ANZJP this month September 2019: Acculturating the brain?

Australia has among the largest proportions of migrants globally, which drives cultural diversity, but these culturally and linguistically diverse (CALD) groups remain under-represented in Australian health research. Notwithstanding the healthy migrant bias, driven by immigration health assessment policies, many experience barriers to accessing services and are more likely to have histories of marginalisation and persecution, as well as higher suicide rates. Murray and colleagues (this issue) argue for CALD inclusion in research, education and training in order to meet the needs of Australia’s increasingly diverse population. Paralleling the theme of service delivery to marginalised people, Spencer and Dean (this issue) explore the thorny issue of involuntary treatment of people in custody, something not authorised in most jurisdictions.

An unpredicted and unintended consequence of deinstitutionalisation is that the forensic system has become the de-facto long-term care system for many people with severe mental health problems (Henderson, 2007). The authors argue that the current approach proscribing involuntary care, supported by the Royal Australian and New Zealand College of Psychiatrists (RANZCP), is not tenable, given that general mental health services (public and private) are insufficiently resour-ced to meet the needs of mentally ill prisoners and creates an environment of adequate or coercive care in prisons at best or abrogation of care at worst. They further argue that people with mental health problems should be diverted into care if possible, that involuntary treatment should be possible, albeit with appropriate legislative safeguards, and that custodial mental health units should be developed for this purpose.

Stiefel and colleagues (this issue) debate the promise and potential of precision psychiatry (Fernandes et al., 2017). Like much in psychiatry, precision medicine is brimming with promises but closer examination reveals its complexities – areas that fit and ironically others that do not. For novel therapies that target specific biomarker targets, concordant with the prevailing Research Domain Criteria (RDoC) zeitgeist, proof of target engagement and mediation of therapeutic outcomes is a key goal. To date, this goal has only been partly met. The seminal study by Raison et al. (2013) of infliximab treatment of depression suggested that those with higher levels of C-reactive protein benefitted from therapy, while those with low levels did not. Unfortunately, this promising finding has not been corroborated by subsequent trials (Berk et al., 2019; McIntyre et al., 2019). Thus, Stiefel and colleagues make the salutary point that clinical formulation is of value in understanding a person’s world. This is a wider truth that is not incompatible with the narrow truth that precision medicine aims to seek.

Meadows and colleagues (this issue) weigh into the vexed debate regarding the paradox of increased mental health expenditure and stable mental health prevalence – a topic that has been hotly debated in this journal (Jorm, 2018). Their principal hypothesis is that socioeconomic gradients may drive this disjoint; in privileged areas, gains from wide access to comprehensive therapy may be offset by high rates of antidepressant therapy and low rates of psychological support and spontaneous self-help activity in disadvantaged groups. This model does not incorporate possible changes in risk factors especially in youth, such as greatly increased ‘screen time’ and decreased sleep, social interaction, sex, dating and driving (Twenge and Park, 2019) as well as declining diet quality and levels of physical activity (Matta et al., 2019). It is a research and public health necessity to confirm that this seemingly stable prevalence is correct, to clarify the role of altering risk factors on prevalence, and to explore the interaction between these risk factors and service delivery models.

One such risk factor is bullying, and Jadambaa and colleagues in a systematic review (this issue) find a concerning 12-month Australian prevalence of bullying of 15.17% and a lifetime prevalence of 25.13%. That is one in four individuals. Cyberbullying is clearly as new as social media and it has a prevalence of 7.02%. How this risk factor has changed in prevalence and how it interacts with other risks and resilience factors remains to be clarified. The authors conclude that school-based interventions to reduce bullying are needed.

O’Kearney and colleagues (this issue) explored the evidence from head-to-head clinical trials comparing face-to-face against Internet-delivered cognitive-behavioural therapy (CBT) for anxiety disorders, obsessive–compulsive disorder and posttraumatic stress disorder. Internet CBT has been shown to beat credible placebo, but the comparison to face-to-face therapy is less clear. They found limited evidence, driven perhaps in part by the methodological limitations of the data, that Internet-delivered CBT for anxiety disorders was not non-inferior to face-to-face person delivery, and recommend that further definitive trials are warranted.

Nosology is always a complex and contentious area, and this is true for the conundrum as to whether skin picking should be considered a valid diagnostic category. Jenkins and colleagues (this issue) weigh into the debate, concluding that there is inadequate evidence for inclusion of skin picking as a discrete disorder. Few studies used validated criteria, and only one criterion of five of the Blashfield et al.’s (1990) criteria for inclusion in Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) was met. Continuing the nosology theme, Chamberlain and colleagues (this issue) explored latent phenotypes of impulsive and compulsive problem behaviours in young adults using a transdiagnostic framework. They found a two-factor model of impulsivity and compulsivity, in addition to a general disinhibition factor, with these two factors having different antecedents, particularly personality traits. Similarly, a latent class analysis study of depression, anxiety and symptoms of posttraumatic stress disorder (PTSD) in Australian refugees was conducted by Nickerson and colleagues (this issue). In order of prevalence, they found a Low Symptom class (31.1%), a Pervasive Symptom class (19.2%), a High PTSD Symptom class (17.1%), a High Depression/Anxiety Symptom class (16.4%), and a Moderate PTSD Symptom class (16.2%). Notably, they found that post-migration stressors played an important role and suggest that such nuanced and transdiagnostic spectral patterns of symptoms may assist with treatment provision.

While changes in thalamocortical anatomical connectivity are known to occur in schizophrenia, whether similar changes occur in unaffected relatives of schizophrenia is uncertain. Intriguingly, Cho and colleagues (this issue) found that clinically unaffected relatives who underwent diffusion-weighted and T1-weighted magnetic resonance scans compared to controls had reduced fractional anisotropy in the left thalamo-orbitofrontal tract – prompting them to hypothesise that this ‘latent hypoconnectivity’ is associated with clinical and familial risk of psychosis and may be attributable to the underlying genetics of schizophrenia.

In summary, once again, this issue of ANZJP reflects the diversity of activity in the discipline. In addition, the journal continues to flag and debate contentious issues, ranging from involuntary care in the forensic system to the promises of precision psychiatry, and the complexities of assessing and caring for migrants and refugees.