Securing the strands of schizophrenia safely

When I first joined the editorial board of the British Journal of Psychiatry in 1975 the then editor, Edward Hare, often had articles linked together in groups with a common theme. One of my first contributions was to express my concern that some authors may be disadvantaged by this procedure as they could have the publication of their articles delayed unfairly. This rather unctuous remark was taken seriously and the system was abandoned shortly afterwards. What has impressed me over the subsequent years of essentially consecutive publications is how many still seem to come together naturally. Schizophrenia, whether you hate it for its pervading ubiquity or embrace its manifold ability to accommodate so much pathology, is nicely set up in this issue. Eugen Bleuler, in his first elegant description of schizophrenia, ^{Reference Bleuler1} frequently used the analogy of an unravelled rope to illustrate the inefficiency of the disintegrated brain, and ever since we seem, like manic seamstresses, to be rushing around trying to tie anarchic strands to the main rope again; but each success is followed by yet another filament breaking off and challenging us defiantly to be tamed.

We have never quite been able to resolve the paradox of treatment in schizophrenia: the archetypal severe mental disorder seemingly crying out for help. If psychiatrists are worth their salt, they should be able to treat this brain disease, but despite the many structural abnormalities identified since the breakthrough by Johnstone and her colleagues in 1976, ^{Reference Johnstone, Crow, Frith, Husband and Kreel2} the latest chapter being the fascinating paper by Walterfang et al (pp. ) suggesting differences in the corpus callosum between early and late stages of the condition, we have never been entirely confident that tackling this brain pathology with drugs is the only correct way forward. The problem is that so many people either do not respond to our treatment, want to avoid it entirely, or are so handicapped by adverse effects that the benefits disappear. We then enter the field of alleged ‘treatment resistance’, a relatively modern concept which Berrios (2008, p. 18) ^{Reference Berrios, Tyrer and Silk3} has described as part of a ‘mercantile transaction’ in which ‘like the selling of faulty goods, “lack of response” is increasingly being considered as a violation of a putative trade descriptions act’. So in the court of public opinion we are often accused of misleadingly selling shoddy goods that flood the market (Paton et al, pp. ), ^{Reference Ito, Koyama and Higuchi4} masquerade as being superior to cheaper ones, ^{Reference Jones, Barnes, Davies, Dunn, Lloyd, Hayhurst, Murray, Markwick and Lewis5–Reference Davies, Lewis, Jones, Barnes, Gaughran, Hayhurst and Markwick6} and lead to dangerous consequences (Smith et al, pp. ). Small wonder therefore, that those who promote treatments initially for schizophrenia are now disbelieved and people wait for the independent trials of effectiveness ‘carried out in “real world” secondary care settings [when] the apparent additional benefits of new treatments are noticeable by their absence’ (Scott, pp. ).

Such a trial is reported in this issue by Garety et al (pp. ), not of the usual suspects of antipsychotic drugs, but of a psychological treatment, cognitive–behavioural therapy, that many would like to see as part of the brave new world of acceptable treatments to be engaged with enthusiasm by the disillusioned shopper with schizophrenia. Unfortunately, this too appears to have been oversold. The benefits of some improvement in secondary depressive symptoms noted by the authors are not considered to be sufficient to recommend this treatment for ‘routine relapse prevention’. Although this conclusion may be challenged, and indeed a recently published trial in our Journal with somewhat similar results reached different conclusions, ^{Reference Turkington, Kingdon, Rathod, Hammond, Pelton and Mehta7} it is clear that ‘panacea’ and ‘treatments for schizophrenia’ are words that remain far apart, and Bleuler's rope remains doggedly unravelled.

A full archive

So begins the first issue of our on-line archive ^{Reference Bucknill8} available to all subscribers to the Journal and covering a fascinating record of over 160 years. You will come across this again in Trevor Turner's accounts of ‘150 years ago’ items (e.g. p. 123 of this volume) as well as Henry Rollin's hardy perennial ‘100 years ago’, but even in this account we can see fascinating glimpses of the growth of gender equality (first beginning in emancipated London), the beginnings of scientific rigour in the Journal (not jumping to conclusions about proprietors), and a preoccupation with hospital beds. On their last point the Commissioners got it wrong but even the cleverest among us sometimes predicts unwisely. Warwick Asylum had not ‘overbuilt’; it started out in an area of 72 acres but expanded to 377 with a population of 1600 patients. The land of the Avon valley, as I know from personal experience as a botanist working in the area, is excellent for cultivation and later in the century the patients working in three farms in the grounds provided almost all the food for the hospital's needs. ^{Reference Bucknill8} Now perhaps we could learn from that experience in our management of schizophrenia.