Examining the entrails

This issue of the ANZJP brings together fascinating clinical studies that compare patients with psychotic and non-psychotic bipolar disorder (Altamura et al., this issue) and the use of neuroimaging to examine brain connectivity of the default mode network in those with autistic spectrum disorder, with, or without, comorbid attention-deficit/hyperactivity disorder (ADHD) (Wang et al., this issue). There is also food for thought in debate and opinion pieces, with a Debate on the Werther effect following suicide among celebrities (Sinyor et al., this issue) and a Commentary on the complexities of mandatory reporting of impaired colleagues (Ford, this issue). In addition, there are several exciting research articles.

Over the last 5 years, there has been an upsurge in gut microbiome research. Unsurprisingly, the gut microbiome is influenced by diet, which may, in part, account for the finding that a poor diet is associated with common mental health problems. It has prompted speculation as to whether dietary changes in the latter half of the 20th century (greater salt, sugar and fat consumption) have contributed to the increase in prevalence of mental illness. Changes in the gut microbiome have been linked to a number of physical illnesses, most likely because of its influence on immune mechanisms and oxidative stress. In addition to modifying diet, this has opened up a range of new interventions including, for instance, the use of probiotics and, more controversially, faecal microbiota transfer (or faecal transplant), which is being trialled as a treatment of conditions such as irritable bowel syndrome and treatment-resistant clostridium difficile. How is this relevant to psychiatry? Green et al. (this issue) put forward some reasons as to why this might be important. Animal studies have linked the gut microbiome to brain function and modifying the gut microbiome (using probiotics or antibiotics) may alter anxiety- and depression-like behaviours. In humans, faecal microbiota transfer has been trialled in autistic spectrum disorder with some success and the gut microbiome has been implicated in the development of depression. More specifically, there are several pathways to the genesis of depression, such as inflammation, neurotransmitter dysregulation and oxidative stress that are all in turn influenced by the gut microbiome. With the advent of providing faecal microbiota transfer by encapsulating faecal material, it means that such transfers will not require a colonoscopy, hopefully making this a more accessible treatment. Furthermore, if clear links between perturbations in the gut microbiome and depression can be found, potential new treatments can be developed.

Sticking with therapy, immune dysfunction has been implicated in the genesis of schizophrenia (and other psychiatric disorders) and recently anti-inflammatory agents have been tested as adjunctive treatment agents. Cho et al. (this issue) report on a meta-analysis of studies examining the use of anti-inflammatories used as adjunctive agents in the treatment of schizophrenia. Overall, they found that anti-inflammatory drugs were effective in reducing positive and negative symptoms. Specifically, aspirin, celecoxib, estrogen, raloxifene and pregnenolone were all effective in reducing symptoms, whereas cognitive benefits were found with adjunctive minocycline and pregnenolone. Similarly, N-acetylcysteine was found to be effective in symptom reduction, principally in negative symptoms. Importantly, these agents were found to have a satisfactory safety profile meaning that they can be potentially considered as adjunctive treatments.

Over the years, there has been considerable debate about the best way psychiatric services (or mental health services) should be delivered and what is the true target population. This has been the focus of multiple reports and enquiries – two of which are currently underway in Australia. Allison et al. (this issue) raise concerns about a recent New Zealand report into mental health and addictive services, the ‘He Ara Oranga’ report, that recommends a shift from, what has been termed, ‘big psychiatry’ towards a new sector ‘big community’. This report argues that most resources for psychiatric treatment should be provided in ‘comprehensive community-based responses’. This is not new. Such a shift in services has been proposed for the better part of the last 50 years, starting with de-institutionalisation and the development of community-based services. However, while this is desirable, translation into practice has ended up with unsatisfactory results as funding has not ‘followed the patient’, leaving extant inpatient and community-based services struggling, as observed by Allison and colleagues. To compound things, the He Ara Oranga report recommends that the target population should be the 20% of the population that report mental distress and not just the 3% with serious mental illness. This is an important issue for psychiatry because we need to ensure that those with serious mental illness have access to the best quality care and follow-up. This includes the provision of an appropriate number of inpatient beds (they are still necessary) and well-resourced comprehensive community-based care and follow-up. Unfortunately, we now have insufficient inpatient beds and inadequately resourced community-based care with the consequence that those with severe mental illness do not get the care they need. Undoubtedly, the 20% that experience mental distress require support and treatment, and much has been done around the world to address this with public health approaches (such as public awareness programmes) and increased provision of psychological services. However, as yet, these have not improved the mental well-being of the population as a whole and this is in part because the social determinants of distress (such as inequality and lack of social connectiveness) are not being adequately dealt with – and these are largely outside the remit of mental health services. However, one area that could have an impact, as noted by Jorm (this issue), is a concerted approach to deal with bullying at schools (and in the workplace) as this seems to be a major risk factor for experiencing distress later in life. In a similar vein, encouraging a healthier diet and lifestyle (exercise and avoidance of drugs) might also have a role to play. Until then, it is critical that we support the provision of good quality integrated psychiatric services for those with severe mental illness.

One reason patients with severe mental illness (schizophrenia and bipolar disorders) require long-term treatment, be it as an inpatient, or ideally through community-based multidisciplinary teams, is to support adherence to medication. Pai and Vella (this issue) discuss the importance of informing patients with schizophrenia, early on in their treatment, as to how long they might have to remain on medication. This will involve discussion about the risks (side-effects) and benefits of the medication. Undoubtedly, some only require antipsychotic medication for the medium term and can then discontinue it, but such a judgement needs to be fully informed, with discussion between the patient and the treatment team. And as pointed out by Bendall (this issue), we need further research to identify those who can safely stop taking an antipsychotic. Explanations to the patient require the clinician to be able to integrate a psychosocial model of schizophrenia with a biomedical model that generally prioritises the use of medication. This includes dealing with side-effects of their medication and the impact medication has on their lives, as pointed out by Bendall (this issue) who, in a response to Pai and Vella, draws upon the lived experiences of those being treated for schizophrenia and their experiences of medication.

The point regarding where treatment should be administered is considered further. For example, inpatient care is sometimes required for children and adolescents. Perkes et al. (this issue), in an important guide for clinicians, outline the major indications for this to occur, in addition to the severity of illness. They suggest admission is indicated when there is a need to have a period of observation to allow for diagnostic clarification or when acute containment of risk is required or when a non-psychiatric medical assessment, that cannot be undertaken in a medical setting, is needed. They emphasise that the ideal is for a community-based multidisciplinary assessment; however, in the circumstances they outline, this may not be feasible, or, in the case of suicide risk, unsafe.

The brain changes associated with delirium are examined elegantly in an imaging study by Oh et al. (this issue). They use a naturalistic experiment recruiting older persons (over 70 years old) about to undergo surgery for a femoral neck fracture. Participants in the study underwent a resting-state functional magnetic resonance imaging (fMRI) scan which was repeated postoperatively allowing for a comparison between those who did and did not develop a delirium. They replicated earlier findings from studies based on scans taken while in a delirium and again on recovery, which showed that delirium was characterised by ‘diminished anticorrelation between the Default Mode Network and task specific regions’ and reduced connectivity between subcortical regions. They also report some novel findings regarding posterior cingulate cortex involvement.

The outcome of pharmacological treatment for patients with ‘anxious depression’ has been reported to be worse than for those with depression without comorbid anxiety. In a study from the large-scale treatment effectiveness study, termed the international Study to Predict Optimized Treatment - Depression (iSPOT-D) study (Braund and colleagues, this issue), the outcome of patients with anxiety and depression was carefully examined. Using different definitions of anxious depression, those with a comorbid anxiety disorder and those who score high on the anxiety subscales of the Hamilton Depression Rating Scale, different groups of participants (with some overlap) were identified. Importantly, there were no real differences in outcome between those with anxious depression (however defined) and those with major depression without anxiety, raising speculation that other factors (such a personality characteristics), rather than anxiety per se, contribute to the poor outcome.

In summary, the ANZJP continues to provide a broad range of research and opinion – and ensures that there is something stimulating, both visceral and mental – for everyone’s taste.