A10 10..10

This month’s editorials question the basis of some accepted beliefs, namely the benefit of minimising the time spent as an in-patient in hospital, and the reasons for favouring atypical antipsychotics in the treatment of schizophrenia. Capdevielle & Ritchie (pp. 164–165) debate the risks and benefits of shorter hospital stays and suggest that the shortest stays occur in countries where community care is most developed, but that the risks of suicide, criminality and readmission may be considerably higher with shorter hospital stays, especially when combined with suboptimal community provision. They advocate a focus on developing best practice guidelines to aid clinical decision-making. Lewis & Lieberman (pp. 161–163) review the results of the recent large antipsychotic treatment studies of schizophrenia, the CATIE and CUtLASS studies, and conclude that there is not only little difference between the effectiveness of older antipsychotic drugs and newer atypical agents, even on negative symptoms or cognition, but also little difference in their side-effect profiles. Clozapine remains the only antipsychotic medication showing a significant advantage over other treatments. They suggest that these data highlight the urgent need to develop safer and more effective treatments for schizophrenia. Cooper and colleagues (pp. 185–190) report that Black ethnic groups had a four-fold higher incidence of first-onset psychosis, and this was significantly associated with a more deprived socio-economic background and a greater perception of being disadvantaged. The authors conclude that this perception of disadvantage was not related to negative self-esteem or to the presence of psychotic symptoms, and question whether it was due to actual discriminatory experiences. Although there is a literature supporting the role of racism in the development of psychosis, the direction of causality can only really be addressed through a prospective longitudinal study. Employment rates are low for patients with schizophrenia, despite many patients expressing a desire to work. Catty et al (pp. 224–231) demonstrate that the use of a targeted individual placement and support (IPS) package shows superiority on all vocational measures, compared with the provision of routine vocational rehabilitation for people with severe mental illness. The quality of the therapeutic relationship and adherence to the IPS model predicted getting a job, and the authors suggest that these are both components that can be addressed through training and supervision.