- Email: [email protected]
PSYCHIATRIC PROBLEMS IN ACCIDENT DEPARTMENTS
1096 EFFECT OF ORAL CONTRACEPTIVES ON GLUCOSE TOLERANCE should be grateful if the interesting report of Mr. SIR,-I Clinch and his colleagues (April 26, p. 857) could be amplified. Do they intend to repeat the tests when the patients have been on oral contraceptives for, say, another four months, and again after the patients stop taking the preparation ? Tests at these times would show whether any further change in glucose tolerance can be expected with increasing months of use, and whether the test reverts to the original level when medication is stopped. I should also be interested to know which preparation was being taken by the ten women who did not have raised bloodglucose values at the time of the second test, particularly since the numbers of women in groups B and C were comparatively small. In interpreting these results it is perhaps important to remember that oral contraceptives vary not only in the size of the dose, but also in composition, containing one of two oestrogens in combination with one of seven different progestogens. The relative proportions of oestrogen and progestogen vary from preparation to preparation. Therefore, in a metabolic study such as this, valid comparison should surely be drawn only between the 25 patients in group A and the 8 patients in group B who took preparations varying only in dose, the constituents and their relative proportions remaining constant.
Family Planning Association,
HILARY HILL.
London W1N 8BO.
*jt,* This letter was shown to Mr. Clinch and his colleagues, who write as follows: " We are grateful to Dr. Hill for her comments. It was originally intended to repeat these tests but the follow-up rate for only one test has been disappointingly small and it is unlikely that future numbers would be large enough to be of any value. The ten women whose mean blood-glucose values during the second test were not raised were evenly distributed throughout the three groups-i.e., 5 in group A, 2 in group B, and 3 in group C. We are unable to account for their response in this respect being different from that of the other 32 women. Dr. Hill is correct in suggesting that valid conclusions should be drawn only between the patients in group A and those in group B. This we have done: the results for group C were included merely to emphasise the finding that effects on carbohydrate tolerance are dosedependent. Their omission does not alter our conclusions."ED. L.
IRON-BINDING COMPONENT IN HUMAN GASTRIC JUICE
SIR,-Dr. Morgan and his colleagues (April 26, p. 861) have confirmed our observations1 on the presence of an iron-binding component, gastroferrin, in human gastric juice. The phenomenon of decreased iron binding beyond a critical iron concentration was also observed. They noted that associated with the decreased iron binding was a decrease in the concentration of hexoses and hexosamines without a corresponding decrease in protein concentration. On this evidence they conclude that gastroferrin is predominantly carbohydrate in nature.
Recently we have isolated and partially purified gastroferrin by techniques involving the prior removal of acid mucopolysaccharides with cetylpyridinium chloride, precipitation with acetone, passage through ’Sephadex G200 ’, and a final purification on diethylaminoethyl (D.E.A.E.) cellulose. The resultant product gastroferrin exhibited a single band on acrylamide electrophoresis, and a single peak on analytical ultracentrifugation. This product consists of predominantly carbohydrate residues (glucosamine, galactosamine, sialic acid, fucose, and galactose). According to the Lowry technique, 1.
Davis, P. S., Luke, C. G., Deller, Lond. 1967, 214, 1126.
D.
J. Lancet, 1966, ii, 1431; Nature,
gastroferrin has virtually no protein content, although on complete acid hydrolysis aminoacids are released. It is likely therefore that gastroferrin is a glycoprotein, and it is of interest that the preparation we have obtained exhibits considerable blood-group activity. The product also shows striking metal specificity for iron, in that its binding of metals such as lead, calcium, zinc, magnesium, and copper is negligible. University Department of Medicine, Adelaide, South Australia.
Z. RUDZKI D. J. DELLER.
PSYCHIATRIC PROBLEMS IN ACCIDENT DEPARTMENTS
SIR,-Dr. Watson’s stimulating article (April 26, p. 877) problems in which I have taken a special interest over many years-i.e., attempted suicide and psychiatric classification. Following Kessell, the author speaks of formal psychiatric illness " as if there were such a class. I have failed to discover the origin of this term, nor have I been able to trace a class of informal " psychiatric illness. I gather that formal " means in this context " typical ", as presented in the textbooks and seen in psychiatric-hospital practice. It has been found on many occasions that even among the suicides-i.e., the fatal suicidal acts-not more than 30-40% of the cases seem to have had " typical " mental disorders. I agree with the
touches upon
"
"
"
author and with Kessell that many of the unselected cases admitted to emergency wards and in need of psychiatric help do not show the clinical pictures seen in the highly selected populations of psychiatric hospitals. To fit them into a classification requires some thought but is not impossible. Not surprisingly, the notes written by busy house-officers with no psychiatric expertise working in an emergency ward often fail to provide information about psychiatric aspects of their patients. However, in committing acts of self-damage the patients had reacted abnormally to stressful situations. It was this reaction which made them psychiatric cases and not their problems primarily. To declare them unclassifiable within the categories of psychiatric conditions, and at the same time to stress their need for psychiatric treatment and even ask for a psychiatric team to be available for them day and night-i.e., two or three teams for every emergency ward-as Dr. Watson does, seems a bit confusing. There are two categories in section V of the new revision of the International Classification of Diseases (7.C.D.) 1where these cases can be fitted in, even if in the time available a proper psychiatric assessment is impossible. One category is " Personality DisordersUnspecified " (301-9), the conjecture being that the abnormal reaction to stress indicates a deficiency in the personality. If " Transient even this should be too definite, the category of " situational disturbances (307) could be used, although the Glossary of Mental Disorders2 recommends a more limited definition of this category. Perhaps a subcategory could be introduced here for cases of attempted suicide which cannot be fitted in elsewhere. Dr. Watson’s procedure of classifying all depressions as psychotic is unacceptable, especially for this particular population. This article demonstrates that precise psychiatric categorisation of cases which could not be subjected to psychiatric examination, including assessment of the personality, is impracticable. For this reason I refrained from attempting it when I was engaged in a similar survey some years ago.3 I should like to appeal to psychiatrists to use the new revision of the I.C.D. with the help of the Glossary,2 which was prepared by the Sub-committee on Classification of Mental Disorders of the Registrar General’s Advisory Committee on Medical Nomenclature and Statistics. Only by doing so will 1. International Classification of Diseases 1965; vol. I. World Health Organisation, Geneva, 1967. 2. General Register Office. A Glossary of Mental Disorders. Studies on Medical and Population Subjects No. 22. H.M. Stationery Office, 1968. 3. Parkin, D., Stengel, E. Br. med. J. 1965, ii, 133.
1097
they make their observations comparable with those of their colleagues. They will also make it possible to improve the Classification and the Glossary. E. STENGEL.
LITHIUM SIR,-Your leading article (April 5, p. 709) deals with an interesting problem concerning the evidence for a prophylactic action of lithium in manic-depressive disorder. In two trials 1 2 the patients were selected on the basis of having experienced psychotic episodes with a frequency higher than a specified minimum during the period before lithium treatment. This could, depending on the degree of randomness with which manic and depressive episodes occur, lead to a lowering of the frequency of relapses during the period of lithium administration. The question arises whether this selection bias accounts for the fall in the frequency of relapses observed during lithium treatment. Your leading article seems to take this for granted, but does not present any evidence in support of the assumption. It might be worth while to examine more closely the magnitude of the bias as well as the role played by other factors. The question of a possible effect of the selection procedure was considered by Baastrup and Schou,l who made a correction by recalculating the relapse frequency for the prelithium period with omission of the last year-i.e., the period of particularly frequent relapses. Even when compared with this recalculated value, the frequency of relapses during lithium treatment was found to be significantly reduced
(P< 0-001). In patients with recurrent affective disorders, the frequency of relapses during two consecutive time periods is influenced not only by the criterion for selection but also by the progressive increase in the frequency of psychotic episodes that is characteristic of this group of disorders.3 One must therefore expect a rise in the frequency of relapses during the second period; such increases have been found in both manicdepressive and schizo-affective patients.4 Two factors are accordingly at work: the selection procedure which tends to lower the frequency of relapses, and the spontaneous course of the disease which tends to raise it. An estimate of their relative magnitudes may be obtained through studies on patients who are selected in a way similar to that of those in the lithium trials and followed during two consecutive periods without prophylactic treatment. Ottosson et al. studied the course of the disease in manic-depressive patients admitted to the Umeå Psychiatric Clinic in the years 1963-65. The first admission during this time was used as a dividing point between two 2-year periods, one (period a) preceding the admission, and another (period b) following it. Sixty-two patients fulfilled the criterion of having had two or more episodes during period a. The study showed that there was no significant change in the number of episodes during period b. This result corresponds closely to that obtained in a similar study from the Zurich Psychiatric Clinic, which was 1. 2. 3.
4.
5.
Baastrup, P. C., Schou, M. Archs gen. psychiat. 1967, 16, 1962; Lancet, 1968, i, 1419. Angst, J., Dittrich, A., Grof, P. Int. Psychopharmac. 1969, 2, 1. Lundquist, G. Acta psychiat. scand. 1945, suppl. 35; Kinkelin, M. Schweiz. Arch. Neurol. Psychiat. 1954, 73, 100; Kielholz, P. Klinik, Differentialdiagnostik und Therapie der depressiven Zustandsbilder. Basle, 1959; Matussek, P., Halbach, A., Troeger, U. Endogene Depression. Munich, 1965; Taschev, T. Fortschr. Neurol. Psychiat. 1965, 33, 25; Angst, J., Weis, P. in Neuro-Psychopharmacology. Amsterdam. Excerpta med. int. Congr. Ser. 1967, no. 129, p. 703; Angst, J., Grof, P., Hippius, H., Pöldinger, W., Varga, E., Weis, P. in Cycles biologiques et Psychiatrie (edited by J. de Ajuriaguerra); p. 339. Paris, 1968. Angst, J., Weis, P. in Melancholie (edited by W. Schulte and W. Mende). Stuttgart (in the press); Angst, J., Baastrup, P. C., Grof, P., Schou, M., Weis, P. Paper read at symposium on die Langzeitbehandlung der Schizophrenen Psychosen, Frankfurt, March 7-8, 1969 (in the press). Laurell, B., Ottosson, J.-O. Lancet, 1968, ii, 1245; Isaksson, A., Ottosson, J.-O., Perris, C. Paper read at symposium on das Depressive Syndrom, Berlin, Feb. 16-17, 1968 (in the press).
occasioned by your leading article. The records were examined for all patients with affective disorders who were admitted in 1959-64. Thirty-seven patients fulfilled the criterion of having had two or more admissions during period a. Comparison of the two periods showed no significant difference in the number of admissions. In these two studies the patients were selected on a criterion similar to that for those in the lithium trials, and the studies must be assumed to reflect the trend in such samples. None of the studies showed evidence of a significance decrease in the frequency of relapses during the second of the two periods investigated. It is therefore unlikely that bias introduced by the selection procedure can account for the very pronounced falls in frequency of episodes and admissions which were seen during the administration of lithium in the two prophylactic trials and in a later extension of these.6The data from the latter study were further subjected to regression analyses, which took into account not only the period immediately before lithium treatment but the entire past history of each patient. Lithium was found to be associated with a highly significant decrease in the frequency of episodes, thus providing additional evidence of a prophylactic action. The leading article criticizes the study by Angst et a1. for having compared two studies that were not comparable. However, although the lithium study and the imipramine study were reported in the same paper, no attempt was made to compare their results. The leading article calls for prophylactic trials in which a group of patients from which lithium is withheld is studied concurrently with the group treated with lithium. This design is an excellent one and may yield valuable information if properly executed and assessed. We hope that those who find the available evidence unconvincing will succeed in carrying such studies through to a meaningful conclusion. Psychiatric University Clinic, J. ANGST. Zurich, Switzerland. Psychiatric Clinic, McMaster University, Hamilton, Ontario, Canada. Psychopharmacology Research Unit, Aarhus University Psychiatric Institute, Risskov, Denmark.
P. GROF.
M. SCHOU.
SiR,łYour leading article seems to me unduly sceptical. This is further evidenced by the opening sentence of the letter of Dr. Hawkins and Dr. Dorken (April 19, p. 839): " Your leading article draws attention to the lack of useful evidence of benefit from treatment with lithium..." ; I assume this sentence to mean " that lithium does not work ". A further statement in your leader, that " there is no evidence to indicate that lithium is superior to conventional treatment of mania, such as the phenothiazines ...", ignores completely the paper by Johnson et al. These writers open their discussion with the following statement: " The results of this study show unequivocally the superior therapeutic efficacy of lithium carbonate in manic states." This was a double-blind controlled study, but I have no doubt that it will be criticised because it is difficult to keep a study such as this blind, when side-effects are so different. I should also like to emphasise the points made by Dr. Whybrow (April 19, p. 839)-not only that we seem to be asking more of lithium than of other treatment but, perhaps more important, the qualitative differences between the two treatments. An extreme example was a young manic male who showed extreme motor overactivity as well as mental symptoms, flights of ideas, &c. High dosages of chlorpromazine were required to slow him down, but even when very parkinsonised he still showed flights of ideas and disturbed thinking. I have yet to see anything similar during lithium therapy, and it is this type of difference that prompts clinicians 6. Angst,
J., Baastrup, P. C., Grof, P., Schou, M., Weis, P. Br. J. Psychiat. (in the press). 7. Johnson, G., Gershon, S., Hekimian, L. J. Compreh. Psychiat. 1968, 9, no. 6.
Family Planning Association,
HILARY HILL.
London W1N 8BO.
*jt,* This letter was shown to Mr. Clinch and his colleagues, who write as follows: " We are grateful to Dr. Hill for her comments. It was originally intended to repeat these tests but the follow-up rate for only one test has been disappointingly small and it is unlikely that future numbers would be large enough to be of any value. The ten women whose mean blood-glucose values during the second test were not raised were evenly distributed throughout the three groups-i.e., 5 in group A, 2 in group B, and 3 in group C. We are unable to account for their response in this respect being different from that of the other 32 women. Dr. Hill is correct in suggesting that valid conclusions should be drawn only between the patients in group A and those in group B. This we have done: the results for group C were included merely to emphasise the finding that effects on carbohydrate tolerance are dosedependent. Their omission does not alter our conclusions."ED. L.
IRON-BINDING COMPONENT IN HUMAN GASTRIC JUICE
SIR,-Dr. Morgan and his colleagues (April 26, p. 861) have confirmed our observations1 on the presence of an iron-binding component, gastroferrin, in human gastric juice. The phenomenon of decreased iron binding beyond a critical iron concentration was also observed. They noted that associated with the decreased iron binding was a decrease in the concentration of hexoses and hexosamines without a corresponding decrease in protein concentration. On this evidence they conclude that gastroferrin is predominantly carbohydrate in nature.
Recently we have isolated and partially purified gastroferrin by techniques involving the prior removal of acid mucopolysaccharides with cetylpyridinium chloride, precipitation with acetone, passage through ’Sephadex G200 ’, and a final purification on diethylaminoethyl (D.E.A.E.) cellulose. The resultant product gastroferrin exhibited a single band on acrylamide electrophoresis, and a single peak on analytical ultracentrifugation. This product consists of predominantly carbohydrate residues (glucosamine, galactosamine, sialic acid, fucose, and galactose). According to the Lowry technique, 1.
Davis, P. S., Luke, C. G., Deller, Lond. 1967, 214, 1126.
D.
J. Lancet, 1966, ii, 1431; Nature,
gastroferrin has virtually no protein content, although on complete acid hydrolysis aminoacids are released. It is likely therefore that gastroferrin is a glycoprotein, and it is of interest that the preparation we have obtained exhibits considerable blood-group activity. The product also shows striking metal specificity for iron, in that its binding of metals such as lead, calcium, zinc, magnesium, and copper is negligible. University Department of Medicine, Adelaide, South Australia.
Z. RUDZKI D. J. DELLER.
PSYCHIATRIC PROBLEMS IN ACCIDENT DEPARTMENTS
SIR,-Dr. Watson’s stimulating article (April 26, p. 877) problems in which I have taken a special interest over many years-i.e., attempted suicide and psychiatric classification. Following Kessell, the author speaks of formal psychiatric illness " as if there were such a class. I have failed to discover the origin of this term, nor have I been able to trace a class of informal " psychiatric illness. I gather that formal " means in this context " typical ", as presented in the textbooks and seen in psychiatric-hospital practice. It has been found on many occasions that even among the suicides-i.e., the fatal suicidal acts-not more than 30-40% of the cases seem to have had " typical " mental disorders. I agree with the
touches upon
"
"
"
author and with Kessell that many of the unselected cases admitted to emergency wards and in need of psychiatric help do not show the clinical pictures seen in the highly selected populations of psychiatric hospitals. To fit them into a classification requires some thought but is not impossible. Not surprisingly, the notes written by busy house-officers with no psychiatric expertise working in an emergency ward often fail to provide information about psychiatric aspects of their patients. However, in committing acts of self-damage the patients had reacted abnormally to stressful situations. It was this reaction which made them psychiatric cases and not their problems primarily. To declare them unclassifiable within the categories of psychiatric conditions, and at the same time to stress their need for psychiatric treatment and even ask for a psychiatric team to be available for them day and night-i.e., two or three teams for every emergency ward-as Dr. Watson does, seems a bit confusing. There are two categories in section V of the new revision of the International Classification of Diseases (7.C.D.) 1where these cases can be fitted in, even if in the time available a proper psychiatric assessment is impossible. One category is " Personality DisordersUnspecified " (301-9), the conjecture being that the abnormal reaction to stress indicates a deficiency in the personality. If " Transient even this should be too definite, the category of " situational disturbances (307) could be used, although the Glossary of Mental Disorders2 recommends a more limited definition of this category. Perhaps a subcategory could be introduced here for cases of attempted suicide which cannot be fitted in elsewhere. Dr. Watson’s procedure of classifying all depressions as psychotic is unacceptable, especially for this particular population. This article demonstrates that precise psychiatric categorisation of cases which could not be subjected to psychiatric examination, including assessment of the personality, is impracticable. For this reason I refrained from attempting it when I was engaged in a similar survey some years ago.3 I should like to appeal to psychiatrists to use the new revision of the I.C.D. with the help of the Glossary,2 which was prepared by the Sub-committee on Classification of Mental Disorders of the Registrar General’s Advisory Committee on Medical Nomenclature and Statistics. Only by doing so will 1. International Classification of Diseases 1965; vol. I. World Health Organisation, Geneva, 1967. 2. General Register Office. A Glossary of Mental Disorders. Studies on Medical and Population Subjects No. 22. H.M. Stationery Office, 1968. 3. Parkin, D., Stengel, E. Br. med. J. 1965, ii, 133.
1097
they make their observations comparable with those of their colleagues. They will also make it possible to improve the Classification and the Glossary. E. STENGEL.
LITHIUM SIR,-Your leading article (April 5, p. 709) deals with an interesting problem concerning the evidence for a prophylactic action of lithium in manic-depressive disorder. In two trials 1 2 the patients were selected on the basis of having experienced psychotic episodes with a frequency higher than a specified minimum during the period before lithium treatment. This could, depending on the degree of randomness with which manic and depressive episodes occur, lead to a lowering of the frequency of relapses during the period of lithium administration. The question arises whether this selection bias accounts for the fall in the frequency of relapses observed during lithium treatment. Your leading article seems to take this for granted, but does not present any evidence in support of the assumption. It might be worth while to examine more closely the magnitude of the bias as well as the role played by other factors. The question of a possible effect of the selection procedure was considered by Baastrup and Schou,l who made a correction by recalculating the relapse frequency for the prelithium period with omission of the last year-i.e., the period of particularly frequent relapses. Even when compared with this recalculated value, the frequency of relapses during lithium treatment was found to be significantly reduced
(P< 0-001). In patients with recurrent affective disorders, the frequency of relapses during two consecutive time periods is influenced not only by the criterion for selection but also by the progressive increase in the frequency of psychotic episodes that is characteristic of this group of disorders.3 One must therefore expect a rise in the frequency of relapses during the second period; such increases have been found in both manicdepressive and schizo-affective patients.4 Two factors are accordingly at work: the selection procedure which tends to lower the frequency of relapses, and the spontaneous course of the disease which tends to raise it. An estimate of their relative magnitudes may be obtained through studies on patients who are selected in a way similar to that of those in the lithium trials and followed during two consecutive periods without prophylactic treatment. Ottosson et al. studied the course of the disease in manic-depressive patients admitted to the Umeå Psychiatric Clinic in the years 1963-65. The first admission during this time was used as a dividing point between two 2-year periods, one (period a) preceding the admission, and another (period b) following it. Sixty-two patients fulfilled the criterion of having had two or more episodes during period a. The study showed that there was no significant change in the number of episodes during period b. This result corresponds closely to that obtained in a similar study from the Zurich Psychiatric Clinic, which was 1. 2. 3.
4.
5.
Baastrup, P. C., Schou, M. Archs gen. psychiat. 1967, 16, 1962; Lancet, 1968, i, 1419. Angst, J., Dittrich, A., Grof, P. Int. Psychopharmac. 1969, 2, 1. Lundquist, G. Acta psychiat. scand. 1945, suppl. 35; Kinkelin, M. Schweiz. Arch. Neurol. Psychiat. 1954, 73, 100; Kielholz, P. Klinik, Differentialdiagnostik und Therapie der depressiven Zustandsbilder. Basle, 1959; Matussek, P., Halbach, A., Troeger, U. Endogene Depression. Munich, 1965; Taschev, T. Fortschr. Neurol. Psychiat. 1965, 33, 25; Angst, J., Weis, P. in Neuro-Psychopharmacology. Amsterdam. Excerpta med. int. Congr. Ser. 1967, no. 129, p. 703; Angst, J., Grof, P., Hippius, H., Pöldinger, W., Varga, E., Weis, P. in Cycles biologiques et Psychiatrie (edited by J. de Ajuriaguerra); p. 339. Paris, 1968. Angst, J., Weis, P. in Melancholie (edited by W. Schulte and W. Mende). Stuttgart (in the press); Angst, J., Baastrup, P. C., Grof, P., Schou, M., Weis, P. Paper read at symposium on die Langzeitbehandlung der Schizophrenen Psychosen, Frankfurt, March 7-8, 1969 (in the press). Laurell, B., Ottosson, J.-O. Lancet, 1968, ii, 1245; Isaksson, A., Ottosson, J.-O., Perris, C. Paper read at symposium on das Depressive Syndrom, Berlin, Feb. 16-17, 1968 (in the press).
occasioned by your leading article. The records were examined for all patients with affective disorders who were admitted in 1959-64. Thirty-seven patients fulfilled the criterion of having had two or more admissions during period a. Comparison of the two periods showed no significant difference in the number of admissions. In these two studies the patients were selected on a criterion similar to that for those in the lithium trials, and the studies must be assumed to reflect the trend in such samples. None of the studies showed evidence of a significance decrease in the frequency of relapses during the second of the two periods investigated. It is therefore unlikely that bias introduced by the selection procedure can account for the very pronounced falls in frequency of episodes and admissions which were seen during the administration of lithium in the two prophylactic trials and in a later extension of these.6The data from the latter study were further subjected to regression analyses, which took into account not only the period immediately before lithium treatment but the entire past history of each patient. Lithium was found to be associated with a highly significant decrease in the frequency of episodes, thus providing additional evidence of a prophylactic action. The leading article criticizes the study by Angst et a1. for having compared two studies that were not comparable. However, although the lithium study and the imipramine study were reported in the same paper, no attempt was made to compare their results. The leading article calls for prophylactic trials in which a group of patients from which lithium is withheld is studied concurrently with the group treated with lithium. This design is an excellent one and may yield valuable information if properly executed and assessed. We hope that those who find the available evidence unconvincing will succeed in carrying such studies through to a meaningful conclusion. Psychiatric University Clinic, J. ANGST. Zurich, Switzerland. Psychiatric Clinic, McMaster University, Hamilton, Ontario, Canada. Psychopharmacology Research Unit, Aarhus University Psychiatric Institute, Risskov, Denmark.
P. GROF.
M. SCHOU.
SiR,łYour leading article seems to me unduly sceptical. This is further evidenced by the opening sentence of the letter of Dr. Hawkins and Dr. Dorken (April 19, p. 839): " Your leading article draws attention to the lack of useful evidence of benefit from treatment with lithium..." ; I assume this sentence to mean " that lithium does not work ". A further statement in your leader, that " there is no evidence to indicate that lithium is superior to conventional treatment of mania, such as the phenothiazines ...", ignores completely the paper by Johnson et al. These writers open their discussion with the following statement: " The results of this study show unequivocally the superior therapeutic efficacy of lithium carbonate in manic states." This was a double-blind controlled study, but I have no doubt that it will be criticised because it is difficult to keep a study such as this blind, when side-effects are so different. I should also like to emphasise the points made by Dr. Whybrow (April 19, p. 839)-not only that we seem to be asking more of lithium than of other treatment but, perhaps more important, the qualitative differences between the two treatments. An extreme example was a young manic male who showed extreme motor overactivity as well as mental symptoms, flights of ideas, &c. High dosages of chlorpromazine were required to slow him down, but even when very parkinsonised he still showed flights of ideas and disturbed thinking. I have yet to see anything similar during lithium therapy, and it is this type of difference that prompts clinicians 6. Angst,
J., Baastrup, P. C., Grof, P., Schou, M., Weis, P. Br. J. Psychiat. (in the press). 7. Johnson, G., Gershon, S., Hekimian, L. J. Compreh. Psychiat. 1968, 9, no. 6.