Making an impact

ANZJP has recently achieved an impressive impact factor of 5.08, ranking it as the leading psychiatry journal in the Asia-Pacific Region and Southern Hemisphere and 18th among psychiatry journals worldwide. Our Captain, Gin Malhi, has set a determined course, avoiding all loose cannons and maintaining an even keel as he steers the ANZJP fearlessly forward. The Impact Factor is calculated as the total number of citations to papers published in the ANZJP over the last 2 years, divided by the total number of papers published during that time (Rajagopal, 2017). Psychiatry journals have a high ranking among medical journals in terms of impact factor, so this achievement reflects the strength of clinical and academic culture among psychiatrists in Australasia.

This months’ issue illustrates the complex nature of clinical psychiatry. Several of the papers present different facets of psychosis assessment and treatment, from violence risk assessment to organic psychosis and evidence-based pharmacotherapy for treatment-resistant schizophrenia.

A clinical guideline regarding N-methyl d-aspartate (NMDA) antibody receptor encephalitis by Scott et al. (this issue) is juxtaposed by a meta-analysis by Siskind et al. (this issue) providing evidence to help guide adjunctive pharmacotherapy for clozapine-resistant schizophrenia. These articles explore the evolving nature of diagnosis and avenues for diagnosis and treatment of newly identified organic causes of psychosis, balanced by evidence-based guidance to inform the day-to-day struggle to help highly disabled people with treatment-resistant psychoses.

A movie based on the popular book ‘Brain on Fire’ by Susannah Cahalan was released on Netflix in June, bringing the issue of NMDA receptor antibody encephalitis into the mainstream. Scott et al. (this issue) define clinical phenotypes in first episode psychosis that can be used to identify patients who should be investigated for autoimmune encephalitis. The pathology request should state Anti-NMDAR Antibodies, Anti-VGKC Antibodies and Antineuronal Antibodies and note that the patient has a psychotic disorder. Scott et al. highlight that this is an emerging field and uncertainties remain regarding identifying appropriate patients for testing, the relative accuracies of differing assays and the necessity or otherwise for obtaining cerebrospinal fluid (CSF) samples. Despite these gaps in knowledge, there has been significant progress over the past decade. Correct diagnosis and treatment of these patients is crucial, as patients found to have autoimmune encephalitis can often improve dramatically with immunotherapy.

Psychotropic polypharmacy is common in treatment-resistant schizophrenia, a condition that affects 20–30% of those with schizophrenia. This is understandable as up to 60% of patients prescribed clozapine have persisting symptoms. Given the side effect burden of clozapine, which can be compounded by additional psychotropic therapy, it is essential for clinicians to be guided by the best available evidence for augmentation. Siskind et al. (this issue) report an important meta-analysis demonstrating superior evidence for the use of aripiprazole, fluoxetine and sodium valproate for positive symptoms and memantine for negative symptoms. Furthering the argument for aggressive symptom control in psychotic illness is a large cohort study by Jordan et al. (this issue) that found regardless of premorbid adjustment, promoting better control of symptoms in the early stages of psychosis improves long-term functional outcomes.

Hieschler et al. (this issue) step back earlier in the course of (possible) illness. They report that psychotic experiences in adolescence which are independent of drug use, and in the absence of a psychotic illness, are found in up to 14% of adolescents. These subclinical psychotic symptoms are associated with an increased risk of major depression, being bullied, psychological distress, low self-esteem, use of mental health services and poor sleep. Most of these adolescents do not go on to develop a psychotic disorder, but clearly these symptoms should elicit further enquiry.

Another clinically relevant review addresses the well-established bidirectional relationship between alcohol abuse and depression. People who misuse alcohol are 2.4 times more likely to have depression than people who don’t abuse alcohol, and depressed people are less likely to succeed in alcohol abuse treatment programmes (Lai et al., 2015). A 2011 meta-analysis (Hobbs et al., 2011) found improvements were greater in alcohol misuse and depression outcomes for people receiving dual treatment compared to people treated for alcohol misuse alone. Hobden et al. (this issue) systematically review available literature to discern whether evidence exists to tell us which is the most effective psychosocial treatment of co-occurring alcohol misuse and depression. Given that the most difficult and costly strategy, ‘integrated care’, is also the strategy recommended in many clinical guidelines, their finding of a lack of evidence to support one treatment modality over another is significant. The authors propose that the various possible treatment options should be considered when planning treatment for an individual patient, as there is no clear evidence that an integrated approach, rather than a sequential or parallel treatment approach, is more efficacious. Attending separate, specialised services may have an advantage; just as fruit and meat bought from a fruit shop and butcher, respectively, is generally better quality than fruit and meat purchased from a supermarket. It’s sometimes worth the inconvenience of going to separate shops, to get better quality products.

There is a general expectation that mental health clinicians can predict and prevent suicide, violence, homicide and more recently massacres. Two papers in this month’s edition provide comment on this, following on from the article in the May edition of this journal by Haeney et al. (2018) on school shootings. Mullen and Pathé (this issue) describe the characteristics of patients who use threats to either communicate distress, gratify their needs or generate attention, labelling them as ‘threateners’. The authors contrast ‘threateners’ with ‘lone wolf/lone actor’ attackers. They comment that most lone actors would have been deemed low risk using violence risk scales, and detecting the rare lone actor among the noise created by the threateners is an unrealistic expectation given current resource limitations. However, threateners are mostly disturbed people seeking to dramatise their plight, and they do need to be taken seriously and provided with care and support. Mullen and Pathé highlight the possibility of expanding the services offered at Fixated Threat Assessment Centres, which are now available in some states in Australia and being developed in other parts of Australia and New Zealand.

Adding further to the debate about the expectation that clinicians quantify the risk of violence by people who have a mental illness, Hachtel et al. (this issue) assessed different patterns of violent and non-violent behaviour, preceding and following diagnosis, in people with schizophrenia spectrum disorders. The authors make the bold recommendation that clinicians should triage patients into different risk bands regarding future violence based on proximal and distal risk factors such as violent and non-violent antisocial behaviour and violent victimisation before diagnosis, substance use, male gender and frequency of inpatient admissions.

In addition to Siskind’s meta-analysis (this issue) on adjunctive therapies for clozapine augmentation, Pan et al. (this issue) comment on successful add-on prescribing in a letter describing the benefits of low-dose lurasidone, added to antidepressants, in a patient with disabling anxiety. In other correspondence, the consideration of rare medical causes of psychosis continues with two case reports of Alice in Wonderland syndrome (King et al. this issue and Trevizol et al. this issue), while Pik (this issue) pursues the ongoing debate regarding the perceived harms of overprescribing psychotropics. This is followed by two letters highlighting severe antipsychotic side effects. Clozapine can cause very severe constipation, and Thomas et al. (this issue) describe a treatment option for this troubling problem, while Reddy et al. (this issue) describe a rare adverse drug response to Olanzapine.

Finally, this month’s journal includes another skirmish over behavioural addictions. This field is evolving much faster than evidence or even theory, as technology expands and people adapt their lifestyles and habits in order to accommodate these new opportunities for stimulation and engagement. This controversy is easily parodied by the media – is taking selfies excessively a mental disorder? Maybe one day there will be a videogame for psychiatrists, with notifications to Australian Health Practitioner Regulation Agency (AHPRA) as the life-threatening injuries and impact factors, h-index and Orders of Australia as the treasure.