Much on early intervention,some thoughts on COVID-19 and a paradox to ponder on

This month’s issue presents some interesting data and debate on early intervention in psychiatry. An influential idea in early intervention is that mental disorders evolve through stages and that intervention at an early stage can prevent transition to a later stage. One approach based on this staging idea that remains contentious (Malhi et al., 2020) is to try to prevent transition to psychosis by treating people who have psychotic experiences. Soneson et al. (this issue) point out that previous systematic reviews of trials have found that no one type of intervention seems to be superior to any other in preventing transition to psychosis. However, these reviews leave unresolved whether intervention can reduce the psychotic experiences themselves and other clinical and functional outcomes. Soneson and colleagues therefore carried out a systematic review and meta-analysis of trials examining these broader outcomes with people with psychotic experiences. They found evidence supporting a positive effect of cognitive behavioral therapy (CBT) on distress associated with psychotic experiences, but no evidence of effect on depression, anxiety, functioning or quality of life.

While psychosocial interventions are also recommended in guidelines for treatment of people at high risk of transition to psychosis, Zhang et al. (this issue) report that in China, it is mainly antipsychotic medications that are commonly used for this purpose. To evaluate the impact of this use, they report the findings from a longitudinal study of high-risk patients, who were prescribed antipsychotics in over two-thirds of cases. They found no benefit of using antipsychotics for preventing transition, with milder cases actually showing an increased rate of transition to psychosis. They conclude that administration of antipsychotics to high-risk patients is ‘potentially harmful with no preventive benefits’.

This month’s issue also contains vigorous responses to opinion pieces on early intervention published previously in the journal. Allison et al. (2019) have previously questioned whether early intervention can prevent chronic psychosis and also whether the high level of investment in youth mental health services in the state of Victoria is justified. In response, Chanen et al. (this issue) argue that modifying the course of disease has been a successful strategy in other areas of medicine. They state that ‘evidence shows that it is possible to reduce the risk for developing psychotic disorder in those at high risk for up to 4 years’ and that ‘Following psychotic disorder onset, early intervention improves outcomes across the early years of illness’. They also support ‘adequate investment to ensure quality of care in the Victorian adult mental health system’ to ensure the gains from early intervention are built upon.

An earlier piece by Looi et al. (2019) also questioned the high level of investment by the Australian government in headspace youth mental health services, which they argued were drawing funding away from under-resourced state mental health services. In response, McGorry et al. (this issue) argue that headspace is not duplicating or competing for funding with state services. They call for ‘unity of purpose and better mental health care for all’ rather than competition for scarce resources in the sector.

While the youth age group has often been the focus of early intervention efforts in psychiatry, the article by Syed Sheriff et al. (this issue) reminds us that there is potential at many life transitions. They identify the transition from regular military service to civilian life as a time of increased vulnerability to suicide. In a study of Australian Defence Force personnel, they found that the risk of suicidality was greater in men who had experienced interpersonal trauma and anxiety in childhood. They argue that ‘these findings have the potential to aid early intervention and prevention strategies in identifying those at risk prior to transition’ and argue for ‘early interventions targeting anxiety and interventions to reduce social instability during the transition period’. However, whether these intervention strategies would work remains to be tested. These findings also remind us of the importance of preventing adverse childhood experiences, which are major risk factors for a broad range of mental health problems across the lifespan (Jorm and Mulder, 2018).

The COVID-19 pandemic continues to dominate the news, with many observers warning of a ‘second wave of mental ill-health’. This issue of the journal has three letters looking at the implications of the pandemic for psychiatrists, with Singh (this issue) discussing the many implications for psychiatric practice, Khanna and Forbes (this issue) calling for greater embracing of telepsychiatry and Siskind et al. (this issue) discussing the implications of physical distancing requirements for monitoring for post-injection delirium/sedation syndrome with long-acting olanzapine.

Finally, if you like the mental gymnastics of a paradox, Mulder et al. (this issue) discuss the ‘vulnerability paradox’. This refers to the fact that within countries, lower socioeconomic status is associated with a higher prevalence of mental disorders. However, in comparisons of prevalence across countries, low- and middle-income countries tend to have a lower prevalence. To add to the puzzlement, studies of subjective well-being (SWB) show that higher wealth is associated with higher life satisfaction both within and between countries. Is there some factor associated with transition to a high-income country that increases average life satisfaction, but at the same time increases the prevalence of mental disorders? Mulder et al. conclude that ‘If we are to achieve a world with both greater SWB and a lower prevalence of mental disorders, we need to investigate the source of this paradox as a matter of priority’.