Down Under matters

Quite by chance, or unless our head of publications, who chooses the contents for each issue, has a secret geographical master plan, we have four papers from Australia and New Zealand in this issue. The flexible English language has more opportunities than most for allowing alternative meanings, and so the double entendre of ‘down under’ is particularly apposite as five of our papers too are preoccupied with the subject of depression. When I was a very junior psychiatrist antidepressants were still new and exciting, and I used to say regularly to my patients that if I had to choose any psychiatric illness from which to suffer, it would be a depressive illness, as it was the condition that we could do most to relieve, especially as we now had some excellent drugs to hand. We have learnt a lot since then, not least that all forms of depression tend to recur and often persist, ^{Reference Lee and Murray1} and this issue illustrates how this apparently simple state of mood is not just a miserable cell but a multi-headed hydra. We remove one form but find it replaced by another, whether it masquerades in other forms of other psychiatric disorder, ^{Reference Das-Munshi, Goldberg, Bebbington, Bhugra, Brugha and Dewey2,Reference Hobson, Patrick, Hobson, Crandell, Bronfman and Lyons-Ruth3} with links well identified in case registers (Morgan & Jablensky, pp. ), a silent reinforcer of physical disease, ^{Reference Farmer, Korszun, Owen, Craddock, Jones and Jones4,Reference Kivimäki, Batty, Singh-Manoux, Nabi, Sabia and Tabak5} where its detection is not always easy (Thombs et al, pp. ), a comorbid shadow dogging other mental illness (Gorman et al, pp. ), or as a gremlin, often visiting in the vulnerability of childhood (Bruffaerts et al, pp. ), that distorts the view of the self to the point of suicide. This is why any ways we can develop for heading off depression are so attractive in public mental health, but in general, despite great efforts in primary care ^{Reference De Graaf, Gerhards, Arntz, Riper, Metsemakers and Evers6} and in high-risk groups such as the elderly (Walker et al, pp. ), we only seem able to make a dent in the problem, never a breakthrough.

The jury is still out on the value of one of the more thought-provoking interventions of recent years, the simple (and very cheap) intervention of sending a series of reassuring postcards to patients who had been admitted to hospital after an episode of self-poisoning. Initial trials suggested this was a highly effective way of preventing recurrence ^{Reference Motto and Bostrom7,Reference Carter, Clover, Whyte, Dawson and D'Este8} but the latest contribution by Beautrais et al (pp. ) gives a different view. We had some difficulty in reviewing this paper, as the trial could be regarded as prematurely abandoned after an interim analysis, and many authorities advise against interim analyses in order to avoid such errors. One of the more telling comments in the paper is that one of the reasons for stopping the trial early was ‘the reluctance of clinical staff to recruit individuals to the trial’ (p. ); if this really is such a simple and straightforward intervention, why did it bother staff so much to take part? There are clearly going to be more ups and downs in this story, and we need to be reminded that the original Postcards from the Edge was not a study, but an amusing and insightful novel by Carrie Fisher, ^{Reference Fisher9} the Hollywood actress who has bipolar disorder. We look forward to the synthesis of all the evidence for the value of these interventions in the forthcoming NICE guidelines for the longer-term management of self-harm (Kapur et al, pp. ). It seems likely that something useful is going on here and the original suggestion of improved ‘social connectedness’ ^{Reference Motto and Bostrom7} might be the reason why simple and generally unsophisticated measures such as postcards, telephone calls and crisis cards might help. In the walled-off state of depression any intervention that can do more than just bounce off the outer bricks has value. But often this breakthrough has nothing to do with us. In one patient I was treating with resistant depression I explained after each combination of drugs that things would suddenly change when his serotonin and noradrenaline receptors had been bathed for long enough in the right concentration of amines for them to be down-regulated. At last he returned completely free of depressive symptoms and I triumphantly produced a diagram of how the drugs had worked. When I had finished he smiled and said, ‘but there's something else I've been bathed in that isn't in your diagram. I've fallen in love’. Now, that's one psychosocial intervention that truly works.

New Executive Contents Editors

We hope our readers continue to enjoy our section of ‘extras’ that add more to the Journal's content without detracting from the main papers. Since the launch of the new-look Journal this section has been edited by Robert Howard, our current Dean, and I think I reflect the views of our readers in concluding that he has chosen his material judiciously and well. Robert has now resigned as Executive Contents Editor and we welcome Femi Oyebode and Peter Byrne as his replacements. Together their profligate interests cover the range of literature and the arts and, although they have many ideas they want to pursue, they are keen to hear from readers about other initiatives and ideas about this section, so do not be inhibited in approaching them or the publications office (emails to [email protected]) with your contributions, while being aware that they will be subjected to full review before acceptance. Meanwhile, as Rob Howard modestly rides away secure in the knowledge that his work will continue to glow from the pages of the Journal, we hope he will not feel discomfited by these 16 syllables of praise: