Saturday, January 22, 2022

Attitudes to psychedelic therapy among people using mental health services

There has been increasing interest in the use of psychedelic drugs as a means for treating certain mental health conditions. For example, there is emerging evidence that psilocybin-assisted therapy may be of benefit in depression, although more trials with larger samples and better control/comparison conditions are required to provide a clearer picture.     

Of course, even if psilocybin is shown to be effective for ameliorating depression, will many people be reluctant to try it? One can imagine that some people with depression, battling the "demons" associated with trauma, may prefer to keep trying anti-depressants that lead to gradual reduction in depression over time, rather than a psychedelic drug recreational users use to induce an experience that alters one's perception of reality; some people may have an understandable fear of a "bad trip" or similar. 

recent article looks at attitudes towards the use of psychedelic drugs among mental health service users in Ireland. The researchers conducted a survey with 99 people, recruited via a psychiatric hospital and a community mental health service. It is interesting to see what the attitudes are among people who are engaging with mental health services, as opposed to a general population survey, where for many respondents, interventions for mental health is a more hypothetical idea, or something that "happens to other people".  

In this survey, a clear majority supported further research (72%). A slimmer majority (59%) supporting psilocybin as a medical treatment; a similar proportion (55%) said they would accept psychedelic drugs if recommended by their doctor, with 20% saying they would not accept them. A fifth of the respondents also said they viewed psychedelics as unsafe even under medical supervision. Although such concerns may be unfounded for some people who could benefit, it was concerning that a handful of people with conditions that could be exacerbated by psilocybin (e.g. psychosis) thought that psilocybin would be useful for them. Some participants reported they would be reluctant to come off existing medication in order to accept psilocybin therapy, given that some were satisfied with their current treatment, as well as the worries relating to previous history of addiction or the broad illegality of psilocybin.       

Perhaps unsurprisingly, the authors found that younger people (the mean age overall was 42) were more likely to have favourable attitudes towards the use of psilocybin; this was also the case for those with previous recreational experience of such drugs, as well as those who were less religious. Males had a higher lifetime rate of using psychedelics, although their attitudes towards therapeutic use did not seem to differ substantially from females. As the sample was not that large, we should be careful about drawing generalisations about how predictive different demographic characteristics will be about the acceptability of psychedelic drugs. Nonetheless, the overall results seem to suggest there is a willingness out there among people using mental health services to try psychedelic drugs if recommended by a clinician, but a substantial minority will be reluctant to do so.  

It should be emphasized that this work is looking at the controlled used of psychedelic drugs under medical supervision. Self-medication with psychedelic drugs (or other drugs, legal or otherwise) is not recommended. If you have concerns about your mental health, speak to your GP. A free listening service is provided by Samaritans for those experiencing mental health problems. Also, I think a lot of people don't realise that many workplaces offer complementary employment assistance programs that allow employees to avail of talk therapy.  

Corrigan, K., Haran, M., McCandliss, C., McManus, R., Cleary, S., Trant, R., ... & Kelly, J. R. (2021). Psychedelic perceptions: mental health service user attitudes to psilocybin therapy. Irish Journal of Medical Science (1971-), 1-13.

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Sunday, January 9, 2022

What we talk about when we talk about the past

Irish society has changed a lot over the last few decades. Along with more international changes like globalisation, the ubiquity of the internet etc., Ireland specifically has seen rapid economic growth as well as sea changes in social policy (e.g. going from criminalisation of homosexual activity at the start of 1990's to legalising gay marriage by a referendum in the 2010's). Even people in their forties and younger will recognise they live in a country that is different in many ways from the Ireland they lived when they were children (notwithstanding often high rates of emigration). As Fintan O'Toole (and others) put it, We don't know ourselves.

The autobiographical intersects with changes over society. Do you reckon that you were ahead of your time when looking back at how things used to be? Or do you remain nostalgic and wish things were more like the past? (It will depend, of course, on the subject or aspect of life). 

A recent chapter in a book on psychobiography followed on from an in-depth look I had with some collaborators from Maynooth University and DIT. The sense of self was not always so stable, and could be affected by changing economic circumstances-one individual mentioned she used to look forward to going away on a holiday for a long time, and would discuss it at length for long after, but would now (in more prosperous times) would get back from holidays and just wonder where she and her family would be going next. (I should say this was from before the COVID-19 pandemic!)

Besides actual changes, counterfactual descriptions of the past can be used to think through the value of different decisions. What if I had taken that job, or married that person? What if that politician hadn't been elected, or if most people had had the internet in the 1980's? These can often be tinged with regret that things could have worked better, with the benefit of hindsight.

People may alternate between a first-person description of autobiographical events and a broader third-person description more routed in the family, friends or society around them (people often use the second person as a generic person, "you'd want to think twice about that" can sometimes mean "one would want to think twice about that", rather than just the listener). The lines between the individual, inter-individual, cultural and societal can get blurred by language. Pre-autobiographical "memories" can have an instructive function when shared with younger relatives, to give a sense of continuing extended self with one's family. 

Indeed, there are various different functions that reminiscence about the past can play. A story from one's past can act as an instructive (perhaps cautionary) tale for a younger person going through a similar phase in life that one went through in the past. At other times, such a story may be used to demonstrate or think through how one's self has been formed over time, or to build rapport with someone by illustrating how two past lives were quite alike, or just for simple entertainment value.

How we talk about the past can vary in terms of the extent to which we situate ourselves in the events that have shaped our lives and our society (Note how I'm segueing into first-person plural here). We don't know ourselves, so we'll have to keep constructing them on the fly.

Allen, A. P., Doyle, C., Doyle, C. M., Monaghan, C., Fitzpatrick, N., & Roche, R. A. (2021). What we talk about when we talk about the past: Discursive psychological analysis of autobiographical reminiscence in older Irish adults. In Psychobiographical illustrations on meaning and identity in sociocultural contexts (pp. 327-344). Palgrave Macmillan, Cham.

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Monday, December 13, 2021

Reminiscence groupwork as meaningful activity


There has been some research interest over the last few years in the effect of reminiscence and its effect on autobiographical memory performance, perhaps particularly in people with impairment in autobiographical memory. In the pre-COVID "before times", I was involved in a project with a service provider that organises various activities for residents and people from the local community.  

We ran reminiscence sessions that covered subjects drawing on personal autobiography as well as some broader social/political events in Irish history (all participants were Irish). There was a comparison condition where we ran sessions with similar topics, but with a focus on the present (e.g. covering lifelong learning/learning new things, whereas the equivalent reminiscence session was about schooldays). We offered both groups to all participants, assessing their autobiographical memory retrieval at baseline and after both of the groups. 

Although I was going in with the idea of running the groups specifically with people with memory impairment, the meaningful activities manager suggested it would work better with a more mixed group. The inclusion of people with no cognitive impairment and those with dementia in the same group might have seemed daunting at first glance, but actually worked well, as participants could remind each other of memories at a more personalised/localised level than I would have been able to. The group had 6-8 people in general, but we were able to break into smaller groups of 2 or 3 so that people had more scope for taking turns in discussing their memories.

When assessed using a structured interview, autobiographical memory retrieval didn't seem to be substantially affected (I should say it was a small sample). However, the meaningful activities manager indicated that the people who took part in the groups and their families reported a greater engagement with reminiscence during their daily lives. There's a general lesson in there about how, although cognitive assessments at a given point in time can be controlled and tight, they may struggle to capture cognition "in the wild".

It's great to see a manuscript based on this project published in Groupwork, whose special issue on groupwork and research prompted us to think about some of the processes of this work in greater depth. I must acknowledge as well that the project wouldn't have been possible without the help of the staff at the service provider. 

Allen, A., Tully, M. L., O’Neill, D., & Roche, R. A. (2021). Reminiscence groupwork and autobiographical memory as part of meaningful activities. Groupwork30(1).

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If you like this post, follow me on Twitter: @ArchivePsych

Monday, September 13, 2021

Seminar: Supporting people with an intellectual disability at end-of-life


Death may be in the news every day, but most of us probably don't want to think about our own deaths, and perhaps are even more reluctant to talk to our family members about the end of our lives or theirs. In the past, people with intellectual disability have been somewhat shielded from the concept of death by people caring for them, which has often left them poorly prepared for their end of their lives. 

Data from the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA) does seem to show that things are changing. Nonetheless, family members do struggle with starting a conversation around the end of life, and wondering when to initiate such a conversation. However, people with intellectual disability have expressed an interest in receiving concrete, unambiguous information about death and dying.

At an interesting seminar for palliative care week, Dr √Čilis Burke from the Trinity Centre of Ageing and Intellectual Disability talked about accessible materials she has developed with her colleagues to help people with intellectual disability build up a picture of what they want for the end of their lives. These materials can help the carer/family member to shift the perspective from themselves to the person with intellectual disability. The documents Dr Burke have prepared are living documents that will be revisited over time.

Small conversations can help to build up sense of what people want for the end of their life. As with the general population, the end of life may come sooner than expected, so having some conversations in advance can be helpful. In having these conversations, it is important to build knowledge of the person with intellectual disability, and take a collaborative approach in delivering information at a level the individual can take on board. 

Transition points in life can be a good point for beginning conversations around death and dying (e.g. shortly after a serious diagnosis) Or it could just be when someone raises the issue themselves - it could be prompted by something as simple as a storyline on a soap opera. Ideally, talking about the end of life is not a one-off conversation, but an ongoing discourse over time. Help the person think about what brings comfort, happiness or dignity to them, get a conversation going with family and friends as well, write it down and review.

Liz Hunt (RNID & Area manager, Brothers of Charity Services) gave an account of the use of this tool. The services take a person-centred approach with a focus on rights. A key theme of this is empowerment (e.g. starting from the assumption that people have the capacity to make decisions for themselves) and engagement (e.g. using accessible materials to assist with decision-making). Staff at the services had generally known the people they were working with for a long time, so close relationships had been developed. A multidisciplinary team collaborated in the process, and worked with the person's family from the beginning. Liz Hunt gave the example of someone's favourite CD being carried to the altar, and angels being part of her final days, as she had talked about angels frequently. 

I imagine for a lot of people this is like starting one's homework or having a talk about the birds and the bees with one's kids - starting is the hard part, but once you have a framework in this place this will help to take the first steps.

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Friday, May 28, 2021

Defining brain health

The term "brain health" is used with increasing frequency. Looking at the scholarly literature, there were only a handful of references to this term through the nineties and noughties, until it increased exponentially in the 2010's (even allowing for exponential increases in academic publishing more generally). Given the amount of money that can be ploughed into products and approaches claiming to enhance brain health, one might think "the experts" had a clear idea of exactly what brain health is. However, there is a lack of consensus on what the term "brain health" means. 

The authors used a hybrid concept analysis method which combined review of the existing literature (from 1990-2020) with original fieldwork. The latter involved an international online survey of the community of the Global Brain Health Institute. In a final analysis, they developed a working definition based on the two bodies of work. From the outset, the authors were keen not to define brain health as simply the absence of brain disease, citing the World Health Organisation's statement that ‘health is a state of complete physical, mental, and social well‐being and not merely the absence of disease or infirmity'. They also wished to avoid equating health with the idea of "average" or "normal".

The review of the existing literature found twelve difference models of "brain health": a biological function model, (absence of) disease model, cognitive model, prevention model, well-being and holistic model, multidomain model, fitness model, dynamic process life course model, optimal function model, autonomy-resilience model, subjective experience model and empirical referents model. Some of the cited papers drew on multiple models, suggesting a multifaceted concept of brain health. Interestingly, a lot of articles did not define the term "brain health", with some only using the term in their title. 

Key attributes of brain health identified by the authors include that it exists along a continuum from poor to optimal, it includes both objective and subjective components, is a dynamic process throughout life, and (as mentioned above) is a multidimensional construct. The authors also mention antecedents to brain health (e.g. lifestyle choices) and consequences (e.g. the ability to live independently), although I think these may not really be defining for what brain health is as a state/process.    

The survey had 73 respondents, most of whom were working in health or basic sciences. Besides respondents from North America and Western/Northern Europe, who are typically over-represented in this kind of work, 15 of these respondents were from South America, 7 from Southern/Eastern Europe, 4 from Africa and 2 from Western Asia. Most respondents in general reported that the term "brain health" was not commonly used in their country of origin. 

The proposed working definition the authors came up with was the following:

Brain health can be defined as a life‐long dynamic state of cognitive, emotional and motor domains underpinned by physiological processes. It is multidimensional and can be objectively measured and subjectively experienced. Brain health is influenced by eco‐ biopsychosocial determinants, resulting in a continuum of quality of life and wellness  

At a first reading, I personally think the final clause is perhaps a bit too focused on consequences, although this is probably necessary when the initial sentence doesn't seems to capture the idea of "positive" or "healthy" (apart from the term "brain health" itself). It is perhaps difficult to separate the following: (i). the consequences of brain processes that allow a brain-owner to function adaptively in their environment and (ii). an appraisal of these processes as healthy or unhealthy.   

In closing out the paper, the authors say their paper will help to operatonalise the concept of brain health for research, policy and practice. It will be interesting to see whether the definition above is taken up by those working in the area of brain health more generally. I hope it will help, given the inconsistencies that are highlighted here between overly reductive biomedical models and approaches that over-emphasise individuals' subjective appraisal of their own brain health. 

Disclosure: I am currently working on a (separate) project on staff mental health with the first author (Dr. Yaohua Chen).

Chen, Y., Demnitz, N., Yamamoto, S., Yaffe, K., Lawlor, B., & Leroi, I. (2021).  Defining brain health: A concept analysis. International Journal of Geriatric Psychiatry. DOI: 10.1002/gps.5564.

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Tuesday, April 27, 2021

NIDMS seminar: Cognitive Stimulation Therapy

I've been attending a masterclass by the National Intellectual Disability Memory Service. The latest session looked at Cognitive Stimulation Therapy for Dementia, with a focus on specialised services for people with intellectual disability.

Gunnar Scheibner (clinical psychologist at St Michael's House) gave a brief introduction to CST. It is a brief psychosocial intervention developed by Aimee Spector to improve or at least maintain cognition and mood. It combines elements of different approaches (e.g. reminiscence therapy, art therapy). It's recommended that it's conducted in small groups (ideally no more than 6 clients taking part). Scheibner pointed out that it's very cost effective; CST does not require much equipment (e.g. some means of playing music, art materials, often available already in care settings), don't need to have highly trained staff. (However, Professor Mary McCarron did mention that a certain level of group facilitating skills are important.) 

CST is particularly interesting for people with intellectual disability, who are more likely to develop dementia, particularly people who have Down syndrome. However, the current data is very limited for this particular population. Some work by Orrell et al. found a positive impact on family relationships, but not on cognitive functioning. Shannahan found some improvements in cognitive functioning in people with intellectual disability but without dementia. 

Pauline Smyth, from the Brothers of Charity Roscommon, described how her team were working with clients who were living with dementia. Her team became interested in CST and they wanted to find an evidenced-based, post-diagnostic support for people with dementia. Smyth emphasised that CST should be delivered in the context of good person-centred care, and cited the importance of social inclusion - the CST group can be an opportunity for social connection. 

For people with intellectual disability in particular, it's better to have smaller groups than with general population, probably no more than 4, also allow greater amount of time per session (e.g. don't want to rush for creative activities). Important to have knowledge of people's preferences (e.g. what music/hobbies they like, their ability/willingness to continue with the sessions for their duration). For cognitive stimulation, Smyth advised to be careful not to put any individual on the spot; rather, it's important to have a fun/enjoyable atmosphere, and to try to avoid school-like vibe. Consistent with the point about social connection, she said it is worth being vigilant that people are included (e.g. someone might be under-engaged, but could benefit from another participant pairing up with them). For reminiscence, care is required not to push people into talking about painful memories (notwithstanding there can be good and bad in broader memories).   

Dr Janette Tyrell emphasised the importance of using non-pharmacological approaches such as CST (notwithstanding the utility of medications such as those targeting acetylcholinesterase etc.). In her clinical opinion, the more services use techniques like CST that keep people active, the less you see the negative behavioural manifestations of dementia. During the COVID-19 pandemic and lockdown, a lot of people have had opportunities for cognitive stimulation reduced, so it was positive to note that a lot of people are doing activities online at this time. The pandemic does seem to have motivated more people with intellectual disability to get more involved in using platforms like ZOOM. 

A question was raised about running CST with people who have more advanced dementia. Gunnar Scheibner cited a PhD student was who is doing work in this area, and the results will be interesting to see. Pauline Smyth suggested not trying to have people at very variable levels of cognitive impairment (consistent with pitching tasks that are doable for the people who are taking part).    

It was certainly an interesting masterclass. I did wonder whether there are a lot of services doing things like cognitive stimulation therapy without necessarily labelling it as such. There are a lot of people with intellectual disability out there (along with families and services) doing their best to keep active during the pandemic, though as one of the panellists noted, a lot of people in general are languishing.         

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Monday, April 12, 2021

Individualised supports for people with intellectual disability and dementia

While looking for something to discuss at a journal club in work, I came across an interesting paper about individualised supports for people with intellectual disability (ID) and dementia. Over the last 50 years, life expectancy has increased substantially in people with ID. Compared to the general population, this cohort has a higher prevalence and earlier onset of dementia. A systematic review found that psychosocial interventions for people with dementia have rarely been implemented with those with both dementia and ID. 

This study by Watchman et al. included five co-researchers with ID who were involved from the initial grant application onwards. The team sampled participants from multiple settings (living alone with some outreach support, group homes for PwID, and generic care home). For the psychosocial interventions, a resource called Jenny's diary was used as a starting point to discuss possible intervention components (e.g. design changes to home, reminiscence), so participants could select intervention activities that appealed to them as an individual.

The researchers used a bespoke measure of studying effects of intervention on behaviour (examining observed behaviour, “observed mood”, body language and verbal communication), to capture this “in the moment”, as well as assessing quality of life with a more standardised measure. They also conducted semi-structured interviews with social care staff, as well as generating data with PwID and dementia, using photovoice (a participatory research method which involves the use of photographs to convey the meaning of different lived experiences). 

Participants had between two and six interventions, and most interventions showed “in the moment” positive effects. Nearly three-quarters of interventions were described as having met or exceeded their goals. The results less clear for quality of life scores, which fell at mid-point before increasing. 

From the semi-structured interviews, social care staff described interventions positively, that they ”brought them (the participants) back”. Key themes were: enabling care (allowing participants to have choice about what interventions were being used, having one-on-one time with staff), interventions for practice (a key point here was a change in perception from seeing interventions as adding to work burden to viewing them as timesavers overall, e.g. by reducing agitation).

From the photovoice images, key themes included the importance of friendship, involvement in future planning (photos included images from Jenny’s diary), and fear of dementia (with an associated fear of return to institutional care/change in living situation).

I thought this paper was interesting, with a wide range of measures and methods to gain a greater understanding of interventions for people with ID and dementia. The use of in-the-moment assessment can overcome difficulties in displaying effects of interventions with retrospective (even recent retrospective) measures.

I wondered to what extent photovoice was a reproduction of materials presented to participants (e.g. Jenny’s voice appeared as an image). However, it may be worth comparing with extent to which participants from the general population can bring truly novel ideas when guided through semi-structured interviews etc.

Watchman, K., Mattheys, K., McKernon, M., Strachan, H., Andreis, F., & Murdoch, J. (2021). A person‐centred approach to implementation of psychosocial interventions with people who have an intellectual disability and dementia—A participatory action study. Journal of Applied Research in Intellectual Disabilities34(1), 164-177.

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