Highlights of this issue

APPRECIATION AND HOPE

Everybody is inspired by a good story and the special article – an appreciation – about Sir Martin Roth (Kerr & Kay, pp. ) definitely falls into this category, as well as providing an informative historical perspective on the prominent figures and changes in British psychiatry during the past century. One of his main contributions was to increase research into dementia, and the editorial by Burke and colleagues (pp. ) highlights the promise of advances in dementia research. They review more recent data suggesting that there is considerable potential for generating new synapses, neurones and cortical networks at all stages of brain development and conclude that there is room for cautious optimism in applying these approaches to cognitive impairment and dementia.

BABY BRAINS, COGNITIVE REMEDIATION AND LEARNING DISABILITY

There are subtle structural changes in the brains of patients with schizophrenia. Clarke et al (pp. ) investigated whether these were evident in the brains of offspring, where the mother had a psychotic illness. Their prenatal ultrasound study showed no significant differences in brain measures between offspring of ill mothers and control participants, but a non-significant trend for increased lateral ventricular size in the former group. Cognitive deficits are common in schizophrenia and they are correlated with patients' functional outcome. Cognitive remediation therapy has been shown shown to result in improvements in working memory in schizophrenia, with associated improvement in social functioning and at little additional financial cost (Wykes et al, pp. ). It is difficult to diagnose dementia in learning disability; Deb et al (pp. ) describe the development and psychometric properties of a dementia screening questionnaire and conclude that this can now be used as a valid, reliable, observer-rated screen for dementia in this population. Antipsychotic treatment is often used to reduce aggressive symptoms in disturbed patients. Haessler et al (pp. ) demonstrate that discontinuation of zuclopenthixol treatment in patients with learning disability and a history of prior aggressive behaviour can result in increased aggression.

DEPRESSION AND ECT

Electroconvulsive therapy (ECT) is an effective treatment for depression, with rapid effects relative to pharmacological interventions. However, the public perception is that of a dangerous intervention; Munk-Olsen et al (pp. ) examined the mortality associated with ECT, using a register-based cohort study. They found lower overall mortality from natural causes in the patients who received ECT but a higher suicide rate, especially within the first week of treatment. They emphasise the importance of monitoring suicide risk, both during and at termination of treatment.

PERSONALITY DISORDER, ADHD, SEROTONIN AND STABILITY

Disturbance of central nervous system serotonergic function has been associated with aggressive behaviour in adults; this relationship is less clear in childhood and adolescence. A prospective study of children with attention-deficit hyperactivity disorder (ADHD) showed that those with lower childhood serotonergic function were more likely to develop antisocial personality disorder as adults at 9-year follow-up (Flory et al, pp. ). The importance of ADHD in adulthood has been demonstrated by Fayyad et al (pp. ), who report a prevalence of 2–4% in adults surveyed as part of an international epidemiological study. It was more prevalent in higher-income countries, often coexisted with other disorders and caused considerable disability. However, the longitudinal course of personality disorder, particularly its stability and the consequences for functioning, remain unclear. Skodol et al (pp. ) found that individuals with persistent personality disorder over their lifetime demonstrated significant impairment in adulthood. However, adult-onset disorders were also associated with similar impairment. Interestingly, only 25% of patients with a personality disorder at the age of 22 retained that diagnosis at the age of 33 years, and those in remission of their symptoms at 33 years demonstrated relatively little impairment.

DANGEROUS PERSONALITY DISORDER

The supplement to the journal includes several well articulated views regarding the often contentious category of dangerous and severe personality disorder. The background to the development of this category, and the opportunities offered by it, are particularly relevant. The articles by Maden (pp. s8–s11) and Mullen (pp. s3–s7) reflect on the fact that politicians and civil servants invented dangerous and severe personality disorder in 1999 in response to public outcry, but that the initial cynicism has been tempered by the knowledge that this programme of work will have tangible benefits for some patients with personality disorder.