Increments

The United Nations is not infallible. It has to be asked whether the UN Report of the Special Rapporteur (United Nations Human Rights Council, 2017), critically examined by Dharmawardene and Menkes (this issue), deserves our profession’s attention. That Report, from the World’s peak body, asserts that psychiatry is dominated by the biomedical model to the neglect of psychosocial treatments. Mental health services are coercive in ways that violate principles of human rights. The UN authors are disappointingly ill-informed about psychiatry as the rest of us know it. For example, the Special Rapporteur says that

..... Academic psychiatry has mostly confined its research agenda to the biological determinants of mental health. That bias also dominates the teaching in medical schools, restricting the knowledge transfer to the next generation of professionals and depriving them of an understanding of the range of factors that affect mental health and contribute to recovery.

Surprisingly, the Report has been endorsed by the British Psychological Society as a landmark publication [sic]. We urge readers to look closely for themselves at the Report and consider what response is called for, or if it is best ignored. For our part, the Journal will shortly be carrying more material on this matter. One issue is very clear: the Report is more concerned about ideological issues such as the biomedical compared with psychosocial interventions, than the mass of humankind who have no access to any mental health care at all. Such a biased perspective is unusual for a UN body.

This month, there are no fewer than four papers on children and adolescents. Tully et al. (this issue) make a powerful case for having much better mental health literacy about childhood disorders in the general public, parents, teachers and the children themselves. Tully et al. remind us that childhood disorders are commonly the prelude to highly significant morbidity in adulthood, yet uptake for intervention at this early stage is very poor. On exactly this point, Sawyer et al. (this issue) use findings from the 2013 to 2014 Australian Child and Adolescent Survey of Mental Health and Wellbeing. They link data on those with major depression, anxiety disorders, attention deficit hyperactivity disorder (ADHD) and conduct disorder to the treatment they received from health professionals. Sawyer et al. found that about half of those with one of the disorders did have contact with a health professional in the next 18 months. Most importantly, though, only about 1 in 10 had contact sufficient for minimally adequate treatment. Even worse, only one in five of those with severe functional impairment received minimally adequate care. These are deeply disturbing findings for an affluent society.

In 2009, over 80,000 children in NSW were assessed by their kindergarten teachers for developmental vulnerability on school entry. Using health records already available, Green et al. (this issue) have used data on these 80,000 children, when 5 years old, to determine the risk to mental health in subsequent childhood. Those considered to have increased developmental risk at school entry had greatly increased risk of subsequent mental disorders. Here is strong evidence for ensuring worthwhile interventions prior to the onset of serious subsequent morbidity. The study is an excellent example of the constructive yet inexpensive use of data already available. Someone should now look at the attributes of those in the 80,000 children who did not go on to develop a mental disorder.

In a completely different study of adolescents, Malhi et al. (this issue) report their unexpected findings in the field of epigenetics. In a sample of Sydney schoolgirls, they first determined exposure to childhood abuse or neglect by self-report, then measured hippocampal volume by magnetic resonance imaging (MRI) and morning cortisol levels from saliva. Third, they determined the girls’ status on three polymorphisms in stress system genes. Surprisingly, they found reduced hippocampal volumes in the girls who had the allele in the glucocorticoid gene usually associated with a protective as opposed to a vulnerability effect. Unexpected findings are never to be ignored. Encouragingly, these authors set out some testable hypotheses which their study generates.

Every practicing clinician knows that quality of life is often more important to patients than their symptoms. Forbes et al. (this issue) have looked at this very issue in persons exposed to a traumatic event recruited from four Australian hospitals. The value of their analysis is to make clearer which post-traumatic stress disorder (PTSD) symptoms have the greatest impact on quality of life and therefore become priority targets.

The limitation of randomised controlled trials (RCTs) has recently had much emphasis, a trend that many have welcomed. Lilienfeld et al. (2018) have spelt out why RCTs are still essential in the comprehensive assessment of any treatment. Glazier et al. (this issue) assessed cognitive-behavioural therapy (CBT) by Internet for insomnia in a modestly sized sample of depressed men. Their RCT over 12 weeks found an effect size rather lower than they expected. The authors carefully consider what would now be required to have a more definitive assessment of this treatment.

The Journal is aware that reviews of challenging topics can prove very useful, whatever stage one has reached in psychiatry. Chin et al. (this issue) give a narrative review of Lewy body dementia, an under-diagnosed condition that brings about a greater cost and burden on carers than Alzheimer’s disease. Their review sets out a useful account of diagnostic features, biomarkers and the place of advanced neuro-imaging where this is available.

The College’s Clinical Practice Guidelines for Anxiety Disorders were published in December 2018. Starcevic (this issue) sees these as unsatisfactory in their consideration of benzodiazepines for panic disorder. These drugs may not be as undesirable as many believe. A constructive Commentary such as this is exactly what the Journal seeks and welcomes. For many of us, the information on how rationally to choose an antidepressant is akin to walking through a tropical rainforest. There is such a diversity of drugs and clinical features to penetrate. Baume et al. (this issue) offer a new way to find a path. Somewhat paradoxically, they propose not a simplification but the addition of five further dimensions of symptoms, in addition to mood. These are to be considered in relation to efficacy balanced with tolerability for each drug. Here is a constructive proposal that is ready for hard data, ideal for a multi-centre collaboration.

Preposterous suggestions can sometimes be useful. Hay (this issue), herself a world expert on eating disorders, endorses the arresting proposal to remove the weight criterion from the diagnostic criteria for anorexia nervosa. Readers will enjoy where she sees this could lead. The present writer has recently drawn attention to the urgent need for innovation in psychiatry, where so much has become stagnant. This month, we have two Commentaries on prospects for ‘digital behavioural biomarkers’ to collect objective diagnostic data. These would complement our only other source of information: what we elicit by listening to and observing our patients (Hidalgo-Mazzei and Young, this issue; Kumari, this issue). The rest of medicine has biomarkers. Psychiatry may yet have them one day.

Is it possible to work too hard? In all professions and trades, there are always a few who feel dysphoric if not working, who crave it and whose health and family life can be jeopardised. While yet more diagnostic categories are to be resisted, Atroszko (this issue), writing from Gdańsk, makes a case for work addiction as a discrete pathological behaviour, often associated with comorbidity. Many doctors and their families might recognise what he describes. As elsewhere in psychiatry, the behaviour is dimensional, with an arbitrary cut-off. With that in mind, here ends this column.