Causalities

Mental disorders are probably as old as our species. In this context, it is interesting that attention-deficit hyperactivity disorder (ADHD) may have been present in Classical Greece. Writing from Brazil, Victor et al. (this issue) propose that the third-century BC scholar Theophrastus described a person with many of the attributes set out for this syndrome in today’s Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5). If this is the case, it weakens the argument that the syndrome is related to adverse living conditions in contemporary Western society and the pharmaceutical industry. As one of our reviewers expressed it,

While the authors’ claim that the ‘obtuse man’ would likely be diagnosed with ADHD today cannot be fully substantiated, the search for antiquity analogues or precursors of present day psychiatric concepts and classifications is meaningful, potentially widening the horizon of psychiatry practitioners and trainees.

The latter is precisely one of our Journal’s aspirations. Readers who find enjoyment in antiquity analogues will appreciate the magisterial work, ‘Mind and Madness in Ancient Greece’ by Simon (1978).

Witt et al. (this issue) correctly state that many persons who have killed themselves or carried out acts of self-harm were intoxicated at the time. They go on to propose that reducing the availability of alcohol would therefore reduce the suicide rate. Yet tackling alcohol misuse is notably absent from suicide prevention strategies, a topic currently accorded so much attention. Witt and her colleagues are almost certainly right. But the chances of successful reform in alcohol misuse are infinitesimal. The resources of the international alcohol industry are so much stronger than the tobacco industry, whose vigorous resistance to reducing smoking is well known. At a global level, the World Health Organization (2014) has tried to do for alcohol what has been achieved for tobacco, so far with little progress. Milner and Maheen (this issue) suggest that there is another anomaly in suicide prevention, this time at a local level. Some readers may not know that the Australian Department of Health recently divided the country into 31 Primary Health Networks (PHNs) to improve the delivery of services. According to these authors’ analysis, the allocation of Commonwealth funds for the prevention of suicide in each PHN is not commensurate with its suicide rate. One has to ask what the consequences of this might be and what factors determine the allocation – which apparently varies more than sixfold! On the topic of attempted suicide, Kerr et al. (this issue) have conducted a cross-sectional case–control study on Military personnel treated as outpatients for post-traumatic stress disorder (PTSD) in a Brisbane hospital with a special treatment programme for this syndrome. They found a number of attributes that characterise those veterans who reported a past suicide attempt. This leads them to propose that interventions targeted at some of these attributes will be useful for prevention of suicidality.

Returning to substance misuse, psychosis after using ‘Ice’ has become an all-too-familiar presentation in our hospitals, but it also raises some important questions on causality. What does amphetamine and methamphetamine do to the brain to produce psychotic symptoms? Why can some people take the drug frequently but not become psychotic? Why do the symptoms persist in some patients but not in others? Above all, what can be done for prevention? In a large collaborative study using exemplary methodology, Arunogiri et al. (this issue) have made an invaluable contribution to our understanding of what factors increase or do not increase the risk of psychosis. Perhaps surprisingly, only one variable was found to have a moderate-to-large effect size: frequency of use. The list of factors showing no association is impressive, but also useful in developing prevention.

Australia and New Zealand have excelled in conducting large-scale population surveys, both cross-sectional and longitudinal. An outstanding example is the Australian National Survey of High Impact Psychosis which has yielded information of great practical use. Waterreus and Morgan (this issue) now take their work further, doing so from the viewpoint of some 1825 patients themselves, but also 1473 general practitioners (GPs) involved in their care. Remarkably, 90% of patients had seen their GP in the previous 12 months, many of them more than monthly, which is much higher than the general population. It is really encouraging that 78% of GPs said they want to look after their psychotic patients but – and this deserves our attention – over a third had had no correspondence from their patients’ psychiatrists. Here is something we could improve in our own practice. Coming from France, a very contrasted paper on psychosis uses latent class analysis on a general population sample of over 38,000 people, confirming that psychosis too may exist as a continuum in the community, its symptoms occurring in more than the people we encounter in our clinics (Pignon et al., this issue). Could it be that once again Sir George Pickering, referring to hypertension, was correct that Medicine in its present state can count up to two, but not beyond?

In another population-based study, Green et al. (this issue) used data from the New South Wales Child Development Study on 67,353 children, but they further enriched it with record-linkage to those children’s parents who had had a mental illness or convictions for offending. They sought to identify not individuals but classes of children at risk for mental disorder in adult life, again using latent class analysis. Their findings deserve close attention, particularly in efforts towards prevention. A strong association was found between child maltreatment before the age of 5 years and membership of all three classes of risk. By comparison, parental mental illness or criminal offending had a relatively small association. To the present writer, such work points once more to the value of using record-linkage whenever the opportunity offers.

The Black Saturday bushfires of 2009 killed 173 people and continue to disable many of the survivors. The mental health of some of them has now been assessed on two occasions, the second being 5 years after the fires. In reporting their findings, Bryant et al. (this issue) start by setting out a most useful overview of the mental health consequences of man-made and natural disasters. In their sample, they found considerable changes in symptom levels had taken place over the 5 years. About half of the respondents with symptoms at the first examination had improved, but an important finding is that 7% who had been well at first had subsequently developed PTSD, depression, heavy drinking or severe distress. This delay in onset needs to be recognised by clinicians and policy-makers alike. Bryant et al. point out that sub-syndromal morbidity, in which individuals do not reach our arbitrary thresholds for a diagnosis but are arithmetically greater in number, is the source of considerable disability and distress.

In the Reflection, ‘We need to talk about Kevin’ (Abbass and Anand, this issue), the fundamental agenda once again is causality. Finally are two refreshing Commentaries. Fletcher et al. (this issue) urge that the recognition and treatment of Bipolar II disorder is unsatisfactory, much to the detriment of people with chronic mood instability and poor quality of life. They call for an improved definition of the disorder. But Malhi et al. (this issue) disagree, arguing that further parsing of the bipolar syndrome, itself a spectrum, will lead nowhere. They say the debate about Bipolar II disorder is over. There is only one entity and they have written a limerick to end the story!