672 postponement of admission to
an institution for, say, a year, would disappointing either in social or in financial terms. Clinical trials are now looking at these issues, but their progress may well be impaired by injudicious comments of the kind made in your editorial. There is a risk that an influential journal such as yours might so alter the climate of scientific opinion as to lead to premature abandonment of systematic therapeutic trials either by withdrawal of financial support or, more immediately, through the cessation of production of relatively pure lecithin by food manufacturers, on whom research workers have to rely upon for their supplies.
be far from
The effect of lecithin on the
course
of Alzheimer dementia is
not
known, and until the results of current trials are reported it would be wiser
not to
judge the issue.
Maudsley Hospital,
RAYMOND LEVY
London SE5 8AZ
POST-PARTUM MANIA, DOPAMINE, AND OESTROGENS are important in the a case can be made but of illness, aetiology puerperal psychiatric for the role of hormonal factors in the schizomanic and the manic 14, p. 387). group, as studied by Dr Whalley and colleagues Such illnesses tend to begin within a week of delivery, and to havea better long-term prognosis and lower genetic loading than does nonpuerperal mania.3Also, confusion is a commoner symptom in puerperal than in non-puerperal psychosis.4These observations could signify that systemic changes following childbirth constitute a trigger for a syndrome resembling mania; genetically predisposed manic-depressives are especially vulnerable. Pregnancy itself tends to protect the mother against psychotic illness for the period of
SiR,-Social and psychological factors
(Au
gestation.s
Among several hormonal changes after delivery, circulating oestrogen levels fall dramatically. Animal studies of the interaction of oestrogens with dopamine pathways are therefore relevant. In both the pituitary and the striatum additional doses of oestrogens lead to a reduction in responsiveness to dopamine, a neurotransmitter which is thought to have a role in the pathogenesis of mania.Chronic treatment with oestradiol leads to an increase in dopamine receptors in the striatum.Post-partum mania and schizomania might therefore be explained in terms of the dopamine hypothesis, with a fall in oestrogens after delivery exposing supersensitive dopamine receptors. In a double-blind comparative trial of pimozide and chlorpromazine in mania,8three patients with post-partum mania were treated with pimozide. Although two of these improved steadily during two weeks of treatment, the third showed little improvement for three days until pimozide was stopped and chlorpromazine was started. Since pimozide is more selective than chlorpromazine in the blockade of dopamine receptors, it seems that interactions of oestrogens with transmitters other than dopamine may also be relevant The London Hospital London E3 4LL
to
post-partum mania.
(St Clements),
1. Editorial. Puerperal psychoses. Lancet 1981; ii: 908-09. 2. Dean C, Kendell RE. The symptomatology of puerperal illness.
3. 4.
5. 6. 7.
8.
J. C. COOKSON Br J Psychiatry 1981;
139: 128-33. Kadrmas A, Winokur G, Crowe R. Post-partum mania. Br J Psychiatry 1979; 135: 551-54. Brockington IF, Cernik KF, Schofield EM, Downing AR, Francis AF, Keelan C. Puerperal psychosis: Phenomena and diagnosis. Arch Gen Psychiatry 1981; 38: 829-33. Pugh TF, Jerath BK, Schmidt WM, Reed RM. Rates of mental disease relating to childbearing. N Engl J Med 1963; 268: 1224-28. Cookson JC. Oestrogens, dopamine and mood. Br J Psychiatry 1981; 139: 365-66. Di Paolo T, Poyet P, Labrie F Effect of chronic estradiol and haloperidol treatment on striatal dopamine receptors Eur J Pharmacol 1981; 73: 105-06. Cookson JC, Silverstone T, Wells B. Double-blind comparative clinical trial of pimozide and chlorpromazine in mania: a test of the dopamine hypothesis. Acta Psychiat Scand 1981; 64: 381-97
Commentary from Westminster Government Determined to Win N.H.S.
Pay Dispute
No early end is in sight to the dispute in the N.H.S. over the nurses’ and ancillary workers’ pay claims. Ministers are still determined that no more cash will be found to increase their offers of 6% for ancillary workers and 7 -5% for nurses, nor are they expecting any significant change in the unions’ attitudes. With the full-hearted backing of the Prime Minister and of the more weighty Cabinet Ministers, the Social Services Secretary, Mr Norman Fowler, is planning simply to sit out the unions’ planned day of action on Sept. 22. He has’ no intention of approaching the key union leaders, before or after that date, to invite them to fresh talks on pay. This Government determination remains, in spite of the fact that Health Ministers know the dispute is causing considerable damage to the N.H.S. in terms of fast-sinking morale throughout as well as specific hardship in the form of increased waiting lists for hospital treatment, particularly in the north and north-west. Mr Fowler, and his Health Minister, Mr Kenneth Clarke, are sticking to the line they have taken ever since they made their second pay offer to the unions in midsummer, which raised the offer to the present level. There is no more money available for another increase, they insist. The unions’ persistence in their claim for an increase of 12% has only served to harden the Government’s line, bringing Mrs Thatcher into the centre of the struggle. With the dispute dragging on through Parliament’s summer recess, the Opposition leader,,Mr Michael Foot, demanded a recall of the Commons so that M.P.s could debate "this mounting crisis which threatens lasting damage to our Health Service." He wrote to Mrs Thatcher to declare that the public’s support for the nurses and ancillary workers, as well as the support of other trade unions, underlined the fact that "simple justice demands a better offer than the Government has so far made." He called on Mrs Thatcher to override Mr Fowler’s determination to "impose a totally inadequate settlement," by her personal intervention. Mrs Thatcher did oblige by intervening personally, but only to give her wholehearted support to the Social Services Secretary. There need be no recall of Parliament, she replied to Mr Foot, since the matter was debated before the recess. The Government’s offer was not inadequate. It compared favourably with increases offered to other similar groups in the public and private sectors of industry. She added provocatively : "It is not true as a general proposition that Health Service workers are among the lowest paid in the country, and they have in addition considerable job security and other advantages". The nurses were being offered a greater percentage increase than other public service workers, and had indeed been made a "special case" by the Government. "I think the record demonstrates how fairly the nurses have been treated by this Government," she added. There was also the point of view of the taxpayer to be taken into account, since the current offer will add f420 million to the N.H.S. pay bill. If anything, Mr Foot’s involvement, and even more so the involvement of the wider trade-union movement, have guaranteed that the Government will not budge. When the Cabinet discussed the matter at length ten days ago there was not a murmur of dissent from other Ministers as Mr Fowler outlined the progress of the dispute and his intention of sitting tight. Mrs Thatcher made it clear to the Cabinet that