Sunday, May 29, 2016

The up and downs of reaching out

Isn't there always something awkward about telling a friend that you think they have a problem? And yet... 

Time and again, when someone takes their own life we hear people wondering aloud why the person didn’t reach out to someone. These stories can motivate us to make more of an effort to try and reach out to family and friends around us who we are concerned may be having mental health trouble. If someone we care about is down, it seems natural to reach out to them. However, it needs to be recognised that when one makes a proactive attempt to reach out to others they may not welcome this.

It’s natural to focus on the most salient aspect of a person’s life and character in any specific interaction. When we wish to talk to someone about problems with their mental health, this is what stands out for us going into the encounter. But people with mental health problems are not just a “victim”, of their mental health issues or of other problems they may have. I certainly don’t mean to imply that everyone with problems is at fault for their issues either, but simply that people have complex lives. One of the symptoms of depression is excessive guilt. However, one can have depression without having excessive guilt. And what if a person has proportionate guilt for a terrible thing they’ve done? If you reach out to this person, and if they do “open up”, what if their opening reveals something that you seriously dislike? Of course, this could be true of anyone without mental health problems as well-the point is that it's good to have a follow-up plan of how to get extra support if a person's opening up leads to stuff that you feel you can't handle yourself. 

For whatever reason, some people may just have a short fuse about the way you speak to them. Advice may be perceived as prosaic or patronising. The suggestion to visit a GP may be greeted with a reminder that the person is well aware that that is an option, thanks. Nonetheless, it may give the person that extra encouragement to go. It’s probably best to phrase advice in such a way as to leave the ball in the person’s court, rather than presenting a suggestion as an original idea or as a command.

Depression is perhaps the condition that’s most discussed in this context. Despite the prevalence of non-response to treatment, it is quite a treatable disorder, and many people do recover with time (notwithstanding the potential for relapses). The encouragement to seek professional help might be the beginning of a road to recovery. But consider personality disorders. These can a substantial amount of time and psychological therapy to ameliorate. Furthermore, if you try to suggest to someone that they should seek help, even if this person can see that their behaviour is leading to difficulties with their life, might you be perceived as trying to change them at some fundamental level? The fact that you may be perceived as doing this when you are a friend rather than a professional may also complicate matters.

I think most people realise at a cognitive level that you can’t just make someone’s problems go away by having a frank discussion with a friend. Nonetheless, when we say “if only” a person had reached out, are we not believing at some gut level that maybe we could have saved them if we had reached out first? And if that's the case, then maybe we should have saved them somehow? Be gentle with yourself.

I am not trying to tell you that you shouldn’t try to speak to people you think may need help. I'm sure the anticipated regret of not having said something will still be a motivator for many people to speak up. I suppose my take-home message here is to manage your expectations when you take it upon yourself to speak to someone you think may be in bad distress, and don’t take it personally if they don't take it too well.

If you are interested in reaching out in a broader way, why not volunteer for an organisation like the The Samaritans or Aware

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Saturday, May 7, 2016

I wanna get technical: notes on writing a systematic review

Just recently I had the pleasure of clicking "submit" on the longest academic paper I have written so far-nearly 30,000 words long. It is a systematic review of cognition and biomarkers of stress in dementia caregivers. It's an important topic, but today I'd like to talk specifically about the method of doing a systematic review and what that entails.

The process of systemically reviewing the literature allows you to take steps to ensure that a review of research literature is not an incomplete or partisan exercise. However, writing a systematic review, particularly a large systematic review, can really take the pleasure out of reading a research article. Interesting discussion sections are raced past when one has over 100 articles from which to extract key methodological details. Here's what you do:

Firstly, one needs to see what literature is out there. After making searches for caregiver stress and a host of stress biomarkers (e.g. cortisol) on a number of research databases, the second reviewer and I found ourselves with circa 4,000 abstracts and titles to look though. Some of these were almost immediately identifiable as not really relevant to the review in question. However, some required a pretty careful reading of the abstract, and about for about 250 we had to look through the full text of the article. For example, we were interested in the impact of dementia caregiving stress on cognition, but it might not be immediately apparent if cognitive assessment was performed on the carers or just the patients with dementia.

Once you've whittled things down to just the articles you want to include in the review, it's time for data extraction. You get an Excel sheet with a whole host of bits of info (e.g. inclusion criteria, sample size, age/gender of the participants, location where the study was run, etc. etc.) and fill in this form for each study. I should say that in the case of this review we had 151 full papers to go through. A mountainous (albeit physically sedentary) task. The second reviewer blasted through the task quite a bit faster than I did-I'm going to assume it's because she is more experienced at conducting systematic reviews, as the alternatives are not so good for my ego.

Anyways, when the data extraction is done you THEN need to assess the quality of the research literature. Another template is put together in an Excel file and again you wade through the articles, ticking boxes about whether or not the articles have fulfilled certain criteria (did they control for potential confounding variables, was the statistical analysis appropriate). In fairness, there's often some overlap here between the data extraction, although not enough in this case to avoid going back through the articles again!

THEN you need to write the thing. When you have results from over 150 research articles to summarise, the mere process of checking the formatting within your tables becomes a dull and onerous task. Uughhhh. Still, when it's finished you can say that you've gone to lengths to avoid being selective in either assessing or reporting the published research in the field.

Obviously this is one account-there are more/less complex ways of doing a systematic review. Generally there will not be quite so many articles included in a systematic review, and if the outcome is more focused one may wish to do a meta-analysis. I think as time goes by more journals will start to strongly encourage or demand that review papers are systematic. All I can say about my near future is the next couple of reviews I write will not be systematic in nature.

If/when the article of this systematic review is published I'll be letting you know about the results ;)