Icing in the cake

I write this as I am putting the finishing touches to a Simnel cake, one of the most tasty of old recipes. Those of my readers who are familiar with cake-making will realise that a Simnel cake is unusual in having icing in the middle of the cake, not just on top. This reminded me in a curious way of the British Journal of Psychiatry, a journal with shiny yellow icing on the outside but quite a helping of icing in the middle as well. The making of a Simnel cake is a staging process, just as Scott et al (pp. ) describe, with the marzipan icing, preferably golden like our journal, making the second and fourth layers, and with a delicate balance of currants and sultanas – no they are not the same but share many features, just like hospital and community psychiatry (Thornicroft & Tansella, pp. ) – as a rich component of the cake mixture. But a Simnel cake needs spices too, so a touch of allspice, just like Warner (pp. ) & Fearon's (pp. ) feisty exchange of opinions about early intervention in psychosis, adds that extra touch of flavour, with just a lemon soupçon of Amsterdam et al (pp. ) and Thase (pp. ) to tickle the palate's outer senses. But as every reader knows, there are extras in the cake, and in the Journal too, and they add to the flavour. It is absolutely clear that Zaara's ‘speed limits’ described by Shabbir Amanullah (p. ) have to refer to the eating of Simnel cake, as with such a marvellous combination of flavours you have to eat slowly to take them all in.

But there is a slightly worrying side to all the joy of baking Simnel cakes. In the countries that used to be called Yugoslavia, three days were linked, Children's Day, when the children are tied up and are only released when they promise to be good, with mother following on Mother's day, when she is bound and only released when she gives the family treats like Simnel cake, and Father's day, when he suffers similarly until he bears gifts. All this imprisonment is a recipe for trauma and for those with FKBP5 constitutions (Collip et al, pp. ) it can become damaging in adult life. So even the simple joyous exercise of baking in childhood might be the cause of a wide range of mental disorders. ^{Reference Power, Thomas, Li and Hertzman1-Reference Keyes, Eaton, Krueger, McLaughlin, Wall, Grant and Hasin4} The cake is not finished until eleven curious shapes are perched on the top of it. These represent the eleven apostles. I will leave it to the readers to decide which eleven might be chosen for the Psychiatric Simnel Cake. Musalek (p. ) would certainly choose Karl Jaspers, and Warner might find a place for a far-sighted British Metropolitan Commissioner of Lunacy (p. ). But who would be equivalent to the twelfth disciple, the betraying one, Judas? I will remain silent as I add the final touch of apricot glaze to my cake, remembering, after all, these figures are only marzipan balls.

Getting costs sorted

Any intervention, even a simple one as wholesome as a Simnel cake, has a cost attached. In a mean world we have become aware that cost-effectiveness is now the key issue in deciding who gets what in medical care. But if we are to concentrate on the bottom line we must make sure all the other lines lead correctly to it. A new statement with the oxymoronic acronym CHEERS (Consolidated Health Economic Evaluation Reporting Standards) has just been published ^{Reference Husereau, Drummond and Petrou5} and will be endorsed in our Journal's instructions to authors. The standards comprise 24 statements extending from a specific statement about the type of economic analysis, its reasoning and perspective, time horizons and outcomes, a clear description of the measurement of effectiveness, valuation of preferred outcomes, and, very importantly, the unit of currency, the form of analysis, clear exposition of results with incremental cost-effectiveness ratios (ICERs) when applicable, and finishing appropriately with the source of funding and declarations of interests. I have looked closely at recent studies of cost-utility and cost-effectiveness in the Journal and think most of them have cause to cheer as they have followed the format of this statement ^{Reference Ekers, Godfrey, Gilbody, Parrott, Richards and Hammond6-Reference Romeo, Knapp, Hellier, Dewey, Ballard and Baldwin9} but we can always do better. For some subjects that we know are expensive it now also seems essential to include some form of cost analysis if we are going to make any headway in clinical practice. ^{Reference Konnopka, Schaefert, Heinrich, Kaufmann, Luppa, Herzog and König10} We also implore our prospective authors to combine clinical and cost outcomes in all relevant papers instead of splitting them up into unwieldy bite-sized pieces and publishing them in different journals. Like the icing and cake mixture in a Simnel cake these ingredients are at their best when combined.