Highlights of this issue

Sukhwinder S. Shergill
BJP 2013, 203:A3.
Access the most recent version at DOI: 10.1192/bjp.203.1.A3

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Highlights of this issue with anxiety. However, they are clear that older people do benefit
from treatment, although it appears that those older patients with
generalised anxiety disorder or panic disorder may require far
By Sukhwinder S. Shergill more intensive treatment to achieve optimal outcomes. An
accompanying editorial by Oude Voshaar (pp. 8–9) argues that
there is a two-fold problem: first, the generally low rates of
treatment of anxiety disorder in old age need to be addressed;
The problem with DSM-5; and second, there needs to be more attention given to
young people, depression and psychosis developing age-specific treatment strategies.
The recent publication of the DSM-5 has raised the profile of
classification systems for disorders of mental health. An editorial
by Frances & Nardo (pp. 1–2) highlights several problematic areas Mental health, ethnicity and cognition
within the new DSM-5, including an increase in sensitivity in cocaine misuse
without a corresponding attention to specificity, problems with Mental health problems are evident in between 10 and 13% of
dimensional systems focused on personality disorder, and the children and adolescents in the UK, with similar rates in other
porous nature of the definitions of milder ‘major’ depressive countries and in different cultures. However, there is a trend from
disorder and anxiety disorders. They make an argument for the UK general population surveys that children of Indian origin have
new ICD-11 to be aware of the mistakes made in DSM-5, to set lower rates of mental illness than White British children. Dogra
higher scientific standards and to ensure more dialogue with and colleagues (pp. 44–50) selected their sample of adolescent
differing viewpoints. In a similar vein, Koukopoulos and children to address this question. They report that adolescents
colleagues (pp. 3–5) focus on the DSM-5 criteria for depressive of Indian ethnic origin did indeed have better mental health than
disorder with mixed features. They use their editorial to raise their their White counterparts. They review possible causes, including
fear that this will lead to more misdiagnosis and less appropriate the effects of differences in parenting and social support networks,
treatment, and suggest that mixed depression should have a and potential beneficial effects of cultural identification and
separate identity, characterised by core psychomotor agitation. minority status when living in areas with higher concentrations
Depressive illness has often been associated with diabetes and of immigrants. Cocaine is the second most widely used illicit drug
cardiovascular disease, but whether this was secondary to the in Europe, and is commonly viewed as being relatively benign, often
impact of depressive illness itself, or as a consequence of shared portrayed in the media as part of a Champagne lifestyle choice.
aetiological factors, was not clear. Mannie et al (pp. 18–23) However, contrary to this view, Vonmoos et al (pp. 35–43) found
assessed healthy young people with a family history of depressive that dependent cocaine use was associated with significant
illness, and found they were more likely to have higher blood cognitive impairments across a range of domains. Interestingly,
pressure and reduced insulin sensitivity. They conclude that recreational use of cocaine was also associated with significant
depression, diabetes and cardiovascular disease appear to share deficits in some cognitive domains, particularly attention and
common pathophysiological mechanisms – but were able to working memory. The authors found earlier age at onset of use
exclude a significant role for inflammation or cortisol hyper- was associated with greater detrimental effects, and suggest that
secretion as the mediating factors. The prognosis of first-onset the observed deficits are underpinned by cocaine-induced changes
psychosis is influenced by the duration of untreated psychosis in prefrontal cortical function.
(DUP). Birchwood and colleagues (pp. 58–64) report that a third
of people presenting to early intervention services in Birmingham
had a DUP of over 6 months, which, paradoxically, increased once Tardive dyskinesia
they entered the mental health system. Given that this was
observed in patients with access to a long-standing and well- The biological basis of the involuntary movements that
established early intervention service, the authors suggest that characterise tardive dyskinesia remains obscure. Tardive dyskinesia
there are structural barriers in the current delivery of services that is present in some patients with untreated schizophrenia, but also
prevent early intervention services from effectively reducing this appears to be related to antipsychotic treatment. Sarró et al
important DUP. (pp. 51–57) use brain imaging to demonstrate a reduction of
brain volume in some key subcortical structures associated with
tardive dyskinesia; the caudate nucleus and putamen were affected
Status, dementia and anxiety disorders across while the globus pallidus was spared. The authors are suitably
the age spectrum cautious in interpreting their findings – the cross-sectional design
Several diseases are differentially influenced by socioeconomic precludes a clear cause and effect. Although antipsychotic
inequalities. In cardiovascular disease and in dementia there is treatment might cause a decrease in these brain volumes and thus
evidence that these social inequalities may play a role in the lead to the development of tardive dyskinesia, it is equally possible
aetiology of the disorder. Russ et al (pp. 10–17) found an that patients with existing smaller brain volumes in these areas
association between leaving full-time education at an early age may be differentially at higher risk of developing tardive
and subsequent death from dementia – but only in women. They dyskinesia. An accompanying editoral by Liddle (pp. 6–7) reviews
highlight the challenge to the prevailing view that greater cognitive the data from similar brain imaging approaches applied to other
reserve is protective against the development of dementia, which symptoms in schizophrenia, and also the effects of antipsychotic
does not account for the observed gender difference. Anxiety treatment on brain structure. He cautions against a simple
disorders are common, and there are some data suggesting that attributional link between changes in brain structure due to
they are more difficult to treat in older patients. Wetherell and antipsychotic medication and the development of symptoms,
colleagues (pp. 65–72) confirm this hypothesis in a large sample and highlights the role of ageing in the development of tardive
of patients with anxiety disorder, reporting that both medication dyskinesia, to illustrate the multifactorial contributors to its
and psychotherapy may be less effective in older individuals pathophysiology.

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