Abstract
While taking their dog for a walk one evening, Anthony Jorm and Betty Kitchener had a new idea. Jorm was immersed then in psychiatric epidemiology at ANU, while his wife was teaching First Aid at the Red Cross. As they walked, the idea came to them that First Aid had always been focused on physical illnesses. But why not have it also for people having acute mental health problems? In this, they made a link that had never been made before – what Arthur Koestler in his book, The Act of Creation [1] called a bisociative act, linking two previously disparate entities. The result has been an enterprise of unprecedented success, as now described by the authors themselves in this issue [2]. What came to them on that walk has now spread to 15 countries as well as Australia, where its uptake is about 1% of the adult population: a successful national export, and a public health activity that must have greatly benefited many communities. Perhaps much more effort should be given to deliberately constructing environments and circumstances where the probability of such creativity is raised.
Western Australia has been a leader in the matter of physical morbidity in persons with mental illness. The “Duty to Care” document in 2001 [3] was quickly taken up by the World Health Organization in Geneva and many groups overseas. Now Stanley and her colleagues provide a systematic method for monitoring patients [4]. It is for mental health staff and consumers, but also for general practitioners. Their package is intended to help doctors keep themselves aware of their patients' physical health, then it sets out what action ought to follow. There can be no doubt of the need for this: it is a matter all too readily overlooked. So Stanley and her colleagues deserve our appreciation for what they have made widely available. One should hope that its uptake will be vigorous, though sceptics will say that the weakness of professional motivation will limit that.
While antipsychotic drugs play a major part in keeping patients well or with manageable symptoms, their side effects can be of concern much more than we would wish. Hyperprolactinaemia is a side effect that can too readily be overlooked, unless the patient complains of these. The paper by Inder and Castle [5] is therefore both timely and a valuable reference to keep on hand. For many readers, some of what it tells us will be new. Hyperprolactinaemia is indeed common. It is particularly associated with two of the most common atypical antipsychotics but – and this is not widely known – a high prolactin level may sometimes be due to something else, such as a pituitary tumour. Where medication has induced hypogonadism, the consequence is osteoporosis with all its undesirable sequelae. Sexual dysfunction is also a further consequence for the patient to bear. Inder and Castle have usefully set out what investigations may be called for, and what corrective action is needed.
Fedyszyn and her colleagues tell us about suicide acts in young people with first episode psychosis [6]. Their sample is impressive: among some 600 patients treated in their Melbourne service over a 3-year period, 73 attempted suicide, with two completing it. The authors deliberately focus on what characterised these acts and their context. Amongst their conclusions, they advocate having risk management plans for all newly recruited patients, thereby introducing what is essentially a universal intervention within this high risk population.
In the current international climate, how pleasing it is to see an attractive piece of psychometric research come out of Iraqi Kurdistan, achieved by psychiatrists there in collaboration with UK colleagues. Mitchell et al [7] used the Rasch model to construct a parsimonious tool for detecting depressive disorder. The Rasch model is the simplest model in Item Response Theory, having only one parameter, the threshold. Rasch was a Danish statistician who in 1960 described a simple model to use when one wants to measure a single dimension. For him, this originally was intelligence [8]. Here, though, that dimension is depression. All individuals are considered to lie somewhere on that continuum. The chances of having a particular symptom will depend on that item's position on it, its so-called ‘threshold’. With a Rasch analysis, one can use data from real cases to make a screening tool that has the fewest items to achieve optimal sensitivity and specificity. This is an example of applying highly attractive statistical theory to the measurement of mental disorders. It is a field that deserves rather more attention, not least when better specification of phenotypes is becoming increasingly important because of advances in the molecular basis of mental disorders.
Opinions and recommendations about the next global classificatory systems are now like an epidemic. The careful examination of veterans' dreams by Phelps et al is one further contribution here, providing some data to guide criteria for Post Traumatic Stress Disorder (PTSD) [9]. A further contribution to phenomenology that bears on better classification comes from Starcevic et al [10]. They found that Obsessive Compulsive Disorder (OCD) patients with avoidance have a more severe illness.
There is much apprehension internationally that psychiatry is not proving attractive to medical students. Indeed, Malhi et al [11] tell us it was the least attractive of all specialties in their sample of three consecutive years of students. They also confirm what others have found: that personality does not contribute much to choice of specialty. What forces are at work that we can tackle to make changes? On the one hand, stigma against psychiatry continues to pervade our communities, including the medical profession, young or old [12]. On the other, as Malhi and his colleagues point out, psychiatry has at least as many attractions as any other specialty. It alone deals with the mind, and it is the mind that makes us human. Research in our field is now “at the frontiers of science”. But alas, the marketing of psychiatry remains very clumsy, while derision can be readily found from within our own profession and certainly from the media. What we can take from that paper is that a well-crafted plan of action is urgently needed through our own and other Colleges internationally.
When one wants to estimate the prevalence of the common mental disorders (anxiety, depression and substance abuse) in a population, but cannot justify the expense of using standardised clinical interviews, Kessler's 10-item scale has established itself as a highly efficient tool. An Australian group has already done much to develop this instrument. For both the K-10 and the ultra-brief K-6 instrument, they now provide regression weights to best estimate the prevalence of DSM-IV mood, anxiety, and substance use disorders in this general population [13]. Sunderland et al rightly caution that what they provide applies only to this general population and could not confidently be used for other groups, here or overseas. Furthermore, it should be used to detect morbidity only for the last month, not a year.
As this issue well illustrates, the Journal is providing a valuable service to psychiatry in Australasia and, increasingly, internationally. It is an important vehicle for further progress.