho15,16, Fiona Gaughran17,18, Brendon Stubbs17,18
1

KU Leuven Department of Rehabilitation Sciences, Leuven, Belgium; 2University Psychiatric Centre KU Leuven, Kortenberg, Belgium; 3NICM Health Research Institute,Western Sydney University, Westmead, Australia; 4Division of Psychology and Mental Health, University of Manchester, Manchester, UK; 5Centre for Youth Mental Health,
University of Melbourne, Melbourne, Australia; 6Hofstra Northwell School of Medicine Hempstead, New York, NY, USA; 7Department of Psychiatry, Zucker Hillside Hospital,
New York, NY, USA; 8Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany; 9Department of Neurosciences, University of Padua,
Padua, Italy; 10Metro South Addiction and Mental Health Service, Brisbane, Australia; 11School of Medicine, University of Queensland, Brisbane, Australia; 12KU Leuven Department of Neurosciences, Leuven, Belgium; 13Research and Development Unit, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu, Barcelona,
Spain; 14Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain; 15Centre for Addiction and Mental Health,Toronto, Ontario, Canada; 16Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; 17South London and Maudsley NHS Foundation Trust, London, UK;
18
Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK

We summarized and compared meta-analyses of pharmacological and non-pharmacological interventions targeting physical health outcomesamong people with schizophrenia spectrum disorders. Major databases were searched until June 1, 2018. Of 3,709 search engine hits, 27 metaanalyses were included, representing 128 meta-analyzed trials and 47,231 study participants. While meta-analyses were generally of adequate
or high quality, meta-analyzed studies were less so. The most effective weight reduction interventions were individual lifestyle counseling (stan­
dardized mean difference, SMD=–0.98) and exercise interventions (SMD=–0.96), followed by psychoeducation (SMD=–0.77), aripiprazole
augmentation (SMD=–0.73), topiramate (SMD=–0.72), d-fenfluramine (SMD=–0.54) and metformin (SMD=–0.53). Regarding waist circumference reduction, aripiprazole augmentation (SMD=–1.10) and topiramate (SMD=–0.69) demonstrated the best evidence, followed by dietaryinterventions (SMD=–0.39). Dietary interventions were the only to significantly improve (diastolic) blood pressure (SMD=–0.39). Switchingfrom olanzapine to quetiapine or aripiprazole (SMD=–0.71) and metformin (SMD=–0.65) demonstrated best efficacy for reducing glucose
levels, followed by glucagon-like peptide-1 receptor agonists (SMD=–0.39), dietary interventions (SMD=–0.37) and aripiprazole augmentation (SMD=–0.34), whereas insulin resistance improved the most with metformin (SMD=–0.75) and rosiglitazone (SMD=–0.44). Topiramate
had the greatest efficacy for triglycerides (SMD=–0.68) and low-density lipoprotein (LDL)-cholesterol (SMD=–0.80), whereas metformin had
the greatest beneficial effects on total cholesterol (SMD=–0.51) and high-density lipoprotein (HDL)-cholesterol (SMD=0.45). Lifestyle interventions yielded small effects for triglycerides, total cholesterol and LDL-cholesterol (SMD=–0.35 to –0.37). Only exercise interventions increased
exercise capacity (SMD=1.81). Despite frequent physical comorbidities and premature mortality mainly due to these increased physical healthrisks, the current evidence for pharmacological and non-pharmacological interventions in people with schizophrenia to prevent and treat these
conditions is still limited and more larger trials are urgently needed.
Key words: Schizophrenia, psychosis, physical health, body weight, blood pressure, glucose, insulin, tryglicerides, cholesterol, lifestyle coun­
seling, exercise interventions, dietary interventions, metformin, topiramate, antipsychotic switching(World Psychiatry 2019;18:53–66)

People with schizophrenia have substantially poorer physi­
cal health than the general population1-4, which is often attrib­
uted to an interaction between social circumstances, lifestylefactors and treatment effects5. For instance, behavioral re­search has demonstrated that people with schizophrenia areless physically active and exhibit more sedentary behavior than
the general population6, have a higher quantity but lower qual­
ity of dietary food intake7, and increased adverse health behav­
iors, such as smoking8. Additionally, psychiatric treatment with
antipsychotics and other commonly prescribed agents, suchas mood stabilizers and antidepressants, further increases therisk of physical health conditions9,10. Consequently, people
with schizophrenia more frequently have cardio-metabolic
diseases11-13, respiratory diseases14, chronic pain15, fractures16,
and lower physical fitness17,18 than the general population.
This increased somatic risk is associated with a lower physi­
cal health related quality of life19,20, but, despite this increased

World Psychiatry 18:1 - February 2019

risk, access to monitoring, physical health care and interven­tion for those with schizophrenia are suboptimal comparedto the general population21,22. Resultantly, people with schizo­
phrenia experience a 10-20 year gap in life expectancy, primar­
ily driven by this poorer physical health13,23. Furthermore, thephysical health inequalities experienced by people with schizo­
phrenia have been observed across the globe24 and have not
improved over time25.
Given this gross inequality, there has been a substantial
increase in efforts to improve the physical health of this atrisk population5,26. To address the physical health disparity, anumber of individual meta-analyses have led to national andinternational evidence-based recommendations for or against
specific pharmacological and non-pharmacological interven­tion options27-34.
Despite this rapid expansion of meta-analytic evidence oninterventions for tackling poor physical health in people with53

schizophrenia, no summary of this top-tier of evidence exists,
nor is there a direct quantitative comparison of the evidence
between all individual and/or combined pharmacological andnon-pharmacological strategies. Moreover, the quality of thesemeta-analyses and the included trials has not been comprehensively evaluated, which is an indispensable step before more
rigorous treatment recommendations can confidently be made.
In order to address this gap within the literature, we set out
to aggregate the existing top-tier evidence from the most re­cent/largest published meta-analyses of randomized trials ofphysical health interventions, in order to determine the com­parative quality of evidence and magnitude of efficacy for phar­macological and non-pharmacological interventions targeting
physical health outcomes among people with schizophrenia
spectrum disorders.

METHODS
Searches
Four authors searched independent from each other MED­
LINE/PubMed, PsycINFO, EMBASE and the Cochrane data­bases, from their respective inception dates until June 1, 2018,
without language restriction, for meta-analyses of randomized
controlled trials in people with schizophrenia spectrum dis­orders where physical health improvements were the primary
outcome.
The search terms included (“meta-analysis” OR “system­
atic review”) AND (“random*” OR “placebo” OR “control*”)AND (“schizophrenia” OR “schizoaffective” OR “schizophreni­form” OR “psychosis” OR “psychotic” OR “severe mental ill­ness”) AND (“physical health” OR “cardio*” OR “metabol*” OR“respir*” OR “*weight” OR “pain” OR “somatic”). We searched
the reference lists of all included articles.

Table 1 Application of the PICOS search strategy
Population – People with schizophrenia spectrum disorders, including
schizophrenia, schizoaffective or schizophreniform disorder or first
episode psychosis, confirmed through validated assessment measures (e.g.,
DSM, ICD). Studies conducted with a severe mental illness subgroup(e.g., also including bipolar disorder or major depressive disorder) were
only included if the schizophrenia spectrum disorder sample was ≥70%.
Interventions – We included all pharmacological interventions that had a
primary aim to improve physical health outcomes. Non-pharmacologicalinterventions included all educational, psychotherapeutic, social andphysical interventions, excluding alternative therapies. Specifically, we
included lifestyle interventions (e.g., physical activity, diet, smoking
cessation).
Comparisons – All relevant control interventions were included (e.g.,placebo, treatment as usual/usual care, waiting list, no treatment).
Outcomes – We considered any physical health outcomes explored,
including the following: a) any physical health markers, such as bodyweight, proportion with overweight or obesity, random or fasting levels of
glucose and lipid metabolism parameters, proportion with abnormalities
in glucose and lipid metabolism parameters, cardiovascular illness (e.g.,
myocardial infarction, stroke, transient ischemic attack, pulmonary
embolism), respiratory illness (lung cancer, chronic obstructive pulmonary
disease); b) parameters of physical fitness (e.g., maximal or peak oxygen
uptake, muscle strength); c) any biomarkers investigated (hemoglobin
A1c, C-reactive protein or other blood and serum markers); d) any
physical health behavior researched (physical activity levels, smoking
behavior, diet patterns, attending physical health appointment, attendance
rates); e) physical health related quality of life; f) side effects (e.g., adverse
drug reactions).
Setting – We considered any setting: hospital (inpatient or outpatient),
community, or remote (e.g., using digital technology).
Study design – Meta-analyses informed by a systematic review that included
randomized controlled trials (RCTs) were included. A paper wasclassified as a systematic review and meta-analysis if the following criteria
were met: clear inclusion criteria, a systematic search strategy, a screening
procedure to identify relevant studies, systematic data extraction andmeta-analysis procedures for RCTs. Meta-analyses meeting the inclusion
criteria were removed if there was a more recently updated meta-analysis
for that same combination strategy and outcome as long as more than
75% of the meta-analyzed trials overlapped and the pooled sample waslarger for that specific intervention and outcome. Conference abstracts
were excluded.

Inclusion criteria
Inclusion criteria were organized in accordance with the population, interventions, comparisons, outcomes and setting/study design (PICOS) reporting structure (see Table 1).

Data extraction, outcomes, and data synthesis
Regarding efficacy and adverse drug reactions, we manually
extracted effect size data (with 95% confidence intervals, CI) for
all relevant outcomes, and the number of participants in theintervention and control arms for each effect size. Specifically,
data for effect sizes of continuous outcomes were extracted orrecalculated as standardized mean difference (SMD), which
expresses the mean difference between the intervention andcontrol groups in standard deviation units, with 95% CI. Gen­erally, an SMD less than 0.2 is considered negligible, an SMD

54

between 0.2 and less than 0.5 is small, an SMD between 0.5 andless than 0.8 is medium, and an SMD of at least 0.8 is large35.
Risk ratios (RRs) were used for categorical outcomes. If odds ra­tios were present, they were recalculated as RRs. For both typesof outcomes, we followed the decisions of the original authors
concerning fixed vs. random effects models.

Quality assessment of the meta-analyzed studies
Included meta-analyses were assessed using “A Measure­ment Tool to Assess Systematic Reviews” (AMSTAR) (range
0-11, with a score of 8 or higher indicating high quality)36.
While AMSTAR is a reliable and valid tool for measuring themethodological quality of meta-analyses, its score does not
capture quality indicators of the meta-analyzed trials, which

World Psychiatry 18:1 - February 2019

could bias pooled results. For instance, a meta-analysis thatmeets all methodological quality criteria, but that meta-analyz­
es potentially biased studies would have a good methodologi­
cal quality but poor content quality.
Thus, for a more comprehensive assessment of the content
validity of included meta-analyses, we used a set of six addition­al, previously developed quality items, each ranging between 0
and 1 or 2, that capture the content quality of the meta-analyzed
trials (AMSTAR-Plus Content, range 0-8, with a score of 4 orhigher indicating high quality)37.

Statistical analysis
We analyzed data as they were directly extracted from the
pub­lished meta-analyses or, if necessary, after they were con­verted to standardized outcomes using comprehensive metaanalysis (CMA, version 3) (Biostat). To compare the SMDs of theexperimental pharmacological and non-pharmacological inter­
ventions vs. the control interventions, we conducted separate
random-effects meta-analyses for each variable using CMA.
The AMSTAR and AMSTAR-Plus Content scores and sample
size were used where possible in meta-regression analyses,
which were done separately for pharmacological and nonpharmacological strategies. Where possible, we also performed
meta-regression and subgroup analyses to examine putative
factors which may influence effect sizes for each individual
physical health outcome, including participant characteristics(e.g., average age, gender distribution) and interventional de­sign (treatment duration in weeks, delivered by mental healthvs. physical health staff, clinical setting, percent of sessions at­tended/adherence, group vs. individual treatment).
Heterogeneity was quantified using the Q and I2 statistic,
with scores of <25%, 25-50% and >50% indicating low, moder­ate and high heterogeneity, respectively38. If it was not possible
to extract effect size data for the comparative meta-analysis, wereported individual review level results in a narrative synthesis.

RESULTS
Systematic search results
Of 3,709 search engine hits, 27 meta-analyses were includ­ed39-65, representing a total of 128 meta-analyzed trials and47,231 study participants.
There were meta-analytic data for 17 different pharma­cological interventions: aripiprazole augmentation43,47,53,55,
fluoxetine55, metformin46,48,49,54,55,61,62, nizatidine54,55, NMDA
receptor antagonists including amantadine and memantine
45,55,57,60, ranitidine42, topiramate39, dextroamphetamine64,
d-fenfluramine64, famotidine64, metformin in combination
with sibutramine64, orlistat64, rosiglitazone64, fluvoxamine64,
glucagon-like peptide-1 receptor agonists (GLP-1 RAs)40, andswitching from olanzapine to quetiapine or aripiprazole65.

World Psychiatry 18:1 - February 2019

Meta-analytic data were available for six different non-phar­macological interventions: individual lifestyle counseling58,59,63,
group lifestyle counseling58,59,63, cognitive behavioral thera­
py58,59, psychoeducation58, exercise50,56,58, and dietary interven­tions44,58. One meta-analysis investigated the pooled effect of a
combined lifestyle and metformin intervention41.
In total, 17 different physical health outcomes were investi­
gated: weight, body mass index, waist circumference, waist to
hip ratio, diastolic and systolic blood pressure, fasting glucose,
insulin, homeostatic model assessment of insulin resistance,
hemoglobin A1c, fasting triglycerides, total cholesterol, highdensity lipoprotein (HDL)-cholesterol, low-density lipoprotein(LDL)-cholesterol, android/gynoid ratio (i.e., percent fat ratio
defined as android fat divided by gynoid fat), visceral fat, andfunctional exercise capacity.
The control interventions included placebo, continued psy­
chotropic treatment, or care as usual for pharmacological trials,
and care as usual for non-pharmacological trials.
The number of trials for a specific health outcome ranged
from one to 29, with a median of five trials (interquartile range =5). Trials lasted six to 72 weeks. When reported, the mean age ofparticipants was 34.9±2.0 years, and 58.4% were men.

Quality assessment of the included meta-analyses
The AMSTAR mean score was 8.8±1.0 in the whole sample,
8.9±0.9 in the pharmacological interventions, and 8.7±1.0 in the
non-pharmacological interventions. Twenty-four (89%) metaanalyzed studies had an AMSTAR score of 8 or higher, but only
two42,65 (4%) had the maximum AMSTAR score of 11. The AM­
STAR-Plus Content mean score was 3.4±1.5 in the whole sample,
3.2±1.6 in the pharmacological interventions, and 3.7±1.1 in the
non-pharmacological interventions. None had the maximum
score of 8.
Only eleven meta-analyses (41%) were rated as high-quality
based on the meta-analyzed studies. Seven of the 27 metaanalyses included only double-blind trials (26%). In 16 metaanalyses (59%), the total pooled sample was less than 500
cases, while only five meta-analyses (18%) had a total sample
of more than 1,000 participants. Only two meta-analyses49,53(7%) had one included trial with at least 200 participants.
­Finally, following the AMSTAR-Plus Content criteria, a signifi­
cant heterogeneity was found for 12 meta-analyses (44%), and18 (67%) could not disprove the presence of a publication bias.
Further, we examined the relationship between the effectsize for both the non-pharmacological and pharmacologicalinterventions versus the control conditions with the quality
assessment measures (AMSTAR and AMSTAR-Plus Content).
The SMDs for pharmacological and non-pharmacological­interventions did not correlate significantly with the meth­odological quality of the meta-analysis as measured by AM­
STAR (p=0.37 to 0.52) nor with the content quality of the metaanalysis as measured by AMSTAR-Plus Content (p=0.17 to0.97).

55

Table 2 Anthropometric physical health outcomes of pharmacological and non-pharmacological interventions in people with schizophrenia
Outcomes

Intervention

SMD

95% CI

N. trials

N. participants

AMSTARAMSTAR
Plus Content

Effect size

Individual lifestylecounseling–0.98***–1.15 to –0.81

14

411

8.3

3.7

Large

Exercise­interventions–0.96***–1.27 to –0.66

4

183

8.0

2.5

Large

Psychoeducation–0.77***–0.98 to –0.55

8

345

8.0

3.0

MediumAripiprazole­augmentation–0.73***–0.97 to –0.48

9

813

8.3

3.0

MediumTopiramate–0.72***–1.56 to –0.33

15

783

10.0

3.0

Mediumd-Fenfluramine–0.54***–1.07 to –0.02

1

16

7.0

6.0

Medium

Metformin–0.53***–0.69 to –0.38

29

1,279

8.2

3.6

Medium

Dietary interventions–0.50***–0.66 to –0.34

22

1,576

8.5

3.5

MediumNMDA receptor
antagonists–0.47***–0.62 to –0.32

5

309

8.0

4.5

Small

Metformin + lifestyleintervention–0.44***–0.69 to –0.19

3

122

9.0

1.0

Small

GLP-1 RAs

–0.44***–0.60 to –0.28

3

168

9.0

1.0

Small

Group lifestyle­counseling–0.39***–0.54 to –0.23

19

883

8.3

3.7

Small

Amantadine–0.30*–0.57 to –0.03

3

205

8.5

3.5

Small

Cognitive behavioral
therapy–0.37*–0.55 to –0.18

11

546

8.3

3.7

Small

Nizatidine–0.12*–0.24 to 0.00

4

357

8.0

3.0

Negligible

Ranitidine–0.24–0.67 to 0.20

4

260

11.0

1.0

Non-significant

Metformin +sibutramine–0.24–0.62 to 0.13

1

28

7.0

6.0

Non-significant

Orlistat–0.21–0.46 to 0.04

1

63

7.0

6.0

Non-significant

Rosiglitazone

0.14–0.21 to 0.52

1

29

7.0

6.0

Non-significant

Fluoxetine

0.14–0.09 to 0.36

2

60

7.0

3.0

Non-significant

Dextroamphetamine

0.11–0.33 to 0.56

1

20

7.0

6.0

Non-significant

Switching fromolanzapine toquetiapine or
aripiprazole–0.11–0.23 to 0.03

2

287

11.0

3.0

Non-significant

Famotidine–0.02–0.48 to 0.43

1

14

7.0

6.0

Non-significant

Weight reduction<0.001

Body mass index
reduction

56

Betweengroup p<0.001Topiramate–0.56***–1.54 to –0.22

11

449

10.0

3.0

MediumIndividual lifestylecounseling–0.49***–0.77 to –0.22

4

202

8.3

3.7

Small

GLP-1 RAs

–0.41***–0.57 to –0.26

3

168

9.0

1.0

Small

Cognitive
behavioral therapy–0.34*–0.67 to –0.07

6

308

8.0

3.7

Small

Group lifestyle­counseling–0.28*–0.54 to 0.00

4

202

8.3

3.7

Small

Metformin–0.41–0.93 to 0.10

23

1,228

9.0

3.7

Non-significant

Exercise ­interventions–0.25–0.56 to 0.06

8

231

8.0

2.5

Non-significant

Ranitidine–0.23–0.44 to 0.00

5

312

11.0

1.0

Non-significant

World Psychiatry 18:1 - February 2019

Table 2 Anthropometric physical health outcomes of pharmacological and non-pharmacological interventions in people with schizophrenia(continued)
Outcomes

Intervention

SMD

95% CI

N. trials

N. participants

AMSTARAMSTAR
Plus Content

Effect size

Switching fromolanzapine toquetiapine–0.12–0.29 to 0.05

1

129

11.0

3.0

Non-significant

Waist
circumference
reduction

Betweengroup p<0.001

Aripiprazole
augmentation–1.10**–1.42 to –0.79

3

174

10.0

2.0

Large

Topiramate–0.69*

Dietaryinterventions–0.39***–0.93 to –0.45

8

310

10.0

3.0

Medium–0.56 to –0.22

11

858

8.5

3.5

Small

Lifestyleinterventions–0.37**–0.60 to –0.13

10

705

8.0

5.0

Small

GLP-1 RAs

–0.34***–0.50 to –0.18

3

167

9.0

1.0

Small

Metformin–0.01–0.68 to 0.65

12

721

9.0

6.0

Non-significant

Waist to hip ratio
reduction

0.07
Topiramate–0.69**–0.90 to 0.27

5

123

10.0

3.0

Medium

Metformin–0.32–1.15 to 0.51

3

133

8.0

5.0

Non-significant

GLP-1 RAs

0.03

–0.13 to 0.18

3

163

9.0

1.0

Non-significant

GLP-1 RAs

–0.03

–0.20 to 0.13

3

131

9.0

1.0

Non-significant

GLP-1 RAs

–0.37*–0.46 to –0.06

3

97

9.0

1.0

Small

Android/gynoid
ratio

Visceral fat
reduction*p<0.05, **p<0.01, ***p<0.001
SMD – standardized mean difference, GLP-1 RAs – glucagon-like peptide-1 receptor agonists, AMSTAR – A Measurement Tool to Assess Systematic Reviewsmean scores

Physical health outcomes of pharmacological andnon-pharmacological interventions
An overview of the different physical health outcomes of phar­macological and non-pharmacological interventions in people
with schizophrenia based on the SMDs and the quality of themeta-analyzed studies as assessed by the AMSTAR and AMSTARPlus scores is presented in Table 2 (anthropometric results) andTable 3 (blood pressure, metabolic and exercise capacity results).

Body weight
Non-pharmacological interventions
Six meta-analyses investigated non-pharmacological inter­
ventions for body weight (78 trials, N=3,944). The mean AM­
STAR score was 8.2±0.2 and the mean AMSTAR-Plus Content
was 3.3±0.4.

World Psychiatry 18:1 - February 2019

Individual lifestyle counseling was the most effective inter­
vention (SMD=–0.98, 95% CI: –1.15 to –0.81, p<0.001; 14 trials,
N=411, I2=0%, Q=0.5, i.e., large effect), followed by exercise in­terventions alone (SMD=–0.96, 95% CI: –1.27 to –0.66, p<0.001;
4 trials, N=183, I2=0, Q=0, i.e., large effect).
Psychoeducation interventions focusing on promoting ahealthy lifestyle showed a medium effect (SMD=–0.77, 95%
CI: –0.98 to –0.55, p<0.001; 8 trials, N=345, I2=0, Q=0). This was
also the case for dietary interventions alone (SMD=–0.50, 95%
CI: –0.66 to –0.34, p<0.001; 22 trials, N=1,576, I2=94%, Q=15.8).
A small effect was observed for cognitive behavioral therapy
focusing on promoting a healthy lifestyle (SMD=–0.37, 95%
CI: –0.55 to –0.18, p=0.022; 11 trials, N=546, I2=0%, Q=0.2) andgroup lifestyle counseling (SMD=–0.39, 95% CI: –0.54 to –0.23,
p<0.001; 19 trials, N=883, I2=28%, Q=2.8).
With regards to prevention of weight increase, multidiscipli­nary lifestyle/behavioral counseling showed a medium effect(SMD=–0.69, 95% CI: –0.84 to –0.54, p<0.001; 14 trials, N=694,
I2=0%, Q=1.4).

57

Table 3 Blood pressure, metabolic and exercise capacity physical health outcomes of pharmacological and non-pharmacological interventions
in people with schizophrenia
Outcomes

Intervention

SMD

95% CI

N. trials

N. participants

AMSTARAMSTAR
Plus Content

Effect size

Systolic bloodpressure
reduction

Betweengroup p
0.14

Metformin–0.24–0.53 to 0.05

3

176

9.0

4.0

Non-significant

Lifestyle interventions–0.22–0.49 to 0.05

7

615

8.0

5.0

Non-significant

GLP-1 RAs

–0.09

–0.24 to 0.06

3

160

9.0

1.0

Non-significant

Dietary interventions

0.05–0.18 to 0.28

7

655

8.5

3.5

Non-significant

Diastolic bloodpressure
reduction<0.001

Dietary interventions–0.39**–0.56 to –0.22

6

654

8.5

3.5

Small

Metformin–0.24–0.53 to 0.05

3

176

9.0

4.0

Non-significant

GLP-1 RAs

–0.12

–0.28 to 0.03

3

160

9.0

1.0

Non-significant

Lifestyle interventions–0.08–0.57 to 0.41

3

171

8.0

5.0

Non-significant

Glucose level
reduction<0.001
Switching fromolanzapine toquetiapine or
aripiprazole–0.71***–0.85 to –0.58

2

280

11.0

3.0

Medium

Metformin–0.65***–0.94 to –0.35

17

1,281

9.6

3.7

Medium

GLP-1 RAs

–0.39***–0.54 to –0.23

3

166

9.0

1.0

Small

Dietary interventions–0.37*–0.69 to –0.05

6

422

8.5

3.5

Small

Aripiprazole
augmentation–0.34***–0.47 to –0.20

10

710

9.3

3.5

Small

Topiramate–0.43–1.00 to 0.14

6

369

10.0

3.0

Non-significant

Lifestyle interventions–0.27–0.59 to 0.05

8

688

8.0

5.0

Non-significant

Insulin level
reduction<0.001
Rosiglitazone–0.42*–0.80 to 0.00

1

29

7.0

6.0

Small

Lifestyle interventions–0.28*–0.55 to 0.00

6

481

8.0

5.0

Small

Metformin–0.37–0.81 to 0.07

15

1,007

9.5

4.5

Non-significant

Dietary interventions–0.19–0.42 to 0.04

11

787

8.5

3.5

Non-significant

HOMA-IR
improvement<0.001
Metformin–0.75***–1.10 to –0.40

11

680

9.0

6.0

Rosiglitazone–0.44*–0.82 to –0.06

GLP-1 RAs

–0.08

–0.23 to 0.08

Metformin–0.38*

GLP-1 RAs

–0.38*

Medium

1

29

7.0

6.0

Small

3

163

9.0

1.0

Non-significant–0.69 to -0.07

4

383

9.0

6.0

Small

–0.53 to –0.22

3

166

9.0

1.0

Small

HbA1c reduction

Triglycerides
reduction

58

<0.001Topiramate–0.68*–1.23 to –0.13

5

268

10.0

3.0

MediumLifestyle interventions–0.37***–0.54 to –0.20

8

659

8.0

5.0

Small

Metformin–0.28***–0.45 to –0.11

11

856

9.0

4.0

Small

World Psychiatry 18:1 - February 2019

Table 3 Blood pressure, metabolic and exercise capacity physical health outcomes of pharmacological and non-pharmacological interventions
in people with schizophrenia (continued)
Outcomes

Intervention

SMD

95% CI

N. trials

N. participants

AMSTARAMSTAR
Plus Content

Effect size

Aripiprazole
augmentation–0.17**–0.30 to –0.04

9

631

9.5

3.5

Negligible

GLP-1 RAs

–0.15*–0.31 to –0.02

3

166

9.0

1.0

Negligible

Dietary interventions–0.15–0.30 to 0.00

7

611

8.5

3.5

Non-significant

Total cholesterol
reduction

0.02
Metformin–0.51***–0.81 to –0.20

8

628

9.0

6.0

MediumLifestyle interventions–0.35**–0.54 to –0.16

7

590

8.0

5.0

Small

Aripiprazole
augmentation–0.32***–0.47 to –0.17

10

692

9.3

3.5

Small

Topiramate–0.75–1.57 to 0.07

3

187

10.0

3.0

Non-significant

Dietary interventions–0.13–0.29 to 0.03

7

621

8.5

3.5

Non-significant

HDL-cholesterolelevation

0.007
Metformin

0.45*

0.00 to 0.90

7

542

9.0

6.0

Small

Lifestyle interventions

0.28–0.16 to 0.72

8

627

8.0

5.0

Non-significant

GLP-1 RAs

–0.04

–0.19 to 0.11

3

166

9.0

1.0

Non-significant

Topiramate–0.07–0.57 to 0.43

4

247

10.0

3.0

Non-significant

Dietary interventions–0.09–0.24 to 0.06

7

547

8.5

3.5

Non-significant

Aripiprazole
augmentation–0.27–0.44 to 0.01

8

544

9.3

3.5

Non-significant

LDL-cholesterol
reduction

Functional
exercise capacity

Betweengroup p<0.001Topiramate–0.80***–1.06 to –0.53

4

247

10.0

3.0

Large

Lifestyle interventions–0.36**–0.60 to –0.12

5

590

8.0

5.0

Small

GLP-1 RAs

–0.17*–0.32 to –0.02

3

162

9.0

1.0

Negligible

Metformin–0.11–0.31 to 0.09

5

433

9.0

6.0

Non-significant

Aripiprazole
augmentation–0.01–0.18 to 0.15

8

540

9.3

3.5

Non-significant

Exercise interventions

1.81**

0.59 to 3.03

1

13

8.0

2.0

Large

*p<0.05, **p<0.01, ***p<0.001
SMD – standardized mean difference, GLP-1 RAs – glucagon-like peptide-1 receptor agonists, AMSTAR – A Measurement Tool to Assess Systematic Reviews meanscores, HbA1c – hemoglobin A1c, HOMA-IR – homeostatic model assessment of insulin resistance, HDL – high-density lipoprotein, LDL – low-density lipoprotein

Pharmacological interventions
Altogether, 14 meta-analyses investigated pharmacologicalinterventions for body weight (82 trials, N=4,691). The mean
AMSTAR score was 8.1±1.3 and the mean AMSTAR-Plus Con­tent was 4.0±1.7.
A medium effect size was observed for aripiprazole aug­
mentation (SMD=–0.73, 95% CI: –0.97 to –0.48, p<0.001; 9 tri­als, N=813, I2=68%, Q=6.2), topiramate (SMD=–0.72, 95% CI:–1.56 to –0.33, p<0.001; 15 trials, N=783, I2=92.7%, Q=13.7),
d-fenfluramine (SMD=–0.54, 95% CI: –1.07 to –0.02, p<0.001;

World Psychiatry 18:1 - February 2019

one trial, N=16) and metformin (SMD=–0.53, 95% CI: –0.69 to–0.38, p<0.001; 29 trials, N=1,279, I2=39.4%, Q=1.6).
A small significant effect was shown by NMDA receptor an­tagonists (SMD=–0.47, 95% CI: –0.62 to –0.32, p<0.001; 5 trials,
N=309, I2=0%, Q=0.1), GLP-1 RAs (SMD=–0.44, 95% CI: –0.60 to–0.28, p<0.001; 3 trials, N=168, I2=0%, Q=0.1) and amantadine(SMD=–0.30, 95% CI: –0.57 to –0.03, p=0.03; 3 trials, N=205,
I2=0%, Q=0). Nizatidine showed a negligible effect (SMD=–0.12,
95% CI: –0.24 to 0.00, p=0.02; 4 trials, N=357, I2=0%, Q=0.4).
No significant weight loss compared to the control condi­tion was observed for fluoxetine (SMD=0.14, 95% CI: –0.09

59

to 0.36, p=0.22; 2 trials, N=60, I2=0%, Q=0), dextroampheta­mine (SMD=0.11, 95% CI: –0.33 to 0.56, p=0.60; one trial,
N=20), ranitidine (SMD=–0.24, 95% CI: –0.67 to 0.20, p=0.05;
4 trials, N=260), famotidine (SMD=–0.02, 95% CI: –0.48 to 0.43,
p=0.91; one trial, N=14), the combination of metformin withsibutramine (SMD=–0.24, 95% CI: –0.62 to 0.13, p=0.19; one tri­al, N=28), orlistat (SMD=–0.21, 95% CI: –0.46 to 0.04, p=0.09; one
trial, N=63) and rosiglitazone (SMD=0.14, 95% CI: –0.21 to 0.52,
p=0.19; one trial, N=29). Switching from olanzapine to que­tiapine or aripiprazole fell also short of statistical significance(SMD=–0.11, 95% CI: –0.23 to 0.03, p=0.06; 2 trials, N=287).

Combined pharmacological and non-pharmacologicalinterventions
The combination of metformin with a lifestyle intervention
was explored in one meta-analysis and demonstrated a small
effect (SMD=–0.44, 95% CI: –0.69 to –0.19, p<0.001; 3 trials,
N=122, I2=0, Q=0).

Body mass index
Non-pharmacological interventions
Four meta-analyses investigated non-pharmacological in­terventions for body mass index (42 trials, N=2,157). The mean
AMSTAR score was 9.7±0.8 and the mean AMSTAR-Plus Con­tent was 2.2±1.2.
A small effect was observed for group lifestyle counseling(SMD=–0.28, 95% CI: –0.54 to 0.00, p=0.04; 4 trials, N=202,
I2=0%, Q=0), individual lifestyle counseling (SMD=–0.49, 95%
CI: –0.77 to –0.22, p<0.001; 4 trials, N=202, I2=0%, Q=0), andcognitive behavioral therapy focusing on promoting healthy
lifestyles (SMD=–0.34, 95% CI: –0.67 to –0.07, p=0.02; 6 trials,
N=308, I2=0%, Q=0.2).
No significant reduction in body mass index compared tothe control condition was observed for exercise interventions(SMD=–0.25, 95% CI: –0.56 to 0.06, p=0.11; 8 trials, N=231, I2=0%, Q=0.4).

Pharmacological interventions
Six meta-analyses investigated pharmacological interven­tions for body mass index (81 trials, N=4,533). The mean AM­
STAR score was 8.1±1.3 and the mean AMSTAR-Plus Content
was 4.0±1.9.
Topiramate (SMD=–0.56, 95% CI: –1.54 to –0.22, p<0.001; 11
trials, N=449, I2=0%, Q=0) had a medium reducing effect, while
GLP-1 RAs demonstrated a small effect (SMD=–0.41, 95% CI:–0.57 to –0.26, p<0.001; 3 trials, N=168, I2=0%, Q=0).
No reduction of body mass index was observed with met­
formin (SMD=–0.41, 95% CI: –0.93 to 0.10, p=0.10; 23 trials,
N=1,228, I2=90%, Q=20.0), ranitidine (SMD=–0.23, 95% CI:–0.44 to 0.00, p=0.55; 5 trials, N=312, I2=0%, Q=0), and switch­60

ing from olanzapine to quetiapine (SMD=–0.12, 95% CI: –0.29
to 0.05, p=0.16; one trial, N=129).

Waist circumference
Non-pharmacological interventions
Three meta-analyses investigated non-pharmacological in­terventions for waist circumference reduction (24 trials, N=
1,709). The mean AMSTAR score was 9.3±0.5 and the mean
AMSTAR-Plus Content was 4.0±0.8.
A small waist circumference reduction effect compared tocare as usual was observed for dietary interventions (SMD=–0.39,
95% CI: –0.56 to –0.22, p<0.001; 11 trials, N=858, I2=0%, Q=0) andmultidisciplinary lifestyle/behavioral interventions (SMD=–0.37,
95% CI: –0.60 to -0.13, p=0.002; 10 trials, N=705, I2=0%, Q=0).

Pharmacological interventions
Seven meta-analyses investigated pharmacological inter­
ventions for waist circumference reduction (32 trials, N=1,755).
The mean AMSTAR score was 9.3±0.7 and the mean AMSTARPlus Content was 2.8±1.6.
Compared with the control condition, the most effective
intervention was aripiprazole augmentation (SMD=–1.10, 95%
CI: –1.42 to –0.79, p=0.001; 3 trials, N=174, I2=0%, Q=0, i.e., large
effect).
Topiramate had a medium effect (SMD=–0.69, 95% CI: –0.93
to –0.45, p<0.05; 8 trials, N=310, I2=0%, Q=0). GLP-1 RAs hada small effect (SMD=–0.34, 95% CI: –0.50 to –0.18, p<0.001; 3
trials, N=167, I2=0%, Q=0). No significant waist circumference
re­duction compared to the placebo control condition was ob­
served for metformin (SMD=–0.01, 95% CI: –0.68 to 0.65, p=0.97;
12 trials, N=721, I2=82%, Q=17.1).

Waist to hip ratio
Three meta-analyses investigated the effects of pharmaco­
logical interventions on the waist to hip ratio (11 trials, N=419).
The mean AMSTAR score was 9.3±0.5 and the mean AMSTARPlus Content was 3.3±2.0.
A small waist to hip ratio reduction compared to the control
condition was observed for topiramate (SMD=–0.69, 95% CI:–0.90 to 0.27, p=0.009; 5 trials, N=123, I2=0%, Q=0) and metformin(SMD=–0.32, 95% CI: –1.15 to 0.51, p=0.29; 3 trials, N=133, I2=0%,
Q=0). GLP-1 RAs demonstrated no significant effect (SMD=0.03,
95% CI: –0.13 to 0.18, p=0.39; 3 trials, N=163, I2=0%, Q=0).

Android/gynoid ratio
Based on data from one meta-analysis, GLP-1 RAs did notoutperform the control condition concerning the effect on an­

World Psychiatry 18:1 - February 2019

droid/gynoid ratio (SMD=–0.03, 95% CI: –0.20 to 0.13, p=0.46;
3 trials, N=131, I2=0%, Q=0).

Visceral fat
Based on data from one meta-analysis, GLP-1 RAs had asmall effect in reducing visceral fat (SMD=–0.37, 95% CI: –0.46
to –0.06, p=0.02; 3 trials, N=97, I2=0%, Q=0).

Blood pressure
Non-pharmacological interventions
Four meta-analyses investigated non-pharmacological in­terventions for blood pressure reduction (23 trials, N=2,095).
The mean AMSTAR score was 9.0±0.0 and the mean AMSTARPlus Content was 4.5±0.5.
When looking at dietary interventions alone, a small reduc­tion in diastolic blood pressure versus care as usual was observed(SMD=–0.39, 95% CI: –0.56 to –0.22, p<0.01; 6 trials, N=654,
I2=0, Q=0).
Compared to care as usual, no significant reduction in sys­
tolic (SMD=–0.22, 95% CI: –0.49 to 0.05, p=0.11; 7 trials, N=615,
I2=0, Q=0) and diastolic blood pressure (SMD=–0.08, 95% CI:–0.57 to 0.41, p=0.74; 3 trials, N=171, I2=0, Q=0) was observed
for multidisciplinary lifestyle/behavioral interventions.

Pharmacological interventions
Two meta-analyses investigated pharmacological interven­tions for blood pressure (6 trials, N=336). The mean AMSTAR score
was 9.5±0.5 and the mean AMSTAR-Plus Content was 1.5±0.5.
Compared to the placebo condition, no significant reduc­tion in systolic and diastolic blood pressure was observed for
metformin and GLP-1 RAs.

GlucoseNon-pharmacological interventions
Three meta-analyses investigated non-pharmacological in­terventions on fasting glucose levels (16 trials, N=1,256). The
mean AMSTAR score was 9.3±0.5 and the mean AMSTAR-Plus
Content was 4.0±0.8.
Dietary interventions showed a small glucose level reduc­ing effect (SMD=–0.37, 95% CI: –0.69 to –0.05, p=0.03; 6 trials,
N=422, I2=0%, Q=0).
No significant reduction in glucose levels compared to careas usual was observed for multidisciplinary lifestyle/behavioral
interventions (SMD=–0.27, 95% CI: –0.59 to 0.05, p=0.10; 8 tri­als, N=688, I2=0%, Q=0).

World Psychiatry 18:1 - February 2019

Pharmacological interventions
Seven meta-analyses investigated the effect of pharmacolog­
ical interventions on fasting glucose levels (54 trials, N=3,617).
The mean AMSTAR score was 9.6±0.6 and the mean AMSTARPlus Content was 3.1±1.9.
A medium fasting glucose level lowering effect was foundfor switching olanzapine to quetiapine or aripiprazole (SMD=–0.71, 95% CI: –0.85 to –0.58, p<0.001; 2 trials, N=280), and for
metformin (SMD=–0.65, 95% CI: –0.94 to –0.35, p<0.001; 17 tri­als, N=1281, I2=0%, Q=0).
The effect was small for aripiprazole augmentation (SMD=–0.34, 95% CI: –0.47 to –0.21, p<0.001; 10 trials, N=710, I2=0%,
Q=0) and GLP-1 RAs (SMD=–0.39, 95% CI: –0.54 to –0.23, p<
0.001; 3 trials, N=166, I2=0%, Q=0).
No significant reduction in glucose levels compared to theplacebo condition was observed for topiramate (SMD=–0.43,
95% CI: –1.00 to 0.14, p=0.14; 6 trials, N=369, I2=0%, Q=0).

InsulinNon-pharmacological interventions
Two meta-analyses investigated the effect of non-pharma­cological interventions on insulin levels (9 trials, N=1,268). The
mean AMSTAR score was 9.0±0.0 and the mean AMSTAR-Plus
Content was 4.5±0.7.
Multidisciplinary lifestyle/behavioral interventions had asmall effect in improving insulin sensitivity (SMD=–0.28, 95%
CI: –0.55 to 0.00, p=0.04; 6 trials, N=481, I2=0%, Q=0). Dietaryinterventions alone did not outperform the control condition(SMD=–0.19, 95% CI: –0.42 to 0.04, p=0.10; 11 trials, N=787,
I2=0%, Q=0).

Pharmacological interventions
Five meta-analyses investigated the impact of pharmaco­
logical interventions on insulin levels (23 trials, N=1,479). The
mean AMSTAR score was 8.4±1.2 and the mean AMSTAR-Plus
Content was 4.2±2.2.
Rosiglitazone had a small effect (SMD=–0.42, 95% CI: –0.80
to 0.00, p=0.03; one trial, N=29). Metformin did not outper­
form the control condition (SMD=–0.37, 95% CI: –0.81 to 0.07,
p=0.10; 15 trials, N=1007, I2=79.2%, Q=4.8).

Homeostatic model assessment of insulin resistancePharmacological interventions
Five meta-analyses investigated the effect of pharmacologi­
cal interventions on homeostatic model assessment of insulin
resistance (19 trials, N=1,158). The mean AMSTAR score was
8.4±1.2 and the mean AMSTAR-Plus Content was 4.2±2.2.

61

Metformin (SMD=–0.75; 95% CI: –1.10 to –0.40, p<0.001; 11
trials, N=680, I2=0%, Q=0, i.e., medium effect) and rosiglitazone(SMD=–0.44; 95% CI: –0.82 to –0.06, p=0.02; one trial, N=29, i.e.,
small effect) significantly outperformed the control condition,
while GLP-1 RAs did not (SMD=–0.08; 95% CI: –0.23 to 0.08,
p=0.10; 3 trials, N=163, I2=0%, Q=0).

Hemoglobin A1c
Two meta-analyses investigated pharmacological interven­tions
on hemoglobin A1c (7 trials, N=549). The mean AMSTAR score
was 9.0±0.0 and the mean AMSTAR-Plus Content was 3.5±3.5.
Metformin (SMD=–0.38; 95% CI: –0.69 to –0.07, p=0.016; 4
trials, N=383, I2=0%, Q=0) and GLP-1 RAs (SMD=–0.38; 95%
CI: –0.53 to –0.22, p=0.02; 3 trials, N=166, I2=0%, Q=0) outper­
formed the placebo condition and showed a small effect.

Triglycerides
Non-pharmacological interventions
Four meta-analyses investigated the impact of non-pharma­cological interventions on triglycerides (22 trials, N=1,671). The
mean AMSTAR score was 8.7±1.1 and the mean AMSTAR-Plus
Content was 4.2±0.8.
Multidisciplinary lifestyle/behavioral interventions had asmall effect compared with care as usual (SMD=–0.37, 95% CI:–0.54 to –0.20, p<0.001; 8 trials, N=659, I2=40.0%, Q=1.7). Die­tary interventions did not outperform care as usual (SMD=–0.15; 95% CI: –0.30 to 0.00, p=0.06; 7 trials, N=611, I2=0%, Q=0).

Pharmacological interventions
Seven meta-analyses investigated the effect of pharmaco­
logical interventions on triglycerides (36 trials, N=2,564). The
mean AMSTAR score was 9.1±1.0 and the mean AMSTAR-Plus
Content was 3.6±1.9.
The effect compared with control condition was medium for
topiramate (SMD=–0.68, 95% CI: –1.23 to –0.13, p=0.016; 5 tri­als, N=268, I2=0%, Q=0), small for metformin (SMD=–0.28, 95%
CI: –0.45 to –0.11, p<0.001; 11 trials, N=856, I2=5%, Q=2.1), andnegligible for aripiprazole augmentation (SMD=–0.17, 95% CI:–0.30 to –0.04, p=0.009; 9 trials, N=631, I2=0%, Q=0) and GLP-1
RAs (SMD=–0.15, 95% CI: –0.31 to –0.02, p=0.04; 3 trials, N=166,
I2=0%, Q=0).

AMSTAR score was 8.5±1.0 and the mean AMSTAR-Plus Con­tent was 4.5±0.7.
Regarding total cholesterol, multidisciplinary lifestyle/behav­
ioral interventions had a small benefit (SMD=–0.35, 95% CI: –0.54
to –0.16, p=0.003; 7 trials, N=590, I2=0%, Q=0.3), while dietary in­terventions alone did not outperform care as usual (SMD=–0.13;
95% CI: –0.29 to 0.03, p=0.10; 7 trials, N=621, I2=0%, Q=0).
Regarding LDL-cholesterol, multidisciplinary lifestyle/be­havioral interventions showed a small benefit (SMD=–0.36,
95% CI: –0.60 to –0.12, p=0.003; 5 trials, N=590, I2=0%, Q=0.2).
No significant effects on HDL-cholesterol elevations were
found with lifestyle or dietary interventions.

Pharmacological interventions
Fifteen meta-analyses investigated pharmacological inter­
ventions for cholesterol levels (74 trials, N=5,295). The mean
AMSTAR score was 9.4±0.8 and the mean AMSTAR-Plus Con­tent was 3.3±1.8.
Regarding total cholesterol, metformin (SMD=–0.51, 95%
CI: –0.81 to –0.20, p<0.001; 8 trials, N=628, I2=0%, Q=0) dem­
onstrated a medium effect, while aripiprazole augmentation
had a small effect (SMD=–0.32, 95% CI=–0.47 to –0.17, p<0.001;
10 trials, N=692, I2=0%, Q=0). No significant reduction com­pared to the control condition was observed for topiramate(SMD=–0.75, 95% CI: –1.57 to 0.07, p=0.07; 3 trials, N=187, I2=0%,
Q=0).
Regarding LDL-cholesterol, topiramate (SMD=–0.80, 95%
CI: –1.06 to –0.53, p<0.001; 4 trials, N=247, I2=0%, Q=0) andGLP-1 RAs (SMD=–0.17, 95% CI: –0.32 to –0.02, p=0.04; 3 tri­als, N=162, I2=0%, Q=0) outperformed the control condition,although for the latter the effect was negligible. No signifi­
cant reductions compared to the control condition were foundfor aripiprazole augmentation (SMD=–0.01, 95% CI: –0.18 to
0.15, p=0.88; 8 trials, N=540, I2=0%, Q=0) and for metformin(SMD=–0.11, 95% CI: –0.31 to 0.09, p=0.29; 5 trials, N=433, I2=0%, Q=0.2).
Regarding HDL-cholesterol, only metformin had a small ef­
fect (SMD=0.45, 95% CI: 0.00 to 0.90, p=0.049; 7 trials, N=542,
I2=0%, Q=0), while aripiprazole augmentation, topiramate and
GLP-1 RAs did not differ from the control condition.

Functional exercise capacity
Based on data from one meta-analysis, exercise outperformed
the treatment as usual condition (SMD=1.81; 95% CI: 0.59 to
3.03, p=0.004; one trial, N=13, I2=0%, Q=0, i.e., large effect).

Cholesterol
Adverse drug reactions
Non-pharmacological interventions
Ten meta-analyses investigated non-pharmacological inter­
ventions for cholesterol levels (56 trials, N=4,288). The mean

62Compared to placebo, aripiprazole had higher rates of anxi­ety (number needed to harm, NNH=8, 95% CI: 5 to 20, p<
0.001)47 and agitation/akathisia (RR=7.59, 95% CI: 1.43 to 40.18,

World Psychiatry 18:1 - February 2019

p=0.02)53. Amantadine was associated with higher rates of in­somnia (RR=3.83, 95% CI: 1.41 to 10.38, p=0.008, NNH=9)57
and abdominal discomfort (quantitative data not provided)60.
GLP-1 RAs were associated with higher rates of nausea (NNH=
3.8, 95% CI: 2.4 to 9.7, p<0.05)40. Among H2 antagonists, famoti­
dine and ranitidine were not associated with higher rates of ad­verse reactions, while nizatidine had higher rates of dry mouth(RR=4.89, p=0.04; NNH=17, p=0.03) and depression (RR=5.00,
p=0.03; NNH=17, p=0.02)52.
Of the six included meta-analyses of metformin, five report­
ed no difference in rates of adverse reactions41,46,48,54,62, while
one reported higher rates of nausea/vomiting (NNH=16, 95%
CI: 10 to 50, p=0.01) and diarrhoea (NNH=6, 95% CI: 3 to 25, p=0.01)49. Although there was no difference in rates of dropoutsfor orlistat, diarrhoea was the main reason for discontinuationof this drug48.
Sibutramine plus metformin were associated with an in­crease of psychotic symptoms. Topiramate was associatedwith a higher rate of paraesthesia (RR=2.31, 95% CI: 1.17 to
4.56, p<0.05)39. There were no data for dextroamphetamine,d-fenfluramine and rosiglitazone. Antipsychotic switching(olanzapine to quetiapine) was associated with higher rates ofpsychiatric adverse events54.
None of the meta-analyses reported on adverse effects of
non-pharmacological interventions.

Meta-regression analyses
Due to limited data, no meta-regression or subgroup analy­
sis could be performed to examine whether duration of treat­ment or illness, delivery of the intervention by mental healthvs. physical health staff, clinical setting, percent of sessions
attended or adherence to treatment could explain variance inthe outcomes of interventions.
Study level variance in age and gender did not explain thevariance in weight, body mass index or triglycerides levels
following pharmacological or non-pharmacological interven­tions.

DISCUSSION
To our knowledge, this meta-review of meta-analyses is thefirst to systematically and quantitatively compare the pharmaco­
logical and non-pharmacological interventions that have been
investigated for improving physical health outcomes in people
with schizophrenia. Our data shed new light on the areas where
there is or there is not evidence to improve physical health inthese people, and should help guide clinical practice and indi­cate where future research priorities should focus.
When looking at non-pharmacological treatments, individ­
ual lifestyle counseling showed a large weight reducing effect.
For dietary interventions, the weight reducing effect size wasmedium, and diastolic blood pressure and glucose level low­

World Psychiatry 18:1 - February 2019

ering effects were small. Exercise demonstrated large weight
reducing effects and large effects on functional exercise ca­
pacity, although the evidence for the latter was limited to one
small study.
The characteristics of the lifestyle interventions were exam­
ined to provide guidelines for future clinical practice. One key
finding was that individualized lifestyle interventions showedlarge effects for reducing body weight, while only a small ef­
fect was observed for group-based approaches. Apparently,
the benefits of an individual strategy, such as personal advice
and attention, meeting patient-specific needs, and a tailoredaction plan, surpasses the benefits of group-based sessions,such as interpersonal learning, imitative behavior, recogni­tion of similarities in other group members, group cohesive­
ness and peer support66. Future research should, however,
explore whether a combined approach, encompassing groupsessions while addressing patient-specific needs with a tai­lored action plan, would be most efficacious.
Cognitive behavioral interventions focusing on weight loss
and psychoeducation demonstrated, respectively, small andmedium weight reducing effects.
Across 17 pharmacological strategies, 12 outperformed thecontrol condition on various physical health outcomes. No
beneficial effects were found for fluoxetine, ranitidine, orlistat,dextroamphetamine and famotidine for any physical healthoutcome.
Topiramate showed a large effect on LDL-cholesterol, anda medium effect on weight, body mass index, waist circumfer­ence and triglycerides. Metformin demonstrated a medium
effect on weight, total cholesterol, fasting glucose levels, andhomeostatic model assessment of insulin resistance; and asmall effect on hemoglobin A1c, triglycerides, and HDL-cho­lesterol.
Switching from olanzapine to quetiapine or aripiprazole
showed a medium fasting glucose lowering effect, while the ef­
fect of aripiprazole augmentation on this parameter was small.
Aripiprazole augmentation also had a large effect on waist cir­
cumference and a medium effect on body weight.
A small weight reducing effect was found for NMDA recep­
tor antagonists. GLP-1 RAs showed small effects on waist cir­
cumference, glucose and hemoglobin A1c. Rosiglitazone hada small improving effect on homeostatic model assessment of
insulin resistance. Finally, negligible effects were observed foraripiprazole augmentation and GLP-1 RAs on triglycerides, andfor GLP-1 RAs on LDL-cholesterol.
In summary, based on the SMDs and the overall high meth­odological quality of the original meta-analyses (but with lower
quality of the meta-analyzed content), individual lifestyle coun­
seling and exercise interventions showed the largest weight
reducing effect, followed by psychoeducation, aripiprazole
augmentation, topiramate, di-fenfluramine and metformin.
With regard to waist circumference, aripiprazole augmentationand topiramate demonstrated the best impact, followed by die­tary interventions. Dietary interventions were the only to sig­
nificantly improve (diastolic) blood pressure.

63

Switching from olanzapine to quetiapine or aripiprazole
and metformin demonstrated the best evidence for glucose
level reductions, followed by GLP-1 RAs, dietary interventions
and aripiprazole augmentation. Hemoglobin A1c was reduced
significantly by both metformin and GLP-1 RAs. Homeostatic
model assessment of insulin resistance improved significantlywith metformin and rosiglitazone.
Reduction of triglycerides levels were the largest with topira­mate, followed by multidisciplinary lifestyle/behavioral inter­
ventions, metformin, aripiprazole augmentation and GLP-1
RAs. Total cholesterol was reduced by metformin, lifestyleinterventions and aripiprazole augmentation, while LDLcholesterol reductions were significant with topiramate, life­
style interventions and GLP-1 RAs. HDL-cholesterol only in­creased significantly with metformin. Finally, only exercise
interventions were meta-analyzed as a means to improve exer­
cise capacity, yielding the largest effect size of all interventionsin this review for any outcome (SMD=1.81), although this was
based on only one trial.
Taken together, our data offer clinicians some perspective on
the potential best methods to address specific physical healthissues in people with schizophrenia. In summary, for weight
reduction, clinicians should consider individual lifestyle coun­
selling as the top non-pharmacological intervention. There issome evidence that exercise interventions can also help reduce
body weight, although we could only include four trials. Dietaryinterventions also showed promise. Regarding pharmacologi­
cal interventions, clinicians could consider the adjunctive useof topiramate, though this should be balanced against the pos­sible emergence of paresthesia and cognitive adverse effects(the latter insufficiently studied). Findings for metformin were
somewhat heterogeneous, as this medication had a medium ef­
fect on body weight but no effect on body mass index, although
the latter was likely due to the smaller number of studies exam­
ining this outcome. Metformin may be associated with nausea
and diarrhea. Further research is required to determine theeffects of combining these strategies.
With regards to other markers of metabolic health and car­diovascular risk, there is good evidence that clinicians can use
metformin for reducing glucose levels, homeostatic model
assessment of insulin resistance and total cholesterol, while
there is only a small effect for triglycerides, hemoglobin A1c and
HDL-cholesterol. For people with schizophrenia on olanzapine,
switching to aripiprazole or quetiapine also shows medium
glucose level lowering effects. Of note, only dietary interventions
were found to significantly improve (diastolic) blood pressure.
Our data should be considered in the light of some limi­
tations. First, although the included meta-analyses were themost updated and/or largest for each specific strategy andoutcome, individual studies published since the last searchdate of included meta-analyses could not be added. Second,
because of limited data for participant characteristics and in­terventional designs, conducting meta-regression analyses
was not possible. Third, while the quality of the methods of themeta-analyses was generally good to very good, the content of64

meta-analyzed studies often lacked quality. Fourth, based on
the AMSTAR-Plus Content scores, publication bias was prob­
lematic for about half of the meta-analyses, potentially overes­
timating the pooled effect sizes. Finally, the preponderance ofstudies with small sample sizes in which only large effects were
statistically significant presents a challenge.
In conclusion, despite the high risk for physical comorbidi­
ties in people with schizophrenia, and the scandal of theirpremature mortality mainly due to these increased physicalhealth risks, the existing evidence for pharmacological andnon-pharmacological interventions to prevent and treat these
conditions is still limited. Qualitatively excellent and suffi­
ciently large individual randomized clinical trials are therefore
essential.
Additionally, the field should move from study-level to pa­
tient-level meta-analyses, as this would provide a more person­
alized picture of treatment effects for individuals, derived from
adequately powered moderator, mediator and subgroup analy­
ses. Comparing pharmacological and non-pharmacological in­terventions in the same trial would also be desirable, and there
is a need for large-scale investigations of combination regimes(i.e., using antipsychotic switching and adjunctive prescribing
alongside lifestyle interventions), as well as preventive inter­
ventions (i.e., those aiming to prevent physical comorbidities,
prior to their development).
ACKNOWLEDGEMENTS
B. Stubbs holds a clinical lectureship supported by Health Education Englandand the National Institute for Health Research (NIHR) Integrated Clinical Aca­
demic Programme (ICA-CL-2017-03-001). B. Stubbs and F. Gaughran are in part
supported by the Maudsley Charity and the NIHR Collaboration for Leadershipin Applied Health Research and Care South London at King’s College Hospital
NHS Foundation Trust. The views expressed in this paper are those of the au­thors and not necessarily those of the above entities.

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DOI:10.1002/wps.20614

World Psychiatry 18:1 - February 2019

RESEARCH REPORTTransdiagnostic dimensions of psychosis in the BipolarSchizophrenia Network on Intermediate Phenotypes (B-SNIP)
Ulrich Reininghaus1-3, Jan R. Böhnke4,5, UnYoung Chavez-Baldini2, Robert Gibbons6, Elena Ivleva7, Brett A. Clementz8, Godfrey D. Pearlson9,
Matcheri S. Keshavan10, John A. Sweeney11, Carol A. Tamminga7
1

Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; 2Department of Psychiatry and Neuropsychology, School for
Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands; 3Centre for Epidemiology and Public Health, Health Service and Population Research
Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK; 4Dundee Centre for Health and Related Research, School of Nursingand Health Sciences, University of Dundee, Dundee, UK; 5Department of Health Sciences, University of York, York, UK; 6Department of Medicine and Public Health Sciences,
University of Chicago, Chicago, IL, USA; 7Department of Psychiatry, UT Southwestern University, Dallas, TX, USA; 8Departments of Psychology and Neuroscience, Bio-Imaging
Research Center, University of Georgia, Athens, GA, USA; 9Department of Psychiatry, Yale University, New Haven, CT, USA; 10Beth Israel Hospital, Harvard University, Boston,
MA, USA; 11Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, USA

The validity of the classification of non-affective and affective psychoses as distinct entities has been disputed, but, despite calls for alternative
approaches to defining psychosis syndromes, there is a dearth of empirical efforts to identify transdiagnostic phenotypes of psychosis. We aimed
to investigate the validity and utility of general and specific symptom dimensions of psychosis cutting across schizophrenia, schizoaffective
disorder and bipolar I disorder with psychosis. Multidimensional item-response modeling was conducted on symptom ratings of the Positive
and Negative Syndrome Scale, Young Mania Rating Scale, and Montgomery-Åsberg Depression Rating Scale in the multicentre BipolarSchizophrenia Network on Intermediate Phenotypes (B-SNIP) consortium, which included 933 patients with a diagnosis of schizophrenia(N=397), schizoaffective disorder (N=224), or bipolar I disorder with psychosis (N=312). A bifactor model with one general symptom dimension,
two distinct dimensions of non-affective and affective psychosis, and five specific symptom dimensions of positive, negative, disorganized,
manic and depressive symptoms provided the best model fit. There was further evidence on the utility of symptom dimensions for predicting
B-SNIP psychosis biotypes with greater accuracy than categorical DSM diagnoses. General, positive, negative and disorganized symptom
dimension scores were higher in African American vs. Caucasian patients. Symptom dimensions accurately classified patients into categorical
DSM diagnoses. This study provides evidence on the validity and utility of transdiagnostic symptom dimensions of psychosis that transcend
traditional diagnostic boundaries of psychotic disorders. Findings further show promising avenues for research at the interface of dimensional
psychopathological phenotypes and basic neurobiological dimensions of psychopathology.
Key words: Psychosis, transdiagnostic phenotypes, schizophrenia, schizoaffective disorder, bipolar disorder with psychosis, general symptom
dimensions, specific symptom dimensions, biotypes(World Psychiatry 2019;18:67–76)

The validity of categorical classification in psychiatry is disputed, because the clinical and neurobiological boundaries
between disorders are dubious1-17. Therefore, there have beencalls for alternative approaches to psychiatric classificationthat are empirically and psychometrically informed throughthe investigation of neural and psychological mechanisms thattranscend current syndromes3,18,19.
Some projects address the shortcomings of classic psychiatric classification, such as the Research Domain Criteria(RDoC) framework, that integrates many levels of information (from genes to self-report) to further our understandingof basic cross-disorder dimensions of functioning6,7,20,21. The
Bipolar-Schizophrenia Network on Intermediate Phenotypes(B-SNIP)22,23 addresses the overlap across psychosis syndromes
by examining a broad array of endophenotypes. Recently, theHierarchical Taxonomy of Psychopathology (HiTOP) consortium has emerged as a research effort that quantifies disorders
according to several levels of psychopathology, including spectra, syndromes and symptom components, and characterizes
them dimensionally24. However, to date, evidence on the link
between transdiagnostic dimensions of clinical phenotypes
and basic brain-based biomarkers is limited.
In psychosis, the overlap of symptoms across diagnostic categories is especially prevalent, which leads to high comorbidity,

World Psychiatry 18:1 - February 2019

as seen with schizophrenia, schizoaffective disorder and bipolar
disorder25,26. While the Kraepelinian dichotomy regarded dementia praecox/schizophrenia and manic depressive illness as
distinct diagnostic entities, recent research has challenged thisdichotomy4,5 and places schizophrenia and bipolar disorder
on a transdiagnostic psychosis spectrum4, with schizoaffective
disorder as an intermediate diagnostic category22. This overlap
may be a result of shared genetic and environmental etiologicalfactors4,27-29. Findings also show, however, non-shared genetic
and environmental risk factors4,27,29, which supports the heterogeneity of psychotic disorders.
There remains a dearth of empirical efforts to identify a trans­
diagnostic phenotype of psychosis. The pentagonal model withfive dimensions of positive symptoms, negative symptoms,
cognitive disorganization, mania, and depression has received
support in previous factor-analytic work30. However, recent
research has demonstrated evidence for a bifactor model, witha general psychosis factor encompassing non-affective andaffective symptoms in patients with schizophrenia, schizoaffective and bipolar disorder, as well as five specific psychosis
dimensions of positive, negative, disorganized, manic and depressive symptoms4,5.
This model was found to better fit empirical symptom data
than a pentagonal model4,5 and a model allowing for distinct

67

non-affective and affective psychosis factors31. It provides support for a psychosis spectrum ranging from bipolar disorderto schizoaffective disorder to schizophrenia. Further, in thisbi­factor model, shared etiological factors may be associatedwith the general psychosis factor, whereas non-shared etiological factors could contribute to more specific psychosis dimensions4, 5. This approach could also hone the diagnostic processby placing p­ atients broadly on the psychosis spectrum and using
the spe­cific symptom dimensions to classify them into specific­diagnoses4,5.
While initial support for the diagnostic utility of these dimensions has been found using the operational criteria system4,
such transdiagnostic models and their diagnostic utility need
to be further tested with more detailed measures of psychosis, mania and depression, and cross-validated across a large
multisite consortium, such as the B-SNIP. This would allow
for improved understanding of the utility of these dimensions
not only for diagnosis in research and clinical care, but also in
relation to basic neurobiological constructs such as the threerecently identified B-SNIP psychosis biotypes32, in an attempt
to connect dimensional psychopathological phenotypes withneurobiological mechanisms12,14,24.
This study aimed to investigate transdiagnostic dimensionsof psychosis spectrum disorders cutting across non-affective
and affective psychotic symptoms in patients with schizophrenia, schizoaffective disorder and psychotic bipolar I disorder,using widely established measures for assessing psychosis,
mania and depression in the B-SNIP consortium.
We aimed to investigate: a) whether there is a general dimension of psychosis spectrum disorders underlying all affective
and non-affective psychotic symptoms; b) whether formationof specific symptom dimensions (positive, negative, disorganized, depressive and manic symptoms) and distinct dimensionsof affective and non-affective psychosis is justified in addition
to a general psychosis dimension; c) associations of socio-demographic and clinical variables with general, affective, nonaffective and specific symptom dimensions; and d) the utilityof these dimensions for classifying patients into categorical
DSM diagnoses of psychotic disorders and the B-SNIP biotypes.

METHODS
Sample and measures
This study used data collected as part of the multisite B-SNIP
consortium22. Specifically, patients with a DSM-IV diagnosis of
schizophrenia, schizoaffective disorder or psychotic bipolar I
disorder (ascertained through the Structured Clinical Interview
for DSM-IV Axis I Disorders, SCID-I33) were recruited from fivesites in the US through regional advertising and from inpatientand outpatient clinics. Patients were in a non-acute symptom
state, clinically stable, and provided informed consent.
Participants were assessed extensively for their socio-­demo­
graphic and clinical features (including age, gender, ethnicity

68

and DSM diagnosis) with a variety of instruments22,23. In thisstudy, the responses of three well-established diag­nostic instruments were investigated: the Positive and Negative Syndrome
Scale (PANSS)34, which is a 30-item cli­nical interview thatmeasures the severity of psychotic symp­toms on a scale of 1
to 7; the Young Mania Rating Scale (YMRS)35, a 11-item mea­
sure to assess manic symptoms; and the Montgomery-Åsberg
Depression Rating Scale (MADRS)36, a 10-item measure to assess depressive symptoms. Social functioning was measured
using the Birchwood Social Functioning Scale (SFS)37.

Statistical analysis
Multidimensional item response modeling was conduct­
ed with the mirt package of the R environment (i.e., theMetropolis-Hastings Robbins-Monro algorithm38) for model
estimation. Model fit was examined using the log-likelihood(LL), the Akaike information criterion (AIC), the Bayesian information criterion (BIC), and the sample size-adjusted BIC(SABIC)39. Better model fit is indicated by lower values than forthe comparison model.
Since there is no definite evidence on the factorial structureof the PANSS, we first analyzed symptom ratings on the PANSS
only and compared eighteen previously published factor solutions5. We then estimated three alternative item responsemodels: a) a unitary (unidimensional) model with one generalfactor explaining all symptom ratings to reflect a general dimension of the psychosis spectrum (model A); b) a pentagonal(multidimensional) model to reflect specific positive, negative,
disorganized, depressive and manic symptom dimensions(model B); and c) a bifactor model with one general factor in­dependent from five uncorrelated (orthogonal) specific factors(model C; corresponding to the bifactor model in our earlier
study5,40). Since this is a full likelihood method, data was assumed to be missing at random.
Using the best-fitting model for the PANSS identified inthis initial step, we next conducted the primary analysis toinvestigate general and specific symptom dimensions basedon all measures for assessing psychosis, mania and depression (i.e., PANSS, YMRS and MADRS) by comparing models A-C, additionally allowing for factor loadings for YMRS
and MADRS items on the general factor as well as on specificmanic and depressive symptom factors, respectively. To investigate whether formation of distinct dimensions for affective
and non-affective psychosis was justified in addition to one
general dimension and five specific symptom dimensions,model comparison of the primary analysis further included:d) a bifactor model with one general psychosis dimension, fiveuncorrelated specific factors (positive, negative, disorganized,
depressive and manic symptom dimensions), and two uncorrelated factors to reflect distinct dimensions of affective andnon-affective psychosis (model D); and e) a model with fiveuncorrelated specific factors (positive, negative, disorganized, depressive and manic symptom dimensions) and two

World Psychiatry 18:1 - February 2019

uncorrelated factors (distinct affective and non-affective psychosis dimensions) but without a general factor (model E). To
ensure stable model estimation, the prevalence of responses
per category per item was set to be at least 10% of the sample.
Due to low coverage in the more severe categories, responses
were collapsed into three categories for the PANSS, YMRS andMADRS.
The association of socio-demographic characteristics (i.e.,age, gender, ethnicity), DSM diagnosis, and social functioning(as independent variables) with factor scores of general andspecific psychosis dimensions (as outcome variables) wereanalyzed using linear regression.
Multinomial receiver operating characteristic (ROC) analysis41 was conducted in Stata version 1442 to investigate the extent to which factor scores of general, affective, non-affective
and specific dimensions allow for accurate classification ofpatients into categorical DSM diagnoses of psychotic disorders
and the B-SNIP biotypes.

RESULTS
Basic sample characteristics
Basic characteristics of the total B-SNIP sample (N=933
patients) and the B-SNIP sample used for estimating item
response models, that included all response vectors with atleast one response to items of the PANSS, YMRS and MADRS(N=860), were almost identical (Table 1). The mean age atinterview was 36 years, and approximately half were male.
The sample primarily consisted of patients with Caucasian or
African American ethnicity. The most common diagnosis was
schizophrenia, followed by psychotic bipolar I disorder andschizoaffective disorder.
Table 1 Basic sample characteristics of B-SNIP sample
Total B-SNIP
sample (N=933)

Current B-SNIP
sample (N=860)

36.2±12.6

36.1±12.6

Men

471 (50.5)433 (50.4)

Women

461 (49.4)

427 (49.7)

Caucasian530 (56.8)

496 (57.7)

African American

338 (36.2)

306 (35.6)

Other

61 (6.5)

57 (6.6)

Schizophrenia

397 (42.6)

353 (41.1)

Schizoaffective disorder224 (24.0)

216 (25.1)

Psychotic bipolar I disorder

312 (33.4)

291 (33.8)

Age (years, mean±SD)
Gender, N (%)

Ethnicity, N (%)

DSM diagnosis, N (%)

B-SNIP – Bipolar-Schizophrenia Network on Intermediate Phenotypes

World Psychiatry 18:1 - February 2019

Dimensionality of psychotic disorders
Initial analysis of symptom ratings on the PANSS indicatedthat a bifactor model with one general and five specific factors best matched the B-SNIP sample data (AIC=53209.8,
BIC=53920.0, SABIC=53443.7). Building on this initial step, wenext compared item response models for symptom ratings on
all measures for assessing psychosis, mania and depression(i.e., PANSS, YMRS, MADRS). This showed that the bifactor
model with general, non-affective, affective and five specificfactors (i.e., model D) provided the best model fit, as indicatedby the lowest AIC, BIC and SABIC (AIC=65988.4, BIC=67201.4,
SABIC=66391.6) compared with alternative models (Table 2).
Findings on the best-fitting model showed that the largest
amount of item variance was explained by the general psychosis dimension (ωH=0.67), followed by negative (ωS=0.45),
depressive (ωS=0.38) and positive (ωS=0.30) symptom dimensions (Table 3).
Overall, factor loadings were heterogeneous in magnitude across symptom dimensions. Factor loadings for thegeneral psychosis dimension were moderate to strong formost positive, negative, disorganized, manic and depressive
symptom ratings of PANSS and YMRS items, but weaker for
MADRS items (Table 4). The non-affective psychosis dimensions showed the strongest factor loadings for negative anddisorganized symptom ratings on the PANSS. Factor loadings for the affective psychosis dimension were strongest for
MADRS depressive symptom ratings and, to a lesser extent,
YMRS manic symptom ratings. Specific positive and negative
symptom dimensions demonstrated moderate to strong factor
loadings for most items of the PANSS, whereas factor loadings
for the specific disorganized symptom dimension were only
weak to moderate at most. Factor loadings for specific manic
and depressive symptom factors were strongest for YMRS andMADRS, respectively.
Symptom profiles showed that, compared with psychotic
bipolar I disorder, factor scores on the general, non-affective,
affective, positive, negative, disorganized and depressive symptom dimensions were higher for schizoaffective disorder (allp<0.05) (Table 4). By contrast, factor scores on the specificmanic symptom dimension were lower for schizoaffective thanpsychotic bipolar I disorder (p<0.001). Further, factor scores on
the non-affective, positive, negative and disorganized symptom
dimensions were higher, and factor scores on the affective andmanic symptom dimensions lower, for schizophrenia than for
psychotic bipolar I disorder (all p<0.001).
Table 4 further shows that factor scores for the general psychosis dimension were significantly higher for patients with
African American than Caucasian ethnicity (p=0.001) and withlower social functioning (p<0.001). Further, factor scores forthe non-affective psychosis dimension were lower in women(p<0.001), but higher in younger patients (p=0.001) and patients with lower social functioning (p=0.023). Factor scoresfor the affective psychosis dimension increased with increasingage (p=0.017) and were higher in female patients (p<0.001) and69

Table 2 Model fit statistics for unitary (unidimensional), pentagonal (multidimensional), and bifactor models of psychosis based on PANSS,YMRS and MADRS symptom ratings
LL

FP

AIC

BIC

SABIC

Unidimensional (unitary) model (Model A)–35660.2

15371626.4

72354.2

71868.3

Multidimensional (pentagonal) model with five correlated specific factors (Model B)–33615.3

16367556.5

68331.967814.3

Bifactor model with one general factor and five specific symptom factors (Model C)–33253.0

20466914.1

67884.567236.6

Bifactor model with one general factor, two factors for non-affective and affective
psychosis, and five specific symptom factors (Model D)–32739.2

25565988.4

67201.4

66391.6

Bifactor model with two factors for non-affective and affective psychosis and five specificsymptom factors (model E)–33372.9

20467153.7

68124.2

67476.3

PANSS – Positive and Negative Syndrome Scale, YMRS – Young Mania Rating Scale, MADRS – Montgomery-Åsberg Depression Rating Scale, LL – log-likelihood,
AIC – Akaike information criterion, BIC – Bayesian information criterion, SABIC – sample size-adjusted Bayesian information criterion. All response vectors with atleast one response were analyzed (N=860). Model D provides the best model fit, as indicated by lower BIC, AIC and SABIC compared to other models.

those with lower social functioning (p=0.020). Older patients
had higher factor scores on specific positive and disorganizedsymptom dimensions. Female patients scored lower on thespecific positive symptom dimension and higher on the specific depressive symptom dimension (all p<0.05).
Compared with Caucasian patients, patients with African
American ethnicity had higher factor scores on the positive,
negative and disorganized symptom dimensions and lower
scores on the depressive symptom dimension (all p<0.05).
Social functioning decreased as scores on positive, negative,
disorganized and depressive symptom dimensions increased,
whereas social functioning increased with increasing scores on
the manic symptom dimension (all p<0.05).
When we examined the utility of symptom dimensions forclassifying patients correctly into categorical DSM diagnosesof psychotic disorders using multinomial ROC analysis, thisshowed that the proportion of patients correctly classified into
diagnostic categories based on factor scores of general, nonaffective, affective and specific symptom dimensions (M=0.57,
95% CI: 0.53-0.62) was higher compared with classifying patients by chance (M=0.39, 95% CI: 0.33-0.44).
We next examined the utility of symptom dimensions for
accurately predicting the B-SNIP psychosis biotypes. Figure 1(and Table 4) shows high non-affective, positive, negative anddisorganized symptom factor scores for Biotype 1; high affective, manic and depressive symptom factor scores for Biotype
3; and high general symptom dimension (and moderate othersymptom dimension) factor scores for Biotype 2.
There was evidence that the proportion of patients correctlyclassified into B-SNIP biotypes based on factor scores of general, non-affective, affective and specific symptom dimensions(M=0.41, 95% CI: 0.35-0.47) was higher than what would be expected by chance (M=0.35, 95% CI: 0.29-0.41). However, this did
not hold for categorical DSM diagnoses (DSM diagnoses: M=0.41,
95% CI: 0.36-0.46; random accuracy: M=0.38, 95% CI: 0.31-0.44).
As can be seen in Figure 2, findings on ROC curves further indicated that patients were classified into B-SNIP biotypes with greater accuracy based on symptom dimensions(AUC=0.87) than DSM diagnoses (AUC=0.68).

70

DISCUSSION
Main findings
This study provides evidence of a transdiagnostic dimen­sion underlying affective and non-affective psychotic symptoms in patients with psychotic disorder in the B-SNIP consortium. There was further evidence to suggest that formationof distinct dimensions of non-affective and affective psychosis
as well as specific psychosis dimensions of positive symptoms,
negative symptoms, disorganization, mania and depression
is justified.
Transdiagnostic, non-affective, affective and specific symptom dimensions were differentially associated with age, gen­der, ethnicity and social functioning, and classified patients
correctly into categorical DSM diagnoses. Finally, there was­evidence on the utility of symptom dimensions for predicting
the B-SNIP biotypes with greater accuracy than DSM diag­noses.

Methodological considerations
In the current study, we examined the dimensionality ofpsychotic disorders in a large sample of patients with schizophrenia, schizoaffective and bipolar I disorder with psychosis.
This sample allowed for multidimensional item response modeling to identify variance driven by a transdiagnostic psychosis
dimension independent from variance due to non-affective, affective and specific symptom dimensions based on extensively
studied measures of psychosis, mania and depression (i.e., the
PANSS, YMRS and MADRS).
While further sub-dimensions of mania, depression andother specific symptom dimensions (positive, negative and­disorganized symptoms) may have been considered, the focusof the current study was on transdiagnostic, affective/nonaffective psychosis and specific symptom dimensions, but not
subcomponents of these (e.g., avolition as a subcomponent of
the negative symptom dimension; euphoria as a subcompo-

World Psychiatry 18:1 - February 2019

World Psychiatry 18:1 - February 2019

71

0.55
0.45
0.54
0.63
0.55
0.48
0.09
0.42
0.38
0.30
0.28
0.27
0.55
0.50
0.58
0.24
0.61
0.55
0.57
0.67
0.68
0.70
0.74
0.72
0.76
0.46
0.52
0.33
0.64
0.40

Hallucinatory behaviour

Grandiosity

Suspiciousness

Unusual thought content

Lack of judgment and insightBlunted affectEmotional withdrawal

Poor rapport

Passive social withdrawal

Lack of spontaneity

Motor retardation

Disturbance of volition

Active social avoidanceConceptual disorganization

Difficulty in abstract thinking

Stereotyped thinking

Mannerisms and posturing

Disorientation

Poor attention

Preoccupation

Excitement

Hostility

Uncooperativeness

Poor impulse control

Somatic concern

Anxiety

Guilt feelings

TensionDepression

GeneralDelusions

PANSS

Items

0.23

0.27

0.22

0.50

0.40

0.32

0.27

0.02

0.30

0.66

0.69

0.16

0.59

0.28

0.69

0.32

0.34

0.04

–0.00

0.20

0.22

Non-affective

0.30

0.22

0.21

0.38

0.16

0.10

–0.07

0.16

0.14

Affective

0.15

0.53

0.32

0.20

0.48

0.75

Positive symptoms

0.71

0.35

0.38

0.39

0.80

0.40

0.73

0.44

Negative symptoms

0.34

0.15

–0.11

0.20

0.46

0.06

0.44

Disorganization

0.05

0.07

0.09

0.32

Mania

0.68

0.17

0.26

0.39

0.14

Depression

Table 3 Factor loadings in bifactor model with general, non-affective, affective, and five specific symptom factors based on PANSS, YMRS, and MADRS symptom ratings

72

World Psychiatry 18:1 - February 2019

0.28
0.24
0.16
0.48
0.38
0.51
0.55
0.63
0.26
0.38

Increased motor activity-energy

Sexual interest

Sleep

Irritability

Speech (rate and amount)

Language-thought disorder

Content

Disruptive-aggressive behavior

Appearance

Insight

0.27
0.39
0.12
0.23
0.31
0.24
0.30
0.27
0.30
0.67

Reported sadness

Inner tension

Reduced sleep

Reduced appetite

Concentration difficulties

Lassitude

Inability to feel

Pessimistic thoughts

Suicidal thoughtsωH / ωS
0.23

Non-affective

0.25

0.39

0.41

0.39

0.36

0.43

0.57

0.96

0.52

0.36

0.29

–0.11

0.07

0.22

0.10

0.19

0.22

0.44

0.88

0.15

0.17

0.11

Affective

0.30

Positive symptoms

0.45

Negative symptoms

0.09

Disorganization

0.20

0.12

0.16

0.27

0.35

0.47

0.73

0.16

0.22

0.52

0.79

0.81

Mania

0.38

0.63

0.60

0.55

0.56

0.37

0.26

–0.03

0.38

0.81

0.74

Depression

PANSS – Positive and Negative Syndrome Scale, YMRS – Young Mania Rating Scale, MADRS – Montgomery-Åsberg Depression Rating Scale, ωH/ωS – proportion of item variance explained by general,
non-affective and affective factors (ωH) and specific factors (ωS)

0.29

Apparent sadness

MADRS

0.31

GeneralElevated mood

YMRS

Items

Table 3 Factor loadings in bifactor model with general, non-affective, affective, and five specific symptom factors based on PANSS, YMRS, and MADRS symptom ratings (Continued)

World Psychiatry 18:1 - February 201973

0.02 (–0.24 to0.28), 0.855–0.01 (–0.01 to–0.00), <0.001

Other vs. CaucasianSocial functioning

0.06 (–0.09 to0.21), 0.417

Schizophrenia vs. bipolar disorder

0.03 (–0.14 to0.20), 0.712

Biotype 3 vs. biotype 1–0.37 (–0.53 to–0.22), <0.001–0.13 (–0.29 to0.04), 0.132

0.70 (0.58 to0.83), <0.001

0.27 (0.13 to0.41), <0.001–0.00 (–0.01 to–0.00), 0.023

0.00 (–0.24 to0.24), 0.976

0.05 (–0.08 to0.17), 0.456–0.33 (–0.44 to–0.22), <0.001–0.01 (–0.01 to0.00), 0.001

B-SNIP – Bipolar-Schizophrenia Network on Intermediate Phenotypes

0.16 (–0.01 to0.34), 0.070

Biotype 2 vs. biotype 1

B-SNIP biotypes

0.34 (0.17 to0.50), <0.001

Schizoaffective vs. bipolar disorder

DSM diagnosis

0.22 (0.09 to0.35), 0.001

0.09 (–0.04 to0.22), 0.156–0.00 (–0.01 to0.00), 0.167

B (95% CI), p

B (95% CI), p

African American vs. CaucasianEthnicity

Women vs. men

GenderAge

Non-affective

General0.12 (–0.03 to0.28), 0.117

0.19 (0.03 to0.35), 0.022–0.40 (–0.54 to–0.28), <0.001

0.15 (0.01 to0.30), 0.042–0.00 (–0.01 to–0.00), 0.020

0.02 (–0.22 to0.26), 0.858–0.04 (–0.17 to0.08), 0.487

0.26 (0.15 to0.38), <0.001

0.01 (0.00 to0.01), 0.017

B (95% CI), p

Affective–0.26 (–0.42 to–0.11), 0.001–0.09 (–0.25 to0.07), 0.283

0.75 (0.63 to0.87), <0.001

0.87 (0.74 to1.00), <0.001–0.01 (–0.01 to–0.01), <0.001

0.22 (–0.02 to0.45), 0.071

0.23 (0.11 to0.35), <0.001–0.16 (–0.27 to–0.05), 0.006

0.01 (0.00 to0.01), 0.010

B (95% CI), p

Positive
symptoms–0.21 (–0.37 to–0.05), 0.010–0.05 (–0.22 to0.12), 0.574

0.55 (0.42 to0.68), <0.001

0.58 (0.43 to0.73), <0.001–0.01 (–0.02 to–0.01), <0.001

0.12 (–0.12 to0.37), 0.325

0.16 (0.03 to0.29), 0.013–0.02 (–0.14 to0.09), 0.683

0.00 (–0.00 to0.01), 0.282

B (95% CI), p

Negative
symptoms–0.30 (–0.44 to–0.16), <0.001–0.16 (–0.30 to–0.01), 0.033

0.53 (0.42 to0.64), <0.001

0.46 (0.33 to0.58), <0.001–0.01 (–0.01 to–0.00), <0.001

0.06 (–0.14 to0.27), 0.554

0.20 (0.09 to0.30), <0.001–0.07 (–0.17 to0.03), 0.179

0.01 (0.01 to0.01), <0.001

B (95% CI), p

Disorganization

Table 4 Factor scores of general, non-affective, affective and specific symptom dimensions by socio-demographic and clinical variables
Mania

0.02 (–0.12 to0.17), 0.751–0.01 (–0.16 to0.15), <0.924–0.24 (–0.37 to–0.12), <0.001–0.30 (–0.48 to–0.15), <0.001

0.01 (0.01 to0.01), <0.001–0.10 (–0.33 to0.13), 0.377

0.00 (–0.11 to0.12), 0.977–0.02 (–0.13 to0.09), 0.684

0.00 (–0.00 to0.01), 0.401

B (95% CI), p

Depression

0.13 (–0.04 to0.29), 0.129

0.11 (–0.06 to0.29), <0.001–0.08 (–0.22 to0.06), 0.286

0.29 (0.13 to0.45), <0.001–0.01 (–0.01 to–0.00), <0.001

0.09 (–0.17 to0.35), 0.489–0.16 (–0.30 to–0.03), 0.017

0.22 (0.10 to0.34), 0.001–0.00 (–0.01 to0.00), 0.356

B (95% CI), pComparison with previous research

General psychosis
Affective psychosis

Non-affective psychosis

Depression

Positive symptoms

0

Mania

Negative symptoms.5

Disorganization

Biotype 1
Biotype 3

Biotype 2

Figure 1 Symptom profiles by the Bipolar-Schizophrenia Network on
Intermediate Phenotypes (B-SNIP) biotypes

nent of mania; or anhedonia as a subcomponent of depression). Models to account for these subcomponents would havebeen difficult to estimate even with the sample size obtainedin this study, given the high number of items required and freeparameters to be estimated in such models. Further, a more
stringent measurement design (e.g., a multitrait-multimethod
design) would have been required to disentangle measurementfrom substantive conceptual variance.
The use of YMRS and MADRS as more detailed measuresof mania and depression, however, did allow us to capture abroader spectrum of variance than would have been the casewhen using the PANSS alone, and hence provided a betterreflection of these specific symptom dimensions. They now
need to be investigated further to disentangle method and substantive conceptual variance, using comprehensive measuresof psychopathology in large samples of psychotic disorders,
including psychotic depression.

Evidence on a transdiagnostic dimension underlying affective and non-affective psychotic symptoms in the current
sample of clinically stable patients is consistent with our earlier
findings on such a dimension in patients with early and enduring psychosis4,5. Reverberating the results of numerous previous studies30, including our own4,5, we identified five specificsymptom dimensions of positive symptoms, negative symptoms, disorganization, mania and depression.
Our findings move beyond those from previous research inproviding evidence of distinct non-affective and affective psychosis dimensions in addition to transdiagnostic and specificsymptom dimensions. These were primarily characterized bynegative and disorganized symptom ratings (for the non-affective dimension) and depressive and manic symptom ratings(for the affective dimension).
According to the recently proposed hierarchical taxonomy
of psychopathology24, the broad transdiagnostic psychosis dimension may best be interpreted at the level of psychopathological super-spectra or higher-order dimensions, whereas specific symptom dimensions may be classified at lower levels as
symptom components, and non-affective and affective psychosis dimensions as psychopathological spectra or syndromes24.
While the latter may resemble the previously reported
thought disorder and internalizing dimensions2, the extent towhich the transdiagnostic psychosis dimension overlaps with,or is independent from, a general psychopathology factor43 re­mains to be established. As the evidence base on the dimensionality of psychotic disorders continues to emerge and strengthen,
the need for transdiagnostic investigations of psychotic andnon-psychotic disorders becomes more pressing to examine
important spectra or syndromes across disorders.
Notably, our finding of higher factor scores on the positive,
negative and disorganized symptom dimensions and lower
scores on the depressive symptom dimension in patients with
African American ethnicity compared with Caucasian patients is
in line with earlier studies reporting higher positive44,45, negative45

AUC=0.87

AUC=0.68
True positive rate

True positive rate

1
0.8
0.6
0.4
0.2
0

0

0.2

0.4

0.6

0.8

1

1
0.8
0.6
0.4
0.2
0

0

0.2

0.4

0.6

0.8

False positive rate

False positive rate

Symptom dimensions

Categorical DSM diagnoses

1

Figure 2 Multinomial receiver operating characteristic (ROC) curves of transdiagnostic symptom dimensions and categorical DSM diagnoses
used in the prediction of Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) biotypes (discontinuities due to rounding of
the estimated density functions)74

World Psychiatry 18:1 - February 2019and disorganized44 symptom scores, as well as lower depressive
symptom scores44, in patients with Black African compared withWhite Dutch and White British ethnicity in the Netherlands45
and the UK44, respectively. Our findings additionally showed thatfactor scores on the transdiagnostic psychosis dimension werehigher for African American than Caucasian patients. Overall,
the associations between transdiagnostic, non-affective, affective
and specific symptom dimensions on the one hand, and age, gender, ethnicity and social functioning on the other, were broadly
consistent with the clinical and social epidemiology of psychosis
and, therefore, in support of their concurrent validity17,46-49.
These dimensions, however, need not only be valid but also
useful14. In order to elucidate the utility of the symptom dimensions we identified here, we investigated their accuracy
for classifying patients into categorical DSM diagnoses and the
B-SNIP psychosis biotypes. Overall, strong diagnostic utility ofthe transdiagnostic, non-affective, affective and specific symptom dimensions for allocating patients to DSM diagnoses wasdemonstrated with the PANSS, YMRS and MADRS, which are
all established clinical symptom measures that can be used inboth research and routine care. Since our findings on symptom
profiles by DSM diagnoses were consistent with operational
definitions of current classification systems, these may provide
a basis for a psychometrically-informed approach for more accurate classification of patients into these diagnoses.
When we examined the utility of symptom dimensions in relation to the recently identified B-SNIP biotypes32, this showedthat patients were classified into these biotypes with greater
accuracy based on symptom dimensions than categorical DSM
diagnoses. Findings further showed more pronounced nonaffective (Biotype 1), affective (Biotype 3) and transdiagnostic (Biotype 2) dimensional symptom profiles for individual
B-SNIP biotypes (Figure 1).
More generally, these findings show how dimensional psychopathological phenotypes can be characterized by connecting them to basic neurobiological constructs and, vice versa,
offer valid dimensional psychopathological phenotypes toresearch into basic neurobiological dimensions of psychopathology such as RDoC12,20,21,24. In other words, joining hands
rather than viewing phenomenological and neurobiologicalapproaches as separate or competing endeavors may be theway forward.

CONCLUSIONS
Our findings provide new evidence on the dimensionalityof psychosis spectrum disorders and, specifically, suggest thata transdiagnostic psychosis dimension, distinct non-affective
and affective psychosis dimensions and five specific symptom
dimensions best account for symptom data collected using
widely established measures in patients with schizophrenia,
schizoaffective and bipolar I disorder with psychosis. There
was also strong evidence on the utility of these dimensions inrelation to categorical DSM diagnoses and B-SNIP psychosis

World Psychiatry 18:1 - February 2019

biotypes. This should inform use of dimensional approaches
in current diagnostic classification systems.
Findings further show promising avenues for research at theinterface of dimensional psychopathological phenotypes andother transdiagnostic approaches such as RDoC focusing on
basic neurobiological dimensions of psychopathology1-17,20,21.
This needs to be extended to transdiagnostic investigations ofshared and non-shared genetic and socio-environmental factors of symptom dimensions of psychotic and non-psychotic
disorders to examine overlap (and independence) of important spectra or syndromes and more fully map and model thedimensionality of mental disorders as a basis for (more) valid
diagnostic classification systems.

ACKNOWLEDGEMENTS
U. Reininghaus and J.R. Böhnke contributed to this work as joint first authors.
The study was supported by the Netherlands Organization for Scientific Re­
search (NOW) Veni grant 451-13-022 and the US National Institute of Mental
Health (NIMH) grants MH-077851, MH-078113, MH-077945, MH-077852 andMH-077862. The authors thank B. Witte and G. Poudyal for their contributions
to data management, which allowed for seamless analysis and inspection of all
B-SNIP data resources, and the patient and family volunteers who joined thestudy and contributed their time and individual data.

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DOI:10.1002/wps.20607

World Psychiatry 18:1 - February 2019

RESEARCH REPORT

Estimating the risk of PTSD in recent trauma survivors: resultsof the International Consortium to Predict PTSD (ICPP)
Arieh Y. Shalev1, Martin Gevonden2, Andrew Ratanatharathorn3, Eugene Laska1, Willem F. van der Mei1, Wei Qi1, Sarah Lowe4, Betty S. Lai5,
Richard A. Bryant6, Douglas Delahanty7, Yutaka J. Matsuoka8, Miranda Olff9, Ulrich Schnyder10, Soraya Seedat11, Terri A. deRoon-Cassini12,
Ronald C. Kessler13, Karestan C. Koenen14; International Consortium to Predict PTSD*
1

Department of Psychiatry, New York University School of Medicine, New York, NY, USA; 2Department of Biological Psychology, Vrije Universiteit, Amsterdam, The Nether­lands; 3Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA; 4Department of Psychology, Montclair State University,Mont­clair, NJ, USA; 5Department of Counseling, Developmental and Educational Psychology, Lynch School of Education, Boston College, Chestnut Hill, MA, USA; 6School of
Psychology, University of New South Wales, Sydney, NSW, Australia; 7Department of Psychological Sciences, Kent State University, Kent, OH, USA; 8Division of Health Care
Research, Center for Public Health Sciences, National Cancer Center Japan, Tokyo, Japan; 9Department of Psychiatry, University of Amsterdam, Amsterdam, The Netherlands,
and Arq Psycho­trauma Expert Group, Diemen, The Netherlands; 10University of Zurich, Zurich, Switzerland; 11Department of Psychiatry, Stellenbosch University, Parow, CapeTown, South Africa; 12Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA; 13Department of Health Care Policy, Harvard Medical School, Boston, MA,
USA; 14Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA*Members of the International Consortium to Predict PTSD are listed in the Appendix

A timely determination of the risk of post-traumatic stress disorder (PTSD) is a prerequisite for efficient service delivery and prevention.
We provide a risk estimate tool allowing a calculation of individuals’ PTSD likelihood from early predictors. Members of the International
Consortium to Predict PTSD (ICPP) shared individual participants’ item-level data from ten longitudinal studies of civilian trauma survivors
admitted to acute care centers in six countries. Eligible participants (N=2,473) completed an initial clinical assessment within 60 days of trauma
exposure, and at least one follow-up assessment 4-15 months later. The Clinician-Administered PTSD Scale for DSM-IV (CAPS) evaluated
PTSD symptom severity and diagnostic status at each assessment. Participants’ education, prior lifetime trauma exposure, marital status andsocio-economic status were assessed and harmonized across studies. The study’s main outcome was the likelihood of a follow-up PTSD given
early predictors. The prevalence of follow-up PTSD was 11.8% (9.2% for male participants and 16.4% for females). A logistic model using early
PTSD symptom severity (initial CAPS total score) as a predictor produced remarkably accurate estimates of follow-up PTSD (predicted vs. raw
probabilities: r=0.976). Adding respondents’ female gender, lower education, and exposure to prior interpersonal trauma to the model yieldedhigher PTSD likelihood estimates, with similar model accuracy (predicted vs. raw probabilities: r=0.941). The current model could be adjusted
for other traumatic circumstances and accommodate risk factors not captured by the ICPP (e.g., biological, social). In line with their use ingeneral medicine, risk estimate models can inform clinical choices in psychiatry. It is hoped that quantifying individuals’ PTSD risk will be afirst step towards systematic prevention of the disorder.
Key words: Post-traumatic stress disorder, prediction, risk assessment tool, trauma survivors, clinician-administered PTSD scale for DSM-IV(CAPS), female gender, lower education, exposure to prior interpersonal trauma, prevention(World Psychiatry 2019;18:77–87)

Post-traumatic stress disorder (PTSD) is the most frequent psy­
chopathological consequence of traumatic events1,2. Chronic
PTSD is tenacious, debilitating and frequently intractable3-9.
Early PTSD symptoms are sensitive but non-specific predictorsof chronic PTSD10. They subside in over 70% of those expressing
them11-13, whilst few initially asymptomatic survivors develop
delayed-onset PTSD14.
Early cognitive behavioral interventions significantly reduce
the prevalence of PTSD, and their effect is stable8,15,16. These
interventions, however, are resource-demanding, and unnecessary for low-risk survivors, whose symptoms subside spontaneously15,17. Thus, an accurate individual estimate of survivors’risk for chronic PTSD is a prerequisite for efficient prevention
and service planning18.
Previous studies have had difficulty producing such estimates, due to the multiplicity, complexity and distributionalvariation of PTSD risk indicators. Additionally, most studies
have attempted to predict cases (i.e., who will develop PTSD)
rather than produce PTSD likelihood estimates for every participant (i.e., how likely is a person to develop PTSD)19,20.
Longitudinal studies have nonetheless reported numer­
ous group-level PTSD risk indicators21,22, such as female gen­World Psychiatry 18:1 - February 2019

der23,24, age23, education25, ethnicity26, lifetime exposure totraumatic events27, and marital status24. Several symptombased case predictions have been developed, consistently performing better than chance28-31, but unable to build a reliable,
personalized risk estimator32. Meta-analyses21,22 and systematic reviews21,22,33,34 have similarly endorsed group-level risk
indicators without a clear path to clinical implementa­tion34.
Trauma admissions to acute care centers and emergency
departments (EDs) offer a first point of contact with numerous
survivors at risk. EDs evaluate in the US over 39 million individuals yearly for treatment of traumatic injury35-39. Worldwide,
road traffic accidents, a mainstay cause of ED admissions,cause an estimated 1.25 million deaths and over 20 million
non-fatal injuries yearly40.
The prevalence of PTSD after ED admissions resembles thatseen in survivors who do not require or receive ED care – e.g., 52%
incidence of new PTSD among women survivors of interperson­
al violence admitted to EDs vs. 51-76% among women surveyed
in shelters, domestic-violence clinics and therapy groups41,42.
The 18-month prevalence of PTSD among drivers admitted togeneral hospitals after injury-producing car crashes (11%) issomewhat higher than that of car drivers not seen in EDs (7%)43.

77

Quantifying individuals’ PTSD risk following acute care trauma admission could provide an empirical foundation for mitigating and preventing a major public health issue. Towards that
goal, members of the International Consortium to Predict PTSD(ICPP) shared item-level data from ten longitudinal, acute carebased studies of the early development of PTSD, performed in
the US, Australia, Japan, Israel, Switzerland, and The Nether­lands. The data were harmonized, pooled into a single individual participant-level dataset (IPD) and submitted to data
analysis.
An analysis of IPD, or mega-analysis, offers a sensible approach to aggregating data across studies44,45. Unlike systematic
reviews and meta-analyses, mega-analyses do not rely on theoriginal studies’ data analytic approaches and reporting perspectives and enable direct estimates of parameters of interest(i.e., predictors, outcomes). This allows data source heterogeneity and subgroup variations to be examined directly, andmakes it possible to interrogate the combined data in ways notconsidered, or impossible, in the component studies, due totheir sample sizes or limited population diversity46,47.
In line with current medical risk assessment practices (e.g.,in oncology48-50, surgery or cardiology51-54), we used the ICPP
IPD to develop a prediction function that estimates the probability of PTSD given a set of early, observable risk indicators.
Following replicated demonstrations of their predictive yield inclassification models55-62, we positioned PTSD symptoms as a
key predictor, subsequently enriching the predictive models by
including other previously documented and clinically-obtainable risk indicators available in the ICPP dataset (e.g., gender,
trauma type, lifetime trauma history).

METHODS
Studies, participants and variables
Using a previously described literature search strategy63, the
ICPP IPD consisted of thirteen longitudinal acute-care based
studies of recent trauma survivors conducted in six countries.
Investigators obtained informed consent using procedures
approved by their local institutional review boards. Item-level
data from studies were shared, harmonized (see below) andcombined into a pooled dataset. All ICPP studies used theDSM-IV PTSD template to infer PTSD diagnosis and symptom
severity. Included in this report are the ten studies15,64-72 thatused the repeatedly validated Clinician-Administered PTSD
Scale for DSM-IV (CAPS)73,74.
Study participants were included if they had an initial CAPS
interview within 60 days of the traumatic event, and at least one
follow-up CAPS assessment 4 to 15 months (122 to 456 days)
after trauma exposure. These criteria were met by 2,473 partic­
ipants (Table 1). To maximize the utility of prediction, we usedthe earliest observation for individuals with two early (<60 days)
assessments, and the latest observation for those with multiple
assessments during follow-up.

78

PTSD severity and diagnosis
The CAPS quantifies the frequency and severity of each of
the seventeen DSM-IV PTSD symptom criteria73 by assigningto each symptom a 0-4 incremental frequency score and a0-4 intensity score. A continuous measure of PTSD severity is
obtained by adding all individual symptom scores (CAPS total
score). A diagnosis of PTSD is determined using DSM-IV PTSD
diagnostic criteria of at least one re-experiencing (CriterionB), three avoidance/numbing (Criterion C), and two hyperarousal (Criterion D) symptoms73. Following recommendations,a PTSD symptom was deemed “present” if its frequency score
was 1 or more, and its intensity score was 2 or more74,75.
Information on DSM-IV Criterion E (duration of at least one
month) and F (clinically significant distress or impairment)
were collected in four out of the ten studies. A sensitivity analysis within these studies found very high concordance between
diagnoses determined by meeting DSM-IV symptom criteria alone (i.e., criteria B through D) and those obtained using
both the symptom criteria and the E and F criteria (sensitivity
0.92, specificity 1.00, Cohen’s kappa=0.95). We consequently
assumed PTSD diagnosis as present, across studies, based on
meeting DSM-IV PTSD symptom criteria alone.

Risk indicators
The study’s primary risk indicator was PTSD severity at
the initial assessment (CAPS0, range 0-136), with age, gender,
ethnicity, educational attainment, lifetime history of trauma
exposure, and current trauma type considered as additional
predictors.
Differences in data collection and instruments across studies required harmonization of four risk indicators. Educational
attainment, which varied by participating countries’ schoolingsystems, was recoded into a binary variable of less than secondary education versus completion of at least secondary education.
Recoding participants’ lifetime exposure to traumatic events followed a previous demonstration of a strong association between
interpersonal trauma and PTSD76 and included: a) exposure
to at least one instance of interpersonal violence (e.g., physical or sexual violence, war or terror), b) in the absence of theformer, exposure to at least one instance of non-interpersonal
trauma (e.g., road traffic accidents), and c) no trauma exposure.
Traumatic events leading to current acute care admission werecategorized as motor vehicle accidents, other non-interpersonal
events, and interpersonal violence (e.g., assaults).

Data completeness and handling missing observations
CAPS0 data were available for all 2,473 participants. Data onage, gender, and current trauma were available for >99% of thesample. Marital status was missing in 4.5%, education in 6.2%,
ethnicity in 12.3%, and prior trauma in 16.8% of the sample.

World Psychiatry 18:1 - February 2019

World Psychiatry 18:1 - February 2019

79

74
85

Gender (% male)High school education (%)

0

22

3.7

25.9

4.3

13.3±13.0

NA

NA

NA

0

69

31

83

67

41.3±12.9

255

SUI

Jenewein
et al679.1

24.8±22.6

7

42

48

0

0

100

93

53

39.1±15.4

143

US

Irish
et al689.9

16.9±15.6

12

61

27

6

29

65

68

72

38.7±13.6

825

AUS

Bryantet al6919.4

25.9±24.7

19

38

42

11

5

82

90

60

31.9±11.7

103

ISR

Shalev
et al7023.6

57.1±24.9

27

32

33

12

6

82

81

51

37.2±12.0

529

ISR

Shalev
et al158.7

20.0±17.4

27

28

45

0

0

100

83

66

38.8±16.1

92

JPN

Matsuoka
et al715.7

20.7±18.5

13

46

41

3

32

65

78

61

44.5±15.7

348

NLD

Mouthaan
et al722.4

38.5±19.4

0

50

50

10

21

69

64

50

36.9±14.0

42

NLD

Frijling
et al6611.8

27.4±25.1

14

40

29

6

25

69

77

63

39.0±13.9

2,473

Total
sampleCAPS – Clinician-Administered PTSD Scale for DSM-IV, PTSD – post-traumatic stress disorder, SUI – Switzerland, ISR – Israel, US – United States, AUS – Australia, JPN – Japan, NLD – The Netherlands,
NA – not available

Endpoint PTSD (%)

33.8±31.5

NA

Baseline CAPS score (mean±SD)21.6±15.3

NA

Non-interpersonalInterpersonal

67

NA

None

Prior trauma (%)
7

7

40

Other non-interpersonalInterpersonal

7

60

85

NA

59

28.4±10.5

27

ISR

Shalev
et al65

Motor vehicle accident

Trauma type (%)

38.0±13.1

109

Eligible participants (N)Age (mean±SD)

SUICountryHepp
et al64

Table 1 Key participant characteristics in contributing studies and in the total sample

Table 2 Comparison of participants with complete and incomplete
data
VariableComplete(N=1,682)

Incomplete(N=791)p

Age (mean±SD)37.5±14.1

39.0±13.6

0.347

CAPS0 (mean±SD)

21.0±26.0

14.0±22.3<0.001Male

1,028 (66)533 (34)<0.001

Female654 (72)251 (28)

1,502 (76)481 (24)

180 (97)5 (3)At least secondary education

1,389 (73)505 (27)

Less than secondary education

293 (69)133 (31)

Married/living with a partner

860 (74)304 (26)

Single/not living with a partner

822 (69)375 (31)

Motor vehicle accident

1,285 (75)421 (25)

Other non-interpersonal291 (47)329 (53)

Interpersonal

106 (77)

31 (23)None

298 (86)

49 (14)

Non-interpersonal626 (87)

93 (13)

Interpersonal758 (76)

233 (24)

No

1,474 (68)708 (32)Yes

208 (71)

83 (29)Gender, N (%)

Ethnicity, N (%)
White
Non-White<0.001

Education, N (%)
0.057

Marital status, N (%)
0.005

Trauma type, N (%)<0.001

Prior trauma, N (%)<0.001

Endpoint PTSD, N (%)
0.178

PTSD – post-traumatic stress disorder, CAPS0 – baseline score on ClinicianAdministered PTSD Scale for DSM-IV

Participants missing at least one variable (N=791; 32%) differed from those with complete data (N=1,682) with respect
to several risk indicators (Table 2). To address these missing
observations, we present analyses in which missing predictors
were handled by multiple imputation using chained equations(MICE) performed on the IPD77. Ten imputed datasets werecreated after twenty iterations and the results were pooled using Rubin’s method78. For completeness, we also computed theresults using individuals who had complete data (i.e., without
imputation). The results did not differ substantially from thoseobtained after imputation and are available upon request.

Data analyses
Differences in frequency and severity of risk predictors
between participants with and without endpoint PTSD were80

assessed using Mann–Whitney tests for continuous risk predictors and χ2 tests for categorical risk predictors. The number ofparticipants endorsing each CAPS0 severity score (smoothed
for five-points intervals) was visualized using a histogram,separately for all participants and for those with PTSD at the
study’s endpoint.
The relatively large sample size in the ICPP dataset enabled
us to obtain simple raw estimates of the probability of downstream PTSD for each CAPS0 score. The estimator used was
the fraction of PTSD cases among all individuals with a given
CAPS0 score, smoothed with a window of five adjacent points.
Logistic regression models were obtained using CAPS0 as
the only predictor (CAPS0 model), CAPS0 plus all risk predictors (full model), and CAPS0 plus significant predictors only
(significant predictors model). The models’ fits were evaluatedusing the Brier score79, Efron’s R2, model’s predicted-to-raw
ratio, and the area under the receiver operating characteristic
curve (AUC).
The Brier score79 measures the accuracy of probabilistic predictions. It expresses the mean standard error of the squared
difference between the estimated probabilities and the true
PTSD classification. Its range is 0 to 1. A Brier score of zero
represents a perfect model and scores of 0.25 or greater signal
a non-informative model. Efron’s R2 is the correlation between
the predicted probabilities and the smoothed probabilities.
Two options were considered for selecting the regression
model’s intercept: a fixed effects intercept, where a common
intercept is estimated after pooling or “stacking” the data together, and a random effects intercept, where the intercept isallowed to vary by study44. Random effects (or stratified approaches) have not been recommended when the prevalenceof an outcome varies substantially between studies44, as is thecase with the ICPP studies. Alternatively, it could be hypothesized that heterogeneity in endpoint PTSD prevalence across
ICPP studies reflected heterogeneity in the distribution of
CAPS0 severity across studies, which was due to variability instudies’ sampling routine. Under this hypothesis, ICPP studies could be seen as representing different samplings from acommon parent population of acute care trauma admissions.
To evaluate the two models, we compared the predictive fitsof the fixed effects and the random effects logistic regressions
with CAPS0 as the only predictor, using a bootstrap approach
where participants were randomly sampled with replacement,
models were obtained, and then predicted probabilities fromboth models were estimated among the left-out participants.
For each approach, the ratio of expected PTSD diagnoses andactual PTSD diagnoses (expected/observed or E/O), the calibration slope βoverall (the slope from a logistic regression of thepredicted probabilities on endpoint PTSD), and the Brier score
were obtained. An E/O far from 1 indicates whether the model’sintercept, which determines the predicted prevalence of PTSD,
is too high or too low, while the calibration slope reflects heterogeneity of the predictor-outcome associations or over-fittingof the data44. This process was repeated 100 times with statistics
averaged across iterations. A finding of poorer r­ esults in theWorld Psychiatry 18:1 - February 2019

fixed effects model compared to the random effects model
would indicate that the studies were too heterogeneous to beanalyzed together after accounting for differences in the distribution of CAPS0.
Differences in the predicted probability of PTSD given different risk factors were estimated by drawing 1,000 posterior
simulations of each model’s β coefficients, predicting endpoint
PTSD at each value of CAPS0 with different risk profiles (e.g.,male versus female gender), and evaluating the differencesin the predicted probabilities across baseline CAPS0 scores80.
The selected time window for determining endpoint PTSD
status (122-456 days; 4-15 months) maximized the number
of ICPP studies included in each time interval. To evaluate
whether the substantial width of that time window affected theresults, and to additionally produce an estimate of prolonged
PTSD likelihood, we repeated the logistic regressions using
participants whose PTSD status was obtained 9 to15 months(273-456 days) after the traumatic events.

RESULTS
Participants’ characteristics, risk predictors, and CAPS0
scoresParticipants’ average age at studies’ onset was 39.0±13.9 years.
There were fewer female participants (37%) in the sample thanmales. Motor vehicle accidents (69%) were the most common in-

Table 3 Sample variables stratified by endpoint post-traumatic stress disorder (PTSD) status
Variable

No endpoint PTSD

Endpoint PTSD

Total sample

p

N (%)

2,182 (88)291 (12)2,473

Age (mean±SD)

38.0±14.2

39.0±11.8

39.0±13.9

0.366

CAPS0 (mean±SD)23.1±21.4

59.6±27.8

27.4±25.1<0.001Male

1,418 (91)143 (9)1,561<0.001

Female757 (84)

148 (16)

Gender, N (%)

Missing905
7 (0.3)Ethnicity, N (%)
White

1,742 (88)241 (12)

1,983

Non-White

165 (89)

20 (11)

185

Missing

0.592

305 (12.3)

Education, N (%)
At least secondary education

1,698 (90)196 (10)Less than secondary education

368 (86)

58 (14)

Missing

1,894

0.051

426
153 (6.2)

Marital status, N (%)
Married/living with a partner

1,035 (89)129 (11)

1,164

Single/not living with a partner

1,060 (89)137 (11)

1,197

Missing

0.780

112 (4.5)

Current trauma type, N (%)
Motor vehicle accident

1,485 (87)221 (13)

1,706

Other non-interpersonal588 (95)

32 (5)

620

Interpersonal

100 (73)37 (27)

Missing<0.001137
10 (0.4)

Prior trauma, N (%)
None

308 (89)

39 (11)

347

Non-interpersonal641 (89)

78 (11)

719

Interpersonal848 (86)

143 (14)

Missing

0.061

991
416 (16.8)

Comparisons (p values) are between participants with vs. without endpoint PTSD
CAPS0 – baseline score on Clinician-Administered PTSD Scale for DSM-IV

World Psychiatry 18:1 - February 2019

81

dex trauma, followed by other types of non-interpersonal trauma(25%) and interpersonal trauma (6%). The median time to theinitial assessment was 15±16.7 days (range 1-60). The median timeto the endpoint assessment was 333±103.1 days (range 122-456).
The prevalence of endpoint PTSD was 11.8% (N=291). End­point PTSD was significantly more frequent among female
participants (16.4%, compared to 9.2% in males, p<0.001) andamong participants who suffered interpersonal trauma compared to a motor vehicle accident or other traumatic events (respectively, 27%, 5% and 13%, p<0.001). No significant differenceswere observed by ethnicity, marital status, or age (see Table 3).
The histogram in Figure 1 displays the number of participants who endorsed each CAPS0 score, smoothed for a five
points interval. As can be seen, the total number of participants declines progressively with increasing CAPS0 scores. The
CAPS0 scores of participants with endpoint PTSD, however,span across the instrument’s severity range, such that the proportion of those with endpoint PTSD increases with increasing
CAPS0 severity.

Prediction of endpoint PTSD
The results from fixed effect models using CAPS0 alone(CAPS0 model), CAPS0 plus all available predictors (full model),and CAPS0 plus significant predictors only (significant predictors model) are presented in Table 4.
The CAPS0 model (plotted in Figure 2 along with its 95% confidence interval) fits well (Efron’s R2=0.230, Brier score=0.080,
AUC=0.847), with a very high correlation between the model’s

predicted probability and the smoothed estimate of conditional
probability (r=0.976). Logistic regression using the full model showed that female gender (β=0.309, SE=0.151, p=0.041),
having less than a secondary education (β=0.486, SE=0.188,
p=0.009), and prior interpersonal trauma (β=0.662, SE=0.238,
p=0.006) contributed significantly to the PTSD outcome.
With the inclusion of all risk indicators (full model) or that ofsignificantly contributing factors (significant predictors model), accuracy remained high (respectively, smoothed probability correlation=0.941, Efron’s R2=0.246, Brier score=0.078,
AUC=0.855; and smoothed probability correlation=0.946, Efron’sR2=0.246, Brier score=0.078, AUC=0.851). Thus, the addition of
female gender, lifetime exposure to interpersonal violence, andless than a secondary education to the CAPS0 model increased
PTSD likelihood whilst keeping the CAPS0 model’s accuracy.
In the bootstrap analysis comparing the fixed effects logistic
model with a random effects model using only CAPS0 as a predictor, the E/O ratio and βoverall from the fixed effects model (1.01
and 1.00, respectively) were closer to 1.00 than the random effects model (1.14 and 0.75, respectively), and the Brier score waslower on average for the fixed effects model (0.081, SD=0.01)
than the random effects model (0.084, SD=0.01). Overall, thefixed effects model seems to estimate the likely number of participants with PTSD at follow-up more accurately, with lessheterogeneity or over-fitting, than the random effects model,
thereby supporting the pooling of participating studies.
After accounting for the CAPS0 effect, female participants
were found to have a maximum of 5% (95% CI: –2% to 12%)higher risk for endpoint PTSD compared to male participants.
Moreover, participants with all significant risk factors (i.e.,

Figure 1 Histogram of participants’ baseline PTSD symptoms severity scores (CAPS0 total scores). Dots represent individual participants;
overlayed triangles those who subsequently developed PTSD. PTSD – post-traumatic stress disorder, CAPS0 – baseline score on ClinicianAdministered PTSD Scale for DSM-IV.

82

World Psychiatry 18:1 - February 2019

Table 4 Coefficients (with SE) and fit statistics from the CAPS0, significant predictors and full models
Model parameters

CAPS0 model

Significant predictors model

Full modelIntercept–3.981*** (0.149)–4.628*** (0.27)–4.659*** (0.377)

CAPS0

0.05*** (0.003)

0.051*** (0.003)

0.05*** (0.003)

Female-0.307* (0.149)

0.309* (0.151)

Age

-

-

0 (0.006)

Less than secondary education-

0.483** (0.186)

0.486** (0.188)

Non-White--

0.42 (0.281)

Single--0.051 (0.164)

Interpersonal--

0.286 (0.255)

Other

-

-

–0.201 (0.222)

Current traumatic event

Lifetime trauma exposure
Non-interpersonal-

0.113 (0.249)

0.128 (0.249)

Interpersonal-

0.656** (0.237)

0.662** (0.238)

Efron’s R2

0.23

0.246

0.246

Smoothed probability correlation

0.976

0.946

0.941

Brier score

0.08

0.078

0.078

AUC

0.847

0.851

0.855

*p<0.05, **p<0.01, ***p<0.001
CAPS0 – baseline score on Clinician-Administered PTSD Scale for DSM-IV, AUC – area under receiver operating characteristic curve

female gender, less than secondary education, and exposure
to prior interpersonal trauma) had a 34% (95% CI: 20-48%)
higher risk of PTSD compared to participants without any
significant risk factors (i.e., male with secondary educationand no prior interpersonal trauma). Estimated probabilities
and 95% confidence intervals for endpoint PTSD based oneach combination of the significant predictors are provided
in Table 5.

Figure 2 Predicted probabilities of endpoint PTSD conditional on initial (CAPS0) severity scores. The dots represent the raw conditional probability of PTSD at follow-up given the CAPS0 score, smoothed with a kernel of width 5. The solid black line represents the logistic model predictedprobability given the CAPS0 score. The gray area is the 95% confidence interval for the prediction model. The dashed line represents the prediction function derived from participants with follow-up observations later than 9 months. PTSD – post-traumatic stress disorder, CAPS0 – baseline
score on Clinician-Administered PTSD Scale for DSM-IV.

World Psychiatry 18:1 - February 2019

83

Table 5 Estimated probabilities (with 95% CIs) of endpoint PTSD diagnosis by incremental values of CAPS0 scores
Probability of PTSD by gender(CAPS0 plus gender)

Probability of PTSD by gender(CAPS0, plus less than secondary education, andprior interpersonal trauma)

CAPS0 total
score

Probability of PTSD(CAPS0 alone)

Males

Females

Males

Females00.018 (0.014-0.024)

0.017 (0.013-0.023)

0.021 (0.015-0.029)

0.030 (0.020-0.043)

0.041 (0.025-0.061)

50.024 (0.018-0.030)

0.022 (0.017-0.029)

0.027 (0.020-0.037)

0.038 (0.026-0.054)

0.052 (0.033-0.076)

10

0.03- (0.024-0.038)

0.028 (0.021-0.036)

0.034 (0.025-0.046)

0.049 (0.034-0.068)

0.065 (0.042-0.095)

15

0.038 (0.031-0.047)

0.035 (0.028-0.045)

0.043 (0.033-0.056)

0.062 (0.044-0.085)

0.083 (0.054-0.119)

20

0.048 (0.040-0.059)

0.045 (0.036-0.056)

0.055 (0.042-0.070)

0.079 (0.056-0.106)

0.104 (0.070-0.147)

25

0.061 (0.051-0.073)

0.057 (0.046-0.069)

0.069 (0.054-0.086)

0.099 (0.071-0.132)

0.130 (0.089-0.181)30

0.077 (0.066-0.090)

0.071 (0.059-0.086)

0.086 (0.069-0.106)

0.124 (0.091-0.163)

0.161 (0.113-0.220)35

0.097 (0.084-0.112)

0.090 (0.075-0.106)

0.108 (0.088-0.130)

0.154 (0.114-0.201)

0.198 (0.142-0.265)40

0.121 (0.106-0.138)

0.112 (0.094-0.132)

0.134 (0.111-0.161)

0.190 (0.143-0.245)

0.241 (0.177-0.317)

450.150 (0.133-0.169)

0.139 (0.117-0.162)

0.165 (0.139-0.195)

0.232 (0.177-0.296)

0.290 (0.218-0.375)

50

0.185 (0.165-0.207)

0.171 (0.145-0.199)

0.202 (0.172-0.235)

0.280 (0.217-0.352)

0.345 (0.264-0.436)55

0.226 (0.201-0.251)

0.208 (0.176-0.241)

0.244 (0.209-0.284)

0.334 (0.262-0.413)

0.404 (0.315-0.500)

60

0.272 (0.243-0.302)

0.252 (0.213-0.292)

0.293 (0.253-0.337)

0.392 (0.312-0.477)

0.466 (0.372-0.564)

65

0.324 (0.289-0.360)

0.301 (0.256-0.349)

0.346 (0.300-0.393)

0.453 (0.367-0.543)

0.528 (0.431-0.626)70

0.381 (0.340-0.423)

0.355 (0.302-0.410)

0.404 (0.352-0.455)

0.516 (0.425-0.608)

0.590 (0.492-0.685)

75

0.442 (0.394-0.488)

0.413 (0.353-0.475)

0.464 (0.406-0.519)

0.579 (0.484-0.670)

0.649 (0.553-0.739)80

0.504 (0.450-0.555)

0.474 (0.409-0.540)

0.525 (0.463-0.582)

0.638 (0.544-0.726)

0.704 (0.612-0.787)

85

0.566 (0.507-0.621)

0.535 (0.465-0.604)

0.586 (0.519-0.644)

0.694 (0.602-0.776)

0.754 (0.668-0.829)

90

0.625 (0.564-0.682)

0.595 (0.524-0.665)

0.644 (0.576-0.702)

0.745 (0.657-0.819)

0.797 (0.720-0.864)

95

0.682 (0.619-0.738)

0.653 (0.579-0.722)

0.698 (0.631-0.752)

0.790 (0.708-0.855)

0.835 (0.765-0.893)

100

0.733 (0.671-0.787)

0.706 (0.632-0.772)

0.747 (0.682-0.798)

0.828 (0.754-0.886)

0.867 (0.805-0.916)

105

0.778 (0.719-0.830)

0.754 (0.682-0.816)

0.790 (0.729-0.838)

0.861 (0.795-0.911)

0.893 (0.840-0.934)

110

0.818 (0.763-0.864)

0.796 (0.730-0.853)

0.828 (0.769-0.871)

0.888 (0.830-0.931)

0.915 (0.869-0.949)

115

0.852 (0.801-0.893)

0.833 (0.773-0.883)

0.860 (0.807-0.899)

0.911 (0.861-0.946)

0.932 (0.894-0.961)

120

0.881 (0.835-0.917)

0.864 (0.809-0.909)

0.887 (0.839-0.921)

0.929 (0.887-0.959)

0.947 (0.915-0.970)

125

0.904 (0.864-0.935)

0.890 (0.840-0.929)

0.909 (0.867-0.938)

0.944 (0.908-0.968)

0.958 (0.931-0.977)

130

0.924 (0.888-0.950)

0.912 (0.868-0.945)

0.927 (0.890-0.952)

0.956 (0.926-0.976)

0.967 (0.945-0.982)

135

0.939 (0.909-0.962)

0.929 (0.892-0.957)

0.942 (0.910-0.963)

0.965 (0.940-0.981)

0.974 (0.956-0.986)

PTSD – post-traumatic stress disorder, CAPS0 – baseline score on Clinician-Administered PTSD Scale for DSM-IV. For the full array of risk indicator combinations, see https://wvdmei.shinyapps.io/PTSD_Risk_Lookup/.

Using data from participants whose last follow-up assessment
fell between 9 and 15 months from the traumatic event (N=1,359)
to fit a CAPS0-only logistic regression yielded similar predic­­tion probabilities (see dotted line in Figure 2), with similar model
accuracy (Efron’s R2=0.195, Brier score=0.071, AUC=0.822).

DISCUSSION
The results of this study demonstrate that the probability ofmeeting PTSD diagnostic criteria 4 to 15 months after acutecare admission is reliably modeled by a logistic function of84

initial PTSD symptom severity. Added to this model, female
gender, having less than secondary education, and prior interpersonal trauma were associated with higher likelihood of
endpoint PTSD. Other previously documented risk factors,
such as age, marital status, and current trauma type, did not
improve the prediction over the model that had CAPS0 scoreas the only predictor. Importantly, the limited margin of errorof the resulting risk estimate enables its clinical use to assess
PTSD likelihood for each combination of the significant risk
indicators.
The limited incremental effect of several known risk factors
was an unexpected finding, suggesting that the contribution ofWorld Psychiatry 18:1 - February 2019these factors to PTSD likelihood is mediated by their effect onearly symptom severity. In line with this view, a previous comparison of PTSD following terror attacks with PTSD following
motor vehicle accidents from the same ED has shown that thehigher prevalence of 4-month PTSD following terror attacks(38% vs. 19%) was entirely accounted for by survivors’ early
responses, that included one-week PTSD symptoms, ED heart
rate and peri-traumatic dissociation61.
Our results extend previous findings of an association between high initial PTSD symptoms and being diagnosed withPTSD55-62 by highlighting the added informational value of
likelihood estimates relative to predictive classification. The
uniform distribution of PTSD participants initial CAPS0 scores
illustrates a barrier to classification models: trauma survivors
who ultimately developed PTSD had their initial symptom severity distributed across the entire range of CAPS0 total scores,
thereby defying the use of a threshold separating future cases
from non-cases. Predicting who will develop PTSD, as muchas predicting who among heavy smokers will develop lungcancer, is a difficult task, frequently replaced by likelihood
estimates. Classification models have significantly informed
our understanding of disorders’ etiology and pathogenesis81-86.
Likelihood estimates, however, may be better suited for quantifying individual risk. As in other areas of medicine48-54, quantifying risk ultimately informs clinical action.
How can our results inform clinical action? Consider, forexample, three female survivors with a CAPS0 score of, respectively, 20, 40, 60; less than secondary education, and lifetime
exposure to interpersonal violence. These individuals will have,respectively, 10.4% (95% CI: 7.0-14.7), 24.1% (95% CI: 17.7-31.7)
and 46.6% (95% CI: 37.2-56.4) likelihood of chronic PTSD. Male
survivors with the same initial scores and no additional risk
factors will have, respectively, 2.7% (95% CI: 1.8-4.0), 7.1% (95%
CI: 4.8-10.1) and 17.3% (95% CI: 12.2-23.4) likelihood of chronic
PTSD. Individuals endorsing the highest CAPS0 score, in bothgenders, might be seen as requiring clinical attention, e.g., anearly intervention. The lower scores may justify a “watchfulwait” with additional assessments.
A strength of this study follows from the use of data on alarge number of participants from culturally and geographically diverse settings. Each included investigation utilized alongitudinal design, assessed PTSD symptoms shortly after
index trauma, and based its appraisal of symptoms and diagnostic status on the repeatedly validated CAPS instrument.
In interpreting our findings, one should nonetheless consider some limitations. First, the time frame to determine PTSD
status in our main analyses was 4-15 months, thus very wide.
However, when the data were restricted to participants reinterviewed more than 9 months after the trauma, the resulting
logistic prediction model remained essentially unchanged. Our
prediction is nonetheless calibrated for the wider and earlier
time bracket and centered on 333.0±103.1 days (less than ayear) from trauma exposure.
Second, several risk predictors were harmonized due to thevariety of instruments used by site investigators, which resulted

World Psychiatry 18:1 - February 2019

in a loss of granularity. While those harmonized variables (lessthan secondary education, lifetime interpersonal trauma) havecontributed to PTSD probability estimates, results involving
recoded variables may miss important predictors’ information.
Simplified predictors, however, might be easier to obtain in clinical practice and are widely used in predictive models in otherareas of medicine (e.g., “smoking yes/no” and “diabetes yes/no”
in the Framingham 10 years cardiovascular disease risk score).
Third, the ICPP data display considerable heterogeneity
among contributing studies, which, as discussed above, raised
methodological concerns about the best approach to poolingthe data. We found that the fixed effects model was more accurate than the data source dependent random effects model andthus justified pooling from different studies. We also believethat a fixed effects model is more applicable to new environments, because a global slope and intercept were estimatedacross studies. Our choice, however, is neither beyond critique
nor without significance: large multi-source data compilations are currently evaluated in genetic, genomic and imaging
research87, all of which have to contend with data source heterogeneity resembling the ICPP effort. Our theoretical premisethat ICPP studies were differentially sampling subsets of anunderlying population of reference (i.e., acute care trauma admissions) should be corroborated by testing the resulting risk
assessment tool in newly admitted acute care trauma survivors.
The use of the CAPS structured clinical interview may add
some burden on service delivery, and that interview is not properly a screening instrument. Moreover, several PTSD (i.e., CAPS)
symptoms (e.g., insomnia, avoidance, inability to recall important aspects of the traumatic event) may not be present during
ED admission. The early CAPS, nonetheless, is a robust risk indicator. Future work should explore earlier and simpler screening
alternatives, or establish stepwise “screening and prediction”
models, starting upon ED admission and predicting the likelihood of expressing high levels of early PTSD symptoms.
Finally, our model was developed using acute care trauma
admissions, and as such its implementation in other traumatic
circumstances (e.g., prolonged adversities such as wars, captivity and relocation) may require adjustments. Notwithstanding
the precise risk estimates for other traumatic circumstances,
we believe that early symptom severity has been convincingly
shown here to be a major predictor of PTSD risk, and that, assuch, its evaluation among individual survivors provides a valid
warning and a call for action.
These limitations do not take away from the robustness of
our likelihood estimates and their ability to support a personalrisk assessment in individual survivors. Similar risk estimate
tools are used in other medical domains to support clinicaldecisions (e.g., for determining breast48 or lung49,50 cancer likelihood given risk indicators). The risk estimates provided in thiswork can be similarly used to trigger action (either watchfulfollow-up or early intervention) according to local resources
and the desirability of prevention.
Quantifying individual risk is a step forward in planning services and interventions, better targeting high-risk individuals,

85

and ultimately decreasing the burden of PTSD following acutecare admission.
APPENDIX
Members of the International Consortium to predict PTSD include: Yael ErreraAnkri, Anna C. Barbano, Sarah Freedman, Jessie Frijling, Carel Goslings, Jan Lui­tse, Alexander McFarlane, Derrick Silove, Hanspeter Moergeli, Joanne Mou­
thaan, Daisuke Nishi, Meaghan O’Donnell, Marit Sijbrandij, Sharain Suliman and
Mirjam van Zuiden.

ACKNOWLEDGEMENTS
A.Y. Shalev, M. Gevonden, A. Ratanatharathorn and E. Laska contributed to thiswork as joint first authors. The study was funded by a US National Institute of
Mental Health grant (MH101227) to A. Shalev, R. Kessler and K. Koenen.

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DOI:10.1002/wps.20608

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REAPPRAISAL

The evidence-based group-level symptom-reduction model as theorganizing principle for mental health care: time for change?
Jim van Os1-3, Sinan Guloksuz2,4, Thomas Willem Vijn5, Anton Hafkenscheid6, Philippe Delespaul2,71

Department of Psychiatry, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands; 2Department of Psychiatry and Psychology, Maastricht
University Medical Centre, Maastricht, The Netherlands; 3Department of Psychosis Studies, King’s College London, King’s Health Partners, Institute of Psychiatry, London, UK;
4
Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; 5Radboud University Medical Center, Radboud Institute for Health Sciences, ScientificCenter for Quality of Healthcare, Nijmegen, The Netherlands; 6Arkin/Sinai Centrum, Amsterdam, The Netherlands; 7Mondriaan, Heerlen/Maastricht, The Netherlands

The content and organization of mental health care have been heavily influenced by the view that mental difficulties come as diagnosable
disorders that can be treated by specialist practitioners who apply evidence-based practice (EBP) guidelines of symptom reduction at the grouplevel. However, the EBP symptom-reduction model is under pressure, as it may be disconnected from what patients need, ignores evidence of thetrans-syndromal nature of mental difficulties, overestimates the contribution of the technical aspects of treatment compared to the relationaland ritual components of care, and underestimates the lack of EBP group-to-individual generalizability. A growing body of knowledge
indicates that mental illnesses are seldom “cured” and are better framed as vulnerabilities. Important gains in well-being can be achieved when
individuals learn to live with mental vulnerabilities through a slow process of strengthening resilience in the social and existential domains. In
this paper, we examine what a mental health service would look like if the above factors were taken into account. The mental health service ofthe 21st century may be best conceived of as a small-scale healing community fostering connectedness and strengthening resilience in learning
to live with mental vulnerability, complemented by a limited number of regional facilities. Peer support, organized at the level of a recovery
college, may form the backbone of the community. Treatments should be aimed at trans-syndromal symptom reduction, tailored to serve
the higher-order process of existential recovery and social participation, and applied by professionals who have been trained to collaborate,embrace idiography and maximize effects mediated by therapeutic relationship and the healing effects of ritualized care interactions. Finally,
integration with a public mental health system of e-communities providing information, peer and citizen support and a range of user-rated
self-management tools may help bridge the gap between the high prevalence of common mental disorder and the relatively low capacity of
any mental health service.
Key words: Mental health care, evidence-based practice, relational components of care, public health, resilience, peer support, trans-­
syndromal symptom reduction, recovery, e-communities(World Psychiatry 2019;18:88–96)

Mental suffering has been the topic of intense academic re­search, covering areas of epidemiology, neurobiology, therapeutics and health services organization, and giving rise toevidence-based practice (EBP) guidelines to achieve symptom
reduction that can be used for specific diagnosable mental
disorders.
Evidence-based medicine, in the sense of trying to find out
what is or is not likely to work for a particular patient, based onwhat is known, makes eminent sense. However, the way inwhich it is (mis)understood and applied may give rise to numer­
ous side effects and limitations, including “cookbook” practice,lack of relevance of EBP outcomes for patients, and lack ofgroup-to-individual generalizability1-3.
The area of mental disorders, and changes therein over time,
may be particularly difficult to capture in the conventional
medical paradigm of diagnosis and treatment-induced symptom reduction at the group level. Nevertheless, according to
the group-level symptom-reduction principle as applied inmental health care, mental suffering comes in the form of universally diagnosable mental disorders which are of bio-psychosocial origin and can be classified on the basis of symptoms.
Treatment guidelines are constructed on the basis of meta-analytic evidence of measurable group-level symptom reduction, the by far most frequently researched mental healthtreatment outcome4. The professionals who populate mental
health services have been trained in, first, diagnosing a mental

88

disorder in those who seek help for symptoms and, second,
providing treatment as prescribed by EBP guidelines.
As different disorders have different symptoms, the diagnosis-EBP concept as organizing principle of language andactivities in mental health service systems has contributed
to diagnostic stratification and specialization of institutions,professionals and researchers. Both patients and professionals
perceive a need for specialized treatments for specific problems as the primary reference for quality. Consumers know ittakes time to search the Internet to find a professional who isadequately specialized in, for example, autism, bipolar disorder, obsessive–compulsive disorder, attention-deficit/hyperactivity disorder (ADHD), post-traumatic stress disorder orborderline personality disorder.
The diagnosis-EBP symptom-reduction model has also impacted health survey technology, which has seen the systematic application of symptom-based diagnostic criteria for mental
disorder to the general population, resulting in high rates ofdisorders like major depression and anxiety disorders, landing
them in the top causes of the global burden of disease.
The total estimated global disease burden of mental illness
accounts for 21.2% of years lived with disability (YLDs) and7.1% of disability-adjusted life-years (DALYs)5, which somehave argued may represent a substantial underestimation6.
Given the limited capacity of the mental health system, datafrom the population surveys indicating that yearly prevalence

World Psychiatry 18:1 - February 2019

rates of mental disorder are around 20% result in the perception of much morbidity remaining untreated.
Mental health awareness campaigns, attuned to the diagnosisEBP model, have contributed to growing public awareness of theexistence of diagnosable mental disorders and the importance ofaccess to care. Western countries have seen a growing demand
for treatments, as evidenced by marked increases in the consumption of psychotropic medications such as antidepressants7,
particularly in young people8, growing use of easy-access manualized non-pharmacological therapy symptom reduction centres9, and increasing rates of involuntary admissions in European
countries10.
Within the diagnosis-EBP symptom-reduction perspective,
the task of mental health services is to “deliver” specialized treatments that should be made available to those who need them,regardless of whether the setting is “inpatient”, “outpatient”, or“community” treatment.
Countries traditionally differ widely in what mental healthservices do and how they are organized11. It is assumed that
better mental health services are more “evidence-based”12,and that “routine outcome monitoring” of symptom reduction
can be used to assess the quality of the mental health service.
However, organizing services around diagnostic specialities
providing evidence-based symptom reduction implies that thediagnosis-EBP group-level symptom-reduction principle isvalid, relevant and useful, and that group-level findings can betranslated to individuals3. It also suggests that symptom reduction is a useful construct as a primary focus in the training ofprofessionals and the organization and evaluation of services.
However, “evidence-based” at the group level may not naturally result in patient-centred care at the idiographic level13
and has been developed around the discourse of diseases andsymptoms, rather than resilience and possibilities14. The question arises to what degree the training of professionals and theplanning and evaluation of mental health services should also
be guided by other factors.
In this paper, we discuss a number of issues that are relevantin this regard. First, we consider factors that are relevant to thevalidity of the diagnosis-EBP symptom-reduction principle
in mental health care, such as the trans-syndromal nature of
psychopathology and the fact that much of the treatment effectobserved in EBP is, in fact, reducible to contextual componentsthat are insufficiently acknowledged and embedded in the service and in the training of mental health professionals.
Second, we discuss to what degree organizing services
around higher-order social, existential and somatic outcome
domains may potentially be more relevant to users than the
traditional focus on evidence-based, group-level symptom
reduction. Third, we point out that, while the high prevalence
rates of mental disorder indicate the need for a coherent public
mental health approach, this has not materialized15.
In the final part, we discuss the consequences of these issues
for the planning, organization and implementation of mental
health services, and make suggestions for change. Althoughmost of the discussion is based on practice as developed in

World Psychiatry 18:1 - February 2019

high-income countries, we believe that some of the core issues
are relevant to mental health services worldwide.

THE ADVENT OF TRANS-SYNDROMALFORMULATIONS OF PSYCHOPATHOLOGYAND BEYOND
The likelihood ratios for etiology, symptoms, treatment response and prognosis, occasioned by traditional diagnostic
categories, are too low to be considered “useful” as required by
EBP16-18. Mental difficulties represent highly variable clustersof trans-syndromal symptom dimensions that defy detailed
diagnostic reduction. The use of 10-15 broad and overlapping“umbrella” syndromes may be sufficient for daily practice19.
If this is the best “evidence” of classification of psychopathology, should clinicians in mental health services work indiagnostic specialization clinics or “care pathways”, or should
they bring their expertise to impact on trans-syndromal psychopathology, regardless of formal diagnosis?
The perceived value of diagnostic specialization is driven, inpart, by the possibility of delineation of homogenous groups interms of psychopathology, treatment response and prognosis.
However, patients with a diagnosis of major depression are heterogeneous in terms of symptoms, treatment response and prognosis,
and show high levels of overlap with patients with other diagnoses
in terms of symptoms, treatment response and prognosis.
Explicit exclusion criteria in diagnostic systems create ahigher-order factor of what diagnostic categories are not20,
resulting in a myriad of categories that may be separately diagnosable but at the same time remain strongly correlated witheach other, resulting in confusingly high “comorbidity” rates
and poor reliability in clinical practice. This status quo often
leaves patients as well as referring general practitioners (GPs)confused.
A patient-centred trans-syndromal framework that flexibly
combines categorical, dimensional and network approaches
may better serve the purpose of maximizing usefulness for different aspects of clinical practice. However, current diagnostic
specialization in research and clinical practice has given rise toa cultural and structural balkanization21 that cannot be readily dismantled, because the professional identity of clinicians
tends to fuse with these specializations. Changing the statusquo, i.e. bringing practice more in line with available scientificevidence, may thus result in an identity crisis and resistance towhat may be seen as a non-professional sham.
In order to constructively deal with this issue, the DSM-5
project attempted to introduce the notion of trans-syndromal
dimensions across the different chapters, which would haveopened the way to a new form of trans-syndromal clinical practice and research. Unfortunately, the project proved too complex and only resulted in some trans-syndromal dimensions
being included in one of the appendixes. These, however, were
not truly trans-syndromal, in the sense of cutting across chapters, as all were about within-chapter dimensional variation22.

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In contrast, the US National Institute of Mental Health (NIMH)
formulated a range of trans-syndromal dimensions of behaviourand functioning, with the specific aim to link dimensional variation to biology in research, but these were not meant for use inclinical practice (Research Domain Criteria, RDoC project)23.
The trans-syndromal approach thus remains an attractive option to bridge the cultural and structural silos that have been built
around correlated diagnostic categories, but requires more work.
It may be productive to develop a trans-syndromal framework ofmental suffering that not only revolves around symptoms, but also
focuses on aspects of behaviour, functioning, psychological traits,
somatic factors, social factors and environmental exposures, depending on clinical diagnostic relevance and user preference. Thismay be productively combined with a limited number of “umbrella” diagnostic categories at the level of the broad syndrome(e.g., psychosis spectrum syndrome)19.

SERVICE AND RELATIONAL EFFECTS AS“INVISIBLE” COMPONENTS OF TREATMENT
Just as there is methodological and statistical doubt as towhat degree even a well-established psychotherapy like cognitive-behavioral therapy (CBT) is at all effective, doubt has been
voiced as to what degree medications like antidepressants havereal effects24-29.
While recent meta-analytic work suggests that antidepressants may have a small effect on symptoms in the short term30,
important factors – like bias due to withdrawal symptoms in
the placebo group and differential expectations due to the lackof use of active placebo in the comparison with side effect-rich
antidepressants – remain unaddressed. In fact, one of the factors underlying the weak effects of psychotherapy and antidepressants as compared to placebo is the issue of expectations,which evidence suggests may be one of the key elements driving change in states of mental ill-health31,32.
As effect sizes of psychotherapy are small, at least in analyses that take into account the many sources of bias and factors
impacting quality26, the likelihood of meaningful differences
between different types of psychotherapy logically must be
similarly small, likely remaining below the threshold of statistical resolution and clinical relevance. This may explain why,
despite much research and debate, there is no meta-analytic
evidence that well-researched psychological treatments forcommon disorders like depression, anxiety, post-traumaticstress disorder and borderline personality disorder show clear
and clinically relevant differences from each other in effect size,
regardless of the level of complexity or underlying anthropological rationale. Instead, meta-analyses reveal the same (small)effects across different treatment approaches33-36.
Similarly, there is therapeutic equivalence between different
classes of antidepressant medications37 and, although many
guidelines suggest that clozapine may be more effective thanother antipsychotics in treatment resistant psychotic disorder,
the evidence on which this is based is not strong38. However,90

clozapine may be more effective than other antipsychotics indifferent outcome areas, which have been researched insufficiently but may stand out clinically.
Where it has been examined, equivalence also applies
across pharmacological and non-pharmacological approaches,for example in depression39. Thus, while some specific differences between treatments may exist in low-prevalence subareas of mental health, for example in anorexia nervosa40 andobsessive-compulsive disorder39, findings more often point toequivalence within and between pharmacological and nonpharmacological treatment approaches for common mental
disorders41.
Findings of equivalence of small effects across pharmacological and non-pharmacological treatments may be, first, suggestive of underlying heterogeneity, in the sense of some people
responding only to treatment A and others only to treatment B,
and all research populations representing a mix of these two andother types. Although this may be relevant, for example in thecase of genetic variation underlying differences in response topharmacological treatment, no reliable markers of such heterogeneity in response have been identified, despite much research.
Also, in psychotherapy research, leaving out critical theoretic
components of the therapy does not impact effect size42,43.
A stronger, although not mutually exclusive, case can bemade for a second explanation of apparent equivalence, i.e.,that it is not only the specific treatment itself (the “what”), butalso generic aspects of treatments (the “how”) which impacts
outcome. In favor of the latter is evidence of small but significant “clinician” random effects, meaning that, under the overall
small effect of specific treatments, reside differences between
the particular patient-clinician mix, some being more conducive to change than others, not just in psychotherapy research44
but also, in the rare instances where it has been examined, in
pharmacological research45.
Thus, if the “how” of treatment contributes to improvement,
what is it? Research suggests that two aspects of the context oftreatment may be important: a general background service-­level effect and a patient-clinician relational effect at the level ofthe therapeutic ritual. These service-level and patient-­clinician
level contextual effects are discussed below.

Service-level contextual effects
Meta-analyses have shown that the placebo response in trials of pharmacological treatments such as antidepressants46,
antipsychotics47,48 and pain medications49 has risen over time.
One of the factors that may contribute to the rise in placebo
response is the change in trial context and design50. If the stan­
dard care context amounts to relative “neglect” by poorly developed services, placebo effects will approach natural course,and be lower compared to placebo effects in the context ofwell-developed supportive services, confounding comparisons
between time periods and countries51. Thus, the early trials are
more likely to reflect the comparison between natural course

World Psychiatry 18:1 - February 2019and active treatment, whereas later trials reflect a more “mature” comparison between placebo in the context of general
supportive treatment and the specific psychotropic agent.
The same contextual issue regarding the role of standard care
may impact trends in psychotherapy research over time, given
meta-analytic evidence that the efficacy of psychotherapeutic
treatments like CBT52 has become progressively smaller overtime. This is likely related to early trials more often including a“waitlist” comparison – amounting to a comparison with natural
course – whereas later trials more often included a more active
comparison treatment. As a result, a temporal effect will emerge
in meta-analyses, given evidence from CBT psychotherapy trials
that comparison with waiting-list conditions yields a substantially higher effect size than against care as usual or pill placebo25.
These temporal effects are important, as they appear to suggest that having interactions with an active mental health service brings about improvement in the same way as specifictreatments do. It may be productive to further study this issue,
as an optimized “general service effect” can impact many patients at the same time in a very cost-effective fashion.

Patient-clinician level contextual effects
In conditions such as depression, effects do not appear todiffer between treatment approaches, whereas they do vary as
a function of the specific patient-clinician mix. This observation has inspired an ongoing debate on the degree to which
so-called “common factors” contribute to the observed phenomenon of equivalence of treatments 31. Common factors
have to do with non-specific relational and ritual elements inthe encounter between patient and clinician, such as offering
an explanatory model, proposing a theory for change, raising
expectations, and inspiring patient engagement, all within thecontext of a productive therapeutic relationship characterized
by empathy, an active and caring attitude, and the capacity tomotivate, collaborate and facilitate emotional expression.
The existence for most mental health problems of a 30-40%“placebo” effect, in the sense of being offered some kind oftherapeutic ritual, and the fact that specific evidence-based
treatments only create a small additional effect, is an argument
in favor of the existence of common factors.
Evidence for common factors comes from research, including some fascinating examples of experimental studies53,54,
showing the effect of expectations32,54, the impact of therapeutic relationship55, and therapist effects44. Other support comesfrom meta-analyses showing that: a) in depression, having thesame number of psychotherapy sessions over a shorter periodof time is more effective, suggesting an effect of the intensity ofhuman contact56; b) leaving out critical theoretic componentsof psychotherapy does not impact effect size42,43 (although adding components may yield a small increase)43; c) comparisons
between active treatments and structurally inequivalent placebos produce larger effects than comparisons between active
treatments and structurally equivalent placebos57.
Furthermore, in depression, the rise in placebo responseover time has been accompanied by a similar rise in antidepressant response46. This suggests that, at least for depression,
the “placebo” response is additive and part of the therapeutic
response, in contrast with other areas of medicine, such as oncology, where placebo response constitutes a negligible part of
the therapeutic effect (see Figure 1).
Meta-analyses of depression trials of antidepressants andtranscranial magnetic stimulation also found a positive correla­tion between the rate of placebo response and active treatment
response in trials58,59. These data are compatible with the notionthat the response to active treatment in depression is “added” tothe placebo response or that the placebo response is an integral
component of the treatment response. In other words, common
factors that are part of the general therapeutic ritual may form
the basis on which antidepressant treatment can build.
This proposition is supported by research showing that a“relationally warm” treatment works better than a “cold” treatment53 and by studies documenting that pharmacological andnon-pharmacological approaches reinforce each other in thesense of their combined effect being additive, at least in depression and anxiety disorders60. In one trial, a simple focus
on positive affect monitoring and feedback on the course of

Figure 1 Contrasting placebo components of therapeutic effect (vertical) over time (horizontal) in psychiatry and oncology

World Psychiatry 18:1 - February 2019

91

positive emotions was sufficient to make the antidepressanttreatment effective61.

THE RELATIVE DISCONNECT OF DIAGNOSIS-EBPSYMPTOM-REDUCTION INTERVENTIONS
The delivery of evidence-based treatments focusing on
symptom reduction should ideally serve the higher-order goalof social participation and existential integration (“recovery”).
However, diagnosis-EBP symptom-reduction interventions, if
they are available at all, are typically delivered by professionals
who work in relative dissociation from the existential, socialand medical needs of the patient62,63. For example, a patient
may receive a course of CBT for hearing voices, be prescribed
antipsychotic medication by a psychiatrist, see a social worker
for help with housing and benefits, and visit his general practitioner to receive medication for diabetes. In daily life, however,he may struggle with social isolation, lack of meaning, feelingsof hopelessness and massive weight gain.
The different professionals involved in his care may know ofeach other’s existence, but have different schedules and work
across different departments and bureaucracies, making it
difficult to integrate their efforts. Most importantly, existential
needs such as loneliness, meaninglessness and hopelessness
are not addressed. While different countries and regions havedifferent levels of integration of care, anecdotal evidence suggests that the situation as depicted here is not rare62,63. Below,
we discuss the issue of integration with social, existential andmedical needs in more detail.

Integration with user knowledge and a focus on
existential values
The diagnosis-EBP symptom-reduction perspective wasdeveloped in the context of a bio-psycho-social model of mental health difficulties. Several novel developments, however,suggest that the bio-psycho-social model requires extension
with an existential component, thus reinventing itself as a biopsycho-socio-existential framework in which the existential
component is central.
First, the concept of “health” as absence of disease is risky,
as it may result in “too much medicine, too little care”64. This
traditional concept, therefore, is increasingly supplanted by thenotion that health is about the ability to adjust to and manage
medical, social and mental challenges in order to pursue life
goals that are meaningful to the person65. In other words, restoration of health is not the goal, but rather the means to enable
the patient to find and pursue meaningful goals.
Accordingly, patient existential values are becoming central
in the practice of a novel “era 3” of evidence-informed (interventions support higher-order social and existential outcomes)
rather than evidence-based (symptom reduction constitutes
the core goal) medicine66,67. In this scenario, doctors naturally92

focus on existential values, practicing shared decision making
in the sense of adjusting interventions to the existential needsof the patient68,69.
Of course, similar developments have been occurring in mental health care, where users over the last 40 years have become
increasingly vocal in asking for more sensitivity on the part ofprofessionals for the existential domain of personal recovery, inthe sense of helping people to overcome and adjust to the often
extreme experience of mental vulnerability and find meaningful
goals to live a fulfilling life, beyond the diagnosis70.
Values associated with the existential recovery perspective
are connectedness, empowerment, identity, meaning, hopeand optimism71,72, all reflecting the work of reinventing andreintegrating oneself and one’s life after experiencing the existential crisis that comes with mental illness.
While the diagnosis-EBP symptom-reduction perspective is
not incompatible with these existential notions, there are clear
challenges in bringing the medical “symptom reduction” andthe existential “meaningful life” perspectives together in one
service73,74. Although research suggests that it is possible toachieve growth in the existential domain in patients attendinga psychiatric service75, the level of organizational readiness of
traditional psychiatric services may be a rate-limiting factor inbringing the two perspectives together76,77.
The diagnosis-EBP model and the existential domain arecomplementary from a treatment perspective, as the former
has its focus on the psychometric outcome of symptom reduction and the latter on the personal process of resilience.
Working on resilience means a focus on things like being connected to other people, narrative development, positive emotions, sense of purpose, material resources and acceptance,
requiring novel service initiatives such as a “recovery college”,
structural peer support, “housing first”, “individual placement
and support”, and “open dialog”, which can be difficult to implement in traditional mental health services78-83.

Integration of mental, medical, substance use
and social care
Perhaps the most persistent unresolved need for people
with complex mental health difficulties is the lack of alignment between social care and medical care on the one hand,and mental health care and, if organized separately, addiction
services on the other84.
People with severe mental health difficulties are more likely
to experience a complex social situation characterized by poverty, social isolation, exclusion, unemployment, stigma andhousing needs, and more likely to die prematurely, smoke, develop obesity, diabetes, addictions and other chronic conditions. Meeting these needs is difficult, as they require life stylechanges for which care is allocated to different services. Optimal
management involves collaboration between complex bureaucracies managing separate budgets85, giving rise to a rangeof barriers86. The available evidence suggests that the simple

World Psychiatry 18:1 - February 2019i­ ntegration of budgets may not be enough to impact outcomes87
and that the area of mental health care can learn from other
health areas where such integration has been attempted88,89.
For example, integration of social and mental health carecan focus on the creation of recovery-oriented social enterprises as a key component of the integrated service90. A userdriven recovery college may be set up as a social enterpriseusing social care funding, thus in effect paying users to help
other users achieve recovery outcomes.
Successful integration of social, existential, mental, substance use and somatic care needs to take into account thedifferent echelons of clinical, service-level and public healthapproaches91. Another factor is scale. It has been suggested
that the scale on which integration is attempted is critical, as
integration may be best served by focusing on local networks ina relatively small area as a model for organizing mental healthservices92. Working together in local networks has the advantageof having first-name-basis interactions, creating opportunities
for flexible needs-based consultation and joint projects in thearea.
A small-scale area may be around 15,000 population with
five-ten GP practices, allowing for collaboration in an “enhanced primary care” model of mental health services93,94.

THE PUBLIC HEALTH PERSPECTIVE
The yearly prevalence of diagnosable mental suffering isaround 20%, whilst mental health services have the capacity
to treat 4-6% of the population in a given year. These figuresindicate that there is considerable scope for public mental
health, in the sense of freely accessible sources of information,
self-management and peer support e-communities.
A public mental health problem cannot be tackled by pushing the diagnosis-EBP symptom-reduction system to absurd
limits, as evidenced by concern about overprescription of antidepressants95 and ADHD medication96, and increasing rates of
involuntary admissions in European countries10.
Although much has been written about the need for a welldeveloped system of public mental health alongside the traditional one-on-one mental health care system, countries havebeen slow to implement any of this15,97.
Nevertheless, in many countries, there is a growing informal network of online, self-help e-communities for people
with a variety of mental health problems, for example, eating disorders, obsessive-compulsive disorder, psychosis andpost-traumatic stress disorder. Although some of these havemillions of visitors each year, and many increasingly offer
forms of e-health and m-health solutions that can be used
for self-management, they lack stable funding, even though it
is increasingly recognized that they form the backbone of an
informal public mental health system which interacts with thetraditional mental health care system98.
A minor shift in funding from one-on-one care in the traditional diagnosis-EBP symptom-reduction mental health care

World Psychiatry 18:1 - February 2019

system towards a public mental health network of complementary e-communities offering information, self-help and peer
support, including a community-rated market of e-health andm-health tools that people help each other using, would bringa welcome balance.
E-communities are not diagnosis-specific, but vary in theirinitial presentation so as to offer people choice in seeking help
for what is most compatible with their experience. They can not
only help people who are not in contact with services, but alsooffer self-help and help in navigating the mental health service
system for people already in care99.

CONSEQUENCES FOR MENTAL HEALTH SERVICES
While the specialist diagnosis-EBP symptom-reduction
principle is dominant or even normative in the way mental
health services are organized and evaluated, the question arises to what degree it is relevant to patients. While this model has
been productive, there is evidence that it is less than optimallyconnected to patient primary needs in the social and existential
domains.
The expectation that the most vulnerable individuals would
naturally reconnect with these domains, when their symptoms
resolve, should not be taken for granted. In contrast with common mental health problems, the circularity (reversal of cause
and effect) of symptoms, participation and existential domains
is the core of the new “severe mental illness” definition developed by a large consensus group in the Netherlands100.
The multitude of randomized controlled trials may have
served as trees through which the wood of the larger question,i.e. what patients actually require, could not be seen. In addition, while the diagnosis-EBP symptom-reduction model isframed in terms of technical skills and specialized knowledge,
the evidence also indicates that a good case can be made forthe relational and healing components of ritualized interactions mediating clinical improvement.
Thus, the larger question may be how an effort can be organized to make mental health services more relevant to those whoneed them, and more in line with a critical analysis of scientificand experiential knowledge. This would require taking a fresh
look at both content and organization of services, based on thecurrent level of knowledge (see Table 1).
If one were to design a mental health service from scratch,taking into account these developments, it is likely that the newservice would bear only moderate resemblance to the current
system of diagnosis-EBP symptom-reduction based specialist
services. It has been suggested that the concept of recovery may
serve as the organizing and integrating principle for the novel
mental health service101.
If integration and connectedness are important values, it
may be more logical to create the mental health service on arelatively small scale (covering around 15,000 population), so
as to have an authentic “look and feel” of a local healing community fostering connectedness and strengthening resilience93

Table 1 Factors in the design of a mental health service•• Mental difficulties represent highly variable clusters of trans-syndromal
symptom dimensions that defy detailed diagnostic reduction. Use of 10-15
broad syndromes may be sufficient for daily practice.
•• The model of “specialist” care in diagnostic silos may be less useful than amodel of applying professional skills in a trans-syndromal fashion.
•• User knowledge describes the prime importance of working on the processof strengthening resilience in the social (e.g., connectedness, social resources) and the existential (e.g., meaning, identity, sense of purpose) domain,rather than symptom reduction per se.
•• The context of the mental health service contributes to clinical change, inthe form of a “general service effect”, suggesting the importance of setting
and design.
•• Critical analysis of professional knowledge indicates that specialist “evidencebased practice” effects may be overly attributed to the technical (the “what”)
rather than the relational/ritual components (the “how”) of treatment.
•• The importance of the “how” of treatment suggests the need for enhanced
research and training on the set of skills and principles mediating relational/
ritual effects.
•• The scale of the mental health service is important in relation to the needfor integration with social, medical and addiction care at the clinical,
service and public health levels.
•• Development of traditional mental health services needs to go handin hand with the development of a public mental health system, thebackbone of which may be formed by a number of complementary
e-communities.

in learning to live with mental vulnerability. Peer support, forexample, organized at the level of a recovery college, may form
the backbone of the community.
The primary process of narrative development and finding
and realizing meaningful goals should be supported by treatments aimed at trans-syndromal symptom reduction, specifically tailored to strengthen the primary process of recovery andparticipation, and applied by professionals who have been
trained to embrace idiography and to maximize effects mediated by therapeutic relationship and aspects of the care ritual.
Education would be organized as person-centered, selfdirected, practice-based and inter-professional interaction
between clients, students of different professions, and different
mental health professionals, to ensure adequate developmentof attitudes, knowledge and skills in collaborating, communicating and relating to each other102. Crisis intervention may beorganized using a combination of peer-supported open dialog
and local shelters, increasing the community capacity for social
holding.
Some aspects of mental health services would continue torequire a regional organization level: for example, high intensive care units, medium security units, and child/youth transition psychiatric services, including “headspace”-type public
mental health approaches103.
Importantly, the local healing community should be integrated with local social care (housing, work, education), focusing on recovery-oriented local social enterprises, working with“enhanced” local GP practices in order to integrate medical care.

94

The mental health service, organized as local healing community and associated regional components, should be able to caterfor around 4-6% of the population and have strong links with apublic mental health system of complementary e-communities
with capacity for up to 20% of the population, integrated witha user-quality rated public health “market” of e-health and mhealth tools for “blended” self-management approaches.
It is clear that the scale and complexity of the proposed change
is such that it cannot be evaluated in a randomized controlled trial. We have, therefore, suggested that it may be more productive
to engage in a form of action-research and create a number ofpilot projects along the lines described above and learn along theway104. A number of these pilot projects are currently underway,
in the Netherlands and undoubtedly in many other countries.
A more ambitious attempt at evaluation would be to study
pilot areas in a quasi-experimental design, with even perhaps
randomization at the county or neighborhood level. While thiswould require considerable funding, it could be argued that it
involves the most pressing, yet perhaps most neglected, area of
mental health research to date.
After decades of funding of large scale efforts to delineate
the biological mechanisms of mental illness and to conduct
randomized clinical trials of symptom reduction strategies, thatare not independent of legitimization issues of the academic
professions of psychiatry and psychology, the time may havecome to coordinate a large-scale effort around the content anddesign of (public) mental health services, taking into accountboth professional and user knowledge.

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DOI:10.1002/wps.20609

World Psychiatry 18:1 - February 2019

INSIGHTS

Towards a consensus around standards for smartphone apps
and digital mental health
Mental disorders impact one in four people worldwide, yetaccess to care is challenging for those who suffer from them1.
Mental health apps offer the potential to overcome access bar­riers for the nearly three billion people projected to own a smart­phone by 2020.
Although there are over 10,000 mental health apps commer­
cially available, there are few resources available to help end
users (patients, clinicians and health care organizations) to eval­uate the quality and suitability of these products. Thus, there isan urgent need for an agreement about appropriate standards,
principles and practices in research and evaluation of these tools.
We represent leaders in mHealth research, industry andhealth care systems from around the globe, and we seek here
to promote consensus on implementing these standards andprinciples for the evaluation of mental health apps. At a mini­
mum, standards should include consideration of: a) data safety
and privacy, b) effectiveness, c) user experience/adherence, d)data integration. Our consensus on the challenges and recom­
mendations in each of these areas is presented below.
Data safety and privacy. Given the climate today regarding
the misuse of online data such as email and social media, men­tal health apps must ensure that data storage, use and shar­ing practices fulfill health care standards for handling patient
health information data2. Like with all sensitive health data,
smartphones-based sensor data such as global positioning
system (GPS), voice, keyboard usage, photos, video and overallphone usage behavior are features that many mental healthapps collect, posing significant privacy challenges2,3.
Our recommendations are: a) agreed upon standards for data
storage, use and sharing are needed; b) data storage, use andsharing policies must be made transparent to users of the app;c) if data are shared with external partners (e.g., researchers),
the partner’s storage, use and sharing plans must be sharedwith the end user; d) the end user must have the option to “optout” of sharing his/her information; e) any language regarding
data storage, use and sharing must be written at a maximum ofa 6th grade reading level; f) technical security reviews and data
audits are necessary to guarantee that apps follow the standards
they set out and ensure that new vulnerabilities are quickly
identified.
App effectiveness. Most mental health apps that are sold astherapeutic tools have not undergone rigorous evaluation, butinstead claim that they are evidence based because they are
informed by evidence based treatments4. Even when apps dohave an evidence base, changes in technology may mean thatapp updates need to be re-evaluated for their efficacy. Small
cosmetic changes, platform changes and aspect changes do
not likely require a retest of an intervention, as long as thetherapeutic principle that has been evaluated remains intact.

World Psychiatry 18:1 - February 2019

Particularly where the aim is to increase reach, engagement
and adherence rather than efficacy, A/B testing may be mostappropriate. However, significant changes, such as adding a
new therapeutic principle or substantial changes to that prin­ciple, must demonstrate efficacy through the same evaluation
pathways as novel therapeutics.
Our recommendations are: a) newly adapted therapeuticprinciples, which should be identified and defined, must un­dergo controlled clinical trials to determine their efficacy andeffectiveness; b) small changes to an app with an evidence baseneed not undergo another clinical trial, but any major change
requires a re-evaluation of app effectiveness; c) a nosology formental health apps5 and guidelines to match the necessarylevel of evidence for each app’s use cases and risks6 should be
developed.
User experience/adherence. Many patient end users stopusing a health app two weeks after download7. Clinician end
user adherence is influenced by familiarity with technology
and app match to the clinician’s therapeutic expertise. Lack ofadherence is likely a function of app usability, as the input ofclinician and patient end users is often missing when a mental
health app is designed, resulting in apps that do not align withthe preferences and goals of the intended users6.
Our recommendations are: a) user-centered/user experience(UX) design methods should be employed when creating an app;
this includes involving the intended end user in the develop­
ment, and conducting as-is workflow analysis to ensure that theapp is useful and usable, and that it fits into the fabric of the per­son’s life, not producing unnecessary burden to the end user; b)
when usability is evaluated, developers should report use statis­
tics to all end users; c) standards concerning best practice in user
design research for mental health apps should be articulated.
Data integration. Apps should allow appropriate electronic
health record (EHR) integration and sharing of health informa­tion with clinicians. One challenge is that EHRs have non-uni­
form data integration requirements and not all support use of
application programming interface (API) for data exchange. In
the US, there is a strong move towards allowing patients accessto their electronic health record information via SMART HealthIT (https://apps.smarthealthit.org/), an open, standards-based
technology platform that enables innovators to create appsthat run across platforms. However, there are few agreed uponinternal data standards to facilitate this level of interoperability.
Our recommendations are: a) mental health apps that are
intended to be used in conjunction with health care systems
should employ methods to ensure interoperability with elec­
tronic health records; b) mental health apps will need to docu­
ment the processes they use to ensure the secure exchange of
information between platforms; c) internal data standards for97

interoperability are needed, much like those outlined in http://
www.openmhealth.org/.
As mHealth transitions towards medical care in the mental
health field, now is the critical moment for researchers, clini­
cians, service-users, policy makers and funders to guide thattransition and ensure that these tools meet rigorous standards,
as is required of any novel therapeutic.
Movement in this direction is taking place. In the US, the Foodand Drug Administration has announced that it is moving awayfrom evaluating individual apps, and focusing its regulatory ef­
forts on the app makers. Additionally, US professional groups likethe American Psychiatric Association and the American Medical
Association are creating app evaluation frameworks8. In the UK,
the National Health Service has recently re-opened the App
Library in beta phase, providing recommendations for apps acrossa range of conditions including mental health, and the British
Standards Institute has published standards for health app devel­
opment. In the European Union, the National Institute of Healthand Care Excellence (NICE) is actively developing standards forapps and other technology based behavioral change interventions.
We thus make a final recommendation that these organiza­
tions, and others, come together to set universal standards formental health app quality control, and that those standards
include at a minimum the review of data security, app effective­
ness, usability, and data integration.

John Torous1, Gerhard Andersson2, Andrew Bertagnoli3,
Helen Christensen4, Pim Cuijpers5, Joseph Firth6,7, Adam Haim8,
Honor Hsin9, Chris Hollis10, Shôn Lewis7, David C. Mohr11,
Abhishek Pratap12, Spencer Roux1, Joel Sherrill8, Patricia A. Arean121Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA;
Linköping University, Linköping, Sweden and Karolinska Institute, Stockholm, Sweden;
Optum, Eden Prairie, MN, USA; 4Black Dog Institute, University of New South
Wales, Sydney, NSW, Australia; 5Vrije Universiteit Amsterdam, Amsterdam, The
Netherlands; 6Western Sydney University, Penrith, NSW, Australia; 7University ofManchester, Manchester, UK; 8National Institute of Mental Health, Bethesda, MD,
USA; 9Verily Life Sciences, South San Francisco, CA, USA; 10University of Nottingham,
Nottingham, UK; 11Northwestern University, Chicago, IL, USA; 12University of Wash­
ington, Seattle, WA, USA2
3

H. Hsin is an employee of Verily Life Sciences. The views expressed here arethose of the authors and do not represent official views of Verily Life Sciences.
1.

2.
3.
4.
5.
6.
7.
8.

World Health Organization. The world health report 2001 – Mental health:
new understanding, new hope. Geneva: World Health Organization, 2001.
Huckvale K, Prieto JT, Tilney M et al. BMC Med 2015;13:214.
Kramer DB, Fu K. JAMA 2017;318:2077-8.
Larsen ME, Nicholas J, Christensen H. PLoS One 2016;11:e0152285.
Hollis C, Falconer CJ, Martin JL et al. J Child Psychol Psychiatry 2017;58:474-503.
Mohr DC, Weingardt KR, Reddy M et al. Psychiatr Serv 2017;68:427-9.
Dorsey ER, McConnell MV, Shaw SY et al. Acad Med 2017;92:157-60.
Torous JB, Chan SR, Gipson SY et al. Psychiatr Serv 2018;69:498-500.

DOI:10.1002/wps.20592

AVATAR therapy: a promising new approach for persistent
distressing voices
AVATAR therapy was invented and first described by J. Leffand colleagues1. The therapy involves a three-way conversation
between therapist, patient and a digital simulation (“avatar”)
of one of his/her hallucinated voices. The avatar comprises avisual representation of the agent that the patient believes is
responsible for the voice and uses a speech transformation
software to change the therapist’s voice into a close match of
the vocal characteristics (e.g., tone and pitch) of the voice thatthe patient has chosen for the therapy.
Therapy takes place over 6-8 short sessions of approximately
45 min, of which around 15 min are spent in dialog with the av­
atar, and the rest reviewing the experiences of the previous week,planning the session and reviewing the experience after the di­alog is complete. The therapist, sitting in a room remotely fromthe patient, speaks either as him/herself or in his/her trans­
formed voice as the avatar. The patient sits in front of a monitor
on which the avatar appears. Starting with verbatim copies ofwhat the patient reports hearing from his voices, the therapist
adjusts what the avatar says according to the unfolding dialog,
in which the patient is encouraged to confront the avatar and,through the dialog, to get to a point where it is no longer intimi­
dating and may even become encouraging and supportive.

98

The origins of the approach lie in dialogic therapies2-4 and isbased on the observation that voices are best understood not
simply as misattributions of internal thoughts, but represent
hallucinated social entities that have personal relevance, mean­
ing and purpose5,6. Thus, the content of therapy is based on aformulation that takes account of the person’s beliefs about
the identity, power and malevolence of the voices. It includes
consideration of whether the voice is of someone he/she knows
and whether what it says echoes earlier difficulties in relation­
ships, as for example experiences of being bullied, shamed or
humiliated.
The therapy proceeds in two broad phases7. The first three
sessions focus on assertively standing up to the avatar and re­jecting its onslaught. The content of the second phase (sessions
4 through 6) is more variable, as it is based on a formulation ofwhat needs to change in the relationship and what might per­suade the avatar to take a more conciliatory and accepting viewof the person. Strategies to improve self-esteem have turned
out to be a key target, both as an end in themselves and in theunderstanding of the origin and maintenance of the voice.
There have now been two pilot studies comparing AVATAR
therapy to a waiting list control1,8 and one powered controlled

World Psychiatry 18:1 - February 2019

trial comparing AVATAR therapy to a supportive counselingintervention9. All have shown benefit over the control conditionin terms of reduced frequency and severity of voices at 12 weeks(all voices, not only the one selected to create the avatar).
The larger trial9 also showed that the early benefit was sus­
tained at 24 weeks, although the comparison supportive coun­
seling group also improved, so that the residual difference
between the two arms was not statistically significant at thatpoint. It is worth emphasizing, however, that it was the im­provement in the control condition that accounted for thisapparent loss of effect and not a dissipation of effect of AVATAR
over the longer follow-up9.
The results of these studies are extremely encouraging andhave generated a huge worldwide interest among therapists,patients and their families. Together, they suggest a significant
advance in the treatment of psychosis. There is, however, stillsome way to go before the therapy is available beyond the re­search setting. Some steps towards this are mundane, albeit
time consuming, such as ensuring that the software has thenecessary regulatory approvals for use outside of research anddistilling the experience of the research into manuals and train­
ing programmes. Both are currently underway.
Another mundane consideration is the technological plat­form required to deliver the therapy. In principle this is not asignificant challenge, as the specialized software runs on stan­
dard desktop and laptop computers with a Microsoft operat­
ing system, and there is no requirement of more elaborate or
expensive immersive virtual reality equipment. However, theapproach requires the use of two rooms, which can be a chal­lenge to find in a busy outpatient clinic, and the host health careorganization has to consent for the therapy computers to beconnected using their ethernet or wireless facilities, with local
protocols in place to manage confidentiality and what they wish
to be recorded from therapy sessions.
Beyond these practical considerations is the availability ofclinical staff with the level of expertise required to safely deliver
therapy. There is no doubt that the therapy is challenging, bothfor patients and the therapist and, although there were no ad­verse events attributed to the therapy in the trials, it is obviousthat AVATAR interventions may frighten and harm, deliberately
or inadvertently.
The therapists in the three studies were all experienced clini­
cians, some with specific psychological therapy skills for psycho­sis. On the other hand, in our trial, substantial improvements
occurred as early as the third session, raising the possibility that,for some people, the straightforward exposure and assertive­
ness component was sufficient. If this can be substantiated infuture work, and rapid responders can be identified in advance,
it would enable the therapy to be delivered by a much wider
workforce, with, of course, appropriate training and supervision.
A further consideration is the timing of the therapy within
the wider envelope of care for psychosis. To date, the therapy
has been delivered as a “stand alone” treatment with a focus

World Psychiatry 18:1 - February 2019

entirely on the hallucinated voices. Participants were only in­cluded if they agreed to remain on their routinely prescribed
medication and were not receiving a psychological therapy
other than those provided by the research. In clinical practice,
it might be more appropriate to consider AVATAR therapy as
one component of a wider psychological intervention. For ex­
ample, in many cases voices were accompanied by persecutory
beliefs and consequent social difficulties. It struck us clinicallythat, for these participants, the timing and impact of AVATAR
therapy would have been better if delivered as a component ofa therapy plan that also addressed these wider problems.
Moreover, the focus to date has been on people sufferingfrom treatment resistant auditory hallucinations in the context
of long-standing illness. It is not clear whether the intervention
would be as effective in younger people experiencing their first
episode of illness. Here, the personification of the voices is of­ten less fixed or elaborated, possibly making the evolution of acoherent dialog more difficult to attain.
Finally, while the benefits seen in all three studies to date are areasonable basis for wider dissemination, there is no doubt thatfurther research is also needed. Larger multicentre replications
are necessary before organizations such as the National Institutefor Health and Care Excellence (NICE) will include AVATAR
therapy in their recommendations, and other studies will beneeded to clarify the subgroup of patients who can benefit fromthe simpler first phase treatment alone. Studies using new vir­tual reality headsets may replace the need for two rooms andperhaps open the way to deal with more than one voice at a time.
To conclude, while there is much to be done to take the exist­
ing research to routine care, there is every reason to be opti­
mistic. The technology is relatively inexpensive and enough is
known to provide training. The immediate practical obstacles
are likely to be resolved shortly, and preparation for dissemina­tion is underway. In the longer run, it seems likely that AVATAR
therapy will be provided as one component of wider psycho­
logical therapy for psychosis, possibly alongside other digitallyenhanced approaches for paranoia and cognitive impairment.
Tom K.J. Craig
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
1.
2.
3.
4.
5.
6.
7.
8.
9.

Leff J, Williams G, Huckvale MA et al. Br J Psychiatry 2013;202:428-3.
Chadwick P. Person-based cognitive therapy for distressing psychosis.
Oxford: Wiley-Blackwell, 2006.
Corstens D, Longden E, May R. Psychosis 2012;4:95-104.
Hayward M, Jones A-M, Bogen-Johnston L et al. Schizophr Res 2017;183:
137-42.
Bell V. PLoS Biol 2013;11:e1001723.
Hayward M, Berry K, Ashton A. Clin Psychol Rev 2011;31:1313-23.
Craig T, Ward T, Rus-Calafell M. In: Pradhan B, Pinninti N, Rathod S (eds).
Brief interventions for psychosis: a clinical compendium. London: Springer,
2016:41-54.
Percie du Sert O, Potvin S, Lipp O et al. Schizophr Res (in press).
Craig T, Rus-Calafell M, Ward T et al. Lancet Psychiatry 2018;5:31-40.

DOI:10.1002/wps.20589

99

Parental divorce or separation and children’s mental health
An increasing number of children across the world experi­ence family instability due to divorce/separation and the con­sequences of non-marital childbearing/cohabitation1.
Alternatives to stable marriage are most common in Westerncountries (including Australia and New Zealand) and less com­
mon but growing in industrializing Asia. Cohabitation, which ismore unstable than marriage, is especially common in Northernand Western Europe, necessarily lowering rates of divorce but
not of single-parent households.
The US has been a “leader” in family change with an early(rising in the late 1960s) and high increase in divorce, followedby an explosion in non-marital birth with or without cohabita­tion. Divorce increased in most other Western nations a decadeor two later; industrializing Asia appears to be in the midst ofchange. Today, only about 60% of US children live with theirmarried, biological parents, a low second only to Latvia.
Some call family instability a major public health problem
for children; others see divorce/separation as relatively innocu­
ous, even a positive change, especially for women in unhappy
marriages or children exposed to high conflict.
Research has documented that parental divorce/separation
is associated with an increased risk for child and adolescent ad­
justment problems, including academic difficulties (e.g., lower
grades and school dropout), disruptive behaviors (e.g., conduct
and substance use problems), and depressed mood2.
Offspring of divorced/separated parents are also more likely
to engage in risky sexual behavior, live in poverty, and experi­ence their own family instability. Risk typically increases by afactor between 1.5 and 2.
Still, most children whose parents divorce are resilient andexhibit no obvious psychological problems. It is important torecognize, however, that even resilient young people from di­vorced families often report painful feelings or encounters, suchas worrying about events like graduations or weddings whenboth parents will be present3.
Many associated risk factors – for example, lower income
and parent conflict – are linked with non-random selection intofamily stability and/or are consequences of family break-up.
To help rule out potential confounds, researchers have used avariety of methods, including measuring covariates and em­
ploying designs, such as children-of-twin studies, that accountfor unmeasured environmental and genetic factors that could
influence both generations2,4. Controls for such confounds
reduce but do not eliminate the risk tied to parental divorce,
consistent with causal inference.
A wealth of research also points to factors mediating the as­sociation, including less effective parenting, interparental con­flict, economic struggles, and limited contact with one parent,
typically the father (listed in decreasing order of the magnitudeof their relation with children’s mental health)5. Marital insta­
bility presents not a single risk factor, but a cascade of sequelae
for children.

100

Individual, family, ethnic and cultural factors moderate therisks associated with changes in children’s family life, under­
scoring the importance of recognizing family diversity. In theUS, for example, parental separation is associated with moresocioemotional problems among white children than black or
Hispanic children2. Acceptance of alternatives to marriage andextended family support contribute to such ethnic variation.
Understanding family change and its consequences is criticalto health care professionals across numerous settings. Physicians
treating children may observe warning signs, be asked to help
children cope with family transitions, or face parental disputes
about a child’s well-being or needed treatment. Schools encoun­ter similar opportunities and difficulties.
Children and adult offspring of separated parents are overrepresented in the mental health system. Most mental healthinterventions target the known mediators of risk, such as parent­ing problems or family conflict. Structured interventions offeringparenting support and education have been shown to reducechildren’s psychological problems6. Unfortunately, few mental
health interventions for divorcing families have been carefully
studied.
Separation/divorce also raises legal concerns bearing on thewell-being and custody of children. The “best interests of chil­dren” is the prevailing custody standard, and “best” typically isinterpreted in psychological terms (as opposed to, for example,
economic ones). Mental health professionals and others may
become involved, willingly or unwillingly, as expert witnesses
in custody contests. Alternatively, some professionals promote
or offer alternative dispute resolution, such as mediation.
Mediators are neutral third parties who help parents living
apart to resolve disputes themselves. In addition to disputesettlement, mediation potentially benefits children by lower­
ing conflict, improving parenting, and encouraging both par­ents to remain an active presence in their children’s lives. One
randomized trial with a 12-year follow-up demonstrated thatmediation produced all of these outcomes relative to litiga­
tion5,7. Another randomized study found that carefully involv­
ing children in the process improved the success of mediation7.
While initial results are promising, mediation and manyother legal and mental health interventions demand rigorous
study, as well-intentioned services may have no effect or may
even be harmful for some individuals, while wasting limited
resources8.
Mental health professionals also can play a critical role inadvising parents, and perhaps in the development of law andpolicy. One controversial issue is how strongly, and underwhat circumstances, to promote joint physical custody, sharing­25­-­50% parenting time9. Joint legal custody, which involves
legally sharing important decisions, including elective medicalcare, is becoming ubiquitous. It has increased in the US and inmany Western countries, but still typically comprises a minor­
ity of separated families (from 15 to 50% across countries)9.

World Psychiatry 18:1 - February 2019

Fathers groups are currently advocating for a universal 50/50
shared time presumption.
While such agreements may benefit numerous families,
many experts, including ourselves, worry that such a presump­tion may offer the “right” solution for the wrong group of par­ents: the 10% or fewer who contest custody in court5. Other
concerns we share include avoiding extensive time away fromattachment figures among very young children, avoiding plac­
ing excessive travel demands on children in order to share par­enting time across long distances, whether shared time needs
to be precisely 50/50, and if some child mental health problems(e.g., autism spectrum) or personality (e.g., high conscientious­ness) make shared custody less likely to work5.
There is, therefore, a critical need for studies on interven­tions, including policy changes, that consider the risks, role ofresiliency, and heterogeneity in the consequences associatedwith family instability.

Brian D’Onofrio1,2, Robert Emery3
1

Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN,
USA; 2Department of Medical Epidemiology and Biostatistics, Karolinska Institutet,
Stockholm, Sweden; 3Department of Psychology, University of Virginia, Charlottesville,
VA, USA
1.
2.
3.
4.
5.
6.
7.
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Organisation for Economic Co-operation and Development. Family data­base. http://www.oecd.org/social/family/database.htm.
Dohoon L, McLanahan S. Am Sociol Rev 2015;80:738-63.
Laumann-Billings L, Emery RE. J Fam Psychol 2000;14:671-87.
D’Onofrio BM, Turkheimer E, Emery R et al. J Abnorm Psychol 2005;114:
1130-44.
Emery RE. Two homes, one childhood: a parenting plan to last a lifetime.
New York: Avery, 2016.
Wolchik SA, Sandler IN, Millsap RE et al. JAMA 2002;16:1874-81.
Ballard RH, Holtzworth-Munroe A, Applegate AG et al. Psychol Publ Policy
Law 2013;19:271-81.
Rudd BN, Poladian AR, Holtzworth-Munroe A et al. J Fam Psychol 2017;31:
381-6.
Smyth BM. Fam Court Rev 2017;55:494-9.

DOI:10.1002/wps.20590

Resilience from a developmental systems perspective
Interest in human resilience is surging in the context of natu­­
ral disasters, war, political conflict, and increasing awareness re­garding possible consequences of adversity in childhood for
health and well-being in adulthood1,2. Although resilience sci­ence is not new, current research is more multidisciplinary,­multilevel and developmental than ever before, reflecting a de­velopmental systems perspective with profound implications
for defining and investigating resilience, as well as for translating
evidence into practice3.
Resilience science emerged from research on etiology of­mental disorders1. Investigators studying children at risk for psy­
chopathology observed striking variation in outcome, as many
individuals with risk factors for mental health problems (e.g.,
maltreatment, poverty) nonetheless developed well. Resilience
research aims to understand this variation in order to inform in­terventions that mitigate risk and promote positive development.
Models of resilience shifted with the infusion of dynamic­sys­tems theory into developmental science4. As a living system, ahuman individual develops through myriad interactions at many
levels, from genetic and neurobiological to social and cultural5,6.
Adaptive systems develop within the person (e.g., immune sys­tem, stress-regulation system, self-regulation system) as the in­di­vidual, embedded in larger systems, adapts simultaneously to
external contexts. All these dynamic interactions shape develop­
ment, yielding diverse pathways of adaptive function3.
The capacity of a developing child to respond to challenges
and adversities depends on the operation of many systems, var­
ying from neurobiological stress-regulation systems to families,
schools, community safety and health care systems, and nu­
merous other sociocultural and ecological systems. Resilience
reflects resources and processes that can be applied to restore
equilibrium, counter challenges, or transform the organism.

World Psychiatry 18:1 - February 2019

Definitions of resilience evolved to reflect insights on devel­
oping systems. Currently, resilience can be defined broadly as“the capacity of a system to adapt successfully to disturbancesthat threaten the viability, function, or development of the sys­tem”1. This definition can be applied to diverse systems, includ­ing individuals, families, businesses, communities, economies,or ecosystems. It has the advantage of scalability across systemlevels, which is increasingly crucial for integrating concepts
and knowledge about human resilience across disciplines andlevels of analysis.
As this definition suggests, the resilience of an individual de­pends on resilience of interconnected systems. Systems inter­dependence is salient in major disasters, when multiple systems
are overwhelmed at the same time, and also in family-level
crises, when disturbances in the mental health of a caregivercan disrupt the quality of care or lead to child maltreatment7. It
is important to remember that resilience of an individual is not
limited to the capacity that person can muster alone. Indeed,much of human resilience is embedded in relationships andsocial support8.
Accumulating evidence on resilience has identified a num­
ber of factors that could explain why some individuals fare somuch better than others. Some factors are common, associatedwith positive adjustment during or following different adverse
experiences, although they vary in form and relevance acrossdevelopment and context. Such factors may well reflect adap­
tive systems preserved by human evolution, biological andsociocultural, because they enhance survival1. Common pro­tective factors include effective caregiving and other support­
ive relationships, problem-solving and self-regulation skills,
self-efficacy and optimism, and beliefs that life has meaning3.
Identified early in resilience studies, common factors were101

corroborated repeatedly in basic studies with diverse popula­tions and in intervention trials designed to promote resilience3.
Other protective factors appear to be relatively unique to aparticular culture or context, such as specific forgiveness rituals
or spiritual practices.
Initial resilience research focused on psychosocial factorsthat might mitigate risk or promote better adaptation. Withadvances in measurement at other levels of analysis, resiliencescience expanded rapidly to include the neurobiology of re­silience, genetic processes, cultural influences, and the cas­cading spread of risk and protection across systems, levels
and generations3. Advances in the study of epigenetic change
raised interesting considerations about biological embeddingof experience, via gene methylation and related processes,
which may explain effects of trauma and caregiving quality
on brain development and lifelong health9. One of the mostprovocative questions posed by recent theories of biologicalsensitivity to experience, and the related concept of differential
susceptibility, is whether children who adapt poorly to adverse
experiences may also be more responsive to positive experi­
ences, such as interventions tailored to foster mental healthand competence among sensitive individuals3.
Resilience research has had a transformative effect on mul­
tiple disciplines concerned with promoting mental health andwell-being, shifting intervention frameworks away from deficit
models toward more comprehensive approaches that include
promotive and protective factors as well as risks and vulner­
abilities, focusing on health as well as illness1. Examples range
from strength-based school counseling to global humanitarianefforts moving beyond child survival to thriving3. A meta-analysisof resilience-oriented school interventions found reductions inmental health symptoms (depression, anxiety), particularly forcognitive-behavioral strategies10.
Current directions in resilience science hold exciting promisefor elucidating how adaptive capacity develops and operates tomitigate risk or promote resilience, guiding intervention models,targets and timing. Strategies could focus on preventing trauma,
lowering stress, inoculating against stress through calibrated
exposures, reducing vulnerability, boosting resources, restor­102

ing and mobilizing powerful adaptive systems, or generating
positive cascades across system levels or generations. Timely­targeted interventions could range from preventing maternal
perinatal stress to boosting social relationships in late adult­
hood. It is conceivable that key adaptive systems adversely af­
fected by early trauma, such as neurobiological stress-regulation
systems, can be “reprogrammed” later in development to im­prove adaptive function9.
Developmentally-informed research on resilience has thepotential to elucidate processes across systems and levels thatwould inform efforts to promote mental health, prevent psy­
chopathology, and facilitate recovery. Developmental studies
may identify windows of opportunity when there is greater
plasticity and leverage for change, so that interventions canbe effectively tailored and timed for efficacy, adapted to in­dividual, developmental and situational differences. Policy
makers and non-governmental organizations are already eval­uating synergistic effects of integrating their services across sys­
tem levels (vertical), sectors (horizontal) and generations. As
knowledge expands, resilience theory can be tested and refined
through randomized trials that target malleable processes withstrategic timing to leverage opportunities for change.
Ann S. Masten
Institute of Child Development, University of Minnesota Twin Cities, Minneapolis, MN,
USA
1.
2.

Masten AS. Child Dev 2014;85:6-20.
Shonkoff JP, Garner AS, the Committee on Psychosocial Aspects of Childand Family Health et al. Pediatrics 2012;129:232-46.
3. Masten AS, Cicchetti D. In: Cicchetti D (ed). Developmental psychopathol­ogy, Vol. 4, 3rd ed. New York: Wiley, 2016:271-333.
4. Masten AS. Psychol Inq 2015;26:187-96.
5. Bronfenbrenner U, Morris PA. In: Damon W, Lerner RM (eds). Handbook ofchild psychology, Vol. 1, 6th ed. New York: Wiley, 2006:793-828.
6. Gottlieb G. Dev Sci 2007;10:1-11.
7. Cicchetti D. Annu Rev Psychol 2016;67:187-211.
8. Southwick SM, Sippel L, Krystal J et al. World Psychiatry 2016;15:77-9.
9. McEwen BS, Gray JD, Nasca C. Neurobiol Stress 2015;1:1-11.
10. Dray J, Bowman J, Campbell E et al. J Am Acad Child Adolesc Psychiatry
2017;56:813-24.
DOI:10.1002/wps.20591

World Psychiatry 18:1 - February 2019

LETTERS TO THE EDITOR

Using biobehavioral technologies to effectively advance research on
negative symptoms
Negative symptoms have been a core component of schizophrenia since the pre-neuroleptic era and are related to particularly poor clinical outcomes (e.g., in terms of recovery,
quality of life, subjective well-being). They are often one of thefirst markers of illness risk, emerging in the premorbid and prodromal phases, and in many patients remain stable throughout
the first episode and chronic phases of illness1. Unfortunately,
the mechanisms underlying these symptoms are poorly understood, and currently available treatments are unsatisfactoryand palliative at best2.
To date, our understanding of negative symptoms is almost
entirely dependent on psychometrically-supported clinical rating scales. Within the last few decades, a literature has emergedusing “biobehavioral” technologies to measure negative symptoms from objective vocal, language, facial, decision making,gestural, electrophysiological, neurobiological, and reaction
time measures.
While clinical ratings reveal abnormalities on the scale ofthree to seven standard deviations in patients versus non-­psychiatric controls1,3, group differences in biobehavioral mea­sures tapping their underlying constructs are much smaller, if
not altogether absent. For example, despite dramatic clinicallyrated patient abnormalities in alogia, blunted affect, anhedonia,
and avolition1,3,4, studies of computerized speech analysis, hedonic experience, and motivation often find negligible or small
effect size abnormalities5,6.
Moreover, biobehavioral measures often show surprisingly
modest and negligible correlations with conceptually overlapping negative symptom ratings6,7, or similarly sized correlations
to a wide array of non-negative symptom ratings8. Thoughstatistical significance may be reported in isolated studies for
specific biobehavioral features, findings often do not replicate
across studies, and the magnitude of effects are generally well
below levels suggestive of acceptable convergent validity3.
In light of this surprisingly low convergence between clinicalratings and biobehavioral technologies, it is tempting to champion one of the two as being superior for measuring negative
symptoms. Clinical ratings tend to be consistent across trainedraters (i.e., reliability) and are associated with a wide range ofimportant clinical variables (i.e., validity). On the other hand,biobehavioral technologies show near perfect reliability (assuming static recording conditions), and are instrumental tomodern biometrics for measuring human functions that potentially underlie negative symptoms. So how can clinical ratingsand biobehavioral technologies both be “reliable” and “valid”
for measuring negative symptoms, yet show such surprisingly
modest convergence?
Clinical ratings and biobehavioral technologies are fundamentally different in how they scale negative symptoms. Clinicalratings reflect the integration of an impressive number of complicated data streams over dynamic conditions. Using clinicalWorld Psychiatry 18:1 - February 2019

rating scales, for example, a clinician is able to derive a gross ordinal value (e.g., “mild”) regarding blunted affect from a highly
complex “spectrum” of vocal, verbal, facial and gestural datathat fluctuate over time, questions and a changing environment.
Unfortunately, an individual negative symptom rating cannot be systematically “downscaled” for quantification. For example, deconstructing clinically-rated blunted affect proves
impossible in terms of which exact psychomotor channel wasabnormal, when it was abnormal, or what factors may havemitigated the abnormality. In contrast, biobehavioral technologies afford the opportunity to precisely quantify continuous
streams of highly specific speech, facial and gestural data, andto isolate, upscale, downscale and integrate them in a myriadof ways.
Unfortunately, it is unclear how to best do this. Which of thethousands of potential features computed from, for example,
vocal analysis should be used, and how should they be weighted when they do not converge? Should computerized facial
analysis reflect aggregate statistics during an entire interview,
only when patients are speaking, during key temporal epochs,
or following specific questions? In short, clinical ratings provide a view of the forest at the expense of being able to see thetrees, whereas biobehavioral technologies afford the opposite.
Ideally, there would be a way to measure negative symptoms
by marrying “low-resolution” but “ecologically-valid” ratings
with “high-resolution” but “dizzyingly-complex” biobehavior­
al data. Within computational psychiatry more generally, anemerging “big data” literature now exists modeling various
clinical diagnoses and ratings using biobehavioral features.
Within these studies, models are typically built and optimized
using a single biobehavioral channel without regard to otherbiobehavioral channels or to temporal, contextual or otherdynamic factors.
While impressive accuracy rates are being reported, themodels produced from this literature have yet to progress beyond “proof of concept” and seem particularly ill-equipped formodeling negative symptoms. This is because clinician ratings
are typically derived from multiple behavioral domains, and
it is difficult to evaluate even one of these domains without
considering context. For example, a patient’s failure to activate
his/her zygomaticus major muscle, language production, or
reward systems can only be interpreted as abnormal whencontext is taken into account. After all, non-patients are notactively smiling, talking or experiencing joy the vast majorityof their day. Further complicating this issue is the reality thatthe behaviors underlying negative symptoms vary dramatically
across and within people as a function of neurodevelopmental
and cultural factors. In this manner, norms regarding smiling,talking and experiencing joy are very difficult to derive.
So, how can biobehavioral-based modeling of negative symp­
toms progress? Technology and software systems have pro-103

gressed so that they are affordable, reliable, highly sensitive, andunobtrusive, with a high potential for large-scale international
data collection across a broad range of behavioral domains.
This allows for biobehavioral data collection that extends wellbeyond the relatively artificial confines of the clinic or researchlaboratory. For this, ecological momentary and ambulatory
assessment methods, such as geolocation, passive vocal recording, activity tracking, and social media analysis, can complement existing measurement approaches.
Efforts to validate these technologies for understanding negative symptoms are currently underway. However, integrating
and understanding these data within a network that can handle
temporally and contextually dynamic data is a complex computational obstacle. Relatively simplistic “connectionist” anddynamic algorithms are being developed for many important
human functions, and there is a growing field of understanding“networks of networks” to model complex interactions (e.g.,“network medicine”)9.
In sum, existing clinical rating measures offer a level of precision that has not promoted advances in understanding underlying mechanisms and developing targeted treatments ofnegative symptoms. This reflects a “scalability” problem thatcan potentially be solved by modeling clinical ratings withmultidimensional biobehavioral data streams.
Developing biobehavioral models can help pinpoint neurobiological and environmental mechanisms, modify themin real time using biobehavioral feedback, and develop, test
and individualize targeted psychosocial and pharmacological agents to ameliorate their severity, and ideally, develop
treatments.
Accurate modeling of negative symptoms is a complex endeavor, and an exciting computational opportunity that may­advance multidisciplinary sciences and bring together researchers, patients and their support teams from around the world.
Alex S. Cohen1, Elana Schwartz1, Thanh P. Le1, Taylor Fedechko1,
Brian Kirkpatrick2, Gregory P. Strauss3
1

Department of Psychology, Louisiana State University, Baton Rouge, LA, USA; 2De­
part­ment of Psychiatry and Behavioral Sciences, Reno School of Medicine, Uni­versity of
Nevada, Reno, NV, USA; 3Department of Psychology, University of Georgia, Athens, GA,
USA
1.
2.
3.
4.
5.
6.
7.
8.
9.

Marder SR, Galderisi S. World Psychiatry 2017;16:14-24.
Miyamoto S, Miyake N, Jarskog LF et al. Mol Psychiatry 2012;17:1206-27.
Cohen AS, Mitchell KR, Elvevåg B. Schizophr Res 2014;159:533-8.
Cohen AS, Najolia GM, Brown LA et al. Clin Psychol Rev 2011;31:440-8.
Green MF, Horan WP, Barch DM et al. Schizophr Bull 2015;41:1035-44.
Cohen AS, Mitchell KR, Docherty NM et al. J Abnorm Psychol 2016;125:299-309.
Cohen AS, Mitchell KR, Strauss GP et al. Schizophr Res 2017;188:141-3.
Kring AM, Gur RE, Blanchard JJ et al. Am J Psychiatry 2013;170:165-72.
Barabási AL, Gulbahce N, Loscalzo J. Nat Rev Genet 2011;12:56-68.

DOI:10.1002/wps.20593

Testing a neurophenomenological model of basic self disturbancein early psychosis
The construct of basic (core, minimal) self disturbance has
emerged in recent years as a possible key phenotypic marker ofthe schizophrenia spectrum1.
Two nested concepts can be identified as constituting this
aspect of selfhood: sense of ownership/mineness (I perceive mybody, perceptions and thoughts as my own) and sense of agency(I experience myself as the source of my actions and their consequences). These are generally implicit or “given” aspects of anormal sense of basic self and facilitate (and are in turn consolidated by) interactions with others/the world. Fragility or instability of the basic self can manifest in a variety of anomalous subjective experiences, which can intensify and crystallize over time
into episodes of positive and negative psychotic symptoms2.
A considerable body of research has accumulated over thelast 15 years indicating that basic self disturbance is a trait vulnerability feature that (though overlapping in some respects
with non-schizophrenic dissociative conditions) has considerable specificity to schizophrenia spectrum disorders and ispresent in the prodromal phase of these disorders3. Indeed,disturbed “self-experience” is included in the criteria for schizophrenia of the beta version of the ICD-11.
Taking basic self disturbance as a phenomenological s­ tarting
point allows researchers to examine correlates and contribut104

ing factors, cross-sectionally and longitudinally. Some progress is now beginning to be made in this respect. Sestito et al4
found that facial reactions in response to negative emotional
stimuli, recorded using electromyography, specifically andstrongly correlated with basic self disturbance in schizophrenia
spectrum patients. Martin et al’s5 findings in schizophrenia
indi­cated a relationship between compromised extraction of
temporally predictive information assessed in experimental
tasks and basic self disturbance. Given the complexity andfoundational nature of the basic self disturbance construct,multiple neural mechanisms are likely to be associated withthis constellation of anomalous subjective phenomena.
Nelson et al6 introduced a theoretical model proposing thatthe neurocognitive constructs of source monitoring deficits
and aberrant salience, both of which have been found to beprominent in schizophrenia spectrum disorders and related
to psychosis risk, may be of particular relevance to basic self
disturbance in schizophrenia. Source monitoring deficits referto difficulties in making attributions about the origins of phenomenal experience – e.g., whether an experience was real or
imagined, or whether its origin was self- or other-generated.
Aberrant salience refers to the reduced ability to suppress attention to irrelevant or familiar information or environmenWorld Psychiatry 18:1 - February 2019tal stimuli (in other words, excessive attention to informationthat is irrelevant or highly familiar), leading to an unusual sa­
lience of stimuli. There is strong face validity that the phenomenological disturbances which might arise from (and in turnconsolidate) these neurocognitive disturbances accord withmany of the experiential alterations associated with basic self
disturbance6 (e.g., diminished “ownership” of mental content,
confusion of self-other boundaries, hyper-reflexivity).
We tested this model empirically in 50 ultra-high risk forpsychosis subjects, 39 first-episode psychosis patients and 34
healthy controls. Participants were assessed with a variety ofclinical measures, including the Examination of Anomalous
Self-Experience (EASE)7, and neurocognitive and neurophysiological measures of source monitoring deficits (Action Memory
Task, Word Recognition Test, Temporal Binding Task, Auditory
Button-Press Task) and aberrant salience (Salience Attribution
Test, Babble Task, Auditory Oddball Paradigm).
Linear regression indicated that source monitoring (composite score across neurocognitive and neurophysiologicalmeasures), with study group as an interaction term, explained
39.8% of the variance in EASE scores (R2=.41, F(3,85)=14.78,
p<0.001). Source monitoring significantly predicted EASE
scores (β=.80, p<0.001), and there was a significant source
monitoring by study group interaction effect (β=.29, p<0.05).
In order to determine the specificity of the relationshipbetween source monitoring deficits and EASE scores, a series of regressions with other clinical scales as dependent
variables were performed. Although source monitoring was
found to significantly predict variance in scores on each ofthese clinical measures, the variance explained was not as
substantial as for the EASE scale: 25% for Brief PsychiatricRating Scale (BPRS) scores (R2=.25, F(3,85)=9.01, p<0.01); 19%
for BPRS positive symptoms (R2=.19, F(3,85)=6.69, p<0.01);
26% for Comprehensive Assessment of At Risk Mental States(CAARMS) positive symptoms (R2=.26, F(3,85)=9.45, p<0.01);
14% for Scale for the Assessment of Negative Symptoms (SANS)
scores (R2=.14, F(3,85)=4.71, p<0.01).
The same analysis was performed with the aberrant sa­lience
composite score. This score explained only 6% of the variance in
EASE scores (R2=.06, F(3,85)=1.44, p=0.93). However, ex­ploratory
analyses indicated moderate relationships between aberrantsalience, particularly the Babble task8, and general psychopathology (BPRS score in first-episode psychosis patients, r=.44,
p<0.05), ­particularly with positive psychotic symptoms (BPRS
positive symptoms in first-episode psychosis patients, r=.53,

p<0.01; CAARMS positive symptoms in ultra-high risk subjects,
r=.44, p<0.01).
This is the first empirical test of a neurophenomenologicalmodel6 organized around the construct of basic self disturbance.
Partial support for the model emerged: there was a significant
relationship between basic self disturbance and source monitoring deficits, while no relationship was found with ­aberrant salience, which was moderately related to g­ eneral p­ sychopathology,
particularly positive psychotic symptoms (and is therefore possibly more a state-based feature of the illness).
The model may need to be expanded from source monitoring deficits to encompass other constructs that recent theoretical and empirical work suggests may be relevant, such as
disturbed temporal processing, intermodal/multisensory integration, and hierarchical predictive processing. These are
overlapping constructs and it is yet to be determined if one orseveral of these constructs have causal or explanatory primacy
with regard to basic self disturbance.
The current data and other related recent research show an
emerging picture of neurocognitive and neurophysiologicalcorrelates of core phenomenological aspects of schizophrenia
spectrum disorders beyond surface-level episodic psychotic
symptoms. Pursuing this approach offers the possibility of integrating levels of research around central features of the schizophrenia spectrum and of “mutual enlightenment” between
these different levels of enquiry.
Barnaby Nelson1,2, Suzie Lavoie1,2, Lukasz Gaweda3,4, Emily Li1,2,Louis A. Sass5, Dan Koren6, Patrick D. McGorry1,2, Bradley N. Jack7,
Josef Parnas8, Andrea Polari1,2,9, Kelly Allott1,2, Jessica A. Hartmann1,2,Thomas J. Whitford7
1

Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne,
Australia; 2Centre for Youth Mental Health, University of Melbourne, Melbourne,
Australia; 3Department of Psychiatry and Psychotherapy, University Medical Center
Hamburg-Eppendorf, Hamburg, Germany; 4II Department of Psychiatry, Medical Uni­
versity of Warsaw, Warsaw, Poland; 5Rutgers University, New York, New York, USA;
6
Psychology Department, University of Haifa, Haifa, Israel; 7School of Psychology,
University of New South Wales, Sydney, Australia; 8University of Copenhagen, Copen­
hagen, Denmark; 9Orygen Youth Health Clinical Program, Melbourne, Australia
1.
2.
3.
4.
5.
6.
7.
8.

Parnas J, Zandersen M. World Psychiatry 2018;17:220-1.
Henriksen MG, Parnas J. Curr Probl Psychiatry 2017;18:177-83.
Parnas J, Henriksen MG. Harv Rev Psychiatry 2014;22:251-65.
Sestito M, Raballo A, Umiltà MA et al. Psychopathology 2015;48:184-91.
Martin B, Franck N, Cermolacce M et al. Sci Rep 2017;7:8278.
Nelson B, Whitford TJ, Lavoie S et al. Schizophr Res 2014;152:12-9.
Parnas J, Moller P, Kircher T et al. Psychopathology 2005;38:236-58.
Hoffman RE, Woods SW, Hawkins KA et al. Br J Psychiatry 2007;191:355-6.

DOI:10.1002/wps.20597

Improving access to evidence-based interventions for youngadolescents: Early Adolescent Skills for Emotions (EASE)
About half of all mental disorders emerge by 14 years of age1.
In adolescents, depression is the main cause of disability, anxiety is ranked seventh, and suicide is the third leading cause ofWorld Psychiatry 18:1 - February 2019

death1. An estimated 10-20% of adolescents worldwide sufferfrom mental disorders2, which are associated with health andsocial problems, such as poor academic attainment, substance105

misuse, and economic difficulties3. Consequently, adolescenceis a critical period in which to intervene.
Adolescents living in low- and middle-income countries(LMICs) may be especially at risk of mental disorders when
they are exposed to adversity, such as extreme poverty and­violence4. While advances have been made, access to evidencebased psychological treatments for adolescents in LMICs israre4.
There is a growing literature on effectiveness of psychosocial
interventions for youth in LMICs. A recent systematic review
and meta-analysis of individual participant data from 3,143
children affected by conflict recruited to eleven randomized
controlled trials found that focused psychosocial interventions can be effective in reducing post-traumatic stress disorder(PTSD) symptoms and in increasing hope, coping and social
support, and reducing functional impairment5.
The World Health Organization (WHO) is seeking to strength­
en the quantity and quality of mental health services. As part of
the Mental Health Gap Action Programme (mhGAP), the WHO
is developing and testing the effectiveness of brief, transdiagnostic psychological interventions, including those for youngadolescents, that can be implemented by trained and supervised non-specialists in multiple settings, including health, pro­tection and education6,7.
Building on ongoing work to develop and test potentiallyscalable psychological interventions for adults8, the WHO hasdeveloped a group intervention for young adolescents (about
10 to 14-year-olds) exhibiting internalizing problems (e.g.,
symptoms of depression or anxiety). The intervention is called
Early Adolescent Skills for Emotions (EASE).
Central to the development of EASE was the capacity to address comorbid emotional problems in one intervention andpromote scale-up in LMICs with the use of briefly trained nonspecialists. The formative process to develop EASE included anarrative review, the identification of empirically-supported
strategies that were most commonly used in effective interventions according to the PracticeWise9 database, and extensive
expert consultation (a concept note on the development of
EASE is available upon request).
EASE aims to mitigate symptoms of internalizing disorders,such as depression and anxiety, by the provision of four core
empirically-supported strategies delivered face-to-face overseven group sessions with adolescents, and three group sessions with their caregivers.
Strategies with young adolescents are introduced in orderof complexity, thus each session reviews and rehearses previously introduced strategies, with practice between sessions
encouraged. Sessions are designed to last 90 min. They include
pictures, stories and activities to encourage youth engagement.
The first session aims to build rapport with participants anddevelop group cohesion. Psychoeducation is presented, informing participants about adversity and emotional distress.
Participants are also taught how to appropriately identify theirown emotions (“Understanding My Feelings”) which is seen as
fundamental to basic emotional regulation. Session 2 addresses

106

problems of physical arousal associated with stress, anxiety andanger, and introduces slow breathing (“Calming My Body”) topromote arousal reduction.
Participants are encouraged to engage in meaningful activities to improve their mood in sessions 3 and 4 (“Changing my
Actions”). Based on behavioral activation, this strategy aims toaddress symptoms of inactivity and help engage adolescents inmore meaningful activities.
Sessions 5 and 6 promote independent problem solving skills
via a simplified problem solving technique called “Managing
my Problems”. Embedded within this strategy are questions toprompt participants to seek social support. Finally, session 7
focuses on relapse prevention and helps participants prepare
to use the strategies independently in the future.
Given difficulties with engagement of employed or overburdened caregivers, and in the context of a brief intervention, only
three two-hour group caregiver sessions are included. They aim
to build on existing strengths and promote adaptive parenting practices to improve the caregiver-child relationship andenhance confidence when responding to adolescent distress.
In the first session, caregivers are provided with psychoeducation and skills to better equip them to respond and provide
comfort to their child when they are overwhelmed by feelings of
distress. Emotion identification, active listening and slow breathing are taught and practiced. The second session focuses on positive parenting strategies including praise, boosting their child’s
confidence and the discontinuation of physical discipline. Finally,
caregiver self-care (e.g., sleep, nutrition, stress reduction strategies) is covered in session 3. This session aims to enhance caregiver’s capacity to cope with challenges related to the environment
and to parenting an adolescent experiencing significant distress.
Education about relapse prevention is also provided in this final session. Practice and application of strategies is encouraged
between sessions. In addition, across all sessions, caregivers are
informed of the strategies being taught in the adolescent sessions.
Beyond the caregiver and youth sessions, facilitators aretrained to monitor and identify indicators of threats to adolescents’ wellbeing in the home environment and to make referrals
as indicated.
The capacity to effectively implement and scale up this intervention in LMICs is critical. Adopting a responsibly implemented (e.g., including ongoing supervision and support) tasksharing approach by employing non-specialists makes EASE
more affordable and scalable. Facilitators of this intervention
are expected to have at least high-school education, but are notrequired to have previous mental health experience. They willcomplete eight to ten days of training in basic mental healtheducation, counseling and group management skills and the
EASE intervention, and receive weekly supervision. Similar tasksharing approaches have been employed in studies demonstrating effectiveness in adults10.
Access to effective psychological interventions for adolescentsis essential to promote healthy development into adulthood.
EASE is a brief, transdiagnostic intervention that aims to mitigate
symptoms of emotional distress in young adolescents. If proven

World Psychiatry 18:1 - February 2019

effective, it can potentially be scaled-up in many settings. The effectiveness of EASE is currently being tested through randomized
controlled trials in Lebanon, Jordan, Pakistan and Tanzania.
Katie S. Dawson1, Sarah Watts2, Kenneth Carswell2,
Melissa Harper Shehadeh2, Mark J.D. Jordans3,4, Richard A. Bryant1,
Kenneth E. Miller3, Aiysha Malik2,5, Felicity L. Brown3, Chiara Servili2,
Mark van Ommeren2
1

School of Psychology, University of New South Wales, Sydney, NSW, Australia;
Department of Mental Health and Substance Abuse, World Health Organization,
Geneva, Switzerland; 3Department of Research and Development, War Child, Amsterdam, The Netherlands; 4Center for Global Mental Health, Institute of Psychiatry, Psy­
chology & Neuroscience, King’s College London, London, UK; 5Oxford Institute ofClinical Psychology Training, Isis Education Centre, University of Oxford, Oxford, UK
2

K.S. Dawson and S. Watts are joint first authors. Development and testing of
EASE is supported by European Commission, Elhra, Jacobs Foundations, Oak
Foundation, War Child Holland and WHO. The authors alone are responsible
for the views expressed in this letter and they do not necessarily represent theviews, decisions or policies of the institutions with which they are affiliated.

1.

World Health Organization. Health for the world’s adolescents: a second
chance in the second decade. Geneva: World Health Organization, 2014.
2. Kieling C, Baker-Henningham H, Belfer M et al. Lancet 2011;378:1515-25.
3. Jenkins R, Baingana F, Ahmad R et al. Ment Health Fam Med 2011;8:87-96.
4. Patel V, Kieling C, Maulik PK et al. Arch Dis Child 2013;98:323-7.
5. Purgato M, Gross AL, Betancourt T et al. Lancet Glob Health 2018;6:e390400.
6. World Health Organization. mhGAP: Mental Health Gap Action Programme:
scaling up care for mental, neurological, and substance use disorders.
Geneva: World Health Organization, 2008.
7. Dua T, Sharma A, Patel A et al. World Psychiatry 2017;16:216-7.
8. Epping-Jordan JE, Harris R, Brown FL et al. World Psychiatry 2016;15:295-6.
9. PracticeWise. Evidence-based youth mental health services literature database. Satellite Beach: PracticeWise, 2015.
10. Singla DR, Kohrt BA, Murray LA et al. Annu Rev Clin Psychol 2017;13:149-81.
DOI:10.1002/wps.20594

Lack of evidence for the efficacy of psychotherapies for PTSD
and depression in child and adolescent refugees
Post-traumatic stress disorder (PTSD) and depression are
known to be prevalent among young refugees and internallydisplaced individuals. The need for effective interventions
for this population is becoming increasingly evident in viewof the large number of recent and current armed conflicts.
We conducted a systematic review and meta-analysis ofrandomized controlled trials on the efficacy of psychologicalinterventions for PTSD and depression in child and adolescent refugees and internally displaced individuals. The aims
and methods of the meta-analysis were registered with the
PROSPERO database (CRD42017071384).
We searched the databases PsycINFO, MEDLINE, andPILOTS up to February 2018. The following search terms in
keywords, titles and abstracts were used: PTSD, depression,refugee (or re­lated terms such as asylum seeker or displaced
person), and treat­ment (or related terms such as intervention
or psychotherapy). Additionally, reference lists of identified
publications and systematic reviews were examined.
The inclusion criteria were: a) trial conducted with childor adolescent refugees or internally displaced individuals;b) partici­pants randomly assigned to treatment conditions;c) at least ten par­ticipants completing an active psychologicaltreatment for PTSD or depression or both. No restrictions weremade upon in­terven­­tion format, publication type, or publication language. If studies did not provide sufficient data for
performing the meta-analysis, the authors were contacted bye-mail to retrieve these data.
We coded and extracted relevant study, intervention andparticipant characteristics, such as number of participants,
comparison group(s), type of outcome measure used, outcome
scores, and number of sessions. Furthermore, we rated thequality of the included trials by applying nine criteria used in

World Psychiatry 18:1 - February 2019

similar meta-analyses1. To conduct the analyses, the control
group mean was subtracted from the treatment group mean at
post-treatment or follow-up, and divided by the pooled stan­
dard deviation. Subsequently, to obtain the effect size Hedges’s
g, the outcome was multiplied by a sample size correction factor and the random effects model was applied. Analyses werecompleted with Comprehensive Meta-Analysis Version 3. Given
that less than ten trials met our inclusion criteria, no test of publication bias could be conducted.
After screening 1,716 potential hits, eight trials met our criteria2-9. All publications were written in English, seven were
published in peer-reviewed journals and one was a doc­toral
thesis7. Seven of the trials were conducted with inter­nally­d isplaced individuals, whereas two were conducted with­refugees6,8. In three trials, treatment was performed in groupformat2,5,9. Four trials assessed both PTSD and depression4,5,7,9,
one focused on depression only2, and three focused on PTSD
only3,6,8.
Experimental conditions consisted of trauma-focused­cognitive behavior therapy that included narrative exposure
therapy3,4,6-8, interpersonal therapy2, classroom-based intervention9, and writing for recovery5. Active treatments werecompared to waitlist in four trials. In two trials, the experimental condition was compared to an inactive control conditionin addition to the waitlist. In three trials, two active conditions
were compared to each other.
The number of participants per condition varied from 11 to
248, with a mean of 78.7±61.9. The mean age of participants
was 13.1±1.9, and 49.9% of them were female. Two and three
trails, respectively, used structured clinical interviews to assess
PTSD or depression; the remaining trials applied self-reports.
The number of sessions ranged from 6 to 16.

107Active treatments for PTSD yielded non-significant aggregated effect sizes at post-treatment (k=7; g=0.02; 95% CI: −0.13
to 0.15) and at follow-up (k=5; g=0.24; 95% CI: −0.13 to 0.62)
when compared to control conditions. Only one trial produced
a significant effect of the experimental condition over the control condition6.
Active treatments for depression also produced non-significant aggregated effect sizes at post-treatment (k=6; g=−0.01;
95% CI: −0.55 to 0.52) and at follow-up (k=3; g=0.02; 95% CI:−0.16 to 0.19) when compared to control conditions. Only one
trial showed a large effect for depression3.
Three trials that reported on functional impairment led to asmall effect size at post-treatment (k=3; g=0.31; 95% CI: 0.080.54) and at follow-up (k=3; g=0.32; 95% CI: 0.01-0.64) when
active treatments were compared to control conditions.
The assessment of quality of the included publications indicated that six trials (75%) were rated with an average score of 2,
indicating good quality.
This meta-analysis demonstrates that there is a limited number of clinical trials on the efficacy of psychotherapies for PTSD
and depression among child and adolescent refugees and internally displaced individuals. The results of existing trials do
not provide support for the efficacy of psychological interventions in this population.

Given the urgent public health issues raised by escalatinglevels of violence and civil conflict around the globe, it is essential for government and non-government agencies to have themost reliable evidence to shape policy and practice. Accordingly,
we urgently need to develop and test effective interventions formental health problems in young refugees and internally displaced individuals.
Nexhmedin Morina, Tim Nicolai Sterr
Institute of Psychology, University of Münster, Münster, Germany
1.
2.
3.
4.
5.
6.
7.
8.
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Morina N, Koerssen R, Pollet TV. Clin Psychol Rev 2016;47:41-54.
Bolton P, Bass J, Betancourt T et al. JAMA 2007;298:519-27.
Catani C, Kohiladevy M, Ruf M et al. BMC Psychiatry 2009;9:22.
Ertl V, Pfeiffer A, Schauer E et al. JAMA 2011;306:503-12.
Lange-Nielsen II, Kolltveit S, Thabet AAM et al. J Loss Trauma 2012;17:403-22.
Ruf M, Schauer M, Neuner F et al. J Trauma Stress 2010;23:437-45.
Schauer M. Trauma treatment for children in war: build-up of an evidencebased large-scale mental health intervention in North-Eastern Sri Lanka.
Doctoral Thesis, University of Konstanz, 2008.
Schottelkorb AA, Doumas DM, Garcia R. Int J Play Ther 2012;21:57-73.
Tol WA, Komproe IH, Jordans MJD et al. World Psychiatry 2012;11:114-22.

DOI:10.1002/wps.20596

The trait-state distinction between schizotypy and clinical high risk:
results from a one-year follow-up
Psychoses are severe, yet heterogeneous psychiatric conditions of multifactorial etiology. Both a clinical high-risk (CHR)
condition and trait anhedonia (as part of the schizotypy construct) have recently been reported in an umbrella review published in this journal1 as promising clinical risk factors for early
detection of psychosis.
These results reflect the two main lines of phenomenologicalresearch in the field of early detection of psychosis prior to its
first episode2: the clinical high-risk approach3 and the schizotypy approach4,5. With few exceptions2,6, these two approaches
were so far examined for their psychosis predictive value independent of each other, as well as by different means in different populations: schizotypy by means of self-report scales
in mostly non-clinical samples, and CHR criteria by means ofclinical interviews in mostly clinical samples2.
Schizotypy is regarded as a latent trait or personality organization, frequently assessed by the Wisconsin Schizotypy Scales(WSS)2,7 (physical anhedonia, social anhedonia, perceptual
aberration and magical ideation). The latter two scales werereported to load on the same factor as attenuated and transient
positive symptoms as well as perceptive basic symptoms8, that,next to cognitive basic symptoms, are commonly used to define
a symptomatic CHR state3.
Supporting the assumption of the trait character of schizotypy, results from non-clinical samples showed relatively good108stability of the WSS scores across short time periods9. In contrast, and supporting their conceptualization as state factors,
CHR criteria and symptoms are rarely stable over time in clinical samples10. Yet, it is so far unknown whether CHR symptoms
influence the report on WSS, especially with regard to the partly
overlapping (attenuated) positive symptoms and the positive
WSS2,6, in clinical samples.
To shed first light on this question, we examined the temporalstability as well as the interrelation of potential temporal changesof WSS and CHR symptoms over one year in 29 patients recruited
at the Bern Early Detection and Intervention Centre for Mental
Crises. At baseline, patients were 18±5 years of age on average(range: 9-27 years) and 41% were male. One patient (3%) alreadyhad a psychotic disorder, 22 (76%) fulfilled CHR criteria, and six(21%) received diagnoses unrelated to the psychotic spectrum.
The Schizophrenia Proneness Instruments were used to assess the 14 basic symptoms included in the two basic symptom
criteria3. The Structured Interview for Psychosis-Risk Syndromes
was used to assess the five positive symptoms included in thesymptomatic UHR criteria3. Schizotypy was assessed by the WSS.
As required by the local ethics committee, patients and, if minors,
their legal guardians gave informed consent for their anonymized
clinical data to be used in scientific analyses and publications.
Using SPSS 24, differences between baseline and followup (delta) of the mostly normally distributed sum scores wereWorld Psychiatry 18:1 - February 2019

analyzed through dependent t-tests with bootstrapping to testfor effects of potential outliers and reliability of results. These
revealed significant temporal differences in basic symptoms(mean delta=3.45, t(28)=2.38, p=0.024) and positive symptoms
sum scores (mean delta=2.00, t(28)=2.48, p=0.021). In contrast,
differences in WSS scores remained non-significant: physicalanhedonia (mean delta=1.55, t(28)=1.79, p=0.106), social anhedonia (mean delta=1.35, t(28)=1.68, p=0.107), magical ideation(mean delta=0.28, t(28)=0.40, p=0.691), and perceptual aberration (mean delta=0.62, t(28)=0.92, p=0.360).
Furthermore, examining Pearson’s correlations between thescales difference scores, we found a significant strong correlation only between magical ideation and perceptual aberration(r=0.506, p=0.005), and trend-level moderate correlations between physical anhedonia and both magical ideation (r=0.337,
p=0.091) and perceptual aberration (r=0.319, p=0.073), as well
as between the two CHR symptoms difference scores (r=0.328,
p=0.083). Difference scores of WSS and CHR symptoms nevercorrelated (r=0.012 to 0.306; p=0.969 to 0.106). In linear regression analyses, WSS difference scores were not predictive of
CHR symptom difference scores, which, in turn, did not predict
WSS difference scores.
Our results strengthen the distinction between CHR symptoms and schizotypy in terms of independent state and trait
factors and, thus, the notion that CHR symptoms occur on
top of a heightened schizotypy, as suggested by the model by
Debbané et al2. Furthermore, their independence support notions that the prediction of psychosis might be improved bytheir combination6. To this aim, physical anhedonia and social
anhedonia, that constitute the negative schizotypy dimension,might be especially promising candidates.
Negative schizotypy might be able to detect those people
most likely to progress to a severe mental disorder among thoseat an already increased risk to experience psychotic or psychoticlike symptoms – detected by CHR criteria. This might explain
why both anhedonia scales showed greater, though still nonsignificant, variation over time.
Future studies on larger samples with longer follow-up andmore assessment times are needed to explore the reliability of
our findings, the potential specific relationships between trait
and state factors, the potential patterns related to conversion
to psychosis, and, ultimately, the role of these likely importantrisk factors of psychoses in their aetiology1.
Chantal Michel1, Rahel Flückiger1, Jochen Kindler1, Daniela Hubl2,
Michael Kaess1,3, Frauke Schultze-Lutter1,4
1

University Hospital of Child and Adolescent Psychiatry and Psychotherapy, Universityof Bern, Bern, Switzerland; 2Translational Research Center, University Hospital of
Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland; 3Department ofChild and Adolescent Psychiatry, Center for Psychosocial Medicine, University of
Heidelberg, Heidelberg, Germany; 4Department of Psychiatry and Psychotherapy,
Heinrich-Heine-University, Düsseldorf, Germany
1.

Radua J, Ramella-Cravaro V, Ioannidis JPA et al. World Psychiatry 2018;17:49-66.
2. Debbané M, Eliez S, Badoud D et al. Schizophr Bull 2015;41(Suppl. 2):
396-407.
3. Schultze-Lutter F, Michel C, Schmidt SJ et al. Eur Psychiatry 2015;30:405-16.
4. Lenzenweger MF. World Psychiatry 2018;17:25-6.
5. Grant P. Front Psychiatry 2015;6:143.
6. Flückiger R, Ruhrmann S, Debbané M et al. J Abnorm Psychol 2016;125:923-32.
7. Chapman LJ, Chapman JP, Kwapil TR et al. J Abnorm Psychol 1994;103:
171-83.
8. Flückiger R, Schmidt SJ, Ruhrmann S et al. Early Interv Psychiatry 2016;
10(Suppl. 1):117.
9. Chan RC, Shi HS, Geng FL et al. Psychiatry Res 2015;228:143-9.
10. Michel C, Ruhrmann S, Klosterkötter J et al. Eur Arch Psychiatry Clin
Neurosci 2018;268:39-48.
DOI:10.1002/wps.20595

Borderline personality disorder or a disorder within theschizophrenia spectrum? A psychopathological study
Borderline personality disorder (BPD) is one of the most frequently used diagnoses in European and American psychiatry.
Nonetheless, the borderline diagnosis is nosologically unclear,especially with respect to its differentiation from the schizophrenia spectrum disorders.
When entering the DSM-III, BPD was separated from schizotypal personality disorder (SPD), formerly often denoted asborderline schizophrenia. In a detailed historical, conceptualand empirical review1, we have argued that the division of theborderline group into BPD and SPD was not entirely justified,
and that the BPD category today is overinclusive and bothclinically and conceptually difficult to differentiate from theschizophrenia spectrum disorders. In a separate study2, wehave pointed out that the BPD criteria of “identity disturbance”
and “chronic feelings of emptiness” refer to multi-layered phe-

World Psychiatry 18:1 - February 2019

nomena which in their basic aspects of structural change ofexperience were both originally ascribed to the schizophrenia
spectrum3.
Informed by these studies, we conducted an empirical studyof 30 patients (28 females, mean age 30.0±8.0 years) who hadreceived a main clinical diagnosis of BPD at three universityaffiliated outpatient clinics specifically dedicated to the treatment of BPD in the capital region of Denmark. Among thesepatients, 56.7% had previously been hospitalized and 70.0%
had previously received a non-BPD diagnosis, mostly affective
or anxiety/stress related disorders, in line with a recent Danish
register study of 10,876 patients4.
The patients underwent a careful psychiatric evaluation bya senior clinical psychologist and researcher. Interviews wereconducted in a semi-structured and conversational manner ac-109

cording to standard phenomenological principles and involved
a composite instrument used for several psychopathologicalstudies at our department5. In addition, we specifically rated all
BPD and SPD criteria according to both DSM-5 and ICD-10. Allinterviews except one were videorecorded and reviewed, andnarrative summaries were made of all of them.
Research diagnoses were made according to DSM-5 andICD-10 at a consensus meeting between MZ and JP. In cases of
uncertainty about crucial psychopathological phenomena, MZ
and JP jointly evaluated extracts of video recordings or madea joint extra interview with the patient. A random sample offive interview summaries was independently diagnosed by an
external senior psychiatrist, who agreed with the consensus
diagnoses.
The study found that the vast majority of patients in fact met
the criteria for a schizophrenia spectrum disorder (66.7% according to DSM-5 and 76.7% according to ICD-10), i.e. schizophrenia(20.0% according to both DSM-5 and ICD-10) or SPD. Amongthe non-schizophrenia patients, 40.0% had “quasi-psychotic
episodes” (SPD criterion in ICD-10). Five patients had psychotic
symptoms that were more articulated than at a “quasi-psychotic”
level, yet still failing to meet the criteria for schizophrenia.
The most frequent diagnostic criteria were the SPD “inappropriate/constricted affect” and “unusual perceptual experiences” , whereas the least frequent were the BPD “impulsivity”
and “intense and unstable relationships” . The BPD criteria of“identity disturbance” and “chronic feelings of emptiness” weresignificantly correlated with the total score of self-disorders as
measured by the Examination of Anomalous Self-Experience(EASE)6.
Patients with schizophrenia and SPD had significantly(p<0.01) higher levels of self-disorders than the non-spectrum
group (17.5±6.0 vs. 6.8±5.4 in DSM-5; 16.9±6.0 vs. 4.1±2.6 in
ICD-10), and these levels are very similar to findings in otherstudies5. There were no significant differences in total EASE
score between the schizophrenia and SPD group according toboth diagnostic systems.
We believe that this state of pronounced diagnostic confusion
may in part be an unintended result of the “operational revolution” and its introduction of polythetic criteria which are definedby short layman statements open to multiple interpretations andsemantic-historical drifts.
The pre-DSM-III borderline concept evolved from several
sources1.
One source was the clinical and psychotherapeutic notionof sub-psychotic cases of schizophrenia originally described aslatent, pseudoneurotic or borderline schizophrenia or “HochPolatin syndrome”7. This Gestalt comprised subtle Bleulerian
fundamental symptoms such as disorders of expressivity and affectivity, formal thought disorder, ambivalence, experiential ego
disorders, and a variety of psychosis-near disintegrative features.

110

Another source came from psychotherapeutic practice describing extroverted, dramatic patients with intense but fluctuating interpersonal relationships, shifting between idealizationand devaluation, and problematic to manage in a psychotherapeutic setting.
Finally, Kernberg’s8 structural-dynamic concept of borderline personality organization influenced the development of
BPD criteria (e.g., identity diffusion and a specific pattern ofdefense mechanisms such as splitting). However, Kernberg’s
concept was a transdiagnostic dimension applicable to suchdifferent categories as schizoid (and presumably schizotypal),paranoid, hypomanic, narcissistic and antisocial personalities
and different psychosis-near disorders.
Since 1980, the founding prototypes and the original psychopathological insights that imbued the creation of the polythetic criteria have gone into oblivion. The polythetic criteria
have resulted in an a-contextual emphasis on single emblematic elements (e.g., self-mutilation) and a general decline inpsychopathological knowledge. This has contributed to thecontemporary diagnostic confusion. For instance, impulsivity
as a personality trait (i.e., manifest in different situations acrossthe span of life) may be confused with disorganized behaviour
or impulsions appearing within the schizophrenia spectrum.
Today, near-psychotic symptoms appear as DSM-5 criteria
in both BPD and SPD. This makes the differentiation of BPD
from the schizophrenia spectrum heavily dependent on thedetection and registration of the schizophrenic fundamental
symptoms. Unfortunately, clinicians and researchers no longer
pay careful attention to those features, and their expressive nature make them impossible to be assessed through self-reportquestionnaires and structured interviews.
Since DSM-III, psychiatric diagnoses have become reified
and considered as “natural kinds”, and only research basedon the diagnostic criteria of the most recent edition of DSM isusually considered for publication9. Instead, we perhaps ought
to re-instantiate theoretical and empirical psychopathology at
the core of scientific psychiatry.
Maja Zandersen1, Josef Parnas1,2
1

Mental Health Centre Glostrup, Institute of Clinical Medicine, University Hospital of
Copenhagen, Copenhagen, Denmark; 2Center for Subjectivity Research, University of
Copenhagen, Copenhagen, Denmark
1.
2.
3.
4.
5.
6.
7.
8.
9.

Zandersen M, Henriksen MG, Parnas J. J Pers Disord (in press).
Zandersen M, Parnas J. Schizophr Bull (in press).
Parnas J, Zandersen M. World Psychiatry 2018;17:220-1.
Kjær JN, Biskin R, Vestergaard C et al. Personal Ment Health 2016;10:181-90.
Nordgaard J, Parnas J. Schizophr Bull 2014;40:1300-7.
Parnas J, Møller P, Kircher T et al. Psychopathology 2005;38:236-58.
Meehl PE. J Abnorm Psychol 2001;110:188-93.
Kernberg O. J Am Psychoanal Assoc 1967;15:641-85.
Hyman SE. Annu Rev Clin Psychol 2010;6:155-79.

DOI:10.1002/wps.20598

World Psychiatry 18:1 - February 2019

Prevention of depression will only succeed when it is structurally
embedded and targets big determinants
About 150 million people worldwide are affected with major
depressive disorder (further depression) at any moment, andone in every ﬁve women and one in every eight men experience an episode of major depression over the course of
their life.
Although, since the 1970s, more and more people in Western countries have received mental health care, most notably pharmacotherapy, epidemiological data do not indicate adrop in the population prevalence of depression1. It is clearthat the effectiveness of current therapies relative to placebo ismodest, and substantial treatment quality gaps still exist1.
However, even with optimal treatment delivery, other approaches are necessary to address the public health burden of
depression and other common mental disorders.
Prevention is a largely neglected option, but has its own
complexities. Recent meta-analyses of randomized controlled
trials of preventive interventions that seek to reduce the incidence of depression consistently report small to occasionallymoderate effectiveness, with numbers needed to treat (NNT)around 222,3. Notably, these effects sizes are similar to thosefor the use of statins to prevent an acute myocardial infarction
during a 5 year period2.
However, the large majority of prevention trials concern
psychological therapies administered to motivated people with
sub-threshold symptoms. In addition, studies are limited toshort-term outcomes and effects decrease over time, suggesting that repeated age-adapted exposures are essential. Active
comparators are rarely used, and higher quality studies report
substantially smaller effects. In addition, adherence is far from
optimal. Populations at the highest risk are often the least motivated to participate in psychological therapies.
The biggest problems of current prevention are that it does
not target the strongest determinants of risk and is not structurally embedded in major social systems.
Strong proximal determinants include exposure to poor
parenting (risky prenatal behavior, emotional neglect, rejection, lack of structure, over-control and over-involvement,inter-parental conﬂict, family instability), as well as children’smaladaptive personality traits (negative affectivity, low selfcontrol) and poor social and problem-solving skills4-6. These
have well-established long-term effects on a broad range ofoutcomes4,7. When both poor parenting and child risks arepresent, maladaptive person-environment transactions may
develop that often result in intractable personality problems
which are resistant to change.
It is therefore essential to target simultaneously both parent- and child-related determinants of risk. Thus, prevention
needs to start early in life, address both child and parent, belong-term and structural, and improve parenting skills andchildren’s self-control, negative affectivity and life skills, partly
through better parenting and partly through better education.

Negative affectivity and self-control are especially important,given the prospective signiﬁcance of early-onset phobia, hyperactivity and oppositional-deﬁant behavior8. Also of interest, but less thoroughly investigated, are the mental health effects of distal socio-economic and cultural factors, such as inferior social status, income inequality, migration, and their effect mediators9.
The second problem of current prevention is that it is not
structurally and socially embedded. Large-scale, long-term
implementation and utilization of prevention can only be successful if prevention is embedded at local, district/state, andnational levels. Two forms of embedment are important. First,
the “socio-political form”, in which local administrations andnational governments embed prevention (programs/activities) in existing institutions in the domains of education, pregnancy and child care, health and social work. Second, the “social-psychological form”, in which mental health values andbehaviors develop into widely accepted social norms (as ishappening with smoking).
The ﬁrst form of embedding is probably the best way toguarantee structural funding, political collaboration and thus
long-term implementation. The second form is important as it
rewards (mental) health behaviors. For instance, if life skills
become part of the regular curriculum of schools (in smallerclasses!), repeated age-adapted exposure to universal “prevention” becomes a normal component of preparation for adultlife.
Mental health professionals and organizations cannot achieve this alone. As advocated by the World Health Organization, it requires the joint collaboration of multiple parties atmultiple levels of organization (community, municipality, district, state).
The major advantages of embedded universal programs arethat they: a) may normalize prevention activities because they
are anchored in systems that are (virtually) mandatory (education, obstetric, child care); b) reduce risk of stigma; c) improveparenting, child characteristics and life skills (and hence lifestyles), which d) will beneﬁt multiple domains of life. This may
range from mental and physical health to educational attainment, occupation and income, but even relationships, social
embeddedness and crime rates. Although ceiling effects certainly exist, even parents and children who do relatively wellon all fronts may beneﬁt from universal programs4.
Despite the expectation that population effects will be substantial, universal programs will not involve everybody at thedesired level. Some people will need additional input: remedial prevention, analogous to remedial teaching for pupils
with unsatisfactory academic progress. In this way, selective/
indicated prevention supplements universal prevention.
We are facing a remarkable paradox. On the one hand,
stakeholders (policy makers, consumers, insurance companies,

World Psychiatry 18:1 - February 2019

111

World Psychiatry 17:3 - October 2018October 2018371

professional organizations and researchers) consider prevention a very self-evident idea and agree that prevention of mental disorders is their top priority. On the other hand, structuraland socially embedment of preventive activities and researchin mental health is minimal.
We believe the only way to substantially scale up and anchor prevention at all levels in society to such an extent that it
will reduce the population prevalence of depression (and improve functional outcomes and quality of life) is large-scale
structural and social embedding of universal and “remedial”
prevention programs targeting the big determinants. It should
start very early in life and target parenting skills of parents andlife skills of children, and be long-term and structural.
Substantial investments are required to develop, implement, and evaluate the proposed prevention. It is also crucial
that research evaluating prevention use methodological rigor
and target long-term outcome, as these limitations continue tofuel doubts and reservations about the effectiveness of prevention.
If politicians really want to reduce the burden of depression, there should be proportionality between burden and
expenditures (treatment, prevention, research). It is about

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112

time to catch up with cancer and cardiovascular disease prevention. Together with other relevant parties such as publichealth, police, insurance companies and educational authorities, mental health professionals will also need to step up theirpolitical inﬂuence and persuade politicians and the public toembed multi-target and multi-level mental health promotion
and prevention.
Johan Ormel1, Pim Cuijpers2, Anthony F. Jorm3, Robert Schoevers1
1

University of Groningen, Groningen, The Netherlands; 2Free University, Amsterdam,
The Netherlands; 3University of Melbourne, Melbourne, SA, Australia
1.
2.
3.
4.
5.
6.
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Jorm AF, Patten SB, Brugha TS et al. World Psychiatry 2017;16:90-9.
van Zoonen K, Buntrock C, Ebert DD et al. Int J Epidemiol 2014;43:318-29.
Werner-Seidler A, Perry Y, Calear AL et al. Clin Psychol Rev 2017;51:30-47.
Mofﬁtt TE, Arseneault L, Belsky D et al. Proc Natl Acad Sci USA 2011;108:2693-8.
Jeronimus BF, Kotov R, Riese H et al. Psychol Med 2016;46:2883-906.
Uher R, Zwicker A. World Psychiatry 2017;16:121-9.
Costello EJ, Maughan B. J Child Psychol Psychiatry 2015;56:324-41.
Kessler RC, Ormel J, Petukhova M et al. Arch Gen Psychiatry 2011;68:
90-100.
Patel V, Burns JK, Dhingra M et al. World Psychiatry 2018;17:76-89.

DOI:10.1002/wps.20580

World Psychiatry- October
2018October
2018
World17:3
Psychiatry
18:1- February 2019

WPA NEWS

Implementing the WPA Action Plan 2017-2020: community
orientation for learning, research and practiceWith each new term of Presidency at
WPA, an Action Plan is implemented thatbuilds on our preceding work. Our 20172020 Plan1,2 strengthens the community
orientation of our profession. It addresses the contribution of psychiatrists to re­sponses to conflicts, emergencies and ad­
versities, and provides a targeted strategy
for reaching young women and men who
face adversity and disadvantage and associated mental ill health or risks.
In March 2018, we took the first major
steps toward executing this strategy, when
WPA representatives met with lead­ers
from citiesRISE, the Juan José López-IborFoundation and senior psychiatrists fromthe Colombian city of Bogotá3. We werejoined by experts from the Departmentof Mental Health and Substance Abuseof the World Health Organization and theInternational Medical Corps. We talked
about how, through collective efforts, we
can link local action with global networks
to accelerate the uptake of best practices
and models and support psychiatrists tocontribute to community-based work inpractical, creative ways. We considered
how WPA and partners might best develop tools and strategies to support thoseat high risk of developing mental healthproblems (for any reason) and those whoare already experiencing these problems,
as well as ways to promote mental healthfor the wider population.
We have now established the WPA-cit­
iesRISE partnership. The WPA is a founding
partner of the citiesRISE platform4 andhas been instrumental in shap­ing its strat­
egy and collective action program, im­plemented initially in five cities and focus­
sed on the mental health of young peo­
ple. The program is supported by a rangeof philanthropic and industry funders.
The WPA has participated in collective
action workshops in Chennai and Nai­robi, as well as supporting foundational
work in Bogotá. Existing initiatives inthese cities, many of them led by small
grassroots entities, are examples of what
community orientation in mental healthlooks like in practice.

World Psychiatry 18:1 - February 2019

The WPA is helping to stimulate productive exchanges between people whorarely have an opportunity to talk to one
another. In Nairobi, for example, there
have been joint meetings with senior psy­
chiatrists, the national directorate of mental health, researchers, civil society leaders and young people such as partic­ipantsin Amazing Minds (a creative network ofstudents dedicated to reaching zero stigma for mental health and increasing help
seeking among campus students). These
kinds of encounters are characteristic of
the WPA-citiesRISE partnership. They are
an exciting way to support mutual understanding between diverse organizations
as they join the global program.
As well as supporting citiesRISE by access to the best available tech­nical andconceptual evidence and experience, theWPA will lead specific programs. Psy­
chiatry will contribute to better community capacity to respond to the men­tal health needs of children and young
people in emergencies and adversities.
Across the cities we will work towards: a)
improved perinatal mental health, andb) support for prevention pro­­grams that
reduce the prevalence of de­p res­s ion,anxiety and suicidal behaviour among
young people. The recent an­n ouncement of the Lancet-WPA Commission“Reducing the global burden of depression”5 is a further step in this direction.
The work will consolidate the perception and role of psychiatrists as membersof a profession with a community orientation. It will demonstrate the practice of
psychiatry within a framework of community care and multi-sector collaboration across low-, medium- and high-income settings. It will show how sustained
support can be achieved for networksof psychiatrists engaged in communitybased work and for psychiatrists working
in community development related to theimprovement of mental health.
The WPA-citiesRISE partnership gains
life from the committed leadership ofpsychiatrists in each of the engaged cities. In the first phase, WPA is appointing

a global task force to guide the development of the partnership activities. We arealso identifying interested psychiatrists
in each city. They will be encouraged toform local representative groups positioned to assist the work of citiesRISE
and develop the community-oriented
work of psychiatrists in their country ofoperation. Each group will ideally include diverse practitioners, drawn froma range of backgrounds and from different points in their careers.
The WPA is appointing psychiatrists
as program leaders. They will have multifaceted roles that include facilitating thedevelopment of the local representative groups and the interaction between
them and the global task force. They willtake a lead in developing the tools andguidelines for the planned activities.
We are actively pursuing other activities. These include support for best practice in working between practitioners,
people with lived experience of mental
ill health and family carers3,6. The WPA
Executive Committee has approved theestablishment of a service user and family carer consulting group to advise on new
initiatives, including reviewing and improving the participation of service users
and family carers in our congresses. This
work is a priority in the new WPA meetings policy. Examples of best practice will
be gathered as the WPA-citiesRISE partnership work proceeds, and will be disseminated through the newly launched
WPA website7 and other channels.
The WPA participated in preparationand launch of the Lancet Commission on
Global Mental Health8, a landmark document in the field. We are concerned withquality of care and human rights in psychiatry. Consequently, we are designinga project with a member society to examine how to create conditions in mental
health services that are free from violence
and abuse and that minimize coercion.
To conclude, I am pleased to reportthese developments in implementing the
WPA Action Plan. Other activities underthe Action Plan have been and will be

113described in detail on other occasions.
There are major changes underway in
the WPA meetings program, in the workof the Early Career Psychiatrists programs, and in WPA communications. A
global survey of psychiatry is being developed in conjunction with a survey oftraining programs, and other programs
are detailed separately by our active officers9-11.
My fellow officers and I are above all
encouraged by the active engagement
and support of the WPA Secretariat, ourMember Societies, Scientific Sections,hard-working Standing Committees andall components of the Association.
Helen Herrman

7.

Kallivayalil RA. World Psychiatry 2018;17:2389.
8. Patel V, Saxena S, Lund C et al. Lancet (in press).
9. Schulze TG. World Psychiatry 2018;17:373-4.
10. Ng RMK. World Psychiatry 2018;17:374-5.
11. Botbol M. World Psychiatry 2018;17:375-6.

WPA President
DOI:10.1002/wps.20613

1.
2.
3.
4.
5.
6.

Herrman H. World Psychiatry 2017;16:329-30.
World Psychiatric Association. WPA 2017-2020
Action Plan. www.wpanet.org.
Herrman H. World Psychiatry 2018;17:236-7.
citiesRISE. http://cities-rise.org/.
Herrman H, Kieling C, McGorry P et al. Lancet(in press).
Wallcraft J, Amering M, Freidin J et al. World Psy­
chiatry 2011;10:229-36.

Collective action for young people’s mental health: the citiesRISE
experience
Globally, most young people with men­tal health problems lack the support andaccess to the care they need1. The rapidly
urbanizing, technology-based societies oftoday present social, political, economic
and culture changes that increase bothrisks to, and opportunities for, young people’s mental health.
However, current approaches to supporting the mental health of young people
typically lack an integrated under­standingof the pressures and challenges they face,especially at critical life tran­sitions. They
do not address the rapidly in­creasing disparities experienced by young people,
particularly by those who are marginalized2. Beyond scaling up a single model,
we believe that the most prom­ising pathforward for mental health leverages placebased solutions, taking ser­vices to young
people through a range of access points
and intervention methods.
citiesRISE is a multi-stakeholder initiative. It was formed as a response to theconcern that fragmented and small-scale
efforts are failing to address the risingtide of mental health problems among
young people worldwide, despite the existence of effective approaches in several
parts of the world3. citiesRISE is using
proven methodologies of collective action and a network approach to introduce and scale up interventions backed
by evidence and experience.
citiesRISE is working now in four coun­tries: India, Kenya, the US and Colombia.
114

Organizations at the local, national andglobal levels are working together to implement programs in the first five cities
of Chennai, Nairobi, Seattle, Sacramento
and Bogotá. In each of these cities we areconvening young leaders, psychiatrists
and other mental health professionals,
government and civil society stakeholders, as well as cross-sectoral partners, tolearn about local initiatives, and connect
to global ideas, insights and resources.
We are jointly designing interventions
that will address supply (e.g., the scale ofservices and support available for earlyintervention) and demand (i.e., awareness, help-seeking behavior) for services
as well as relevant societal factors. The
vision of this initiative and the approach
has attracted a range of investors fromphilanthropy and industry.
citiesRISE is currently developing five
key offerings:•• City platforms that are testing a collective action approach: identifying theneeds of the city, connecting different
sectors, and evaluating opportunities toscale up existing community interventions while also recommending new
and promising approaches.
•• Youth leadership: it is critical to tap into
the insights and energy of young people in the design and delivery of mental
health interventions. Our early work in
Nairobi and Chennai has demonstrated that youth are engaged in improving

local mental health locally, bringing energy and passion to the cause; just as
young people everywhere are foundat the center of movements for socialchange, in the process of growing into
the leaders of tomorrow.
•• The Learning Collaborative is a knowledge forum that will pool and provide
access to information. Cities will use it
to compare local information and experiences and learn about emerging
best practices. The Collaborative will
col­lect data from each city, contribute to city-level processes, and provide opportu­nities to share ideas andknowledge.
•• The Accelerator was launched withGrand Challenges Canada to support
prom­ising social businesses and youngin­novators. It has been working to identify innovative approaches to improving
mental health as well as proven models that are ready for scaling up, suchas the Friendship Bench, StrongMinds,
Atmiyata, Drumbeat and others. In thisinitial phase it is being set up to provide financial and technical assistanceto test and scale ideas rapidly. The vision is to offer cities and communities
new tools for adoption into their coreprograms along with the scaling up ofproven models.
•• A global framework for monitoring andevaluating the work in each city is being
finalized, with site-specific and shared
indicators.
World Psychiatry 18:1 - February 2019

Partnerships are vital to implement
strat­egies on prevention and treatment of­men­tal illness and the promotion of mental health through the citiesRISE plat­form.
The WPA-citiesRISE partnership, for ex­
ample, gives the opportunity to demon­strate the community orientation of
psychiatry while contributing to the local
and global efforts to improving the mental health of young women and men inadversity4,5.
The citiesRISE concept differs fromapproaches that focus primarily on mental health care delivery by trained specialists alone. citiesRISE aims to mobilize
all available resources, including young
people, non-specialists and sectors beyond health care. Psychiatrists and othermental health specialists are centrally
involved in several roles such as advocates, advisors, clinical supervisors andtrainers, as well as in direct clinical care.
Building on successful models sourced
from cities around the globe, our process
involves:•• Identifying local leaders, specificallyamong a city’s youth population.
•• Hosting a series of working sessions to
identify community needs and capabilities.

•• Building consensus on shared goals anda framework for monitoring and evaluation.
•• Providing funding and technical assis­
tance to accelerate the work at the citylevel.
•• Evaluating the work with the goal ofbuilding sustainable initiatives andstrategies that can scale.
•• Sharing and implementing successful
initiatives in cities worldwide.
Achieving better mental health needsa broad strategy that engages many disciplines and sectors, such as neigh­­­bor­
hood safety, commercial development,
public spaces, and cultural life, in­cluding
education, arts and sports1. Including andacti­vating young people at every stage
has provided energy and insight for thiswork. With the right kind of leadershipfrom pub­lic and private sectors, we believe that affordable support for mental
health can be developed by connecting
formal and in­formal services across housing, transport, law enforcement, edu­ca­tion and health systems.
Accessible psychosocial support ser­vices can mitigate the impacts of con­tem­
porary urban problems such as home­lessness, poverty, and loss of educationand job opportunities. Cities can therefore lead the way in accelerating the scal­­ing up of solutions and catalyzing local
collective action towards addressing men­tal illness and improving mental health.
In this way, we encourage a broad approach to include, for example, awarenessraising and education programs, the use
and design of public spaces, and the roleof technology to support communities andcomplement the development of clinicalservices for those that use and need them.
Moitreyee Sinha1, Pamela Collins2,
Helen Herrman3,4
1

citiesRISE; 2University of Washington, Seattle, WA,
USA; 3World Psychiatric Association; 4Orygen, The Na­tional Centre of Excellence in Youth Mental Health, andUni­versity of Melbourne, Melbourne, Australia
1.
2.
3.
4.
5.

Patel V, Saxena S, Lund C et al. Lancet (in press).
Patton GC, Sawyer S, Santelli M et al. Lancet
2016;387:2423-4.
Malla A, Iyer S, McGorry P et al. Soc Psychiatry
Psychiatr Epidemiol 2016;51:319-26.
Herrman H. World Psychiatry 2017;16:329-30.
Herrman H. World Psychiatry 2018;17:236-7.

DOI:10.1002/wps.20615

ICD-11 sessions within the 18th World Congress of Psychiatry
Within the 18th World Congress of Psy­
chiatry, held in Mexico City from 27 to 30
September 2018, one presidential symposium, one course and several individual
presentations focused on various aspectsof the chapter on mental and behaviour­aldisorders of the 11th edition of the Inter­national Classification of Diseases and
Health Problems (ICD-11).
The statistical version of the chapter,
containing the hierarchical structure, thecategory names, the code numbers, brief
definitions of each disorder, and inclusionand exclusion terms, was released to theWorld Health Organization (WHO) Member States in June 2018 to prepare for im­
plementation. This version is available
online at https://icd.who.int/dev11/l-m/
en.

World Psychiatry 18:1 - February 2019

The ICD-11 is scheduled for approval by
the World Health Assembly in May 2019.
The Clinical Descriptions and Di­agnostic
Guidelines, intended for use by healthprofessionals in clinical settings, will be
published as soon as possible after that.
A primary care version of the chapter isalso being developed, whereas a researchversion may be developed later.
The field testing of the chapter has
been now completed. It is important toemphasize that it was conducted before
the finalization of the chapter (not after,
as often happened for other classification
systems), so that changes to some sections of the chapter could be made on thebasis of the results of the trials.
The field studies included: a) twolarge international surveys of views ofpsychi­atrists and psychologists about
the features that could increase the clinical utility of the classification of mental disorders; b) formative field studies,
aimed to guide decisions about the basic structure and content of the classi­
fication by exploring clinicians’ conceptualization of the interrelationships
among categories of mental disorders; c)Internet-based field studies, implemented through the Global Clinical Practice
Network (which includes now more than
15,000 mental health and primary care
professionals from 155 countries, comprising more than 5,000 from Europe,
more than 3,000 from the Americas, morethan 3,000 from Western Pacific, morethan 600 from South East Asia, more than
400 from Eastern Mediterranean, and115

more than 300 from Africa), which usedcase vignette methodologies to examine
clinical decision-making in relationshipto the proposed ICD-11 diagnostic categories and guidelines; d) clinic-based(or eco­logical implementation) fieldstudies, to assess the reliability and clinical utility of the diagnostic guidelines
with real patients in ordinary clinical settings; e) service user/carer studies, providing feedback on the diagnostic guide­lines.
The results of the Internet-based andecological implementation field studies
were presented at the Congress.
In the Internet-based field studies, thediagnostic agreement for disorders specifically associated with stress was consistently higher for the ICD-11 as compared with the ICD-10 categories (e.g.,
81.8% vs. 76.8% for post-traumatic stressdisorder; 75.8% vs. 71.8% for adjustment
disorder). The same applies to feedingand eating disorders (e.g., 96.8% vs. 95.1%
for anorexia nervosa; 87.5% vs. 78.4% forbulimia nervosa).
In the ecological implementation fieldstudies (whose detailed results have been
recently published in this journal1,2), theclinical consistency (reliability) ranged
from moderate to almost perfect (.45 to.88) for the various disorders and was
generally superior to results obtained for116

ICD-10. Concerning clinical utility, the diagnostic guidelines for schizophrenia andother primary psychotic disorders, mooddisorders, anxiety and fear-related disorders, and disorders specifically associated with stress were perceived as easy touse, corresponding accurately to patients’presentations (i.e., goodness of fit), clear
and understandable, providing an appropriate level of detail, taking about the sameor less time than clinicians’ usual practice,and providing useful guidance about distinguishing disorder from normality andfrom other disorders. Clinicians evaluated
the guidelines as less useful for treatment
selection and assessing prognosis than forcommunicating with other health professionals3, although the former ratings werestill positive overall.
At the Congress, the good reliability inthe use of the diagnostic guidelines was
confirmed in the course, in which clinicians from all regions of the world were
presented with clinical vignettes relevantto the sections on psychotic disorders,mood disorders, anxiety and fear-relateddisorders, and disorders specifically associated with stress.
In the presidential symposium, several
general issues concerning diagnosis andclassification of mental disorders weread­dressed, including culture fairness,
valid­ity in predicting response to treat­ments, and the possible complementaryrole of systems or models based on psychopathological dimensions, neurobiological variables, the network theory ofmental disorders, or a transdiagnostic ap­
proach4-14.
Vincenzo Giallonardo
WHO Collaborating Centre for Research and Training
in Mental Health, University of Campania L. Vanvitelli,
Naples, Italy
1.

Reed GM, Sharan P, Rebello TJ et al. World Psy­
chiatry 2018;17:174-86.
2. Reed GM, Keeley JW, Rebello TJ et al. World
Psychiatry 2018;17:306-15.
3. First MB, Rebello TJ, Keeley JW et al. World­Psy­chiatry 2018;17:187-95.
4. Borsboom D. World Psychiatry 2017;16:5-13.
5. Lahey BB, Krueger RF, Rathouz PJ et al. World
Psychiatry 2017;16:144-5.
6. Berk M, Post R, Ratheesh A et al. World Psy­
chiatry 2017;16:236-44.
7. Kotov R, Krueger RF, Watson D. World Psy­
chiatry 2018;17:24-5.
8. Borsboom D, Robinaugh DJ, The Psychosys­
tems Group et al. World Psychiatry 2018;17:1434.
9. McGorry PD, Hartman JA, Spooner R et al. World
Psychiatry 2018;17:133-42.
10. Kendler KS. World Psychiatry 2018;17:241-2.
11. Krueger RF, Kotov R, Watson D et al. World­Psy­chiatry 2018;17:282-93.
12. Zachar P. World Psychiatry 2018;17:294-5.
13. Jablensky A. World Psychiatry 2018;17:300-1.
14. Ghaemi SN. World Psychiatry 2018;17:301-2.
DOI:10.1002/wps.20612

World Psychiatry 18:1 - February 2019Acknowledgement
This publication has been partially supported byan unrestricted educational grant from Lundbeck Italia SpA,
which is hereby gratefully acknowledged.
© 2019 by WPA

Notice No responsibility is assumed by the Publisher for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use oroperation of any methods, products, instructions or ideas contained in the material herein.
Because of rapid advances in the medical sciences, in particular, independent verification ofdiagnoses and drug dosages should be made.