Abstract
As many psychiatric journals become dominated by large pharmaceutical studies and neuroimaging, several papers in this month’s ANZJP focus on what are comparatively neglected areas of psychiatric research and practice.
In her Viewpoint, Kulkarni (2014) makes a strong argument that women’s mental health merits separate research that specifically targets the needs of women because these are relatively neglected in clinical practice. Kulkarni suggests that particular areas that are under researched, under recognised, or even misclassified, include peri-menopausal mood disorders and borderline personality disorder. She suggests that the latter might usefully be re-classified as a chronic stress disorder, thereby reducing stigma and perhaps placing it more accurately within diagnostic systems. Kulkarni also points to the over-representation amongst women of the diagnosis of bipolar II disorder and argues that female patients with borderline personality disorder may be misdiagnosed as having bipolar disorder. This diagnosis potentially leads to the prescription of mood stabilisers, antidepressants and, of course, atypical antipsychotics.
The argument that Kulkarni puts forward in this regard is re-iterated in the Editorial by Malhi and Porter (2014), which discusses the issue of bipolar disorder being a ‘preferred’ diagnosis, perhaps particularly where borderline personality disorder is the alternative. This Editorial also addresses the further expansion of the diagnosis of bipolar II disorder and the resultant potential for significant overuse of pharmaceuticals.
In bipolar disorder, there have been many recent, large-scale studies, particularly of atypical antipsychotics in depression and mania. However, despite the increasing use of these agents, some patients continue to experience prolonged episodes of mania and most experience considerable inter-episode symptoms including insomnia and anxiety. This month’s two Review articles address this issue. The first, a Key Review by Baek et al. (2014), focuses on the treatment of residual symptoms with herbal agents, something that is particularly pertinent given their widespread and often undisclosed use. Baek et al. review the efficacy of such agents for anxiety and insomnia, their possible adverse effects and potential drug interactions. This Key Review provides a rigorous and concise overview of the likely effects of herbal agents, which is likely to prove invaluable to clinicians treating bipolar disorder.
The second of this month’s Reviews, from Crowe and Porter (2014), considers what else, other than just awaiting a drug response, can be done while patients are hospitalised with mania. Many clinicians have experienced busy inpatient units in which disturbed manic patients are simply contained while waiting for a response to pharmacotherapy. Crowe and Porter suggest that additional therapies, such as simple chrono-therapeutic measures, may enhance treatment response. Further research into this area is needed to produce models of practice for inpatient units that enhance response to pharmacotherapy.
Research into the effects of natural disasters is limited by a number of factors, including the involvement of local researchers in the disaster and the difficulty of gaining funding and ethical approval for studies in time to study acute issues. Last month two Viewpoints (Fergusson and Boden, 2014; McFarlane and Van Hoof, 2014) discussed such research, and this month Bryant (2014), in reply, further reviews some of the aspects that make studies in this area so difficult including, in particular, low rates of recruitment into studies and the ensuing problem of selective recruitment. These factors make it difficult to examine either the rates of mental health problems or, indeed, their predictors.
In Christchurch, following the devastating earthquake series, two studies have serendipitously addressed some of these issues by being in progress prior to the event. The first of these, Spittlehouse et al. (2014), reports on a cohort study of 50-year-old people that began just before the quakes, with recruitment continuing during the quake series. This study provides insight into the mental health of people living through this sequence and compares measures of physical and mental health conducted in the study with results taken from an earlier study conducted prior to the quakes. Not surprisingly, with many people in Christchurch displaced and under various pressures during the quake sequence, recruitment was 64% and necessarily selective, to some extent. However, this compares with rates discussed by Bryant (2014) of 16% in his study of the Black Saturday fires.
In the second study, a birth cohort of participants has been followed up for 30 years. At the time of the quakes, approximately half were living in Christchurch and half elsewhere. The response rate in the interviews conducted after the earthquakes was 78%. These results are published elsewhere (Fergusson et al., 2014a). However, in this issue, Fergusson et al. (2014b) present data from the same study examining the psychosocial effects of unemployment. The high response rate at multiple time points (in this paper data from assessments at 18, 21, 25 and 30 years is reported) makes it possible to begin to examine causation in a meaningful way and to conclude that exposure to unemployment does have ‘small but pervasive effects on psychosocial adjustment in adolescence and young adulthood’.
Finally, Meadows et al. (2014) engage in the much neglected area of translational clinical trials. Large pharmaceutical trials are almost always funded by the pharmaceutical industry, while psychotherapy trials are conducted by originators of the therapy being examined. Results from these trials do not always translate into clinical practice. In the trial of Meadows et al., a pragmatic design was used in real clinical practice. Exclusion criteria were minimised and the trial studied patients with three or more episodes of depression, regardless of underlying diagnosis (unipolar or bipolar). Interestingly, in the context of the previous discussion on bipolar II disorder, no-one with this diagnosis was recruited (21 patients had bipolar I disorder). The study showed a large reduction in the number of days with major depression, in the 2-year period of the study, in the group that received mindfulness-based cognitive therapy.
These and other papers in this month’s issue represent a collection of data, reviews and viewpoints that explore areas of psychiatry that seem to receive scant attention in many psychiatric journals, reflecting ANZJP’s continued commitment to highlight and discuss these sometimes neglected areas of psychiatric practice and research.