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PSYCHOPHARMACOLOGY AND SOCIETY
1201
asthma from methylmethacrylate has been described in a dental technician;14 and cobalt, nickel, and chromium are potential hazards, since they have been reported as causes of asthma in other occupational groups.’, 16 Most dental laboratories are small concerns, and Rom et al found that work and hygiene practices were sometimes poor. Dust masks and ventilation were inadequate and threshold limit values were often exceeded. To avoid recognised hazards and to reduce the potential hazards of new materials, dental laboratories need to keep a close eye on work practices.
PSYCHOPHARMACOLOGY AND SOCIETY EVEN the most blinkered of psychopharmacologists will have realised that attitudes towards psychotropic drugs have been changing. We have moved from an era of wonder drugs introduced in the 1960s with the promise of fundamental cures for many mental illnesses to one in which there is increasing scepticism about the value of such drugs in any mental disorder. The extent of this change, and possible reasons for it, were discussed at a symposium of the British Association for Psychopharmacology. A common theme at the meeting was that society now needs to know a great deal more about the benefits and risks of drug treatment than was the case in the past. This is a phenomenon that has accompanied all drug treatment but has been more prominent with psychotropics. Paul Williams of the Institute of Psychiatry showed that an increasing proportion of the prescriptions for psychotropic drugs were not being taken up by patients. This suggested that patients were less certain of the value of psychotropic drugs and were preferring to do without them if they could. The only patients who seemed to be taking their psychotropic drugs regulaly were those who were dependent on tranquillisers, particularly the benzodiazepines; and although the numbers taking psychotropic drugs had not increased, the duration of treatment was getting progressively longer. Ronald Lacey, of MIND, justified the organisation’s campaign in the Press and on television about the dangers of tranquillisers by emphasising the patient’s right to know about the dangers. He understood that doctors felt attacked and pilloried unfairly, but felt they should exchange their knowledge more readily with the public. In response it was pointed out that such campaigns had a negative effect by suggesting that all patients were being treated unnecessarily. This often created distress and provoked relapse that would otherwise not have occurred. W. H. Inman, of the University of Southampton, also took the Press to task for creating a climate of opinion that regarded any serious adverse effect, no matter how rare, as a reason for banning use of a drug. Prescription event monitoring had proved a highly effective way of detecting both adverse drug reactions and events independent of drug consumption. He emphasised the importance of comparing event rates in people taking other compounds and in people taking no drugs at all. Quoting with approval Rothschild’s dictum that "comparisons, far from being odious, are the best antidote to panic" he showed that most of the drugs recently taken off the market because of adverse effects differed little, in their adverse effects, from existing drugs retaining the stamp of approval. An attack on the limited list with respect to benzodiazepines was made by Ian Hindmarch, who emphasised the adverse effects of psychotropic drugs on
driving. He regarded it as unfortunate that two benzodiazepines with little effect on driving performance, clobazam and bromazepam, were no longer available whereas nitrazepam and diazepam, despite obvious psychomotor impairment with clinical dosage, were still permitted. M. Plant had further gloomy thoughts on the reaction of society to advice from the medical profession. He described how ineffective had been attempts to educate the public into avoiding misuse of alcohol and psychoactive drugs. Despite increased efforts at education, the UK has seen a three-fold increase in illegal drug use in the past 12 years. Even though education programmes have proved completely ineffective, the UK Government has lately spent 21/2 million pounds on a campaign to emphasise the dangers of drug abuse-a decision taken against the opinion of their own advisory group. The thorny and topical issue of cost benefit analysis was dissected by P. West, who concluded that evaluation of benefits was even more difficult for psychotropic drugs than for other spheres of medicine. An important consideration in all forms of health care was the quality of life produced by a treatment. This is difficult to measure and depends largely on asking patients how they feel. If they feel well, but the feeling is an artificial one produced by a psychotropic drug, how is the
quality of life to be recorded? The meeting emphasised that society has legitimate questions to ask of doctors prescribing drugs, and psychotropic drugs in particular. Doctors must take public opinion into account to a much greater extent than they did 20 years ago. This is not easy and involves the profession in activities that some find demeaning and distasteful, including use of Press and television to counter misleading and damaging propaganda. If public sympathy is lost, there will be little future in medical campaigns to improve care or to retain
treatments
that
are
under threat.
ONE KNIFE IS ENOUGH PICTURE the traditional scene in the operating theatre at the start of an operation. The surgeon uses one scalpel for the skin incision, discards it, and takes another for deeper dissection. Time-honoured practice but is it really necessary? The answer-a resounding "no"-seems to have fallen on deaf ears, according to Hill and his colleagues at Crawley Hospital, West Sussex.’ The use of two knives, for skin and deeper dissection, grew out of studies in the 1890s but repeated investigations have failed to show that normal skin harbours pathogenic organisms. Despite convincing bacteriological evidence that postoperative wound infection rates differ hardly at all after the use of one or two scalpels, Hill found that 142 out of 143 surgeons (surveyed via questionnaire of theatre superintendents) in thirteen hospitals in the South-West Thames Region used the twoknife technique (and so, presumably, do most of their juniors). Hill et al also conducted their own bacteriological study of scalpel blades on a general surgical unit and confirmed that under normal conditions pathogenic organisms do not contaminate the blade and are not carried into the wound by it. They conclude that this "wasteful and unnecessary ritual has no theoretical, scientific, or clinical basis and can be discontinued".
1. Hill R, Blair S, Neely J, Ramanathan M. Changing knives ritual. Ann R Coll Surg Engl 1985; 67: 149-51.
a
wasteful and unnecessary
asthma from methylmethacrylate has been described in a dental technician;14 and cobalt, nickel, and chromium are potential hazards, since they have been reported as causes of asthma in other occupational groups.’, 16 Most dental laboratories are small concerns, and Rom et al found that work and hygiene practices were sometimes poor. Dust masks and ventilation were inadequate and threshold limit values were often exceeded. To avoid recognised hazards and to reduce the potential hazards of new materials, dental laboratories need to keep a close eye on work practices.
PSYCHOPHARMACOLOGY AND SOCIETY EVEN the most blinkered of psychopharmacologists will have realised that attitudes towards psychotropic drugs have been changing. We have moved from an era of wonder drugs introduced in the 1960s with the promise of fundamental cures for many mental illnesses to one in which there is increasing scepticism about the value of such drugs in any mental disorder. The extent of this change, and possible reasons for it, were discussed at a symposium of the British Association for Psychopharmacology. A common theme at the meeting was that society now needs to know a great deal more about the benefits and risks of drug treatment than was the case in the past. This is a phenomenon that has accompanied all drug treatment but has been more prominent with psychotropics. Paul Williams of the Institute of Psychiatry showed that an increasing proportion of the prescriptions for psychotropic drugs were not being taken up by patients. This suggested that patients were less certain of the value of psychotropic drugs and were preferring to do without them if they could. The only patients who seemed to be taking their psychotropic drugs regulaly were those who were dependent on tranquillisers, particularly the benzodiazepines; and although the numbers taking psychotropic drugs had not increased, the duration of treatment was getting progressively longer. Ronald Lacey, of MIND, justified the organisation’s campaign in the Press and on television about the dangers of tranquillisers by emphasising the patient’s right to know about the dangers. He understood that doctors felt attacked and pilloried unfairly, but felt they should exchange their knowledge more readily with the public. In response it was pointed out that such campaigns had a negative effect by suggesting that all patients were being treated unnecessarily. This often created distress and provoked relapse that would otherwise not have occurred. W. H. Inman, of the University of Southampton, also took the Press to task for creating a climate of opinion that regarded any serious adverse effect, no matter how rare, as a reason for banning use of a drug. Prescription event monitoring had proved a highly effective way of detecting both adverse drug reactions and events independent of drug consumption. He emphasised the importance of comparing event rates in people taking other compounds and in people taking no drugs at all. Quoting with approval Rothschild’s dictum that "comparisons, far from being odious, are the best antidote to panic" he showed that most of the drugs recently taken off the market because of adverse effects differed little, in their adverse effects, from existing drugs retaining the stamp of approval. An attack on the limited list with respect to benzodiazepines was made by Ian Hindmarch, who emphasised the adverse effects of psychotropic drugs on
driving. He regarded it as unfortunate that two benzodiazepines with little effect on driving performance, clobazam and bromazepam, were no longer available whereas nitrazepam and diazepam, despite obvious psychomotor impairment with clinical dosage, were still permitted. M. Plant had further gloomy thoughts on the reaction of society to advice from the medical profession. He described how ineffective had been attempts to educate the public into avoiding misuse of alcohol and psychoactive drugs. Despite increased efforts at education, the UK has seen a three-fold increase in illegal drug use in the past 12 years. Even though education programmes have proved completely ineffective, the UK Government has lately spent 21/2 million pounds on a campaign to emphasise the dangers of drug abuse-a decision taken against the opinion of their own advisory group. The thorny and topical issue of cost benefit analysis was dissected by P. West, who concluded that evaluation of benefits was even more difficult for psychotropic drugs than for other spheres of medicine. An important consideration in all forms of health care was the quality of life produced by a treatment. This is difficult to measure and depends largely on asking patients how they feel. If they feel well, but the feeling is an artificial one produced by a psychotropic drug, how is the
quality of life to be recorded? The meeting emphasised that society has legitimate questions to ask of doctors prescribing drugs, and psychotropic drugs in particular. Doctors must take public opinion into account to a much greater extent than they did 20 years ago. This is not easy and involves the profession in activities that some find demeaning and distasteful, including use of Press and television to counter misleading and damaging propaganda. If public sympathy is lost, there will be little future in medical campaigns to improve care or to retain
treatments
that
are
under threat.
ONE KNIFE IS ENOUGH PICTURE the traditional scene in the operating theatre at the start of an operation. The surgeon uses one scalpel for the skin incision, discards it, and takes another for deeper dissection. Time-honoured practice but is it really necessary? The answer-a resounding "no"-seems to have fallen on deaf ears, according to Hill and his colleagues at Crawley Hospital, West Sussex.’ The use of two knives, for skin and deeper dissection, grew out of studies in the 1890s but repeated investigations have failed to show that normal skin harbours pathogenic organisms. Despite convincing bacteriological evidence that postoperative wound infection rates differ hardly at all after the use of one or two scalpels, Hill found that 142 out of 143 surgeons (surveyed via questionnaire of theatre superintendents) in thirteen hospitals in the South-West Thames Region used the twoknife technique (and so, presumably, do most of their juniors). Hill et al also conducted their own bacteriological study of scalpel blades on a general surgical unit and confirmed that under normal conditions pathogenic organisms do not contaminate the blade and are not carried into the wound by it. They conclude that this "wasteful and unnecessary ritual has no theoretical, scientific, or clinical basis and can be discontinued".
1. Hill R, Blair S, Neely J, Ramanathan M. Changing knives ritual. Ann R Coll Surg Engl 1985; 67: 149-51.
a
wasteful and unnecessary