Dominance of second-generation antipsychotics - time for reflection?

Bleakley et al ( Psychiatric Bulletin , March 2007, 31 , [94–96][1]) address an interesting and relevant question regarding which antipsychotics healthcare professionals would choose for themselves. It is reassuring that their choices are broadly in keeping with the medications that they give

Bleakley et al (Psychiatric Bulletin, March 2007, 31, 94^96) address an interesting and relevant question regarding which antipsychotics healthcare professionals would choose for themselves. It is reassuring that their choices are broadly in keeping with the medications that they give their patients.
What is striking is the overwhelming preference for second-generation antipsychotics. The authors cite this preference as support for the widespread use of these drugs and state that risperidone and olanzapine have advantages in effectiveness over conventional antipsychotics. The evidence base for this is not as clear as it once appeared. Three recent, large, independent trials have not found superior effectiveness for secondgeneration antipsychotics (although they did not consider aripiprazole) and have failed to show an advantage in terms of quality of life or patient preference compared with conventional antipsychotics (Rosenheck et al, 2003;Lieberman et al, 2005;Jones et al, 2006).
How then do we explain the enthusiasm for these medicines among healthcare professionals? It is perhaps worth considering that although some of the side-effects of typical antipsychotics are rapid (e.g. extrapyramidal symptoms), the side-effects of the second-generation atypical antipsychotics (e.g. metabolic syndrome) may be delayed, and this may reduce their impact on health professionals. Other possible explanations include clinical optimism for new treatments, greater familiarity with secondgeneration antipsychotics, delayed dissemination of new evidence and effective marketing of these drugs.
It is no longer the case that the literature overwhelmingly supports the use of atypical over conventional antipsychotics. Perhaps it is time to revisit the evidence and debate current practice.
Declaration of interest. B.U. has received hospitality from all major drug companies involved in the manufacture of antipsychotics. Bed numbers and acute in-patient care I am pleased that Mat Kinton has given some views on bed numbers as a limitation to acute in-patient care (Psychiatric Bulletin, February 2007, 31, 76) as it provides an opportunity to extend the debate further.
To my mind arguing that 'improvement may be reliant upon a much more fundamental question of resources: beds for the patients' is an unjustified oversimplification. Of course it is highly unsatisfactory when over-occupancy does occur but as Mat himself acknowledges this is not a universal experience. The 2004 survey of acute care (Sainsbury Centre for Mental Health, 2004) found a range of regional average bed occupancy rates of 911 09%. Furthermore, overall rates of admission are falling (Glover et al, 2006) and figures from the Department of Health (http://www.performance.doh. gov.uk/hospitalactivity) suggest that this is reflected in falling national bed occupancy rates (from 91.4% in 2002^2003 to 85.6% in 2005^2006).
As the situation is not homogenous, there will be places where bed numbers are unsatisfactory, and there, local action might be needed to correct shortcomings, but arguing simply for more resources for more beds detracts from the need to look in detail at what the shortcomings might be. Mat acknowledges that improvement of patient services requires a multi-agency approach; surely that includes close attention to reasons for delayed discharge, the background to admissions of uncertain purpose, process delays and cumbersome interprofessional practices and power relationships.
Glover et al (2006) highlight the influence that home treatment/crisis resolution teams can have upon bed use, and that as this is a delayed effect, the mechanism is likely to be complex. Besides (or perhaps instead of) complaining once again about inadequate resources, perhaps we should also continue to question whether those resources we have are being used as well as they might. In the case of acute psychiatric in-patient beds this might include critical reappraisal of how clearly the purpose of an admission is articulated, how readily discharge can happen when it is due, how successfully communications between in-patient and community teams support care planning, and so on. Merely highlighting bed shortages oversimplifies and detracts from more relevant but possibly more complex and challenging aspects of the very necessary agenda to improve acute in-patient care. Sexual dysfunction among patients of south-east Asian origin As psychiatrists, we do not ask often enough about sexual symptoms, for fear of embarrassment, a perceived lack of importance or sensitivity (Abbasian, 2002). Among patients from a south-east Asian background who are unable to speak English, eliciting symptoms can be Columns Correspondence difficult and using interpreters is often the only solution. Asking questions of a sexual nature requires tact. A patient is unlikely to reveal problems of a sensitive nature to an interpreter, for fear of embarrassment, especially if they are from the same cultural background. Sex has always been a taboo subject in this community and it is difficult to find literal translations of terms used when taking a sexual history, without having to resort to colloquial slang. The accuracy of histories could be doubted.
With psychiatric illness already associated with stigma in south-east Asian communities, patients are unlikely to freely admit to sexual dysfunction as well, in a community in which male virility and fertility among males and females is seen as culturally desirable. Asian women are unlikely to want to discuss such sensitive issues with a male or agree to initimate examinations. Understanding of psychiatric illness can be limited, and sexual dysfunction may not be recognised as a symptom of illness or side-effect of medication.
Questioning patients about sexual dysfunction is a sensitive issue, especially when the patient is from another culture. As clinicians we must be aware of the need to ask about such symptoms. Opportunity for subspecialty recruitment The importance that undergraduate experience of psychiatry has in shaping the career choices of medical students is highlighted by Eagles et al (Psychiatric Bulletin, February 2007, 31, 70^72). However, although some form of psychiatric experience is included in all medical school curricula the psychiatric sub-specialties often miss out, with possible consequences for recruitment.
It is important to address this, and one of the best ways of doing so is through the provision of special study modules. These are clinical attachments chosen by the student that usually last 3 weeks and may be in clinical environments to which the student is not routinely exposed. These modules should have a strong clinical focus and give the student the opportunity to see what the clinician actually does from day to day. The General Medical Council states that 25^33% of the medical school curriculum should now be delivered in this way (General Medical Council, 2003). This gives scope for many of the psychiatric sub-specialties to be included as possible options.
The observation that exposure to clinical psychiatry tends to promote positive attitudes suggests that this would be a good way of boosting sub-specialty recruitment. Special study modules present clinicians in psychiatric sub-specialties with a great chance to convey their enthusiasm and educate medical students in their areas of work. We should seize the chance and contact the special study module coordinators of the local medical schools to put our specialties forward. GENERAL MEDICAL COUNCIL (2003)

Therapeutic use of soap operas
Dr Breen describes the therapeutic use of soap operas in a boy with autistic-spectrum disorders (Psychiatric Bulletin, February 2007, 31, 67^69). The use of soap operas is already widespread in old age psychiatry as a tool for informal assessment of cognition. Personally, I cannot bear their blend of stereotypical characters, exaggerated emotions and simplistic conflict, yet feel duty bound to monitor plot lines as a matter of professional obligation. Now it seems our colleagues in child and adolescent psychiatry may become similarly compelled to watch these grinding pantomimes in the name of enhancing the social intelligence of their flock. Is now the time to call for such activities to be formally incorporated into our job plans? Blood glucose monitoring in a regional secure unit Dr Tarrant (Psychiatric Bulletin, August 2006, 30, 286^288) reaffirms the shortfalls in blood glucose monitoring in psychiatric practice, and we have confirmed this in two audits at a regional secure unit. The first (conducted in 2003) found that 30% of the in-patient sample on antipsychotic medication (an indicator of potential risk of hyperglycaemia) had random blood glucose measurement, and only one patient (who was diabetic) had regular blood glucose monitoring and measurement of glycosylated haemoglobin (HbAlc). The second audit (conducted in 2006) found that 58% of patients had their blood glucose measured at baseline, and half or less had appropriate monitoring.
These audits suggest that monitoring of blood glucose was unsatisfactory and recommendations (e.g. robust review of physical healthcare at care programmed approach meetings) to improve standards have subsequently been put into place. However, what is not known is the impact that the poor monitoring had on patient morbidity. One might predict that early detection and treatment of hyperglycaemia would prevent secondary problems such as coronary, renal and vascular complications in this patient population. It is therefore imperative that monitoring of blood glucose and other indicators of metabolic risk, such as HbA1c, lipid profiles and hormone levels (e.g. thyroid function tests), is undertaken whatever the setting (primary or secondary care and prisons) for all people on antipsychotic medication. It is also important that adherence to local/ national protocols is audited regularly. We are all nidotherapists We disagree with Tyrer et al's comparison of 'standard and nidotherapy perspectives of the environment for those with mental illness' (Psychiatric Bulletin, January 2007, 31, 1-3). The views attributed to 'standard' perspective (which we assume refers to usual clinical practice) do not represent the practice or belief of any clinician we know. The authors' suggestion (for standard perspective) that the 'environment is of secondary importance in psychiatric practice' sharply contrasts with the biopsychosocial approach which is drummed into trainees from their first day in psychiatry. Similarly, we are not aware of any clinician who believes that 'once people with mental illness get better their original environmental problems resolve'. On the contrary, all clinicians we know identify with the perspectives attributed to nidotherapy even if limited resources constrain their implementation.
Although it is helpful to highlight the importance of the environment in the management of people with mental illness, giving this a fancy name sounds like 'rebranding old wine in new bottles'. What we need are the resources to continue to improve all aspects of the lives of people with mental illness.