Prescribing antipsychotics in child psychiatry

Sir: Slaveska et al (Psychiatric Bulletin, Novem ber 1998. 22. 685-687) have highlighted an important problem for child psychiatrists. Over two years only 64% of respondents had had contact with a child with psychosis. The number of cases seen was between one and 12 (median one case per consultant). One has to ask if these child psychiatrists can retain competence as prescribers of antipsychotics. Although the pre valence of psychosis is low in child psychiatry, the next child referred may be psychotic and in urgent need of medication. Child psychiatrists cannot therefore absolve themselves from re sponsibility for keeping up-to-date with new antipsychotics and prescribing them when ap propriate. Another complication arises with the prescribing of clozapine in paediatric popula tions. In the study by Kumra et al (1996). toxic effects including neutropenia and seizures were more common than in adult populations. One approach to keeping child psychiatrists up-todate with drug treatment might be to set up groups where the ongoing management of psychotic child referrals was discussed.


Prescribing antipsychotics in child psychiatry
Sir: Slaveska et al (Psychiatric Bulletin, Novem ber 1998. 22. 685-687) have highlighted an important problem for child psychiatrists. Over two years only 64% of respondents had had contact with a child with psychosis. The number of cases seen was between one and 12 (median one case per consultant). One has to ask if these child psychiatrists can retain competence as prescribers of antipsychotics. Although the pre valence of psychosis is low in child psychiatry, the next child referred may be psychotic and in urgent need of medication. Child psychiatrists cannot therefore absolve themselves from re sponsibility for keeping up-to-date with new antipsychotics and prescribing them when ap propriate. Another complication arises with the prescribing of clozapine in paediatric popula tions. In the study by Kumra et al (1996). toxic effects including neutropenia and seizures were more common than in adult populations. One approach to keeping child psychiatrists up-todate with drug treatment might be to set up groups where the ongoing management of psychotic child referrals was discussed. KUMRAS.. FRAZIER.J. A., JACODSEN, L. K.. et al (1996) Childhood

Use of antipsychotics by child and adolescent psychiatrists
Sir: Having recently completed a survey of 46 child and adolescent psychiatrists in the Wessex region (37 consultants and nine senior registrars) on the use of antipsychotics in first-episode psychoses, we found Slaveska et al's (1998) paper particularly apposite. Our findings, however, contrast sharply. We developed a questionnaire, asking about the drugs psychiatrists would use to treat first episodes of psychotic illnesses. Forty-one out of 46 (89%) questionnaires were returned. Four respondents reported they never prescribed antipsychotics and did not complete the questionnaire, while one returned a blank questionnaire. The respondents had a mean of 9.8 years of experience in child and adolescent psychiatry. Fifty per cent would use risperidone, olanzapine or "a new antipsychotic" as their first choice, 24% would not prescribe new atypical antipsychotic as their first or second choice, while 12% would only use conventional anti psychotics as defined by Thomas & Lewis (1998). The doses used ranged between 200 and 800mg chlorpromazine equivalents. Clinicians reported that differing side-effect profile, observing trends in psychiatric practice, training with clinicians with an established prescribing practice and adverse personal experience guided them most in their prescribing. Therefore, we found that the majority of the Wessex child and adolescent psychiatrists would prescribe atypical antipsy chotics, as first choice, a finding that is very different from that found by Slaveska et al (1998). The wide variations in findings, however, high lights the need for further discussions on good medical treatment in this particular age group, especially as their first experience with psychopharmacological treatment may well significantly influence their future compliance.

Psychiatry, post-modernism and politics
Sir: Allan Beveridge believes medicine, and psychiatry in particular, to be vulnerable to a post-modernist critique if it is founded upon the belief that there is a "single, objective, verifiable reality" (Psychiatric Bulletin, September 1998, 22, 573-574). This may be the case, but the question that is perhaps more true to the origins and traditions of medicine, as opposed to many of the natural sciences, is less 'what is' than 'what works'. Employing a technique that amel iorates or abolishes the features that are trou bling the patient, and being concerned with evidence that this is in fact the effect of the treatment, bypasses the critique. This argument is tacitly accepted when post-modern theorists become seriously ill: concerns about treatment effectiveness quickly take precedence over dis agreements regarding the possibility of accu rately representing reality.
Beveridge highlights the potential for a post modern approach leading to a better under standing between the psychiatrist, who attributes disease to neurotransmitters, and the patient, who complains of poor housing and poverty. Such an approach might be expected to facilitate a widening of the scope of medical/ psychiatric interest to include areas politicians might prefer remain unscrutinised, but this is not necessarily the case. Indeed, post-modern ism has itself been accused of engendering political hopelessness and inertia, or of being a product of perceived political impotence (Choms ky, 1994). When there are so many equally valid ways of formulating a problem, how can a particular solution be implemented with conviction?
Patients' knowledge of their lithium therapy Sir: I was interested to note the results of knowledge of lithium treatment among patients attending a lithium clinic (Anderson & Sowerbutts, Psychiatric Bulletin. December 1998, 22, 740-843). I conducted a similar study in 1995 on patients in an area without a lithium clinic (Oxford). I recruited recently discharged inpatients and day patients on lithium. I devised a questionnaire on knowledge of lithium and sent it to 28 people.
I received 16 replies. In my sample eight had received a lithium information leaflet, five re ported having received no information, the remainder having been informed by their doctor. None of the patients correctly identified the signs of lithium toxicity, only one knew of any drug interactions and none knew what other factors could affect lithium levels, although two women recorded pregnancy as a reason to contact a doctor or community psychiatric nurse. The study had obvious limitations, but the 16 respondents clearly showed an inadequate knowledge of the most dangerous aspects of their treatment.
It has been suggested that the most appro priate setting for lithium surveillance is a specialised lithium clinic (Guscott & Taylor, 1994). However, this can be difficult to organise with the move towards sectorised clinical ser vices. The resultant idiosyncrasies of lithium management could lead to inadequate know ledge among patients and poor compliance. I suggest the need for a national protocol of minimum standards of education on treatment for patients which involves multimedia edu cational techniques as well as regular re-check ing of information retained.