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DOUBTS ABOUT THE VALUE OF MAINTENANCE LITHIUM
424
with proper evaluation of even a handful of these agents. Epilepsy has a long history. Its dramatic clinical presentation has ensured that all literate civilisations have recorded comments on aetiology and treatment. The fear engendered by the disorder over the centuries led to a medieval association with sorcery and witchcraft which has translated to a modem, more "civilised", indifference. More worrying is the possibility that this indifference extends to the medical profession which does not perceive epilepsy as an area of diagnostic and therapeutic difficulty. Sadly there seems to be a low priority for this common condition, which is so demanding of time and effort, yet not usually life-threatening. Nor is there the emotional element that attaches to heart disease or cancer to stimulate public interest. The resource implications of the latest recommendations are modest, and coordination of the presently scattered facilities makes excellent economic sense. Ominous, however, is the delay of two years in publication of the report and the lack of practical recommendations by the DHSS in their covering letter to health authorities. A degree of political will is required. The time to act is now.
DOUBTS ABOUT THE VALUE OF MAINTENANCE LITHIUM IN the past fifteen years there has been an enormous in the use of maintenance drug therapy in the management of functional psychoses. Although
expansion
prophylactic neuroleptics undoubtedly produce a significant reduction in the relapse rate of schizophrenia,l such drugs are perhaps prescribed with rather less confidence and optimism now because it has been shown that even when compliance is assured the relapse rate remains substantial and, moreover, because the extrapyramidal side-effects are difficult to ignore.3 However, the initial enthusiasm for lithium has not waned. The value of this treatment in terms of reduction in the frequency of relapses of affective illness has been confirmed in many carefully controlled trials." Although lithium is not free from side-effects, those that occur are not disabling, and irreversible and untreatable conditions do not arise as a result of its use. Many psychiatrists believe that prophylactic lithium is a treatment that they can recommend with confidence as being likely to provide substantial benefit for appropriate S, Gaind R, Rohde PD, Stevens BC, Wing LK Outpatient maintenance of chronic schizophrenic patients with long acting fluphenazine: double blind placebo trial. Report to the Medical Research Council Committee on Clinical Trials in Psychiatry Br Med J 1973, i: 633-37 2. Hogarty GE, Schooler NR, Ulrich T, Mussare F, Ferro P, Herron E. Fluphenazine and social therapy in the after care of schizophrenic patients Arch Gen Psychiatry 1979; 36: 1283-94. 3 Baldessarini RJ, Cole JO, Davis JM, et al Tardive dyskinesia. Summary of an APA Task Force Report Am J Psychiatry 1980; 137: 1163-72. 4. Baastrup PC, Poulsen JC, Schou M, Thomsen K, Amdisen A Prophylactic lithium. double blind discontinuation in manic-depressive and recurrent-depressive disorders. Lancet 1970; ii: 326-30. 5. Coppen A, Noguera R, Bailey J, et al. Prophylactic lithium m affective disorders. Controlled trial Lancet 1971; ii: 275-79. 6 Pnen RF, Klett L, Caffey EM. Lithium carbonate and imipramine m the prevention of affective episodes Arch Gen Psychiatry 1973, 29: 420-25. 1. Hirsch
patients. This confidence may well be shaken by the findings of a study by Dickson and Kendel,’who examined the number of patients per annum in Edinburgh for whom lithium was prescribed between 1970 and 1971 and admission rates for mania, schizophrenia, and depressive psychosis over the same period. The number of patients for whom lithium was prescribed rose from 65 in 1970 to over 700 in 1979 and subsequent years. However, this rise was associated with the fall in admission rates for affective illness which would have been expected on the basis of the evidence that lithium is an effective prophylactic agent. There was a three-fold rise in the admission rate for mania between 1970 and 1981; the admission rate for depression also rose while that for schizophrenia fell. In this careful paper, Dickson and KendelF considered the possibilities of changing diagnostic criteria, admission of patients with milder affective illnesses, or poor and deteriorating lithium surveillance as causes of the changed rates but found no evidence to support any of these suggestions. Nevertheless, the retrospective methods necessary because of the nature of the study are not ideal for the assessment of such issues. Itis not easy to ascertain the severity of mania from case-notes. Whilst the fact that the proportion of patients with the clinical diagnosis of mania who fulfilled the Research Diagnostic Criteria8 for manic disorder, hypomanic disorder, or schizo-affective disorder manic type on the basis of case-note scrutiny did not alter between 1970-72 and 1979-81 suggests that diagnostic criteria did not change, another interpretation is possible. Psychiatric symptoms that are sought are more likely to be found, and it may be that manic symptoms were sought with more enthusiasm in Edinburgh once lithium became widely used. Studies of prophylactic medication are conducted in patients who will comply with a trial protocol for considerable periods of time, and in such studies the motivation of the investigators to ensure strict adherence to drug regimens is high. The circumstances of routine practice may be rather different and may partly explain the substantial discrepancy between the results of the trials of prophylactic lithium and the fmdings of Dickson and Kendel1.7 Whatever the cause of the discrepancy, the Edinburgh fmdings, as the authors themselves point out, offer little comfort to those who have believed that maintenance lithium provides an effective prophylactic treatment for at least a substantial minority of patients with recurrent affective disorders. not
TOTAL ISCHAEMIC BURDEN TOTAL ischaemic burden has been called "an exciting concept":1 it is a phrase used to describe the total number of ischaemic episodes, both painful and painless. occurring in an individual subject. It is suggested that the concept helps to "individualise" the treatment of a patient with ischaemic heart disease by adjusting therapy to take account of both painful and painless ischaemia. But is total ischaemic burden anything more than a potential misleading piece of jargon?
new
7. Dickson
WE, Kendell RE. Does maintenance lithium therapy prevent recurrences of under ordinary clinical conditions? Psychol Med 1986; 16: 521-30 8. Spitzer RL, Endicott J, Robins E. Research diagnostic criteria New York: Biometrics Research Division, New York State Psychiatric Institute, 1975. 1. Cohn PF. Total ischemic burden: definition, mechanisms, and therapeutic implications. Am J Med 1986: 81 (suppl 4A). 2-6. mania
with proper evaluation of even a handful of these agents. Epilepsy has a long history. Its dramatic clinical presentation has ensured that all literate civilisations have recorded comments on aetiology and treatment. The fear engendered by the disorder over the centuries led to a medieval association with sorcery and witchcraft which has translated to a modem, more "civilised", indifference. More worrying is the possibility that this indifference extends to the medical profession which does not perceive epilepsy as an area of diagnostic and therapeutic difficulty. Sadly there seems to be a low priority for this common condition, which is so demanding of time and effort, yet not usually life-threatening. Nor is there the emotional element that attaches to heart disease or cancer to stimulate public interest. The resource implications of the latest recommendations are modest, and coordination of the presently scattered facilities makes excellent economic sense. Ominous, however, is the delay of two years in publication of the report and the lack of practical recommendations by the DHSS in their covering letter to health authorities. A degree of political will is required. The time to act is now.
DOUBTS ABOUT THE VALUE OF MAINTENANCE LITHIUM IN the past fifteen years there has been an enormous in the use of maintenance drug therapy in the management of functional psychoses. Although
expansion
prophylactic neuroleptics undoubtedly produce a significant reduction in the relapse rate of schizophrenia,l such drugs are perhaps prescribed with rather less confidence and optimism now because it has been shown that even when compliance is assured the relapse rate remains substantial and, moreover, because the extrapyramidal side-effects are difficult to ignore.3 However, the initial enthusiasm for lithium has not waned. The value of this treatment in terms of reduction in the frequency of relapses of affective illness has been confirmed in many carefully controlled trials." Although lithium is not free from side-effects, those that occur are not disabling, and irreversible and untreatable conditions do not arise as a result of its use. Many psychiatrists believe that prophylactic lithium is a treatment that they can recommend with confidence as being likely to provide substantial benefit for appropriate S, Gaind R, Rohde PD, Stevens BC, Wing LK Outpatient maintenance of chronic schizophrenic patients with long acting fluphenazine: double blind placebo trial. Report to the Medical Research Council Committee on Clinical Trials in Psychiatry Br Med J 1973, i: 633-37 2. Hogarty GE, Schooler NR, Ulrich T, Mussare F, Ferro P, Herron E. Fluphenazine and social therapy in the after care of schizophrenic patients Arch Gen Psychiatry 1979; 36: 1283-94. 3 Baldessarini RJ, Cole JO, Davis JM, et al Tardive dyskinesia. Summary of an APA Task Force Report Am J Psychiatry 1980; 137: 1163-72. 4. Baastrup PC, Poulsen JC, Schou M, Thomsen K, Amdisen A Prophylactic lithium. double blind discontinuation in manic-depressive and recurrent-depressive disorders. Lancet 1970; ii: 326-30. 5. Coppen A, Noguera R, Bailey J, et al. Prophylactic lithium m affective disorders. Controlled trial Lancet 1971; ii: 275-79. 6 Pnen RF, Klett L, Caffey EM. Lithium carbonate and imipramine m the prevention of affective episodes Arch Gen Psychiatry 1973, 29: 420-25. 1. Hirsch
patients. This confidence may well be shaken by the findings of a study by Dickson and Kendel,’who examined the number of patients per annum in Edinburgh for whom lithium was prescribed between 1970 and 1971 and admission rates for mania, schizophrenia, and depressive psychosis over the same period. The number of patients for whom lithium was prescribed rose from 65 in 1970 to over 700 in 1979 and subsequent years. However, this rise was associated with the fall in admission rates for affective illness which would have been expected on the basis of the evidence that lithium is an effective prophylactic agent. There was a three-fold rise in the admission rate for mania between 1970 and 1981; the admission rate for depression also rose while that for schizophrenia fell. In this careful paper, Dickson and KendelF considered the possibilities of changing diagnostic criteria, admission of patients with milder affective illnesses, or poor and deteriorating lithium surveillance as causes of the changed rates but found no evidence to support any of these suggestions. Nevertheless, the retrospective methods necessary because of the nature of the study are not ideal for the assessment of such issues. Itis not easy to ascertain the severity of mania from case-notes. Whilst the fact that the proportion of patients with the clinical diagnosis of mania who fulfilled the Research Diagnostic Criteria8 for manic disorder, hypomanic disorder, or schizo-affective disorder manic type on the basis of case-note scrutiny did not alter between 1970-72 and 1979-81 suggests that diagnostic criteria did not change, another interpretation is possible. Psychiatric symptoms that are sought are more likely to be found, and it may be that manic symptoms were sought with more enthusiasm in Edinburgh once lithium became widely used. Studies of prophylactic medication are conducted in patients who will comply with a trial protocol for considerable periods of time, and in such studies the motivation of the investigators to ensure strict adherence to drug regimens is high. The circumstances of routine practice may be rather different and may partly explain the substantial discrepancy between the results of the trials of prophylactic lithium and the fmdings of Dickson and Kendel1.7 Whatever the cause of the discrepancy, the Edinburgh fmdings, as the authors themselves point out, offer little comfort to those who have believed that maintenance lithium provides an effective prophylactic treatment for at least a substantial minority of patients with recurrent affective disorders. not
TOTAL ISCHAEMIC BURDEN TOTAL ischaemic burden has been called "an exciting concept":1 it is a phrase used to describe the total number of ischaemic episodes, both painful and painless. occurring in an individual subject. It is suggested that the concept helps to "individualise" the treatment of a patient with ischaemic heart disease by adjusting therapy to take account of both painful and painless ischaemia. But is total ischaemic burden anything more than a potential misleading piece of jargon?
new
7. Dickson
WE, Kendell RE. Does maintenance lithium therapy prevent recurrences of under ordinary clinical conditions? Psychol Med 1986; 16: 521-30 8. Spitzer RL, Endicott J, Robins E. Research diagnostic criteria New York: Biometrics Research Division, New York State Psychiatric Institute, 1975. 1. Cohn PF. Total ischemic burden: definition, mechanisms, and therapeutic implications. Am J Med 1986: 81 (suppl 4A). 2-6. mania