Progress in suicide prevention

EPA kicked off with an extremely popular and illuminating plenary presentation from Dr John Mann, on progress in suicide prevention over the past 30 years.

The key knowledge we have gleaned in recent years includes:

• Predisposition to suicide is partly heritable
• Social factors and alcoholism are risk factors
• Most suicides have a psychiatric illness
• Developments in understanding risk biomarkers

Indeed, specific genes are being sought for both illness and suicide predisposition and there is a need for further research into epigenetic effects.

Dr Mann also highlighted that in Western nations at least 90% of suicides occur during psychiatric illness and 60% of those patients have a mood disorder. I was particularly surprised to hear that only 20% of those mood disorders are treated and only 10% are adequately treated, clearly revealing a huge gap in effective management.

Suicidal brains have been found to have abnormalities in the serotonin pathway; low serotonin and growth factors lead to disordered neural circuitry, which in turn leads to depression, more impulsive decision-making under stress and altered perception of environmental cues and mood instability resulting in a higher risk for suicide. Further research into genomics and brain imaging should reveal further causes and treatment targets to help us improve suicide prevention.

For me, the first day at EPA was one showcasing best practice under challenging conditions.

At one extreme, Greenland psychiatrist Poul Bisgaard, using telehealth to minister to a patient base spread across over 830,000 square miles in a country with no roads; an attempt which has allowed him to cut hospitalisation rates by 39%.

At the other, Professor Dame Sue Bailey, president of the UK’s Royal College of Psychiatrists, detailing her vision for parity of physical and mental health in the gargantuan NHS. However this vision, where mental health patients finally have the same access to timely and appropriate therapies as those suffering physical illnesses, is one which she says seems a long way off.

However, my key session of the day was the pro-con debate, “Psychiatric assessment before psychotherapy: Mandatory?”, a debate which became a battle of aspirations vs. practicalities.

In the ‘Pro’ corner, Professor Patrice Boyer. His argument; that the task of properly assessing then choosing out of roughly 500 therapeutic approaches is too complex for psychotherapy alone.

Textbooks, he said, could not provide an exhaustive guide and many symptoms have somatic AND psychological causes or, like depression with mixed features, require differential diagnosis. This means that assessment by one, non-medically trained therapist is simply not an option without more comprehensive treatment guidelines.

This led him to the lack of systematic research on the relationship between psychiatric assessment and psychotherapy and the conclusion that, until the knowledge base had been built on, psychiatric assessment to properly characterise a patient and define treatment was the only route to a definite answer. “And”, he said “to be happy with not having an answer is simply not scientific”

Professor Franz Caspar’s rebuttal to this argument was, actually, largely an agreement. He also championed the need for medical assessment of patients but, he challenged, need this always be the FIRST step of the treatment path?

Europe, he argued, is facing a growing mental health epidemic with treatment bottlenecks resulting from a relative lack of qualified psychiatrists. By allowing psychotherapists to make the first assessment and then refer unresolved cases for medical assessment, he said, the process could be streamlined. He highlighted that similar systems to this were already in place in Germany and Switzerland, with no apparent reduction in quality of care.

In fact, Professor Caspar pointed out, in countries with many overseas psychiatrists, an initial psychological consult with a native psychologist may be more effective than a psychiatric assessment. The lack of language barrier could help patients to open up and provide the contextual clues which are an equally valuable aspect of diagnosis.

In short, the answer seems to depend on the aim; perfection or pragmatism?