Hello Future: post-pandemic and beyond

I remember people making jokes about coronavirus back in early 2020. I thought, as did many others, that it would be just another bird flu or swine flu. Then everything changed quickly. Even in Australia, where the impact of the pandemic was nowhere near as severe as in other places in the world, we isolated, got locked down, wore masks and got vaccinated. People lost jobs, reputations and relationships. Anxiety and stress built up, and I wondered whether the pandemic would ever end. I kept asking myself: Are we there yet?

In this issue of the BJPsych, we have two articles related to the pandemic. First, Oloyede et al (pp: 382–388) identify a potentially positive consequence of the pandemic in reducing clozapine monitoring: 459 patients on clozapine who were switched to 12-weekly extended monitoring during the pandemic were compared with 110 patients registered for the extended monitoring but still receiving 4-weekly monitoring. At 1-year follow-up, there were no differences in adverse haematological events, clozapine discontinuation rate, hospital admission rate or clozapine dose change between the two groups, or in the rate of COVID-19 infection. As the authors argue, this may be a good opportunity to revise the protocol for good. While people on clozapine were considered a particularly vulnerable patient cohort during the Pandemic, another at-risk group identified was those with pre-existing neurodegenerative disorders. In the comprehensive systematic review and meta-analysis of 97 643 494 individuals, Smadi et al (pp: 348–361) found that COVID-19 infection rates were significantly higher for those with pre-existing neurodegenerative disorders (odds ratios of 1.51–2.86). In general, they were at higher risks of hospitalisation and mortality related to COVID-19. Interestingly, they also found that people with dementia were significantly less likely to be admitted to ICU (as opposed to those with Alzheimer disease and Parkinson disease who were more likely to have ICU admission). The authors postulated that this might be due to the triage criteria implemented in many countries during the Pandemic to maximise the number of survivors.

For my undergraduate studies, I initially enrolled in a neuroscience degree. I dropped out after a couple of months when I discovered the course included a weekly 4-hour neuroanatomy laboratory session. Still, I dream of a future when we can use blood test results and brain images to diagnose mental disorders and formulate treatment plans. The study by Zhou et al (pp: 377–381) provides a sneak preview of what my desired future might look like.

Using the data from the UK Biobank, the authors examined the association between maltreatment during childhood and the mean telomere length in middle to older adulthood (age range from 37 to 73). This retrospective cohort study of 141,748 participants found that exposure to childhood maltreatment was associated with shorter telomere length later in life. The authors speculate that psychological stress may accelerate telomere shortening via higher oxidative stress levels, lower telomerase activity and inhibition of telomere maintenance. In another study in this Issue, Atkins et al (pp: 389–393) validated the clinical utility of a point-of-care test for finger-stick capillary blood concentration of aripiprazole to monitor medication adherence. The more objective data we can obtain, the more precise and effective our interventions will be. Serum concentration measurements feel much more helpful than self-reported adherence for optimisation of pharmacological intervention. How far are we from relying more on serum serotonin concentration than self-reported happiness to guide our formulation?

But life is complicated. A systemic review by Jin et al (pp: 362–376) investigated the cost-effectiveness of physical activity interventions for weight management among people with schizophrenia and bipolar disorder. The findings were inconclusive. Five studies found physical activity interventions to be more effective and more expensive – so the cost-effectiveness depended on the local willingness to pay. One study found the interventions to be no more effective but no less expensive. Another study found them to be no more effective but more expensive. Yet another study found physical activity interventions to be less effective and less expensive. Only one study found physical activity interventions to be clearly more cost-effective: more effective and no more expensive.

Oliver Sacks once said that biologically we are not so different from each other, but historically, as narratives, we are unique. I hear Avril singing: why do you have to go and make things so complicated? I still wonder whether small, even tiny, biological differences among us may help psychiatrists to assess and treat our patients more uniquely and effectively. For the past 3 years, I have frequently wondered what the world would look like after the pandemic. As we move into the post-pandemic phase and beyond, the future from yesterday looks much like the past we had before the pandemic. As a (short-lived) neuroscience student at the turn of the century, with all the promises and hype associated with the Decade of the Brain and the Human Genome Project, I dreamed a dream, a big dream for us. Sure, our brain is complex and our lives are complicated, but the future from yesteryears looked bright. Twenty years on, I keep asking myself: Are we there yet?