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Medicine, technical, Uncategorized

Saturday Journal Club.

This has been a challenging week. I ended up putting a medical piece up in mid week, and then kept on going with my current research issues. The local press continues to stigmatize my craft and my profession. But the press is the enemy.

My beloved says I’m angry most days returning from work. She is correct. I work in a system that has half the resources of Australia, and this is a description of what Australia is like.

Rather than increased funding, the opposite has occurred with staffing, infrastructure and resources constrained by state and federal governmental drives for ‘efficiency dividends’. Accordingly, these public sector services remain seriously underfunded, with insufficient capacity for timely and effective treatment of patients. Furthermore, acute mental health services have been sidelined in favour of ultra-specialised programmes with wide variations in levels of effectiveness. This under-resourcing means that public mental health services cannot recruit, retain and develop a healthcare workforce or have adequate infrastructure to provide comprehensive care for the most severely mentally ill . This workforce is winnowed by increased risks of violence and abuse arising from the staffing and resource shortfalls in the sector (RANZCP, 2017). This further exacerbates staff recruitment problems . The situation is compounded by the under-resourcing of overburdened emergency and general hospital facilities, with the result that psychiatrists are increasingly pressured to assume care in inappropriate situations.

Strained and under-resourced services cannot invest in clinical research that can inform evidence-based care, let alone host academic appointments that can improve recruitment and retention of the medical workforce .

There have been attempts to address deficiencies in the provision of community care by funding non-governmental organisations (NGOs), including through primary health networks, but without consideration of their capacity to undertake these greatly enhanced roles. As a result, care for some of the most severely ill has been contracted out to NGOs staffed by a workforce of variable training who are dependent on the renewal of short-term contestable contracts. Case management within mental health services is largely restricted to people on compulsory community treatment.

Jeffrey CL Looi and Stephen R Kisely. So we beat on, boats against the current, borne back ceaselessly into the past – Continued inaction on public mental health servicesAustralian & New Zealand Journal of Psychiatry First Published August 9, 2018 https://doi.org/10.1177/0004867418791292

The issue of classification of psychiatric disorders has a problem. The current categorical system (DSM) defines criteria around the boundaries of conditions, not always the core symptoms of them. For instance, a sense of unremitting fatigue, inner emptiness and physical pain is part of melancholia, but poorly captured because that can be many things. The analogy I use in teaching is that the criteria are akin to fences around fields.

Which would work, but for this: the fields overlap.

For years there has been considerable documentation of the comorbidity of many disorders (e.g. bipolar disorder versus borderline personality disorder or social phobia versus avoidant personality disorder), leading many to question whether there is a shared underlying cause or set of causes for such problems. Because the literature to date has not helped resolved the problem of comorbidity and how to better differentiate these conditions, and dimensional models help to better account for this problem, it would be reasonable for the field to consider a new framework that more effectively addresses this problem. This is the aim of a research consortium known as the Hierarchical Taxonomy of Psychopathology (HiTOP15). Collectively, this group has derived a model based on a number of reviews of the empirical literature, diagnostic co-occurrence studies and large twin studies, and found a consistent pattern of co-occurrence and factor analytic organisation in a number of disorders, For instance, within the detachment spectrum in the HiTOP framework, one could anticipate seeing schizoid, avoidant and dependent characteristics in the same person, and concerns about which diagnosis fits best, or whether two or more diagnoses are appropriate, would be minimised. If the application of dimensions is extended to all psychopathology, one could envision a diagnostic system in which pathology across a dimension would alert clinicians to other types of psychopathology that could be likely, and even anticipated, as the patient is being assessed and treated.

Huprich, Br J Psychiatry 2018 https://doi.org/10.1192/bjp.2018.149

Today, the main news was a large article in the Lancet, which suggests that the correct amount of alcohol to drink is zero. The paper relies on a series of meta analyses and the methodology is quite complex, relies on regressions, and any such model has to be taken with a grain of salt.

In 2016, alcohol use led to 2·8 million deaths and was the leading risk factor for premature death and disability among people aged 15–49 years, with nearly 9% of all attributable DALYs for men and more than 2% for women. Our findings indicate that alcohol use was associated with far more health loss for males than for females, with the attributable burden for men around three times higher than that for women in 2016. By evaluating all associated relative risks for alcohol use, we found that consuming zero standard drinks daily minimises the overall risk to health.

GBD 2016 Alcohol Collaborators. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Available online 23 August 2018 In Press, Corrected Proof https://doi.org/10.1016/S0140-6736(18)31310-2

That is what has been happening this week.


  1. The thing I noted about the alcohol article is that the confidence range included 1.0 at up to about 1.5 drinks per day. In other words, when you do the stats right, they proved exactly the same thing that we’ve been told for the past 30 years.

    Plus, 1 drink per day can be one drink each day (what I do), or it can be seven drinks in one sitting. I am guessing that the accident mortality numbers, as well as some of the other of the 23 factors they’re talking about, have something to do with the answer about how one drinks.

    Hang in there with work.

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