Threading psychiatry towards brain disease

John Bucknill, founding editor of this Journal, always argued that psychiatric illness was a brain disease ^{Reference Bucknill and Tuke1} and the study of the brain was the answer to professional advancement for psychiatrists. Today I think he would have become a neurologist – and of course he was one of the founders of the journal Brain. I have to be frank and say that I would not have contemplated becoming a psychiatrist if it had been a branch of neurology at the time. When I was a medical student my experiences with neurology were similar to the feelings I get when I see the sport of synchronised swimming. I admire their skills, coordination and professionalism but am left absolutely cold by what they do. Similarly the brilliance and diagnostic acumen of the good neurologist provoked similar regard but when the outcome of consultations rarely involved anything that I could remotely call therapy I switched off. So I opted for the rough and tumble of core psychiatric practice even though it required very different skills. I suspect the practice of therapeutics within neurology has improved since my medical student times but from our recent work it still appears that one in four patients attending neurology clinics has a treatable mental illness that is unrecognised and often mismanaged, ^{Reference Tyrer, Cooper, Crawford, Dupont, Green and Murphy2} although many of these patients have complex functional somatic problems (Morriss, pp. ) that we are only just beginning to understand and manage successfully (Schröder et al, pp. ).

But of course, however interested we are in the practice of psychiatry we cannot ignore brain function in our work, and increasingly we are linking clinical features to neurophysiology and neuropathology. Four papers in the issue do exactly this. Jeremy Holmes (pp. ) joins up the unlikely bedfellows of neuropsychology and psychoanalysis and gives a hint that we may soon be able to identify the bourne of the unconscious mind in the depths of the brain. Duijff et al (pp. ) take a genetic disorder, velocardiofacial syndrome, that is commonly associated with schizophrenia, and show that many, but not all, children with this condition show cognitive decline between 5 and 10 years of age. Most clinicians are aware that dementia with Lewy bodies is frequently associated with visual hallucinations, and the studies of Taylor et al (pp. ) ^{Reference Taylor, Firbank, Barnett, Pearce, Livingstone and Mosimann3} are beginning to unravel the role of the higher regions of the occipito-parietal cortex in this pathology. Finally, Eccles et al (pp. ) in their challenging paper suggest that amygdala abnormalities may account for the double pathology of hypermobility and the stress/anxiety diathesis in such patients, but of course interpretation is limited as the participants were only volunteers. These studies, and similar ones we have published recently ^{Reference Yatham, Liddle, Lam, Zis, Stoessl and Sossi4,Reference John, Halahalli, Vasudev, Jayakumar and Jain5} add to knowledge in an incremental way but only rarely ^{Reference Köhler, Thomas, Lloyd, Barber, Almeida and O'Brien6} do they have a message that is of direct relevance to the practising clinician, and at this stage they seem unlikely to have a quick impact on the bulge of mental disorders in the 20–40 age group, where they dominate all other pathologies. ^{Reference Insel7}

So neurology and psychiatry have some way to go before they join in harmony. And when it comes to synchronised swimming, now an Olympic event, I am ashamed that I get more satisfaction, some would call it Schadenfreude but I think it is closer to immature glee, when the performers get it wrong and arms and legs flap akimbo. I hope I can shake off this undesirable weakness when I now work with neurologists and other physicians, as there is a clear need from the paper from Bruffaerts and colleagues (pp. ) for all of us to be more cooperative in dealing with comorbid mental and physical illness if we are to improve life quality.

An endangered species?

As we move closer towards the brain I detect a loss of confidence in the profession about its role. I have recently been at an East European and Serbian Congress in Belgrade where there was an open debate about the future of psychiatry and its practitioners. We live in turbulent economic times and may have a right to be gloomy, but I was quite disturbed to hear speaker after speaker predicting the demise of our profession or its absorption into neurology or some other discipline, as the funding for mental illness and respect for psychiatrists gets progressively less. Retrenchment seems to be the current message, together with a return to old disciplines echoed in our columns. ^{Reference Oyebode and Humphreys8,Reference Harrison, Baldwin, Barnes, Burns, Ebmeier and Ferrier9} What disturbed me even more was the claim that stigma and discrimination against people with mental illness is getting worse and that our lack of direction is contributing to this. I certainly do not detect this in the UK and with so many initiatives working to promote optimism and reduce stigma ^{Reference Leamy, Bird, Le Boutillier, Williams and Slade10} I honestly do think we have reasons to be cheerful, if not now, at least in the longer term.