Abstract
In a previous ANZJP This Month, Does evidence lead to policy change? (Porter, 2012), I introduced a number of papers from the Survey of High Impact Psychosis (SHIP) study (Morgan et al., 2012), a study with the potential to inform policy relating to patients suffering from psychosis. In this issue of ANZJP, there is a more direct discussion of mental health policy in a series of Viewpoints designed to predate the Australian General Election. Drawing on evidence regarding changes between the first and more recent SHIP studies, Carr and Waghorn (2013) argue that two particular areas in which there has been little change, and which should therefore be prime targets for reform, are the unacceptably low level of employment and the issue of social isolation amongst sufferers from psychosis. In particular, they argue for an increased adoption of the evidence-based individual placement and support model. Castle (2013), in his Viewpoint, argues for a change in the funding model, with funding linked to individual patients, and patients and carers being ‘empowered to effect their own care supported rather than managed by the system’. Finally, Whiteford et al. (2013) argue for a model involving assessing the burden of mental illness, identifying what may reduce that burden, organising a service delivery framework and adapting policy to implement the desired framework. One of the examples given of an area in which improvements could be made is the integration of physical and mental health treatment for people with long-term, severe mental disorders, given the increased physical morbidity and gaps in life expectancy between these people and the general population. In light of this suggestion, it is interesting to note the paper of Saha et al. (2013), which examines mental health and physical health in the first-degree relatives of patients with major depression, anxiety disorders or drug and alcohol dependence. This study found that not only were the same conditions more common, but so too were other mental health disorders, along with a broad range of general physical conditions.
Further papers in this edition of ANZJP discuss some of the major issues in the treatment and service provision for people with psychotic illnesses. Allnutt et al. (2013) debate the issue of violence risk assessment and the problem of prediction of violence in people with mental illness. Previous research has shown that risk assessment lacks predictive power, and therefore it has been suggested that clinical decisions should not be based on it (Ryan et al., 2010). However, Allnutt and colleagues argue that this is no reason to abandon risk assessment as an important part of psychiatric practice and that despite group-based research, individual risk assessment is still important in guiding individual management.
An important factor in risk of violence, a burden for patients and an important target for any mental health system, is the risk of relapse in psychosis. Hui et al. (2013) address the possible factors predicting relapse of first-episode psychosis in a paper that shows that nearly half of first-episode patients relapsed within 3 years. A number of factors emerged as being associated with an increased risk of relapse, including smoking, which the authors highlight as a particularly intriguing new finding.
Finally, the finding that psychosocial functioning is compromised in patients at ultra-high risk of psychosis and that this is associated with reduced adaptive coping and resilience (Kim et al., 2013), adds to data suggesting that these functions should be potential targets for treatment in early psychosis. This harks back to the June issue of the Journal in which several authors (Dark et al., 2013; Harris and Boyce, 2013) argued that psychosocial intervention in various forms should be a fundamental component in the treatment of schizophrenia.
While psychosocial treatments are also central to the treatment of mood disorders, an issue that has always hampered treatment of depression, regardless of the mode of treatment, is that of speed of response. However, arguably one of the promising ‘new’ treatments for depression, both unipolar and bipolar, is ketamine, which is distinguished by evidence of a particularly early response. In a comprehensive and rigorous review, Katalinic et al. (2013) examine the current state of the evidence and make recommendations for future research, concluding that relapse following response is perhaps the greatest challenge this agent faces.
That the Journal is developing a reputation for open debate of important and challenging topics is illustrated by contributions from extremely high-profile authors on controversial subjects. Caroll (2013) and Tyrer (2013) robustly add to the debates on conflict of interest and borderline personality disorder, respectively. The determination of the Journal to tackle these issues makes for interesting and informative reading.