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Parenteral Clozapine (Clozaril)

DEAR SIR,

There has been no reported use ofparenteral clozapine in Australia orNew Zealand. The intramuscular routehas been used in Israel,1 and in Europe(including Austria, Switzerland, Ger-many, Italy, Yugoslavia). The longestperiod of IMI administration reportedin the English language literature is 8 days in one patient.

Our patient, a 64-year-old female, was registered with Clozaril PatientMonitoring System (CPMS) andparenteral clozapine was obtained withTherapeutic Goods Administration(TGA) permission. The patient’sdiagnosis was treatment resistantschizo-affective disorder with previousnon-compliance to oral clozapine.Previously, the patient was non-responsive to typical (depot and oral)and atypical antipsychosis medica-tions, antidepressants, mood stabilisersand ECT. IMI clozapine was com-menced at 12.5 mg daily increasing toa maximum dose of 250 mg/day(equivalent to 500 mg oral dose). After30 days, the patient was successfullytransferred to oral clozapine.

While the parenteral form hadadvantages of overcoming non-compliance, it was a temporarymeasure. There were disadvantages.The volume injected was large,requiring a total of 10 mL to beinjected at separate sites (50 mg per 2 mL). The injections were painful.

We would appreciate the experience ofothers who may have used this formof medication.

REFERENCE

1. Lokshin P, Lerner V, Moidownik C, Dobrushin M,Belmaker RH. Parenteral clozapine: Five years ofexperience. Journal of Clinical Psychopharmacol-ogy 1999; 19: 479–480.

Greg McLeanNorth Ryde,NSW

Lisa JuckesNorth Ryde, NSW

CORRESPONDENCEHow to conduct poor butrewarding psychiatric research

DEAR SIR,Ellard’s satirical review of contem-porary psychiatric research1 wasinsightful but makes serious omis-sions in relation to research grants.May I suggest:

1. When applying for grants bewareof modesty. No grant body can riskprecious dollars on persons ofmodest abilities. Treble the likelycosts and you may be seen as ofgreater stature. You can oh so dis-creetly use the extra money forwriting other grant proposals.

2. Writing grant disposals is a skillthat most doctors are untrainedfor. I suggest a sabbatical at a usedcar lot. Modesty must be aban-doned. Slick, grandiose claimsabout how wisely the moneywould be invested in one’s projectare the way to go. By the time yourresearch is published the grantcommittee will have mostlychanged members and those thatremain will have lost interest inyour project long ago. Also, theyare accountable for having recom-mended grant allocation in thefirst place and may not be tooinclined to embarrass themselves.

3. Be aware that medical researchgrant bodies are so concerned aboutvalue for money, that they will notrisk uncertain ventures into newterritories. Confirming the alreadyknown or obvious is preferred.

4. Avoid discoveries. The inherentconservatism of medical publica-tions and “knowledgable” paperreviewers will ensure that knowl-edge remains as is.

PP a l/n K

(p = probability of, P = Publication,n = new, K = knowledge)

5. Realise that if you work for a learnedinstitution, discovery without finan-cial backing is unlikely to be toler-ated, whereas financial backingwithout discovery is applauded.

Those of you with fantasies of makingbig discoveries, reflect carefully.Freud’s theories on infantile sexuality(which can be confirmed by anyonewho has changed babies’ nappies)saw him branded a pervert. Darwin

remains a fascist, especially in psychi-atric circles, and Einstein’s knowledgewas used for weapons of mass des-truction. That used car lot may bemuch safer.

REFERENCES

1. Ellard J. How to conduct poor but rewarding psy-chiatric research. Australian Psychiatry 2001; 9:171–172.

Chris CantorNoosa Junction, Queensland

College restructure andimplications for advancedtraining

DEAR SIR,

I write to raise concerns about theeffect of the proposed college restruc-ture1 on recruitment to areas of sub-specialty training, in particular thelong established area of AdvancedTraining in Child and AdolescentPsychiatry. Paradoxically there arealso new opportunities for collabora-tion between areas of sub specialtytraining as the advanced trainingprocess is formalised.

With the introduction of the newcollege structure, there will be overtcompetition for trainees in their lasttwo years of training, in a way thathas not occurred before. This is at atime, certainly in NSW, when thereare increasing and diverse careeropportunities for Child and Adoles-cent Psychiatrists in the public andprivate sector, as the mental healthneeds of children and their familiesare recognised in workforce decisionsthat allocate more adequate resourcesto this previously under-funded sector.

Advanced Child and Adolescenttraining is also in a very healthy statewith great enthusiasm within, andincreased collaboration between, theseven well-supported training pro-grammes across our two countries. Allsites now have established andfunded positions for Directors ofTraining, ensuring that the quality oftraining and support for traineesremains high. Innovative use of videolinked grand rounds is enablingtrainees to develop a sense of sharedcommunity with trainees in othersites, and allows exposure to “experts”outside the local training zone.Collaboration between individual

sites enhances the already rich con-tent of local training programmes,with the added aim of reducing theisolation of trainees in smaller centres.

All programmes now deliver inno-vative and engaging course contentthat – in the jargon – applies prin-ciples of adult learning and problembased delivery of course material. Inpractice this means training isenjoyable, engaging and emphasisesthe integration of theoretical andclinical material in ways that areappropriate for senior trainees, butpotentially also relevant to CollegeFellows wanting to update their skillsin this area, as part of continuingprofessional education.

This model might well also be appliedto collaboration between advancedtraining programmes. There areopportunities for example to shareteaching in areas where competenceis likely to be required of all advancedtrainees, for example, administrationand management, or teaching andconsultancy. Senior trainees may alsowish to develop skills in areas thatbridge two at present discrete areas oftraining, for example, medico-legaltrainees may want training in workwith Juvenile Justice services, whichclearly overlaps with the child andadolescent training programme.

This requires enormous flexibilityboth within and between pro-grammes and clear guidance fromthe RANZCP about shared areas ofcompetence, and core and optionalaspects of advanced training. There is a risk of each programmeattempting to “reinvent the wheel”with competition at the expense ofcollaboration, across training sitesand between areas of specialisation.

In advanced Child and Adolescenttraining we are attempting to buildon our long experience of providingtraining to senior trainees whileresponding to the changing Collegeand medico–political environment.

I would appreciate correspondencefrom colleagues and others respon-sible for recruitment and training ofadvanced trainees about these issues.

REFERENCE

1. RANZCP Project Team. Preparing psychiatrists for achanging world: review of Training, Examinationsand Continuing Education. Australasian Psychiatry2001, 9: 5–18.

Sarah MaresDirector of Training, Child,Adolescent and Family PsychiatryNSW Institute of Psychiatry

Obsessive–compulsive disorder:treatment and treatmentresistance

DEAR SIR,

I am writing about the above paperrecently published in your journal.1I note that failure to respond to alltreatments is said to be an indicationto consider psychosurgery in the guidelines, but surgical treatment is appar-ently now largely avoided. It fell intodisrepute after the notorious ‘ice pickleucotomy’ craze in the 1960s in USAproduced a large number of failuresand disastrous consequences. Howeverit should not be forgotten that in thelate 1950s and early 1960s we had aNeurosurgical Unit at Mont Parkpsychiatric hospital in Melbourne and I was assigned to work there with aneurosurgeon Professor Bradley in1958/59, during which time a largenumber of stereotactic leucotomieswere performed with varying degreesof success on intractable cases ofdepression and OCD. Selection ofsuitable cases for this modified pro-cedure was decided by Dr E. Cunning-ham Dax after I presented thosereferred for consideration. I later had apersonal series of about ten privatepatients who under my care hadpsychosurgery performed at the RoyalMelbourne Hospital using this samestereotactic technique which waspioneered by Dr Dax. Most of thesecases had very favourable results, andsome of them were almost miraculousin the degree of improvement.

I would also like to comment on theuse of ECT in a patient with OCD, andsuggest that whilst ECT in thiscondition is generally ineffective andassociated with rapid relapse, I foundit useful in one case of failedleucotomy where ECT was extremelyeffective and the patient has now beenwell, on a small dose of psychotropics,for 15 years.

I do agree with the guidelines that havebeen outlined in this well researchedexposition but have found that manyyounger psychiatrists are not familiarwith the excellent results obtainable in

cases resistant to psychological treat-ments and pharmacotherapy.

REFERENCE1. Hood S, Alderton D, Castle D. Obsessive–compul-

sive disorder: treatment and treatment resistance.Australasian Psychiatry 2001; 9: 118–127.

Philip CohenCaulfield South, Victoria

Availability of nortriptyline

DEAR SIR,

Some College Fellows may be awarethat recently the manufacturer ofnortriptyline, Eli Lilly, decided towithdraw it from the PBS followingfailure to reach agreement with thePBAC over pricing. The Committee for Psychotropic Drugs and OtherPhysical Treatments made representa-tions to Dr Ray Parkin, the MedicalDirector of Eli Lilly and to the PBACstrongly urging that further negotia-tions be held in order to ensure thatthis valuable antidepressant remainsavailable to Australian patients. DrParkin informed the Committee thatthere are two problems which threatenthe ongoing supply of nortriptyline.The issue of an agreed price is one ofthese. The other is that the companyhas decided to withdraw the drugworldwide in approximately 12 monthstime. Dr Parkin acknowledged theconcerns of the Committee andAustralian psychiatrists and Eli Lillyundertook to re-enter negotiationswith the PBAC with the aim of tryingto retain nortriptyline on the PBS forthe present. The company will alsoendeavour to find an alternativesupplier for the Australian marketduring the next twelve months andwill keep the Committee informed ofprogress. The PBAC also agreed to re-enter negotiations with Eli Lilly and ithas now informed the Committee thatnortriptyline will be retained on thePBS as a restricted benefit when otherantidepressants are inappropriate.

The Committee considers this to be anissue of extreme importance to Austral-ian psychiatry and will provide pro-gress reports to Fellows of the College.

Dr Bill LyndonChair, Committee for PsychotropicDrugs and Other PhysicalTreatments

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Aboriginal suicide is differentColin Tatz, Aboriginal Studies Press,Canberra, 2001, ISBN 0 85575 371 4,pp 249, $33.00.

Colin Tatz has researched and com-mented upon Aboriginal Admini-stration for almost forty years. This book is adapted from a studyfunded by the Criminology ResearchCouncil and presented in July 1999.Writing both painfully and pain-stakingly, Tatz unequivocally noteshis emotional involvement with theresearch and its findings.

Tatz’s main hypothesis is that forcesexist which raise the suicide rate inthe Aboriginal population up to fivetimes the national average, that thisis a difference of quality as well asquantity, and that understandingthem is vital to alleviating theproblem. Tatz’s focus is explicitlyanthropological and political; heeschews qualitative analysis (p 42)and focuses on social and politicalcontext.

A brief history of this context is wellworth reading (pp 3–7). Tatz rep-resents most policy and practice aspervasively ambiguous, supportingthis with a clear summary of issuessuch as land rights, control ofAboriginal affairs and the troubledissue of identity.

Tatz states that violence in Abori-ginal communities is ‘appealingviolence’ – ‘confined to self, to kinand, at times, to those who workwith and for communities’. He dif-ferentiates this from coercive viol-ence, used ‘in a premeditated andcontrolled manner as an extreme but often effective means towardsachieving a social objective’. Hestates categorically that ‘at no pointin Australia in this century haveAborigines resorted to coerciveviolence’ – a statement whichappears unsupported in his text, andintuitively unlikely.

Loss of social cohesion is consideredas a source of violence. Despitecircumstantial evidence, much ismade of the possibility that suicidewas a virtually unknown phenom-enon prior to European settlement,

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Tribute to psychiatrist

DEAR SIR,

I would like to dedicate the following poems to my psychiatrist, Dr PaulGill. The tenth anniversary of Dr Gill’s death occurs on 24 January 2002.The first poem sums up my situation when I first came into contact withhim; I was a “prisoner behind black bars”. Over the years Dr Gill becamemy reliable friend and confidant. He helped me enormously.

SCHIZOPHRENIA

The prisoner watches

behind black bars;

longing for humanity

an ache.

Petrified,

he rejects the wish

to be free, warm, loved:

reached.

Like a cancer

longing grows

for something, anything,

to breathe life

into the stillborn soul

of his existence.

The price?

omnipotent self

shattering,

falling as dust

on the fleshless flesh

of his feet.

In the empty cell.

a ghost calls.

Unheard.

For P.G.

I,

and those many others

self-imprisoned

in a waste-land

of non-being

have felt the fellowship

of your acceptance.

Wary, watchful,

moved tentatively

to test the touch

of your outstretched hand.

Opened slowly

the locked floodgates of memory,

shed un-shed tears,

grieved,

mourned loss

of might-have-been,

accepted a non-event.

Now,

in a greener land,

experiencing the warmth

of proffered friendship,

sharing man’s fear

and pain,

rejoicing in another’s joy,

receiving your gift

of each new day,

I live.Avril Smith

Merimbula, NSW

VALEIt is with sadness and regret that we advise College Fellows and colleaguesof the recent death of Dr Colin Degotardi, Professor Wallace Ironside andProfessor Julian Katz of New South Wales, Dr Terence Hardiker and DrGwendolyn Nash of Victoria, and Dr Bronte Pulsford of South Australia.

BOOK REVIEWS

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will still allow them to do. There arevery detailed discussions on a broadrange of topics – the aetiology ofdepression, the tools of diagnosisand treatment, legal rights andprotection and practical advice onrelationships and money manage-ment. The chapter discussing theimpact on children is particu-larly topical and praiseworthy. Thefootnotes and bibliography provide awealth of material for furtherreading. The appendices provide a‘jargon decoder’; details of mentalhealth organisations and other placesfor help, for example Legal Aidoffices. The unmistakable localflavour adds to the reader’s enjoy-ment – ‘reactive depression’ ismemorably explained as ‘Colling-wood supporter’s depression’! Thelayout of the book allows it to bedipped into again and again, the textis broken up with clear diagrams,tables and lists, making the mainpoints and tips for how to managethe more difficult aspects of life withmanic depression easily remembered.There is a balanced view of the roleof some of the more difficult andfeared aspects of psychiatry. The roleof ECT, for example, is discussed in avery clear and frank manner, andvery admirably dispels some mythsby categorically stating ‘ECT happensunder general anaesthetic and with a muscle relaxant and there are no convulsions or screams’ (p 56).There is thoughtful discussion on therelationships with psychiatrists, with a tip to remember psychiatristsenjoy working with a patient who is motivated and that motivationimproves treatment outcome (p 78).At all times, even when very subtlyencoded, the reader is urged to ‘never accept that these [illness]experiences must therefore mean alifetime of submissiveness and loss’ (ix).

This is a work which illustrates beauti-fully how best to ensure the WorldHealth Organization’s Mental HealthCampaign for 2001 succeeds – itremoves stigma, it explains and mostimportantly shows patients, familiesand health professionals alike how to‘Stop Exclusion’ and ‘Dare to Care’, inthe most practical way possible.

Karen FisherMascot, NSW

Youth Suicide Prevention Strategy isimperative, with a more rationalapproach to societal problems pol-itically and within the Aboriginalcommunities. Warrakoo, in S.A., isexamined as a healthier model of acorrectional program. Tatz proposesadaptations of existing programssuch as AA, SmokeFree (NewZealand) and GOAL (NZ). Focus onparenting, conflict resolution, griefcounselling, school programs onsuicide (similar to Canadian pro-grams), Federal and State sportinitiatives and literacy programs arediscussed, as well as improvedreporting and investigation of suicideat medical, police, custodial andcoronial levels.

This book addresses a difficult issuewith a clarity increased by Tatz’narrative focus. Challenging observa-tions are made; some poorly sub-stantiated claims are made, yetoverall the book is cohesive. Tatz’arguments are steeped in the cultureunder study, and are well worthreading. It is, however, ironic thatthe original research was funded by acriminology grant.

Angela HarteWest Melbourne, Victoria

Life on a Roller Coaster: living well with depression andmanic depressionMadeleine Kelly, Simon and Schuster,Sydney, 2000, ISBN 0 7318 0948 3, pp 242, $24.95.

It is not surprising that this book proudly displays a stickerannouncing it as SANE’s book of theyear. Written in a breezy, cheerfulmanner, the book speaks directly tosufferers of depression and manicdepression, explaining in a conciseand balanced way just what suchdiagnoses mean and how theirimpact upon one’s life can be shapedto cause the least disruption. Its toneis soothing; from the outset, theauthor states her desire is not tocontribute to the tomes, which veertowards voyeurism in descriptions ofsymptoms of mania and depression‘because I want to keep the focus onwhat we can do to make the most of our lives’ (author’s italics). The booknever loses sight of this aim; it seeksto imbue its readers with the powerto understand what their illnesses

and relatively uncommon untilthirty years ago (pp 24–7). Thenotion of cultural denial is visited, asis the absence of officially recordedcensus statistics until 1971 (p 58).The concept that external controlson Aboriginal culture supportedsocial cohesion despite a repressiveagenda, and that ‘decolonisation’underlies much current violence isinvoked convincingly.

In Chapters 4 and 5, raw data onmethods of death (pp 80–85) is dis-tressing in terms of the violence andfinality of methods employed, andthe phenomenon of child suicide.The discussion of hanging and itsimplications (pp 87–89) is particu-larly confronting.

Tatz adopts the suicide classificationof Louis Wekstein, concentrating onexistential suicide. Chapter 6 alsoexamines Dr Joseph Reser’s theory of‘reactance’ as a contributing cause –‘To imitate the style of suicide onone’s kin, friends or Aboriginalcompatriots in other communities asa type of mass protest in oppositionagainst the forces of authority andinstitutionalism’. More frighten-ingly, Tatz states that ‘suicidalbehaviours in communities havebecome patterned, ritualised andeven institutionalised, perhaps evencontagious’. The uses of suicide –including a demand for respect – are discussed, but few conclusionsdrawn. Tatz explicitly rejects sui-cide as a psychiatric phenomenon (p 119), querying the usefulness ofthe DSM.

Chapter 7 examines existential lossesin the Aboriginal community and the associated social problems, pos-tulating that projection of blamehinders the ability of the com-munities to alleviate these. Prejudiceagainst suicide, the question ofownership of a life, and the affront(narcissistic wound?) that Aboriginalsuicide inflicts on white society are touched on in Chapter 8. Theplethora of Aboriginal organisationsis critiqued briefly as an agent of disempowerment rather thanempowerment (p 158).

Comparative suicide studies areexamined in Chapter 9, and ‘allevia-tion’ dominates the remainder of thebook. Tatz again rejects medicalisingsuicide, and feels that to search forbiochemical or genetic markers ispotentially damaging. He states thatan Aboriginal focus in the National