Community identity stability

In this issue of BJPsych, the editorial by Goodday et al (pp. 51–53) argues that digital health technologies could potentially redesign the psychiatry field. We base our assessment and treatment on self-reported symptoms in intermittent clinical encounters. What if we could bring more objectivity to our practice? Like Holter monitoring for blood pressure, can we monitor dynamic behaviour, emotion and physiological responses in real time? In the related Analysis, Rocheteau elegantly outlines the issues associated with artificial intelligence in psychiatry. Of note, Rocheteau touches on the idea of online psychotherapy. What if we replace human therapists with ‘robo-therapists’ who can recall your story, deep learn and stick to manualised therapy perfectly? We already have the technology to produce speech that is indistinguishable from that of humans. The future may be closer than we think it is.

The multicentre randomised control trial by Gnanapragasam et al (pp. 58–66) brings us back to reality. The study examines the effectiveness of the ‘Foundations’ app among UK healthcare workers. The app reduced general psychiatric morbidity and insomnia while improving the mental well-being of the intervention group. The app did not, however, have any significant impact on symptoms of depression or anxiety, or on resilience, presenteeism and functioning. Another paper on COVID in this issue Fancourt et al (pp. 74–81) further examines depressive and anxiety symptoms. Using data from the UCL COVID-19 Social Study, the authors found that compared with the short-COVID group, those with long COVID experienced significantly higher levels of depressive symptoms but comparable levels of anxiety symptoms at the onset of COVID infection. Over the subsequent 22 months, both the depressive and anxiety symptoms for the long-COVID group remained elevated whereas the symptoms were reduced back to the baseline for the short-COVID group.

Even in a developed nation like Australia where I practice, pharmacological intervention is vastly more available and affordable (and thus accessible) than psychological intervention. I can only imagine how limited access might be in low- and middle-income countries with a distinct lack of trained professionals. The Healthy Activity Program trial demonstrated that you don't need fancy degrees to help people. Through the programme, behavioural activation delivered by lay counsellors in Goa, India, significantly improved the remission rate from depression. In this issue, Seward et al (pp. 67–73) further explore the data from the trial to see if they could find specific aspects that improved outcomes. The authors found that the reduction in depressive symptoms was mediated through improved levels of behavioural activation. Surprisingly, they found no mediating effects through factors such as the number of sessions, homework completed, response to therapy or number of additional sessions. Given the findings, the authors suggested that if people are not responding to the behavioural activation, alternative treatment should be offered rather than persisting with additional sessions. Perhaps we can offer ‘robo-therapy’ soon.

Finally, Goto et al (pp. 82–87) evaluate the state of Ukrainian in-patient mental health services in April 2022, a couple of months after the war began. Based on interviews with the heads of 32 in-patient mental health facilities in Ukraine, the authors found that the hospital admission rate decreased by nearly a quarter compared with before the war, with much of the reduction coming from the eastern regions occupied by Russia. Despite the decrease in hospital admission, the authors argued that there remain significant unmet mental health needs in Ukraine. One potential solution suggested was seeking the help of non-mental-health specialists (as described in the Healthy Activity Program). Another solution was to strengthen remote mental health support (perhaps an app like ‘Foundations’ may be adapted to fit the Ukrainian setting).

I recently re-read Aldous Huxley's Brave New World for the first time since high school. This issue of BJPsych contains artificial intelligence, robo-therapy, ‘Foundations’, a pandemic, behavioural activation and a war in Europe. Our community feels much smaller yet much more divided. As we seek our identity in this era of confusion and chaos, stability remains a couple of steps away. Reading through this month's BJPsych, I wondered what Huxley would have made of the brave new world we live in now.