ANZJP this month

This issue of Australian & New Zealand Journal of Psychiatry (ANZJP) presents a number of important questions around population mental health. Articles discuss the definition of mental disorders, the prevalence of these disorders and their disease burden, as well as raising issues around the efficacy of current interventions and suggesting alternative population-based preventive approaches.

Starcevic et al. (in this issue) consider the irresistible appeal of labelling problematic behaviours and distress with medical terminology. They point out that almost every activity has been ‘prey to a tendency to make it look addictive’ including taking selfies, using twitter, sexual behaviour, stock market activity and even dancing. Of more concern, is the often uncritical acceptance of problematic behaviours as mental disorders by the public and many mental health professionals. One reason for the increasing burden of mental disorders may be that more and more individuals are being labelled as having one.

Ciobanu et al. (in this issue) discuss this mental disorder burden in their article. Using the Global Burden of Disease Study (GBD) data they examine the burden due to mental and substance use disorders (MSDs) in Australia. They report that MSDs are the leading cause of non-fatal burden explaining 24.3% of total years lived with disability (DALYS) in 2015 and the second leading cause of total burden accounting for 14.6% of total disability – adjusted life years (YLL) in Australia.

While these figures are bad enough, of more concern is that there has been no significant change in DALY rates between 1990 and 2015 and a significant increase in YLLs (largely due to drug use disorders). This is despite a large rise in spending and availability of mental health services in Australia over this period. The findings are also put in context with other disorders, such as cardiovascular disease, where there has been a significant reduction in disease burden in most countries including Australia.

Sia et al. (in this issue) also note that the prevalence of depression in Australia has remained unchanged between the 1997 and 2007 National Survey of Mental Health and Wellbeing. While access to mental health care has almost doubled this has yet to show an effect on the epidemiology of depression. They suggest the possibility that measuring and targeting the population mean mood may be a more effective public health policy. The authors report that mean subpopulation questionnaire scores correlated well with the prevalence of depression across socio-economic status groups in women but not men. They note that the implication of their findings is that the prevalence of depression depends on the living circumstances of the population from which the cases arise. Depression is more common in a ‘depressogenic’ environment. Identifying the determinants and environmental exposures that influence the population mean mood could be useful if they were amenable to change. Tackling depression risk factors such as parenting styles, diet, wealth inequality and exercise on a population scale might be effective and cost saving they suggest.

Spence et al. (in this issue) report on a more traditional epidemiological study. They note that in a survey of 6310 Australian 4- to 17-year-olds, 6.6% had experienced at least one of social (SOC) separation (SEP) or generalised anxiety disorders (GAD). Estimates from other countries vary widely depending on the methodology used, but the figure reported is consistent with other studies using the same instrument. Interestingly, a much higher rate of professional help was received in Australia than has generally been reported in the literature. Over half had received help from a mental health professional. The obvious question is whether this high level of treatment has been effective in reducing rates of anxiety. Unfortunately, as the authors note, there are no prior Australian prevalence studies to compare their data to.

The important theme of questioning the efficacy and scientific basis of our treatments is also found in other articles. Rosenman (in this issue) questions the provenance and implication of seizure threshold titration in electroconvulsive therapy (ECT). He suggests that it is not a proven technique for dose optimisation and provides a prematurely settled answer to an unsettled question. Elias et al. (in this issue) report that confirmation and maintenance ECT has a poor evidence base with few randomised controlled trials (RCTs). However, the treatment may have moderate efficacy with concomitant pharmacotherapy in preventing relapse and recurrence of depressive episodes. The one study comparing continuation ECT alone with pharmacotherapy failed to demonstrate a difference implying a possible synergistic role for ECT and psychotropic medications. Like most psychiatric studies, the trials were of limited duration.

On a somewhat more optimistic note, Campbell et al. (in this issue) report that 75% of patients with psychosis were not identified to have any dysfunction in the quality of care provided to their children. Not surprisingly severity of illness and adaptive functioning were reliably associated with the quality of childcare.

Finally the paper by Bach et al. (in this issue) studies the relationship between the International Statistical Classification of Diseases and Related Health Problems 11 (ICD-11) and Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) trait domains and categorical personality disorders. I should declare a conflict of interest in that I am a member of the ICD-11 Personality Disorders Classification Committee and took the lead in developing the ICD-11 domain descriptions. There is some reassurance by the fact that there is substantial overlap between the DSM-5 and ICD-11 domains despite them being derived independently. Both models also capture a substantial amount of the information contained in the current categorical personality disorders and show meaningful continuity with these diagnoses. The major difference is around schizotypal personality disorders which has always been placed in the schizophrenia spectrum section in ICD but in the personality disorders section of DSM. In summary, and I am biased, both ICD-11 and the DSM-5 alternative personality disorders model offer some progress towards a more clinically valid and useful classification system.

Overall, this ANZJP volume does not allow psychiatry to be complacent. We need to be careful about how we transform behaviours into mental disorders and how we classify behaviours within our current diagnostic systems. We need to constantly evaluate the scientific basis of our treatments and how effective our treatments are at the community level. Finally, we need to be open to new and innovative ways to measure psychological distress and frame public policy to help reduce the burden of this distress within our communities.