THE RESURGENCE OF PUBLIC MENTAL HEALTH

I was once head of a department of public mental health, and am proud to have this association with our public health colleagues (Reference Tyrer and TyrerTyrer & Tyrer, 2002). For too long I had felt that psychiatry had failed to make as much impact in medicine as it deserved because it had concentrated too many of its resources on a favoured few and there was little evidence of a ‘trickle down effect’ to the many. Well, things are beginning to change, and this issue is a good illustration. Weiser and his colleagues (pp. ) remind us gently that many of the precursors to major mental illness such as schizophrenia, autism and eating disorders over-lap and may therefore constitute broad and relatively non-specific endophenotypes, which, widely prevalent in the community, may be the real biological markers of illness, not the specific diagnoses that currently foist their suspect criteria on every aspiring examinee. Similarly, Gunnell & Lewis (pp. ) show the possible role of general prevention in promoting resilience and resistance to suicidal behaviour, and Hansson et al (pp. ) describe the results of a telephone interview not just for a specific childhood diagnosis, but across the range from autistic-spectrum disorder to attention-deficit hyperactivity disorder. These findings all suggest that there is a wide prevalence in the community of potential pathology below the level of formal diagnostic status; other examples include a history of child sexual abuse and maternal eating disorder (Reference Spataro, Mullen and BurgessSpataro et al, 2004; Senior et al, pp. ). The potential importance of neuropsychology in identifying these broad endophenotypes is illustrated by the report of Toulopoulou et al (pp. ), who show that putative obligate carriers for psychosis can be identified, at a time when they are free of mental illness, by their impaired cognition and visuospatial awareness. If some findings reported here are developed and reinforced by further evidence, it is likely that we could easily be using public mental health interventions more widely. Thus, we might have neuropsychological tests for evidence of paracingulate sulcus pathology soon after childbirth as a marker of early schizophrenia (Reference Le Provost, Bartrés-Faz and Pailiére-MartinotLe Provost et al, 2003) with consequent early intervention (Reference Morrison, French and WalfordMorrison et al, 2004). Similar screening procedures in childhood and adolescence for whole populations could lead for the first time to a lowering of the incidence of serious mental illnesses equivalent to the dramatic consequences of the introduction of clean water. Well, perhaps, but as I am not proposing to become the editor of the Journal for Mental Hygiene, I should stop here.

TERRORISM AND PSYCHIATRY

The recent terrorist bombings in London have been expected but are none the less highly disturbing to our tolerant islands. Psychiatry has to be careful not to be too dogmatic in its interventions, particularly when proposing solutions, as Desmond Curran reminded us many years ago (Reference CurranCurran, 1952), but we can play a part. Contributors to the Journal have already anticipated these events in recent articles (Reference Alexander and KleinAlexander & Klein, 2003; Reference SalibSalib, 2003a ). Much will be learnt in the next few months but what is already clear is that much of the threat is home-grown rather than external. In assessing the risks and precursors of the Al Qaeda type of terrorism we need to be better aware of the pathological influences that prey on good religious beliefs so that they are ‘distorted and abused by charismatic inducers of folie à plusieurs of delusional martyrdom, or by ignorant, fanatical preachers who turn religion into the opium of angry people, and ordinary young men and women into human bombs’ (Reference SalibSalib, 2003a ). This is far from easy. As one of my patients put it to me recently, ‘you will never understand this, ‘cos you don't live in my yard’, and we need as much help as we can get from those who have greater cultural awareness of those who are susceptible to these influences.

We also need to be measured in our response, and not create a climate of fear that leads to a fortress mentality in which security can only be achieved by destroying or excluding everyone perceived to be dangerous, so that we become anxiously imprisoned in small areas of safety, while the other areas (the O-Zone of Paul Theroux's 1986 novel) become no-go places. At least no one is suggesting that the ‘ordinary people’ that become suicide bombers are suffering ‘dangerous and severe personality disorder’ that makes them eligible for long-term intervention, and we must not be hasty in attributing labels that reassure the rest of us but are ultimately counterproductive. Ultimately, it is the community's reaction to these tragedies – a reaction that can have positive effects on mental health (Reference SalibSalib, 2003b )–that will determine their long-term outcome and I hope that all psychiatrists will show the resolve and support demonstrated by the British Pakistani Psychiatric Association in its recent vigil to ensure that we are not divided.