Here Comes Everybody
The Lancet Psychiatry _____August, 2021 _____WHO IS PSYCHIATRY FOR? _____The prevalence of mental disorders worldwide would suggest that it is a specialty relevant to everyone. But this is not always reflected in the data. For example, when Mikkel Højlund and colleagues looked for evidence comparing standard versus reduced dose of antipsychotics for relapse prevention in multi-episode schizophrenia, they retrieved 7854 references from literature searches, assessed 5744 abstracts, did a full-text review of 101 references, and in the final meta-analysis reported on 24 trials with 3282 individuals. However, besides addressing an important clinical question, this study also revealed biases in both the data available and the assumptions underlying its collection and analysis. _____Two-thirds of the patients included in the trials were male. Furthermore, the basis on which the recommended target dose range of antipsychotic drugs is set suggests an even greater bias. The International Consensus Study of Antipsychotic Dosing target dose was derived in a Delphi study with 43 respondents (91% male, “despite efforts to recruit more women”). The consensus study included a recommendation that females should receive a 10% lower dose, but this was not incorporated into the calculations for the meta-analysis by Højlund and colleagues. As the authors discussed, “Although this could introduce a bias, we consider this to be a conservative bias. Because some females might require lower antipsychotic doses than men, the finding that lower antipsychotic doses were associated with a higher risk for relapse than were standard doses is a conservative finding because for at least some females the lower antipsychotic dose might result in plasma concentrations that are still in the therapeutic concentration range.” So, in this instance, all was well, but if the analysis had suggested the opposite, no conclusions could have been drawn._____
The absence of women from clinical trials and subsequent steps to address this problem have been covered extensively, as recently summarised in The Lancet Rheumatology. Although the topic is receiving greater attention, results are less satisfactory. As Catherine Tang and Nada Hamad have written, “Improving and facilitating the inclusion of women in clinical research is a moral imperative. This move should start with understanding women's experiences of living with disease and their barriers to participating in research.”_____
Several psychiatric disorders are unevenly distributed across the population; for example, eating disorders are more prevalent in women, whereas substance misuse is more prevalent in men. Many socioeconomic risk factors for common mental disorders disproportionately affect women. The same applies to all socially disadvantaged groups, in terms of not just susceptibility, but also access to treatment, and outcomes. Without data to quantify such biases and the awareness and planning to counteract them, mental health services, whatever their intentions, will reinforce inherent inequalities. Engagement of the people who will ultimately receive the treatments is needed at all stages of design and implementation of both research and services. Although studies should reflect the populations affected by specific conditions, we also need to be careful not to neglect the needs of subgroups; for example, some men do have eating disorders and require evidence-based care tailored to them. Thus, better understanding of sex and gender factors should inform personalised care both biologically and psychosocially._____
Age is another variable that can create minority groups. Dementia care is targeted at older adults but are different approaches needed for younger people diagnosed with early-onset dementia? Similarly, early intervention services should consider the needs to those with adult-onset psychosis. The question in psychiatry, as in all medicine, is not just what works—it is what is acceptable to patients, their families, and carers. This needs to be informed by social and cultural understanding to build a therapeutic alliance._____
What role can journals play in this process? As an international journal, The Lancet Psychiatry aims to publish research that is relevant to as broad a population as possible, but acknowledges the inherent tension between precision and generalisability. At present, The Lancet Psychiatry will join The Lancet Rheumatology in a commitment to better reporting, not just of sex and gender, but also ethnicity and age ranges, across all research, not only interventional studies. Observant readers should notice more detail in abstracts as well as in text and tables. The research community needs to open its doors wider and work together towards better outcomes for all those living with psychiatric disorders.
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