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The Royal College of Psychiatrists Improving the lives of people with mental illness

Kaleidoscope November 2017


BJPsych November 2017We’ve seen a range of global natural disasters in recent months: the worst flooding in Bangladesh for a century, and hurricanes Irma and Harvey devastating the Caribbean. In Britain we got Storm Brian, which knocked over a hay-bale in Devon, but at least it allowed those unsung heroes in news-broadcasting to rush around the country to do breathless broadcasts with waves breaking over walls behind them. We shouldn’t get smug: global warming is increasing the frequency of all such events, and there is growing focus on better post-disaster longitudinal management of physical health (especially spread of infectious disease) and mental health sequelae. One’s mental health can be impacted by natural disasters in several ways: as a direct result of the natural trauma, psychological hardships in the aftermath (think Puerto Rico), and through interruption to mental health services. Post-traumatic stress disorder is the obvious issue, but anxiety disorders are actually probably a greater problem. Kaleidoscope reviews a really great editorial from the Journal of the American Medical Association that argues our post-disaster efforts are misplaced: rather than focus on emergency mental health input, the devastation is an opportunity for much-needed social reorganisation, to improve infrastructure and services for those who were always in need, with or without a disaster.

Nocebo. The classic counter argument to antidepressant trials: they’re not really ‘blinded’ as trial participants on the drug feel side effects, recognise they’re in the active arm, and a placebo response takes over. The difficulty is that whilst a reasonable argument, how to test or counter it? Kaleidoscope reports on an interesting patient-level post-hoc meta-analysis that has attempted to do just that. What was different about this work was that they stratified participants by side-effect profile and compared those on placebo to those on the active compound but without any side-effects. The result? Drug beats placebo. Further, they sub-analysed by degree of side-effect to see if stronger drug-symptoms would produce a more effective compound (which the nocebo argument would suggest): this was not found. The authors propose that they’ve killed off the nocebo debate: we doubt that.

Far be it from the Kaleidoscope team to push political messages, but we also looked at research on the American DACA programme (the so-called ‘dreamers’ – children of illegal immigrants born in the US). Their future looks uncertain as changes in legislation mean they face deportation, even though they were born in the US and have no experience of life anywhere else. It’s very difficult to do research on this group for obvious reasons: they are understandably shy about answering messages from official bodies asking to speak to them. However a methodologically very clever study has found a way round this (it’s too complex to do justice to it here – read the full column), and shown that they are facing really very significant levels of mental distress – which is hardly surprising given their plight – but they are stuck as they are in a legal limbo, and fear accessing services in case it leads to deportation. All so very far away from us across an ocean – like Hurricane Harvey to Storm Brian – and it’s difficult to imagine there might be an analogy we could draw to a political situation closer to home.


November 2017 Kaleidoscope monthly Quiz (True or False)

Q1: Neurophysiology data (N400 event-related potentials on EEG) have been shown to be more accurate than pollsters in predicting individuals’ voting in the Brexit referendum.
A1: True. A brave new world beckons...

Q2: Patient-level meta-analysis of antidepressant trials has shown that, fitting with the ‘nocebo hypothesis’, in clinical trials the greater the perceived medication-induced side-effects, the greater the clinical response.
A2: False, this was not found, and the results undermine the nocebo hypothesis.

Q3: Cognitive Behavioural Therapy (CBT) is the go-to gold standard psychological intervention in depression. However, robust analyses suggest it typically produces only a 50% response rate.
A3: True.

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