What would an ideal mental health service for primary care look like?

Key messages: In order to commission an ideal mental health service for primary care, GP commissioners should challenge accepted distinctions and divisions. These include the division between mental health clinics and the GP surgery, and between short GP consultations and extended mental health ones. They also include the division between mental and physical illness, between severe and enduring mental illness and other difficulties, and between the individual and the family. GPs should also call into question the divisions between the mental, social and economic domains, between all the different mental health disciplines and ideologies, and between neighbouring localities or boroughs. Finally, they should challenge the distinctions between offering a diagnosis and treatment, and having a therapeutic conversation; and between the patient's voice and the doctor's decision-making. Why this matters to me: As a GP who is also a part-time consultant in a mental health trust, I have spent the last 15 years trying to promote innovative thinking and ways of working at the interface between primary and secondary care. In spite of all the obvious risks and constraints that will accompany GP commissioning consortia, I believe they may offer an opportunity to challenge some or all of the false divisions and distinctions that currently bedevil mental health services and often lead to fragmented, inflexible, inappropriate or poor care for patients. Mounting such challenges could lead to mental health services that were more attuned to the realities of primary care and served patients far better. The creation of GP commissioning consortia offers potential opportunities for GPs to challenge a number of divisions and distinctions that are currently taken for granted in mental health services, but may be neither necessary nor logical. I examine a range of these and suggest what GPs and patients might reasonably expect if we challenged them in order to imagine and commission an ideal mental health service for primary care. Among its features, an ideal service would cross the boundaries of mental and physical care, individual and family care, and the mental, social and economic domains. It would also transcend mental health ideologies, geographical borders and the artificial distinction between making a diagnosis, offering treatment and holding a therapeutic conversation

Carl Jung’s relationship with Sabina Spielrein: A reassessment

The aim of this article is to give an accurate account of the relationship between Sabina Spielrein and Carl Gustav Jung, based on a close reading of the available documentary evidence. I challenge many of the commonly held assumptions about their relationship. These include the belief that Spielrein was Jung’s first analytic patient, that they had a long and mutually passionate affair, and that Spielrein was the inspiration behind Jung’s conception of the ‘anima’. I argue that there is little evidence for these and a number of other beliefs that have been passed down through successive cultural iterations without careful documentary analysis

How evolution can help us understand child development and behaviour

The traditional disease model, still dominant in psychiatry, is less than ideal for making sense of psychological issues such as the effects of early childhood experiences on development. We argue that a model based on evolutionary thinking can deepen understanding and aid clinical practice by showing how behaviours, bodily responses and psychological beliefs tend to develop for ‘adaptive’ reasons, even when these ways of being might on first appearance seem pathological. Such understanding has implications for treatment. It also challenges the genetic determinist model, by showing that developmental pathways have evolved to be responsive to the physical and social environment in which the individual matures. Thought can now be given to how biological or psychological treatments – and changing a child’s environment – can foster well-being. Evolutionary thinking has major implications for how we think about psychopathology and for targeting the optimum sites, levels and timings for intervention

Reproductive period and risk of dementia in postmenopausal women

CONTEXT: Exogenous estrogen use may lower risk of dementia in postmenopausal women. A relationship between long-term exposure to endogenous estrogens and incident dementia has been hypothesized but not studied. OBJECTIVE: To determine whether a longer reproductive period, as an indicator of longer exposure to endogenous estrogens, is associated with lower risk of dementia and Alzheimer disease (AD) in women who have natural menopause. DESIGN AND SETTING: The Rotterdam Study, a population-based prospective cohort study conducted in the Netherlands. PARTICIPANTS: A total of 3601 women aged 55 years or older who did not have dementia at baseline (1990-1993) and had information on age at menarche

Drug-gene interactions of antihypertensive medications and risk of incident cardiovascular disease: a pharmacogenomics study from the CHARGE consortium

Background Hypertension is a major risk factor for a spectrum of cardiovascular diseases (CVD), including myocardial infarction, sudden death, and stroke. In the US, over 65 million people have high blood pressure and a large proportion of these individuals are prescribed antihypertensive medications. Although large long-term clinical trials conducted in the last several decades have identified a number of effective antihypertensive treatments that reduce the risk of future clinical complications, responses to therapy and protection from cardiovascular events vary among individuals. Methods Using a genome-wide association study among 21,267 participants with pharmaceutically treated hypertension, we explored the hypothesis that genetic variants might influence or modify the effectiveness of common antihypertensive therapies on the risk of major cardiovascular outcomes. The classes of drug treatments included angiotensin-converting enzyme inhibitors, beta-blockers, calcium channel blockers, and diuretics. In the setting of the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) consortium, each study performed array-based genome-wide genotyping, imputed to HapMap Phase II reference panels, and used additive genetic models in proportional hazards or logistic regression models to evaluate drug-gene interactions for each of four therapeutic drug classes. We used meta-analysis to combine study-specific interaction estimates for approximately 2 million single nucleotide polymorphisms (SNPs) in a discovery analysis among 15,375 European Ancestry participants (3,527 CVD cases) with targeted follow-up in a case-only study of 1,751 European Ancestry GenHAT participants as well as among 4,141 African-Americans (1,267 CVD cases). Results Although drug-SNP interactions were biologically plausible, exposures and outcomes were well measured, and power was sufficient to detect modest interactions, we did not identify any statistically significant interactions from the four antihypertensive therapy meta-analyses (Pinteraction > 5.0×10−8). Similarly, findings were null for meta-analyses restricted to 66 SNPs with significant main effects on coronary artery disease or blood pressure from large published genome-wide association studies (Pinteraction ≥ 0.01). Our results suggest that there are no major pharmacogenetic influences of common SNPs on the relationship between blood pressure medications and the risk of incident CVD

Evolutionary perspectives on neurodevelopmental disorders

We discuss evolutionary perspectives on two neurodevelopmental disorders: attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Both have a genetic background, and we explore why these genes may have survived the process of natural selection. We draw on the concept of evolutionary mismatch, in which a trait that may have conferred advantages in the past can become disadvantageous when the environment changes. We also describe the non-genetic influences on these conditions. We point out that children with neurodevelopmental conditions are more likely to suffer maltreatment, so it is important to consider both the genes and the environment in which children have grown up. In hunter-gatherer societies, ADHD may have favoured risk-taking, which may explain why it has survived. The contemporary model of schooling, in which children are expected to sit still for many hours a day, does not favour this. Understanding ADHD in terms of an evolutionary mismatch therefore raises ethical issues regarding both medication and the school environment. ASDs are far more heterogeneous and are characterised by high heritability and low reproductive success. At the severe end of the spectrum, ASD is highly disadvantageous and often co-occurs with intellectual disability. On the other hand, high-functioning ASD may have been adaptive in our evolutionary past in terms of the potential for the development of specialist skills and can still be so today in the right environment