Challenges for psychiatry and a call to arms

Getting the right services, to the right people, and meeting unmet needs are clearly major challenges for the mental health system. Previous issues of the ANZJP have broached this issue, but now there is some new data about the population impact of the better access initiative.

It seemed to be perfectly reasonable to make psychological treatments for patients with common mental disorders more accessible and affordable – and the ‘Better Access’ scheme was introduced to achieve this. But is it working? Is it making a difference at the population level?

According to an analysis by Jorm (this issue), while, to date, the number of general practitioners (GPs), psychologists and allied health services funded through this scheme has increased since 2006 (with little change in the number of services provided by psychiatrists), there has been negligible impact on the population rates of mental distress as measured by the K10, which remains stubbornly stable. What then is going wrong? In his erudite article, Jorm offers four possibilities: an insufficient dose of psychological treatment, services provided to the wrong people, the quality of services not matching up to established, evidence-based, manualised treatments or, perhaps, psychological interventions failing to target the real problem – the psychosocial and socioeconomic factors that underpin the common mental disorders. The Better Access programme is costly, and we should expect more from it and engage in debate about what should be done to improve the overall well-being of our population; this will involve engagement with social policy and advocating for the kind of social changes that improve social engagement and reduce inequality – discussed further in an editorial by Scott Henderson and myself in this issue.

Two debate pieces in this issue of ANZJP reflect on the role of psychiatrists and urge us to become more engaged in public discourse. Looi and Cartledge (this issue) point out that psychiatry has been subject to undue criticism, especially by those who lack our expertise. Psychiatrists have a broad training covering assessment, diagnosis along with expertise in medical, pharmacological and psychological treatments and, importantly, dealing with complexity. They urge us to assert our expertise in contributing to public discourse; otherwise, the narrower views of ‘disciplinary’ experts will prevail. In our editorial, Scott Henderson and I (Henderson and Boyce, this issue) also ponder on this, rueing how, in some areas, we have been relegated to the role of providing a medication review! We observe that psychiatrists have a broad range of skills, especially the ability to provide complex biopsychosocial formulations that go beyond simplistic diagnosis. We point out that the advances made in improving mental health literacy and reducing stigma (and increases in funding) have been mainly for the common mental disorders, while there has not been the investment in the more-severe psychotic disorders. We also make a plea for more investment in academic psychiatry; we need the psychiatric researchers for the future, those who can integrate the extraordinary findings from neurosciences with the clinical needs of our patients.

Another concerning area of neglect, brought to our attention in a Debate by Foulds and Monasterio (this issue), is the mental health services provided to jails. Our prison population has grown by 30% in both Australia and New Zealand over the past decade; much of this among those held on remand. They are on remand because they are unable to access bail (the ‘law and order’ agenda by populist politicians). There are inadequate psychiatric services provided in jails, especially for those in remand. Here is an area, where investment in psychiatric services will pay great dividends in reducing chronicity and the distress of the individuals that have fallen foul of the law. The police are frequently the ones at the front line to deal with people with mental illness in crisis – they are the ones that have to deal with floridly psychotic patients or individuals in crisis in the community. Relatedly, Reavley et al. (this issue) measured health literacy and helping behaviours among police officers in Victoria. Reassuringly, they have comparable levels of mental health literacy to that of the general population, especially in recognising the helpfulness of GP and psychologists. They were more circumspect about evidence-based treatments than the general population, especially the helpfulness of antidepressants. Perhaps, this is the result of them having to deal with the situations where antidepressants have not worked (or had time to work).

One of the frustrations we, and our patients, have to contend with is the length of time it takes for psychotropic medications to work, particularly when we are dealing with acutely depressed suicidal patients. Berk et al. (this issue) wonder if there is a necessary time-limiting step with response to antidepressant treatments. Psychotropic medications have a time lag to them achieving efficacy, perhaps as there need to be homeostatic changes for them to have their full effect. There are also agents that can produce rapid psychotropic effects (ketamine, stimulants, etc.) but here effects are not long-lasting and can lead to dependence. The interesting question they put is whether we will ever be able to get a rapid onset effect without the downside. A vexing problem for us is what to do while we wait for the antidepressant effect to kick in, especially for those acutely unwell patients that remain suicidal. Horgan and Malhi (this issue) suggest that having more frequent contact with acutely suicidal patients through text and phone messages maybe a way of helping people that are acutely suicidal. This extra caring and support, they argue, can be life-saving for some. They point out that this extra support, seemingly breaking strict rules of psychotherapy, needs to be titrated down when the acute suicidality settles. They emphasise that these extra contacts need to be noted in the patient’s record. They also provocatively suggest using combinations of antidepressant medications as first-line treatment given that the first antidepressant we use is often not effective; they suggest some combinations worthy of trial.

In a similar vein, the stimulants, especially amphetamines, are popular for their immediate psychotropic effect, but they are associated with significant abuse and can lead to individuals being admitted for psychosis. Sara et al. (this issue) linked together crime and health service data and demonstrated that the availability of amphetamines was associated with the rates of admission for amphetamine-related admissions. A challenge here is to work out a way to stop people from taking such dangerous substances – but there are no obvious answers to this problem.

One contentious area of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) was the introduction of a new chapter in Obsessive-Compulsive and Related Disorders. Body dysmorphic disorder (BDD) was placed in this chapter, although some have argued that is not the most appropriate place for it. There are clearly overlaps between BDD and obsessive–compulsive disorder (OCD), and these are explored in detail in a review by Malcom et al. (this issue). While there are areas of similarity between the disorders, there are also significant differences between them, notably that illness insight is worse in BDD. Clearly, further examination is needed into the nosological status of BDD.

Finally, we have two interesting neuroimaging papers in this issue of the ANZJP. In the first, Minuzzi et al. (this issue) examined functional connectivity among euthymic women with bipolar disorder and compared them with healthy controls. They found the bipolar women had increased resting-state functional connectivity in the areas involved with affective regulation. In this paper, Minuzzi et al. provide a useful review of functional magnetic resonance imaging (fMRI) studies in bipolar disorder. In the second study, Hu et al. (this issue) performed a structural magnetic resonance imaging (MRI) 48 hours after individuals had been victims of a motor vehicle accident (and who had had no loss of consciousness) to see if they could identify any markers that could identify those that would develop post-traumatic stress disorder (PTSD). Those who developed PTSD had decreased cortical volume and cortical areas in the frontal and temporal regions compared with those that did not develop PTSD. Could this prove to be a potential biomarker to identify those that might develop PTSD? If so, the challenge would be what interventions would be able to overcome this?