Can we sing along in harmony?

A call for action is such an old song that we can sing along in harmony, and nowhere is it stronger than in psychiatry. Mental disorders are common and costly. We need to change for the better. In their editorial, Cujipers et al (pp. 227–229) outline the important take-home messages from the recently published World Health Organization (WHO) World Mental Health Report – another call for action – and urge us to galvanise our collective efforts.

So how do we make a change? Take suicide, one of the priorities for change in the Report, as an example. Using the National Coronial Information System data in Australia, Burnett et al (pp. 234–240) investigate suicide rates by occupational class between 2007 and 2018. To me, the most striking finding of the study is not the occupational class suicide risk per se but the fact that the majority (83.4%) of 11 195 employed people who died of suicide were men. Surely, this is the inequality we need to address. How, then, do we prevent suicide? Can we eliminate suicide? The thought-provoking Analysis in this issue of BJPsych by Sjörstrand and Eyal (pp. 230–233) uses ethical principles to argue that aiming for zero may not be the best idea. The analysis reminds me of something that an emergency physician told me when I was an intern: ‘When someone dies of suicide, they kill themselves. The final decision to end the life is taken by the person who takes the life’. I remember feeling awfully uncomfortable with her statement, and I still do. Sjörstrand and Eyal argue that we ‘should fight the “fire” of social injustice instead of the “smoke” of suicide’. We do so by strengthening social and economic safety nets and extending universal access to healthcare and high-quality mental health services. At the individual level, we should strive to identify psychosocial needs and offer person-centred care for psychiatric disorders and medical conditions. Yes, we are talking about good psychiatry practice, much like what is described in the WHO Mental Health Report (seamless prevention, mental health promotion and treatment services).

One way to improve the quality of psychiatric care is to improve the way we evaluate our treatment options. A Mendelian randomisation study by Konzok et al (pp. 257–263) in this issue examines the bidirectional relationship between vitamin D and internalising disorders to find no evidence of any association. What is the Mendelian randomisation method? In essence, the method uses genetic variants to estimate causality unbiased by potential confounding factors. Unfortunately, the main downside of the study is that because the researchers used European data, the findings are not generalisable to a non-European like me. So, I continue to take my Vitamin D supplement every morning, still trying to figure out its benefit, wondering if this is an example of the significant gap between people in high-income countries and low-income countries that the WHO World Mental Health Report talks about.

Another way to improve the quality of psychiatric care is to improve the precision of the tools that we use. Northwood et al (pp. 241–245) use receiver operating characteristic curve analysis of data from 294 individual participants from nine studies to determine the optimal clozapine level. Although this is not as sexy as the Mendelian randomisation method, their approach – using a robust mathematical model to solve a common clinical question – is both inspiring and impressive. The paper's senior author was my last supervisor as I was finishing my psychiatry training. I would like to think that some of the conversations we had in our supervision sessions inspired him to conduct this impressive study. By the way, if you are wondering about the most optimal level for clozapine, it was lower than I expected – 372 ng/mL.

Finally, in this issue, Byng et al (pp. 246–256) conduct a good old cluster randomised controlled trial to investigate the effectiveness of the PARTNERS2 programme in England. The programme incorporates person-centred coaching support and liaison work for people with diagnoses of psychotic disorders in the primary health sector. The programme does not improve the quality of life among the participants. Like vitamin D, something that makes intuitive sense isn't always effective. What seems safe enough isn't always sufficient. We must find other ways to identify psychosocial needs and offer person-centred care for people with psychotic disorders.

How many calls for action does a man need, before he makes a change? Mental disorders are common and costly. We are blessed with many valuable tools in psychiatry: ethical principles, Mendelian randomisation and regular supervision sessions. We need to continue to harness different tools to improve our craft. We progress by testing ideas and rejecting ideologies. Can we sing along in harmony one more time? We need to change for the better.