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Lithium

Has half a century dimmed lithium's lustre? Data vary, but there is some evidence that its clinical use may have waned somewhat in more recent times –a victim of a lack of pharma promotion or concern about side-effects? This month no fewer than three BJPsych articles discuss the amazing ion. A key worry is prescribing in women of childbearing age, and Angelika Wieck's editorial (pp. ) notes that about two-thirds on lithium have it discontinued in the first trimester of pregnancy. As well as the natural concerns about teratogenicity and toxicity in utero – which newer data suggest may have been overstated in early work – the physiological changes of pregnancy mean that lithium levels can alter. We are all very clear that guidelines typically advocate against use during pregnancy where adequate alternatives are available, but equally aware that real-world practice and realities mean that this is not always the case, and an evidence-based approach to such instances is needed. Wesseloo et al (pp. ) retrospectively explored over a thousand serum samples in over one hundred pregnancies: lithium levels decreased by a mean of about 24% in the first trimester, 36% in the second, and rebounded somewhat to a 24% reduction by the third. Delivery itself was not associated with acute changes, and the authors propose guidelines for routine monitoring in this cohort. An editorial by Berk et al (pp. ) reckons that we need to recalibrate how we conceptualise lithium's risk profile more generally. Contrary to initial concerns, more recent and methodologically robust work shows no association with the development of renal or gastrointestinal cancers, and indeed it may reduce such risks. Similarly, intriguing nascent epidemiological data are linking it with lower rates of dementia. The intracellular effects of lithium are many and complex; while putative mechanisms for these therapeutic gains have been speculated upon, they remain at an early stage of scientific investigation.

Come as you are

Lots on comorbidities in this month's BJPsych. Hassiotis et al (pp. ) address the recognised but understudied relationship between psychotic symptoms and borderline intellectual functioning (IQ 70–85). Both can be conceptualised as neurodevelopmental conditions, and intellectual disability may present specific vulnerabilities, including altering how stimuli are interpreted. Using a national survey data-set, they found that those with borderline intellectual functioning (N = 1701) were over twice as likely to have psychosis and to report hallucinations, but interestingly, and against hypothesis, there was no increase in persecutory ideation. Low mood and life traumas were important symptom mediators, suggesting that appropriate interventions may help.

Three meta-analyses explore different physical and mental health links. Zhuo et al (pp. ) demonstrate the significantly greater cancer mortality in individuals with schizophrenia, while Jung and colleagues (pp. ) show that being underweight increases the risk of depression, not just being overweight, though the challenge of the direction of causality remains. There were important gender differences, with women more vulnerable. Fascinatingly, overweight men had significantly decreased risks of depression: the authors reference the erstwhile – perhaps controversial and pejorative – ‘jolly fat’ hypothesis. Giles Newton-Howes and colleagues (pp. ) tackle the important question of alcohol use disorder (AUD) in individuals with personality disorder – specifically their outcomes in treatment for AUD. Comorbidity is common, and indeed they remind us that until the late 1960s ‘alcoholism’ was considered a form of personality disorder. While such individuals have greater alcohol-related impairment at baseline and less retention during treatment, follow-up studies show equal gain to the general population. An important message of hope in a group that can all too often face stigmatising (pre)judgements about their outcomes.

Something in the way

Few interventions in mental health seem as beguilingly simple and obvious as befriending. But is ‘beguiling’ the key phrase: besides seeming ‘right’, does it ‘do’ anything? Measuring sunshine is always a challenge, but Turkington et al (pp. ) try just that in a stimulating editorial on this intervention that combines showing interest and sympathy, active listening, patience, and sharing of feelings and trust. They note how an approach that focuses on enjoyable aspects of life may prove a catalyst to enhancing therapeutic alliances. In psychosis, in particular, a non-confrontational (but non-colluding) accepting approach may have particular value, and the limited evidence on the topic shows some equivalence to more formalised psychological approaches. Patients certainly value it, and it has been shown to lead to greater disclosure, including of painful experiences. The authors propose that befriending is more than ‘just’ a placebo, and worthy of investigation as a stepping-stone intervention with unique merits of its own.

Taylor Salisbury et al (pp. ) ask another question that seems self-evident, but like many ‘obvious’ issues, has not previously been adequately explored: is greater expenditure on mental illness associated with better outcomes? A key issue is whether or not national expenditure trickles locally, so the authors utilised an internationally standardised tool to assess care quality, indexed by individuals with longer-term severe and complex mental health problems – utilisers of a significant portion of health budgets – across ten European countries. The findings are clear: greater spend was associated with higher-quality care, service user autonomy, and positive patient experience. As part of our on-going series with the Mental Elf, Kwame McKenzie discusses this paper and its findings in more detail in our new blog at https://elfi.sh/bjpme4.

Finally, exploring everything from why some people have red hair to who are rated the best-dressed medics, Kaleidoscope (pp. ) has lots of genes, and something on jeans.