Breaking with tradition: marriage, prison and non-expert psychological treatment

The Journal ushers in the New Year with some exciting research challenging several pieces of traditional wisdom, with respect to mental health and marriage, imprisonment and treatment by non-specialist workers. Married individuals have been shown to have improved levels of mental health, with some earlier data suggesting that this benefit may be greater for individuals who are married rather than in unmarried relationships, and that this benefit was greater for males than females. Gibb and colleagues (pp. ) carried out a longitudinal study reporting that a longer duration of relationship, within or outside marriage, was protective for individuals’ mental health. This was associated with lower rates of depressive illness and suicidal behaviour, with equal benefit for both men and women, and lower rates of substance misuse showing a differential benefit for women. Incarceration in prison has traditionally been considered to have a detrimental effect on mental health, but Hassan et al (pp. ) show that this is not invariably so. They found that psychiatric symptoms did not increase in any group over 2 months of imprisonment and actually declined in several groups, including males, convicted prisoners and those with depressive illness. However, being on remand and having a severe mental illness were related to increasing symptoms over time, and the crucial first week of imprisonment continued to be a period of high distress. Psychological treatments, predominantly cognitive–behavioural therapy (CBT), are recommended for the treatment of depressive illness. A more elementary behavioural activation approach, focused on the development of behavioural strategies, has been shown to deliver comparable results. Ekers et al (pp. ) used generic mental health workers, rather than expert therapists, to deliver a behavioural activation treatment to individuals with depression, and demonstrated clear positive change. They suggest that this offers an efficient and cost-effective method for treating long-standing depressive illness.

Eating disorders classification, the media and minor depression

The DSM–IV diagnostic system has two main categories of eating disorder, anorexia nervosa and bulimia nervosa, with a third ‘not otherwise specified’ (NOS) category. Fairburn & Cooper (pp. ) highlight the concern that half the cases seen in clinical practice occupy this NOS category, suggesting that there needs to be a change in the diagnostic classification to reflect this reality. They review how this might be achieved, and express their concern that eating disorders in general are not stable over an individual's life, the same individual potentially fulfilling different diagnostic criteria at different times. They also question the utility of diagnostic categories that do not appear to carry robust prognostic value, said to be one of the main purposes of a diagnostic system. They suggest that applying broader criteria for inclusion into treatment trials of eating disorder may offer one way forward, through allowing differentiation of natural clinical trajectories. Exposure to mass media has been shown to contribute to the development of eating disorder; Becker et al (pp. ) examined the influence of indirect social media on eating disorders in Fiji. They found that both direct mass media exposure and indirect social network media exposure were associated with greater levels of eating pathology in adolescent girls in Fiji, but the indirect social network media exerted a more significant influence on outcome. They highlight the fact that current interventions targeting direct media influence are relatively easy to apply, but it is far more difficult to control the effects of indirect social network exposure. Minor depressive illness is common in the population and increases the risk of developing a major depressive illness, as well as being related to a host of other detrimental effects on quality of life. Barbui et al (pp. ) review the literature on pharmacological treatment of minor depression and conclude that antidepressant treatment is unlikely to offer any advantage over placebo in the management of this group of patients. They propose that the absence of robust support for pharmacological treatment may indirectly offer support for psychological treatments, which appear to be well-tolerated and effective in the presence of these low-grade symptoms of depression.

Schizophrenia, agitation and cost-effectiveness of psychological treatment

The treatment of agitation in schizophrenia is an important clinical need, as this agitation can often be a precursor to aggressive behaviour. Lesem and colleagues (pp. ) describe data from a study of inhaled loxapine, which significantly reduced levels of agitation when compared with placebo treatment. They propose that the inhaled route offers the advantage of easy access and speedy absorption, suggesting that this is a viable alternative to parenteral administration, but only in patients willing to accept medication. Van der Gaag et al (pp. ) report that CBT was effective in schizophrenia, leading to an increase in the number of days of normal functioning, compared with treatment as usual, although showing no difference in overall symptom scores. However, the CBT was more expensive to implement – by €47 per day. As with so much in these uncertain economic times, the decision of whether the additional cost is worth the extra benefit is left to the policy makers.

May we take this opportunity to wish our readers a very peaceful and happy New Year.