From the Editor's desk

Passion and reason in the art and science of mental healthcare

David Hume, in his Treatise on Human Nature, observed that ‘Reason is, and ought only to be the slave of the passions, and can never pretend to any other office than to serve and obey them’. He asserts that reason and logic are not primary phenomena. Desires and passions, the stuff of life, are the driving force of relationships and society. It is these that determine decisions and judgements and actions that show worth and value. Such an assertion seems to call into question the value of research data, the scientific method, and the production of facts.

Yet, too much passion, or emotion as it has come to be called, may do a disservice to the management of science, hospitals, local and national government, where competing priorities are considered in the face of limited resources. Debates about the costs of HIV and dementia medicines, for example, are resolved on evidence and comparison with existing treatments as well as by taking account of the strained financial realities. ¹ Industry is not producing new psychopharmacological agents when they are much needed, not only for severe psychosis but also to prevent the future health burden of dementia. ¹

Given the lack of radically different interventions in mental healthcare, what might scientific progress look like? New delivery methods, nanotechnology for example, may improve the toxicity and adverse effect profile of known drug treatments. ² Better definition of the phenotype and targeting may improve outcomes, for example, in mood disorders. ³ Yet there continues to be insufficient investment, despite a better awareness of the importance of health promotion and of prevention and treatment of illness, and we face an epidemic of dementia and premature mortality in people with poor mental health. What is the appropriate balance of passion and reason to remedy this?

Some suggestions might be found from historical investigations of the doctor–patient relationship. John Gregory, an 18th-century doctor, fought for understanding that medicine was (and is) an art and not just a trade, the latter risking social injustices, less care and sympathy, and less willingness to accept contradictions and partial compliance with treatments. ⁴ He argued for a medical ethics in which the doctor's emotional sensibilities had to be moderated, not excessive or too little; and the doctor should show flexibility and gentleness. Yet a similar ethical treatise suited to modern healthcare providers, regulators (whether government- or patient-led) and industry, has not emerged. There is still a need to recognise the importance of medicine as art, trade and science. Healthcare providers must be creative in searching for new interventions, and by inventive repurposing of well-established and inexpensive interventions. To this end, significant energy is now expended on stratified medicine, improving phenotype recognition and validity, and seeking out biomarkers as well as social markers of response and non-response to treatment.

This month's BJPsych includes example of repurposing with important applications for prevention and treatment. Lithium is known to be a remarkable medication that reduces suicide and depression, and even more might be achieved if we can better target responders. ³ The novel and magical use of lithium to prevent dementia has previously been considered in the BJPsych ⁵ with some cautions but hope for better research to define the size of the effect. New studies show that lithium is associated with a lower rate of dementia (Gerhard et al, pp. ), and reduced mortality due to suicide and non-suicidal causes (Smith et al, pp. ). The inverse association between lithium in the drinking water and suicide mortality seems unique to men rather than women (Helbich et al, pp. ). Future trials of lithium should assess poor memory, dementia, mortality, and mood as outcomes.

A systematic review of heroin-assisted treatment for heroin addiction shows significant crime reduction and favorable cost-effectiveness profile (Strang et al, pp. ). Yet there is caution among policy makers and no government commitment towards heroin-assisted medical treatment (Farrell & Hall, pp. ). Substance misuse services in England are now located in local government, and this further challenges the level of priority a medical intervention might receive, even if proven to be effective, as all health and non-health public services are drastically reducing expenditure.

Premature mortality is more common in people with psychosis (Sharifi et al, pp. ). This is accounted for by suicide and poor physical health. Partti and colleagues' study (pp. ) of over 8000 adults in Finland shows that people with schizophrenia are more likely to suffer pneumonia, obstructive lung disease and bronchitis. These findings may partially explain a higher mortality and highlight where to target preventive interventions.

A different sort of passion is expressed in nightmares. Nightmares can be caused by anxiety, sleep disturbance states, and histories of extreme trauma. In Thompson et al's intriguing study (pp. ), nightmares at age 12 predicted psychosis at 18, posing difficult questions about the mechanism and the role of unresolved confounding. For example, underlying anxiety as an early marker of later risk of psychosis seems to plausibly account for this association, notwithstanding those with sleep disorders can experience hallucinatory phenomena in the waking state that are not associated with the chronic deterioration in function found in serious mental illnesses. The authors optimistically propose that, in the presence of a family history or predictors of future psychosis, psychological interventions targeted at this early stage may confer preventive benefits.

The arts have been valuable in reducing stigma and encouraging public debates about the nature of mental illness and recovery. ^6,7 However, film portrayals of suicide, in a new study by Till et al (pp. ), have varying impact; there is a worsening of mood in those with low levels of suicidality, increased serious suicidal thinking in those identifying with the character, and improved life satisfaction in those seeing positive coping. The emotional engagement of the audience is important, but how much heightened emotion is appropriate as a dramatic device and could there be harmful effects? There are media guidelines to protect the public, to prevent epidemics of suicide. ⁸ Artists and theatres do consider the impact of differing portrayals of violence, death and mental illness as part of their craft. ⁹ Audience expectation now and in the past, and the meaning and purpose of excess emotion in theatres are under investigation by artists. ¹⁰ Such analyses may yield a better understanding of how arts can temper or provoke emotion for health benefits, and where it might harm through the provocation of excessive sensibilities in the audience.