Lost but strangely found

When my son was 9 – he often asked whether he was a vertical or a curly 9 – he went to the zoo with his class at school. This might be considered an event unworthy of report but for one small thing. He was not always fully aware of his surroundings and frequently became detached from others when in a group. So when he came back intact from the zoo at the end of the day the first question we asked was, ‘Did you get lost?’ ‘No’, he responded brightly, ‘everyone else did – but they found the right way in the end’. Several articles in this issue, including those by Shah et al (pp. ) and Coleman (pp. ) that may stir quite a few memories, reminded me of the zoo story, as we have strangely found again lost nuggets from the past. An association between anxiety disorders, particularly when panic was present, and mitral valve prolapse, was first reported over 30 years ago ^{Reference Venkatesh, Pauls, Crowe, Noyes, Van Valkenburg and Martins1} and at various times has been felt to be a potential biomarker for panic disorder in particular. Filho et al (pp. ) have resurrected this subject and although they find a tiny excess of cases of mitral valve prolapse in anxious patients compared with controls, this is too small to be of any clinical significance and perhaps this line of biological research could now be dropped quietly but reverently. A more relevant research question, also posed over 30 years ago, was whether people with schizophrenia really do have a better outcome in low- and middle-income countries than in others. How can a disorder characterised biologically by impaired dopaminergic transmission ^{Reference Vyas, Patel, Nijran, Al-Nahhas and Puri2} that also shows such great overlap with other psychoses ^{Reference Bora, Yucel and Pantelis3} be singled out specifically for a good or poor outcome by culture, income and geography? Gureje & Cohen (pp. ) and Haro et al (pp. ) address this question with its strange counterintuitive findings and move us a little way further along the evidence highway. Although selection bias probably has a part to play here, it is extremely bothering that people with schizophrenia from countries in Northern Europe, with its much vaunted joined-up community and hospital services backed up by crisis resolution and assertive outreach teams, are not clearly associated with a better outcome than those in other, less favoured countries. One worrying and perfectly possible reason is that our treatments are less adequate in schizophrenia in richer countries because of an abundance of choice, ^{Reference Adams, Tharyan, Coutinho and Stroup4} consequent polypharmacy and more adverse effects, and when choice is limited or no treatment is given at all, mortality and suicide rates are just the same as for those who are treated. ^{Reference Ran, Chan, Chen, Mao, Hu and Tang5} And why does insight in schizophrenia return more rapidly in India than in Indianapolis? ^{Reference Saravanan, Jacob, Johnson, Prince, Bhugra and David6} Where could we be going wrong?

Another strange reawakening is the report from Kisely et al (pp. ) about the poor dental state of patients with severe mental illness. In 1938 the then medical superintendent of Worcester Mental Hospital, Dr Fenton, was very exercised by this problem, as dental sepsis was felt to be one of the major causes of schizophrenia and severe mental illness, so an ENT surgeon was appointed to the hospital. ‘In our efforts’, Dr Fenton wrote, ‘to improve the mental and physical health of our patients, I regard it as essential that all new admissions should be examined by the dental and the ear, nose and throat surgeons for the presence of oro-naso-pharyngeal sepsis, and that all treatment necessary should be carried out as soon as is advisedly possible.’ ^{Reference Fenton7} His theory, held by many at the time, was that this treatment alone was curative of the mental illness, and although it was clearly not, it may have helped more than many other treatments at the time. So when you read about strange and unfathomable findings in our Journal (and elsewhere) do not put them out of your mind entirely; park them somewhere where they can be rekindled.

The Impact Factory Song

In the 2010 journal ratings, just published, the impact factor of the British Journal of Psychiatry has risen to 5.95. My uncomfortable ambivalence about this statistic could only be overcome by a song, whose tune has yet, if ever, to be identified. Thanks again to my reviewers, who have been punished already by seeing an advance version, and to all others who toil at the Impact Factory.