Abstract

Background
General practitioners play a pivotal role in the diagnosis attention-deficit/hyperactivity disorder (ADHD) in adults. This systematic review aims to determine the effectivity and feasibility of screening tools for ADHD in adults in primary care.

Method
A literature search was performed in PubMed, Cochrane Library, Ovid, ERIC, PsycInfo, PSYNDEX and Embase in November 2022. Sensitivity and specificity were considered as primary outcomes. Further psychometric properties, feasibility in general practice as well as digital practicability were evaluated as secondary outcomes. Risk of bias was assessed via QUADAS-2/C. A narrative data synthesis and meta-analysis was performed (PROSPERO: CRD42022374597).

Results
A total of fifty-eight studies were included in data analysis. These studies referred to eighty-four various screening tools. ASRS-6 (DSM-V), WURS-25, CAARS-s:sV and TRAQ10 are suitable instruments for screening of ADHD in adults in primary care. The highest test accuracy was shown by ASRS 6 (DSM-V) (Sensitivity=0.83 [0.67–0.92], Specificity=0.87 [0.93–0.8], AUC=0.92, I2=8.6–12.3 %).

Limitations
Included studies used rating scales as reference standard. Some studies compared study groups to control groups with an unknown ADHD status and there is a large degree of heterogeneity between the populations. Some studies referred to the best-balanced results of sensitivity and specificity under a certain cut-off, that has not been determined before.

Conclusion
Feasibility studies are needed to provide more evidence for WURS-25 and CAARS-s:sV. The determination of sufficient cut-offs is important, to improve the identification of ADHD in adults by general physicians.

Introduction

Attention-deficit/hyperactive disorder (ADHD) according to the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) and hyperkinetic disorder (F90) or attention deficit without hyperactivity (F98.8) according to the International Classification of Diseases, editions 10 and 11 (ICD-10/11)) is commonly known as a childhood disorder which is characterized by altered hyperactivity, inattention and impulsivity (Drechsler et al., 2020). These symptoms persist until adulthood in about 50 % of all diagnosed patients (Sibley et al., 2017, 2022). Moreover, patients show characteristic features, which include executive dysfunction, disorganization and emotional distress, leading to an impairment of their daily lives (Barkley, 1997; Wender, 1998). Common comorbidities are depression, borderline personality disorder, social phobia, anxiety, or substance abuse (Fayyad et al., 2017; Kessler et al., 2006). Although a prevalence of approximately 2–3 % of ADHD in adults is estimated, only 0.2–0.4 % are actually diagnosed in Germany (Fayyad et al., 2017; Bachmann et al., 2017; de Zwaan et al., 2012). A possible reason seems to be a gap in medical care for young adults in a time of transition after leaving the pediatric setting (Eklund et al., 2016; Robb and Findling, 2013). Moreover, ADHD might be masked by other psychiatric symptoms and comorbidities (Retz et al., 2013). A missing or failed diagnosis prevents access to optimal medical care in the form of an evidence-based treatment of affected adults. General practitioners are considered to act as so-called „gatekeepers“, a role that is characterized by the initial identification of patients (Kwon et al., 2023; French et al., 2020). Consequently, there is a distinct need for appropriate diagnostic tools in primary care, as has already been identified in relevant guidelines (Eom and Kim, 2023; National Institute for Health and Care Excellence: Guidelines, 2018). There are many different screening tools, which differ in relevant aspects of the disorder. Some screening tools evaluate childhood symptoms, whereas others focus on current adult symptoms. Some screening tools are based on DSM-5 criteria, others on Utah criteria or no specified criteria. They differ in time or way of application, number of items, and scoring methods. For example, the choice of cutoff scores in ADHD screening tools directly influences clinical decision-making, including the initiation of treatment interventions. A higher cutoff score may exclude individuals who, despite exhibiting significant symptoms, do not meet the stringent criteria, potentially denying them access to necessary interventions. Conversely, a lower cutoff score could lead to the inclusion of individuals with mild symptoms, leading to over-treatment. The variability in cutoff points complicates the determination of treatment eligibility, potentially affecting the efficacy and efficiency of ADHD management strategies. Until, there is no comprehensive overview of validated studies including a quantitative meta-analysis (Taylor et al., 2011). Therefore, the aim of the study was to evaluate screening tools for ADHD in adults, considering sensitivity, specificity and feasibility for primary care.

Conclusion

Our findings show that screening tools as the ASRS-6 (DSM-V), the WURS-25, the CAARS-s:sV and the TRAQ10 are suitable instruments for screening of ADHD in adults in primary care due to their high validity and perceived feasibility in this setting. The best evidence exists for the ASRS-6, which was included in our meta-analysis. For more evidence concerning feasibility of the WURS-25 as well as the CAARS-s:sV, which also were part of the meta-analysis, feasibility studies are required. Regarding other tests like the TRAQ10 with equivalent promising results but insufficient options of comparison there is a need of further validation studies to create more evidence in that part. The determination of cut-offs is of great importance since it affects the ability of a screening tool distinguishing between real and false positives respectively negatives. Further research is required to identify the optimal cut-off of the different tests for a general population sample as we find it in primary care. Hence, the identification of ADHD in adults by general physicians would be improved without leading to increased misdiagnoses.

Abstract

Background. Psychological distress is a progressive health problem that has been linked to decreased quality of life among university students. This meta-analysis reviews existing randomized controlled trials (RCTs) that have examined the effects of mindfulness-based stress reduction (MBSR) on the relief of psychosomatic stress-related outcomes and quality of life among university students. Methods. The PubMed, EMBASE, Web of Science, PsycINFO (formerly PsychLit), Ovid MEDLINE, ERIC, Scopus, Google Scholar, ProQuest, and Cochrane Library databases were searched in November 2023 to identify the RCTs for analysis. Data on pathology (anxiety, depression, and perceived stress), physical capacity (sleep quality and physical health), and well-being (mindfulness, self-kindness, social function, and subjective well-being) were analyzed. Results. Of the 276 articles retrieved, 29 met the inclusion criteria. Compared with control therapies, the pooled results suggested that MBSR had significant effects, reducing anxiety (SMD = −0.29; 95% CI: −0.49 to −0.09), depression (SMD = −0.32; 95% CI: −0.62 to −0.02), and perceived stress (SMD = −0.41; 95% CI: −0.60 to −0.29) and improving mindfulness (SMD = 0.34; 95% CI: 0.08 to 0.59), self-kindness (SMD = 0.57; 95% CI: 0.30 to 1.12), and physical health (SMD = −0.59; 95% CI: −1.14 to −0.04). No significant differences were observed in sleep quality (SMD = −0.20; 95% CI: −0.06 to 0.20), social function (SMD = −0.71; 95% CI: −2.40 to 0.97), or subjective well-being (SMD = 0.07; 95% CI: −0.18 to 0.32). The quality of the evidence regarding sleep quality and physical health outcomes was low. Conclusions. MBSR therapy appears to be potentially useful in relieving functional emotional disorders. However, additional evidence-based large-sample trials are required to definitively determine the forms of mindfulness-based therapy that may be effective in this context and ensure that the benefits obtained are ongoing. Future studies should investigate more personalized approaches involving interventions that are tailored to various barriers and students’ clinical characteristics. To optimize the effects of such interventions, they should be developed and evaluated using various designs such as the multiphase optimization strategy, which allows for the identification and tailoring of the most valuable intervention components.

Introduction

Mindfulness therapy is a standardized psychological intervention that aims to reduce stress, encourage mindful thinking habits, and allow recipients to manage difficult emotional processing. It focuses on the concentration of one’s attention in the moment, nonsubjective judgment, and openness to accepting personal experience and involves corresponding behavioral training, such as attention training, body scanning, and sitting meditation [1]. Previous research on psychological interventions has found that mindfulness therapy can help reduce stress among university students and affects their overall quality of life and the psychological functions to which they adapt [2].

The theoretical support and the understanding of the operating mode are reasonable but still have differences. Thus, the mental health benefits, potential effects, and limitations of mindfulness therapy for university students warrant further examination. Although education and social support can be effective in preventing and treating the underlying psychological problems among university students with poor mental health, such interventions do not always affect or improve psychological well-being [3, 4].

The most prevalent psychological symptoms among university students are anxiety, mental stress, and emotional distress, which can result in decreased functioning in the context of academic and interpersonal stress. Global mental health surveys conducted by the World Health Organization (WHO) indicate that mental disorders are highly prevalent among university students, with 12-month prevalence rates ranging from 20.3% to 45% of university students over the age of 18 [5–7]. The prevalence rates of insomnia, depressive symptoms, and anxiety symptoms were 37.80%, 48.20%, and 36.70%, respectively, among Chinese university students during the COVID-19 pandemic [8]. In a randomized controlled trial with 11,169 university students conducted by the WHO, students had increasing intentions to use mental health services: The results indicated lifetime use rates of 12.6% and 7.3% for psychotherapy and medication for emotional problems, respectively. Suicidal thoughts and behaviors and nonsuicidal self-injury within the preceding 12 months were also common, with 21.1% of students in the sample reporting suicidal ideation, 10.6% reporting suicide plans, 0.4% reporting suicide attempts, and 6.8% reporting nonsuicidal self-injury [5]. Furthermore, one previous study found that high-compliance mental health services had a significant effect on students’ intention to seek mental health services in the next semester [9–11].

Results

3.1. Description of Studies
A total of 276 studies items were initially obtained through the database search. Using NoteExpress, 193 deduplicated studies were obtained, and the remaining 220 items were obtained. After reviewing their titles and abstracts, 135 studies that were of incompatible research types were excluded. A total of 13 articles were further excluded after reading the full text, and the remaining 29 studies [24–53] were retained for data extraction. The baselines of the trials were comparable. The literature search process and results are shown in Figure 1.

Abstract

Background
Progress has been achieved in many fields in understanding the biological mechanisms of depression, including genome-wide association analysis, neurotransmitter system function, brain regions and neural networks, inflammatory response, neuroplasticity, neuroimaging, and neuro electrophysiology. These progresses provide a reliable basis for developing the medical and physical therapies for depression. However, the current treatments developed from biological mechanisms can only address less than 60% of depressive symptoms and have limited efficacy in improving social functioning and reducing recurrence. Studies have explored the non-biological mechanisms of depression in mental fields. These progresses are helpful to develop more interventions that could alleviate depressive symptoms, improve functional impairments, and reduce recurrence, thereby promoting a more comprehensive recovery in depressed patients. However, there is not a systematic and deep review to highlight the non-biological mechanisms of depression.

Methods
This study summarizes the recent progress in the non-biological fields of depression by searching publications on human studies in PubMed, PMC, and Google Schooler with exclusion of animal studies.

Results
This study reviews the intergenerational transmission characteristics, the relationship between depression and emotional trauma, cognitive deficit, relationship impairment, self-function, sense of the meaning of life, motivation deficit, and psycho-rationality of depression.

Conclusions
This study was clarified the non-biological mechanisms and characteristics of depression and provided a theoretical basis for the development of non-drug interventions.

Introduction

To date, studies on the pathogenesis of depression are mainly focus on its biological mechanisms (Miao & Chang, 2021), including studies on epigenetic alterations, genome-wide association, neurotransmitter system, brain regions and neural networks, inflammatory responses, neuroplasticity, neuroimaging, and neuro electrophysiological changes (Li et al., 2021). The outstanding contributions of these studies provide a theoretical basis for pharmacotherapy and physical therapy of depression (Li et al., 2019). However, the current treatments developed from biological mechanisms can only relieve 58% of depressive symptoms (Ormel et al., 2019). Moreover, these current pharmacotherapy and physical therapy have limited efficacy in improving prognosis and social function, as well as reducing relapse rates (Cieślik et al., 2020). The cognitive behavioral therapy has been shown to be highly effective in treating depression but has limited impact on generational deficits and trauma-related emotional responses in the symptomatic components of depressive symptoms (Johnsen, T. J., & Friborg, O. 2015). The eye movement desensitization and reprocessing therapy has shown some positive outcomes in helping individuals to reprocess traumatic memories of some emotional traumas, but it is not appropriate for traumatized populations of all backgrounds and can exacerbate symptoms in some populations. Therefore, its limitations and side effects need to be considered (Shapiro, F. 2014). Thus, exploration of new mechanisms and subsequent development of new treatments is an urgent need for patients with depression.

Results

3.1. Non-biological transgenerational transmission of depression
Intergenerational transmission of pathological psychology refers to the phenomenon that psychological disorders or problems presented in the previous generation can reappear in the next generation, or that the behavior or psychological trauma of the previous generation causes mental and psychological problems in the next generation. These problems may span generations and manifest in different ways and degrees (Cooke et al., 2019). In recent years, evidence on the intergenerational transmission of depression has been accumulated. In the biomedical field, family and twin studies have repeatedly validated that the intergenerational transmission of depression is often a result of gene-mediated genetic disorders or epigenetic inheritance (Goodman, 2020, Park et al., 2019). However, the non-biological transgenerational mechanisms of depression have also attracted attention recently (Gotlib et al., 2020).

More and more non-biological transmissions have been observed, while the intergenerational phenomenon of depression and its transmission ways have different explanations (Hentges et al., 2021). For example, parental depression may be transmitted to the next generation through multiple pathways: intergenerational transmission of trauma (Hankerson et al., 2022); intergenerational damage to emotions, self-esteem, and cognition; family culture; parenting style; and behavioral consequences etc. (Kang et al., 2021, Risi et al., 2021, Kujawa et al., 2020, Johnco et al., 2021). These transgenerational mechanisms may indirectly influence the biological changes that evolve into the symptoms of depression (Allison et al., 2023). In the intergenerational transmission of depression, offspring may not inherit the symptoms of depression, but instead display a variety of psychological dysfunctions a variety of psychological dysfunctions, including a tendency to react negatively to emotions (Israel & Gibb, 2024), a state of self-esteem hypersensitivity, cognitive biases, and excessive self-focus (Woody et al., 2022). In addition, offspring may also display relationships with alienation, control, and unclear boundaries (Wei et al., 2023), and even the characteristics of illness that appear in early adulthood or suicidal tendencies (Gijzen et al., 2021).

Abstract

Language impairments often appear in patients with schizophrenia and are potential targets for rehabilitation. Clinical practice and research should be intimately connected. The aim was to perform a narrative review of the assessment and intervention tools that have been used for the rehabilitation of schizophrenia patients with language and communication impairments. Two types of tools, general and specific, were developed for both purposes. General tools include the Positive and Negative Syndrome Scale for assessment, and the Integrated Psychological Therapy for intervention. The specific tools used to evaluate language and communication impairments include the Scale for the Assessment of Thought, Language and Communication, the Formal Thought Disorder scales (for caregivers and patients), and the Thought and Language Disorder scale. The most recent language-specific intervention tools include the Cognitive Pragmatic Treatment, Conecta-2, Let’s talk! Multimodal Speech-Gesture training, Speech Therapy Intervention Group, and PragmaCom. These tools primarily involve psychopathology/psychiatry, psychology, linguistics, speech and language therapy, and nursing. In conclusion, a wide range of assessment and intervention tools are available for the rehabilitation of language and communication impairments associated with schizophrenia. An integrative and interdisciplinary approach should always be considered for rehabilitation of language and communication in patients with schizophrenia throughout their lifetime.

Introduction

Language is a basic skill in humans that facilitates communication with their environment, mainly with other humans. Communication has also been recognized by the International Communication Project as a human right which is embedded within Article 19 of the Universal Declaration of Human Rights [1]. This project highlights the importance of human communication and the significant impact of communication disabilities on every aspect of life, including positive social relationships, literacy, and employment, and the need to enable those with communication disability to fully access and participate in society [2].

1.1. Heterogeneity of language and communication impairments in schizophreniaAccording to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [3], a key feature of the schizophrenia spectrum as well as of other psychotic disorders is disorganized speech. However, the term ‘disorganized speech’ remains ambiguous and is often used as a replacement of the formerly used term ‘formal thought disorder’ (FTD), clinically considered as ‘impairments in the production of language and subjective alterations in the thought process’ [4]. In fact, the term FTD was replaced by ‘disorganized speech’ as the latter can be object to direct observation and assessment, whereas the former can only be deduced from other deviations in overt behaviour.

Conclusions

We conclude that: i) there is currently a wide range of assessment and intervention tools that cover various language and communication impairments in schizophrenia; ii) the rehabilitation of language and communication requires an integrative and interdisciplinary approach, and should always be considered in patients with schizophrenia throughout their lifetime; and iii) further research on the assessment and intervention tools for the rehabilitation of language and communication in patients with schizophrenia is needed.

Abstract

Bipolar disorder (BD) is worldwide a prevalent mental illness and a leading risk factor for suicide. Over the past three decades, it has been discovered that sex differences exist throughout the entire panorama of BD, but the etiologic regions and mechanisms that generate such differences remain poorly characterized. Available evidence indicates that the dorsolateral prefrontal cortex (DLPFC), a critical region that controls higher-order cognitive processing and mood, exhibits biological disparities between male and female patients with psychiatric disorders, which are highly correlated with the co-occurrence of psychotic symptoms. This review addresses the sex differences in BD concerning epidemiology, cognitive impairments, clinical manifestations, neuroimaging, and laboratory abnormalities. It also provides strong evidence linking DLPFC to the etiopathogenesis of these sex differences. We emphasize the importance of identifying gene signatures using human brain transcriptomics, which can depict sexually different variations, explain sex-biased symptomatic features, and provide novel targets for sex-specific therapeutics.

Introduction

Bipolar disorder (BD) is a severe mood disorder that is categorized by extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). According to the intensity of mood elevation, two major forms of BD are distinguished: bipolar I disorder (with mania) and bipolar II disorder (with hypomania). In 2019, more than 40 million people experienced BD worldwide (Kakhramonovich, 2022). Approximately half to 70% of BD patients develop psychotic features during their lifetime (Van Bergen et al., 2019). A history of psychotic features has been associated with earlier onset of BD, more frequent hospitalizations, severer cognitive impairments, lower response to lithium, and worse psychosocial prognosis, particularly for manic episodes (Van Bergen et al., 2019, Maj, 2003, Glahn et al., 2007, Maj et al., 2002). As a major hazard of psychiatric illnesses, life expectancy in patients with BD has been reported to be decreased by 10–20 years, with suicide serving as the primary culprit (Kessing et al., 2015). Suicidal behaviors are prevalent among patients with BD, as 20–60% of them attempt suicide at least once in their lifetime (Dome et al., 2019). The incidence of suicide death among patients with BD can be more than 20 times higher than in the general population, particularly when untreated (Grande et al., 2016). In addition, the lethal index, a parameter defined as the ratio of suicidal attempts to suicide completion, is more than 10 times lower for BD patients (3:1) than for the general population (35:1) (Dome et al., 2019).

A distinct feature that underpins the high suicidality in BD is its sex difference. Among bipolar patients, suicide attempters were 35% more frequent in females than in males, regardless of the diagnostic subtypes (Tondo et al., 2016). When patients had manic episodes, females were 2.4 times more likely to die by suicide than males (Bhattacharya et al., 2011). This sex-related suicide rate was up to 3 times higher in female patients with a first-episode psychosis than in male counterparts, but suicidality can be better remitted by therapeutic interventions in female than in males (Chang et al., 2011, Tseliou et al., 2017). These data suggest that the manic episodes and psychotic features are major risk factors for suicide. The higher prevalence of suicide rate in females with BD, and the observation that suicidality increased with the development of psychotic symptoms and was reduced after medical care, have led to the idea that unraveling the neurobiological basis of sex differences in BD, particularly in patients with comorbid psychosis (bipolar psychosis), may provide novel therapeutic targets for extending the lifespan of BD populations.

Conclusions

Due to the asymmetry in research intensity between the clinical and biological literature that has controlled for sex, at present, we could merely provide our speculative explanation for the origin of sex disparities in clinical symptoms and cognitive impairments in BD. While there are highly promising preliminary findings, research on the pathophysiology of BD has yet to fully analyze the confounding factors, particularly psychotic features, and suicide in relation to sex. Transcriptomic approaches to study the neurobiology of BD in both sexes have been discussed. These techniques place a strong emphasis on discovering the key cells and molecules across psychiatric diagnoses as well as comorbidities based on diverse clusters of symptoms.

Despite the fact that the effect of female sex hormones and neurosteroids on BD is beginning to be understood, studies should evaluate treatments in terms of female hormonal fluctuations, such as entering puberty, menstrual cycle stage, menopausal stage, or use of hormonal contraception. There should be clinical and laboratorial consensus that, in BD research at multi-dimensional levels, data are analyzed including sex as a confounder.

Abstract

Schizophrenia (SCZ) and obsessive–compulsive disorder (OCD) typically have distinct diagnostic criteria and treatment approaches. SCZ is characterized by delusions, hallucinations, disorganized speech, and cognitive impairments, while OCD involves persistent, intrusive thoughts (obsessions) and repetitive behaviors (compulsions). The co-occurrence of these disorders increases clinical complexity and poses significant challenges for diagnosis and treatment. Epidemiological studies indicate a significant overlap, with prevalence rates of comorbid OCD in SCZ patients ranging from 12% to 25%, which is higher than in the general population. Etiological hypotheses suggest shared genetic, neurobiological, and environmental factors, with genetic studies identifying common loci and pathways, such as glutamatergic and dopaminergic systems. Neuroimaging studies reveal both overlapping and distinct neural abnormalities, indicating shared and unique neurobiological substrates. Environmental factors, like early life stressors and urbanicity, also contribute to the comorbidity. The overlapping clinical features of both disorders complicate diagnosis. Treatment approaches include combining SSRIs with antipsychotics and cognitive behavioral therapy (CBT). The complexity of SCZ and OCD comorbidity underscores the need for a dimensional, spectrum-based perspective on psychiatric disorders, alongside traditional categorical approaches, to improve diagnosis and treatment outcomes.

Introduction

Schizophrenia (SCZ) and obsessive–compulsive disorder (OCD) are both debilitating psychiatric conditions, each with distinct diagnostic criteria and treatment approaches. SCZ, as defined in the DSM-5 [1], is a chronic mental disorder characterized by a range of symptoms, including delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and cognitive impairments [2,3]. These symptoms must be present for a significant portion of time during a one-month period, with continuous signs of disturbance persisting for at least six months, significantly impacting various areas of functioning, such as work, interpersonal relations, and self-care [1]. SCZ’s influence on everyday life can be profound, often leading to significant disabilities and incomplete recovery for many individuals [4]. Those with relatively positive outcomes still contend with social isolation, the stigma associated with the disorder, and fewer opportunities to build close relationships. Unemployment rates are exceptionally high among those with SCZ [5,6]. Common issues, such as unhealthy diet, weight gain, smoking, and substance abuse, contribute to a decreased life expectancy, shortening it by about 13 to 15 years [5,6]. Moreover, the risk of suicide over a lifetime for individuals with SCZ is estimated to be between 5% and 10% [7].

OCD, on the other hand, involves persistent, intrusive thoughts (obsessions) and repetitive behaviors (compulsions) aimed at reducing the anxiety generated by these thoughts [8,9]. Obsessions are defined as recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, causing marked anxiety or distress. Compulsions are defined as repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rigid rules and as being time-consuming or causing significant distress or impairment in important areas of functioning [1]. OCD profoundly affects daily life, causing significant distress and impairment. Individuals with OCD often devote excessive time to their obsessions and compulsions, disrupting work, education, and personal relationships [10]. The disorder severely limits social and occupational functioning, with studies indicating that up to 60% of those with OCD experience moderate to severe daily impairment [10,11]. The quality of life for these individuals is considerably lower than that of the general population, with high comorbidity rates for depression and anxiety [9,10]. Regarding mortality, OCD is linked to a heightened risk of suicide; the lifetime prevalence of suicidal thoughts among individuals with OCD ranges from 36% to 63%, and the risk of suicide attempts is between 10% and 27% [12].

Discussion

The literature shows various overlapping factors between SCZ and OCD. Both disorders are fundamental pathological entities in psychiatry, due to their prevalence and the burden they impose [11,15,16,17,18]. They share a complex etiological and pathophysiological component, comprising genetic, environmental, and neurostructural elements [23,38,54,82]. Our review highlights how some of these elements demonstrate the following commonalities: shared genetic factors, environmental circumstances that may underlie both disorders, and shared neurostructural alterations. It is important, therefore, to consider studies that demonstrate common etiological and clinical characteristics. For example, a recent study using integrated bioinformatic analysis has highlighted shared genetic and molecular mechanisms between SCZ and OCD [119].

Due to the shared features and differing elements between the two disorders, treatment remains challenging. The pharmacological profiles of treatments for SCZ and OCD differ significantly, with SGAs potentially inducing obsessive symptoms by antagonizing the 5HT2A receptor [90]. Hence, further studies are necessary to determine the best treatment for OCSs in patients with schizophrenia. Preliminary recommendations include combining an antipsychotic with an SSRI, such as escitalopram [95].

Summary

The public health approach to suicide prevention requires us to move away from thinking about suicide as a purely clinical problem and to pay heed to the array of social determinants (such as financial hardship or domestic violence and abuse) that might lead people to consider suicide as an option. Clinical factors are important, and, indeed, clinical or indicated interventions are entirely appropriate for people who have reached a point of crisis and should be a mainstay of national suicide prevention strategies. However, our Series stresses the need for selective and universal interventions that tackle the pervasive problem of suicide in a more upstream way, preventing people reaching a crisis point. Many social determinants can best be addressed by sectors outside health, so we are calling for a whole-of-government commitment to suicide prevention. We make recommendations for actions in the areas of policy, practice, research, and advocacy. People with lived experience of suicide should have genuine involvement in all of these actions.

Introduction

The Comprehensive Mental Health Action Plan, initially released by WHO in 2013 and updated in 2021, sets a target of a 30% reduction in the suicide rate internationally by 2030.1 Figure 1 indicates how the annual figures are tracking against that target.2 In 2013, the age-adjusted global suicide rate was 10·0 per 100 000 population, and by 2019, the year for which the most recent international data are available, the figure was 9·0 per 100 000 (a 10% decrease), which seems promising. However, the trend line suggests that the reduction might be levelling off. In addition, the aggregate figures mask between-country and between-region inequalities. Low-income and-middle-income countries (LMICs), which account for 77% of the world’s suicides,3 have not fared as well as high-income countries (HICs) in reducing suicide, with factors such as access to means,4 poverty,5 alcohol use,6 and domestic violence and abuse7 being implicated. Suicide rates have also varied over time according to region, with a notable outlier being the Americas. The suicide rate in that region has not reduced, potentially due—at least in part—to a failure to address gun ownership in the USA.8 In this Series, we have argued that the only way we will make substantial inroads into the major problem of suicide is by reorienting suicide prevention activities through a public health approach.

Conclusion

Widespread adoption of a public health approach to suicide prevention is crucial for ensuring that the overall decreases in suicide rates that are being seen globally continue on a downward trajectory and occur across countries and regions. Suicide is a societal issue that requires a societal response; preventing suicide is everybody’s business. Garnering cross-sectoral commitment from all levels of government and meaningfully involving all stakeholders at every step on the journey will be transformative.

Abstract

Schizophrenia, influenced by genetic and environmental factors, may involve epigenetic alterations, notably histone modifications, in its pathogenesis. This review summarizes various histone modifications including acetylation, methylation, phosphorylation, ubiquitination, serotonylation, lactylation, palmitoylation, and dopaminylation, and their implications in schizophrenia. Current research predominantly focuses on histone acetylation and methylation, though other modifications also play significant roles. These modifications are crucial in regulating transcription through chromatin remodeling, which is vital for understanding schizophrenia’s development. For instance, histone acetylation enhances transcriptional efficiency by loosening chromatin, while increased histone methyltransferase activity on H3K9 and altered histone phosphorylation, which reduces DNA affinity and destabilizes chromatin structure, are significant markers of schizophrenia.

Schizophrenia

Schizophrenia is a complex, heterogeneous psychiatric disorder influenced by both genetic and environmental factors, with a lifetime prevalence of approximately 1 % in the general population [1] . This condition manifests through a spectrum of symptoms: (i) positive symptoms such as delusions, hallucinations, paranoia, thought disorders, and psychomotor agitation; (ii) negative symptoms including emotional blunting, social withdrawal, and deficits in motivation and reward processing; (iii) cognitive impairment affecting learning, attention, executive function, and memory, particularly working memory [2] , [3] . Mood disturbances such as depression and anxiety are also common among patients.

The pathogenesis of schizophrenia is currently explained by several theories, the most notable being the dopaminergic hypothesis. This hypothesis proposes that positive symptoms arise from dysregulated dopaminergic neurotransmission in the limbic system of the midbrain, while disruptions in cortical pathways contribute to negative symptoms [4] . The glutamatergic hypothesis posits that changes in NMDA receptor-mediated glutamatergic transmission affect prefrontal neuronal connectivity [5] , and the serotonergic hypothesis attributes disturbances in neuronal activity to serotonin overload from the dorsal raphe nucleus serotonergic hypothesis suggests that stress causes overload of serotonin from the dorsal raphe nucleus [6] . The GABAergic hypothesis suggests that an imbalance between cortical excitation and inhibition, driven by disruptions in GABAergic neurotransmission, underlies the disorder [7] . Additionally, nicotinic receptors play a role in cholinergic transmission; studies have shown that nicotine can improve attention and memory performance in schizophrenic patients [8] . Cognitive dysfunction, a core feature observed in over 80 % of individuals with schizophrenics, involves multiple brain regions, including the dorsolateral and medial prefrontal cortices and the parietal regions [9] , [10] , [11] . Structural abnormalities in the medial temporal lobe, particularly the hippocampus, have been linked to memory deficits and play a significant role in the neural networks responsible for memory and spatial navigation [12] , [13] , [14] , [15] , [16] .

Abstract
Objectives
Postpartum depression estimated prevalence in women is between 5 and 26% and it has adverse effects both on the mother, infant and her partner. Psychological treatments have proved to be effective for women with mild-to-moderate symptoms. Whereas several systematic reviews have assessed the effects of different psychological interventions for postpartum depression, such as cognitive-behavioural therapy or interpersonal therapy, no review assessing psychodynamic therapy has been carried out. A systematic review was conducted to evaluate the efficacy of psychodynamic therapy for postpartum depression.

Methods
Studies were identified using the following databases: PsycINFO, Psycarticles and Pubmed over January 2023. The requirements for the studies were the following: they had to be quantitative, available in English, including a psychodynamic intervention targeting treatment or prevention of postpartum depression which starts during pregnancy or within the first 12 months after giving birth. Case studies, qualitative studies or studies focused on improving parent-infant relationship or infant outcome were excluded from this research.

Results
Seven trials including 521 women met the inclusion criteria. In summary, three randomized controlled trials and four longitudinal studies were found. The most frequently used assessment tool was EPDS, five were individual interventions and the other two were group interventions.

Discussion
All studies reported the efficacy of psychodynamic interventions for postpartum depression, both in home and clinical settings and both in group and individual format. The limited number of trials, small sample sizes and lack of appropriate control groups were the main limitations.

Conclusions for practice
Psychodynamic therapy is probably efficient intervention for postpartum depression. Future research with strong methodological designs is needed to confirm these findings.

Significance
What is already known on this subject? Several systematic reviews have assessed the effects of different psychological interventions for postpartum depression, but no review assessing psychodynamic therapy has been carried out. What this study adds? A systematic review was conducted to evaluate the efficacy of psychodynamic therapy for postpartumdepression. This makes the systematic review a unique contribution to the literature.

Introduction

Historically parent’s mental health during the perinatal period has been overlooked, as it was conceived as a time of joy and emotional stability. Only in 1950’s some authors started to write about maternity blues, postpartum depression, and puerperal psychosis (Besser et al., 2008). Studies have generally targeted mothers and their psychological wellbeing. On the contrary, paternal mental health remains under-investigated even though non-gestational parents may also suffer from mental disorders in the peripartum period.

     Postpartum depression encompasses a depression disorder occurring within the 12 months following childbirth (Branquinho et al., 2021) and the disorder can be compared to a major depressive episode in any moment of a woman’s life. However, symptoms such as anxiety, anhedonia, aggressive obsessional thoughts, restlessness or concentration and decision-making difficulties are more frequent or severe in the immediate postpartum (Batt et al., 2020). Postpartum depression has adverse effects on the woman and, therefore, on the infant as the disorder is closely related to difficulty to carry out different parenting tasks, such as breastfeeding, sleeping, or responding to the infant’s needs (Branquinho et al., 2021; Nanzer et al., 2012). It is also the strongest predictor of paternal depression during the perinatal period (Kaźmierczak et al., 2020). In addition, it is one of the main causes of maternal deaths in the first year after childbirth as the mother may develop suicidal thoughts and intentions. (Al-Halabí et al., 2021). The estimated prevalence of postpartum depression in women varies across countries, assessment criteria or time frame ranging from 5 to 26% (Liu et al., 2022).

Conclusions

     Psychodynamic approach still plays a minor role in the mainstream theory, research, and treatment for postpartum depression, even though the amount of data has kept growing for the last decade. BDP is probably efficient intervention for postpartum depression. Therefore, it is suggested that research should be continued to assess the effectiveness of psychodynamic interventions in postpartum depression compared to other effective treatments.

Abstract

Considerable work has advanced understanding of the nature, causes, management, and prevention of anxiety disorders in children and adolescents over the past 30 years. Prior to this time the primary focus was on school refusal and specific phobias. It is now recognised that children and adolescents experience the full gamut of anxiety disorders in very similar ways to adults and that anxiety disorders in the paediatric years can predict a lifelong mental-health struggle. Given the vast array of specific studies in this field, the current review summarises current knowledge about these high prevalence disorders, points to overarching limitations, and suggests potentially important future directions. Following a brief historical overview, the review summarises knowledge about demographic and epidemiological characteristics, distal and proximal risk factors, current treatment directions, and prevention. There is still a great deal to learn about the causes and treatments of child and adolescent anxiety disorders. By amalgamating our current knowledge, this review provides a window to the research directions that are likely to lead to future advances.

Introduction and historical overview

Like much research in applied psychology, the history of treating anxiety in young people1 can be traced back over a century. For the most part, the history of evaluating treatment for anxiety disorders in young people can be described as rigorous, highly informative, and an exemplar of incremental science. In short, much has been learned (Higa-McMillan et al, 2015; Southam-Gerow & Prinstein, 2014) and reasonable confidence can be ascribed to the findings, given the overall methodological quality of the work.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) exemplifies such progress, and across the several editions and even within versions of the DSM, the labels for the anxiety disorders in young people have evolved. For example, overanxious disorder was described in the third edition of the DSM reflecting excessive worry, concerns about personal competence, need for reassurance, and self-consciousness. This specific disorder was later eliminated partly due to its overlap with social phobia. Thus, most young people who would have met criteria for this diagnosis would now be diagnosed with the more clearly delineated generalised anxiety disorder, reflecting persistent and excessive worry, with excessive concern about routine matters and difficulty managing worry. Social phobia has been renamed social anxiety disorder, the persistent fear of social/performance situations involving potential scrutiny by others. In contrast, the label separation anxiety disorder, referring to young people who have an unusual-for-their-level-of-development severity of intense anxiety tied to separating from a caregiver, has remained over time. The more recent iterations of DSM, to its credit, provide detailed diagnostic criteria that are useful, though not without limitations, for making differential diagnoses. For example, selective mutism has appropriately now been moved into the anxiety disorders (American Psychiatric Association, 2013) from its previous placement among a broad range of disorders first evident in childhood. However, strong overlap with social anxiety disorder (Milic, Carl, & Rapee, 2020), raises serious questions about whether these disorders really require separate diagnostic labels. On the other hand, obsessive compulsive disorder has been moved out of the group of anxiety disorders with the publication of the DSM-5. However, the marked overlap between obsessive compulsive disorder and anxiety disorders (Stein et al., 2010), its similar response to treatment (Hudson, Rapee, et al., 2015), and its historical conceptualisation as an anxiety disorder, raise questions about this decision. Similar concerns exist for post-traumatic stress disorder, which was also moved outside of the anxiety disorder category in DSM-5.

Conclusion

Scientific research into paediatric anxiety disorders has increased dramatically over the past 30 years. As a result, we now have far greater knowledge about key characteristics, risk and maintaining factors, treatments, and prevention of these highly prevalent disorders. Nonetheless, the field has a long way to go. As an example, although we now have very well-established programs for the treatment of anxiety disorders in young people, less than half are free of all anxiety disorders immediately following treatment (James et al., 2020). This proportion typically increases over the following months (Hudson et al., 2009; Rapee, Abbott, Baillie, & Gaston, 2007), but the fact remains that a significant proportion of young people with anxiety disorders continue to meet criteria for their disorder even following our current best efforts at treatment. This, combined with the very low proportion of anxious young people in the community who receives empirically-validated treatment (Gandhi et al., 2022; Reardon et al., 2020) makes paediatric anxiety disorders a serious risk for long-term disability (King et al., 2020; Swan et al., 2018). By summarising the current state of the literature into paediatric anxiety disorders, we have highlighted key gaps in our knowledge and potentially important directions for future research. Among the many remaining important issues, a few in particular, stand out.

Abstract

Background

     While Cognitive Behavioral Therapy (CBT) is recommended as first-line treatment for depression, a significant minority do not show an adequate treatment response. Despite evidence for the efficacy of Mindfulness-Based Therapies (MBT) both in treating current depression and preventing relapse, it remains unknown whether MBT and CBT are equivalent in the treatment of current depression.

Methods

     Five databases were searched for randomized controlled trials (RCTs) directly comparing MBT with CBT and including depression as primary or secondary outcome.

Results

     When pooling the results of 30 independent RCTs with a total of 2750 participants, MBT and CBT were statistically significantly equivalent at both post-intervention (Hedges’s g = −0.009; p < .001) and follow-up (g = −0.033; p = .001). Supplementary Bayesian analyses provided further support for the alternative hypothesis of no difference between MBT and CBT. When exploring possible sources of heterogeneity, the differences at follow-up were smaller between CBT and mindfulness-based cognitive therapy (MBCT) than between CBT and mindfulness-based stress-reduction (MBSR) (Slope = 0.37;p = .022).

Conclusion

     The currently available evidence suggests that that MBT and CBT are equally efficacious in treating current adult depression. It remains unclear whether the similar effects of the two intervention types are due to different mechanisms or common factors.

Introduction

     Depression is one of the most common mental disorders worldwide, and it is estimated that around 280 million people suffer from depression at any time (World Health Organization, 2021). Depression affects not only the depressed individual and his or her immediate family but also has consequences for society at large (Lépine & Briley, 2011). Due to impaired functioning and early mortality, depression is an economic burden in terms of reduced or lost work and increased use of health care services (Lépine & Briley, 2011; P. S. Wang, Simon, & Kessler, 2003). The World_Health_Organization (2021) considers depression to be a substantial contributor to global disability, confirming the severe negative impact of depression.

     Cognitive-behavioral therapy (CBT) has proven efficacious in the treatment of depression (e.g., Butler, Chapman, Forman, & Beck, 2006; Cuijpers et al., 2013) and is recommended as a first-line psychological treatment for depression (American Psychological Association, 2019; The_National_Institute_for_Health_and_Care_Excellence, 2009). However, many patients relapse or continue to show residual symptoms (Paykel, 2007; Thase et al., 1992; Vittengl, Clark, Dunn, & Jarrett, 2007) or continue to experience residual symptoms (Taylor, Walters, Vittengl, Krebaum, & Jarrett, 2010). During the last two decades, mindfulness-based therapies (MBT) have received increased attention as possible interventions for depression, and the results of several meta-analyses provide support for the efficacy of MBT in treating current adult depression, e.g. (Goldberg et al., 2018; Khoury et al., 2013; Y.-Y. Wang et al., 2018). Mindfulness has been defined as \the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment” (J. Kabat-Zinn, 2003). The two most investigated MBTs are mindfulness-based stress reduction (MBSR) (Kabat-Zinn, 1990) and mindfulness-based cognitive therapy (MBCT) (Segal, Williams, & Teasdale, 2012). Both teach mindfulness meditation techniques to help individuals become aware of their thoughts, feelings, and bodily sensations in the present moment and to subsequently help them change how they relate to these experiences. The MBSR program was developed for people with chronic illnesses and stress-related disorders, and is an eight-week course consisting of eight weekly 2.5-h group sessions and a silent retreat day, with focus on systematic training in mindfulness (Kabat-Zinn, 1990). In addition, the participants engage in home practice between sessions, including both formal (e.g., body scan) and informal practice (e.g., mindful awareness to everyday activities).

Conclusion

     Taken together, the present study fills a gap in the literature by systematically reviewing RCTs that have directly compared the efficacy of MBT and CBT for adult depression and by conducting a meta-analysis of equivalence showing not only that MBT and CBT did not differ in their effects but also that they were statistically significantly equivalent. While the results of the available studies do not allow a conclusion that the effects of the two therapies stem from common factors, the equivalent efficacy of MBT and CBT in treating depression opens up for increased flexibility in the choice of treatment.

Role of funding sources

     TrygFonden (Denmark), grant number: 7-12.0736, funded EN. The remaining authors did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors for this research.

Abstract

     Several lines of research suggest that reproductive-related hormonal events may affect the course of bipolar disorder in some women. However, data on associations between bipolar disorder and menarche, menstrual cycle, and menopause are mixed. This article reviews the literature on the potential effects of menarche, menstrual cycle, and menopause on bipolar disorder.

     A narrative review of published articles on bipolar disorder and menstrual cycle events was conducted. The primary outcome assessed was the impact of menarche, menstrual cycle and menopause on the course of bipolar illness. Databases searched were PubMed, Ovid, Scopus, PsycINFO, Medline, and Cochrane Libraries from inception to August 2021.

     Twenty-two studies were identified and included in the narrative synthesis. Research suggested that a subset of women with bipolar disorder are vulnerable to the impact of menstrual cycle events. Menarche seems to be associated with age at onset of bipolar illness especially in case of bipolar disorder type I and the specific age at menarche may predict some clinical features of the disorder. Menstrual cycle likely affects the course of bipolar disorder but the pattern of mood variability is not clear. Menopause appears to be not only a period of vulnerability to mood alteration, especially depressive episodes, and impairment of quality of life, but also a potential trigger of bipolar illness onset.

     The impact of menarche, menstrual cycle, and menopause on bipolar disorder is largely understudied. Preliminary evidence suggests that a subset of women with bipolar disorder may have their mood shifts affected by menstrual cycle events, with different patterns depending on the type of bipolar disorder also. Further researches are needed to deep the impact of menarche, menstrual cycle, and menopause on bipolar illness.

Introduction

     Bipolar disorder is a lifelong episodic illness characterized by fuctuations in mood state and energy (Grande et al. 2016). The course of bipolar disorder is associated with both inter-individual variation and heterogeneity between patients and can lead to functional, occupational, and cognitive impairments (Miller and Black 2020). Thus, over a lifetime any one patient may experience many forms of the disorder including depressive and manic or hypomanic episodes, mixed emotional states, and psychosis (Vieta et al. 2011). Bipolar disorders are classifed according to the longitudinal course: bipolar I disorder requires the occurrence of at least one fully syndromal lifetime manic episode, although depressive episodes are common; bipolar II disorder requires the occurrence of at least one hypomanic episode and one major depressive episode (American Psychiatric Association, 2013). The prevalence of bipolar illness is consistent across diverse cultures and ethnic groups, with an aggregate lifetime prevalence of 2.4% (Carvalho et al. 2020). Although bipolar disorder has an equal rate among men and women, some gender-related diferences have been found in the clinical features of the illness(Diforio and Jones 2010). Overall, it is reported that depressive episodes, rapid cycling, and mixed mania are more frequent in women than men (Altshuler et al. 2010; Marsh et al. 2012). Furthermore, there is accumulating evidence that bipolar disorder course is affected by reproductive-related hormonal events in women (Diforio and Jones 2010). Sex diferences have been hypothesized to be related to organizational and activational efects of sex hormones on the nervous system (Steiner et al. 2003). Gonadal steroids play a role in all stages of neurodevelopment, including neurogenesis, synaptogenesis, neural migration, growth, diferentiation, and cell survival (Payne 2003).

Results

     A fowchart of studies selected and included in the narrative review is provided in Fig. 1. From all databases combined, the initial search yielded 1229 results. After duplicates had been removed, 1197 articles remained. At title and abstract screening, 1028 articles were removed as they were not clinically relevant. A total of 169 articles were found to be suitable for inclusion in the full text screening. Full text screening of these articles eliminated 147 articles that did not meet the inclusion criteria. Twenty-two articles in total were included. Table 1, Table 2, and Table 3 list the studies that were included in the narrative synthesis.

Abstract

     Historically, empathy has been thought to motivate prosocial behaviour and inhibit aggressive behaviour. Contrary to current assumptions and theoretical support, a recent meta-analysis revealed a small effect of empathy on aggression among adults (Vachon, Lynam, & Johnson, 2013). The current study sought to determine whether broadening the focus from empathy to include other socially relevant affective characteristics (such as in CU traits) was advantageous in predicting aggressive behaviour. As little is known about the strength of this association among youth, the current study meta-analytically examined 192 unique effect sizes drawn from published and unpublished studies reporting on samples of children and adolescents. Analyses were conducted across general, cognitive, and emotional empathy, as well as callous-unemotional traits, and general, direct, indirect, proactive, and reactive aggression. Significant variability was noted across effect sizes. Consistent with a recent meta-analysis involving adults (Vachon et al., 2013), small to moderate associations were identified between aggression and traditional measures of empathy (i.e., general, emotional, cognitive); these effects ranged from r = −0.06 to −0.26. Among broader measures of emotional style (i.e., callous-unemotional traits), moderate to large effects were found; ranging from r = 0.30 to 0.37. Results suggested that broader affective measures may be more strongly associated with aggression than empathy alone. The results raise questions about the nature of empathy assessment and indicate the utility of targeting multiple emotion-related factors during treatment to effectively reduce aggressive behaviour. In particular, the results underscore of the importance of considering the limited prosocial emotions specifier (perhaps trans-diagnostically given the varied nature of the sample) when considering implications for prognosis and treatment targets.

Introduction

     The prevalence of disorders characterized by aggression (e.g., conduct disorder, oppositional defiant disorder) is alarmingly high among children and adolescents (approximately 10%; Angold & Costello, 2001; Nock, Kazdin, Hiripi, & Kessler, 2007). Youth aggression has demonstrated continuity into adulthood and has been associated with several negative outcomes later in life (e.g., antisocial behaviour in adulthood, work/school problems, substance use, physical and mental health concerns; e.g., Frick, Ray, Thornton, & Kahn, 2014; Frick & Viding, 2009; Karantanos, 2012; Moffitt, 2018). Given this problematic trajectory, early detection and effective interventions are imperative to preventing disruptive patterns of behaviour in adulthood. While deficits in empathy have been incorporated into the criteria used to diagnose disruptive behaviour disorders (American Psychiatric Association, 2013) and have been identified as a potential treatment target (Frick & Kemp, 2021), empirical support for an association between empathy and aggression is mixed. Disagreement surrounding the relevance of these constructs may be fueled by variations in the conceptualization of empathy (broader versus more narrowly defined) and type of aggression assessed (Vachon et al., 2013; Frick & Kemp, 2021). As such, the true magnitude of association remains unclear. To help address this gap in the literature, the current study sought to clarify the association between subtypes of empathy and aggression, and to examine whether broader affective measures (i.e., callous unemotional [CU] trait measures) predict aggression above and beyond traditional empathy measures.

Conclusions

     The current meta-analysis provides evidence of an association between empathy and aggression among children and adolescents. With 188 unique studies, the current meta-analysis provides the most comprehensive review of the association between empathy, CU traits, and the forms and functions of aggression among youth to date. Consistent with adult samples (Vachon et al., 2013), only a small to moderate association was found between traditional measures of empathy (i.e., general, emotional, cognitive empathy) and aggression in children and adolescents. By considering multiple types of empathy and aggression, and expanding beyond the traditional definition of empathy to include indices of emotional style indexed via CU traits (e.g., lack of guilt/remorse, shallow affect), we were able to, for the first time, provide evidence that broader measures of emotional style appear to be better predictors of aggressive behaviour than empathy alone; where moderate to larger correlations were noted between CU trait measures and aggression. These findings suggest consideration of a constellation of affective traits, rather than empathy deficits exclusively, is important to the prediction of aggression among children and adolescents.

     Although contrary to contemporary theory, the ostensibly small to moderate effect between traditional measures of empathy and aggression in itself does not dismiss the potential relevance of considering empathy in relation to risk for aggression. Instead, the current study highlights the utility of targeting multiple affective features in treatment to effectively reduce aggressive behaviour. In the DSM-5 (APA 2013), the Limited Prosocial Emotions specifier was incorporated into the conduct disorder diagnosis. This work underscores the importance of considering these traits in the diagnosis and treatment of not only conduct disorder, but also trans-diagnostically given the varied nature of the sample. As effect sizes estimated in the current meta-analysis are reflective of a single time-point, it is also important to acknowledge that continuous dynamical interactions may substantially intensify the effects when compounded over time. Before dismissing the importance of empathy to aggression, one must consider the function of empathy both within a larger constellation of affective traits, and a broader range of socially relevant behaviours.