The nature and impact of antidepressant withdrawal symptoms and proposal of the Discriminatory Antidepressant Withdrawal Symptoms Scale (DAWSS)

Background: We sought to understand more about the nature and possible consequences of antidepressant withdrawal. Methods: We surveyed members of 20 peer-led, online groups, assessing 31 commonly reported antidepressant withdrawal symptoms. Results: There were 1148 respondents, who were mostly white, female and educated. For 40% of respondents, withdrawal symptoms had lasted more than 2 years and 80% were moderately or severely impacted by them. One in four were unable to stop their antidepressant. Reported consequences of withdrawal included impaired work function (56%), losing jobs (20%), taking sick leave (27%), and relationship breakdown (25%). Both emotional and physical symptoms newly occurred or increased in severity following antidepressant withdrawal compared to before starting antidepressants. There was no difference in the nature of symptoms, severity or duration between people with physical or mental health diagnoses. We have proposed a potential Discriminatory Antidepressant Withdrawal Symptoms Scale (DAWSS), comprising the 15 symptoms most specific to withdrawal (including electric shock sensations, dizziness, akathisia or restlessness, vertigo, and vomiting), which requires further validation. Limitations: The sample was derived from peer support groups and is not representative of everyone who undergoes antidepressant withdrawal. The cross-sectional design precludes establishing causal relationships between variables. Conclusions: Our findings suggest there is a distinctive antidepressant withdrawal syndrome characterised by a range of emotional and physical symptoms, which can be severe, prolonged and have profound impact. The DAWSS may be helpful in distinguishing withdrawal from underlying conditions. Health services need to provide evidence-based clinical advice and support to people on long-term antidepressant

History, Violence and Collective Memory: Implications for Mental Health in Ecuador

National histories of violence shape experiences of suffering and professional responses. In Ecuador, mental health literature addressing this crucial issue is scarce and little debated. In contrast, local psychiatrists and psychologists within the country face contemporary challenges that are deeply rooted in a violent colonial past and the perpetuation of its fundamental ethos. This paper critically reviews relevant literature on collective memory and historical trauma, and focuses on Ecuador as a case study on how to incorporate history into modern mental health challenges. The discussion poses key questions and outlines possible ways for Ecuador to address the link between history and mental health, including insights from countries that have struggled with their violent pasts. This paper contributes to ongoing international debate on the role of cultural history in mental health with implications for social scientists and practising clinicians in former colonised nations

Medicalising the moral: the case of depression as revealed in internet blogs

Depression is regularly declared to be equivalent to a bodily illness, yet critics have long contested this ‘medical’ view of mental disorders. Following the ideas of Szasz and Foucault, we describe an alternative ‘moral’ view of depression, which emphasises the agency of the individual and presents depression as a potentially problematic but meaningful response that can be regarded as an aspect of character. We use popular internet blogs by people with depression to explore these contrasting conceptions, which can also be found in other research and information on depression. In blogs, the medical view is used to challenge what bloggers perceive as a persistently influential moral view, by deflecting criticism and responsibility and disowning unwanted aspects of the self. At the same time, bloggers make positive use of the moral concept of depression when discussing recovery. The moral view enables people to take active steps to address their difficulties and to integrate the experience of depression into their understanding of themselves in a challenging yet rewarding process of personal development. We suggest that the moral view of depression represents an enduring aspect of our understanding of ourselves, which the medical view has been superimposed onto, but has not managed to suppress

Later is not necessarily better: limitations of survival analysis in studies of long-term drug treatment of psychiatric conditions

Survival analysis is routinely used to assess differences between groups in relapse prevention and treatment discontinuation studies involving people with long-term psychiatric conditions. The actual outcome in survival analysis is 'time to event', yet, in the mental health field, there has been little consideration of whether a temporary delay to relapse is clinically relevant in a condition that can last for decades. Moreover, in psychiatric drug trials, a pattern of elevated early relapses following randomisation to placebo or no treatment is common. This may be the result of the withdrawal of previous treatment leading to physiological withdrawal effects, which may be mistaken for relapse, or genuine relapse precipitated by the process of withdrawal. Such withdrawal effects typically produce converging survival curves eventually. They inevitably lead to differences in time to relapse, even when there is little or no difference in the cumulative risk of relapse at final follow-up. Therefore, statistical tests based on survival analyses can be misleading because they obscure these withdrawal effects. We illustrate these difficulties in a trial of antipsychotic reduction versus maintenance, and a trial of prophylactic esketamine in people with treatment-resistant depression. Both illustrate withdrawal-related effects that underline the importance of long-term follow-up and question the use of tests based on time to event. Further discussion of the most relevant outcome and appropriate approach to analysis, and research on patient and carer preferences is important to inform the design of future trials and interpretation of existing ones

Bound to shop: corporate social responsibility and the market

The social and environmental responsibility of corporations is a subject that continues to ignite public passions. No wonder, given the regular reminders of the kinds of trouble that irresponsible business practice can get society in! The persistence of corporate social responsibility in this context has proved controversial. A strategy for managing the social and environmental responsibility of business that relies on self-regulation, CSR is a concept that strikes an uncomfortable chord with the already high levels of corporate autonomy. Yet, there seems to be no shifting from CSR. The activist shopping, of which it boasts, has ingratiated itself with democratic politics and, as such, seems set to remain. Everyone today agrees on the need for business to be more responsible. CSR is an important part of how this responsibility is managed and organised today. This thesis analyses this entrenchment of CSR in terms of what it describes as ‘the double play.’ Markets first make demands on people, time and resources, in order to secure productivity and profitability. They then make a second play to service the social and environmental fall-out of this first drive for marketisation. CSR takes place on this second play, deploying market incentives and techniques to the remedy of market generated problems. Corporations participate, drawn to the security accorded their autonomy. They see in CSR a chance to right wrongs created in earlier cycles of exchange, without the risks created by external interference. The public engage where, as the ultimate source of economic demand, they feel the responsibility for everything that goes on in the market. They try to ‘shop better’ on the second wave, to instil recovery and prevent the rematerialisation of harm. This thesis problematises CSR and the double play. It does so in a series of critical provocations directed at CSR informed by the philosophy of Jean Baudrillard. It discusses CSR’s capacity to politically disempower public participants, by drawing their energies into a perpetual cycle of economic imperialism and exchange. It discusses the difficulty CSR creates, in terms of raising conflict with business actors, and the tendency for the system to leave inert, or exposed and abandoned, those that try. Finally, the thesis pushes up against an ultimatum in CSR – ‘buy, or people perish!’ – through which the market is able to indefinitely extend and regenerate itself. The thesis argues for the disengagement of this ultimatum. For only when social and environmental concern is not held hostage to the market can the political ambition, which is somewhere present in all of this, be realised

The Neutrophil-Lymphocyte Ratio and Locoregional Melanoma: A Multicentre Cohort Study

Objectives The neutrophil–lymphocyte ratio (NLR) is an inflammatory biomarker which is useful in cancer prognostication. We aimed to investigate the differences in baseline NLR between patients with localised and metastatic cutaneous melanoma and how this biomarker changed over time with the recurrence of disease. Methods This multicentre cohort study describes patients treated for Stage I–III cutaneous melanoma over 10 years. The baseline NLR was measured immediately prior to surgery and again at the time of discharge or disease recurrence. The odds ratios (OR) for sentinel node involvement are estimated using mixed-effects logistic regression. The risk of recurrence is estimated using multivariable Cox regression. Results Overall 1489 individuals were included. The mean baseline NLR was higher in patients with palpable nodal disease compared to those with microscopic nodal or localised disease (2.8 versus 2.4 and 2.3, respectively; p < 0.001). A baseline NLR ≥ 2.3 was associated with 30% higher odds of microscopic metastatic melanoma in the sentinel lymph node [adjusted OR 1.3 (95% CI 1.3, 1.3)]. Following surgery, 253 patients (18.7%) developed recurrent melanoma during surveillance although there was no statistically significant association between the baseline NLR and the risk of recurrence [adjusted HR 0.9 (0.7, 1.1)]. Conclusion The NLR is associated with the volume of melanoma at presentation and may predict occult sentinel lymph metastases. Further prospective work is required to investigate how NLR may be modelled against other clinicopathological variables to predict outcomes and to understand the temporal changes in NLR following surgery for melanoma

Machine Learning for Stochastic Parameterization: Generative Adversarial Networks in the Lorenz '96 Model

Stochastic parameterizations account for uncertainty in the representation of unresolved sub-grid processes by sampling from the distribution of possible sub-grid forcings. Some existing stochastic parameterizations utilize data-driven approaches to characterize uncertainty, but these approaches require significant structural assumptions that can limit their scalability. Machine learning models, including neural networks, are able to represent a wide range of distributions and build optimized mappings between a large number of inputs and sub-grid forcings. Recent research on machine learning parameterizations has focused only on deterministic parameterizations. In this study, we develop a stochastic parameterization using the generative adversarial network (GAN) machine learning framework. The GAN stochastic parameterization is trained and evaluated on output from the Lorenz '96 model, which is a common baseline model for evaluating both parameterization and data assimilation techniques. We evaluate different ways of characterizing the input noise for the model and perform model runs with the GAN parameterization at weather and climate timescales. Some of the GAN configurations perform better than a baseline bespoke parameterization at both timescales, and the networks closely reproduce the spatio-temporal correlations and regimes of the Lorenz '96 system. We also find that in general those models which produce skillful forecasts are also associated with the best climate simulations.Comment: Submitted to Journal of Advances in Modeling Earth Systems (JAMES