Putting the CART before the horse?

This month’s issue opens with an acknowledgement by Sachdev (this issue), of the leading role of Australian researchers in dementia and cognition research, with this theme continued in the debate regarding cognitive remediation, highlighted in this issue. Noting that mood disorders (and for that matter many other psychiatric disorders) carry a burden of cognitive and executive functioning deficits that contribute to impairment and impair recovery, Porter and colleagues (this issue) debate the potential role for cognitive and affective remediation training (CART). CART entails exercising a range of cognitive capacities, which should theoretically generalise to cognitive functioning, and hence social and functional capacity. They, however, note that this promise remains to be empirically determined. They conclude with recommendations that include incorporating mechanisms into treatment, tailoring treatments to individuals and they discuss strategies for disseminating CART. Baune (this issue) extends this debate, noting that cognitive and affective remediation would need to target specific brain networks, emphasising the need to demonstrate a measurable change in underlying brain networks predicated on neurocircuitry-based target selection. Baune also cautions that the jury remains out as to whether cognitive training indeed leads to generalised cognitive benefits or improvements in key psychosocial domains, additionally cautioning about the complexity of linking specific cognitive function to underlying neural networks.

The physical health burden of people with psychotic illnesses has long been recognised, leading to distressing and disproportionate morbidity and mortality among this population. Recent data suggest that people with schizophrenia lose an average of 14.5 years of life, with this truncation affecting men more so than women (Hjorthøj et al., 2017). A critical element in addressing this is accurate documentation of health status and risk factors allied to recommendations for screening, monitoring and management of common medical comorbidities. Lambert and colleagues (this issue) use the Delphi method to produce a consensus statement to guide clinicians in managing this issue. The consensus statement includes detailed and clear checklists for use at initial screening, medical assessment and follow-up assessments. If followed, and this is a big if, they should make a significant contribution to the neglected health needs of this population.

Similar concerns surround smoking. While smoking is a widely understood risk factor for multiple medical illnesses, its role as a risk factor in its own right for the genesis and prognosis of psychiatric disorders is only recently beginning to be understood (Pasco et al., 2008). Following the theme of the paper by Lambert (this issue), focussing on reduction of medical comorbidity, targeting smoking cessation is a critical component of an integrated strategy capable of improving both physical and mental health outcomes. A recent meta-analysis has emphasised that smoking cessation is associated with improved mental health outcomes, reinforcing the importance of this imperative (Taylor et al., 2014). Fortunately, the profession has moved away from a tacit acceptance of smoking to a much more interventionist stance. The paper by Metse and colleagues (this issue), showing in a large randomised controlled trial that an inpatient intervention for smoking cessation was effective in increasing both 7-day and 6-month quitting behaviours, is thus a major and important advance for the field that merits wide translation into clinical practice and widespread adoption.

In an interesting systematic review of instruments used to assess functioning, Burgess and colleagues (this issue) attempt to separate the wheat from the chaff using this methodology and ended up with a recommendation of five preferred instruments. This approach is both welcome and long overdue. For many major health domains, there is a superfluity of instruments to choose between and researchers and clinicians recurrently and individually go through the exercise of deciding what instruments are better for a given purpose. Having expert methodological and psychometric criteria to guide instrument choice is a welcome contribution that should both save time and increase study quality. It would not be hard to imagine the utility of this methodology adapted to the large number of domains where a plethora of competing instruments exists.

The role of immune activation in a wide range of psychiatric disorders is now a given. However, what is lacking is clarity about what simple available and cheap markers might be useful to guide clinical practice and/or research. Köhler and colleagues (this issue) describe an analysis from two large effectiveness studies where they found a correlation between white cell count (even within the normal range) and the number of markers of disease severity (Nierenberg et al., 2009, 2014). Curiously, this effect was most marked in males and only weakly associated among females. This interesting finding supports the existing inflammatory hypothesis using a far simpler and more accessible marker than peripheral blood cytokines, and successful replication in other datasets would reinforce the veracity of the finding.

This issue of Australian & New Zealand Journal of Psychiatry (ANZJP) concludes with a couple of papers looking at risk factors for course and outcome of psychiatric disorders. Etain and colleagues (this issue) explore the relationship between childhood attention deficit disorder and bipolar disorder, finding that attention deficits in childhood are associated with more severe bipolar disorder later in adulthood. In a similar vein, Mulraney and colleagues (this issue) explored the antecedents of irritability in a longitudinal cohort of children with attention deficit disorder, finding that externalising symptoms at age 10 are associated with greater adolescent irritability. Interestingly, irritability was also associated with a variety of adverse outcomes from symptom severity, emotional and social functioning and care-giver burden among their parents.