Denmark: Psychiatric offenders

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LANCET

packaging and for production of various formulations) in the interests of quality and patient response. The draft of the new drug policy proposes a decrease in the number of drugs under price control, a merging of the two lists into one, and simplification of the price-revision procedures. To check the possible abrupt increase in prices due to decontrol, the Government may fix what the maximum permissible increase should be (as a percentage of existing price), put a ceiling on prices, and make it obligatory for small units to conform to the prices fixed. The Indian Drug Manufacturers’ Association is objecting to the inclusion of the 8000 small-scale industrial (SSI) units under the price-control regulations on grounds that it would make price control more complex, more cumbersome, and administratively impossible. Furthermore, it believes that some SSI units may have to close down. SSI units help to maintain the prices at competitive levels and employ about 300 000 "technocrats". Meanwhile, the Tamil Nadu Medical and Sales Representatives’ Association, a branch of the Federation of Medical and Sales Representatives of India, has designated March 16 as a protest day against the proposed changes. The association alleges that the changes have been proposed in the interests of the multinationals and to please the International Monetary Fund and World Bank, and has sent telegrams to the Prime Minister, Mr P. V. Narasimha Rao, demanding rejection of the proposals.

Bhupesh Mangla

New Zealand: Youth suicide This country has the shameful record of having the highest female youth suicide rate and the third highest male youth suicide rate among 23 OECD countries. According to the Department of Health’s recently released Youth Suicide Prevention Project report, between 1974 and 1990 the suicide rate among young males rose from 9-8/100 000 to 380/100 000. Two-thirds of these suicides were by people aged between 20 and 24 years. The rate among females is lower and relatively static. The rate for young males increased sharply in the late 1980s, as did that among young Maori men (Maori rates are generally lower). What happened in New Zealand in the late 1980s? That

period saw the sharemarket crash and rising unemployment figures, which neither party as government has been able to staunch. One-third of school leavers go straight onto the dole. New Zealand also has the unwelcome distinction of

having one of the highest teenaged pregnancy rates in the world. Understandably, politicians of both the national Government and Labour opposition (the Government changed in 1990) were not keen to isolate unemployment as the key factor in the leap in the suicide statistics. Instead they were generally vague about causes, and solutions. The youth suicide problem, said Associate Minister of Health, Katherine O’Regan, "should be addressed within the broader context of youth mental health... depression is one of the key risk factors...". Elsewhere O’Regan has exhorted adult New Zealanders to be more optimistic as a way of preventing youth suicides. If adults are gloomy, she said, "youngsters will be too". Unable to suggest any promising preventive strategies, the Government has formed a steering group of key government agencies to coordinate and promote preventive efforts. A former youth affairs senior adviser and suicide specialist, Mr Barry Taylor, welcomed the committee, but said that it was not enough. Access to mental health services

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for young people is appalling, he said, and he was concerned the Government was wasting time talking rather than acting. He pointed to West Australia, where the suicide rate dropped after the state increased funding for crisis services, training of professionals, and mental-health campaigns. But, said a senior Health Department manager, there will be no extra money. It remains to be seen what, if anything, can be achieved within the existing resources. Mental health has always been the Cinderella of the New Zealand health-care system, and health-promotion work fits poorly in the market model of health being implemented from July.

Sandra Coney

Denmark: Psychiatric offenders Crime by psychiatric patients is rising. According to a report by Peter Kramp, head of the Ministry of Justice’s Forensic Psychiatric Clinic, this increase could be a result of policy changes during the 1970s, with the move towards community care (Kramp P. Kanedsskrift Praktisk Laegegerning 1993; 1: 17-23). The number of hospital beds for psychiatric patients has dropped from 12 000 in 1976 to 4500 in 1992. On the other hand, the number of psychiatric patients being supervised by the Department of Prison and Probation has risen from 300 in 1980 to 700 in 1992. Section 16 of the penal code rules that "persons who, at the time of the act, had diminished responsibility owing to mental illness or similar conditions, or to pronounced mental deficiency, are not punishable". In acquitting an offender in accordance with this section, the court can order psychiatric treatment--detention in a psychiatric hospital, perhaps a maximum-security institution, with discharge only by court order; treatment in a psychiatric ward, where doctors are free to take therapeutic decisions independently; or

outpatient treatment.

Between 1970 and 1983 the number of orders for psychiatric ward treatment and outpatient treatment increased from 14 and 1, respectively, to 64 and 53 (Lund J. Nord Tidsskr Kriminalvidenskab 1987; 34: 46-49), whereas placements in a psychiatric institution remained steady at an average of 12 per year. "This can be due to a general tendency in the Danish legal system towards milder sentences", explains Kramp. His report also records a change in the ratio between psychotic and non-psychotic offenders sent for psychiatric treatment. The number of psychotics being supervised by the Department of Prison and Probation rose by 60%, from 335 in 1987 to 538 in 1991, whereas the number of non-psychotics (eg, those with neurotic conditions, alcohol and drug abuse, or character disorders) fell by 35%, from 186 to 120. Kramp notes that these trends cannot be attributed to changes in diagnostic criteria. Schizophrenics (who are responsible for most of the criminal acts by psychotics) sometimes commit "survival crimes" to obtain basic necessities that they cannot get from social authorities, but they also commit murders and arson. Kramp’s report states that from 1946 to the start of the seventies there was one murder by schizophrenics per year, but now there are four to five. The increase has occurred in both urban and rural areas. It has not been noted among those with other psychotic disorders. The increase in treatment orders, plus the emphasis on community care, have led to an insufficiency of psychiatric beds, so some patients are being put in prison instead, says Kramp. To cope with the shortage of beds, wards are being opened specifically for forensic patients. "Ten years ago

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they did not exist in Denmark, now there are three", he says, "and three more are already planned. This is happening even though the reduction of normal psychiatric beds still continues". In addition the National Board of Health, the Department of Prison and Probation, and local authorities have set up a joint task force to tackle the rise in crime and the bed shortage. Cláudio Csillag

Germany: Barefoot clinical pharmacologists As early as 1979 the Conference of the Health Ministers of the German States agreed that the country did not have enough clinical pharmacologists. Not much has happened, despite the valiant efforts of several official bodies. Medical graduates who want to become clinical pharmacologists find only few places for specialty training in non-industrial institutes; a recent survey showed that none of the few approved institutes could afford a trainee’s salary. A trainee would therefore have to pay his own way for the minimum of four years’ training to be eligible for the board examination. As often happens, if the medical profession is not able to carry out its function, others are ready to take over. Thus clinical pharmacologists found in the latest issue of their society’s (DGPT) newsletter a proposal to create the title "Klinischer Fachpharmakologe (DGPT)". Many years ago the society defined who could call themselves non-medical pharmacologists (Fachpharmakologe)-there was the possibility that researchers in small firms, for example, were calling themselves pharmacologists. Clinical pharmacology is, however, different. An important function of the specialty is the development of new medicines, during which the clinical pharmacologists treat, at least in phases I-II, with full medical responsibility, healthy volunteers and patients. A non-physician would be unable to meet the stringent good clinical practice guidelines on clinical trials-eg, on the evaluation of risk/benefit. A non-clinician would also not be able to advise clinicians on rational and safe pharmacotherapy. The American Board of Clinical Pharmacology defined tight criteria for acceptance of non-physicians as specialists in the discipline in 1991. For those who are already Fachpharmakologe, the DGPT requires only two years’ training at established institutions "with clinical pharmacology", plus 3 first-authored papers, 3 posters, and for certificates training in subjects such as "pathophysiology" and "therapeutic principles (in depth in 2 indications)". Karl H. Kimbel

Europe: Tissue devices Medical device companies are fighting a move that could leave products made from human and viable animal tissue outside either European Community device or pharmaceutical law. Tissue products could remain under national laws, which would render European trade difficult and may limit the range of devices available. The contamination scandal that rocked the French transfusion service last year led France to insist that tissue products be excluded from the scope of the draft medical device directive before signing the preliminary formal agreement, the "common position". The directive is expected to apply from Jan 1, 1995. Last December the EC Commission offered to write a supplementary directive covering devices either made from or that used human or viable animal tissue (the draft device

directive still covers non-viable animal tissue products) if ministers continued to insist that such products had to be excluded from the device directive. This would have introduced the same type of rules as the active implantable medical device directive and the draft medical device directive and so would have been relatively easy for industry to respect. Ministers backed the plan at the time, as did industry, which saw it as the next best option to having tissue products included in the device directive. Now, however, it looks as though ministers could bow to French pressure to have EC pharmaceutical legislation extended to cover tissue products such as arterial replacements made from human umbilical cord. Such a move would be a disaster for the device industry. Manufacturers that make both tissue products and other devices would face extra costs meeting two sets of legal requirements. However, France believes that strict EC pharmaceutical rules offer the best guarantee against future contamination problems. If other EC member states are not convinced and push for the supplementary directive, a decision could be stalled. This would leave device firms having to comply with multifarious national laws.

Sara Lewis

India: Anti-AIDS

policies

AIDS will not be a notifiable disease in India, in the interests of maintaining confidentiality for people with HIV/AIDS. This decision was made at the first meeting, last month, of the National AIDS Committee, constituted under the chairmanship of the Minister of Health and Family Welfare last October, to provide policy direction and oversee the work of the National AIDS Control

Organisation (NACO). The committee also decided that providing needles or syringes to injecting drug users would give wrong signals about government policy on drug abuse. Here, drug abuse is a criminal offence punishable by imprisonment. Intravenous drug use (and needle sharing) is widespread in some north-eastern states of India, particularly Manipur, where 54% of injecting drug users have been found to be HIV positive. Most of them are now in jail. In the many other parts of the country where drugs are rarely injected, the first priority is to prevent a shift towards drug injection. Media campaigns against injecting might arouse curiosity rather than deter from injection-as happened in 1991 in Nepal, where after such a campaign, there was a rapid switch from oral to injecting drug use. Only low-key peer programmes are likely to be effective in such situations. The committee also raised concern about how hospitals have refused to treat AIDS patients, and called on physicians to educate themselves first. Such a refusal had in early February led the Government to instruct the All India Institute of Medical Sciences not to refuse any AIDS/HIV patient even if surgery were needed-this instruction followed an inquiry into how, in 1991, the institute had to call in a private practitioner to deliver an HIV-positive woman of her baby because its own doctors has refused to do so.

Bhupesh Mangla France: Tissue banks and organ

transplants

The Italian and French Ministers of Health want to regulate how Italians flock across the border for organ transplantation at France’s expense, as reported by the General Inspectorate of Social Affairs (see Lancet July 11,