Taking action to reduce mental disorders: Clinical intervention and beyond

A welcome trend in the Journal has been the increase in papers reporting trials of interventions. In the current issue, there are two reports of randomized controlled trials that have been completed and a report of an innovative program of work that is ongoing. There are also some papers that remind us that reducing the impact of mental disorders in society may require more than clinical intervention.

The first trial involves a lifestyle and quit-smoking intervention for people with psychotic disorders (Baker and colleagues, this issue). Although the RANZCP Clinical Practice Guidelines for the Management of Schizophrenia and Related Psychoses recommend both engagement of patients in healthy living strategies and provision of programs to help smokers quit, the evidence base on such interventions is limited (Galletly et al., 2016), hence the need for additional trials. The participants in this trial were all smokers and received nicotine replacement therapy plus either a healthy lifestyle intervention or a control intervention consisting of telephone-delivered support for smoking cessation. Surprisingly, both interventions showed reduction in smoking and cardiovascular disease risk. While the findings failed to show an advantage of the healthy lifestyle intervention, they do indicate benefits from a simpler intervention consisting of nicotine replacement plus telephone support.

The second trial involves the treatment of post-traumatic stress disorder (PTSD) in children affected by civil conflict in Aceh, Indonesia (Dawson and colleagues, this issue). The children were randomized to receive either trauma-focused cognitive behavioral therapy (CBT) or problem-solving therapy, both of which were provided by lay counselors after brief training. Reductions in PTSD were found in both conditions, with no differences between the two. While the lack of a difference raises the possibility that the benefits reflect non-specific components of counseling, the findings are welcome news because they show the feasibility and the value of intervention for these vulnerable children.

Also on the theme of intervention, Thompson and colleagues (this issue) report on some innovative work using technology to enhance clinical care of people with psychotic disorders, including the use of online social media to improve clinical and social outcomes, and virtual reality to monitor symptoms and provide treatment. While the use of online therapies is now common for depression, anxiety and substance use disorders, the potential for assisting people with psychotic disorders has received far less attention.

While clinical intervention is an essential component of a society’s response to mental disorders, two of this month’s contributions remind us that there are also broader social factors involved that cannot be ignored. Enticott and colleagues (this issue) compare the prevalence of psychological distress in Australia and Canada. They report a strong social gradient in both countries, with prevalence being much higher in the lowest-income quintile than in the highest. Mulder et al. (2017) have previously noted a similar gradient in New Zealand. Such evidence shows that living in countries that are among the most fortunate in the world does not benefit all of its citizens equally.

Another example of the role of broader social forces is seen in the contribution of Chitty and colleagues (this issue) on deliberate self-poisoning using alcohol. They conclude that alcohol consumption is a major source of self-poisoning and that it ‘may be driven by alcohol consumption patterns in society’. The authors point out the importance of drug and alcohol services for reducing alcohol-related harm, but the findings might also be seen as indicating a need for greater societal action on alcohol availability.

In thinking about the roles of clinical intervention and these broader social factors, I am reminded of the conclusions that Mulder et al. (2017) recently made in the Journal: ‘It may be time for psychiatry to focus more on factors outside the delivery of good clinical practice to those with a mental illness’, including the ‘the provision of basic necessities of everyday living’ and a greater emphasis on prevention through risk factor modification.