What really happens

Australian & New Zealand Journal of Psychiatry, 48(10) The care of those disabled by severe and persistent mental illness involves much more than antipsychotics and intermittent contact by clinical staff. Such people are also helped by having access to general medical care, housing, human contact, community and domiciliary services, income security and employment. But these resources, coming as they do from governmental and non-governmental agencies separate from mental health, will act in a haphazard and fragmented manner if not coordinated. Yet they rarely are. In an exemplary undertaking in health services research, Whiteford et al. (2014) in this issue ask if intersectoral linkage really does improve the outcome. For this, they have examined no fewer than 40 studies. They try to identify what promotes or hinders the sought-after coordination. The context of this magisterial work is that in 2011, some $550 million was allocated by the Australian Government (prior to the Election) to improve between-service partnerships. To this writer, a particular merit of the study is how the authors dissect their data to identify what meets with success or failure, and indeed how either of these is to be recognised. It seems that where the agencies are well-harnessed together, they themselves function better, as well as bringing patient benefit according to some hard indicators. Exceptions to success were also identified, which is always useful in bringing about real change. Also in this issue, Stanley and Laugharne (2014) present algorithms for the management of physical health problems that may lead to better care of people with severe mental illness. While there is full recognition that much greater medical morbidity exists in this population in all countries, its actual recognition in clinical practice invariably lags, followed inevitably by medical neglect. In an era where human rights are accorded such prominence, surely here is an indisputable example of inequality? In addition to the familiar components of general health assessment, the authors explicitly add a physical examination to routine assessment. Would that this became standard practice. Stanley and Laugharne go further than ascertainment of pathology in that their algorithms propose what specific action should be taken where abnormality is detected. From a touch of despondency we move with a whiff of excitement to another paper in this issue on functional magnetic resonance imaging (fMRI) studies. Scognamiglio and Houenou (2014), writing from an INSERM Unit in France (the equivalent of NHMRC, ARC or MRC), introduce us to a relatively new way of examining the brain with neuroimaging. These authors do not have their own data, but synthesise 21 fMRI studies of the brains, not of people with schizophrenia, but of their relatives who, so far, had not developed that syndrome. Their meta-analysis is ‘voxel-based’, a voxel being a compound of volume and pixel (or tiny picture). The study compares the concentration of grey or white matter in the whole brains of relatives and controls. So far, so good. Their study seems to be innovative in one important respect. In the past, investigators have focused on brain regions selected a priori on some hypothesised grounds, thereby often depriving themselves (and others) of finding the unexpected elsewhere. The voxelbased approach looks at the whole brain and is thereby unbiased in this regard. This study found that relatives were different in engagement of the cingulate gyrus when undertaking either cognitive or emotional tasks. The authors propose that this finding could be used as a new endophenotype for this group of psychoses. All psychotropic medication is being used at an ever-increasing rate, here as in the USA and UK. Now Karanges et al. (2014), publishing in this issue, have made admirable use of Australia’s database for prescriptions, maintained for many years by the Department of Human Services. They look at the 4-year period 2009–2013, paying particular attention to young persons and prescriber specialty. Admittedly the data do not include scripts for inpatients or private scripts and the database is limited in its ability to identify off-label prescribing. The latter is probably considerable for antipsychotics being used for anxiety and insomnia, especially in general practice. That apart, the increased rates, taking place over no more than these 4 years, are striking. And this holds for all the psychotropics. When What really happens