Description of primary delusions: confusion in standard texts and among clinicians

Sir: Appleby (Psychiatric Bulletin. April 1997, 21, 193-194) recognises the absence of convincing evidence for the effectiveness of clinical services in reducing suicide. He goes on to support the need to promote risk assessment. The case for this emphasis on risk assessment is often based on the finding that a significant proportion of patients who commit suicide communicate in some way the possibility that this may occur. However, I believe the much larger group of patients, who communicate such ideas for whom suicide is not the outcome, may suffer as a result of the unquestioning acceptance of some fea tures of conventional methods of assessing risk. Thoughts of self-harm or suicide do not exist in isolation. By focusing our questions on these cognitions we fail to acknowledge the complex and varied aetiology of such thoughts and to a certain degree ignore other cognitive manifesta tions of emotions. In addition we develop a specific vocabulary in which emotional distress is replaced by terms purported to reflect risk. Patients recognise our disproportionate interest in this aspect of their 'complaints' and in an attempt to convey their distress soon 'learn' this


RAJAN NATHAN, Psychiatric Registrar, Roundhay
Wing, St James's University Hospital, Beckett Street. Leeds LS9 7TF Sir: As Director of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Louis Appleby begins his editorial (Psychiatric Bulletin, April 1997, 21, 193-194) by correctly asserting that the main causes of suicide are social and that there is no evidence that psychiatrists can do anything to exert a meaningful influence upon suicide rates. However, he appears to retain the assumption that doctors could still do better if they tried harder. In describing a study by his own group (Dennehy et al 1996), he notes that half of the patients who went on to suicide did not express suicidal ideas to medical attendants "suggesting that some people indicate their risk in less direct ways". It is possible that many people will not indicate the risk in any way and that doctors, being neither omniscient nor omnipo tent, are very frequently incapable of doing anything at all.
Despite the lack of any evidence to support the view, I believe that what psychiatrists can do to prevent suicide is little better than rearranging the deckchairs on the Titanic. At least while the country is steered on a course, from which the profession has little power to deflect it, towards the icebergs of growing social inequalities, youth unemployment and underfunded health and community care, perhaps the best we can hope for is to help some of our suicidal patients to clamber into the lifeboats. Given the present evidence, we delude ourselves and we risk a dangerous and counterproductive collusion with the captains of the ship, if we suggest that we can do more. DENNEHY, J. A.. APPLEBY.L.. THOMAS,C. S.. et al (1996) Case-control study of suicide by discharged psychiatric patients.

Description of primary delusions: confusion in standard texts and among clinicians
Sir: McAllister-Williams highlights the confu sion that exists in the definition of the term "primary delusion" (Psychiatric Bulletin. June 1997, 21, 346-349). The second version of the Schedules for the Clinical Assessment in Neuropsychiatry (SCAN; World Health Organi zation, 1994) offers another view on this and related terms. SCAN refers to "delusional perception or primary delusion", suggesting that these terms are synonymous. If this interpretation is correct it implies that delusional mood, delusional memory (as denned by some) and the autochtho nous delusion are not different forms of primary delusion, but are altogether different entities according to SCAN. SCAN defines delusional perception as "an intrusive, often sudden knowledge that a com mon perception has a radically transformed meaning ..." but goes on to add ". . .a normal perception, image or memory takes on an entirely new significance." Thus this definition includes what some would term a delusional memory.
Delusional memory 'proper' is recognised and rated as a separate item in SCAN and is defined as "experiences of past events which clearly did not occur." This is consistent with Sims' view (1988) of a delusion retrojected in time, although not so with Gelder et afs view (1989) that delusional memories are delusional interpreta tions of real memories.
Similarly delusional mood is not a form of primary delusion according to SCAN. Being both rare and difficult to distinguish from other psychotic and non-psychotic symptoms, delu sional mood is only rated as present when other delusions are subsequently formed. Further more, no mention is made at all of the auto chthonous delusion in SCAN.
SCAN is now an established research instru ment which aims to improve interrater reliability in the recognition and assessment of a variety of psychiatric phenomena. This is achieved through the use of strict differential definitions of psychopathological symptoms and signs, as described in the SCAN glossary. While these do not fully concur with other authorities, adopting these definitions in clinical practice does at least provide the opportunity to improve reliability between clinicians and reduce the confusion which currently exists. GELDER

Phlebotomists -not always a good thing
Sir: Like many others we have introduced phlebotomists onto our admission ward, as taking blood is now seen as a non-educational activity for junior doctors. However, our juniors themselves have noticed some unexpected draw backs. If blood is taken at the end of the initial consultation, a patient may often speak a little more freely, believing that the formal interview is over, thereby revealing further important fea tures of his/her mental state. Taking blood for liver function tests serves as a useful aide-mÃ©moireto enquire about an alcohol history. All too often, the less demanding in-patients can easily be forgotten by the doctors. A blood sample can be a useful way to at least keep an eye on one or two. Finally, incoming general practice regis trars can feel uncertain and lost at the start of a six-month psychiatry attachment. The task of taking blood can be a familiar landmark in an otherwise confusing experience, and can be the start of adjustment to and integration within the team.

Responsible medical officers and keyworkers: a conflict of roles
Sir: I have been involved in the teaching of a course for keyworkers for some time. A particular question has arisen with practically every one of these groups, namely: How do we resolve whether the responsible medical officer or the keyworker coordinates the care plan for each patient, given that both are given the same role under the Care Programme Approach?
This is a reasonable question. Paragraph 15.5 of the Code of Practice (Department of Health & the Welsh Office, 1993) states that "treatment plans are essential for both informal and detained patients. Consultants should coordi nate the formulation of a treatment plan in consultation with their professional colleagues. The plan should be recorded in the patient's clinical notes". At the same time. Paragraph 3.2.18 of Building Bridges -a Guide to Arrange ments for Inter-Agency Working for the Care and Protection of Severely Mentally III People (Depart ment of Health, 1995) states: "As well as coordinating the Care Plan, keyworkers/care managers may also provide an element of the plan in their own right".
Insofar as Treatment Plans and Care Plans are one and the same, it is true that government