ANXIETY AND DEPRESSION IN INPATIENTS

1425 SYRINGE SHARING AMONG LONDON DRUG ABUSERS

having antibodies to HTLV-III, and having fever, general malaise, prolonged diarrhoea, oral candidiasis, and, most prominently, severe wasting and weight loss. Serwadda et al stress that slim disease can be distinguished from AIDS and AIDS related complex (ARC) by extreme weight loss and diarrhoea. Weight loss and diarrhoea may not distinguish slim disease from AIDS. The table summarises the signs and symptoms reported by Clumeck et all in 18 African patients with AIDS who were in hospital in Belgium; by Van de Perre et al2 in 17 heferosexually promiscuous patients with AIDS in Rwanda, part of the definition of illness being "loss of more than0% of body weight and diarrhoea for at least 2 months with no pathogen isolated"; by Piot et al, reporting on 38 heterosexual AIDS patients in Zaire, the most striking clinical features of whom were "profound weight loss and

SIR,-17% of cases of AIDS in the United States have been in intravenous drug abusers. The major risk factor in this group is the sharing of syringes. Most cases have been in New York State, where clean syringes cannot be purchased over the counter. In the UK pharmacists may sell syringes over the counter at their discretion. The frequency of needle-sharing in British intravenous drug abusers is unknown. 57 intravenous drug abusers were interviewed at the drug dependency unit, St Mary’s Hospital, London. 38 were members of couples in which both partners were drug abusers. 27/38 members of couples shared syringes, 14 with people other than their partner. Of the individual users 11/19 shared syringes. The medical experiences of these patients were reviewed to identify episodes of frank disease. This was done through reports from the patients themselves so rates of disease are likely to be

severe chronic diarrhoea, which was often the initial manifestation of the disease and was refractory to therapy"; and by Serwadda et al. The data are comparable, although Serwadda and colleagues’ definition of weight loss is more restrictive than that of the other groups. Van de Perre et al give the mean weight loss in their patients as 18% (range 12-32%).

underestimates. Disease

Hepatitis B

Sharers

Non-sharers

(n=38)

6

(n = 19)

30 7 1

14 1 0

Abscesses

Septicaemia Sub-bacterial endocarditis

2

Disease episodes thus averaged 1 -16 in sharers and 0 - 89 in nonsharers. Rates of syringe-sharing in London drug abusers seem high and such people will be at greater risk of HTLV-111 infection. Those who shared a syringe with their partner usually did so unintentionally. Those who shared with non-partners did so because a syringe was not available when required. Few of the patients interviewed were aware of the risk of HTLV-III infection or other health risks that syringe sharing carries. 2 men and 6 women were or had been prostitutes, usually to buy heroin. If they acquired HTLV-III infection they might pass it on to a wide range of sexual partners. All agencies in contact with intravenous drug abusers should make every attempt to persuade patients never to share syringes. Drug dependency clinics should make clean syringes available to users on demand, possibly, as in the Netherlands, in return for the old syringe. As Mr Andreyev has suggested (Nov 2, p 1192) pharmacists could make syringes readily available over the counter. It is the availability of heroin, not syringes, that causes intravenous drug abuse. Drug Dependency Unit, and National AIDS Counselling Training Unit, St Mary’s Hospital, London W2 1NY

GERALDINE MULLEADY JOHN GREEN

SIR,-Mr Andreyev’s suggestion that needles and syringes should be made available to drug addicts could well improve the health of intravenous drug abusers. However, an inevitable result would be a great increase in the numbers of needles left lying around in places such as public lavatories and urban waste ground. Surely it is optimistic to believe that restricting sales to those over 18 would keep these items out of the hands of children. Porters disposing of hospital waste are often injured by discarded needles, despite the elaborate precautions taken for the safe disposal of sharp objects. There is a risk that such accidents could spread to the community. The careless addict will leave contaminated needles lying around where he has used them. The conscientious addict will presumably place them in the nearest litterbin or wastepaper basket. Ealing Hospital, Southall, Middlesex UB13HW SLIM DISEASE

M. W. BECKETT

(AIDS)

SiR,-Dr Serwadda and co-workers (Oct 19, p 849) describe "slim disease" as a new disease in Uganda. While caring for a patient with slim disease we wondered if slim disease might be identical to African AIDS. Our 56-year-old patient from Kampala meets the criteria for slim disease in coming from Uganda, being heterosexually promiscuous,

FREQUENCY

(%) OF CLINICAL MANIFESTATIONS IN THREE

SERIES OF AFRICAN AIDS PATIENTS AND IN SERWADDA’S PATIENTS WITH SLIM DISEASE

= information not available. *More than 10% (Van de Perre, Plot) or 20% (Serwadda) loss of body tcandida alblcans oesophagtus (Van de Perre) or oral thrush (Piot). .

weight.

All the

patients were in the upper socioeconomic classes, were heterosexually promiscuous, and denied homosexual activity, drug abuse, and transfusions. The male:female ratio is much the same in all four series (about 1 2:1). The table suggests that slim disease cannot be distinguished from AIDS and ARC by extreme weight loss and diarrhoea. Thus slim disease may not be a new syndrome but simply identical with AIDS as seen in Africa. Medical Clinic, University of Bonn, D-5300 Bonn-Venusberg, West

Germany

T. KAMRADT D. NIESE F. VOGEL

1 Clumeck

N, Sonnet J, Taelman H, et al Acquired immunodeficiency syndrome in African patients. N Engl J Med 1984; 310: 492-97. 2. Van de Perre P, Rouvroy D, Lepage P, et al. Acquired immunodeficiency syndrome in Rwanda. Lancet 1984, ii: 62-65 3. Plot P, Quinn T, Taelman H, et al Acquired immunodeficiency syndrome in a heterosexual population in Zaire. Lancet 1984; ii: 65-69.

ANXIETY AND DEPRESSION IN INPATIENTS

SIR,-We are very interested in the work of Dr Channer and colleagues (Oct 12, p 820). The hospital anxiety and depression scale (HAD) of Zigmond and Snaith offers many advantages. Its items are clear and this self-assessment scale can be completed quickly, making its use possible in all departments of medicine. We have tested the French version of the scale in a department of internal medicine.’ During a validation study, in 100 consecutive inpatients, we compared each subscale of the HAD with other selfevaluation and mixed clinical assessment scales-namely, the Befindlichkeits Skala of von Zerssen for depression, the anxiety state questionnaire of de Bonis for anxiety, the Montgomery and Asberg depression rating scale, and the Hamilton anxiety rating

1426 scale. Results were analysed by Pearson’s correlation coefficient (r):

countered

by

calm debate about the failure of the definition and

guidance to a better one. HAD

Self-assessment

Climcal assessment

0-65 0-69

0-44 0.62

Anxiety Depression All r values

significant (p<0

00 1).

Department of Psychiatry, University of Leeds, St James’s University Hospital,

R. P. SNAITH C. M. TAYLOR

Leeds LS9 7TF

Thus the HAD scale correlates well with other self-assessment and clinical assessment scales, the clinical ones requiring a long interview with a highly trained person. Our interest in the epidemiology of anxiety and depression in medical populations prompted us to wonder if the use of this instrument could be extended from a symptomatic approach to a diagnostic one. We did a second study, this time in 133 patients admitted to the same hospital department.2 We compared HAD results with those of a structured questionnaire adapted from the composite international diagnostic interview.3 This interview4 permits the diagnosis of affective disorders according to DSM 111. The results, with a current major depressive episode as an external validation criterion, vary greatly according to the cut-off score of the HAD:

Taylor CM Irritability Definition, assessment and associated factors. Br J Psychiatry 1985, 147: 129-36

1. Snaith RP,

EFFECTS OF 1983 MENTAL HEALTH ACT

SIR,-In 19841 we reported a reduction in the use of emergency and 6 month orders for the first six months after the new mental health legislation came into force on Sept 30, 1983. This change has been maintained, as has the change to using the 28 day order in preference to the 6 month and emergency orders (table). IMPACT OF

1983 MENTAL

HEALTH LEGISLATION ON ADMISSIONS

UNDER SECTION

HAD

Cut-off Senmivlly (%) 8 9 10 11

77-7 72.2 69-4

SpecificllY (%) 80-4 83-5 87.6 90-7

PVP (%) 59-6 61-9 67-9 67-8

PVN (%)

52’8 PVP, PVN=predicuve values of positive, negative result.

90-7 89 88,5 83-8

Thus, as the cut-off increases, sensitivity is reduced while specificity improves. Since there is a high prevalence of anxious and depressive disorders in medical patients, a quick assessment scale to evaluate the degree of psychopathology is of interest. However, even though the HAD scale correlates with other quantitative psychopathological scales, one must be careful when using it for diagnostic purposes. Used to evaluate the prevalence of depression in medical settings (outpatient or inpatient), this assessment scale can only provide an estimate of depressive symptoms; it cannot be used to study depressive disease.

*Sections of 1959 Mental Health Act

m

parentheses Years in this table run Oct 1 to Sept 30.

These findings suggest that, for Southampfon, the changes noted for the first six months were not the transitory result of the novelty of a new procedure, but a permanent change in medical and social work practice before people are, in their own interests, deprived of

liberty. Department of Psychiatry, Royal South Hants Hospital, Southampton SO9 4PE

M. J. WINTERSON B. M. BARRACLOUGH

MJ, Barraclough BM. Effects of 1983 Mental Health Legislation compulsory admissions to a District General Hospital Lancet 1984, ii. 44

1 Winterson

Psychiatric and Internal Medicine Services, Hôpital Bichat,

J. P. LEPINE M. GODCHAU P. BRUN

75018 Paris, France

on

PLASMA CONCENTRATION OF ATRIAL NATRIURETIC POLYPEPTIDE IN ESSENTIAL

HYPERTENSION 1.

2.

Lepine JP, Godchau M, Brun P, Lemperière Th. Evaluation de l’anxiété et de la dépression chez des patients hospitalisés dans un service de médecine interne. Ann Médico-Psychol 1985; 2: 175-89. Lepine JP, Godchau M, Brun P. Utilité des échelles d’auto-évaluation de l’anxiété et de la dépression en médecine interne. Presented at 3rd International Congress of the International Federation of Psychiatric Epidemiology (Brussels, Sept 9-11, 1985) Abst 119.

3. Wing J, Robins L, Helzer J, Stoltzman R. Composite international diagnostic interview. Copenhagen: WHO, 1982. 4. DSM III. Diagnostic and statistical manual of mental disorders, 3rd ed. Washington, DC American Psychiatric Association, 1980

IRRITABILITY

SIR,-Your Nov 30 editorial (p 1223) should perhaps have been entitled Irritability with Psychiatric Nosologists. We share some of your views, but your diatribe against names or categories given to disorders is not constructive. You offer no solution to the "utter confusion"; surely, terms such as paranoid schizophrenia are more helpful in communication than no system at all. You dismiss our paper,which is the first attempt to define irritability in a medical context. We did not offer a new category of "irritability neurosis". What we did was offer a definition of irritability and consider how this defined state differed from the concepts of hostility and aggression. We then drew attention to the many areas of medical and psychiatric practice in which irritability might be a prominent feature and in so doing we hoped that the concept might be studied scientifically. You conclude that "Psychiatric nosology remains utterly confused" but surely attempts to offer definitions should be

SIR,-Atrial natriuretic polypeptide(s) (ANP) isolated from atrial tissue has potent diuretic, natriuretic, and vasorelaxant activities in manl2 and is thought to be an endogenous antihypertensive agent. Using a radioimmunoassay for human a-ANP (a-hANp)3,4 we demonstrated large amounts of a-hANP-like immunoreactivity (a-hANP-LI) in the human atrium3 and found that a-hANP is released from the heart and circulates in the body as a hormone. We need to know if ANP secretion from the heart into the blood is decreased in essential hypertension because several lines of evidence 6 suggest a close link between sodium regulation and hypertension, and, besides being a circulating sodium transport inhibitor, ANP is implicated in the control of water and electrolyte balance and blood pressure. We have measured concentrations of a-hANP-LI in the plasma of ten patients with essential hypertension before treatment and in fourteen age-matched normotensive controls. The patients had stage I (five), stage II (three), and stage III (two) hypertension on the World Health Organisation classification.Blood was sampled and blood pressure measured at 0900 hours with the subject recumbent and after an overnight fast. Plasma a-hANP-LI in patients with essential hypertension (before treatment) was 77 - 8 (SEM 9 - 5) pg/ml; in the controls it was 37 - 8 (6 - 0) pg/ml (p<0 0 1) (see figure). Plasma levels ofa-hANP-LI in the five patients with WHO stage I hypertension (67-77 [ 10 0] pg/ml) was also significantly higher than that of the controls (p<0 . 05). Concentrations in patients with plasma renin activities