A Whale of an issue

In 2019, Looi et al. (2019) wrote a Debate piece, provocatively titled ‘Leviathans: Headspace-like behemoths swallow resources’. Leviathans and behemoths are both monsters – in the Bible, leviathans are multi-headed sea monsters, and behemoths are grass-eating monsters whose bones are tubes of bronze, and limbs like bars of iron. In the article by Looi et al. (2019), the monstrous leviathans and behemoths are the non-governmental organisations (NGOs) such as headspace, gobbling up precious resources. Looi et al. (2019) write that because of the leviathans’ dominance of Australian mental health services, these have been haphazard in terms of providing necessary care for patients; they have reduced the funding available to other mental health services and yet increased their workloads. The Commonwealth is portrayed as Captain Ahab in Moby Dick, futilely chasing the great white whales of large NGO programmes.

Not surprisingly, these assertions elicited a vigorous response from McGorry et al. (2020). They commented that Looi et al. (2019) resembled Don Quixote, attacking windmills in the mistaken belief that they were giants, while bystanders laughed and mocked. They cited indicators of the success of headspace and called for consensus and unity among those seeking to improve youth mental health.

The ANZJP this month includes the response to the response. And if you are so inclined, you may wish to write a letter to the ANZJP responding to the response to the response – as we can never have too many responses! In this issue, Looi et al. move on from monsters but now invoke straw men and hollow men, both fallacious strategies that they assert were used by McGorry et al. (2020) in their response. However, they also share McGorry et al.’s (2020) aspiration to improve mental health care for young Australians and thus provide an example of the successful integration of headspace into a State child and youth mental health service. They propose that all current and future headspaces should also be part of State mental health services. This proposal may indeed provide a way to improve youth services and certainly warrants further evaluation.

This rather robust debate (hallmark of the ANZJP) concerned the best means to provide mental health services for young people, across all diagnostic groups. However, another aspect of youth mental health is the identification and appropriate management of those at risk of transition to psychosis. Malhi et al. (this issue) kick off a debate specifically addressing early intervention for those identified as being at risk of developing a psychotic illness. They draw on a series of papers looking at detection and intervention in ultra-high-risk (UHR) populations – also called Clinical High Risk for Psychosis (CHR-P). There is discussion of the accuracy and utility of these classifications, and the most effective strategies to help young people identified as being at risk of psychosis (Fusar-Poli et al., 2020). Cognitive behaviour therapy (CBT), addressing social stressors, and cessation of substance abuse are reasonable approaches. The use of antipsychotic medications in these young people, contrary to published guidelines and recent evidence, is sometimes invoked as a reason not to use these classifications, although addressing poor adherence to guidelines would seem more appropriate. Ongoing scrutiny and review of the concepts, social aspects, research and economics of early psychosis will hopefully lead to rapid progress, addressing these controversial areas. Orygen and collaborators recently received a $33 million grant from the United States National Institutes of Health (NIH) to develop models for predicting outcomes for young people who are at imminent and high risk of psychotic illness, so clearly, the NIH regard this issue as critically important.

Continuing with child and youth mental health and early intervention, Hoare et al. (this issue) describe Be You, a national programme for mental health promotion and early intervention for children and adolescents. This supersedes previous programmes, MindMatters and KidsMatter. A number of educational and mental health organisations have been involved in developing the programme, which includes building capacity among educators, along with strengthened family, home and community partnerships. The programme is funded by the Australian Government and will be freely available to all early learning centres, primary and secondary schools. The name Be You is intriguing – one has to wonder, is the child at risk of being someone else?

Someshwar et al. (this issue) investigate a bleaker aspect of childhood, adverse childhood experiences (ACE) including sexual, physical and emotional abuse and neglect, bullying, and parental issues such as substance abuse, incarceration and mental illness. ACE are known to be associated with later psychiatric illnesses, and this research examined links between these damaging experiences and age of onset of psychiatric disorders. This study took place in India. The participants were individuals from families with at least two first-degree relatives with major psychiatric conditions, so they most likely have an increased genetic loading for psychiatric disorder. Within this cohort, males had higher scores for ACE exposure and severity. Someshwar et al. (this issue) found that a greater exposure to these experiences significantly increased risk for an earlier age of onset of obsessive-compulsive disorder and substance dependence, but interestingly not for schizophrenia and bipolar disorder.

Bhui et al. (this issue) have developed a short survey to measure Sympathies for Violent Protest and Terrorism, and they investigated associations between such sympathies, and self-reported violence and convictions. Their participants were of Pakistani, Bangladeshi or White British ethnicity, living in the United Kingdom. While Bhui et al. (this issue) reported that their survey was accessible and valid, the main limitation was that all data were self-reported. An intelligent terrorist would most likely not answer truthfully when asked ‘to what extent do you condemn or sympathise with the use of suicide bombs to fight injustice?’

This month’s ANZJP also has a series of papers about bipolar disorder. A New Zealand (NZ) study (Cunningham et al., this issue) found that Māori with bipolar disorder had a higher level of physical morbidity and higher risk of death from natural causes, compared with non-Māori with the same diagnosis. In the NZ population, Māori have a reduced life expectancy, compared to the non- Māori. It seems likely that the systemic factors responsible for this disparity might also be responsible for differences in morbidity and mortality in those with severe mental illness such as bipolar disorder. Cunningham et al. (this issue) reported that under-treatment of physical disorders seemed to contribute to the poorer outcomes for Māori, indicating a potential target for improvement. Continuing the brain–body association, Tsai et al. (this issue) describe a novel perspective on the links between psychiatric disorders and cardiovascular health. Their study had very small numbers, but nevertheless suggests that treatment with lithium may be associated with less carotid arteriosclerosis in adults with bipolar disorder, whereas antipsychotic drugs might be associated with more arteriosclerosis. Returning to bipolar disorder, Valerio et al. (this issue) report that global cognitive deficits predict hypomanic/manic episode severity and duration but do not predict depression. And Gong et al. (this issue) describe alterations in temporal variability in the precuneus/posterior cingulate cortex in people with bipolar disorder, along with specific abnormalities associated with suicidality.

It is unlikely that a journal published in 2020 could avoid mentioning COVID-19. This month’s ANZJP is no exception. Tan et al. (this issue) provide an overview of potential research into the impact of COVID-19 on the mental health of Australians and describe a series of online surveys (the COLLATE project) which will run periodically until 2024. Finlay and Looi (this issue) write about the need for surge capacity in both private and public mental health services, to manage an anticipated increase in demand for mental health care related to the COVID-19 pandemic. Rees and Wells (this issue) also touch on this topic and include COVID-19, bushfires and gender in a single letter, noting that disasters often result in an increase in domestic violence due to factors including stress, economic hardship and increased use of alcohol. They propose that the Federal Government should establish an Australian Task Force on gender, mental health and disaster.

Continuing with the theme of the role of the Federal Government in mental health services and research, Kisely and Looi (this issue) critique the Productivity Commission’s draft report on the effects of poor mental health on economic participation and productivity. They conclude with two very solid recommendations that reform should be based on evidence and should be achieved without increasing administrative complexity.

In a similar vein, Mulder et al. (this issue) are also keen on reducing complexity. The International Classification of Diseases, 11th Revision (ICD-11) classification of personality disorders removes categories and instead has a spectrum of trait domains (Negative Affectivity, Detachment, Disinhibition, Dissociability and Anankastia). There is one qualifier, borderline pattern. Mulder et al. (this issue) demonstrate that borderline symptoms are already well represented within the severity/domain matrix and that the borderline qualifier is perhaps not necessary.

Once again, the ANZJP addresses a broad range of issues and does so in a variety of formats. It also offers opportunities to those that wish to contribute and comment as exemplified by the stellar efforts of A/Prof Jeff Looi – whose articles feature throughout this issue across a range of topics.