Cross-Cultural Psychiatry

Halcion-Tablets

(l!iazolam)

INDIUnoNS AIID USAGE

,

HAlCION Tablets are Inclicaled in the shOrt-term management of insomnia characterized by diflicully in tailing asleep. lrequent nocturnal awakenings, and/or early morning awakenings. It Is recommended that HAlCION not be prescribed in quantities exceeding aone-month supply.

CDNTRAlNDIUnDNS Patients with known hypmensitivity to this drug or other benzodiazepines. HAlCION is contrainclicated In pregnant women due 10 potenbal fetal damage. Patients likely to become pregnanl while receiving HAlCION shoIJld be warned of the potenlial risIl to IIle tetus.

WAII.I.GS Ownlosage may occur at2 mg. lour times the maximum recommended therapeutic dose (0.5 mol. Patients shoIJld be cautioned not to exceed prescribed dosage. Because ot its depressant CNS eltec:ts. patients should be cautioned against engaging in hazardous occupations requiring complete mental alertness ancl also about IIle simultaneous lngesbon of alcohol and other CNS depressant drugs. Anterograde amnesia ancl paradoxical reactions ha..e been reported wilh HALCION ancl some oIher benzodiazepines.

BOOK Cross-Cultural Psychiatry Edited by Albert Gaw, Boston. John Wright • PSG. 1982. 384 pp, $35.

PtlEUunoNS ......: In elderly andior debililated patients. lreallllelli should be inibaled at 0.125 mo 10 decrease 1lle possibllrty of dMlopment of O'Ierseda1ion, dizziness. or Impaired coordination. caution shoukl be exertised in patients with signs or symptoms of depression which coukl be intensitlecl by IIypnotic drugs. SuicidaltenClencies ancl intentional O'Ienlosage is more common in these patients. The usual precautions should be obser'led in patients with impaired renal or hepatic function and ChroniC pulmonalY insufficiencY ......... IIfPdlllll: Alert patients about: (a) COl\$Umplion of alcohol ancl drugs. (bl possible letal abnormalities. lc) operating machinelY or driving. (d) nol increasing dose of the drug due 10 risk of dependence, (e) possible worsening of sleep alter discontinuing HALCION. taolIllMy TIItI: Nol ordinarily required in otherwise healthy patients. DnIt IlIlIIIClI-= Addi1M CNS depressant ellects with OIIler psychotropics. anticonvulsants, antihistaminiCs. ethanol, ancl other CNS depressants. Pharmacokinelic interactions of benzodiazepines with other drugs ha'Ie been reported. ~.......... ...,....... " FIIlIIIIy: No eYidence of cartinooeniC polenlial was obseMd in miCe during a24-mon1h Sludy with HAlCION in doses up to 4000 times 1lle human dose.......-,: Benzodiazepines may cause letal damage n adminiSlered during pregnaney. The Child born of amOther who is on benzodiazepines may be at some risk for withdrawal symplOms ancl neonataillaccidrty during the pos1natal period. ...............: Administration 10 nursing mothers is not recommended. NIIlrIc ....: 5aleIy ancl elIicacy in Children below the age of 18 ha..e nol been established.

ADVERSE REACnDNS During pIacebo-controiled clinical studies in whiCh 1003 palients received HALCION Tablets, the moS1troublesome side eftects were extensions of the pharmacologiC aetivi1y of HAlCION. e.g.. drowsiness. dizziness, or light-headedness. HAlCION Number of Patients 1003 997 • % of Patients Reporting: C8n1ra1 Nerwus System Orowslness 14.0 ·6.4 Heactaclle 9. 7 8.4 Oizziness 7.8 3.1 Nervousness 5.2 4.5 Light-headedness 4.9 0.9 COOrdination Disorder/Ataxia 4.6 0.8 Gas1rointestinal NauseatVomiting 4.6 3.7

In addition. the following ad'Ierse events hM been reported less frequenUy (i.e., 0.9-0.5%): euphoria. taehycardia. tiredness. confusional SlatestmemolY impairment, Cl1lI1pstpain. depression. visual diSlurbances. Rare (i.e.• less than 0.5") ad'Ierse reactions included constipation. taste ailerations. diarrhea. dlY mouth. dermatitiS/allergy. dreaming/nightmares, insomnia. paresthesia. tinn~us. dysesthesia, weakness. congestion. death from hepatic failure in a pabent also receiving diuretiC drugs. The following ad..erse MntS ha..e been reported in associalion with 1lle use of benzodiazepines: dystonia. irritabilrty. anorexia. fatigue, sedation. slurred speech. jauncliCe, pruritus. dysarthria, Changes in libido. menSlrual irregularities. incontinence ancl uriOi'Y retenflOl'l. As with all benzodiazepines, paradoxical reaclions suCh as stimulation. agitation. increased muscle spaslicrty. sleep diSlurbances. hallucinations and otller ad'Ierse behavioral ellects may occur rarely ancl in aranclom lashion. Should these occur. use of IIle drug shoIJld be dlsconbnued. No laboratory changes were considered to be of physiological signilicance. When IrealIlleIIt is protracted. periodiC blood counts. urinalysis ancl blood Chemistly analyses are advisable. Minor changes in EEG patterns. usually Iow-vollage fm activity hM been obseMd in pabents during HAlCION therapy ancl are of no known signnicanee.

DRUG ABUSE AIID DEPENDENCE CIIIlnII..........: HALCION Tablets are aControlled Substance in SChedule IV. ....... ~ : WIthdrawal symptoms ha'Ie occurred followino abrupt discontinuance of benzodiazepines. Patients with a histolY of seizures are al particular risIl. Addiction-prone patients shOuld be closely monitored. Repeat prescriptions should be limited 10 thOse under medical supeMsion.

OVERDOSAGE Because ofllle poteney oltriazolam. O'Ienlosage may occur at2 mg. four times the maximum recommended therapeuliC dose (0.5 mg). Mannestations of O'Ienlosage include somnolence. contuSion. impaired coordination, slurred speech. and ultimately. coma. Respiration. pulse. ancl blood pressure should be mon~ored and supported by general measures when necessalY. Immediate gaslric lavage should be perfOrmed. Multiple agents may ha'Ie been ingested.

DOSAGE AIID ADMINISTRAnDN The dosage of HAlCION Tablets muSl be inclividuaJized for maximum benefiClat efleet and to help avoid signnicant ad'Ierse eftects. The recommended dosage range for adults is 0.25 to 0.5 mo before retiring. In geriatric and/or debilitaled patients, the dosage range is 0.12510 0.25 mo. Therapy should be In~iated at 0.125 mg (hall of a0.25 mg scored tablet) until inclividual response is determined. NDW SUPPliED HAlCION Tablets scored. are available in the following strengths ancl package sizes: 0.25 mg (powder blue) BoI1leS of tOO NDC 0009-001Hll Un~DosePkg(too) NDC0009-0017-08 Un~ Dose Pkg (100) NDC 0009-0017-17 0.5 mg (wh~e) BoI1leS 01100 NDC 0009-0027-01 Un~ Dose Pkg (tOO) NOC 0009-0027-08 Un~ Oose Pkg (100) NOC 0009-0027-18 SlOre at controlled room temperalure 15'-3O'C (59'-86'f). caution: Federal law prohibits dispensiAO without prescriplion.

~ THE UPJOHN COMPANY ~ Kalamazoo. M149OO1. U.S.A. J';~470B

• Perceptive psychiatrists who travel the world inevitably have their preconceptions challenged by broadening experiences. They may find the social controls of alcoholism best developed in Yugoslavia; the most culturally adaptive modalities for the rehabilitation of "schizophrenics" in India; effective educational and judicial restraints on youthful delinquents in Czechoslovakia; minor deviations of behavior well-handled by paramedical counseling and guidance in China-and so on, to similarly enriching reorientations in other countries. For the non-traveling mental health professional, CrossCultural Psychiatry offers correspondingly valuable information about ethnic groups in this country. In this volume, authors personally acquainted and trained in various cultures alert the reader to the unique beliefs, linguistics, semantics, existential orientations, and special therapeutic techniques required to work with each group. I shall avoid the reviewer's stereotyped cliche about the chapters varying in quality, other than to say that they range from fair through excellent to superb. Among the last-mentioned is the editor's literate, historically empathetic, and clinically sensitive chapter on Chinese and ChineseAmerican patients. Similarly intriguing is Yamamoto's discussion of retained Japanese concepts of hierarchic familial obedience that modify therapeutic interactions, especially with regard to precautions against traditional suicide. 498

May 1983

PSYCHOSOMATICS

REVIEWS Within the parameters of ethologic and clinical cogency are ensuing chapters by Araneta on the beliefs of Filipino immigrants; by Ruiz on mixtures of pagan and Christian healing practices (santeria) among Cubans; Wilkerson's emphasis on the importance of mother-child symbiosis for Mexican immigrants, and their retained susceptibility to esoteric afflictions such as mal ojo (evil eye), susto (exhaustion), mal puesto (evil possession); and the special understanding and modified therapeutic modalities required for Puerto Ricans (Gomez), American Indians (Clevenger), and blacks (Spurlock, Bragg, and Shedar). A terminal section on training psychiatric residents in the dynamic cultural vectors of therapy is especially relevant in our heterogeneous society. This book will help broaden the cultural horizons, expand the global understanding, and refine the therapeutic techniques of every mental health professional who reads it with merited appreciation. Jules H. Masserman, M.D. Northwestern University

Psychotherapeutic Treatment of Cancer Patients Edited by Jane G. Goldberg. New York. The Free Press. 1981.364 pp. $25.

• This book is beneath contempt for its trivialization of human suffering. The obfuscation, by interpretive psychology, of those imponderably painful experiences arising from the most ungodly scourge thus far visited on mankind gives this volume status, both moral and medical, equivalent to laetrile. In 15 chapters, grouped into five MAY 1983· VOL 24' NO 5

sections, the 20 authors-mostly nonmedical-parade their ignorance of a disease with which they show little acquaintance. It is a cruel, but continuing, example of the price the ill are paying for American psychiatry's overzealous pursuit of psychoanalytical explanations of human behavior. The book's principal aim is to show the psychological determinants of cancer and offer adjunctive psychological treatment. It is a mission pursued by many these days with a feryor reminiscent of the search for th'e Holy Grail. The fruitlessness of similar crusades to find the emotional causes of tuberculosis, polio, and heart disease fails to deter the delusional. The current overemphasis on emotions and cancer has itself become an insufferable malignancy. The book's editor is a psychologist in the private practice of psychoanalysis. Of the authors she has brought together, seven are physicians but none appear to be oncologists. One is an internist in the private practice ofsomething called medical orgonomy. His chapter on Wilhelm Reich's Cancer Biopathy will leave the rational person speechless. The book stands condemned by its own statements. For instance: "Cancer has been described as a type of suicide, a way out, a mode of death, as one of the ways we choose [italics are the author's] to die." This is hardly destined to lessen the anguish of patients faced with an agonizing death. Today no book in the behavioral sciences is complete without a chapter or two on stress and immunology. It functions as the scientific imprimatur. This book has not ig-

nored contemporary sophistry and so a chapter by one of Hans Selye's former colleagues is conveniently and fashionably included. Because the editor and her authors do not know cancer, they do not know cancer patients and tlieir needs. Agitation, depression, terror, anxiety in seriously ill cancer patients are not the result of longstanding intrapsychic conflicts. Rather, they are a reasonably accurate reflection of the severity of organic illness: Psychology is an epiphenomenon of physiology. Most cancer patients for whom psychiatric consultation is requested have cerebral dysfunction secondary to the disease: metastatic brain tumors, molecular invasion of the central nervous system by malignant hematologic spread, or toxic effects of chemotherapy. Feelings are usually centered around immediate concerns with perceived physical deterioration or are symptomatic of abnormal sensation states heralding CNS catastrophe, much of it treatable and reversible. The book is devoid of any saving features. The emphasis on symbolic and dynamic interpretations in this population of uniq ue sufferers serves to deny them the benefits of a thorough mental status examination, the only meaningful and responsible psychiatric approach to the sick. A similar volume of demonology on diabetes mellitus, pernicious anemia, lupus or infectious diseases would not get published. To treat cancer patients with less respect and medical concern must become just as unacceptable. Frank Adams, M.D. M. D. Anderson Hospital and Tumor Institute, Houston 499