The sentiment expressed in the article “Different”1 is laudable, but
simplistic and inaccurate.
The author describes a patient with schizophrenia wandering away
harmlessly during physical examination. Although he sounds psychotic, the
reason for this behaviour could be delirium, boredom, or even bemusement
at the appearance of our bowtie-clad medical student. The author follows
him into a cramped space and tries to take his hand, to the alarm of the
patient, who is quickly medicated. Subsequently he kills himself. From
this the author learns to “tolerate non-dangerous variations of normality”
without immediately prescribing drugs, which is creditable but
superficial.
The reference to drugs which “may have been too strong and had
provoked his voices” is unclear. While it is true that medications for
hepatic disease can worsen psychosis, the author appears to mean
antipsychotics. These medications, especially in the high doses sometimes
mistakenly administered on general wards, can cause agitation and lead to
suicide. However there will be no increased hallucinations, unless
excessive doses cause delirium.
Implicit in this article is the sloppy assumption that antipsychotic
medications cause psychosis and increase suicide risk, when the reverse is
true. I wonder would your journal have published the piece if it had
suggested diabetic medications invariably kill patients with
hyperglycaemia, or that bronchodilators are best avoided in acute asthma?
Perhaps less glib conclusions are that patients with enduring mental
illness and co-morbid physical conditions would benefit from increased
support, improved communication between psychiatric and general medical
services, and rational prescribing of psychotropic medications.
Rapid Response:
Different
Editor,
The sentiment expressed in the article “Different”1 is laudable, but
simplistic and inaccurate.
The author describes a patient with schizophrenia wandering away
harmlessly during physical examination. Although he sounds psychotic, the
reason for this behaviour could be delirium, boredom, or even bemusement
at the appearance of our bowtie-clad medical student. The author follows
him into a cramped space and tries to take his hand, to the alarm of the
patient, who is quickly medicated. Subsequently he kills himself. From
this the author learns to “tolerate non-dangerous variations of normality”
without immediately prescribing drugs, which is creditable but
superficial.
The reference to drugs which “may have been too strong and had
provoked his voices” is unclear. While it is true that medications for
hepatic disease can worsen psychosis, the author appears to mean
antipsychotics. These medications, especially in the high doses sometimes
mistakenly administered on general wards, can cause agitation and lead to
suicide. However there will be no increased hallucinations, unless
excessive doses cause delirium.
Implicit in this article is the sloppy assumption that antipsychotic
medications cause psychosis and increase suicide risk, when the reverse is
true. I wonder would your journal have published the piece if it had
suggested diabetic medications invariably kill patients with
hyperglycaemia, or that bronchodilators are best avoided in acute asthma?
Perhaps less glib conclusions are that patients with enduring mental
illness and co-morbid physical conditions would benefit from increased
support, improved communication between psychiatric and general medical
services, and rational prescribing of psychotropic medications.
1 BMJ 2009;339:b1929.
Competing interests:
None declared
Competing interests: No competing interests