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Major depressive disorder (MDD) is a leading cause of morbidity and mortality. Shortfalls in treatment quantity and quality are well-established, but the specific gaps in pharmacotherapy and psychotherapy are poorly understood. This paper analyzes the gap in treatment coverage for MDD and identifies critical bottlenecks.
Seventeen surveys were conducted across 15 countries by the World Health Organization-World Mental Health Surveys Initiative. Of 35 012 respondents, 3341 met DSM-IV criteria for 12-month MDD. The following components of effective treatment coverage were analyzed: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) adequate severity-specific combination of both.
MDD prevalence was 4.8% (s.e., 0.2). A total of 41.8% (s.e., 1.1) received any mental health services, 23.2% (s.e., 1.5) of which was deemed effective. This 90% gap in effective treatment is due to lack of utilization (58%) and inadequate quality or adherence (32%). Critical bottlenecks are underutilization of psychotherapy (26 percentage-points reduction in coverage), underutilization of psychopharmacology (13-point reduction), inadequate physician monitoring (13-point reduction), and inadequate drug-type (10-point reduction). High-income countries double low-income countries in any mental health service utilization, adequate pharmacotherapy, adequate psychotherapy, and adequate combination of both. Severe cases are more likely than mild-moderate cases to receive either adequate pharmacotherapy or psychotherapy, but less likely to receive an adequate combination.
Decision-makers need to increase the utilization and quality of pharmacotherapy and psychotherapy. Innovations such as telehealth for training and supervision plus non-specialist or community resources to deliver pharmacotherapy and psychotherapy could address these bottlenecks.
While the idea that fictional works have ethical value dates back to Aristotle at least, the recent empirical evidence, outlined in our first chapter, that they nurture empathy and social understanding seems likely to be welcome news for the literary scholar. Teachers of literature, including teachers of literature in a foreign language, like myself, are often required by their managers, and more generally by the laws of the market, to package what they do in the language of employability and transferable skills, so scientific evidence for the quantifiable benefits of studying novels must surely be welcome. However, while it is true that various literary specialists have, in recent years, contributed meaningfully to the debate about whether engagement with literature can improve the empathy of readers, there is not yet much local evidence that university departments of English and modern languages are rewriting their prospectuses or projected learning outcomes to incorporate the new evidence that engagement with literary fiction can enhance the empathic capabilities and social cognition of their students. What explains this apparent modesty?
At first glance, reticence seems an odd attitude. The novel has, after all, been closely associated with the cultivation of sympathy, a forerunner and occasional near-synonym of empathy, for a very long time. George Eliot wrote, for example, that ‘the greatest benefit we owe the artist, whether painter, poet or novelist, is the extension of our sympathies’. For Eliot, art (including novels) offers ‘a mode of amplifying experience and extending our contact with our fellow-men beyond the bounds of our personal lot’. It is nonetheless true that literary scholars do not generally embrace the argument that reading novels makes us more empathetic. This reluctance can be caricatured as intellectual snobbery; it has been argued for example by one prominent commentator that literary scholars consider the idea of ‘the reading of fiction as an empathy expander and a force toward humanitarian progress’ to be ‘too middlebrow, too therapeutic, too kitsch, too sentimental, too Oprah’. Let us analyse this alleged phobia of the middlebrow and the sentimental on the part of literary scholars.
Firstly, every student and specialist in the field of literary studies knows that the very first rule of being a good reader is the maintenance of a degree of critical distance.
This book set out to see whether a close reading of literary texts could yield insights into the question of how, and possibly why, fiction engages affective sharing and mind-reading skills. On the basis of recent work in psychology and cognitive studies, the first chapter proposed an idea that, to my knowledge, has not been explored in those fields but that is likely to find fairly ready acceptance among literary scholars, at least once the terms of the argument are shifted from affective sharing and mind-reading to seduction and suspicion. This new but not new idea is that the closely connected skills of affective sharing and mind-reading are regularly brought into creative conflict by fictional texts, both at the thematic level and at the level of reception. In order to make its case, this book proposed, in its third chapter, that literary texts can thematise their own reception in the representation of responses inspired by a stranger figure who is closely associated with fiction. Close readings of three novels were subsequently proposed by way of illustration. This concluding chapter will outline a couple of general conclusions about the fiction–empathy relationship that might tentatively but plausibly be drawn from this book's close readings of fictional responses to fictional stranger figures. It will also ask, in closing, what specific contributions this study might be considered to make to the wider cross-disciplinary conversation on the subject of the relationship between fiction and empathy.
The Limits of Mind-Reading
As discussed in the chapter on La Fille aux yeux d’or, the realist novel appears to promise total legibility of character, and of the social world more generally. However, the more or less realist fictions selected for study here show us on an explicit, thematic level that characters, and by extension people, can be other than they seem, and resistant to mindreading. Whether or not Henri finally succeeds in deciphering the truth of Paquita's desire is a moot point. Julien's motivations for shooting Madame de Rênal remain opaque at the end of Le Rouge et le Noir, not least to himself. Even the generous nature of Ralph's intentions towards Indiana is at least partially thrown into doubt by elements in his self-presentation.
This book studies recent psychological findings which suggest that reading fiction cultivates empathy, encouraging us to be critically reflective, suspicious readers as well as participatory, 'naïve' readers.
In one of Balzac's novels, he personifies the nineteenth century as a questing surgeon or archaeologist:
There played out in La Baudraye one of those long and monotonous conjugal tragedies that would remain unknown for all eternity if the avid scalpel of the nineteenth century, driven by the need to find the new, did not go searching in the darkest corners of the heart or, if you prefer, those parts that the discretion of previous centuries had respected.
As this passage indirectly suggests, Balzac's century was a time of accelerated scientific discovery: it saw revolutionary advances in the medical understanding of disease, for example, and in the fields of archaeology and palaeontology. It is no coincidence that hieroglyphs are referenced so frequently in Balzac's novels: the author was a contemporary of Jean-François Champollion, who in the 1820s effectively completed the decryption of the Rosetta Stone, thereby unlocking the secrets of hieroglyphic script. Indeed, Balzac considered his own role as a writer to be one of quasi-scientific exploration; he compared his novelistic project to the investigations undertaken by his older contemporary, the French zoologist Geoffroy Saint-Hilaire, and used the metaphor of the scalpel, tacitly in the above passage and more explicitly elsewhere, to describe the observational skills of the novelist.
Balzac's writerly scalpel was just as avid and as lacking in discretion as the one he attributes to the nineteenth century in the passage quoted above. Not only are his novels driven by a desire for knowledge, they also appeal very shrewdly to the reader's own curiosity. Barthes has written about the operation of what he calls the hermeneutic code in the classic (and, as it happens, Balzacian) novel: this is the set of textual elements that both construct a question and then lead towards– and present obstacles to– its answer. Balzac's novels characteristically present enigmas, which they then proceed to solve, thereby following the basic structure of a detective novel (not coincidentally an invention of the nineteenth century) or, as Barthes puts it, a striptease (which also, as it happens, has its origins in the nineteenth century).
Stendhal, who as well as being a novelist, literary critic and would-be playwright, wrote extensively about the visual arts and enthusiastically about music, placed emotional experience at the heart of the aesthetic encounter. On the one hand, he gave emotion a fundamental role in artistic creation. Stendhal described passion as ‘the possibility and the subject of the fine arts’. On the other hand, emotion played a key role in aesthetic reception for this author. In one of his autobiographical works, the author compares the novel to a bow designed to produce music by acting upon the soul of its reader. When one views the work of Michelangelo, he claims, ‘the soul is agitated by sensations that it is not used to receiving through the eyes’. Stendhal famously believed that some people were more open than others to the experience of being moved, whether by a novel, a piece of music, a play or a painting: these sensitive souls, he suggests in various places, are ‘the Happy Few’. He argues for example that ‘an eye that knows how to see and a soul that knows how to feel’ are necessary in order truly to see what Michelangelo achieved on the Sistine Chapel ceiling. To be under forty years old was a distinct advantage in this respect, but a passionate disposition was decisive: ‘A passionate man who submits to the effect of the fine arts finds everything in his heart.’
For Stendhal, encounters with works of art tended to take the form of a sharing of emotion, which he associated with the phenomenon of ‘sympathie’, defined by him as ‘the ability to identify with another person’. Even the success of works that do not primarily appeal to sympathy could depend upon this faculty, to the extent that attendance at a theatre or concert could produce a ‘nervous sympathy’ or ‘reciprocal sympathy’ felt with other people in the room. Novel-reading lacked this collective dimension, but could nevertheless itself be a rich source of sympathetic communication. For example, Stendhal included fictional characters, whether on the stage or on the page, among those to whom a reader's sympathy might be extended:
If the [stage] character appears in the slightest way to think about his style, mistrust emerges, sympathy flees, and pleasure in the drama disappears.
Of all of George Sand's novels, only one– her first as a solo author– can be considered predominantly realist in its style, even if it is true that aspects of this first novel also undermine its realism. From its first chapter, Indiana presents a world that is, ostensibly at least, legible in its every detail, not least because it is mediated by a narrator who adopts the recognisably all-knowing and seductive tone of the Balzacian omniscient narrator. Both narrator and characters regularly decipher facial expressions and the messages conveyed by glances or bodily movement, and in fact the performance of, and obstacles to, mind-reading are central to the novel's plot. The novel also makes a theme of narrative seduction, in its depiction of the charming but duplicitous Raymon de Ramière. This chapter will argue that Indiana both suggests that narrative seduction is to be resisted and highlights the limits of mind-reading.
There are two very obvious figures of the stranger in Indiana: both the eponymous heroine and Noun, her childhood companion and maid, are designated as ‘créoles’ (creoles) from Île Bourbon (now Réunion). Indiana is of European origin, her father having moved from Spain to the French colony, while there are numerous suggestions that Noun is of African origin. In Sand's representation, both heroines are perceived by other characters as foreign to different degrees. These figures will not be the main focus of study in this chapter, however, because there are two other stranger figures who are more closely associated in the novel with pretence, and who might therefore serve as more appropriate figures of fiction in the text.
The ability to seduce others is particularly closely linked, in this novel, to the ability to arouse the sympathy of others. One male protagonist has no difficulties in attracting either erotic partners or friends, while the other is defined by his lack of erotic charm as well as by his inability to inspire any feelings of sympathy in those around him. This chapter will begin by arguing that the character of Raymon, in Indiana, is one of two fiction-connoted figures of the stranger in the novel, and that he embodies the dangerous seductions of fiction. Indiana and Noun both fall for him; only the former survives the encounter, due at least in part to a capacity for resistance that appears to be innate.
What is a stranger, and on what basis might a fictional stranger be understood as a figure of narrative fiction?
For the sociologist and philosopher Georg Simmel, the stranger is somebody who has come from outside the group: he brings qualities into a group ‘that are not, and cannot be, indigenous to it’. The OED defines the stranger along these lines: he is a ‘a foreigner; an alien’, ‘a newcomer’ or an ‘unknown person’. The French word for stranger, ‘l’étranger’, doubles up to mean ‘foreigner’, and therefore conveys more strongly than in English the sense that the stranger is an outsider from the perspective of a particular group. In the modern world, however, where individuals can belong to numerous groups, often in an ephemeral or virtual way, most of us define strangers simply as people we don’t (yet) know, rather than as outsiders: most of the people that many of us see every day are strangers in this banal sense. As the social scientist Margaret Wood put it in 1934, ‘everyone outside of the city-dweller’s own relatively small circle of friends and acquaintances is a stranger to him’, so that ‘there is no distinction as between the group and the stranger or between host and guest’. Anyone who is not an acquaintance of mine is therefore a stranger to me. However, in certain situations we can become keenly aware of other people as strangers in a stronger sense. For example, the friendly man at the cash register in the supermarket does not become a fully fledged stranger, to my mind, until he asks me a question that I find inappropriately personal (‘Will you be sharing that chocolate cake with anyone special?’). The woman standing behind me in the post office queue is simply somebody I don't know, until she asks if she can try on my watch to see how it looks on her wrist. People I don't know have suddenly become people that I am aware I don't know: unless I am a very trusting individual, I am likely to consider their possible motivations before deciding how to respond to them. Could they have a hidden agenda?
For a long time, it has been suspected that exposure to fiction, and particularly literary fiction, has a valuable social function. This is one of the reasons why novels and short stories have featured, historically, on school curricula, why prison reading groups are considered a good thing and why student doctors can be required to read novels as part of their training. Efforts to quantify the social effects of engagement with fiction– often understood narrowly as narrative fiction in prose, or even more narrowly as literary prose fiction, but also regularly understood to include film and television drama– have become intensive over the past two decades. Various studies have found that people who engage frequently with fiction tend to have better social cognition or empathy than those who do not. As this wording suggests, preliminary experiments only proved correlation, rather than any causal relation, between exposure to fiction and capacity for empathy; in other words, it was possible that fiction-readers performed better on empathy tests simply because empathetic people are more likely than others to be drawn to fictional stories, rather than because fiction actively nurtures empathy. From 2012 onwards, however, psychological studies began to point more forcefully towards the existence of a causal link between exposure to fiction and the development of empathy.
One 2013 Dutch study, entitled ‘How Does Fiction Reading Influence Empathy?’, set out to ascertain whether the experience of emotional transportation while reading fiction would produce a measurable change in participants’ empathy levels one week after the event. This study proposed that fiction-readers who experienced emotional transportation while reading were likely to have integrated, over the following days, the fictional world into their own mental and emotional universes, thereby opening themselves up to the possibility of change. Using a standard self-reported empathy test, the degree of ‘empathic concern’ of each participant was measured directly before, directly after and one week after reading either a narrative fiction or a newspaper account. The study indicated that readers who had reported high levels of emotional involvement in the fictional story also reported an increase in their level of empathic concern one week later. The results of this study appeared to indicate causal links between emotionally involved fiction reading and higher levels of empathy.
Disturbed sleep and activity are prominent features of bipolar disorder type I (BP-I). However, the relationship of sleep and activity characteristics to brain structure and behavior in euthymic BP-I patients and their non-BP-I relatives is unknown. Additionally, underlying genetic relationships between these traits have not been investigated.
Relationships between sleep and activity phenotypes, assessed using actigraphy, with structural neuroimaging (brain) and cognitive and temperament (behavior) phenotypes were investigated in 558 euthymic individuals from multi-generational pedigrees including at least one member with BP-I. Genetic correlations between actigraphy-brain and actigraphy-behavior associations were assessed, and bivariate linkage analysis was conducted for trait pairs with evidence of shared genetic influences.
More physical activity and longer awake time were significantly associated with increased brain volumes and cortical thickness, better performance on neurocognitive measures of long-term memory and executive function, and less extreme scores on measures of temperament (impulsivity, cyclothymia). These associations did not differ between BP-I patients and their non-BP-I relatives. For nine activity-brain or activity-behavior pairs there was evidence for shared genetic influence (genetic correlations); of these pairs, a suggestive bivariate quantitative trait locus on chromosome 7 for wake duration and verbal working memory was identified.
Our findings indicate that increased physical activity and more adequate sleep are associated with increased brain size, better cognitive function and more stable temperament in BP-I patients and their non-BP-I relatives. Additionally, we found evidence for pleiotropy of several actigraphy-behavior and actigraphy-brain phenotypes, suggesting a shared genetic basis for these traits.
The Late Formative period immediately precedes the emergence of Tiwanaku, one of the earliest South American states, yet it is one of the most poorly understood periods in the southern Lake Titicaca Basin (Bolivia). In this article, we refine the ceramic chronology of this period with large sets of dates from eight sites, focusing on temporal inflection points in decorated ceramic styles. These points, estimated here by Bayesian models, index specific moments of change: (1) cal AD 120 (60–170, 95% probability): the first deposition of Kalasasaya red-rimmed and zonally incised styles; (2) cal AD 240 (190–340, 95% probability): a tentative estimate of the final deposition of Kalasasaya zonally incised vessels; (3) cal AD 420 (380–470, 95% probability): the final deposition of Kalasasaya red-rimmed vessels; and (4) cal AD 590 (500–660, 95% probability): the first deposition of Tiwanaku Redwares. These four modeled boundaries anchor an updated Late Formative chronology, which includes the Initial Late Formative phase, a newly identified decorative hiatus between the Middle and Late Formative periods. The models place Qeya and transitional vessels between inflection points 3 and 4 based on regionally consistent stratigraphic sequences. This more precise chronology will enable researchers to explore the trajectories of other contemporary shifts during this crucial period in Lake Titicaca Basin's prehistory.
Children vary in the extent to which they benefit from parenting programs for conduct problems. How does parental mental health change if children benefit less or more? We assessed whether changes in conduct problems and maternal depressive symptoms co-occur following participation in the Incredible Years parenting program. We integrated individual participant data from 10 randomized trials (N = 1280; children aged 2–10 years) and distinguished latent classes based on families' baseline and post-test conduct problems and maternal depressive symptoms, using repeated measures latent class analysis (RMLCA) and latent transition analysis (LTA). Classes differed mainly in severity of conduct problems and depression (RMLCA; 4 classes). Conduct problems reduced in all classes. Depressive symptoms did not change in most classes, except in a class of families where conduct problems and depression were particularly severe. Incredible Years led to a greater likelihood of families with particularly severe conduct problems and depression moving to a class with mild problems (LTA; 3 classes). Our findings suggest that for the majority of families, children's conduct problems reduce, but maternal depressive symptoms do not, suggesting relative independence, with the exception of families with severe depression and severe conduct problems where changes for the better do co-occur.
A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.
Neighbourhood greenness or vegetative presence has been associated with indicators of health and well-being, but its relationship to depression in older adults has been less studied. Understanding the role of environmental factors in depression may inform and complement traditional depression interventions, including both prevention and treatment.
This study examines the relationship between neighbourhood greenness and depression diagnoses among older adults in Miami-Dade County, Florida, USA.
Analyses examined 249 405 beneficiaries enrolled in Medicare, a USA federal health insurance programme for older adults. Participants were 65 years and older, living in the same Miami location across 2 years (2010–2011). Multilevel analyses assessed the relationship between neighbourhood greenness, assessed by average block-level normalised difference vegetative index via satellite imagery, and depression diagnosis using USA Medicare claims data. Covariates were individual age, gender, race/ethnicity, number of comorbid health conditions and neighbourhood median household income.
Over 9% of beneficiaries had a depression diagnosis. Higher levels of greenness were associated with lower odds of depression, even after adjusting for demographics and health comorbidities. When compared with individuals residing in the lowest tertile of greenness, individuals from the middle tertile (medium greenness) had 8% lower odds of depression (odds ratio 0.92; 95% CI 0.88, 0.96; P = 0.0004) and those from the high tertile (high greenness) had 16% lower odds of depression (odds ratio 0.84; 95% CI 0.79, 0.88; P < 0.0001).
Higher levels of greenness may reduce depression odds among older adults. Increasing greenery – even to moderate levels – may enhance individual-level approaches to promoting wellness.
To identify, in caregivers of patients with Alzheimer’s disease (AD) dementia, factors associated with subjective (personal, physical, emotional, and social) and objective (informal caregiver time and costs) caregiver burden.
Prospective longitudinal European observational study: post-hoc analysis.
Community-dwelling patients in France and Germany aged ≥ 55 years (n = 969) with probable AD and their informal caregivers.
Mini-Mental State Examination (MMSE), Alzheimer’s Disease Cooperative Study—Activities of Daily Living (ADCS-ADL), 12-item Neuropsychiatric Inventory (NPI-12), Zarit Burden Interview (ZBI), informal caregiver basic and instrumental ADL hours (Resource Utilization in Dementia instrument), and informal caregiver costs. Mixed-effect models of repeated measures (MMRM) were run, including baseline and time-dependent covariates (change from baseline [CFB] to 18 months in MMSE, ADCS-ADL, and NPI-12 scores) associated with CFB in ZBI score/informal caregiver time over 36 months (analyzed using linear regression models) and informal caregiver costs over 36 months (analyzed using generalized linear models).
Greater decline in patient function (ADCS-ADL) over 18 months was associated with increased subjective caregiver burden (ZBI), hours, and costs over 36 months. Increased behavioral problems (NPI-12) over 18 months also negatively impacted ZBI. Cognitive decline (MMSE) over 18 months did not affect change in caregiver burden.
Long-term informal caregiver burden was driven by worsening functional abilities and behavioral symptoms but not cognitive decline, over 18 months in community-dwelling patients with AD dementia. Identifying the drivers of caregiver burden could highlight areas in which interventions may benefit both caregivers and patients.