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Psychiatry has many frontiers

Australian & New Zealand Journal of Psychiatry, 49(7) Psychiatry is a constantly evolving discipline and profession. While the frontiers of knowledge and practice are often seen as coming from the neurosciences, this month’s issue deals with several new frontiers, without a gene or brain scan in sight. Mindfulness meditation had its origins in Buddhist practice, but has influenced the development of a new wave of psychological therapies, including mindfulness-based cognitive therapy and acceptance and commitment therapy (ACT), which have a growing evidence base. These adaptations of mindfulness meditation have been secular and separated off from the Buddhist origins of the practice. In this issue, Van Gordon and colleagues question whether important elements have been lost by extracting mindfulness from its traditional Buddhist setting and discuss a newer generation of interventions that retain these roots. Murray, also in this issue, notes the need to build these new therapies on ‘better understanding of the specific mechanisms of mindfulness in its various contexts’. This month’s issue also deals with the contribution that psychiatry can make to preventing violence towards prominent people. Every-Palmer and colleagues report on a survey of New Zealand Members of Parliament, which found that 87% had experienced ‘harassment ranging from disturbing communications to physical violence’. Some of these threats come from individuals who get fixated on a prominent person, and these fixations may be associated with mental illness. In a related article in this issue, Pathé and colleagues note that ‘the main risk of serious harm at major public figure gatherings comes not from terrorists or criminal activity but from fixated persons’. They describe the work of the Queensland Fixated Threat Assessment Centre in assessing and managing this threat, using the G20 Summit as an example. Risk at the G20 Summit was reduced by identifying and treating fixated people who had a mental illness. Concepts of psychopathology are also changing. Hikikimori is a syndrome described in Japan, where young people seclude themselves in their rooms, do not attend school or work and have little social contact with peers. While first identified in Japan, similar problems may occur in other cultures. In a systematic review of youth social withdrawal, Li and Wong distinguish three mechanisms that can produce such withdrawal and propose that each mechanism requires a different type of intervention. However, while proposing ideas, they note the lack of evidence on what are effective interventions. An area where the evidence base has been slowly building is on childhood trauma as a risk factor for psychosis. However, little has been done on risk in early psychosis. In the current issue, Duhig and colleagues report that a history of childhood trauma is very common in young people with early psychosis, with more than three-quarters affected. The most common forms of trauma were emotional abuse, emotional neglect and physical neglect. Although there was no control group, it is clear that these rates are far beyond those found in the general community. The authors recommend that clinicians should inquire about childhood trauma in patients in order to inform treatment. A final frontier is a methodological one. While randomized controlled trials (RCTs) are quite familiar, they present particular challenges when applied to psychiatric interventions, as argued in an entertaining piece by Andrew Mackinnon (this issue). Qualitative methods have traditionally had a much smaller role in psychiatric research. However, this is changing, as the field recognizes that quantitative and qualitative methods complement each other. In this issue, Crowe and colleagues explain the differences between two qualitative methods, thematic analysis and content analysis, and illustrate their use to answer a very practical question—what strategies do people use for managing their bipolar disorder. A previous review on qualitative methods (Fossey et al., 2002) is one of the most cited in the journal and has obviously been of great use to psychiatric researchers seeking an introduction to these approaches. The new review by Crowe and colleagues may find a similar welcoming reception.