MENTAL HEALTH, MIGRATION AND MARGINALISATION

This first issue of 2006 covers an impressively broad range of research and sets a high standard for future issues. The personal consequences of working within a demanding environment such as a mental health team are often ignored. A survey of mental health social workers highlights high levels of stress and emotional exhaustion. Respondents related these to high job demands and not feeling valued for their work. Unsurprisingly, there was a high level of job dissatisfaction, with many participants expressing a strong desire to leave their current posts. Evans et al () suggest that unless theses issues are adequately addressed, there may be increasing problems in recruitment and retention. There has been some concern about the mental health of migrants, particularly in respect of appropriate policies for detention and dispersion, and some countries within the European Union have been examining the more ‘strict’ system used in Australia. Steel et al () demonstrate that insecurity about residence status and fears of repatriation contributed to the persistence of psychiatric symptoms in refugees given ‘temporary protection’ status. Psychiatric symptoms were more severe when refugees were isolated from family members. The authors advocate caution in the application of this Australian protection or detention strategy to other countries. There is little doubt that health research underpins developments in clinical science, but there are obvious inequalities within published research output. Relevant issues are the under-representation of mental health research and, within that, the research output from low- and middle-income countries. Saxena and colleagues () show that the 10/90 divide between the respective research outputs from lower-income and high-income countries remained present in mental health research over the past decade. They suggest that implementation of recent World Health Organization statements may be overdue.

BIPOLAR DISORDER, EPIDEMIOLOGY, GENETICS AND TREATMENT

Longitudinal studies in bipolar disorder remove many confounders of crosssectional assessment. Robertson Blackmore et al () assessed the obstetric variables associated with bipolar affective puerperal psychosis in women with unaffected deliveries and found that two factors - primiparity and delivery complications - were independently associated with episodes of puerperal psychosis. This study raises questions about possible differences between the first and subsequent pregnancies and the possible mediating role of stress hormones which also show a heightened response during obstetric complications. A genetic association between brain-derived neurotrophic factor (BDNF) and bipolar disorder has been demonstrated. However, in the largest sample to date, Green et al () found no evidence of such an association in their UK study. However, they did find an association with the rapid-cycling subtype of bipolar disorder. They suggest that the lack of a clear differentiation between clinical phenotype and broad diagnostic categorisation may explain the variability in the results of other BDNF and bipolar studies. Especially relevant to the current vogue for natural treatments, Frangou et al () report beneficial results from the first randomised double-blind placebo-controlled clinical trial of adjunctive ethyl-eicosapentaenoic acid (EPA; fish oil) in the treatment of bipolar depression. Patients had reduced depression scores after a 12-week study, and the treatment was well tolerated and did not precipitate mania.

PSYCHOSIS AND PERSONALITY DISORDER

The dorsolateral prefrontal cortex (DLPFC), associated with evaluating evidence and decision-making, has been proposed to be dysfunctional in schizophrenia, and may be linked to prominent negative symptoms. Cullen et al () examined post-mortem brains and reported loss of the normal asymmetry with the contralateral DLPFC. They suggest that abnormal connections between the two hemispheres may underpin the crucial loss of connectivity that is seen in schizophrenia. Garety et al () show that a specialised early psychosis service may yield better functional (both social and vocational) outcomes than routine care at 18-month follow-up. This provides support for the current UK policy focused on early intervention. A literature review demonstrates the adverse influence of comorbid personality disorder on the outcome of depression. However, Newton-Howes et al () caution against therapeutic nihilism; these patients should not automatically be considered as having a poor prognosis, but should be offered treatment for both disorders. On this point, Fonagy & Bateman () offer a contemporary perspective on the treatment of borderline personality disorder, which not only follows a more benign course than previously thought, but also has relatively effective psychosocial therapeutic interventions. They discuss the psychological mechanisms operating in these patients and the difficulties in their treatment.

PSYCHIATRYAND ETHICS

A thought-provoking focus on ethical issues is provided by Bloch & Green (), who use an interesting clinical vignette to examine the ethical complexities of clinical care within different theoretical frameworks; and Birmingham et al () consider the practical implications of applying an ethical approach and the ethos of equivalence to patients who are in prison.

We take this opportunity to wish a healthy, peaceful and scientifically stimulating New Year to the readers of the Journal.