Highlights of this issue

Johnson

Adverse health outcomes from early-life maltreatment are long-recognised phenomena, although the mediator specifics are only more recently being elucidated. Emphasising the importance of this point, Hosang et al (pp. 645–653) remind us that those with mood disorders die up to a decade earlier than the general population, a figure that perhaps gets a little lost among the even worse data in psychoses. They report on what is – somewhat astonishingly – the first study to look at relative medical outcomes in unipolar depression and bipolar affective disorder following childhood maltreatment. Both direct abuse and indirect neglect forms were associated with significant, dose–response, medical morbidity in bipolar affective disorder, but the associations were not seen in unipolar depression. The apparent lack of impact on unipolar depression is curious, and as such individuals do, indeed, have worse health outcomes something else must be moderating.

Lithium is often a central agent in bipolar affective disorder conversations although, despite being used for over 60 years, we remain uncertain about its therapeutic mechanisms of action and the timing of its effects. Matt Taylor analysed (pp. 664–666) data from three placebo-controlled randomised trials of lithium for relapse prevention in bipolar affective disorder. The amazing ion reduced relapse manic episodes within the first 4 weeks of instigation, but this was not so for bipolar depression where benefits appear to take longer to accrue. This reminds us that depressive phases typically account for about two-thirds of ‘bipolar burden’.

Do scales help in bipolar affective disorder? Jan Scott & Greg Murray give them low ratings and say not adequately in their current form (pp. 627–629). Those most commonly used are getting on a bit in age and, the authors argue, reflect an era where affective symptoms were given undue weighting over activity and energy, not mapping well onto recent and proposed diagnostic system changes.

Nixon

Pieces on preventing cognitive decline and dementia fill the pages of the mainstream media, but it can often feel like #fakenews and hype. Nevertheless, when faced with the daunting projected growth in incidence, identifying modifiers of disease development is as key an issue as novel treatments. Becker et al (pp. 654–660) systematically reviewed the literature to assay the impact of anxiety on Alzheimer's disease and vascular dementia. Seven relevant studies, encompassing big numbers of over 26 000 individuals, found anxiety a risk for both conditions, including after controlling for sociodemographic factors. Zheng et al (pp. 638–644) ask an analogous question regarding depressive symptoms and cognitive functioning, analysing 7610 individuals tracked as part of the English Longitudinal Study of Ageing (ELSA). A strength of this work is its prospective nature and that participants had repeated measurements of both mental state and cognitive functioning. The findings are stark in this cohort with a mean age of 65 (57% women): depression was associated, in a dose–response pattern, with subsequent cognitive decline both globally and in the subdomains of memory, executive and orientation function. Akin to the aforementioned data on early-life traumas and later health outcomes, numerous candidate mechanisms have been proposed for moderating the likelihood of developing neurodegenerative conditions, often herded under rather broad umbrellas such as ‘inflammation’ and ‘oxidative stress’; more precise functional relationships are yet to be uncovered.

What about reducing risk through stimulation of the mind? Personally, I get all the culture and urbanity I need from Fox News and watching monster truck rallies, but what about for all you liberal snowflakes out there who like something a bit more upmarket, like museum attendance? (Sad!) Fancourt and colleagues (pp. 661–663) test this, also utilising the ELSA cohort (but no collusion between the research teams!). Attendance every few months or more was associated with lower incidence of dementia over the 10-year follow-up, and this held firm when the obvious confounders of socioeconomic status and demographics were controlled for. There are underpinning arguments about cognitive reserve and a brain ‘disuse syndrome’; a good excuse to drag a special other away from watching repeat episodes of The Apprentice to visit a gallery or exhibition. Dafni Katsampa from University College London adds some Greek culture to the debate with our latest Mental Elf blog at: https://elfi.sh/bjp-me15.

Clinton

Supreme Court decisions settle law at the highest level, from the issue of the right to die to overseeing cases of impeachment. In 2015 the UK Supreme Court judgement in Montgomery determined that consent to treatment requires adequate shared decision-making between patient and doctor. Adshed et al (pp. 630–632) discuss the implications of this upon good psychiatric practice. While the Bolam test established that one's actions are benchmarked against a body of one's peers, Montgomery adds to this in defining the type of dialogue clinicians need to be having with their patients in making informed decisions about care. The piece is rich stimulating fodder for peer-group reflective practice or a trainee journal club.

What can you tell from a distance about someone's personality and mental health through what they write, say or even tweet? The backdrop is the so-called Goldwater principle: in 1964, then presidential nominee Barry Goldwater elicited concern from some quarters about his mental well-being, and his ability to lead the country. The upshot was the American Psychiatric Association's statement that ‘it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement’. The issue has a somewhat contemporary feel to it, and the BJPsych has risen to the occasion with a fascinating debate piece (pp. 633–637). So, can and should, potential psychiatric diagnoses of the powerful be made from afar without examining an individual? Low-energy rocket man John Gartner says yes we can, and yes we should; Alex Langford, who is strong on borders and loves our military and vets, says no; Aileen O'Brien takes on the role of Sean Hannity, arbitrating the fair and balanced middle ground. My guess is you have lots of opinions on this; my challenge to you is to question what is really pushing you: your professional practice or your political passions? Maybe some of us really are on subconscious rigged witch hunts – are you just a conflicted angry Democrat? As for us here at the BJPsych, well we are going to build a wall around our headquarters on Prescot Street, and we are going to make the failing Lancet Psychiatry pay for it. Enjoy!