Sexist case-notes can be useful

Sir: The article by Dr Clarke (Psychiatric Bulletin 1993, 17, 469-470) made interesting reading. The possibilities of adverse drug reactions in psychiatric patients are very real and can be overlooked. One factor not mentioned was the possibility of deliberate patient deception and, although infrequent, we feel it bears mention. Recently we encountered two patients with atypi cal symptoms related to this area whose behav iour proved hazardous to themselves and the treatment process. One 30-year-old woman presented with ataxia and sedation while receiving treatment with antidepressants, and subsequently responded well to treatment as an in-patient. She later admitted using her child's methylphenidate and carbamazepine along with over-the-counter prepar ations. A second woman presented with bizarre neurological complaints during treatment with a tricyclic agent; the symptoms of meningism and headache persisted after the tricyclic was stop ped. Later, she revealed that she was receiving oral retinoid therapy for acne but did not mention this lest the treatment was discontinued. Her subsequent response to treatment was good. Patients may therefore wilfully mislead their psychiatrists on occasion especially regarding medication. The quality of the information we receive depends on a number of factors, and the use of over-the-counter preparations, herbal remedies and medications prescribed for others may jeopardise the patient and the treatment process. The fault may lie with the patient rather than the specialist who adheres too rigidly to his or her own area. The information may simply not be forthcoming despite exhaustive enquiry.

Sir: The article by Dr Clarke (Psychiatric Bulletin 1993, 17, 469-470) made interesting reading. The possibilities of adverse drug reactions in psychiatric patients are very real and can be overlooked. One factor not mentioned was the possibility of deliberate patient deception and, although infrequent, we feel it bears mention. Recently we encountered two patients with atypi cal symptoms related to this area whose behav iour proved hazardous to themselves and the treatment process.
One 30-year-old woman presented with ataxia and sedation while receiving treatment with antidepressants, and subsequently responded well to treatment as an in-patient. She later admitted using her child's methylphenidate and carbamazepine along with over-the-counter prepar ations. A second woman presented with bizarre neurological complaints during treatment with a tricyclic agent; the symptoms of meningism and headache persisted after the tricyclic was stop ped. Later, she revealed that she was receiving oral retinoid therapy for acne but did not mention this lest the treatment was discontinued. Her subsequent response to treatment was good.
Patients may therefore wilfully mislead their psychiatrists on occasion especially regarding medication. The quality of the information we receive depends on a number of factors, and the use of over-the-counter preparations, herbal remedies and medications prescribed for others may jeopardise the patient and the treatment process. The fault may lie with the patient rather than the specialist who adheres too rigidly to his or her own area. The information may simply not be forthcoming despite exhaustive enquiry.
ALAN BYRNE, and GARY HNATKO,University of Alberta. Edmonton, Canada

Sexist case-notes can be useful
Sir: How sad that M. Phillips (Psychiatric Bulletin, 1993, 17, 432) has revealed to the world the 'sexist' nature of medical record files kept at the Maudsley Hospital (women, buff colour; men, green). The reason for the differential colour cod ing has nothing to do with ease of retrieval etc (though this is commonly used as the pretext). It is, in reality, a subtle test of common sense for new Maudsley recruits. Common sense is a no toriously difficult ability to assess at interview and has no correlation with number of publica tions (O'Brien et al. unpublished observations on a frighteningly large and ever growing personal series). A registrar's 'time to realisation' that males and females have different coloured files is a reliable and valid measure which, in addition, never ceases to amuse those who have already attained this milestone. Although I do not have detailed figures to hand, I feel that the 18 months described by Dr Phillips is perilously close to being outside 2 standard deviations of the mean. However, Dr Phillips can be reassured in the knowledge that several leading academics (they know who they are) have failed to reach this goal without assistance from others.
On a more serious note, colour coded casenotes can be an invaluable part of the psychiatric examination. I became aware of such benefits when working in a clinic performing assess ments on potential candidates for gender re assignment surgery. If potential male-to-female transsexuals appeared carrying buff (female) files after registering, they had demonstrated their ability to live successfully as the opposite sex, by fooling the reception staff. But if they failed to demonstrate 'O'Brien's sign', and walked in with a green file, then it was clear more work needed to be done before surgery could be considered. This simple measure, of which patients (like Dr Phillips) were blissfully unaware, saved hours of informant history gathering. Despite my experi ences in the gender identity clinic, I remain convinced that important differences do exist be tween men and women. I would suggest that 'sexist' colour coding of notes is not only a reflec tion of this but can aid in psychiatric assessment. JOHNT Sir: Dr Ball (Psychiatric Bulletin, 1993, 17, 427-428) attempts a critique of day care in old age psychiatry. As in all NHS services, historical factors determine the development of services. The 'Worthing experiment ' (Carse et al., 1958) is perhaps the original demonstration of active treatment in a day hospital to prevent admission Correspondence 53