Abstract
This issue of the Journal has a thematic focus on the interplay between social factors and mental health. Despite the fact that surveys of mental health consumers consistently identify treatment and prevention as priorities, neither attracts the lion’s share of resources, with prevention in particular retaining orphan status as a research topic. Jacka and colleagues (2013) argue that, in many other branches of medicine, preventive initiatives have delivered the greatest contribution to public health and treatment breakthroughs. They hypothesise that there is likely to be similar utility in the common mental disorders from embracing prevention strategies. They explore what is known about modifiable risk factors at a social, biological and environmental level and attempt to capitalise on the knowledge derived from the successes and failures of preventive efforts in other disorders, including obesity, cancer and cardiovascular disease. This is based on an expanding evidence base suggesting the importance of social and environmental factors, including stress, diet and lifestyle, to mental illness operative from early childhood (Pasco et al., 2011). They argue that there are common risk pathways, and hence significant synergies between preventive strategies for high-prevalence mental disorders and other non-communicable disorders. They additionally argue that most of the successes in the preventive sphere have been in the arena of public policy, and that partnering with agencies and disciplines with shared goals is likely to be a critical path to success.
One of the unintended consequences of the policy of deinstitutionalisation and changes in attitudes to compulsory treatment (Callaghan and Ryan, 2012) has been a dramatic rise in the proportion of people in the forensic system with psychiatric problems and/or intellectual disability. Indeed, the forensic system has become, by default, the new asylums (Konrad, 2002). The needs of individuals with mental health problems and intellectual disability in the forensic system are therefore an increasingly pressing issue. Dias and colleagues (2013) explore the prevalence of mental co-morbidity amongst prisoners who have intellectual disability, arguing that the high rates of psychiatric burden and unmet treatment needs merit a coordinated approach to treatment delivery for this marginalised and disadvantaged cohort (Lawn, 2012). This need is borne out by an earlier study into high rates of psychotropic prescribing in this group (Griffiths et al., 2012). Concluding the forensic theme, Ducat and colleagues (2013) report that firesetters have high rates of psychiatric co-morbidity, particularly substance use, mood and personality disorders. Nevertheless, they emphasise that most firesetters have not had prior contact with mental health services nor received a psychiatric diagnosis. A means of identifying firesetters in advance would be of great benefit and, better still, would be the ability to administer effective treatment, perhaps even compulsorily.
Anand and Pennington-Smith (2013) detail the complexities around the issue of compulsory treatment. They focus on the shifting landscape of societal attitudes to the balance of individual freedoms and personal and societal risks. They highlight the tensions and oscillations of the political pendulum between the personal and societal risks of not treating severe mental illness and the deprivation of personal liberty. Griffiths (2013) highlights the prevalence and disability of social anxiety and contrasts this with low levels of help-seeking behaviour. They highlight high levels of stigma and low levels of mental health literacy as drivers of low help-seeking. In an attempt to alleviate this, they have mapped a framework for help-seeking behaviour, in which a variety of modifiable factors have been identified. These include attitudes, beliefs, knowledge and the availability of help, as well as intervening with the behavioural elements secondary to the illness itself that impair motivation and the intention to seek help. Continuing the social theme, Coombs and colleagues (2013) review measures of social inclusion to complement the suite of outcome measures that are routinely used in public mental health services. They highlight the protective nature of social inclusion and the profound extent to which people with mental health difficulties feel excluded from the social mainstream, as evidenced in earlier work (McDermott et al., 2012). Because of this, they argue that measures of social inclusion are such a key determinant that they merit routine inclusion as an outcome measure. The authors review the literature, narrow the list of suitable measures and conclude that two candidate measures may be suitable, but suggest that neither is fit for purpose in their current form, arguing that specific measures may need to be developed.
Additional topics of note in this issue of the Journal include the paper by Narayanaswamy and colleagues (2013), who attempt to explore the neurobiological and neuroanatomical foundation of obsessive-compulsive disorder by examining the nucleus accumbens, which has a critical role in reinstatement and reward behaviour. They found a link between right nucleus accumbens volume and severity of obsessive compulsive disorder, hypothesising that this is based on dopaminergically mediated reward mechanisms and that it underpins the role of this nucleus in obsessional thinking and behaviour (Fineberg et al., 2013). They additionally postulate that this finding perhaps provides support for the role of deep brain stimulation in the disorder.
As exemplified in this issue, all aspects of psychiatric research have value, and especially so when the findings can be meaningfully linked and leveraged. Prevention is the ideal, but clarifying what it is that we are trying to prevent and having knowledge of how it actually comes about, in terms of the operative neurobiological, social and environmental pathways, is likely to facilitate and enhance our success in achieving this objective.