Life: childhood to older age

This first issue of 2010 brings in the New Year with an exciting and eclectic mix of clinically related research. The papers range both in content, across the lifespan from childhood through adulthood into older age; and in origin, from Benin, through Britain and India to Taiwan. Although childhood experience in Western countries has improved in material terms, there has been an increase in behavioural difficulties over the past 30 years. A thought-provoking editorial by Scott (pp. ), Director of the National Academy for Parenting Practitioners, examines the role of parenting in improving childhood outcomes and how interventions to improve parenting could serve not only to reduce distress during childhood, but also to ameliorate the longer-term costs of behavioural disorder in childhood. This relationship between childhood symptoms and adult outcomes has also been observed in psychotic disorders, where the presence of auditory hallucinations in childhood has been noted to increase the risk of adult psychotic illness. Bartels-Velthuis and colleagues (pp. ) found that 9% of 7- to 8-year-old children experienced auditory hallucinations but this was not generally associated with functional decrement. They suggest that a subgroup of these children, who experience hallucinations and demonstrate functional decrement, may potentially show continuity with psychotic outcomes during their follow-up into adulthood. Moving to adulthood, the NICE guidelines for treatment of borderline personality disorder suggest that pharmacological treatment has little role to play in its management. However, a review by Lieb et al (pp. ) challenges this view; they conclude that mood-stabilising and antipsychotic medication is useful for affective dysregulation, mood stabilisers are useful in impulsive behavioural dyscontrol symptoms and selective serotonin reuptake inhibitors should be reserved only for treatment of comorbid depressive illness. They suggest that the NICE guidelines, published in January 2009, are already in need of reassessment. At the other end of the lifespan, there is an increased incidence of mild cognitive impairment and dementia with increasing age, and the presence of mild cognitive impairment has been suggested as an intermediate stage conferring increased risk of conversion to dementia. However, the actual risk of conversion varies considerably and there are no unequivocal predictors of this change. Velayudhan et al (pp. ) report that the presence of diabetes mellitus was associated with a significant increase in the risk of conversion to dementia and suggest that the potential for improved diabetic control may warrant further examination.

Bipolar disorder: white matter, serotonin and relapse prevention

Regional cortical white matter changes have been observed in bipolar disorder, and Macritchie and colleagues (pp. ) examined cortical white matter in patients with euthymic bipolar disorder, using diffusion weighted magnetic resonance imaging, and found significant changes in these patients compared with controls. They suggest that there are generalised white matter abnormalities present in bipolar disorder and these may be influenced by substance misuse and treatment with lithium. The underlying mechanism is uncertain but genetic variation may play a prominent role. The importance of serotonin in depression, both in treatment and in the mechanism of cortical action, has been extensively examined; the role of serotonin in mania has received less attention. Yatham et al (pp. ) describe decreased levels of cortical 5-HT₂ receptors in drug-free patients with bipolar disorder, scanned using positron emission tomography during a manic phase. They did not find a correlation of severity of mania with receptor density and speculate whether these changes reflect a trait marker for bipolar disorder, rather than a state expression of mania. Even after successful treatment, the recurrence rates in bipolar illness are relatively high, in the order of 50% at 1 year, and relapse prevention may be a useful intervention to reduce this figure. Lobban and colleagues (pp. ) provided training in enhanced relapse prevention to community mental health teams, and when compared with treatment as usual, report a modest but non-significant decrease in the time to the next episode of the illness. They comment that this study demonstrates the feasibility and potential benefit of this approach, which now requires larger trials to determine its role in practice.

World view: self-harm, suicide and obstetric complications

Self-harm continues to be a serious problem worldwide, with relatively high rates of repetition and of suicide. There are limited data on self-harm rates in Asia and Chen et al (pp. ) report from Taiwan, observing that the risks of repetition were significantly elevated in the first year, but generally lower than the rates reported in the UK. They speculate that this may be due to the methods used to self-harm in Taiwan, where in a quarter of cases the individuals ingested pesticide, with extremely physically aversive consequences. They suggest that this may act as a powerful behavioural deterrent, when compared with self-cutting or ingestion of medication – the prominent methods described in Western cultures. In line with this theme of cultural variation in psychiatric presentation, Manoranjitham et al (pp. ) examined risk factors for suicide in southern India and found alcohol dependence and adjustment disorders to be the most frequently associated psychiatric diagnoses. However, ongoing stress, chronic pain and breakup of a relationship were also significant factors. Overall, they conclude that psychosocial stress and social isolation rather than psychiatric disorder were the significant risk factors for suicide; they discuss differences with the Western data – suggesting that overall levels of suicide are higher in low- and middle-income countries and thus psychiatric disorder forms a much smaller proportion of the risk in these countries. They also speculate whether the depression associated with suicide is actually distress rather than disease, and the different emphasis placed on this distinction by different models within social care and healthcare. Fottrell and colleagues (pp. ) report that experiencing severe obstetric complications was not associated with greater subsequent psychological distress in women in the Republic of Benin. However, they found that women suffering obstetric complications with perinatal death had significantly elevated levels of psychological distress, but that this was mediated by psychosocial variables such as debt, physical illness and marital disharmony. They discuss the protective effects of having a child within this culture.

We take this opportunity to wish readers of the Journal a very peaceful and harmonious New Year.