Intervening to address adversity associated with severe mental illness

Three papers in the BJPsych this month consider interventions to address aspects of adversity suffered by those with severe mental illness. Heslin et al (pp. ) consider the potential costs associated with implementing three recommended service enhancements intended to improve care pathways for individuals with enduring mental health needs who have contact with the police. Using a case-linkage modelling methodology, the three enhancements (street triage, Mental Health Act assessments for all Section 136 detainees and outreach custody link workers) were each found to increase healthcare and policing costs to a marginal degree only – the cost per police incident was estimated to be £522. The authors comment on the possibility that any increase in costs associated with the enhancements considered might be offset by savings in other service areas.

The poor physical health of individuals with severe mental illness has been well established, with poor nutrition being an important target for prevention particularly in relation to obesity. Teasdale et al (pp. ) undertook a systematic review and meta-analysis of randomised controlled trials (RCTs) of nutritional interventions in severe mental illness and found evidence that such interventions led to significant weight loss, reduced body mass index, decreased waist circumference and lowered blood glucose levels. The largest effect sizes were found for interventions led by a dietician and those delivered at antipsychotic initiation. In a linked editorial, Meader (pp. ) comments on the current evidence that nutritional interventions are likely to be at least as effective, if not more effective, in people with severe mental illness compared with other populations, and calls for future research to address a number of unanswered questions regarding the important components of nutritional interventions and whether or not they should be considered in the context of other health risk behaviours.

Cognitive–behavioural therapy for psychosis (CBTp) has long been used to address the persistence of medication-resistant psychotic symptoms but has limitations. Shawyer et al (pp. ) tested an emerging alternative psychological therapy – acceptance and commitment therapy (ACT) – in a sample of community-dwelling patients with persistent psychotic symptoms. Those randomised to receive ACT did not demonstrate any difference in overall mental state post-therapy compared with those receiving the befriending control intervention but did show greater improvement in positive symptoms and hallucination distress. The authors also highlight the implications of benefits seen in satisfaction and self-reported symptoms in the ACT group but note that expected changes in process measures were not seen.

Under-awareness and under-treatment of common mental disorders

Beyond dementia and depression, little is known about the occurrence of common mental disorders in elderly people. In a cross-sectional multicentre survey of men and women aged 65–84 years across a number of European centres, Andreas et al (pp. ) found that one in two individuals had experienced lifetime mental disorder, one in three in the past year and one in four had evidence of current mental disorder. Anxiety disorders were the most prevalent followed by affective and substance-related disorders. The authors comment on the need to raise awareness of psychosocial problems in elderly populations and the need to adapt assessments to the cognitive capacities of individuals in this age range. Utilising data from the World Health Organization World Mental Health Surveys conducted in 21 countries, Thornicroft et al (pp. ) identified evidence of significant under-treatment of major depressive disorder (MDD) internationally, with only 16.5% of individuals with 12-month MDD receiving minimally adequate treatment. The proportion was much smaller in low-/lower-middle-income countries (1 in 27) despite the prevalence rates also being lower. The authors call for national and international organisations to make commitments to resourcing the scaling-up of service provision that is required to address the ‘treatment gap’ seen for people with MDD.

Interventions for depression and personality disorder

Depression screening plus patient-targeted feedback in patients with coronary heart disease or hypertension was found to be associated with greater improvements in depression severity and information seeking behaviour at 6 months after screening compared with a control group who did not receive written post-screening feedback (Löwe et al, pp. ). The primary study hypothesis, improvement in depression 1 month after screening, was not supported by the study findings, however, and the clinical improvement seen at 6 months did not appear to be explained by differences in mental health treatment. The authors comment on the need for further research to replicate their study findings and to focus on investigating the underlying mechanisms of patient-targeted feedback. In a systematic review and meta-analysis by Fischer et al (pp. ), cortisol levels prior to starting psychological therapy for depression were found to be associated with an increased level of symptoms at the end of treatment and/or smaller symptom change. The authors comment on the possibility that cognitive impairment mediates the association found and suggest that future research should stratify patients according to their levels of childhood trauma to test whether their findings are driven by a specific patient subgroup.

Pearce et al (pp. ) subjected democratic therapeutic community (DTC) treatment, used for many years to help individuals with personality disorder, to rigorous evaluation in an RCT and found that in-patient days at follow-up were low for both the intervention and the control condition (crisis planning plus treatment as usual) and did not differ. At 24 months however, aggression and satisfaction with care were both improved in the intervention group. In addition to the potential benefits identified, this study of DCT treatment has demonstrated that it is possible to overcome previously identified obstacles to carrying out an RCT, supporting the potential for a larger multicentre trial to be undertaken.