RESUMO
By manipulating inclusion criteria, one can prove whatever point one wishes in meta-analysis. This critique examines a recent meta-analysis claiming lithium ineffectiveness for suicidality, based on three biased features: inclusion of many large studies specifically designed to exclude suicidality, producing zero suicide outcomes in all groups (n = 1856), thereby artificially decreasing statistical significance; arbitrary exclusion of all trials prior to the year 2000, thereby excluding two randomized clinical trials which demonstrated benefit for lithium; and underreporting of placebo suicide events in a recent randomized trial. It thereby created a smaller effect size (two suicides with lithium versus five with placebo = RR = 0.42), though still beneficial for lithium, and a larger denominator of no events (total n for included studies = 2578), leading to the claim of statistical non-significance (95% confidence intervals (CIs) 0.1-4.5). The same literature can be analyzed including the two excluded older studies, and including the two placebo deaths in the recent trial, producing a larger effect size (two suicides with lithium versus nine with placebo, RR = 0.25). Furthermore, uninformative studies with no events could be excluded (total n for included studies = 1203), as is standard practice in meta-analysis, producing statistically significant results (95% CIs 0.05, 0.83). This more complete, more accurate, and less biased meta-analysis is provided in this article.In short, including all studies with non-zero suicide outcomes, there is clear benefit for lithium. The recent meta-analysis is a classic example of pseudoscience, using scientific technique superficially to confirm, rather than refute, one's own opinions.
RESUMO
Despite the unprecedented wave of research and publications sparked by the recent pandemic, only few studies have investigated the impact of COVID-19 on the Italian community-based system of mental health care. We aimed to summarize the available evidence from the literature also considering what we have learned from our daily clinical practice. As hospital care was restricted by COVID-19, although reducing their opening hours and activities, Community Mental Health Centers promoted continuity of care for at-risk populations, supporting them to cope with loneliness and hopelessness during quarantine and self-isolation. Ensuring continuity of care also remotely, via teleconsultation, lowered the risk of psychopathological decompensation and consequent need of hospitalization for mental health patients, with satisfaction expressed both by patients and mental health workers. Considering what we have learned from the pandemic, the organization and the activity of the Italian community-based system of mental health care would need to be implemented through 1) the promotion of a "territorial epidemiology" that makes mental health needs visible in terms of health care workers involved, 2) the increase of mental health resources in line with the other European high-income countries, 3) the formalization of structured initiatives of primary care and mental health cooperation, 4) the creation of youth mental health services following a multidimensional and multidisciplinary approach and encouraging family participation, 5) the promotion of day centers, to build competence and self-identity within a more participatory life, and programs geared to employment as valid models of recovery-oriented rehabilitation.
RESUMO
PURPOSE OF REVIEW: To assess paradigms of psychiatry, assessing their strengths and limitations. RECENT FINDINGS: The biopsychosocial model, and eclecticism in general, serves as the primary paradigm of mainstream contemporary psychiatry. In the past few decades, the biopsychosocial model served as a cease-fire between the biological and psychoanalytic extremism that characterized much of the 19th and 20th century history of psychiatry. Despite being broad and fostering an 'anything goes' mentality, it fails to provide much guidance as a model. In recent years, the biological school has gained prominence and now is under attack from many quarters. Critics tend toward dogmatism themselves, usually of postmodernist or libertarian varieties. Three alternate approaches include pragmatism, integrationism, and pluralism. Pluralism, as technically defined here based on the work of Karl Jaspers, rejects or accepts different methods but holds that some methods are better than others for specific circumstances or conditions. SUMMARY: The compromise paradigm of biopsychosocial eclecticism has failed to sufficiently guide contemporary psychiatry. The concurrent revival of the biological model has led to postmodernist counter-reactions which, though valid in many specifics, promise to replace one ideological dogma with another. New paradigms are needed.
