Spaces for mood care: prevention and intervention in digital, community and health systems

Depression accounts for 4.4% of the global burden of disease.^{1, 2} Mood disorders more generally, including bipolar disorders, emotional dysregulation, mood and anxiety disorders, and mood disorders due to or caused by medical illness account for even more disability, poor general health and costs to the individual, carers and families, and society. Advances in aetiological and care-related research for depression can help identify effective care approaches for psychiatric and medical illnesses more generally. For example, depressed mood may also be a marker for, and potential mediating mechanism of, the physiological processes that lead to later-life dementia (see Schmitz et al, pp. 96–102); associations with other chronic medical conditions such as diabetes, heart and lung disease, and cancer make for an even greater impact on quality of life and functioning and mortality.^3–6

People with affective disorders may use a variety of methods to regulate their moods, including the use of psychoactive substances and self-treatment with alcohol, with associated harmful consequences including dementia. Alcohol-related dementia is not well researched, visible or a preventive priority (see Rao & Draper, pp. 67–68). Community-based interventions show promise in the treatment of common mental disorders (see Williams et al, pp. 88–95; Delgadillo, pp. 65–66) and hold some preventive value.

There is now a greater emphasis on digital interventions for mental illness and poor mental health (see Janse et al, pp. 112–118);^7–9 digital interventions are promising as they extend the reach of care to people who feel stigmatised and avoid help-seeking. They can improve confidence, self-efficacy and empowerment; yet such approaches may seem risky if those with the most severe mental illnesses are expected to rely on technology-based self-management rather than careful and skilled assessment and personalised therapeutics. We need both types of care approaches. For example, for those with severe psychosis with associated impaired function, social isolation, worry, depression and a lack of motivation and suicidal thinking. People with immediate distress wish to see a skilled professional for urgent and reliable longer-term care, and their preference it seems is to see the same clinician whether as an in-patient or out-patient (see Bird et al, pp. 81–87). When mental illnesses are not responding to conventional and well-established treatments, innovations are needed for care in health services, but also in school-, work-based and population venues with the twin aims of preventing illness and promoting recovery from an established illness. Singing is good for you. Singing improves confidence, respiratory regulation, performance skills, emotional activation and social support; this month, we report that it seems to be helpful for postnatal depression (Fancourt & Perkins, pp. 119–121), the treatment of which also improves the health of children of mothers with depression.¹⁰

Treatment-resistant depression is a most worrisome condition, not least because the fear, worry and misery experienced by people is compounded as people become even more hopeless when treatments are not working. BJPsych is calling for original research on treatment-resistant mood disorders (see http://bit.ly/2DmdkrV). This reflects the relative neglect of a common and disabling group of illnesses that remain poorly understood. Electroconvulsive therapy (ECT) is still a recommended element of the care pathway for depression that is not responding to other treatments or where there is some life-threatening urgency. It is still stigmatised, but clearly helpful for some people. Severe depression in elderly people and in individuals with depression with psychosis appears to show the best response to ECT. This has driven a search for new approaches such as ketamine^11–13 and even opiates.¹⁴ Scherrer et al (pp. 103–111) show that treatment of depression with antidepressants leads to a reduction in the use of opiates being used for chronic pain, suggesting opiates may not be helpful. The studies linking mood disorders to other chronic conditions and drug use show that knowledge about the causes and treatments for mood disorders are needed for all health practitioners, not just in the mental health system, and in public health campaigns.

The Psychiatry Ashes

It is with great pleasure that I announce that the 2018 Psychiatry Ashes are underway, and full details will follow in the journal next month. If you simply cannot wait to hear more, please see our opponent's January issue.¹⁵