Highlights of this issue

MEDICATION MANAGEMENT TRAINING FOR NURSES

Poor compliance can reduce the efficacy of treatments, resulting in worse health outcomes for patients. Using a randomised design, Gray et al () trained community psychiatric nurses for 80 hours in medication management. Independent researchers interviewed their patients and the patients of nurses who did not receive training, at recruitment and 6 months later. Patients who were cared for by nurses who had received the training showed a greater reduction in overall psychopathology compared with treatment as usual. Attitudes towards treatment and compliance also improved more favourably in the intervention group. Given its positive effects, this manualised training package could be disseminated widely.

LIFE EVENTS, FAMILIAL LOADING AND MOOD DISORDERS

Hillegers et al () explore the impact of life events, familial loading and their interaction on mood disorder onset in a high-risk cohort of adolescent offspring of parents with bipolar disorder. Results revealed a strong relationship between life events and the risk of mood disorder, but familial loading did not confound or modify the relationship. Familial loading itself was an independent predictor of mood disorder in the cohort. Kim et al (), in a Korean community study, demonstrate an association between previous stroke and lower levels of high-density lipoprotein and late-life depression. The link with other established risk factors for cerebrovascular disease were not found. From a public health perspective with regard to preventing depression, these results support a focus on post-stroke populations and on reducing levels of general disability rather than specifically targeting those with vascular risk factors.

DIABETES - A LARGER PROBLEM THAN REALISED

In recent years the use of atypical antipsychotics has been strongly linked to emergent diabetes. Questions have been raised as to whether this finding in part reflects greater monitoring, and hence detection, of glucose abnormalities in patients receiving the newer drugs. Taylor et al () obtained prescription cards and examined case files of 606 patients prescribed antipsychotics. Testing for diabetes was undertaken in less than half of the patients studied and was more common in those receiving atypical antipsychotics. These findings have important consequences for the interpretation of diabetes prevalence studies using databases.

POLYMORPHISM AND PROLACTIN

Antipsychotic drugs vary widely in their binding affinity for the D₂ dopamine receptor. Hyperprolactinaemia is associated with the tighter-binding agents at D₂ receptors. The A1 allele of the D₂ receptor gene is associated with significantly decreased density of D₂ receptors and thus may influence D₂ receptor antagonism. Young et al () examine the role of the DRD2 polymorphism on prolactin levels in patients treated with antipsychotic medication. Patients with this polymorphism had higher prolactin levels and were over-represented among those with hyperprolactinaemia. The authors suggest that the A1 allele of DRD2 may be a useful clinical marker for identification of those at risk of hyperprolactimaemia and associated adverse effects.

CHILDHOOD FACTORS LEAD TO FREQUENT CONSULTATION

A small number of patients account for a disproportionately large amount of health care use. The reason for this is poorly understood. Using a nested case-control design, Kapur et al () reveal that childhood illness exposures and reports of childhood adversity were independently associated with adult consultation behaviour, even after adjustment for adult psychiatric disorder. Interventions for high users of health care should thus address childhood illness experiences and adversities in addition to adult psychiatric disorder.

PREMORBID FUNCTIONING AND INTERPRETING FACIAL EXPRESSION IN SCHIZOPHRENIA

Larsen et al () suggest that the heterogeneity of schizophrenia begins early, long before the onset of psychosis. They administered the Premorbid Adjustment Scale to 335 patients with schizophrenia and found that social and academic functioning constituted fairly independent dimensions. Patients with a stable social course compared with a deteriorating one had a shorter duration of untreated psychosis, were older, had more friends and fewer negative symptoms. Good academic childhood functioning was associated with meaningful activities, more education and better working memory. Results support both neurodevelopmental and neuroregressive pathways to psychosis. Hall et al (), in a small case-control study, show that people with schizophrenia have marked deficits in their ability to interpret social cues from faces. They suggest that impairments in social cognition represent a core deficit in schizophrenia, which is likely to be related to abnormal frontotemporal functioning.

ONE OR MANY FUNCTIONAL SOMATIC SYNDROMES?

Both Simon Wessely and Peter White provide remarkably convincing arguments in this month's debate (). Can functional somatic syndromes really be narrowed into a single entity, or is it a complex array of different disorders?