Scotoma in psychiatric practice and research

Stigma in practice-evidence-based care

The notion of recovery, either complete symptom absence or a personal process of self-care meeting aspirations despite the persistence of symptoms, can be improved by peer support. In this context, Corrigan et al (pp. 130–132) critiques the role of confrontation as a therapeutic strategy in abstinence-oriented approaches to recovery, reflecting a symptom-based definition of recovery that may not be entirely appropriate or helpful in addictions care services. The degree to which confrontation and abstinence reflect stigma or differing societal attitudes to substance misuse versus mental illness are gently and elegantly exposed. The expectation that confrontation is reasonable only in addictions care, and not appropriate in mental healthcare, seems problematic, not least as the two often coexist with other conditions and life experiences that are causally associated.

Societal and legal concepts of mental illnesses, and legislative protections, can sometimes be out of sync. Pugh et al (pp. 133–136) expose an oversight whereby patients receiving deep brain stimulation are not subject to the same legal protections afforded those receiving electroconvulsive therapy (ECT) or neurosurgical treatments. Thus, we find in practices, values and structural procedures that evidence stigma and oversights of the evidence. In a similar correctional editorial, Cox (pp. 127–129) updates recommendations for use of the Edinburgh Postnatal Depression scale, grounding these in observations of use and misuse. A modernisation of communications and care systems, the digitalisation of healthcare, and the relocation of care to the community and populations mandates the need to develop and validate online versions and to ensure research in community populations assesses the risks and benefits.

Adverse childhood experiences

Adverse childhood experiences (ACEs) include abuse, victimisation and violence. ACEs are precursors of adult psychopathology.^1–4 A school-based health survey in three provinces in China shows ACEs and low social support are together associated with non-suicidal self-injury, suicidal thinking and suicidal behaviours (Wan et al, pp. 146–152). A thoughtful analysis of a birth cohort of 1265 children in New Zealand, assessed from birth to the age of 35, finds severe childhood sexual abuse is associated with a greater incidence of psychotic experiences in adulthood, especially thought and perceptual symptoms. The associations between physical abuses and psychosis, the authors argue, were a reflection of confounders and time dynamic variables including mental health, substance misuse and life stress (Bell et al, pp. 153–158). The male Quebec Longitudinal Study followed 410 kindergarten children into adolescence and young adulthood (Langevin et al, pp. 137–145). The research team shows that cumulative effects of multiple haplotypes of serotonergic genes confer both risk and protections against male antisocial behaviour.

Electroconvulsive therapy

The BJPsych celebrated the start of 2019 with an exciting themed issue on treatment-resistant mood disorders. The collection provided a critique of the varying concepts and definitions of the terms ‘treatment’ or ‘multitherapy’ resistance, and provided some examples of new interventions and efforts to refine the staging of therapeutic efforts. Included were studies of antidepressant response, inflammatory markers, genome-wide association studies, augmentation therapies and new evidence on the role of ketamine, all to guide practice and inform policy. In the March issue, two excellent papers on ECT offer optimism and reassurances about this neglected but powerful therapeutic choice. ECT does not add to stroke risk, a real concern given ECT is used commonly among older patients with comorbid conditions (Rozing et al, pp. 168–170). There are suggestions that ECT induces neuroplastic changes in brain structures, and these may be implicated in both the therapeutic and potential adverse effects.^5–10 ECT is also used in conjunction with other treatments to offer a more powerful effect, for example, with clozapine in treatment-resistant schizophrenia,¹¹ although the combination with ketamine in treatment-resistant depression remains unproven.¹² Gryglewski et al (pp. 159–167) find increases in the volume of the right hippocampus, amygdala and putamen and increased thickness of the temporal, parietal and insular cortices of the right hemisphere, following right-sided unipolar ECT. These changes are implicated in the pathophysiology of mood- and stress-related disorders, while the regions identified are known to show high potential for neuroplasticity. Therefore, the findings may be revealing trait markers for therapeutic responses, yet more research is necessary.