ANZJP This Month

The time has come, the Walrus said, to talk of many things: Of shoes and ships and sealing wax, of cabbages and kings

From: The Walrus and The Carpenter, Lewis Carroll

This month’s issue opens with two debates. First, Rucklidge opens with the intriguing question as to whether nutrients could treat mental illness (Rucklidge et al., this issue). With the recent accumulation of evidence suggesting that nutrition plays a significant role in risk for diverse psychiatric disorders, this question has moved from the fringes to the mainstream. The question is particularly germane, given that across medicine, there is a well-worn path first suggesting that an exposure leads to risk for a disorder, and then interventional studies struggling to translate this into a viable therapeutic strategy. Nevertheless, given the contribution of nutrition to a multitude of non-communicable disorders, many of which are commonly co-morbid with psychiatric disorders, this is still a most promising area of research. Notably, this area has latterly expanded to incorporate the role of the gut microbiome in brain function (Dash et al., 2015), opening the door tofurther intervention strategies. Thesecond debate asks the question of who is best to lead health services, professional managers or doctors. There has been a substantial shift in recent years away from clinical and academic managers towards professional managers. Goodall and colleagues (this issue) compellingly argue that expert clinical leaders have distinct advantages in leadership. They first note that managerial and leadership skills need to be taught. They then argue that the advantages that physician leaders have include credibility as part of the discipline being led and an inherent understanding of the cultures and motivations of their colleagues. They also argue that outstanding leaders are more likely to attract and retain outstanding professionals and lead by example.

Black and colleagues (this issue) aim to review the prevalence of psychiatric disorders among the indigenous population. This is of particular importance given the substantially higher rates of many chronic disorders, lower life expectancy and higher rates of social and environmental risk factors. Unsurprisingly, limited data and methodological inconsistencies notwithstanding, very high rates of prevalence were found, particularly alcohol abuse and depression. Such data are necessary to form a coordinated policy to reduce the burden of disease in this most disadvantaged group. Veerman and colleagues (this issue) highlight the workplace burden of depression and propose a cost-effective intervention. While it is well understood that depression imposes the largest burden of disability, it is less well appreciated that the bulk of the indirect costs of depression accrue to employers through absenteeism and presenteeism (Goetzel et al., 2004). They conducted an epidemiological and economic modelling exercise to determine the health economic implications of an efficacious group therapy programme and found that preventing depression will not only aid the individual but would have direct economic benefits, first to employers but also to government through taxes and support payments.

Another area of substantive public health importance that has only recently emerged is the dual impact of both depression and antidepressant therapy on bone health. Both of these have profound potential deleterious impacts on bone mineral density with magnitudes of effect equal to or greater than known risk factors for osteoporosis (Williams et al., 2009). Given that osteoporosis evolves over the lifespan and that antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), have only been available for a couple of decades, the true implications of this are yet to emerge. Rauma and colleagues (this issue) used quantitative ultrasound to measure bone mineral quality. This screening method has substantial theoretical advantages lacking ionising radiation and being of far lower cost. They confirmed that antidepressant use impaired bone quality and suggested that ultrasound might be a pragmatic screening tool for clinical use.

Some of the most debilitating consequences of a psychotic illness are social and functional impairment. Consequently, it is of considerable importance whether this is amenable to intervention. Minor and colleagues (this issue) explored how the impact of 6 months of treatment in a rehabilitation programme impacted these parameters. They found large improvement in role functioning and social functioning. They also found that pre-morbid adjustment in adolescence was predictive of social and role functioning change, concluding that randomised trials to verify these encouraging naturalistic findings are warranted.

Psychotherapy is of established efficacy in bipolar disorder; however, access to and participation in psychotherapy are not uniform, and the factors that drive people to select psychotherapy as a treatment modality are not well established (Lauder et al., 2010). Utilising an existing dataset, Sylvia and colleagues (this issue) found that psychotherapy users were more likely to have a higher level of education, an anxiety disorder, high suicide risk and high medication side-effect burden. There were no differences between users and non-users of psychotherapy in illness severity, bipolar symptoms or quality of life; however, given that the psychotherapy group might have been more ill, this in itself is an interesting finding. Worryingly, in this sample, less than one-third of participants utilised psychotherapy, suggesting that it is an underutilised option in this population.