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EBMH notebook

Schizophrenia and the Art of War

2 Sep, 09 | by Steven Reid, Evidence-Based Mental Health

We have had a War on Terror, a War on Drugs, a War on Cancer, and a War on Poverty. We do have a mental health czar – it seems a czar is essential when forces need to be mobilized – but no War on Mental Illness as yet. Maybe we should…Mark Salter sees parallels in our responses to war and schizophrenia in his trenchant critique of the updated NICE guidance on the management of schizophrenia. You can find it on the EBMH homepage. The parallels are not especially favourable although he doesn’t mention lions or donkeys. Maybe he should…

The Holistic Prince and Mental Health

24 Feb, 09 | by Steven Reid, Evidence-Based Mental Health

I recently stumbled across the homepage for The Prince’s Foundation for Integrated Health and found this. Yes, HRH is coming to the rescue of mental health services in the UK by introducing guidelines on nutritional therapy, reflexology and aromatherapy. No specific mention of homeopathy or intercessory prayer but we live in hope. These guidelines will “set out the governance infrastructure for bringing these therapies into NHS mental health services and will provide a guide to service development”. Prince Charles’s partners in this venture are the Mental Health Foundation, Mind and of course the Royal College of Psychiatrists (of which he is the patron). The guidelines are due to be published in May but the funding comes from Lloyds TSB…oh dear.

St John’s wort has been discussed here before, but if you want a balanced overview of complementary treatments in mental health, Ursula Werneke’s article in Evidence Based Mental Health is this month’s Editor’s Choice (so it’s free to access). For a slightly more jaundiced view of alternative medicine in general David Colquhoun’s blog is well worth a look.

A Gorilla in the Mist

3 Nov, 08 | by Steven Reid, Evidence-Based Mental Health

Trying to find evidence to guide practice in mental health can be perplexing at the best of times. Take antidepressants for example: seemingly prescribed by the bucketload (170 million prescriptions issued per year in the US, 31 million in the UK) many GPs and psychiatrists will admit that when it comes to choice of drug, more often than not it’s a case of ‘suck it and see’. We may have a raft of sophisticated neuroimaging techniques but we still struggle to explain how they work and when it comes to predicting response – well that’s anybody’s guess.

These days, we view pharma-funded trials with a jaundiced eye, particularly when they are promoted by ‘key opinion leaders’ (to see one KOI meet his nemesis, take a look at the Carlat Psychiatry Blog), so I would recommend this month’s Editor’s Choice (that means it’s free to access) in Evidence-Based Mental Health. Simon Hatcher casts a critical gaze over the STAR*D trial, the largest study of treatments for depression ever undertaken. It is one of the new breed of pragmatic trials – studies that assign ‘real world’ patients to licensed drugs aiming to assess their effectiveness (do they work in real life?) rather than efficacy (do they work in ideal conditions?). Publicly funded, at a cost of $35 million, and enrolling almost 3000 participants STAR*D really is, as Hatcher states, the 300lb gorilla of antidepressant trials. So what does STAR*D tell us? Well, read the review to find out but it’s clear that quality is just as important as quantity.

A Place of Greater Safety

11 Sep, 08 | by Steven Reid, Evidence-Based Mental Health

In the current issue of EBMH John Markowitz makes an impassioned plea for the revival of inpatient psychiatry – which if trends in the US continue may soon become a thing of the past. He pours scorn on the idea that bed days and numbers have been cut because of increased clinical effectiveness and is convinced that the primary motivating factor is reduced costs. This is a view that will be shared, I’m sure, by many mental health professionals in the UK.

Psychiatric beds in England have been cut to about one fifth of the number available in the 1960s. Social and political pressures originally drove the reduction, with perhaps some help from the introduction of chlorpromazine. A principal aim of course was to close the asylums. As a junior doctor I worked in one of these forbidding institutions on the outskirts of London, shortly before its closure. I have to say my abiding memory of working there is one of plentiful space, greenery, and a fairly easy workload. A singular perspective though and anyone looking for a less nostalgic view should take a look at the recently published “Bedlam: London and It’s Mad” by Catherine Arnold. This richly anecdotal social history chronicles the development of the asylum to the Victorian institutions: with as many as 3000 beds these were warehouses where brutality and neglect were commonplace.

Care in the community, to use that rather trite label, is now widely regarded as the ideal model but what remains of inpatient psychiatry? With the development of community services and more stringent criteria for admission, only the most unwell and often most difficult patients get into hospital, an environment that you might struggle to call therapeutic. Unsafe, understaffed, and unsanitary: not surprisingly, newly trained nursing staff are keen to abandon ship as soon as possible and join the specialist community teams. Is ‘the patient experience’ on an inpatient ward really any better than what was provided 40 years ago? Cost, as Markowitz argues, is important and it remains the case that mental health struggles to attract funding, but we also have to ask what we want of inpatient services? Are psychiatric wards simply holding cells for the topping up of antipsychotics, or do we have more to offer?

Welcome to HeadtoHead

28 Jul, 08 | by BMJ

Welcome to HeadtoHead, the new blog for readers of Evidence-Based Mental Health. If talk of Mozilla, RSS feeds, or Web 2.0 (whatever was wrong with Web 1.0?) leaves you, like me, in a mild state of delirium, here is a quick definition: in a nutshell a blog (short for web-log) is a website that allows you to “post” comments, and then lists those comments in chronological order (I had a tutorial). Why are we blogging at EBMH? Well, the aim is to make the journal more interactive, immediate and responsive to what you, the reader, want. So feel free to join in and comment on any of the journal’s contents, or draw our attention to what else is going on in the world of mental health.

There is plenty to talk about in this issue. In EBMH notebook Hamish McAllister-Williams reviews a review. Not just any review, but the meta-analysis by Irvine Kirsch and colleagues that made headlines in the popular press and also drew fierce criticism from many. Are antidepressants really no better than placebo? Or is it all a matter of interpretation – do you see a full glass or an empty one? Whatever your thoughts on the study, six months later and after so much publicity, has this paper had any effect on your clinical practice or prescribing of antidepressants?

Meanwhile, speaking of meta-analyses, Peter Tyrer, Editor of the British Journal of Psychiatry, wants to knock them off the top rung of the evidence ladder. To muddle my metaphors even further, he views them as ‘interim stations on the evidence journey but never the final destination’. The role of the meta-analysis is to guide us toward undertaking better trials that will in turn provide definitive answers. I’m not sure the Cochranistas would agree.

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