Evaluating treatments: pills for PTSD, mindfulness, social recovery CBT and treating the worried well

Although widely used, pharmacotherapeutic approaches to the treatment of post-traumatic stress disorder (PTSD) have been undermined by uncertainty about efficacy. Hoskins et al (pp. ) systematically reviewed the relevant literature and found that selective serotonin reuptake inhibitors (SSRIs) appear to be superior to placebo in reducing PTSD symptoms but with a small associated effect size. Fluoxetine, paroxetine and venlafaxine were individually identified as potential treatments. The authors highlight the lack of evidence to support the use of other pharmacological agents and also the absence of adequately controlled head-to-head trials of pharmacological and psychological interventions for PTSD. Set in primary care, Sundquist et al (pp. ) undertook a randomised controlled trial of mindfulness group therapy for patients with depression, anxiety or stress and adjustment disorders, with a treatment-as-usual control arm (treatment as usual was individual cognitive-behavioural therapy (CBT) primarily). Improvement was seen in both treatment groups with no difference found between the groups. The authors comment on the potential resource- and cost-saving implications for mindfulness group therapy delivered by certified instructors in primary care compared with individual CBT delivered by psychologists or counsellors.

Two different approaches to evaluating mental health treatment are presented in the BJPsych this month – one a qualitative substudy linked to a pilot trial and the other an analysis of international survey data. Notley et al (pp. ) qualitatively examined participant views and experiences in relation to involvement in the PRODIGY trial, a pilot trial of social recovery CBT for young people with emerging psychological difficulties. They found that participants in both arms reported perceived benefits of involvement in the trial beyond the intervention itself. The authors discuss the implications of their findings for addressing ethical concerns associated with trial recruitment in this group, including the issue of disclosure during assessments, which was found by many of the participants to be beneficial. Concerns about the extent to which mental health treatments and services are wasted on the ‘worried well’ prompted Bruffaerts et al (pp. ) to analyse data from the World Health Organization’s World Mental Health Surveys of community samples recruited from 23 countries. Around half of those reporting mental health treatment in the previous 12 months were found to meet criteria for a past-year DSM-IV disorder, an additional 18% for a lifetime disorder and a further 13% for another indicator of need (multiple subthreshold disorders, recent stressors or suicidal behaviours).

General hospital admission and SPECT imaging in dementia

On the basis that those with dementia are vulnerable to poorer outcomes when admitted to general hospitals and thus unscheduled admissions should be prevented where possible, Russ et al (pp. ) examined data from a cohort of 730 persons with dementia to identify predictors of such admission. Neuropsychiatric symptoms were identified as independently predictive of non-psychiatric hospital admission, prompting the authors to call for research to examine whether or not treatment of such symptoms can reduce admission. The authors also note that neuropsychiatric symptoms have been linked to carer burden in previous studies. Seeking to improve the certainty of a clinical diagnosis of dementia with Lewy bodies (DLB), Walker et al (pp. ) found that among those with clinically determined possible DLB, randomisation to undergo dopamine transporter single photon emission computed tomography (SPECT) imaging with ¹²³I-FP-CIT was significantly associated with a change in clinician diagnosis (from possible to probable DLB or possible to non-DLB) and thus appeared to improve diagnostic certainty.

Mental ill health following pregnancy, civil war and among those attending veterinary clinics

Common mental disorder (CMD) in pregnancy and immediately after giving birth is relatively common among women in low- and lower-middle-income countries with rates found to be higher than in higher-income countries. In a population-based prospective study in rural Vietnam, Nguyen et al (pp. ) found that 70% of women with perinatal CMD had recovered within the first postpartum year. Such recovery was associated with the quality of intimate and domestic relationships and participation by family members in domestic work and infant care. The authors comment on the modifiability of these social factors, which are thus potential targets for improving recovery from perinatal mental ill health in resource-constrained settings. Newnham et al (pp. ) also identified a range of potentially modifiable factors mediating associations between war exposures and post-traumatic stress symptoms in a sample of young people living in Sierra Leone. Daily stressors such as poor economic circumstances, including unemployment of the household’s main earner, poor personal health, having experienced the death of someone close, and depression suffered by a member of the household, played an important role in mediating the association between war exposure and post-traumatic stress symptoms. Such factors were also found to be associated with depression, while the extent of war exposure was not.

In the novel setting of veterinary clinics, Lepping et al (pp. ) conducted a survey of clinicians to determine the extent of apparent psychosis among pet owners. Among over 30 000 respondents, 724 suspected cases of delusional infestation by proxy in a pet were reported, with a proportion of such pet owners reporting double delusional infestation – believing themselves to be affected also.