Blowing in the wind

If Bob Dylan is to be believed, the wind is where we will find answers to many of the conundrums of life. My considered view is that Bob got it a little bit wrong. The wind does not contribute the answers, it constitutes them. The wind of science is not just a metaphor, it is the real McCoy, as it tells you which way to go and how fast it is going. This issue is a good anemometer; it tells us that we are moving at quite a rate in the general direction of public health, and although there is the occasional eddy or gust in the opposite direction, we should accept this without suddenly needing to change course. The shift in public health towards the essentials of psychiatry is a direct consequence of the recognition of the advantages of happiness. Although a great deal of empty guff has been, and will continue to be, written about happiness, it is a state profoundly desired by most people, and is impossible to contemplate without dealing with mental health. ^{Reference Layard1} It is now entering into the day-to-day discourse of our discipline. How many of our readers now work in a Centre of Well-Being, and how many of our patients complain of a lesser-known adverse effect of drugs, the ‘reduction in a wide range of positive emotions, including happiness, enjoyment, excitement, anticipation, passion, love, affection and enthusiasm,’ ^{Reference Price, Cole and Goodwin2} that was barely mentioned or readily dismissed in the past? Bhui & Dinos (pp. 417–419) point out that this shift in attitudes has to be embraced cautiously and constructively with the emphasis on appropriate targeted interventions, and this is also reinforced by Walters et al (pp. 472–478) in their evidence of the generally good outcome of those with mixed anxiety and depressive disorder. I know there are contradictory views on the expansion of psychiatric disorders to cover what used to be the territory of normal health, but one big asset of expansion is that it helps to reduce stigma. The more we can help people to identify with mental disorder as part of their own personal experiences rather than an alien force, the more likely are anti-stigma campaigns to be effective ^{Reference Mehta, Kassam, Leese, Butler and Thornicroft3} and improve the take-up of offered services. ^{Reference Rüsch, Corrigan, Wassel, Michaels, Larson and Olschewski4}

One of the big debates going on in psychiatry at present, the significance of gene–environment interactions, is given a good shout in this issue, and this also has a great deal to do with public health. The reason why we have continued to air this subject on so many occasions is partly because it is the source of cutting edge research ^{Reference Goodyer, Bacon, Ban, Croudace and Herbert5,Reference Fergusson, Horwood, Miller and Kennedy6} but also because it is critical to public health and has many ethical concerns associated with it. ^{Reference Wilhelm, Meiser, Mitchell, Finch, Siegel and Parker7–Reference Tyrer9} I suspect the average clinical psychiatrist does not lose too much sleep over the polymorphism of the 5-HTTLPR gene, not least as the evidence has been so conflicting and the hypothesis that those with the short form of the allele are more likely to become depressed when faced with adversity is far from proven, ^{Reference Risch, Herrell, Lehner, Liang, Eaves and Hoh10} and in this issue Lewis et al (pp. 464–471) could also find no association with antidepressant response. But if this hypothesis happens to be true, even if only to a small degree as McGuffin et al (pp. 424–427) suggest in their bold editorial promulgating the truth, the public health implications are enormous. Just as those with compromised immune systems have to be protected from the normal pathogens in the environment, those with compromised genetic systems may have to be protected from adversity, particularly in the sensitive years of childhood ^{Reference Brown and Harris11} (Fergusson et al, pp. 457–463), and new forms of prevention introduced. The other big public health matter we discuss here is the future of forensic psychiatry. This is only addressed through the examination of an unusual but small group that in statistical terms would be regarded as outliers, those with DSPD. This condition was one I used to refer to as the Jack Straw syndrome as it is the only psychiatric diagnosis yet introduced by a politician; the hubris syndrome ^{Reference Owen12} is the second competing for attention. But outliers may help people to focus on essential elements that become fuzzy when diluted in others. Both Duggan (pp. 431–433) and Buchanan & Grounds (pp. 420–423) lay down the gauntlet in challenging forensic psychiatrists to face up to a critical question: is their main task to act as specialised risk managers or to treat patients? Buchanan & Grounds regard ‘ethical integrity’ as perhaps the most important guiding principle in answering this question, and here I think they are absolutely right. The McGuffin et al directional hypothesis – when all the straws point in the same direction you have a good idea which way the wind is blowing – suggests that public health is moving away from the soft zephyrs of compassion to the cold blasts of coercion, and we will have to take stock before taking the honourable course.

Under the influence

As happiness is so attractive and in such short supply to many people, can we really be surprised that people take short cuts to its generation? Drug and alcohol use often foster the illusion that happiness just needs the right currency to take a bus ride around the corner, but the papers by Swinson et al (pp. 485–489) and Fontes et al (pp. 442–447) show its darker side. The trouble is – no matter how we try to alter people's behaviour by educational efforts – it remains so difficult to shift. Perhaps Maria Fontes and her colleagues should get their message over by using a different idiom: