Abstract
‘Schizophrenia is arguably the worst disease affecting mankind, even AIDS not excepted.’
These are not the words of a psychiatric evangelist. They were written by the editor of Nature (Anonymous, 1988), and they hold 25 years later. The profound disablement caused by schizophrenia is largely due to the negative, and particularly the cognitive, symptoms. These, along with delusions and hallucinations, are often resistant to all currently available antipsychotic medication. Yet psychosocial treatments are used sparingly. In their Editorial for this issue, Harris and Boyce (2013) introduce us to a better understanding of non-pharmacological treatments. Over 90% of the patient population receive antipsychotic medication, but only about one-third reach any form of social rehabilitation (Morgan et al., 2012). Five papers have been assembled to provide a much-needed understanding of psychosocial treatments and what they achieve. Three are directed at the patient to help reduce cognitive disabilities (Dark et al., 2013; Farhall and Thomas, 2013; Marsh et al., 2013). The fourth, family psychoeducation, includes teaching practical strategies to reduce expressed emotion in family life (Harvey and O’Hanlon, 2013). It is salutary to recall that family psychoeducation was developed some 60 years ago. George Brown and his colleagues were looking at discharge data at the Maudsley Hospital, London when they had the wit to notice a pattern: counterintuitively, psychotic patients did better if they were not discharged to their own families (Brown et al., 1958). That observation fuelled a whole new research program on ways to reduce expressed emotion in families, thereby reducing the chances of relapse. Here is an elegant example of translational medicine, though that rather meretricious entity had not yet been conceived. The fifth paper is about patients re-joining the workforce (Killackey and Allott, 2013). To be able to work again, we are reminded, is what most persons with persistent psychotic illness strongly desire, contrary to common assumption. Yet most of them stay unemployed. By undertaking neurocognitive and social enhancement, vocational intervention is a demonstratively successful component in their true rehabilitation.
All five papers confirm that psychosocial treatments are effective. They also explain why they are not more used. Three barriers impede uptake: resistance in the patient, often because of the negative symptoms themselves; inadequate training of mental health professionals including psychiatrists; and the manner in which administrators currently choose to deploy staff. All mental health professionals, and psychiatrists in particular, may even face deskilling in psychosocial treatments because of the relentless demand for acute care. One particular anomaly is the ubiquitous employment of clinical psychologists as case managers. When Thornicroft and Betts (2002) were contracted to provide advice on the Australian National Mental Health Strategy, they spelt it out: ‘Psychologists’ expertise is often unnecessarily diluted by their work as case managers at a time when increasing evidence supports the effectiveness of cognitive behavioural interventions for depression, anxiety-related and psychotic disorders. Psychologists do not have their skills best used as generic case managers.’ That advice has so far not led to change.
In his magisterial paper on schizophrenia in Nature, Insel (2010) pointed out that patients with long-established psychosis are in the final stage of a disorder that often has had its beginnings in utero. It is unsurprising that pharmacology does little to reverse the brain damage that has taken place over many years, but psychosocial treatments offer greater promise. For this reason, we would welcome a bi-national reconsideration of non-pharmacological treatments for mental disorders. This issue of the Journal helps set the scene.
Screening for disease has always called for good sense and clear thinking to temper enthusiasm. Our August 2012 issue carried several papers on an intended national program to screen Australian 3-year-old children for mental health problems, an intention seen by some as ill-conceived, unwise and potentially harmful. An eminent overseas expert concluded, ‘Simply stated, this is a bad idea on psychiatric grounds and unjustifiable as public policy’ (Frances, 2012). The topic returns this month and calls for further scrutiny. Alexander et al. (2013) report the views of parents, general practitioners and practice nurses in Melbourne. When any screening procedure is being assessed for its merits, the irrefutable principles set out by Wilson and Jungner (1968) should be applied. Their 10 principles must be applied individually to each of the mental health problems that the children’s program has as its target, according to how these are specified then operationally defined. To this writer, the most demanding of the Wilson and Jungner requirements are as follows: there should be a suitable test for the disorder, facilities for subsequent diagnosis and treatment should exist, there should be agreement on who requires treatment, and case-finding should be a continuous process rather than a once-only examination. In addition, it must be asked if screening can ever be harmful. And what will happen to false positives? As Sackett and Holland (1975) forcibly declared, detecting disease must be able to promise some health benefit to the individual. In the present state of knowledge, to screen children aged 3 years for mental disorders is an ill-advised attempt at preventive medicine. It would be scientifically and ethically unjustified.