The British Journal of Psychiatry
From the Editor’s desk
Peter Tyrer

The proper exercise of choice

It is now self-evident that the exercise of personal choice in mental healthcare is a necessary prerequisite of a good-quality service. The trouble with choice, as the former Soviet foreign minister Molotov once said referring to democracy, is that you can never be sure who is going to win. We can of course have rigid guidance, or what I have referred to in a previous column as ‘ guidebinds’,1 that tell us what to do on the basis of best evidence, but good practice must not be a slave to this. Uncertainty is never far away from our decision-making, even though we are sometimes reluctant to admit it. Patients’ views are also changing fast. Nearly 40 years ago I was working in a southern county of England where I felt many were still secretly attracted to the feudal system, and mentioned to a 22-year-old mood-disorded patient whom I suspected might be developing bipolar disorder, that I was not sure whether to prescribe lithium carbonate or do nothing until things became clearer – a policy that might still be defended today.2, 3 When I expressed my doubts he gave me a withering look and replied, ‘ you’re the doctor and are supposed to know – if you don’t know oi don’t think you’re much of a doctor’.

In this issue we demonstrate a kaleidoscope of choices: those of patients wishing to have psychological treatments for common mood disorders (Harris et al, pp. 99–108); those of clinicians in looking for indications of improvement in severe depression (Douglas et al, pp. 115–122); those of US reservists coming from war duties where decisions were made by others, to civilian life where they have to make their own (Riviere et al, pp. 136–142); and the ultimate choice, whether to live or die by your own hand, and in such cases Hotopf et al (pp. 83–84) argue cogently that psychiatrists should not sit on their hands and do nothing. Psychiatrists are almost the only medical practitioners left who have the power to overrule individual wishes, even if they are powerfully held, and although we may do a great deal to persuade patients to do what they initially do not like4, 5 we need the back-up of coercion when we are convinced that mental capacity is sufficiently impaired for a contrary path to be taken. As Appelbaum6 has pointed out, it is the crystal element of ‘the ability to reason’ that separates those with capacity from those without, but we must be absolutely sure, preferably supported by the corroboration of others, when we judge this ability to be deficient. But in discussing all these aspects of choice we must also acknowledge, sadly, that choice is a luxury not available to most of those on this globe who have a mental illness, and that the recent expansion of provision of psychological therapy to satisfy need in the UK (Richards & Bower, pp. 91–92) and preferred options to in-patient care7 are rare exceptions. For the rest of the world’s mentally ill there is either no choice, or Hobson’s choice – taking the only option available or none at all – and Patel et al (pp. 88–90) are right to highlight this and promote the atmosphere of change.

Publication ahead of print

Diligent readers will have noted that we are now publishing research articles online ahead of print. Like most changes it has advantages and disadvantages. While bringing the published contributions even more quickly to public gaze – the essential principle of open access – it still is associated with allegations of bias8 and can sometimes delay, truncate or otherwise distort the paper publication of the article. We are currently publishing most of our papers within 5 months of acceptance but even this time period is proving too long in an era of rapid change and publishing frenzy and many of our authors want to ensure the primacy of their own work if there is chronological debate.

One part of the Journal that will not be published ahead of print – not least because it is created after ‘ahead of print’ has done its work and retired to bed – is ‘From the Editor’s desk’. This item appears to puzzle official citation indices, who sometimes give the title of the text or cite it as ‘Untitled’ even though it clearly is not, nor is it an anonymous editorial comment. It also has other odd features. It appears at the end of the paper version but for some reason – never explained to me satisfactorily by our inscrutable scientific editor, Andrew Morris – it appears at the head of the on-line version. Never mind, the important point is that it appears to be read, and this appears to be irrespective of its placement. One of our readers, Dr Emer Bowman of Dublin, has also encouraged me not to abhor the use of rhyme in sending a short message of support for back-tracking:

I think it’s time the Editor Was given formal credit for The buzz and the attack That prompts discerning general readers To start it at the back.