Assessing the Impact of Evidence-Based Mental Health Guidance During the COVID-19 Pandemic: Systematic Review and Qualitative Evaluation.

BACKGROUND: During the COVID-19 pandemic, the Oxford Precision Psychiatry Lab (OxPPL) developed open-access web-based summaries of mental health care guidelines (OxPPL guidance) in key areas such as digital approaches and telepsychiatry, suicide and self-harm, domestic violence and abuse, perinatal care, and vaccine hesitancy and prioritization in the context of mental illness, to inform timely clinical decision-making. OBJECTIVE: This study aimed to evaluate the practice of creating evidence-based health guidelines during health emergencies using the OxPPL guidance as an example. An international network of clinical sites and colleagues (in Australia, New Zealand, and the United Kingdom) including clinicians, researchers, and experts by experience aimed to (1) evaluate the clinical impact of the OxPPL guidance, as an example of an evidence-based summary of guidelines; (2) review the literature for other evidence-based summaries of COVID-19 guidelines regarding mental health care; and (3) produce a framework for response to future global health emergencies. METHODS: The impact and clinical utility of the OxPPL guidance were assessed using clinicians' feedback via an international survey and focus groups. A systematic review (protocol registered on Open Science Framework) identified summaries or syntheses of guidelines for mental health care during and after the COVID-19 pandemic and assessed the accuracy of the methods used in the OxPPL guidance by identifying any resources that the guidance had not included. RESULTS: Overall, 80.2% (146/182) of the clinicians agreed or strongly agreed that the OxPPL guidance answered important clinical questions, 73.1% (133/182) stated that the guidance was relevant to their service, 59.3% (108/182) said that the guidelines had or would have a positive impact on their clinical practice, 42.9% (78/182) that they had shared or would share the guidance, and 80.2% (146/182) stated that the methodology could be used during future health crises. The focus groups found that the combination of evidence-based knowledge, clinical viewpoint, and visibility was crucial for clinical implementation. The systematic review identified 2543 records, of which 2 syntheses of guidelines met all the inclusion criteria, but only 1 (the OxPPL guidance) used evidence-based methodology. The review showed that the OxPPL guidance had included the majority of eligible guidelines, but 6 were identified that had not been included. CONCLUSIONS: The study identified an unmet need for web-based, evidence-based mental health care guidance during the COVID-19 pandemic. The OxPPL guidance was evaluated by clinicians as having a real-world clinical impact. Robust evidence-based methodology and expertise in mental health are necessary, but easy accessibility is also needed, and digital technology can materially help. Further health emergencies are inevitable and now is the ideal time to prepare, including addressing the training needs of clinicians, patients, and carers, especially in areas such as telepsychiatry and digital mental health. For future planning, guidance should be widely disseminated on an international platform, with allocated resources to support adaptive updates.

Digital mental health: challenges and next steps.

Digital innovations in mental health offer great potential, but present unique challenges. Using a consensus development panel approach, an expert, international, cross-disciplinary panel met to provide a framework to conceptualise digital mental health innovations, research into mechanisms and effectiveness and approaches for clinical implementation. Key questions and outputs from the group were agreed by consensus, and are presented and discussed in the text and supported by case examples in an accompanying appendix. A number of key themes emerged. (1) Digital approaches may work best across traditional diagnostic systems: we do not have effective ontologies of mental illness and transdiagnostic/symptom-based approaches may be more fruitful. (2) Approaches in clinical implementation of digital tools/interventions need to be creative and require organisational change: not only do clinicians and patients need training and education to be more confident and skilled in using digital technologies to support shared care decision-making, but traditional roles need to be extended, with clinicians working alongside digital navigators and non-clinicians who are delivering protocolised treatments. (3) Designing appropriate studies to measure the effectiveness of implementation is also key: including digital data raises unique ethical issues, and measurement of potential harms is only just beginning. (4) Accessibility and codesign are needed to ensure innovations are long lasting. (5) Standardised guidelines for reporting would ensure effective synthesis of the evidence to inform clinical implementation. COVID-19 and the transition to virtual consultations have shown us the potential for digital innovations to improve access and quality of care in mental health: now is the ideal time to act.

Explainable artificial intelligence for mental health through transparency and interpretability for understandability.

The literature on artificial intelligence (AI) or machine learning (ML) in mental health and psychiatry lacks consensus on what "explainability" means. In the more general XAI (eXplainable AI) literature, there has been some convergence on explainability meaning model-agnostic techniques that augment a complex model (with internal mechanics intractable for human understanding) with a simpler model argued to deliver results that humans can comprehend. Given the differing usage and intended meaning of the term "explainability" in AI and ML, we propose instead to approximate model/algorithm explainability by understandability defined as a function of transparency and interpretability. These concepts are easier to articulate, to "ground" in our understanding of how algorithms and models operate and are used more consistently in the literature. We describe the TIFU (Transparency and Interpretability For Understandability) framework and examine how this applies to the landscape of AI/ML in mental health research. We argue that the need for understandablity is heightened in psychiatry because data describing the syndromes, outcomes, disorders and signs/symptoms possess probabilistic relationships to each other-as do the tentative aetiologies and multifactorial social- and psychological-determinants of disorders. If we develop and deploy AI/ML models, ensuring human understandability of the inputs, processes and outputs of these models is essential to develop trustworthy systems fit for deployment.

Perinatal mental health and COVID-19: Navigating a way forward.

The COVID-19 pandemic and its aftermath have increased pre-existing inequalities and risk factors for mental disorders in general, but perinatal mental disorders are of particular concern. They are already underdiagnosed and undertreated, and this has been magnified by the pandemic. Access to services (both psychiatric and obstetric) has been reduced, and in-person contact has been restricted because of the increased risks. Rates of perinatal anxiety and depressive symptoms have increased. In the face of these challenges, clear guidance in perinatal mental health is needed for patients and clinicians. However, a systematic search of the available resources showed only a small amount of guidance from a few countries, with a focus on the acute phase of the pandemic rather than the challenges of new variants and variable rates of infection. Telepsychiatry offers advantages during times of restricted social contact and also as an additional route for accessing a wide range of digital technologies. While there is a strong evidence base for general telepsychiatry, the particular issues in perinatal mental health need further examination. Clinicians will need expertise and training to navigate a hybrid model, flexibly combining in person and remote assessments according to risk, clinical need and individual patient preferences. There are also wider issues of care planning in the context of varying infection rates, restrictions and vaccination access in different countries. Clinicians will need to focus on prevention, treatment, risk assessment and symptom monitoring, but there will also need to be an urgent and coordinated focus on guidance and planning across all organisations involved in perinatal mental health care.

Impact of the COVID-19 Pandemic on the Global Delivery of Mental Health Services and Telemental Health: Systematic Review.

BACKGROUND: The COVID-19 pandemic required mental health services around the world to adapt quickly to the new restrictions and regulations put in place to reduce the risk of transmission. As face-to-face contact became difficult, virtual methods were implemented to continue to safely provide mental health care. However, it is unclear to what extent service provision transitioned to telemental health worldwide. OBJECTIVE: We aimed to systematically review the global research literature on how mental health service provision adapted during the first year of the pandemic. METHODS: We searched systematically for quantitative papers focusing on the impact of the COVID-19 pandemic on mental health services published until April 13, 2021, in the PubMed, Embase, medRxiv, and bioXriv electronic bibliographic databases, using the COVID-19 Open Access Project online platform. The screening process and data extraction were independently completed by at least two authors, and any disagreement was resolved by discussion with a senior member of the team. The findings were summarized narratively in the context of each country's COVID-19 Stringency Index, which reflects the stringency of a government's response to COVID-19 restrictions at a specific time. RESULTS: Of the identified 24,339 records, 101 papers were included after the screening process. Reports on general services (n=72) showed that several countries' face-to-face services reduced their activities at the start of the pandemic, with reductions in the total number of delivered visits and with some services forced to close. In contrast, telemental health use rapidly increased in many countries across the world at the beginning of the pandemic (n=55), with almost complete virtualization of general and specialistic care services by the end of the first year. Considering the reported COVID-19 Stringency Index values, the increased use of virtual means seems to correspond to periods when the Stringency Index values were at their highest in several countries. However, due to specific care requirements, telemental health could not be used in certain subgroups of patients, such as those on clozapine or depot treatments and those who continued to need face-to-face visits. CONCLUSIONS: During the pandemic, mental health services had to adapt quickly in the short term, implementing or increasing the use of telemental health services across the globe. Limited access to digital means, poor digital skills, and patients' preferences and individual needs may have contributed to differences in implementing and accessing telemental health services during the pandemic. In the long term, a blended approach, combining in-person and virtual modalities, that takes into consideration the needs, preferences, and digital skills of patients may better support the future development of mental health services. It will be required to improve confidence with digital device use, training, and experience in all modalities for both clinicians and service users.

Surface slicks are pelagic nurseries for diverse ocean fauna.

Most marine animals have a pelagic larval phase that develops in the coastal or open ocean. The fate of larvae has profound effects on replenishment of marine populations that are critical for human and ecosystem health. Larval ecology is expected to be tightly coupled to oceanic features, but for most taxa we know little about the interactions between larvae and the pelagic environment. Here, we provide evidence that surface slicks, a common coastal convergence feature, provide nursery habitat for diverse marine larvae, including > 100 species of commercially and ecologically important fishes. The vast majority of invertebrate and larval fish taxa sampled had mean densities 2-110 times higher in slicks than in ambient water. Combining in-situ surveys with remote sensing, we estimate that slicks contain 39% of neustonic larval fishes, 26% of surface-dwelling zooplankton (prey), and 75% of floating organic debris (shelter) in our 1000 km2 study area in Hawai'i. Results indicate late-larval fishes actively select slick habitats to capitalize on concentrations of diverse prey and shelter. By providing these survival advantages, surface slicks enhance larval supply and replenishment of adult populations from coral reef, epipelagic, and deep-water ecosystems. Our findings suggest that slicks play a critically important role in enhancing productivity in tropical marine ecosystems.

Prey-size plastics are invading larval fish nurseries.

Life for many of the world's marine fish begins at the ocean surface. Ocean conditions dictate food availability and govern survivorship, yet little is known about the habitat preferences of larval fish during this highly vulnerable life-history stage. Here we show that surface slicks, a ubiquitous coastal ocean convergence feature, are important nurseries for larval fish from many ocean habitats at ecosystem scales. Slicks had higher densities of marine phytoplankton (1.7-fold), zooplankton (larval fish prey; 3.7-fold), and larval fish (8.1-fold) than nearby ambient waters across our study region in Hawai'i. Slicks contained larger, more well-developed individuals with competent swimming abilities compared to ambient waters, suggesting a physiological benefit to increased prey resources. Slicks also disproportionately accumulated prey-size plastics, resulting in a 60-fold higher ratio of plastics to larval fish prey than nearby waters. Dissections of hundreds of larval fish found that 8.6% of individuals in slicks had ingested plastics, a 2.3-fold higher occurrence than larval fish from ambient waters. Plastics were found in 7 of 8 families dissected, including swordfish (Xiphiidae), a commercially targeted species, and flying fish (Exocoetidae), a principal prey item for tuna and seabirds. Scaling up across an ∼1,000 km2 coastal ecosystem in Hawai'i revealed slicks occupied only 8.3% of ocean surface habitat but contained 42.3% of all neustonic larval fish and 91.8% of all floating plastics. The ingestion of plastics by larval fish could reduce survivorship, compounding threats to fisheries productivity posed by overfishing, climate change, and habitat loss.

Lithium and suicide in mood disorders: Updated meta-review of the scientific literature.

OBJECTIVES: Suicide and suicidal behaviour are increased in mood disorders, particularly bipolar disorders. Observational studies and small randomized controlled trials (RCTs) support the idea that taking lithium is associated with a reduction in these rates. This paper aims to review the best evidence for the effect of lithium on rates of suicide and self harm. METHODS: We searched PubMed, PsycINFO, and the Cochrane Library systematically for systematic reviews and meta-analyses of RCTs of lithium and suicide and self harm published between January 1980 and June 2017. In the case of multiple publications on the same topic, only the most recent or most comprehensive review was considered. RESULTS: A large number of reviews were identified, but only 16 publications were systematic reviews. Of these, three systematic reviews of lithium and suicide rates and one of lithium and self harm confined only to RCTs were identified. Despite some methodological concerns and heterogeneity in terms of participants, diagnoses, comparators, durations, and phase of illness, the evidence to date is overwhelmingly in favour of lithium as an antisuicidal agent, even balanced against any potential disadvantages of its use in regular clinical practice. CONCLUSIONS: The anti-suicidal effects of lithium have been consistently reported over the past 40 years. The most robust evidence comes from RCTs, but these results are also discussed in the context of the difficulties in conducting high quality studies in this area, and the supporting evidence that observational and non-randomized studies can also provide. Given this evidence, however, the use of lithium is still underrepresented in clinical practice and should be incorporated more assertively into current guidelines.

Interventions to prevent self-harm: what does the evidence say?

Self-harm is a major public health concern and a risk factor for future suicide. It predominantly occurs in young people with around 65% of self-harm occurring before the age of 35. Self-harm causes distress to families and is associated with poorer educational outcomes as well as increased health and social care costs. Repetition is common with a quarter of individuals presenting to hospital with a further episode of self-harm within a year. We review the evidence from randomised controlled trials of treatments for self-harm, focusing on pharmacological and psychological approaches. We then contrast this with the current observational evidence and reflect on the challenges and limitations of randomised controlled trials for the treatment of self-harm.

Methamphetamine activates reward circuitry in drug naïve human subjects.

Amphetamines are highly addictive drugs that have pronounced effects on emotional and cognitive behavior in humans. These effects are mediated through their potent dopaminergic agonistic properties. Dopamine has also been implicated in the modulation of responses of the 'reward circuit' in animal and human studies. In this study we use functional magnetic resonance imaging (fMRI) to identify the brain circuitry involved in the psychostimulant effect of methamphetamine in psychostimulant-naïve human subjects. Seven healthy volunteers were scanned in a 3T MR imaging system. They received single-blind intravenous infusions of methamphetamine (0.15 mg/kg), and rated their experience of 'mind-racing' on a button press throughout the experiment. Data were analyzed with statistical parametric mapping methods. Amphetamine administration activated the medial orbitofrontal cortex, the rostral part of the anterior cingulate cortex, and the ventral striatum. Ratings of 'mind-racing' after methamphetamine infusion correlated with activations in the rostral part of the anterior cingulate cortex and in the ventral striatum. In addition, activations in the medial orbitofrontal cortex were independent of motor and related responses involved in making the ratings. These findings indicate that the first administration of a psychostimulant to human subjects activates classical reward circuitry. Our data also support recent hypotheses suggesting a central role for the orbitofrontal cortex in drug reinforcement and the development of addiction.

Diffuse pleural fibrosis--an unreliable indicator of heavy asbestos exposure?

OBJECTIVES: This study aimed at testing the hypothesis that diffuse pleural fibrosis is associated with a heavier exposure to asbestos than that of benign pleural plaques, and hence diffuse pleural fibrosis can be used as a marker of heavy exposure. METHODS: Asbestos burden was estimated for 192 naval dockyard workers (96 with diffuse pleural fibrosis, 96 with plaques) by calculating the exposure ratings from the trade and the years spent in that trade. In 53 cases the diffuse pleural fibrosis was bilateral. RESULTS: No difference was found in the mean estimated asbestos burden between all diffuse pleural fibrosis and plaques, nor between plaques and unilateral and bilateral diffuse pleural fibrosis, analyzed separately by a one-factor analysis of variance. The mean asbestos burden was significantly greater for bilateral than for unilateral diffuse pleural fibrosis. A wide spread of asbestos exposure was noted among the men with diffuse pleural fibrosis. CONCLUSIONS: Diffuse pleural fibrosis may arise after widely varying exposure to asbestos. The mean exposure ratings for diffuse pleural fibrosis do not differ from those for pleural plaques, although the ratings are significantly higher for men with bilateral diffuse pleural fibrosis than for those with unilateral diffuse pleural fibrosis. Diffuse pleural fibrosis cannot be used as a reliable marker of heavy asbestos exposure.

Predictors of mood response to acute tryptophan depletion. A reanalysis.

Acute tryptophan depletion (ATD) induces depressive symptoms in 50-60% of selective serotonin reuptake inhibitor (SSRI) treated, recovered depressed patients. However, no reliable predictors of mood response to ATD have been established. In the present study, individual subject data of six ATD studies were pooled ('mega-analysis') in order to investigate the mediating role of clinical, demographic and biochemical characteristics in the mood response to ATD. A procedure was developed to make different versions of the Hamilton scale comparable. Recurrent depressive episodes, female gender, prior exposure to SSRI antidepressant treatment and previous serious suicidal thoughts/attempts all appear to be independent predictors of mood response to ATD. Chronicity of illness is the most powerful predictor. Residual symptoms of depression were not found to predict response to ATD. ATD may be useful to study the mechanism of action of SSRI antidepressants and individual biological vulnerability of the serotonin system. Whether the effects of ATD represent a reversal of the action of SSRI antidepressants or individual vulnerability probably depends upon the timing of the procedure in the course of remission of a depressive episode.