Treating maternal depression?

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P. J. McGrath, F. J. Elgar, C. Johnston, D. J. A. Dozois and S. Reyno
Treating maternal depression?
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A new dawn for the yellow journal?A new dawn for the yellow journal?
I welcome the new Editor’s plans to bringI welcome the new Editor’s plans to bring
thethe JournalJournal firmly into the 21st century byfirmly into the 21st century by
making it intellectually stimulating but alsomaking it intellectually stimulating but also
inviting and readable for all (Tyrer, 2003).inviting and readable for all (Tyrer, 2003).
The previous Editor may have done muchThe previous Editor may have done much
to improve theto improve the JournalJournal’s impact factor to’s impact factor to
the scientific community by increasing itsthe scientific community by increasing its
citation rate but what has not been studiedcitation rate but what has not been studied
are the views of the core readership. Shouldare the views of the core readership. Should
not a survey of readers be carried out to seenot a survey of readers be carried out to see
what people think of thewhat people think of the JournalJournal and whoand who
reads how much and of what? I suspectreads how much and of what? I suspect
the answer may be not much of very little,the answer may be not much of very little,
and that for most of us theand that for most of us the JournalJournal has ahas a
fairly short ‘wrapper off to bookshelf time’.fairly short ‘wrapper off to bookshelf time’.
TheThe JournalJournal’s core readers are many’s core readers are many
thousands of jobbing psychiatrists. We arethousands of jobbing psychiatrists. We are
looking for important new information thatlooking for important new information that
has bearing on our day-to-day clinical prac-has bearing on our day-to-day clinical prac-
tice. Yes, we have thetice. Yes, we have the Psychiatric BulletinPsychiatric Bulletin,,
with its zippy and original offerings, butwith its zippy and original offerings, but
sometimes a subject needs a more academicsometimes a subject needs a more academic
and lengthy airing. Perhaps the readershipand lengthy airing. Perhaps the readership
could suggest subjects for editorials, andcould suggest subjects for editorials, and
why not have each book review writtenwhy not have each book review written
by both an expert in the field and an ordin-by both an expert in the field and an ordin-
ary reader, so as to capture differentary reader, so as to capture different
perspectives? I hope that the new Editorperspectives? I hope that the new Editor
can increase the interaction between thecan increase the interaction between the
JournalJournal and all psychiatrists. Good luck.and all psychiatrists. Good luck.
Tyrer, P. (2003)Tyrer, P. (2003) Entertaining eminence in theEntertaining eminence in the BritishBritish
Journal of PsychiatryJournal of Psychiatry.. British Journal of PsychiatryBritish Journal of Psychiatry,, 183183,1^2.,1^2.
C. HawC. Haw St Andrew’s Hospital, Billing Ro ad,St Andrew’s Hospital, Billing Ro ad,
Northampton NN1 5DG,UKNorthampton NN1 5DG,UK
Editor’sresponse:Editor’sresponse: Dr Haw is probably rightDr Haw is probably right
in her assertions that the jobbing psy-in her assertions that the jobbing psy-
chiatrist is likely to become the bobbingchiatrist is likely to become the bobbing
psychiatrist when reading thepsychiatrist when reading the JournalJournal ––
jumping from one item to the next withjumping from one item to the next with
little close examination of the content –little close examination of the content –
and it is clear from a recent paper that theand it is clear from a recent paper that the
ability of good ghostwriting to make anability of good ghostwriting to make an
arresting impact on the reader paysarresting impact on the reader pays
dividends (Healy & Cattell, 2003). Wedividends (Healy & Cattell, 2003). We
are taking notice of this by trying toare taking notice of this by trying to
improve and shorten the titles of papersimprove and shorten the titles of papers
submitted to thesubmitted to the JournalJournal; prospective; prospective
authors please note. However, Dr Hawauthors please note. However, Dr Haw
has stimulated me to go further; I have ahas stimulated me to go further; I have a
hypothesis that readers of thehypothesis that readers of the JournalJournal mightmight
help me in testing. It is a hypothesis that ishelp me in testing. It is a hypothesis that is
best kept blind at this stage, and I am dis-best kept blind at this stage, and I am dis-
closing it only to the Associate Editors.closing it only to the Associate Editors.
For each of the main sections of theFor each of the main sections of the JournalJournal
(editorials, debates, original papers, review(editorials, debates, original papers, review
articles, book reviews and correspondence)articles, book reviews and correspondence)
I invite readers to score on a four-pointI invite readers to score on a four-point
scale (0scale (0¼rarely or never read, 1rarely or never read, 1¼seldomseldom
read, 2read, 2¼frequently read and 3frequently read and 3¼regularlyregularly
or always read) in which ‘read’ is taken toor always read) in which ‘read’ is taken to
be a reasonably full examination of thebe a reasonably full examination of the
article (a good test of this is that you couldarticle (a good test of this is that you could
summarise the main impact of the article tosummarise the main impact of the article to
others). Could you send your responses to meothers). Could you send your responses to me
at the address below by the end of Januaryat the address below by the end of January
2004, and I will report the results – and the2004, and I will report the results – and the
hypothesis – shortly afterwards.hypothesis – shortly afterwards.
Meanwhile, I hope our readers areMeanwhile, I hope our readers are
aware of a third journal published by theaware of a third journal published by the
Royal College of Psychiatrists –Royal College of Psychiatrists – AdvancesAdvances
in Psychiatric Treatmentin Psychiatric Treatment (APT). Although(APT). Although
not an organ for original research, APTnot an organ for original research, APT
publishes expert, in-depth reviews ofpublishes expert, in-depth reviews of
topics of current clinical interest (http://topics of current clinical interest (http://
apt.rcpsych.org/).apt.rcpsych.org/).
Healy, D. & Cattell, D. (2003)Healy, D. & Cattell, D. (2003) Interface betwe enInterface b etween
authorship, industry and science in the domain ofauthorship, industry and science in the domain of
therapeutics.therapeutics. British Journal of PsychiatryBritish Journal of Psychiatry,, 183183, 22^27.,22^27.
Peter TyrerPeter Tyrer Editor,Editor, British Journal of PsychiatryBritish Journal of Psychiatry,17,17
Belgrave Square, London SW1X 8P G, UK. E-mail:Belgrave Square, London SW1X 8PG, UK. E-mail:
bjpbjp@@rcpsych.ac.ukrcpsych.ac.uk
Mental health of refugeesMental health of refugees
Using quantitative measures TurnerUsing quantitative measures Turner et alet al
(2003) found that about half of a sample(2003) found that about half of a sample
of 842 Kosovan refugees in the UK hadof 842 Kosovan refugees in the UK had
post-traumatic stress disorder, with sub-post-traumatic stress disorder, with sub-
stantial comorbid depressive disorder andstantial comorbid depressive disorder and
anxiety disorder. But there is more to beanxiety disorder. But there is more to be
reported. I was involved in having a fewreported. I was involved in having a few
open-ended questions tacked on to theopen-ended questions tacked on to the
study, tapping subjects’ own views of theirstudy, tapping subjects’ own views of their
health/mental health and what they sawhealth/mental health and what they saw
as their most urgent priorities for recovery.as their most urgent priorities for recovery.
Only a tiny number saw themselves asOnly a tiny number saw themselves as
having a mental health problem of anyhaving a mental health problem of any
kind, bearing out observations by refugeekind, bearing out observations by refugee
workers in the reception centres housingworkers in the reception centres housing
them that there was no interest in coun-them that there was no interest in coun-
selling. Almost everyone nominated work,selling. Almost everyone nominated work,
schooling and family reunion as their majorschooling and family reunion as their major
concerns. This chimes with what I andconcerns. This chimes with what I and
others have found in clinical settings withothers have found in clinical settings with
refugees over many years.Significant psycho-refugees over many years.Significant psycho-
pathology is uncommon (Summerfield,pathology is uncommon (Summerfield,
2002).2002).
The responses to the open-endedThe responses to the open-ended
questions paint a picture that is a worldquestions paint a picture that is a world
away from that reported by Turner andaway from that reported by Turner and
colleagues; how is this contradiction to becolleagues; how is this contradiction to be
explained? First, the question of validity.explained? First, the question of validity.
Translation/back-translation of psychiatricTranslation/back-translation of psychiatric
inventories originating in the USA andinventories originating in the USA and
Western Europe does not by itself overcomeWestern Europe does not by itself overcome
the category fallacy to which Kleinmanthe category fallacy to which Kleinman
(1987) pointed: particular phenomena(1987) pointed: particular phenomena
may be identified in different settings butmay be identified in different settings but
it does not follow that they mean the sameit does not follow that they mean the same
thing in each setting. Moreover, refugees inthing in each setting. Moreover, refugees in
distressed and insecure circumstances maydistressed and insecure circumstances may
be particularly susceptible to the demandbe particularly susceptible to the demand
characteristics of questionnaires. Second,characteristics of questionnaires. Second,
and fundamentally, how human beingsand fundamentally, how human beings
experience an adverse event, and whatexperience an adverse event, and what
they say and do about it, is primarily athey say and do about it, is primarily a
function of the social meanings and under-function of the social meanings and under-
standings attached to it. No psychiatricstandings attached to it. No psychiatric
category captures this active appraisal andcategory captures this active appraisal and
meaning-making.meaning-making.
Quantitative methodologies servingQuantitative methodologies serving
psychiatric categorisations risk a distortingpsychiatric categorisations risk a distorting
pathologisation of refugee distress, withpathologisation of refugee distress, with
what is social and collective beingwhat is social and collective being
reassigned as individual and biologicalreassigned as individual and biological
(Summerfield, 1999). Turner(Summerfield, 1999). Turner et alet al cautioncaution
against ‘the tendency of some to reject theagainst ‘the tendency of some to reject the
diagnostic paradigm in refugee popula-diagnostic paradigm in refugee popula-
tions’, but they do not make a persuasivetions’, but they do not make a persuasive
case here that they know better than thecase here that they know better than the
Kosovan refugees themselves, and thatKosovan refugees themselves, and that
many of the refugees really do need psy-many of the refugees really do need psy-
chiatric treatment. There is simply no goodchiatric treatment. There is simply no good
evidence to back their conclusion thatevidence to back their conclusion that
refugee populations anywhere are carryingrefugee populations anywhere are carrying
a major burden of clinically significanta major burden of clinically significant
mental ill health. As the answers to mymental ill health. As the answers to my
questions demonstrated, refugees seequestions demonstrated, refugees see
recovery as primarily something that mustrecovery as primarily something that must
459459
BRITISH JOURNAL OF P SYCHIATRYBRITISH JOURNAL OF PSYCHIATRY (2003), 183, 459^465(2003), 183, 459^465
CorrespondenceCorrespondence
EDITED BY STANLEY Z AMMITEDITED BY STANLEY Z AMMIT
ContentsContents && Anew dawnfor the yellowjournal?A new dawnfor the yellowjournal? && MentalhealthofrefugeesMental health of refugee s && EffectofEffectof
clozapineonmortalityclozapine on mortality && HealthcarecontactandsuicideHealthcarecontactand suicide && AssertiveoutreachinTynesideAssertiveoutreachinTyneside
&& Treating maternal depression?Treating maternal depression? && Cognitive ^behavioural therapy as atreatmentforCognitive^ behavioural therapyas a treatmentfor
psychosispsychosis && Efficacy of antidepressant medicationEfficacy of antidepressant medication && Integrity a nd bia s in a cademicIntegrity an d bias in a cademic
psychiatrypsychiatry && Go od pra ctice in publication of clinical trial resultsGoo d prac tice in publication of clinical trial results

CORRESP ONDENCECORRESPONDENCE
happen in their social worlds, not in thehappen in their social worlds, not in the
space between their ears.space between their ears.
Kleinman, A. (1987)Kleinman, A. (1987) Anthropology and psychiatry: theAnthropology andpsychiatry: the
role of culture in cross-cultural research on illness.role of culturein cross-cultural research on illness. BritishBritish
Journal of PsychiatryJournal of Psychiatry,, 151151, 447^454., 447^454.
Summer field, D. (199 9)Summerfield, D. (1999) A critique of sevenA critique of seven
assumptions behind psychological trauma programmesassumptions behind psychological trauma programmes
in war-affected areas.in war-affected areas. Social S cience and M edicin eSocial Science an d Me dicine ,, 4848,,
1449^1462.1449^1462.
__
(2002)(2002) Mental health of refugees and asylum-Mental health of refugees and asylum-
seekers.Commentary.seekers. Commentary. Advances in Psychiatric TreatmentA dvances in Psychiatric Treatment,,
88,247^248., 247^248.
Turner, S.W., Bowie,C. , Dunn, G.,Turner, S.W., Bowie, C., Dunn,G., et alet al (2003)(2003) MentalMental
health of Kosovan Albanian refugees in the UK.health of Kosovan Albanian refugeesin the UK. BritishBritish
Journal of PsychiatryJournal of Psychiatry,, 182182, 4 44^448., 4 44^448.
D. SummerfieldD. Summerfield Institute of P sychiatr y, King’sInstitu te o f Psyc hiatry, King’s
College, London SE 5 8 AF, UKCollege, London SE5 8AF,UK
Author’s reply :Author ’s reply: Newly arrived refugees willNewly arrived refugees will
often see their problems initially in termsoften see their problems initially in terms
of past experience (e.g. war-violence orof past experience (e.g. war-violence or
torture) rather than emotional impact.torture) rather than emotional impact.
They share a need for security and safety.They share a need for security and safety.
However, it would be illogical to concludeHowever, it would be illogical to conclude
that they are thereby free of psychopathol-that they are thereby free of psychopathol-
ogy. It is not a case of either one state orogy. It is not a case of either one state or
the other. Factors operating in differentthe other. Factors operating in different
domains frequently interact. This is thedomains frequently interact. This is the
situation here.situation here.
Interestingly, as many as 11.1% of 522Interestingly, as many as 11.1% of 522
subjects responded that they had a mentalsubjects responded that they had a mental
health problemhealth problem andand that they now wantedthat they now wanted
help (i.e. ‘Western’ treatment). We wouldhelp (i.e. ‘Western’ treatment). We would
expect help-seeking to increase in thoseexpect help-seeking to increase in those
with persisting symptoms, in line withwith persisting symptoms, in line with
experience in treatment services after anyexperience in treatment services after any
major incident.major incident.
To assert that significant psychopathol-To assert that significant psychopathol-
ogy is ‘uncommon’ is wrong. It implies thatogy is ‘uncommon’ is wrong. It implies that
civil war, rape and torture do notcivil war, rape and torture do not
have important psychopathological conse-have important psychopathological conse-
quences in significant numbers of people.quences in significant numbers of people.
This flies in the face of the evidence. It isThis flies in the face of the evidence. It is
reminiscent of the problems that Eitingerreminiscent of the problems that Eitinger
and others had when trying to justifyand others had when trying to justify
reparation for some concentration campreparation for some concentration camp
survivors on the basis of psychologicalsurvivors on the basis of psychological
injury. Surely we have moved on since then.injury. Surely we have moved on since then.
In this instance, we do not assert psy-In this instance, we do not assert psy-
chopathology on the basis of self-reportchopathology on the basis of self-report
measures. This would have been an over-measures. This would have been an over-
estimate as we demonstrated in our report.estimate as we demonstrated in our report.
An Albanian-speaking doctor undertookAn Albanian-speaking doctor undertook
semi-structured clinical interviews (insemi-structured clinical interviews (in
Albanian).Albanian).
Summerfield refers to additional dataSummerfield refers to additional data
in our survey. We wish to present a fac-in our survey. We wish to present a fac-
tual analysis of these. We asked an opentual analysis of these. We asked an open
question about respondents’ main con-question about respondents’ main con-
cerns. The responses to this question arecerns. The responses to this question are
in the respondents’ own words but if anxi-in the respondents’ own words but if anxi-
ety, tension, nervousness, stress or trem-ety, tension, nervousness, stress or trem-
bling are grouped together as likelybling are grouped together as likely
anxiety symptoms, these were in fact theanxiety symptoms, these were in fact the
most frequent of the first priority problemsmost frequent of the first priority problems
and overall were reported by 21% (of 509and overall were reported by 21% (of 509
respondents). Sleep disturbance wasrespondents). Sleep disturbance was
reported by 16%, depression, hopelessness,reported by 16%, depression, hopelessness,
sadness, mental problems and (poor)sadness, mental problems and (poor)
concentration by 8%. Many reportedconcentration by 8%. Many reported
additional somatic complaints or generaladditional somatic complaints or general
health problems, probably including a sig-health problems, probably including a sig-
nificant additional burden of psychologicalnificant additional burden of psychological
difficulty. Surprisingly, worries aboutdifficulty. Surprisingly, worries about
family and friends were reported by onlyfamily and friends were reported by only
17%. Concerns about work/economy17%. Concerns about work/economy
(6%) and school/language (3%) were(6%) and school/language (3%) were
infrequent.infrequent.
Rather than contradict the responses toRather than contradict the responses to
the more structured questions, answers tothe more structured questions, answers to
these open questions reinforce our morethese open questions reinforce our more
quantitative findings.quantitative findings.
Declaration of interestDeclaration of interest
This work was undertaken with fundingThis work was undertaken with funding
from the National Health Service (NHS)from the National Health Service (NHS)
Executive London, Research and Develop-Executive London, Research and Develop-
ment Programme. The views expressed inment Programme. The views expressed in
this publication are those of the authorsthis publication are those of the authors
and not necessarily those of the NHSand not necessarily those of the NHS
Executive or the Department of Health.Executive or the Department of Health.
S.W.TurnerS. W.Turner Traumatic Stress Clinic,Camden andTraumatic Stress Clinic,Camden and
Islington Mental Health and Social CareTrust, 73Islington Mental Health and Social CareTrust, 73
Charlotte Street, London W1T 4 PL,UKCharlotte Street, London W1T 4 PL,UK
Effect of clozapine on mortalityEffect of clozapine on mortality
DugganDuggan et alet al (2003) elegantly model the(2003) elegantly model the
effect of clozapine on suicide, and highlighteffect of clozapine on suicide, and highlight
that 53 lives could be saved each year if allthat 53 lives could be saved each year if all
patients with treatment-resistant schizo-patients with treatment-resistant schizo-
phrenia were offered clozapine treatment.phrenia were offered clozapine treatment.
The model does not, however, take intoThe model does not, however, take into
account the effect of clozapine on mortalityaccount the effect of clozapine on mortality
from causes other than suicide. Clozapine isfrom causes other than suicide. Clozapine is
associated with weight gain, diabetesassociated with weight gain, diabetes
mellitus, and increased mortality frommellitus, and increased mortality from
pulmonary embolism and other adversepulmonary embolism and other adverse
events in addition to the risk of agranulo-events in addition to the risk of agranulo-
cytosis (Walkercytosis (Walker et alet al, 1997). Fontaine, 1997). Fontaine et alet al
(2001) estimated mortality due to clozapine-(2001) estimated mortality due to clozapine-
associated weight gain using data from theassociated weight gain using data from the
Framingham Heart Study. They concludeFramingham Heart Study. They conclude
that the reduction in the suicide rate wouldthat the reduction in the suicide rate would
be almost entirely offset over 10 years bybe almost entirely offset over 10 years by
the increased mortality associated withthe increased mortality associated with
weight gain of 10 kg. Walkerweight gain of 10 kg. Walker et alet al (1997)(1997)
report that mortality from causes otherreport that mortality from causes other
than suicide is increased with clozapinethan suicide is increased with clozapine
treatment, although overall mortality istreatment, although overall mortality is
lower. To completely model the effect oflower. To completely model the effect of
clozapine on mortality, the effects of theclozapine on mortality, the effects of the
alternatives – active treatment and noalternatives – active treatment and no
treatment – on mortality, including suicidetreatment – on mortality, including suicide
and adverse events related to treatmentand adverse events related to treatment
with other antipsychotics, should bewith other antipsychotics, should be
included. These remarks do not detractincluded. These remarks do not detract
from the main point that clozapine is stillfrom the main point that clozapine is still
the most effective intervention for treat-the most effective intervention for treat-
ment-resistant schizophrenia, and mortalityment-resistant schizophrenia, and mortality
is only one outcome to be weighed in theis only one outcome to be weighed in the
overall risk–benefit analysis.overall risk–benefit analysis.
Declaration of interestDeclaration of interest
L.S.P. is a UK Medical Research CouncilL.S.P. is a UK Medical Research Council
Senior Research Fellow and has receivedSenior Research Fellow and has received
investigator-led charitable researchinvestigator-led charitable research
grants from Novartis, AstraZeneca,grants from Novartis, AstraZeneca,
Janssen and Sanofi-Synthelabo. O.H. andJanssen and Sanofi-Synthelabo. O.H. and
R.O. have conducted research throughR.O. have conducted research through
these investigator-led charitable researchthese investigator-led charitable research
grants.grants.
Duggan, A.,Warner, J., Knapp, M.,Duggan, A. ,Warner, J., Knapp, M., et alet al (2003)(2003)
Modelling the impact of clozapine on suicid e in patientsModelling the impact of clozapine on suicide in patients
with treatment-resistant schizophrenia in the UK.with treatment-resistant schizophrenia in the UK. BritishBritish
Journal of PsychiatryJournal of Psychiatry,, 182182, 505^508., 505^508.
Fontaine, K. R., Heo, M., Harrigan, E. P.,Fontaine, K. R., Heo, M., Harrigan, E. P., et alet al (2001)(2001)
Estimating the consequences of anti-psychotic inducedEstimating the consequencesof anti-psychoticinduced
weight gain on health and mortalityrate.weightgain on health and mortality rate. PsychiatryPsychiatry
ResearchResearch,, 101101, 277^288., 277^288.
Walker, A. M., Lanza, L. L ., Arellano, F.,Walker, A. M., Lanza, L. L ., Arellano, F., et alet al (19 9 7 )(19 97)
Mortality in current and former users of clozapine.Mortality in current an d former users of clozapine.
EpidemiologyEpidemiology,, 88,671^677., 671^677.
O. Howes, R . Ohlsen, L. S. PilowskyO. Howes, R. Ohlse n, L. S. Pilowsky DivisionDivision
of Psychological Medicine, In stitute of Psychiatry, Deof Psychological Medicine, Institute of Psychiatry, De
Crespigny Park, London SE 5 8AF,UKCrespigny Park,London SE5 8AF, UK
Health care contact and suicideHealth care contact and suicide
We read with interest the study by GairinWe read with interest the study by Gairin etet
alal (2003), which highlighted the suboptimal(2003), which highlighted the suboptimal
working relationship between the accidentworking relationship between the accident
and emergency department as a first pointand emergency department as a first point
of contact and psychiatric services. Thirty-of contact and psychiatric services. Thirty-
nine per cent of suicide victims got in con-nine per cent of suicide victims got in con-
tact with the accident and emergencytact with the accident and emergency
department at some point in the last yeardepartment at some point in the last year
of their lives and, according to the Nationalof their lives and, according to the National
Confidential Inquiry into Suicides inConfidential Inquiry into Suicides in
England and Wales, only a quarter of sui-England and Wales, only a quarter of sui-
cides are preceded by mental health servicecides are preceded by mental health service
contact in that same period.contact in that same period.
Although I appreciate the above point, IAlthough I appreciate the above point, I
still think that contact with primary ser-still think that contact with primary ser-
vices has an equal if not greater role to playvices has an equal if not greater role to play
460460

CORRESPONDENCECORRES PONDENCE
in reducing suicide, especially in those agein reducing suicide, especially in those age
groups whose members are less likely togroups whose members are less likely to
attend the accident and emergency depart-attend the accident and emergency depart-
ment at times of crisis, such as childrenment at times of crisis, such as children
and the elderly.and the elderly.
Duckworth & McBride (1996) haveDuckworth & McBride (1996) have
reported that 80% of elderly suicide victimsreported that 80% of elderly suicide victims
received no psychiatric referrals, andreceived no psychiatric referrals, and
according to Harwoodaccording to Harwood et alet al (2001), only(2001), only
15% of elderly people who died by suicide15% of elderly people who died by suicide
were under psychiatric care at the time ofwere under psychiatric care at the time of
death.death.
In our study, analysing coroners’In our study, analysing coroners’
inquests of 200 cases of suicide in old ageinquests of 200 cases of suicide in old age
in Cheshire, 1989–2001 (Salib & El-Nimr,in Cheshire, 1989–2001 (Salib & El-Nimr,
2003), the role of primary care was empha-2003), the role of primary care was empha-
sised. Interestingly, even those victims whosised. Interestingly, even those victims who
were known to psychiatric services still pre-were known to psychiatric services still pre-
ferred to contact their general practitionersferred to contact their general practitioners
(GPs) in the last few weeks before the fatal(GPs) in the last few weeks before the fatal
act.act.
One conclusion might be that peopleOne conclusion might be that people
whose GPs acknowledged their mentalwhose GPs acknowledged their mental
health problems and cared to refer themhealth problems and cared to refer them
to a specialist service were able to build ato a specialist service were able to build a
more meaningful therapeutic relationshipmore meaningful therapeutic relationship
with their doctors and readily contactedwith their doctors and readily contacted
them as a final desperate act in the lastthem as a final desperate act in the last
period of their lives. A well-trained GPperiod of their lives. A well-trained GP
can act not only as an effective first pointcan act not only as an effective first point
of contact but also a final one!of contact but also a final one!
Duckworth,G. & McBride,H. (1996)Duckworth,G. & McBride,H. (1996) Suicide in oldSuicide in old
age: a tragedy of neglect.age: a tragedy of neglect.Canadian Journal of PsychiatryCanadian Journal of Psychiatry,,
4141,217^222., 217^222.
Gairin, I., House, A. & Owens, D. (20 03)Gairin, I., House, A. & Owens, D. (2 003) Attend anceAttendance
at the accident and emergency department inthe yearat the accident a nd emergency depar tment in the year
before suicide: retrospective study.before suicide: retrospective study. British Journal ofBritish Journal of
PsychiatryPsychiatry,, 183183, 28^33.,28^33.
Har wood D., Hawt on, K ., Hop e, T.,Harwood D., Hawton, K., Hope, T., et alet al (2001)(20 01)
Psychiatric disorder and personality associated withPsychiatric disorder and personality associated with
suicide in older pe ople: a de scriptive a nd ca se ^ controlsuicide in older pe ople: a descriptive a nd ca se ^ control
study.study. International Journal of Geriatric PsychiatryInternational Journal of Geriatric Psychiatry,, 1616,,
155 ^ 15 6 .15 5 ^ 156.
Salib, E. & El-Nimr, G. (20 03)S alib, E. & El-Nimr,G. (2003) Gender and utilisationGender and utilisation
of psychiatric services in elderly suicide.of psychiatric s ervices in elderly suicide. InternationalInternational
Journal of Psychiatry in Clinical PracticeJournal of Psychiatryin Clinical Practice,inpress., in press.
G. El-NimrG. El-Nimr Neurob ehavioural Unit, Haywo odNeurobehavioural Unit, Haywo od
Hospital,High Lane, Burslem, Stoke- on-Trent,Hospital,High Lane, Burslem, Stoke- on-Trent,
Sta fford shire ST 6 7 AG, UKStaff ordshir e S T6 7 AG, UK
Assertive outreach inTynesideAssertive outreach inTyneside
PriebePriebe et alet al (2003) have questioned whether(2003) have questioned whether
the findings of the Pan-London Assertivethe findings of the Pan-London Assertive
Outreach Study can be generalised to asser-Outreach Study can be generalised to asser-
tive outreach services in the rest of the UK.tive outreach services in the rest of the UK.
Cornwall & Haveman (2003) evaluated theCornwall & Haveman (2003) evaluated the
Newcastle and North Tyneside assertiveNewcastle and North Tyneside assertive
outreach service using the same researchoutreach service using the same research
instruments as those in the Pan-Londoninstruments as those in the Pan-London
study, so direct comparisons can be made.study, so direct comparisons can be made.
After 17 months of operation, theAfter 17 months of operation, the
Newcastle and North Tyneside team wasNewcastle and North Tyneside team was
similar in size to the London mean (similar in size to the London mean (nn¼56)56)
with a score on the Dartmouth Assertivewith a score on the Dartmouth Assertive
Community Treatment Scale (TeagueCommunity Treatment Scale (Teague etet
alal, 1998) of 3.5 (medium fidelity to the, 1998) of 3.5 (medium fidelity to the
model). The team has care programmemodel). The team has care programme
approach (CPA) responsibility and smallapproach (CPA) responsibility and small
case-loads, operates out of office hourscase-loads, operates out of office hours
but without dedicated in-patient beds and,but without dedicated in-patient beds and,
at the time of evaluation, no consultantat the time of evaluation, no consultant
psychiatrist. It thus corresponds to apsychiatrist. It thus corresponds to a
Cluster B team in the Pan-London studyCluster B team in the Pan-London study
(Wright(Wright et alet al, 2003)., 2003).
Patient contact frequency and durationPatient contact frequency and duration
was higher than the London mean with anwas higher than the London mean with an
average face-to-face contact of 94 minutesaverage face-to-face contact of 94 minutes
per week. There was also a greater focusper week. There was also a greater focus
on patient engagement, with this being theon patient engagement, with this being the
primary focus in 33.1% of contacts.primary focus in 33.1% of contacts.
Engagement with the service in assertiveEngagement with the service in assertive
outreach patients was compared with a ran-outreach patients was compared with a ran-
dom sample of community mental healthdom sample of community mental health
team (CMHT) patients on enhanced CPA.team (CMHT) patients on enhanced CPA.
There was no difference in the level ofThere was no difference in the level of
engagement, raising the possibility that theengagement, raising the possibility that the
focus on engagement was having an impactfocus on engagement was having an impact
in a previously hard-to-engage patient group.in a previously hard-to-engage patient group.
Similar to the London study (BillingsSimilar to the London study (Billings
et alet al, 2003), team members were fairly, 2003), team members were fairly
satisfied with their jobs and most weresatisfied with their jobs and most were
not experiencing high levels of burnout.not experiencing high levels of burnout.
Compared with two local CMHTs, asser-Compared with two local CMHTs, asser-
tive outreach staff reported a higher leveltive outreach staff reported a higher level
of personal accomplishment, replicatingof personal accomplishment, replicating
the Pan-London study finding. Anotherthe Pan-London study finding. Another
common finding was that the assertive out-common finding was that the assertive out-
reach staff rated lack of support fromreach staff rated lack of support from
senior staff in the service as a greater sourcesenior staff in the service as a greater source
of stress than did CMHT staff. Team mem-of stress than did CMHT staff. Team mem-
bers also identified dual diagnosis as anbers also identified dual diagnosis as an
unmet training need.unmet training need.
Newcastle and North Tyneside patientsNewcastle and North Tyneside patients
were more likely than London patients towere more likely than London patients to
be White (86%be White (86% vv. 45%) or living alone. 45%) or living alone
(68%(68% vv. 52%). More surprisingly, they. 52%). More surprisingly, they
had significantly higher levels of alcoholhad significantly higher levels of alcohol
misuse or dependency (31%misuse or dependency (31% vv. 16%) and. 16%) and
drug misuse or dependency (40%drug misuse or dependency (40% vv..
20%). This reflects the fact that the20%). This reflects the fact that the
Newcastle and North Tyneside serviceNewcastle and North Tyneside service
may be managing a more severely ill patientmay be managing a more severely ill patient
group, with 93% having experience ofgroup, with 93% having experience of
compulsory admission and 70% havingcompulsory admission and 70% having
had an in-patient admission lasting morehad an in-patient admission lasting more
than 6 months. Using the mean MARCthan 6 months. Using the mean MARC
severity score (Huxleyseverity score (Huxley et alet al, 2000), asser-, 2000), asser-
tive outreach patients in Newcastle andtive outreach patients in Newcastle and
North Tyneside had significantly moreNorth Tyneside had significantly more
severe problems than the sample of localsevere problems than the sample of local
CMHT patients on enhanced CPA (7.4CMHT patients on enhanced CPA (7.4 vv..
3.4;3.4; tt¼6.35, d.f.6.35, d.f.¼83,83, PP550.01; mean0.01; mean
differencedifference¼4.0, 95% CI 2.7–5.3).4.0, 95% CI 2.7–5.3).
WrightWright et alet al (2003) have suggested that(2003) have suggested that
the London teams are assertive communitythe London teams are assertive community
treatment-like teams, but that the US asser-treatment-like teams, but that the US asser-
tive community treatment model may nottive community treatment model may not
easily translate to the UK context. Theeasily translate to the UK context. The
Newcastle and North Tyneside data con-Newcastle and North Tyneside data con-
trast with both the London data and datatrast with both the London data and data
from the UK700 study (Burnsfrom the UK700 study (Burns et alet al, 1999), 1999)
in terms of the strong focus on patientin terms of the strong focus on patient
engagement. Longitudinal studies areengagement. Longitudinal studies are
needed to determine whether this willneeded to determine whether this will
actually enhance engagement and whetheractually enhance engagement and whether
that improves outcome.that improves outcome.
Billings, J., Johnson, S., Bebbington, P.,Billings, J., Johnson, S., Bebbington, P., et alet al (2003)(2003)
Assertive outreach teams in London: staff exp eriencesAssertive outreach teams in London: staff experiences
and perceptions.Pan-London Assertive Outreach Study,and perceptions.Pan-London Assertive Outreach Study,
Part 2.Part 2. British Journal of PsychiatryBritish Journal of Psychiatry,, 183183,139^147.,139^147.
Burns,T., Creed, F., Fahy,T.,Burns, T., Creed, F., Fahy, T., et alet al (1999)(1999) IntensiveInten sive
versus standard case managementfor severe psychoticversus stand ard case management for severe psychotic
illness: a randomised trial.UK 70 0 Group.illness: a randomised trial.UK 700 Group. LancetLancet,, 353353,,
2185 ^ 218 9.2185^218 9.
Cornwall, P. L. & Haveman, J. (2003)Cornwall, P. L. & Haveman, J. (2003) An Evaluation ofAn Evaluation of
the Newcastle and NorthTyneside Assertive Outreachthe Newcastle and NorthTyneside Assertive Outreach
ServiceService. Newcastle uponTyne: University of Newcastle. Newcastle uponTyne: University of Newcastle
Scho ol of Neurolog y, Ne urobiology and Psychiatry.S chool o f Neurol ogy, Neurobio logy a nd Psyc hiatry.
Huxley, P., Reilly, S., Gater, R.,Huxley, P., Reilly, S., Gater, R., et alet al (200 0)(2000) MatchingMatching
resources to care: the acceptability, validity and inter-resources to care: the acceptability, validity and inter-
rater reliability of a new instrument to a ssess severerater reliabilityof a new instrument to assess severe
mental illness (MARC-1).mental illness ( MARC-1). So cial P sychia try and Ps ychia tricSocial P sychia try a nd Psychiatric
EpidemiologyEpidemiology,, 3535, 312^317., 312 ^317.
Priebe, S., Fakhoury,W.,Watts, J.,Priebe, S., Fakhoury,W.,Watts, J., et alet al (2003)(2003)
Assertive outreach teams in London: patientAssertive outreach teams in London: patient
characteristics and outcomes. Pan-London Assertivecharacteristics a nd outcomes. Pan-London A ssertive
Outrea ch Study, Part 3.Outrea ch Study, Part 3. British Journal of PsychiatryBritish Journal of Psychiatry,, 183183,,
148^154.148^154.
Teague, G. B., Bond,G. R. & Drake, R. E. (1998)Teague,G. B., Bond, G. R. & Drake, R. E. (1998)
Progr am f idelity in asser tive community treatment:Pro gram fidelity in a ssertive community treatment :
development and use of a mea sure.development and use of a measure. American Journal ofAmerican Journal of
OrthopsychiatryOrthopsychiatry,, 6868, 216^ 2 32 ., 216^232.
Wright, C., Burns,T., James, P.,Wright,C. , Burns,T., James, P., et alet al (2003)(20 03) AssertiveAssertive
outreach teams in London: models of op eration.Pan -outreach teams in London: models of op eration. Pan-
London Assertive Outreach Study,Part 1.London Assertive Outreach Study,Par t 1. British Jo urnalBritish Journal
of Psychiatryof Psychiatry,, 183183,132^138.,132^138.
P. L . C o r n w a l lP. L . C o r nw a ll Tees & North East YorkshireTees & North East Yorkshire
NHS Trust, Fern Lodge CMHC,153 High Street,NHS Trust, Fern Lodge CMHC,153 High Street,
Eston, MiddlesbroughTS6 9JQ,UKEston,MiddlesbroughTS6 9JQ,UK
Treating maternal depression?Treating maternal depression?
CooperCooper et alet al (2003) reported a randomised(2003) reported a randomised
trial with mothers with post-partumtrial with mothers with post-partum
depression that compared routine primarydepression that compared routine primary
care, non-directive counselling, cognitive–care, non-directive counselling, cognitive–
behavioural therapy (CBT) and psycho-behavioural therapy (CBT) and psycho-
dynamic therapy and found that psycho-dynamic therapy and found that psycho-
logical therapy improved maternal moodlogical therapy improved maternal mood
in the short term but the long-term effectin the short term but the long-term effect
was no better than spontaneous remission.was no better than spontaneous remission.
461461

CORRESP ONDENCECORRESPONDENCE
The trial was generally well done and theThe trial was generally well done and the
procedures reasonably described. However,procedures reasonably described. However,
the researchers did not, from a cognitive–the researchers did not, from a cognitive–
behavioural perspective, treat maternalbehavioural perspective, treat maternal
depression.depression. CooperCooper et alet al describe thatdescribe that
treatment used cognitive–behaviouraltreatment used cognitive–behavioural
techniques buttechniques but focused not on depressionfocused not on depression
but on the management of mother–infantbut on the management of mother–infant
interactions.interactions.
Several randomised placebo-controlledSeveral randomised placebo-controlled
trials have shown that CBT – when donetrials have shown that CBT – when done
properly – is an effective treatment forproperly – is an effective treatment for
post-partum depression (Holdenpost-partum depression (Holden et alet al,,
1989; Appleby1989; Appleby et alet al, 1997; Chabrol, 1997; Chabrol et alet al,,
2002) and for major depressive disorders2002) and for major depressive disorders
(Hollon(Hollon et alet al, 2002). There is an important, 2002). There is an important
relationship between post-partum depres-relationship between post-partum depres-
sion and mother–infant interactions but itsion and mother–infant interactions but it
is not, by any means, the entirety or evenis not, by any means, the entirety or even
the essence of post-partum depression.the essence of post-partum depression.
Although it is advisable to customise CBTAlthough it is advisable to customise CBT
to patients’ circumstances, exclusive use ofto patients’ circumstances, exclusive use of
one focus, such as mother–child inter-one focus, such as mother–child inter-
actions, is not a test of the therapy. If theactions, is not a test of the therapy. If the
goal is to change depression, one shouldgoal is to change depression, one should
treat depression. Thus, the title is inaccuratetreat depression. Thus, the title is inaccurate
and the discussion of the lack of effect ofand the discussion of the lack of effect of
CBT for maternal depression is misleading.CBT for maternal depression is misleading.
Appleby, L.,Warner, R.,Whitton, A.,Appleby, L.,Warner, R.,Whitton, A., et alet al (19 9 7 )(1 9 9 7) AA
controlled study of fluoxetine an d cognitive ^ beh aviouralcontrolled s tudy of f luoxetine and co gnitive^ b ehavioural
counselling in the treatmentof postnatal depression.counselling in the treatment of postnatal depression.
BMJBMJ,, 314314, 932^936.,932^936.
Chabrol, H., Teissedre, F., Saint-Jean, M.,Chabrol, H.,Teissedre, F., Saint-Jean, M., et alet al (2002)(2002)
Prevention and treatment of post-partum depression: aPrevention and treatment of post-par tum depression: a
controlled randomized study on women at risk.controlled randomized study on women at risk.
Psych ological MedicinePsychological Medicine ,, 3232,1039^1047., 1039^1047.
Cooper, P. J., Murray, L.,Wilson, A.,Cooper, P. J., Murray, L.,Wilson, A., et alet al (2003)(2003)
Controlled trial of the short- and long-term effect ofControlled trial of the short- and long-term effect of
psychological treatment of post-partum depression. I.psychological treatment of po st-partum d epression.I.
Impact on maternal mood.Impact on maternal mood. British Journal of PsychiatryBritish Journal of Psychiatry,,
182182, 412^419.,412^419.
Holden, J. M., Sagovsky, R. & Cox, J. L. (1989)Holden, J. M., Sagovsky, R. & Cox, J. L. (1989)
Counselling in a generalpractice setting: controlledCounselling in a general practice setting: controlled
study of health visitor intervention in treatment ofstudy of health visitor intervention in treatment of
postnatal depression.postnatal depression. BMJBMJ,, 298298, 223^226., 223^226.
Hollon, S. D.,Haman,K. L. & Brown,L. L. (2002)Hollon, S. D., Haman,K. L. & Brown, L. L. (2002)
Cognitiv e ^ beh avioral trea tment of dep ressio n. InCognitiv e ^ beha vioral tre atment o f de pres sion. In
Handbook of D epressionHandbook of Depression (e ds I. H. Gotlib & C. L.(eds I. H. Gotlib & C. L .
Hammen), pp. 383^4 03, NewYork: Guilford Press.Hammen), pp.383 ^403, NewYork:Guilford Press.
P. J . M c G r at hP. J . M c G r a t h Psychology Department,Psychology Department,
Dalhousie University, Halifax, and IWK HealthDalhousie University,Halifax, and IWKHealth
Centre, Halifax B 3H 4J1, Nova Scotia,CanadaCentre,Halifax B 3H 4J1, Nova Scotia,Canada
F. J. Elg a rF. J. Elgar School of Social Sciences,CardiffSchoolof Social Sciences,Cardiff
University,Cardiff,UKUniversity,Cardiff,UK
C. JohnstonC. Johnston Department of Psychology,Department of Psychology,
University of British Columbia,Vancouver, BritishUnive rsity o f Britis h Columbia ,Vanc ouver, British
Columbia, CanadaColumbia,Canada
D. J. A . DozoisD. J. A. D ozois Department of Psychology,Department of Psychology,
University of Western Ontario, London, Ontario,University of Western Ontario, London, Ontario,
CanadaCanada
S. ReynoS. Reyno Dalhousie University, Halifax, NovaDalhousie University, Halifax, Nova
Scotia,CanadaScotia,Canada
Authors’ reply:Authors’ reply: There are many cognitive–There are many cognitive–
behavioural therapies, with the precisebehavioural therapies, with the precise
form of the CBT shaped to the nature andform of the CBT shaped to the nature and
context of the particular disorder. So, forcontext of the particular disorder. So, for
example, CBT for panic disorder and CBTexample, CBT for panic disorder and CBT
for bulimia nervosa (Hawtonfor bulimia nervosa (Hawton et alet al, 1989),, 1989),
although sharing a basic orientation andalthough sharing a basic orientation and
broad therapeutic principles, are verybroad therapeutic principles, are very
different from one another. The form ofdifferent from one another. The form of
CBT in which we were interested had asCBT in which we were interested had as
its principal focus the mother–infantits principal focus the mother–infant
relationship and aspects of infant manage-relationship and aspects of infant manage-
ment. The reason for this was quite clear.ment. The reason for this was quite clear.
It is well established that many forms ofIt is well established that many forms of
treatment for post-partum depression,treatment for post-partum depression,
including counselling (Holdenincluding counselling (Holden et alet al, 1989),, 1989),
interpersonal psychotherapy (O’Harainterpersonal psychotherapy (O’Hara etet
alal, 2000), ‘cognitive–behavioural counsel-, 2000), ‘cognitive–behavioural counsel-
ling’ (Applebyling’ (Appleby et alet al, 1997) and fluoxetine, 1997) and fluoxetine
(Appleby(Appleby et alet al, 1997), have significant anti-, 1997), have significant anti-
depressant effects, but it has not been estab-depressant effects, but it has not been estab-
lished that any of these interventions has anlished that any of these interventions has an
impact on the quality of the mother–infantimpact on the quality of the mother–infant
relationship and child developmental pro-relationship and child developmental pro-
gress, both known to be compromised ingress, both known to be compromised in
the context of post-partum depression.the context of post-partum depression.
(The evidence for the efficacy of CBT in this(The evidence for the efficacy of CBT in this
context is, incidentally, less certain. Indeed,context is, incidentally, less certain. Indeed,
none of the three studies cited by Professornone of the three studies cited by Professor
McGrath and colleagues in support of thisMcGrath and colleagues in support of this
form of treatment delivered an orthodoxform of treatment delivered an orthodox
CBT; and one, in fact, was not a study ofCBT; and one, in fact, was not a study of
CBT at all, but of non-directive counsel-CBT at all, but of non-directive counsel-
ling.) We were interested in determiningling.) We were interested in determining
whether treatment that addressed thewhether treatment that addressed the
maternal role, as part of a wider supportivematernal role, as part of a wider supportive
therapeutic relationship, would have widertherapeutic relationship, would have wider
benefits. The form of CBT we investigatedbenefits. The form of CBT we investigated
was shaped by these concerns, and the dis-was shaped by these concerns, and the dis-
cussion refers explicitly to this treatmentcussion refers explicitly to this treatment
and is, therefore, wholly apposite.and is, therefore, wholly apposite.
In several respects the findings of ourIn several respects the findings of our
trial were not what we had expected andtrial were not what we had expected and
were, to us, disappointing. However, thewere, to us, disappointing. However, the
data were what they were, and it was ourdata were what they were, and it was our
job to try to understand them. When thejob to try to understand them. When the
first trials comparing CBT with interperso-first trials comparing CBT with interperso-
nal psychotherapy for major depressionnal psychotherapy for major depression
were published in the 1980s, British clinicalwere published in the 1980s, British clinical
psychology reverberated with the chunter-psychology reverberated with the chunter-
ings of the CBT faithful whose instinctiveings of the CBT faithful whose instinctive
reaction to the equivalence conclusion wasreaction to the equivalence conclusion was
to query the probity of the trial CBT thera-to query the probity of the trial CBT thera-
pists. With time, a more mature positionpists. With time, a more mature position
was evolved. The findings of our study,was evolved. The findings of our study,
along with the broad failure of the trialsalong with the broad failure of the trials
of preventive treatments for post-partumof preventive treatments for post-partum
depression, would seem to us to be causedepression, would seem to us to be cause
for pause and reflection, rather thanfor pause and reflection, rather than
instinctive defensiveness.instinctive defensiveness.
Appleby, L.,Warner, R.,Whitton, A.,Appleby, L.,Warner, R., Whitton, A. , et alet al (1997 )(19 9 7 ) AA
controlled s tudy of fluoxetine an d cognitive ^ beh aviouralcontrolled study of fluoxetine and cognitive ^ beh avioural
counselling in the treatmentof p ostnatal depression.counselling in the treatment of postnatal depression.
BMJBMJ,, 314314,932^936., 932^936.
Hawton, K. , Salkov skis, P., Kirk , J.,Hawton, K., Salkovskis, P., Kirk, J., et alet al (19 8 9 )(1 9 8 9)
Cognitive B ehaviourTherapy for Psychiatric Problems: ACognitive BehaviourTherapy for Psychiatric Problems: A
Practical GuidePractical Guide .Oxford:Oxford UniversityPress.. Oxford: Oxford University Press.
Holden, J. M., Sagovsky, R. & Cox, J. L. (1989)Holden, J. M., Sagovsky, R. & Cox, J. L. (1989)
Counsellingin a general practice setting: controlledCounselling in a general practice setting: controlled
study of health visitor inter vention in treatment ofstudy of he alth visitor intervention in treatment of
postnatal depression.postnatal depression. BMJBMJ,, 298298, 223^226., 223^226.
O’Hara, M., Stuart, S. & Gormon, L. L.,O’Hara, M., Stuart, S. & Gormon, L. L., et alet al
(200 0)(200 0) Efficacy of interpersonal psychotherapy forEfficacy of interpersonal psychotherapy for
postpartum depression.postpartum depression. Archives of General PsychiatryArchives of General Psychiatry,,
5757, 1039^1045., 1039^1045.
P. J.Cooper, L. MurrayP. J. Cooper, L. Murray Winnicott ResearchWinnicott Research
Unit , De par tmen t of Psyc holo gy, Univer sity ofUnit , De par tment of Psyc holo gy, Univer sity o f
Reading,Whiteknights, 3 Earley Gate, Reading,Reading,Whiteknights, 3 Earley Gate,Reading,
Berkshire RG6 6AL,UKBerkshire RG6 6AL,UK
Cognitive^ behavioural therapyCognitive^behavioural therapy
as a treatment for psychosisas a treatment for psychosis
McKenna (2003) comments that SenskyMcKenna (2003) comments that Sensky
et alet al (2000), in their trial of cognitive–(2000), in their trial of cognitive–
behavioural therapy (CBT)behavioural therapy (CBT) vv. befriending. befriending
for the treatment of schizophrenia, foundfor the treatment of schizophrenia, found
no advantage of CBT over befriending atno advantage of CBT over befriending at
the end of the 9-month intervention period.the end of the 9-month intervention period.
In his view, they were therefore not justifiedIn his view, they were therefore not justified
in making the claim that CBT is effective inin making the claim that CBT is effective in
treating negative as well as positive symp-treating negative as well as positive symp-
toms in schizophrenia. This assertion failstoms in schizophrenia. This assertion fails
to recognise the different mechanisms byto recognise the different mechanisms by
which CBT and drugs may benefit psy-which CBT and drugs may benefit psy-
chotic symptoms. While drugs are likelychotic symptoms. While drugs are likely
to produce a (relatively) immediate effectto produce a (relatively) immediate effect
in altering neurotransmitter pathways,in altering neurotransmitter pathways,
CBT (as is the case with other psychologicalCBT (as is the case with other psychological
therapies) is postulated to alter attachment-therapies) is postulated to alter attachment-
related memory (Gabbard, 2000) andrelated memory (Gabbard, 2000) and
develop an understanding of the illness.develop an understanding of the illness.
Cognitive–behavioural therapy utilisesCognitive–behavioural therapy utilises
skills which, if successful, can be main-skills which, if successful, can be main-
tained by the patient long after therapytained by the patient long after therapy
has ended. This would explain why Senskyhas ended. This would explain why Sensky
et alet al (2000) witnessed a non-significant(2000) witnessed a non-significant
difference between the control and inter-difference between the control and inter-
vention groups at the end of the inter-vention groups at the end of the inter-
vention period but a significant continuedvention period but a significant continued
improvement in those receiving CBT (andimprovement in those receiving CBT (and
not in those receiving befriending) at 9-not in those receiving befriending) at 9-
month follow-up. It would not be expectedmonth follow-up. It would not be expected
that drugs would maintain a benefitthat drugs would maintain a benefit
9 months after being stopped. Preliminary9 months after being stopped. Preliminary
results of a 5-year follow-up of the cohortresults of a 5-year follow-up of the cohort
of patients in this study indicate thatof patients in this study indicate that
these gains in the CBT group have beenthese gains in the CBT group have been
maintained (D. Turkington, personalmaintained (D. Turkington, personal
communication, 2001).communication, 2001).
462462

CORRESPONDENCECORRES PONDENCE
As a result of the distrust of psycho-As a result of the distrust of psycho-
logical approaches, studies of CBT (e.g.logical approaches, studies of CBT (e.g.
KuipersKuipers et alet al, 1997; Sensky, 1997; Sensky et alet al, 2000), 2000)
have invariably recruited patients whosehave invariably recruited patients whose
symptoms are ‘resistant’ to medication.symptoms are ‘resistant’ to medication.
The fact that these studies have still shownThe fact that these studies have still shown
significant improvement over either asignificant improvement over either a
control intervention or routine care iscontrol intervention or routine care is
testament to the greater benefits that mighttestament to the greater benefits that might
be demonstrated if the patients enrolled inbe demonstrated if the patients enrolled in
research were representative of those inresearch were representative of those in
clinical practice targeted for psychologicalclinical practice targeted for psychological
intervention.intervention.
In any case, surely the question isIn any case, surely the question is
not which is more effective, but hownot which is more effective, but how
both pharmacological and psychologicalboth pharmacological and psychological
approaches could be combined for greatestapproaches could be combined for greatest
effect.effect.
Declaration of interestDeclaration of interest
The author has received grants from theThe author has received grants from the
Wolfson Foundation and the AssociationWolfson Foundation and the Association
of Physicians of Great Britain and Northernof Physicians of Great Britain and Northern
Ireland for research into the durability ofIreland for research into the durability of
cognitive–behavioural therapy for thecognitive–behavioural therapy for the
treatment of schizophrenia.treatment of schizophrenia.
Gabbard,G. O. (2 000)Gabbard,G. O. (2 000) A neurobiologically informedA neurobiologically informed
perspective on psychotherapy.perspective on psychotherapy. British Journal ofBritish Journal of
PsychiatryPsychiatry,, 177177,117^122.,117^122.
Kuipers, E., Garety, P., Fowler, D.,Kuipers, E., Garety, P., Fowler, D., et alet al (19 97)(19 9 7 )
London^ East Anglia randomised controlled trial ofLondon^East Anglia randomised controlled trial of
cognitive^ behavioural therapy for psychosis:I: Effects ofcognitive ^behaviouraltherapy for psychosis: I:Effects of
the treatment phase.the treatment phase. British Journal of PsychiatryBritish Journal of Psychiatry,, 171171,,
319^3 27.319^ 32 7.
McKenna, P. J. (2003)McKenna, P. J. (20 03) In debate: Is cognitive^In debate: Is cognitive^
behavioural therapy a worthwhile treatment forbehavioural therapy a worthwhile treatment for
psychosis (against)?psychosis (against)? British Journal of PsychiatryBritish Journal of Psychiatry,, 182182,,
477^479.477^479.
Sensky,T.,Turkington, D., Kingdon,D.,Sensky,T.,Turkington, D., Kingdon, D., et alet al (2000)(2000) AA
randomized controlled trial of cognitive^ behaviouralrandomized controlled trial of cognitive^ behavioural
therapy for persistent symptoms in schizophreniathera py for p ersistent symptoms in schizophrenia
resista ntto me dication.re sistant to medication. Archives of General PsychiatryArchives of General Psychiatry,, 5757,,
165 ^ 17 2.165^172.
N. SamarasekeraN. Samarasekera NorthTyneside Hospital,RakeNorthTyneside Hospital,Rake
Lane,North Shields,Tyne and Wear NE29 8NH,UKLane,North Shields,Tyne and Wear NE29 8NH,UK
Thank you for the debate on CBT andThank you for the debate on CBT and
schizophrenia (Turkington/McKenna, 2003).schizophrenia (Turkington/McKenna, 2003).
I would like to make the following points.I would like to make the following points.
First, CBT is not a single treatment – itFirst, CBT is not a single treatment – it
contains many complex components andcontains many complex components and
skills, and therapist variables must be anskills, and therapist variables must be an
essential issue for careful evaluation as withessential issue for careful evaluation as with
all psychological therapies.all psychological therapies.
Second, befriending fares significantlySecond, befriending fares significantly
better than ‘treatment as usual’ in muchbetter than ‘treatment as usual’ in much
CBT research. McKenna dismisses this asCBT research. McKenna dismisses this as
placebo or ‘special treatment’. The factplacebo or ‘special treatment’. The fact
of such significant improvement fromof such significant improvement from
befriending says something very seriousbefriending says something very serious
about treatment as usual. Why should thoseabout treatment as usual. Why should those
suffering from psychosissuffering from psychosis notnot receive specialreceive special
treatment? The finding points to the needtreatment? The finding points to the need
for more consideration of the (poorlyfor more consideration of the (poorly
termed) ‘non-specific factors in psycho-termed) ‘non-specific factors in psycho-
therapy’ – factors clearly not treated astherapy’ – factors clearly not treated as
sufficiently important in basic care insufficiently important in basic care in
psychosis (Paley & Shapiro, 2002).psychosis (Paley & Shapiro, 2002).
Third, in the SenskyThird, in the Sensky et alet al (2000) trial(2000) trial
quoted, CBT patients maintained their (sig-quoted, CBT patients maintained their (sig-
nificant) clinical improvement at follow-up,nificant) clinical improvement at follow-up,
whereas the befriending controls fell backwhereas the befriending controls fell back
towards previous levels. It seems that CBTtowards previous levels. It seems that CBT
gives the patients a thinking structure togives the patients a thinking structure to
help manage some of their symptoms inhelp manage some of their symptoms in
the longer term.the longer term.
Fourth, many people believe that youFourth, many people believe that you
cannot treat persons with psychosis as ifcannot treat persons with psychosis as if
they were suffering from something suchthey were suffering from something such
as diabetes, for which a single remedy likeas diabetes, for which a single remedy like
insulin might be sufficient. McKenna’s pro-insulin might be sufficient. McKenna’s pro-
nouncement on randomised controllednouncement on randomised controlled
trials is, therefore, open to serious question-trials is, therefore, open to serious question-
ing. The need adapted approach is theing. The need adapted approach is the
antithesis of the randomised controlled trialantithesis of the randomised controlled trial
method. In the former, the treatment ismethod. In the former, the treatment is
individualised and intentionally differentindividualised and intentionally different
(qualitatively and quantitatively) from one(qualitatively and quantitatively) from one
case to another and may well change overcase to another and may well change over
time. A randomised controlled trial, equallytime. A randomised controlled trial, equally
intentionally, eliminates individuality in theintentionally, eliminates individuality in the
treatment. Because the idea of relationshipstreatment. Because the idea of relationships
can be especially disturbing to patients withcan be especially disturbing to patients with
psychosis, psychological therapies can bepsychosis, psychological therapies can be
seen by patients as threatening; therefore,seen by patients as threatening; therefore,
the therapy has to be very carefullythe therapy has to be very carefully
‘administered’ – individually and flexibly.‘administered’ – individually and flexibly.
Fifth, there are other outcome measure-Fifth, there are other outcome measure-
ments at least as important as psychiatricments at least as important as psychiatric
symptoms. The experience of treatment issymptoms. The experience of treatment is
very important, as well as quality of lifevery important, as well as quality of life
measurements. Turkington emphasises themeasurements. Turkington emphasises the
high take-up rate of CBT, far higher thanhigh take-up rate of CBT, far higher than
uptake of medication in psychosis.uptake of medication in psychosis.
Sixth, thank goodness for CBT, justSixth, thank goodness for CBT, just
one of several ways for practitioners toone of several ways for practitioners to
re-discover some tools that enable them tore-discover some tools that enable them to
relate to patients with psychosis. McCaberelate to patients with psychosis. McCabe
et alet al (2002) show how uncomfortable(2002) show how uncomfortable
ordinary psychiatrists are without suchordinary psychiatrists are without such
tools when engaging with patients whentools when engaging with patients when
the latter want to discuss symptoms.the latter want to discuss symptoms.
Seventh, CBT and psychodynamicSeventh, CBT and psychodynamic
approaches overlap to a degree, at least asapproaches overlap to a degree, at least as
practised by Turkington (Martindale,practised by Turkington (Martindale,
1998; Turkington & Siddle, 1998). Much1998; Turkington & Siddle, 1998). Much
has changed in psychodynamic therapyhas changed in psychodynamic therapy
since the flawed studies of old. Modernsince the flawed studies of old. Modern
psychodynamic approaches to psychosispsychodynamic approaches to psychosis
have a much more flexible technique inhave a much more flexible technique in
engaging patients, and a greater and broad-engaging patients, and a greater and broad-
er appreciation of mental mechanisms iner appreciation of mental mechanisms in
psychosis.psychosis.
Finally, relationship approaches inFinally, relationship approaches in
psychosis need encouragement, supportpsychosis need encouragement, support
and research. All psychiatrists need basicand research. All psychiatrists need basic
training in engaging with patients with psy-training in engaging with patients with psy-
chosis. Research indicates that befriendingchosis. Research indicates that befriending
might be a good place to start, but it ismight be a good place to start, but it is
clearly not so easy – as the outcome ofclearly not so easy – as the outcome of
‘treatment as usual’ indicates.‘treatment as usual’ indicates.
Declaration of interestDeclaration of interest
B.M. is Chair of ISPS (International SocietyB.M. is Chair of ISPS (International Society
for the Psychological Treatments offor the Psychological Treatments of
Schizophrenia) UK, a network the mainSchizophrenia) UK, a network the main
objective of which is to promote psycho-objective of which is to promote psycho-
logical approaches to psychosis (treatment,logical approaches to psychosis (treatment,
education and research).education and research).
Martindale, B. (1998)Martindale, B. (1998) Commentary (on CognitiveCommentary (on Cognitive
therapy for the treatment of delusions).therapy for the treatment of delusions). Advances inAdvances in
PsychiatricTreatmentPsychiatricTreatment,, 44, 241^242., 241^242.
McCabe, R., Heath,C., Burns,T. (20 02)McCabe, R., Heath,C., Burns,T. (2002) EngagementEngagement
of patients with psychosis in the consultation:of patients with psychosis in the consultation:
conversation analytic study.conversation analytic study. BMJBMJ,, 325325,1148^1151.,1148^1151.
Paley, A. & Shapiro, A. (2002)Paley, A. & Shapiro, A. (2002) Lessons fromLesson s from
psychotherapy research for psychological interventionspsychotherapy research for psychological interventions
for people with schizophrenia .for people with schizophrenia. Psychology andPsychology and
Psychotherapy:Theory, Research and PracticePsychotherapy:Theory, Research and Practice,, 7575, 5^17., 5^17.
Sensky,T.,Turkington, D., Kingdon,D.,Sensky,T.,Turkington, D., Kingdon, D., et alet al (2000)(20 00) AA
randomized controlled trial of cognitive^ behaviouralrandomized controlled trial of cognitive ^behavioural
therapy for persistent symptoms in schizophreniatherapy for persistent symptoms in schizophrenia
resistant to me dication.re sistant to me dication. Archives of General PsychiatryArchives of General Psychiatry,, 5757,,
165^172.165 ^ 172 .
Turkington,D.,Siddle,R.(1998)Turkington,D.,Siddle,R.(1998)Cognitive therapy forCognitive therapy for
the treatment of delusions.the treatment of delusions. Advances in PsychiatricA dvances in Psychiatric
TreatmentTreatment,, 44, 235^241., 235^241.
__
/McKenna, P. (2003)/McKenna, P. (20 03) In debate:Is cognitive^In debate: Is cognitive^
behavioural therapy a worthwhile treatment forbehavioural therapy aworthwhile treatment for
psychosis?psychosis? British Journal of PsychiatryBritish Journal of Psychiatry,, 182182, 477^479.,477^479.
B. MartindaleB. Martindale Psychotherapy De partment, JohnPsychother apy D epartm ent, John
Conolly Wing,West London Mental Health NHSConolly Wing,West London Mental Health NHS
Trust,Uxbridge Road, Southall UB13EU,UKTrust,Uxbridge Road,Southall UB13EU,UK
Efficacy of antidepressantEfficacy of antidepressant
medicationmedication
The debate between Parker and AndersonThe debate between Parker and Anderson
& Haddad (2003) neatly summarised& Haddad (2003) neatly summarised
contemporary thinking on the question ofcontemporary thinking on the question of
antidepressant effect. It was a pity, though,antidepressant effect. It was a pity, though,
that they provided no discussion of anythat they provided no discussion of any
historical perspective. The wonderfullyhistorical perspective. The wonderfully
clear account provided by David Healyclear account provided by David Healy
(2002), for instance, shows how the mar-(2002), for instance, shows how the mar-
keting tail of psychopharmaceuticals nowketing tail of psychopharmaceuticals now
often wags the entire dog. The process byoften wags the entire dog. The process by
which this came about has been gatheringwhich this came about has been gathering
momentum since the early 1960s. Healymomentum since the early 1960s. Healy
explores its various causes and corollariesexplores its various causes and corollaries
463463

CORRESP ONDENCECORRESPONDENCE
in detail. It is not, he argues, due to anyin detail. It is not, he argues, due to any
uniquely pernicious qualities of druguniquely pernicious qualities of drug
companies since similar trends can be seencompanies since similar trends can be seen
in relation to some other types of therapy.in relation to some other types of therapy.
If this additional, temporal dimensionIf this additional, temporal dimension
had been taken into account, one suspectshad been taken into account, one suspects
that Gordon Parker might have placedthat Gordon Parker might have placed
greater emphasis on one of the factors thatgreater emphasis on one of the factors that
he identified as contributing to the currenthe identified as contributing to the current
situation: namely that ‘ ‘‘depression’’ issituation: namely that ‘ ‘‘depression’’ is
currently modelled as a single entity,currently modelled as a single entity,
varying only in severity’ (p. 102). The termvarying only in severity’ (p. 102). The term
‘depression’ is thus semantically equivalent‘depression’ is thus semantically equivalent
nowadays to ‘abdominal pain’, not tonowadays to ‘abdominal pain’, not to
‘appendicitis’ or ‘peptic ulcer’. If trials of‘appendicitis’ or ‘peptic ulcer’. If trials of
an antacid, say, were undertaken onan antacid, say, were undertaken on
patients selected for ‘abdominal pain’ thepatients selected for ‘abdominal pain’ the
results obtained would sometimes beresults obtained would sometimes be
favourable, sometimes not. Debate over antfavourable, sometimes not. Debate over ant--
acid usefulness would exactly parallel thatacid usefulness would exactly parallel that
over the effectiveness of antidepressants.over the effectiveness of antidepressants.
How did we get into this situation? ItHow did we get into this situation? It
seems likely that a lot of the blame can beseems likely that a lot of the blame can be
laid at the door of DSM–III (Americanlaid at the door of DSM–III (American
Psychiatric Association, 1980), which ex-Psychiatric Association, 1980), which ex-
plicitly aimed for reliability of diagnosis.plicitly aimed for reliability of diagnosis.
Unhappily, there was an implicit downside.Unhappily, there was an implicit downside.
The state of the art in psychiatry, whenThe state of the art in psychiatry, when
DSM–III was under development, was suchDSM–III was under development, was such
that reliability could be attained only at thethat reliability could be attained only at the
expense of validity. Partly as a consequenceexpense of validity. Partly as a consequence
of choices that were made then, this prob-of choices that were made then, this prob-
lem still remains. It is no good blaminglem still remains. It is no good blaming
the failings of clinical trials, the machina-the failings of clinical trials, the machina-
tions of drug companies, the uselessness oftions of drug companies, the uselessness of
antidepressants or reporting bias, for ourantidepressants or reporting bias, for our
predicament. The main fault lies in the con-predicament. The main fault lies in the con-
sequences of a bad choice of diagnostic sys-sequences of a bad choice of diagnostic sys-
tem, made by our predecessors for whattem, made by our predecessors for what
seemed, at the time, good reasons. The re-seemed, at the time, good reasons. The re-
medy must lie primarily in seeing DSMmedy must lie primarily in seeing DSM
for the hindrance that it is, and one dayfor the hindrance that it is, and one day
replacing it with a system that separatesreplacing it with a system that separates
the ‘peptic ulcers’ from the ‘appendicitises’.the ‘peptic ulcers’ from the ‘appendicitises’.
American Psychiatric Association (1980)American Psychiatric Association (1980) Diagnos ticDiagno stic
and Statistical Manual of Mental Disordersand Statist ical M anual o f Mental Dis order s (3rd edn)(3rd edn)
(DSM^ III).Washington,DC: APA.(D SM ^ III). Washin gton, D C: APA.
Healy, D. (2 002)Healy, D. (2 002) The Creation of PsychopharmacologyThe Creation of Psychopharmacology..
Cambridge,MA: Harvard University Press.Cambridge, MA: Harvard University Press.
Parker,G./Anderson I. M. & Haddad, P. (2003)Parker, G./Anderson I. M. & Haddad, P. (2003) InIn
debate: Clinical trials of antidepressants are producingdebate: Clinical trials of antidepressants are producing
meaningless results.meaningless results. British Journal of PsychiatryBritish Journal of Psychiatry,, 183183,,
102 ^10 4.10 2^ 104.
C. M. H. NunnC. M. H. Nunn Barfad Beag, Ardfern, ArgyllBarfadBeag,Ardfern,Argyll
PA 31 8 Q N, UKPA 3 1 8 Q N, UK
Integrity and bias in academicIntegrity and bias in academic
psychiatrypsychiatry
The illuminating discussion by Drs HealyThe illuminating discussion by Drs Healy
and Thase (2003) focuses on the magnitudeand Thase (2003) focuses on the magnitude
of the pharmaceutical industry’s influenceof the pharmaceutical industry’s influence
on academic medicine. However, thison academic medicine. However, this
discussion needs to be taken a step further,discussion needs to be taken a step further,
and evaluated in relation to patient care.and evaluated in relation to patient care.
From my perspective, the central questionFrom my perspective, the central question
is: ‘Does the influence of the pharmaceuti-is: ‘Does the influence of the pharmaceuti-
cal industry on academia result in biasedcal industry on academia result in biased
knowledge?’ Professionals are charged withknowledge?’ Professionals are charged with
serving the best interests of patients/clients.serving the best interests of patients/clients.
In order to accomplish this, professionalsIn order to accomplish this, professionals
need unbiased knowledge that can lead toneed unbiased knowledge that can lead to
an accurate risk–benefit assessment andan accurate risk–benefit assessment and
serve to guide clinical decisions. If availableserve to guide clinical decisions. If available
knowledge is biased, decisions will beknowledge is biased, decisions will be
affected and clients will suffer accordingly.affected and clients will suffer accordingly.
The frequently touted disclosure of poten-The frequently touted disclosure of poten-
tial conflicts of interest in academic publi-tial conflicts of interest in academic publi-
cations is a small step in addressing thecations is a small step in addressing the
much more difficult question of whethermuch more difficult question of whether
existing knowledge is biased. Recognisingexisting knowledge is biased. Recognising
potential bias is an initial step towardspotential bias is an initial step towards
assessing and removing it from the collect-assessing and removing it from the collect-
ive knowledge used to make decisions inive knowledge used to make decisions in
practice. For example, registering clinicalpractice. For example, registering clinical
trials is an approach to reducing publica-trials is an approach to reducing publica-
tion bias (Dickersin & Rennie, 2003).tion bias (Dickersin & Rennie, 2003).
Meta-analysis is an approach to removingMeta-analysis is an approach to removing
bias from expert reviews of the literaturebias from expert reviews of the literature
(Beaman, 1991), although expert reviews(Beaman, 1991), although expert reviews
still retain influence in the formulation ofstill retain influence in the formulation of
some practice guidelines (e.g. Americansome practice guidelines (e.g. American
Psychiatric Association, 1997). As the fieldPsychiatric Association, 1997). As the field
moves more towards the implementation ofmoves more towards the implementation of
evidence-based practice guidelines, theevidence-based practice guidelines, the
importance of removing bias remainsimportance of removing bias remains
central to providing optimal clinical care.central to providing optimal clinical care.
If the extensive financial arrangementsIf the extensive financial arrangements
between industry and academia resulted inbetween industry and academia resulted in
no bias to knowledge, I would probablyno bias to knowledge, I would probably
agree with Dr Thase that no new policiesagree with Dr Thase that no new policies
are necessary to ‘safeguard our integrity’are necessary to ‘safeguard our integrity’
(p. 390). However a recent systematic(p. 390). However a recent systematic
review and meta-analysis of evidence bear-review and meta-analysis of evidence bear-
ing on this question found ‘strong and con-ing on this question found ‘strong and con-
sistent evidence . . . that industry-sponsoredsistent evidence . . . that industry-sponsored
research tends to draw pro-industry conclu-research tends to draw pro-industry conclu-
sions’ (Bekelmansions’ (Bekelman et alet al, 2003: p. 463). The, 2003: p. 463). The
question now becomes, ‘What safeguardsquestion now becomes, ‘What safeguards
should be implemented to remove this biasshould be implemented to remove this bias
from the knowledge that guides clinicalfrom the knowledge that guides clinical
practice (cf. Bodenheimer, 2000)?’ Com-practice (cf. Bodenheimer, 2000)?’ Com-
mitment to our patients’ well-being requiresmitment to our patients’ well-being requires
that we act from this integrity.that we act from this integrity.
American Psychiatric Association (1997)American Psychiatric Association (1997) PracticePractice
guidelines for the treatment of patients withguidelines for the treatment of patients with
schizophrenia.schizophrenia . American Journal of PsychiatryAmerican Journal of Psychiatry,, 154154, 1^63.,1^63.
Beaman, A. I. (1991)Beaman, A. I. (1991) An empirical comparison ofmeta-An empirical comparison of meta-
analytic and traditional reviews.analytic and traditionalreviews. Personality and SocialPerso nality an d So cial
Psychology BulletinPsychology Bulletin,, 1717,252^257., 252^257.
Bekelman, J. E., Li,Y. & Gross,C. P. (2003)Bekelman, J. E., Li,Y. & Gross, C. P. (2003) Scope andScope and
impact of financial conflicts of interest in biomedicalimpact of financial conflicts of interest in biomedical
research: a systematic review.re search: a systematic review. JAMAJAMA,, 289289,454^4 65., 454^465.
Bodenheimer,T. (200 0)Bodenheimer,T. (2000) Uneasy alliance ^ clinicalUne asy alliance ^ clinic al
investigators and the ph armaceutical industry.investigators and the pharmaceutical industry. NewNew
England Journal of MedicineEngland Journal of Medicine,, 342342, 1539^1544.,1539^1544.
Dickersin,K. & Rennie, D. (2003)Dickersin, K. & Rennie, D. (2003) Registering clinicalRegistering clinical
trials.trials. JAMAJA MA,, 290290, 516^52 3.,516^523.
Healy, D./Thase, M. E. (2 003)Healy, D./Thase, M. E. (20 03) Is academic psychiatryIs academic psychiatry
for sale ?for sale? British Journal of PsychiatryBritish Journal of Psychiatry,, 182182,388^390., 388 ^390.
J. R. BolaJ. R. Bola School of Social Work,UniversityofSchool of Social Work,Universityof
Southern California,Los Angeles,CA 90089^0411,Southern California,Los Angeles,CA 90089^0411,
USAUSA
Good practice in publicationGood practice in publication
of clinical trial resultsof clinical trial results
As the name implies, ghostwriting is oftenAs the name implies, ghostwriting is often
hard to detect, so Healy & Cattell (2003)hard to detect, so Healy & Cattell (2003)
have made a valuable contribution to ourhave made a valuable contribution to our
understanding of this important subject byunderstanding of this important subject by
their measurement and thoughtful analysistheir measurement and thoughtful analysis
of the practice. It is also refreshing to seeof the practice. It is also refreshing to see
such a balanced account which discussessuch a balanced account which discusses
both the benefits and potential dangers ofboth the benefits and potential dangers of
ghostwriting.ghostwriting.
Perhaps their most alarming obser-Perhaps their most alarming obser-
vation is that the papers sponsored by thevation is that the papers sponsored by the
manufacturer reported ‘universally positivemanufacturer reported ‘universally positive
results’, which implies the existence ofresults’, which implies the existence of
considerable publication bias. Such distor-considerable publication bias. Such distor-
tions to the published literature probablytions to the published literature probably
exist across all therapeutic areas and haveexist across all therapeutic areas and have
been shown to distort the outcomes ofbeen shown to distort the outcomes of
meta-analyses (Tramermeta-analyses (Trame
`ret alet al, 1997) and, 1997) and
therefore to have serious implications fortherefore to have serious implications for
evidence-based medicine (Melanderevidence-based medicine (Melander et alet al,,
2003).2003).
Readers may be interested to know thatReaders may be interested to know that
guidelines have recently been publishedguidelines have recently been published
which call on pharmaceutical companieswhich call on pharmaceutical companies
to endeavour to publish results of all clinicalto endeavour to publish results of all clinical
trials of marketed products (Wagertrials of marketed products (Wager et alet al,,
2003). The guidelines also provide recom-2003). The guidelines also provide recom-
mendations to ensure that professional med-mendations to ensure that professional med-
ical (ghost)writers are used appropriately soical (ghost)writers are used appropriately so
that their contribution can be beneficialthat their contribution can be beneficial
rather than harmful. The Good Publicationrather than harmful. The Good Publication
Practice (GPP) for pharmaceutical compa-Practice (GPP) for pharmaceutical compa-
nies guidelines have been publicly endorsednies guidelines have been publicly endorsed
by several drug companies and communica-by several drug companies and communica-
tions agencies. Further details are availabletions agencies. Further details are available
at http://www.gpp-guidelines.org.at http://www.gpp-guidelines.org.
Declaration of interestDeclaration of interest
E.W. is an author of the GPP for pharma-E.W. is an author of the GPP for pharma-
ceutical companies guidelines. He alsoceutical companies guidelines. He also
makes a living as a freelance medical writer,makes a living as a freelance medical writer,
which sometimes involves ghostwriting.which sometimes involves ghostwriting.
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CORRESPONDENCECORRES PONDENCE
Healy, D. & Cattell, D. (2003)Healy, D. & Cattell, D. (2003) Inter face betweenInterf ace b etween
authorship, industry and science in the domainauthorship, industry and science in the domain
of therapeutics.of therapeutics. British Journal of PsychiatryBritish Journal of Psychiatry,, 183183,,
22^27.22^27.
Melander, H., Ahlqvist-Rastad, J., Meijer,G.,Melander, H., Ahlqvist-Rastad, J., Meijer,G., et alet al
(2003)(2 003) Evidence b(i)ased medicine ^ selectiveEvidence b(i)ased medicine ^ selective
repor ting from studies sp onsored by pharmaceuticalreporting from studies sponsored by pharmaceutical
industry: review of studies innew drugapplications.industry: reviewof studies in new drug applications. BMJBMJ,,
326326, 1171^1173., 1171^ 1173.
Tramer, M. R., Reynolds, J. M., Moore, R. A.,Trame
'r, M. R., Reynolds, J. M., Moore, R. A.,
et alet al (19 9 7)(19 9 7 ) Impact of cover t duplicate publicationImpact of covert duplicate publication
on meta-analysis: a case study.on meta-analysis: a case study. BMJBMJ,, 315315,,
635^640.635^640.
Wager, E., Field, E. A. & Grossman, L. (20 03)Wager, E., Field, E. A. & Grossman, L. (20 03)
Goo d Publication Practice for pharmaceuticalGood Publication Practice for pharmaceutical
companies.companies. Current Medical Research and OpinionCurrent M edical R esearch and O pinion,,
1919,149^154.,149^154.
E.WagerE.Wager Sideview, 19 Station Road,PrincesSideview, 19 Station Road,Princes
Risborough HP27 9DE,UKRisborough HP27 9DE, UK
One hundred years agoOne hundred years ago
Psychological medicinePsychological medicine
Friday, August 1st. Dr. F. W. Mott (Lon-Friday, August 1st. Dr. F. W. Mott (Lon-
don) opened a discussion ondon) opened a discussion on Syphilis as aSyphilis as a
Cause of InsanityCause of Insanity . . . A number of statisti-. . . A number of statisti-
cal data were cited by Dr. Mott fromcal data were cited by Dr. Mott from
different observers and it was shown thatdifferent observers and it was shown that
the most recent observations concurredthe most recent observations concurred
in assigning the first place among the etio-in assigning the first place among the etio-
logical factors to syphilis. Juvenile generallogical factors to syphilis. Juvenile general
paralysis was almost invariably found toparalysis was almost invariably found to
be a result of congenital syphilis and inbe a result of congenital syphilis and in
20 per cent. of the cases observed it was20 per cent. of the cases observed it was
found that the fathers of the patients hadfound that the fathers of the patients had
had general paralysis. Dr. Mott concludedhad general paralysis. Dr. Mott concluded
by adopting, for the purposes of raising aby adopting, for the purposes of raising a
discussion, the thesis, ‘‘No syphilis, nodiscussion, the thesis, ‘‘No syphilis, no
general paralysis’’.general paralysis’’.
REFERENCEREFERENCE
LancetLancet,23August1902,525.,23August1902,525.
Rese arched by Henry Rollin, Emeritus ConsultantResearched by Henry Rollin,Emeritus Consultant
Psychiatrist, Horton Hospit al, Epsom, SurreyPsychiatrist, Ho rton Ho spital, Epsom, Surrey
465465