Wednesday, August 10, 2022

Sensible risk management in mental health

Hawton et al (2022) discuss why reliance on risk prediction of suicide in clinical practice has failed and outline an alternative therapeutic risk assessment, formulation and management model, which uses a person-centred approach. The focus on risk prediction and documenting risk assessment has actually misdirected the effort to prevent suicide.

Time needs to be spent on gaining therapeutic alliances rather than ticking boxes. Risk assessment is not a separate process from a full psychiatric history and mental state examination and formulation. A psychiatric management plan includes planning for safety. 

An ever more rigid and bureaucratic interpretation of risk assessment has been counterproductive, even destructive. Merely knowing about risks, even if these could be calculated precisely, may not improve practice. The fear that things may go wrong in mental health services has distracted from the task of actually making things better for people. Health care is more than a case of following rules and procedures. Conditions to improve patient safety are those that facilitate staff to bridge gaps in care, not the reverse. Risk management is actually the management of uncertainty, not the creating of an illusion of certainty.

Monday, August 08, 2022

Individual response to antidepressants in clinical trials

Stone et al (2022) provide data on response distributions of individual participants in antidepressant trials. It confirms previous data that shows a small 1.75 point random effects difference on the Hamilton Rating scale between drug and placebo (see previous post). The best fitting model of response distributions was three normal distributions, with mean improvements from baseline to end of treatment of 16.0, 8.9, and 1.7 points. These distributions were designated Large, Non-specific, and Minimal responses, respectively. Participants who were treated with a drug were more likely to have a Large response (24.5% v 9.6%) and less likely to have a Minimal response (12.2.% v 21.5%).

It’s important to keep in mind that this is only a best fit model and not necessarily think about it too absolutely. Also, this is not new data proving that antidepressants “work”, even if only for those that have a large or minimal response. As is said in the paper, it is still not possible to exclude the possibility that the effects of antidepressants are accounted for by functional unblinding. The placebo amplification hypothesis could still be a valid explanation of the antidepressant data (see eg. previous post). Raters' expectations and patients' suggestibility could entirely explain the small effect size found.

Stone et al suggest if the placebo amplification hypothesis is true that we "might expect shifts in the means of the response distributions for active drug relative to placebo”, which were not found. However, I'm not sure if this is true as I’m unclear if any lack of shift could instead be a result of the model. To my mind, those in the large or minimal groups could actually be the ones that are more likely to unblinded, whereas the nonspecific group essentially remains blinded. 

Florian Naudet in a useful Twitter thread emphasises that we need to start from the fact that it has been known for a long time that mean antidepressant effects in clinical trials are small. The limitations, at least, of antidepressants do need to be acknowledged. If the further claim that antidepressants are no better than placebo is true (which I think it may well be), it would have extraordinary implications for clinical practice (see eg. previous post). This is why people find it very difficult to consider that antidepressants may be no better than placebo. People do not want to undermine their faith in antidepressants (see another previous post).

Sunday, August 07, 2022

Radical reform of psychiatry in Italy and beyond

Excellent podcast interview with John Foot on the politics of Franco Basaglia, based on his book (see eg. previous post). Asylums have closed across the world but as John says there is a need for a new movement.

Tuesday, August 02, 2022

Improving the draft Mental Health bill

The draft Mental Health Bill for England and Wales currently undergoing parliamentary scrutiny (see eg. previous post), essentially amounts to an amendment of current legislation. I would have preferred (see eg. previous post) if the government had been more ambitious and looked to replace both the current the Mental Health Act (MHA) and the Mental Capacity Act (MCA). 

As I've also mentioned previously (see post), the Victoria state government in Australia is enacting a new Mental Health and Wellbeing bill, now published in its second reading. I find it an impressive document. It has very clear principles, including decision making principles for treatment and intervention, laid out on the face of the Act, which is not really the case for the draft Mental Health bill, although the White paper said it would do this (see another previous post). As I've also said before, the right to a second opinion from any psychiatrist on both detention and treatment is being strengthened in Victoria, whereas the draft bill does not go far enough in this respect (see eg. previous post). 

The Joint Committee on the draft Mental Health bill has called for evidence (see webpage). It wants to hear views on how the draft Bill could be improved, and how issues identified could be resolved. It lists particular areas of interest but answers do not need to be confined to those topics. Response are required by 16 September 2022.