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SCHIZOPHRENIA, ENDOPHENOTYPES AND PSYCHOSIS
Impaired cognitive, social and emotional functioning, the endophenotypes of schizophrenia, are also implicated in other psychiatric disorders, including bipolar, depressive and anxiety disorders. These intermediate phenotypes are conceptualised as the measurable components of the pathophysiological pathway from aetiology to disease. Weiser et al (pp. 203–205) discuss the change in research focus from more conventional, narrow phenotype-based research to a more broad-based thematic approach, as advocated by the National Institutes of Health in the USA, and review the case for studying such endophenotypes rather than concentrating on the much narrower and rarer syndrome of schizophrenia. This approach is used by Toulopoulou and colleagues (pp. 284–285) to demonstrate that unaffected relatives of patients with psychotic illness, who may be carriers of susceptibility genes, suffer from deficits in verbal memory and visuospatial manipulation tasks, in the absence of any general decrements in IQ or educational level. They suggest that the liability to psychosis may be linked to the transmission of these endophenotypes. Pillmann & Marneros (pp. 286–287) use the more traditional diagnostic distinction between schizophrenia and acute and transient psychotic disorders to show that the latter diagnosis has a more favourable outcome as measured by general functioning over a 12-year follow-up period. Interestingly, the number of patients suffering a relapse was similar between the two groups, but the patients with a diagnosis of schizophrenia were less able to maintain their general level of functioning.
ANTIPSYCHOTIC TREATMENT OF MANIA
Mood stabilisers, antipsychotic medication and benzodiazepines are widely used in the treatment of mania. In this issue, two antipsychotic medications were evaluated, within randomised double-blind trials, in the treatment of mania. Khanna et al (pp. 229–234) demonstrated that risperidone, at a mean dose of 5.6 mg/day, was significantly more effective than placebo in the treatment of the manic phase of bipolar illness. Risperidone appeared to be effective in mania with and without prominent psychotic features. Vieta et al (pp. 235–242) showed that aripiprazole, at a mean daily dose of 21.6 mg, showed similar efficacy to haloperidol, at a mean dose of 11.1 mg, in a similarly defined sample of patients. However, aripiprazole was better tolerated than the haloperidol and more aripiprazole-treated patients continued to show a response at the end of the 12-week study. In both the studies there was no increase in the numbers of patients switching to depression in the atypical-treated group.
IMAGING ADHD AND SUBSTANCE MISUSE
Functional MRI findings in adolescents with attention-deficit hyperactivity disorder (ADHD) show decreased activation within brain regions associated with attention to action and visuospatial manipulation. Silk et al (pp. 282–283) conclude that these findings may reflect a slower maturation of these fronto-parietal neural systems in patients with ADHD. Dom et al (pp. 209–220) review the imaging literature related to substance misuse and highlight the role of the orbitofrontal cortex, site of the injury in the famous case of Phineas Gage, in the addictive process. They suggest that there is a decrease in the functionality of the orbitofrontal cortex during drug withdrawal which may contribute to dysregulation of the normal hedonic processes, as reflected in dysthymia following detoxification from a range of substances and also during chronic stimulant use. This region may therefore contribute to goal-directed behaviour leading to compulsive drug-seeking and consequent relapse.
EATING DISORDERS IN PREGNANCY AND PATIENTS’ NEEDS
Both lifetime and antenatal eating disorder symptoms, in a sample of over 7000 pregnant women, were most strongly linked with reported aversive early experiences of parental cruelty, sexual abuse and parental depression or alcohol problems. Senior et al (pp. 268–273) suggest that health professionals dealing with pregnant women need to be aware of the high prevalence of eating disorder symptoms and the possible association with aversive childhood antecedents.
A fundamental question is what should modern mental healthcare aim to provide? One view is that the possibilities lie between two poles, one position is that patient’s experiences need to be evaluated using scientific knowledge and clinical judgement, and appropriate evidence-based care provided and adherence to treatment regimens encouraged. The other position is that each individual’s experience and needs are unique and there is no value in comparing them with others; therefore each person should exercise total choice about how their needs should be met. Slade et al (pp. 256–261) demonstrate that the patient-rated assessment of unmet need has a direct effect on patients’ quality of life, perhaps even greater than other clinical or social variables. The implication is that if clinicians want to improve their patients’ quality of life, then health service provision may need to be more focused towards each patient’s choice of priorities – leading to a different, more collaborative but possibly higher-risk service.
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