Mental health for all Australians

This issue returns to the increasingly topical and complex issue of Aboriginal health. Shepherd and Phillips (this issue) discuss the manifold and largely unmet health needs of Aboriginal people in custody, complicated by the need to deliver care to people with intense distrust of the system predicated on experience of social injustice. They argue that incorporation of Aboriginal worldviews into program development and delivery is essential, and that ‘a top down commitment to diversity and reflexivity’ is needed to effectively address this major health need. Following this theme, the relevance of western constructs of behaviour and disease is discussed in terms of attention deficit hyperactivity disorder (ADHD) occurring in Aboriginal and Torres Strait Islander people (Loh et al., this issue). This is particularly salient given research suggesting higher rates of ADHD in Aboriginal than non-Aboriginal children. While parents endorsed that hyperactive behaviour was not desirable, it was framed through the cultural lens of ‘respect’, acknowledging that kids still need to live active lives, and unsurprisingly was not congruent with the perceived need to medicate and was associated with negative perceptions of treatment. Such cultural understanding is essential to appropriately tailor interventions to better engage and retain people in treatment.

Turning to an altogether different type of engagement – while we now appreciate that network connectivity, or the way that information is transferred between different brain regions, plays a critical role in the aetiology and phenomenology of psychiatric disorders, somewhat less well understood is the extent to which psychological interventions can hope to alter these networks. Arguably, the neural impact of psychological interventions is ‘purer’ and ultimately more informative with respect to underpinning neurobiology than the equivalent effects of pharmacotherapy, because of the absence of confounding drug effects, although specificity of action is not necessarily any greater. In particular, functional connectivity changes in the prefrontal-limbic circuit – such as reduced amygdala activity – have been shown to predict the outcome of psychotherapy (Mason et al., this issue).

While anorexia nervosa is an all too familiar problem and a relatively well-understood phenomenon, the male counterpart ‘bigorexia’, or muscle dysmorphia, a condition in which men consider themselves insufficiently muscular, is far less well understood. It was first noted among the users of anabolic steroids, and is thought to be related to body dysmorphic disorder. The question asked was whether muscle dysmorphia meets Blashfield’s criteria for formal classification as a diagnostic category (Celso Alves dos Santos Filho et al., this issue). The conclusion was no, predicated at least in part on the absence of adequate source data. A fall-back position suggested by the authors is that it should be listed among disorders requiring greater clarification of validity, although including it as a body image disorder was also debated. Making equally intriguing associations Phillipou and colleagues (this issue) raise the possibility that abnormalities in cerebral blood flow, glucose utilisation and mitochondrial energy generation form part of the pathophysiology of schizophrenia. Expounding further in this issue, Ma and colleagues (this issue) show a higher cerebral blood flow in anterior brain regions and a corresponding decrease in posterior brain regions, a finding seen exclusively in males. These data are broadly concordant with previous studies examining regional cerebral blood flow using blood-oxygen-level-dependent (BOLD) to model brain function. This understanding of the bioenergetics basis of a number of major psychiatric disorders has important translational consequences, including forming part of a potential treatment strategy.

Clinically, understanding risk factors is critical for treatment and prevention and in this context substance abuse, particularly alcohol, is a highly prevalent health issue. Simhandl and colleagues (this issue) prospectively explored the prevalence of alcohol use disorder in people with bipolar disorder and the influence on relapse risk. They found that, in keeping with the prevailing literature, the rates of alcohol use were very high and surprisingly, were higher in bipolar II than bipolar I disorder. Again but unsurprisingly, males had a higher predilection than females, and alcohol use disorders as a group were associated with a greater risk of recurrence of depression. This study and its findings highlight the importance of identification and management of risk factors in general, and of the desirability of integrated treatment paradigms that incorporate dual diagnosis strategies.

Turning from a neurochemical toxin to a social one – while it is abundantly known that bullying is also a risk factor for diverse mental health problems, the precise role of the type of bullying is less well understood. Interestingly, it seems that social exclusion is particularly noxious, linked to higher distress and poorer emotional wellbeing. Here, it is women that are more vulnerable and in females the spreading of rumours was linked to emotional distress (Thomas et al., this issue). This specific impact of bullying points to the potential value of preventive approaches, including school-wide programmes attempting to better target relational types of bullying such as social exclusion. Sticking with children, Levy and colleagues (this issue) highlight the importance of play therapy and provide some insights into this intervention by presenting two cases – that might prompt registrars to attempt to explore this approach as part of their training and supervision.

Switching to the opposite end of the age spectrum – while there is significant concern about both prescription rates and the efficacy of medications for elderly people with dementia, the parallel situation of medication use among elderly adults with intellectual disability is less well documented. Chitty and colleagues (this issue) explored prescription data among elderly people with an intellectual disability, and found that almost two thirds were on medication (mainly anticonvulsants and antipsychotics) and almost half were experiencing polypharmacy. While the needs of this population are heterogenous and substantive, the benefits of pharmacological therapy in this population are not well established. Many psychotropics carry significant known risks, and in the context of unknown benefits, despite the authors’ perception that the use of psychotropic medication is generally justified, and broadly concordant with guidelines for prescribing in intellectual disability, the necessity for cautious ongoing medication review in older people with intellectual disability is highlighted.

Finally, considering instances where medication is mandated by means of Community Treatment Orders (CTOs) – a mainstay of public mental health – thought to reduce the need for inpatient treatment by enhancing medication adherence which in turn reduces the risk of relapse and impact of morbidity and mortality, there is now emerging conflicting data that this is necessarily so. Indeed, as important as CTOs are to treatment, it is equally important how an epoch of involuntary care is ended. To this end, Vine and colleagues (this issue) suggest that a planned termination of a CTO by clinicians is associated with better outcomes than simple time-based expiry or unplanned discharge by a review board. They emphasise the importance of continuity of care and engagement with treating services, and controversially reinforce the primacy of clinical decision making in discharge planning over legal process in driving clinical outcomes – a point reinforced further by Kisley (this issue).

In aggregate, the papers in this issue, highlighting populations at greatest need particularly Aboriginal peoples, salient risk factors and operative pathoplastic pathways, and suggesting ways of optimising systems of care, go towards improving the mental health of all Australians – at least one goal that we can all agree upon.