The eye of Horus

Editor, - The crossing of the leg on the letter R (of recipe) comes from the pagan diagonal cross, which was then an invocation to the God Jove for good fortune.

The action of forming the cross was adapted by the early Christian Church for both public and personal ceremonial. The personal form has also passed down to us in the form of crossing fingers for good luck - and as a talisman against evil spirits.

For the early physicians with phytomedicinals of doubtful value, crossing the R on their prescriptions was all too often a genuine and heartfelt request for good fortune.

Peter J. Mack Dental Surgeon Perth, W.A.

Treatment of attention deficit hyperactivity disorder

Editor, - Dr P. Hazell (Aust Prescr 1995;18:60-3) and Professor R. Adler (Aust Prescr 1995;18:64), writing on stimulant treatment for ADHD, demonstrate the 'medical model' approach to the problem.

Further consideration of the DSM-IV Dr Hazell refers to, may enable one to determine some common characteristics of personality amongst the parents in these cases. This then becomes a delicate matter. Having brought their child for treatment to various medical specialists authorised to prescribe methylphenidate and amphetamines for ADHD, parents may not take kindly to any suggestion that the origins of the problem of the child are rooted in their personalities and that the child's best chance of staying out of gaol as an adult, or being killed or seriously injured in a motor accident, or becoming psychotic, lies in the parents entering therapy as well.

This is hardly a popular concept and an even less popular option. It can be applicable for a myriad of 'medical' problems, with not only parents, but also often medical practitioners, loathe to consult appropriately trained psychologists. Whilst, as Dr Hazell says, there is evidence of brain injury in some cases, remember ADHD was also known as 'minimal brain dysfunction' before the euphemism 'ADHD' was invented to make parents and child and others more comfortable with the diagnosis.

The realistic possibility of schizophrenia in early adulthood is better faced at the outset. Whilst I see no value in causing patients or their relatives undue concern, they might better appreciate some indication of what the future might hold.

Karl R. Wood Pharmacist and Member Psychologists' Association of Australia Cabramatta, N.S.W.

Dr P. Hazell, the author of the article, comments:
Mr Wood has raised concern about schizophrenia being overlooked as a differential diagnosis in ADHD, and the possibility that the child's problems may be due to other problems in the family. While there are individual case reports of children diagnosed with ADHD developing schizophrenia1, and some retrospective evidence that adults with schizophrenia may have childhood histories of attentional problems2, longitudinal research has found ADHD children to be no more likely than control subjects to develop schizophrenia in adulthood.3 Since the possibility of schizophrenia is remote in most ADHD children, I would not recommend that clinicians raise with parents schizophrenia as a potential outcome. Conduct, emotional and educational difficulties are of greater concern.³

Family difficulties must be considered in the assessment and management of ADHD children4; however, it is unlikely that these problems cause ADHD. Parent psychopathology, including personality disturbance, seems to be of greater relevance to the development of conduct problems than to ADHD.5 Any association of ADHD with parent psychopathology is almost certainly due to the common co-occurrence of ADHD with conduct problems. ADHD children may be more vulnerable than their non-affected siblings to the pathogenic effects of living with a disturbed parent.

R E F E R E N C E S
1. Schmidt K, Freidson S. Atypical outcome in attention deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 1990;29:566-70.

2. Erlenmeyer-Kimling L, Cornblatt BA, Rock D, Roberts S, Bell M, West A. The New York High-Risk Project: anhedonia, attentional deviance, and psychopathology. Schizophr Bull 1993;19:141-53.

3. Weiss G, Hechtman L, Milroy T, Perlman T. Psychiatric status of hyperactives as adults: a controlled prospective 15-year follow-up of 63 hyperactive children. J Am Acad Child Psychiatry 1985;24:211 -20.

4. Hazell P. Stimulant treatment for attention deficit hyperactivity disorder. Aust Prescr 1995;18:60-3.

5. Lahey BB, Russo MF, Walker JL, Piacentini JC. Personality characteristics of the mothers of children with disruptive behavior disorders. J Consult Clin Psychol 1989;57:512-5.

The new antidepressants

Editor, - I refer to the articles by Professor J. Tiller (Aust Prescr 1995;18:92-6) and Professor G. Shenfield (Aust Prescr 1995;18:100-1) on the new antidepressants. The new drugs are being compared with tricyclics (TCAs) in a way which one can only describe as disingenuously simplistic. The tricyclics are a heterogeneous group and vary greatly in their binding affinity at various receptors. For instance, desipramine is 1000-fold more potent, as a noradrenaline reuptake inhibitor, than trimipramine. Also plasma levels of TCAs vary greatly. Thus, comparing all 'TCAs' with SSRIs is misleading. Comparing therapeutic levels of desipramine and nortriptyline would be more appropriate.

The statement by Professor Shenfield regarding MAOIs that 'numerous serious interactions with a range of other drugs including TCAs.....' requires putting into perspective. Despite treating about 1000 patients with MAOIs in my career, I have rarely seen even minor morbidity from hypertensive reactions, which are easily treatable. I have managed many thousand 'patient years' of combinations (of MAOIs with TCAs) and never seen problems (one avoids clomipramine and imipramine which have clinically significant serotonin reuptake inhibition capacity).

In contrast, I have seen quite a few serious serotonin syndrome reactions already and a computer search shows a rapid increase in reports from 8 in 1992, to 16 in 1994, and 12 in the first 7 months of 1995. There is no effective treatment for this potentially fatal interaction; bathroom cupboards everywhere now contain both moclobemide and SSRIs; individually very safe, when combined, potentially fatal.

P.K. Gillman Psychiatrist Mount Pleasant, Qld

Professor G. Shenfield, the author of the article on the use of moclobemide with other antidepressants, comments:
I am grateful to Dr Gillman for his comments which support my suggestion that moclobemide may have serious interactions with the SSRIs. My statement on the potential for dangerous interactions between classical MAOIs and tricyclic antidepressants was based on extensive literature and is clearly endorsed by the product information for the drugs in question.

All prescribing must maintain a balance between efficacy and safety. In the case of combination antidepressants, there is no objective evidence of benefit and good evidence of potential for harm. The purpose of my article was to suggest that moclobemide, although both a selective and reversible MAOI, is not necessarily safe in combination with other antidepressants. Dr Gillman appears to agree with me!

Associate Professor J.W.G. Tiller, the author of the article on the new antidepressants, comments:
There is extensive data on TCA-MAOI interactions which can be serious and fatal. Data on increased efficacy (if any) with drug combinations are, in contrast, scant. Such data usually do not compare the use of one or the other drug, in higher dosage, with the combination. Moclobemide is a reversible selective inhibitor of MAO-A with a short half -life, and clinically quite different to traditional MAOIs. Combination antidepressant treatment with moclobemide is not recommended but research data suggest that it may be used with other antidepressants in low dosage. This would normally be in the context of changing from one antidepressant to another as the former drug is washed out. Moclobemide and clomipramine co-prescribing is contraindicated.

The advent of a wide range of new drugs and a better understanding of augmentation strategies with lithium and anticonvulsants has, for practical purposes, almost totally eliminated the need for combination antidepressant therapy.

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