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the columns c orre sp ondence Liaison services collaborative working We read with interest Kewley & Bolton’s survey on liaison psychiatry ( Psychiatric Bulletin, July 2006, 30, 260-263) and the related correspondence of Pitman & Catala¤n ( Psychiatric Bulletin, January 2007, 31, 33). In the wake of threats to close or merge liaison service with crisis resolution teams, it is imperative not to compromise patient care. The liaison psychiatry service in Birmingham Heartlands Hospital has developed a way of working to adhere to the time targets in accident and emergency (A & E) departments which neither compromises psychosocial assessment (National Institute for Clinical Excellence, 2004) nor overburdens the existing psychiatric services. The protocol for psychiatric assessment is based on the SAD PERSONS scale (Juhnke, 1994) and has been devised in consultation with the A & E department. The A & E department is responsible for initiating the psychosocial assessment and classifying patients either as high or low priority, based on needs and risks. The majority of psychiatric patients attending A & E departments out of hours are needing assessment and treatment for self-harm. The patients who are deemed high priority are referred to the local crisis resolution teams for emergency assessment. Low-priority patients are referred after medical assessment to the psychiatry clinic in the A & E department on the next working day. This efficient collaboration reduces the number of ‘did not wait’ patients and possibly avoids breaching A & E waiting time targets. In a 6-month period, 46% of psychiatric patients attending the A & E department out of hours have been referred to the clinic. If this way of collaborative working can be adapted to meet local hospital needs, it might address some of the concerns raised by Kewley & Bolton. JUHNKE, G. (1994) SAD PERSONS Scale review. Measurement and evaluation. Counselling and Development, 27, 325-327. NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2004) Self-Harm.The Short-Term Physical and Psychological Management and Secondary Prevention of Self-Harm in Primary and Secondary
Care. NICE. http://www.nice.org.uk/pdf/ CG016NICEguideline.pdf
leics.part.nhs.uk, Stephen J. Frost Brandon Mental Health Unit, Leicester General Hospital
Sathish Masil Specialist Registrar, General Adult Psychiatry, New Bridge House,130 Hobmoor Road, Birmingham B10 9JH, email gmashil@ yahoo.co.uk, Dhruba Bagchi Consultant in Liaison Psychiatry, New Bridge House, Birmingham
doi: 10.1192/pb.31.5.191a
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Clozapine-induced speech dysfluency: further cases Lyall et al ( Psychiatric Bulletin, January 2007, 31, 16-18) presented two cases of clozapine-induced speech dysfluency and suggest that there are only four cases in the British and American literature. However, we do not think that their literature search was comprehensive. Begum (2005) reported stuttering, facial tics and myoclonic seizures, which developed a few days after initiation of clozapine for treatment-resistant schizophrenia. Furthermore, Ba«r et al (2004) examined the hospital records of about 6000 German patients receiving antipsychotic treatment over 3 years for evidence of stuttering as a possible sideeffect. They described seven patients with stuttering induced by the atypical antipsychotics olanzapine (six cases), and clozapine (one case). We also observed a man in his early 40s who developed stuttering when his clozapine was increased from 400 mg/ day to 450 mg/day. This was also associated with a marked increase in seizure activity which necessitated reducing and stopping clozapine. We suggest that future case reports in the Psychiatric Bulletin should describe a systematic search of standard databases for other case reports and the time period covered by such a search. This would be beneficial to the Psychiatric Bulletin and the wider readership. BA«R, K. J., HA«GER, F. & SAUER, H. (2004) Olanzapineand clozapine-induced stuttering: a case series. Pharmacopsychiatry, 37,131-134. BEGUM, M. (2005) Clozapine-induced stuttering, facial tics and myoclonic seizures: a case report. Australian and New Zealand Journal of Psychiatry, 39, 202. *Nasser Abdelmawla Brandon Mental Health Unit, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, email: Nasser.Abdelmawla@
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We read with interest the report by Lyall et al ( Psychiatric Bulletin, January 2007, 31, 16-18) of speech dysfluency associated with clozapine and would like to report our experience in a patient we are treating. Our patient is currently 44 and experienced his initial episode of psychosis when he was 23. Aged 27 he was diagnosed with schizophrenia and maintenance typical antipsychotic medication was prescribed, with initial good effect. However, he continued to have low-grade positive symptoms and the negative syndrome also became apparent. Over the subsequent 10 years he had many changes of medication with little positive effect. At the age of 38 he was commenced on clozapine and his positive symptoms rapidly receded. At a dose of 200 mg he developed a stutter (he had not had this problem as a child), but the dose was increased to 350 mg daily because of its overall positive effect. However, the stutter was so disabling that clozapine optimisation strategies were employed and the clozapine dose was gradually reduced. Owing to a lack of local speech therapy services our patient was referred to a neurologist, who confirmed our findings and supported our medication strategy. Amisulpride and low-dose benzodiazepines were added and the dose of clozapine was reduced. The stutter reduced with these changes and disappeared when the clozapine was stopped. His illness is currently well controlled and his current prescription is amisulpride 400 mg twice daily with clonazepam 0.5 mg twice daily. Laki Kranidiotis Consultant Psychiatrist, Kidderminster Hospital, Kidderminster DY11 6RJ, email:
[email protected], SheilaThomas Community Psychiatric Nurse, Kidderminster Hospital doi: 10.1192/pb.31.5.191b
Medication side-effects informing the MHRA Lyall et al ( Psychiatric Bulletin, January 2007, 31, 16-18) described how two
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patients with psychotic illnesses developed stuttering while being treated with clozapine. The Government’s Medicines and Healthcare Products Regulatory Agency (MHRA) is responsible for ensuring that medicines are acceptably safe. It takes action in relation to safety concerns and changes in the balances of risks and benefits. There is no mention by Lyall et al of informing the MHRA about the stuttering side-effect. I would like to urge readers of Psychiatric Bulletin to report to the MHRA any side-effects, suspected or otherwise, caused by a medicine through the Yellow Card Scheme. This scheme plays an essential role in protecting public health by helping the MHRA to monitor the safety of medicines on the market. Psychiatrists and other healthcare professionals can complete a form online at www. yellowcard.gov.uk, or on a Yellow Card available in the British National Formulary, or directly from the MHRA (by telephoning 0800 731 6789). I would also urge readers to encourage patients to report any side-effects. With these reports, we can actively look for signs of potential safety issues requiring further investigation. Reporting of adverse drug reactions is the professional duty of all healthcare professionals. The continued success of the Yellow Card Scheme depends on the continued support of health professionals and patients in completing Yellow Cards. We encourage Yellow Card reports from patients, but it is also vitally important that we continue to receive reports from psychiatrists and other health professionals. June Raine Director of Vigilance and Risk Management of Medicines, Medicines and Healthcare Products RegulatoryAgency (MHRA), London SW8 5NQ, email:
[email protected] doi: 10.1192/pb.31.5.191c
Work-related stress in psychiatry I read with admiration Dr Harrison’s report on work-related stress ( Psychiatric Bulletin, October 2006, 30, 385-387) but I felt a sense of disappointment that we as psychiatrists and the wider medical profession continue to deny our health needs and general fallibility, and that our employers exhibit similar impotence. Our training focuses our energies on succeeding both academically and later clinically. We are a competitive breed, entering our working life with high personal expectations of our performance on a day-to-day basis. The effect of daily consultation with morbidity and mortality on ourselves has to be addressed somehow. Denial becomes a handy defence mechanism. As a profession we are more likely to develop alcohol misuse and dependence
problems, as well as having a higher suicide rate. Yet how often do the precursors to these go unchecked or unnoticed. Taking time off sick is often accompanied by guilt and a sense of failure. We seem to believe that it shouldn’t happen to us. Currently, our junior doctors are in a heightened state of performance anxiety as Modernising Medical Careers goes live. The usual anxieties related to finding a job are magnified considerably by the number of jobs being applied for. How are we and our employers protecting this vital part of the work force from the inevitable stressrelated symptoms that are likely to ensue? When will we start to be honest with ourselves about our susceptibility to illness and look to prevent and manage it? When will our employers? Amy M. Macaskill Specialist Registrar in General Adult Psychiatry, Royal Cornhill Hospital, 26 Cornhill Road, Aberdeen AB25 2ZH, email: amy.macaskill@ nhs.net doi: 10.1192/pb.31.5.192
How safe are interview rooms? Campbell & Fung ( Psychiatric Bulletin, January 2007, 31, 10-13) highlighted some important deficiencies in safety of patient interview rooms. We conducted a similar audit of 119 interview rooms in southern Hampshire in 2004, which was a repeat of an earlier study by local trainees in 2000. We were therefore able to look at whether interview room safety had improved and whether newly commissioned facilities had been provided in accordance with the Department of Health’s advice regarding the safety of interview rooms (Department of Health, 2004). Our results were largely similar to Campbell & Fung’s but in southern Hampshire 75% of in-patient rooms were not isolated ( v. 23%), 75% had a functioning panic alarm system ( v. 0) and 52% had doors that opened outwards ( v. 6%). Of particular concern was that rooms used in accident and emergency departments to assess acutely disturbed and unknown patients were isolated, had no viewing window, no panic button and were cluttered. It was reassuring to note that those rooms which had been commissioned in the past 3-4 years demonstrated a higher level of adherence to the standards: 92% had an unimpeded exit, 100% had a functioning alarm and 77% had an internal inspection window. However, 67% remained isolated and 61% were cluttered. DEPARTMENT OF HEALTH (2004) Mental Health Policy Implementation Guide - Developing Positive Practice to Support the Safe andTherapeutic Management of Aggression and Violence in Mental Health In-Patient Settings. Department of Health.
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Natasha Rae Specialist Registrar in Forensic Psychiatry,Wessex Forensic Rotation, Ravenswood House Medium Secure Unit, Knowle, Fareham PO17 2NP, email:
[email protected], Abigail Hewitt Specialist Registrar in Adult Psychiatry, St Anne’s Hospital, Poole doi: 10.1192/pb.31.5.192a
BMA guidance on problem gambling The British Medical Association (BMA) has recently published a document on problem gambling in the UK prior to the Gambling Act 2005 coming fully into force in September. The document focuses on various aspects of problem gambling and particularly emphasises the potential impact on young people (British Medical Association, 2007). Also emphasised is the need for the National Health Service to provide help for those with this problem. Two important areas that the document does not emphasise however, are the impact on the elderly and their carers. The UK has an ageing population, with 16% of the population currently aged over 65. This is forecast to increase, with the elderly making up 19% of the population by 2021 (projected data from Office of Health Economics, 2002). The elderly can be at risk of problem gambling and are more likely to fall prey to the psychosocial consequences. It is therefore surprising that the BMA document did not make specific mention of this particularly vulnerable group of people. The government has emphasised the importance of caring for carers (Department of Health, 1999). Carers of those with problem gambling could also suffer psychosocial distress and they require recognition and support. In the UK, where more and more elderly couples have only each other for support, this is particularly important. Again it is surprising that the BMA did not mention this in its recommendations. BRITISH MEDICAL ASSOCIATION (2007) Gambling Addiction and itsTreatment within the NHS: A Guide for Healthcare Professionals. BMA. DEPARTMENT OF HEALTH (1999) Caring about Carers: A National Strategy for Carers. Department of Health. Ishaan Gosai Specialist Registrar, Assertive Outreach Service, Plymouth, email: ishaang@ hotmail.co.uk doi: 10.1192/pb.31.5.192b
Modified ‘mooting’ should be part of psychiatric training Naeem et al ( Psychiatric Bulletin, January 2007, 31, 29-32) describe the incorporation of simulated mental health review tribunal workshops in psychiatric
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training. It is my experience that psychiatric trainees currently receive adequate preparation for successful participation in mental health review tribunals (MHRTs) via on the job experience under consultant supervision. However, the legal profession has long employed ‘mooting’ in their training. This involves a mock trial in which lawyers argue the legal principles of a fictitious case. The purpose is to improve analytical skills, the presentation of information and public speaking (http:// www.oup.co.uk/oxfordtextbooks/law/ mooting/more/). These principles can also be applied to giving oral evidence at a MHRT. Tribunals appear to be increasingly legalistic. In forensic psychiatry it is not uncommon for the patient to be represented by a senior barrister. Cross-examination of the doctor can be a lengthy, complex and stressful experience. The manner in which MHRTs are conducted in general psychiatry may also be affected in the future. The proposed amendments to the Mental Health Act 1983 focus the doctor’s role on issues that relate to the detention of patients and hence increase the importance of adequate formal training. Following the recent report of the Barrett homicide inquiry (NHS London, 2006) consultants may provide the only psychiatric input into MHRTs in the future, thus lessening training experience at work. Modified mooting or simulated MHRTs should be provided as part of psychiatric training, and should be introduced into both basic and higher training. Liaison with lawyers would be important in designing these exercises. This might also produce more mutual understanding of professional roles. NHS LONDON (2006) Report of the Independent Inquiry in the Care andTreatment ofJohn Barrett. NHS London. Mark H. Taylor Specialist Registrar in Forensic Psychiatry, Fleming House, Rampton Hospital, Nottinghamshire DN22 0PD, email: Mark.Taylor2@ nottshc.nhs.uk doi: 10.1192/pb.31.5.192c
Incentives for medication adherence As members of an assertive outreach team covering a socially deprived area of south-west Dublin, we read with interest the paper on money for medication by Claassen et al ( Psychiatric Bulletin, January 2007, 31, 4-7) and congratulate the authors for applying contingency management measures, which are useful in other areas of medicine, in such an innovative, pragmatic way. Our team has not used financial incentives but has used other incentives to improve adherence to
depot antipsychotics in a number of patients with severe illness and a high rate of hospitalisation. The incentives were negotiated with the patient and involved judicious and appropriate prescription of low doses of medications requested by the patient (such as lowdose hypnotics). We discerned that the key ethical issues were undue influence and imbalance of power. We accept Claassen et al’s differentiation of offer and threat, although we should point out that when a patient is taking medication for payment, an implicit threat exists in that failure to continue results in a loss for the patient. However, against a background of several hospitalisations associated with serious reduction in quality of life because of nonadherence to effective medications, it does appear reasonable and ethical to regard the benefits to the patient of adherence as overcoming such negative factors as imperfect consent. We would counsel that such arrangements be subject to external review and monitoring. *Guy Molyneux Specialist Registrar in Psychiatry, Psychiatric Unit, Adelaide Meath National Children’s Hospital, Dublin 24, email:
[email protected], Patrick Devitt Consultant Psychiatrist, Adelaide Meath National Children’s Hospital, Dublin doi: 10.1192/pb.31.5.193
Claassen et al bring ‘token economies’ into the 21st century through offering financial incentives for single depot injections. The prejudices of the majority of team managers were not explored in detail. Of more interest is the process by which their ‘operational policy’ was developed and its progress through the local research ethics committee. How were the ethical considerations discussed by the authors addressed by the committee? Two particular concerns arise from this study: the possible unwanted outcomes of payment and the process of discontinuation. The amount of payments ‘depended on the frequency of depot injections’. It is not clear whether more or less frequent injections qualified for higher sums. Differential rewarding might have the unwanted effect of encouraging patients to modify their presentations to maximise payments. There is little possibility of discontinuation while payments are given for adherence and concordance is ignored. Claassen et al comment that adherence achieved through use of financial incentives may lead to greater insight and concordance. In a financially moribund National Health Service, it is likely that the small cost of paying patients to adhere to a treatment plan will obviate the need to provide more costly psychosocial interventions. This would be counterproductive and damaging to the clinical relationship.
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Payments tied to a care plan that included psychosocial work with the aim of the patient moving into personally rewarding and possibly paid occupation would avoid problems associated with immediate payment based on adherence to medication. They could also provide an impetus to establishing concordance within a longer-term understanding of the recovery process. Solmaz Sadaghiani Senior House Officer in Psychiatry, *Chris Fear Consultant Psychiatrist, Gloucestershire Partnership NHS Trust,Wotton Lawn Hospital, Horton Road, Gloucester GL13WL, email:
[email protected] doi: 10.1192/pb.31.5.193a
Claassen et al state that financial incentives to increase adherence to depot medication should be considered further and welcome a debate upon the ethical implications of this management strategy. They identify autonomy, as defined by Beauchamp’s four-principles approach, as a specific area of concern (Beauchamp, 2003). The key issue here therefore is whether the payment is coercive or not. If it is coercive, the individual’s ability to act autonomously has been reduced. Claassen et al use Wertheimer’s definition that ‘threats coerce but offers do not’, with a threat being an action that makes the individual worse off than a baseline whereas an offer does not (Wertheimer, 1993). They argue that the offer is not coercive and is therefore ethically neutral. It can be argued, however, that routine payment for receiving a depot will become the new baseline, rendering the removal of payment a threat. Removal of payment therefore becomes coercive, reducing autonomy. The loss of money is minimised by Claassen et al because they consider its small value to mean that its removal is seen as non-threatening. However, this contradicts the hypothesis that it is the money that encourages the individual to accept the depot. Inevitably the use of payment will be coercive for some groups, reducing their autonomy. At the same time payment promotes access to essential treatment, in keeping with Beauchamp’s principle of justice. A tension clearly exists between the principles of autonomy and justice; this is brought into sharper focus for disenfranchised, economically deprived groups. BEAUCHAMP,T. L. (2003) Methods and principles in biomedical ethics. Journal of Medical Ethics, 29, 269-274. WERTHEIMER, A. (1993) A philosophical examination of coercion for mental health issues. Behavioural Sciences and the Law, 11, 239-258. Giles Berrisford Specialist Registrar in General Adult Psychiatry, Queen Elizabeth Psychiatric Hospital, Edgbaston, Birmingham B15 2QX, email:
[email protected] doi: 10.1192/pb.31.5.193b
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Personality disorder a stigmatising diagnosis? We were interested in John Gunn’s anecdote ( Psychiatric Bulletin, January 2007, 31, 25-28) regarding a patient who had apparently been informed that he ‘was a personality disorder’ by the registrar. Professor Gunn’s reply is worth quoting in full: ‘I never use that term, I don’t use that term in my clinic, it’s not something I ever say to any patient.’ This raises the questions: does Professor Gunn not believe in the diagnostic category, as seems to be implied (rather than not believing that this diagnostic category fits this person), or does he acknowledge the category but perceives the label as stigmatising? Either is interesting, given that the category itself is well recognised in both ICD-10 and DSM-IV, and is therefore likely to be used by at least some practising psychiatrists. If Professor Gunn perceives the term ‘personality disorder’ as stigmatising and/or unhelpful, would it not be better to discuss the possibility of this label being applied, and the grounds for its application, with the individual concerned, rather than distancing himself from the concept? Presumably the person to whom the label was applied remained the same person before and after the diagnosis. If psychiatrists genuinely believe in reducing the stigma still attached to mental illness in general and personality disorder in particular (Lewis & Appleby, 1988), is avoidance a rational way to deal with diagnostic labels perceived to be stigmatising? It seems that even among the most justly esteemed psychiatrists, the label personality disorder still elicits aversive responses. Perhaps psychiatric fear of personality disorder still needs exploring. LEWIS, G. & APPLEBY, L. (1988) Personality disorder: the patients psychiatrists dislike. British Journal of Psychiatry, 153, 44-49. *Kate Robertson Senior House Officer, Bushey Fields Hospital, Dudley DY2 1LZ, email: Kate.
[email protected], Floriana Coccia Senior House Officer, Bushey Fields Hospital, Dudley doi: 10.1192/pb.31.5.194
Is the Mental Health (Care and Treatment) (Scotland) Act 2003 the least restrictive option? The Mental Health (Care and Treatment) (Scotland) Act 2003 became effective in October 2005 but the paucity of literature and debate surrounding it has been disappointing. The Act changed mental healthcare delivery in Scotland, and its positive aspects are described elsewhere (Darjee & Crighton, 2004; Thomson, 2005). The Act has defined principles (e.g. interventions should involve the minimum
restriction of the patient), but paradoxically introduced a number of new restrictions on patients. The ‘gateway order’ in the 2003 Act is a 28-day short term detention certificate. Proponents suggest that this 28-day detention order with compulsory treatment is less restrictive than a 72 h (emergency) detention period with no compulsory treatment, as the latter gives no right of appeal. Previously, it was common psychiatric practice to grant ‘time off the ward’. Now formal suspension of detention is required before patients leave hospital grounds, even for short periods. The responsible medical officer may attach formal conditions to this. The Act introduced the Mental Health Tribunal for Scotland which hears all applications for 6-month detentions. These formal and often adversarial hearings occur irrespective of patients’ objections and can be an ordeal for many patients. Administrative demands on services have increased significantly, diverting clinical resources from the majority of (informal) patients, thereby limiting their service provision. We therefore propose that the 2003 Act does not fulfil the principle of minimum restriction. DARJEE, R. & CRIGHTON, J. (2004) New mental health legislation. BMJ, 329, 634-635. THOMSON, L. D. G. (2005) The Mental Health (Care andTreatment) (Scotland) Act 2003: civil legislation. Psychiatric Bulletin, 29, 381-384. *Daniel M. Bennett Senior House Officer in Psychiatry, Royal Cornhill Hospital, Aberdeen ABH 2ZH, email:
[email protected], Kenneth M. Mitchell Consultant Psychiatrist, Royal Cornhill Hospital, Aberdeen doi: 10.1192/pb.31.5.194a
Are old age services equipped to cope with immigrant elders? As a trainee psychiatrist of ethnic origin, I wonder whether old age psychiatric services are aware of problems they are likely to face in the future and how they plan to adapt to them. Those migrants who came to the UK from India, Pakistan and Bangladesh in the late 50s and 60s are now reaching retirement age and consequently any mental health problems they experience would need to be addressed by old age psychiatry services. Some services may have had experience of treating the parents of these migrants, but not in the numbers they are likely to face. Traditionally, elders have been cared for in older age by the extended family, who have been able to meet their cultural, social and physical needs. As the current generation of descendants becomes more integrated into Western society, the break
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up of the extended family is both evident and inevitable. There are also wider implications. Are there culturally sensitive and appropriate placements available for such people once they are discharged, if going home is no longer an option? Surely we need to plan ahead and address these issues which we are highly likely to face in the near future. Asad Raffi Senior House Officer in General Adult Psychiatry, Royal Oldham Hospital, Oldham OL12JH, email:
[email protected] doi: 10.1192/pb.31.5.194b
Which medications for sideeffects should be included on forms 38 and 39? We recently surveyed the medication prescribed to 145 detained in-patients to determine which drugs for the sideeffects of psychotropics were included on Mental Health Act forms 38 and 39 and which were not. Clinicians were largely in agreement that drugs for motor disorders, hypersalivation and antipsychoticinduced seizures should be included whereas drugs for constipation, dyspepsia and metabolic syndrome should not. There was, however, disagreement about inclusion of drugs for weight reduction. Neither the Code of Practice (Department of Health & Welsh Office, 1999) nor the Memorandum (Department of Health & Welsh Office, 1998) indicates which medicines should or should not be included on treatment authorisation forms. According to the Mental Health Act Commission guidance note for commissioners on consent to treatment, ‘adjuvant medication without which the therapeutic objectives of alleviation of the symptoms of mental disorder . . . could not be achieved’ should be included, but laxatives are specifically excluded (Mental Health Act Commission, 2002). It appears that current practice regarding which drugs for side-effects to include or exclude has arisen haphazardly. The simplest solution would be to include none. The Mental Health Act is concerned with treatment for mental disorder and makes no mention of medications for side-effects. DEPARTMENT OF HEALTH & WELSH OFFICE (1998) Mental Health Act1983. Memorandum on Parts I toVI, VIII and X. TSO (The Stationery Office). DEPARTMENT OF HEALTH & WELSH OFFICE (1999) Code of Practice Mental Health Act1983.TSO (The Stationery Office). MENTAL HEALTH ACT COMMISSION (2002) Guidance for Commissioners on Consent toTreatment and Section 58 of the Mental Health Act. Mental Health Act Commission. *Camilla Haw Consultant Psychiatrist, St Andrew’s Healthcare, Billing Road, Northampton NN1 5DG, email:
[email protected], Maria McIntyre Clinical Pharmacist, St Andrew’s Healthcare, Northampton doi: 10.1192/pb.31.5.194c
Incentives for medication adherence
Guy Molyneux and Patrick Devitt Psychiatric Bulletin 2007, 31:193. Access the most recent version at DOI: 10.1192/pb.31.5.193
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