Highlights of this issue

The maelstrom of psychosocial adversity created by COVID-19 will continue to leave an indelible imprint on psychiatry for years to come. No doubt, we will continue to see more in this column about how the global pandemic will shape our collective futures and the mental health of those for whom we care. Kesner & Horácek (pp. 475–476) speak of the ‘new normal’ as one riddled with existential threats, but also one that is transformative and can help psychiatry to gain a deeper insight into the relationship between trauma and mental disorders. But for this issue, we steer towards severe mental illness and its outcomes.

Blinded by the dark

However much Western psychiatry has encouraged a movement away from a one diagnosis, one-approach model of treatment for psychotic disorders, its post-colonial legacy casts a long shadow over holistic approaches to recovery. Summerfield (pp. 467–468) describes a ‘crude and homogenised version of Western Psychiatry’ that plays out across in-patient units in Zimbabwe. Patients are often given a diagnosis of schizophrenia when cultural beliefs influence a misinterpretation of phenomenology. It betrays astute clinical acumen and eschews best practice, with overuse of antipsychotic drugs that are perceived by families to be a treatment for life –Zimbabwe may not be alone and psychiatry needs to watch a very large space.

In contrast, the power of community support from families cannot be underestimated. Malla et al (pp. 514–520) compared 2-year clinical outcomes in first-episode psychosis between a higher income and a low–middle-income country. It may not surprise us that patients in the low–middle-income country have better family support, but negative symptom outcomes were also significantly better in these patients. Better outcomes were also observed for level of symptoms, length of remission and the proportion of patients in remission. Evidently a tale of two cities.

Resistance, reinstatement and revolving doors

The long-term maintenance of clozapine in patients with treatment-resistant psychosis can be limited by adherence to taking oral medication. We know little about whether intramuscular prescriptions can offer something better. Casetta et al (pp. 506–513) followed-up patients prescribed intramuscular clozapine after 3 years and compared discontinuation rates with a cohort of patients prescribed oral clozapine. Not only did 92% of the group receiving intramuscular clozapine switch to oral clozapine within the follow-up period, the intervention group also had a lower rate of discontinuation. Although the small sample size raises the possibility of a lack of statistical power, the results are promising for the use of intramuscular clozapine as a transition to longer-term oral treatment. It is a sentiment echoed strongly by Luykx et al (pp. 471–474) in a study examining ward readmission following clozapine discontinuation. Clozapine came out as one of the most effective and safest treatment options in those who had previously discontinued this drug. The future appears bright for clozapine as a mainstay in treatment-resistant psychosis.

An early start

Patients living with psychotic disorders face innumerable challenges in many aspects of their lives. One of these is the prospect of employment. In a comparison of patients with first-onset schizophrenia spectrum disorders who received early intervention compared with standard care, Chan et al (pp. 491–497) found that the number of relapses, months of full-time employment and years of education positively differentiated the early-intervention group from that receiving standard care. But this is not the only positive news for psychiatry. Health economists and commissioners will also be heartened by the cost–benefits of early-intervention services. Behan et al (pp. 484–490) expound the virtues of such interventions in a further paper, pointing out the benefits to health services and even greater benefits to society.

This issue continues to drive forward the message that there remains considerable hope for the early treatment of psychotic disorders with drugs that are known to be clinically effective. It also paints a picture of positivity for both the mental health of the nation and for society as a whole. Let's take heart in that.