Highlights of this issue

HEART- OR HINTER LAND IN PSYCHIATRY

A fundamental question about the development of psychiatry in the UK is raised in an editorial in this issue of the Journal. Goodwin & Geddes (pp. ) argue that the use of schizophrenia as the defining disorder of psychiatry has had a detrimental effect on psychiatry as a medical specialty. They illustrate the ways in which the focus on schizophrenia has distorted both the provision of care and the research agenda in psychiatry, and served to enhance negative views of psychiatry; they contend that other types of illness, such as bipolar disorder, may usefully replace schizophrenia as the model of a prototypical psychiatric disorder.

ANTIPSYCHOTICS: TARDIVE DYSKINESIA AND DELUSIONAL PARASITOSIS

The cost-effectiveness of second-generation antipsychotic medication has been called into question by more recent treatment studies suggesting that there are no substantial differences in health outcomes or side-effects compared with some first-generation drugs. Rosenheck (pp. ) examines the cost-effectiveness of using second-generation antipsychotic medication in reducing the risk of tardive dyskinesia, which may be left as the main perceived advantage of this class of drug. The reduction in tardive dyskinesia with the use of second-generation antipsychotic treatment is shown not to be cost-effective, unless the costs of the first- and second-generation drugs are made comparable. A review by Lepping et al (pp. ) of the utility of antipsychotic treatment in primary delusional parasitosis, a relatively rare but extremely challenging disorder, found limited evidence that antipsychotic treatment was effective in this condition and that remission rates did not differ between first- and second-generation antipsychotics.

NEUROSCIENCE, AFFECTIVE DISORDERS AND AUTISM

There has been increasing interest in the brain mechanisms underlying emotional behaviour – both in mood disorders and its relevance to normal and dysfunctional social intercourse. In their editorial, Harrison & Critchley (pp. ) provide an elegant contemporary review of this developing area of affective neuroscience, and provocatively conclude that the recognition that emotion influences a broad spectrum of human functioning could result in a rebranding of biological psychiatry as clinical affective neuroscience. Stress is a fairly endemic part of contemporary life-styles and its relationship with mood states remains difficult to disentangle. Wichers and colleagues (pp. ) used twin data and daily life measures to demonstrate that there is a significant genetic component in the manner that people evaluated stressful events during their day-to-day existence. Moderately stressful events resulted in little negative affect in healthy participants but induced significant negative affect in those with a high familial loading of depression, suggesting that this may be an endophenotype for depression. Depressive illness in older people has been linked to changes in cerebral white matter, but the temporal relationship has not been clear. Teodorczuk et al (pp. ) report that white matter changes pre-date the development of depressive illness in a longitudinal pan-European study of older people. They clarify that while white matter changes were correlated with subsequent depressive symptoms at a 1-year follow-up, these were not predictive of the onset of depressive episodes; this suggests that white matter changes on magnetic resonance imaging (MRI) should be included with other independent predictors of illness, such as previous illness and quality of life, in assessing risk of depression in this group. Craig et al (pp. ) report an MRI study of women with a diagnosis of autistic-spectrum disorder, demonstrating changes in their brain structure in multiple cortical regions, but with decrements in the right limbic cortex associated with dysfunctional social interaction. They suggest that this is compatible with the role of this region in affective processing, noted in the lesion literature in both monkeys and humans.

INSOMNIA, AVAILABILITY OF FIREARMS AND SOCIAL PHOBIA

Insomnia is a common clinical complaint and Wilson & Nutt (pp. ) provide a concise reappraisal of the routine treatments in current use, and their mechanisms of action. They note that it may be reassuring that longer-term data on the newer hypnotic medications suggest that they maintain their efficacy over 12 months, but caution that withdrawal reactions may occur in some patients. Reducing the availability of higher-risk means of suicide is accepted as a useful strategy for reduction of suicide. The availability of firearms at home has been shown to be a risk factor for both suicide and homicide. The implementation of a new firearms law in Austria provided the opportunity to examine the effects of this change on firearms-related suicides and homicides. Kapusta et al (pp. ) found that both firearm suicide and homicide rates were reduced following the implementation of a new, more stringent, firearms law. They suggest that this may be useful strategy for other countries to follow. Social phobia is amenable to psychological treatment, but it is not clear whether the therapist is necessary to for treatment. Rapee and colleagues (pp. ) compared a ‘pure’ self-help treatment with self-help augmented by a therapist group session, and the more standard therapist-led group therapy. They found that the augmented option was superior to the pure self-help condition, and equivalent to the more intensive standard group therapy. This may offer an effective treatment, but requires less therapist time.