SEAS OF TROUBLES

Depression and suicide feature prominently in this issue, but we are increasingly recognising that their precursors are a complex mix of genes, gender, geography, germination and guesswork. There has been tremendous interest in the first clear evidence of gene–environment interactions in mental disorders described by Caspi et al (Reference Caspi, McClay and Moffitt2002, Reference Caspi, Sugden and Moffitt2003) but we need replications before we can be certain that this represents real progress. The results of the paper by Wilhelm and her colleagues from Sydney () are a partial replication of the earlier findings showing that people with the short allele on the serotonin transporter gene are more likely to respond to adverse life events by getting depressed than those with the long allele. (I can envisage the bright little boy of the future, called before the head teacher for some misdemeanour, saying, ‘before you say anything sir, I ought to tell you I'm a short alleler and if you upset me I may become severely depressed, so – can I go now?’. One interesting finding is that those with the short allele who have no adverse life events seem to remain the healthiest of all). However, Zammit & Owen () show from their review that not all studies produce results consistent with the short allele hypothesis and we still need more replications; nevertheless, the building blocks are beginning to pile up and could make a solid foundation for further enquiries that could extend well beyond depression (e.g. Reference Mol, Arntz and MetsemakersMol et al, 2005).

The absence of depression, or indeed any other obvious emotion, led to the term la belle indifférence being attributed to those with conversion hysteria, but it now appears that its value, like much deriving from hysteria, was overstated. Stone et al () suggest that the term should now be abandoned except by romantic Francophiles, and then only when off duty. La belle indifférence was a largely feminine attribute, and depression still afflicts women more than men, but Dunn & Goodyer () show that, at least in those referred to child psychiatric services, persistent depression and other more severe mental illness was more common in boys. With these statistics it seems we are approaching the time when it will be such bliss to be born a girl and such sorrow to be a boy. The difficulties may start even before birth but Patel & Prince (), in showing the effects of maternal psychiatric morbidity on birth weight, spare us the details of gender differences in the babies. Alcohol misuse and suicide also tend to follow the male of the species but the downtrodden XY chromosome may get some reassurance from the results of Akechi et al (), which suggest that men who drink moderately in Japan are less at risk of suicide than non-drinkers and heavy drinkers. The authors suggest that the social support generated by moderate drinking (even if it is only ruminating about the unfairness of their allotted gender) may prevent suicide.

But before we get too depressed we should remind ourselves that suicide rates are going down in most countries, and that the populations seen by psychiatrists all have higher mortality rates (Reference Kisely, Smith and LawrenceKisely et al, 2005). However, the suggestion that schizophrenia now has suicide rates 20 times higher than a century ago (Healy et al, ) is alarming and reinforces the concern that we are still marking time when it comes to major therapeutic advances in schizophrenia. Turner () rightly points out the problems of making historical comparisons but a 20-fold difference is difficult to explain away. Taking my own clinical experience into account, the results do not seem that surprising. We are doing our best to improve and normalise the lives of those with schizophrenia by keeping most of them outside hospital and encouraging integration into society. But schizophrenia remains a terrible disease, and much of its treatment leads to only partial success, often at the cost of unpleasant adverse effects and poor physical health (Osborn et al, ; Reference Zhang, Yao and LiuZhang et al, 2004). The patients I have known with schizophrenia who have taken their lives have done so more out of anger and frustration than as a consequence of major schizophrenic symptoms such as hallucinations, a finding also shown in a systematic review (Reference Hawton, Sutton and HawHawton et al, 2005). A century ago we did not give our psychotic patients any hope; now we give them hope that is so often unrealised.

FAR CITED

The review paper by Louise Arseneault and her colleagues on cannabis and psychosis (Reference Arseneault, Cannon and WittonArsenault et al, 2004) is, according to the Essential Science Indicators, the third most cited paper in the psychology and psychiatry literature in the two years 2003 and 2004 and the most cited in 2004 (http://www.in-cites.com/hotpapers/2006/jan06-psy.html). I have come to conclude that good citations are best represented by the equation ‘excellence × timeliness’, so I am glad we helped Dr Arseneault and her co-authors to get them both right. The timeliness aspect is well reinforced by Barnes et al in this issue ().