My attempt to respond to this editorial * in the 'house journal ' of the Royal College of Psychiatrists.
The first attempt turned down by the Correspondence Editor, I appealed to the Editor who asked the Correspondent Editoer to review his decision, who, after courteously speaking extensively to me over the phone, turned this slightly revised version down again.
( The Journal allows five references only )
Fiona Gaughran and Shitij Kapur: editorial: The Psychiatrist; September 2011
How change comes: translating biological research into careQuote from the editorial
[ 'Thousands of papers have been published on the biological associations with psychosis yet this has had a limited impact on the routine clinical care of people with psychosis' ]
My final letter
David H Yates FRC Psych; family carerLost in Translation
" Certainly not much has come to practising psychiatry from biological research but it is down to clinical disregard rather than irrelevance in the research.
Clinical studies [1] agree memory falters in continuing schizophrenia in the community. Cognitive weakness is linked to that, is a trait in the illness. Memory management requires intact neurogenesis in the hippocampal area in the brain. It correlates with the level of neurogenesis in the hippocampus. [2]
This post-mortem study on banked material [3] looking for some connection between neurogenesis in the hippocampus and mood illness found no connection there, but instead demonstrated depletion of neurogenesis in the hippocampus of a control sample, taken from sufferers with continuing schizophrenia.
There has been no attempt to replicate nor to foster interest in this crucial finding. I can't imagine such indifference towards an equivalent possible discovery in cancer or arthritis.
Subsequent studies [4] [5] in the area of working memory give confirmation to the finding. They show poor working memory capacity in sufferers with continuing schizophrenia, sufficient to explain how and why they fail to cope with outside engagement.
They are unable on that account - to move on, to rehabilitate themselves.
They need help, at present an unmet need.
With hippocampal neurogenesis failing at the onset of the illness , they are unable to acquire, to build on, new experience, to take from it so as to advance personal, domestic, and social supporting skills.Their peers,friends, family, move on. They do not.
Where depleted neurogenesis in the hippocampus is there at the beginning of the illness, consequences follow that should receive clinical attention.
1. Those developing schizophrenia later have more built in experience than when the illness starts at the earlier age. Presentation and capability will be different.
2. Working memory capacity is required for recall. Without it, memory for previous illness behaviour is faulty. Choice cannot be from full awareness. If there is evidence of both illness and neglect it is not 'their choice'.
3. Estimation of capacity, of insight, of the degree of illness, during professional interview alone, will be inadequate.
'Not ill as I saw them' is insufficiently based.
If declared authoritatively, it is misleading when given without the benefit of access to other, different observation, from community and family.
That used to come from the 'history' taken by the Social Worker - who remained in touch and was the subsequent open contact for the family or community observer.4. Although the studies on working memory capacity explain the failure in coping with ordinary living choices and decisions, this study (5)confirms the ability to 'automate' .
5. Automation - 'chunking' - allows working memory to build up internal stores of experience bit by bit, until a whole process can be managed.
6. Rehabilitation into outside activities can be established in this way at the pace suitable to the degree of disability.
Something like a regular 'normalising' routine of outside engagement can be achieved, giving meaningful breaks for those with residual schizophrenia, giving breaks away from the burden of care on community and family carers.7. Family carers have long known that following a routine is what helps caring, and care and treatment most, retaining regular contact, preventing relapse by relieving uncertainty and unreconciled high emotional differences.
Service provision, divided as it is between Local Authority and NHS provision., is neglecting it is neglect - to provide the sheltering resource that will allow those with continuing schizophrenia to go into recovery.
How many OT staff are there in after-care teams ?References : -
1.
Al-usri J. Bruce, MBChB, MRCPsych, S. Frost, MBBS, MRCPsych and D.
Mackintosh, MBChB, MRCPsych
Measuring memory impairment in community-based patients with schizophrenia B J PSYCHIATRY 2006 189 132-13
2.
Florian A. Siebzehnrubl and Ingmar Blumcke
in the human hippocampus and its relevance to temporal lobe epilepsies
Epilepsia, 49(Suppl. 5):5565, 2008
3.
A Reif,, S Fritzen,, M Finger, A Strobel, M Lauer, A SchmittK-P Lesch
stem cell proliferation is decreased inschizophrenia, but not in depression
Molecular Psychiatry (2006) 11, 514522
4.
JM Gold, Ph.D., Hahn, Ph.D., Zhang, Ph.D. Robinson, , Kappenman, , Becket al ...
Reduced capacity but spared precision and maintenance of working memory representations in schizophrenia
Arch Gen Psychiatry. 2010 June ; 67(6): 570577.
5.
Tamar R. van Raalten , Nick F. Ramsey , J. Martijn Jansma , Gerry Jager , Renι S. Kahn
Automatization and working memory capacity in schizophrenia
Schizophrenia Research 100 (2008) 161171
"go to Fresh Look at Rehabilitation