Augmented Reality as an Aid to Behavior Therapy for Anxiety Disorders: A Narrative Review.

Anxiety disorders are among the most common mental disorders worldwide. These conditions are characterized by excessive anxiety that is difficult to control. In most anxiety disorders, symptoms are triggered by exposure to specific objects or situations. This leads sufferers to avoid such exposures, leading to impaired social and occupational functioning and reduced quality of life. Therapies based on behavioral principles, either alone or in combination with cognitive techniques, are the most effective psychological interventions for anxiety disorders. However, the effectiveness of these therapies may be limited due to a lack of generalization from clinic to real-world settings. Augmented reality (AR) is a technology that provides an interactive experience by superimposing computer-generated content, often in multiple sensory modalities, on the real world. Emerging evidence suggests that AR may be useful in treating a broad range of mental disorders, including anxiety disorders. This review examines the evidence for the use of AR-based techniques as an aid to behavioral or cognitive-behavioral therapies for anxiety disorders. The available evidence suggests that this method may offer significant advantages over conventional therapies, particularly in the case of specific phobias, but also in social anxiety disorder. AR can also be combined with other novel technologies to monitor psychophysiological markers of anxiety and its reduction over the course of treatment. The advantages of AR could be related to its combination of real and simulated content, allowing for better generalization of the benefits of conventional exposure-based therapy. Though the safety, efficacy, and cost-effectiveness of this method need to be confirmed in larger samples, it could lead to a paradigm shift in the way behavioral therapies for anxiety disorders are conceptualized and delivered.

The Relationship Between Access to Abortion and Mental Health in Women of Childbearing Age: Analyses of Data From the Global Burden of Disease Studies.

Background It has often been suggested that restricting access to legal abortion could have a negative impact on the mental health of women seeking this procedure. The recent judgment of the United States Supreme Court in the Dobbs case has brought the question of the psychological impact of changes in abortion policy into focus. The results of studies on the link between induced abortion and mental health are contradictory, and interpreting the results of these studies is complex due to a multitude of potential confounding factors. However, there is little data on the relationship between the availability of legal abortion and its effects on the mental health of women of childbearing age in the general population. Objective The objective of the current study was to examine cross-sectional and longitudinal associations between access to legal abortion and the prevalence of common mental disorders in women of childbearing age at a cross-national level while correcting for potential confounding factors. Methods The current study employs both cross-sectional and longitudinal analyses of nation-level data for 197 countries and regions. As data on global abortion policy were compiled in 2009 and 2017 by the Guttmacher Institute, data on access to legal abortion for these years were examined in relation to the prevalence of anxiety disorders and depression in women of childbearing age for each country, obtained from the Global Burden of Disease Studies for the most recent subsequent year (2010 and 2019). The relationship between changes in abortion policy and changes in the prevalence of these disorders in each country was examined for the aforementioned period. All analyses were adjusted for the potential confounding effects of gender development, gender inequality, and intimate partner violence. Cross-sectional associations were examined using Pearson's bivariate and partial correlations, while longitudinal associations were examined using a general linear model and analyses of covariance. Results  At the cross-sectional level, broad legal access to abortion was associated with a lower prevalence of depression in women aged 25-49 years, however, this association was not significant after correcting for measures of gender development, gender inequality, and intimate partner violence. At the longitudinal level, a slight but significant decrease in the prevalence of anxiety disorders in women aged 25-49 years was observed in countries where access to legal abortion was broadened in the period 2009-2017. This association remained marginally significant after adjustment for the above confounders. Conclusions The current study suggests that there is a modest relationship between access to legal abortion and its effects on the mental health of women aged 25-49 years. However, this relationship appears to be largely indirect in nature and influenced by factors, such as gender development, gender inequality, and intimate partner violence. These results may lead to further exploration of the links between reproductive rights and mental health of women in the general population and draw attention to the influence of gender inequality and intimate partner violence on mental health of women of childbearing age.

The Correlates of Government Expenditure on Mental Health Services: An Analysis of Data From 78 Countries and Regions.

Background Governmental investment in mental health is of vital importance for the implementation and maintenance of educational, preventive, and therapeutic services related to mental illness, particularly in low- and middle-income countries (LMICs). However, mental health expenditures represent only a small portion of total health spending in many countries. Little is known about the economic, social, or health-related factors that may influence variations in governmental spending in this sector. Methods Data on government expenditure on mental health as a percentage of total healthcare expenditure, collected by the WHO from 78 countries and regions in the period 2013-2014, was available for study. These data were analyzed in relation to key economic, social, and health-related indicators. The selection of these indicators was based on prior national and regional research and expert opinion as reported in the existing literature. Results Government spending on mental health was below 1% of health expenditure in 24.4% of the countries studied. A number of economic, social, and health-related indicators were significantly associated with variations in spending on mental health. Based on the partial correlation, sub-group, and multivariate linear regression analyses, the variables most significantly associated with low government spending on mental health were the burden of communicable diseases (ß = -.47, p = .001) and cultural collectivism (ß = -.37, p = .008). Conclusions These results suggest that low government investment in mental health may be associated not only with economic or political factors but also with variations in disease burden and in cultural attitudes across countries. Though no direct assumption regarding causation can be made, such findings may be of value when advocating for greater public investment in mental health, particularly in non-Western cultures with a high competing burden of infectious diseases.

The Relationship Between Pre-pandemic Measures of Religiosity and Psychological Responses to the COVID-19 Pandemic: A Secondary Analysis of Data From a Multi-Country Study.

Background The uncertainty and socioeconomic disruption caused by the COVID-19 pandemic have been frequently associated with negative affective responses, particularly depression and anxiety. People from countries across the globe have frequently resorted to religious coping to deal with these emotions. However, there are conflicting results in the literature about the impact of prior patterns of religious belief and practice on emotional responses to COVID-19. Methods In this cross-sectional, country-level study, the association between pre-pandemic measures of religious affiliation and practice, obtained from prior survey data and self-reported symptoms of depression, anxiety, and stress across 29 countries from a recent multi-country study, were examined while correcting for potential confounders. Results There was a trend towards a positive association between pre-pandemic religious belief and practice and anxiety in response to the pandemic (r = .36, p = .057), but this was not significant on multivariate analysis (ß = .08, p = .691). Cultural individualism and urbanization were negatively associated with anxiety during the pandemic. There was also preliminary evidence of a non-linear relationship between religiosity and pandemic-related anxiety. Conclusions The relationship between religiosity and mental health during the COVID-19 pandemic is unlikely to be a direct one and can be influenced by demographic and cultural factors.

What Are the Correlates of Global Variations in the Prevalence of Opioid Use Disorders? An Analysis of Data From the Global Burden of Disease Study, 2019.

Introduction The recent opioid crisis in North America has brought the problem of opioid use disorders (OUD) into clinical and public health focus, with experts warning that other countries or regions may be at future risk of experiencing such crises. The existing literature suggests that a wide range of social, cultural and economic factors may be associated with the onset, course and outcome of OUD in individuals. The current study uses data on the estimated prevalence of OUDs across 115 countries, obtained from the Global Burden of Disease Study, 2019, to examine the bivariate and multivariate associations between national prevalence of OUD and these factors. Methods Data on the estimated prevalence of OUDs was obtained via a database query from the Global Burden of Disease (GBD) Collaborative Network database for the year 2019. Recent (2018-2019) data on 10 relevant variables identified in the literature (gross national income, economic inequality, urbanization, social capital, religious affiliation and practice, unemployment, divorce, cultural individualism, and prevalence of depression) were obtained from the GBD, World Bank and Our World in Data databases. After transformation to a normal distribution, bivariate and univariate analyses were conducted to identify the significance and strength of the associations between these variables and the prevalence of OUD. Results Of the 10 variables studied, all variables except the divorce rate and religious affiliation were significantly correlated with the prevalence of OUD on bivariate analyses, though the strength of these associations was in the poor to fair range. On multivariate analysis, a significant association was observed only for the prevalence of depression, with trends towards a positive association for cultural individualism and unemployment, and a protective trend observed for religious practice. Discussion Though subject to certain limitations inherent in cross-sectional analyses, these results suggest that certain variables may be associated with a higher prevalence of OUD at the national level. Replication and refinement of these analyses may prove useful in identifying countries or regions at risk of a future opioid epidemic or crisis, which could facilitate the institution of preventive measures or early intervention strategies.

The Relationship Between Four Measures of Religiosity and Cross-National Variations in the Burden of Dementia.

Background Several researchers have identified a possible protective effect of religiosity on the risk of dementia. Specific aspects of religiosity may be associated with this attenuation of risk, and it may be partially mediated through an effect on depressive symptoms or social support. However, this effect has only been demonstrated in selected cohorts to date. Methods This study was based on a cross-national analysis of associations. Correlations between World Health Organization estimates of the burden of dementia and four survey-derived measures of religiosity were examined across 101 countries, while controlling for estimates of late-life depression and social capital. Results Specific aspects of religiosity, such as attendance at religious services (Pearson's r= -0.57), daily prayer (r = -0.58), and perception of religion as very important (r = -0.65), were associated with lower national levels of Alzheimer's and other dementias (p< 0.01 for all correlations). This effect was partially mediated through an inverse relationship between religiosity and depression, but remained significant even after controlling for it and on multivariate analyses (ß = -0.38 to -0.57, p< 0.01 for all measures). There was no evidence for a mediating effect of social capital. Conclusions Specific religious beliefs and practices may have a protective effect on dementia risk at the population level. These may involve group effects that require further study, such as reductions in depression in the elderly, or may involve beneficial effects on the stress response and cellular ageing in vulnerable individuals; however, the latter cannot be inferred with certainty from a group-level analysis. These results are consistent with earlier research and suggest a potential role for religious-based preventive strategies at the population level.

Does Culture Influence Antidepressant Response? A Preliminary Investigation of Randomized Controlled Trials of Fluoxetine.

Background Contemporary models of depression view the disorder as arising from an interaction between genetic vulnerability and adverse life experiences. The nature of these experiences is strongly influenced by social-cultural factors, and there is preliminary evidence that these factors may influence the response to treatment. Methods In this pilot study, pooled response rates obtained from 56 randomized controlled trials of fluoxetine for major depression, conducted across 21 countries, were analyzed in relation to Hofstede's six dimensions of culture in these countries, while controlling for methodological quality. Results The cultural dimensions of power distance (r = .62, p = .002), masculinity (r = .45, p = .04) and indulgence (r = -.52, p = .016) were significantly correlated with antidepressant response rates, though only the first of these remained significant after correction for multiple comparisons. On linear regression analysis, the association between power distance and antidepressant response remained significant (ß = .62, p = .002). Conclusions These preliminary results suggest that certain cultural factors may be significantly associated with cross-national variations in antidepressant response rates during clinical trials.

Warriors, Worriers, and COVID-19: An Exploratory Study of the Catechol O-Methyltransferase Val158Met Polymorphism Across Populations.

Background Prevalence and mortality rates during the coronavirus disease 2019 (COVID-19) pandemic have varied widely across nations. This phenomenon may be partly due to regional variations in health-related behaviours, some of which may be influenced by health anxiety. A functional polymorphism of the catechol O-methyltransferase (COMT) gene, designated rs4680 or Val158Met, has been associated with anxiety-related behaviours and the so-called "worrier" phenotype. Methods In this exploratory study, an analysis of the correlation between the frequencies of the Met allele of the COMT gene across 28 countries, obtained from the public domain Allele Frequency Database (ALFRED), and the COVID-19 prevalence and mortality rates in these countries, obtained from the Johns Hopkins Medical University web-based dashboard, was carried out while controlling for population size and median age in each country. Results Allele frequencies varied widely across populations. Met allele frequency was positively correlated with COVID-19 prevalence (ρ = 0.527, p = 0.004) and mortality rate (ρ = 0.542, p = 0.003) across nations. However, this correlation was no longer significant after controlling for confounders. Conclusions These preliminary results suggest that there may be a relationship between the COMT Val158Met or rs4680 functional polymorphism and the impact of COVID-19 across nations, which could plausibly be mediated by maladaptive anxiety-related behaviours.

Assessing catatonia using four different instruments: Inter-rater reliability and prevalence in inpatient clinical population.

BACKGROUND AND AIMS: The present study aimed to assess inter-rater reliability and prevalence of catatonia according to four diagnostic methods: Bush Francis Catatonia Rating Scale (BFCRS) both screening and complete scale, Braunig's Catatonia Rating Scale (CRS), ICD 10 and DSM5. METHODS: For inter-rater reliability, different raters evaluated patients using the definitions provides by the four scales: BFCRS Screen and Total, CRS, ICD10 and DSM5. Kippendorff'α was used to compute the inter-rater reliability. Concordance between different systems was assessed using spearman correlation. Prevalence of catatonia was studied using the four definitions in a clinical sample of consecutive adult admissions in a psychiatry ward of a tertiary care hospital. RESULTS: The inter-rater reliability was found to be good for BFCRS Total (α=0.779), moderate for DSM5 and BFCRS screen (α=0.575 and α=0.514 respectively) and low for CRS and ICD10 (α=0.111 and α=0.018 respectively). BFCRS Total and DSM5 definitions of catatonia had highest concordance (rs=0.892 p<0.001). In the prevalence sample of consecutive hospital admissions, the prevalence was found to be highest with the definitions of BFCRS Screen and ICD 10 (10.3%, confidence intervals [CI] 3.9% to 16.7%), followed by BFCRS Total and DSM5 definitions 6.9%, CI 1.6% to 12.2%) and while CRS yielded the lowest prevalence rate (3.4%, CI 0% to 7.2%). CONCLUSION: Different methods used to determine catatonia in the clinical sample yield different prevalence of this condition.

What happens to episode duration and cycle length over the course of bipolar disorder?

OBJECTIVES: Published scientific literature on cycle acceleration over the course of bipolar disorder has been equivocal. The present analysis aimed to find whether episode duration and cycle lengths become shorter over the course of bipolar disorder with predominantly manic polarity. METHODS: The present study comprised 150 patients diagnosed with bipolar I disorder using SCID-I for DSM-IV TR. The course of illness was charted according to the NIMH Life Chart Methodology - Clinician Retrospective Chart (NIMH - LCM CRC). Spearman correlation was used to assess the relationship of episode duration and cycle length with the number of episodes. RESULTS: The mean age of the sample was 37.8 years and the average duration of illness was 13.4 years. Unipolar mania comprised 52.7% of the sample. The episode duration and the cycle length decreased with increasing number of episodes (r=-0.245, p<0.001 & r=-0.299, p<0.001 respectively). CONCLUSION: The present study suggests that over the course of bipolar I disorder, cycle length and episode duration become shorter.

Quality of Sleep in Patients With Bipolar I Disorder During Remission.

BACKGROUND AND GOALS: Sleep disturbances have been noted not only during affective episodes in bipolar disorder, but also between affective episodes. The goal of this study was to assess and identify determinants of sleep quality in patients with bipolar I disorder. METHODS: This cross-sectional study enrolled patients with bipolar disorder who were currently in remission. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Mood symptoms were evaluated using the Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (Ham-D). Adherence was assessed using the Medication Adherence Rating Scale. RESULTS: The mean age in the sample (N=103) was 37.4 years; 44.7% of the sample were men. On the basis of PSQI scores, 41 patients (39.8%) were poor sleepers. Poor sleepers had significantly higher Ham-D scores (mean score of 1.8 vs. 0.9, P=0.012) and higher rates of medication nonadherence (36.6% vs. 11.3%, P=0.002). The relationship between Ham-D scores and sleep quality did not remain significant when the sleep-related items on the Ham-D were removed. Logistic regression analysis suggested that medication nonadherence was the only independent predictor of poor sleep quality in this study. CONCLUSIONS: A significant proportion of patients with bipolar disorder who are in remission have sleep problems that seem to be independent of core symptoms of depression.

The impact of disrupted childhood attachment on the presentation of psychogenic erectile dysfunction: an exploratory study.

INTRODUCTION: Erectile dysfunction (ED) is a common form of male sexual dysfunction. Psychological factors play an important role in the onset and persistence of ED. Disturbed childhood attachment is a biologically and psychologically plausible predisposing factor for psychogenic ED that has not been systematically studied to date. AIM: This study aims to assess the frequency and correlates of events associated with parental separation (actual or threatened) and loss in men with a diagnosis of psychogenic ED. METHODS: The case records of 46 men who presented to a clinic for psychosexual disorders in the period 2012-2013, and were diagnosed with psychogenic ED using a semi-structured interview schedule, were reviewed. RESULTS: Events causing actual or potential disturbed attachment (DA) in childhood were reported by 20 of 46 men with psychogenic ED (43.5%). This group of men (DA+) had an earlier age at onset of ED (median 25 vs. 29 years, P = 0.005), were more likely to be single (15/20 vs. 5/26 (χ(2) = 14.307, P < 0.001), reported sexual performance anxiety more frequently (12/20 vs. 7/26, χ(2) = 5.101, P = 0.024), and were more likely to develop ED in the absence of a proximate stressor (4/20 vs. 15/26, P = 0.015). They also showed a trend toward being more likely to report guilt over early sexual experiences as a contributory factor (5/20 vs. 1/26, P = 0.072). In a binary logistic regression analysis, the presence of performance anxiety (B = 2.01, P = 0.023) and marital status (B = -2.85, P = 0.001) were significantly associated with events causing DA. CONCLUSIONS: Disrupted childhood attachment was common in our sample of men with ED and is associated with significant differences in their clinical profile, particularly an earlier onset, a lower likelihood of being married, and higher rates of performance anxiety. This study highlights the need to consider early childhood experiences, particularly using an attachment theory framework, when examining the origins of psychogenic erectile dysfunction.

More questions than answers! Clinical dilemmas in psychopharmacology in pregnancy and lactation.

Women in childbearing age frequently suffer from mental illness. Maternal psychiatric disorders may have a devastating impact on the fetus and the newborn. Thus treating or preventing relapse of these disorders during pregnancy and puerperium is a clinical and ethical duty with the necessity to avoid or minimize fetal or neonatal drug exposure. Though there are many guidelines and comprehensive reviews regarding drug safety in pregnancy and lactation, the application of these recommendations into clinical practice appears to be complex. Hence, we present some clinical questions with answers considering the available literature on safety of psychotropics in pregnancy and lactation.

Does areca nut use lead to dependence?

BACKGROUND: The areca nut is consumed by approximately 10% of the world's population, and its consumption is associated with long-term health risks, with or without tobacco additives. However, it is not known whether its use is associated with a dependence syndrome, as is seen with other psychoactive substances. OBJECTIVE: To examine whether areca nut usage (with or without tobacco additives) could lead to the development of a dependence syndrome. METHODS: Three groups: [a] persons using areca nut preparations without tobacco additives [n=98]; [b] persons using areca nut preparations with tobacco additives [n=44]; and [c] 'Non-users' were systematically assessed using a checklist for the use of areca or areca+tobacco products, patterns of use, presence of a dependence syndrome in users, features of stimulant withdrawal and desired/beneficial effects. RESULTS: 38.8% and 40.8% of the 'areca' group satisfied definitions of current substance-dependence according to DSM-IV and ICD-10 criteria respectively. 79.5% of the areca+tobacco group satisfied criteria for current dependent use according to both DSM-IV and ICD-10 criteria. Both the groups reported a well-delineated withdrawal syndrome and similar attributions for desirable effects of use. CONCLUSION: Areca nut use by itself and more so with tobacco additives, is associated with the development of a dependence syndrome in a substantial numbers of users.