In search of more nuanced understanding

Christopher Davey, the Editor in Chief of the Australian and New Zealand Journal of Psychiatry, started the first issue of 2023 with an editorial arguing that: ‘Our capacity for empathy is part of what we seek to develop from those who share their lived experiences. But more than this, it is how we use those perspectives to reform and reshape mental health care […] We have to respect that our perspectives are in many ways different, and find in those differences a more nuanced understanding of mental illness and mental health care’.^{Reference Davey1} In this issue of BJPsych, Professor Bebbington shares his experience of living with Alzheimer's disease. It is one of the most powerful articles I have read this year (pp. 151–152). Similarly, Chown et al in their invited commentary (pp. 157–159) provide an alternative perspective on the recently published definition of terms from Scotland's National Autism Implementation Team by Shah et al.^{Reference Shah, Boilson, Rutherford, Prior, Johnston and Maciver2} The commentary highlights the differences in our perspectives on how we conceptualise neurodiversity. I don't think we have reached a more nuanced understanding on this one.

Moving from personal experiences to service provision, Peckham et al (pp. 160–166) used data from the Closing the Gap health study to find that the majority of the 9914 participants with severe mental illness perceived maintaining a healthy lifestyle as being either a top priority (45.5%) or moderately important (39.0%). The authors argue that the potential impact of our therapeutic nihilism may be leading to suboptimal access among our patients to interventions with clear evidence of managing behavioural risk factors. I am not sure whether this is entirely true. I have been hearing about mortality and morbidity gaps among people with mental illness since I started training more than a decade ago. As a trainee, I felt more comfortable talking about physical activity and monitoring serum cardiometabolic parameters than providing any structured psychotherapy. If anything, I think there is a sense of academic nihilism among clinicians best captured by the title of an editorial: ‘Mental disorders and mortality: so many publications, so little change’.^{Reference Stewart3} As Peckham et al point out, we need to work out how to change motivation into action. We need a more nuanced understanding of turning efficacy into effectiveness.

Another study in this issue explores data from over four million individuals in Denmark to examine the association between COVID infection and self-harm (Erlangsen et al; pp. 167–174). Studies like this make my heart skip a beat, as a failed statistician. Stalin is often (mis)attributed with a quote: ‘The death of one man is a tragedy. The death of millions is a statistic’. Well, a statistical analysis of four million people just proved that there is no association between COVID infection and self-harm. If a statistic can bust a myth, what about a tragedy? Can we learn from the death of one man? Root cause analysis is a regular and often mandated method of learning from individual adverse events. In their thought-provoking article, Deshpande et al in this issue question (pp. 153–156) the validity of this method in psychiatry. To date, there is little evidence to show that conducting root cause analyses will improve mental healthcare provision. Are we doing something because it makes us look like we are doing something without actually doing something?

I am not happy with where we are in psychiatry. The best interventions for depression, bipolar disorder and schizophrenia were all discovered well over half a century ago. We somehow manage to oversimplify and overcomplicate mental illness at the same time. Can we reform and reshape different perspectives into something meaningful? We often overpromise and underdeliver in mental healthcare. Can we find a more nuanced understanding in psychiatry? We seem to spend more time talking about what we should be doing rather than doing something about it. How do we turn experience, conceptualisation, nihilism and motivation into a cure? I don't know. But I am still naive and inexperienced enough to remain optimistic that we will get there before too long.