Abstract
One of the criticisms of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is that the developers did not take the opportunity to develop a new way of classifying psychiatric disorders; opting instead to make incremental changes to its descriptive categorical approach. Eppel, in this issue of ANZJP, questions whether we have reached the limits of our descriptive, psychoanalytic and psychopharmacological paradigms (Eppel, 2013). He proposes two alternative explanatory paradigms: one based upon affective neuroscience and the other on attachment theory. Eppel cites the work of Panksepp, who identified seven basic emotional operating systems and their corresponding neurocircuits (social bonding and separation distress, fear, anger exploration, maternal care, sexual behaviour and play). This neuroscience approach is consistent with the Research Domain Criteria (RDoC) that the National Institute of Mental Health (NIMH) has proposed as an alternative model to DSM-5 for research purposes (Insel et al., 2010). He proposes linking this neuroscience approach to attachment theory; attachment theory provides us with a set of testable hypotheses about human development and we are beginning to understand more about its neurobiological basis. Should Eppel’s paper provoke us to think more about alternative approaches to our classification of psychiatric disorders?
A problem with a descriptive categorical approach to diagnosis is that the heterogeneity of disorders is not captured. This is highlighted in an article by Goldberg (2013), who discusses the importance of anxiety in depression. He points out that anxiety symptoms with depression make the illness worse in both unipolar and bipolar depression. He also notes, interestingly, that first-degree relatives of those with anxiety and depression have an increased risk of depression, whereas the first-degree relatives of those with non-anxious depression do not. These observations should make us think more carefully about the salience of findings in genetic and treatment studies of depression, especially when anxious depressions are lumped in with non-anxious depression.
We all know that there is significant impairment associated with depression, in particular occupational impairment with absenteeism and poor productivity. A major contributor to this is fatigue; however, this depressive symptom has attracted little attention according to Lam et al. (2013). These authors suggest we pay more attention to this symptom when assessing depressed patients and advise greater rigor in the assessment of functioning.
Psychoeducation is an essential component of the good clinical care of patients with depression, yet its role as a treatment has received modest attention when compared to bipolar disorder or schizophrenia. The systematic review of psychoeducation for depression by Tursi et al. (2013) is therefore timely, especially as it has identified that increased knowledge about depression and its treatment is indeed associated with a better outcome and is likely to reduce the associated burden on the family.
The use of selective serotonin reuptake inhibitors (SSRIs) to treat depression during pregnancy has been controversial because of the risk of congenital abnormalities. Myles et al. (2013) have conducted a systematic review of SSRIs in pregnancy (the eighth such review according to Galbally (2013)), which concludes that there is a small, but significant risk of congenital abnormalities associated with fluoxetine and paroxetine and suggests clinicians should be cautious prescribing these agents to women of childbearing age. Galbally (2013), in her commentary, points out that we need to think beyond structural abnormalities to consider possible neurodevelopmental effects following SSRI foetal exposure.
For some time, we have regarded psychotropic medications as being ‘disease’-specific and this is reflected in their descriptors; for example, antipsychotics, antidepressants or mood stabilisers. We tend to think this way based upon the neurotransmitters involved; for example, antipsychotics have their basis in blocking dopamine. However, there may be alternative ways of thinking about the mechanism of action of psychotropic drugs. Atigari and Healy (2013) point out that clozapine and lithium have pro-convulsant properties that may underpin their therapeutic effects. It is important for us to think beyond the monoamine models of psychiatric disease and consider alternative mechanisms, such as the use of folate, as discussed in an informative paper by Baek et al. (2013). They discuss folate’s role as an essential cofactor in the methylation reactions essential for monoamine synthesis and implications of genetic variations in folate metabolism.
The mental health and well-being of individuals living in rural communities is an important public health issue. The Australian Rural Mental Health Study (ARMHS) will become a rich resource informing us about rural mental health issues. This is a large epidemiological study surveying rural participants over a 3-year period. In this issue of the ANZJP, Handley et al. (2013) report on suicidal ideation and its fluctuations over time. The rate of suicidal ideation is high, with 8.1% reporting suicidal ideation at one point over the study. They note that suicidal ideation fluctuates over time and is associated with psychological distress, neuroticism and social support, and, to some extent, with unemployment. Clearly these are important areas for public health interventions to reduce distress in rural communities.
Attitudes and beliefs are the focus of a paper by Youssef and Deane who conducted a study on the attitudes of Arabic-speaking clerics regarding mental illness (Youssef and Deane, 2013). This illuminating study gives us further insights into the attitudes of both Christian and Muslim clerics towards mental illness and its appropriate treatment. This paper will provide important insights to assist those working with Arabic-speaking patients and their community.
We are all too familiar with adolescents spending considerable time on their mobile phones, the Internet or playing video games. King et al. (2013) conducted a survey among adolescent youth in South Australia to examine the extent of pathological technology usage. They found high rates of pathological Internet usage and playing video games. Surprisingly, while males were overrepresented in pathological video gaming, the rates did not differ between males and females for pathological Internet use. They also noted that adolescents with pathological Internet usage appeared to be at greater risk of axis I comorbidity than those with pathological video gaming on its own. Internet use disorder is in the appendix in DSM-5 for consideration as a new diagnostic entity. Careful thought will be required regarding this: do we want to pathologise these behaviours or are they sufficiently disabling to be considered a disorder? Perhaps it is also time to have a rethink about adolescents’ use of the Internet and social media.