Psychosis: quality of services, cost and neuroanatomy

In the current economic climate of increased austerity, there is an awareness of demonstrating that increased quality of service provision correlates with clinical outcomes. Many policy decisions are made on this basis but there is little direct evidence addressing this complex question. Killaspy and colleagues (pp. ) found a positive association between quality of NHS mental health rehabilitation services and the clinical outcomes of these services. Interestingly, they report that rehabilitation delivered in hospital-based units was largely of equivalent quality to that of community-based units, and the psychiatric morbidity of the local area had a greater impact on quality than the characteristics of the patients placed there. They conclude that ongoing investment is necessary to deliver high-quality care and achieve a positive impact on patient's autonomy. First-episode services lie at the other end of the spectrum from rehabilitation and ever since they were implemented, in the face of limited evidence of benefit, there has been a question about their cost-effectiveness. Hastrup et al (pp. ) found that there was no difference in the costs of their first-episode service, compared with standard treatment, over a 5-year follow-up period, but there was also no difference in health outcomes, with the loss of earlier benefits evident within the specialised first-episode treatment group at 3-year follow-up. The authors suggest that a longer period of intensive treatment may serve to maintain these earlier gains. Psychotic illness has been demonstrated to be associated with widespread changes in cortical structures, with decreased hippocampal size being one of the more robust findings. Brambilla and colleagues (pp. ) used a novel 3D magnetic resonance imaging mapping of the hippocampus to show that while there were no morphological differences between groups of patients and controls, decreases in 3D structure of the hippocampus correlated with increased severity of disease, and with poorer social outcomes in patients. The authors conclude that this supports the use of more advanced imaging and analysis techniques to study brain changes, and that decrements in hippocampal structure may index a subgroup of patients with psychosis with poorer clinical and social outcomes.

Depression: outcomes in subthreshold states and post-stroke

Major depressive illness is associated with a high level of morbidity and mortality but the impact of subthreshold depression is not clear. Cuipers and colleagues (pp. ) carried out a meta-analysis demonstrating that both major depression and subthreshold depression were associated with significantly increased levels of mortality, and that there were no significant differences in mortality between major and subthreshold depression. They support the view that depression lies on a continuum from no depression at one end to severe depression at the other, and that there is a need for an enhanced emphasis on the benefits of interventions addressing subthreshold depression. There is evidence that there is an increased incidence of depressive illness following a stroke. Ayerbe et al (pp. ) reported a cumulative incidence of depressive illness of 52% within 5 years of a stroke, from their systematic review and meta-analysis of 50 studies in this area. They also found a prevalence of depression of approximately 30% in the first 10 years following stroke. A pre-stroke history of depressive illness and the extent of post-stroke disability were the most consistent predictive factors for post-stroke depression; other risk factors included cognitive impairment, lack of social support and anxiety. The authors highlight that depression following a stroke requires clinical attention in the long term, which should be focused on patients at the highest risk.

Genetics, smoking cessation and oestrogen therapy

Genes have been recognised to influence the development of psychiatric illness but only recently has technology developed to allow screening of large numbers of genetic markers in large sample sizes, characterised by the genome-wide association studies. In their editorial, Collins & Sullivan (pp. ) provide an elegant overview of these studies in psychiatry, both of the methodology and the conclusions that can be drawn from the data so far. They suggest that the evidence supports a polygenic view of psychiatric disorders, acting on a diverse range of biological pathways. They are encouraged that these larger studies are throwing up new hypotheses, leading to investigation of novel mechanisms. There has been a renewed public health focus on decreasing the number of people smoking cigarettes. Smoking is more prevalent in patients with psychiatric disorder and there is a popular belief that smoking reduces anxiety. McDermott and colleagues (pp. ) followed up smokers attending NHS smoking cessation clinics over 6 months and demonstrated that people achieving abstinence experienced a marked reduction in anxiety, while those who continued smoking showed a modest increase in anxiety. The decrease in anxiety at follow-up was greater for those with a psychiatric disorder at baseline, and those reporting smoking to cope with stress. There are gender differences in the incidence of several psychiatric disorders and an increased interest in oestrogen treatment across a range of diagnoses, including premenstrual syndrome, depression, Alzheimer's disease and schizophrenia. Craig (pp. ) reappraises the evidence for oestrogen therapy in psychiatry and concludes that it may have a therapeutic role in premenstrual dysphoric disorder, postpartum and perimenopausal depression, although evidence for efficacy in Alzheimer's disease and schizophrenia is more limited.

We take this opportunity to wish a healthy, harmonious and happy new year to the readers of the Journal.