The richness of paradigms in child and adolescent psychiatry

We all need evidence to support our patients and to serve public health. European Child and Adolescent Psychiatry (ECAP) acts like the necessary bridge that allows this evidence to travel from science to clinical practice and policy. The precise clinical need for evidence varies a fair bit. We need evidence for assessment, for treatment, and for community-based intervention. Also, going a step back, we need the science to explain to ourselves and to our patients the mechanisms for the problems we are dealing with—this is the knowledge that comes from the sciences basic to psychiatry, such as epidemiology and neuroscience. However, it is also a discipline that is dependent on other sciences, sociology, and economics if it is to understand in depth the phenomena it is dealing with.

This edition of ECAP provides some important examples of how this evidence is generated and presented to its readership. Below, I will discuss some exemplars of this variety and the way in which each contributes to our knowledge. Perhaps, the most interesting theme that emerges from these papers is this variety of sources of evidence required for a thorough understanding of mental health problems. Interestingly, environmental factors, such as income, inequalities, or one’s position in society, were neglected or even dismissed as not belonging to the domain of psychiatric research. Indeed, a false dichotomy was created between the “biological” and the “social” or “cultural” as if only the former were a product of evolution and biological processes or as if biological processes were immune to effects from society or culture itself. This has meant that clinicians and scientists deprived themselves of important sources of knowledge, which by extension meant that necessary evidence did not reach our patients or policy makers.

Science should be open to sources of knowledge and should rejoice in the updating of its paradigms, which sometimes also involves getting rid of entrenched views. Below, I will discuss some papers from this edition of ECAP that do this.

I will start from the clinical level, discussing fears in young people. Impressionistically, I would say that clinicians may either forget to ask about them or not take them as seriously when they encounter them. They are easily overshadowed by other problems for which people come to clinic and we are taught that they are often self-limited and decline with age. The study by Husky et al. [1] in this issue reports on the prevalence of fears and their association with internalising and externalising psychopathology across eight European countries.

Unsurprisingly, fears are common, and they decline with age in boys more than in girls. Perhaps equally unsurprisingly given what we know from work in adults, fears are also associated with internalising and externalising psychopathology. The association is substantial, though looking at Table 3, one notes that over 70% of children with fears will not have psychopathology—an important information to bear in mind when encountering a young person with a fear. It is also important to note that this cross-sectional study cannot inform us about whether fears come before or after or at the same time as other psychopathology. Nor can it inform us about whether they all have the same (genetic or environmental) roots.

An interesting question for therapists is whether treating phobias first could help with other co-occurring disorders. At the risk of over-using clinical anecdote, my colleagues and I have found that intervening first with the simpler-to-treat phobias makes it easier to deal with the more complex problems such as depression or generalised anxiety—perhaps because a positive treatment experience helps. I hope that someone will do the study too for this.

On a related topic, Kolaitis et al. [2] in this Journal made use of the Generation R dataset to answer a pertinent clinical question: does chronic pain precede or follow internalising problems? Anyone who has worked at the interface of paediatrics and psychiatry will be aware of the problems with chronic pain. Traditionally, patients’ mental health had been left out of the picture, or when asked about often explained away as a mere consequence of any physical health problems and pain. As a result, interventions for such co-occurring mental health problems may not even be considered. The Kolaitis et al.’s article shows that internalising problems at 3 years appear to predict significantly chronic pain at 6 years, but not vice versa, that is, chronic pain at 3 years does not predict internalising problems.

It is important to note here that the prediction is significant, but that the effects are modest with odds ratios of 1.05 for the prediction from internalising problems to chronic pain and the effect perhaps mainly driven by an association with somatic complaints (odds ratio of 1.20).

The article does raise important questions though about how to identify early those who will go on to develop chronic pain and the possibilities afforded to prevention by targeting early onset internalising problems.

Clinicians mainly see those who come to see them or are brought to them, the source of the sometimes-biased view of illness that we can have as clinicians. It is therefore always illuminating to see data on who comes to us. The article by Seminog et al. [3] presents hospital-admission data from the population-based study using person-linked data for England (available between 2001 and 2016). As perhaps expected, they find that childhood-onset schizophrenia is an extremely rare reason for admission in children and that this does not seem to be different between boys and girls. Also, the authors find that there is a substantial increase in schizophrenia-related admissions during adolescence, when a clear male preponderance also kicks in.

However, the authors also find a staggering reduction in the number of schizophrenia-related admissions for adolescents with rates of about 6.6 per 100,000 in the early 2000s dropping down to 1.4 between 2013 and 2016.

The reasons for this drop are unclear and may be related to the advent of early intervention services for psychosis, though it is not clear how this explanation could also account for the relative increase of rates of overall psychosis admission diagnoses over time in girls.

In general, hospital-admission diagnoses often mirror sociological trends, rather than necessarily changes in scientific evidence about the true incidence, the assessment, or the treatment of schizophrenia and related conditions. The overall male preponderance in admissions, the over-representation of children from low socioeconomic strata, and the excess of black girls amongst those admitted with a schizophrenia diagnosis illustrate this point and emphasise that medicine is not practiced in a vacuum and that sociological and economic evidence may be just as valuable.

The final paper I want to discuss here is the one by Kearns et al. [4] that makes use of the cross-national Global School-based Health Survey 2003–2017 to describe the association between worry-related sleep problems and suicidal thoughts and behaviours across 88 countries. For a clinician, the relationship between sleep problems, particularly those related to worries, and suicidal thoughts and behaviours (for short STB) appears very evident. Kearns et al. show that this is true in the community too and also evident across countries: worry-related sleep problems were significantly associated with suicide ideation, plans, and attempts. Using multi-level models, the authors can partition individual from country-level effects. They find that the relationship is stronger in boys, and most evident in richer countries and those where inequalities were most pronounced. Once again, this paper makes evident some striking differences that are unlikely to be due to what is traditionally regarded to be a “biological” effect. Whilst causal evidence is not presented in the Kearns et al.’s paper, their paper adds to the need to examine more closely how inequality itself or what leads to it and is associated with it, impact on youth mental health. It is possible that inequality is a marker for other macro-economic processes or it may be causal itself. Moreover, the Kearns et al.’s paper makes it clear that we should be careful in assuming that happiness or mental wellbeing is simply a function of income. Recent studies uncover seemingly paradoxical findings [5] and suggest that more-nuanced approaches to the evidence are required, one that takes cultural and societal factors into account.

Necessary change may be underway in our discipline. At a recent conference, I experienced philosophers speaking next to scientists deeply committed to quantitative research in child mental health. There was very little awkwardness and a lot of curiosity on both sides. Discussions at the conference highlighted the need for integration across different sources of knowledge and certainties about knowledge status and direction were questioned, as appropriate in science. This Issue of the Journal moves along the same lines, and it integrates across areas of knowledge. One hopes that there will be yet more to come.

留言 (0)

沒有登入
gif