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to support it. However, these factors must be considered when
deciding what is immediately implementable, versus that which
requires a supportive framework which has yet to be created.
All digital health research and claims are informative. Some
offer immediate solutions to health care that should be imple-
mented today and others highlight the potential of what may
be possible. However, blurring the line between actual and aspi-
rational can be counterproductive. Claiming that aspirational
digital health research is ready for immediate use can lead to
immediate negative results and broad disappointment. It may
even inadvertently contribute to digital health “hype” and foster
undue skepticism for the field.
However, ignoring digital health technologies with good evi-
dence for real-world implementation is a missed opportunity
for improving patient outcomes. Appreciating how aspiration-
al research can guide, inform, and inspire current efforts is
also important. Likewise, appreciating the real world success
of actualized efforts can help guide aspirational research to be
more translatable into health care systems.
There is no superior designation, as both ends of the actual
and aspirational spectrum have critical roles that cannot be sepa-
rated. However, the value of both depends upon correct identifi-
cation of where any given project lies on this spectrum – and
further consideration of populations sampled and incentives
used are critical to determining this.
John Torous
1
, Joseph Firth
2
1
Department of Psychiatry and Division of Clinical Informatics, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, MA, USA;
2
NICM, School of Science
and Health, Western Sydney University, Sydney, Australia
1. Lee JM, Hirschfeld E, Wedding J. JAMA 2016;315:1447-8.
2. Eyre HA, Singh AB, Reynolds C. World Psychiatry 2016;15:21-2.
3. Walch OJ, Cochran A, Forger DB. Sci Adv 2016;2:e1501705.
4. Kroenke K, Spitzer RL, Williams JB. J Gen Intern Med 2001;16:606-13.
5. Place S, Blanch-Hartigan D, Rubin C et al. J Med Internet Res 2017;19:e75.
6. Gustafson DH, McTavish FM, Chih MY et al. JAMA Psychiatry 2014;71:
566-72.
7. Ford JH II, Alagoz E, Dinauer S et al. J Med Internet Res 2015;17:e201.
DOI:10.1002/wps.20464
Compulsive sexual behaviour disorder in the ICD-11
During the last decade, there has been heated debate regarding
whether compulsive sexual behaviour should be classified as
a mental/behavioural disorder. Compulsive sexual behaviour
disorder has been proposed for inclusion as an impulse control
disorder in the ICD-11
1
. It is characterized by a persistent pattern
of failure to control intense, repetitive sexual impulses or urges,
resulting in repetitive sexual behaviour over an extended period
(e.g., six months or more) that causes marked distress or impair-
ment in personal, family, social, educational, occupational or
other important areas of functioning.
The pattern is manifested in one or more of the following: a)
engaging in repetitive sexual activities has become a central focus
of the person’s life to the point of neglecting health and personal
care or other interests, activities and responsibilities; b) the person
has made numerous unsuccessful efforts to control or signifi-
cantly reduce repetitive sexual behaviour; c) the person continues
to engage in repetitive sexual behaviour despite adverse conse-
quences (e.g., repeated relationship disruption, occupational con-
sequences, negative impact on health); or d) the person continues
to engage in repetitive sexual behaviour even when he/she derives
little or no satisfaction from it.
Concerns about overpathologizing sexual behaviours are
explicitly addressed in the diagnostic guidelines proposed for
the disorder. Individuals with high levels of sexual interest and
behaviour (e.g., due to a high sex drive) who do not exhibit
impaired control over their sexual behaviour and significant
distress or impairment in functioning should not be diagnosed
with compulsive sexual behaviour disorder. The diagnosis
should also not be assigned to describe high levels of sexual
interest and behaviour (e.g., masturbation) that are common
among adolescents, even when this is associated with distress.
The proposed diagnostic guidelines also emphasize that com-
pulsive sexual behaviour disorder should not be diagnosed bas-
ed on psychological distress related to moral judgments or
disapproval about sexual impulses, urges or behaviours that
would otherwise not be considered indicative of psychopathol-
ogy. Sexual behaviours that are egodystonic can cause psycho-
logical distress; however, psychological distress due to sexual
behaviour by itself does not warrant a diagnosis of compulsive
sexual behaviour disorder.
Careful attention must be paid to the evaluation of individu-
als who self-identify as having the disorder (e.g., calling them-
selves “sex addicts” or “porn addicts”). Upon examination, such
individuals may not actually exhibit the clinical characteristics
of the disorder, although they might still be treated for other
mental health problems (e.g., anxiety, depression). Additionally,
individuals often experience feelings such as shame and guilt in
relationship to their sexual behaviour
2
, but these experiences
are not reliably indicative of an underlying disorder.
The proposed diagnostic guidelines also assist the clinician
in differentiating compulsive sexual behaviour disorder from
other mental disorders and other health conditions. For example,
although bipolar disorder has been found at elevated rates
among individuals with compulsive sexual behaviour disor-
der
3
, sexual behaviours must be persistent and occur indepen-
dently of hypomanic or manic episodes to provide a basis for a
possible diagnosis of the disorder. A diagnosis of compulsive
sexual behaviour disorder should not be made when the be-
haviour can be explained by other medical conditions (e.g., de-
mentia) or by the effects of certain medications prescribed to
treat specific medical conditions (e.g., Parkinson’s disease)
4
or
is entirely attributable to the direct effects of illicit substances
World Psychiatry 17:1 - February 2018 109
on the central nervous system (e.g., cocaine, crystal metham-
phetamine).
Currently, there is an active scientific discussion about wheth-
er compulsive sexual behaviour disorder can constitute the
manifestation of a behavioural addiction
5
. For ICD-11, a rela-
tively conservative position has been recommended, recogniz-
ing that we do not yet have definitive information on whether
the processes involved in the development and maintenance
of the disorder are equivalent to those observed in substance
use disorders, gambling and gaming
6
. For this reason, compul-
sive sexual behaviour disorder is not included in the ICD-11
grouping of disorders due to substance use and addictive be-
haviours, but rather in that of impulse control disorders. The
understanding of compulsive sexual behaviour disorder will
evolve as research elucidates the phenomenology and neuro-
biological underpinnings of the condition
7
.
In the absence of consistent definitions and community-
based epidemiological data, determining accurate prevalence
rates of compulsive sexual behaviour disorder has been diffi-
cult. Epidemiological estimates have ranged up to 3-6% in
adults
8
, though recent studies have produced somewhat lower
estimates of 1 to 3%
9
. The more restrictive diagnostic require-
ments proposed for ICD-11 would be expected to produce low-
er prevalence rates.
In general, men exhibit the disorder more frequently than
women, although robust data examining gender differences
are lacking. Additionally, higher rates of the disorder have
been noted among individuals with substance use disorders.
Among treatment seekers, the disorder negatively impacts
occupational, relationship, physical health and mental health
functioning. However, systematic data are lacking regarding
the prevalence of the disorder across different populations
and associated socio-cultural and socio-demographic factors,
including among non-treatment seekers.
Growing evidence suggests that compulsive sexual behaviour
disorder is an important clinical problem with potentially seri-
ous consequences if left untreated. We believe that including
the disorder in the ICD-11 will improve the consistency with
which health professionals approach the diagnosis and treat-
ment of persons with this condition, including consistency
regarding when a disorder should not be diagnosed. Legitimate
concerns about overpathologizing sexual behaviours have been
carefully addressed in the proposed diagnostic guidelines. We
posit that inclusion of this category in the ICD-11 will provide a
better tool for addressing the unmet clinical needs of treatment
seeking patients as well as possibly reduce shame and guilt
associated with help seeking among distressed individuals.
The proposed diagnostic guidelines will be tested in interna-
tional multilingual Internet-based field studies using standard-
ized case material, which will help to assess the generalizability
of the construct across different regions and cultures, and clini-
cians’ ability to distinguish it from normal variations in sexual
behaviour and from other disorders. Additional field studies in
clinical settings will provide further information about the clini-
cal utility of the proposed diagnostic guidelines for the disorder
among clinical populations.
Shane W. Kraus
1
, Richard B. Krueger
2
, Peer Briken
3
, Michael B. First
2
,
Dan J. Stein
4
, Meg S. Kaplan
2
, Valerie Voon
5
, Carmita H.N. Abdo
6
,
Jon E. Grant
7
, Elham Atalla
8
, Geoffrey M. Reed
9,10
1
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA;
2
Department
of Psychiatry, Columbia University, College of Physicians and Surgeons and New York
State Psychiatric Institute, New York, NY, USA;
3
Institute for Sex Research and
Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Ger-
many;
4
Department of Psychiatry, University of Cape Town and Groote Schuur Hos-
pital, Cape Town, South Africa;
5
Department of Psychiatry, University of Cambridge,
Cambridge, UK;
6
Department of Psychiatry, Faculty of Medicine, University of S~
ao Paulo,
S~
ao Paulo, Brazil;
7
Department of Psychiatry and Behavioral Neuroscience, University of
Chicago, Chicago, IL, USA;
8
Primary Care and Public Health Directorate, Ministry of
Health, Manama, Bahrain;
9
Department of Mental Health and Substance Abuse, World
Health Organization, Geneva, Switzerland;
10
Global Mental Health Program, Columbia
University Medical Center, New York, NY, USA
1. Grant JE, Atmaca M, Fineberg NA et al. World Psychiatry 2014;13:125-7.
2. Gilliland R, South M, Carpenter BN et al. Sex Addict Compulsivity 2011;18:
12-29.
3. Raymond NC, Coleman E, Miner MH. Compr Psychiatry 2003:44:370-80.
4. Weintraub D, Koester J, Potenza MN et al. Arch Neurol 2010;67:589-95.
5. Griffiths MD. Addict Res Theory 2012:20:111-24.
6. Kraus SW, Voon V, Potenza MN. Addiction 2016;111:2097-106.
7. Kraus SW, Voon V, Potenza MN. Neuropsychopharmacology 2016;41:
385-6.
8. Kuzma JM, Black DW. Psychiatr Clin N Am 2008;31:603-11.
9. Klein V, Rettenberger M, Briken P. J Sex Med 2014;11:1974-81.
DOI:10.1002/wps.20499
Decline in suicide mortality after psychiatric hospitalization for
depression in Finland between 1991 and 2014
Depression is the most important mental disorder in terms
of suicide mortality. Numerous studies over time have esti-
mated the lifetime risk of suicide in depression, including a
recent Danish national study
1
. Organization of services and
treatment practices for depression have undergone major
changes over the past decades, including remarkable growth
in the use of antidepressants, emphasis on community-based
services, and deinstitutionalization. Temporal trends in suicide
mortality among psychiatric patients with depression can be
expected, but have not been investigated.
We followed a Finnish population-based cohort of depres-
sive patients (N556,826), with a first lifetime hospitalization
due to depression between 1991 and 2011, up to the end of the
year 2014 (maximum follow-up: 24 years). Here we report both
cumulative risk of suicide and temporal trends in suicide mor-
tality.
110 World Psychiatry 17:1 - February 2018
