New treatment paradigms for mental health conditions: A time for renewed enthusiasm?

Australian & New Zealand Journal of Psychiatry, 53(12) Given the complexity of mental health conditions and apparent lack of progress in improving the prevalence of these at a population level, it is easy to become negative about progress in psychiatric treatment. Indeed, some have argued in recent years that despite increased development and provision of treatment, the prevalence of common mental disorders has increased, or at least not decreased (Mulder et al., 2017). This month in ANZJP, not only is this argument refuted, but several authors present new ideas and paradigms for improvements in the treatment of important mental health conditions, which give considerable cause for optimism. Regarding the prevalence of mental disorders, Furukawa and Kessler (this issue) argue cogently that this situation is not as negative as it might appear. First, they argue that years lived with disability due to mental health disorders may not have increased, when figures are adjusted for age and population. Second, they argue that prevalence in psychiatric epidemiological studies may not always be an accurate reflection of the situation, being influenced significantly by participation rates and the readiness of participants to admit to symptoms of depression, which may have changed significantly over time. Third, they argue that while rates of mental disorder may not have altered, they may, however, be better controlled by current treatments, resulting in an improved quality of life for sufferers. This then sets the scene for several papers in this month’s issue that discuss exciting new paradigms for the treatment of common mental health conditions. Anorexia nervosa is a condition which is particularly difficult to treat and Phillipou et al. (this issue) point out that compared with other mental health conditions, relatively modest advances in treatment have been made. These authors argue that although the biopsychosocial model has frequently been applied to anorexia nervosa, the biological aspects of the disorder have been relatively under researched resulting in a paucity of neurobiological therapies. They note that most of the neurobiological therapies employed are used to treat comorbidity with other conditions. They also emphasise the importance of interactions between different aspects of the biopsychosocial model. For example, they point to the interaction between the gut/brain axis and the behavioural aspects of what is ingested. In a condition in which therapeutic nihilism may easily emerge, this erudite paper that concludes with a plea to fund truly multidisciplinary initiatives to help to provide individualised treatment for anorexia nervosa signals a positive future. In their model, reference to the importance of the gut/brain axis draws the attention of readers to the relationship between the gut microbiome, the ‘leaky brain’ and mental health – an area that is of increasing interest and reviewed in detail recently in this journal (Morris et al., 2018). This is also the subject of an excellent review by McGovern et al. (this issue), which examines the likely effects of serotonin reuptake inhibitors on gut microbiota. Based on literature regarding the pharmacokinetic and gastrointestinal transit properties of selective serotonin reuptake inhibitors (SSRIs), and their antimicrobial effects in situ, the authors conclude that for at least 4 hours per day at usual doses, SSRIs are likely to exert a significant antimicrobial effect in the gut. The review raises important questions about the possible mechanism of action of SSRIs and a possible pathway via an effect on gut microbiota. The authors suggest that not only does this have implications for the mechanism of action of SSRIs but also for understanding the effects of other treatments which may improve outcomes in depressive disorder by effects on the gut microbiome. Another area of research in mood disorders that has attracted increasing interest in recent years is the role of cognitive dysfunction. This is often an important feature of mood disorders that can impact very significantly on functioning. Hence, the use of cognitive remediation, which has been extensively studied especially in schizophrenia, has now begun to feature in research studies of mood disorders (Porter et al., 2013). This month New treatment paradigms for mental health conditions: A time for renewed enthusiasm?