THIS MONTH’S ISSUE

There is much that activates one of the higher levels of thought, reflection, in this issue of the Journal. Somatoform disorders, surely the ugliest construction in psychiatric classification, comes under the scrutiny of de Waal and her colleagues (pp. ) and we can see what a pot-pourri of confusion it has created, with the classical syndrome originally described by Samuel Guze and his colleagues dwarfed by ‘undifferentiated somatoform disorder’, a diagnosis about as informative and useful as ‘depression – not otherwise specified’. Small wonder that Sharpe and Mayou (pp. ) look forward to a ‘post-somatoform world’ where sense can be reasserted. Other diagnostic reconstructions are predicated in McArdle's stimulating editorial (pp. ) suggesting that attention-deficit hyperactivity disorder is a developmental disorder that links to conduct disorder, hyperkinetic disorder and probable personality disorder in later life. Chronic fatigue syndrome needs no such restructuring in childhood and adolescence; Farmer et al (pp. ) show that its features are very similar to the adult syndrome. Interestingly, her sample consisted entirely of twins, but are these more liable to fatigue than singletons? Ayonrinde and his colleagues might suggest a comparative study with the Yoruba population of Nigeria (pp. ; see Conclusions, p. ) to find out. And if you want to tickle activity in those higher cortical synapses, look closely at the article by Gavin Andrews and colleagues (pp. ) on cost-effectiveness. Everything we do in medicine is rationed, and there is always a point in treatment at which further effort is no longer sufficiently productive to justify continuing. But is 60% of the burden of mental disorders ‘unavertable’ and is the efficiency of treatment for bipolar disorders eight and a half times greater than that for harmful use of alcohol? Look at the arguments closely because if Andrews is right, we should be moving shortly towards what our policy makers would call a ‘management resource paradigm shift’.

PROBLEMS WITH CASE REPORTS

I cannot help noticing from recent correspondence that many are bemoaning the downgrading of case reports from the Journal, a process begun by Greg Wilkinson during his time as editor (British Journal of Psychiatry (2003), 182, ) and not reversed by me. I accept that case reports are often extremely readable and much easier to attune to clinical practice than the large group studies that make up the bulk of our original papers. However, the difference between now and the past is that we have much greater pressure on space in the Journal and much better ways of demonstrating association and effectiveness. When Joseph Lister first decided 140 years ago that antiseptic surgery was the right operative path for surgeons, he was able to describe his first case – a Glasgow lad named McFie – in the Lancet long before he had a series of patients to report. His account nicely began the antiseptic surgery story but his account of Master McFie, whose compound leg fracture did not become infected as its repair was carried out in a fog of phenol, was only a prelude that could well have been wrong. Indeed it was to some extent, as Lister wrongly assumed that bacteria in the air needed to be killed to maintain asepsis, so there was no need for the phenol sprayer. Many of our old case reports were similar in having face validity only. But the case report that refutes a negative hypothesis (e.g. blood products do not transmit variant Creutzfeld–Jakob disease) is still an essential aid to science, so do send these in.

YET MORE PROBLEMS WITH CASE REPORTS - AND MORE ETHICS

In the future the whole contents of the British Journal of Psychiatry and its predecessor, the Journal of Mental Science, dating from 1858, will be online. This highly desirable development has also exposed an ethical dilemma. We now have very strict rules about the publication of material that describes patients, and full signed consent is needed for each case report. Twenty years ago this was not required, and 50 years ago no one even considered the views of the patients when publishing reports about them. We therefore debated whether to edit, attenuate or omit case reports from early issues of the journal at a recent meeting of COPE (Committee on Publication Ethics), an admirable body which now oversees ethical standards in medical journals. After a lively debate we agreed that no action is necessary. We could of course make changes to sensitive material but this might be construed as Orwellian rewriting of history and, as all this material was already (officially) in the public domain, its transfer to the website would not influence this position fundamentally. But when indeed we do go online we know we are bound to surprise some by our past contents, but trust we will educate even more.

CONCLUDING THE ALPHABET OF DEPRESSION

(The story so far – our intrepid investigators (Gordon Parker, Kay Parker and Kerrie Eyers) have now extended their search to the Oxford Textbook of Psychiatry to test the hypothesis that in depression research favours those whose name begins with K.)

Analyses involved counting the number of authors, not the number of publications, thus weighting numbers in the field rather than productivity. Here the raw K-rate was highest (or equal highest) for two chapters (i.e. Introduction, Historical Review; Diagnosis, Classification and Differentiation) and occupied the second to sixth rank for the remaining seven chapters. An overall ranking of equal fourth (n=100) was exceeded only by B (131), S (126) and M (122). Two control groups were selected. The first comprised the alphabetical distribution of surnames in the Sydney telephone directory. When that (normal) distribution was controlled for, the K-rate (of depression researchers) was 55% higher than expected (χ²=4.44, P<0.05), while the representation of B's was non-significantly increased (χ²=1.32) and the representation of M's and S's actually lower than expected.

As some might argue against use of telephone representation and an Australian database as a ‘normal distribution’, we selected another area of medical research specialisation as a control group – cardiology investigators. Specifically, we collected the first three authors listed on papers published in 2003 – and referenced in the ‘cardiac’ section of the Science Citation Index. Here raw data established the K-rate as fourth highest, being exceeded (again) by B, S and M. However, when we directly compared representation of depression and cardiac authors, none of those four differed in their representation across the two fields. Specifically, the K representation was almost identical (χ²=1.01, NS). This result could be viewed as perturbing in terms of the original hypothesis – but fails to respect a confounder. It is now widely recognised that depression increases the risk of several cardiac conditions (e.g. myocardial infarct, heart failure) and that post-infarct depression predicts long-term mortality. Clearly, depression researchers (e.g. Krishnan) have now moved on to another field (i.e. cardiology) and so ensured a similar K-rate distribution across the two domains of interest.

Such analyses offer substantive support for the proposition, a phenomenon demanding an explanation. One possibility is that, as German surnames have a high K-rate, there is a Teutonic personality influence in play – and, more relevantly, at hard work. Clarification could emerge by questioning whether there are other endeavours marked by a high K-rate. In chess, K is King and the K-rate of chess masters is also high. Conversely, breakfast cereal comes up as a candidate and clearly offers food for thought.

There are, as usual, consequences of our conclusion that a successful depression researcher is to be more likely to have a surname beginning with a K. As academic recruitment and competitive grant procedures risk now being simplified, and peer review made largely redundant, the implications for intellectual equity will need to be carefully considered.