Trauma,treatment and temperament: From troubling times to troubled thinking

We seem to be living in times when natural disasters (most likely the result of climate change) and man-made disasters, especially arising from terrorism, are on the increase. At the time of writing, we are all coming to terms with the most recent terrorist attack at the Manchester Arena in which young people were targeted by a ‘suicide’ bomber while attending a pop concert. One reassuring thing coming from this most recent atrocity is that communities rally and reach out to each other following such events – the opposite of what the terrorists want.

We have known for a long time that disasters can have an adverse impact on mental health for some. Identifying those who have a diagnosable mental disorder and providing appropriate evidence-based interventions are clearly a priority in the post-disaster phase. Strategies to prevent disorders emerging among those who experience time-limited minor difficulties are also required. Here, universal interventions to enhance individual and community resilience and cohesion are recommended. But what of those who go on to develop sub-threshold and clinical conditions that can persist for many years and have an adverse impact on family and social functioning? Forbes et al. (this issue) in an Editorial discuss a new international initiative to provide interventions to this group. Following an international roundtable meeting, a consensus was formed regarding an optimal disaster recovery programme for those with ongoing adjustment problems following the disaster. The key elements of this programme are promoting healthy living, arousal and affect management, emotional processing, value-based behavioural activation, maintaining healthy relationships, and rumination and worry control. This structured manualised programme will be conducted by primary care workers as a short- to medium-term intervention and as part of a stepped care approach. We look forward to an evaluation of this much-needed intervention package.

Australian Defence Force (ADF) personnel are one group at particular risk of exposure to traumatic events, especially if they have been deployed to combat zones or peacekeeping missions. They have higher rates of lifetime mental illness, especially depression, posttraumatic stress disorder (PTSD) and alcohol use disorder, and higher levels of psychological distress according to a study conducted by Wade et al. (this issue). The ADF personnel, not unexpectedly, experience higher rates of deployment-related traumatic events compared to the general population; they also had higher rates of exposure to other traumatic events, such as accidents, disasters and/or trauma to someone close. They considered that the higher rates of lifetime disorders were attributable their deployment. Could the intervention programme suggested by Forbes et al. have helped to reduce this morbidity among the ADF personnel? That remains to be seen, but this is a group that would clearly benefit from effective interventions.

The aftermath of natural disasters can continue with the events that follow: injury or death of family members and friends, loss of housing, employment and social networks. These follow-on events can be distressing: a phenomenon named disruption distress. Both the disaster itself and disruption distress can lead to the onset of major depression. Bell and colleagues (this issue) used path analysis to examine the contributions of peri-traumatic stress and disruption distress to depression in participants of the Christchurch Health and Development Study who had been exposed to the Canterbury earthquake prior to the wave of interviews when they were 35 years old. The experience of peri-traumatic stress following exposure to the earthquakes had a direct impact on developing major depression, whereas the disruption distress did not have a direct link with major depression. Bell et al. provide an interesting discussion about this somewhat counterintuitive finding.

The ANZJP has published a series of updated clinical practice guidelines (CPGs) over the past couple of years. These CPGs sometimes fall short in their recommendations, and at other times, it is the implementation of the recommendations that falls short. The Mood Disorders CPG (Malhi et al., 2015) had only limited recommendations regarding management of patients with comorbid substance use, disorder and depression. Foulds and Lubman (this issue) point out that it is difficult to determine which disorder is primary, especially when alcohol or drug misuse is actively ongoing. They propose that an integrated psychotherapy, targeting substance misuse, mood and anxiety, should be the first first-line intervention with pharmacotherapy delayed until it is clear that the mood symptoms are persistent. Antidepressant medication, in this population, may induce side effects that may aggravate the unwanted effects of substance misuse, so caution should be exercised when administering them.

When clear recommendations are made in CPGs, all too often they are not implemented in routine clinical care. Nielssen et al. (this issue) note that many of the recommendations from the Royal Australian and New Zealand College of Psychiatrists (RANZCP) schizophrenia guidelines (Galletly et al., 2016) have not been implemented in routine practice, mainly as a result of inadequacy of the mental health ‘system’, rather than individual practitioners not wanting to provide the best treatments for their patients. They note gaps in our mental health services, such as transitioning from specialised early psychosis services to community services that do not offer a full range of interventions. Other necessary and essential interventions, ranging from supported housing, vocational rehabilitation, family therapy and cognitive therapy, are not routinely applied despite clear evidence of their effectiveness. If we want to improve patient outcomes, we need to advocate for these services to be routinely applied. While not directly related to the schizophrenia guidelines, the prescribing of antipsychotic medications for concession card holder raises some concerns. Kjosavik et al. (this issue) in their study noted that the majority of the long-term prescriptions come from general practitioners (GPs; not psychiatrists) and the high rates of prescriptions for quetiapine at doses that would not be effective for the treatment of psychosis.

Deliberate self-harm is a major risk factor for subsequent suicide. A key point from the deliberate self-harm CPG is to improve access to aftercare (Carter et al., 2016). This does not seem to be happening in routine care as close to 60% of those who self-harmed were not followed up by community mental health according to a study by Spittal et al. (this issue) that used linkage data from New South Wales. Alarmingly, patients who had not been in contact with community mental health services previously were less likely to be followed up.

One would think that high-quality communication skills would be absolutely necessary in the practice of psychiatry. Communication skills are considered to be necessary competencies in training programmes, yet little is done about evaluation of the effectiveness of training in communication skills according to a systematic review conducted by Ditton-Phare et al. (this issue). If we are to have the best communications skills training for our trainees, we need to be confident that training packages are feasible, effective and lead to better patient outcomes.

Recently, a patient told me he had discovered on the Internet that he could get a DNA test done to make sure he was being prescribed the correct antidepressant. He asked whether he should get one done. I am sure that many of you will have been asked similar questions, especially by the more health literate of your patients. Fortunately, Singh et al. (this issue) provide an interesting commentary on the issue of pharmacogenetic testing. There is not yet enough robust evidence to support routine pharmacogenetic testing, particularly for the standard psychotropic drug. They do point out there is good evidence for doing human leukocyte antigen (HLS) genotyping for Asian patients prior to starting them on carbamazepine as this could reduce the risk of Stevens–Johnson syndrome emerging. They argue, based on the extant literature, that it is premature to order pharmacogenetic testing. That is not to say that this may become a useful intervention in the future (and we hope that precision medicine might become a reality). In the meantime, based on recommendations made by the authors of this paper, I would suggest to my patients that their money would be better spent elsewhere.

I am sure that many of you will share the frustration of trying to get our patients with serious mental illness to quit smoking. We know how harmful it is to their general health, and it is a key contributor to shortened life expectancy. Armed with this knowledge, and the impact smoking has on their limited budget, they remain hooked on their cigarettes. Why not then get them to switch to e-cigarettes, argue Sharma et al. (this issue) in a provocative debate article. They enumerate the positive aspects of ‘clean’ nicotine (without the toxins found in the smoke) – alleviating the cravings of nicotine withdrawal and releasing dopamine and other neurotransmitters – and its positive impact on cognitive functioning by improving attention, working memory and sensory gating; it is also possible it may counter the negative symptoms of schizophrenia. If you want to do this, an important issue is the effect of switching to e-cigarettes on the metabolism of antipsychotics. E-cigarettes do not contain the polycyclic aromatic hydrocarbons found in cigarettes that induce the metabolism of clozapine and olanzapine. The doses of these medications will need to be reduced if your patient switches to e-cigarettes.

Bassett (this issue), in a Retrospective on the personality disorders, provides a concise history of how the concepts of personality disorders have changed over the past 50 years. One important change he comments on is how personality disorders have been included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) system. Initially, they were subordinate to the major psychiatric disorders in the multiaxial system as the Axis II disorders. But now, he notes favourably, they are included in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) on the same axis as the other mental disorders. He notes the comprehensive understanding of personality disorders and the use of taking a biopsychosocial model in their understanding.

In summary, this issue of the ANZJP has a series of papers that will be of theoretical and clinical interest to all psychiatrists. There are also papers that will be uncomfortable reading to those working on the implementation of guidelines.