Pre-emptive early intervention

Prince Edward Island is not very well known internationally. It is a sausage-shaped island in the St Lawrence basin best known for two stories, one of a young girl growing up in an alien social environment - Lucy Montgomery's Anne of Green Gables - and a somewhat boozy national conference in 1864 where no one had sufficient capacity to record the minutes, but where the leaders of the provinces north of the United States decided they enjoyed each other's company so much that, even when the effects of alcohol had worn off, they must join to form a greater Canada. But both these events have had long-lasting impact, and in June I heard a presentation on the island that may have similar longevity and influence on psychiatric thinking, the FORBOW (Families Overcoming Risks and Building Opportunities for Well-being) project, presented by its lead researcher, Rudolf Uher, at the Atlantic Provinces Psychiatric Association annual meeting. FORBOW is an early intervention project but one with a difference. The jury is still out on whether early intervention for severe mental illness has been the success that it promised. Some would say that it is an undoubted asset to our care, in McGorry's words, ‘an increasingly evidence-based “best buy’”, ^{Reference McGorry1} but the subject still arouses the same level of debate as it did 10 years ago. ^{Reference Pelosi and Birchwood2} Although the results in the short term are fairly good, after 5 years most seem to have evaporated. ^{Reference Bertelsen, Jeppesen, Petersen, Thorup, Øhlenschlaeger and le Quach3,Reference Gafoor, Nitsch, McCrone, Craig, Garety, Power and McGuire4} This finding for an established treatment might be expected after the treatment is withdrawn but if early intervention services are really doing their job, they should prevent, not just delay, the onset of severe mental illness. One worry that has dogged research in the area is that most people with brief psychotic symptoms do not have any long-lasting pathology and aggressive early intervention may do more harm than good. ^{Reference Warner5} We all have to be aware of what I call the NSC (Norman Sartorius Conundrum) - the case of a mentally stable and highly productive psychiatrist who had a clear episode of hallucinosis in childhood ^{Reference Tyrer6} but who fortunately did not suffer the handicap of treatment and spontaneously improved. The FORBOW project differs from other forms of early intervention in identifying early antecedents of severe mental illness at a much earlier stage. It has already started this work in testing out what are called ‘low-risk psychosocial interventions’ in the relevant population. They plan to recruit 480 offspring aged 3 to 21, of whom around 120 will have a parent with schizophrenia, 120 will have a parent with bipolar disorder, 120 will have a parent with severe depression and 120 will have no parent with severe mental illness, offer acceptable interventions such as parenting training or learning self-management skills in randomised trials, and examine their short- and long-term outcomes. This could be the best form of early intervention and PEIS (pre-emptive early intervention services) could then replace our present ones; there is reason to believe they would be more effective in at least one group of disorders ^{Reference Treasure and Russell7} and may resolve some of the issues over ethnic variation. ^{Reference Kirkbride, Stubbins and Jones8}

This type of project has the ability to unify the different strands of our profession that are in danger of becoming unravelled and ineffective in isolation. Stepped care for depression is now undoubtedly effective (Oosterbaan et al, pp. ; Roy-Byrne, pp. ) but PEIS could offer an even earlier step. Attention-deficit hyperactivity disorder creates havoc in classification but the increasing evidence that it is genetically linked to bipolar disorder and schizophrenia (Hamshere et al, pp. ; Larsson et al, pp. ; Faraone, pp. ) is not, as some people see it, a brutal end-point when it comes to intervention, but an opportunity to help early, and the evidence that Kuyken et al (pp. ) give for the effectiveness of mindfulness in schoolchildren could be focused even more on those who are more vulnerable. With genetics now becoming more aware of the importance of gene-environment interaction (Nair & Howard, pp. ) this could be a unifying time for psychiatry.

The Editor's prejudice is final

I am coming to the end of my time as Editor of this Journal. This is a fixed-term appointment and it is right that this should be so. I have always regarded the position of Editor as the ‘last remaining bastion of true dictatorship’ ^{Reference Tyrer and Craddock9} and, as dictators have a habit of staying longer than is wise, a fixed term is desirable. In reviewing my decisions over the past 10 years I have come to realise that ‘evidence-based editorship’ is still at the primitive level of expert opinion and prejudice. In my first editorial ^{Reference Tyrer10} I made the somewhat pompous promise that during my editorship ‘scholarship must not be compromised’. At one level this may be true; the really good papers I receive, by and large, get unequivocally good reviews and move forward to publication quickly. For most of the rest, accounting for about 60% of all papers published, I am trying to find a mix of novelty, interest, readability and topicality that puts the paper ahead of its competitors, and scholarship tends to hide in the background against these competitors. So this is where editoriaI prejudice comes in. My own interests, beliefs and opinions influence acceptances and rejections, and no matter how I try to disguise this in phrases such as ‘doubts about the methodology’ or ‘uncertainties about its contribution to science’, the prejudice remains. So here I apologise to all those authors who feel I have been unfair in rejecting their papers; you can say to your colleagues who ask you why your papers have not been published, ‘the Editor was prejudiced, and his word was final’.