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

Macrophages come to mind as keys to cognitive decline

Cognitive impairment, an underappreciated consequence of hypertension, is linked to cerebral arteriolar disease through poorly defined mechanisms. A study by Faraco et al. in this issue of the JCI points to perturbations of neurovascular unit coupling caused by perivascular macrophages (PVMs) as a cause of hypertension-related cognitive impairment. Angiotensin II (Ang II) was shown to activate PVMs, causing them to produce superoxide and thereby alter the proper functioning of the adjacent arterioles. Faraco and colleagues also show that disruption of the blood-brain barrier occurs in hypertension, allowing circulating Ang II to access PVMs. This study provides important new insight into the role of inflammatory cells in the genesis of vascular dementia

Constraints on QCD Sum-rules from the H\"older Inequalities

A new technique based on H\"older's integral inequality is applied to QCD sum-rules to provide fundamental constraints on the sum-rule parameters. These constraints must be satisfied if the sum-rules are to consistently describe integrated physical cross-sections, but these constraints do not require any experimental data and therefore can be applied to any hadronic spectral function. As an illustration of this technique the Laplace sum-rules of the light-quark correlation function for the vector and the axial-vector currents are examined in detail. We find examples of inconsistency between the inequalities and sum-rule parameters used in some previous analyses of the vector and axial-vector channels.Comment: 13 pages, RevTeX, 4 figures available upon request, to appear in Phys. Lett

Migraine and vascular disease biomarkers: A population-based case-control study.

Background The underpinnings of the migraine-stroke association remain uncertain, but endothelial activation is a potential mechanism. We evaluated the association of migraine and vascular disease biomarkers in a community-based population. Methods Participants (300 women, 117 men) were recruited as a part of the Dutch CAMERA 1 (Cerebral Abnormalities in Migraine, an Epidemiologic Risk Analysis) study. Participants were aged 30-60 (mean 48) years, 155 migraine had with aura (MA), 128 migraine without aura (MO), and 134 were controls with no severe headaches. Plasma concentrations of fibrinogen, Factor II, D-dimer, high sensitivity C-reactive protein (hs-CRP), and von Willebrand factor antigen were compared between groups, also stratifying by sex. Results Fibrinogen and hs-CRP were elevated in migraineurs compared to controls. In logistic regression analyses, MO and MA had increased likelihood of elevated fibrinogen, and MA had increased likelihood of elevated Factor II and hs-CRP. Fibrinogen and Factor II were associated with MA in women but not men. In the migraine subgroup, the total number of years of aura, but not headache, predicted elevated hs-CRP, and the average number of aura, but not headache, attacks predicted all biomarkers but Factor II. Conclusions Elevated vascular biomarkers were associated with migraine, particularly MA, as well as with years of aura and number of aura attacks

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