Highlights of this issue

Impact of treatments for depression

In order to identify predictors of electroconvulsive therapy response and remission in major depression, van Diermen et al (pp. 71–80) conducted a meta-analysis, including 34 studies. The authors identified two factors – the presence of psychotic features and older age – that predicted both remission and response. Depression severity was found to predict response but not remission, and the findings were inconclusive for depression with melancholic features. The authors noted the large number of small studies including only a limited range of potential predictors and call for future research efforts to be focused on conducting larger studies considering the combined effect of a range of predictors.

Chronic prescription opioid analgesic use (OAU) is known to be associated with depression; the two being likely to be mutually reinforcing. Whether or not adhering to antidepressant treatment for depression can lead to opioid cessation was considered by Scherrer et al (pp. 103–111) in a retrospective cohort analysis. Among 2821 patients with non-cancer, non-HIV pain and a new episode of depression following >90 days of OAU and leading to at least one antidepressant prescription, antidepressant adherence was associated with a subsequent increased incidence of opioid cessation compared with non-adherence. The authors highlight the calculated number-needed-to-treat – for every 20 patients adherent to antidepressant medication, one will stop OAU who would not have stopped if they had been non-adherent.

Trials of guided self-help and web-based cognitive–behavioural therapy

The findings arising from two randomised controlled trials of cognitive–behavioural therapy (CBT) delivered other than by an individual face-to-face approach are presented in the Journal this month – one focused on chronic fatigue syndrome (CFS) and one on low mood and stress. Janse et al (pp. 112–118) examined whether or not the known benefit of face-to-face CBT on fatigue in CFS is also seen when the intervention is delivered online. Compared with a waiting-list control group, those receiving either of two internet-based CBT conditions (with protocol-driven therapist feedback or with therapist feedback on demand) showed a significant reduction in fatigue, with no difference found between the two internet-based CBT groups. The authors highlighted the additional finding that therapist feedback on demand required less therapist time, and also on the future possibilities of enhancing communication via video conferencing and using physical activity apps with affirmative feedback.

In the second reported CBT trial, Williams et al (pp. 88–95) found evidence of effectiveness and cost-effectiveness for guided self-help CBT classes for low mood and stress delivered in a community setting (the Living Life To The Full classes). The study's recruitment methods identified individuals in the community with depression, anxiety and impaired social function, who were often not prescribed medication and not attending their general practitioner. The authors call for further investigation of community-based interventions such as group guided self-help, which they describe as a promising addition to mental healthcare provision. In a linked editorial, Delgadillo (pp. 65–66) describes the emergence of an evidence-based self-help movement, considering the social and historical context of its development and the current scientific literature supporting its role in healthcare provision. The author calls for a commitment to scientific rigour, caution and ideological impartiality in the field, if the gains of the movement are to be further advanced.

Approaches to in-patient care and a cautionary note about the asylum returning

There has been a movement across the National Health Service in England away from ‘sectorised care’, where patients are treated by the same psychiatrist across both community and in-patient settings, towards a ‘functional care’ model, where care is provided to patients by different psychiatrists in the two settings. In a natural experimental study involving 23 hospitals across England, Bird et al (pp. 81–87) found that patient satisfaction with in-patient treatment was higher among those experiencing sectorised care, although the reduced length of in-patient stay also associated with sectorised care was no longer statistically significant when adjustment was made for clustering by hospital. The authors comment on the importance of patient satisfaction with care, both as an outcome in its own right and as an outcome associated with longer-term clinical outcomes, and call for the current trend of transforming services from sectorised to functional models to be reconsidered.

Gilhooley & Kelly (pp. 69–70) warn that rising rates of involuntary admission, the widespread use of physical coercion on in-patient units and the impact of changes in mental health legislation informed by a focus on public safety, are leading to concern that the restrictive institutional practices of the past are returning in many jurisdictions. The authors call for legal reforms and, in particular, the exclusion of personality disorder from legislation allowing for involuntary admission, as well as statutory restraint reduction programmes and clear communication of our limited ability to assess risk.