Abstract
In this month’s issue, I see a skyline of true scholarship lying comfortably alongside what is internationally topical. The material comes from far and wide, not just Australia and New Zealand, but also from India and both coasts of North America. The scholarship is to be seen in four powerful papers. Mulder and Frampton (2014) reach back some 120 years, involving some 14,000 patients, to ask if mood disorders have done better since antidepressants became available. Apparently not. The long-term outcome has not demonstrably changed, at least on the basis of their data and its analysis. The reader should have a good look at the way these authors formulate their questions and then adopt innovative methods to answer them. The second piece of exemplary scholarship is in the field of health economics. Neil et al. (2014) have set an international benchmark in studies of the cost of psychosis. Australia is unusual in having two excellent data sets on its psychotic members, obtained a decade apart, though admittedly excluding those treated by psychiatrists in private practice, by GPs or those not treated at all. Neil et al. have seized this opportunity to compare costs in 2000 and in 2010. There has been little overall change. But there has been significant redistribution with a drop in inpatient costs. Medication has, of course, risen sharply thanks to the atypicals, now standing at AU$2560 per person-year. The overwhelming cost, though, is a very human one: lost productivity due to disability, now costing almost AU$40,000 per person-year. This holds for the psychoses collectively, not just schizophrenia, so consider what it must be for the nation, even with the most conservative estimate of point prevalence. The third contribution of high scientific merit is from India’s National Institute of Mental Health and Neuroscience in Bangalore, which this year celebrates 60 years of postgraduate training. Recently in these pages, Harris and Boyce (2013) drew attention to the neglect of psychosocial treatments in the psychoses. Now Mehta et al. (2014) take the matter further in their innovative study of impaired parenting in people with schizophrenia. Their work prompts us to get a better grasp of theory of mind because the capacity to infer the intentions and beliefs of others – in this case of children – is where part of the psychotic parents’ disabilities lie. Although Mehta et al. concede that the association they have found is limited by being only cross-sectional, their findings provide a starting point for intervention, in the same way that treatment for strong expressed emotion was developed from a simple epidemiological observation (Brown et al., 1962). The fourth research contribution is on what happens to people who are released into the community after being found not guilty of an offence by reason of mental illness (Hayes et al., 2014). Encouragingly, they find that the current treatment and rehabilitation, together with administrative action by tribunals, prove to be effective in protecting the community.
Two papers touch on matters of much public concern. Scott et al. (2014) chillingly describe the expansion of bullying through teenagers’ use of the Internet. In light of a carefully thought out argument, they make firm recommendations on how bullying might be reduced. A second matter of social concern is the contemporary emphasis on food, as any television guide will attest. Pai et al. (2014) consider if one consequence, what is now being called food addiction, is a valid entity. What does that question mean? What indeed is a valid diagnosis, how would one know if it is valid and would it be useful? In this, readers would do well to look first at the classic paper by Kendell and Jablensky (2003) on the distinction between validity and utility of diagnosis, then try to decide for themselves. The issue of utility of diagnosis emerges again in the Commentary on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by Looi and Velakoulis (2014). They show good reason to be dissatisfied with the new map DSM-5 provides for the neurocognitive disorders.
Everyone is very conscious that DSM-5 has now been promulgated and is exported with vigour from the United States. But now Jorm and Reavley (2014) ask if the United States is unwittingly exporting something else: stigma about mental illness. Their argument is a model of clarity. Belief that the mentally ill are dangerous is more influenced by the media than by personal experience; Americans believe more than others that the mentally ill are dangerous; and America has higher rates of homicide than other industrialised countries. Meanwhile, media reports of homicide by mentally ill persons now have worldwide coverage, irrespective of where they take place. So the high homicide rate in America, especially its mass shootings, may have an adverse effect on stigma well beyond its own shores.