This issue reports a community-based study quantifying the extent to whichsubthreshold hypomanic or depressive symptoms in childhood or adolescencepredicted subsequent formal bipolar disorder status and mental healthservice attendance. This editorial emphasises the low predictive power ofthe signal and considers early intervention implications.

Although living standards have increased in the past 40 years, children's behaviour problems have become worse. Good parenting can help by maximising children's potential and promoting resilience. Effective programmes are available that improve parenting, but unfortunately ineffective approaches are still used widely. A new National Academy for Parenting Practitioners has been set up in England, which offers free training in evidence-based interventions and conducts research to increase their effectiveness.

The number of illegal internet pharmacies selling prescription-only medicines without a prescription is increasing. Large quantities of drugs are dispensed, making drugs of abuse readily available, and further risks are posed by counterfeit medication. Urgent national and international action is required to stop further proliferation of illegal pharmacies.

During the period of austerity that we now face, the National Health Service (NHS), including mental health services, will have to make efficiency savings at a time when demand for services is likely to rise. It is critical to highlight that investment in evidence-based prevention, early intervention and treatment for mental disorders can have economic benefits that go far beyond the health sector. Many potential areas for efficiency savings, such as resources invested in management and administration, are relevant across the whole of the health system. The economic downturn may, however, also present a specific opportunity for radical innovation within the mental health system.

Specialised treatment programmes for people with first-episode psychosis are cost-effective as long as the treatment continues. But the effect seems to be the result of an ongoing active treatment rather than a cure. The main challenges are to secure long-term involvement in treatment and to develop strategies for prevention.

This issue includes the findings from the largest randomised controlled trial ever conducted with bilateral, unilateral and bifrontal electroconvulsive therapy (ECT). The background to the study and its findings are discussed.

Cigarette smokers frequently describe the anxiolytic and antidepressant effects of smoking, but evidence suggests that cigarette smoking may itself increase negative affect, so that the causal direction of this association remains unclear. Although increasingly sophisticated analyses of epidemiological data may help to answer this question, observational data can never unequivocally provide evidence of causation. Here we discuss the potential utility of genetic information in determining the causal basis of the relationship of cigarette smoking and depression.

Akathisia remains one of the most prevalent and distressful antipsychotic-induced adverse events. Effective and well-tolerated treatment is a major unmet need in akathisia that merits a search for new remedies. Accumulating evidence indicates that agents with marked serotonin-2A receptor antagonism may represent a new class of potential anti-akathisia treatment.

Evidence to date indicates that the individual placement and support model of supported employment helps people with mental illness to obtain competitive jobs. The study by Howard et al (this issue) is the first unsuccessful trial of this model. Vocational workers had far fewer contacts with clients and employers than normal.

The sculptor Ismond Rosen was a distinguished psychoanalyst and consultant psychiatrist who became a fellow to both the Royal College of Psychiatrists and the Society of Portrait Sculptors. He presented this 1947 white marble carving to the Royal Society of Medicine in 1987, where it can now be seen framed by a window on the south fac, ade. The stillness of its simple curves symbolises the importance of early attachments as a template for all subsequent relationships. In Dr Rosen's own words, ‘The two heads relate above and fuse below in a manner expressive of human loving, both in its earliest mother-child relationship and in adult sexual congress.’

Recent genetic studies reinforce the view that current approaches to thediagnosis and classification of major psychiatric illness are inadequate.These findings challenge the distinction between schizophrenia and bipolardisorder, and suggest that more attention should be given to therelationship between the functional psychoses and neurodevelopmentaldisorders such as autism. We are entering a transitional period of severalyears during which psychiatry will need to move from using traditionaldescriptive diagnoses to clinical entities (categories and/or dimensions)that relate more closely to the underlying workings of the brain.