Does "concept creep" affect the way we think about mental health problems?
Plus: screen use and sleep in young people; using the placebo effect to enhance psychotherapies; roads or brains?
Margin call
There’s been a lot of discussion—and controversy—around “concept creep” in mental health lately. Of course, the application of ideas originating in the world of “mental illness” to problems of life in general has been around since the days of psychoanalysis, and possibly before. And with this has come concern about the blurring of lines between mental health conditions, and what Freud would call “ordinary unhappiness”. Or as Frasier Crane put it: “I am not trying to make him happy! I am trying to cure his depression.”
This new paper in PLOS Mental Health reports on two studies in which US-based participants recruited via the Prolific platform were given vignettes about “marginal cases”, in which “it is ambiguous whether the application of a diagnostic label is warranted, so the provision of a label simulates diagnostic expansion.” These vignettes ended with a “label” of a specific mental health diagnosis (eg, PTSD), or no label.
Participants were then asked questions about the empathy they felt, whether accommodations were warranted in the light of the person’s condition, appropriateness for professional treatment, and the stability of the condition.
The studies had some differences in design, but the authors summarise:
The studies found consistent evidence that diagnostic labeling increases the perception that people experiencing marginal problems require professional treatment, and some evidence that it increases empathy towards them and support for affording them special allowances at work, school, and home.
The authors note that this means the theory that labels increase stigmatisation is not supported, possibly because destigmatisation efforts over the past decade or so have actually worked.
However, the flip side of this is that people may assume that mental health problems are essentially enduring, and that the sufferer is in a position of little control. Ideally, the authors would have further explored survey participants’ belief in the effectiveness of treatments for these diagnoses. Nevertheless, it’s good to see this data published, and I hope we see much more work to analyse the extent and implications of “concept creep”.
Hanging on the telephone
Should young people abjure screentime before bed? Maybe not, according to this JAMA Pediatrics study from New Zealand, which adds precision to previous efforts in this field. The authors used wearables to record screen use—and type of screen use—around bedtime on four nonconsecutive nights in a cohort of 79 young people aged 11 to 14 years. For those wondering, the wearables were the Axivity accelerometer, and the PatrolEyes SC-DV7 Ultra video camera, the latter usually utilised by law enforcement officers. Use of such methods and technology clearly raises ethical issues, but it’s worth noting that this study was approved by the local ethics committee and consent was obtained from both parents and young people.
The good news? For parents struggling to implement a “no screen time before bed” policy, this might not actually be necessary. Screen time in the two hours before bed didn’t affect sleep quality. However, once these young people were in bed, it was a different story: all types of screen time were associated with shorter sleep time, but especially “interactive” screen use (gaming, messaging, multitasking, educational or creative tasks, as opposed to “passive” reading/viewing). “The mean difference in total sleep time was −9 minutes (95% CI, −16 to −2 minutes) for every 10 minutes of interactive screen use and −4 minutes (95% CI, −7 to 0 minutes) for passive screen use.”
This is a small and necessarily limited study. But the smart use of wearable technology to get granular data in such a controversial field is a real step forward.
How to use the placebo effect
Psychotherapy and Psychosomatics dives into the strange world of placebos, and how we can apply learning from this area to potentiate psychological treatments in practice, leveraging factors such as positive treatment expectations, negative treatment expectations, and side-effect expectations. While they conclude that “A major tool is to improve outcome expectations”, this comes with the caveat that expecting a better outcome might also come with increased anticipation of side-effects.
This put me in mind of the work of Arthur Hurst at Seale Hayne, UK, back in the First World War. Seale Hayne specialised in functional motor conditions associated with trauma, and gained much publicity from the apparent effectiveness of its methods. As Hurst put it:
Directly the patient is admitted, the sister encourages him to believe that he will be cured as soon as the doctor has time to see him… The medical officer… tells him as a matter of course that he will be cured the next day. The patient is made to understand that any treatment he has already received has prepared the way, so that nothing now remains but a properly directed effort on his part for a complete recovery to take place.
(However, Hurst’s methods and reporting have been called into question: see here for more details.)
Roads or brains?
A new LSE report Value for money: How to improve wellbeing and reduce misery analyses UK government spending options through a wellbeing lens to estimate cost-benefit. According to the authors, spending money on brains has a greater benefit than spending it on roads: see Figure 0.1, which sets out the options where savings exceed expenditure. These include:
· NHS Talking Therapies
· Psychological therapy service for addiction
· Employment support for moderate mental illness
· Mental Health Support Teams in schools
The only transport-related item in the list is “Relaxing Green Belt near commuter stations”.
I’m particularly interested to see addiction-focused services here—not traditionally a vote winner, but hugely important. Will this report help to finally unlock investment?