From the Editor's desk

The merits of a global perspectiveIt has almost become a pointless mantra to repeat ‘we are now international’ but there is important substance to the wish for a more global perspective in psychiatry. For those involved in developing community services it is amazing to follow the time change zones round the world. In the Czech Republic services are at the stage we were in the UK in 1977, in Slovakia it is 1972, in the Ukraine it is 1965, in Rwanda 1964, in Tibet 1960 and in Belarus 1953. So why not take advantage of this time warp and help Belarus now to develop the best possible services from the 50 extra years of accumulated knowledge? The reverse is also true. We can test hypotheses now that we might have considered many years ago by looking at the experiences of other countries. Schizophrenia remains difficult to treat and much concern has been expressed about its excess mortality, particularly the suspicion that this is a consequence of antipsychotic drug treatment.1These drugs may lead to obesity, a growing problem with increasing age (Kivimäkiet al, pp. 149–155), and its associated metabolic syndrome.2,3In low- and middle-income countries our view of outcome has been influenced greatly by data from Chandigarh in North India, where better results may be related to different family structures with low expressed emotion, conferring protection.4But long-term outcome is poor in such countries also5and Ranet al(pp. 126–131) suggest that those never treated for schizophrenia, even though they may have received traditional remedies,6have the same mortality as those treated with Western evidence-based interventions. When we get consistency across very different countries we can have much more confidence in our conclusions, and the association of urbanicity and schizophrenia first identified by Faris & Dunham 70 years ago,7and repeatedly identified in all population groups,8now seems to have its final badge of approval from Lundberget al(pp. 156–162) in their study from Uganda. I cannot help noticing from their paper that grandiosity as a psychotic experience is a marked distinguishing feature between urban and rural rearing; perhaps being surrounded by all those tall city buildings unduly raises expectations. We need to be reminded that increased mortality is also common in other psychiatric disorders. This is illustrated in depression by Mykletunet al(pp. 118–125), who also intriguingly find that greater trait anxiety increases your lifespan, so perhaps there is some gain from constant worry and increased help-seeking behaviour.