Sentinels on the road to disaster

One of the consequences of the uncertainties in our profession that were prodded in last month's Editor's desk is the natural wish to look for sources of external guidance that serve to reassure us at times when we feel lost. For reasons that do not seem entirely clear, in this quest we find many more sentinels on the road to disaster than beacons on the path of enlightenment. Some of these sentinels, like cannabis beckoning towards psychosis, are now well established ^{Reference Arseneault, Cannon, Witton and Murray1} but others may be false prophets. The sentinels may be life experiences such as childhood middle-ear disease ^{Reference Mason, Rimmer, Richman, Garg, Johnson and Mottram2} or something apparently minor such as delayed growth ^{Reference Perrin, Chen, Sandberg, Malaspina and Brown3} but we also have a habit of making our own. Biomarker sentinels such as P-selectin in autism, ^{Reference Iwata, Tsuchiya, Mikawa, Nakamura, Takai and Suda4} serum folate and homocysteine levels in late-onset depression, ^{Reference Kim, Stewart, Kim, Yang, Shin and Yoon5} and plasma levels of essential fatty acids in self-harming behaviour ^{Reference Garland, Hallahan, McNamara, Carney, Grimes and Hibbeln6,Reference Hallahan, Hibbeln, Davis and Garland7} are all examples we have published recently. To what extent we should take notice of these sombre warnings in clinical practice is far from clear and we have several illustrations in this issue. For example, Zammit et al (pp. ) suggest that there is a 20% greater likelihood that the offspring of mothers who smoked during pregnancy will have psychotic symptoms in adolescence than if they had not smoked. If this had been said to my mother, who also smoked during pregnancy, would this have avoided my nicotine-stained early months, or would it have been ignored as yet another health scare? Does the evidence that mothers with borderline personality disorder have poor affective relationships with their infants (Hobson et al, pp. ) just lead to wise nods of ‘I told you so’, or generate changes in what Tansella & Thornicroft (pp. ) now call ‘implementation science’? Added to this, why is it that experiences that might appear to be the most obvious predictors of future disorder, such as the awfulness of the Holocaust (Sharon et al, pp. ) (please note the results for post-traumatic stress disorder) and childhood sexual abuse as a marker of subsequent self-harming behaviour, ^{Reference Hart, Michie and Cooke8} have relatively little value as sentinels?

The suggestion that the chocolate bar or the lollipop might be among those sentinels (Moore et al, pp. ), an adumbrator of violence in adult life, is of great interest to me. I have always had a very sweet tooth but growing up in the 1940s meant that I was sugar-deprived from July 1942 onwards. I well remember when rationing was eased in 1948 queuing up with dozens of other slavering youngsters for 2 hours just to get a small bag of boiled sweets. These I treasured like Midas, assiduously and parsimoniously, taking them out and gazing at each before consuming one a day until they all ran out, and even then I kept the empty bag as a keepsake. But we may have gained with rationing; the 1950s and 1960s were non-violent decades in the UK and in many other countries that had war rationing, and the most violence we expressed was against the spread of nuclear weapons, rarely against each other. So perhaps another sentinel, a Mephistopheles more seductive than its fellows, can take its place on the road to disaster. But even if we are seduced by glucose we can be reassured that the risk of violence at an individual level is very low ^{Reference Watson and Crick9} and, you never know, the risk might all be due to added saccharine.

Short reports are short reports

The paper by Moore et al (pp. ) is a short report, and its place seems to be a little uncertain in the eyes of many who submit manuscripts to the Journal. Our instructions to authors do not indicate which papers should be long and which should be short and perhaps some guidance is needed. I would like to think that a short report is a really excellent long paper that has been worked carefully to reveal the pure essentials, exemplified in correspondence by Bernard Shaw, ‘I am sorry this is such a long letter; I did not have time to write a short one’. But short reports are more often regarded as preliminary reports in which findings are reported in the knowledge that they need to be replicated in a larger study. But a good study presented as a short report may also be a definitive one; the elucidation of the structure of DNA by Watson & Crick, ^{Reference Watson and Crick9} in no more words than we require in our reports, is a celebrated example. One recent short report by Paula Nunes and her colleagues from Sao Paulo, ^{Reference Nunes, Forlenza and Gattaz10} also illustrates this. Although this might only be regarded as a preliminary report – 66 elderly euthymic patients with bipolar disorder on chronic lithium therapy, in a case–control study, were compared with 48 similar patients not on lithium, and Alzheimer's disease was found to be less prevalent in the lithium group – it might well be a ‘turning point’ paper that moves science forward in a large step. Although lithium does not appear to be a good acute treatment for Alzheimer's disease ^{Reference Hampel, Ewers, Bürger, Annas, Mörtberg and Bogstedt11} it may well exert a protective function when given long-term. ^{Reference Kessing, Søndergård, Forman and Andersen12} Aspiring authors please note when preparing your papers.