Letters

Sir,

A 56 years old woman suffering from Down's Syndrome with moderate learning disability presented with increasing short term memory problem, disorientation and episodes of agitation.

She was going to toilet but forgetting why she went there and consequently she became incontinent of urine and faeces. She was treated with antidepressant, which lifted her mood and resolved her agitation.

However, her memory difficulties and progressive loss in her complex living skills were causing concern to her carers. The day centre she was attending was finding it difficult to manage her behaviour that related to her memory disturbance. She has a family history of dementia and her mother died of Alzheimer disease.

Since Donepezil has been found to be useful in frontal lobe symptoms of dementia, it was thought that it might perhaps reduce her challenging behaviour and slow the progress of the decline of her dementia.

She was commenced on a small dose of Donepezil i.e. 5mg Daily but unfortunately after 2 -1/2 weeks of it, she developed behavioural problems, wandering at night, incontinence of urine and faeces and got confused. She started lying on the floor hitting it with her fist. She became agitated again.

Under the circumstances, the carers were not in favour of continuing this medication as their perception was that it all happened due to Donepezil although another carer did admit that she developed similar behaviour when she was commenced on a small dose of Haloperidol. However, respecting the wishes of her carers and their reluctance to administer this medication anymore, it was stopped. Subsequently she improved mood wise and became more manageable following the treatment of a Urinary tract infection, which she happened to be suffering at that time.

In spite of considerable achievement of psychopharmacology and psychopharmacotherapeutics, there is opinion in the clinical psychiatry, that psychopharmacotherapeutics is at the limit of its possibilities with the current set of psychotropic medicines. We are interested in a pharmacology based on specific combinations of caffeine, ironcontaining and nitric oxide producing. As a result of our long term theoretical and experimental studies and clinical practice we came up with a new original Concept of the complex psychopharmacotherapy of the variety kind of mental disorders and a New Hypothesis on basic processes in the regulation of the main intraneuronal metabolic processes and stipulation of possibilities for control of the activity of such key intracellular regulatory enzymes as guanylate cyclase (GC) and adenylate cyclase (AC).We hope to present the results of our recent theoretical, experimental and clinical studies concerning this theme on the example of the treatment of variety kind of depression as a future article in Psychiatry-on-line.

Doctor Mekhti M. KULIEV, Psy. Dr., M. D., Leading Doctor - Psychiatrist of the Azerbaijan Republican Neurosurgical Centre.

Professor Dshavanchir I. ALIEV, Doctor of Biology and Biophysics, General Research Worker of the Problem Laboratory of Molecular Biophysics of the Baku State University.

Doctor Irada N. ALIEVA, B. D., Leading Research Worker of the Problem Laboratory of Molecular Biophysics of the Baku State University.

Under Main Direction of Academician Professor Damir V. GADJIEV (Azerbaijan Medical University).

Clozapine and HIV+ Patients?

I am a Spanish psychiatrist working in a psychiatric rehabilitation unit, which has 40 inpatients with an average stay between 6 and 12 months. I have a schizophrenic patient, who is HIV+ . He has severe behavioural disorders with aggressiveness. Treatment with conventional neuroleptics cause him important side effects and Risperidone doesn't control his behavioural disorders. I am considering prescribing Clozapine, but I am not sure if the haematological side effects of Clozapine may be enhanced in HIV+ patients. Are there any readers who have experience in this issue?
I have done a bibliographical search in MEDLINE and I didn't find anything.
Yours sincerely

Rafael Casas
Rivera

RAFACASA@santandersupernet.com

Has any reader any experience of treating treating patients with DSM-IV diagnosis of Panic Attack and/or severe Social Phobia with Gabapentin ? The efficacy of Tricyclics, SSRI's, and MAOI's has been less than desirable in some patients. Clonazepam has been strongly supplementing the anti-depressants, but significant side effects, particularly severe short-term memory loss and sedation have made this less than ideal for a number of patients. Gabapentin, however, as a GABA analog, would appear to be an alternative, possibly offering efficacy similar to that of Clonazepam, without sedation and memory effect.

Please respond with experience, dosage recommendations and/or contraindications.

Spectrum disorder seems to have become the acceptable, if not fashionable, way of admitting our incompetence in distinguishing between mental illness and 'normality'. Personality spectrum, schizophrenia spectrum, depressive spectrum, whatever next? We appear to be moving further and further away from the fundemental idea that there is a distinct break from normality to mental illness. This 'rainbow' approach to diagnosis may well suit interior decoration but does nothing to further our patients treatments. As an 'out-clause' for our not unusual treatment failures it may have some merit, and also protect us from worry induced insomnia, but there is surely more utility in definitive diagnosis, even if eventually modified. These tendencies seem to go hand-in hand with our reluctance to diagnose personality disorder. "Depressed" we say and 'treat' accordingly. So we empty our prisons and fill our ever shrinking hospitals. Apart from the resulting eugenic disaster created by ill-conceived mixed wards, which have become the norm despite any evidence of their benefit and much of their harm, what of the financial implications? Is "diagnose or be damned" to be our new motto.

Andrew Al-Adwani Department of Psychiatry Doncaster Royal Infirmary Armthorpe Road Doncaster S. Yorks.

A meeting was held at St John of God Psychiatric hospital, Sydney , Australia, recently and a hard copy of the e-mail I have received from the letter published in Psychiatry On Line was handed to all concerned. This latter information balanced the American position it was felt and there was general consensus to ;

1 not mandate Unilateral ECT as it was felt Bilateral ECT is more effective and by using it there is often the need to have a larger number of ECT and thus subject the patient to a greater risk in terms of a greater number of anaesthetics.

2 Not mandate titration as it had been pointed out by Dr Littlejohn, Consultant Psychiatrist in North Wales that sub threshold stimuli can cause increased confusion and the process was thought to extend the anaesthetic for a longer time while the titration took place.As he pointed out " why subject the patient to this ? ".

3 Possibly reduce the dose on antidepressant medication but make sure that other tranquillisers and other medication that could interfere with the ECT process at a minimum. If one does not leave the patient on some antidepressant ( if the patient is have the ECT for Major Depression ) there is the risk that the patient will become depressed again in the time it takes to stabilise them after ECT is finished.

There were a number of other issues canvassed such as the starting energy level for particular patients and generally it was felt that the age of the patient is the best guide.I do not expect many psychiatrists will be using the stick on electrode either in view of the pressure needed to hold them on during treatment.

The views obtained through the " Psychiatry on line " have been a great help in this matter and they were able to be obtained quickly which meant that they were able to be presented at the next ECT meeting and the special committee that was formed to investigate all this has been disbanded now as all the issues have been satisfactorily dealt with.

We are in the middle of reviewing ECT procedures in our hospital ( St John of God Hospital , Burwood, Sydney Australia) Some of us recently went to the Melbourne Clinic where they do 10-20 ECTs three times a week . They are into titration of the dose (that is finding the threshold by slowly increasing the dose) and unilateral ECT in high doses . What is the position in other countries on this ? Is Unilateral in high dose better than low dose bilateral ? I gather the Royal College recommended Bilateral in low dose some years ago but what is the current normal practice in UK?I made some notes after the trip to Melbourne as follows :

1. Unilateral high dose is the same as Bilateral in most patients with the exception of the following who it may be should have bilateral from the start;

2. Unilateral should be the first choice in ECT ( with the above exceptions) and only if there is a poor response should bilateral be

3. Titration of the dose should start at 5 % under the age of the patient and if no response should go up at 5% intervals until a response is achieved ( the Melbourne Clinic starts at a lower level then this but it seems that it may take too long to titrate )

4. Bilateral should start at half the unilateral dose and titrated up also at 5% each attempt to have ECT.

6. One stimulus electrode can be lateral to the right eye ( if the person is left dominant ) and it is best if it is a stick on disposable electrode.

7. Skin for all electrodes , both stimulus and recording, should be cleaned with the special solution " Pre Tac " or saline and then wiped off.

10 Imovane ( Zopiclone ) is better to use as a tranquiliser during ECT as it does not interfere with the Epileptic fit as much. It does not have the same respitatory depression nor affect the threshold for ECT as other tranquilisers.

We would be extremely interested in any comments readers might make on this policy, compared to their national current opinion or local guidelines.

I read with interest Dr.Boza's comprehensive article on the nature of hallucinations and illusions of non-psychiatric etiologies⁽¹⁾, but found myself disagreeing with him on the concept of pseudohallucinations. Dr.Boza defined the phenomena as "hallucinations that the patient knows as such; altough perceptions are rather vivid and crisp, the patient has the insight that it has no external foundation"⁽²⁾. To my knowledge, the concept of pseudohallucinations was coined by the German psychiatrist Karl Jaspers in the several editions of his textbook "General Psychopathology"⁽³⁾. To Jaspers, pseudohallucinations were introspected images of great vividness. They were considered figurative experiences, located in the inner eye (or ear) -the "internal experiencial space", in sharp contrast with the perceptual disturbance found in true hallucinations⁽⁴⁾. Even though both phenomena could occur in the same patient and be described as a single experience, Jaspers stressed the qualitative distinction between them and accounted for the existance of a gradation between pseudohallucinations and fantasy (imagery) experiences.

The nature of pseudohallucinations (adapted from Sims, 1995)
Perception = Hallucination ------------------Pseudohallucination Fantasy=Imagery
1.Experience is concrete, tangible, objective, real	1.Inner eye--pictorial, subjective
2.Location in outer objective space	2.Location in inner subjective space
3.Good definition	3. Indefinite, incomplete
4. Sensory wealth	4. Neutral or dim elements to sensory quality
5. Constant	5. Evanescent
6.Independent from volition(experience of passivity)	6. More of a voluntary creation(experience of activity)
7.Perceptual flavour	7. Ideational flavour
8. Could experience object in another sensory modality	8. Could not experience object in another sensory modality

According to Sims ⁽⁴⁾, the confusion over the meaning of these terms had arisen due to an a posteriori definition of pseudohallucinations as self-recognized hallucinations (either "exterocepted" or "introcepted"). However, this concept conflicts with the 1932 definition of the French psychiatrist Henry Ey of hallucinosis, considered as "neurologic hallucinations " in which a (true) perception without external object is criticized by the patient⁽⁵⁾.

2. Hinse, L; Campbell, R. (1970) Psychiatric Dictionary, Fourth Edition. Oxford University Press, New York.

4. Sims, A.(1995) Symptoms in the mind: an introduction to descriptive psychopathology. (2nd Edition) Saunders.

5. Alonso, FA.(1979) Fundamentos de la psiquiatria actual, Quarta Edici�n. Paz Montalvo, Madrid, p.447.

Ethics Committees

My present problem is a crazy ethics committee which wants reassurance that asking people about suicide will not "give them the idea". Apart from the whole of psychiatric clinical experience, are there any relevant references that I could use to deal with this lunacy.

It reminds me of the time the consumer representative asserted that it was an invasion of the patient's privacy for us to look at the notes we had written 5 years before. Any assistance would be most gratefully received. The measure we are using is the Zung depression Scale to assess carers of patients with dementia. It is the Zung which has caused angst for one member of the Management Board - i.e. because carers will be asked about suicide. Despite the psychiatrist on the panel explaining that the concern had not emerged as an issue in 30 years of clinical and research use of the measure worldwide, I have been asked to travel from Sydney (where I live) to Adelaide (the location of the host agency) to argue my case ... Otherwise, no study!

Native Americans

Sir,

As a Commanding Officer within the Navajo Indian Nation's Department of Law Enforcement. I am searching for any and all materials, publications, etc. that pertain to psychological disorders confronting Native Americans as the result of 130 years of oppression and governmental dependancy. Thus far I have found nothing pertaining to this subject matter. I would also be extremely interested in proposals to conduct research related to a variety of aspects pertaining to Native American Social and Psychological Disorders.

**A point to ponder is that this form of research has intentionally been avoided.

Modecate and risperidone

The Psychiatric Hospital that I am involved with has a number of psychiatrists who are using fluphenazine decanoate ( depot neuroleptic) and risperidone, in middle range doses, together. We would be interested if readers feel could envisage any situtations in which such a combination is reasonable?

Auditing counselling in General Practice

I belong to a fund holding general practice that now provides quite a range of psychological services: 2 counsellors, one specialising in substance abuse (working on one to one basis but, also using groups), a CPN, a clinical psychologist, a GP, trained in gestalt counselling (using one to one and groups) and a trainee counsellor. We are proud of what we provide but would like to demonstrate that we are making a significant effect and that we are worthwhile.

Any resulting audit tool should be easy to use and acceptable to patients and perhaps even be part of the therapy in its usefulness.

I am sure we are not alone in this quest and I would be interested to hear of anyone who would like to help.

Dysfunctional Attitude Scale.

Sir,

Your On-line journal deeply impressed me and I hope that your many readers can help me. I am a psychiatrist in South Korea. My main area of concern is cognitive therapy of depression and now I am planning to study about depression symptoms and distorted cognition of general population. I have been trying to locate article about Dysfunctional Attitude Scale for 5 months and found many. But I can not locate paper about rating scale itself and validity study. Now I know that author of this instrument is Dr. Weissman and he presented many papers in many meetings but in Korea it is hard to assess papers presented in scientific meetings. Does anybody have or know where I can get these articles and where Dr. Weissman is . Also I want to get permission to translate this instrument into Korean and use in my study. So I want to know how to get permission.

Weisseman,A., & Beck, A.T.(1978, November). Development and validation of the Dysfunctional Attitude Scale(DAS). paper presented at the 12th annual meeting of the Association for the Advancement of Behavior Therapy, Chicago.
Weissman AN: The Dysfunctional Attitude Scale: A Validation Study, thesis. University of Pennsylvania Graduate School of Arts and Science, Philadelphia, 1979.
Weissman, A.N. & Beck, A.T.(1978, March). Development and validation of the Dysfunctional Attitude Scale; A preliminary investigation. Paper presented at the Annual Meeting of the American Educational Research Association, Toronto, Canada.
Weissman, A.N. (1980). Assessing depressogenic attitudes: A validity study. Paper presented at the 51st Annual Meeting of the Eastern Psychological Association, Hartford, Connecticut.

Please E-mail or Fax me.

jsnoh@madang.ajou.ac.kr
Fax : 82-331-219-5179
Address : Jai-Sung Noh MD
Department of Psychiatry & Behavioral Sciences. School of Medicine. Ajou University.
5 WONCHON-DONG, PALDAL-GU, SUWON 442-749 , South Korea

Evidence-based psychiatry

Sir,

We recently attempted to replicate, on an acute psychiatric ward, David Sackett's study (Ellis et al Lancet 346:407-410, 1995) of the proportion of primary medical interventions based on randomised controlled trials or systematic overviews. We found that there was evidence from randomised controlled trials or systematic overviews for 65% of our primary interventions (which represented the most important attempt to cure or alleviate the primary diagnosis). This compares favourably with the rate reported by Ellis et al in general medicine (53%). However, I was struck by the relative poverty of the evidence available for many of our interventions in psychiatry.

In 1971, Archie Cochrane declared that psychiatry was basically inefficient: i.e. it uses large numbers of therapies for which there is limited evidence. For example, in the UK, a psychiatrist can prescribe around 20 antipsychotic drugs although, perhaps with the exception of clozapine, there is little evidence to tell them apart. The clinician therefore selects his/her own favourite drug or uses some form of brain chemistry theory or just plain trial and error. A similar situation exists for antidepressants (consider the huge increase in SSRI prescribing despite the lack of clear cut evidence of superiority). One of the main reasons for this is that new drugs are introduced when they are shown to be superior to placebo but of equivalent efficacy to established treatments (perhaps with fewer side effects). The comparative studies rarely have sufficient power to clearly demonstrate even considerable differences in efficacy and are highly prone to type 2 errors. For example, one of the main studies of acuphase compared to haloperidol had only 20% power to detect a real difference of 20% (between 40% and 60% improvement rates)

My suggestion is that there is a real need for some large, pragmatic, simple randomised controlled trials in psychiatry to provide a firm evidence base for our clinical decision making. These would need to be performed at least on a national, and preferably an international, basis.

I would be interested in any comments on this from readers of Psychiatry On-Line, and if there is any support for my proposal.

Letters

Care to reply or have a point of your own to make?

DONEPEZIL FOR DOWN'S

Clozapine and HIV+ Patients?

Ethics Committees

Native Americans

Sir,

Modecate and risperidone

Auditing counselling in General Practice

Dysfunctional Attitude Scale.

Sir,

Evidence-based psychiatry

Sir,