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DEATH, TOXINS AND REPRESENTATION
Benjamin Franklin’s famous remark (in a private letter) ‘In this world nothing is certain but death and taxes’, was written at a time when taxation in the new United States was still a vexed issue. ‘No taxation without representation’ had been one of the slogans fuelling the American Revolution and emphasised that when pain is administered by those who are unanswerable it is demonstrably unfair. In this issue of the Journal the taxing subject of death features strongly. Chlorpromazine signalled the start of another revolution (the psychopharmacological one) and ‘no treatment without representation’ has long been the silent slogan of those treated with this drug and all its successors. Joukamaa et al (pp. 122–127) add early death to the equation of benefit and risk with antipsychotic drugs, and, although the demonstration of association is not necessarily causal, it is disturbing that the greater the number of these drugs prescribed, the higher the mortality. Fifty years ago, as Healy (p. 128) quotes from Heinz Lehmann, early death might have been accepted as a risk of these drugs; now it is not. Meanwhile, we have to continue to discuss more openly with our patients the benefits and risks of antipsychotic drugs, to give them the option of interventions such as cognitive–behavioural therapy early in the game instead of ‘as a substitute in extra time’ (Birchwood & Trower, pp. 107–108), and to give them a little more say and assistance in their management at all levels (Gray et al, 2004; Jeppesen et al, 2005; Li & Arthur, 2005) to deliver a cost-effective treatment for what remains the most expensive psychiatric disorder (Andrews et al, 2004).
Many years ago I worked for an orthopaedic surgeon whose watchword for success in his profession was ‘masterly inactivity’. He defined this ‘as appearing to do a great deal but actually doing absolutely nothing’. This is certainly one way of avoiding the benefit–risk controversy and until a few decades ago many psychiatrists may have acted in this way and been extraordinarily successful at promoting a sophisticated range of placebo interventions for disorders with a short natural history. Now we can no longer get away with doing nothing, with evidence-based medicine shining its torch into the shadows of odd practice, and yet we may act a little too impatiently at times. Those keen to dispel worries about conventional antidepressants will be pleased to note that they may begin to show their positive effects within a few days, depending on your definition of ‘onset of action’ (Mitchell, pp. 105–106), and will point to the many adverse effects of complementary medicines (Werneke et al, pp. 109–121). It is an odd paradox that the most effective remedies always seem to have the most adverse effects, and kava, one of the most promising natural anxiolytic drugs, has now been withdrawn because of hepatotoxicity. Finally, the universal alarm that both suicide and homicide create, with earnest attempts to ‘make sure that this horrific event/mistake/set of circumstances will never happen again’, is shown by Hunt et al (pp. 135–142) and Shaw et al (pp. 143–147) to be an inadequate call to action. Simple measures, such as removing potential ligature points to reduce the risk of hanging in high-risk settings (Shaw et al, 2004), or breakaway techniques to get out of trouble when threatened, are likely to be much more useful than specific psychiatric interventions.
ANALYSIS OF AN INTERNATIONAL JOURNAL
In 2005 we received 991 submissions from 44 countries, an increase in 24.2% over 2004, but I hope that this will not continue to rise at quite the same rate, as ‘refusal may offend’ is likely to become ‘rejection will outrage’ for many diligent authors. Although we are soliciting many more papers from around the world, we are still doing relatively little to reverse the 10/90 divide that continues to irk us (Saxena et al, 2006). The submission rates of the top eight countries by residence of senior author are UK (37%), The Netherlands (8%), USA (7%), Germany (5%), Canada (4%), India (2.4%), Australia (2.2%) and Italy (2.0%). When separated into the six continents, 66% of submissions are from Europe, 13% from North America, 11% from Asia, 7% from Australasia, with only 1.5% from South America (almost all from Brazil) and 1.3% from Africa. China and Japan have the highest proportionate increases and together submitted 25 papers last year. However, the eight most cited papers of 2004 show a smaller UK bias, with three from England, and one each from China, Finland, Sweden, Switzerland and the USA. This is a good stimulus for our international development that we hope can proceed apace with the help of our International Editorial Board.
REFERENCES
Andrews, G., Issakidis, C., Sanderson, K., et al
(2004) Utilising survey data to inform public policy:
comparison of the cost-effectiveness cost-effectiveness of treatment of ten
mental disorders. British Journal of Psychiatry,
184, 526
–533.
Gray, R., Wykes, T., Edmonds, M., et al
(2004) Effect of a medication management training package for
nurses on clinical outcomes for patients with schizophrenia. Cluster
randomised controlled trial. British Journal of
Psychiatry, 185, 157
–162.
Jeppesen, P., Petersen, L., Thorup, A., et al (2005) Integrated treatment of first-episode episode psychosis: effect of treatment on family burden. OPUS trial. British Journal of Psychiatry, 187 (suppl. 48), s85 –s90.
Li, Z. & Arthur, D. (2005) Family education
for people with schizophrenia in Beijing, China. Randomised controlled trial.
British Journal of Psychiatry,
187, 339
–345.
Saxena, Saxena, S., Paraje, G, Sharan, P., et al
(2006) The 10/90 divide in mental health research: trends
over a 10-year period. British Journal of Psychiatry,
188, 81
–82.
Shaw, J., Baker, D., Hunt, I. M., et al
(2004) Suicide by prisoners. National clinical survey.
British Journal of Psychiatry,
184, 263
–267.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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