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A series of editorials in this Journal have argued that psychiatry is in the midst of a crisis. The various solutions proposed would all involve a strengthening of psychiatry's identity as essentially ‘applied neuroscience’. Although not discounting the importance of the brain sciences and psychopharmacology, we argue that psychiatry needs to move beyond the dominance of the current, technological paradigm. This would be more in keeping with the evidence about how positive outcomes are achieved and could also serve to foster more meaningful collaboration with the growing service user movement.

Trials have demonstrated benefits of long-chain omega-3 essential fatty acid (n-3 EFA) supplementation in a variety of psychiatric disorders. To assess the efficacy of n-3 EFAs in improving psychological well-being in patients with recurrent self-harm. Patients (n=49) presenting after an act of repeated self-harm were randomised to receive 1.2 g eicosapentaenoic acid plus 0.9 g decosahexaenoic acid (n=22) or placebo (n=27) for 12 weeks in addition to standard psychiatric care. Six psychological domains were measured at baseline and end point. At 12 weeks, the n-3 EFA group had significantly greater improvements in scores for depression, suicidality and daily stresses. Scores for impulsivity, aggression and hostility did not differ. Supplementation achieved substantial reductions in surrogate markers of suicidal behaviour and improvements in well-being. Larger studies are warranted to determine if insufficient dietary intake of n-3 EFAs is a reversible risk factor for self-harm.

[...]the vast bulk of biological research, from genetics to psychopharmacology and from the study of signal transduction systems to in vivo molecular imaging, has placed the neurotransmitter and its target proteins centre-stage. [...]the well-documented shift in the Western diet away from EFAs (and the omega-3 family in particular) parallels the large rise in all psychiatric disorders seen over the past century. [...]along with the resurgence of interest in lipid–neuronal membrane interactions, there are now a considerable number of quality randomised controlled trials demonstrating the efficacy of EFAs in a diverse number of psychiatric conditions. The ω-6:ω-3 ratio is now estimated to have risen to 17:1 in our typical Western diet (Eaton et al, 1998). [...]wild and free-ranging animals have significantly more ω-3 fatty acids in their tissues than do currently produced commercial livestock.

Low cholesterol has been reliably demonstrated in people who self-harm. To determine whether people who self-harm also have low levels of essential fatty acids (EFAs) and to examine associations between the EFAs and serotonergic function. Depression, impulsivity and suicidal intent were measured in patients with self-harm (n=40) and matched controls, together with plasma lipids and EFAs. Platelet serotonergic studies were carried out in a subgroup (n=27). Patients with self-harm had significantly more pathology on all psychometric measures, lower mean total cholesterol levels (4.18 (s.d.=0.93) v. 4.87 (s.d.=0.83) mmol/l, P=0.003) and lower mean total EFA levels (89. 5 (15.6) v.103.7 (17.1) microg/ml, P=0.0001) than controls after adjustment for confounding variables. Total n-3 and n-6 EFA levels were also significantly lower. Impulsivity and depression scores were significantly inversely correlated with both n-6 EFAs and n-3 EFAs, but were not associated with total or low-density lipoprotein cholesterol levels. Platelet serotonergic measures did not differ between groups, and were not related to psychobiological measures. Lower plasma EFA levels combined with low cholesterol concentrations were associated with self-harm as well as impulsivity and affect. This was not related to platelet serotonergic measures.

Dr R C Kessler, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA; kessler@hcp.med.harvard.edu Sources of funding: National Institute of Mental Health, National Institute of Drug Abuse, Substance Abuse and Mental Health Services Administration, Robert Wood Johnson Foundation, and Eli Lilly, USA.

Background. There is evidence that depression impairs natural killer cell activity (NKA); this could have implications for anti-tumour immunity. Our aim was to examine the role of the hypothalamic–pituitary–adrenal (HPA) axis in suppressing NKA in a population of patients with early breast cancer, screened for depression. Secondary aims were to study the relationship between psychological, endocrine and immune variables and baseline tumour characteristics. Methods. A cross-sectional population of female patients (n=55) with early breast cancer was sampled prior to primary surgery. Structured interview and psychometric instruments measured psychological distress. Flow cytometry was used to enumerate NK cells and lymphocytes were cryopreserved for use in a 51Cr-release assay, to estimate NKA. Midnight and three early morning saliva samples were collected to measure free cortisol levels. Tumour characteristics were obtained from hospital laboratory data. Results. A high rate of psychological morbidity (40%) was observed in the population. NKA was reduced in those with past or current psychiatric illness compared to those without (344 v. 553 LU20 and 455 v. 569 LU20 respectively, p<0·05 for both). Cortisol was not related to psychological status but was modestly positively correlated to NKA. A positive correlation was observed between the Fighting Spirit subscale of the Mental Adjustment to Cancer Scale and tumour size (r=0·383, p=0·012) Conclusions. Our data support the evidence that psychological morbidity is associated with immune dysfunction; however, the most obvious candidate mediator of this effect, the HPA axis, does not appear responsible for this effect. Possible reasons for this are discussed.

Bill Fulford has argued convincingly that the widely held view that bodily illness is ‘relatively transparent in meaning’ and less ‘value-laden’ than mental illness does not stand up to scrutiny. 1 For him, it is simply that the values inherent in our concepts of bodily disorder are just not as obvious as those involved in our discourse of mental illness. When the presenting problem is pain from an arthritic joint or from a myocardial infarction, there is usually agreement between the doctor, the patient and the carer about what the priorities are and what would count as recovery. In the world of mental health, disagreements about values, priorities and frameworks have always been part of day-to-day work and thus value judgements more obvious.