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There has been debate about the frequency and severity of antidepressant withdrawal effects.
Methods
We set out to appraise and reanalyze an influential systematic review by Henssler and colleagues that concluded that withdrawal effects are not particularly common and rarely severe. We repeated the meta-analysis, including only studies where data were derived from systematic measures of withdrawal symptoms.
Results
Most data in the Henssler review are derived from pharmaceutical industry–sponsored efficacy studies in which withdrawal was a minor consideration. Shortcomings of the review include the use of spontaneously reported adverse events to estimate withdrawal symptoms, potential misclassification of withdrawal symptoms as relapse, inclusion of data from retrospective case-note studies, short duration of prior antidepressant use, short observation periods, the overlooking of differences between placebo and drug withdrawal effects, and the use of questionable proxies for severe withdrawal. There were also discrepancies and uncertainties in some figures used. In our reanalysis, we included only the five studies that used a systematic and relevant method to assess the incidence of any withdrawal symptom. Prior treatment was short-term (12 weeks or less) in all but one of these. The pooled percentage was 55% (95% confidence interval, CI, 31% to 81%; N = 601) without subtracting nocebo effects, with high heterogeneity.
Conclusions
Henssler’s review is based on unreliable data and does not provide an adequate basis for the evaluation of antidepressant withdrawal effects. Further good-quality research on antidepressant withdrawal is required.
We present the Evolutionary Map of the Universe (EMU) survey conducted with the Australian Square Kilometre Array Pathfinder (ASKAP). EMU aims to deliver the touchstone radio atlas of the southern hemisphere. We introduce EMU and review its science drivers and key science goals, updated and tailored to the current ASKAP five-year survey plan. The development of the survey strategy and planned sky coverage is presented, along with the operational aspects of the survey and associated data analysis, together with a selection of diagnostics demonstrating the imaging quality and data characteristics. We give a general description of the value-added data pipeline and data products before concluding with a discussion of links to other surveys and projects and an outline of EMU’s legacy value.
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.
Precision or “Personalized Medicine” and “Big Data” are growing trends in the biomedical research community and highlight an increased focus on access to larger datasets to effectively explore disease processes at the molecular level versus the previously common one-size-fits all approach. This focus necessitated a local transition from independent lab and siloed projects to a single software application utilizing a common ontology to create access to data from multiple repositories. Use of a common system has allowed for increased ease of collaboration and access to quality biospecimens that are extensively annotated with clinical, molecular, and patient associated data. The software needed to function at an enterprise level while continuing to allow investigators the autonomy and security access they desire. To identify a solution, a working group comprised of representation from independent repositories and areas of research focus across departments was established and responsible for review and implementation of an enterprise-wide biospecimen management system. Central to this process was the creation of a unified vocabulary across all repositories, including consensus around source of truth, standardized field definitions, and shared terminology.
This book describes the politically charged afterlife of Israeli electronics gathered by and processed in a cluster of rural Palestinian villages that has emerged as an informal regional e-waste hub. As with many such hubs throughout the global South, rudimentary recycling practices represent a remarkable entrepreneurial means of livelihood amidst poverty and constraint, that generates staggering damage to local health and the environment, with tensions between these reaching a breaking point. John-Michael Davis and Yaakov Garb draw on a decade of community-based action research with and within these villages to contextualise the emergence, realities and future options of the Palestinian hub within both the geo-political realities of Israel's occupation of the West Bank as well as shifting understandings of e-waste and recycling dynamics and policies globally. Their stories and analysis are a poignant window into this troubled region and a key sustainability challenge in polarized globalized world.
We describe the minute details of cable copper extraction through burning, and the persistence of the phenomenon despite local harms and frustrations, and our development of a sustainable and economically viable alternative to burning, in the form of a mechanical cable grinding facility. We describe the successful piloting of this facility, through initial subsidy for free grinding in tandem with a community policing mechanism, in which community volunteers would report burns as they occurred, and a response team would rapidly approach the burners to interview them and offer them vouchers for free grinding of their materials. Alongside the indicators of the success of this pilot intervention, we also report on the political barriers we encountered in institutionalising and expanding it for the longer term.
This chapter opens with a community meeting in the West Line about the e-waste issue as an example of how multiple social locations and perspectives of different community actors can be selectively narrowed in public forums and community interfaces with outside actors. In this case, the meeting foregrounded e-waste’s pollution harms and dumping narratives while eclipsing its economic/livelihood dimension. This episode leads us to a review of the complexity, challenges, and importance of representative community engagement in development projects, and how shortcuts to “participatory” development can overlook social heterogeneity, bolstering the visibility and power of certain segments within a diverse and at times contentious community. We describe the social and political divisions within the West Line villages, and our effort to generate a broadly endorsed development proposal with this community through a novel Delphi-like method. We describe the iterative procedure we adopted and how it enabled convergence on a development trajectory that proved broadly consensual, namely a social and environmental upgrading of the e-waste industry that would preserve livelihoods while reducing its harms. We reflect on the irony of the apparent success of this outside intervention in broadening and facilitating a community participation process.
We review the emergence of the West Line hub that has processed most of Israel’s e-waste for over two decades against the background of the global phenomena of e-waste policies and hubs often characterised as simply dumping grounds at the receiving end of flows of contaminating processes and materials to less regulated settings (the Pollution Haven Hypothesis, PHH). Its emergence was facilitated by factors common to the occupied West Bank as a whole (de-development, lower labor costs, dominance of the informal sector, a porous border and spatial fragmentation), and others especially important in the West Line area. These include the disruption of work opportunities in Israel alongside a rise in the amounts and value of e-waste; proximity to Israeli urban centers and distance from Palestinian ones; the historical presence of a scrap trade; a population comprised of a handful of extended families facilitating trust-based economies, on the one hand, while overcoming stigma and opposition on the other; and availability of areas of governance vacuum allowing dumping and burning. The PHH’s crudely global account of e-waste hub emergence must be refined to include the context-specific presence and operation of hubs as forceful economic agents, not simply passive recipients of waste dumping.
Our focus in this chapter is the burn sites themselves. We describe the toxic substances released, the massive environmental and health problems these present, the importance of including remediation of these sites as an integral part of e-waste policies, and our piloting of such remediation. While such toxic sites figure centrally in the scientific literature on e-waste and iconic portrayals of e-waste hubs, figuring implicitly or explicitly as a key motivator for EPR policies that would redirect waste away from e-waste hubs, they figure very little in e-waste policies themselves. Thus, such policies risk giving e-waste hubs the worst of two worlds: relocating the sources of their livelihood away to central capital-heavy recycling facilities without removing the contamination that would continue to harm their landscapes and health for decades to come. We describe the details of our pilot cleanup of one such site, our development of a framework for scaling this up to remediate the most serious sites in the West Line, and how this scaleup fell afoul of disputes of principle regarding national sovereignty and more mundane tensions between central and local authorities within the Palestinian Authority.
This chapter describes the global and local ramifications of the emergence, dominance, and policy derivatives of an e-waste dumping paradigm focused on the transfer of contaminants from the Global North to helpless “digital dumpsites”: peripheral locations suffering grievous environmental and health impacts. Though derived with only a thin linkage to realities in these locations, these caricatured portrayals resonate strongly in the Global North, and undergird key platforms of e-waste regulation, the Ban Amendment to the Basel Convention and Extended Producer Responsibility (EPR) policies now a hegemonic model for e-waste collection and recycling. Ironically, this paradigm bypasses the informal sector, its vital livelihood contributions to these places and central role within the scrap value chain, and redirects resources, attention, and agency away from dynamics and actors key to systemic reform and local sustainability. Thus, EPR’s forwarding-looking and formalizing agenda can leave the places it aspires to save with the worst of both worlds: deprived of livelihoods and saddled with the legacy of past contamination. We describe this global paradigm’s local resonances in the ironically convergent thrusts of emerging Israeli EPR legislation, local and national NGO voices in Israel and Palestine, and the sovereignty aspirations of a distant Palestinian Authority.
We build on Chapter three’s description of e-waste hubs as vital economic actors, rather than simply dumping sites, and Chapter four’s account of a consensual development vision for the West Line hub, to argue for the pragmatic and ethical necessity and advantages of centering e-waste hubs in e-waste policies. Existing EPR e-waste policies, generated in the Global North and adopted globally, usually ignore informal actors and dynamics, or propose formalizing them in a way that redirects attention and resources away from the value chains and sites that have historically collected and recycled most of the world’s e-waste. A hub-centered policy would boost the effectiveness and coherence of e-waste policies by accounting for and building on their entrepreneurial agility and expertise, decentralising decisions and interventions to actors with nuanced local knowledge, greater accountability, and long-term stakes in policies that not only propose solutions in the center but grapple with existing capacities and toxic legacies in the periphery. We briefly describe the interlocked arms of the West Line model for such restructuring elaborated in the following three chapters: curbing destructive practices through local enforcement; remediating past damage; and preserving livelihoods though environmental upgrading of the recycling processes.
This chapter details the West Line e-waste economy as an example of global destruction networks operating globally as an under-examined shadow of the more familiar and visible phases of the economy. It traces the highly effective collection pathways developed by Palestinian entrepreneurs to locate and funnel end-of-life materials from Israeli households, institutions, and scrapyards to the West Line, along with lesser inputs from Palestinian areas. We describe the navigation of borders, including through mediation of Israeli settlers, as a cascading flow of scrap arrives to the West Line, for resale, repair, and processing, with valuable metals extracted for export back to Israel, and low value remnants disposed. This informal economic value chain employs a complex hierarchy of a thousand workers, operating in an ecosystem of interlocked dynamic niches of specialization and synergy, ranging from multi-million dollar metal traders to children picking through ash for pieces of copper, producing one of the largest Palestinian exports to Israel. At the same time, similar to other hubs globally, these vibrant economic contributions in a context of scarce opportunity are in increasingly tense relations with the wide-ranging severe environmental and health impacts of the crude extraction and disposal practices employed and international scrutiny.
This chapter describes the cross border geopolitical terrain within which we advocated Israeli and Palestinian authorities on behalf of the hub-driven path to reform described in previous chapters. The impressive entrepreneurial accomplishments of the West-Line’s informal recycling industry, and our arguments for its social and environmental upgrading came up against the harsh constraints of regional politics and policies. On the Israeli side, an increasingly tense and militarized response to waste smuggling and burning meshed with a narrow vision of Israeli e-waste management policies modeled on the internationally dominant EPR system. This impulse converged, ironically, with the stance of the Palestinian Authority. Here, officials regarded waste flows as a joint manifestation of Israeli dumping and the criminality of marginal individual Palestinians. The Authority’s battle for symbolic expressions of sovereignty in a context where it possesses almost none of its substance, formally allows the recycling of only that small fraction of e-waste that is indigenously Palestinian—a convenient fiction that blocks formal commercial recycling. For example, the foremost example of a Palestinian company performing large scale clean recycling on a commercial basis is not showcased as a way forward, but faces constant friction from both Israeli and Palestinian institutional and regulatory barriers.