Abstract
The first few months of this year have brought reports of an increase in the unemployment rate and the planned closure of Australian car manufacturing and other industries, with the consequent loss of many jobs. The impact of unemployment, especially in socially disadvantaged areas, is well recognised, with increased rates of depression being reported. In this issue of the Journal, Milner et al. (2014) report the findings of a timely new population-based study of young adults. Using a case–control design, comparing cases of suicide and attempted suicide with a matched control group, they found close to a twofold increased risk of suicide and attempted suicide associated with involuntary job loss. Increased risk of suicide and attempted suicide were also associated with low socio-economic status and mental disorder. An accompanying commentary by Burns (2014) reviews the implications of these findings and our changing economic landscape.
Moving from the social factors that might perhaps influence the future need for services to the existing provision of those services, Raudino et al. (2014) use data from the Survey of High Impact Psychosis (SHIP) (which has provided us with valuable epidemiological information about the psychotic disorders) to examine the pattern of service utilisation for those currently, or previously, in contact with specialised mental health services or non-governmental organisations (NGOs). Raudino and colleagues found that service utilisation varied according to clinical acuity and socio-demographic factors. Frequent service users tended to be younger and with poor social supports. High levels of comorbid anxiety/phobic symptoms were predictors of the use of a range of services, highlighting the importance of providing anxiety management to those with psychotic disorders. Comorbid substance use did not predict service utilisation, but this was most likely the result of a ceiling effect. Raudino and colleagues note a decline in inpatient service use and an increase in community-based services since the first national survey of psychosis.
Data from the SHIP study was also used to generate the incidence and mortality of psychotic disorders; key factors in planning and evaluating services. The incident rate of psychosis, extrapolated from the prevalence data in this study, was 28 cases per 100,000 population and broadly consistent with other international studies. A worrying finding is the high mortality associated with psychosis, with a standardised mortality ratio of 5.5 reminding us of the physical health impact of these disorders.
Discussions of the bipolar spectrum can lead to very polarised views, ranging from an emphasis on the importance of the concept, to criticisms and suggestions of over-diagnosis. Perhaps this disagreement results in part from a lack of clarity about what is meant by the bipolar spectrum. In a ‘must read’ for trainee psychiatrists, Ghaemi and Dally (2014) provide a thoughtful review of the concept of the bipolar spectrum, correcting some common misconceptions and providing some clarity about its definition. Part of the problem is confusion about how bipolar disorder (and manic depressive illness) is conceptualised. Ghaemi and Dalley point out that when the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) introduced ‘bipolar disorder’ as a diagnostic category, it differed from that originally conceptualised by Kraepelin as manic depressive illness. The defining characteristic of bipolar disorder in DSM-III was polarity, building on Leonhard’s unipolar–bipolar dichotomy, not the episodic nature and longitudinal course that underpinned Kraepelin’s descriptions of manic depressive illness. DSM Bipolar disorder is a much narrower definition, and much of what was considered as manic depressive illness was put into the broad and heterogeneous major depressive disorder (i.e. recurrent depressive episodes and mixed states). Bipolar disorder became broader in DSM-IV, when hypomania was allowed for a diagnosis of bipolar II disorder, but mixed states and severe recurrent depression were still excluded. Ghaemi and Dalley discuss factors that have led to confusion between bipolar disorder and borderline personality disorder (an issue touched on in a number of ANZJP papers such as those by Bassett (2012) and Coulston et al. (2012)), first by pointing out the misuse of the term ‘disorder’ in the context of borderline personality. This is not a ‘disease of the body and brain’ in the same manner as manic depressive illness, and there are problems with considering ‘mood lability’ as a core feature of these conditions. Ghaemi and Dalley also emphasise the important, but often misunderstood, difference between aetiology (genetic and biological) for manic depressive illness and pathogenesis (the psychosocial factors that influence the course of illness and contribute to personality formation).
The diagnostic criteria of borderline personality disorder are the focus of a research article by Sellbom et al. (2014). When DSM-5 was being developed, there was a proposal to move away from the ‘arbitrary polythetic criterion approach’ entrenched in DSM-III and beyond and instead to take a dimensional approach in the diagnosis of personality disorders, taking into account both personality functioning and pathological personality traits. After much discussion, this dimensional approach was not adopted and the status quo prevailed; the alternative model for personality disorders was put into Section III of DSM-5. Sellbom and colleagues report on an innovative study comparing the standard DSM-5 criteria for borderline personality disorder with the Section III criteria, with participants completing questionnaires that indexed both criteria sets. Sellbom et al. used structural equation modelling to examine the relationship between the different sets of criteria and reported significant overlap between underlying constructs of borderline personality disorder identified by the differing systems. Five specific traits/facets from Section III accounted for much of the variance in the traditional diagnosis of borderline personality disorder: ‘depressivity’, ‘emotional lability’, ‘hostility’, ‘separation insecurity’ and ‘risk taking’. This demonstrates that a dimensional approach captures the essence of a categorical approach to personality disorders; thus, Section III of DSM-5 might prove to be an advance and a more coherent way of diagnosing personality disorders.
Continuing the discussion of DSM-5 and the upcoming International Classification of Diseases, 11th Revision (ICD-11), Allen Frances (2014) laments the failure to harmonise the two systems, leaving us with a ‘Tower of Babel’. In his explanation of some of the reasons for this, one noteworthy issue concerns the differing budgets available to the developers of each system: around US$25 million for the developers of DSM-5 and ‘almost no funding’ for ICD-11. Frances has high hopes, but low expectations, that ICD-11 will avoid making the same fundamental errors as DSM-5, such as turning ‘normal temper tantrums into Disruptive Mood Dysregulation Disorder’ or ‘expectable worry about physical symptoms into Somatic Symptom Disorder’.
The latter point is taken up by Starcevic (2014), who provides us with a detailed analysis of the removal of hypochondriasis from DSM-5 and its replacement with two new diagnostic categories: Somatic Symptom Disorder and Illness Anxiety Disorder. Starcevic poses the question of whether this is a premature end to the familiar concept of hypochondriasis. One reason for its removal was the pejorative or stigmatising implications associated with it (Starcevic, 2014). Reducing stigma is important, as individuals suffering from mental illness still experience significant discrimination, despite programs such as ‘Like Minds, Like Mine’ (developed in New Zealand) being put in place to reduce discrimination. This program, according to Thornicroft et al. (2014), has had a positive impact, with the levels of perceived and anticipated discrimination reducing over the previous 5 years. Interestingly, the highest levels of discrimination came from within families, highlighting the need for more work to be done on family interventions. One wonders about the impact of such discrimination on the course of illness.
In a thought-provoking article, Shipton and Shipton (2014) argue a case for synthetic cannabinoids (nabiximol, dronabinol and nabilone) to be made legally available, on a limited basis, to patients with specific pain conditions. They review evidence for the efficacy of cannabinoids in reducing neuropathic pain and a potential therapeutic role for them, of course balancing therapeutic benefits against potential adverse effects, particularly the psychological effects, such as paranoid thinking, agitation, dissociation and dysphoria, and the potential harmful effects of cannabis on the developing brain.
Finally, Looi et al. (2014) outline a new approach to researching neurodegenerative disease utilising functional magnetic resonance imaging to map connectivity between different brain regions. Such an approach may lead to greater insights into these diseases.