(Aust Prescr 1999;22:103-5)
The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. Letters are usually published together with their responses or comments in the same issue. The Editorial Executive Committee screens out discourteous, inaccurate or libellous statements and sub-edits letters before publication. The Committee's decision on publication is final.
Post-traumatic stress disorder
Editor, – I refer to the excellent article on post-traumatic stress disorder (Aust Prescr 1999;22:32-4). As the authors note, it took millennia for the disorder to be formally recognised. I wonder how long it will be before persistent duress stress disorder (PDSD) is recognised. This disorder carries exactly the same features as outlined in Table 1 of the DSM-IV criteria, except there is no single traumatic event.
Many cases of so-called shell shock or battle fatigue resulted from persistent duress, especially during World War I (compared to World War II) when trench warfare was the main tactic. During Vietnam, tense jungle patrolling without many contacts was the main issue. There is no doubt that many refugees and other victims of the threat of violence, as much as violence itself, suffer PDSD. Often there is no opportunity for sufferers to adapt: the stressors are persistent and unrelenting, and there is no escape.
Unfortunately, our governments have demanded that we ascribe the symptomatology to single traumatic events. As a profession we cravenly comply, thus being iatrogenic contributors to the disorder.
Even though the disorder is simply treated early enough in its genesis just by separating patients from their stressors, if possible, PDSD is not politically acceptable, because governments, large employers and compensation underwriters(the last at great cost to us all) all have a stake in not recognising it. For example, in a report from Griffith University a few years ago, the authors estimated that workplace bullying cost the Queensland Government $2.2 billion annually.
PDSD is thus a major public health issue, carrying considerable, perhaps immeasurable morbidity and cost. It is capable of affecting whole families, groups and even organisations (there is considerable management literature about organizational dysfunction which is the principal aetiology of much PDSD).
Maarten de Vries
MDV Leadership and Management
Ashgrove, Qld
Mark Creamer and Alexander McFarlane, authors of the article, comment:
This letter raises the interesting issue about the extent to which a malevolent environment, combined with a significant threat to personal welfare, can be a major contributor to PTSD. A recent meeting of the Repatriation Medical Authority concluded that this was, indeed, a factor warranting assessment.
The letter also raises the question of how severe the stressor, and the stress response, must be before we allow a diagnosis of PTSD (or, indeed, PDSD). For many reasons, it is important not to 'over-pathologise' normal human distress but, rather, to reserve psychiatric diagnoses for the more severe abnormal reactions. It is important also to ask the question of whether or not the proposed PDSD is actually something distinct and different from other disorders (such as adjustment disorder, depression, or another anxiety disorder). Before introducing a new category of mental illness to our nomenclature, clear empirical evidence is required to demonstrate that it is a distinct entity and not adequately covered by existing disorders.
Finally, the letter raises an important theoretical question as to whether an event such as a tour in Vietnam should be considered as a single event or whether episodes of combat should qualify as separate and cumulative experiences. At this stage, adequate epidemiological work to examine these questions remains to be done.
Editor, – The excellent article by Professors Creamer and McFarlane, 'Post-traumatic stress disorder' (Aust Prescr 1999;22:32-4) did not endeavour to describe this disorder as it affects specific patient groups. It is important however, to highlight the different manifestations of this syndrome depending on the circumstances surrounding the traumatic events that occurred.
Holocaust survivors are of particular relevance in the Australian setting owing to the relatively large numbers who arrived in Australia in the post-war years. On a per capita basis we have the second highest number (next to Israel) in the world. The suppression of their symptoms, the desire by their hosts and themselves to 'leave the past behind', the limited understanding until recent years, about this syndrome, and the more recent prominence in the media and entertainment industries, has brought these issues, and their problems, to light.
The additional dimensions of the ageing of this group, coupled with increasing disability and the prevalence of dementia, have added complexities that not only increase the suffering of patients (and their carers) but also complicate management greatly. The need for doctors to be aware of, and prepared to deal with these complexities is considerable. I hope that the article may contribute to addressing this challenge.
Tuly Rosenfeld
Senior Staff Specialist Geriatrician
Department of Geriatric Medicine
The Prince of Wales Hospital
Sydney, N.S.W.
Editor, – I refer to the article 'Post-traumatic stress disorder' (Aust Prescr1999;22:32-4). I was surprised to find no mention of the existence of this disorder in children who have been exposed to trauma of various kinds, including child abuse. There is an argument that children exposed to trauma are at much greater risk of long-term sequelae than adults, particularly if that exposure occurs during the early years of childhood. There is considerable work on this being undertaken in the U.S.A. where one of the leading researchers in the area, Dr Bruce Perry, has published extensively. His work can be accessed via the Internet site http://www.bcm.tmc.edu/civitas/ .
Graham Vimpani
Director Child Adolescent and Family Health Service
Professor of Community Child and Family Health
Child and Youth Health Network
Wallsend, N.S.W.
Editor, – I refer to the comment on naltrexone published recently in your 'New drugs' section (Aust Prescr 1999;22:45-6).
Opiate and alcohol dependencies are complex disease states. Successful management requires both medical and psychosocial interventions. Therefore naltrexone should be considered as only one of many factors determining the success of treatment. There is clinical evidence1 to support the efficacy of naltrexone when used in conjunction with psychosocial therapy in the maintenance treatment of opiate dependence. Relapse rate should not be considered as the only evidence of efficacy, which should also include decrease of craving, and reduction of heroin taking during treatment. There is substantial evidence that naltrexone reduces alcohol craving, supports abstinence, prevents relapse and decreases alcohol consumption.
I would like to put the statement 'the drug can damage the liver', into perspective. Elevations of liver enzymes were observed previously in patients participating in studies to evaluate high doses of naltrexone (up to 300 mg/day) as a potential treatment of obesity or dementia.2,3,4,5 However, in recent studies in which naltrexone was administered at recommended dosages to patients with alcohol dependence, hepatotoxicity was not identified as a concern.6 Nevertheless, the product information for naltrexone contains a caution of the potential risk of hepatocellular injury when given in excessive doses. It also states that evaluations using appropriate batteries of tests to detect hepatic injury are recommended at a frequency appropriate to the clinical situation and the dose of naltrexone. Naltrexone does not appear to be a hepatotoxin at the currently recommended doses.
Gennaro D'Alesandro
Product Manager
Orphan Australia
Berwick, Vic.
References
1. Judson BA, Carney TM, Goldstein A. Naltrexone treatment of heroin addiction: efficacy and safety in a double-blind dosage comparison. Drug Alcohol Depend 1981;7:325-46.
2. Atkinson RL, Berke LK, Drake CR, Bibbs ML, Williams FL, Kaiser DL. Effects of long-term therapy with naltrexone on body weight in obesity. Clin Pharmacol Ther 1985;38:419-22.
3. Malcolm R, O'Neil PM, Sexauer JD, Riddle FE, Currey HS, Counts C. A controlled trial of naltrexone in obese humans. Int J Obes 1985;9:347-53.
4. Mitchell JE, Morley JE, Levine AS, Hatsukami D, Gannon M, Pfohl D. High-dose naltrexone therapy and dietary counseling for obesity. Biol Psychiatry 1987;22:35-42.
5. Pfohl DN, Allen JI, Atkinson RL, Knopman DS, Malcolm RJ, Mitchell JE, et al. Naltrexone hydrochloride (Trexan): a review of serum transaminase elevations at high dosage. NIDA Res Monogr 1986;67:66-72.
6. Croop RS, Faulkner EB, Labriola DF. The safety profile of naltrexone in the treatment of alcoholism. Results from a multi center usage study. Arch Gen Psychiatry 1997;54:1130-5.
Editor, – We read with interest the comment about primaquine phosphate ('New drugs' Aust Prescr 1999;22:70). We would like to comment on the statement'... but all patients should be tested for glucose-6-phosphate dehydrogenase deficiency'.
Although, when circumstances permit, it is always preferable to test for glucose-6-phosphatedehydrogenase deficiency (G6PD) before prescribing primaquine phosphate (and other drugs liable to cause haemolysis in G6PD-deficient patients), the following points weigh against routine testing in a developing country like India.
- Although G6PD deficiency is not uncommon in India, it is less common than in some parts of the world like Mediterranean Africa, the Middle East and South-East Asia. Severe deficiency is still less common.
- G6PD deficiency is an X-linked recessive trait. Like other X-linked recessive disorders males are affected while females are carriers. Homozygous females would be extremely rare. In carrier females, the likelihood of severe haemolysis is remote as the extent of deficiency would seldom exceed50% of normal.
- G6PD deficiency testing is not universally available.
- The average cost of this test is Indian Rs.250 (approximately US$ 5.95) while the cost of one course of primaquine phosphate for radical cure (at 15 mg base daily in an adult for 14 days) is Indian Rs.36 (approximately US$ 0.86). The cost of the test is a strong disincentive, even when facilities for testing are available.
In this scenario Indian practitioners have, for years, been prescribing primaquine phosphate for radical cure of vivax malaria without routine testing for G6PDdeficiency beforehand and no great harm seems to be done. However, patients are warned to report immediately if signs of haemolysis such as unusually dark urine or unusual pallor or tiredness are noted, so that the drug may be withdrawn. In the National Malaria Control Program a course of primaquine phosphate is recommended in confirmed cases of vivax malaria without mandatory G6PD testing. Incidentally, it is a moot point how 'radical' can the 'radical cure' of vivax malaria be, when almost the entire population of the country is residing in an endemic area and is therefore always susceptible to re infection.
It would be interesting to know the comments of your other readers on these observations.
Avijit Hazra
Unit Co-ordinator
Community Development Medicinal Unit
Documentation Centre
Calcutta, India
Editor, – We have recently had several patients who have experienced clinically significant haemorrhages whilst on warfarin. Two of these incidents occurred in patients who had been on stable doses of long-term warfarin but then suddenly developed unexplained elevations in the results of their INR tests. One of these incidents was possibly due to mixing warfarin 2 mg and 3 mg tablets from different brands (Coumadin and Marevan). This can occur when patients are admitted to our Base hospital; they are only allowed to take one brand of warfarin as the other is not in the hospital formulary.
I have been attempting to unravel the statements from Boots Healthcare that 'the bioequivalence of the various strengths of warfarin manufactured in Australia under the Marevan and Coumadin brand names has never been tested rather than they are not bioequivalent' and 'the formulation and manufacturing methods are significantly different' (Aust Prescr 1997;20:33).
Patients taking warfarin have a relatively high incidence of adverse reactions- mainly haemorrhage - and patient safety issues should be considered of primary importance. The company should therefore be encouraged to standardise the bioequivalence of their products - or remove one brand from production - as there are overlapping products available (Marevan 1 mg, 3 mg, 5 mg and Coumadin 1 mg, 2 mg, 5 mg).
Leslie E. Bolitho
Consultant Physician in Internal Medicine
Wangaratta, Vic.
