Ten years of APT

This anniversary editorial narrowly escaped the title ‘Advances in Psychiatric Treatment: 10 years that changed the face of psychiatry’. Too grandiose and clichéd of course, but psychiatry has changed almost beyond recognition since the journal Advances in Psychiatric Treatment (APT) began 10 years ago. Although APT has (mercifully) not been responsible for making all of the running, the journal has usually kept up with the pace; and sometimes I think it may even have been ahead of the game.

Early days

APT began with four papers in each bi-monthly issue. To promote the then newly emerging continuous professional development (CPD) movement, the Department of Health sponsored circulation of the first three issues to all members of the Royal College of Psychiatrists. After that the journal was on its own, with a business plan to break even within 12 months. Even the optimists on the editorial board had to acknowledge that few, if any, journals had ever managed this.

We were fortunate to have the support of the College’s excellent publications department, under the leadership of David Jago, and to find a popular design and an effective educational format which compromised between a didactic approach and a systematic review. We were lucky to identify contributors who submitted first-class material, on time, and for a relatively nominal fee. The goal was to provide high-quality reviews that were topical and offered practical advice to senior psychiatrists regarding all aspects of treatment and management. We aimed for these to be easy to read, well organised, accurate and evidence based as far as possible. Rigorous peer review and an energetic and expert editorial board helped to maintain high standards.

The editorial board, in its idealism, also sought for the journal to be accessible, independent and impartial. This meant keeping subscription costs as low as possible, while steering away from advertising or other forms of sponsorship. Inspired by Andrew Sims’ vision and leadership, we hoped that we would be able to create a balanced and wide-ranging body of authoritative literature which could be trusted and would bridge the gap between academic theory and day-to-day clinical practice.

Success

Over its 10-year life the journal has grown far beyond early expectation, so that we are now heading for 3000 subscribers. There are usually 10 papers in each issue, covering a wide range of topics and all subspecialties. In 10 years we have published almost 500 full-length educational papers, about 15% of which have had associated commentaries or editorials. Surveys indicate that most subscribers do actually read much of APT. Two books have been published based on core articles from the journal, with psychiatric trainees as a target audience. These have sold very well, and this may have contributed to the finding that 74% of candidates for Part II of the Royal College of Psychiatrists’ Membership Examination now cite APT as their preferred source of revision material.

College members can still receive the journal for less than £50 a year. Since 2000, APT has also been available online (http://apt.rcpsych.org). This provides a range of useful facilities, including full-text searching of all issues from January 2000; direct reference links to PubMed; e-mail alerts; and downloading of contents and abstracts to personal digital assistants (PDAs, handheld computers). Online access is free to developing countries and for articles more than 1 year old, and the searchable archive of issues will shortly be extended back to Volume 1, Issue 1. APT articles are accessed online almost one-third of a million times each year and we have growing feedback from an international mental health audience, including service users and carers.

APT began as integral to the College’s CPD initiative, and the editor of the journal was also director of CPD. These two roles soon separated, and APT became financially independent of College subscriptions. There is still close collaboration, with the director of CPD sitting on the journal’s editorial board, and a reciprocal arrangement for the editor of APT to be a member of the CPD committee. This structure keeps APT within the College but allows editorial independence, so that the journal is not seen as necessarily toeing the College line on controversial topics, or issuing yet more directives from the centre.

Disappointment

Over the years of excitement in developing APT, one frustration has been the lack of published correspondence from our UK target readers. Without this, how can we be sure that we are achieving our heady goals of relevance, impartiality and balance? Are our articles just too good (or too bad)? Or are we beginning to be seen as merely another purveyor of received wisdom, vested interest and yet more unachievable guidelines?

An online APT discussion forum somehow missed the mark. After 4 months the only posted comment had been: ‘It’s very quiet in here’. This flew in the face of avowed interest from a large number of College members who responded to a CPD questionnaire by indicating a great appetite for more electronic CPD and interaction. Advertised under the banner ‘free speech’, perhaps this first attempt was naïve and our technology inadequate. Or perhaps there are two classes of College member – those who read APT and those who would like more electronic exchange. The introduction of eLetters, and our emerging partnership with eCPD (Katona, 2004), will offer new tests for these hypotheses. No matter how we achieve it, our hope is for an expanding correspondence and the vitality that dialogue can bring.

Editorials

Surveying 10 years of APT editorials gives an interesting perspective on the changing concerns of senior psychiatrists. Early themes included information technology, issues of confidentiality, sickness among doctors and fitness to practice. The founding editor Andrew Sims introduced the ideas and practices of CPD and explored tensions between controversy and received wisdom. More recent editorials have addressed personal development plans, peer groups, revalidation, mentoring, audit, the proposed new Mental Health Act for England and Wales, devolution, the user and carer movement, the life-span perspective, and proposals to extend the biopsychosocial formulation into cultural and spiritual domains. In this issue, Rowan Williams offers a fascinating glimpse of what it might be to care for souls (Williams, 2005, this issue).

Editors have no favourites, but I enjoyed reading the College President Mike Shooter identifying the growing threats to our professionalism within the NHS: the endless stream of political imperatives, which can undermine any sense of stability in our services; the unachievable drive to eliminate hazards from an increasingly risk-averse society; the perennial pressure from drug companies tempting doctors into medicalising human unhappiness; the potential loss of the intimacy and joint ownership of the doctor–patient relationship (Shooter, 2003). Rowan Williams in his editorial suggests that a renewed focus on psychiatric encounters as intensified listening may help keep us on track, and he gives us a rallying call which could strengthen resistance against half truths and propaganda in these days when functionalism must have the upper hand.

A question of trust

In her Reith Lectures a few years ago, Baroness Onora O’Neill described eloquently how the new drive for public accountability is taking on the form of detailed control, with an unending stream of departmental directives and protocols. She reported that a visit to the Department of Health website induced despair and disbelief: ‘Central planning may have failed in the former Soviet Union but it is alive and well in Britain today’ (O’Neill, 2002: p. 46). She noted that many public sector professionals find that the new demands damage their real work, and that attempts to micromanage complex institutions from the centre result in over-complex and inadequate rather than good and effective governance.

Baroness O’Neill asked: is there an alternative way of achieving the governance that the public definitely require? One solution which has increasing support is the attempt to resurrect the notion of professionals who continually re-educate themselves in the broadest sense. This is the philosophy that underpins the CPD movement, and it is good to think that, within psychiatry, APT might be at its core.

The future

Hubris apart, what of my own hopes for APT? Obviously, more of the same – although success gets harder to sustain. As time passes, core topics seem exhausted and there is drift towards more specialised material and esoteric themes. To correct this, the board have begun to commission the authors of key articles from early issues to revisit their subject. The first two articles in this series are published in this anniversary issue, and I strongly recommend them (Cowen, 2005; Gournay, 2005).

Threats and opportunities come and go. APT has been unusual in continuing to expand its circulation while electronic media are becoming more widely read and predictions of the demise of paper journals proliferate. The open-access publication movement proposes that the costs of publication be borne by authors rather than readers. This threatens to transform the landscape of journal publishing and offers challenges to an educational journal such as ours. The Royal College of Psychiatrists’ eCPD initiative (Katona, 2004) is an exciting prospect. It offers great opportunities for partnership, with joint commissioning and linkage of material. These benefits far outweigh any threat of competition, although the eCPD business plan anticipates a subscription base uncannily similar to that of APT.

Other issues that exercise our editorial board range from the sublime to the potentially surreal. It has been suggested that we embrace a wider readership by changing the journal’s title to something along the lines of Towards Better Mental Health. This meets with almost unanimous opposition among the College’s CPD committee, who argue that APT is an important factor in cementing senior psychiatrists’ medical identities in times of rapid change. Although our outstanding scientific editorial team continues to improve the journal’s readability and has achieved a superbly clean design, there is massive resistance elsewhere to proposals for change to our surely anachronistic cover. Or is the original design now exquisitely post-modern? Multiple choice questions are very popular despite their fall from grace in educational circles: should we continue them? Should we include photographs, poetry or even obituaries? Should there be a merger of APT and the Psychiatric Bulletin? Should APT abandon its idealism and accept advertising in order to further subsidise and promote other College activities?

Andrew Sims often concluded his APT editorials with a plea: ‘Let us know what you think – it is your journal’. The journal has been successful beyond all expectation, but for 10 years it has been rather quiet out there. There are understandable difficulties in establishing a genuine dialogue with readers, but please find a way to tell us what you think and feel, and what it is that you would like to see.