MENTAL HEALTH AND PUBLIC SAFETY: ‘THE GOVERNMENT V. PSYCHIATRY’
The Government's proposals for reform of the Mental Health Act, as set forth in the Green Paper, seek primarily to reduce the risk of harm to the patient, and especially to others. Szmukler & Holloway () take issue with this and argue that measures that have protection of the public as the sole interest should have no place in a mental health act. They feel that there is no justification for singling out only those with a mental disorder for preventive detention or involuntary treatment on the grounds of public safety. This debate is set to run and run
SKIMPING ON MENTAL HEALTH
Bindman et al () find that health authorities in deprived areas in England are actually spending less on mental health than the amount allocated for that purpose. The exception is inner London where there is a relative overspend on mental health relative to allocation.
DOUBTS ABOUT EARLY INTERVENTION FOR SCHIZOPHRENIA
First-episode studies of schizophrenia show that a long duration of untreated psychosis is related to poor outcome, thus providing the rationale for early intervention strategies. A paper by Barnes et al (), from the West London first-episode study of schizophrenia, reports that duration of untreated psychosis does not appear to influence baseline neuropsychological test performance or response to medication at six weeks. On the basis of their initial findings, the authors controversially question the weight of evidence in favour of early intervention.
LEARNING DISABILITY: PSYCHIATRY BEYOND WORDS
Sheila Hollins () gives a personal and reflective account of changes in the field of learning disability psychiatry in England over a 20-year period. She describes how her recognition of the importance of non-verbal communication with clients led to the creation of the Books Beyond Words series. She has ‘no regrets’ about choosing this complex, varied and stimulating branch of psychiatry.
ETHNICITY MATTERS IN FORENSIC MENTAL HEALTH
Rates of compulsory admission to forensic secure units for Black males in England and Wales are over five times higher than for White males. Coid et al () argue that socio-economic disadvantage or racial bias are not entirely responsible for these striking results since Asian males have much lower rates of compulsory admission than the other groups.
DETOXIFICATION - YOU GET WHAT YOU PAY FOR!
In-patient detoxification is considered to be much more expensive than out-patient treatment. However, a clever analysis by Gossop & Strang () demonstrates that when adjustments are made for successful outcome, the cost per abstinent case in a 10-day in-patient detoxification is actually less than the cost per abstinent case in an out-patient programme. As the authors point out, “ an ineffective service can never be cost-effective, no matter how cheaply it is provided”.
SCHIZOPHRENIA: TOO MANY DEATHS
Whether psychiatrists or general practitioners are best placed to diagnose and treat medical illness in the mentally ill is uncertain. Brown et al () report that rates of ‘avoidable’ natural deaths were five times higher than expected in a cohort of people with schizophrenia followed up over 13 years. Improvements in recognition of acute medical illnesses and treatment of chronic medical conditions might have prevented some of this excess mortality.
INSIGHT WITH HINDSIGHT
A longitudinal study by Cuesta et al () confirms what we all suspected - moderate to severe disturbances of insight in psychosis persist over time. Fortunately, though, certain aspects of insight do seem to improve, in particular recognition of the need for treatment during previous episodes of psychosis.
HEAVY BRAINS AND SUICIDE
Salib & Tadros () report an intriguing, although admittedly exploratory, finding that brains of elderly suicide victims are heavier than those who die from natural causes. Many sources of bias could have contributed to this finding and a large prospective study is needed.
BREAST NOT BEST FOR PSYCHOSIS
There are many good reasons for promoting breast-feeding, but Leask et al () show that prevention of psychosis is not one of them!
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