Challenging accepted notions

Several papers in the BJPsych this month present findings that challenge accepted notions in psychiatry, and one paper focuses specifically on the extent to which the findings of highly cited papers are subsequently replicated. Tajika et al (pp. ) identified highly cited studies claiming evidence of effective treatments reported in a range of high-impact general medical and psychiatric journals. Following the progress of attempts at replication in the literature over 10 years, the authors found almost half had not been subject to any attempt at replication (40 of 83), 16 were contradicted and 11 were found to have substantially smaller effects. The authors advise readers to exercise caution when interpreting the significance of studies reporting large treatment effects on the basis of small study samples, even if the studies are published in high-impact journals and are highly cited.

Challenging the notion that stigma is the explanation for the reluctance of military personnel to seek treatment for mental ill health, Adler et al (pp. ) found evidence to support a broadening of the conceptualisation of barriers to and facilitators of mental healthcare and, in particular, found an important preference for self-management among surveyed US soldiers. In the field of interventions for mental health vocational rehabilitation, the effectiveness of individual placement and support (IPS) is well accepted. However, its implementation has been limited by the requirements for time-unlimited support and fixed case-loads. Burns et al (pp. ) challenge the essential nature of these requirements and find that IPS-LITE (time-limited) is equally effective to IPS and, the authors argue, may be more cost-effective.

Also challenging current notions are arguments made in favour of applying a developmental perspective to psychiatric classification in an editorial by Hall & Owen (pp. ), while Castle and Singh (pp. ) debate the current notion that separate early intervention in psychosis is still the best option.

Recognising the impact of personality disorder

Three papers in the BJPsych this month highlight the impact of personality disorder – on mortality, psychosocial morbidity and outcomes following adolescent self-harm. Using nationwide register-based data, Björkenstam et al (pp. ) explored the cause-specific mortality excess for those with in-patient-treated personality disorder. All-cause mortality was found to be increased for those admitted to hospital with a primary diagnosis of personality disorder, for all clusters of personality disorder and for both natural and unnatural causes of death. The authors found little difference between clusters of personality disorder, at least with respect to natural causes of death. Zimmerman et al (pp. ) undertook to compare the psychosocial morbidity associated with borderline personality disorder compared with bipolar disorder, a comparison justified on the basis of apparent clinical similarities between the two disorders but with a stronger emphasis on the public health necessity of improving detection and treatment for the latter. In a sample of patients recruited from a community-based out-patient practice, those with borderline personality disorder were found to have levels of psychosocial morbidity at least as high as those with bipolar disorder; higher levels of comorbidity, historical substance use disorder, suicidal ideation, and historical suicide attempts, among other factors, were identified for those diagnosed with borderline personality disorder.

Ayodeji et al (pp. ) found that 60% of adolescents referred following repeated self-harm demonstrated evidence of one or more forms of personality disorder and that the presence of personality disorder was associated with negative outcomes at 1 year. The authors call on clinicians to consider underlying personality disorder in adolescents presenting with self-harm in order to inform treatment decisions and argue that such diagnostic information can be reliably obtained in this group, even though adulthood has not been reached. Interestingly, another paper in the BJPsych this month focused on self-harm in adolescence and found an association with sleep problems, an association which persisted after depressive symptoms were accounted for (Hysing et al, pp. ).

Eating disorders: oral health and gender-specific risk factors in young people

In a systematic review and meta-analysis, Kisely et al (pp. ) found that patients with an eating disorder were more likely to suffer a range of dental problems, with dental erosion being the most commonly encountered problem and with a further increased risk of this outcome being associated with self-induced vomiting. The authors of the review comment on the likelihood that dentists may sometimes be the first clinicians to suspect an eating disorder and that mental health clinicians need to be more aware of the oral health consequences of eating disorders. Utilising data from the Avon Longitudinal Study of Parents and Children, Micali et al (pp. ) found that risk factors for adolescent eating disorder behaviours and cognitions were gender-specific – for example, childhood body dissatisfaction strongly predicted eating disorder cognitions in girls but only in interaction with body mass index in boys. The authors call for a targeted rather than universal approach to prevention strategies given the differences found in risk–outcome associations by gender and weight status.