SWIMMING UNDER WATER

Michael King (pp. ), in his intriguing list of ten books, includes Jamie O'Neill's novel At Swim Two Boys and invokes the pleasure of swimming as it ‘provides an unequalled time for reflection and meditation.’ I agree, but set my sights rather lower. I love swimming, but having more respiratory reserve than efficient stroke action, prefer gliding in the deep to thrashing on the surface. This serenity of silent propulsion is an excellent environment to get everything into proportion. This issue of the Journal is a reflective one and while I could not pretend that reading it should simulate exactly all the sensations of swimming underwater, I hope it helps to restore the balance we all have to maintain in psychiatric practice. It includes the first of the articles in our Reappraisal section, in which subjects that have long provoked argument and debate are reviewed. Wilson & Nutt (pp. ) show that there is now much more to the treatment of insomnia than the traditional benzodiazepines and I am glad to note the word ‘addiction’ is not mentioned once. Goodwin & Geddes (pp. ) challenge the view that schizophrenia should be at the centre of our secondary care system in psychiatry. In making out the case for bipolar disorder as an alternative, backed up by Harrison & Critchley (pp. ), it might be worth reminding you now that Oxford swings and is bidding to become the Bipolar Capital of the World, so there could be a little partiality here. And, as we are reminded, bipolar disorder and schizophrenia are part of the same spectrum recently remoulded roughly from the neat split imposed by that former colossus, Emil Kraepelin (Reference Craddock and OwenCraddock & Owen, 2005).

But it is certainly right to question the attention given to what has become a ubiquitous diagnosis in anyone who has the misfortune to stay for more than a few days in a psychiatric unit in a developed country, and whose attribution is now so closely linked to hospital care. My new specialist registrar came to me brightly burnished for his job a year ago but has now ruefully remarked, ‘I thought I was coming here to learn how to treat psychiatric patients, but now realise that I had to learn how to treat beds’. The real problem for those trying to make psychiatric care more cost-effective is that the relentless preoccupation of services with insightless psychosis prevents us looking at other matters of great import. So anything we can do that can break this pattern is invaluable, and measures such as ‘symptom relabelling’ (Crumlish et al, pp. ) or other forms of relearning (Cooke et al, pp. ) to improve insight would be excellent if they worked, and might allow some time to look at other issues such as the influence of personality abnormality and outcome of schizophrenia, completely virgin territory at present (Reference Newton-Howes, Tyrer and MooreNewton-Howes et al, 2007), or some clinical developments following from the many demonstrated neuroanatomical abnormalities such as cortical sulcal thickness (Goghari et al, pp. ) that now compete for our souls. Anything, indeed anything, that takes our minds off the Premier Antipsychotic Drug League where millions of pounds in transfer fees are spent in moving a drug up a notch or two in an increasingly irrelevant table (Rosenheck, pp. ), would be welcome, could prevent early death (Reference Joukamaa, Heliövaara and KnektJoukamaa et al, 2006) and allow more attention to be paid to the risk of suicide (Reference Hawton, Sutton and HawHawton et al, 2005). And, almost by default, the care of significant affective and anxiety problems has become lost to psychiatry and transferred to other technology in the form of self-help and computer-controlled therapy. We will return to this subject in a later issue but it must be of some solace to the humans who traditionally deliver this care that the ‘pure’ form of self-help has some deficiencies (Rapee et al, pp. ) and that patients appreciate at least a little guidance before reading the instructions and swimming under the cure-all waters (Khan et al, pp. ).

STIGMA AND THE MEDIA

While in reflective mode it is worth reminding ourselves that in our well-intentioned attempts to protect our patients from the perils of outrageous fortune we may sometimes stigmatise them. If we are to make schizophrenia no more discriminatory than diabetes (Reference Lee, Lee and ChiuLee et al, 2005), we have to expose patients and problems of mental illness more openly to the media and not clothe them awkwardly in ill-fitting garments derived from the Data Protection Act. The Royal College of Psychiatrists has just reported a success with a new publications venture (Reference PersaudPersaud, 2007), a book written with the help of many College experts that includes a case history at the beginning of every chapter. It is edited by Raj Persaud and briefly enjoyed 6th spot in the UK best-selling books list before Harry Potter and the Deathly Hallows rudely pushed it aside. Some people smile ruefully when I tell them about this success and regard it as all slightly unseemly. I don't agree. If we can get the world reading about mental ill health in all its guises and can show how it can be resolved in language that everyone understands, we are half-way there. So watch out, diabetes.