Accepting the Incomprehensible: What Samuel Beckett Can Tell Psychiatrists Today.

ABSTRACT: The aim of this article is to propose that reading Samuel Beckett's novels can improve compassionate acceptance of mental phenomena and human behavior deemed incomprehensible. In a narrative inquiry into all of Beckett's novels, we could discern nihilism and existential insecurity as themes both central to Beckett's prose and relevant in working with people with severe mental disorders. By deconstructing narrative structures and struggling to say the unsayable, Beckett can provide a perspective that goes beyond rational understanding. Beckett's prose can extend our imagination of mental and embodied phenomena by describing absurd and incomprehensible aspects of human experience and behavior. His unique sense of humor in dealing with bleak, meaningless situations and the acceptance and perseverance that his characters show in their struggles could help promote compassionate therapeutic relationships and improve clinical teaching in psychiatry. This can help psychiatrists and patients to face the existential aspects of mental illness, "limit situations" according to Jaspers, in a manner both respectful and open to subjective views.

Psychosocial Reactions to Plagues in the Cultural History of Medicine: A Medical Humanities Approach.

The aim of this work is to elucidate psychosocial reactions to plagues by analyzing three landmark descriptions from different eras: Thucydides' description of the plague of Athens (430 BC) in The History of the Peloponnesian War, Giovanni Boccaccio's description of the plague in Florence (1348) in The Decameron, and Albert Camus' description in The Plague (1947). Using a narrative inquiry, we found psychosocial reactions to be complex and ambivalent and could discern several coping strategies. We propose that this knowledge can help psychiatrists and other healthcare professionals during the ongoing COVID-19 pandemic.

Disclosure and Quality of Life Among Unemployed Individuals With Mental Health Problems: A Longitudinal Study.

Unemployment and mental disorders are associated with impaired quality of life. Because of the stigma associated with mental illness, unemployed individuals with mental health problems face the difficult decision whether to disclose their condition to others. Disclosure has both risks and benefits, and it is unclear how it affects quality of life. We therefore examined disclosure attitudes at baseline as predictors of quality of life after 6 months and also assessed social support, depressive symptoms, self-stigma, and perceived discrimination among 301 unemployed individuals with mental health problems. Better quality of life at follow-up was predicted by better attitudes toward disclosure among family and friends, shorter length of unemployment, less symptoms, and, at a trend level, less self-stigma at baseline. Thus disclosure in one's private environment may improve quality of life among unemployed individuals with mental health problems.

A longitudinal approach to biological psychiatric research: The PsyCourse study.

In current diagnostic systems, schizophrenia and bipolar disorder are still conceptualized as distinct categorical entities. Recently, both clinical and genomic evidence have challenged this Kraepelinian dichotomy. There are only few longitudinal studies addressing potential overlaps between these conditions. Here, we present design and first results of the PsyCourse study (N = 891 individuals at baseline), an ongoing transdiagnostic study of the affective-to-psychotic continuum that combines longitudinal deep phenotyping and dimensional assessment of psychopathology with an extensive collection of biomaterial. To provide an initial characterization of the PsyCourse study sample, we compare two broad diagnostic groups defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classification system, that is, predominantly affective (n = 367 individuals) versus predominantly psychotic disorders (n = 524 individuals). Depressive, manic, and psychotic symptoms as well as global functioning over time were contrasted using linear mixed models. Furthermore, we explored the effects of polygenic risk scores for schizophrenia on diagnostic group membership and addressed their effects on nonparticipation in follow-up visits. While phenotypic results confirmed expected differences in current psychotic symptoms and global functioning, both manic and depressive symptoms did not vary between both groups after correction for multiple testing. Polygenic risk scores for schizophrenia significantly explained part of the variability of diagnostic group. The PsyCourse study presents a unique resource to research the complex relationships of psychopathology and biology in severe mental disorders not confined to traditional diagnostic boundaries and is open for collaborations.

Psychosis Is Mutable over Time: A Longitudinal Psychopathology Study.

BACKGROUND: A neurobiologically informed, system-specific psychopathological approach has been suggested for use in schizophrenia. However, to our knowledge, such an approach has not been used to prospectively describe the course of schizophrenia. SAMPLING AND METHODS: We assessed psychopathology in a well-described sample of 100 patients with schizophrenia or schizoaffective disorder with the Bern Psychopathology Scale (BPS) at 6-month intervals for up to 18 months. The BPS groups symptoms into the 3 domains language, affectivity and motor behaviour; each domain is rated as being normal, inhibited or disinhibited. In addition, we collected qualitative psychopathological data in the form of case reports. RESULTS: Forty-eight patients completed at least 2 assessments over the course of at least 1 year. Of these, 16 patients (33.3%) showed a bipolar course pattern (i.e., a switch from inhibited to disinhibited or vice versa) in 1 domain and 6 patients (12.5%) in more than 1 domain. Shifts from 1 dominant domain to another were seen frequently (n = 20, 41.7%), but shifts between 1 dominant domain and a combination of dominant domains were more common (n = 33, 68.8%). CONCLUSIONS: The course of schizophrenia is heterogeneous and shows frequent changes in psychopathology. This should be taken into account in the communication with patients and in the research on underlying illness mechanisms and treatment. A major limitation of this study is the small sample size.

Severe clinical events in 100 patients with schizophrenia: a retrospective clinical description using a system-specific psychopathological approach.

Catatonic states and numerous other severe clinical events can complicate the course of schizophrenia. Whether these severe courses are associated with particular system-specific symptom dimensions remain unclear. Aim is to assess the frequency of severe clinical events in a clinical population and to investigate the association of these events with sociodemographic data and system-specific psychopathology, combining qualitative and quantitative data. We performed a comprehensive retrospective description of a well-described and geographically stable sample of 100 patients with schizophrenia or schizoaffective disorder and linked severe clinical events with sociodemographic data at inclusion into the study (as indicators of social functioning) and symptoms at first admission, classified with the Bern Psychopathology Scale (BPS). We found 12 mentions of catatonic stupor or excitement, 45 of suicide attempts, 26 of suicidality, 18 of deliberate self-harm, 18 of self-threatening behaviour other than deliberate self-harm, 34 of violence against other persons, 18 of violence against objects and six of sexual harassment. Disinhibited language on first admission seemed to be a protective factor against suicidality and disinhibited motor behaviour seemed to predict self-threatening and violent behaviour. Catatonia and violence in particular seemed to be socially disabling. This exploratory study showed that the BPS is a promising instrument and might represent a system-specific approach in identifying patients at risk for severe sequelae of schizophrenia. This will have to be tested in future prospective studies.

Jack Kerouac Revisited: "Madness" in On the Road Between Stigma and Glorification.

On the Road is a classic American novel that appeared at a time of great political, cultural, and psychiatric upheaval. Published almost 60 years ago, it still exerts great influence. We propose that the affirmative approach toward "madness" in the novel can enlighten our understanding of alternative perceptions of mental illness. The novel is analyzed with quantifying and narrative methods focusing on the concept of madness, which is a prominent theme in the novel. Stigma and glorification of madness can be found throughout the text. The positive sides and the pitfalls of an overly positive attitude toward mental illness and minority group members are discussed, including benevolent discrimination, recovery, and positive psychiatry.

Psychopathological Course Typology in Schizophrenia Spectrum Disorders: A Heuristic Approach in a Sample of 100 Patients.

BACKGROUND: Despite several previous attempts at subtyping schizophrenia, a typology that reflects neurobiological knowledge and reliably predicts course and outcome is lacking. We applied the system-specific concept of the Bern Psychopathology Scale (BPS) to generate a course typology based on three domains: language, affectivity, and motor behaviour. SAMPLING AND METHODS: A cohort of 100 patients with schizophrenia or schizoaffective disorders according to DSM-IV criteria underwent psychopathological assessment, and all their available medical records were retrospectively analysed on the basis of the BPS. RESULTS: Overall, 39% of the patients showed dominant abnormalities in only one domain, 37% in two domains, and 24% in all three domains. The motor domain was affected in the majority of patients (76%), followed by affectivity (63%) and language (46%). Eighty-six percent of patients showed a bipolar course pattern in at least one domain. CONCLUSIONS: In a retrospective analysis of 100 patient records we described system-specific course patterns of schizophrenia by using a neurobiologically informed psychopathological assessment. The results showed a surprisingly high proportion of bipolar courses and a pattern of pure and mixed subtypes, which speaks for an overlap of domains with regards to psychopathological symptoms. A limitation of this heuristic and retrospective approach is that it was largely based on clinical judgement. Prospective studies with more rigorous threshold definitions are needed to clarify the neurobiological and clinical implications of the proposed reorganization of psychotic disorders.

Climate Change, Pollution, Deforestation, and Mental Health: Research Trends, Gaps, and Ethical Considerations.

Climate change, pollution, and deforestation have a negative impact on global mental health. There is an environmental justice dimension to this challenge as wealthy people and high-income countries are major contributors to climate change and pollution, while poor people and low-income countries are heavily affected by the consequences. Using state-of-the art data mining, we analyzed and visualized the global research landscape on mental health, climate change, pollution and deforestation over a 15-year period. Metadata of papers were exported from PubMed®, and both relevance and relatedness of terms in different time frames were computed using VOSviewer. Co-occurrence graphs were used to visualize results. The development of exemplary terms over time was plotted separately. The number of research papers on mental health and environmental challenges is growing in a linear fashion. Major topics are climate change, chemical pollution, including psychiatric medication in wastewater, and neurobiological effects. Research on specific psychiatric syndromes and diseases, particularly on their ethical and social aspects is less prominent. There is a growing body of research literature on links between mental health, climate change, pollution, and deforestation. This research provides a graphic overview to mental healthcare professionals and political stakeholders. Social and ethical aspects of the climate change-mental health link have been neglected, and more research is needed.

Historical forerunners of neuropsychiatry: The psychiatric works of Albert W. Adamkiewicz (1850-1921).

Albert Wojciech Adamkiewicz (1850-1821) was a Polish neurologist and researcher who is best known for his description of the so-called Adamkiewicz-artery. In contrast to his achievements in neurology, his research in psychiatry from his time in Vienna (1891-1921) is commonly overlooked. We examined all titles of his publications from 1891 to 1921 and provided a close reading of those works that were related to his research on the neural basis of mental phenomena and disorders. We demonstrate that, in later stages of his scientific career, Adamkiewicz critically engaged with contemporary positions in psychiatry and the psychogenic explanation of mental disorders. He developed a theory based on his neurological research, correlating central theorems of late-nineteenth-century psychiatry to neural networks in the human cortex. These achievements make him a historical forerunner of neuropsychiatric concepts of mental phenomena and disorders.

Post-traumatic stress disorder, human rights and access to healthcare: an analysis of judgments of the European Court of Human Rights from an ethical perspective.

Background: Human rights violations such as torture are associated with a high risk of post-traumatic stress disorder (PTSD). The judgements of the European Court of Human Rights (ECtHR) include a normative perspective on PTSD and address central ethical questions. Objective: To help bridge the gap between the psycho-medical and the legal discourse on human rights violations and to illustrate their medico-ethical implications by systematically assessing and categorizing all judgements by the ECtHR dealing with PTSD. Method: The ECtHR database was searched for 'post-traumatic stress disorder'. A descriptive statistic was performed on the Articles of the European Convention on Human Rights involved and violations to these articles. In a qualitative analysis, the judgements were thematically grouped. Results: The search yielded n = 103 judgements, of which n = 90 were included. There were mostly violations of Article 3 (prohibition of torture), Article 8 (Right to respect for private and family life) and Article 6 (Right to a fair trial). PTSD in these judgements is normatively discussed with regards to ethical, social and political themes such as inadequate access to healthcare, especially in prison, matters of asylum, expulsion and extradition, protection of minorities and minors, as well as rights and duties of traumatized witnesses. Conclusion: PTSD plays a central role in a large number of ECtHR judgements. Our results show that PTSD as a medical diagnosis also encompasses legal, ethical, social, and political dimensions. This knowledge is essential for healthcare professionals working with traumatized persons, but can also be relevant for political decision-makers.

Antecedentes: las violaciones de derechos humanos como la tortura están asociadas con un alto riesgo de trastorno de estrés postraumático (TEPT). Las sentencias del Tribunal Europeo de Derechos Humanos (TEDH) incluyen una perspectiva normativa sobre el trastorno de estrés postraumático y abordan cuestiones éticas fundamentales.Objetivo: ayudar a cerrar la brecha entre el discurso psico-médico y legal sobre las violaciones de los derechos humanos e ilustrar sus implicaciones médico-éticas evaluando y categorizando sistemáticamente todas las sentencias del TEDH relacionados con el trastorno de estrés postraumático.Método: Se buscó en la base de datos del TEDH para 'trastorno por estrés postraumático'. Se realizó una estadística descriptiva sobre los artículos del Convenio Europeo de Derechos Humanos involucrados y las violaciones a estos artículos. En un análisis cualitativo, las sentencias se agruparon temáticamente.Resultados: La búsqueda arrojó n = 103 sentencias, de las cuales se incluyeron n = 90. En su mayoría fueron violaciones del artículo 3 (prohibición de la tortura), artículo 8 (derecho al respeto de la vida privada y familiar) y artículo 6 (derecho a un juicio justo). El TEPT en estas sentencias se discute normativamente con respecto a temas éticos, sociales y políticos como el acceso inadecuado a la atención médica, especialmente en prisión, asuntos de asilo, expulsión y extradición, protección de minorías y menores, así como derechos y deberes de testigos traumatizados.Conclusión: TEPT juega un papel central en un gran número de sentencias del TEDH. Nuestros resultados muestran que el TEPT como diagnóstico médico también abarca dimensiones legales, éticas, sociales y políticas. Este conocimiento es esencial para que los profesionales sanitarios trabajen con personas traumatizadas, pero también puede ser relevante para los responsables de la toma de decisiones políticas.

To whose good? Directions and gaps in psychiatric research.

BACKGROUND: Psychiatry's evidence-, implementation-, and treatment-gaps. AIMS: The aim of this study is to uncover current trends and gaps in psychiatric research. Understanding where psychiatric research is going and where there might be blind spots is important to better align it with global mental health challenges and with service users' needs. METHOD: 10 top-ranking scientific journals (highest impact factors) in psychiatry were identified for 3 years (1999, 2009, 2019) using Clarivate Analytics. Metadata of all papers published by these journals in the index years were downloaded, and the relevance and relatedness of terms from all titles and abstracts were computed and visualized using VOSviewer. RESULTS: In 1999, prominent themes included schizophrenia and novel antipsychotics as well as research on families. Ten and 20 years later, neurobiological research, especially genetic and animal studies, had gained importance. Social and psychological themes were less present across all three time points. CONCLUSIONS: In high-ranking psychiatric journals, neurobiological research appears to gain importance while social themes are under-represented. In view of challenges such as implementation gaps, marginalization of people with severe mental illness and mental health risks through social inequality, there seems to be a dissociation between research and patient needs. We suggest a systems approach to bring together different kinds of knowledge.

Schizophrenia, human rights and access to health care: A systematic search and review of judgements by the European Court of Human Rights.

BACKGROUND: Persons with schizophrenia are vulnerable regarding human rights violations. AIMS: The aim of this research is to systematically analyse judgements by the European Court of Human Rights (ECtHR) involving persons with schizophrenia. METHODS: A systematic search of judgements by the ECtHR, using the search term 'schizophrenia'. Descriptive statistics and a qualitative thematic analysis were performed. RESULTS: A total of n = 105 judgements were included, originating in n = 29 countries. Article 5 (Right to liberty and security) of the European Convention on Human Rights was ruled by the ECtHR to have been violated in 45.7% of judgements, Article 3 (Prohibition of torture) in 20.0% and Article 8 (Right to respect for private and family life) in 19.0%. Relevant themes were inadequate access to mental health care, especially in prisons and during police operations, involuntary confinement, detention and ill-treatment as a risk factor for psychosis, the right to family life versus the rights of others, extradition/expulsion and protection of other persons' human rights against violent behaviour by persons with schizophrenia. DISCUSSION: Persons with schizophrenia often do not receive adequate treatment and are especially vulnerable in prisons, where ill-treatment can be an additional risk factor. They can have both offender and victim status. The judgements suggest that the ECtHR has a balanced view on involuntary confinement. National legislation and internal hospital guidelines should be written in a manner to help minimise human rights violations against persons with schizophrenia.

Polygenic risk scores across the extended psychosis spectrum.

As early detection of symptoms in the subclinical to clinical psychosis spectrum may improve health outcomes, knowing the probabilistic susceptibility of developing a disorder could guide mitigation measures and clinical intervention. In this context, polygenic risk scores (PRSs) quantifying the additive effects of multiple common genetic variants hold the potential to predict complex diseases and index severity gradients. PRSs for schizophrenia (SZ) and bipolar disorder (BD) were computed using Bayesian regression and continuous shrinkage priors based on the latest SZ and BD genome-wide association studies (Psychiatric Genomics Consortium, third release). Eight well-phenotyped groups (n = 1580; 56% males) were assessed: control (n = 305), lower (n = 117) and higher (n = 113) schizotypy (both groups of healthy individuals), at-risk for psychosis (n = 120), BD type-I (n = 359), BD type-II (n = 96), schizoaffective disorder (n = 86), and SZ groups (n = 384). PRS differences were investigated for binary traits and the quantitative Positive and Negative Syndrome Scale. Both BD-PRS and SZ-PRS significantly differentiated controls from at-risk and clinical groups (Nagelkerke's pseudo-R2: 1.3-7.7%), except for BD type-II for SZ-PRS. Out of 28 pairwise comparisons for SZ-PRS and BD-PRS, 9 and 12, respectively, reached the Bonferroni-corrected significance. BD-PRS differed between control and at-risk groups, but not between at-risk and BD type-I groups. There was no difference between controls and schizotypy. SZ-PRSs, but not BD-PRSs, were positively associated with transdiagnostic symptomology. Overall, PRSs support the continuum model across the psychosis spectrum at the genomic level with possible irregularities for schizotypy. The at-risk state demands heightened clinical attention and research addressing symptom course specifiers. Continued efforts are needed to refine the diagnostic and prognostic accuracy of PRSs in mental healthcare.

An Investigation of Psychosis Subgroups With Prognostic Validation and Exploration of Genetic Underpinnings: The PsyCourse Study.

Importance: Identifying psychosis subgroups could improve clinical and research precision. Research has focused on symptom subgroups, but there is a need to consider a broader clinical spectrum, disentangle illness trajectories, and investigate genetic associations. Objective: To detect psychosis subgroups using data-driven methods and examine their illness courses over 1.5 years and polygenic scores for schizophrenia, bipolar disorder, major depression disorder, and educational achievement. Design, Setting, and Participants: This ongoing multisite, naturalistic, longitudinal (6-month intervals) cohort study began in January 2012 across 18 sites. Data from a referred sample of 1223 individuals (765 in the discovery sample and 458 in the validation sample) with DSM-IV diagnoses of schizophrenia, bipolar affective disorder (I/II), schizoaffective disorder, schizophreniform disorder, and brief psychotic disorder were collected from secondary and tertiary care sites. Discovery data were extracted in September 2016 and analyzed from November 2016 to January 2018, and prospective validation data were extracted in October 2018 and analyzed from January to May 2019. Main Outcomes and Measures: A clinical battery of 188 variables measuring demographic characteristics, clinical history, symptoms, functioning, and cognition was decomposed using nonnegative matrix factorization clustering. Subtype-specific illness courses were compared with mixed models and polygenic scores with analysis of covariance. Supervised learning was used to replicate results in validation data with the most reliably discriminative 45 variables. Results: Of the 765 individuals in the discovery sample, 341 (44.6%) were women, and the mean (SD) age was 42.7 (12.9) years. Five subgroups were found and labeled as affective psychosis (n = 252), suicidal psychosis (n = 44), depressive psychosis (n = 131), high-functioning psychosis (n = 252), and severe psychosis (n = 86). Illness courses with significant quadratic interaction terms were found for psychosis symptoms (R2 = 0.41; 95% CI, 0.38-0.44), depression symptoms (R2 = 0.28; 95% CI, 0.25-0.32), global functioning (R2 = 0.16; 95% CI, 0.14-0.20), and quality of life (R2 = 0.20; 95% CI, 0.17-0.23). The depressive and severe psychosis subgroups exhibited the lowest functioning and quadratic illness courses with partial recovery followed by reoccurrence of severe illness. Differences were found for educational attainment polygenic scores (mean [SD] partial η2 = 0.014 [0.003]) but not for diagnostic polygenic risk. Results were largely replicated in the validation cohort. Conclusions and Relevance: Psychosis subgroups were detected with distinctive clinical signatures and illness courses and specificity for a nondiagnostic genetic marker. New data-driven clinical approaches are important for future psychosis taxonomies. The findings suggest a need to consider short-term to medium-term service provision to restore functioning in patients stratified into the depressive and severe psychosis subgroups.

Predictors of help-seeking in unemployed people with mental health problems.

BACKGROUND: Unemployment and mental ill health often contribute to each other and lead to social exclusion with negative consequences for individuals and society. Yet, unemployed people with mental health problems often do not seek care. AIMS: The aim of this study was to assess predictors of help-seeking among unemployed people with mental health problems. METHODS: At baseline, 301 unemployed participants with mental health problems reported potential predictors of help-seeking in terms of mental health literacy, perceived barriers to care, self-concept as having a mental illness and current mental health service use. At 6-month follow-up, 240 participants reported whether or not they had started new mental health treatment since baseline. RESULTS: Adjusted for symptoms, sociodemographic and work-related variables, help-seeking was predicted by previous mental health service use and by fewer non-stigma-related barriers, not by stigma-related barriers. CONCLUSION: Implications for interventions to increase help-seeking among this vulnerable group are discussed.

Migration, Identity, and Threatened Mental Health: Examples from Contemporary Fiction.

In 2015, the world saw 244 million international migrants. Migration has been shown to be both a protective and a risk factor for mental health, depending on circumstances. Furthermore, culture has an impact on perceptions and constructions of mental illness and identity, both of which can be challenged through migration. Using a qualitative research approach, we analysed five internationally acclaimed and influential novels and one theatre play that focus on aspects of identity, migration, and threatened mental health. As a mirror of society, fiction can help to understand perceptions of identity and mental suffering on an intrapsychic and societal level, while at the same time society itself can be influenced by works of fiction. Fiction is also increasingly used for didactic purposes in medical education. We found that the works of fiction discussed embrace a multifaceted biopsychosocial concept of mental illness. Constructs such as unstable premigration identity, visible minority status (in the host country) and identity confusion in second-generation migrants are conceptualised as risk factors for mental illness. Factors portrayed as protective comprised a stable premigration identity, being safe with a family member or good friend, (romantic) love, therapeutic writing, art, and the concept of time having an element of simultaneousness. This literature challenges the idiocentric model of identity. Analysing fictional texts on migration experiences can be a promising hypothesis-generating approach for further research.

Causal attributions and secrecy in unemployed people with mental health problems.

Many people with mental illness struggle with stigma. Secrecy is one coping mechanism to deal with mental illness stigma but has some major pitfalls. In this study with 301 unemployed persons with mental health problems, we assessed whether disease concepts are associated with secrecy. We found that genetic and neurobiological disease models are significantly associated with more secrecy. This might be due to a cognitive bias called genetic essentialism. Critical awareness of biogenetic disease models and programmes helping with disclosure decisions might be helpful.

The genetic relationship between educational attainment and cognitive performance in major psychiatric disorders.

Cognitive deficits are a core feature of psychiatric disorders like schizophrenia and bipolar disorder. Evidence supports a genome-wide polygenic score (GPS) for educational attainment (GPSEDU) can be used to explain variability in cognitive performance. We aimed to identify different cognitive domains associated with GPSEDU in a transdiagnostic clinical cohort of chronic psychiatric patients with known cognitive deficits. Bipolar and schizophrenia patients from the PsyCourse cohort (N = 730; 43% female) were used. Likewise, we tested whether GPSs for schizophrenia (GPSSZ) and bipolar disorder (GPSBD) were associated with cognitive outcomes. GPSEDU explained 1.5% of variance in the backward verbal digit span, 1.9% in the number of correctly recalled words of the Verbal Learning and Memory Test, and 1.1% in crystallized intelligence. These effects were robust to the influences of treatment and diagnosis. No significant associations between GPSSZ or GPSBD with cognitive outcomes were found. Furthermore, these risk scores did not confound the effect of GPSEDU on cognitive outcomes. GPSEDU explains a small fraction of cognitive performance in adults with psychiatric disorders, specifically for domains related to linguistic learning and working memory. Investigating such a proxy-phenotype longitudinally, could give intriguing insight into the disease course, highlighting at what time genes play a more influential role on cognitive performance. Better understanding the origin of these deficits might help identify those patients at risk for lower levels of functioning and poor social outcomes. Polygenic estimates may in the future be part of predictive models for more personalized interventions.