A proverbial double-edged sword

The notion of family and carer involvement appears throughout European mental health policy and guidelines. However, it has been noted that carer involvement policy may derive from a responsibilization agenda rather than from evidence that it genuinely supports re- covery. We review qualitative research on family life with depression from the perspective of people with depression. Studies were included if they elicited accounts from adults with a professional diagnosis of depression. Nineteen studies were included which incorporated the experiences of 493 adults with depression. A metasynthesis of findings from these stu- dies is discussed within three themes: family issues and depression interact; family support as a double-edged sword; benefits and limitations of psychosocial interventions. Findings reveal a complex inter-relationship between family roles, relationship dynamics, gender, culture and attitudes towards depression. Family involvement in primary care and medical settings can be a double-edged sword and the perceived benefit may depend on the extent to which family perspectives on treatment fit with the depressed person’s understanding of their depression as medical or psychosocial. Psychosocial interventions for individual cli- ents have several limitations in terms of improving family relationships while family-based group interventions may be more beneficial, depending on the engagement of the family and the partner in particular. The review findings emphasise the complexity of family life with depression indicating that the requirement for ‘carer involvement’ as simplified in cur- rent policies and guidelines is naïve policy at best and that family or couple psychosocial interventions may often be more appropriate

War of conscience: antivaccination and the battle for medical freedom during World War I

The nineteenth century British antivaccination movement attracted popular and parliamentary support and ultimately saw the 1853 law which had made smallpox vaccination compulsory nullified by the 1898 ‘conscientious objector’ clause. In keeping with popular public health discourse of the time, the movement had employed rhetoric associated with sanitary science and liberalism. In the early twentieth century new discoveries in bacteriology were fuelling advances in vaccination and the medical establishment was increasingly pushing for public health to move towards more interventionist medical approaches. With the onset of war in 1914, the medical establishment hoped to persuade the government to introduce compulsory typhoid inoculation for soldiers. This article analyses antivaccination literature, mainstream newspapers and medical press along with parliamentary debates to examine how the British antivaccination movement engaged with this new threat of compulsion by expanding the rhetoric of ‘conscience’ and emphasising medical freedom while also asserting scientific critique concerning the effectiveness of vaccines and the new laboratory based diagnostic practices. In spite of ‘conscience’ fitting well with an emerging public health discourse of individual subjectivity, the mainstream press ridiculed the idea of working-class soldiers having a conscience, coalescing around the idea that ‘conscientious objection’ be reserved for spiritual, philosophical and educated men who objected to military service. Moreover, in spite of engaging in reasoned scientific critique, parliament and press consorted in the demarcation of scientific knowledge as exclusive to medical scientists, reflecting a growing allegiance between the state and the medical establishment during the war. Any scientific arguments critical of medical orthodoxy were subjugated, labelled as ‘crank’ or ‘faddist’ as well as unpatriotic. The antivaccination narratives around conscience contributed to or were part of an evolving discourse on consent and ethics in medicine. Potential parallels are drawn with current and likely future debates around vaccination and counterhegemonic scientific approaches

A NICE game of Minecraft: philosophical flaws underpinning UK depression guideline nosology

Categorising mental disorders for purposes of diagnosis, research and practice has historically been justified on philosophical terms as a pragmatic activity; categories which have been subject to wide-ranging philosophical critique have been defended on the grounds that they serve as heuristic devices providing loose representations of shared experiences, not labels for real structures. In acknowledgement of this, there has been increasing recognition that subclassifying multiple discrete forms of persistent depression moves too far away from the notion of a heuristic and that attempts to create more precise categories become less clinically useful. Hence the most recent Diagnostic and Statistical Manual of Mental Disorders (V.5) and International Classification of Diseases (V.11) both group persistent forms of depression together. However, the UK National Institute for Health and Care Excellence has delineated certain subclassifications of persistent depression in its new guideline, which grossly distorts the phenomenology of depression. This approach commits a fundamental philosophical error in conflating absence of knowledge with knowledge of absence. In this sense, the new guideline appears to be engaging in an activity akin to the digital game Minecraft, in which the craft of building structures from units of construction is largely divorced from the laws of physics. The risk of ignoring these philosophical errors and making false claims about scientific plausibility is that the guideline recommendations inevitably represent a highly distorted phenomenology of depression and will be of very little value to patients or practitioners looking for guidance on best possible treatment options

The Dobson–Rawlins pact and the National Institute for Health and Care Excellence: impact of political independence on scientific and legal accountability

This analysis considers whether the independence of the National Institute for Health and Care Excellence (NICE), while safeguarding guidelines from commercial lobbying, may render NICE legally and scientifically unaccountable. The analysis examines the role of judicial reviews and stakeholder consultations in place of peer review in light of current debates concerning the depression guideline

A proverbial double-edged sword: A qualitative metasynthesis of family involvement in depression from the perspective of people with depression

The notion of family and carer involvement appears throughout European mental health policy and guidelines. However, it has been noted that carer involvement policy may derive from a responsibilization agenda rather than from evidence that it genuinely supports re- covery. We review qualitative research on family life with depression from the perspective of people with depression. Studies were included if they elicited accounts from adults with a professional diagnosis of depression. Nineteen studies were included which incorporated the experiences of 493 adults with depression. A metasynthesis of findings from these stu- dies is discussed within three themes: family issues and depression interact; family support as a double-edged sword; benefits and limitations of psychosocial interventions. Findings reveal a complex inter-relationship between family roles, relationship dynamics, gender, culture and attitudes towards depression. Family involvement in primary care and medical settings can be a double-edged sword and the perceived benefit may depend on the extent to which family perspectives on treatment fit with the depressed person’s understanding of their depression as medical or psychosocial. Psychosocial interventions for individual cli- ents have several limitations in terms of improving family relationships while family-based group interventions may be more beneficial, depending on the engagement of the family and the partner in particular. The review findings emphasise the complexity of family life with depression indicating that the requirement for ‘carer involvement’ as simplified in cur- rent policies and guidelines is naïve policy at best and that family or couple psychosocial interventions may often be more appropriate

Psychological treatments for persistent depression: A systematic review and meta-analysis of quality of life and functioning outcomes.

To date it is unclear whether psychological therapies have potential to improve quality of life and functioning in patients with persistent depression. This meta-analysis examines the effect of psychological therapies for improving quality of life and functioning in patients with persistent forms of depression. Data sources include Medline and Meta-Analytic Psychotherapy Database (METAPSY), searched 07/2021. Eligible studies were randomized controlled trials where participants had major depressive disorder on entry and met criteria for a persistent form of depression, for example, chronic, treatment resistant or recurrent depression. Standardized mean differences (Hedge’s g) were calculated in random-effects meta-analyses. Fourteen studies met inclusion criteria (N = 1898). Psychological interventions were associated with improvements in patients’ quality of life at the end of treatment: pooled g = 0.24 (95% confidence intervals [CIs] 0.13–0.34); low to moderate levels of heterogeneity (I² = 0% [95% CI 0%–41.2%]). Quality of life at follow-up: pooled g = 0.21 (95% CI 0.01–0.32); low to high levels of heterogeneity considering the wide CI for I² (I² = 10.36% [95% CI 0%–77.5%]). The psychological interventions were associated with improvements in patients’ functioning at end of treatment: pooled g = 0.34 (95% CI 0.21–0.48); low to high levels of heterogeneity considering the wide CI for I² (I² = 0% [95% CI 0%–81.7%]). Functioning at follow-up resulted in: pooled g = 0.33 (95% CI 0.15–0.50); low to high levels of heterogeneity considering the wide CI for I² (I² = 0% [95% CI 0%–86.2%]). This meta-analysis highlights the potential benefits of psychological therapies for improving quality of life and functioning in patients with persistent depression, with strongest long-term effects for mindfulness-based cognitive therapy, interpersonal therapy in combination with antidepression medication, and long-term psychoanalytic psychotherapy

Psychometric origins of depression

This article examines the historical construction of depression over about a hundred years, employing the social life of methods as an explanatory framework. Specifically, it considers how emerging methodologies in the measurement of psychological constructs contributed to changes in epistemological approaches to mental illness and created the conditions of possibility for major shifts in the construction of depression. While depression was once seen as a feature of psychotic personality, measurement technologies made it possible for it to be reconstructed as changeable and treatable. Different types of scaling techniques (Likert versus dichotomous scales) enabled the separation of depressive personality from reactive depression, paving the way for measuring the severity and intensity of emotions. Techniques to test sensitivity to change provided a means of demonstrating the efficacy of new psychoactive drug treatments. Later, more advanced techniques of precision scaling enabled the management of a new measurement problem, clinician unreliability, associated with the growing number of professionals involved in mental health care. Through statistical management of unreliability, the construct of depression has dramatically reduced over this period from hundreds of questionnaire items to potentially just two. Exploring the history of depression through this lens produces an alternative narrative to those that have emerged as a result of medicalisation and the actions of individuals and pressure groups

Semantics of patient choice: how the UK national guideline for depression silences patients

Several stakeholders, including the National Survivor User Network and the British Psychological Society, have called for the National Institute for Health and Care Excellence (NICE) to include an up-to-date review of patient experience research in the new depression guideline. In response, the Guideline Committee (GC) postponed publication, the guideline now due in February 2020. Yet the GC also stated it will not review patient experience research. Instead, it will incorporate a new element of ‘patient choice’, without elaborating what this entails. Here, we attempt to untangle a number of similar sounding terms including ‘patient choice’, ‘patient preference’, ‘patient experience research’ and ‘service user involvement’ in terms of how they relate to the NICE depression guideline. We argue that by conflating these concepts and implying that one will serve the purpose of another equally well, NICE risks leaving patients without a real voice, their perspectives buried in semantically void rhetorical jargon

A systematic review on the mental health of parents of individuals with learning disabilities

The transforming care programme aims to increase care provision in the community for individuals with learning disabilities (LDs) in the United Kingdom resulting in more parents taking on carer responsibilities. Previous research suggests that having a child with LD may be associated with impaired mental health in parents. However, previous reviews have often conflated poor mental health with wellbeing or quality of life and have grouped people with LD together despite the LD severity and/or the underlying cause of LD, both of which may have different types of impact on parents. This review aims to critically appraise and synthesise the literature on the mental health of parents with children with LD of unknown cause to answer the question, ‘Do parents of individuals with LD of unknown cause experience diagnosable mental health difficulties?’ Following PRISMA guidance, this systematic review found seven studies, obtained from four databases, meeting a strict set of inclusion and exclusion criteria. Studies were assessed against the Quality Assessment Tool for Quantitative Studies. A narrative synthesis of the results found that rates and severity of diagnosable mental health difficulties were higher in mothers of children with LD of unknown cause than mothers of typically developing children, Down syndrome and LD of known cause, but lower than mothers of individuals with autism spectrum disorder. LD severity also appears to be a factor impacting parental mental health. Findings suggest that LD services need to provide more psychological support for parents and families