Samir El Alaoui

Prosocial behavior, the tendency to act for others’ benefit, is essential for mental health. Although social contexts strongly shape prosocial behavior in healthy individuals, its relevance across psychiatric disorders remains unclear. We examined whether context-dependent prosocial behaviors were associated with baseline psychiatric symptoms and longitudinal symptom trajectories. In a one-year longitudinal cohort study, Swedish adults ( n = 4484) with at least one self-reported psychiatric disorder completed standardized questionnaires of six prosocial behavior subtypes at baseline, followed by monthly reports of alcohol use, substance use, anxiety, and depressive symptoms. Latent class linear mixed models identified longitudinal symptom trajectories, and logistic regression models investigated their associations with baseline prosocial behavior subtypes. All models adjusted for demographic covariates and shared variance across psychiatric symptom domains. Three prosocial behavior subtypes showed longitudinal associations with stable psychiatric symptom trajectory classes. Higher anonymous prosociality was associated with lower odds of belonging to the stable high alcohol use trajectory (OR = 0.89, p = 0.013). Higher public prosociality was associated with higher odds of belonging to the stable high substance use trajectory (OR = 1.15, p = 0.036). Higher emotional prosociality was associated with higher odds of belonging to the stable high anxiety trajectory (OR = 1.25, p < 0.001). No prosocial subtype was associated with depressive symptom trajectories. Overall, context-dependent prosocial behaviors were associated with persistent levels of alcohol use, substance use, and anxiety symptoms. These findings suggest that specific prosocial behaviors may refine transdiagnostic models of social dysfunction by indexing stable patterns of psychiatric symptom burden.

Mental disorders are the leading cause of years lived with disability worldwide, yet the dominant clinical model remains reactive, intervening only after diagnostic thresholds are met. Drawing on the engineering distinction between run-to-failure and condition-based maintenance, this review argues that psychiatry faces a quantifiable intervention threshold gap. Synthesising recent meta-analytic evidence, we show that psychological interventions at subclinical symptom levels reduce major depression incidence by 43% at post-treatment and 33% at 12-month follow-up (individual-participant-data meta-analysis; 30 trials; N = 7,201), that shorter duration of untreated illness is associated with 70% greater likelihood of treatment response, and that early intervention for first-episode psychosis reduces hospitalisation by 26%. We review convergent evidence across five modifiable domains — sleep and glymphatic clearance, nutritional psychiatry, allostatic load regulation, autonomic function, and psychoneuroimmunological monitoring — selected for objective measurability, meta-analytic interventional support, identified mechanistic pathways, and population-level scalability. These domains form a mechanistically interconnected network in which deterioration in one can cascade across others. Clinical staging models, adapted from oncology, provide the graduated diagnostic architecture for condition-based care. We present a speculative multi-domain monitoring protocol with parameters, frequencies, and action thresholds calibrated to clinical stage. Among the five domains, inflammatory monitoring via C-reactive protein emerges as the most implementation-ready, with established clinical thresholds, demonstrated treatment-selection utility, and symptom-specific associations with neurovegetative features consistent with an immuno-metabolic depression subtype. Prospective multi-domain monitoring trials are identified as the most urgent research priority.

Background. Prosocial behavior, the tendency to act for others’ benefit, is essential for mental health. Although social contexts strongly shape prosocial behavior in healthy individuals, its relevance across psychiatric disorders remains unclear. We examined whether context-dependent prosocial behaviors were associated with baseline psychiatric symptoms and longitudinal symptom trajectories. Methods. In a one-year longitudinal cohort study, Swedish adults ( n =4484) with at least one self-reported psychiatric disorder completed standardized questionnaires of six prosocial behavior subtypes at baseline, followed by monthly reports of alcohol use, substance use, anxiety, and depression. Latent class linear mixed models identified longitudinal symptom trajectories, and logistic regression models investigated its associations with baseline prosocial behavior subtypes. All models adjusted for demographic covariates and shared variance across psychiatric symptom domains. Results. Three prosocial behavior subtypes showed longitudinal associations with stable psychiatric symptom classes. Higher anonymous prosociality was associated with lower odds of belonging to the stable high alcohol use trajectory (OR = 0.89, P = .013). Higher public prosociality was associated with higher odds of belonging to the stable high substance use trajectory (OR = 1.15, p = .036). Higher emotional prosociality was associated with increased odds of belonging to the stable high anxiety trajectory (OR = 1.25, P < .001). No prosocial subtype was associated with depressive symptom trajectories. Conclusions. Context-dependent prosocial behaviors were associated with persistent levels of alcohol use, substance use, and anxiety symptoms. These findings suggest that specific prosocial behaviors may refine transdiagnostic models of social dysfunction by indexing stable patterns of psychiatric symptom burden.

Background: Intimate partner violence (IPV) is a major public health concern, and healthcare staff must be competent in identifying and responding to IPV. However, training opportunities to handle such cases remain limited. This study examined whether integrating a virtual patient (VP) simulation into nursing education improves confidence, self-efficacy, and knowledge in addressing IPV. Methods: In this randomized controlled trial (RCT), fifty-four nursing students (87% female) were randomly assigned to an intervention group ( n = 29) receiving a VP module in addition to standard training, or a control group ( n = 25) receiving standard training only. Students were assessed at baseline and after each educational activity: (1) a web-based module (both groups) (2), VP training for the intervention group while the control group had no corresponding module, and (3) a teacher-led seminar (both groups). Primary outcomes were confidence in asking about IPV, general self-efficacy, self-assessed knowledge, and objective knowledge. Linear mixed-effects models were used to analyse changes over time. Results: The VP group showed a significantly greater improvement in confidence in asking about IPV (between-group difference + 1.26, 95% CI 0.40–2.15; p = 0.010). Objective knowledge scores were consistently higher in the VP group, although the group × time interaction was not significant. General self-efficacy and self-assessed knowledge improved similarly in both groups. Conclusions: Integrating an interactive VP simulation into a nursing curriculum enhances learners’ confidence in addressing IPV and is associated with higher levels of factual knowledge. VP simulations may represent a scalable complement to conventional teaching for complex and sensitive clinical topics. Trial registration: ClinicalTrials.gov ID: NCT06706011.

Background: Routine outcome measurement is a core element of measurement-based care (MBC), yet its use in everyday psychiatric practice remains limited. Even minimal follow-up assessment is often missing despite explicit clinical guideline recommendations. Methods: We conducted a retrospective cohort study of 2431 adult outpatient episodes of depression treatment within Stockholm’s public mental health system (2020–2023). Guideline-concordant outcome measurement was defined as documentation of at least one Patient Health Questionnaire-9 (PHQ-9) or clinician-rated Montgomery–Åsberg Depression Rating Scale (MADRS) within 60 days of treatment initiation for all modalities, or within ten sessions for psychotherapy. Adherence rates were compared across antidepressant pharmacotherapy, face-to-face psychotherapy, and internet-based cognitive behavioral therapy (iCBT). Results: Among treatment episodes lasting ≥ 30 days (n = 2242), 28.2% included a PHQ-9 or MADRS within 60 days. Adherence was higher in psychological treatments (71.6%) than in pharmacotherapy (10.2%), χ²(1, N = 2242) = 865.14, p <.001, Cramer’s V = .62. Within psychotherapy, iCBT showed markedly greater adherence (80.1%) than traditional psychotherapy (18.0%), χ²(1, N = 656) = 146.00, p <.001, V = .47. When iCBT was excluded, adherence fell to 10.6% overall. Among psychotherapy episodes with ≥ 10 sessions (n = 482), 73.4% met the ten-session guideline, with 79.5% adherence in iCBT and 23.1% in traditional psychotherapy, χ²(1, N = 482) = 75.82, p <.001, V = .40. Younger clinicians (M = 39.8 vs. 46.8 years, p <.001) and psychologists (73%) showed higher adherence than physicians (10%) or other professions. Conclusion: Even under conservative criteria, minimal outcome measurement was documented in fewer than one-third of depression treatment episodes. Adherence was particularly low in pharmacotherapy and traditional psychotherapy but substantially higher in iCBT, reflecting the advantages of automated, integrated digital workflows. These findings underscore that policy guidelines alone are insufficient; scalable implementation of MBC requires integrated digital systems, structured workflows, and targeted clinician support.

Major depressive disorder and the anxiety disorders are highly prevalent, disabling and moderately heritable. Depression and anxiety are also highly comorbid and have a strong genetic correlation (r_g ≈ 1). Cognitive behavioural therapy is a leading evidence-based treatment but has variable outcomes. Currently, there are no strong predictors of outcome. Therapygenetics research aims to identify genetic predictors of prognosis following therapy. We performed genome-wide association meta-analyses of symptoms following cognitive behavioural therapy in adults with anxiety disorders (n = 972), adults with major depressive disorder (n = 832) and children with anxiety disorders (n = 920; meta-analysis n = 2724). We estimated the variance in therapy outcomes that could be explained by common genetic variants (h²_SNP) and polygenic scoring was used to examine genetic associations between therapy outcomes and psychopathology, personality and learning. No single nucleotide polymorphisms were strongly associated with treatment outcomes. No significant estimate of h²_SNP could be obtained, suggesting the heritability of therapy outcome is smaller than our analysis was powered to detect. Polygenic scoring failed to detect genetic overlap between therapy outcome and psychopathology, personality or learning. This study is the largest therapygenetics study to date. Results are consistent with previous, similarly powered genome-wide association studies of complex traits.

Major depressive disorder is heritable and a leading cause of disability. Cognitive behavior therapy is an effective treatment for major depression. By quantifying genetic risk scores based on common genetic variants, the aim of this report was to explore the utility of psychiatric and cognitive trait genetic risk scores, for predicting the response of 894 adults with major depressive disorder to cognitive behavior therapy. The participants were recruited in a psychiatric setting, and the primary outcome score was measured using the Montgomery Åsberg Depression Rating Scale-Self Rated. Single-nucleotide polymorphism genotyping arrays were used to calculate the genomic risk scores based on large genetic studies of six phenotypes: major depressive disorder, bipolar disorder, attention-deficit/hyperactivity disorder, autism spectrum disorder, intelligence, and educational attainment. Linear mixed-effect models were used to test the relationships between the six genetic risk scores and cognitive behavior therapy outcome. Our analyses yielded one significant interaction effect (B = 0.09, p < 0.001): the autism spectrum disorder genetic risk score correlated with Montgomery Åsberg Depression Rating Scale-Self Rated changes during treatment, and the higher the autism spectrum disorder genetic load, the less the depressive symptoms decreased over time. The genetic risk scores for the other psychiatric and cognitive traits were not related to depressive symptom severity or change over time. Our preliminary results indicated, as expected, that the genomics of the response of patients with major depression to cognitive behavior therapy were complex and that future efforts should aim to maximize sample size and limit subject heterogeneity in order to gain a better understanding of the use of genetic risk factors to predict treatment outcome.

A major challenge of mental health care is to provide safe and effective treatment with limited resources. The main purpose of this study was to examine a value-based approach in clinical psychiatry when evaluating a process improvement initiative. This was accomplished by using the relatively new time driven activity based costing (TDABC) method within the more widely adopted cost-effectiveness analysis framework for economic evaluation of healthcare technologies. The objective was to evaluate the cost-effectiveness of allowing psychologists to perform post-treatment assessment previously performed by psychiatrists at an outpatient clinic treating depression using internet-based cognitive-behavioral therapy (ICBT). Data was collected from 568 adult patients treated with ICBT for depression during 2013–2014. The TDABC methodology was used to estimate total healthcare costs, including development of process maps for the complete cycle of care and estimation of resource use and minute costs of staff, hospital space and materials based on their relative proportions used. Clinical outcomes were measured using the Patient Health Questionnaire depression scale (PHQ-9) before and after treatment and at 6-month follow-up. Cost-effectiveness analyses (CEA) was performed and the results presented as incremental net benefits (INB), cost-effectiveness acceptability curves (CEACs) and confidence ellipses to demonstrate uncertainty around the value of the organizational intervention. Taking into account the complete healthcare process (from referral to follow-up assessment), treatment costs decreased from $709 (SD = $130) per patient in 2013 to $659 (SD = $134) in 2014 while treatment effectiveness was maintained; 27% had achieved full remission from depression after treatment (PHQ-9 < 5) during both 2013 and 2014 and an additional 35% and 33% had achieved partial remission in 2013 and 2014, respectively. At follow-up, 42% were in full remission after treatment during both 2013 and 2014; an additional 35% and 33% were in partial remission during 2013 and 2014, respectively. Confidence ellipses occupied the south-east (SE) and south-west (SW) quadrants of the incremental cost-effectiveness plane at both post-treatment and at follow-up, indicating that the ICBT treatment was less costly and equally effective after staff reallocation. Treating patients to the target of full remission using psychologists instead of medical specialists for post-treatment assessment is cost-saving and consequently a more valuable use of limited resources. TDABC may be a useful tool for measuring resource costs, identifying quality improvement opportunities and evaluating the consequences of such initiatives. Combining TDABC with clinical outcome measures in CEA is potentially a useful approach in mental healthcare to estimate the value of process improvement initiatives.

Although the effectiveness of therapist-guided internet-based cognitive behaviour therapy (ICBT) for treating depression has been well documented, knowledge of outcome predictors and risk factors associated with lower treatment response is limited, especially when the treatment has been conducted within a naturalistic clinical setting. Identification of such factors is important for clinicians when making treatment recommendations. Data from a large cohort (N = 1738) of adult outpatients having been treated with ICBT for depression at an outpatient psychiatric clinic were analysed. A multilevel modelling approach was used to identify patient and treatment variables associated with the speed of recovery during treatment using weekly measurements of the Montgomery Åsberg Depression Rating Scale Self-Rated (MADRS-S). Adhering to the treatment, perceiving it as credible and working full-time emerged as predictors of a faster pace of recovery and were also associated with a lower level of depression at the end of treatment. Higher pre-treatment depression and sleep problems were associated with a greater improvement rate, but predicted higher depression after treatment. Having a history of psychotropic medication was associated with both slower improvement and higher post-treatment depression. Perceived credibility of ICBT is a strong predictor of treatment response. Assessing patient beliefs and expectations may be a useful aid for clinicians when identifying those who are more or less likely to benefit from ICBT. Helping patients improve expectations prior to treatment may be an important goal for clinicians during the initial assessment phase.

Internet-based cognitive-behavioral therapy (ICBT) has received increased attention as an innovative approach to improve access to evidence-based psychological treatments. Although the efficacy of ICBT for social anxiety disorder has been established in several studies, there is limited knowledge of its effectiveness and application in clinical psychiatric care. The purpose of this study was to evaluate the effectiveness of ICBT in the treatment of social anxiety disorder and to determine the significance of patient adherence and the clinic's years of experience in delivering ICBT. A longitudinal cohort study was conducted using latent growth curve modeling of patients (N = 654) treated with ICBT at an outpatient psychiatric clinic between 2009 and 2013. The primary outcome measure was the Liebowitz Social Anxiety Scale-Self-Rated. Significant reductions in symptoms of social anxiety were observed after treatment (effect size d = 0.86, 99% CI [0.74, 0.98]). Improvements were sustained at 6-month follow-up (d = 1.15, 99% CI [0.99, 1.32]). Patient adherence had a positive effect on the rate of improvement. A positive association between the clinic's years of experience with ICBT and treatment outcome was also observed. This study suggests that ICBT for social anxiety disorder is effective when delivered within the context of a unit specialized in Internet-based psychiatric care and may be considered as a treatment alternative for implementation within the mental health care system.