773
ANZJP Correspondence McManus F, Surawy C, Muse K, et al. (2012) A randomized clinical trial of mindfulness-based cognitive therapy versus unrestricted services for health anxiety (hypochondriasis). Journal of Consulting and Clinical Psychology 80: 817–828. Muse K, McManus F, Leung C, et al. (2012) Cyberchondriasis: Fact or fiction? A preliminary examination of the relationship between health anxiety and searching for health infor-
mation on the Internet. Journal of Anxiety Disorders 26: 189–196. Starcevic V (2013) Hypochondriasis and health anxiety: Conceptual challenges. British Journal of Psychiatry 202: 7–8. Starcevic V (2014) Should we deplore the disappearance of hypochondriasis from DSM-5? Australian and New Zealand Journal of Psychiatry 48: 373–374. Sunderland M, Newby JM and Andrews G (2013) Health anxiety in Australia: Prevalence,
comorbidity, disability and service use. British Journal of Psychiatry 202: 56–61. Tyrer P, Cooper S, Salkovskis P, et al. (2014a) Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: A multicentre randomised controlled trial. Lancet 383: 219–225. Tyrer P, Salkovskis P, Tyrer H, et al. (2014b) Cognitive behaviour therapy for health anxiety. Lancet 383: 1295–1296.
Response to Fergusson and Boden: The psychological impact of major disasters Richard A Bryant
epidemiological study of post-war mental health functioning in the Mekong Delta in Vietnam and obtained a stunning 98% response rate. It seems that the price we pay for living in a more democratic and less compliant society is that our participation rates in such studies is compromised. How we overcome this problem is a challenge. In this study, enormous effort was put into engaging with each of the communities, as well as ongoing liaison with the relevant support agencies, such as the Red Cross. Other postdisaster studies have also reported poor compliance rates; a comparable telephone study conducted 5–7 months after Hurricane Katrina had a response rate of 41.9% (Kessler et al., 2008). It is possible that a major reason our response rate was so low was that our study was conducted 3–4 years after the Black Saturday fires when people’s motivation to discuss these events had diminished. This interpretation is consistent with most studies that report marked decrease retention in longitudinal studies as time elapses. The thorny issue of third or extraneous variables contributing to the observed outcomes is a very substantive issue. We can never be sure that we have exhaustively measured the correct predictor variables or the optimal outcomes. There are many risk factors for the onset of post-traumatic stress disorder (PTSD), as well as a myriad of moderators of adaption in the months and years after trauma exposure (Brewin, Andrews and Valentine, 2000). No single study can possibly incorporate all the potential factors that can influence outcome;
however, it is important to always remember that many possible influences are not being measured and these may be pivotal to explaining specific outcomes. Relatedly, it is important to keep in mind that our study of the Black Saturday fires was cross-sectional. By assessing mental health outcomes at 3–4 years after the fires, we essentially took a ‘snapshot’ of adaptation. In recent years the field has realized that people’s responses following trauma fluctuate greatly over time; one study of traumatically injured patients across Australia showed that whereas the incidence of PTSD remained stable over multiple assessments in the 2 years after injury, half the patients altered their diagnostic status at each assessment (Bryant et al., 2013). This problem is addressed to a degree by longitudinal designs that assess people on three or four occasions, which allows latent growth mixture modeling to map distinct trajectories that people follow across time. Multiple studies converge on documenting four distinct trajectories: (1) chronically distressed, (2) initial distress followed by recovery, (3) delayed or worsening symptoms, and (4) consistently resilient or resistant pattern that is characterized by ongoing stable mental health (Bonanno et al., 2012, Pietrzak et al., 2013). We are conducting ongoing follow-ups of the participants in our study, with the hope that we can map the longer-term trajectories of people as they manage both the aftereffects of the fires and also the ongoing challenges of future weather events and difficulties facing regional districts of Australia.
School of Psychology, University of New South Wales, Sydney, Australia Corresponding author: Richard Bryant, School of Psychology, University of New South Wales, NSW 2052, Australia. Email: [email protected] DOI: 10.1177/0004867414541816
The comments put forward by Fergusson and Boden (2014) reflect the experience of researchers who have attempted the tough task of disentangling the different contributors to post-disaster adjustment – in these authors’ case, it has been the Christchurch earthquake. Here I will focus on a few of the points they raise. They mention the issue of preferential sampling of disaster survivors, partly as a result of relocation but mainly because of reluctance to take part in research. This is a perennial problem for trauma researchers (and for many other mental health researchers). Our finding that those who did participate (only a disappointing 16%) were older, more likely to be female and were better educated, highlights the problem we face because each of these factors represents a risk factor for posttraumatic mental health (Ozer et al., 2003). It is interesting to juxtapose the response rate we achieved with other posttraumatic studies in different contexts. For example, Steel et al. (2009) conducted an
Australian & New Zealand Journal of Psychiatry, 48(8)
Downloaded from anp.sagepub.com at The University of Iowa Libraries on June 1, 2015
774
ANZJP Correspondence
Understanding how people cope in the long-term after disasters is critical. Considering the increasing impact of climate change on our environment, including extreme weather events that will include damaging episodes, we must comprehend the consequences so adequate planning can be implemented. To date the emphasis has been on the acute and intermediate effects, but it is just as important to understand the longer-term ripple effects of disasters upon individuals and communities. These more subtle effects can impact psychological functioning, social and family cohesion, community structures and economies. Further, many disasters affect communities in the context of ongoing stressors, such as drought or economic downturn, which compound the longer-term effects. In this sense, we need to see the role of traumatic events in the context of broader environmental challenges rather than a discrete event that happens in isolation. By adopting a more comprehensive
and longer-term view of the effects on mental health, more targeted prevention and intervention programs may facilitate the longer-term adaptation of those affected by these extreme events.
Bonanno GA, Mancini AD, Horton JL, et al. (2012) Trajectories of trauma symptoms and resilience in deployed U.S. military service members: Prospective cohort study. British Journal of Psychiatry 200: 317–323.
Brewin CR, Andrews B and Valentine JD (2000) Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology 68: 748–766. Bryant RA, O’Donnell M, Creamer M, et al. (2013) A multi-site analysis of the fluctuating course of posttraumatic stress disorder. JAMA: Psychiatry 70: 839–846. Fergusson D and Boden J (2014) The psychological impacts of major disasters: A commentary on Bryant et al.’s study of the Victorian Black Saturday Bushfires. Australian and New Zealand Journal of Psychiatry 48: 597–599. Kessler RC, Galea S, Gruber MJ, et al. (2008) Trends in mental illness and suicidality after Hurricane Katrina. Molecular Psychiatry 13: 374–384. Ozer EJ, Best SR, Lipsey TL, et al. (2003) Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin 129: 52–73. Pietrzak RH, Van Ness PH, Fried TR, et al. (2013) Trajectories of posttraumatic stress symptomatology in older persons affected by a large-magnitude disaster. Journal of Psychiatric Research 47: 520–526. Steel Z, Silove D, Giao NM, et al. (2009). International and indigenous diagnoses of mental disorder among Vietnamese living in Vietnam and Australia. British Journal of Psychiatry 194: 326–333.
Classifying teenage depression Paul Terence Dignam
Who tries desperately to please but somehow can’t seem to make things work around her? Who regularly wonders if there is any point in going on and has been covertly cutting for a year or more? To hear some people speak, or even my new trainee, fresh from his first year in adult psychiatry, you would think depression was a neatly defined entity, recognisable at 100 metres, for which a treatment algorithm will generate a positive outcome. My trainee, with repeated exposure under supervision, will gradually learn life is messier than that, and that ‘major depressive disorder’ is not a single entity at all, but a way of describing the experience of a number of people who travel different paths to arrive at similar but by no means identical destinations. He will learn to formulate and to individualise treatment, and to recognise what can and cannot be changed.
Why was no one able to help this girl? It would be nice to imagine that if we had seen her the outcome would have been different: we’re the experts after all. I’m not so sure. Treating depression in a ‘stuck’ predicament is uphill work. It’s hard to think if you can’t move and if you’ve been in the habit of keeping your pain to yourself you don’t drop your guard easily. I haven’t been impressed by the usefulness of medication in these situations and the evidence of efficacy for antidepressants in teenagers is hardly overwhelming (Cox et al., 2012). It can be slow, plodding work, and their suicidal thinking just sits there in a corner of the room with you, week after week, month after month. Kuiper et al. (2014) highlight the fact that the better management of many cases of depression hangs on a fuller understanding of the psychosocial context and developmental history: something that should, of course,
Child and Adolescent Mental Health Service (CAMHS), Elizabeth, Australia Corresponding author: Paul Terence Dignam, CAMHS, Elizabeth Shopping Centre, Elizabeth, SA 5112, Australia. Email: [email protected] DOI: 10.1177/0004867414536936
What is the right term to describe a 15-year-old who has been unhappy for as long as she can remember? Who is stuck in a family situation that seems unsolvable, with hostile separated parents who can’t talk to each other? Whose genuinely happy moments are contingent on fleeting circumstances, on a background of chronic but largely masked dysphoria?
Funding The study was funded by an Australian Research Council Linkage Grant (LP100200164). Funding and/or grant number: LP100200164.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. See Viewpoint by Fergusson and Boden, 2014, 48(7): 597–599.
References
Australian & New Zealand Journal of Psychiatry, 48(8) Downloaded from anp.sagepub.com at The University of Iowa Libraries on June 1, 2015
ANZJP Correspondence McManus F, Surawy C, Muse K, et al. (2012) A randomized clinical trial of mindfulness-based cognitive therapy versus unrestricted services for health anxiety (hypochondriasis). Journal of Consulting and Clinical Psychology 80: 817–828. Muse K, McManus F, Leung C, et al. (2012) Cyberchondriasis: Fact or fiction? A preliminary examination of the relationship between health anxiety and searching for health infor-
mation on the Internet. Journal of Anxiety Disorders 26: 189–196. Starcevic V (2013) Hypochondriasis and health anxiety: Conceptual challenges. British Journal of Psychiatry 202: 7–8. Starcevic V (2014) Should we deplore the disappearance of hypochondriasis from DSM-5? Australian and New Zealand Journal of Psychiatry 48: 373–374. Sunderland M, Newby JM and Andrews G (2013) Health anxiety in Australia: Prevalence,
comorbidity, disability and service use. British Journal of Psychiatry 202: 56–61. Tyrer P, Cooper S, Salkovskis P, et al. (2014a) Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: A multicentre randomised controlled trial. Lancet 383: 219–225. Tyrer P, Salkovskis P, Tyrer H, et al. (2014b) Cognitive behaviour therapy for health anxiety. Lancet 383: 1295–1296.
Response to Fergusson and Boden: The psychological impact of major disasters Richard A Bryant
epidemiological study of post-war mental health functioning in the Mekong Delta in Vietnam and obtained a stunning 98% response rate. It seems that the price we pay for living in a more democratic and less compliant society is that our participation rates in such studies is compromised. How we overcome this problem is a challenge. In this study, enormous effort was put into engaging with each of the communities, as well as ongoing liaison with the relevant support agencies, such as the Red Cross. Other postdisaster studies have also reported poor compliance rates; a comparable telephone study conducted 5–7 months after Hurricane Katrina had a response rate of 41.9% (Kessler et al., 2008). It is possible that a major reason our response rate was so low was that our study was conducted 3–4 years after the Black Saturday fires when people’s motivation to discuss these events had diminished. This interpretation is consistent with most studies that report marked decrease retention in longitudinal studies as time elapses. The thorny issue of third or extraneous variables contributing to the observed outcomes is a very substantive issue. We can never be sure that we have exhaustively measured the correct predictor variables or the optimal outcomes. There are many risk factors for the onset of post-traumatic stress disorder (PTSD), as well as a myriad of moderators of adaption in the months and years after trauma exposure (Brewin, Andrews and Valentine, 2000). No single study can possibly incorporate all the potential factors that can influence outcome;
however, it is important to always remember that many possible influences are not being measured and these may be pivotal to explaining specific outcomes. Relatedly, it is important to keep in mind that our study of the Black Saturday fires was cross-sectional. By assessing mental health outcomes at 3–4 years after the fires, we essentially took a ‘snapshot’ of adaptation. In recent years the field has realized that people’s responses following trauma fluctuate greatly over time; one study of traumatically injured patients across Australia showed that whereas the incidence of PTSD remained stable over multiple assessments in the 2 years after injury, half the patients altered their diagnostic status at each assessment (Bryant et al., 2013). This problem is addressed to a degree by longitudinal designs that assess people on three or four occasions, which allows latent growth mixture modeling to map distinct trajectories that people follow across time. Multiple studies converge on documenting four distinct trajectories: (1) chronically distressed, (2) initial distress followed by recovery, (3) delayed or worsening symptoms, and (4) consistently resilient or resistant pattern that is characterized by ongoing stable mental health (Bonanno et al., 2012, Pietrzak et al., 2013). We are conducting ongoing follow-ups of the participants in our study, with the hope that we can map the longer-term trajectories of people as they manage both the aftereffects of the fires and also the ongoing challenges of future weather events and difficulties facing regional districts of Australia.
School of Psychology, University of New South Wales, Sydney, Australia Corresponding author: Richard Bryant, School of Psychology, University of New South Wales, NSW 2052, Australia. Email: [email protected] DOI: 10.1177/0004867414541816
The comments put forward by Fergusson and Boden (2014) reflect the experience of researchers who have attempted the tough task of disentangling the different contributors to post-disaster adjustment – in these authors’ case, it has been the Christchurch earthquake. Here I will focus on a few of the points they raise. They mention the issue of preferential sampling of disaster survivors, partly as a result of relocation but mainly because of reluctance to take part in research. This is a perennial problem for trauma researchers (and for many other mental health researchers). Our finding that those who did participate (only a disappointing 16%) were older, more likely to be female and were better educated, highlights the problem we face because each of these factors represents a risk factor for posttraumatic mental health (Ozer et al., 2003). It is interesting to juxtapose the response rate we achieved with other posttraumatic studies in different contexts. For example, Steel et al. (2009) conducted an
Australian & New Zealand Journal of Psychiatry, 48(8)
Downloaded from anp.sagepub.com at The University of Iowa Libraries on June 1, 2015
774
ANZJP Correspondence
Understanding how people cope in the long-term after disasters is critical. Considering the increasing impact of climate change on our environment, including extreme weather events that will include damaging episodes, we must comprehend the consequences so adequate planning can be implemented. To date the emphasis has been on the acute and intermediate effects, but it is just as important to understand the longer-term ripple effects of disasters upon individuals and communities. These more subtle effects can impact psychological functioning, social and family cohesion, community structures and economies. Further, many disasters affect communities in the context of ongoing stressors, such as drought or economic downturn, which compound the longer-term effects. In this sense, we need to see the role of traumatic events in the context of broader environmental challenges rather than a discrete event that happens in isolation. By adopting a more comprehensive
and longer-term view of the effects on mental health, more targeted prevention and intervention programs may facilitate the longer-term adaptation of those affected by these extreme events.
Bonanno GA, Mancini AD, Horton JL, et al. (2012) Trajectories of trauma symptoms and resilience in deployed U.S. military service members: Prospective cohort study. British Journal of Psychiatry 200: 317–323.
Brewin CR, Andrews B and Valentine JD (2000) Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology 68: 748–766. Bryant RA, O’Donnell M, Creamer M, et al. (2013) A multi-site analysis of the fluctuating course of posttraumatic stress disorder. JAMA: Psychiatry 70: 839–846. Fergusson D and Boden J (2014) The psychological impacts of major disasters: A commentary on Bryant et al.’s study of the Victorian Black Saturday Bushfires. Australian and New Zealand Journal of Psychiatry 48: 597–599. Kessler RC, Galea S, Gruber MJ, et al. (2008) Trends in mental illness and suicidality after Hurricane Katrina. Molecular Psychiatry 13: 374–384. Ozer EJ, Best SR, Lipsey TL, et al. (2003) Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin 129: 52–73. Pietrzak RH, Van Ness PH, Fried TR, et al. (2013) Trajectories of posttraumatic stress symptomatology in older persons affected by a large-magnitude disaster. Journal of Psychiatric Research 47: 520–526. Steel Z, Silove D, Giao NM, et al. (2009). International and indigenous diagnoses of mental disorder among Vietnamese living in Vietnam and Australia. British Journal of Psychiatry 194: 326–333.
Classifying teenage depression Paul Terence Dignam
Who tries desperately to please but somehow can’t seem to make things work around her? Who regularly wonders if there is any point in going on and has been covertly cutting for a year or more? To hear some people speak, or even my new trainee, fresh from his first year in adult psychiatry, you would think depression was a neatly defined entity, recognisable at 100 metres, for which a treatment algorithm will generate a positive outcome. My trainee, with repeated exposure under supervision, will gradually learn life is messier than that, and that ‘major depressive disorder’ is not a single entity at all, but a way of describing the experience of a number of people who travel different paths to arrive at similar but by no means identical destinations. He will learn to formulate and to individualise treatment, and to recognise what can and cannot be changed.
Why was no one able to help this girl? It would be nice to imagine that if we had seen her the outcome would have been different: we’re the experts after all. I’m not so sure. Treating depression in a ‘stuck’ predicament is uphill work. It’s hard to think if you can’t move and if you’ve been in the habit of keeping your pain to yourself you don’t drop your guard easily. I haven’t been impressed by the usefulness of medication in these situations and the evidence of efficacy for antidepressants in teenagers is hardly overwhelming (Cox et al., 2012). It can be slow, plodding work, and their suicidal thinking just sits there in a corner of the room with you, week after week, month after month. Kuiper et al. (2014) highlight the fact that the better management of many cases of depression hangs on a fuller understanding of the psychosocial context and developmental history: something that should, of course,
Child and Adolescent Mental Health Service (CAMHS), Elizabeth, Australia Corresponding author: Paul Terence Dignam, CAMHS, Elizabeth Shopping Centre, Elizabeth, SA 5112, Australia. Email: [email protected] DOI: 10.1177/0004867414536936
What is the right term to describe a 15-year-old who has been unhappy for as long as she can remember? Who is stuck in a family situation that seems unsolvable, with hostile separated parents who can’t talk to each other? Whose genuinely happy moments are contingent on fleeting circumstances, on a background of chronic but largely masked dysphoria?
Funding The study was funded by an Australian Research Council Linkage Grant (LP100200164). Funding and/or grant number: LP100200164.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. See Viewpoint by Fergusson and Boden, 2014, 48(7): 597–599.
References
Australian & New Zealand Journal of Psychiatry, 48(8) Downloaded from anp.sagepub.com at The University of Iowa Libraries on June 1, 2015
