Coming up for air

We all like to have anchor points of certainty in our lives, and even in psychiatry, with its whirlpools and eddies of doubt, we are searching for reminders that some fundamentals remain unchanged. The trouble is that relatively few are left. In George Orwell's pessimistic novel Coming up for Air ^{Reference Orwell1} a man tries to recapture the aspirations and certainties of his youth by going back to the town of his childhood. He is systematically rebuffed by his experiences, the most depressing of which is his return to the idyllic pond where he used to fish only to find it is now a rubbish tip. Reading some of the articles in this issue might at first seem to slap you in the face like the sight of that rubbish tip, but I exhort you not to turn away in horror but read and reflect carefully on some powerful papers. We all love the biopsychosocial model in psychiatry because it gives us a warm inclusive glow and the knowledge that almost every aspect of practice can be incorporated within it. Ghaemi (pp. ) stops this woolly thinking in its tracks and what others describe as eclectic he relabels as anarchy. Strong stuff, but we are ripe for reform here; ^{Reference Shah and Mountain2,Reference Rosen, Spitzer and McHugh3} Ghaemi invokes other options and these, particularly Osler's post-Hippocratic model, deserve a closer look. Schizoaffective disorder is often regarded as a mealy weakling of a diagnosis that is a let-out clause for the indecisive psychiatrist wishing to keep all options open, but Hamshere et al (pp. ) give it a genetic buttress that may lead us to reconsider, but although already receiving some support ^{Reference Lencz, Lipsky, De Rosse, Burdick, Kane and Malhotra4} it will need replication. The notion of placebo control is another long-standing certainty in evidence-based psychopharmacology, but the wished for equivalent in evaluating psychological treatments, the clumsy triplet ‘treatment as usual’ (TAU), given phoney respectability by its acronym as a Greek letter, is savaged by Burns (pp. ) and it may be time for it to be put to rest quietly before it is completely torn apart.

So we now want new anchors to stop us drifting. One is genuine shared collaboration, something introduced systematically by Aaron Beck in introducing cognitive–behavioural therapy, ^{Reference Beck5} which has been repeatedly reinforced by the need to train and supervise therapists fully, ^{Reference French, Shryane, Bentall, Lewis and Morrison6} to persist with treatment ^{Reference Keen and Freeston7} and not to rely on computerised systems of management entirely. ^{Reference Mackinnon, Griffiths and Christensen8,Reference Andersson and Cuijpers9} This notion of continuing active feedback receives added support from Knaup et al (pp. ). Another aspiration is the urgent wish of clinicians to embrace the advances of neurobiology in clinical decision-making, the rainbow-buried pot of gold that was rudely takenawayfromusbythefailureofthedexamethasonesuppression test to diagnose depression independently and which has never been replaced. Well, do not get too excited, but the work of Huezo-Diaz et al (pp. ) may represent an early sign that at least one gene, the serotonin transporter gene, may determine the efficacy of antidepressant treatment and so reduce all that uncertainty that flutters in those few weeks after prescribing an antidepressant drug.

So do not be alarmed by the loss of certainties in mental science. They are being replaced by better ones, but these too will reign only briefly. Orwell may not have realised that his fisherman's loss was a botanist's gain; the imported seeds that germinate on rubbish tips grow into some of the most exciting plants of our national flora.

Fraud in medical journals

It is now one of the tasks of every scientific editor to both detect and blow an international whistle whenever fraud is detected in a publication. Sometimes this is easy. The advances of electronic communication and databases can detect immediately when an allegedly original article is virtually the same as an already published one. ‘That is quite amazing’, said one miscreant on being told that his article was an exact copy of a previous one, ‘I must have memorised it unconsciously and thought it was entirely my own work’. But systematic fraud by experts is much more difficult to detect. One of the frauds that persisted longer than others was that initiated by Emil Abderhalden in Germany over the period between 1908 and 1950. Abderhalden was a physiologist who worked with Emil Fischer, the Nobel prizewinning chemist, and probably realised his own inadequacies as an original thinker at this time. So he had to have a great idea. He hit on the notion of defence enzymes (Schutzfermente, ^{Reference Abderhalden10} later named Abwehrfermente). He claimed that these enzymes were proteases produced by animals and humans when challenged with foreign proteins. In the case of pregnancy, for example, the serum contains proteases that were a direct reaction to contact with the proteins of the placenta. The development of the tests constituted the building of an empire, even psychiatry was dragged into the Abderhalden system and used to validate Kretchmer's constitutional types ^{Reference Kretschmer and Mall11} and later his students, including Joseph Mengele, extended it to eugenics.

It is only in recent years that the breath-taking extent of this fraud has been realised. ^{Reference Deichmann and Benno12} Abderhalden was a major figure in German science and those who criticised his tests were excluded from promotion, and when scientists in other nations failed to replicate his findings they were dismissed as anti-German propagandists. He also edited a major journal on ethics and no mention of the subject ever appeared in that organ. I hope fervently that the checks and balances in our current systems of assessment and review would prevent this from occurring again but I am not entirely reassured. We need to be reminded, as Singh (pp. ) does so persuasively in this issue, that the strongest certainties are often the most suspect, and until they have allowed science to give them a good going over, they should be continuously challenged.