With head and heart and hand
  Portraits of 20th century British doctors by Nick Sinclair


BMJ No 7083 Volume 314 Saturday 15 March 1997

This Week in BMJ | Editor's Choice | Press releases | Advertisement details

Editorials
763 Antidepressants and chronic pain Henry J McQuay, R Andrew Moore

764 Breast cancer screening in women aged under 50 Suzanne Fletcher

765 Interdepartmental peer review R L , B D W Harrison

766 Disease modifying drugs in rheumatoid arthritis Frank A Wollheim

767 Setting the agenda for health after the election A W Macara

768 Correction: Dietary treatment of active Crohn's disease N Wight, B B Scott

News
769 Alcohol tests for doctors urged NHS "good news" unit to close * Abattoirs are breeding grounds for E coli * Labour plans evolution not revolution * Insurance scheme planned for elderly care * Norwegian GPs move to list based system * South African AIDS "cure" attacked * China bans smoking on public transport * Dutch move to end consultants' freedom * Citizens juries vote to extend nurse roles * Care of schizophrenic man criticised * Welsh Office attacked over Morriston affair * US plan to tackle surplus of junior doctors

Papers
775 Population based study of rates of multiple pregnancies in Denmark, 1980-94 Tine Westergaard, Jan Wohlfahrt, Peter Aaby, Mads Melbye

779 Prevalence of gastrointestinal symptoms six months after bacterial gastroenteritis and risk factors for development of the irritable bowel syndrome: postal survey of patients Keith R Neal, John Hebden, Robin Spiller

783 Risk factors for development of incipient and overt diabetic nephropathy in patients with non-insulin dependent diabetes mellitus: prospective, observational study Mari-Anne Gall, Philip Hougaard, Knut Borch-Johnsen, Hans-Henrik Parving

789 Regression analysis of recent changes in cardiovascular morbidity and mortality in the Netherlands Luc Bonneux, Caspar W N Looman, Jan J Barendregt, Paul J Van der Maas

792 The prevalence of adult onset wheeze: longitudinal study Coreen Bodner, Sue Ross, Graham Douglas, Julian Little, Joseph Legge, James Friend, David Godden

793 Cohort study of relation between donating blood and risk of myocardial infarction in 2682 men in eastern Finland Tomi-Pekka Tuomainen, Riitta Salonen, Kristiina Nyyssonen, Jukka T Salonen

794 Social deprivation and bacterial meningitis in North East Thames region: three year study using small area statistics Ian Rees Jones, Gillian Urwin; Roger A Feldman, Nicholas Banatvala

General practice
796 Hormone replacement therapy and risk of venous thromboembolism: population based case-control study Susanne Perez Gutthann, Luis A Garcia Rodriguez, Jordi Castellsague, Alberto Duque Oliart

Clinical review
801 Recent advances: Paediatrics - I: Infancy and early childhood John Pearn

805 Grand Round - University Hospital of Wales: Focal myositis mimicking acute psoas abscess T M Lawson

809 ABC of clinical haematology: Platelet disorders R J Liesner, S J Machin

812 Correction: ABC of clinical haematology: Chronic myeloid leukaemia John Goodman

Education and debate
813 Child mental health: who is responsible? An overextended remit Robert Goodman

814 Commentary: Child mental health services are not medical empires Alyson Hall

815 Commentary: The medical model is unhelpful Bob Daines

816 Commentary: Ordinary misery should not be mistaken for pathology Sue White

817 Primary care - opportunities and threats: Developing professional knowledge: Making primary care education and research more relevant Pauline Pearson, Kevin Jones

820 The rationing debate: Rationing health care by age
The case for Alan Williams

822 The case against J Grimley Evans

Letters
826 Prescribing antidepressants in general practice D Fish; M V Moore; D Gill; R S Tan; I M Ali; K Milligan; A F Bisset and J P Reid; T Johnson and others; S Gilbody and others; V Murray and others; D B Double

829 Afghanistan: a biased report A O Gebreel

830 Ratio of abdominal sagittal diameter to height is strong indicator of coronary risk L Kumlin and others

830 Baby milk companies accused of breaching code C M A Campbell; A Lucas

831 Strategies to reduce dosing errors J A Nelder

831 Evidence to be given to the public must be presented accurately and fairly H C Irving

831 Skin scraping is a useful investigation in meningococcal disease M R H Taylor and others

832 Mental health should be measured by same instrument in different ethnic populations S Ebrahim

832 Opinions given by medical experts in court are honest and objective G A Norfolk

832 Making the most of self citation P J Morrison

Obituaries
833 D R Bromham, R de Mowbray, J L Griffin, C Glancy

Medicopolitical digest
834 Overseas doctors' GP training * Review body answers criticisms * GP pilot schemes * Access to specialist register * Helping patients to use the health service

Views & reviews

Personal views

835 Auchendreich declares Colin Douglas

836 Protease inhibitors pros and cons John Nicholson

Medicine and the media
837 Milk scare hits New Zealand Sarah Catherall

Medicine and books
838 A Very Greedy Drug: Cocaine in Context
Jason Ditton, Richard Hammersley, Samuel Philips, Alasdair Forsyth, Furzana Khan for the Scottish Cocaine Research Group Carmen L Masson, Amy L Copeland, James L Sorensen

Making Health Work: Human Growth in Modern Japan Carl Mosk
John Garrow

Minerva
S2 Career Focus Classified supplement
Specialty manpower targets in trouble Rajesh Jain and Stephen Atherton

Editor's choice

Arguing over antidepressants

Antidepressants are long established, widely used, extensively researched, and poorly understood. We have had one of our largest postbags in response to an editorial that argued "watchful waiting for minor depression, full dose treatment for major depression" (5 October, p 829). Poppycock, say some of our correspondents.

Correspondents disagree over whether non-drug treatments are helpful for mild depression. "Options desired by patients such as counselling seem to be ineffective," says David Gill (p 826). But Robert Tan says that "An attentive ear is often more effective than drugs" (p 827). Next, there is the suggestion that patients with mild depression may be responding not to any antidepressant action but to a "placebo with side effects" (p 827) Alternatively, it may be the hypnotic, anxiolytic, and analgesic effects of the drugs that make patients appreciate them (p 827). This may be part of the explanation of why most of the general practitioners among our correspondents are convinced that antidepressants do work in lower doses than are usually recommended. They resent authorities lecturing them for prescribing in doses that are supposedly too low to be effective.

An editorial points out that antidepressants are widely used to treat neuropathic pain, irritable bowel syndrome, temperomandibular joint dysfunction, atypical pain, and fibromyalgia (p 763). Yet in Britain no antidepressant is licensed for these indications. But, argue the editorialists convincingly, they work in these conditions. Indeed, in patients with postherpetic neuralgia the number needed to treat to achieve 50% reduction in pain after three to six weeks is 2.3. This is comparable to the benefit achieved by the most effective analgesics in acute pain.

Sometimes it can be hard to get people to pay attention to things that matter, but two short reports may help. The first may help encourage people to donate blood. Those unmoved by arguments of public good might be impressed by Finnish data suggesting that those who give blood have a reduced chance of a heart attack (p 793). The second report may be useful in getting through to the media, who tend to be obsessed with meningitis but uninterested in the effects of poverty on health: the study finds a strong link between deprivation and rates of meningitis (p  794).

Finally, Patrick J Morrison responds enthusiastically (p 832) to the description in our Christmas issue of software called Selfcite 2.0 that will increase your citation rate by helping you to cite your own papers. Morrison's Egocite 6.0 has extra features including the possibility of updating your curriculum vitae every week and spreading a one page paper over two pages. The 1997 upgrade of the software will also include Salami-cite.

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