The ambulances at the top of the cliff

Often, and on purpose, the pages of Australian and New Zealand Journal of Psychiatry (ANZJP) are burgeoning with papers on treatment of mental illnesses. This month’s ANZJP, however, focusses on the important issues of prevention, early intervention and the psychosocial determinants of mental illness.

Starting logically with maternal and infant health, and following on from Judd et al. (2018), Sved Williams (this issue) further discusses the importance of perinatal infant mental health and the need to disrupt the well-documented intergenerational transfer of difficulties from mother to child. The paper narrows its focus further on the critical and, as argued by Sved Williams, seriously neglected problem of borderline personality disorder (BPD) in mothers, pointing out that there are no studies on the prevalence of BPD either in antenatal or post-natal populations. There is also a lack of evidence regarding interventions for BPD in the post-natal period. Sved Williams also argues that even intensive and complex interventions at this stage have the potential to save significantly when costs of child protection, later forensic and mental health services and loss of potential employment are taken into account. A small part of this problem is appropriate treatment of perinatal major depression and depressive symptoms. Molenaar et al. (this issue) examine guidelines for treatment of these issues worldwide, discovering eight guidelines that are specific to this topic and an equal number that are not (i.e. not wholly focussed on perinatal treatment). Among these a consensus regarding whether to continue or discontinue antidepressants during pregnancy was lacking, although all agreed that first-line treatment for new episodes of depression should be psychological, where possible.

Jorm and Mulder (this issue) also argue strongly for research into how mental disorders might be prevented, suggesting that despite undoubted advances in psychiatric treatment, there seems to be a worsening of certain indices of the mental health of populations (Mulder et al., 2017). They focus on what they argue is the biggest risk factor – childhood adverse experiences – and point to data suggesting that if childhood adverse experiences were removed then the rates of common mental disorders would reduce by 10–40% according to data which includes studies in Australia and New Zealand. They also discuss evidence regarding the enduring nature of these experiences as a risk factor for mental health disorders, which continue to confer risk across the life cycle. Jorm and Mulder discuss the findings of a US report into possible interventions for this problem, noting that currently the evidence for effective interventions is unfortunately lacking but that this is clearly an area which should be a priority for international research. They conclude that the Royal Commission into Institutional Responses to Child Sexual Abuse (2017) provides a focus and opportunity to raise awareness of the link between adverse childhood experiences and later mental health consequences and offers the potential for action.

Such experiences are risk factors for most categories of mental disorder, including in a very recent analysis suicide attempts (Ng et al., 2018). In a study in New Zealand, among secondary school children (Chan et al., this issue), the impact of exposure to suicide attempts and completed suicide in family, friends and school community was investigated specifically with regard to self-reported suicide attempts and self-harm among these students. Not surprisingly, low mood was associated with suicide attempts and self-harm, but so was the exposure to these behaviours. The authors suggest that adolescents who experience these events should receive greater support, particularly if they themselves have low mood.

Le et al. (this issue) also examine prevention – in this case the prevention of eating disorders, for which several interventions have been shown to have some degree of effectiveness. In order for these programmes to be accepted by service planners, cost effectiveness may need to be demonstrated. The review conducted by the authors identified four economic studies of prevention of eating disorder which showed some preliminary evidence of cost effectiveness.

Two further New Zealand studies investigate factors which may be modified and which are implicated in mental health disorders. The first examines loneliness, which is an important risk factor for mental health conditions. However, while loneliness could appear to be a simple construct, Hawkins-Elder et al. (this issue) report on the findings of a large questionnaire study which used a latent profiles analysis to determine whether there were subtypes of loneliness. Interestingly, four subtypes were identified which tended to display a gradient of other factors such as mental well-being – with the low loneliness group having the best perceived mental health, the high loneliness having the worst mental health – with two intermediate groups – ‘superficially connected’ and ‘appreciated outsiders’ being in between these two groups. The study links well with a related study of 21,000 people in New Zealand which had the advantage of sequential sampling (Saeri et al., this issue). The authors point out that poor ‘social connectedness’ has often been seen as a consequence of mental illness or at least it has been supposed that the causation in that direction is stronger. They examined this issue in a cross-lagged, longitudinal study (essentially a study which examines the extent to which related variables predict each other at a future time). The results were clear – poor social connectedness was a stronger predictor of poor mental health than vice versa. The implication is clear that improving social connectedness may have significant benefits for future mental health.

Overall then, mental health may be improved in the long term by rectifying dysfunctional mother infant dyads, reducing adverse childhood experiences, improving maternal perinatal treatment for mood disorders and increasing social connectedness so as to reduce the complex phenomenon of loneliness. The points raised by these studies and their findings are critical and while clarity is sought as to what they mean and how they should translate to in clinical practice, it is crystal clear that improving mental health at the top of the cliff will require considerable further research and investment.