Abstract
Mental disorders are generally extremely complex and making the progression from recognition of a particular disorder to implementation of ways of truly helping people with that disorder is a very long and difficult process. While clinical trials are clearly important in informing practice, there is a wider process that is much needed. First, the condition being examined needs to be understood, including an understanding of the real impact upon sufferers and the most important issues for them. Second, we need an understanding of what symptoms or aspects of the disorder should be targeted in order to effect significant change for the better. Third, especially in the modern economic era, treatments need to be evaluated for ‘cost effectiveness’. This complexity is often lost in the process of making policy decisions, making it particularly important for clinicians and academics to be forthright in debating evidence and its implications for mental health policy.
This month in ANZJP there are no reports of clinical trials, but instead there are excellent examples of studies at other stages of this pathway, all relating to the understanding of and treatment of psychosis. Of particular note, this issue of the Journal features the first group of papers resulting from the Australian Survey of High Impact Psychosis (2010) or SHIP study, the second national Australian survey of psychosis, the first survey having been completed in 1997–98. This landmark survey represents an immense collaboration between researchers around Australia that have together collated a huge resource of valuable data. It will add greatly to our understanding of the reality of psychotic illness and has already highlighted the major challenges as perceived by the sufferers of psychosis. The methodology and main findings of the project are presented in the paper by Morgan et al. (2012), with further papers featuring different aspects of the study, including pharmacological treatment (Waterreus et al., 2012), metabolic health (Galletly et al., 2012), and employment and education (Waghorn et al., 2012).
There has been considerable debate about the effectiveness of Early Intervention services but to date relatively little detailed discussion of the economic viability of such approaches. However, Amos (2012) has attempted to fill this void and in this paper that reviews the cost of early intervention in psychosis, concludes that in fact ‘The published literature does not support the contention that early intervention for psychosis reduces costs or achieves cost-effectiveness’. This is an important conclusion and I am confident that akin to the long-running debate regarding Early Intervention and Ultra High Risk States (Rosenman and Anderson, 2012), discourse in response to this issue will continue in the Journal for some time to come.
In an ideal world, the sort of detailed and rigorous evidence provided by the SHIP study and other studies in this issue would eventually be translated into treatments and models of care. However, in Australia and New Zealand, evidence is often ignored in favour of policy based on political expedience and reaction to the latest adverse events. Carr et al. (2012) explore some of the policy implications of the SHIP study and some of the changes that have taken place since the last survey. To this, Norman (2012) adds a commentary and discussion of the possible reasons for the ‘gap’ between research findings and implementation in clinical services.
There is further intense discussion regarding mental health policy following the announcement that the Federal Government of Australia is allocating $11 million over 5 years to introduce a universal voluntary health check for 3-year-olds, including social and emotional well-being and development. Viewpoints and debate regarding the possible pros and cons of such a policy are eloquently presented (Frances, 2012; Levy, 2012; Newman, 2012; Prior, 2012; Toumbourou, 2012) and, once again, I hope that there will be further exchange of opinion on this issue in these pages. It is interesting to note that a similar check at a slightly later age (4 years), involving amongst other checks a questionnaire designed to screen for developmental and behavioural difficulties, was introduced in New Zealand in June 2008, with relatively little academic debate regarding possible unintended negative consequences.
Robust debate has become an important part of the Journal in recent years, as part of a deliberate policy to encourage discussion of difficult and contentious issues. The June edition contained important discussion of the issue of Conflicts of Interest in psychiatry. This month takes the debate further with a viewpoint by Professor David Healy (2012). In this, he argues for a wider view of the issue of conflicts of interest, beyond a simple consideration of financial or career gain related to Pharma involvement. Once again, I eagerly await and encourage further correspondence and viewpoints in response to this perspective.
In closing, I should note that the Australia-wide collaboration on the SHIP study meant that most Australian researchers with expertise in this area were excluded from the review process. This meant that all the reviewers were from overseas and without necessarily any particular investment in the Journal. In this context, the extent of their input was remarkable and we are extremely grateful for this. That some have extended this to contribute insightful and useful commentaries (Norman, 2012) is even further appreciated.