Thought-provoking contributions in this month’s issue

This month’s issue contains a diverse range of contributions, with a few that are notably thought-provoking highlighted below.

The strong association between psychosis and tobacco use is well known, with the Survey of High Impact Psychosis finding a current smoking prevalence of 67% and a lifetime prevalence of 81% in people with psychotic disorders (Cooper et al., 2012). The conventional interpretation is that psychotic illness leads to tobacco use. However, McGrath et al. (this issue) report data from a large birth cohort followed up to 21 years of age, finding an association between age at first tobacco use and subsequent psychosis-related outcomes. They hypothesize that early tobacco use may contribute to the risk of developing psychosis-related outcomes. If confirmed, this hypothesis gives tobacco a status similar to cannabis as a risk factor for psychosis and adds further weight to public health efforts to eliminate smoking initiation in adolescents.

A different type of substance use risk is raised by Parsaik et al. (this issue). They report a meta-analysis of the association between hypnotic and anxiolytic (HA) medication use and mortality. With combined data from 2.35 million participants, they found a 43% increase in mortality. While causality is uncertain, given the possibility of confounding variables, the authors caution that ‘physicians should carefully consider the increased mortality risk while prescribing HA drugs’ and ‘patients should be informed about the increased association of mortality with HA use’. In light of these findings, it interesting that the Australian Bureau of Statistics (2016) recently released data that, in 2011, 4% of the population had at least one subsidized prescription filled for HA medication, peaking at 23% for women aged 75 years or over. If HA medications really do increase mortality, there could be some important public health impacts.

On a more philosophical note, Rosenman (this issue) discusses the uses of medical models in psychiatry and how they influence psychiatric thinking. He points out that a dominant medical model involves thinking of mental disorders as being alien processes affecting a host, much like an infectious disease. We therefore treat them using medications which are given labels like ‘antidepressant’ or ‘antipsychotic’, analogous with ‘antibiotic’, which are supposed to eliminate the alien process. However, Rosenman argues that other medical models are possible, including one based on auto-immune disease, where ‘It is not an alien process invading the body but the body’s own vital processes’ which are over-reacting. This model has very different implications for how we think about treatment. Although Rosenman does not mention it, another noteworthy medical model is the clinical staging model of McGorry et al. (2006), which is based on ideas from cancer staging and is one of the most cited articles ever published in this journal. This model leads to a developmental approach based on early intervention.

Finally, this month sees a continuation of the discussion about climate change and mental health. In a previous issue, Henderson and Mulder (2015) acknowledged the reality of climate change, but argued that the impact on mental health is unlikely to be great and that climate change could have positive effects on social capital. In a subsequent issue, Every-Palmer et al. (2016) argued that climate change is likely to lead to an increase in incidence of mental disorders and in demand for services, with the greatest impact being on disadvantaged populations. They called on psychiatrists to engage in greater advocacy for action on climate change. Now, Ticehurst (this issue) challenges the argument of Henderson and Mulder (2015) and points out that there are substantial data on the effects of heat waves on mortality. He predicts that older people with mental illness will be particularly affected by climate change.

I have no doubt our readers will be thoughtfully provoked by these and other contributions.