ABC of sleep disorders. Withdrawal from hypnotic drugs

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The Nottingham study of neurotic disorder. Effect of personality status on response to drug treatment, cognitive therapy and self-help over two years

Repeated assessments of psychopathology, together with personality status, were made over two years on 181 psychiatric out-patients with generalised anxiety disorder (59), panic disorder (66), or dysthymic disorder (56) diagnosed using an interview schedule for DSM-III. Patients were randomly allocated to drug treatment, cognitive and behaviour therapy, or a self-help treatment programme. Although there were no overall differences in compliance rate and efficacy between the three modes of treatment, the psychological treatment methods, particularly self-help, were more effective in patients without personality disorder, and those with personality disorder responded better to drug treatment, primarily antidepressants. The findings suggest that assessment of personality status could be a valuable aid to selection of treatment in neurotic disorders and that self-help approaches are particularly valuable once personality disorder has been excluded.

Benzodiazepine dependence: a shadowy diagnosis

When benzodiazepines were introduced into clinical practice in the 1950s they were hailed as efficacious minor tranquillizers, largely devoid of unwanted side effects, in contrast to the barbiturates and similar drugs that they largely superseded. It was 30 years before the phenomenon of low-dose dependence on benzodiazepines was recognized. Benzodiazepine dependence differs from other psychotropic drug addictions because the benzodiazepines do not produce either euphoria or drug-seeking behaviour (except in those who are already addicted to other drugs). However, benzodiazepine use is associated in some individuals with a marked withdrawal (abstinence) syndrome that provides the best evidence of dependence. Just over half the people prescribed long-term benzodiazepines do not develop any sign of a withdrawal reaction (Fig. 1): this reflects factors including the type of benzodiazepine prescribed, the dosage and duration of treatment, as well as characteristics of the patient. Individuals with passive-dependent personalities appear to be more likely to experience withdrawal symptoms than other patients, although this remains a controversial issue. Therefore benzodiazepine use should follow certain guidelines, and if these are adhered to the benzodiazepines will continue to be valuable drugs in clinical practice.

Compulsive personality as predictor of response to serotonergic antidepressants

A short paper of this title reported a study by Ansseau et al (1991). The present authors were invited to comment upon the study.

Early intervention in psychiatric emergencies: a controlled clinical trial

In the UK, psychiatric care of patients with acute and chronic disorders has increasingly moved from hospital to the community. We have evaluated in a controlled trial patients with severe mental illness, who were assigned to early intervention by community services or to standard hospital treatment. 100 patients aged 16 to 65 years presenting as psychiatric emergencies to an inner London teaching hospital were randomly allocated to a multidisciplinary community-based team (n = 48) or conventional hospital-based psychiatric services (n = 52) and assessed over a 3-month period. Ratings of psychopathology and social functioning were made before treatment and after 2, 4, and 12 weeks by independent assessors. 85 patients completed all assessments, and all patients had evaluable data beyond 2 weeks. 3 patients died during the study, 2 from natural causes and 1 from an accident. Patients referred to the community service showed greater improvement in symptoms and were more satisfied with services than those in the hospital-based service. Patients treated in the hospital-based service spent eight times as many days as psychiatric inpatients as those treated in the community-based service. Patients both prefer and seem to benefit from community-based psychiatric care, and our early-intervention community service might be a good model for such care.

The clinical evaluation of a new community psychiatric service based on general practice psychiatric clinics

A new community psychiatric service in Nottingham based on general practice clinics was compared with a conventional hospital-orientated model. Despite providing treatment for an inner-city population of significantly greater social disadvantage, the community service was associated with similar levels of symptom morbidity as assessed by the CRPS and the SFS. It also involved greater use of day-hospital facilities, more extensive multidisciplinary care, and a commitment to longer-term follow-up of chronically ill patients. Such a model is offered as a basis for future developments of urban community psychiatric services.

Factors predicting long-term outcome after chronic benzodiazepine therapy

41 patients who took part in a withdrawal programme from long-term treatment with diazepam in a controlled clinical trial were followed up five years later. Assessments were made of outcome derived from clinical symptomatology, formal psychiatric diagnosis, psychotropic drug use and frequency of contact with both primary care and psychiatric services. Using discriminant function analysis it was found that better outcome was associated with younger patients, fewer symptoms at time of withdrawal and, more particularly, six months later, less personality disturbance, and longer duration of diazepam use before withdrawal. The implications are discussed with particular reference to policies for withdrawing benzodiazepines.

The general neurotic syndrome: a coaxial diagnosis of anxiety, depression and personality disorder

The validity of the general neurotic syndrome, a combination of anxiety, depression and dependent personality disorder, was examined in a 2-year study of outpatients with dysthymic, panic and generalized anxiety disorder diagnosed using a structured interview schedule. The general neurotic syndrome, found in a third of the patients, was associated with greater mental disorder and a significantly worse outcome than patients without the syndrome. It did not, however, predict response to treatment. Further analysis revealed that the general neurotic syndrome was a better predictor of short- and long-term outcome than any other variable apart from initial psychopathology score. It is argued that the syndrome may represent a personality diathesis that makes the individual more vulnerable to both anxiety and depressive symptoms.

Anxiolytics not acting at the benzodiazepine receptor: beta blockers

1. Although there is clear evidence for many controlled trials in the past 25 years that beta blockers are effective in anxiety disorders clear indications for their use are lacking. 2. The balance of evidence suggests that the mechanism of action of beta-blocking drugs is through peripheral blockade of beta-mediated symptoms. 3. Most evidence to the efficacy of beta-blockers comes from study of their use in generalized anxiety and in acute stress. 4. Because beta-blockers carry no risks of pharmacological dependence they may be preferred to many other anti-anxiety drugs.

Personality disorder in perspective

Personality disorders have for many years been on the fringe of psychiatry, with considerable doubts expressed about the usefulness, implications and validity of the concept. It is argued here that developments in the past few years have brought personality disorders into the mainstream of psychiatric practice. In particular, the recognition that personality function can be separated usefully from clinical symptoms, and that both mental state and personality can be disordered simultaneously, has led to better assessment and understanding. Advances in the classification, epidemiology, treatment and prognosis of personality disorders show that these conditions are common, extensive in their pathology, and cause much suffering. They cannot be ignored or dismissed as peripheral to psychiatry for they are an essential part of good psychiatric practice.

A three-year follow-up of psychiatric morbidity in urban and rural primary care

Follow-up by examination of medical and psychiatric records was carried out on 357 patients with conspicuous psychiatric morbidity in two general practices three years after clinical and personality assessment using structured interview schedules. One practice was an inner-city urban one and the other was rural. Full follow-up data over the 3-year period was available for 301 patients (84.3%). After three years patients with personality disorder and those in the urban practice had greater morbidity, more contacts with all levels of the psychiatric service and more psychotropic drugs, particularly benzodiazepines. Despite this increased morbidity, the number of consultations with the general practitioner for psychiatric illness was no higher in the urban group and those for medical illness were significantly higher in the rural one. The implications of the findings are discussed with particular reference to developments in community psychiatric care.

A double-blind comparison of the effects of gradual withdrawal of lorazepam, diazepam and bromazepam in benzodiazepine dependence

Using a double-blind procedure, 68 patients with putative benzodiazepine dependence were randomly allocated to one of three groups given lorazepam (n = 22), diazepam (n = 23) or bromazepam (n = 23) in doses equivalent to those of the patients' original benzodiazepine. After four weeks the dosage was reduced in 25% quantities until no further benzodiazepines were taken. A total of 23 patients dropped out during the study, ten on lorazepam (one of whom committed suicide), seven on diazepam and six on bromazepam. There were few differences in withdrawal symptoms between the three groups but, despite the higher dropout rate, these symptoms were somewhat less marked in the lorazepam group. Withdrawal symptoms were greater in patients who had taken a benzodiazepine for greater than 5 years and were most marked in those with personality disorders, predominantly dependent ones.

Clinical and humoral effects of beta-blockade with ICI 118,551 in the general neurotic syndrome

Fifty-six patients satisfying the diagnostic criteria for the general neurotic syndrome, a mixed anxiety-depressive disorder, were randomly allocated to treatment with a selective β( 2)-blocking drug, ICI 118,551, in a dose of 50 mg tds, or placebo for 4 weeks after a 2-week placebo run-in period. Ratings of anxiety using the Hamilton anxiety rating scale and patient self-assessments in 46 evaluable patients showed no significant difference in the outcome of active drug and placebo groups, and also no significant improvement over time during the study. This unusual finding supports the impression of the general neurotic syndrome as a severe form of neurotic disorder which shows little evidence of placebo response. Diastolic blood pressure was increased and heart rate reduced after 2 weeks on ICI 118,551, and plasma levels of noradrenaline and adrenaline showed no evidence of an expected decrease with active drug; on the contrary the data showed some evidence of increased catecholamine levels. The results suggest that selective β-blockade has little part to play in the treatment of anxiety and that on repeated dosage the effects of selective blockade are attenuated or reversed.

Does division of the left renal vein during aortic surgery adversely affect renal function?

Between July 1980 and July 1988, 478 consecutive patients underwent aortic aneurysm operations at Royal Prince Alfred Hospital. Renal function was assessed by measurement of serum creatinine levels. The left renal vein was divided in 28 (8%) of the 355 patients undergoing elective aneurysm resection. The mean immediate postoperative creatinine values were significantly higher after left renal vein division, 193 +/- 174 mumol/L, compared to 133 +/- 93 mumol/l for those whose left renal vein remained intact (p less than 0.05 by Mann-Whitney U test). After one month, serum creatinine levels had decreased but were still significantly higher in those patients in whom the left renal vein had been divided, 170 +/- 166 mumol/l, compared to those in whom it was left intact 109 +/- 49 mumol/l (p less than 0.05 by Mann-Whitney U test). The suprarenal aorta was cross-clamped in seven (25%) of the 28 patients in whom the left renal vein was divided, compared to 21 (6%) of the 327 with the left renal vein intact. A rise in creatinine level was observed after suprarenal aortic cross-clamping. The left renal vein was divided in 17 (14%) of the 123 patients having emergency surgery for ruptured aortic aneurysm, 61 (49%) of whom survived more than 30 days. The mean immediate postoperative creatinine values were significantly higher after left renal vein division, 426 +/- 277 mumol/l, compared to those in whom the vein was left intact, 178 +/- 136 mumol/l (p less than 0.05 by Mann-Whitney U test). After one month, serum creatinine levels were still significantly higher in those patients in whom the left renal vein had been divided. Although division of the left renal vein is a useful way to improve exposure of the juxtarenal aorta, the maneuver is associated with an adverse effect on renal function.

The role of the community psychiatric nurse

The community psychiatric nurse is an essential element in a comprehensive mental health service. At present each nurse is expected to be a trained counsellor and psychotherapist, a skilled behaviour therapist and an expert assessor of clinical status. This superhuman role is unrealistic; a more appropriate one is outlined.