From the Editor
My advocacy for him included speaking with his parents, calling his landlord, and completing his insurance-related paperwork. But I rarely asked him about his relationships, and I never offered advice on dating or finding a partner. During a tearful session, he spoke at length about his profound isolation. Should I have done more?
In a new study published in PLOS Mental Health, Angelica Emery-Rhowbotham (of University College London) and her co-authors explore the problem of relationships and our patients. They report both qualitative and quantitative data from 63 providers. “Staff were willing to help service users seek an intimate relationship but may need specific training or guidance to facilitate this confidently and safely.” We consider the paper and its implications.
In the second selection, the Editors of The Lancet reflect on the fiftieth anniversary of SSRIs. They note controversies over time, including the argument that clinicians are overly reliant on this type of depression treatment. “50 years on from landmark developments in drug treatment that were the cause of so much hope, we remain a long way from providing the level of care that so many people need, and this need continues to demand the attention of the scientific and medical communities.”
And in the third selection, from World Psychiatry, Joseph Firth (of The University of Manchester) and his co-authors describe the priorities and opportunities for lifestyle psychiatry. In a letter, they present the consensus of the LifePsych Society. “As lifestyle psychiatry is poised to become an integral component of global mental health care, the LifePsych Society aims to facilitate global collaborations, establish shared priorities, and enhance the capacity for meaningful research across diverse settings.”
DG
Selection 1: “‘Finding a relationship’: Conversations between mental health and social care staff, and service users about service users’ romantic relationships”
Angelica Emery-Rhowbotham, Helen Killaspy, Sharon Eager, Brynmor Lloyd-Evans
PLOS Mental Health, 8 May 2025
Intimate relationships are a ‘central aspect of being human’ and a ‘fundamental human right for all’. They affect our environment, quality of life, and without them, basic psychological needs remain unfulfilled… Social relationships are associated with many facets of psychological health, including feelings of self worth and self-esteem and low levels of depression, anxiety, and substance use… Moreover, loneliness is a common problem reported amongst individuals with mental health problems, which may increase one’s risk of both physical and mental health problems, and predict poor recovery for those with an existing mental health problem. For instance, up to 40% of individuals with depression report feeling lonely most of the time…
Besides struggling with maintaining relationships – for reasons including chronic low relationship satisfaction, and a hesitancy to trust and be intimate with another – those with mental illness consistently report struggling to establish an intimate relationship in the first place. Relatively few people with serious mental illness (15% in one study) have romantic relationships when compared to the general population, despite 71% spontaneously identifying intimate relationships as facilitating recovery… Relationships of an intimate nature are not routinely discussed in clinical mental health settings, and have not often been the focus of research. Limited literature that investigates this omission suggests that mental healthcare staff are ambivalent as to whether they should support service users in the domain of intimate relationships.
Here’s what they did:
- They conducted a “cross-sectional, mixed-methods design, to collect both quantitative and qualitative data through an online survey.”
- The online survey was “circulated to mental health organisations across the U.K. via social media [and] professional networks” and they used snowball sampling. In all, 28 different organizations were approached.
- “Quantitative data were collected using closed, multiple choice survey questions, and qualitative data were collected using open, free text response questions.”
- Quantitative data was analyzed using statistical methods. “For the free text responses, Braun and Clarke’s thematic analysis approach was utilised.”
Here’s what they found:
- 63 people participated.
- Background. Participants included clinically trained staff (psychiatrists, nurses, social workers and occupational therapists) and non-clinically qualified staff (e.g., support workers). Many worked in health services.
- Demographics. The majority of respondents were female (n = 54); most were white (n = 49); many fell in the age range of 26-35 years (n = 24).
- Conversations. 70% reported that they either “strongly” or “somewhat” agreed with the statement that it was appropriate to help patients in “finding a relationship” in their job role. That said, few had such conversations with patients. (!)
- Barriers. “Participants also described barriers to offering this support, including not having training on the topic, breaking professional boundaries, concerns about service users’ vulnerability and capacity to engage in a relationship, and concerns about seeming intrusive.”
- Hesitation. Some participants (13/45) expressed reasons not to engage in “finding a relationship” conversations; 8 discussed ethical issues. One stated directly: “I feel like it would be unethical to help them find a relationship.”
A few thoughts:
1. This is a thought-provoking paper, raising a relevant problem, but not offering a particularly robust dataset.
2. The core finding in a sentence: “Although most participants reported that ‘finding a relationship’ conversations were appropriate in their job role, many barriers to supporting service users were identified…”
3. There are many limitations with this study. Start here: the online survey only involved 63 participants (and only 44 answered all the questions). Part of the problem was its short timeline for participation. The qualitative data drew from free-text responses – which tended to be short.
4. Still, the core questions of this study are important. Indeed, the paper is thoughtful. Like most papers, the authors close by calling for more research in the area. Loneliness, isolation, relationships – why hasn’t more work been done here previously?
5. A major barrier described by participants in the study: many felt untrained and unqualified for such conversations. Should our education include more on relationships?
6. How to improve the situation? The authors suggest, among other things, that patients be accompanied to social events and receive coaching on how to use dating apps.
7. In some ways, the study illustrates the deep hesitations of providers on all things sexual. How often do we ask people with schizophrenia about their dating? Or inquire about the sexual desires of older patients? Or carefully ask about sexual side effects of the medications we prescribe?
The full PLOS Mental Health paper can be found here:
https://journals.plos.org/mentalhealth/article?id=10.1371/journal.pmen.0000184
Selection 2: “50 years of SSRIs: weighing benefits and harms”
The Lancet, 10 May 2025
More than 50 years have passed since the discovery of fluoxetine, better known by its trade name Prozac. Together with the development of several other compounds, collectively known as selective serotonin reuptake inhibitors (SSRIs), fluoxetine transformed the treatment of depression and associated psychiatric conditions. SSRIs were better tolerated compared with older tricyclic antidepressants and a week’s supply was not lethal in overdose. An estimated 332 million cases of major depressive disorder occurred in 2021. For many, SSRIs have been profoundly helpful in managing their health and continue to have an important place in care.
However, use of SSRIs has not been far from controversy and criticism.
So begins an Editorial.
Drawing primarily from a book of Dr. Joanna Moncrieff (of University College London), they note several controversies.
- Effectiveness. “Moncrieff references a 2002 meta-analysis, which concluded that compared with placebo their effects were clinically negligible. However, other studies have shown effectiveness, including a 2018 meta-analysis in The Lancet, which concluded that all antidepressants are more efficacious than placebo in adults with a diagnosis of major depressive disorder, with odds ratios ranging between 2.23 and 1.37.”
- Serotonin hypothesis of depression. “In 1975, Wong and colleagues reported that fluoxetine increased levels of serotonin in rat brains by blocking reuptake in the synapse. However, Moncrieff argues, indubitable evidence for the idea that low concentrations or reduced activity of serotonin in the brain is the problem remains elusive. Some psychiatrists have argued that delineating a clear mechanism of action is unimportant as long as the treatment is effective.”
- “Creeping medicalisation.” There has been a growing tendency to medicalise misery or unhappiness, along with other aspects of the human condition, including worry, bad behaviour, and grief.”
They point out that the UK’s NICE guidelines call for non-pharmacologic approaches as a first-line treatment for less severe depression and a combination of CBT and antidepressants for severe depression. “However, provision of and access to non-pharmaceutical psychiatric services is patchy for many people and non-existent for others, funding is lacking, and many general practitioners are pressed for time and short on options. A pill, the reasoning goes, might be better than nothing. But the result is that for too many patients antidepressants are used readily…”
A few thoughts:
1. This is an interesting Editorial in a major journal.
2. While SSRIs were developed 50 years ago, the more significant anniversary is the FDA approval of fluoxetine in 1987. (For the record, Health Canada approval followed a couple of years later.)
3. Is it a bit odd that the Editorial centres on a single book written by a critic? Dr. Moncrieff raises important points – but her arguments are not without controversy. Some argue that the psychiatrist is, well, quite anti-psychiatry.
4. Past Readings have considered the effectiveness of antidepressants and the frequency of discontinuation symptoms. See:
and
The full Lancet Editorial can be found here:
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)00981-X/fulltext
Selection 3: “Priorities and opportunities for lifestyle psychiatry: consensus from the LifePsych Society”
Joseph Firth, Jeroen Deenik, Nazareth Castellanos, et al.
World Psychiatry, June 2025
‘Lifestyle psychiatry’ encompasses the role of modifiable behavioral health factors – such as physical activity, sleep, diet, and stress management – in preventing and treating mental health conditions. Since lifestyle interventions are gaining recognition as fundamental components of psychology and psychiatry, the LifePsych Society has been established to advance research, education, and global integration of lifestyle medicine into mental health.
The inaugural LifePsych Society summit, held in June 2024, convened international experts working across various sectors, to discuss practical and sustainable integration of evidence-based lifestyle interventions into diverse mental health care contexts. Here we summarize the priorities and opportunities identified from the summit…
So begins a paper by Firth et al.
Implementation strategies
“There was broad consensus that, while published evidence has increased dramatically, more effort is needed to implement evidence-based interventions sustainably and effectively in diverse mental health care settings. Various examples illustrated how principles of implementation science can be adopted to deploy lifestyle interventions flexibly across the continuum of care. The importance of continuously evaluating locally implemented interventions was highlighted; this is essential in supporting adaptations based on feedback and changing circumstances, while providing a foundation for research to support their translation across different settings. Advancing lifestyle psychiatry also requires developing and implementing culturally responsive and sustainable interventions in collaboration with colleagues from low- and middle-income countries. To meet the needs of target populations, interventions must be deeply rooted in the cultural fabric of the communities they aim to serve.”
They call for “co-creating interventions with local experts as equal partners fosters a sense of ownership, helping to maintain momentum and continuous improvement as needs evolve.” They suggest that “community-based lay health workers can be trained to deliver interventions, thereby expanding reach and reducing costs,” an approach that “empowers individuals and strengthens community bonds.”
Emerging research
“Broadening the scope of lifestyle psychiatry by researching and evaluating innovative therapeutic modalities is essential for securing its role in the future of mental health care. Summit discussions highlighted the potential of mobile health applications and wearable devices to monitor real-time physiological and behavioral data – such as activity levels, sleep patterns, and heart rate variability. This supports the delivery of scalable, personalized lifestyle interventions with regular feedback and tailored adjustments.”
They recognize “the many opportunities that digital technologies offer for health promotion, especially for individuals with mental illness. However, it was emphasized that these technologies should complement, rather than replace, the traditional elements of health promotion, and that low-resource settings may face additional barriers towards technology adoption, which have yet to be overcome.”
“Mindfulness, in particular, was highlighted as an increasingly evidence-based approach for improving mental health, especially in trauma recovery and stress reduction. The broad applicability of mindfulness-based interventions was also recognized, as they are accessible, adaptable across cultures, and require minimal resources. Additionally, more nascent context-specific therapeutic approaches were discussed, including outdoor activities combining physical exercise, exposure to nature, nutritional interventions, psychoeducation, and community engagement to enhance mental health outcomes.”
Future directions
“Lifestyle psychiatry holds significant promise, driven by a commitment to continuous research and refinement of evidence-based, culturally sensitive, and scalable approaches. The LifePsych Society aims to propel the field by fostering an international network that generates support, motivation, and exchange of resources and materials. Within this, a central priority is to make a tangible impact on global health care systems through accelerating the implementation of evidence-based interventions to improve mental health outcomes.”
A few thoughts:
1. This is a thoughtful letter.
2. The first meeting of an international society and the resulting publication of a letter in a major journal indicate the ongoing interest in this area.
3. There are vocal proponents within our field, including the past president of the APA.
4. It’s tough to argue against recognizing the importance of things like diet and exercise for those with major mental illness. But is the field too broadly defined to be effective? Does it risk moving from a call for better health and prevention to niche services offered to the worried well?
5. For those interested in reading more about lifestyle psychiatry, Psychiatry News published a report that provides a nice overview. “Among adults, sedentary behavior – which has increased in recent years – has been correlated with an increased risk for suicidal behavior, depression, cognitive decline associated with aging, and psychosis. These trends point to the importance of careful assessment of the role of lifestyle factors in the mental and physical health of people who present to us for care.” You can find it here:
https://psychiatryonline.org/doi/full/10.1176/appi.pn.2024.03.3.19
6. In a past Reading, Dr. Vanika Chawla (of Stanford University), co-author of that report, spoke about yoga and practice in a Quick Takes podcast interview. “I think yoga is a wonderful way to expand providers’ toolbox of existing treatments.” You can find it here:
The full World Psychiatry letter can be found here:
https://onlinelibrary.wiley.com/doi/10.1002/wps.21325
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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