Social upheaval and lifestyle matters

The social environment and lifestyle are increasingly being recognised as important factors affecting mental health – possibly more so when individuals are confronted with social and economic changes such as with urbanisation. The impact of urbanisation on mental health is clearly demonstrated in a study of a small ethnic group in China. Yang et al. (this issue) conducted a longitudinal study from 1979 to 2009 charting the changes that have occurred in association with the urbanisation of the Jino people (a Chinese ethnic minority group). Overall, urbanisation was not good for the Jino people; there were increases in the divorce rate, criminal activity and gambling. The prevalence of the more biologically determined disorders, schizophrenia and mental retardation did not change significantly over the 30-year study, although the outcomes for those with schizophrenia got worse. The prevalence of mental disorders that are more associated with socio-economic factors increased; the 1-month prevalence of depression significantly increased from 0.15% in 1999 to 3.63% in 2009. Alcohol-related disorders increased. Alcohol had previously been reserved for festive occasions, but with urbanisation this changed and the per capita alcohol consumption markedly increased along with a significant increase in the 1-month prevalence of alcohol dependence (from 0.67% to 15.93%) and, alarmingly, the prevalence of Korsakov’s psychosis rose from 0.3% to 4.83%. Unsurprisingly, the suicide rate also increased up to 30.16/100,000, a consequence of deteriorating family relationships, chronic illness and alcohol-related suicides. These sobering findings underscore the importance of socio-economic factors in the genesis of mental disorder and the impact that urbanisation has upon communities.

One aspect of our modern way of life has been how our diet has changed, with fast food trumping healthy eating and obesity on the increase. The problem is that an unhealthy diet is a risk factor to developing depression as demonstrated in a study by Dipnall et al. (this issue). They made use of sophisticated statistical modelling and machine learning, on data from the National Health and Nutrition Examination Study, to develop a risk model for depression. A poor diet stood out above the other lifestyle and environmental factors as being significantly associated with depression (the more familiar psychosocial risk factors were not part of this dataset). Of course, the other consequence of poor diet has been the obesity epidemic. We sometimes forget the distress that some obese individuals experience; they carry with them significant comorbidities (Griffiths et al., this issue; Larkin et al., this issue). Over and above this, some will experience significant, and distressing, body dissatisfaction as noted by Larkin et al. They observe that Diagnostic and Statistical Manual of Mental Disorders (DSM) does not categorise individuals with significant distress associated with obesity (nor, indeed, is obesity per se considered a mental disorder). They propose a new category of ‘Obesity Dysmorphia’, pointing out similarities between the body dissatisfaction found among some obese individuals with that found with Body Dysmorphic Disorder (BDD), in particular the harmful behaviours associated with it such as body sculpting. An advantage of this diagnosis is that it would be a driver to the development of more effective interventions. Griffiths et al. agree that there is significant distress and comorbidity associated with obesity, but disagree with adapting the BDD criteria; while both conditions are associated with distress associated with body image, those with obesity do not fulfil the key criterion of being preoccupied with their body image.

We have all, at times, become frustrated with trying to encourage our patients suffering from serious mental disorders to quit smoking. What is the best strategy to use? Will guidelines be of value in helping us provide quitting strategies? Fortunately, Sharma et al. (this issue) have critically appraised quit smoking guidelines and, while there is room for improvement in having good evidence-based recommendations, their review does highlight key recommendations and point us to the better-quality guidelines to use.

The Christchurch earthquakes have provided us with some important information on the impact of natural disasters; in this issue of the Australian & New Zealand Journal of Psychiatry (ANZJP), Beaglehole et al. examine the impact of the earthquakes on patients attending mental health services making use of the routinely collected Health of the Nation Outcome Scale (HoNOS) data. Admission scores, following the earthquakes, were significantly higher when compared to other District Health Boards suggesting that patients experienced significant distress following this natural disaster and indicates the need for mental health services to plan for such an eventuality. Traumatic events, be they natural or arising from human behaviour, can have long-term repercussions, particularly posttraumatic stress disorder (PTSD) and even suicidal behaviour. In this month’s ANZJP, Afzali et al. tease out the relationship between type of trauma, PTSD symptoms and suicidal ideation using data from the National Survey of Mental Health and Wellbeing. While the number of traumatic events is important, the type of trauma, especially sexual and interpersonal violence are most strongly linked with suicidal ideation. Emotional numbing and re-experiencing the trauma, perhaps emphasising for the individual a sense of thwarted belongingness and perceived burdensomeness, were also strongly linked with suicidal ideation along with major depression. When patients present following these traumatic events and have this cluster of symptoms, we should be vigilant to the increased risk.

The pharmacological management of psychiatric disorders has to take into account the impact of any medications on the developing foetus and so accurate diagnosis is essential to determine whether medications are required (Boyce et al., this issue). Hitherto, the main concern has been on teratogenic effects of psychotropic medications, but there is now more emphasis on the impact of medications on the developing brain. This was brought to the fore with the recognition that the children exposed to sodium valproate had significant intellectual impairment (Meador et al., 2009). But what about other mood stabilisers that may be essential to prevent relapse? Haskey and Galbally (this issue) have conducted a systematic review of the impact of mood stabilisers (lithium, anticonvulsant mood stabilisers and second-generation antipsychotics) on child developmental outcomes. While the results of this review are somewhat reassuring (other than for valproate), the quality of studies examining for this outcome are limited and there is a clear need for further research in the area.

There is widespread dissatisfaction with how psychiatric disorders are classified, especially as we do not yet have clear-cut biomarkers or endophenotypes to define them (Looi and Santillo, this issue). Perhaps the most unsatisfactory area lies in the classification of the personality disorders or, as Tyrer (this issue) puts it, ‘complicated, unprincipled and useless’. He outlines for us the proposed International Classification of Diseases (11th Revision; ICD-11) approach to the classification of the personality disorders, going where the DSM dared not go (moving from a categorical to a dimensional system). The ICD committee proposes a simple dimensional spectrum ranging from normal personality through to severe personality disorder and abandoning categories and replacing them with domain traits. The domain traits are derived from psychology – the detached (schizoid), negative affectivity (or neurotic), antisocial (dissocial), obsessional (anakastic) and disinhibited – that seem to have some heuristic value. The one disorder that does not seem to fit in is borderline personality disorder as it seems to straddle all domains – a pan personality disorder – why should we not be surprised? Mullen (this issue) provides a pithy rejoinder to Tyrer’s proposed system (a must read), pointing out that a clearer description of a person’s attitudes, responses to the world, strengths and weakness is of more value. He questions the circularity of arguments put forward to validate the domains proposed by the ICD-11 committee. But in the end, I think he possibly has some support for this approach over the current DSM categorical system.