From risk to remediation

This issue opens with the increasingly burning issue of smoking and psychosis (Large and MacCabe, this issue). While smoking is known to increase the risk for other psychiatric disorders, with depression the best evidenced, there is now evidence that smoking is simultaneously associated with an earlier age of disease onset, and there is a meta-analysis suggesting it is a risk factor for schizophrenia. Additionally, the risk for de-novo psychosis in those who are daily smokers is more than doubled, corroborating earlier findings (Bittoun et al., 2014), and justifying discussion. Given that psychiatry is unlikely to achieve large-scale complex preventive interventions like tobacco control solo, it adds voice to the argument for cross-silo integration of preventive approaches, in particular for integrating psychiatric endpoints in such preventive endeavours (Stockings et al., 2014).

Following the theme of risk and prevention, Stirling et al. (this issue) explored those individual and family domains that might play a role as risk or preventive factors in the development of depression among children and adolescents. School-aged children exposed to safety risks, those from ethnic minority backgrounds and who experienced discrimination were at risk for depressive symptoms. However, community level disadvantage was not a significant risk in this analysis, nor was community connectedness protective, although the authors note these may still operate through alternative pathways. Again, although knowledge of risk and protective pathways informs preventive interventions, these are likely to require integrated and cross-endpoint approaches to be realised in practice (Jorm, 2014).

Within a social context, stigma and discrimination are major issues for those with mental health problems and have a noxious effect by amplifying psychological distress, inhibiting social engagement, blocking help-seeking and reducing treatment adherence (Reavley et al., 2014). Reavley and Jorm (this issue) in a population-based national survey of people with mental health problems explored community experiences of discrimination, avoidance, as well as positive experiences of treatment. Reassuringly, positive treatment experiences were more commonly reported than discrimination or avoidance. Notably, friends and family were less likely to discriminate than to avoid the person. Because families, social networks and workplaces are simultaneously sources of support and discrimination, tools to assist formal and informal caregivers are needed (Berk and Berk, this issue). Such data inform and highlight the role of active educational and counter-stigma approaches (Thornicroft et al., 2014).

Nowhere is stigma more reinforced than in the association of mental illness and violence. Chang et al. (this issue) examined associations of violence among young people with psychosis, a particularly high risk group. They found that 9.4% of their cohort committed a violent act and 4.3% committed acts of serious violence over a follow-up period of 3 years. Risk of violence was associated with unemployment, involuntary treatment, male gender, poorer educational attainment, prior suicide attempt or violence, substance abuse and poorer baseline functioning. This information in conjunction with an understanding of the motivation for violence and the temporal relationship to florid psychopathology will aid better prediction and risk management of potential violence.

Winckel et al. (this issue) debate the thorny issue of balancing cost and access against safety in the context of shifting clozapine access into community and primary care settings. In an environment of prioritising integrated community-based care, they note that the current hospital-based prescribing arrangement risks leading to fragmented delivery of care between primary and secondary settings. Additionally, they highlight the importance of improving communication and fostering integrated management of psychiatric and physical comorbidities among multiple healthcare providers. In this context, the paper by Henry et al. (this issue) describing the profile of people referred to a French bipolar disorder expert centre network is noteworthy. They found that most referrals were not in the context of acute or resistant illness, instead reflecting chronic residual symptoms and functional impairment. Half were poorly adherent to medication, rates of medical and psychiatric comorbidity were high and there were high rates of lifestyle dysfunction such as sleep wake dysregulation, and obesity, with these factors associated with residual depression. Despite both studies addressing these issues from different angles, both argue for a more integrated approach to chronic disease management.

Jorm (this issue) provides a methodological overview of the Delphi expert consensus method in mental health research. There are many critical issues that are not appropriate for epidemiological or experimental methodologies. Additionally, many critical practice issues in medicine are not answered by the extant literature, and expert consensus is necessary to guide practice. The paper notes the foundation of the method, explores its utility in mental health research and, most importantly, provides a pragmatic users-guide to conducting a Delphi study.

Risks are inevitable in psychiatry while psychiatrists strive to provide remediation – but this is only possible with evidence and experience and this is the gap that ANZJP attempts to fill – perhaps more noticeably than usual in this particular issue of the Journal.