Can we prevent PTSD after disasters?
Plus: selling psilocybin in Canada; mental health problems as "brain diseases"; and the definitive evidence (for now) on childhood adversity and psychosis
A perfect storm
This BMJ Mental Health meta-analysis asks one of the most urgent questions in mental health in the age of climate change: can we prevent PTSD after natural disasters, and if so, how? The evidence the authors uncover is alarmingly thin.
Just ten RCTs were found—seven in adults, three in youth—with a little over 5000 total participants. The interventions used were all psychological (mostly CBT-based) or psychosocial. Overall study quality was low. And as for the results… pretty disappointing. The authors conclude that “survivors do not seem to benefit from mental health prevention programmes in the aftermath of natural hazards, while two studies found significant effects for disaster responders.” There was insufficient evidence to recommend anything.
This important paper points to an urgent need to refocus our thinking around climate and mental health. The debate around “eco-anxiety” is best left for another day, but this meta-analysis tells us that here and now, we have no reliable RCT evidence on how to prevent PTSD in the people most affected by natural disasters. We need to cultivate genuine innovation informed by the experience of living through natural calamities, and get trials ready for implementation when disasters happen—otherwise we risk blundering about, doing what feels like it should work intuitively while providing no help whatsoever. We have been here before.
Mushroom for improvement
This JAMA Open Science article takes a hard look at some of the marketing practices of 57 psilocybin dispensaries in Canada. It’s an eye-opener. I was particularly intrigued by the phenomenon of the “psilocybin-infused product specifically designed to mimic a common brand-name snack food item”, including “Mushtella, a Nutella spread mimic; a psilocybin-infused tea mimicking the Arizona Iced Tea brand; and psilocybin-infused chocolate bars mimicking brands such as Skor or Reese’s Peanut Butter Cup”.
On a more serious note, the authors also found “a variety of unverified health claims” alongside a lack of warnings of potential harms. The authors conclude that better regulation is needed; I’d add that better public information is also a priority.
Is it right to call a mental health problem a “brain disease”?
This fascinating opinion piece in The Lancet Psychiatry reviews the brain disease model of substance use disorder, which “framed addiction as a chronic and relapsing brain disease caused by structural and functional brain alterations” back in the late 1990s and has proved very influential over subsequent decades. The authors argue that labelling addiction as a “brain disease” hasn’t been helpful; we still lack biomarkers and targeted treatments. And if the aim was to reduce stigma, that hasn’t worked either.
But hold on a minute: isn’t there a case for saying all mental health problems are by definition brain diseases? The authors point out that it might be trivially true that “all mental activity involves brain activity”, but “without identifying reliable, specific, and targetable brain dysfunctions [this view] does not advance the understanding of addiction or lead to improved treatments.” And if we take the perspective that symptoms mediated by neurobiology equals brain disease, this doesn’t necessarily point us towards better interventions: for example, “the effects of divorce on symptoms of depression are also likely mediated by neurobiology, and divorce is indisputably not a brain disease.”
It’s a sharp, well-written piece; personally, I wonder if perspectives based on the idea of the extended mind, that “Cognitive processes ain't (all) in the head” but that some are mediated in the external world, might help us to untangle some of the conceptual issues that the authors raise here. Substance use disorders—and other mental health problems—could be said to exist in the mind, but “the mind” might not just refer to the contents of your skull.
Childhood adversity and psychosis
This edition of Thought Formation ends with another meta-analysis: a massive effort in AJP that extracts data from 183 studies comprising 349,265 individuals to examine the relationship between childhood adversity and psychosis. Case-control studies, cross-sectional studies, cohorts… they all showed a significant association; the overall odds ratio was 2.80 (95% CI = 2.18, 3.60), and moreover onset was earlier in individuals exposed to adversity. The highest odds ratio was for “emotional abuse”, and the lowest for “parental antipathy”.
The authors describe plausible mechanisms through which childhood adversity might relate to psychosis, from altered cognitive biases and attachment styles to neurobiological and epigenetic alterations. While emphasising that these data don’t nail down causality, they do suggest that addressing childhood adversity might be a good way to mitigate the risk of psychosis—as well, of course, as being a noble end in itself.