911
19. Serri O, Beauregard H, Brazeau P, et al. Sandostatin reduces increased kidney function and size in type I diabetes. Diabetologia 1990; 33 (suppl): A76. 20. Morgan JS, Groszmann RJ. Somatostatin in portal hypertension. Dig Dis Sci 1989; 34: 40-47S. 21. McKee R. A study of octreotide in oesophageal varices. Digestion 1990; 45 (suppl 1): 60-65. 22. Christiansen J, Ottenjann R, Von Arx F, et al. Placebo-controlled trial with the somatostatin analogue SMS 201-995 in peptic ulcer bleeding. Gastroenterology 1989; 97: 568-74. 23. Prinz RA, Pickleman J, Hoffman JP. Treatment of pancreatic cutaneous fistulas with a somatostatin analog. Am J Surg 1988; 155: 36-42. 24. Nubiola P, Badia JM, Martinez-Rodenas F, et al. Treatment of 27 postoperative enterocutaneous fistulas with the long half-life somatostatin analog SMS 201-995. Ann Surg 1989; 210: 56-58. 25. Williams ST, Woltering EA, O’Donsio TM, et al. Effect of octreotide acetate on pancreatic exocrine function. Am J Surg 1989; 157: 459-62. 26. Jaros W, Biller J, Greer S, et al. Successful treatment of idiopathic secretory diarrhea of infancy with the somatostatin analog SMS 201-995. Gastroenterology 1988; 94: 189-93. 27. Cello JP, Grendell J, Basuk P, et al. Controlled clinical trial of octreotide for refractory AIDS-associated diarrhea. Gastroenterology 1990; 98 (suppl): A163. 28. Vinik AI, Isai ST, Moattari AR, et al. Somatostatin analog (SMS 201-995) in the management of gastroenteropancreatic tumors and diarrhea syndrome. Am J Med 1986; 81 (suppl 6B): 23-40. 29. Edwards CA, Cann PA, Read NW, et al. The effects of somatostatin analogue SMS 201-995 on fluid and electrolyte transport in a patient with secretory diarrhoea. Scand J Gastroenterol 1986; 21 (suppl 119): 259-61. 30. Williams G, Ball JA, Lawson RA, et al. Analgesic effect of somatostatin analogue (octreotide) in headache associated with pituitary tumours. Br Med J 1987; 295: 247-48. 31. Penn RD, Paice JA, Kroin JS, et al. Intrathecal octreotide for cancer pain. Lancet 1990; i: 738. 32. Camisa C, Mehle AL, Benedetto E, et al. A somatostatin analog (octreotide acetate) vs placebo in the treatment of psoriasis. Clin Res 1989; 37: 968A.
Mental health services for migrants in Europe The mental health of immigrants in the UK has lately been the subject of intense scrutiny.l-4 However, the issues have wider importance, as shown by the migration conference held earlier this year under the joint auspices of the International Organisation for Migration and the World Health Organisation. The importance of migrant groups is likely to increase still further after the adoption of the single European market in 1992.5 One of the most consistent findings in UK studies of immigrants is an increased rate of admission for
schizophrenia and related illnesses, but the underlying reasons may not be the same in all migrant groups. For example, the exceptionally high rates of schizophrenia that have been reported among immigrants in some studies6 cannot be explained entirely by factors such as the age structure of the migrant population in question. However, standardisation for age does appear to reduce the disparity in the rates between English-born subjects and other immigrant subgroups.’ Longitudinal studies on patients who were initially diagnosed as psychotic indicate that some migrant groups use inpatient psychiatric services less than the indigenous population.8 Some studies suggest that immigrants may have reduced rates of non-psychotic disorders, but others have found no difference or have
even
shown
an
increased
Rack9 suggests, on the basis of anecdotal evidence, that there may be a considerable unmet need for psychological intervention among immigrants, but attempts to test this hypothesis have not provided a clear answer. For example, community surveys carried out in the UK have not usually found high rates of psychiatric morbidity among migrants. However, the findings are often difficult to interpret because of methodological difficulties or because the comparison groups may not have been appropriate.’ Thus anxiety that many immigrants may not be getting the type of service that they require has persisted,l° and much attention has focused on the relation between such individuals and those who provide care." Special transcultural psychiatry units,12 day centres, 13 or other voluntary facilities that offer a specific service to ethnic minority subgroups14 have been established in some areas to help circumvent cultural barriers between indigenous psychiatrists and their immigrant patients. To what extent does the British experience mirror that of mainland Europe? A 1988 WHO reportl-5 suggests that in 1974 about 5-5 million immigrants from southern European countries were living in the northern and western parts of the continent. Many of these people are migrant workers.16 For example, a survey of Turkish workers in the Netherlandsl’ showed that neurotic illnesses may be common in such subjects, and were often associated with concern for their families at home. The need to recognise heterogeneity among foreign-born groups is illustrated by a German
study,18 which showed little evidence for a single guest-worker syndrome that could be applied across different ethnic groups. Similarly, in a study in Denmark, Jensen et a119 found notable differences in the mode of presentation between refugees and other immigrants. Nevertheless, in both groups treatment was often terminated prematurely, either by the patient or by the therapist, and the Danish workers believe that special transcultural teams would be helpful. Levandero has described the formation of a self-help group for immigrant women in Sweden, and there have been attempts to provide native psychiatric therapists in neighbouring Finland.Z1 Many immigrants turn to unconventional agencies for help-eg, African women living in Paris may direct specific psychological and behavioural problems in children towards traditional healers and holy men.22 In a study of African immigrants attending two voluntary centres in Rome,23 the apparent prevalence of psychiatric symptoms was low, but assessment of subjects was noted to be difficult because the scales used were culturally inappropriate. Van der Stuyft and colleagues24 in Belgium suggest that the effects of acculturation are complex. Immigrants there tended to underutilise primary health care services for milder psychological
912
disturbances; this observation accords with UK results.25 However, in the Belgian study there was no simple relation between acculturation and underutilisation, and lengthy residence among the indigenous population did not necessarily bring the health care behaviour of migrants closer to that of the local norm. The highly heterogeneous nature of migrants living in Europe deserves widespread recognition. Future research needs to identify the reasons for the apparently very high rates of schizophrenia in some groups, and should try to include comparisons between first and second generation subjects. However, underutilisation of psychiatric services relative to the host community has also been reported for other groups and for other disorders. It is not clear whether this finding reflects a disproportionate degree of unrecognised and untreated morbidity. For this reason epidemiological studies are needed which take into account the difficulties in diagnosing mental disorders in patients from a foreign culture. Prospective studies are also required to determine the fate of migrants who initially enter the health care system but who may later be lost to follow-up. Finally it is necessary to evaluate the effectiveness of the special interventions that have been implemented to help immigrant patients. Such studies could, of course, be sponsored by individual countries or centres, but the imminent changes within Europe present a unique opportunity for cross-national collaboration which should not be lost.
Leff J. Psychiatry around the globe: a transcultural view. 2nd ed. London: Gaskell, 1988. 2. Littlewood R, Lipsedge M. Psychiatric illness among British AfroCaribbeans. Br Med J 1988; 296: 950-51. 3. Cruickshank JK, Beevers DG, eds. Ethnic factors in health and disease. Bristol: Wright, 1989. 4. Ineichen B. The mental health of Asians in Britain. Br Med J 1990; 300: 1.
1669-70. 5. O’Neill P. Global medicine on your doorstep. Br Med J 1990; 300: 625. 6. Harrison G, Owens D, Holton A, Neilson D, Boot D. A prospective study of severe mental disorder in Afro-Caribbean patients. Psychol Med 1988; 18: 643-57. 7. Cochrane R, Bal SS. Migration and schizophrenia: an examination of five
8.
hypotheses. Soc Psychiatry 1987; 22: 181-91. Gupta S. Ethnic differences in consultation rates. Br Med J 1989; 299:
1338. 9. Rack PH.
Psychiatric and social problems Psychiatr Scand 1988; 344 (suppl): 167-73.
among
immigrants.
Acta
10. Editorial. Black and white health. Lancet 1984; ii: 115. 11. Schwab B, et al. Health care of the chronically mentally ill: The culture broker model. Community Ment Health J 1988; 24: 174-84. 12. Manning M. Transcultural psychiatry. Community Care 1979; Jan 25: 19-21. 13. Moodley P. The Fanon project: a day centre in Brixton. Bull R Coll Psychiatrists 1987; ii: 417-18. 14. Gupta S. The mental health of Asians in Britain. Br Med J 1990; 301:240. 15. World Health Organisation. Mental health services in southern countries of the European region: report on a WHO meeting. Copenhagen: WHO Regional Office for Europe, 1988. 16. Steinhausen H. Psychiatric disorders m children and family dysfunction: a study of migrant workers’ families. Soc Psychiatry 1985; 20: 11-16. 17. Sayil I. Psychiatric problems of Turkish labourers in Holland. Int J Soc Psychiatry 1984; 30: 267-73. 18. Lazaridis K. Psychiatrische Erkrankungen bei Auslandem Hospitalisations - und nationalitatsspezifische Inzidenz. Nervenarzt 1987; 58: 250-55.
19.
Jensen SB, Schaumburg E, Leroy B, Larsen O, Thorup M. Psychiatric care of refugees exposed to organised violence. Acta Psychiatr Scand 1989; 80: 125-31.
20. Levander S. Community work as part of the psychiatric services of Nacka. Acta Psychiatr Scand 1987; 76 (suppl 337): 23-29. 21. Jansson B. Experience from a psychiatric service to immigrant groups using native therapists. Acta Psychiatr Scand 1988; 344 (suppl 175-78. 22. Wornham WC. Cultural targeted health services for immigrant children and adolescents. Can J Public Health 1988; 79 (suppl 2): 534-38. 23. Frighi L, Cuzzolaro M. Ricerche e interventi di igiene mentale su una poplazione di immigrati a Roma da Paesi in via di sviluppo. Min Psich 1987; 28: 179-83. 24. Van der Stuyft P, de Muynch A, Schillemans L, Timmerman C. Migration, acculturation and utilisation of primary health care. Soc Sci Med 1989; 29: 53-60. 25. Gillam SJ, Jarman B, White P, Law R. Ethnic differences in consultation rates in urban general practice. Br Med J 1989: 299: 953-57.
KORSAKOFF’S SYNDROME Since the 1880s there has been a general recognition that a unique amnesic syndrome can develop in alcoholics, associated with a neuropathy and other "psychic" symptoms. Korsakoff, who provided the original description, used the terms psychosis polyneuritica and cerebropathia psychica toxaemica, but it soon became known as his disease. A few years earlier Wernicke had described the triad of ataxia, ophthalmoplegia, and a confusional state (which he called haemorrhagic polioencephalitis), although the relation between the two disorders was not at first apparent. By the turn of the century pathological observations, especially of the mamillary bodies and the walls of the third ventricle, had established the link, and in the 1930s thiamine deficiency was shown to be central to both conditions.1 The eponymous glories of Korsakoff’s psychosis and Wernicke’s encephalopathy are now giving way, at least in DSM lII,2 to alcohol amnesic syndrome, but they have spread much confusion and forgetfulness in many a medical mind. In essence, the two conditions seem to represent different stages of the same deficiency process, and the most detailed monograph1 was entitled the Wernicke-Korsakoff syndrome. Victor and colleagues described 245 patients, (nearly all alcoholics, although puerperal sepsis, typhoid, and persistent vomiting are other known causes) and their conclusions remain central to our understanding. Thus, the symptoms follow a characteristic pattern, starting as a Wernicke state and proceeding, if untreated, via Korsakoffian amnesic-confabulation to a permanent amnesic defect. Sometimes Korsakoff symptoms are also apparent from the start, and they may be the only manifestations. The pure Korsakoff state consists of a loss of past memories, an inability to learn or form new memories, minor impairments of perceptual and conceptual functions, and an apathetic loss of insight and initiative. Confabulation (the "making up of stories") is not invariable and tends to disappear with chronicity. This feature is more an inability "to recall the temporal sequence of events" than a filling in of memory gaps. It has been suggested that frontal lobe changes are additionally required for the rarer "spontaneous" form, while "provoked" confabulation is equally common in Alzheimer’s disease.3 By contrast, other mental functions are relatively intact. Patients are alert, aware of their surroundings, able to speak and understand what is spoken, and can think and solve problems. Neuroanatomical studies show that the lesions are symmetrical and concentrated in the periaqueductal area.
19. Serri O, Beauregard H, Brazeau P, et al. Sandostatin reduces increased kidney function and size in type I diabetes. Diabetologia 1990; 33 (suppl): A76. 20. Morgan JS, Groszmann RJ. Somatostatin in portal hypertension. Dig Dis Sci 1989; 34: 40-47S. 21. McKee R. A study of octreotide in oesophageal varices. Digestion 1990; 45 (suppl 1): 60-65. 22. Christiansen J, Ottenjann R, Von Arx F, et al. Placebo-controlled trial with the somatostatin analogue SMS 201-995 in peptic ulcer bleeding. Gastroenterology 1989; 97: 568-74. 23. Prinz RA, Pickleman J, Hoffman JP. Treatment of pancreatic cutaneous fistulas with a somatostatin analog. Am J Surg 1988; 155: 36-42. 24. Nubiola P, Badia JM, Martinez-Rodenas F, et al. Treatment of 27 postoperative enterocutaneous fistulas with the long half-life somatostatin analog SMS 201-995. Ann Surg 1989; 210: 56-58. 25. Williams ST, Woltering EA, O’Donsio TM, et al. Effect of octreotide acetate on pancreatic exocrine function. Am J Surg 1989; 157: 459-62. 26. Jaros W, Biller J, Greer S, et al. Successful treatment of idiopathic secretory diarrhea of infancy with the somatostatin analog SMS 201-995. Gastroenterology 1988; 94: 189-93. 27. Cello JP, Grendell J, Basuk P, et al. Controlled clinical trial of octreotide for refractory AIDS-associated diarrhea. Gastroenterology 1990; 98 (suppl): A163. 28. Vinik AI, Isai ST, Moattari AR, et al. Somatostatin analog (SMS 201-995) in the management of gastroenteropancreatic tumors and diarrhea syndrome. Am J Med 1986; 81 (suppl 6B): 23-40. 29. Edwards CA, Cann PA, Read NW, et al. The effects of somatostatin analogue SMS 201-995 on fluid and electrolyte transport in a patient with secretory diarrhoea. Scand J Gastroenterol 1986; 21 (suppl 119): 259-61. 30. Williams G, Ball JA, Lawson RA, et al. Analgesic effect of somatostatin analogue (octreotide) in headache associated with pituitary tumours. Br Med J 1987; 295: 247-48. 31. Penn RD, Paice JA, Kroin JS, et al. Intrathecal octreotide for cancer pain. Lancet 1990; i: 738. 32. Camisa C, Mehle AL, Benedetto E, et al. A somatostatin analog (octreotide acetate) vs placebo in the treatment of psoriasis. Clin Res 1989; 37: 968A.
Mental health services for migrants in Europe The mental health of immigrants in the UK has lately been the subject of intense scrutiny.l-4 However, the issues have wider importance, as shown by the migration conference held earlier this year under the joint auspices of the International Organisation for Migration and the World Health Organisation. The importance of migrant groups is likely to increase still further after the adoption of the single European market in 1992.5 One of the most consistent findings in UK studies of immigrants is an increased rate of admission for
schizophrenia and related illnesses, but the underlying reasons may not be the same in all migrant groups. For example, the exceptionally high rates of schizophrenia that have been reported among immigrants in some studies6 cannot be explained entirely by factors such as the age structure of the migrant population in question. However, standardisation for age does appear to reduce the disparity in the rates between English-born subjects and other immigrant subgroups.’ Longitudinal studies on patients who were initially diagnosed as psychotic indicate that some migrant groups use inpatient psychiatric services less than the indigenous population.8 Some studies suggest that immigrants may have reduced rates of non-psychotic disorders, but others have found no difference or have
even
shown
an
increased
Rack9 suggests, on the basis of anecdotal evidence, that there may be a considerable unmet need for psychological intervention among immigrants, but attempts to test this hypothesis have not provided a clear answer. For example, community surveys carried out in the UK have not usually found high rates of psychiatric morbidity among migrants. However, the findings are often difficult to interpret because of methodological difficulties or because the comparison groups may not have been appropriate.’ Thus anxiety that many immigrants may not be getting the type of service that they require has persisted,l° and much attention has focused on the relation between such individuals and those who provide care." Special transcultural psychiatry units,12 day centres, 13 or other voluntary facilities that offer a specific service to ethnic minority subgroups14 have been established in some areas to help circumvent cultural barriers between indigenous psychiatrists and their immigrant patients. To what extent does the British experience mirror that of mainland Europe? A 1988 WHO reportl-5 suggests that in 1974 about 5-5 million immigrants from southern European countries were living in the northern and western parts of the continent. Many of these people are migrant workers.16 For example, a survey of Turkish workers in the Netherlandsl’ showed that neurotic illnesses may be common in such subjects, and were often associated with concern for their families at home. The need to recognise heterogeneity among foreign-born groups is illustrated by a German
study,18 which showed little evidence for a single guest-worker syndrome that could be applied across different ethnic groups. Similarly, in a study in Denmark, Jensen et a119 found notable differences in the mode of presentation between refugees and other immigrants. Nevertheless, in both groups treatment was often terminated prematurely, either by the patient or by the therapist, and the Danish workers believe that special transcultural teams would be helpful. Levandero has described the formation of a self-help group for immigrant women in Sweden, and there have been attempts to provide native psychiatric therapists in neighbouring Finland.Z1 Many immigrants turn to unconventional agencies for help-eg, African women living in Paris may direct specific psychological and behavioural problems in children towards traditional healers and holy men.22 In a study of African immigrants attending two voluntary centres in Rome,23 the apparent prevalence of psychiatric symptoms was low, but assessment of subjects was noted to be difficult because the scales used were culturally inappropriate. Van der Stuyft and colleagues24 in Belgium suggest that the effects of acculturation are complex. Immigrants there tended to underutilise primary health care services for milder psychological
912
disturbances; this observation accords with UK results.25 However, in the Belgian study there was no simple relation between acculturation and underutilisation, and lengthy residence among the indigenous population did not necessarily bring the health care behaviour of migrants closer to that of the local norm. The highly heterogeneous nature of migrants living in Europe deserves widespread recognition. Future research needs to identify the reasons for the apparently very high rates of schizophrenia in some groups, and should try to include comparisons between first and second generation subjects. However, underutilisation of psychiatric services relative to the host community has also been reported for other groups and for other disorders. It is not clear whether this finding reflects a disproportionate degree of unrecognised and untreated morbidity. For this reason epidemiological studies are needed which take into account the difficulties in diagnosing mental disorders in patients from a foreign culture. Prospective studies are also required to determine the fate of migrants who initially enter the health care system but who may later be lost to follow-up. Finally it is necessary to evaluate the effectiveness of the special interventions that have been implemented to help immigrant patients. Such studies could, of course, be sponsored by individual countries or centres, but the imminent changes within Europe present a unique opportunity for cross-national collaboration which should not be lost.
Leff J. Psychiatry around the globe: a transcultural view. 2nd ed. London: Gaskell, 1988. 2. Littlewood R, Lipsedge M. Psychiatric illness among British AfroCaribbeans. Br Med J 1988; 296: 950-51. 3. Cruickshank JK, Beevers DG, eds. Ethnic factors in health and disease. Bristol: Wright, 1989. 4. Ineichen B. The mental health of Asians in Britain. Br Med J 1990; 300: 1.
1669-70. 5. O’Neill P. Global medicine on your doorstep. Br Med J 1990; 300: 625. 6. Harrison G, Owens D, Holton A, Neilson D, Boot D. A prospective study of severe mental disorder in Afro-Caribbean patients. Psychol Med 1988; 18: 643-57. 7. Cochrane R, Bal SS. Migration and schizophrenia: an examination of five
8.
hypotheses. Soc Psychiatry 1987; 22: 181-91. Gupta S. Ethnic differences in consultation rates. Br Med J 1989; 299:
1338. 9. Rack PH.
Psychiatric and social problems Psychiatr Scand 1988; 344 (suppl): 167-73.
among
immigrants.
Acta
10. Editorial. Black and white health. Lancet 1984; ii: 115. 11. Schwab B, et al. Health care of the chronically mentally ill: The culture broker model. Community Ment Health J 1988; 24: 174-84. 12. Manning M. Transcultural psychiatry. Community Care 1979; Jan 25: 19-21. 13. Moodley P. The Fanon project: a day centre in Brixton. Bull R Coll Psychiatrists 1987; ii: 417-18. 14. Gupta S. The mental health of Asians in Britain. Br Med J 1990; 301:240. 15. World Health Organisation. Mental health services in southern countries of the European region: report on a WHO meeting. Copenhagen: WHO Regional Office for Europe, 1988. 16. Steinhausen H. Psychiatric disorders m children and family dysfunction: a study of migrant workers’ families. Soc Psychiatry 1985; 20: 11-16. 17. Sayil I. Psychiatric problems of Turkish labourers in Holland. Int J Soc Psychiatry 1984; 30: 267-73. 18. Lazaridis K. Psychiatrische Erkrankungen bei Auslandem Hospitalisations - und nationalitatsspezifische Inzidenz. Nervenarzt 1987; 58: 250-55.
19.
Jensen SB, Schaumburg E, Leroy B, Larsen O, Thorup M. Psychiatric care of refugees exposed to organised violence. Acta Psychiatr Scand 1989; 80: 125-31.
20. Levander S. Community work as part of the psychiatric services of Nacka. Acta Psychiatr Scand 1987; 76 (suppl 337): 23-29. 21. Jansson B. Experience from a psychiatric service to immigrant groups using native therapists. Acta Psychiatr Scand 1988; 344 (suppl 175-78. 22. Wornham WC. Cultural targeted health services for immigrant children and adolescents. Can J Public Health 1988; 79 (suppl 2): 534-38. 23. Frighi L, Cuzzolaro M. Ricerche e interventi di igiene mentale su una poplazione di immigrati a Roma da Paesi in via di sviluppo. Min Psich 1987; 28: 179-83. 24. Van der Stuyft P, de Muynch A, Schillemans L, Timmerman C. Migration, acculturation and utilisation of primary health care. Soc Sci Med 1989; 29: 53-60. 25. Gillam SJ, Jarman B, White P, Law R. Ethnic differences in consultation rates in urban general practice. Br Med J 1989: 299: 953-57.
KORSAKOFF’S SYNDROME Since the 1880s there has been a general recognition that a unique amnesic syndrome can develop in alcoholics, associated with a neuropathy and other "psychic" symptoms. Korsakoff, who provided the original description, used the terms psychosis polyneuritica and cerebropathia psychica toxaemica, but it soon became known as his disease. A few years earlier Wernicke had described the triad of ataxia, ophthalmoplegia, and a confusional state (which he called haemorrhagic polioencephalitis), although the relation between the two disorders was not at first apparent. By the turn of the century pathological observations, especially of the mamillary bodies and the walls of the third ventricle, had established the link, and in the 1930s thiamine deficiency was shown to be central to both conditions.1 The eponymous glories of Korsakoff’s psychosis and Wernicke’s encephalopathy are now giving way, at least in DSM lII,2 to alcohol amnesic syndrome, but they have spread much confusion and forgetfulness in many a medical mind. In essence, the two conditions seem to represent different stages of the same deficiency process, and the most detailed monograph1 was entitled the Wernicke-Korsakoff syndrome. Victor and colleagues described 245 patients, (nearly all alcoholics, although puerperal sepsis, typhoid, and persistent vomiting are other known causes) and their conclusions remain central to our understanding. Thus, the symptoms follow a characteristic pattern, starting as a Wernicke state and proceeding, if untreated, via Korsakoffian amnesic-confabulation to a permanent amnesic defect. Sometimes Korsakoff symptoms are also apparent from the start, and they may be the only manifestations. The pure Korsakoff state consists of a loss of past memories, an inability to learn or form new memories, minor impairments of perceptual and conceptual functions, and an apathetic loss of insight and initiative. Confabulation (the "making up of stories") is not invariable and tends to disappear with chronicity. This feature is more an inability "to recall the temporal sequence of events" than a filling in of memory gaps. It has been suggested that frontal lobe changes are additionally required for the rarer "spontaneous" form, while "provoked" confabulation is equally common in Alzheimer’s disease.3 By contrast, other mental functions are relatively intact. Patients are alert, aware of their surroundings, able to speak and understand what is spoken, and can think and solve problems. Neuroanatomical studies show that the lesions are symmetrical and concentrated in the periaqueductal area.
