From the Editor's desk

Quite by chance, or unless our head of publications, who chooses the contents for each issue, has a secret geographical master plan, we have four papers from Australia and New Zealand in this issue. The flexible English language has more opportunities than most for allowing alternative meanings, and so the double entendre of ‘down under’ is particularly apposite as five of our papers too are preoccupied with the subject of depression. When I was a very junior psychiatrist antidepressants were still new and exciting, and I used to say regularly to my patients that if I had to choose any psychiatric illness from which to suffer, it would be a depressive illness, as it was the condition that we could do most to relieve, especially as we now had some excellent drugs to hand. We have learnt a lot since then, not least that all forms of depression tend to recur and often persist, and this issue illustrates how this apparently simple state of mood is not just a miserable cell but a multi-headed hydra. We remove one form but find it replaced by another, whether it masquerades in other forms of other psychiatric disorder, with links well identified in case registers (Morgan & Jablensky, pp. 8–10), a silent reinforcer of physical disease, where its detection is not always easy (Thombs et al, pp. 61–66), a comorbid shadow dogging other mental illness (Gorman et al, pp. 36–44), or as a gremlin, often visiting in the vulnerability of childhood (Bruffaerts et al, pp. 20–27), that distorts the view of the self to the point of suicide. This is why any ways we can develop for heading off depression are so attractive in public mental health, but in general, despite great efforts in primary care and in high-risk groups such as the elderly (Walker et al, pp. 45–54), we only seem able to make a dent in the problem, never a breakthrough. The jury is still out on the value of one of the more thoughtprovoking interventions of recent years, the simple (and very cheap) intervention of sending a series of reassuring postcards to patients who had been admitted to hospital after an episode of self-poisoning. Initial trials suggested this was a highly effective way of preventing recurrence but the latest contribution by Beautrais et al (pp. 55–60) gives a different view. We had some difficulty in reviewing this paper, as the trial could be regarded as prematurely abandoned after an interim analysis, and many authorities advise against interim analyses in order to avoid such errors. One of the more telling comments in the paper is that one of the reasons for stopping the trial early was ‘the reluctance of clinical staff to recruit individuals to the trial’ (p. 59); if this really is such a simple and straightforward intervention, why did it bother staff so much to take part? There are clearly going to be more ups and downs in this story, and we need to be reminded that the original Postcards from the Edge was not a study, but an amusing and insightful novel by Carrie Fisher, the Hollywood actress who has bipolar disorder. We look forward to the synthesis of all the evidence for the value of these interventions in the forthcoming NICE guidelines for the longer-term management of self-harm (Kapur et al, pp. 5–7). It seems likely that something useful is going on here and the original suggestion of improved ‘social connectedness’ might be the reason why simple and generally unsophisticated measures such as postcards, telephone calls and crisis cards might help. In the walled-off state of depression any intervention that can do more than just bounce off the outer bricks has value. But often this breakthrough has nothing to do with us. In one patient I was treating with resistant depression I explained after each combination of drugs that things would suddenly change when his serotonin and noradrenaline receptors had been bathed for long enough in the right concentration of amines for them to be down-regulated. At last he returned completely free of depressive symptoms and I triumphantly produced a diagram of how the drugs had worked. When I had finished he smiled and said, ‘but there’s something else I’ve been bathed in that isn’t in your diagram. I’ve fallen in love’. Now, that’s one psychosocial intervention that truly works.