Abstract
As psychiatrists and other mental health professionals, perhaps more than in any other medical speciality, we deal with uncertainty and complexity in every aspect of our work. We also deal with tragic illnesses and outcomes such as psychosis in young people, homicide and suicide which exert significant impact on the community and of course are of great interest to politicians and the media. This presents a particular challenge. How can information be presented clearly, and in an easily understandable form but still adequately represent the true complexity of any situation? This month's journal both illustrates some of the potential problems in this area and presents examples of how these dilemmas may be dealt with.
Kalucy et al (1) examine the important issue of the reporting of homicide by people with mental illness and produce interesting and encouraging evidence that, at least during the study duration, there was not a bias in British newspapers towards reporting homicides committed by offenders with a history of contact with mental health services as compared with those without any history of contact. However, as they point out, this does not mean that the reporting of homicides by mentally unwell people is done in a way which does not lead to further stigma of people with mental illness.
It is often said that people get the “Press” they deserve and perhaps such media coverage is more indicative of the attitudes of the general population. Education initiatives, either for specific groups or the general population, may represent an important method to counter stigma. O'Reilly et al (2) report such an initiative amongst Pharmacists – a group who often have close and repeated contact with those with a mental illness and who, by virtue of their attitudes, potentially have a significant impact on the well being of patients. The results are encouraging with Mental Health First Aid training having a measurably positive effect on pharmacists’ attitudes towards mental illness.
The same challenge of balancing uncertainty and complexity with the need for rigor attends the training of junior psychiatrists who will of course go on to become advocates and opinion leaders in the mental health field themselves. MacDonald and Ellis (3) studied the supervision of registrars and its relationship to the requirements of the RANZCP examinations. Generally, supervision did not focus on theoretical study and structured case presentation until close to the examination. MacDonald and Ellis suggest that “if the requirements of the examination do represent the standards expected of psychiatrists, then it is the daily practise and supervision of trainees that needs to change, rather than the examination”. Perhaps adopting these standards in supervision might help psychiatrists in general, despite the uncertainties that they face, to be more rigorous and structured in their day to day practise.
Finally, a balance cannot be reached unless mental health professionals are able to acknowledge and debate the uncertainties in our practise. The journal begins this month with a debate about an important and much publicised area of psychiatry. In their Editorial, Rosenman and Anderson (4) question not only the “zealous pursuit of prodromal diagnosis of psychosis” but go on to question the whole concept of “psychosis”. The subsequent two Editorials by McGorry (5) and then Jorm (6) illustrate a great deal of common ground in this debate including the need for rigorous assessment of the symptoms and needs of patients in the “ultra high risk” group, without pre-conceptions regarding the likely outcome, and the need for careful evaluation of therapies that may be helpful in these groups. Such vigorous debate is essential in helping us reach a middle ground where we accept the uncertainty of our field but continue to work positively within the limits of the evidence we have.