I - Assessment

Note: Content is not peer-reviewed, does not constitute medical advice, and is provided for educational/interest purposes only.

1. Human Nature and Well-Being

General Social Survey (GSS)

• According to the GSS here are key factors associated with an increased likelihood of reporting being “very happy”:

• Marriage: +19%; Health ≥ Good: +15%; Finance ≥ Average: +9%; Religious attendance 2+/yr: +9%; Seeing relatives ≥ 1/mo: +7%; Having children: +7%; Seeing friends > 1/yr: +6%. Post. 

Big 5, OCEAN

• Life satisfaction correlates with low neuroticism, high extraversion, high consciousness - Link

• Women are higher on agreeableness and neuroticism. N=143,313 from different countries - Rammstedt et al. Link

Life Satisfaction

• Life events can change OCEAN: Review of N=196,256 individuals. Getting married lowers openness, new employment improves conscientiousness, and lowers neuroticism. The factors most correlating with life satisfaction are: new relationship, marriage, and new employment. Link. 

Importance of fathers

• There is often an implication in psychiatry that mothers are crucial to healthy development and attachment. While true, we shouldn’t dismiss the consequences of absent or unengaged fathers. A study of 1,300 Virginia children found that daughters of less engaged fathers had x10 the rate of depression (1% vs. 10%) and x2.1 the rate of school contacts for misbehavior or performance problems (17% vs. 36%). Less engaged fathers were defined by self-report as less than “very well” at handling family demands or fewer than 4 family meals per week.  Link. Ref: Good Fathers, Flourishing Kids by Wilcox et al. 2025.

The Spirit

There are people who feel that the realm of the spiritual, however they define that word, is the most central, crucial, and core element of their whole being, and that ignoring this essential part of themselves in an attempt to make life better would be a major oversight and would make the effort futile.  On the other hand, there are people who see in the very word "spiritual" a reference to "spirits" whose existence they not only deny but relegate to superstition. The relation of spirituality to religion involves two terms that many people define in different ways, with nouniversal agreement. For example, Confucianism, sometimes referred to as a religion, is at least in some of its variants a system of virtue ethics without reference to the supernatural. Depending on one’s definitions, this may be an example of religion without spirituality.  Conversely, many people refer to themselves as spiritual but not religious; using the word spiritual to refer to aspects of their inner experience and religion to refer to the activity of organized groups. The contrast they are making seems to imply the definitions they are using. The task presented to those who would heal the psyche is to work with people across the spectra of spirituality and religiosity, from strong endorsers to strong rejectors. The challenge is compounded by the fact that clinicians themselves may occupy any point on these same spectra.  Indeed, the differences among clinicians manifested itself early in the history of psychotherapy. On the one hand, Sigmund Freud, in The Future of an Illusion (1927), spoke of religion as "certain dogmas, assertions about facts and conditions of external and internal reality which tell one something that one has not oneself discovered, and which claim that one should give them credence."  These religious concepts are accepted and transmitted: Firstly because our primal ancestors already believed them; secondly, because we possess proofs which have been handed down to us from antiquity, and thirdly because it is forbidden to raise the question of their authenticity at all.  Freud went on to analyze religious beliefs as wish-fulfillment, much as he tended to analyze dreams. On the other hand, Carl Jung famously said, “I have treated many hundreds of patients. Among those in the second half of life – that is to say, over 35 – there has not been one whose problem in the last resort was not that of finding a religious outlook on life.”  Jung wrote that Freud's views "move within the confines of the outmoded rationalism and scientific materialism of the late nineteenth century."  What is the role of the mental health clinician in assisting with our patients; spiritual or religious life? Indeed, there are empirical studies that have found efficacy for such interventions, suggesting that simply avoiding the spiritual/religious is missing out on a way to be helpful to many patients (Gonçalves et al., 2015).  Admittedly, the depth of empirical study of specific methods for clinicians to be helpful in this way, of manuals for spiritual intervention, of categorizing patients with respect to when to intervene and with whom, is not yet as well developed as it is for cognitive therapy, behavior therapy, psychoanalysis, or medication management. Thus, the ideas provided here are more the product of clinical judgment than meta-analyses of randomized clinical trials.

Gonçalves, J. P., Lucchetti, G., Menezes, P. R., & Vallada, H. (2015). Religious and spiritual interventions in mental health care: a systematic review and meta-analysis of randomized controlled clinical trials. Psychological medicine, 45(14), 2937–2949.

2. Neurobiology

Sigma-1 Receptors

• • σ1R have been receiving increasing attention. They modulate activity and move around cells to have varied functions including: upregulating BDNF, enhance glutamate, enhance monoamines, modulate ion channels. It may help mood (monoamines), neurodegeneration (BDNF), and pain (through NMDA).

  • σ1R antagonist ki: Haloperidol 1.1, Perphenazine 13, Sertraline 32, Fluphenazine 62, Chlorpromazine 100, 

  • σ1R agonist ki: Donepezil 15, Fluvoxamine 17, Dextromethorphan 63, Fluoxetine 191, Escitalopram 288, Imipramine 343, Citalopram 400, 

  • >1,000: Desipramine 2000, Paroxetine 2000, Duloxetine 3500, Venlafaxine >10,000 , Milnacipran >10,000 , Mirtazapine >10,000 

  • Ref: Largent 1984, Lang 1994, Schotte 1996, Narita 1996, Ishikawa 2009, Ishima 2014, Lever 2016,

3. Psychopathology

4. Etiology

Genetics

• Heritability ≠ genetic causation: A trait can be genetically determined without heritability if there's no genetic variation for that trait (e.g., having two eyes).

• Large study and missing heritability: n=347,630. It appears that a lot of the missing heritiability problems can be resolved by looking at the whole genome. However, interestingly, this large study found lower contribution of genetics for most mental-related traits. Neuroticism (18.5%), Education attainment (34.9%), Sleep (12.5%), Smoking (17.4%) (looking at the genetic contribution supplemental table 4). This is in contrast to height that showed 70.9% whole genome heritability. Link

• A study of the heritability of childhood ADHD symptoms showed that parents' estimates indicated approximately 70% heritability, compared to a DNA-based (SNP) heritability of roughly 5%. Link

• “the measurable heritability of a trait does not tell us how 'genetically inheritable' that trait is.” Link

5. Assessment

• DSM quote on need for a thorough interview "The case formulation for any given individual should involve a careful clinical history and concise summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder. It is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis. A thorough evaluation of these criteria may assure more reliable assessment”

• DSM-II quote on not making too many diagnoses "The diagnostician, however, should not lose sight of the rule of parsimony and diagnose more conditions than are necessary to account for the clinical picture."

• PHQ-9 up to ⅔ false positive - In a study, researchers evaluated the widely used PHQ-9 scale. 153 individuals at a psychiatric clinic received the scale and clinicians interviews. How did I get 2/3?  Table 2, last column, using the the typical cut-off of 10.  61 individuals tested positive yet didn’t have a major depressive disorder. 38 test positive and were confirmed by the clinician. That is 62% false positive among those who tested positive. Note: You could use the PHQ-9 in other ways that wouldn’t show such high false positive rates. The author notes “Among 73 positive cases for the PHQ-9 diagnostic algorithmic threshold, 34 cases (46.6 %) were falsely positive”. Link. DOI: 10.1186/1471-244X-12-73

• The consequence of psychiatric labels

  • The issue of ever increasing prevalence of mental illness in youth is already a concern. In a 2023 study of sixth grade students, 51.2% adopted mental health labels at some point. Furthermore, the study found that adopting such a label significantly correlated with lower self-esteem. DOI: 10.1177/00221465231175936. Link

  • "At Brown and Harvard, more than 20% of undergraduates are registered as disabled. At Amherst, that figure is 34%." Link

• Problem with scales like PHQ-9, GAD-7, PCL-5, too many positives - link

  • PHQ-9: False positives among positives = 65%, PCL-5 False positives among positives = 55%. Despite a 2/3 false positive rate, 86.7% of patients testing positive for the PHQ-9 are prescribed antidepressants, 42.0% of those testing negative are also prescribed antidepressants, only 5-7% of those who tested positive got referred to psychiatry/psychology. Link. DOI:10.1136/bmj.b750

  • PHQ-9: •Kroenke et al. (2001) - DOI: 10.1046/j.1525-1497.2001.016009606.x

  • GAD-7 •Spitzer et al. (2006) DOI: 10.1001/archinte.166.10.1092 

  • PCL-5 •Georgescu et al. 2024 DOI: 10.1080/20008066.2024.2333222

  • A more recent article with concerns for checklists for PTSD. 2025 - Comparing checklists to clinical interviews, only 21% of reported trauma was true positive, (79% was false positive). For symptoms, only 34% were true positive, (65.9% were false positive). Link. DOI: 10/1089/cap.2024.0126.

  • 2025 - Only 11.7% of clinical interpret the PHQ correctly. Link. DOI: 10.1001/jamapsychiatry.2025.3796

• Simple psych-ed (like an ADHD workshop) doubles self-perception of the disorder in healthy individuals ("I believe I have ADHD" 28% to 58%) - Link. DOI: 10.1017/S0033291725101979

• Will consider adding "amafufunyana" to culture bound syndrome: Amafufunyana is a culture-bound syndrome recognized among Xhosa and Zulu communities in South Africa, traditionally interpreted as demonic or evil spirit possession. Sufferers may exhibit symptoms such as hearing voices emanating from the stomach, speaking in unfamiliar languages or altered tones, and agitation.

6. Diagnosis & Prognosis

7. Risk Assessment

Suicide risk assessment

• Many suicides happen rapidly. Studies show large numbers that unfold within minutes of the decision (Wyder, 2004). Rapid access to a loaded gun can turn a fleeting thought into a permanent outcome.

  • Wyder, 2004: 67% of attempters considered self-harm for under 30 minutes. 93% under 24 hours. 

  • Deisenhammer et al., 2009: Nearly half (47.6%) thought about it for 10 minutes or less. Link. DOI: 10.4088/JCP.07m03904

• 2025 UK suicide guidelines - Link

  • • 1st recommendation “do not use risk assessment tools and scales to predict future suicide”

  • • 2nd recommendation “do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged”

• 2025 US paper advocating for Zero Suicide and suicide risk assessments for all. Post. Link. DOI: 10.1001/jamanetworkopen.2025.3721

• 2025 Safety planning - 80% reduction in suicide in original study, 90% increase in replication study - Link. DOI: 10.1016/j.jad.2025.04.023

• The mention of command auditory hallucination as a risk factor for suicide didn't have a reference "command auditory hallucinations may identify or even place psychotic individuals at greater risk for acute, suicidal behavior — these symptoms should be the target of immediate and aggressive characterization and treatment". Link. DOI: 10.1016/j.comppsych.2012.12.022

Suicide & Durkheim

• For the next edition, we may do a segment on Durkheim's conceptualization of suicide

• Social Regulation (Organization): Anomic Suicide: Lack of regulation; normlessness from social disruption (e.g., “I’m lost without clear societal norms”) vs Fatalistic Suicide: Excessive regulation; despair from oppressive control (e.g., “I’m trapped by society’s rigid rules”).

• Social Integration (People): Egoistic Suicide: Low integration; isolation from social ties (e.g., “I feel disconnected from society” or “No one loves me”) vs Altruistic Suicide: High integration; self-sacrifice for the group (e.g., “I’m dying for others, self-sacrifice”).

• It should be noted that Durkheim was interested in social construct and this would not cover individual psychological reason for suicide. However psychological concepts can be deduced from Durkheim. Social regulation can be viewed as individual regulation: are you disorganized and acting impulsively or are you very rational and considered all possibilities but nothing worked. Social integration can be viewed as how you feel connected/dependent/responsible for others

Violence and schizophrenia

• For unconventional stranger homicide (this is a much narrower group than regular murder); severe mental illness is 43.3% versus 2.4% for conventional stranger homicide (though 43.6% of larger group were intoxicated) - Link. DOI: 10.1177/00258024241255779

• Antipsychotics adherence lower risk of violence (not in the paper - this could be a confounder of adherence rather than the effect of antipsychotics) - link. DOI: 10.1016/S0140-6736(14)60379-2

• Mental illness increase risk of being subject and perpetrator of violence. Schizophrenia specifically increased risk of being perpetrator but not subject (Figure 4 B). n=250,419 large Swedish study.- link. DOI: 10.1001/jamapsychiatry.2019.4275

• 2025 - Risk factors of violence in individuals with schizophrenia/psychosis (#1 Past crime, #2 drugs, #3 suicidality, rest wasn’t significant including symptoms of psychosis) - Link. DOI: 10.1192/bjp.2024.120

• Predictors of violence (deliquency/substance use/conduct problems): Poverty didn't predict violence when controlling for "positive parenting, single mother status, divorce, or child to adult ratio". Other predictor "Higher peer deviance in later adolescence." Paper also show that while violence varies some with age, it is much more heterogenous among individuals. Link. DOI: 10.1017/S0954579414000789

• Receiving money (universal basic income) doesn't reduce violence but increases drug use by 14% (the day of). Link. DOI: 10.1162/rest_a_00834

• In a Swedish population-based study from 1973 to 2004, 1% of the population was responsible for 63% of violent crimes due to high violent recidivism. It was also noted that if violence could be stopped after two violent recidivisms, a 53% reduction in violent crime would result, lending support to three-strikes laws when applied to violent convictions. Link. DOI: 10.1007/s00127-013-0783-y

APA in 1982 in the Amicus Brief for Barefoot v. Estelle

• Limitation of violence risk assessment as described by the APA in 1982 in the Amicus Brief for Barefoot v. Estelle Link 

  • “even under the best of conditions, psychiatric predictions of long-term future dangerousness are wrong in at least two out of every three”

  • “medical knowledge has simply not advanced to the point where long-term predictions [ ] may be made with even reasonable accuracy”

  • “The unreliability of psychiatric predictions of long-term future dangerousness is by now an established fact”

  • psychiatry “permits the jury to avoid the difficult actuarial questions by seeking refuge in a medical diagnosis that provides a false aura of certainty”

  • This may also be relevant to assessment or diagnosis chapter

Medications and suicide

• Lithium study of suicide in veterans that was stopped due to futility analysis. 519 veterans with depression and bipolar given medium dose of lithium (lvl: 0.5) followed about 310 days (slight difference between groups). There were 65 events in the lithium group and 62 in the placebo group so the study was stopped for futility. Severe blow to the idea that Lithium reduces suicide. Link. DOI: 10.1001/jamapsychiatry.2021.3170

Psychopathy

• Update last paragraph to: While the PCL-R is commonly used in many forensic settings, it has significant limitations and critics. In practice, as applied to criminal cases, its interrater reliability has been found to be mediocre. A 2014 review reported an intraclass correlation coefficient of 0.58 (DeMatteo et al., 2014). Higher scores from prosecution experts highlight its subjective nature. Furthermore, systematic reviews question the empirical basis for its widespread forensic use (Larsen et al., 2020). The instrument’s ability to predict criminal behavior is only weak to moderate, driven primarily by historical behavioral items rather than core psychopathic personality traits. Applying the psychopathy label can lead to harmful consequences, such as juror stigma, discriminatory rehabilitation practices. While the PCL-R’s forensic utility is rightfully contested, we believe psychopathy remains a helpful construct, especially outside the adversarial court system.

  • • Larsen, R. R., Jalava, J., & Griffiths, S. (2020). Are Psychopathy Checklist (PCL) psychopaths dangerous, untreatable, and without conscience? A systematic review of the empirical evidence. Psychology, Public Policy, and Law, 26(3), 297–311.