Psychosis: specialised v. generic teams
Early intervention by teams specialising in the treatment of early psychosis has been suggested to enhance outcome in the early phase of psychotic illness. Two papers in the Journal address this topic. The first examines the cost-effectiveness of these services, while the second examines the 5-year outcome of one such service. McCrone and colleagues (pp. ) report that although their specialised early-onset service did not increase costs relative to treatment as usual over an 18-month period, it failed to show any significant benefit in cost-effectiveness. A 5-year follow-up study in the same service found that there were no differences in outcome, as assessed by number of admissions or bed-days, compared with those patients receiving the routine service. Gafoor et al (pp. ) suggest that this result is surprising given the clear benefit observed at the earlier 18-month follow-up, but highlight that the specialised interventions were stopped at 18 months, and that a longer duration of treatment was required for it to maintain its advantage. An accompanying editorial by Friis (pp. ) places both these studies in a wider context and considers the reasons for these patients not retaining the advantageous outcomes observed at the earlier follow-up. He suggests that the critical factor is reduced engagement with key personnel, as the early-intervention services invest a lot of energy into engagement with patients, and this may not be possible in the standard community services. A related reappraisal by Singh (pp. ) provides an erudite background to the development of early-onset services. Commenting on both the articles, Singh concludes that these services make a difference to outcomes in the early phase of the illness, but that the transition to generic teams may undo this advantage. He suggests that the answer may lie in restructuring generic teams to have a more specialised, possibly disorder-specific, role; interestingly, this is the path that some services in the UK are now following.
Non-pharmacological management of severe mental illness
Psychosocial interventions in bipolar disorder have been shown to be effective, but there are limited data supporting group-based therapy. Castle and colleagues (pp. ) report reduced relapse rates in a group of patients with bipolar disorder receiving a group-based psychosocial intervention for 12 weeks. They suggest that this should be implemented more widely, offering a highly cost-effective strategy as an adjunct to standard treatment. Transference-focused psychotherapy, a modified psychodynamic approach, delivered twice a week to patients with borderline personality disorder was superior to standard community psychotherapists using a mixture of approaches. Doering et al (pp. ) reported lower drop-out rates and fewer suicide attempts during the year of the treatment. They highlight the range of psychotherapeutic approaches which have now been shown to be effective in the treatment of borderline personality disorder and suggest that there needs to be a synthesis of the evidence to guide the practitioner towards the optimal treatment for an individual patient. The individual placement and support (IPS) model has been effective in assisting patients with severe mental illness in gaining competitive employment. Howard and colleagues (pp. ) found that the IPS showed no benefit, compared with standard treatment, in helping patients gain employment in the UK. The authors, and Latimer (pp. ) writing in an accompanying editorial, suggest that the lack of faithful implementation of the model may be at fault and that this is not an indication to throw the baby out with the bathwater or to assume that the IPS model cannot deliver results in the UK.
Auditory hallucinations, antidepressant toxicity and smoking
Auditory hallucinations in schizophrenia have been associated with a range of abnormalities in the temporal cortex in magnetic resonance imaging studies. Nenadic et al (pp. ) show that auditory hallucinations were correlated with changes in the bilateral superior temporal gyrus, including primary and secondary auditory cortex, and inferior parietal cortex. They suggest that these regions show a dimensional relationship with hallucinatory activity rather than a categorical one. Self-poisoning is a common means of suicide and antidepressants account for a fifth of UK suicide attempts. Hawton and colleagues (pp. ) assessed the relative toxicity of the commonly used antidepressants and report that, as anticipated, the tricyclic antidepressants have the highest toxicity, followed by venlafaxine and mirtazapine, with the selective serotonin reuptake inhibitors (SSRIs) having the lowest toxicity index. Interestingly, within the family of SSRIs, citalopram had a higher toxicity index than the other SSRIs. They suggest that these data could feed into clinical decisions during the risk assessment of patients being prescribed antidepressants. High rates of smoking are a major problem in patients with schizophrenia. A review and meta-analysis of bupropion reports that it may be a useful adjunct in increasing rates of smoking cessation in smokers with schizophrenia. Most importantly, Tsoi and colleagues (pp. ) show that this can be achieved without any adverse effects on mental state.
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