551668 research-article2014
ANP0010.1177/0004867414551668Australian & New Zealand Journal of PsychiatryHenderson
ANZJP This Month
What really happens
Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(10) 887–888 DOI: 10.1177/0004867414551668
Scott Henderson
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
The care of those disabled by severe and persistent mental illness involves much more than antipsychotics and intermittent contact by clinical staff. Such people are also helped by having access to general medical care, housing, human contact, community and domiciliary services, income security and employment. But these resources, coming as they do from governmental and non-governmental agencies separate from mental health, will act in a haphazard and fragmented manner if not coordinated. Yet they rarely are. In an exemplary undertaking in health services research, Whiteford et al. (2014) in this issue ask if intersectoral linkage really does improve the outcome. For this, they have examined no fewer than 40 studies. They try to identify what promotes or hinders the sought-after coordination. The context of this magisterial work is that in 2011, some $550 million was allocated by the Australian Government (prior to the Election) to improve between-service partnerships. To this writer, a particular merit of the study is how the authors dissect their data to identify what meets with success or failure, and indeed how either of these is to be recognised. It seems that where the agencies are well-harnessed together, they themselves function better, as well as bringing patient benefit according to some hard indicators. Exceptions to success were also identified, which is always useful in bringing about real change. Also in this issue, Stanley and Laugharne (2014) present algorithms for the management of physical health problems that may lead to better care of people with severe mental illness.
While there is full recognition that much greater medical morbidity exists in this population in all countries, its actual recognition in clinical practice invariably lags, followed inevitably by medical neglect. In an era where human rights are accorded such prominence, surely here is an indisputable example of inequality? In addition to the familiar components of general health assessment, the authors explicitly add a physical examination to routine assessment. Would that this became standard practice. Stanley and Laugharne go further than ascertainment of pathology in that their algorithms propose what specific action should be taken where abnormality is detected. From a touch of despondency we move with a whiff of excitement to another paper in this issue on functional magnetic resonance imaging (fMRI) studies. Scognamiglio and Houenou (2014), writing from an INSERM Unit in France (the equivalent of NHMRC, ARC or MRC), introduce us to a relatively new way of examining the brain with neuroimaging. These authors do not have their own data, but synthesise 21 fMRI studies of the brains, not of people with schizophrenia, but of their relatives who, so far, had not developed that syndrome. Their meta-analysis is ‘voxel-based’, a voxel being a compound of volume and pixel (or tiny picture). The study compares the concentration of grey or white matter in the whole brains of relatives and controls. So far, so good. Their study seems to be innovative in one important respect. In the past, investigators have focused on brain regions selected
a priori on some hypothesised grounds, thereby often depriving themselves (and others) of finding the unexpected elsewhere. The voxelbased approach looks at the whole brain and is thereby unbiased in this regard. This study found that relatives were different in engagement of the cingulate gyrus when undertaking either cognitive or emotional tasks. The authors propose that this finding could be used as a new endophenotype for this group of psychoses. All psychotropic medication is being used at an ever-increasing rate, here as in the USA and UK. Now Karanges et al. (2014), publishing in this issue, have made admirable use of Australia’s database for prescriptions, maintained for many years by the Department of Human Services. They look at the 4-year period 2009–2013, paying particular attention to young persons and prescriber specialty. Admittedly the data do not include scripts for inpatients or private scripts and the database is limited in its ability to identify off-label prescribing. The latter is probably considerable for antipsychotics being used for anxiety and insomnia, especially in general practice. That apart, the increased rates, taking place over no more than these 4 years, are striking. And this holds for all the psychotropics. When National Institute for Mental Health Research, The Australian National University, Canberra, Australia Corresponding author: Scott Henderson, National Institute for Mental Health Research, The Australian National University, Canberra, ACT 0200, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(10)
Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
888 the Better Access program was introduced in Australia in 2006 – to the envy of other countries – there was hope that the availability of psychotherapy from psychologists might encourage a reduction in psychotropic prescribing by GPs. That has not happened. In fact, for children and adolescents there are dramatic increases in antidepressants and antipsychotics over the 4-year period. Medication for attention deficit hyperactivity disorder in those aged over 25 years has risen markedly. As the pharmaceutical industry has long known, GPs account for most scripts for antidepressants. Now the figure is 90% of all such prescriptions. For antipsychotics, GPs prescribed 70% in 2012, with an increase particularly in the atypicals over the 4 years. The authors draw attention to the possible consequences for weight gain and sedation at the population level. Having grasped from this study what is happening nationally, one cannot fail to ask to what use the present findings will now be put? Should the pattern of prescribing be changed, and, if so, by what agencies, and by what mechanism? Jordan et al. (2014) in this issue describe their pilot study of the latest psychological treatment: metacognitive therapy. Metacognitive therapy sets out selectively to target the sources of distress, but they found little difference between the efficacy of it and the original. This pilot study,
ANZJP This Month conducted independently of those who developed the metacognitive variant, is too limited in size to establish any real differences in efficacy. It does, though, lead to a better estimate of the numbers needed in future comparative trials. In a prospective population-based study of 618 women examined three times at 4-year intervals, Leach et al. (2014) report in this issue that in the 76 who became pregnant, there was a reduction in anxiety, but no change in depressive symptoms. This suggests that pregnancy is not detrimental to women’s health. Symptoms were measured by self-report on a wellestablished scale, appropriately modified for bias due to pregnancy. This work comes from the prospective longitudinal PATH (Personal and Total Health Through Life) Study of a large cohort from the general population in Canberra and Queanbeyan, started 15 years ago (e.g. Caldwell et al., 2002). The authors interpret their findings with commendable care by considering how these compare with other population-based estimates. Alas, as so often emerges when epidemiological data are used for comparisons, whether within or between countries or across time periods, no clear conclusion can be reached because so many other variables are at play. The people examined, their social environment and the way their symptoms were elicited can
so often account for any observed differences. In the contemporary world, being pregnant must, as it always has, bring very diverse experiences in its train, with equally diverse affective accompaniments. References Caldwell TM, Rodgers B, Jorm AF, et al. (2002) Patterns of association between alcohol consumption and symptoms of depression and anxiety in young adults. Addiction 97: 583–594. Jordan J, Carter JD, McIntosh VV, et al. (2014) Metacognitive therapy versus cognitive behaviour therapy for depression: A randomised pilot study. Australian and New Zealand Journal of Psychiatry 48: 932–943. Karanges EA, Stephenson CP and McGregor IS (2014) Longitudinal trends in the dispensing of psychotropic medications in Australia from 2009–2012: Focus on children, adolescents and prescriber specialty. Australian and New Zealand Journal of Psychiatry 48: 917–931. Leach LS, Christensen H and Mackinnon A (2014) Pregnancy and levels of depression and anxiety: A prospective cohort study of Australian women. Australian and New Zealand Journal of Psychiatry 48: 944–951. Scognamiglio C and Houenou J (2014) A metaanalysis of fMRI studies in healthy relatives of patients with schizophrenia. Australian and New Zealand Journal of Psychiatry 48: 907–916. Stanley S and Laugharne J (2014) Physical health algorithms for mental health care. Australian and New Zealand Journal of Psychiatry 48: 889–894. Whiteford H, McKeon G, Harris M, et al. (2014) System-level intersectoral linkages between the mental health and non-clinical support sectors: A qualitative systematic review. Australian and New Zealand Journal of Psychiatry 48: 895–906.
Australian & New Zealand Journal of Psychiatry, 48(10) Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
ANP0010.1177/0004867414551668Australian & New Zealand Journal of PsychiatryHenderson
ANZJP This Month
What really happens
Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(10) 887–888 DOI: 10.1177/0004867414551668
Scott Henderson
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
The care of those disabled by severe and persistent mental illness involves much more than antipsychotics and intermittent contact by clinical staff. Such people are also helped by having access to general medical care, housing, human contact, community and domiciliary services, income security and employment. But these resources, coming as they do from governmental and non-governmental agencies separate from mental health, will act in a haphazard and fragmented manner if not coordinated. Yet they rarely are. In an exemplary undertaking in health services research, Whiteford et al. (2014) in this issue ask if intersectoral linkage really does improve the outcome. For this, they have examined no fewer than 40 studies. They try to identify what promotes or hinders the sought-after coordination. The context of this magisterial work is that in 2011, some $550 million was allocated by the Australian Government (prior to the Election) to improve between-service partnerships. To this writer, a particular merit of the study is how the authors dissect their data to identify what meets with success or failure, and indeed how either of these is to be recognised. It seems that where the agencies are well-harnessed together, they themselves function better, as well as bringing patient benefit according to some hard indicators. Exceptions to success were also identified, which is always useful in bringing about real change. Also in this issue, Stanley and Laugharne (2014) present algorithms for the management of physical health problems that may lead to better care of people with severe mental illness.
While there is full recognition that much greater medical morbidity exists in this population in all countries, its actual recognition in clinical practice invariably lags, followed inevitably by medical neglect. In an era where human rights are accorded such prominence, surely here is an indisputable example of inequality? In addition to the familiar components of general health assessment, the authors explicitly add a physical examination to routine assessment. Would that this became standard practice. Stanley and Laugharne go further than ascertainment of pathology in that their algorithms propose what specific action should be taken where abnormality is detected. From a touch of despondency we move with a whiff of excitement to another paper in this issue on functional magnetic resonance imaging (fMRI) studies. Scognamiglio and Houenou (2014), writing from an INSERM Unit in France (the equivalent of NHMRC, ARC or MRC), introduce us to a relatively new way of examining the brain with neuroimaging. These authors do not have their own data, but synthesise 21 fMRI studies of the brains, not of people with schizophrenia, but of their relatives who, so far, had not developed that syndrome. Their meta-analysis is ‘voxel-based’, a voxel being a compound of volume and pixel (or tiny picture). The study compares the concentration of grey or white matter in the whole brains of relatives and controls. So far, so good. Their study seems to be innovative in one important respect. In the past, investigators have focused on brain regions selected
a priori on some hypothesised grounds, thereby often depriving themselves (and others) of finding the unexpected elsewhere. The voxelbased approach looks at the whole brain and is thereby unbiased in this regard. This study found that relatives were different in engagement of the cingulate gyrus when undertaking either cognitive or emotional tasks. The authors propose that this finding could be used as a new endophenotype for this group of psychoses. All psychotropic medication is being used at an ever-increasing rate, here as in the USA and UK. Now Karanges et al. (2014), publishing in this issue, have made admirable use of Australia’s database for prescriptions, maintained for many years by the Department of Human Services. They look at the 4-year period 2009–2013, paying particular attention to young persons and prescriber specialty. Admittedly the data do not include scripts for inpatients or private scripts and the database is limited in its ability to identify off-label prescribing. The latter is probably considerable for antipsychotics being used for anxiety and insomnia, especially in general practice. That apart, the increased rates, taking place over no more than these 4 years, are striking. And this holds for all the psychotropics. When National Institute for Mental Health Research, The Australian National University, Canberra, Australia Corresponding author: Scott Henderson, National Institute for Mental Health Research, The Australian National University, Canberra, ACT 0200, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(10)
Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
888 the Better Access program was introduced in Australia in 2006 – to the envy of other countries – there was hope that the availability of psychotherapy from psychologists might encourage a reduction in psychotropic prescribing by GPs. That has not happened. In fact, for children and adolescents there are dramatic increases in antidepressants and antipsychotics over the 4-year period. Medication for attention deficit hyperactivity disorder in those aged over 25 years has risen markedly. As the pharmaceutical industry has long known, GPs account for most scripts for antidepressants. Now the figure is 90% of all such prescriptions. For antipsychotics, GPs prescribed 70% in 2012, with an increase particularly in the atypicals over the 4 years. The authors draw attention to the possible consequences for weight gain and sedation at the population level. Having grasped from this study what is happening nationally, one cannot fail to ask to what use the present findings will now be put? Should the pattern of prescribing be changed, and, if so, by what agencies, and by what mechanism? Jordan et al. (2014) in this issue describe their pilot study of the latest psychological treatment: metacognitive therapy. Metacognitive therapy sets out selectively to target the sources of distress, but they found little difference between the efficacy of it and the original. This pilot study,
ANZJP This Month conducted independently of those who developed the metacognitive variant, is too limited in size to establish any real differences in efficacy. It does, though, lead to a better estimate of the numbers needed in future comparative trials. In a prospective population-based study of 618 women examined three times at 4-year intervals, Leach et al. (2014) report in this issue that in the 76 who became pregnant, there was a reduction in anxiety, but no change in depressive symptoms. This suggests that pregnancy is not detrimental to women’s health. Symptoms were measured by self-report on a wellestablished scale, appropriately modified for bias due to pregnancy. This work comes from the prospective longitudinal PATH (Personal and Total Health Through Life) Study of a large cohort from the general population in Canberra and Queanbeyan, started 15 years ago (e.g. Caldwell et al., 2002). The authors interpret their findings with commendable care by considering how these compare with other population-based estimates. Alas, as so often emerges when epidemiological data are used for comparisons, whether within or between countries or across time periods, no clear conclusion can be reached because so many other variables are at play. The people examined, their social environment and the way their symptoms were elicited can
so often account for any observed differences. In the contemporary world, being pregnant must, as it always has, bring very diverse experiences in its train, with equally diverse affective accompaniments. References Caldwell TM, Rodgers B, Jorm AF, et al. (2002) Patterns of association between alcohol consumption and symptoms of depression and anxiety in young adults. Addiction 97: 583–594. Jordan J, Carter JD, McIntosh VV, et al. (2014) Metacognitive therapy versus cognitive behaviour therapy for depression: A randomised pilot study. Australian and New Zealand Journal of Psychiatry 48: 932–943. Karanges EA, Stephenson CP and McGregor IS (2014) Longitudinal trends in the dispensing of psychotropic medications in Australia from 2009–2012: Focus on children, adolescents and prescriber specialty. Australian and New Zealand Journal of Psychiatry 48: 917–931. Leach LS, Christensen H and Mackinnon A (2014) Pregnancy and levels of depression and anxiety: A prospective cohort study of Australian women. Australian and New Zealand Journal of Psychiatry 48: 944–951. Scognamiglio C and Houenou J (2014) A metaanalysis of fMRI studies in healthy relatives of patients with schizophrenia. Australian and New Zealand Journal of Psychiatry 48: 907–916. Stanley S and Laugharne J (2014) Physical health algorithms for mental health care. Australian and New Zealand Journal of Psychiatry 48: 889–894. Whiteford H, McKeon G, Harris M, et al. (2014) System-level intersectoral linkages between the mental health and non-clinical support sectors: A qualitative systematic review. Australian and New Zealand Journal of Psychiatry 48: 895–906.
Australian & New Zealand Journal of Psychiatry, 48(10) Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 4, 2015
