Let it be

When I was a trainee, one of my supervisors said that the real learning in psychiatry starts after you finish all your exams and qualify. I politely nodded but quickly returned to memorising the facts from my Kaplan & Sadock's, thinking my father used to say something similar about high school. For the 12th and final BJPsych issue for 2023, let me highlight four articles and the broader lessons I learned from reading them.

First, Loo et al (pp. 533–541) conducted a 4 week, randomised, double-blind, active-controlled, multicentre phase 3 trial comparing the efficacy of racemic ketamine and midazolam for treatment-resistant depression. The trial covered seven sites from Australia and Aotearoa New Zealand. Of note, racemic ketamine (as opposed to esketamine) is the low-cost, generic version of ketamine, which is globally available owing to it being on the World Health Organization's Essential Medicines List. In cohort 1 (n = 73), where a fixed dose of ketamine was administered at 0.5 mg/kg, the remission rates between the two groups were not statistically different (6.3% v. 8.8%, P = 0.76). In cohort 2 (n = 106), where the dosing was revised to a flexible dose (0.5–0.9 mg/kg for ketamine), the ketamine group had a significantly higher remission rate than the midazolam group (19.6% v. 2.0%, P = 0.005). However, it is important to note that the difference in the remission rates in cohort 2 was no longer significant even at the 4 week follow-up point (8.0% v. 2.1%, P = 0.4). The study reminds me of the Goldilocks principle: it is essential to find the therapeutic dose of poison. I am excited that we might have a potential game-changer for depression.

Second, Fan et al (pp. 542–554) took a deep dive into the diagnostic entity of internalising disorders. The study used a data-driven strategy to determine impulsivity-dependent subtypes among children with internalising disorders. They sought to determine subtype-specific signatures via brain morphology, cognition and clinical trajectory. Through their investigations, the authors found two distinct internalising disorder subtypes (impulsivity enhanced and impulsivity decreased). The study reminds me of the Dunning–Kruger effect: the more you understand something, the more you realise that you don't really understand it. I am thrilled that we are rapidly learning how to use different tools to explore the knowns and unknowns in psychiatry.

Somewhat similarly, Gillespie and Elliot (pp. 555–561) analysed psychological test data of over 2000 adult males convicted of sexual offences to identify latent profiles based on indicators of dynamic risk. They identified five distinct profiles with various individual characteristics, offence histories, victim preferences and levels of risk. The study reminds me of a lyric from Mary Poppins Returns: ‘A cover is not the book, so open it up and take a look. ‘Cause under the covers one discovers, that the King may be a crook’. I guess this is why we value the art of formulation so much in psychiatry. I would not have said this 5 years ago, but I am thankful that I was taught formulation in my training.

Finally, Roberts et al (pp. 562–568) examined drug-related deaths among housed and homeless individuals in the UK and the USA. The findings from their study showed a remarkable set of differences in the characteristics of drug-related deaths between the two nations. Some of the most striking results for me were: (a) homeless individuals accounted for 16.3% of the total deaths in the USA but only 3.4% in the UK; (b) homeless individuals in the UK had a significantly increased risk of opioid-implicated death compared with housed individuals, whereas homeless individuals in the USA had a significantly decreased risk compared with housed individuals; and (c) two-thirds (66.7%) of homeless individuals in the USA had methamphetamine implicated in death, compared with only 0.4% in the UK. The study reminds me of a line by The Streets: ‘Two nations divided by a common language’. We are not always describing the same experiences just because we speak the same language. I am optimistic, however, that our ongoing communication may lead to a better understanding.

Now that I have passed all my exams and qualified, I read more academic articles than I did as a trainee. I also feel like I take more out of reading them than I ever did as a trainee. Sometimes, I wonder whether there is a difference between knowledge and wisdom. Then I think to myself: that sounds like something that my father would have said.