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It remains unclear which individuals with subthreshold depression benefit most from psychological intervention, and what long-term effects this has on symptom deterioration, response and remission.
Aims
To synthesise psychological intervention benefits in adults with subthreshold depression up to 2 years, and explore participant-level effect-modifiers.
Method
Randomised trials comparing psychological intervention with inactive control were identified via systematic search. Authors were contacted to obtain individual participant data (IPD), analysed using Bayesian one-stage meta-analysis. Treatment–covariate interactions were added to examine moderators. Hierarchical-additive models were used to explore treatment benefits conditional on baseline Patient Health Questionnaire 9 (PHQ-9) values.
Results
IPD of 10 671 individuals (50 studies) could be included. We found significant effects on depressive symptom severity up to 12 months (standardised mean-difference [s.m.d.] = −0.48 to −0.27). Effects could not be ascertained up to 24 months (s.m.d. = −0.18). Similar findings emerged for 50% symptom reduction (relative risk = 1.27–2.79), reliable improvement (relative risk = 1.38–3.17), deterioration (relative risk = 0.67–0.54) and close-to-symptom-free status (relative risk = 1.41–2.80). Among participant-level moderators, only initial depression and anxiety severity were highly credible (P > 0.99). Predicted treatment benefits decreased with lower symptom severity but remained minimally important even for very mild symptoms (s.m.d. = −0.33 for PHQ-9 = 5).
Conclusions
Psychological intervention reduces the symptom burden in individuals with subthreshold depression up to 1 year, and protects against symptom deterioration. Benefits up to 2 years are less certain. We find strong support for intervention in subthreshold depression, particularly with PHQ-9 scores ≥ 10. For very mild symptoms, scalable treatments could be an attractive option.
What do we in the West owe those who grow our food, sew our clothes and produce our electronics? And what have we always owed one another, but forgotten, avoided, or simply disregarded?
Looking back on nearly a century of colonial war and genocide, in 1990 the poet and philosopher Édouard Glissant appealed directly to his readers, calling them to re-orient their lives in service of the political struggles of their time: 'You must choose your bearing'.
Informed by the prayer camps at Standing Rock, and presenting Glissant alongside Stuart Hall, Emmanuel Levinas, Simone Weil, Enrique Dussel, Gloria Anzaldúa and W. E. B. Du Bois, this book offers an urgent ethics for the present - an ethics of risk, commitment and care that together form a new sense of decolonial responsibility.
The presence of an intraluminal thrombus in acutely symptomatic carotid stenosis is thought to represent a high-risk lesion for short-term stroke reccurrence though evidence on natural history and treatment is lacking, leading to equipoise and much variation in practice. The objective of this study was to map these variations in practice (medical management and timing of revascularization), determine the considerations that influence clinician decision-making in this condition and gather opinions that inform the development and design of future trials in the area.
Methods:
This was a mixed-methods study using both quantitative survey methods and qualitative interview-based methods. International perspectives were gathered by distributing a case-based survey via the “Practice Current” section of Neurology: Clinical Practice and interviewing international experts using established qualitative research methods.
Results:
The presence of an intraluminal thrombus significantly increased the likelihood of using a regimen containing anticoagulation agents (p < 0.001) in acutely symptomatic carotid stenosis in the case-based survey. Themes that emerged from qualitative interview analysis were therapeutic uncertainty regarding anticoagulation, decision to reimage, revascularization choices and future trial design and anticipated challenges.
Conclusion:
Results of this study demonstrate a preference for anticoagulation and delayed revascularization after reimaging to examine for clot resolution, though much equipoise remains. While there is interest from international experts in future trials, further study is needed to understand the natural history of this condition in order to inform trial design.
The rapid growth of cultural evolutionary science, its expansion into numerous fields, its use of diverse methods, and several conceptual problems have outpaced corollary developments in theory and philosophy of science. This has led to concern, exemplified in results from a recent survey conducted with members of the Cultural Evolution Society, that the field lacks ‘knowledge synthesis’, is poorly supported by ‘theory’, has an ambiguous relation to biological evolution and uses key terms (e.g. ‘culture’, ‘social learning’, ‘cumulative culture’) in ways that hamper operationalization in models, experiments and field studies. Although numerous review papers in the field represent and categorize its empirical findings, the field's theoretical challenges receive less critical attention even though challenges of a theoretical or conceptual nature underlie most of the problems identified by Cultural Evolution Society members. Guided by the heterogeneous ‘grand challenges’ emergent in this survey, this paper restates those challenges and adopts an organizational style requisite to discussion of them. The paper's goal is to contribute to increasing conceptual clarity and theoretical discernment around the most pressing challenges facing the field of cultural evolutionary science. It will be of most interest to cultural evolutionary scientists, theoreticians, philosophers of science and interdisciplinary researchers.
Hospital-treated self-harm is common, costly and associated with repeated self-harm and suicide. Providing a comprehensive psychosocial assessment following self-harm is recommended by professional bodies and may improve outcomes.
Aims
To review the provision of psychosocial assessments after hospital-presenting self-harm and the extent to which macro-level factors indicative of service provision explain variability in these estimates.
Method
We searched five electronic databases to 3 January 2023 for studies reporting data on the proportion of patients and/or events that were provided a psychosocial assessment. Pooled weighted prevalence estimates were calculated with the random-effects model. Random-effects meta-regression was used to investigate between-study variability.
Results
119 publications (69 unique samples) were included. Across ages, two-thirds of patients had a psychosocial assessment (0.67, 95% CI 0.58–0.76). The proportion was higher for young people and older adults (0.75, 95% CI 0.36–0.99 and 0.83, 95% CI 0.48–1.00, respectively) compared with adults (0.64, 95% CI 0.54–0.73). For events, around half of all presentations had these assessments across the age range. No macro-level factor explained between-study heterogeneity.
Conclusions
There is room for improvement in the universal provision of psychosocial assessments for self-harm. This represents a missed opportunity to review and tailor aftercare supports for those at risk. Given the marked unexplained heterogeneity between studies, the person- and system-level factors that influence provision of psychosocial assessments after self-harm should be studied further.
In this short report, we describe an outbreak of COVID-19 caused by Omicron subvariant BA.5.2.1 in highly vaccinated patients in a respiratory ward in a large acute general hospital in North West London, United Kingdom. The attack rate was high (14/33 (42%)) but the clinical impact was relatively non-severe including in patients who were at high risk of severe COVID-19. Twelve of fourteen patients had COVID-19 vaccinations. There was only one death due to COVID-19 pneumonitis. The findings of this outbreak investigation suggest that while the transmissibility of Omicron BA.5.2.1 subvariant is high, infections caused by this strain are non-severe in vaccinated patients, even if they are at high risk of severe COVID-19 infection.
Looking back at the three or four years it took to write and revise this book, I can say that it has become something different from what I had originally envisioned. This project started as a relatively narrow intervention into how a line of Latin American philosophy that Enrique Dussel called ‘the philosophy of liberation’, what is increasingly called ‘decolonial philosophy’, took up the ethical vocabulary of Emmanuel Levinas. My argument remains that Édouard Glissant's relative ethics of opacity is more capable of speaking to today's ethical problems and possibilities than Levinas's absolute ethics of alterity. As I revised this book over the past year and read the work of, as well as engaged in conversation with, a few others – Gerard Aching, Kris Sealey, Nancy Mithlo, Neil Roberts, Allison Weir, LaRose Parris, Frieda Ekotto and Chris Tinson especially – I started to think of the book differently. In its placement in this series, and in the questions it raises, Choose Your Bearing can be read as asking Continental ethics and human rights discourse to take seriously Caribbean philosophy and Indigenous philosophy, and by extension Black Studies and Indigenous Studies, as sites of critical theory, epistemological correctives, and conceptual creation. What results from this engagement is a political theory that can no longer assume that the nation state protects rights, an ethical theory that can no longer withdraw into carefree abstractions, and a human rights discourse that can no longer maintain the goal of ‘developing’ humans, cultures and economies. Perhaps from such a renewed philosophy, one that looks back to Caribbean philosophy in the past century, we will gain ethical modes attuned to the rhythms of this century. At the very least, we will take one step toward a truer academic philosophy, one finally made to the measure of the world.
This chapter begins from and stays with two tensions regarding theorising the state. The first is perhaps the constitutive tension in scholarship on human rights: the understanding of the modern state as both predatory and protective. In his 2013 Universal Human Rights in Theory and Practice, Jack Donnelly observes that ‘the modern state has emerged as both the principal threat to the enjoyment of human rights and the essential institution for their effective implementation and enforcement’. He goes on to place his faith in human rights to prohibit ‘a wide range of state interferences’ and thereby to carve out ‘zones of state exclusion’. In this way, ‘human rights place the people above and in positive control of their government’, a position achieved through ‘extensive rights of political participation’. Donnelly's trajectory moves toward ‘the moral standing of the state’, concluding with ‘paths of incremental change’. His position epitomises what I will call ‘the critical-reformist tension’, which notes and criticises state-caused rights violations before returning to a call for state reform. This first tension is important because many justice-oriented actors feel it today. It leads to conflicting demands for practice. It is carried out in practice when students consider the risk of working as radical artists, activists or community organisers only to go to law school before garnering stable jobs in government or accepting positions at prestigious NGOs.
James Griffin's 2008 On Human Rights typifies a thin version of the critical-reformist tension. Griffin's analysis of human rights violations centres not state violence but relations between rights, such as how a state's enforcement of welfare rights can violate liberty rights. Ultimately, he argues that ‘states are the main agents of security of person’ and that ‘in some states one can vote and enjoy the protection of the police and army without being a citizen, but only citizenship makes their possession secure’. In stressing police protection, Griffin lacks a robust accounting for Indigenous displacement and police violence. His focus on security, which comes at the expense of attending to state predation on made-precarious peoples, recalls A. Dirk Moses’ recent observation that ‘the security imperative can justify permanent occupation, that is, colonial rule’. This point brings me to the second tension.
Today many humanitarian and human rights organisations project their ethical ideals through colonial models of development and protection. A more critical strand of human rights discourse responds to acknowledged global injustices with minimal demands that are simply not enough to challenge capitalism and coloniality. In light of this context, Choose Your Bearing has argued that if theorists of rights discourse are to take decolonial concerns seriously, we will both recognise the nation state as a generally predatory entity (against minorities and immigrants) and move from a model of minimal advocacy for the downtrodden to a model of maximal activism. In this way, we would make demands on the institutions and actors that keep a majority of people across the world down in the first place. Conversely, this book has also suggested that decolonial theory should reconsider its critique of human rights. The primary and secondary duties that third-generation (solidarity) rights claims entail provide a way for people to connect to decolonial work through the terms that are already the most important to them. More specifically, the duties of Glissant's right to opacity fall on elite actors in the West. Standing with others is a primary duty that supports the right to opacity in an age of colonial resource extraction and blatant violations of land rights across the planet. Enacting the secondary duties around the right to opacity could look like attending to what we purchase or boycott, where we live, to what we belong, whom we consider kin, and what risks we are willing to take in our personal and professional lives. As opposed to the position- and career-maintaining efforts of professional reforms, this is ethical work found in much more banal, much less prestigious disengagements from professional spaces as they are. But this is not a withdrawal in the sense of denying the world. Like a boycott, this is an action verified by a community, and this community can be organised by rights claims made in different parts of the world. Its collective actions aim to uphold political, economic and cultural rights internationally. In this way, the local mode of engagement that lives out the primary and secondary duties of a right to opacity embodies a provincial bearing that does not become a provincialism, but that instead participates in a radical internationalism (DA 438/CD 146).
In a 2020 op-ed in The Guardian, Nemonte Nenquimo, a leader of the Waorani people, an Indigenous nation whose home is the Amazon rainforest, stated: ‘This is my message to the western world – your civilization is killing life on earth.’ Could this be true? Could a way of life in one place not only harm people and damage environments in other places, but also destroy life itself across the planet? If this is true, then do those in the West have a duty to change their way of life? How could this change occur across societies? Are the concepts and ideas we currently use to speak about social justice, such as human rights, sufficient to bring about this needed social change, change that would honour and preserve life on earth?
This book's argument rests on the following premises: as a result of European colonisation, the way of life in any Western country today relies on resource extraction and commodity production in other countries it thereby renders poor. This international division of labour involves practices that deny the human rights – the political, economic and cultural rights – of the workers who mine the minerals, sew the clothes, and otherwise provide the basic substances for life in the West. Fair trade programmes and wage increases do not change the fact that some spend their days hunched over sewing machines while others continually update their wardrobes.
Even a cursory reading of international news, or literature from a variety of places, makes clear that the West's way of life depends on resource extraction that violates human rights in different parts of the planet. Poor people the world over often make ethical appeals asking people in the West to change their basic habits of living in order to allow for others to live, to live with dignity, and to live amidst sustaining land and water. By leveraging rights claims in pronouncing what dominant powers have tried to silence, philosophers such as W. E. B. Du Bois and Édouard Glissant have also called for the West to change its political and economic foundations.
Contemporary ethical theory needs to speak to globalisation and coloniality. Globalisation has generated social relations in which lifestyles and values are somewhat shared. Across the world, from the beginning of European colonial rule to the present, a combination of legal, economic, educational, as well as military and police forces have imposed, promoted and maintained some forms of life, such as the heterosexual, patriarchal family, at the expense of alternative ways of life. A key question for decolonial ethics is how to relate to others in a way that affirms cultural rights in response to these standardising impositions. In this chapter, I argue that Édouard Glissant's framing of an ethical relation as emerging from ‘contacts’ with others, defending the ‘opacity’ of others and ultimately standing in solidarity with others, is more fruitful for decolonial pursuits than Emmanuel Levinas's framing of an ‘encounter’ with a single Other, whose difference is understood in terms of ‘alterity’, and who is ultimately served through reverence. I start from Levinas because the philosophy of liberation, decolonial ethics and decolonial political theology continue to use his vocabulary: difference is framed in terms of alterity, and the ethical relation is exemplified in bearing witness. Calling into question Levinas's ethical vocabulary also shows the limitations of contemporary ethical theory that relies on his terms.
Levinas's concept for difference is ‘alterity’, ‘the radical heterogeneity of the other’ such that this other is ‘absolutely other’. He reserves the term ‘religion’ for the face-to-face ‘ethical relation’, ‘a relation without relation’ in which ‘the encounter with the Other opens the infinite’. He asserts: ‘The Other remains infinitely transcendent, infinitely foreign; his face in which his epiphany is produced and which appeals to me breaks with the world that can be common to us.’ The Other is a rupture, breaking the possibility for a shared world of relation and communication. The language Levinas uses to describe the ethical relation is not compassion or care, but extreme and hyperbolic terms such as obsession, persecution, trauma and substitution. He insists further that the Other is not different with only ‘a relative alterity’ and in doing so avoids considerations of cultural difference.
So far this study has argued for a shift in the vocabulary of decolonial ethics: from alterity to opacity, from exile to errancy, from root identity to relational identity (‘expansive belonging’), and from hospitality to solidarity – where solidarity allows a reconsideration of politics, as Nitzan Lebovic puts it, ‘not as a binary relation between friend and enemy, but as a network … united against abuse and coercive power’. In arguing for this shift, this study has advanced a politicised sense of responsibility that works to demand opacity against state and market forces as well as to break from familiar identifications, such as one's nation and class. The promise of re-description is that it re-presents ‘responsibility’, suggesting different associations with the term, different ways of hearing it and thinking about it. An alternative understanding leads to aberrant actions. In other words, the promise of our shift in linguistic practices lies in our non-linguistic practices, our bearings of engagement with the world. If this is right, then it would be instructive to elaborate on what makes possible relational politics as well as to describe already ongoing practices that exemplify such relational work. Such an elaboration is the task of this chapter.
Among the francophone Left of his generation, Glissant was famous for saying we must ‘put the poetic back into the heart of the political’. To some this sounds like a superficial aesthetic statement, a fundamental misunderstanding of materialist politics, or perhaps, at best, a call for richer language in slogans and speeches. Even if these were the only ways to hear Glissant's point, it should not be underestimated. As Martin Puchner's scholarship shows, Marx's Manifesto was successful as a political provocation in part because of its reinvention of a genre. Of course, there are other ways to hear Glissant's saying. As Loichot has commented, ‘Poetry, for Glissant, is not just the art of accommodating words in a lyrical mode by the use of sound, rhythm, or metaphorical language.’ ‘Poetry also means “making” in a material way’, she continues: ‘Poétrie, the seeming neologism that Glissant uses in French, evokes simultaneously the poem, inhabited by the English word “poetry”, and the verb pétrir, to knead dough or to give shape to clay.’
In this chapter, in order to build on the political participation I described in Chapters 1 and 2, I consider the deeper demands of solidarity. Participation in coalitional action is necessary but not sufficient for a robust ethics that learns from decolonial movements. My inquiry here is partially inspired by Hannah Arendt's theorisation of ‘the fleeting moment of action’ that characterises a ‘space of appearance’, which ‘does not survive the actuality of the movement which brought it into being’. What is at stake in this inquiry is how an ethical turn could gain a sustained political edge. For this to happen, actors need to maintain political action beyond its initial appearance – not participating in a single march but making political responsibility a larger part of their lives, well beyond the start of the movement. Put differently, participation needs to be more than what Ortega has called ‘political excursions’, meaning ‘a type of politically correct tourism – fleeting moments of experimenting with being political while not really being committed to effecting change’. If we are to think of responsibility in terms of our most central commitments, then we must address the shift from coalitions to communities, from contacts to relations, in Glissant's terms. The oppositional action of demanding a right to opacity is important, but it says little about the ‘meanwhile’ present between connected instances of direct action. ‘[P]olitical resistance often begins in a meanwhile’, novelist and artist John Berger writes. Griffin's concept of ‘secondary duties’ speaks to this meanwhile, as does Lugones's concept of ‘complex communication’. Lugones's starting point – not opposition but communication – introduces a sense of ‘relational identity’ that I will expand on in this chapter. It is in living out a relational identity that one moves from participation to solidarity.
In regard to the question of relational identity, we can immediately raise four concerns. The first is that a focus on the level of the individual and their identity presupposes a neoliberal subject of unlimited growth and change. Yet even when we are discussing how global forces and movements affect cultures, actual interactions always occur on the level of individuals. As the anthropologist Richard Price puts it in an essay on creolisation in the Caribbean, ‘Human beings meet and engage one another; cultures do not. Individuals who claim multiple identities interact with one another; ethnicities do not.’