536668 research-article2014
ANP0010.1177/0004867414536668Australian and New Zealand Journal of PsychiatryBerk et al.
ANZJP This Month
Psychiatric disorders in primary care
Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(6) 497–499 DOI: 10.1177/0004867414536668
Michael Berk1,2, Lesley Berk3,4 and Tim Denton5,6
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
The focus of this month’s issue of the Journal is primary care, with articles examining both the practice of psychiatry in a primary care setting, as well as a focus on specific clinical disorders that manifest predominantly in the context of primary care. One of the most common groups of problems in primary care pertains to the consequences of alcohol abuse, which causes a diversity of health, social and behavioural harms. Sellman and colleagues (2014) document the evolution of the conceptualisation of alcohol use in the community. One of the critical challenges in the care of people with alcohol abuse or dependence is what advice a clinician should give regarding either abstinence or controlled drinking. Now that alcoholism in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), rebadged as ‘alcohol use disorder’, is seen as representing a severity spectrum across a continuum, the authors suggest that abstinence goals too should be considered on a continuum, and should be individualised and defined according to flexible time-based goals. They argue that removing the judgemental term ‘abuse’ facilitates a greater integration into mainstream approaches, such as primary care, removing the moral implications of the term abuse. As exemplars they cite reports from public health campaigns advocating a month’s abstinence, showing that they may be associated with health benefits. Nevertheless, they recommend that well-conducted randomised trials need to be implemented to explore the suitability of advice across the
continuum of severity of alcohol intake. Bou Khalil (2014) tackles the thorny issue of suicide. He firstly examines whether this equates to the presence of psychiatric disorders, and, secondly, the conceptualisation of suicide among ideologically militarised individuals who commit suicide in an attempt to meet other social, religious or political objectives. The paper debates the boundaries between auto- and hetero-aggressive behaviours, emphasising the perceived stressful environmental context of such behaviour. Goldney (2014), however, argues that, in this context, it is timely to consider altering the terminology we use for politically motivated harm to self and others. Nosology has the capacity to modify attitudes and, hence, behaviour. While suicide has the aura of potentially being altruistic, there is nothing glamorous or altruistic about homicide, suggesting that a change in nosology from ‘suicide bomber’ to ‘homicide bomber’ may gradually change the interpretation and acceptability of this behaviour. A parochial example is the replacement of the term ‘king hit’ by ‘coward punch’ in the reporting of violent behaviour. Goldney urges a similar gradual transition to new terminology. The twin models of staging and early intervention (McGorry, 2012) have been a powerful influence on clinical thinking. These two models have been major drivers of service reform in Australia and the launch of the EPPIC (Early Psychosis Prevention and Intervention Centre) service
models in primary care settings is the fulfillment of this translational initiative (Henry et al., 2010). In this context, Davis and colleagues (2014) examine the mechanistic pathways of the process of neuroprogression in schizophrenia that is thought to underpin clinical staging. Concordant with the ‘two hits’ hypothesis of schizophrenia (Maynard et al., 2001), this paper suggests that hits occurring in early development lead to a sensitised inflammatory response, epigenetic changes and neuronal disruption, sensitising the system to a second hit. The unfolding process of neuroprogression includes further inflammation, oxidative distress, mitochondrial dysfunction, apoptosis and changes in neural plasticity. This conceptualisation suggests a novel family of potential therapeutic and preventive targets (Jacka and Berk, 2014).
1IMPACT
Strategic Research Centre, Deakin University, Melbourne, Australia 2Department of Psychiatry, Orygen Research Centre, and the Florey Institute for Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia 3Mental Health and Wellbeing Strategic Research Centre, School of Psychology, Deakin University, Melbourne, Australia 4Department of Psychiatry, University of Melbourne, Melbourne, Australia 5School of Medicine, Deakin University, Geelong, Australia 6Barwon Medicare Local, Geelong, Australia Corresponding author: Michael Berk, IMPACT Strategic Research Centre, School of Medicine, Deakin University, 75 Pigdon’s Road, Waurn Ponds, Geelong, VIC 3216, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(6)
498 Chronic renal disease is a common and complex problem in primary care. Bautovich and colleagues (2014) review the management of depression in chronic kidney disease. As is the case with the comorbidity of depression and other medical disorders such as cardiovascular disease, obesity, diabetes and osteoporosis, these relationships are complex, bidirectional and multifactorial (O’Neil et al., 2012; Pasco et al., 2013). These guidelines highlight the clinical management of this comorbidity, providing guidance for contemporary management. Continuing the primary care theme, Malhi and colleagues (2014) look at the diagnosis of depression in primary care, examining which symptoms and clinical patterns primary care practitioners use in diagnosing and grading depression. They find that, although practitioners use a range of somatic, emotional and related symptomatology to assess depression, somatic phenomenology is weighted most heavily in their assessments. Additionally, in the assessment of severity, suicidal thoughts and risk of self-harm dominate, together with anhedonia and difficulty with activities. The authors recommend that more information about subtyping depression and its treatment implications, as well as how to differentiate self-harm and suicide attempt, would result in more effective care. If assessment is difficult in adults, it is fraught in childhood. Sawyer and colleagues (2014) examine the predictive capacity of screening 4–5-year-old children to predict mental health problems 2 years later. Using the Strengths and Difficulties Questionnaire, they found very poor sensitivity, but high specificity for parent-reported childhood mental health problems predicting subsequent teacher-rated difficulties. In simple terms, three-quarters of children identified as ‘at risk’ were incorrectly labelled. From a preventative perspective, these children would be at risk of stigmatisation and inappropriate therapy. This difficulty in
ANZJP This Month accurate identification is a major obstacle in the implementation of early intervention programs. Following on the theme of assessment of depression in primary care, Carey and colleagues (2014) compared the use of a screening instrument, the Patient Health Questionnaire-9, to clinical assessment. While the two methods of assessment resulted in similar depression prevalence rates, clinical judgement had relatively poor sensitivity, although high specificity in the diagnosis of depression. Put simply, using the instrument as the gold standard, a person identified as having depression has only a 50% chance of being diagnosed by a general practitioner (GP). While this may represent true misclassification, it may also reflect a conservative approach to diagnosis or a problembased rather than diagnosis-based approach to management. The authors suggested ways to increase the utilisation of validated screening instruments, including the potential of online and tablet-based methodologies. Lastly, Watson and colleagues (2014) compared a cohort of individuals with bipolar disorder to a healthy control group to evaluate the impact of childhood trauma in bipolar disorder. They found that childhood trauma, in particular emotional neglect, was more common in people with bipolar disorder. This adds to the literature confirming that childhood trauma is a non-specific risk factor for a wide array of psychiatric disorders and may be an adverse prognostic indicator (Conus et al., 2010; Singh et al., 2013). It reinforces the imperative in a clinical context for a high degree of acuity in the detection of abuse and suggests the importance of intervention. It also highlights the critical role of changing societal attitudes to abuse and its consequences as exemplified by the current Royal Commission into Institutional Responses to Child Sexual Abuse (Berk et al., 2014). Ultimately, these articles lead us to conclude that more effective earlier
Australian & New Zealand Journal of Psychiatry, 48(6)
intervention in chronic disease could be achieved by liaising more closely with primary health care. Essentially, general practice manages multiple morbidity well, but if a shared-care concept were developed to further the management of high-prevalence psychiatric conditions in the setting of chronic disease management, it would no doubt streamline the patent’s journey. This could be achieved quite easily by psychiatric services, public or private, working in close collaboration with primary health care clinics, where a patient would be managed day to day in the primary health care setting, but, in more difficult times, could hopefully gain access to specialist services in a timely manner. This works well, for example, in sharedcare obstetrics in the public sector, and with clozapine clinics where GPs see clozapine patients monthly with 6-month reviews by the psychiatric team. The national youth mental health foundation ‘headspace’ has shown that good collaboration between a youth-focused primary health team and the area mental health service gives a better outcome for the patients who are reaching out to such services in increasing numbers. If early intervention in chronic disease is to be adopted, then primary health care must be a crucial part of an integrated service. Better collaboration will promote greater professional development of primary health care professionals, who would then be able to help share more of the burden in mental health, especially where there is multi-morbidity. References Bautovich A, Katz I, Smith M, et al. (2014) Depression and chronic kidney disease: A review for clinicians. Australian and New Zealand Journal of Psychiatry 48: 530–541. Berk M, Moylan S and Jacka FN (2014) A Royal gift to prevention efforts. Australian and New Zealand Journal of Psychiatry 48: 110–111. Bou Khalil R (2014) To be or not to let others be: Is it relevant to the mental health field? Australian and New Zealand Journal of Psychiatry 48: 505–506. Carey M, Jones K, Meadows G, et al. (2014) Accuracy of general practitioner unassisted
499
Berk et al. detection of depression. Australian and New Zealand Journal of Psychiatry 48: 571–578. Conus P, Cotton S, Schimmelmann BG, et al. (2010) Pretreatment and outcome correlates of past sexual and physical trauma in 118 bipolar I disorder patients with a first episode of psychotic mania. Bipolar Disorders 12: 244–252. Davis J, Moylan S, Harvey BH, et al. (2014) Neuroprogression in schizophrenia: Pathways underpinning clinical staging and therapeutic corollaries. Australian and New Zealand Journal of Psychiatry 48: 512–529. Goldney RD (2014) Time for change: Homicide bombers, not suicide bombers. Australian and New Zealand Journal of Psychiatry 48: 579–580. Henry LP, Amminger GP, Harris MG, et al. (2010) The EPPIC follow-up study of first-episode psychosis: Longer-term clinical and functional outcome 7 years after index admission. Journal of Clinical Psychiatry 71: 716–728. Jacka FN and Berk M (2014) Prevention of schizophrenia – Will a broader prevention agenda
support this aim? Schizophrenia Bulletin 40: 237–239. McGorry PD (2012) Truth and reality in early intervention. Australian and New Zealand Journal of Psychiatry 46: 313–316. Malhi GS, Coulston CM, Fritz K, et al. (2014) Unlocking the diagnosis of depression in primary care: Which key symptoms are GPs using to determine diagnosis and severity? Australian and New Zealand Journal of Psychiatry 48: 542–547. Maynard TM, Sikich L, Lieberman JA, et al. (2001) Neural development, cell-cell signaling, and the ‘two-hit’ hypothesis of schizophrenia. Schizophrenia Bulletin 27: 457–476. O’Neil A, Williams ED, Stevenson CE, et al. (2012) Co-morbid cardiovascular disease and depression: Sequence of disease onset is linked to mental but not physical self-rated health. Results from a cross-sectional, populationbased study. Social Psychiatry and Psychiatric Epidemiology 47: 1145–1151.
Pasco JA, Williams LJ, Jacka FN, et al. (2013) Obesity and the relationship with positive and negative affect. Australian and New Zealand Journal of Psychiatry 47: 477–482. Sawyer ACP, Chittleborough CR and Lynch JW (2014) Can screening 4–5 year olds accurately identify children who will have teacherreported mental health problems when children are aged 6–7 years? Australian and New Zealand Journal of Psychiatry 48: 554–563. Sellman JD, Foulds JA, Adamson SJ, et al. (2014) DSM-5 alcoholism: A 60-year perspective. Australian and New Zealand Journal of Psychiatry 48: 507–511. Singh AB, Bousman CA, Ng CH, et al. (2013) High impact child abuse may predict risk of elevated suicidality during antidepressant initiation. Australian and New Zealand Journal of Psychiatry 47: 1191–1195. Watson S, Gallagher P, Dougall D, et al. (2014) Childhood trauma in bipolar disorder. Australian and New Zealand Journal of Psychiatry 48: 564–570.
Australian & New Zealand Journal of Psychiatry, 48(6)
ANP0010.1177/0004867414536668Australian and New Zealand Journal of PsychiatryBerk et al.
ANZJP This Month
Psychiatric disorders in primary care
Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(6) 497–499 DOI: 10.1177/0004867414536668
Michael Berk1,2, Lesley Berk3,4 and Tim Denton5,6
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
The focus of this month’s issue of the Journal is primary care, with articles examining both the practice of psychiatry in a primary care setting, as well as a focus on specific clinical disorders that manifest predominantly in the context of primary care. One of the most common groups of problems in primary care pertains to the consequences of alcohol abuse, which causes a diversity of health, social and behavioural harms. Sellman and colleagues (2014) document the evolution of the conceptualisation of alcohol use in the community. One of the critical challenges in the care of people with alcohol abuse or dependence is what advice a clinician should give regarding either abstinence or controlled drinking. Now that alcoholism in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), rebadged as ‘alcohol use disorder’, is seen as representing a severity spectrum across a continuum, the authors suggest that abstinence goals too should be considered on a continuum, and should be individualised and defined according to flexible time-based goals. They argue that removing the judgemental term ‘abuse’ facilitates a greater integration into mainstream approaches, such as primary care, removing the moral implications of the term abuse. As exemplars they cite reports from public health campaigns advocating a month’s abstinence, showing that they may be associated with health benefits. Nevertheless, they recommend that well-conducted randomised trials need to be implemented to explore the suitability of advice across the
continuum of severity of alcohol intake. Bou Khalil (2014) tackles the thorny issue of suicide. He firstly examines whether this equates to the presence of psychiatric disorders, and, secondly, the conceptualisation of suicide among ideologically militarised individuals who commit suicide in an attempt to meet other social, religious or political objectives. The paper debates the boundaries between auto- and hetero-aggressive behaviours, emphasising the perceived stressful environmental context of such behaviour. Goldney (2014), however, argues that, in this context, it is timely to consider altering the terminology we use for politically motivated harm to self and others. Nosology has the capacity to modify attitudes and, hence, behaviour. While suicide has the aura of potentially being altruistic, there is nothing glamorous or altruistic about homicide, suggesting that a change in nosology from ‘suicide bomber’ to ‘homicide bomber’ may gradually change the interpretation and acceptability of this behaviour. A parochial example is the replacement of the term ‘king hit’ by ‘coward punch’ in the reporting of violent behaviour. Goldney urges a similar gradual transition to new terminology. The twin models of staging and early intervention (McGorry, 2012) have been a powerful influence on clinical thinking. These two models have been major drivers of service reform in Australia and the launch of the EPPIC (Early Psychosis Prevention and Intervention Centre) service
models in primary care settings is the fulfillment of this translational initiative (Henry et al., 2010). In this context, Davis and colleagues (2014) examine the mechanistic pathways of the process of neuroprogression in schizophrenia that is thought to underpin clinical staging. Concordant with the ‘two hits’ hypothesis of schizophrenia (Maynard et al., 2001), this paper suggests that hits occurring in early development lead to a sensitised inflammatory response, epigenetic changes and neuronal disruption, sensitising the system to a second hit. The unfolding process of neuroprogression includes further inflammation, oxidative distress, mitochondrial dysfunction, apoptosis and changes in neural plasticity. This conceptualisation suggests a novel family of potential therapeutic and preventive targets (Jacka and Berk, 2014).
1IMPACT
Strategic Research Centre, Deakin University, Melbourne, Australia 2Department of Psychiatry, Orygen Research Centre, and the Florey Institute for Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia 3Mental Health and Wellbeing Strategic Research Centre, School of Psychology, Deakin University, Melbourne, Australia 4Department of Psychiatry, University of Melbourne, Melbourne, Australia 5School of Medicine, Deakin University, Geelong, Australia 6Barwon Medicare Local, Geelong, Australia Corresponding author: Michael Berk, IMPACT Strategic Research Centre, School of Medicine, Deakin University, 75 Pigdon’s Road, Waurn Ponds, Geelong, VIC 3216, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(6)
498 Chronic renal disease is a common and complex problem in primary care. Bautovich and colleagues (2014) review the management of depression in chronic kidney disease. As is the case with the comorbidity of depression and other medical disorders such as cardiovascular disease, obesity, diabetes and osteoporosis, these relationships are complex, bidirectional and multifactorial (O’Neil et al., 2012; Pasco et al., 2013). These guidelines highlight the clinical management of this comorbidity, providing guidance for contemporary management. Continuing the primary care theme, Malhi and colleagues (2014) look at the diagnosis of depression in primary care, examining which symptoms and clinical patterns primary care practitioners use in diagnosing and grading depression. They find that, although practitioners use a range of somatic, emotional and related symptomatology to assess depression, somatic phenomenology is weighted most heavily in their assessments. Additionally, in the assessment of severity, suicidal thoughts and risk of self-harm dominate, together with anhedonia and difficulty with activities. The authors recommend that more information about subtyping depression and its treatment implications, as well as how to differentiate self-harm and suicide attempt, would result in more effective care. If assessment is difficult in adults, it is fraught in childhood. Sawyer and colleagues (2014) examine the predictive capacity of screening 4–5-year-old children to predict mental health problems 2 years later. Using the Strengths and Difficulties Questionnaire, they found very poor sensitivity, but high specificity for parent-reported childhood mental health problems predicting subsequent teacher-rated difficulties. In simple terms, three-quarters of children identified as ‘at risk’ were incorrectly labelled. From a preventative perspective, these children would be at risk of stigmatisation and inappropriate therapy. This difficulty in
ANZJP This Month accurate identification is a major obstacle in the implementation of early intervention programs. Following on the theme of assessment of depression in primary care, Carey and colleagues (2014) compared the use of a screening instrument, the Patient Health Questionnaire-9, to clinical assessment. While the two methods of assessment resulted in similar depression prevalence rates, clinical judgement had relatively poor sensitivity, although high specificity in the diagnosis of depression. Put simply, using the instrument as the gold standard, a person identified as having depression has only a 50% chance of being diagnosed by a general practitioner (GP). While this may represent true misclassification, it may also reflect a conservative approach to diagnosis or a problembased rather than diagnosis-based approach to management. The authors suggested ways to increase the utilisation of validated screening instruments, including the potential of online and tablet-based methodologies. Lastly, Watson and colleagues (2014) compared a cohort of individuals with bipolar disorder to a healthy control group to evaluate the impact of childhood trauma in bipolar disorder. They found that childhood trauma, in particular emotional neglect, was more common in people with bipolar disorder. This adds to the literature confirming that childhood trauma is a non-specific risk factor for a wide array of psychiatric disorders and may be an adverse prognostic indicator (Conus et al., 2010; Singh et al., 2013). It reinforces the imperative in a clinical context for a high degree of acuity in the detection of abuse and suggests the importance of intervention. It also highlights the critical role of changing societal attitudes to abuse and its consequences as exemplified by the current Royal Commission into Institutional Responses to Child Sexual Abuse (Berk et al., 2014). Ultimately, these articles lead us to conclude that more effective earlier
Australian & New Zealand Journal of Psychiatry, 48(6)
intervention in chronic disease could be achieved by liaising more closely with primary health care. Essentially, general practice manages multiple morbidity well, but if a shared-care concept were developed to further the management of high-prevalence psychiatric conditions in the setting of chronic disease management, it would no doubt streamline the patent’s journey. This could be achieved quite easily by psychiatric services, public or private, working in close collaboration with primary health care clinics, where a patient would be managed day to day in the primary health care setting, but, in more difficult times, could hopefully gain access to specialist services in a timely manner. This works well, for example, in sharedcare obstetrics in the public sector, and with clozapine clinics where GPs see clozapine patients monthly with 6-month reviews by the psychiatric team. The national youth mental health foundation ‘headspace’ has shown that good collaboration between a youth-focused primary health team and the area mental health service gives a better outcome for the patients who are reaching out to such services in increasing numbers. If early intervention in chronic disease is to be adopted, then primary health care must be a crucial part of an integrated service. Better collaboration will promote greater professional development of primary health care professionals, who would then be able to help share more of the burden in mental health, especially where there is multi-morbidity. References Bautovich A, Katz I, Smith M, et al. (2014) Depression and chronic kidney disease: A review for clinicians. Australian and New Zealand Journal of Psychiatry 48: 530–541. Berk M, Moylan S and Jacka FN (2014) A Royal gift to prevention efforts. Australian and New Zealand Journal of Psychiatry 48: 110–111. Bou Khalil R (2014) To be or not to let others be: Is it relevant to the mental health field? Australian and New Zealand Journal of Psychiatry 48: 505–506. Carey M, Jones K, Meadows G, et al. (2014) Accuracy of general practitioner unassisted
499
Berk et al. detection of depression. Australian and New Zealand Journal of Psychiatry 48: 571–578. Conus P, Cotton S, Schimmelmann BG, et al. (2010) Pretreatment and outcome correlates of past sexual and physical trauma in 118 bipolar I disorder patients with a first episode of psychotic mania. Bipolar Disorders 12: 244–252. Davis J, Moylan S, Harvey BH, et al. (2014) Neuroprogression in schizophrenia: Pathways underpinning clinical staging and therapeutic corollaries. Australian and New Zealand Journal of Psychiatry 48: 512–529. Goldney RD (2014) Time for change: Homicide bombers, not suicide bombers. Australian and New Zealand Journal of Psychiatry 48: 579–580. Henry LP, Amminger GP, Harris MG, et al. (2010) The EPPIC follow-up study of first-episode psychosis: Longer-term clinical and functional outcome 7 years after index admission. Journal of Clinical Psychiatry 71: 716–728. Jacka FN and Berk M (2014) Prevention of schizophrenia – Will a broader prevention agenda
support this aim? Schizophrenia Bulletin 40: 237–239. McGorry PD (2012) Truth and reality in early intervention. Australian and New Zealand Journal of Psychiatry 46: 313–316. Malhi GS, Coulston CM, Fritz K, et al. (2014) Unlocking the diagnosis of depression in primary care: Which key symptoms are GPs using to determine diagnosis and severity? Australian and New Zealand Journal of Psychiatry 48: 542–547. Maynard TM, Sikich L, Lieberman JA, et al. (2001) Neural development, cell-cell signaling, and the ‘two-hit’ hypothesis of schizophrenia. Schizophrenia Bulletin 27: 457–476. O’Neil A, Williams ED, Stevenson CE, et al. (2012) Co-morbid cardiovascular disease and depression: Sequence of disease onset is linked to mental but not physical self-rated health. Results from a cross-sectional, populationbased study. Social Psychiatry and Psychiatric Epidemiology 47: 1145–1151.
Pasco JA, Williams LJ, Jacka FN, et al. (2013) Obesity and the relationship with positive and negative affect. Australian and New Zealand Journal of Psychiatry 47: 477–482. Sawyer ACP, Chittleborough CR and Lynch JW (2014) Can screening 4–5 year olds accurately identify children who will have teacherreported mental health problems when children are aged 6–7 years? Australian and New Zealand Journal of Psychiatry 48: 554–563. Sellman JD, Foulds JA, Adamson SJ, et al. (2014) DSM-5 alcoholism: A 60-year perspective. Australian and New Zealand Journal of Psychiatry 48: 507–511. Singh AB, Bousman CA, Ng CH, et al. (2013) High impact child abuse may predict risk of elevated suicidality during antidepressant initiation. Australian and New Zealand Journal of Psychiatry 47: 1191–1195. Watson S, Gallagher P, Dougall D, et al. (2014) Childhood trauma in bipolar disorder. Australian and New Zealand Journal of Psychiatry 48: 564–570.
Australian & New Zealand Journal of Psychiatry, 48(6)
