The British Journal of Psychiatry
Highlights of this issue
Sukhwinder S. Shergill

Schizophrenia: outcome, culture, cognition and genes

There is a diversity of outcomes in schizophrenia, at odds with the invariably poor outcome described originally by Kraepelin, and data from earlier World Health Organization (WHO) studies suggests that outcomes may be more favourable in lower-income countries. This has now been examined in a more recent sample. Haro et al (pp. 194–201) report that clinical outcomes of schizophrenia were indeed poorer in Europe than in lower-income countries, particularly those in Latin America, but that functional outcomes were often better in Europe. They suggest that this difference in outcomes may reflect differences in culture and environment rather than in the disorder itself. An accompanying editorial, by Gureje & Cohen (pp. 173–175), reviews the outcomes from the original WHO studies and highlights the difficulties in capturing large differences in social, economic and cultural milieux into one regional label. They propose that a more detailed analysis of within-country studies of outcome may be necessary to complement the between-country studies. Cognitive impairment is increasingly recognised to be part of the core difficulty in schizophrenia, but the underlying mechanism remains unclear. Ortiz-Gil and colleagues (pp. 202–210) demonstrate that there is no structural deficit differentiating patients with significant cognitive deficits from other patients. However, functional imaging demonstrated decreased frontal cortical activation in the patients with greater cognitive deficits; they suggest that while evident structural changes in schizophrenia are not associated with cognitive impairment, the functional changes reflect cognitive impairment. Multiple genes of small effect are thought to combine in patients developing schizophrenia. The 22q11.2 deletion syndrome is associated with increased rates of schizophrenia, with up to 50% of these individuals developing a psychotic illness. Toyosima et al (pp. 245–246) present a case report highlighting changes in additional genes associated with schizophrenia, a GLO1 mutation and a 5-alanine deletion, which may combine in a multi-hit model contributing to the development of schizophrenia in these patients.

Anxiety, alcohol and neuropsychology

The link between anxiety disorders and alcohol misuse is well established, but the direction of causality is not clear. Liang & Chikritzhs (pp. 219–224) report from a longitudinal study that participants with pre-existing anxiety disorders and affective disorders were at much higher risk of alcohol misuse and dependence. They suggest that this could be used to identify and intervene at an earlier stage. An editorial by Wilson (pp. 176–177) highlights the difficulties faced by patients with alcohol-related brain damage, an increasing problem lacking a satisfactory solution. He highlights the evidence in favour of successful interventions which are proven to be cost-effective, and proposes national-level leadership to promote coordinated help and support for these patients within neurorehabilitation services. Classic risk factors in the aetiology of an anxiety disorder include mitral valve prolapse, although the supporting data are far from consistent. Filho and colleagues (pp. 247–248) demonstrate that that there was no association of mitral valve prolapse with panic disorder or social anxiety disorder. They found that that diagnosis of valve prolapse was increased when using older, less rigorous diagnostic criteria, and this may have contributed to earlier positive associations. Generalised anxiety disorder is often associated with neuropsychological impairment in older adults, which has an impact on function. In a treatment study, improved neuropsychological functioning was seen in those patients showing improvements in anxiety. Butters et al (pp. 211–218) suggest that reductions in anxiety may drive improvements in cognition, with potential benefits on functioning and quality of life.

Abortion, mental health and dental disease

Having an abortion is often a highly stressful event and the consequent implications for the person’s mental health have been hotly disputed. A comprehensive review of the literature suggests that there is a significant increase in mental health problems after abortion. Coleman (pp. 180–186) suggests that these risks need to be reflected in the delivery of abortion services, and raises the thorny issue that 90% of UK abortions are justified on the presumption that abortion actually reduces the risk to mental health associated with continuing the pregnancy. There is an increasing awareness of increased comorbid physical illness in patients with severe mental illness. Kisely and colleagues (pp. 187–193) found that the levels of advanced dental disease were increased threefold in patients with severe mental illness. The authors suggest that there needs to be improved recognition of this problem – reflected in a more proactive approach to dental hygiene in these patients.

DoLS and PBR: outcomes and costs

The Deprivation of Liberty Safeguards (DoLS) were put in place to protect the rights of those deprived of their liberty but not detained under the Mental Health Act. The implementation costs of these DoLS were assessed by Shah et al (pp. 232–238), who suggest that the costs were more than double those originally anticipated. However, there were many fewer assessments than anticipated, ensuring that overall costs were within the preliminary budgets. ‘Payment by Results’ (PbR) is the next stage of encouraging standardised measurement of clinical outcomes in mental health services. The aspiration was also to use the same data to provide quality indicators for commissioning. An editorial by Macdonald & Elphick (pp. 178–179) reviews the core issues involved in PbR and concludes that it will gain the necessary management support and a financial imperative; however, they question whether it will encourage the routine measurement of clinical outcomes.