Edgar Jones and Simon Wessely Psychiatric Bulletin 2000, 24:353. Access the most recent version at doi: 10.1192/pb.24.9.353-a
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the columns c orre sp ondence Monitoring of carbamazepine and valproate prescribing practice Sir: In their audit-type study of carbamazepine and valproate use, Taylor et al (all pharmacists) ( Psychiatric Bulletin, May 2000, 24, 174^177) seem to assume `standards'that are open to question.They take as a starting point that the drug companies'licence represents a gold standard for prescribing practice from which the practitioner deviates at his or her peril. Commenting on the fact that 52% of prescribing of valproate was apparently for indications not listed in the drug's product licence, they issue a sinister warning: ``Prescribers should be aware of the potential legal consequences of adverse effects resulting from off-licence use.'' The difficulty with this is that most controlled trials on psychotropic drugs leading to eventual licences that are carried out by the pharmaceutical companies are on general adult psychiatric populations. One line of explanation for this is that it is easier to gain consent in this population than in others. Whatever the reason, the drug companies' licences often leave glaring gaps in other fields such as child psychiatry and learning disability. Apart from methylphenidate for hyperkinesis and imipramine for enuresis, there are virtually no licences for other drugs in child psychiatry, leaving the practitioner with no choice but to prescribe `offlicence' in other conditions. In psychiatry of learning disabilities, service users are rarely able to give accounts of their troubled mental states and full ICD diagnoses are the exceptions rather than the rule. In these circumstances, psychiatrists must make educated guesses as to probable psychopathology if they are to practise ethically. Again, cautious off-licence prescribing in conditions such as aggressive (challenging) behaviour is sometimes mandatory. Carbamazepine and valproate frequently alleviate such behaviour and there may well be a connection between explosive outbursts (`episodic dyscontrol') and epileptic activity.
In January 1997, the British Association of Psychopharmacology convened a `Round Table' to look at this issue of drug companies' licences. Members included scientists, clinicians, pharmaceutical representatives and pharmacists. It is worth quoting directly from their article, if only to rebut the argument about litigation: ``There is a great lack of clarity about the meaning of a licence that a company is offered. Many clinicians in the UK and France appear to think that they cannot prescribe off-licence ^ that it would be almost illegal to do so and that they would be exposing themselves to considerable risks of litigation. In fact, the Medicines Act and the EC Pharmaceutical Directive 89/341/EEC allows doctors to prescribe unlicensed medicines or to use licensed medicines for indications or in doses or by routes of administrations outside the recommendations of the licence as well as to over-ride warnings or precautions given in the licence.'' Another assumption the authors make is that there is a consensus that serum carbamazepine and sodium valproate levels should be regularly monitored in the same way as serum lithium. I know of no such consensus and it would seem that most clinicians take blood levels only when there is some suggestion of untoward side-effects. The British National Formulary makes no comment on serum carbamazepine levels but is explicit about valproate: ``Plasma-valproate concentrations are not a useful index of efficacy, therefore routine monitoring is unhelpful.'' ( British National Formulary,1998) Indeed, I am told that some laboratories will only do valproate levels under special circumstances. These two objections apart, the study was a salutary reminder that full blood counts and liver function tests are frequently neglected in patients who are on these two anti-epileptic medications in the long term. Also, the point that serum levels, when indicated, need to be taken at trough times (probably 4.00 p.m. before the teatime dose) was well made. BRITISH ASSOCIATION OF PSYCHOPHARMACOLOGY (1997) BAP Consensus Statement. Journal of Psychopharmacology, 11, 291^294.
BRITISH NATIONAL FORMULARY (1998) British National Formulary. September1998. London: British Medical Association & Royal Pharmaceutical Society of Great Britain. Padraig Quinn Consultant Psychiatrist, Clevedon and District CLDT, 4 Argyle Road, Clevedon BS217BP
Sale of St John's wort Sir: Maidment's ( Psychiatric Bulletin, June 2000, 24, 232^234) review of St John's wort is timely, but fails to mention the problem of its wide availability as a herbal preparation. Randomised trials indicate that it is an effective antidepressant, with a variety of plausible mechanisms for action. Because it is a herbal remedy it is subject to none of the usual regulations applied to drugs. On a recent visit to a well-known high street chemist I found St John's wort on sale with no information about indications, side-effects or interactions, or any of the information which would be expected in a patient information leaflet for prescribed or over the counter medication. This may have serious consequences. First, patients are unaware of the potential interactions (including two recent cases where an interaction with cyclosporin caused rejection of a heart transplant (Ruschitzka et al, 2000)). Second, there is no mechanism for reporting serious adverse events. St John's wort is a drug and should be marketed as such. The current situation, where effective herbal remedies are not subject to the usual scrutiny, is an unacceptable double standard. RUSCHITZKA, F., MEIER, F. J.,TURINA, M., et al (2000) Acute heart transplant rejection due to Saint John's wort. Lancet, 355, 548^549. Matthew Hotopf Clinical Senior Lecturer in Psychological Medicine, GKT School of Medicine, Department of Psychological Medicine,103 Denmark Hill, London SE5 8AZ
Informing patients about the side-effects of antipsychotic medication Sir: The study by Smith & Henderson ( Psychiatric Bulletin, May 2000, 24, 172^174) highlights the selectivity of information given to patients by doctors about antipsychotic medication. However, the information gathered is in effect about doctors' attitudes, about those side-effects on which they thought it worth volunteering information, and much remains to be understood about actual practice and patients' response. Psychiatrists tend not to be aware of which sideeffects of antipsychotic medication are most likely to cause distress to patients (Day et al, 1998). In the last few years there has been a major shift in prescribing practice from conventional antipsychotics to atypicals. Atypicals have a very different profile of side-effects and we need to know how troublesome their particular side-effects (weight gain and sedation) are to patients. Studies have shown little positive evidence that informing patients with schizophrenia about side-effects improves adherence (MacPherson et al,1996; Chaplin & Kent,1998). One cancertainly imagine that patients will feel happier in their awareness of side-effects when they can also be told of coping strategies, for example, ``this medicine can cause weight gain but we will monitor your weight and ask the dietician to advise you about what to eat''. We are currently studying in-patients' knowledge of the side-effects of antipsychotic medication, their sources of information and their desire for more information. We are asking doctors which side-effects they have discussed with their patients and are auditing case notes for details of the information offered. Our preliminary results show that the level of knowledge and understanding about sideeffects is low, many patients suffer physical problems but are unsure whether these are caused by their antipsychotic medication and most patients say they do not wish for more information. When asked, one in three patients said their side-effects were so bad they wanted to stop their medication. CHAPLIN, R. & KENT, A. (1998) Informing patients about tardive dyskinesia. Controlled trial of patient education. British Journal of Psychiatry, 172, 78^81. DAY, J. C., KINDERMAN, P. & BENTALL, R. (1998) A comparison of patients'and prescribers' beliefs about neuroleptic side-effects, prevalence, distress and causation. Acta Psychiatrica Scandinavica, 97, 93^97. MACPHERSON, R., JERROM, B. & HUGHES, A. (1996) A controlled study of education about drug treatment in schizophrenia. British Journal of Psychiatry, 168, 709^717. *Camilla Haw Consultant Psychiatrist, Jean Stubbs Head of Pharmacy, St Andrew's Hospital, Billing Road, Northampton NN1 5DG
Shell-shock Sir: We read with interest Howorth's ( Psychiatric Bulletin, June 2000, 24, 225^ 227) paper on the treatment of shellshock and, while agreeing with much of what he wrote, question the accuracy of several points. In general, he implies that psychological knowledge grew in a smooth progression from insights gained in the First World War to the present day. In fact, our research has shown that these new ideas were largely abandoned in the interwar period and had to be resurrected when war threatened in 1939 (Jones & Wessely, 2000). Both Myers and McDougall were so disillusioned by their experiences that the former moved to the field of industrial psychology and the latter emigrated to the USA. So upset was Myers by the rejection of his ideas by the military authorities that he refused to give evidence to the Southborough Committee on shell-shock because, as he wrote in 1940, ``the recall of my past five years' work proved too painful for me''. Millais Culpin, Professor of Medical Industrial Psychology at the London School of Hygiene, observed that few doctors with any regard for their reputation would mention an interest in psychoanalysis during the 1920s ``without the verbal equivalent of spitting three times over the left shoulder, and even to speak about the revival of war memories carried the risk of being accused of advocating free fornication for everyone'' (Culpin, 1952). While post-traumatic stress disorder (PTSD) and shell-shock undoubtedly have some elements in common, both disorders have been influenced by cultural forces, so that it may not be true to say that one is a precursor of the other. Shellshock is a reflection of the medical ideas of the early 20th century and its very name encapsulates the terrifying qualities of trench warfare. PTSD, first identified in the 1960s, was originally termed `postVietnam syndrome' and it expresses many of the conflicts of that war. In our detailed examination of the medical records of shell-shock cases, we have found that the majority of servicemen did not exhibit delayed symptoms (even though their applications for a war pension may not have been made until the early 1920s). Clinicians of the time commented how symptoms could readily become chronic unless they were treated swiftly by the methods of abreaction that Howorth describes. Finally, the notion that all soldiers, even those that were well led and highly trained, could break down in action was not accepted by the military authorities until the Second World War. The Southborough Report (War Office Committee of Enquiry into `Shell-Shock', 1922) concluded in 1922 that regular units with high morale were virtually immune from such disorders as shell-shock.
CULPIN, M. (1952) A criticism of modern trends in the treatment of psychoneuroses, pp.71^73. Medical Press. JONES, E. & WESSELY, S. (2000) The impact of total war on the practice of British psychiatry. InThe Shadows ofTotalWar: Europe, East Asia and the United States1919^1939 (eds R. Chickering & D. S. Mattern) Cambridge: Cambridge University Press. MYERS, C. S. (1940) Shell-Shock in France1914^1918, Based on aWar Diary kept by C. S. Myers. Cambridge: Cambridge University Press. WAR OFFICE COMMITTEE OF ENQUIRY INTO `SHELLSHOCK' (1922) Southborough Report. London: HMSO. *Edgar Jones Senior Research Fellow, Simon Wessely Professor of Epidemiology and Liaison Psychiatry, GKT School of Medicine, Department of Psychological Medicine,103 Denmark Hill, London SE5 8AZ
Flexible training in psychiatry Sir: I am writing on behalf of the Executive of the Woman in Psychiatry Special Interest Group, where I hold the brief for flexible training. We were very interested to read the recent articles on flexible training. As a general comment, we think it is encouraging that more information is becoming available on part-time training in psychiatry. Findings are overall encouraging: the Dean et al ( Psychiatric Bulletin, November 1999, 23, 613^615) study found that flexible trainees were satisfied with the quality of their training in spite of some drawbacks mentioned, including perceived lack of status, some inequality in training opportunities and a lack of part-time consultant posts at the end of training. Herzberg & Goldberg ( Psychiatric Bulletin, November 1999, 23, 616^619) found that the quality of flexible trainees compares favourably with that of full-time trainees. There is general agreement that there is an increased demand for flexible training and working which needs to be addressed. Job-sharing both at training and consultant levels has been suggested as an alternative. In connection with this, we would like to make two specific points arising from Garrard's ( Psychiatric Bulletin, November 1999, 23, 610^612) paper. The first point relates to the author's own experience of setting up her own jobshare in an approved senior house officer post. Regarding the negotiation of her contract she says ``We agreed to share our on-call duties, study and annual leave, pro rata and return to full-time training if the other left''. We believe this is not a good arrangement, as it does not protect the trainee's basic requirement to work part-time. Further, we suggest that study leave ideally should not be shared pro rata, as both partners are expected to gain continuing professional development points on an equal basis to full-time trainees.
We believe that protective arrangements should be negotiated for a consultant job-share, to secure the part-time position if the job-share partner leaves. In that case, it should be up to the employing trust to advertise the vacant part-time position. In fact it may be better altogether for separate part-time training contracts to be issued in all cases. If flexible training and working is to be seen as a valid and solid option, it has to be respected as such. Although job-shares may be convenient for financial or managerial reasons, they should not be binding for the incumbents to revert to full-time occupation. The second point relates to the comment ``Additional funding from the postgraduate dean's budget was arranged by our medical staffing department for us to overlap in one session per week''. This is a welcome development. We are pleased to report that the Flexible Training Office Thames Region has taken the initiative to make this `overlapping' session available for all job-share schemes. It has been pointed out that there may be financial implications, such as increased administrative costs, for trusts to employ two people. We would argue that the possible additional cost should be balanced against the possibility of recruiting and retaining well-trained doctors into the speciality. Alicia Etchegoyen Consultant Child and Family Psychiatrist, Chelsea and Westminster Hospital, 869 Fulham Road, London SW10 9NH
Social networks in `community care' Sir: Leff et al's finding ( Psychiatric Bulletin, May 2000, 24, 165^168) that the majority of the `TAPS' cohort lead impoverished social lives contrasts with the original vision of community care. Their reference to the nature of severe psychiatric illness seems to imply that this is responsible. Many seriously ill former long-stay patients have shown unexpected potential for social and personal relationships in coping with a relocation that would have taxed any demographically similar population, irrespective of mental illness. Most also faced a policy of confining them to small, dispersed groups (Heginbotham, 1985) on the assumption that this would automatically spawn social networks in `the community' and with an unpleasant implication that relationships among themselves were second best that has not been entirely avoided by TAPS. Such impoverishment should not be accepted for de-institutionalised patients, even at this late stage, and services for other groups, including assertive outreach and home care, also need fully to incorporate social network considerations if they are not to lead to
similar disappointments. The TAPS review will hopefully stimulate debate; and I would suggest an approach based on the promotion of a network of varied relationships across a range of activities and settings (Abrahamson, 1997). ABRAHAMSON, D. (1997) Social networks and their development in the Community. In Communication and the Mentally Ill Patient (eds J. France & N. Muir). London: Jessica Kingsley. HEGINBOTHAM, C. (1985) Good Practice in Housing for People with Long-Term Mental Illnesses. London: Good Practices in Mental Health. David Abrahamson Consultant Psychiatrist, Community Mental Health RehabilitationTeam, 313 Shrewsbury Road, London E7 8QU
Chlordiazepoxide dosage for alcohol withdrawal Sir: I would like to comment on the data of Naik et al ( Psychiatric Bulletin, June 2000, 24, 214^215). The initial mean daily dose of chlordiazepoxide equivalents used by general practitioners and specialist alcohol services ^ namely 45.8 mg and 98.1mg ^ approximates to 12 mg four times daily (q.d.s.) and 25 mg q.d.s. respectively. The former is very low, the latter low in more severe dependence. An inadequate initial daily prescription of chlordiazepoxide can have two adverse consequences: (a) the emergence of aversive (e.g. agitation and/or withdrawal hallucinations) and/or dangerous (e.g. withdrawal seizures) complications; (b) an inability of the patient to cope with the withdrawal symptoms, resulting in the resumption of drinking. Moderate to severely dependent individuals (as judged by the Severity of Alcohol Dependence Questionnaire, Stockwell et al, 1979) may require in the order of 40 mg of chlordiazepoxide q.d.s. and one or two extra `as required doses of 40 mg' for comfortable withdrawal in the first one to two days. Patients and their carers can be given the advice to reduce the amount of chlordiazepoxide if it causes excessive sedation or ataxia. Experience suggests that the as-required medication is needed by most patients at least in the first night when withdrawal symptoms are worse. Initial undermedication is an iatrogenic cause of non-adherence and needs to be emphasised in the training of those undertaking alcohol detoxification. Furthermore, clinicians managing a patient defaulting after the first day of detoxification should establish (by assertively seeking the patient) whether their initial daily prescription was too low.
STOCKWELL,T., MURPHY, D. & HODGSON,T. (1979) The severity of alcohol dependence questionnaire: its use reliability and validity. British Journal of Addiction, 78,145^155. Roger Howells Consultant Psychiatrist, Maudsley Hospital, Denmark Hill, London SE5 8AZ; e-mail: [email protected]
Multi-professional training in psychiatry Sir: I read with interest Bamforth et al's proposal for more multi-professional learning for psychiatry trainees ( Psychiatric Bulletin, February 2000, 24, 72^73). I am a psychiatry trainee from the UK currently working in Melbourne on a Crisis Assessment and Treatment Team. Apart from the consultant and registrar, the other members of the 10-person team come from non-medical backgrounds such as nursing, social work, occupational therapy and clinical psychology. Many have over 15 years' experience of working in mental health and as a result our daily discussions of patient management make use of a broad range of expertise. I have found this experience very instructive, particularly as the hierarchy of decision-making which prevails in the UK is largely unrecognised. Furthermore, non-medically trained clinicians often bring to discussions of management their experience of having worked in the past as patient advocates and case managers. Medical schools have begun to recognise the value of multi-agency involvement in teaching (Lennox & Peterson, 1998). I agree with the suggestion that psychiatry trainees would benefit if experienced nurses, occupational therapists, social workers and psychologists were given a more formal role in teaching. LENNOX, L. & PETERSON, S. (1998) Development and evaluation of a community-based, multi-agency course for medical students: descriptive study. British Medical Journal, 316, 595^599. Daniel J. Smith Registrar in Psychiatry, NorthWest Crisis Assessment and TreatmentTeam, 200 Sydney Road, Brunswick, Melbourne 3056,Victoria, Australia; e-mail: [email protected]
Homicide inquiries Sir: Not many would disagree with Szmukler's article ( Psychiatric Bulletin, January 2000, 24, 6^10) but I have to take issue with his interpretation of the inquiries regarding ``the patient as an automaton''. One of the concepts he elaborates in support of his argument that patients have feelings and a mind of
their own is to ask us to imagine that an aeroplane with a mind of its own decided not to follow the pilot's landing instructions. But I do not think the analogy is very valid in relation to homicide inquiries. One will surely agree that when a plane crashes, the inquiry will have to look at what part or parts failed and why. If there was wear and tear, why was this not identified and rectified prior to the flight, and more important was this oversight a negligent act? If the plane had a structural defect due to a `harsh' landing the previous day, which was not corrected prior to the next flight, surely some one was culpable and possibly negligent? Equating a crash enquiry with a homicide inquiry is oversimplifying a very complex
and quite understandably an emotional issue. Maybe if we had civil suits of negligence in homicide cases instead of inquiries, we would not feel so aggrieved, as the team would have its chance to defend its practices (which should in any case be within standards of reasonable care adopted by the profession). Sameer P. Sarkar Specialist Registrar in Forensic Psychiatry, Ashen Hill,The Drive, Hellingly, Hailsham, East Sussex BN27 4ER
Split posts register for psychotherapy Sir: At the recent Psychotherapy Faculty meeting in Bristol some consultants
working both as psychotherapists and as general psychiatrists felt it would be helpful to liaise with others who also hold `split' posts. I have been asked to coordinate an informal register of such individuals which would form the basis of a future network. I would like to invite anyone in a substantive split post involving psychotherapy to contact me with their details: who they are, where they work and what the designated split is in terms of specalisms and sessions. Sally Mitchison Consultant Psychiatrist with Special Responsibility for Psychotherapy, Cherry Knowle Hospital, Ryhope, Sunderland S22 0NB
the c olle ge Proposal for a Special Interest Group in Neuropsychiatry Procedure for establishing a Special Interest Group: (a) Any member wishing to establish a Special Interest Group shall write to the Registrar with relevant details. (b) The Registrar shall forward the application to Council. (c) If Council approves the principle of establishing such a Special Interest Group, then it will direct the Registrar to place a notice in the Psychiatric Bulletin, or its equivalent, asking members of the College to write in support of such a Group and expressing willingness to participate in its activities. (d) If at least 120 members reply to this notice, then Council shall formally approve the establishment of the Special Interest Group. In accordance with this procedure, Council has approved the establishment of a Special Interest Group in Neuropsychiatry, to provide a focus within the College in relation to this area of practice. Members are invited to write in support of this Group and express willingness to participate in its activities. Interested members should write to Miss Sue Duncan at the College. If 120 members reply to this notice, then Council shall formally approve the establishment of this Special Interest Group. Mike Shooter Registrar, Royal College of Psychiatrists,17 Belgrave Square, London SW1X 8PG
New College policies The College has always been committed to providing a supportive working environment for all of its employees. Council has recently approved a formal College policy providing protection from harassment in employment. The policy specifically covers sexual and racial harassment and bullying in the context of working relationships, not only between employees of the College, but also between College Members and employees.
Sexual and racial harassment Harassment may be defined as inappropriate behaviour, actions, comments or physical contact that is objectionable or causes offence. Harassment can take many forms, from that which may appear relatively minor (e.g. a single insensitive comment) to the more serious (e.g. persistent offensive remarks, physical contact or abuse). What is acceptable to one person may not be to another, so the issue is not one of intention, but of the effect the actions or behaviour of an individual or individuals have on another individual or group.
Bullying Bullying is persistent, abusive, intimidating, malicious or offensive behaviour and/or abuse of power which makes the target feel upset, threatened, humiliated or vulnerable and which undermines their
self-confidence. While it is unpleasant to be the recipient of someone's occasional aggressive behaviour, such behaviour would normally be considered to fall outside the definition of bullying or harassment.
Resolution (a) If an employee feels that he or she has been the victim of harassment, they are advised to make it clear to the harasser either verbally or in writing, explaining the distress which the unacceptable behaviour is causing and that it must stop. (b) Where informal methods fail or where serious harassment occurs, employees are advised to seek the assistance of the Head of Central Secretariat and Personnel who may be able to resolve the matter or who can assist in invoking the College's grievance procedure. (c) The College will treat seriously any breaches of this policy and all instances of actual or alleged inappropriate behaviour will be fully investigated and appropriate action taken. If an allegation is made by a College employee against a College member, the Registrar will be involved in any investigation. This is a summary of the main provisions of the policy. Further information is available from the Head of Central Secretariat and Personnel. Roberta Wheeler Head of Central Secretariat and Personnel, Royal College of Psychiatrists,17 Belgrave Square, London SW1X 8PG