On wisdom in mental health care

Data is not necessarily Information.Information is not necessarily Knowledge,Knowledge is not necessarily WisdomAnd none of the above is ActionIn my previous editorial in this journal (Advances in Mental Health 10(2): 'On being online'), I addressed some aspects of this aphorism - specifically Data, Information and Knowledge, and if you did not read that, it may be useful to do so prior to reading this one. In the present editorial I want to examine some recent works that draw on these three constructs, but take the additional leap toward suggesting wise ways in which we should be working in mental health and in mental health services. Finally from this perspective, I want to examine a proposed set of National Health and Medical Research Council (NHMRC) guidelines that (to my mind, and at least at this time) may fall short of wisdom.A recent multi-site randomised controlled trial on emerging psychosis (Morrison et al., 2012), the largest of its kind, should have a profound impact on our thinking about how to manage young people with signs of being at risk for psychosis. From five UK sites, they included 288 people between 14 and 35 years seeking help for psychotic symptoms. A major exclusion was being on antipsychotic medication. They randomised half to Cognitive Behavioural Therapy (CBT) plus monitoring of mental state, the other half to simply monitoring mental state, and followed participants up for between 12 and 24 months. Their outcome measure was the Comprehensive Assessment of At-risk Mental States (CAARMS), an internationally accepted measure that can indicate whether participants 'transition to psychosis' or not. The results are intriguing.Where previous studies have suggested that those 'at high risk for psychosis' have up to a 50% chance of becoming psychotic, Morrison's group found only 8% 'transitioned'; that is over 90% may have had anxiety about symptoms, or have been depressed, but they did not become psychotic. As clinicians, we should find this very reassuring.The second point is that effectively there was no difference between the two randomised groups as to whether people became psychotic. Again, as clinicians, we should find this very reassuring. The routine care group (what they term 'active monitoring' - which may have included 'supportive listening, access to crisis care, and signposting') did just as well in not becoming psychotic. The single difference was that participants in the CBT group were significantly overall less distressed about their symptoms. Morrison et al. (2012) discuss their own study very carefully, critiquing it from many standpoints (sampling, intervention, statistical approach), but we are leftwith some very strong data from which they extract useful information to add to our knowledge about this complex group of clients.Morrison et al. (2012) go further. They suggest their study has implications for prevention, and that perhaps there is a need for review of the 'ultra high risk' strategy; that perhaps there is a problem with our ideas about the cost-benefit from providing highly specialised treatment to a group of whom 90% are going to improve with routine care and monitoring. They raise two more issues that need much more discussion. The first relates to premature prescribing of anti-psychotic drugs for which they provide three recent references citing anti-psychotics as the cause of changes in brain volume previously ascribed to schizophrenia itself. The second is the move toward a category of 'psychosis risk syndrome' in the proposed 5th version of the Diagnostic and Statistical Manual for Mental Disorder due for publication and distribution in 2013.So there are wisdoms for mental health practice in this work: 'Don't jump to conclusions about outcome' even where there are psychotic symptoms or what may appear to be high or ultra high risk for psychosis. A second might be: 'Very little is likely to be lost by a period of (what Morrison et al. …