222 CORRESPONDENCE

5. GALDT,J. & BONATO,it (i@) Alcoholism and agitated depression and mania. Nitrazepam and
psychiatric disorder: an evaluation of a ‘¿com similar compounds are just not adequate in these
pensation' hypothesis. Submitted for publication. instances, and while one would rarely prescribe
4. HERNER,T. (1972) The frequencyof patientswith barbiturates otherwise they are surely indicated here.
disorders associated with alcoholism in mental
hospitals and psychiatric departments in general
I would applaud Dr Shaw's emphasis on using
hospitals in Sweden during the period 1954—1964. adequate doses of tricyclic antidepressants, but he
Ada Psyciziat. &an@L, Suppl @. makes no reference to work done on the cardiac
@.Woiu.n Ha*im OROANIZA11ON (sg@7) Manual of the effects of different tricyclic antidepressant drugs (see
International Siatistical Clc@ssificatio* •¿f
Diseases, the work of Burrows et al, Brit. J. Pgichiat., 1976, zag,
Ijjuriss, and Causes of Death, Vol i, pp 1 pp 335—41).This work would suggest that cioxepin
Geneva: Switzerland: World Health Organiza is safer than the other tricyclics in patients with heart
tion. disease. Dr Shaw gives the impression of therapeutic
zeal, which is refreshing, but I feel that in cases of
so-called resistant depression it is important to
2.0 emphasize re-examining closely one's diagnosis
‘¿p before embarking on a series of drugs, some of which
Fl carry significant problems of toxicity.
N. Basuxua
1.0 Oldham and District
GeneralHospital,
Rochdale Road,
Oldham OLi 2JH
0.5

BTh* HALOPERIDOL IN NORMALS

@ I I @& A - I_ I DEAR Sm,
1954 t958 1@ 1957 1958 1169 1@ 1961 1962 Haloperidol is an effective antipsychotic agent
which is a relatively specific blocker of dopamine
Veer'
transmission in the brain (Anden et al, 1970). As
Fm 1.-.—Proportion increases in male admissions to
Sweden Mental Hospitals between 1954 and ig6i part of the preliminary trials in a study of possible
calculated from 1954 baselines. dopaminergic mechanism in affective disorder, the
two authors each were given haloperidol 5 mg
* Data for the year is plotted at the mid-year. intravenously in a two-minute push. The effect was
marked and very similar in both of us: within ten
minutes a marked slowing of thinking and move
MANAGEMENT OF AFFECTIVE DISORDERS
ment developed, along with profound inner restless
DEAR SIR, ness. Neither subject could continue work, and
I found Dr David Shaw's review article on ‘¿Theeach left work @rover 36 hours. Each subject
Practical Management of Affective Disorders (Journal, complained of a paralysis of volition, a lack of
May 1977, 530, pp 432—51)stimulating and full of physical and psychic energy. The subjects felt unable
information. However, there are some points with to read, telephone or perform household tasks of
which I would take issue. It is ‘¿difficult
to know how their own will, but could perform these tasks if
he justifies giving as many as 14 ECTs in a case of demanded to do so. There was no sleepiness or
depression. I would have thought if the patient did sedation; on the contrary, both subjects complained
not respond to a maximum of 8 ECTs, the possibility of severe anxiety.
of improving with further ECT is small. Perhaps he The present experience was similar to that pre
has some basis for his figure of 14, but he does not viously reported of neuroleptic effects in normal
state it. There is also a-conspicuous failure to mention subjects (DiMascio et al, ig6g; Heninger at al, 1965),
the remarkable effect of ECT given in a brisk, brief though previous studies used neuroleptics which
course in mania. This would -seem to be far safer block both dopamine and noradrenaline receptors
than the heroic doses of haloperidol which Dr Shaw (Anden et a!, ‘¿970).We used a relatively specific
recommends, namely 10—30mg i.m. initially and dopamine blocker, haloperidol, and experienced
@ further doses i—i hours later repeated till either profound cognitive and emotional restriction. Dopa
hypotension ensues or the mania subsides. There is mine blocking by neuroleptics may function to
also no mention of the role of barbiturates, which restrict cognitive and emotional processes in normals
can be most helpful in the severe sleep impairment of as well as in ‘¿schizopbrenics,and thus it is possible
 CORRESPONDENCE 223

that it does not specifically antagonize schizophrenic discontinue lithium treatment. Carter (1972) re
pathology. In the presence of psychotic anxiety or ported exacerbation of psoriasis in three patients on
delusions, such cognitive or emotional restriction lithium. In his patients lithium treatment was
may be desirable and therapeutic. However, the discontinued, which led to prompt improvement of
restrictive effect may be a general one, and is certainly the skin disorder. Voorhees et a! (1975a) reported
useful in mania as well as in schizophrenia (Shopsin three patients, and Bakker and Pepplinkhuizen
et al, 1975). The similarity of the above-described (i@'@) reported four patients with psoriasis who
stateto that of some casesof agitateddepressionand showed deterioration
on lithium.
post-psychotic depression suggests involvement of A possible explanation for the observed effect
<lopamine in these affective states (Post et a!, 1976; could be through reduction of cyclic AMP, which is
Gerner et al, 1976), as well as in schizophrenia considered to be a stimulus to epidermal prolifera
(Snyder et al, 1974). tion, important in psoriasis. Preliminary data from
ROBERT H. BELMAKER in vitro studies suggest that lithium affects the epi
DAVID WALD dermal cyclic AMP (Voorhees et a!, 1975b).
Department of Research, Sincethe completionof our reportthreesimilar
Jerusalem Mental Health Centre, cases have been referred to us. In one of these cases
POB 140, Jerusalem, Israel it was possible to discontinue lithium whereupon the
skin disease improved to its previous appearance.
References The question whether lithium may actually
ANDEN, N. E., BUTCHER., S. G., CoaaoDl, H., Fuxa, K. aggravate psoriasis has practical importance. Fur
& UNGERSTEDT,U. (ig7o) Europ. 3. Pharmacol., @, ther studies are now in progress to confirm this
303. clinical observation.
DIMASC10, A., HAVENS, L L. & Kiza@, G. L. (1963) A@r.nxASKO1-r
3. nerv.men!.Dir., 136, i68. BIu'rr-LouIsE MAGNTJSSON
GERNER, R. H., PosT, R. M. & Buiorrx, W. E. JR (1976) HAIA.N MOBAOKEN
Amer. 3. Psychiat., 133, 1177.
ju@i-ERiK STA.IuLs.nz
HENINGER, G., DIMAscIo, A. & K .RSIAr4,G. L. (1965)
Amer. 3. Psychiat., 121, 1091. P@ychiatric Research Centre,
PosT, R. M., GERNER, R. H., CAiuw@, J. S. & BuNEv, St Jorgen's Hospital,
W. E. JR (1976) Lance!,i, 203. S-422 03 Hisings Backa,
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(‘975)Arch. Gas. Psjclziat., 32, 34.
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@ GREENBERG, D. (i97i@) Science, 1243. BAKKER,J. B. & Pappur'muwizza, L. (1976) More about
the relationship of lithium to psoriasis. flychosomatics,
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LITHIUM AND PSORIASIS CAama, T. N. (Ig'72) The relationship of lithium car
DEAR SIR, bonatetopsoriasis.
Psychosamatics,
13,325.
We have recently reported (Skott et ci, 1977) three SKo'rr,
A.,MonAcicaN,H. & SrAiuw@x,J. E. (ig@r@')
patients with bipolar affective disorder who have Exacerbation of psoriasis during lithium treatment.
psoriasis vulgaris and who showed a marked deterio British Journal of Dermatology,96, 445.
ration of their skin disease during lithium treatment. Vooiuszss, J. J. & DUELL, E. A. In DRUMMOND,G. I.,
GREENGARD,P. & RoBINSoN, G. A. (Ig@if,a) In Advances
Within the first two months on lithium carbonate or in Cyclic Xucleotide Research. New York: Raven Press.
sustained-release lithium sulphate their psoriasis —¿ MARcaw, C. L. & DUELL, E. A. (1975b) Cyclic
increased heavily and did not respond to conventional AMP and glucocorticoids as potential metabolic
means of topical treatment which had earlier been regulators of epidermal proliferation and differentia
@effective. In all cases it was judged inadvisable to tion. Journal of Investigative Dermatology, 65, 179.
Haloperidol in normals.
R H Belmaker and D Wald
BJP 1977, 131:222-223.
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