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UCL Mental Health Research at the time of COVID

iomh12 May 2021

researcher testing with pipette

This blog was written by Ana Antunes-Martins, Research Coordinator for UCL Institute of Mental Health.

The COVID-19 pandemic has had multiple effects on mental health, some of which are likely to be long-lasting. UCL mental health researchers have been busy investigating how the infection affects the nervous system, how we adapted to life in lockdown, and how we have been coping with the hardships brought by the pandemic. This blog post is a broad overview of UCL’s contributions to the fight against the ‘mental health pandemic’ over the last year. For more in-depth discussions of specific mental health topics and COVID, read our series of blog posts published on the IoMH website over the last year.

Learning from previous coronavirus outbreaks and early COVID-19 data, in July 2020, Jonathan Rogers and Tony David suggested that lasting mental disorders may follow severe COVID-19 infection in some patients (1). They also found that, while thoughts of suicide and self-harm have shown increases in some groups around the world (e.g., the young and those suffering from the viral infection), suicide has not generally increased (2). Perhaps increased social cohesion – the feeling that we are stronger together – has been a protective factor.

But we cannot necessarily rely on this. A group of clinical academics led by Michael Bloomfield banded together to form the COVID Trauma Response Group. The group recommends that COVID survivors should be monitored to address risks of PTSD, anxiety, and depression. Long-COVID sufferers also describe mental health symptoms (fatigue and so-called ‘brain fog’). Two NIHR/UKRI-funded studies will follow Long-COVID patients to understand how the disease progresses, whether it can be treated, and who is most vulnerable. One of these studies, led by the MRC Unit for Lifelong Health and Ageing at UCL, will focus on adults, while the other, led by Great Ormond Street Institute of Child Health, will focus on those who contracted the virus as adolescents.

Beyond the direct effects of the virus, the pandemic caused sudden changes to our lives and livelihoods and put massive strains on society. To understand how these challenges impacted our mental health and wellbeing, UCL researchers conducted interviews and surveys with large numbers of people. Some of these studies were added to ongoing research, while others were set up from scratch. For example, studies at the UCL Centre for Longitudinal Studies are taking advantage of birth cohorts (samples of the population followed regularly since birth) to investigate how mental health and behaviours compare to pre-pandemic levels and change as the pandemic progresses. Another large study is the COVID-19 Social Study, led by Daisy Fancourt, which was set up in March 2020 to keep track of the feelings and habits of 70,000 adults in the UK every week.

These types of studies provided snapshots of our lives during the pandemic: how depressed, worried, lonely, and anxious we felt and how much we slept, exercised, and drank alcohol, and whether we ate our 5-a-day (3,4). Most importantly, because the studies followed such a large slice of the population, researchers could pinpoint which groups struggled the most. Amongst adults: women, younger adults, and those facing financial hardship, those with mental illnesses before the pandemic, and those who were lonely fared poorly in several mental health and wellbeing measures.

UCL researchers homed in on these groups. In many cases, people in these groups already suffered from poor mental health before the pandemic, and the pandemic just made it worse: women’s psychological distress was worsened by increased childcare responsibilities (5), young people were more affected by job uncertainties and worried about the future and consequently more depressed, anxious, and lonely (6), those with precarious working conditions had worse physical and mental health outlooks, and even increased mortality during the first year of the pandemic (7).

The sudden changes brought by the pandemic were particularly challenging to those who already had mental health disorders and saw their support networks and access to healthcare compromised. The Mental Health Policy Research Unit (MHPRU), led by Sonia Johnson, is researching ‘what works’ in mental health services. For example, a literature review of mental health services worldwide, identified the evidence needed to inform policy and best practice (8). Central to this research is the voices of those with lived experience. In this spirit, the MHPRU and the Loneliness and Social Isolation Network work with ‘experts by experience’ to co-develop surveys and interviews to understand the specific challenges faced by the patients and how they can be supported, especially in navigating remote health care (9).

Loneliness is a big player in poor mental health. The good news is that maintaining remote contact with friends and family (10) and engaging in arts (11) may be helpful tools to combat loneliness and improve mental health. The ‘Community COVID’ study led by Prof Helen Chatterjee will address how well ‘creative resources’ work to improve mental health and how we can make the most of them.

Children and adolescents had their routines and social lives completely changed by school closures. Researchers at the UCL Institute of Education and the Anna Freud Centre are devoting significant efforts to understanding pupils’ experiences from different ages and socio-economic backgrounds (12,13). They ask who coped better and worse (and why), what pupils found most upsetting, what they did to improve their moods, how families managed, and whether school staff could cater to children’s wellbeing remotely. But research is only worthwhile if it can help people, and these researchers are doing precisely that, by producing up-to-date homeschooling resources and lay summaries to help families support their children’s wellbeing.

So, what next? Fourteen months since the beginning of the pandemic, the UCL mental health research community has generated invaluable data and resources to help society and individuals cope better and hopefully, to some extent, reduce the long-term repercussions of the pandemic. Lessons learned to date have informed clinical mental health practice, education, social and community support strategies, and will have impacts well-beyond the pandemic. Of course, there are many unanswered questions, and studies that are just starting, and we look forward to hearing what this new research holds.

 

References

  1. Rogers, J. P. et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 7, 611-627, doi:10.1016/S2215-0366(20)30203-0 (2020).
  2. Rogers, J. P. et al. Suicide, self-harm and thoughts of suicide or self-harm in infectious disease epidemics: a systematic review and meta-analysis. Epidemiol Psychiatr Sci 30, e32, doi:10.1017/S2045796021000214 (2021).
  3. Villadsen, A. et al. Mental health in relation to changes in sleep, exercise, alcohol and diet during the COVID-19 pandemic: examination of four UK cohort studies. medRxiv 03.26.21254424; doi:https://doi.org/10.1101/2021.03.26.21254424
  4. Saunders, R., Buckman, J. E. J., Fonagy, P. & Fancourt, D. Understanding different trajectories of mental health across the general population during the COVID-19 pandemic. Psychological Medicine, 1-9, doi:10.1017/s0033291721000957.
  5. Xue, B. & McMunn, A. Gender differences in unpaid care work and psychological distress in the UK Covid-19 lockdown. PLoS One 16, e0247959, doi:10.1371/journal.pone.0247959 (2021).
  6. https://www.ucl.ac.uk/ioe/news/2021/apr/more-half-16-25-year-olds-fear-their-futures-and-job-prospects
  7. https://www.ifow.org/resources/the-good-work-monitor
  8. Sheridan Rains, L. et al. Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses. Social Psychiatry and Psychiatric Epidemiology, 1-12, doi:10.1007/s00127-020-01924-7.
  9. Gillard, S. et al. Experiences of living with mental health problems during the COVID-19 pandemic in the UK: a coproduced, participatory qualitative interview study. Soc Psychiatry Psychiatr Epidemiol, doi:10.1007/s00127-021-02051-7 (2021).
  10. Sommerlad, A. et al. Social relationships and depression during the COVID-19 lockdown: longitudinal analysis of the COVID-19 Social Study. Psychol Med, 1-10, doi:10.1017/S0033291721000039 (2021).
  11. Mak, H.W. et al. Predictors and Impact of Arts Engagement During the COVID-19 Pandemic: Analyses of Data From 19,384 Adults in the COVID-19 Social Study. Front Psychol, doi: 3389/fpsyg.2021.626263 (2021)
  12. https://www.ucl.ac.uk/ioe/research/covid-19-research-ucl-institute-education/research-related-covid-19
  13. https://www.annafreud.org/coronavirus-support/our-research/

Architecture and Mental Health – How built environment and healthcare professionals can work together to improve psychiatric environments

iomh11 May 2021

patient room

This blog was written by Dr Evangelia Chrysikou, Lecturer at The Bartlett School of Sustainable Construction, Program Director of the MSc Healthcare Facilities at UCL and medical architect.

Foucault’s History of Madness (1964) was the book that triggered my interest on spaces for psychiatric patients. Even though the spaces of confinement where not the purpose in the book, being an architect with skills on visualising spaces, those asylum buildings provided an incredibly dystopian scenery for the actual context. It was clear to me that those spaces, even if that were not necessarily the intention, were facilitating the alienation of mentally ill people at multiple levels, from social to personal. Looking at the plans and the narratives one could understand that deprivation and inequality were principles embedded in their architecture. So, what was the situation now, what was the physical context of mental illness? Did the movements of anti-psychiatry or the efforts for psychiatric rehabilitation have a tangible effect in stopping this coercive paradigm of neglect and at the same time help facilitate the change that was happening at that time in the care for psychiatric patients? This was in the mid-nineties, at a period where in several parts of Europe the old asylums would be gradually replaced by smaller psychiatric facilities, mostly but not necessarily in the community, in an uneven journey of trial and error. I started working with the teams that moved the patients from the notorious Leros asylum back to the community. I soon realised that the available literature was mainly from health services research rather than architecture. The new paradigm advocated for small (but then how small?), domestic (but what does this actually mean?) structures of various types and purposes, preferably in the centre of their catchment area with welcoming accents of tablecloths and cutlery. Those descriptions reflected how a healthcare professional would describe spaces but would leave a lot unanswered in terms of an architectural inquiry. Taking people from Leros asylum to their original places in mainland Greece was a task for the psychiatrists. How they would bring people back from a courtyard where the single tree was always leafy –a eucalyptus tree– so patients did not know what the word “autumn” meant and they had forgotten the seasons. How would they explain inner city traffic jams and crossings to somebody who left their rural village in the thirties, or modern flats and electrical appliances? How would these people be transferred into the modern era and in a busy urban context that they had never met? What sort of buildings should facilitate this transition?

This is where my research started. I had to look at the available provision first in Greece and then to Belgium, the UK and France. I could see a variety of structures, urban or rural, embedded in the community or isolated, small or multi-storey and complex, with different levels of security, interaction and stimuli. There was no unified model of care and that was apparent if one looked at the building stock. My research initially looked at these various options and then I concentrated on understanding the therapeutic spaces available for the acute spectrum of mental illness. I involved patients and staff and sought to understand their perspectives on how such spaces should be shaped. It was the first time that a researcher asked psychiatric spaces to give feedback about the place and space of the wards. At the same time I evaluated the architecture of spaces using theories of space and place making. My research generated various tools: a very useful one and very simple to use was a checklist that classified the psychiatric buildings in terms of domesticity vs institutionalization and the SCP model for the planning and evaluation of psychiatric spaces (Chrysikou, 2014). For the benefit of PhD researchers, you might be interested to know that the model was developed from my PhD and has shaped much of my research since as well as providing a useful tool for other research projects I have been involved over the years, including my Marie Curie Individual Fellowship project (Chrysikou, 2019). This model offers a three dimensional perspective of analysing psychiatric buildings in relation to their therapeutic purpose. Each axis refers to a different priority –safety and security, competence and personalisation and choice—and at the same time refers to a different era in the design for mental health –the coercive, the medical and the psychosocial (Figure 1). That way, professionals and stakeholders involved in the planning, the design and the evaluation of such premises can have context and references, even for simple decision-making. For example, in the case of a forensic facility we need to focus more on safety and security as dangerousness might have a significant impact, but at the same time we have to think and acknowledge clinical needs and the ultimate aim of psychosocial rehabilitation and the principles of valorisation that could still be suitable for forensic accommodation. So, we would have secure windows but at the same time we could prioritise views to green and blue. The tools developed would help evaluate the environment of the wards in relation to their surroundings, the closed space within the ward and even details.

When I first conducted research in the UK in the late nineties, I could detect remnants of the previous mental health care model, the medical model, in the architecture of the wards. The older wards might be situated in hospital premises and even if they had evolved they still retain general ward typologies. Those co-existed with some new typologies, experimenting on what a psychiatric ward should be. Those would demonstrate investment in design and innovation. This period of experimentation has been replaced by a more uniform reality supporting single ensuite rooms, light spaces and the introduction of visual art. Yet, at the same time we could detect some institutional re-introductions in the name of anti-ligature: bathroom fixtures and fittings that cannot cause harm but are quite uncomfortable to use, heavy, immobile furniture very similar to what the old asylums would have, absence of door panels or drawers in storage units, making clutter more visible. To a system that is understaffed such practices prove a viable solution yet at the same time convey the message that patients are not to be trusted. They are also present in North American psychiatric hospitals but we do not see them in the European equivalents, making the comparison inevitable. More cross-country comparisons would be important to help us learn from those differences. Transdisciplinarity would be another critical element for future research. As psychiatric environments have to support a variety of functions and purposes, they present challenges that other types of healthcare environments do not necessarily have. Transdisciplinary and user-inclusive research would be our best chance to capture that complexity. Researchers from health disciplines have to collaborate with researchers who are familiar with built environment perspectives and grow the area in between.

References

Fouqault, M. (1964). Histoire de la Folie, a l’ age classique. Paris: Plon

Chrysikou, Ε. (2014). Architecture for psychiatric environments and therapeutic spaces. Amsterdam: IOS Press. ISBN 978-1-61499-459-6

Chrysikou, E. (2019). Psychiatric institutions and the physical environment: combining medical architecture methodologies and architectural morphology to increase our understanding. Journal of Healthcare Engineering, vol. 2019, Article ID 4076259, 16 pages, https://doi.org/10.1155/2019/4076259

Figure 1: The SCP model

Biography

Dr Evangelia Chrysikou is Lecturer at The Bartlett School of Sustainable Construction, Program Director of the MSc Healthcare Facilities and medical architect. She is Vice-President of the Urban Health Section (EUPHA) and RIBA Chartered Member. She specialises in healthcare facilities, holding a rare PhD on mental health facilities from UCL and a very prestigious Marie Curie H2020 Individual Fellowship. She has been actively involved in policy, being Coordinator on D4 Action Group of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) of the European Commission (EC). Evangelia has received several international awards for her healthcare architectural projects and her research. She authored the national guidelines for mental health facilities in the community for Greece on behalf of the European Union. Additionally, she authored the books ‘Architecture for psychiatric environments and therapeutic spaces’ and ‘The social invisibility of mental health facilities’, is a healthcare architecture editor, reviewer, active member of several professional and scientific associations and TED-MED speaker.

Suicide and COVID-19: ‘Careless Talk Costs Lives’

tonydavid8 February 2021

Suicidologists, not famed for their optimism, are bracing themselves for an increase in suicide rates following the pandemic. Some have called it a perfect storm (1). It is not an easy subject to discuss for two main reasons. A person bereaved by suicide described it to me as like having a hand grenade explode in your living room. But precisely because suicide is such a singular event, it can only really be studied – in a way that useful lessons can be learned – from a distance, looking at large numbers and trends over time, by taking a kind of aerial view. The other reason is contagion. That’s why there are strict guidelines from the ‘Samaritans’ and others, on the way suicide is reported in the media (2) – which include avoidance of sensationalism, of the idea that the act is heroic, dwelling on methods, and that suicide was inevitable – for fear of copycats. Indeed the worst kind of newspaper reports did emerge early in the pandemic from India of people unexpectedly and violently taking their own lives after being told they had the virus but this did not continue and mercifully did not foretell of any similar trends. And I am conscious of even now having to be careful about my use of language even in the context of an article intended for a largely academic and educated audience (3,4).

Even asking about suicidal thoughts in a clinical context has made people anxious that it ‘puts thought into people’s heads’. Reassuringly, summarising several studies on this question, authors of a systematic review conclude that it is safe and can, as would be hoped, relieve distress (5). Our instincts and those motivating the bulk of mental health awareness campaigns tell us that it is good to talk. I should add that listening to someone who looks you in the eye and tells you of their intention to kill themselves feels like that grenade has just landed in your lap. It’s not an easy subject to talk or hear about.

Knowing of the possibility of suicide is arguably the uniquely human existential curse, as elaborated by 20th Century philosophers like Heidegger. But does being reminded of it really make a difference? Goethe’s hapless hero Werther takes his own life due to unrequited love. This sparked a minor craze in the mid 1770s of imitations by romantic young men donning the same blue coat and yellow waistcoat, and leaving the tell-tale eponymous novel by their sides. The moral panic that ensued has repeated itself many times with ‘13 Reason’s Why’ being a notable recent example (6).

Such outbreaks, spatial-temporal clustering to use the technical term, are fiendishly hard to prove statistically (7). In the age of social media and the internet the ‘where’ of a suicide hardly matters – unless within an institution like a prison or a psychiatric hospital – and the timing of a cluster is not obvious either; the next day, week, month? Indeed if there is to be an increase in suicides in the wake of this pandemic when should we expect it? Suicide statistics accumulate slowly and in the UK may wait months for a coroner’s verdict. Suicide is, thankfully, rare enough that it takes a while to see enough instances to say whether rates have increased even nationally, in comparison to, for example, the same time last year, even using provisional statistics.

Efforts have been accelerated around the world by the pandemic to provide real-time surveillance information so that rates can be tracked and if rising, perhaps mitigated (8). Early reports from Queensland Australia (pop approx. 5m) have made use of police reports to the coroner. There were tragically 434 suicides from February through August 2020, a rate which did not differ compared to the preceding 5 years (9). The social context of the suicides did not show any particular emphasis on say unemployment or domestic violence and just 36 were judged initially at least as being related to Covid-19 – in what way, was not made explicit. A study from Japan (10), which has suffered less than the most European countries from the pandemic, normally has an average of 1596 suicides per month but this dropped by 14% between February and June last year but then increased by 16% in July to October. Interpreting such fluctuation is tricky. Could it be that suicide was delayed during the first wave only to rebound or are we seeing a cumulative effect? The study authors wonder whether it has to do with the prospect of withdrawal of government financial support packages. Work in progress reported by the UK’s National Confidential Enquiry into Suicide and Safety in Mental Health shows no increase in the monthly average from April-August 2020 compared with Jan-March (11). A similar picture of no increases is emerging from Norway (12) and preliminary data from the US (8).

The nearest we have in the UK to official rolling figures are monthly statistics on mortality in people under 18 (13). In the 82 days before the first lockdown in March 2020 there were a heart-rending 26 deaths by suicide compared with 25 in the first 56 days after, an post-lockdown increase in rate by about 40% but with a very wide margin of error such that the difference fails to meet conventional levels of statistical significance. A third of the young people were known to services.

Experience from the Severe Acute Respiratory Syndrome (SARS) outbreak in Hong Kong in the spring of 2003 – also caused by a coronavirus (14) showed an uptick of about 30% in deaths by suicide paralleling SARS mortality – over its 4 month course (15). This affected older women particularly, a group more prone to suicide in China for some reason unlike the general rule around the world that older men have the highest rates. However the summer peak did not occur leading the authors to wonder if suicide had simply been brought forward by the epidemic (16).

What of the Spanish flu pandemic of 1918-19? Very little data on suicide are available but one US (17) and one Swedish study (18) using fairly reliable contemporaneous figures found no increase. It’s true, that there was a lot going on then! The Great War (like all wars) showed the expected drop in suicide, perhaps due to an increase in social cohesion, followed by an increase which coincided with Spanish flu, so teasing out the effects of each is impossible. As an aside, rates following the two world wars did rise again but not quite to pre-war levels and then peaked around the great depression. Rates in Europe and the UK have been gradually falling ever since. Indeed if there is a predictable harbinger of increased suicide on the large demographic scale it is economic hardship. It is therefore suicide rates over the next few years that will be most scrutinised.

There is no vaccine for suicide but there are some ways to increase immunity. Social proximity, economic support for those in poverty, agile and responsive mental health services, control of alcohol consumption being the most obvious.

One of my patients etched on my memory suffered depression severe enough to require in-patient care. He was driven to despair by religious guilt over a seemingly minor misdemeanour. As his mood improved with antidepressants and psychological support there seemed to be a glimmer of light, and he’d had enough of all that ‘religious nonsense’. I was reassured only for him to take his own life dramatically during a period of home leave a few weeks later (see 19). My lesson: whatever binds people together in society – shared values, beliefs, rituals – keeps us alive, regardless of their rationality.

In sum, when it comes to suicide, especially in the midst of a pandemic, it may be good to talk but it depends what you say. We might remember the WW2 safety slogan – “careless talk costs lives”. Perhaps the next mental health awareness campaign should be promoting the benefits of listening. Listening to what people are saying as well as what evidence and data are showing; we all need to try and learn from that.

And for every Werther there is a Papageno from the Magic Flute or George Bailey in ‘It’s a Wonderful Life’ – numinous tales of people turning away from suicide thanks to others sharing ways to value continued living – despite moments of desperation. Don’t ever say it’s inevitable.

Professor Anthony David

Director, UCL Institute of Mental Health

 

References:

  1. Reger MA, Stanley IH, Joiner TE. Suicide mortality and coronavirus disease 2019—a perfect storm? JAMA Psychiatry. 2020. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2764584
  2. World Health Organization. Preventing suicide: A resource for media professionals. 2017 https://www.who.int/mental_health/suicide-prevention/resource_booklet_2017/en/.
  3. Gunnell D, Appleby L, Arensman E et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry 2020. 7: 468–71. http://www.ncbi.nlm.nih.gov/pubmed/32330430
  4. Hawton K, Marzano L, Fraser L, Hawley M, Harris E, Lainez Y. Reporting on suicidal behaviour and covid-19—need for caution. Lancet Psychiatry 2021. 8:15-7. doi: 10.1016/S2215-0366(20)30484-3.
  5. Polihronis C, Cloutier P, Kaur J, Skinner R, Cappelli M. What’s the harm in asking? A systematic review and meta-analysis on the risks of asking about suicide-related behaviors and self-harm with quality appraisal, Archives of Suicide Research, 2020. DOI: 10.1080/13811118.2020.1793857
  6. Ortiz P, Khin E. Traditional and new media’s influence on suicidal behavior and contagion. Behaviour Science and Law. 2018. 36:245–256.
  7. Niedzwiedz C, Haw C, Hawton K, Platt S. The definition and epidemiology of clusters of suicidal behavior: a systematic review. Suicide Life Threatening Behavior.2014. 44, 569–581.
  8. John A, Pirkis A, Gunnell D, Appleby L, Morrissey J. Trends in suicide during the covid-19 pandemic: Prevention must be prioritised while we wait for a clearer picture. BMJ 2020;371:m4352
  9. Leske S, Kõlves K, Crompton D, Arensman E, Leo DD. Real-time suicide mortality data from police reports in Queensland, Australia, during the COVID-19 pandemic: an interrupted time-series analysis. Lancet Psychiatry 2021; 8: 58–63
  10. Increase in suicide following an initial decline during the COVID-19 pandemic in Japan. Tanaka T, Okamoto S. Nature: Human Behaviour. 2021. doi.org/10.1038/s41562-020-01042-z
  11. National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide in England since the COVID-19 pandemic- early figures from real-time surveillance. 2020. http://documents.manchester.ac.uk/display.aspx?DocID=51861
  12. Qin P, Mehlum L. National observation of death by suicide in the first 3 months under COVID-19 pandemic. Acta Psychiatr Scand 2020.pmid: 33111325
  13. National Child Mortality Database. Child suicide rates during the covid-19 pandemic in England: real-time surveillance. 2020. https://www.ncmd.info/wp-content/uploads/2020/07/REF253-2020-NCMD-Summary-Report-on-Child-Suicide-July-2020.pdf
  14. Rogers JP et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 2020. 7: 611–27. http://www.ncbi.nlm.nih.gov/pubmed/32437679
  15. Chan SM et al. 2006. Elderly suicide and the 2003 SARS epidemic in Hong Kong. International Journal of Geriatric Psychiatry 2006. 21: 113–18.
  16. Cheung YT, Chau PH, Yip PSF. A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong. International Journal of Geriatric Psychiatry 2008. 23: 1231–38
  17. Wasserman IM. The impact of epidemic, war, prohibition and media on suicide: United States, 1910–1920. Suicide and Life‐Threatening Behavior 1992. 22: 240–54.
  18. Rück C, Mataix-Cols D, Malki K, Adler M, Flygare O, Runeson B, Sidorchuk A. Will the COVID-19 pandemic lead to a tsunami of suicides? A Swedish nationwide analysis of historical and 2020 data. medRxiv preprint doi: https://doi.org/10.1101/2020.12.10.20244699
  19. David A. Into the Abyss: a neuropsychiatrist’s notes on troubled lives. Oneworld Publications, 2020, London.

 

Awareness is just the start

tonydavid9 October 2020

World Mental Health Day 2020 poster by Mental Health Foundation

World Mental Health Day 2020 poster by Mental Health Foundation

The 10th October 2020 is World Mental Health Day. This marking of the calendar was launched in 1992 by the World Health Organisation and has become well established. The UK Charity, the Mental Health Foundation proposed a regular awareness week (occurring in May – 18th to 24th this year), back in 2001. Time to Talk day was 6th February 2020, following Blue Monday – 20th January – spuriously claimed to be the most depressing day of the year. In fact, there are mental health days or weeks for fathers, mothers, men and women in general, children (3rd– 9th Feb) and many more – helpfully gathered on the website: therapyforyou.co.uk/post/mental-health-calendar.

It would be easy – and wrong – to be cynical about all this. Wrong because awareness should be the first step towards understanding – for those who are ignorant or unduly frightened by mental illness. Greater awareness in the minds of politicians, philanthropists and scientists should lead to more research and better funding for services. Above all, greater awareness should replace prejudice and stigma with realistic appreciation and empathy. However, as with many anti-stigma initiatives, this can have unintended consequences (watch my talk on this for last year’s World Mental Health Day). In the case of awareness days and weeks – it can lead to complacency and apathy. A better response is to try and propel the agenda forward from awareness to deeper understanding and most important of all, action.

One undeniably positive consequence of greater awareness is the empowerment of people with lived experience of mental health problems to not only tell their stories in their own words but also to become an essential part of “the solution”. I put that in inverted commas to indicate clearly that there is certainly no simple or single solution to mental illness or disorder but that research – from basic science to clinical care to public policy – is the driver towards such an ideal.

The UCL Institute of Mental Health (IoMH) is lucky to have on its advisory board a number of highly qualified and motivated  individuals who are able to use their experience of being patients (let’s not say ‘users’) and carers within the psychiatric care system. Here Jackie Hardy and Jason Grant share some thoughts prompted by World Mental Health day.

Nothing about us, without us

I have welcomed being involved in the IoMH and some mental health research with UCL looking at COVID19 and its impact on people’s mental health during this exceptional period in history. The research really has tried to involve Lived Experience Researchers in all pieces of the work, which I have so welcomed. It will be good when some of the papers around this come out.

Being involved has meant I have felt part of something and can share my lived experience in helping to shape things.

Right now we live in uncertain times and I feel mental health services are due an overhaul and have been for a long time. Despite statutory services asking people with lived experience of mental distress, and carers, their views, the same medical model still seems to exist. I would like to see the social model of disability embraced, along with a model of peer support, designed and delivered by people with lived experience of mental distress. Unless you have been there you really cannot know what it is like. The right model of peer support has the person leading their discovery journey – I prefer this term, as ‘recovery’ is pressure; so many of us discover a lot about ourselves, but may never truly recover, as it can be very up and down, as life has its events.

Mental health services should be holistic, looking at the whole person and their whole life and be ‘person centred’. We are all unique individuals, so please do not try to put a square peg in a round hole. Such support needs to be joined up with health professionals and our support network (if we have one, if not ask peers if they can help link the person in to a support network).

If peer support can be person centred, why cannot statutory services? If you do not know how, then please, please talk to us – “nothing about us, without us”, is a term regularly used.

One place to start is NSUN https://www.nsun.org.uk/ – they are: “a network of people and groups living in England who have and do experience mental distress and want to change things for the better.” They can help with research, decide on what should be researched by reaching out to their network of people. I would like to see more lived experience researchers, along with us receiving funding, leading in research and on papers. We can work and learn together.

Change is long overdue, so this is my personal plea for a change.

Jackie Hardy

From Patient to Peer-Support Worker

In the summer of 2015, I had a psychotic episode whilst travelling in Brazil and ended up walking around for three days without sleeping. As I had no insight at the time, I thought that it was just a bad experience and thought nothing more of it. I even went travelling again in Europe a month later where I experienced another psychotic episode. This time I was taken to a psychiatric hospital in Prague and my family had to come and get me out of the country.

I still wasn’t entirely sure what was happening and resolved to not go travelling again for a while. Unfortunately for me, I had another psychotic episode and ended on a section 136 (brought into hospital as an emergency) in Eastbourne Hospital. After being admitted onto the ward for a couple of days, I was then transferred to Meadowfield in Worthing. At this point, I finally realised that it was my mental health that was causing me all of the problems that I was facing and I was determined to do something about it.

I made sure that my time in hospital was spent doing as many activities as possible, from mindfulness, art classes, playing basketball and badminton, walking around the grounds, and even making paper birds using origami.

I was discharged after 10 days into the care of the Crisis Team who referred me to the Early Intervention Service.

I had support for a couple of months then was transferred to Glasgow services as I decided to go back to university. When I returned to Sussex, my care continued for just over three years. During that time, I was able to receive support from a care co-ordinator, participated in various research studies, attended groups and meetings within the Trust, and managed to gain insight around my signs, symptoms, what to do in a crisis and how to manage my condition.

Just to clarify, psychosis is a condition which affects the mind. It changes the way you think, feel, and behave. Some may lose sense of reality and fall into their imagination. Psychosis can occur when drug misuse is an issue and as a reaction to extreme stress or trauma. Psychosis can happen to anyone and like any other illness, it can be treated.

In March of 2020, I interviewed for the position of peer support worker within the same Early Intervention Service that I went through and was successful in securing the role. It took a little while to finally get into post, due to the pandemic and remote working, but I have been working part time since August.

For those that don’t know, Early Intervention is a community-based service for people aged up to 65 years old who are experiencing their first episode of psychosis. The idea is to help people have a positive first experience of mental health services, to reduce symptoms and support recovery, to support the family/carers and involve them as much as possible, and to use evidence-based treatments for psychosis.

The team consists of doctors, nurses, social workers, occupational therapists, psychologists, pharmacists, and peer support workers (of which I am the first in the team). My role is to provide an element of hope based on my recovery, resilience, and self-determination. I will also be able to help others navigate the service and signpost people to other peer activities within the Trust like working-together groups, recovery college, and people participation.

Jason Grant

When Private Optimism meets Public Despair: People adapt to threats like Covid-19 by maintaining positive and protective biases while reducing negative perceptions and emotions

Maria Thomas29 June 2020

This blog was written by PhD Student Laura K. Globig from the Department of Experimental Psychology, UCL. 

woman wearing face mask

Humans tend to be optimistic. They overestimate their financial prosperity and marriage longevity, while underestimating their risk of disease, such as cancer or suffering other hardships, like being burgled (Sharot, 2011, Weinstein, 1980).

What is surprising about such observations is that anecdotally, people also often express pessimism regarding the state of society as a whole. Following the financial collapse of 2008, polls showed that people were extremely pessimistic about the financial future of their country. By contrast, they were optimistic about their own financial prospects (Ipsos MORI, 2008).

Now these seemingly opposing but coexisting beliefs integrate to shape a person’s response becomes especially relevant when danger faces the self and others. How someone estimates their own vulnerability will likely affect their well-being and the choices they make. Simultaneously, someone’s predictions about the vulnerability of society at large could also affect their personal well-being and behavior. The latter is particularly pertinent, when one’s own behavior can affect others’ well-being.

As COVID-19 swept the globe and stay at home orders were issued we surveyed a representative sample of 1145 Americans in 30 states across two timepoints. Our aim was two-fold: 1) To investigate how people perceived the danger COVID-19 posed to themselves and to their fellow citizens. 2) To determine how these perceived risks influenced their own well-being and behavior.

We found that people believed they were at lower risk of getting COVID-19 relative to others their age and gender. We refer to this as private optimism. At the same time, people also believed that COVID-19 posed a tremendous danger to the health of the human population as whole. We refer to this as public pessimism.

We found that private optimism can be explained by people’s sense of control. People believe their fate is in their own hands, and thus they believe they can avoid negative outcomes (Zakay, 1984). During the pandemic, this may relate to people believing they are in control over being exposed to the virus. This then leads them to believe they are less likely than others to catch the virus. But because this sense of control does not extend to society, they are less optimistic about global issues. We cannot control how others behave during the pandemic.

Those who were optimistic about their own chances of being infected were also happier and less anxious compared to those who were not. How people estimated the danger posed by COVID-19 to society as a whole however did not influence personal happiness, but did affect anxiety. Those who were pessimistic about the danger to society, were more anxious. Thus, our perception of our own vulnerability can influence both positive and negative aspects of well-being, while how vulnerable we perceive others relates specifically to anxiety.

When it comes to slowing the spread of COVID-19, to what extent we adopt preventative measures, such as social distancing, not only mitigates our own risk of getting infected, but also that of others. It enables us to protect those who are particularly vulnerable.

Our study shows that public pessimism predicted how likely people were to adhere to public health advice to slow the spread. That is, people who believed the virus posed a great danger to society as a whole reported putting greater effort in social distancing, hand washing and avoiding touching their faces. How people considered the risk to the self, however, did not affect compliance. This suggests that people predominantly engage in protective behaviors for the benefit of others.

Finally, we also observed that people adapted well to the restrictions imposed by the pandemic. Their well-being increased as lockdown progressed. Compared to the start of lockdown, people were less anxious and reported an increased sense of control. They considered the danger of COVID-19 to humanity as less than they did at the beginning of lockdown. Private optimism and happiness remained stable throughout. This suggests that humans adapt to threats by maintaining positive and protective biases while reducing negative perceptions and emotions.

We surveyed Americans across 30 US states, thereby allowing us to sample a diverse representation of US citizens. Notably, we did not observe an effect of state or number of COVID-19 cases or COVID-19 related fatalities at the time of testing. It is therefore likely that our findings will also apply to other countries, such as the United Kingdom.

Rather than an effect of location, we did find that political orientation, age, gender and socioeconomic status had a differential effect on well-being and behavior. Older individuals and females were more like to comply with government advice related to COVID-19 mitigation. Moreover, those with high income were happier. Finally, males and republicans were more likely to express private and public optimism. Additionally, younger individuals were also more likely to express private optimism. Future research is needed to explore how government policies in response to COVID-19 influence well-being and behavior. There may well be differential effects on an international scale.

Given the recent decline in COVID-19 cases and easing restrictions, it is possible that risk perception in general will decrease, due to the actual risk of infection being reduced. Nevertheless, some preliminary data we collected indicates that people still consider the risk of getting infected themselves as low, relative to others of same age and gender. More work is needed to explore how this optimistic tendency relates to reports of an increasing number of people believing they have already contracted the virus and are thereby immune. As official statistics indicate the true percentage of the population that has actually tested positive for COVID-19 is still relatively small. Therefore, it is in fact possible that the belief to have had COVID-19 already is in itself, also a form of private optimism in which people falsely believe they are immune, and thereby no longer at risk of infection.

One might believe that private optimism may deter individuals from getting vaccinated against COVID-19 once a vaccine becomes available. However, vaccinations rely on the concept of herd immunity and thereby only work to prevent the spread of infectious diseases if the majority of the population is vaccinated. They could therefore be considered a form of behavioral compliance to protect those who are vulnerable and thus one’s willingness to get vaccinated likely relies more on how we estimate the danger to the human population. Of course, this relies on effective communication and education of the public.

There is reason to believe, that the paradoxical existence of private optimism and public pessimism generalizes to other threats such as war, financial collapse and climate change. For example, we speculate that people’s tendency to make “green choices” is linked to the belief that climate change poses a threat to humanity, regardless of whether they believe that they are themselves at risk. Such knowledge can be useful for advocates and policy makers in framing information to encourage individuals to select actions that protect themselves and others from natural and man-made threats. In the future we also hope to explore the mechanistic link between sense of control, private optimism and well-being further. If we can strengthen people’s sense of control, we might be able to harness the positive effects on personal well-being in times of crisis.

 

References

Globig, L. K., Blain, B., & Sharot, T. (2020, May 29). When Private Optimism meets Public Despair: Dissociable effects on behavior and well-being. https://doi.org/10.31234/osf.io/gbdn8

Ipsos MORI. (2008). Political Monitor, March 2008, [UK]. [Data set].  Retrieved from: https://www.ipsos.com/ipsos-mori/en-uk/ipsos-mori-political-monitor-march-2008

Sharot, T. (2011). The optimism bias. Current Biology, 21(23), R941–R945. https://doi.org/10.1016/j.cub.2011.10.030

Weinstein, N. D. (1980). Unrealistic optimism about future life events. Journal of Personality and Social Psychology, 39(5), 806–820. https://doi.org/10.1037//0022-3514.39.5.806

Zakay, D. (1984). The Influence of Perceived Event’s Controllability on Its Subjective Occurrence Probability. The Psychological Record, 34(2), 233–240. https://doi.org/10.1007/BF03394867

Researching student mental health during the pandemic: a PhD student tries to remain objective

Maria Thomas4 May 2020

This blog has been guest written by PhD Student Tayla McCloud, UCL Division of Psychiatry.

Woman anxious at desk with laptop

It is difficult to think of anyone who is unaffected in some way by the current coronavirus pandemic and resulting UK lockdown. Whilst practical adjustments and physical health concerns spring to mind, there are myriad mental health implications, too.

Results from two early online surveys conducted by the mental health charity MQ and the Academy of Medical Sciences (AMS) showed that the main concerns among people with lived experience of a mental illness and others in the general population were the impact of the pandemic on anxiety, isolation, and access to support. These are likely to affect everyone to differing degrees throughout the lockdown.

On April 15th, a team of prominent psychiatric researchers published a piece in Lancet Psychiatry calling for high-quality research monitoring the mental health impact on the general population overall and in specific vulnerable groups. These are defined as including children and young people affected by school closures, older adults who may be isolated, and frontline healthcare workers. This is undoubtedly of utmost importance.

One group also experiencing a lot of disruption, though, is university students. Universities have been forced to close physically, meaning that this year’s exam and graduation season has been upended. Teaching is being conducted remotely and assessments have mostly been moved to different formats online. Like primary and secondary education students, university students will be adjusting to a completely new routine and way of learning.

Unlike primary and secondary students, though, for university students studying ‘at home’ may mean moving back in with parents in a completely different city, town or even country to where they usually study. This is likely to be a considerable upheaval at an already difficult time, with concerns around when it will be safe to return, but students who do not go back to where they lived before university risk being left to live alone without their usual support networks as many others leave.

Most university courses are attempting to continue as close to normal as possible, delivering teaching remotely, which means assessments are still largely going ahead. This means that students are under a lot of pressure to be as productive and focused as usual during what is a very tough time psychologically. Without access to libraries and equipment, they also may not have the resources or study spaces they usually have in which to complete their work. Under-performance, as well as the pandemic itself, could negatively impact their future career.

For these reasons, among others, university students may be at increased risk of experiencing negative mental health consequences of the coronavirus pandemic. It is, however, difficult to know this without relevant data.

SENSE Study Logo

This is where my PhD project, the SENSE study, comes in. SENSE is a longitudinal survey of the mental health of UCL students, conducted online beginning in October 2019. The last wave was in February 2020 and the next wave will begin shortly, in May. It covers such areas as students’ demographics, accommodation, financial situation and social lives, and we are adding new questions relating to the pandemic. This means that we will be able to compare UCL students’ mental health before and during the UK coronavirus outbreak. This could help us to understand more about which groups are more vulnerable to the impact of UCL’s closure and the UK lockdown, potentially highlighting areas for intervention. Follow @SENSEstudy on Twitter for updates, or visit our website www.sensestudy.co.uk.

I am also involved in a new study, You-COPE, which aims to measure the mental health of young people aged 16-24 in the UK throughout the lockdown and public health response and in the months afterwards. Follow me on Twitter (@TaylaMcCloud) for updates on this when it launches. This will include university students as well as non-students, and as such will complement the SENSE data findings and allow comparisons between these two groups.

I am attempting to continue this PhD work as usual, whilst conscious that I am a university student living through the coronavirus pandemic researching the mental health of university students during the coronavirus pandemic. It can be difficult to continue work as a “professional” when your work involves focusing on how students are being negatively affected.

Being a student who is researching student mental health is often quite odd like this. I talk about ‘university students’ in the third person, making hypotheses about this abstract group that it is easy to forget I am part of. I often bring my own university experience into the conversation as an example, as do my supervisors, but I am usually referring to a (somewhat) far away undergraduate version of myself and not my present experience. PhD students occupy a confusing space somewhere between staff and student that means we never quite feel like either.

The current coronavirus pandemic, and the resulting UK lockdown and UCL closure, has undoubtedly impacted my PhD work, as well as seemingly every other aspect of my life. I am trying to use this as an advantage; considering how I can use my experience as a UCL student during this time to inform my research, and my interpretation of the findings of this research. I hope that this will add value to the research I am conducting, and that SENSE and You-COPE will be able to shed new light on our understanding of the mental health of university students at a time when they may be particularly vulnerable.

Psychiatry needs a(nother) dose of wellbeing

Maria Thomas24 February 2020

This blog has been guest written by Rochelle Burgess from UCL Institute for Global Health – prompted by our previous blogs from Prof Tony David (Insight and Psychosis: the next 30 years and What is mental health?)

Group of people holding hands in the air

 

 

 

 

 

Earlier this month, the New York Times published an obituary for Dr. Bonnie Burstow, feminist therapist, professor and anti-psychiatrist. Once discovered, I promptly fell through a rabbit hole of Twitter feeds and debates reflecting on her career, most notably her critiques of a psychiatric care system that situates women’s (and everyone’s) mental health problems in the brain, instead of the problematic worlds where these brains and bodies live. This critique has always resonated deeply with me on many levels – as a mental health service user but also more systematically in my research, studying the mental health needs and treatment experiences of marginalised groups exposed to poverty, oppression and various forms of violence, in high-income and low-income settings. That day’s rabbit hole was full of people confirming the ongoing relevance of her work, viewing mental health sciences as disciplines still grappling with some pretty old problems and a rage that is as robust today as it was in the early days of Burstow’s work.

There are probably many reasons to explain this persistence. But they all converge around a long standing critique of the psy-disciplines, well-articulated by Foucault, R.D.Laing, and more recently, Thomas and Bracken’s Post-psychiatry framework, and some critical spaces of the global mental health world. Essentially, patients don’t feel seen. Not fully. Service users are seen in a partial sense – a way that prioritises diagnosis, biological and neurological mechanisms, over what it means to be in the world with a condition, and to the full range of needs of a person.

This is not for a lack of trying. Social and community psychiatry have embraced recovery paradigms and more recently, responding to calls for social interventions. Each in their own way complicates our approach to supporting a process of being ‘in’ the world and experiencing mental distress. But even in this, mental health feels a little stuck in the idea that a person is primarily their diagnosis (see – recovery in the bin movement), and what counts as treatment remains fairly narrow. We still forget the world where bodies live – in spite of the wealth of evidence we have that highlights the structural drivers of mental illness, the impacts of those drivers on treatment outcomes. But we just can’t seem to shift things, probably because the way we define the problem still doesn’t give enough space to the complex needs of people.

We need a new way. Anti-psychiatry doesn’t feel right, as that in its own way removes complexity – ignoring that there are places, spaces and people who will benefit tremendously from access to diagnostics and medications.

This is where wellbeing paradigms have something to offer. Though seen as a hot new topic popularised (and arguably distilled) by ‘happiness’ studies and indexes, wellbeing paradigms are rooted in classical philosophical concepts of Eudaimonia and hedonia – and reflect our earliest attempts to understand the roots of happiness wellbeing. For me, Hedonic perspectives, focused largely on pleasure, are less helpful here. But Eudaimonic perspectives, which looks at meaning, self-actualisation and the ‘full functioning’ of a person, provide the foundations for more holistic, meaningful and potentially radical mental health spaces – where all kinds of care are on the table.

Sociologist Corey Keys, and psychologist Carol Ryff have made considerable contributions to our understandings of how wellbeing principles relate to mental health and mental illness. Importantly, their analyses place mental health and mental illness as two separate but related spectrums, rather than the opposite ends of a single spectrum. Using a framework of ‘complete mental health’ they suggest that the absence of mental illness doesn’t automatically lead to mental health (though they are often co-related), and for this to occur, we need the presence of social, psychological and emotional wellbeing – defined as the ability to flourish. Most importantly for marginalised groups, flourishing encapsulates social wellbeing concerns beyond our relationships, demanding attention be paid to socio-political structures and the world where we live. It’s a model of person-centred care where addressing social-structural realities is as important as psychological and relational ones.

Imagine a field where this is our dominant framing? Where minds, bodies and the places they live are treated as one? Lately, I feel like we’re getting there. Daisy Fancourt is doing amazing things to push forward an evidence base for the importance of social prescribing and community networks to positive mental health, and for the biological dimensions of wellbeing. In communities where I work in the global south, a wellbeing perspective has driven the exploration and testing of intervention models that combine, within treatment programmes, psychological and community development support. Early findings from my recent pilot study of collective narrative therapy for women with complex trauma in South Africa suggests there is a positive booster effect when a focus on how to tackle problematic social environments is included in the intervention.

Burstow wanted a psychiatry/psychology that was as much about the brain, as it was about the world. This is entirely possible – all we need is a healthy dose of wellbeing.

Photo credit: MARCH network – Groups

Insight and Psychosis: The next 30 years

tonydavid25 October 2019

I published my first paper on the topic of insight in relation to psychosis about 30 years ago in the British Journal of Psychiatry. An anonymous Lancet editorialist commented at the time that studying insight was, “academically nourishing but clinically sterile”. Torn between feeling flattered by the attention and insulted by the judgement, I persisted. Now seems a good time to take stock and look forward to the next 30 years. We can now say that we have some ‘facts’ about insight in psychosis: first that it is possible to measure in ways that are at least as valid and reliable as any other psychopathological phenomenon. Next, that there are some very well replicated associations: poorer insight, worse psychopathology; lower IQ, lower insight; and lower mood, better insight. Finally there is the obvious and clinically relevant relationship between insight and treatment adherence and hence outcome.

The relation between insight and adherence, or rather poor insight and coercive treatment is, naturally, where critics of the insight concept converge. ‘Insight’ they say is mere agreeing with the doctor. But where a patient’s self-appraisal as not being unwell or needing help is at odds with their peers and family, might this not be regarded as a lack of insight? The interface between insight and capacity to decide upon treatment is where current ethical debate is concentrated and is seen most vividly in the ability to a ‘use and weigh’ information, a key criterion for mental capacity used in the Mental Capacity Act (2005) definition. It is hard to see how the benefits and harms of a proposed treatment can be weighed in the balance if you don’t believe you are ill in the first place.

Metacognition is a relatively new area of psychology examining people’s ability to reflect upon their own cognition and appears to be related to insight as used in psychiatry. The cognitive neuroscience of metacognition is beginning to make important contributions to psychopathology. Lack of metacognitive awareness – not reflecting on whether a decision is correct – underpins much thinking in say, depression, while excessive metacognition can inhibit decision making as in obsessive compulsive disorder. The lack of ability to change one’s mind in the light of new evidence is a core feature of delusions. Paradigms that build on advances in metacognitive research and make use of computational modelling also promise much in this regard.

For insight in psychiatry, the metacognitive challenge posed is to reflect on one’s own mental and interpersonal functioning. It involves an attempt to see one’s thinking and behaviour ‘objectively’ as if through another person’s eyes and then comparing it to some representation of mental health. There is just one fundamental question asked in relation to clinical insight (after Aubrey Lewis): do I have an illness and is the Illness mental? It includes the moment-to-moment evaluation of mental activity (e.g., was someone speaking to me or was it my imagination?) as well as more enduring ‘semantic’ evaluations such as whether my beliefs are true and shared by others. Note that while that representation of mental health will be the amalgam of received opinion and experience, there is no judging doctor, as it were, in sight.

Cognitive insight is a new construct put forward by pioneer of cognitive therapy, Aaron (Tim) Beck. It refers to a cognitive style or propensity to question one’s ideas, beliefs and behaviour. One advantage it affords research is that it enables insight to be studied in healthy individuals without confounders such as stigma and the effects of treatment, and thus linked to normal psychological processes. An early area of interest is the relationship between cognitive and clinical insight – which surprisingly, turns about to be rather weak. We still do not know if poor cognitive insight in a vulnerable individual may be a risk factor for later psychosis per se.

Can insight be fostered?

Restoring or improving insight is a worthwhile psychotherapeutic aim.  It should be in the form of acknowledging difficulties as a first step in gaining mastery over them. Then, encouraging openness to taking up an effective treatment for those symptoms that cause distress at least as a start, and not at all the forced acceptance of some abstract illness model. This was the aim of the now retro-sounding ‘Compliance Therapy’ trials back in the 1990s. Talking therapies designed to improve metacognition (Metacognitive Therapy and Metacognitive Training) across a range of mental disorders have been developed and tested in small clinical trials and subjected to meta-analysis – and the results are promising. To some extent the success of all these therapies depends on the closeness of the link between metacognition and insight which, as discussed is itself a topic of ongoing enquiry.

Apart from medication, which if effective at relieving symptoms is correspondingly effective at improving insight – a new area of therapeutic research is neuromodulation. Transcranial direct current stimulation (tDCS) is a simple, safe and non-invasive method for selectively modulating cortical excitability. Of interest, tDCS over the dorso-lateral prefrontal cortex has been reported to significantly increase awareness of errors on attention tasks in the elderly. Also, a pilot study showed that tDCS to same region increased insight in patients with schizophrenia – replication with a control condition is obviously required.

In conclusion, the study of insight has proved to be both academically simulating and clinically fertile. It is a biopsychosocial construct par excellence.  I am looking forward to what new insights the next 30 years will bring.

A fuller version of this blog will be published soon as a comment piece in the British Journal of Psychiatry. *The full comment can be found at https://doi.org/10.1192/bjp.2019.217

 

A.S.David, Director, UCL Institute of Mental Health

October 17th 2019

Further Reading

  1. David AS. Insight and psychosis. Br J Psychiatry 1990; 156: 798-808. https://doi.org/10.1192/bjp.156.6.798
  2. Amador XF, David AS. (Eds). Insight and psychosis: awareness of illness in schizophrenia and related disorders. 2nd edn. Oxford: Oxford University Press, 2004.
  3. Beck AT, Baruch E, Balter JM, Steer RA, Warman DM. A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophr Res 2004; 68: 319-329.
  4. Philipp R, Kriston L, Lanio J, Kühne F, Härter M, Moritz S, Meistert R. Effectiveness of metacognitive interventions for mental disorders in adults—A systematic review and meta‐analysis (METACOG). Clin Psychol Psychother 2019; 26: 227– 240. https://doi.org/10.1002/cpp.2345
  5. De Jong S, van Donkersgoed R, Timmerman M, Aan het Rot M, Wunderink L, Arends J, Pijnenborg G. Metacognitive reflection and insight therapy (MERIT) for patients with schizophrenia. Psychological Medicine 2019; 49: 303-313
  6. Harty S, Robertson IH, Miniussi C, Sheehy OC, Devine CA, McCreery S, O’Connell RG. Transcranial direct current stimulation over right dorsolateral prefrontal cortex enhances error awareness in older age. J Neurosci 2010; 34:3646 –3652.

Bose A, Shivakumar V, Narayanaswamy JC, Nawani H, Subramaniam A, Agarwal SM, Chhabra H, Kalmady SV, Venkatasubramanian G. Insight facilitation with add-on tDCS in schizophrenia. Schizophr Res 2014; 156:63-65.