Abstract
Some readers may recall the classic episode of the TV series Yes Minister in which a new hospital is running beautifully, with 500 administrators but no patients – ‘First of all you have to sort out the smooth running of the hospital. Having patients around would be no help at all’. This month’s issue of the Journal opens with a fascinating article by an architect, Dr Jan Golembiewski, in which he argues that our current facilities for psychiatric care are designed around staff efficiency, routines and protocols, and do not provide person-centred care with a focus on recovery. He describes the ‘honey-pot syndrome’ with patients gathered around the nursing station, waiting like supplicants for a nurse to attend to their request. In contrast, some overseas hospitals do not have a nurses’ station, instead providing nurses with small, open workstations scattered through the day rooms.
Many factors other than patient welfare influence the design of new buildings – the budget, the size of the footprint available, occupational health and safety considerations, risk reduction, and, perhaps, a rather traditional view of what a psychiatric inpatient unit should look like. However, these considerations should not take priority over the purpose of the building. Our current ward environments may actually have an adverse effect on patient well-being; so, while we are trying to help people to recover and leave hospital, the setting where we are doing this may be counter-therapeutic. One small example has been the implementation of smoke-free policies. It’s hard to have much dignity and self-respect sitting on an upturned milk crate on a public footpath, whatever the weather, in order to have a cigarette.
Crowe et al. (this issue) also touch on these issues in their review of non-pharmacological strategies for the inpatient treatment of depression. Behavioural activation and exercise interventions can be effective, and it is far more pleasant to walk around a garden than a carpark; the old mental hospitals did at least have large grounds. Crowe et al. describe a study that showed that patients with non-psychotic depression allocated to rooms that received direct sunlight in the morning had a shorter duration of admission than those allocated to rooms that received sunlight in the evening. Given our knowledge about the benefits of light, especially in the morning, for people with depression, the design of new mental health buildings should maximise sunlight to bedrooms and communal areas, and provide attractive outdoor areas.
Since the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) arrived, researchers and commentators have been worrying away at it like a child with a new toy: turning it over, shaking it, and poking at it. Our next new toy, the revised International Classification of Diseases (ICD-11), will be available by 2017 (World Health Organization, 2015). The differences between DSM-IV, DSM-5 and ICD-10 classifications of psychosis are discussed by Kumari (this issue) and obviously the prevalence, and the nature, of the different psychotic disorders vary depending on the classification system. For example, DSM-5 and ICD-10 have a different criterion for the minimum duration of psychosis required to make the diagnosis of schizophrenia.
The concern that the DSM and ICD categories of mental illness do not represent valid disease entities has led the National Institute of Mental Health (NIMH) in the USA to develop the Research Domain Criteria (RDoC). Discussing RDoC, Jablensky and Waters (2014) quote Kraeplin: ‘It is now necessary to turn away from arranging illnesses in orderly, well defined groups and to set ourselves instead the undoubtedly higher and more satisfying goal of understanding their essential structure’.
RDoC has the long-term goal of developing a biologically based classification system, beginning by looking at specific neurobiological or behavioural domains or constructs (e.g. anxiety, attention, working memory) via various units of analysis (e.g. genetic, molecular, physiological, behavioural) regardless of the DSM-5 or ICD-10 diagnostic category. RDoC does not try to define a cut-off between normal and abnormal, instead examining the dimensional trajectory between normal and disturbed. Not everyone is happy with RDoC, with some doubting it will deliver anything clinically useful in the next decade (Frances, 2014).
Kleinman et al. (this issue) use the RDoC framework, taking distractibility as the unit of analysis, and evaluating distractibility in children and adolescents with bipolar disorder, ADHD, comorbid bipolar disorder and ADHD, and controls. They report that distractibility is not specific to a diagnostic group, but is associated with more severe functional impairment. Kleinman et al. comment that the new RDoC research approach highlights the heterogeneity within groups divided by categorical diagnoses, and contributes to a better understanding of why it has been so difficult to identify unique biological mechanisms for each psychiatric disorder.
Crome et al. (this issue) describe the prevalence of social anxiety disorder (SAD) in the Australian community. They find that the change from DSM-IV to DSM-5 has made little difference. There was a high rate of comorbidity between SAD and other mental health disorders, with low rates of treatment seeking, and Rapee et al. (this issue) provide a commentary on these findings.
In addition to Crowe’s article, this month’s issue of the Journal has two further papers on depression. Milgrom et al. (this issue) compared sertraline, cognitive behavioural therapy (CBT) and combined CBT/sertraline in women with postnatal depression. They found CBT to be more effective, and interestingly there was no advantage to combining CBT and medication. Paige et al. (this issue) looked at antidepressant use in Australians aged 45 years and older, and found that antidepressant users were, in general, a disadvantaged group. They were more likely to be female, older, poorly educated, and in poor physical health. Antidepressant users also had more psychological distress (despite the antidepressants), and were more likely to be taking low-dose antipsychotics, and more than 10 medications in total.
There are a couple of articles about schizophrenia this month. Lyu et al. (this issue), based in China, have been able to undertake MRI scans of 52 drug-naïve people with first-episode schizophrenia (FES), 45 unaffected siblings and 59 controls. These are large numbers for this type of study – persuading young people who are psychotic and unmedicated to lie still in an MRI scanner is not easy. Lyu et al. found specific white matter deficits in the FES patients and their siblings, but not the controls, in regions associated with cognitive processes such as executive function, semantic processing and verbal fluency. These abnormalities may reflect a common genetic vulnerability to schizophrenia. Heering et al. (this issue) take a more clinical perspective, finding that current criteria for remission from schizophrenia do seem to be valid. Encouragingly, over a follow-up period averaging 3.3 years, quality of life increased for all patients, even those not in remission at either baseline or follow-up. Heering et al. attribute this to a growing adaptation to the illness.
Finally, Keightly et al. (this issue) review the relatively new field of gut–brain interactions. They make the point that the gut contains microbiota that excrete various substances, some of which are psychoactive. There is two-way communication between the gut and the brain via the bloodstream, nervous systems, and hormonal systems. So how does the gut influence mental health? Besides the obvious associations between functional gastrointestinal disorders and anxiety and depression, animal studies suggest that changes in gut bacteria are associated with changes in behaviour, and that a probiotic strain of bacteria may have a protective effect against early psychological trauma! It would appear that a glimmer of light can be found in even the darkest of places.