Highlights of this issue

Cognitive function and mental illness

The various elements of cognitive function lie at the core of psychiatric illness. Several papers in this issue of the Journal examine the contribution of cognition to a range of signs and symptoms of illness. There is an increasing awareness of the presence of a continuum of psychotic symptoms within the general population, and that symptoms in childhood, within this non-clinical population, may be predictive of a schizophreniform illness in later life. Horwood and colleagues (pp. ) found that psychotic symptoms were reported by a significant proportion of 12-year-old children, 13.7% reporting at least one symptom over a 6-month period, and the prevalence was highest in those with lower IQ scores, contributed to mainly by the verbal IQ. The authors concluded that self-report questionnaires were inadequate for screening for symptoms, as they tended to inflate the prevalence figures, and that although psychotic symptoms are relatively common in childhood, the relationship with IQ differs from that seen later in schizophrenia, and thus different mechanisms appear to be at play. Dazzan et al (pp. ) examined neurological soft signs and cognitive ability in a sample of people with first-episode schizophrenia and showed increased rates of a range of soft signs in schizophrenia compared with control participants; however, when matched for IQ, only primary signs and motor coordination appeared specific to the presence of psychosis. Fullam & Dolan (pp. ) demonstrate that neuropsychological variables such as executive function did not distinguish between in-patients with schizophrenia who had been violent and those who had not. They suggest that personality factors such as psychopathy and low current IQ may be more important in understanding in-patient violence.

Cognitive–behavioural therapy: depression and PTSD

The cost of delivering CBT is often seen as skewing the cost–benefit ratio, and therefore there has been interest in using technology, particularly computerised CBT, to reduce these costs. Kaltenthaler et al (pp. ) performed a systematic review of computerised CBT for depression and conclude that three out of four trials showed evidence of effectiveness. However, they expressed some concerns about the self-selected nature of the participants and lack of adequate data on drop-out rates and raise the issue of effectiveness in a more representative group of patients. Wild & Gur (pp. ) examined whether memory deficits in post-traumatic stress disorder could influence treatment outcome. They report that patients with poor verbal memory were less likely to respond to a course of CBT. The authors suggest that these patients may require additional cues to aid their progress, or could perhaps be considered for other treatment modalities, such as eye movement desensitisation reprocessing, which has a lower verbal memory demand.

Psychosis: white matter, duration of untreated illness and social functioning

Schizophrenia is considered to be a disorder of brain connectivity and Walterfang and colleagues (pp. ) examined white matter in the brains of individuals considered to be at high risk of developing a psychotic illness. They found that people who later developed psychosis had increased white matter in their frontal cortex at baseline imaging, and demonstrated a progressive reduction in the white matter of the fronto-occipital fasciculus. They suggest that this may be indicative of changes in the connectivity between the frontal and temporal, parietal and occipital regions that are connected by these tracts. Barnes et al (pp. ) addressed the role of duration of untreated psychosis (DUP) in social functioning of patients 1 year after presenting with a first episode of schizophrenia. They hypothesised that the relationship between these would be mediated by the level of symptomology. Although they did find the expected relationship between a longer DUP and poorer social function, this was independent of the level of symptoms, as a longer DUP was also predictive of poorer clinical outcome with more persistent symptoms at follow up.

Ethnicity: carers and prescribing antidepressants

The majority of people with dementia are looked after in the community, often with considerable support from family members. This is especially so in Black and minority ethnic populations, who tend to be less likely to access services. Lawrence and colleagues (pp. ) pose the question – what is the best way of supporting these carers? They identified that carers' attitudes could be used to divide them into two groups: first, those with traditional beliefs, exemplified by implicitly prioritising the patient's needs over their own, and viewing the seeking of professional help as a failure to fulfil their own responsibilities; and a second group with non-traditional beliefs. The majority of south Asian carers, half the Black Caribbean and the minority of White British participants held the traditional ideology. The authors suggest how different approaches will be necessary to support these different carer profiles.