From the Editor's desk

The masters of time

Those who predict successfully are the real masters of time. But what is predicted correctly is often the stuff of depression; excitement lies in uncertainty tinged with anxiety. I would like to think the British Journal of Psychiatry occupies the latter slot in readers' minds: we are struggling down in the foothills of successful prediction, but the doubt we acknowledge makes it a more interesting area than the tiny stony summit of certainty with its fixed perspectives. This has always been a worry behind the genetic advances in psychiatry, as the fear that your genes might predestine your future mental state can provoke real alarm. Newson (pp. ) reassures us that this bleak world of genetic determinism is a long way off, but there are still ethical concerns even with our current predictive ability. We have been seduced by the idea that the earlier we can predict a mental disorder the better we can treat it successfully, so that at present we have diligent researchers determined to identify those ‘at risk’ of disorders such as schizophrenia and depression by neuroimaging approaches ^1–3 or sophisticated psychological tests ⁴ in the hope that early intervention can minister to a mind already slightly diseased. To do this we have to be certain our diagnoses are right and our continued debate about the overlap between psychosis, bipolar disorder and schizophrenia exhorts us to find better assessments such as magnetic resonance imaging studies (Arnone et al, pp. , Koutsouleris et al, pp. ), or in-depth testing of those with an adolescent onset of psychosis (Janssen et al, pp. ). The presence of even minor abnormalities of mental state earlier in life seems to predict more major disturbance later (Johnson et al, pp. ) and reinforces the quest for early identification.

If our predictions are wrong and we intervene unnecessarily, we create iatrogenic disease and much more. The famous experiment by David Rosenhan ⁵ which showed that ‘pseudopatients’ presenting with invented crude hallucinatory experiences were admitted to mental hospitals, misdiagnosed and generally misunderstood, shows how defective our mental state assessments are, and we must not fool ourselves into believing our diagnostic practices are so much better a generation later. The adverse effects of commonly prescribed psychotropic drugs are sometimes worse than the symptoms of the disorder and may deserve assessment as major outcomes, ⁶ and the paper by Price et al (pp. ) on the variety of reactions to selective serotonin reuptake inhibitors shows the value of a qualitative approach here. As the adverse effects often overlap with clinical symptoms we are always looking for better assessments and Uher et al (pp. ) may have made an important contribution to this quest. But despite all these advances, in the end we are still floundering with prediction. Basically, we are gambling when we make most clinical decisions in psychiatry. True, it is intelligent gambling, and I hope we do not need the treatments suggested by Grant et al (pp. ) to solve it, but our world is inhabited by the language of the betting shop, and whether we cloak it in fancy terms such as probability values, odds ratios or relative risks, we are all still just guessing.

Where do our papers come from?

Some years ago I examined the international contribution to the Journal and found that two-thirds came from Europe (mainly UK), with 13% from North America, 11% from Asia and 7% from Australasia. ⁷ I have now examined again the origins of the 300 papers most recently accepted for publication (by address of main author, so the international contribution may be understated). The results showed that all continents are represented with articles from 27 countries, 161 (54%) from the UK, 43 (14%) from the USA, 14 (5%) from Australia, 13 (4%) from Canada, 6 each (2%) from Germany and Switzerland and 5 (1.7%) from Ireland. I note with odd vicarious pleasure that this is roughly the same proportion as the origins of my ‘Ten books’ in this issue (Tyrer, pp. ), although the poetic Irish have a somewhat bigger say in literature. Over the past 5 years authors from the USA and Australia have increased their representation but we have not made major inroads into filling the yawning gap between publications from high-, middle- and low-income countries. ⁸ Yet I think it is right to conclude that we are becoming more international, and it is good to see that North America is looking east a little more frequently. Melvin Shabsin, Medical Director of the American Psychiatric Association for many years, deserves credit for ensuring that his colleagues have not become too inward-looking, and our figures suggest that his aspirations outlined in a recent publication ⁹ are being met:

‘An American psychiatry that is respected and admired across the world and that is able to perceive and absorb creative new ideas will be more likely to achieve equity than will an organisation that functions as a self-absorbed isolated trade union’ (p. 98).

With Barack Obama adding his weight to the equity debate we may well do even better in the next 5 years.