Highlights of this issue

The Maltese Falcon

I'm a bit of a sucker for a neatly titled paper, and Will Lee (pp. 580–582) hits all the right notes with his: ‘The integrity of the research record: a mess so big and so deep and so tall’. It sums up the state of the nation with data that are profoundly disheartening. Frank fraud is thankfully rare, but a broad range of more common and insidious ‘questionable research practices’ abound, from selective reporting, through ‘p-hacking’ to ‘gift authorship’. There are various perverse systemic incentives driving this, and anyone working in academia will be very familiar with the pressures. There are always dangers that things that are everyone's business become no one's business, but here the response of our journal, via its new Research Integrity Group, is laid out. Check out our author video interview, where I chat with Will – the Sam Spade detective of the BJPsych – at https://vimeo.com/723023056. Kaleidoscope (pp. 585–586) takes up the reins, asking what happens in practice when a journal retracts a paper and whether that stops it being cited?

Another editorial, another interesting challenge: Shah et al (pp. 577–579) note how individuals with neurodevelopmental disorders (NDDs) frequently present to mental health services but can feel that they uneasily fit within typical existing structures. They emphasise the importance of general services identifying NDDs to enhance outcomes – not least when there is comorbidity with other conditions – but many with NDDs report receiving suboptimal understanding and care. As part of Scotland's national autism implementation team, the authors provide definitions and emerging perspectives related to autism spectrum disorders and attention-deficit hyperactivity disorder to assist the more general clinician both in understanding NDDs and in communication with those who have them. As one of the aforementioned average psychiatrists, I found the piece hugely helpful.

To have and have not

Common mental disorders (CMDs, namely depression, anxiety and somatoform disorders) are, well, common. But how well are we meeting need? Roberts et al (pp. 553–557) call out a treatment gap – that is, the proportion who meet criteria for a condition without getting any help for it. They note that, globally, services fundamentally fail to address the needs of disadvantaged communities: treatment gaps of a shocking 82–98% exist for CMDs across the planet and are highest in the most marginalised and lowest-resourced groups. However, the authors, the majority of whom are from such backgrounds, argue that well-meaning attempts to narrow these gaps may miss a more fundamental point about why so few people access treatment and how that should influence putative solutions. Primarily, low demand arises from non-medical interpretations of CMDs. The authors counter the more traditional argument that we ‘just’ need more evidence-based interventions and say that we must advance measures that target structural social and political determinants of mental health. Their statement ‘The way we respond to a problem is shaped by how we frame and describe it’ feels apposite.

Ahmad et al (pp. 520–527) take up the issue of CMDs and minoritised communities in England, using repeated cross-sectional surveys from 2007 and 2014. CMD prevalence was highest in Black populations, but variation between ethnic groups could be explained by demographic and socioeconomic factors. However, even after these were adjusted for, the odds ratios for treatment remained lower in Black communities than in Asian and ‘White other’ groups. Most devastatingly, this gap has been widening with time. The authors talk through the nuance of how reducing socioeconomic inequalities might help in terms of the disproportionate burden of mental illnesses, but, echoing the earlier piece by Roberts, these data suggest that won't of itself improve treatment inequity. It's just not good enough: if you are working in healthcare, then this is your problem – what are you doing to try redress this where you work? Moran et al (pp. 558–566) round off the work on CMDs by reminding us how effective interventions can be – if people can access them – especially if instigated in a timely manner. Their 20 year prospective data show clearly that intervening in adolescent and young adult groups with CMDs significantly reduces recurrence or prevalence by the age of 35.

In a lonely place

In 2020, the first updated Cochrane Review in 8 years on psychological therapies in borderline personality disorder (BPD) was published. Although broadly supportive of such approaches, the literature more generally is problematically marked by single-trial randomised controlled trials (RCTs) of small participant numbers, often instigated by the treatment developers. Stoffers-Winterling et al (pp. 538–552) try to rectify this, focusing their systematic review on interventions with at least two RCTs and increasing the generalisability of their findings by subanalysing therapies delivered in isolation form those given as an adjunct. Their data reinforce Cochrane but with some nuance: dialectical behavioural therapy (DBT) and mentalisation-based treatment showed significant effects when given alone; as adjunctive interventions, DBT skills training, emotional regulation group work and manual-assisted cognitive therapy were effective.

Psychological approaches are also first-line treatments for panic disorder, although interestingly there has been relatively little comparative work on their varying effectiveness as first-line treatments. Papola et al (pp. 507–519) redress this with a systematic review and meta-analysis of 136 RCTs. After removing RCTs considered to have high risk of bias, only cognitive–behavioural therapy remained more efficacious than treatment as usual. The authors conclude that short-term psychodynamic therapy might still be a reasonable first option, but its effects appear to be inflated through research biases. Finally, Mutz et al (pp. 528–537) note how anxiety disorders contribute considerably to wider morbidity through their impact on physiological functioning. They explored how this varied across the lifespan, taking data from the UK biobank (N = 330,000). In both sexes, lower hand-grip strength and blood pressure and higher pulse rate and body composition measures were found compared with the general population, with sex-specific differences seen at varying ages.