Listening to people who hear voices
Plus: anticholinergics and cognitive impairment in psychosis; new figures on physician suicide; and the benefits of mixed methods research
Listening to people who hear voices
Back when I was in training, clinicians were not really encouraged to engage with voice-hearing. It was enough to establish its presence, and maybe do a bit of risk assessment based around it, but that was that. The work of projects such as Durham University’s Hearing the Voice, and the approach of the AVATAR team, which engages therapeutically with voice-hearing, have been long-overdue correctives.
This new Psychological Medicine paper uses data from the AVATAR2 trial to examine the relationship between attachment, trauma, voice appraisals, and the experience of voice hearing in psychosis. Having analysed data from 345 individuals, the authors identified four profiles:
Adverse voices and relational trauma (44.5% n=157)
Low malevolent and omnipotent voices (25.2%, n=84)
Adverse voices yet low relational trauma (16.5%, n=57)
High benevolent voices (13.8%, n=47)
The first of these, “Adverse voices and relational trauma” had the highest proportions of female and other non-male genders; it was also had the highest voice severity and worst emotional distress. The authors conclude that this study “can inform individualized assessments including careful consideration of voice appraisals, especially benevolent voices, and how these are linked to interpersonal adversities, to support decisions around helpful interventions.”
Anticholinergics and cognitive impairment in psychosis
Recent years have seen growing interest in cognitive impairment associated with psychosis. And rightly so; as the authors of this new AJP paper point out, 80% of people affected by psychosis show clinically relevant impairment, and “On average, the cognitive performance of people with psychosis is two standard deviations below that of the general population”.
New treatments are needed. But what if we could also improve the situation by rethinking our use of current treatments? That’s the question these researchers asked, carrying out a systematic review and meta-analysis to quantify the relationship between cognitive impairment and anticholinergic drugs, which are often prescribed to counteract the extrapyramidal side-effects of antipsychotics such as stiffness and involuntary movements.
They found that anticholinergic burden was associated with impaired cognitive function, and that tapering off the drugs was associated with improvement. While anticholinergics might account for “a significant but not large proportion of the overall deficits”, this is, the authors state, nevertheless a potentially modifiable risk factor, so worth exploring further. While they conclude that “tapering off anticholinergic medication may be beneficial”, they stress a trial is needed to fully quantify what this benefit might be.
Physicians and suicide risk
Sobering findings in this JAMA Psychiatry paper looking at physician suicide in the US, using National Violent Death Reporting System data from 30 US states and Washington, DC, recorded between 2017 and 2021. While male physicians had significantly lower suicide incidence that their male non-physician counterparts, the opposite was the case for female physicians.
Why is this? The authors write:
“It is not possible to determine from these data why female physicians, like female nurses, are at higher risk of suicide. It cannot be ignored that there may be factors yet unknown about being a woman in health care that increases suicide risk. Possible contributors include underrecognition for similar work and achievements, inequitable pay and opportunities for promotion, greater domestic responsibilities leading to work-life imbalance, and risk of sexual harassment.”
What can be done? The authors identify some risks that can be addressed, including mental health, employment, and legal problems, as well as the presence of various drugs and some method-specific factors. They also point to the need for a culture change in medicine, highlighting in particular the fine work of the Lorna Breen Foundation.
Mixed up
I’ve said it before: mental health is complex stuff. But I prefer to see this as a positive; it means that everyone has something to contribute in figuring out the multiple causes of mental health problems, and hence the multiple solutions. So this new paper in BMJ Mental Health is very welcome: a quick primer on mixed-methods research, with a summary of useful examples. One issue highlighted is the capacity of journals to publish mixed quantitative and qualitative research with current restrictions on word count; it’s amazing that three decades of online publication have not yet managed to solve this problem.