World Psychiatry June 2021 (1) (1)

WPA
OFFICIAL JOURNAL OF THE WORLD PSYCHIATRIC ASSOCIATION (WPA)
Volume 20, Number 2 June 2021
World Psychiatry
ISSN 1723-8617
IMPACT FACTOR: 40.595
EDITORIALS
Rediscovering the mental health of populations 151
G.C. PATTON, M. RANITI, N. REAVLEY
Enabling a youth- and mental health-sensitive 152
greener post-pandemic recovery
H.L. BERRY
SPECIAL ARTICLES
The promise of machine learning in predicting 154
treatment outcomes in psychiatry
A.M. CHEKROUD, J. BONDAR, J. DELGADILLO ET AL
Validity and utility of Hierarchical Taxonomy 171
of Psychopathology (HiTOP): II. Externalizing
superspectrum
R.F. KRUEGER, K.A. HOBBS, C.C. CONWAY ET AL
PERSPECTIVES
Racism and mental health 194
D.R. WILLIAMS, O.S. ETKINS
The epidemic of fentanyl misuse and overdoses: 195
challenges and strategies
N.D. VOLKOW
The need for publicly funded research on 197
therapeutic use of psychedelic drugs
W. HALL
Rationale for and usefulness of the inclusion 198
of gaming disorder in the ICD-11
J. BILLIEUX, D.J. STEIN, J. CASTRO-CALVO ET AL
FORUM – PREVENTION OF MENTAL
DISORDERS IN YOUNG PEOPLE: RESEARCH
EVIDENCE AND FUTURE DIRECTIONS
Preventive psychiatry: a blueprint for improving 200
the mental health of young people
P. FUSAR-POLI, C.U. CORRELL, C. ARANGO ET AL
Commentaries
Public health psychiatry: an idea whose 222
time has come
R.M. MURRAY, M. CANNON
Full speed ahead on indicated prevention 223
of psychosis
S.W. WOODS, J. CHOI, D. MAMAH
Most at-risk individuals will not develop a mental 224
disorder: the limited predictive strength of risk
factors
P. CUIJPERS, F. SMIT, T.A. FURUKAWA
Prenatal prevention of psychiatric illness 226
and childhood development population-wide
R. FREEDMAN, S.K. HUNTER, A.J. LAW ET AL
Prevention in psychiatry: a role for epigenetics? 227
K. DOMSCHKE
Primary challenges and practical solutions 228
in preventive psychiatry
A. REICHENBERG, S.Z. LEVINE
Prevention in the mental health field should 230
be implemented synergically at different levels
M. NORDENTOFT, P. JEPPESEN, A.A.E. THORUP
Characterizing transdiagnostic premorbid 231
biotypes can help progress in selective
prevention in psychiatry
M.S. KESHAVAN
RESEARCH REPORTS
The Horyzons project: a randomized controlled 233
trial of a novel online social therapy to maintain
treatment effects from specialist first-episode
psychosis services
M. ALVAREZ-JIMENEZ, P. KOVAL, L. SCHMAAL ET AL
Efficacy and acceptability of pharmacological, 244
psychosocial, and brain stimulation interventions
in children and adolescents with mental
disorders: an umbrella review
C.U. CORRELL, S. CORTESE, G. CROATTO ET AL
Internalizing psychopathology and all-cause 276
mortality: a comparison of transdiagnostic
vs. diagnosis-based risk prediction
H. KIM, N.A. TURIANO, M.K. FORBES ET AL
Psychotherapies for depression: a network 283
meta-analysis covering efficacy, acceptability
and long-term outcomes of all main
treatment types
P. CUIJPERS, S. QUERO, H. NOMA ET AL
INSIGHTS
Explaining the missing heritability 294
of psychiatric disorders
M.J. OWEN, N.M. WILLIAMS
Toward a systems-based approach to 295
understanding the role of the sympathetic
nervous system in depression
A.J. FISHER, J. SONG, P.D. SOYSTER
Cardiac vagal tone: a neurophysiological 296
mechanism that evolved in mammals to
dampen threat reactions and promote sociality
S.W. PORGES
Psychiatric comorbidity in immune-mediated 298
inflammatory diseases
R.A. MARRIE, C.N. BERNSTEIN
LETTERS TO THE EDITOR 300
WPA NEWS 308

The World Psychiatric Association (WPA)
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aimed to increase knowledge and skills necessary for work in
the field of mental health and the care for the mentally ill. Its
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1. Cuijpers P, Sijbrandij M, Koole SL et al. Adding psychother-
apy to antidepressant medication in depression and anx-
iety disorders: a meta-analysis. World Psychiatry 2014;13:
56-67.
2. McRae TW. The impact of computers on accounting. Lon-
don: Wiley, 1964.
3. Fraeijs de Veubeke B. Displacement and equilibrium mod-
els in the finite element method. In: Zienkiewicz OC,
Hollister GS (eds). Stress analysis. London: Wiley, 1965:145-
97.
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EDITORIALS
World Psychiatry 20:2 - June 2021 151
Rediscovering the mental health of populations
e principles of prevention espoused by G. Rose1 have under-
pinned many modern successes in health care. In areas such as
cardiometabolic diseases, injuries and violence, and substance
abuse, shifting the community distribution of risk factors has
become the primary strategy. e ensuing reductions in disease
burden have been striking.
Psychiatry remains an outlier. Over decades, the quality of clini-
cal care has been improved, greater funding has been attracted,
more and better trained mental health professionals have been
grown, and the governance of mental health care has been up-
graded2. However, the emphasis in recent initiatives in high-in-
come countries has been overwhelmingly a further extension of
treatment: early clinical intervention has been the dominant ini-
tiative taken up in government investments into the mental health
of young people3.
Yet, this continuing expansion of government expenditure,
prescribing of antidepressants and availability of psychologi-
cal services has still not been accompanied by reductions in
the prevalence of common mental disorders3. While it remains
possible that this in part reects a continuing failure to scale
minimally-sucient treatments, the evidence from other elds
of medicine suggests that a more likely explanation is the lack of
scalable risk-focused prevention strategies.
is failure to embrace population-based approaches to pre-
vention in psychiatry is understandable. Most clinicians find
the endorsement of population perspectives dicult. For them,
the individual is the unit of study1. For psychiatry, the opacity
of pathophysiological processes has supported the tendency to
focus on interventions directed at the individual. Recent excite-
ment about progress in genetics and neuroscience has reinforced
this tendency, with both major research funding agencies and
the pharmaceutical industry emphasizing the individual over
the social context.
In this scenario, the paper by Fusar-Poli et al in this issue of
the journal4 raises questions around the optimal strategies for
prevention in psychiatry. e overwhelming emphasis to date
across common mental disorders, psychosis and bipolar disor-
der has been on individuals at high risk by virtue of early clini-
cal symptoms or genetic predisposition. These selective and
indicated approaches to prevention have targeted subjects at the
tail of the distribution, with an aim of reducing the likelihood of
transition to clinical caseness. However, this emphasis on indi-
viduals has been accompanied by a failure to address structural
and social determinants.
E. Durkheim’s work, well over a century ago, drew the conclu-
sion that suicide rates are stable and distinctive characteristics of
populations. He viewed suicide as a collective phenomenon in
which personal factors are less important than the social context.
Similarly, strategies focused on the social, economic and regula-
tory context that bring a reduction in average alcohol consump-
tion have been far more successful in reducing levels of alcohol
use disorders than individually targeted interventions5. This
principle that actions to reduce modest risks in a large group will
generate greater benets than targeting conspicuous risks in a
small number should guide the prevention of mental disorders.
One challenge is that most risks for mental disorders lie out-
side the direct inuence of the health sector. For young people,
social determinants of mental health derive from inequitable
gender norms, shifts in family structure and function, culture
and religion, economic development and its consequences, digi-
tal technology, urbanization and planetary change. ese social
and structural determinants shape peer, family and community
relationships, accessibility of service systems, the likelihood of ex-
periencing major external events, as well as risks related to life-
style and individual behaviour. For mental disorders, as for the
physiological processes underpinning physical health, there are
also sensitive periods in which risks are more likely to become
embedded and when prevention will be more eective.
e COVID-19 pandemic illustrates the inuence of social
and structural factors on the mental health of all age groups, but
particularly the young. It also illustrates areas where psychiatry
should be acting. e eects of lifestyle risk factors for mental
disorders, including physical inactivity, screen time, irregular
sleep and poor diets, have been enhanced. Even more profound
have been the shifts in relationships, with disruption to friendships
and peer interactions, heightened worries about and sometimes
conict with family members, connement to home and loss of
the social milieu of schools, including extracurricular activities.
In taking prevention in psychiatry forward, there are further
lessons to be drawn from other areas of medicine1. Epidemiol-
ogy remains the underpinning discipline of public health, and,
for psychiatry, epidemiology should adopt both life-course and
population perspectives. However, psychiatric epidemiology
remains in a parlous state, particularly for children and young
people. Global coverage for even basic estimates of prevalence
lies under seven percent, with rates in low- and middle-income
countries substantially lower, and 124 countries having absolute-
ly no data6. Coverage of risk factors is even weaker.
As noted by Fusar-Poli et al, a life-course perspective on men-
tal health is essential4. Yet, a life-course perspective would ideal-
ly extend across generations, given that familial clustering is the
clearest of all risk factors. Beyond genetics, there are malleable in-
tergenerational risk factors for mental disorders, ranging from the
biological (e.g., epigenetic) through to the structural (e.g., inequi-
table gender norms), including those risks that become embed-
ded prior to conception7. Longer-term perspectives derived from
prospective life-course studies have the potential to guide pre-
vention research and policy, particularly when combined with
powerful new analytic tools for causal inference.
Recent intervention trials provide grounds for optimism.
Schools will be one important context for prevention. Chil-
dren and young people spend close to half their waking hours in
school and education. Policy-makers increasingly understand
that poor student mental health aects learning and academic

achievement. ere are now examples from both high- and low-
resource settings that interventions promoting a positive school
social climate and reducing bullying can substantially reduce
symptoms of common mental disorder8. Other promising plat-
forms include those based in local communities (e.g., girls clubs)
and the new social environments created by digital media.
Interventions well beyond those traditionally regarded as the
focus for prevention of mental disorders will also be important.
Cash transfers have been widely adopted by governments in oth-
er areas of health and social policy, and seem to bring reductions
in symptoms of mental disorder and promotion of well-being in
low-resource settings where psychological interventions based
on cognitive behaviour therapy have little or no eect9. Such nd-
ings suggest the value of inclusion of mental health into trials of
non-mental health interventions.
e dramatic deterioration in community mental health dur-
ing the COVID-19 pandemic heightens the imperative for psy-
chiatry to shift beyond its comfort zone of the individual patient,
and engage with the social, structural and political determinants
of mental health.
George C. Patton1,2, Monika Raniti1,2, Nicola Reavley3
1Centre for Adolescent Health, Murdoch Children’s Research Institute, Parkville, VIC,
Australia; 2Department of Paediatrics, Melbourne Medical School, University of Mel-
bourne, Melbourne, VIC, Australia; 3Melbourne School of Population and Global Health,
University of Melbourne, Melbourne, VIC, Australia
1. Rose G. e strategy of preventive medicine. Oxford: Oxford University Press,
1992.
2. Priebe S, Burns T, Craig TK. Br J Psychiatry 2013;202:319-20.
3. Jorm AF, Patten SB, Brugha TS et al. World Psychiatry 2017;16:90-9.
4. Fusar-Poli P, Correll CU, Arango C et al. World Psychiatry 2021;20:200-21.
5. Rose G. In: Williams P, Wilkinson G, Rawnsley K (eds). e scope of epide-
miological psychiatry. London: Routledge, 1989:77-85.
6. Erskine HE, Baxter AJ, Patton G et al. Epidemiol Psychiatr Sci 2017;26:395-402.
7. Patton G, Olsson C, Skirbekk V et al. Nature 2018;554:458-66.
8. Shinde S, Weiss HA, Varghese B et al. Lancet 2018;392:2465-77.
9. McGuire J, Kaiser C, Bach-Mortensen A. https://doi.org/10.31235/osf.io/
ydr54.
DOI:10.1002/wps.20842
152 World Psychiatry 20:2 - June 2021
Enabling a youth- and mental health-sensitive greener post-pandemic
recovery
International bodies such as the United Nations (UN), the
World Health Organization (WHO), the International Labour Or-
ganization (ILO) and the Organization for Economic Co-opera-
tion and Development (OECD) have warned that the COVID-19
pandemic has made the world a yet more dicult place to be
young.
e ILO report Youth & COVID-19: Impacts on Jobs, Education,
Rights and Mental Well-Being1 found that nearly three-quarters
of people aged 18-29 years reported pandemic-related educa-
tional disruptions, one-half described themselves as depressed,
and one-in-six of those who were employed before the outbreak
had stopped working. e eects have been worst among youth
in low- and middle-income countries (LMICs) and among young
women everywhere, exacerbating pre-existing inequalities.
Perversely, pandemic-related hardship has pushed some
young people prematurely into work, particularly in Asia and the
Pacic region. In India and Indonesia, for instance, the UN Chil-
dren’s Fund (UNICEF), the Asian Development Bank and the ILO
have jointly reported that poor households are increasingly likely
to take underage children out of school to work in the home or
away in cities, or to marry them o early to boost family income.
In this issue of the journal, Fusar-Poli et al2 emphasize that
“universal public health approaches targeting the social deter-
minants of mental disorders hold the greatest potential for re-
ducing the risk prole of the whole population”. We can extend
the focus on inequalities in the socioeconomic environment to
incorporate the role that physical environments, built and natu-
ral, play in shaping youth mental health, and what can be done
in this respect.
By May 2020, governments globally had invested over 10 tril-
lion USD in responses to the pandemic, mostly for crisis initia-
tives such as furlough schemes, nancial support for businesses,
and the acquisition of medical supplies. e world is now talking
about recovery. Scientists and major international bodies – e.g.,
the International Monetary Fund, the ILO, the International En-
ergy Agency (IEA), the European Union, and the InterAcademy
Partnership – have proposed a green approach to rebuilding
economies.
Statista’s survey of 28,000 individuals from fifteen nations,
Global Green Economic Recovery Support After COVID-19 20203,
found that two-thirds want a green recovery, especially young
people. e ILO has hosted a meeting of ministers from thirty
countries to discuss how to “build back better”, and the UN
Secretary-General went so far as to suggest that a green recov-
ery approach in LMICs could help post-pandemic economic
development switch from “grey to green”. e message is clear:
post-pandemic rebuilding cannot continue the over-exploitation
of the resources of the planet and its peoples – especially young
people – without regard for the costs to either.
Substantial steps have been made in the right direction. e
IEA’s Global Energy Review 2020 found that COVID-19 restric-
tions on travel reduced global carbon emissions by 8%, the
kind of fall needed to keep the world within the so-called 1.5°C
guardrail beyond which global warming becomes dangerous.
However, emissions have started to rise again with the relaxation
of restrictions. A commitment to a green recovery, which could
avoid 0.3°C warming by 20504, is urgently needed.
Leading economists have identied ve recovery strategies
with particularly strong potential for retaining and even accel-
erating the emission reductions that the pandemic achieved5.

World Psychiatry 20:2 - June 2021 153
e strategies embrace building clean physical infrastructure,
retrotting buildings, and investing in education, training, clean
research and development, and natural capital. ese are con-
sistent with the WHO’s six “prescriptions” for simultaneously
promoting planetary and human health outlined in their Mani-
festo for a Healthy Recovery from COVID-196: protecting and
preserving nature; investing in essential services for health (e.g.,
clean water, health care facilities); moving quickly to green en-
ergy; healthy and sustainable food systems; stopping subsidiz-
ing polluters; and building healthy cities. e UN and the World
Bank note that cities are an important focus for a green recov-
ery; the latest UN-HABITAT report has estimated that 60% of the
world’s population will live in cities by 2030, and 60% of these
will be children.
All of these prescriptions and strategies could support univer-
sal approaches to promoting young people’s future health and
prosperity, but it may seem hard to sell some of these ideas politi-
cally. However, as the WHO Manifesto points out6, the pandemic
has shown that people can accept dicult policies where these
are evidently necessary. Further, though politicians may not al-
ways listen to scientists and health experts, they listen to public
opinion. e large majority of the world’s adults wants action on
climate change and, as the School Strike for Climate led by Greta
unberg has shown, those under voting age can be inuential.
Clinicians, researchers and their representative bodies have a
role to play in persuading opinion leaders of the mental health
benets of a green recovery, especially for young people. is
is challenging because its greatest benets are not immediately
obvious. Climate change and mental health are both complex
phenomena and their relationship is complicated. It begins high
up the causal chain, where climate change aggravates the root
causes of mental illness, and ultimately involves multiple recip-
rocal direct and indirect linkages between a host of proximal,
intervening and distal factors that lie on interacting paths of in-
uence7.
Taking a systems approach to elucidating these relationships
can help simplify the complexity meaningfully and shift thinking
from the narrow perspective of treating illness to the bigger pic-
ture that also incorporates promoting well-being and preventing
illness. Systems thinking in this case involves mapping the fac-
tors linking climate change to mental health outcomes, from direct,
pro ximate causes to distal root causes, and specifying their inter-
actions. For example, one eect of climate change is to increase
the frequency, intensity, unpredictability and duration of extreme
events, such as the wildres that ravaged South-Eastern Australia
and California in 2020. Destruction on this scale inevitably has
mental health implications that go beyond the immediately obvi-
ous, incorporating risks as diverse as signicant injury or death,
and losses to education and employment, cultural practices, out-
door recreation, access to fresh foods and Internet connectivity.
Every one of these cascading factors, separately and interactively,
is a potential threat to mental health7.
Young people can be highly motivated to help in health crises
and can mobilize whole communities when needed. Indeed, the
ILO report1 found that, by August 2020, nearly one-third of young
people globally was engaged in pandemic-related volunteering.
ey are also leading a research initiative established by the UN
Educational, Scientic and Cultural Organization (UNESCO),
Youth As Researchers8, investigating how the pandemic has af-
fected young people.
Developing a youth- and mental health-sensitive approach to
COVID-19 recovery would harness the interest, optimism, con-
dence and energy of young people. It would also address their
yearning for a greener future. e Tony Blair Institute for Global
Change’s report, Listening to Covid-19’s “Lost Generation”: In-
sights From Our Global Youth Survey9, has pointed out that young
people should help design pandemic recovery pathways.
Members of older generations may feel uneasy about a cli-
mate crisis that is their collective bequest to younger cohorts,
and may want to help. One thing they can do is to come together
more eectively to apply the resources, capabilities and wisdom
they have acquired in life to helping young people contribute to
the pandemic recovery. Young people are ready to meet the chal-
lenge – their way, a green way.
Helen L. Berry
Australian Institute of Health Innovation, Faculty of Medicine, Health and HumanSci-
ences, Macquarie University, Sydney, NSW, Australia
1. International Labour Organization. Youth & COVID-19: impacts on jobs,
education, rights and mental well-being. www.ilo.org.
2. Fusar-Poli P, Correll CU, Arango C et al. World Psychiatry 2021;20:200-21.
3. Statista. Global green economic recovery support after COVID-19 2020.
www.statista.com.
4. Forster PM, Forster HI, Evans MJet al. Nat Clim Chang 2020;10:913-9.
5. Hepburn C, O’Callaghan B, Stern N et al. Oxford Review of Economic Poli-
cy (in press).
6. World Health Organization. Manifesto for a healthy recovery from COV-
ID-19. www.who.int.
7. Berry HL, Waite TD, Dear KBG et al. Nat Clim Chang 2018;8:282-90.
8. UNESCO. Youth As Researchers: exploring the impact of COVID-19. en.
unesco.org.
9. Tony Blair Institute for Global Change. Listening to Covid-19’s “lost genera-
tion”: insights from our global youth survey. institute.global.
DOI:10.1002/wps.20843