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10 MARCH 1979


logy alone greatly limits the concept; the medical model embraces psychopathology as well as somatic pathology. Had the correct model been employed in evaluating the authenticity of the "hyperkinetic syndrome" it would soon have become apparent that hyperkinesis is a symptom rather than a syndrome and in a particular patient represents somatic pathology or psychopathology, or an interaction of both; indeed the data given in your editorial point clearly in ings to be published by Raven Press). 4Lena, B, Surtees, S J, and Maggs, R, in Lithium in this direction. Medical Practice, p 79-83 ed F N Johnson, and S SIR,-There is one particular area I would Johnson, p 79. Lancaster, Medical and Technical J G HowELLs Publishing Press, 1978. like to comment on regarding your otherwise Institute of Family Psychiatry, Ipswich, Suffolk comprehensive leading article (27 January, p 214) on this topic-namely, side effects of lithium therapy in the young. Some special Is there a hyperkinetic syndrome? Labetalol and urinary catecholamines precautions are necessary because of the vulnerability of the age group under considera- SIR,-Whatever the merits of the "hypertion. The narrow margin between the thera- kinetic syndrome" one has to accept that SIR,-We have already reported (24-31 peutic and toxic levels of lithium in the serum hyperactive children present a real problem December 1977, p 1673) that elevated levels of is well known, and side effects such as and one which is often referred to child urinary catecholamines occur after the abdominal pain, vomiting, tremors, and drow- psychiatrists for treatment. It may well be administration of labetalol. Further reports siness when they occur in the young could be that hyperactivity, a most striking symptom, have been published in this journal which particularly distressing. Hence not only must is a child's common response to a number of indicate that when radioenzymatic detection methods are used for the measurement of the parent have easy access to the therapist separate clinical and aetiological entities. In my practice I have found it useful to catecholamines, then normal levels are when toxic effects appear, but the young person should be seen by the therapist at more look at hyperactivity as a psychomotor observed after labetalol administration by Dr frequent intervals than adults. The suppressant manifestation akin to the psychomotor C A Hamilton and others (16 September, action of lithium on the thyroid has been acceleration of adult hypomania. Dynamically, p 800) and by Dr R Kolloch and others established. Although pre-existing renal dys- one can consider adult motor acceleration to (27 January, p 268). This is in contrast with function is a contraindication of lithium be a manic defence against depression. the finding that conspicuously elevated in children does not present itself levels occur when fluorimetric method therapy, whether lithium itself causes renal Depression damage is not clear and is currently under in the adult pattern. For one thing, the motor measurements are used, as reported by the investigation. It is also now known that control and the psychic developments are same authors. We have shown that no significant elevation lithium affects calcium metabolism. Hence it incomplete. Psychic awareness of depression is clear that lithium therapy in the young by the child generally begins in adolescence. of plasma noradrenaline or adrenaline occurs However, many of the other symptoms of after acute intravenous administration of should be carried out with extreme caution. The Federal Drug Administration cautions adult depression are present in conjunction labetalol.1 Measurement of catecholamines against the use of lithium in children under 12. with the child's psychomotor acceleration. was performed using the high-performance Lithium thus should not be used in this group I have often found in the history a disturbance liquid chromatography (HPLC) method of unless there are special indications. The in the mother-child relationship dating back Riggin and Kissinger2 and our results are special implications and precautions necessary to the time of birth, the infant not seeming to similar to those already reported.2 Further regarding side effects of lithium therapy with respond satisfactorily to maternal care extensive studies in our laboratories have young people have recently been described.'-3 (depressed infant ?) or maternal care being shown that when fluorimetric methods of For the past three years a double-blind con- clumsy or otherwise unsatisfactory to the catecholamine measurement are used elevated trolled investigation sponsored by the South- infant (maternal depression often present). levels do occur after the use of labetalol. Thus east Thames Regional Health Authority has The fact that children in the United States we can confirm that labetalol in biological been carried out in this hospital.4 More respond to psychic stimulants such as fluids interferes with fluorimetric methods of detailed accounts of this work are in prepara- dexamphetamine and methylphenidate is, in analysis but that no such interference occurs tion and I will be quite happy to provide my opinion, not a "paradoxical response" when HPLC methods are used. but rather the response which one would It is therefore important not to attribute details for anyone who is interested. Proteinurea, although not an established usually expect from depressed adults after clinical significance to elevated plasma or urinary catecholamine levels if these measureside effect of lithium therapy in adults, has intake of the very same psychic stimulants. Haloperidol (plus orphenadrine) is probably ments have been made using fluorimetric occurred with disturbing frequency in our group of children. Two other side effects which the most effective drug in controlling the methods. Furthermore, we recommend that need to be emphasised are the occurrence of child's motor acceleration but it does not urinary 4-hydroxy-3-methoxymandelic acid memory impairment and fine tremors of the affect favourably the psychic depressive (HMMA) and not catecholamine or metahands which affect the handwriting. The component in the syndrome. The administra- nephrine excretion should be measured when implications of these two side effects for a tion of a tricyclic antidepressant by itself or screening for phaeochromocytoma in patients together with the haloperidol appears to be who are being treated with labetalol. child at school are obvious. I would like to endorse one of the indications much more effective and certainly a more D A RICHARDS for lithium therapy in young people referred rational treatment. Appropriate drug treatment D M HARRIs to in your leader-aggressive behaviour. for the mother should also be considered. L E MARTIN However, I would qualify this by saying that Family therapy and psychotherapy focusing this should be hyperaggressive behaviour on the mother-child relationship, both present Glaxo-Allenburys Research (Ware) Ltd, Ware, Herts occurring in an adolescent over 12 not amen- and past, is an invaluable aid. Ros ZINNA able to other intense psychological methods of Family Psychiatry Clinic, Richards, D A, Prichard, B N C, and Hernandez, R, intervention (family group therapy, behaviour Christchurch, Dorset British Journal of Clinical Pharmacology, 1979, in press. modification, etc). In these circumstances 2 Riggin, M, and Kissinger, T, Annals of Chemistry, short-term lithium therapy for up to six 1977, 49, 2109. months could be beneficial.2 Long-term SIR,-The notion of the medical model for lithium therapy in the young should be definining diagnosis expressed in your leading avoided. There is some evidence that the anti- article of 24 February (p 506), is false. You No more textbooks on primary care? aggressive action of lithium probably requires state that the medical model is based on a lower dose and lower serum concentration "bacterial infections with distinctive symptoms SIR,-I agree with Dr Ian Tait (27 January, than those recommended-namely, 0 6-1-5 and signs, predictable course and outcome, and p 256) in praying for no more textbooks on mmol(mEq)/1.3 Lithium, when given to young a relatively consistent response to treatment- general practice. A book which covered people, should be given in a sustained release and all backed up with positive cultures." To everything the GP ought to know would preparation-because then there is less peaking equate the medical model with somatic patho- prove a daunting load for a strong man with a

mood distorting his experience and behaviour; of the serum lithium level and hence the potenand where effective medication is known it tial for renal damage is decreased. cannot responsibly be withheld. B LENA Psychotherapeutic support is always needed Department of Child and Family Psychiatry, Eastbourne District General Hospital, by the child and his family but by itself leads Eastbourne, East Sussex to the danger that the child will merely adapt to his illness and circumstances, and only 'Lena, B, Excerpta Medica, International Congress Series, in press. appear to improve. The aim of treatment must 2Lena, B, paper presented to quarterly meeting of the be to restore him fully to his previous personRoyal College of Psychiatrists, London, 1978. B, in Symposium on the Psychopharmacology of ality, perhaps of many years ago.-ED, BMJ. 3Lena, Aggression, Royal Society, London, 1978 (proceed-