Weighty matters

The 50-year Retrospectives in the Journal show where we stand today. Sometimes, real advances have been achieved. But it does no harm to recognise where the going has proved hard or even impassable. We need to ask what has led to success and what has impeded progress where the situation is little better now. In both health services and research, we have made an outstanding contribution internationally. Note that the composition of who ‘we’ are is changing. In his Commentary, Jorm (this issue) points out that in research, the work is no longer coming almost entirely from male psychiatrists as he noted in early issues of the Journal. Readers would do well to take aboard what Jorm is saying. Other disciplines are needed now, with the participation of able people with a very different academic training. For them, research is the main part of the working week, with none of their time accorded to face-to-face contact with patients, clients or consumers and their families. In research, clinical practice and the media, it seems to this writer that the word ‘psychiatry’ is increasingly being replaced by ‘mental health’. One even hears now of ‘mental health disorders’. This change has already happened to what was the Australasian Society for Psychiatric Research, now the Society for Mental Health Research. The expression ‘mental health’ is becoming increasingly salient internationally. The prominence of anorexia nervosa (AN) in this issue is both welcome and appropriate. In her Retrospective, Phillipa Hay (this issue), herself an internationally recognised contributor in the field, points out that in research and treatment, the contributions of Australian and New Zealand psychiatrists have been seminal. It was a pleasure to be reminded of Hilda Bruch’s work, with her early articulation of the three dominant features of this severely disabling disorder. Few registrars have ever heard of her, so here is where a Retrospective can help ensure the survival of original thinking by our forebears. Hay points out that work on AN and obesity has drifted apart, despite their close connection and public health importance. Kirk et al. (this issue) describe what is sure to prove a very wise investment towards understanding the genetic origins of AN. This is the Australasian contribution of close to 4000 persons with AN. With other input from the United States, Sweden and Denmark, the consortium will have DNA from over 13,000 individuals. Such large numbers are statistically necessary for genome-wide association studies (GWAS) to identify the genes involved. One by-product from the local sample is the striking finding that only one half of the individuals with a body mass index (BMI) of ≤18 kg/m² were under medical care. Highly relevant for intervention strategies is the pattern that emerges for the age of onset in weight-control behaviours. The dimensional nature of much psychiatric morbidity, and certainly the eating disorders, once again becomes clear in the study by Phillipou et al. (this issue). They have looked at the grounds for seeing people with AN as having overvalued ideas as a central symptom. They find that some do have these, but for others the ideas are delusions, and not just about their body shape. This needs to be brought out in the diagnostic criteria. Body dysmorphic disorder is characterised by symptoms, including delusions, closely allied to AN. Schneider et al. (this issue) have obtained data from a sample of high school students to show that self-reported symptoms of this disorder are usually accompanied by anxiety, depression and obsessional ideas. So there are usually symptoms in many domains, if one knows to look for these in the examination.

In another Debate, Newton et al. (this issue) take us to a topic of core concern in our public hospitals. Is serious harm unavoidable? They set out three indisputable requirements for patients and staff: no person should be raped, no person should be assaulted and no person should die by their own hand. Is each of these truly achievable? The authors point to where some action might help. A starting point is the unexplained variation that occurs between services in three key indicators of their performance. Our ultimate aim is to have a zero probability of serious harm in our hospitals. The diminishing probability of an adverse event is an asymptote, the value dropping towards zero but never actually reaching it. The latter is reality. But by assertively changing conditions in our hospitals, can we at least move a lot further towards zero? The authors’ final paragraph carries their recommendation for achieving this.

Treating schizophrenia, a horrible disease, is indisputably one of psychiatry’s most important commitments. The recent paper by Catts and O’Toole (2016) has stimulated much interest, which we enthusiastically welcome. Jayaram et al. (this issue) set out some of the fundamental questions, thereby making the real agenda clearer. Is schizophrenia a progressive disease? Does relapse contribute to treatment resistance? Is relapse associated with neurobiological change? Do antipsychotics cause changes in grey matter? On the same agenda, Stroup and Lieberman (this issue) give a useful summary of how to work towards best practice when treating first episode cases. They look at the place for depot medication or clozapine in those who do not improve. For those fortunate patients who make some recovery, Killackey (this issue) considers what options there are for avoiding relapse. This includes the difficult issue of dose reduction or discontinuation. Most importantly, he invites us to rethink what recovery means, and to whom?

In research, it is not always necessary to obtain fresh data, invariably a laboursome, costly and challenging task. Invaluable information, which may exist not only in the health domain, can lie dormant until someone has the initiative to use it creatively. This particularly applies when bodies of personally de-identified data can be linked, when technology and ethics can both allow. In an exceptionally able piece of work, Papalia et al. (this issue) have achieved a finer-grained analysis of what happens to children who have been sexually abused. In complete contrast to the standard practice of using self-reported data, they identified 2759 cases from forensic records in Victoria. The records included the age at which the abuse took place, gender, whether it was penetrative or not and, for some, other important information on the circumstances. It is then that the study takes on a real sparkle. They linked this to a matched sample from the Victorian Electoral Roll, but also with three other data banks: Victoria’s celebrated Psychiatric Case Register and its successor, the Victorian Police criminal records database and the State records for fatal self-harm including drug overdose. Readers can be assured of the ethical acceptability by reference to their paper. The findings are striking. More than half of the sexually abused children had one or more of the following in their later years: further serious adversity, contact with mental health services, further victimisation, offending by themselves or fatal self-harm, all of this with a dose–response association. This finding makes targeted intervention all the more needed. But note the inverse. Half of the sample did not have any of these adverse outcomes. It would be invaluable for prevention to know what has protected them.

Attention has started to be given to the relevance of immunology in the causes of some psychiatric disorders. Could it be that depressive states and tissue inflammation are related? Even more boldly, could cognitive behavioural therapy (CBT) reduce inflammation? These are unusual ideas, but they have now been examined. In his Review, Lopresti (this issue) has looked for evidence in the literature. It will intrigue readers to look at what he finds and then perhaps speculate on how any effect, in either direction, could be biologically plausible. For this writer, it is much too early to say, but one could yet be surprised. Surprise in the practice of medicine is one of its delights.