The Need to Adapt the Psychiatric Clinical Assessment to the Digital Age: A Practical Approach.

The use of electronic devices and social media is becoming a ubiquitous part of most people's lives. Although researchers are exploring the sequelae of such use, little attention has been given to the importance of digital media use in routine psychiatric assessments of patients. The nature of technology use is relevant to understanding a patient's lifestyle and activities, the same way that it is important to evaluate the patient's occupation, functioning, and general activities. The authors propose a framework for psychiatric inquiry into digital media use, emphasizing that such inquiry should focus on quality of use, including emotional and behavioral consequences, rather than simply the amount of use.

Addressing the Increasing Mental Health Distress and Mental Illness Among Young Adults in the United States.

ABSTRACT: Recent surveys show rising numbers of young people who report anxiety and depression. Although much attention has focused on mental health of adolescent youth, less attention has been paid to young people as they transition into adulthood. Multiple factors may have contributed to this steady increase: greater exposure to social media, information, and distressing news via personal electronic devices; increased concerns regarding social determinants of health and climate change; and changing social norms due to increased mental health literacy and reduced stigma. The COVID-19 pandemic may have temporarily exacerbated symptoms and impacted treatment availability. Strategies to mitigate causal factors for depression and anxiety in young adults may include education and skills training for cognitive, behavioral, and social coping strategies, as well as healthier use of technology and social media. Policies must support the availability of health insurance and treatment, and clinicians can adapt interventions to encompass the specific concerns and needs of young adults.

Prolonged Grief Disorder and the DSM: A History.

ABSTRACT: In the early 1990s, a research group that included Holly Prigerson and Charles Reynolds established that disordered grief overlaps with depression and anxiety but is not the same. They also developed a research inventory for studying disordered grief. Subsequently, Prigerson focused on measuring disordered grief using advanced psychometric techniques. Because treatment for grief-related depression reduced symptoms of depression but not grief, Katherine Shear was recruited to develop a more effective therapy. Prigerson came to conceptualize disordered grief as prolonged grief that is associated with negative outcomes. Shear came to conceptualize disordered grief as intense grief that is complicated by features that interfere with adaption to the loss. In 2013 a hybrid disorder composed of criteria from both groups was placed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) appendix. Under the leadership of the DSM Steering Committee, a summit meeting in 2019 helped break an impasse, and a revised prolonged grief disorder became an official DSM diagnosis.

What to do about atypical anorexia nervosa? Commentary on Walsh et al. (2023).

Changes made to the DSM Eating Disorders over the years have aimed to reduce the prevalence of the residual DSM Eating Disorder categories (e.g., Other Specified Eating Disorder). Atypical Anorexia Nervosa (AN), included since DSM-IV as an example of a presentation not meeting criteria for a specific eating disorder, appears to be more prevalent than AN. It is defined as meeting all of the criteria for AN except that, after significant weight loss, weight is at or above normal. As suggested by the Walsh et al. review, lack of definitional precision will likely complicate efforts to determine whether atypical AN is best considered a variant of AN or a distinct category. Problems with the current definition of atypical AN include (1) a lack of precision regarding what constitutes "significant" weight loss; (2) whether the weight loss can occur at any point in the individual's lifetime; and (3) whether there an upper limit to weight being above normal. It is suggested that researchers develop consensus diagnostic criteria and assessment tools to facilitate the collection of empirical data about atypical AN in order to lay the groundwork for future decisions about its nosological status.

DSM-5-TR: Rationale, Process, and Overview of Changes.

The DSM-5 text revision (DSM-5-TR) is the first published revision of the DSM-5 since its publication in 2013. Like the previous text revision (DSM-IV-TR), the main goal of the DSM-5-TR is to comprehensively update the descriptive text accompanying each DSM disorder on the basis of reviews of the literature over the past 10 years. In contrast to the DSM-IV-TR, in which updates were confined almost exclusively to the text, the DSM-5-TR includes many other changes and enhancements of interest to practicing clinicians, such as the addition of diagnostic categories (prolonged grief disorder, stimulant-induced mild neurocognitive disorder, unspecified mood disorder, and a category to indicate the absence of a diagnosis); the provision of ICD-10-CM symptom codes for reporting suicidal and nonsuicidal self-injurious behavior; modifications, mostly for clarity, of the diagnostic criteria for more than 70 disorders; and updates in terminology (e.g., replacing "neuroleptic medications" with "antipsychotic medications or other dopamine receptor blocking agents" throughout the text and replacing "desired gender" with "experienced gender" in the text for gender dysphoria). Finally, the entire text was reviewed by an Ethnoracial Equity and Inclusion Work Group to ensure appropriate attention to risk factors such as the experience of racism and discrimination, as well as the use of nonstigmatizing language.

The Influence of Clinician Gender and Attitudes on Judgments Related to Forensic Considerations in ICD-11 Paraphilic Disorders: An Internet-based Field Study

Aim: This study aimed to identify whether clinicians’ gender, clinical experience, and personal attitudes influenced their perception of criminality of specific sexual behaviours, their judgments about criminal liability if mentally disordered, and the need for treatment as part of criminal settings for those having ICD-11 paraphilic disorders. Method: In a secondary analysis of data only vignettes with the least (do not meet paraphilic disorder diagnostic requirements) and most extreme (met paraphilic disorder diagnostic requirements) descriptions of ICD-11 frotteuristic, coercive sexual sadism, and exhibitionistic arousal patterns and related behavior were randomly presented to participants. A total of 1,101 clinicians rated one to three vignettes (a total of 1,884) answering questions regarding diagnosis, criminal features, and their own attitudes. Results: The ICD-11 diagnostic guidelines were adequately used to distinguish paraphilic disorders from non-pathological arousal patterns.Vignette severity was the most important predictor for clinicians’ determination that a crime was committed. Results showed an interaction of the classification of paraphilic disorders, clinicians’ gender, and personal attitudes with judgments about concepts associated with criminality, criminal liability if a diagnosis was indicated, and the need for treatment in forensic settings. Conclusions: Increased formal education, clinical training about these disorders, and evidence-based treatment guidelines are required to avoid biases that may come from preconceived ideas and personal attitudes. Laws and policies that unnecessarily restrict the treatment of these patients in non-forensic settings—for example, when the individual is distress about the arousal pattern but no crime has been committed—should be examined. (AU)

Objetivo: Se diseñó un estudio con el objetivo de identificar si el género, la experiencia clínica y las actitudes personales de los clínicos influyen en su percepción de la criminalidad de conductas sexuales concretas, sus juicios sobre la responsabilidad criminal en evaluaciones forenses en presencia de un trastorno mental y con la necesidad de tratamiento para aquellos que tienen un trastorno parafílico de la CIE-11. Método: En un análisis secundario de los datos, se presentaron al azar viñetas con una descripción mínima (no cumple con los requisitos diagnósticos para un trastorno parafílico) y una descripción completa (cumple con los requisitos diagnósticos para un trastorno parafílico) de los patrones de excitación froteurismo, sadismo sexual coercitivo, exhibicionismo y conductas relacionadas de la CIE-11. Un total de 1,101 clínicos calificaron de una a tres viñetas (un total de 1,884) respondiendo a preguntas sobre el diagnóstico, las características criminales y sus propias actitudes. Resultados: Las guías diagnósticas de la CIE-11 fueron adecuadamente utilizadas por los clínicos para distinguir los trastornos parafílicos de los patrones de excitación no patológicos. La gravedad de la viñeta fue el predictor más importante para la determinación de los clínicos de que se había cometido un delito. Los resultados mostraron una interacción de la clasificación de los trastornos parafílicos, el género de los clínicos y las actitudes personales con los juicios sobre conceptos asociados con la criminalidad, la responsabilidad criminal en presencia de un trastorno mental y la necesidad de tratamiento en contextos de evaluación forenses. Conclusiones: Se requiere mayor educación formal, entrenamiento clínico sobre estos trastornos y guías de tratamiento basadas en evidencia para evitar sesgos que puedan provenir de ideas preconcebidas y actitudes personales. (AU)

The Hierarchical Taxonomy of Psychopathology (HiTOP) in psychiatric practice and research.

The Hierarchical Taxonomy of Psychopathology (HiTOP) has emerged out of the quantitative approach to psychiatric nosology. This approach identifies psychopathology constructs based on patterns of co-variation among signs and symptoms. The initial HiTOP model, which was published in 2017, is based on a large literature that spans decades of research. HiTOP is a living model that undergoes revision as new data become available. Here we discuss advantages and practical considerations of using this system in psychiatric practice and research. We especially highlight limitations of HiTOP and ongoing efforts to address them. We describe differences and similarities between HiTOP and existing diagnostic systems. Next, we review the types of evidence that informed development of HiTOP, including populations in which it has been studied and data on its validity. The paper also describes how HiTOP can facilitate research on genetic and environmental causes of psychopathology as well as the search for neurobiologic mechanisms and novel treatments. Furthermore, we consider implications for public health programs and prevention of mental disorders. We also review data on clinical utility and illustrate clinical application of HiTOP. Importantly, the model is based on measures and practices that are already used widely in clinical settings. HiTOP offers a way to organize and formalize these techniques. This model already can contribute to progress in psychiatry and complement traditional nosologies. Moreover, HiTOP seeks to facilitate research on linkages between phenotypes and biological processes, which may enable construction of a system that encompasses both biomarkers and precise clinical description.

Emerging experience with selected new categories in the ICD-11: complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder.

Among the important changes in the ICD-11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD-11 implementation. This paper focuses on four disorders: complex post-traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD-11 represents a different decision than was made for the DSM-5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD-11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD-11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD-11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.

Revising Substance-Related Disorders in the DSM-5: A History.

OBJECTIVE: This article narrates a history of several important changes to the substance-related disorders chapter in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), based on interviews with people involved in the pre-planning and the development of the revisions. These changes include collapsing substance abuse and substance dependence into a single substance use disorder, adding craving as a diagnostic criterion, and incorporating a behavioral addiction--gambling disorder--into the substance-related disorders chapter. Studies using Item Response Theory (IRT) supported the new substance use disorder diagnosis. The IRT analyses demonstrated that the abuse and dependence items can be ordered on a single latent dimension and that some of the presumably milder abuse items indexed a greater level of severity than the presumably more pathological dependence items. Those who opposed collapsing abuse and dependence emphasized the validity and clinical utility of the dependence syndrome on which much important treatment research was based. Both those who favored and those who opposed adding craving agreed that it was redundant with the other diagnostic criteria and did not improve the performance of the criterion set. Nevertheless, some clinicians supported adding craving because of its importance in the conceptualization of substance use disorders, and some researchers supported it because of its potential to be validated as a diagnostically useful biomarker. Those who opposed adding craving argued that considering the validity of an individual criterion alone rather than its contribution to the incremental validity of the criterion set represented a major shift in diagnostic philosophy that had potentially far-reaching implications for future revisions of the DSM. CONCLUSIONS: We conclude by observing that, unlike what occurred in the broader DSM-5 process, despite differences of opinion the work group reached consensus. In part, this may be explained by some shared standards within the work group versus the disagreement about standards across the broader DSM-5 process.

Structural Racism and Psychiatric Practice: A Call for Sustained Change.

ABSTRACT: Structural racism has received renewed focus over the past year, fueled by the convergence of major political and social events. Psychiatry as a field has been forced to confront a legacy of systemic inequities. Here, we use examples from our clinical and supervisory work to highlight the urgent need to integrate techniques addressing racial identity and racism into psychiatric practice and teaching. This urgency is underlined by extensive evidence of psychiatry's long-standing systemic inequities. We argue that our field suffers not from a lack of available techniques, but rather a lack of sustained commitment to understand and integrate those techniques into our work; indeed, there are multiple published examples of strategies to address racism and racial identity in psychiatric clinical practice. We conclude with recommendations geared toward more firmly institutionalizing a focus on racism and racial identity in psychiatry, and suggest applications of existing techniques to our initial clinical examples.

A global field study of the international classification of diseases (ICD-11) mood disorders clinical descriptions and diagnostic guidelines.

BACKGROUND: We report results of an internet-based field study evaluating the diagnostic guidelines for ICD-11 mood disorders. Accuracy of clinicians' diagnostic judgments applying draft ICD-11 as compared to the ICD-10 guidelines to standardized case vignettes was assessed as well as perceived clinical utility. METHODS: 1357 clinician members of the World Health Organization's Global Clinical Practice Network completed the study in English, Spanish, Japanese or Russian. Participants were randomly assigned to apply ICD-11 or ICD-10 guidelines to one of eleven pairs of case vignettes. RESULTS: Clinicians using the ICD-11 and ICD-10 guidelines achieved similar levels of accuracy in diagnosing mood disorders depicted in vignettes. Those using the ICD-11 were more accurate in identifying depressive episode in recurrent depressive disorder. There were no statistically significant differences detected across classifications in the accuracy of identifying dysthymic or cyclothymic disorder. Circumscribed problems with the proposed ICD-11 guidelines were identified including difficulties differentiating bipolar type I from bipolar type II disorder and applying revised severity ratings to depressive episodes. Clinical utility of ICD-11 bipolar disorders was found to be significantly lower than for ICD-10 equivalent categories. LIMITATIONS: Standardized case vignettes were manipulated to evaluate specific changes. The degree of accuracy of clinicians' diagnostic judgments may not reflect clinical decision-making with patients. CONCLUSIONS: Alignment of the ICD-11 with current research appears to have been achieved without sacrificing diagnostic accuracy or clinical utility though specific training may be necessary as ICD-11 is implemented worldwide. Areas in which the ICD-11 guidelines did not perform as intended resulted in further revisions.

Psychiatry in the Time of COVID: Credibility, Uncertainty, and Self-Reflection.

ABSTRACT: Public trust in the credibility of medicine and physicians has been severely tested amid the COVID-19 pandemic and growing sociopolitical fissures in the United States. Physicians are being asked to be ambassadors to the public of scientific information. Psychiatrists have an opportunity to help the public understand and accept a "new normal" during a time of such uncertainty. Using a case example, we review the impact of uncertainty and fear on scientific and medical credibility. Although the pandemic provides an opportunity for systemic change, the consequences of any change remain unknown. To help patients navigate the uncertainty, we conclude by offering four guidelines to clinicians: the public has little interest in understanding the scientific method; we need to acknowledge that we do not have all the answers; credibility and trustworthiness are linked to our ability to be trusted, believable messengers; and we can retain scientific credibility while acknowledging uncertainty.

Can Clinicians Use Dimensional Information to Make a Categorical Diagnosis of Paraphilic Disorders? An ICD-11 Field Study.

BACKGROUND: The diagnosis of paraphilic disorder is a complicated clinical judgment based on the integration of information from multiple dimensions to arrive at a categorical (present/absent) conclusion. The recent update of the guidelines for paraphilic disorders in ICD-11 presents an opportunity to investigate how mental health professionals use the diagnostic guidelines to arrive at a diagnosis which thereby can optimize the guidelines for clinical use. AIM: This study examined clinicians' ability to use the ICD-11 diagnostic guidelines for paraphilic disorders which contain multiple dimensions that must be simultaneously assessed to arrive at a diagnosis. METHODS: The study investigated the ability of 1,263 international clinicians to identify the dimensions of paraphilic disorder in the context of written case vignettes that varied on a single dimension only. OUTCOMES: Participants provided diagnoses for the case vignettes along with dimensional ratings of the degree of presence of five dimensions of paraphilic disorder (arousal, consent, action, distress, and risk). RESULTS: Across a series of analyses, clinicians demonstrated a clear ability to recognize and appropriately integrate the dimensions of paraphilic disorders; however, there was some evidence that clinicians may over-diagnose non-pathological cases. CLINICAL TRANSLATION: Clinicians would likely benefit from targeted training on the ICD-11 definition of paraphilic disorder and should be cautious of over-diagnosing. STRENGTHS AND LIMITATIONS: This study represents a large international sample of health professionals and is the first to examine clinicians' ability to apply the ICD-11 diagnostic guidelines for paraphilic disorders. Important limitations include not generalizing to all clinicians and acknowledging that results may be different in direct clinical interactions vs written case vignettes. CONCLUSION: These results indicate that clinicians appear capable of interpreting and implementing the diagnostic guidelines for paraphilic disorders in ICD-11. Keeley JW, Briken P, Evans SC, et al. Can Clinicians Use Dimensional Information to Make a Categorical Diagnosis of Paraphilic Disorders? An ICD-11 Field Study. J Sex Med 2021;18:1592-1606.

Les progrès dans la réalisation de la classification quantitative de la psychopathologie.

Shortcomings of approaches to classifying psychopathology based on expert consensus have given rise to contemporary efforts to classify psychopathology quantitatively. In this paper, we review progress in achieving a quantitative and empirical classification of psychopathology. A substantial empirical literature indicates that psychopathology is generally more dimensional than categorical. When the discreteness versus continuity of psychopathology is treated as a research question, as opposed to being decided as a matter of tradition, the evidence clearly supports the hypothesis of continuity. In addition, a related body of literature shows how psychopathology dimensions can be arranged in a hierarchy, ranging from very broad "spectrum level" dimensions, to specific and narrow clusters of symptoms. In this way, a quantitative approach solves the "problem of comorbidity" by explicitly modeling patterns of co-occurrence among signs and symptoms within a detailed and variegated hierarchy of dimensional concepts with direct clinical utility. Indeed, extensive evidence pertaining to the dimensional and hierarchical structure of psychopathology has led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium. This is a group of 70 investigators working together to study empirical classification of psychopathology. In this paper, we describe the aims and current foci of the HiTOP Consortium. These aims pertain to continued research on the empirical organization of psychopathology; the connection between personality and psychopathology; the utility of empirically based psychopathology constructs in both research and the clinic; and the development of novel and comprehensive models and corresponding assessment instruments for psychopathology constructs derived from an empirical approach.

An organization- and category-level comparison of diagnostic requirements for mental disorders in ICD-11 and DSM-5.

In 2013, the American Psychiatric Association (APA) published the 5th edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In 2019, the World Health Assembly approved the 11th revision of the International Classification of Diseases (ICD-11). It has often been suggested that the field would benefit from a single, unified classification of mental disorders, although the priorities and constituencies of the two sponsoring organizations are quite different. During the development of the ICD-11 and DSM-5, the World Health Organization (WHO) and the APA made efforts toward harmonizing the two systems, including the appointment of an ICD-DSM Harmonization Group. This paper evaluates the success of these harmonization efforts and provides a guide for practitioners, researchers and policy makers describing the differences between the two systems at both the organizational and the disorder level. The organization of the two classifications of mental disorders is substantially similar. There are nineteen ICD-11 disorder categories that do not appear in DSM-5, and seven DSM-5 disorder categories that do not appear in the ICD-11. We compared the Essential Features section of the ICD-11 Clinical Descriptions and Diagnostic Guidelines (CDDG) with the DSM-5 criteria sets for 103 diagnostic entities that appear in both systems. We rated 20 disorders (19.4%) as having major differences, 42 disorders (40.8%) as having minor definitional differences, 10 disorders (9.7%) as having minor differences due to greater degree of specification in DSM-5, and 31 disorders (30.1%) as essentially identical. Detailed descriptions of the major differences and some of the most important minor differences, with their rationale and related evidence, are provided. The ICD and DSM are now closer than at any time since the ICD-8 and DSM-II. Differences are largely based on the differing priorities and uses of the two diagnostic systems and on differing interpretations of the evidence. Substantively divergent approaches allow for empirical comparisons of validity and utility and can contribute to advances in the field.

Telehealth and the Community SMI Population: Reflections on the Disrupter Experience of COVID-19.

The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change.

Recency and intensification of positive symptoms enhance prediction of conversion to syndromal psychosis in clinical high-risk patients.

BACKGROUND: Early detection and intervention strategies in patients at clinical high-risk (CHR) for syndromal psychosis have the potential to contain the morbidity of schizophrenia and similar conditions. However, research criteria that have relied on severity and number of positive symptoms are limited in their specificity and risk high false-positive rates. Our objective was to examine the degree to which measures of recency of onset or intensification of positive symptoms [a.k.a., new or worsening (NOW) symptoms] contribute to predictive capacity. METHODS: We recruited 109 help-seeking individuals whose symptoms met criteria for the Progression Subtype of the Attenuated Positive Symptom Psychosis-Risk Syndrome defined by the Structured Interview for Psychosis-Risk Syndromes and followed every three months for two years or onset of syndromal psychosis. RESULTS: Forty-one (40.6%) of 101 participants meeting CHR criteria developed a syndromal psychotic disorder [mostly (80.5%) schizophrenia] with half converting within 142 days (interquartile range: 69-410 days). Patients with more NOW symptoms were more likely to convert (converters: 3.63 ± 0.89; non-converters: 2.90 ± 1.27; p = 0.001). Patients with stable attenuated positive symptoms were less likely to convert than those with NOW symptoms. New, but not worsening, symptoms, in isolation, also predicted conversion. CONCLUSIONS: Results suggest that the severity and number of attenuated positive symptoms are less predictive of conversion to syndromal psychosis than the timing of their emergence and intensification. These findings also suggest that the earliest phase of psychotic illness involves a rapid, dynamic process, beginning before the syndromal first episode, with potentially substantial implications for CHR research and understanding the neurobiology of psychosis.

Association of self-reported religiosity with the development of major depression in multireligious country Japan.

AIM: In Western Christian countries, religiosity is generally believed to be associated with a lower risk for depression, which is supported by epidemiological evidence. However, the association between religiosity and depression in multireligious countries is unknown. The objective was to evaluate the association between religiosity and subsequent depression in a multireligious population. METHODS: A longitudinal study was conducted in a large hospital in Tokyo, Japan, from 2005 to 2018. All participants who underwent health check-ups without a prior history of depression or depression at baseline were included. Our outcome was development of major depressive disorder (MDD), which was compared according to the degree of religiosity, adjusting for potential confounders. RESULTS: Among 67 723 adult participants, those who were more religious tended to be older, female, married, and to have healthier habits but also more medical comorbidities at baseline. During a median follow-up of 2528 days, 1911 (2.8%) participants developed MDD. Compared to the reference group, religious group participants tended to have higher odds ratios (OR) for developing MDD in a dose-dependent manner. Among them, the extremely religious group (OR, 1.51; 95% confidence interval [CI], 1.28-1.78) and the moderately religious group (OR, 1.30; 95% CI, 1.14-1.49) were statistically associated with increased development of MDD compared to the not-religious-at-all group. Those who had increased their religiosity from baseline had statistically lower development of MDD (OR, 0.85; 95% CI, 0.75-0.97) compared to those who remained in the same degree of religiosity from baseline. CONCLUSION: Religiosity was associated with future MDD in a dose-dependent manner in a multireligious population, which was in the opposite direction from that seen in previous Western longitudinal studies.