BJP Online -- Highlights of the Current Issue
- June 2017; Vol. 210, No. 6
- The complete Table of Contents for the current issue is available online at: http://bjp.rcpsych.org/content/vol210/issue6/ The following content is available online at: http://bjp.rcpsych.org/cgi/content/full/210/6/A23
Highlights of this issue
Kimberlie Dean Suicide – prediction and prevention
There is a strong focus in the BJPsych this month on the important topics of prediction and prevention of suicide. Carter et al (pp. 387–395) conducted a systematic review and meta-analysis of 39 risk scales used to predict suicidal behaviours, specifically with regard to examining the positive predictive values (PPVs) obtained from studies of these scales. The pooled PPVs for suicide, self-harm and self-harm plus suicide were all found to be too low to support the use of such risk scales as the basis of clinical intervention allocation decisions (ranging from 5.5% for suicide to 35.9% for the combined outcome). The authors propose alternatives to risk prediction stratification, recommending clinical assessment to identify modifiable risk factors and the provision of specific interventions tailored to selected self-harm subpopulations (e.g. those with borderline personality disorder) and to unselected clinical self -harm populations. In a multisite prospective cohort study of adults referred to liaison psychiatry services following self-harm, Quinlivan et al (pp. 429–436) found that the seven risk scales considered performed poorly with regard to prediction of repeat self-harm within 6 months (e.g. PPVs ranged from 13% to 47%). They found most scales performed no better than clinician or patient global ratings of risk and some actually performed worse. In a linked editorial, Owens & Kelley (pp. 384–386) comment on the mounting evidence supporting the avoidance of risk scales in clinical practice and instead recommend an individual-based 'needs assessment' approach following self-harm.
Moving from prediction of self-harm and suicide to prevention, Riblet et al (pp. 396–402) conducted a meta-analysis of randomised controlled trials (RCTs) of strategies employed to prevent death by suicide. Despite a recent increase in the number of RCTs targeting suicide, most interventions were not found to lead to a significant reduction in suicide events. Three RCTs found that the WHO brief intervention and contact (BIC) approach was associated with lower odds of death by suicide and a number of RCTs of lithium and cognitive–behavioural therapy produced positive but non-significant results. The authors comment on the small size of many trials and limited evidence for generalisability of findings across settings. In a linked editorial, Hawton & Pirkis (pp. 381–383) comment on the limitations of focusing only on the results of RCT-based evaluations of interventio ns given the likelihood that a broad range of approaches will be needed to prevent a complex problem like suicide across the range of universal, selective and indicated interventions. The authors call on researchers to complement the results of RCTs with findings from studies employing a range of methods and data from a variety of sources, as well as acknowledging that using suicide as an outcome may not be feasible for all intervention evaluations.
Ketamine and electroconvulsive therapy
In a previous systematic review and meta-analysis, increased seizure duration but a lack of efficacy was found for ketamine when used as an ECT adjunct in depression. In an updated review published in the BJPsych this month, McGirr et al (pp. 403–407) focused on RCTs examining the index course of ECT and specifically considered the role of barbiturate co-administration in limiting the efficacy of ketamine. Overall, the authors found no evidence to support using ketamine over other induction agents in ECT, with the lack of efficacy finding holding true when trials which included barbiturate anaesthetic co-administration were excluded. They also found evidence of an increase in reported confusion associated with ketamine use. In a new RCT of ketamine used as the anaesthetic agent for ECT, Fernie et al (pp. 422–428) found no significant differences between ketamin e and the control agent propofol on any outcome measure (i.e. depression severity, number of ECT treatments or memory impairment) either during, at the end or at 1 month following the course of ECT.
Treatment following a first episode of mania
Lithium and quetiapine are both considered standard maintenance agents for bipolar disorder but their comparative efficacy and roles at different stages of the illness course are insufficiently understood. In a sample of young people with first-episode mania stabilised with a combination of the two agents, Berk et al (pp. 413–421) undertook an RCT of lithium v. quetiapine during the maintenance phase of treatment and found an advantage for lithium in terms of symptom levels over 1 year. The authors comment on lithium's role as a 'gold standard' of bipolar maintenance treatment and highlight the particular role for lithium early in the course of illness, in those with severe illness and for those with a manic index polarity.
- May 2017; Vol. 210, No. 5
- The complete Table of Contents for the current issue is available online at: http://bjp.rcpsych.org/content/vol210/issue5/ The following content is available online at: http://bjp.rcpsych.org/cgi/content/full/210/5/A19
Highlights of this issue
Derek K. Tracy The psychosocial in psychosis
Longer-term outcomes in psychotic illnesses have scarcely improved in half a century. A primary reason is our general inability to ameliorate negative and cognitive symptoms that so heavily impact the factors by which we measure our lives: work, relationships and leisure activities. Mesolimbic hyperdopaminergia may be what Laruelle called the 'wind of the psychotic fire' in terms of positive symptomatology, but this is less predictive of quality of life, and antipsychotic medications have little useful effect elsewhere in the brain. Lutgens et al (pp. 324–332) update with a meta-analysis of 95 studies on psychological and psychosocial interventions for negative symptoms. The surveyed literature was of moderate quality overall, and with a high level of heterogeneity. Guidelines have typically advocated cognitive–behavioural therapy (CBT), and while this work supports that, skills-based interventions provid ed similar significant benefit over treatment as usual (TAU) in managing negative symptoms. The data that exist for exercise and music treatments were encouraging but limited, but there was no evidence to support neurocognitive, family-based or humour therapies. Interestingly, those with the greatest initial deficits showed the biggest gains: while such individuals clearly have the most room to improve, the finding goes (optimistically) against a clinical narrative that those with the more severe negative symptoms fare worst.
Lasalvia and colleagues advance this, reporting on the GET UP pragmatic cluster randomised controlled trial (pp. 342–349). This is a multi-element psychosocial intervention for individuals with a first psychotic episode, and had previously been reported to be feasible to implement and superior to TAU. Here, the authors tested whether particular sociodemographic or clinical factors predict or moderate response to such interventions. In their 'real world' setting, better education, reduced duration of untreated psychosis, and better premorbid adjustment and insight were predictors of positive outcomes more generally in the 444 completing patients. The only moderator of specific treatments was that the intervention provided additional improvements in psychopathology to those over the age of 35.
As part of the BJPsych's growing social media strategy (we'll be updating in more detail in a forthcoming editorial), we are now blogging with the Mental Elf each month: do check out Rachel Upthegrove's excellent piece on Lutgens et al's paper at http://bit.ly/bjpme3. You can join the conversation by commenting on the blog, or via the new journal twitter handle @TheBJPsych.
North by Northfield
Therapeutic communities are, for many younger psychiatrists, a historical footnote of Bion and colleagues' Northfield experiments, covered for College Membership training and examinations. They still exist, though unicorns may be more common in some parts of the country. Rex Haigh's editorial (pp. 313–314) reorientates us, providing a timely overview of their evolution, taking us to contemporary practice, and a move to enhancing evidence-based practice. Initially based on Rapoport's proposed themes of democratisation, permissiveness, reality confrontation, and communalism, those that have survived into the contemporary NHS now exist as day units with a focus on empowerment, openness and 'ordinariness'. Their scientific underpinnings have historically faced the challenge of being primarily qualitative and sociological, but Haigh notes the recent randomised controlled trial on their effectiveness in personality disorder . In a constrained healthcare budget, such research will need to continue, even if some practitioners may balk at 'selling' these complex interventions as 'commodities'.
Jumping to a very 21st-century intervention, and computerised CBT (cCBT) continues to attract interest as a potentially cost-effective and easily upscaled treatment in resource-scarce times. However, data from primary care trials show that engagement can be poor. The REEACT trial, the largest primary care trial of cCBT, failed to show any benefit over ordinary GP care, but it was argued that uptake in the study's real-world conditions was poor, and needed augmentation or support. Gilbody et al (pp. 362–367) tested the benefits of adding structured facilitation whereby a support worker provided weekly telephone calls alongside the computerised programme. The first of these calls lasted about half an hour, introducing participants to the programme, explaining the process, and helping identify participants' goals and potential difficulties; subsequent calls were briefer, aimed at motivating and problem-solving. They found th at this increased use of the therapy by a factor of 1.5 to 2 over just telephone technical support; at 4 months PHQ-9 scores were lower in those receiving the additional support, though these gains had dissipated by 12 months. The authors propose that the lack of benefit by the 1-year mark may be explained by the fact that most depressive episodes last less than this amount of time.
Mind and body, body in mind
Individuals with depression have greater rates of myocardial infarction (MI), but although they also commonly have poorer adherence to necessary post-MI lifestyle changes, any prognostic impact of depression upon survival has been poorly understood. The issue is important: while the incidence of MIs has significantly decreased in recent decades, the prevalence of survivors has increased. Sundbøll and colleagues (pp. 356–361) explored a Danish population-based cohort of over 170 000 patients with first-time MIs, of whom 6015 had a prior diagnosis of depression; the median age was just over 70, and follow-up was about 3 years. All comorbidities were more common in those with a history of depression, and they had a moderately increased all-cause mortality that was independent of depression severity and MI type.
Being teased by peers about one's weight is very common in young people, estimated to problematically occur for one in four. As well as other negative psychological sequelae, it has been considered to be a potentially powerful risk factor for subsequently developing an eating disorder. However, clearly not all who are so teased develop such problems, suggesting an interplay of these environmental factors with genetic susceptibility. Fairweather-Schmidt & Wade (pp. 350–355) modelled this in almost 700 adolescent female twins, with self-report questionnaires to parents, and telephone interviews with participating individuals. This was followed up with two further interview cycles, each about 1 year apart. Disordered eating was associated with teasing, and while both environment and genetics were important moderators of this, vulnerability varied primarily with the individual's genotype. Finally, more longitudinal outcomes are considered in this month's Kaleidoscope (pp. 375–376), with important and moving work describing the long-term outcomes of adults who faced enormous early-life deprivation in Ceausescu's Romanian orphanages of the 1980s.
BJP Online -- Highlights of the Current Issue
- February 2017; Vol. 210, No. 2
- The complete Table of Contents for the current issue is available online at: http://bjp.rcpsych.org/content/vol210/issue2/ The following content is available online at: http://bjp.rcpsych.org/cgi/content/full/210/2/A7
Highlights of this issue
Kimberlie Dean Intervening to address adversity associated with severe mental illness
Three papers in the BJPsych this month consider interventions to address aspects of adversity suffered by those with severe mental illness. Heslin et al (pp. 157–164) consider the potential costs associated with implementing three recommended service enhancements intended to improve care pathways for individuals with enduring mental health needs who have contact with the police. Using a case-linkage modelling methodology, the three enhancements (street triage, Mental Health Act assessments for all Section 136 detainees and outreach custody link workers) were each found to increase healthcare and policing costs to a marginal degree only – the cost per police incident was estimated to be £522. The authors comment on the possibility that any increase in costs associated with the enhancements considered might be offset by savings in other service areas.
The poor physical health of individuals with severe mental illness has been well established, with poor nutrition being an important target for prevention particularly in relation to obesity. Teasdale et al (pp. 110–118) undertook a systematic review and meta-analysis of randomised controlled trials (RCTs) of nutritional interventions in severe mental illness and found evidence that such interventions led to significant weight loss, reduced body mass index, decreased waist circumference and lowered blood glucose levels. The largest effect sizes were found for interventions led by a dietician and those delivered at antipsychotic initiation. In a linked editorial, Meader (pp. 94–95) comments on the current evidence that nutritional interventions are likely to be at least as effective, if not more effective, in people with severe mental illness compared with other populations, a nd calls for future research to address a number of unanswered questions regarding the important components of nutritional interventions and whether or not they should be considered in the context of other health risk behaviours.
Cognitive–behavioural therapy for psychosis (CBTp) has long been used to address the persistence of medication-resistant psychotic symptoms but has limitations. Shawyer et al (pp. 140–148) tested an emerging alternative psychological therapy – acceptance and commitment therapy (ACT) – in a sample of community-dwelling patients with persistent psychotic symptoms. Those randomised to receive ACT did not demonstrate any difference in overall mental state post-therapy compared with those receiving the befriending control intervention but did show greater improvement in positive symptoms and hallucination distress. The authors also highlight the implications of benefits seen in satisfaction and self-reported symptoms in the ACT group but note that expected changes in process measures were not seen.
Under-awareness and under-treatment of common mental disorders
Beyond dementia and depression, little is known about the occurrence of common mental disorders in elderly people. In a cross-sectional multicentre survey of men and women aged 65–84 years across a number of European centres, Andreas et al (pp. 125–131) found that one in two individuals had experienced lifetime mental disorder, one in three in the past year and one in four had evidence of current mental disorder. Anxiety disorders were the most prevalent followed by affective and substance-related disorders. The authors comment on the need to raise awareness of psychosocial problems in elderly populations and the need to adapt assessments to the cognitive capacities of individuals in this age range. Utilising data from the World Health Organization World Mental Health Surveys conducted in 21 countries, Thornicroft et al (pp. 119–124) identified evidence of signi ficant under-treatment of major depressive disorder (MDD) internationally, with only 16.5% of individuals with 12-month MDD receiving minimally adequate treatment. The proportion was much smaller in low-/lower-middle-income countries (1 in 27) despite the prevalence rates also being lower. The authors call for national and international organisations to make commitments to resourcing the scaling-up of service provision that is required to address the 'treatment gap' seen for people with MDD.
Interventions for depression and personality disorder
Depression screening plus patient-targeted feedback in patients with coronary heart disease or hypertension was found to be associated with greater improvements in depression severity and information seeking behaviour at 6 months after screening compared with a control group who did not receive written post-screening feedback (Löwe et al, pp. 132–139). The primary study hypothesis, improvement in depression 1 month after screening, was not supported by the study findings, however, and the clinical improvement seen at 6 months did not appear to be explained by differences in mental health treatment. The authors comment on the need for further research to replicate their study findings and to focus on investigating the underlying mechanisms of patient-targeted feedback. In a systematic review and meta-analysis by Fischer et al (pp. 105–109), cortisol levels prio r to starting psychological therapy for depression were found to be associated with an increased level of symptoms at the end of treatment and/or smaller symptom change. The authors comment on the possibility that cognitive impairment mediates the association found and suggest that future research should stratify patients according to their levels of childhood trauma to test whether their findings are driven by a specific patient subgroup.
Pearce et al (pp. 149–156) subjected democratic therapeutic community (DTC) treatment, used for many years to help individuals with personality disorder, to rigorous evaluation in an RCT and found that in-patient days at follow-up were low for both the intervention and the control condition (crisis planning plus treatment as usual) and did not differ. At 24 months however, aggression and satisfaction with care were both improved in the intervention group. In addition to the potential benefits identified, this study of DCT treatment has demonstrated that it is possible to overcome previously identified obstacles to carrying out an RCT, supporting the potential for a larger multicentre trial to be undertaken.
- January 2017; Vol. 210, No. 1
- The complete Table of Contents for the current issue is available online at: http://bjp.rcpsych.org/content/vol210/issue1/ The following content is available online at: http://bjp.rcpsych.org/cgi/content/full/210/1/A3
Highlights of this issue
Derek K. Tracy Medical models and model medics
Two topics always liable to get psychiatrists hot under the collar: throwing about the phrase 'biopsychosocial' and debating the merits (or otherwise) of functional splits in services. What does biopsychosocial mean to you? Engel coined it in 1977, and it's been a bit of an albatross ever since. Davies & Roache reassess (pp. 3–5), arguing that psychiatry uncomfortably spans biological and psychosocial perspectives on mental illness. They ask whether psychiatry is a science of brain or mind, of individual or society, of dysfunction or deviance. In a highly stimulating editorial they appraise four conceptual aspects: psychiatric classification, psychiatric causation, prevention and treatment of illness, and metaphysics. I'm not sure the biopsychosocial concept is uncomfortable but, like the term 'medical model', its pejorative accusatory misuse may well be. Many truths and levels of explanation can be held at the same time, even when they do not perfectly align: perhaps our responsibility is in whether and how we satisfactorily explain these to others.
Remember the halcyon days when consultants continued care from community to in-patient settings (and it was always sunny and there was no crime or rude behaviour, if memory serves)? Were they as good, or as effective, as some of us seem to recall? Tom Burns and Martin Baggaley debate (pp. 6–9). The widespread move to functional services was neither evidence based, nor the result of significant consultation, but fell from the 2000 NHS Plan (as did, in a similarly evidenceless manner, home treatment teams). Opinions tend to form behind preferred ideas of specialism versus continuity, effective throughput, and job satisfaction/burnout. The most fascinating thing is the lack of research to underpin either model or any of these issues. One figure stands prominent: 50% of the secondary mental healthcare budget is expended on the 3% of patients who are admitted to wards at any given time. That certainly infers a need for some robust work on the topic.
Evidence, bias and clinical practice
We are all signed-up evidence-based practitioners, immune to advertising and spin, caring only for P-values less than 0.05 (though I recommend reading David Colquhoun's investigation of the false discovery rate and the misinterpretation of P-values). Cristea et al test this (pp. 16–23), looking at the impact of sponsorship bias, taking the novel angle of looking at studies comparing medications with non-pharmacological treatments for depression. To date, no one had analysed trials including talking therapies: most investigations of sponsorship bias have focused on medication v. placebo studies (the principle being that there's more noise in the standard head-to-head non-inferiority work). They identified 45 suitable trials: those sponsored by industry favoured pharmacotherapy and, problematically, researchers had not disclosed relevant financial conflicts of interests in five of them.
Girlanda et al (pp. 24–30) take a different tack. Why, when we do have good evidence bases, do we not always follow through and implement in practice? (Oscar Daly's editorial on physical illness (pp. 1–2) exemplifies the problem.) There are multiple strategies for embedding guidelines, including disseminating them to staff, having formal educational sessions, audits of practice, and psychological evaluation of factors facilitating or inhibiting uptake. The authors systematically reviewed randomised controlled clinical trials and before-and-after studies evaluating guideline implementation. Fascinatingly there was not a consistent positive effect of guideline implementation on clinical performance. Under the aegis of the Royal College of Psychiatrists and NICE, the National Collaborating Centre for Mental Health is in the process of issuing guidelines on achieving better access to relevant pathways of care, moving beyond 'condition specific' advice (say, on depression). Will these prove more effective in positively enhancing our practice?
Call of duty or final fantasy?
Computer games often evoke the same type of vague and largely unsubstantiated worries and anxieties we find surrounding the topic of violence on television (the term 'screen time' will provoke nervous twitches in parents). All overblown hype? Kaleidoscope (pp. 87–88) reports on the first large study to test the proposed phenomenon of 'internet gaming disorder'. The data suggest that any risks of addiction are minimal – information you might wish to share with, or withhold from, a significant other or child, depending on who is stuck to the game console. Recently, there has been a lot of interest and publicity about the computer game Sea Hero Quest, a free to download (http://www.seaheroquest.com/en/) game testing visuospatial functioning, a key area of deficit in neurodegeneration, which provides data (from over 2.5 million people to date) to research teams at University College London and the University of East Anglia. It won't diagnose dementia, but it is an imaginative way to collect very big data-sets ('tech for good' will be 2017's neologism, replacing the now gauche and passé 'screen time'). However, this is a field filled with hype and even sober broadsheets got caught up in 'dementia cure' stories at the end of 2016 ('tantalising' seemingly the journalistic equivalent of 'statistically significant but with a small effect size'). So it is pleasing to read in this month's BJPsych the work of Huntley et al (pp. 61–66), who describe a novel cognitive training paradigm in Alzheimer's disease. Thirty patients with mild Alzheimer's disease were randomised to 8 weeks (18 sessions) of either so-called 'adaptive chunking training' or an active control intervention. Chunking is a technique of clust ering patterns of information, making it easier to hold in the limited stores of working memory. The novel intervention resulted in significant improvements in verbal working memory and, importantly, transferred to untrained general cognitive functioning. Neuroimaging data showed that the enhanced performance was accompanied by reduced functional brain activity in specified regions of activity, which can be inferred to represent more efficient cortical processing. It is heartening to see a practical, implementable intervention for Alzheimer's disease.
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