Genomics, economics and histrionics

Happy New Year from the Journal, and welcome to a challenging issue to scatter the cobwebs from 2012. Genes tend to start at the very beginning and so it is apposite that they kick off our 2013 volume with our first two papers. These illustrate that the genetics of psychiatry have come a very long way since my first meagre published piece of work, a review of a book edited by James Shields and Irving Gottesman of the essential papers of Eliot Slater. ^{Reference Shields and Gottesman1} These papers included a sentence of Eliot's that impressed me at the time and has stuck with me ever since, ‘as schizophrenia is a good deal more common than any single genetically determined disorder is otherwise known to be, heterogeneity is inherently probable’. And my oh my, what heterogeneity has unfolded in the 40 years since. We now have endophenotypes and epigenetic dysregulation, rare alleles with many mutations at hotspots on the gene, and now a whole host of genome-wide association studies of schizophrenia, summarised by Collins & Sullivan (pp. ). But, despite a mushrooming of genetic knowledge, we are still far from understanding where we are in terms of aetiology, and even when there is a well-established genetic link, such as 22q11.2 deletion, a combination of other factors seems to be necessary to cross the threshold into disorder. ^{Reference Toyosima, Maekawa, Toyota, Iwayama, Arai and Ichikawa2} St Clair (pp. ) points out that the study of copy number variant loci is likely to be exciting for research into disorders of neurodevelopment but its implications for clinical psychiatry are ‘only modest’, and McClellan & King conclude that genome-wide association studies have been disappointing and it is ‘Individually rare mutations, many de novo and others a few generations old, that may be collectively responsible for a substantial portion of mental illness’. ^{Reference McClellan and King3} I have to say that this evidence of chaotic genetic disturbance in psychosis, some might call it ‘schizogenia’, rather pleases me, as I have always been troubled by the notion of simple predestined outcomes of mental illness, whether postulated from a psychodynamic or a biological cause. Where genetic studies have been more helpful is in linking apparently separate mental disorders into a common framework ^{Reference Morgan, Croft, Valuri, Zubrick, Bower, McNeil and Jablensky4,Reference Owen5} and in time this should help our classification systems, particularly in areas where our diagnostic thresholds need improving (Cuijpers et al, pp. ).

Economics currently controls most of our destinies, and so good cost-effectiveness studies are gold dust in planning our future services. So would early intervention services get the green light from the financial planners? Hastrup et al (pp. ) suggest that they would, but some might argue that a 17% reduction in costs after 5 years compared with standard treatment in the OPUS study was a relatively low gain when clinical outcomes are equivalent, a finding that has been replicated by others. ^{Reference Gafoor, Nitsch, McCrone, Craig, Garety and Power6} The more prosaic activity, stopping smoking, would seem to be a much better example of a cost-effective intervention, especially as McDermott et al (pp. ) have exploded the myth that smoking reduces anxiety. But there are many other areas where money can be saved in our services. In my first medical post, almost the first patient I had to clerk was a very pleasant 50-year-old housewife who had a host of bodily symptoms and was petrified of having a serious illness. As the consultant came round to her bedside he asked her how she was and as she started replying at length, he cast his gaze downwards to look at the medical notes and a list of normal investigations. As he moved away from the bed he said to me, in a voice that I hope did not reach to the patient, ‘so you're interested in psychiatry; that woman is a classical case of the most common condition in my practice, hysterical hypochondriasis, so there's a challenge for you’. These pejorative terms, and the cost of its consequent investigational non-treatment, have echoed with me ever since and I am now pleased we have moved towards the more euphonious term of health anxiety, whose prevalence has now been determined formally by Sunderland et al (pp. ). Starcevic (pp. ) notes that the prevalence of health anxiety of between 5% and 6% in the population is much higher than for previous studies of hypochondriasis, and this may represent a threshold problem in the same way as depression (Cuijpers et al, pp. ). But there is no doubt from the data of Sunderland et al that health anxiety causes great distress and is widespread, with prevalence rates four times higher in patients attending medical clinics. ^{Reference Tyrer, Cooper, Crawford, Dupont, Green and Murphy7} So we need to dispense with the wasteful economics of alleged histrionics in this population and move towards cost-effective interventions on a wider scale ^{Reference Hedman, Andersson, Andersson, Ljøtsson, Ruck and Asmundson8} if we are going to be able to afford early intervention and other novel services that still need a little more time to show their mettle.

John Maddox Prize for Standing up for Science 2012

Simon Wessely, the Deputy Editor of our Journal, has been awarded one of the two John Maddox prizes for Standing up for Science by the journal Nature and the organisation Sense About Science. This is a highly prestigious honour and could not be more well-deserved. Many may not know of the tribulations and pressures faced by Simon in having to withstand a constant assault on his credibility, his scientific standing, and his probity in carrying out studies on chronic fatigue and Gulf War syndrome. This assault has been continuous for many years and comes from pressure groups who have intimidated many from working in these sensitive subjects, but not Simon, where his skills in military psychiatry have almost certainly been of assistance. The way he has dealt honestly, openly and bravely with this intimidation and harassment reflects great credit on him and his many colleagues working in these areas of research ^{Reference Clark, Goodwin, Stansfeld, Hotopf and White9} and we in psychiatry should be very proud.