Highlights of this issue

Paranoia, psychopathology and PTSD

The presence of paranoid thoughts is not exclusive to clinical disorder; recent data suggest that their prevalence follows an exponential-shaped curve, with many people experiencing a few such thoughts, while a few people experience many such thoughts. Wong et al (pp. ) found that this exponential curve was also evident in their assessment of paranoid thoughts in children, but the frequency of these paranoid thoughts decreased with increasing age. They found similar rates of paranoid thoughts in children in Hong Kong and the UK, who demonstrated higher levels of suspiciousness at school relative to home, and both countries showed strong correlations with anxiety symptoms. However, in the UK suspiciousness at home was strongly linked to aggression. This study of symptoms is an example used to demonstrate the value of psychopathology to psychiatry; an editoral by Stanghellini & Broome (pp. ) makes the point that psychopathology consists of more than the evaluation of symptoms; it also has a person-oriented focus. Taken together, psychopathology describes the person’s experience, in relationship both to themselves and to the world. They make a case for the centrality of psychopathological examination, based on an emphasis of form over content, as the core of psychiatric practice. The importance of this focus on psychopathology and symptoms is made crystal clear in the differences observed in the prevalence of post-traumatic stress disorder (PTSD) within the same sample, depending on the classification used - the DSM-5 or the new proposed criteria for ICD-11. Each of these two systems identified a proportion of people with PTSD that was not identified by the other - and thus revealed a significant difference in the prevalence of PTSD as assessed by the different classification systems. O’Donnell et al (pp. ) point out the problems of this discrepancy, particularly for international research on PTSD.

Lithium and cancer in affective disorders, and carers’ well-being

Lithium is widely indicated as a first-line treatment for the prophylaxis of bipolar disorder but there is some doubt as to when this prophylaxis should commence. Kessing et al (pp. ) demonstrate that patients who started their lithium prophylaxis earlier in their illness demonstrated better outcomes, as indexed by decreased frequency of hospitalisation and increased use of lithium monotherapy. Given the robust data supporting the use of lithium in prophylaxis, the authors suggest that early treatment, started after the first episode of illness, is likely to improve long-term response to lithium. Bipolar disorder and depressive illness are associated with significant comorbidity, including poorer physical health outcomes. Hung and colleagues (pp. ) show that risk of cancer is elevated in patients with affective disorder, with a greater increase in depressive illness compared with bipolar disorder. The authors suggest that there needs to be a specific focus on lifestyle behaviours in patients with affective disorder, in order to attenuate the risk of cancer. There is an enormous burden of care, often provided informally, by carers of patients with both physical and mental illness. Smith and colleagues (pp. ) found that one in four people was caring for somebody, and that this caregiving role was associated with poorer mental health outcomes, with a dose effect in relation to the time spent in caregiving activity. The authors suggest that there is a need for a national strategy to identify and engage caregivers at an early stage in order to offer targeted information and support.

Space, striatum and secure units

In-patient psychiatry bed numbers have reduced over the years, initially as a response to a renewed focus on treatment in the community, and again more recently, putatively as a consequence of economic circumstances. However, the current level of overcrowding and bed shortages have indicated that the pendulum may have swung too far in this direction, and there is an argument for expansion of in-patient provision. Unfortunately, there is a dearth of data assessing the optimal design of in-patient units, to facilitate positive outcomes in mental health. Papoulias and colleagues (pp. ) performed a systematic review of the psychiatric ward as a therapeutic space and identified a lack of robust data linking design to outcomes; however, they report that the presence of private spaces and a homely environment within the unit may contribute to increased social interaction and patient well-being. The authors discuss the different mechanisms, both explicit and implicit, through which the environment interacts with the patient to contribute to well-being. The striatum is a brain region traditionally associated with well-being, though more conventionally linked to feedback and reward processing, both of which have been demonstrated to be impaired in schizophrenia. Koch and colleagues (pp. ) use neuroimaging to show that the connectivity of the striatum in schizophrenia is reduced in key cortical areas relative to controls. This reduction correlated positively with the volume of the striatum and inversely with the magnitude of negative symptoms. Interestingly, this is also the site of action of most of our antipsychotic medications. Medium secure forensic services were created to facilitate step-down in care from high secure hospitals on the pathway towards community care. The mean length of stay of patients in medium secure units has progressively increased, and is positively associated with poor treatment response, presence of restriction orders and fewer discharge placement options. Doyle and colleagues (pp. ) found that over 20% of patients discharged from medium score units were discharged back to prison, double the figure 15 years ago. These patients returning to prison were characterised as posing a higher risk to others, being more symptomatic, more likely to have a personality disorder and less motivated to engage with treatment. The authors question whether this transfer from and back to prison is an effective use of medium secure resource and discuss alternatives such as enhancing in-prison services for this group - as well as highlighting the urgent need for greater liaison between prison and medium secure working.

Finally, the new Kaleidoscope section (pp. ) brings scientific colour from outside the BJPsych into our readers’ view.