A marathon, not a sprint

The devastation created by COVID-19 has echoes of The Plague by Albert Camus. In it, the author writes ‘But, now they had abruptly become aware that they were undergoing a sort of incarceration…’. The editorial by Kelly (pp. 352–353) reminds us that our patients are at both increased direct and indirect risk from the ravages of COVID-19. This includes those who are homeless, people with disabilities, with long-term illnesses and those in institutional settings. People in these groups often have multiple comorbid risk factors that include poor physical and mental health, impaired access to services and little control over their daily lives. Their needs are great and they need us now, more than ever. Not only is this a mental health emergency, it is also a physical health crisis. We must stand firm in solidarity with them, helping also to buffer them from news overload with trusted sources of information.

COVID-19 infection in patients with both psychiatric symptoms and in those with mental disorders also has implications for treatment with psychotropic drugs. In an accompanying editorial, Zhang et al (pp. 351–351) give us a pharmacokinetic bird's eye view of potential interactions with antiviral drugs that rely heavily on the cytochrome P450 pathway for their metabolism.

Back to the future

The influence of adverse childhood experiences on mental health has improved our understanding of risk and resilience, but a simple cause and effect model without an overview of complexity may become a bland and repetitive offering. For this reason, Siddaway et al (pp. 397–398) offer us a delicacy to savour, focusing our perspective through a different lens. The author argues that adverse childhood experiences need to be integrated into the wider literature on trauma, stress and adjustment. Individual interpretations such as meaning-making may, for example, be more important predictors than objective interpretation.

While on the subject of mental health in childhood, Basu et al (pp. 377–382) carried out the first prospective longitudinal population-based study of school-aged children and adolescents with a range of stress disorders to examine rates of incident psychiatric disorders. Children with post-traumatic stress disorder, adjustment disorder or reaction to severe stress unspecified were more likely to have one or more psychiatric disorders such as depression, anxiety and behavioural disorder at follow-up. It may be that causal pathways for incident psychiatric disorder occur through stress disorders or through other mechanisms.

Further along the age spectrum to young adulthood, a study by Nyberg et al (pp. 370–376) involving just shy of a million male military conscripts in Sweden, revealed drug and alcohol use disorders, low stress resilience and low cognitive performance to be strong independent predictors of suicide in those aged between the ages of 45 and 64 years.

Covering all the bases

The elegant repertoire of psychiatric research is no better demonstrated than in children and younger people. Our final stop is a showcase of research to show just this.

Moving away from an established routine and social bonds can have a profound impact on mental health. In a study of 10- to 14-year-olds in Denmark, Paksarian et al (pp. 390–396) explore the relationship between moving location and subsequent severe mental illness. They report a ‘dose–response’ relationship between the number of moves during early adolescence and the risk of schizophrenia, bipolar disorder and major depressive disorder, even after adjustment for genetic liability and demographic covariates. Environmental factors, it would seem, have a profound effect on the developing brain. So too do the sequelae of negative emotional symptoms. Malhi et al (pp. 383–389) postulate that ineffective reappraisal strategies involving a self-focusing rather than self-distancing approach limits the ability to achieve desired development outcomes. This, in turn, may be instrumental in the development of depression. The authors also find evidence for a neural basis to the association between emotional symptoms and the reappraisal of negative emotions.

To conclude where we began, the external validity of research should always be patient facing. Mulraney et al (pp. 364–369) rightly hold mental health services to account through the benchmark of ‘minimally adequate treatment’ for children and young people with mental health problems. Through examination of the Longitudinal Study of Australian Children Kindergarten cohort, they conclude that a large proportion of children with persisting, and worsening, high levels of mental health problems do not receive care meeting minimal treatment guidelines. Given that 50% of mental health disorders have an onset prior to 14 years of age it is a shot across the bow to improve mental health service provision for children and younger people.