Highlights of this issue

The state of psychiatry: population mental health and the profession itself

Trends in mental health outcomes, public perceptions of service provision, and the state of psychiatry as a specialty are addressed in the Journal this month. Wahlbeck et al (pp. ) examined trends in life expectancy in Denmark, Sweden and Finland over a 20-year period and found that although the gap between those with a mental disorder compared with the general population has persisted, it has decreased, particularly among women. The authors conclude that further development of the Nordic welfare-state model is supported by these trends, and they call for a greater emphasis on health promotion, health access and interventions to prevent suicide and violence. Thornicroft (pp. ) argues in a linked editorial that the picture presented by the paper is damning given that only a modest reduction in life expectancy disparity has been achieved over the past two decades, despite the high quality and relatively equitable distribution of mental health care provided in the three Nordic countries. In another high-resource setting, Meadows & Bobevski (pp. ) found that perceived need for mental health information, counselling and skills training increased among those consulting a mental health professional in Australia over the period 1997 to 2007. Results from this national study also indicated that perceived responses from services had improved, at least for those with needs for information and counselling. The authors comment that the changes seen appear to be in the direction intended by policy and service changes made during the period. In a linked editorial, Jorm (pp. ) suggests that although availability of mental health treatment in Australia has increased and unmet need has reduced over the past decade, there is little evidence that mental health in the population has improved. In addressing the future of psychiatry as a profession, one considered by many to be in crisis, Oyebode & Humphreys (pp. ) call for a reform of the current training template for psychiatrists in light of advances in theoretical knowledge and our basic understanding of mental disorders. The authors warn that psychiatry might otherwise be in danger of going the way of the apothecaries, a now extinct medical specialty.

Trials of treatment interventions in resource-poor settings

Farooq et al (pp. ) evaluated a randomised controlled trial of supervised outpatient treatment for schizophrenia conducted in the Peshawar region of Pakistan. The intervention was intended to improve non-adherence rates and outcomes by involving a family member in the supervision of medication administration. The authors found that those receiving the intervention had better adherence at 1 year and improved levels of both symptoms and functioning. A trial of an intervention to improve outcomes for those with common mental disorders in primary care in Goa, India, was conducted by Patel et al (pp. ). The collaborative stepped-care intervention for depressive and anxiety disorders led by lay health workers was found to reduce the prevalence of common mental disorders, suicidal behaviour, psychological morbidity and disability days. Both studies highlight the importance of identifying and testing affordable and locally appropriate interventions if mental health is to be improved in low- and middle-income countries. Another study in the Journal this month contributes to the literature describing the extent of mental ill health in such settings by reporting on the prevalence of anxiety among older adults in Latin America, India and China (Prina et al; pp. ). Levels of anxiety in Latin America were found to be similar to estimates from high-income European countries while low levels (0.1%) were found in rural China. The authors found evidence of an association between level of urbanisation and increased prevalence of anxiety.

Clinically important findings regarding use of risk assessment on wards and the ‘true’ effect of antidepressants

Two papers in the Journal this month examine common clinical interventions whose effectiveness has been questioned. Van de Sande et al (pp. ) found that regular use of structured short-term risk assessment scales on acute psychiatric wards resulted in a reduction in the number of aggressive incidents, the number of patients who engaged in aggression and the time spent by in-patients in seclusion. Using a mixture model to identify patient subgroups, Thase et al (pp. ) found evidence that the small average antidepressant–placebo difference found in many antidepressant trials may mask a much larger effect among those in the subgroup benefiting from treatment.