Psychiatry in war

of agreement among psychiatrists as to what this label represents, it has been suggested that clinicians discard the term (Thornicroft, 1990) and instead employ the appropriate diagnosis from ICD-9 or DSM-III-R. Cases where there is clouding of con sciousness would be coded as "transient organic psy chotic conditions" (293.0) in ICD-9 and as "cannabis delirium" (292.81) in DSM-III-R. Those occurring in clear consciousness would be coded as "paranoid and/or hallucinatory states induced by drugs" (292.1) in ICD-9 and as "cannabis delusional disorder" (292.11) in DSM-III-R.

''Cannabis psychosis DEARSIRS I read with interest the letter by Dr Cembrowicz (Psychiatric Bulletin, May 1991, 15, 303) which reported on the popularity of "cannabis psychosis" as a diagnosis used by health workers in Tobago, West Indies. The study of psychiatrists in Birmingham which Dr Cembrowicz referred to (Littlewood, 1988) reported that although most did not find "cannabis psychosis" a useful diagnosis, a significant minority (40 out of 104 respondents) did. In view of the lack of evidence to support the separate clinical entity of "cannabis psychosis", and the lack of agreement among psychiatrists as to what this label represents, it has been suggested that clinicians discard the term ( Thornicroft, 1990) and instead employ the appropriate diagnosis from ICD-9 or DSM-III-R. Cases where there is clouding of con sciousness would be coded as "transient organic psy chotic conditions" (293.0) in ICD-9 and as "cannabis delirium" (292.81) in DSM-III-R. Those occurring in clear consciousness would be coded as "paranoid and/or hallucinatory states induced by drugs" (292.1) in ICD-9 and as "cannabis delusional disorder" (292.11) in DSM-III-R.
Littlewood commented on the readiness of the psychiatrists he studied to prescribe major tranquil lisers for cases of "cannabis psychosis", despite their perception of this as a self-limiting condition. Improvement in our knowledge of how to treat such cases is likely to be hampered if clinicians fail to dis tinguish between those showing features of an acute organic reaction and those resembling a functional psychosis.
The diagnosis of "cannabis psychosis" may sur vive in clinical practice, like the "amotivational syndrome" did for many years, not because of its  (Psychiatric Bulletin, May 1991, 15, 274-275) with some interest. My interest was abruptly interrupted in the paragraph dealing with guardianship, by two intrusive pieces of obfuscation. Being a psychiatrist and therefore in the know with respect to the private, and often stigmatising, language which we seem to develop, I was able to understand it on second or third reading. I am fairly sure though that those who are not in the know would becompletely puzzled. May I therefore make yet another plea for dropping curi ous neologisms and new definitions of commonplace words which add nothing to comprehension. The passage that gave me a problem is "guardian ship is to be considered as an alternative to section ing". The aggressive word "sectioning" here does not of course refer to some frightful fate which befalls the patient, but simply compulsory admission. Further more, guardianship has its own sections of the Mental Health Act 1983. In the next sentence we are told that it is sad that those mentally disordered indi viduals under guardianship are referred to as patients? This puzzle is illuminated by an implied new definition that an individual has to be in hospital before they can qualify for the term patient. What on earth am I supposed to call my out-patients? I treat "patients" on guardianship orders and I expect many other psychiatrists do also. JOHNGUNN

Institute of Psychiatry De Crespigny Park London SES 8AF
Psychiatry in war DEARSIRS There are a couple of ambiguities in Jacqueline Atkinson's two informative articles (Psychiatric Correspondence Bulletin. April 1991.15,199-203) which if not cleared up might cause unnecessary alarm.
In the first she states that "overall psychiatric casualties are approximately 30%" and in the second "Overall... an incidence of psychiatric casualties of about 20-30% could be expected". The question is 30% of what? What is not clear is that these projec tions from historical data obtained from a variety of nations and wars in this century refer to percentages of surviving casualties and not to percentages of personnel involved. If the 30% yardstick were ap plied to the Gulf War in which 43 were injured, the estimated number of psychiatric casualties would be 19 not 13,500 (that is 30% of the total force of 45,000).
In her second article, the author asserts that "it is clear that military services cannot deal with all the current problems". If this taken to mean "deal with all the problems remaining from all the wars of this century" she is of course right, although your readers may be surprised to learn how many ex-service per sonnel, ranging from veterans of the Falklands con flict to Far East prisoners of war from the 1939-45 War, have in fact received help from the military psychiatric services. If, however, she means "deal with the problems of those currently entitled to military care" or "deal with the problems currently arising from the Gulf War", the statement is quite simply not true. We can and we do. Provision was made for dealing with 100 times the number of casualties evacuated, had the war taken a greater toll of our forces.
Finally, under the heading Service provision the author says: "The NHS's role will be determined, at least in part, by the adequacy and availability of front-line CRS treatment." Your readers will be glad to learn that Field Psychiatric Teams were deployed for the first time in support of the Armed Forces of the Crown in War. They were seen at work during the BBC/ITN news bulletins of 23 January 1991. As a result of education and training the number and quality of psychiatrically trained personnel involved, and the system of deployment used, the adequacy and availability of front-line treatment was unrivalled. Happily it was scarcely tested. P. ABRAHAM Royal Army Medical College Millbank, London SW1P4RJ DEARSIRS I have recently returned from the Gulf War and have been catching up on a backlog of journals. It was with interest that I read the trilogy of articles about psychiatry and war (Psychiatric Bulletin, April 1991, 15,199-204). and in particularJacqueline Atkinson's article 'The demand for psychiatric services as a result of the Gulf War'.

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I was a psychiatrist in a Field Psychiatric Team (FPT) travelling in support of the British Division as it prepared for war and as it fought through southern Iraq and eastward into Kuwait. This FPT was the most forward element of a comprehensive Psychi atric Service supporting Servicemen and women in the Middle East Theatre of Operations.
I disagree with Jacqueline Atkinson where she states that "Current mental health services in the field are unlikely to be able to deal with all those requiring assistance". I am confident that the Service would have dealt admirably with the theoretical maximum estimate of battleshock casualties, had this occurred. That this did not occur (no casualties were referred to our team during and after the ground battles) was due to two main factors. First, the nature of the battles -fast, successful, minimal physical casualties -precluded the development of large numbers of acute cases. Second, military units were well prepared for prevention, recognition and management of the problem within their own lines. In the transition-to-war phase the psychiatric service was involved in the education of all troops, and especially commanders, in this respect. Units knew to refer cases only when they could not manage them themselves. The other teams coped easily with the relatively small number of combat-related stress casualties which came to them from the rear areas.
Jacqueline Atkinson also writes that "The NHS's role will be determined, at least in part, by the adequacy and availability of front-line CRS treat ment". I trust that the NHS will have little to do in the wake of this war. So far the Psychiatry Division of the Army Medical Services has seen but a very small number of cases of a chronic nature. D. S. C. GAMBLE Queen Elizabeth Military Hospital Woolwich, London SE18 4QH DEARSIRS In response to Brigadier Abraham and Major Gamble. I would point out that these articles were written during the height of the Gulf War when there was speculation about a protracted land war and when provision was being made by NHS hospitals to receive psychiatric casualties. The first sentence was changed as the Bulletin went to press and hostilities ceased. That there was not a prolonged war means there will be fewer people suffering PTSD but does not negate the arguments for potential problems under other conditions as outlined in the articles. With no clear epidemiological data from the Falklands War, it is difficult to estimate how many people will suffer PTSD in the years to come. That Britain has been fortunate in the military conditions (including the use of Field Psychiatric Teams) being likely to contribute to lower incidence of