Brief Reports Puerperal Affective Psychosis: Is There a Case for Lithium Prophylaxis? M-P. V. AUSTIN
it Is wall known that women with a history of manic depressive or puorperal affective psychosis are at particularly
high risk of relapse
in the puneperlum.
This
actually placed on, prophylactic
medication
either during
pregnancy or within 48 hours of childbirth. All the patients (except one who was given low-dose
paper describes the use of lithium given during or after pregnancy to women with a history of bipolar Illness or puerperal affective psychosis. The rate of puerperal relapse In these subjects was compared with that In a similar group of women not on lithium. The significantly better outcome ofthe vestment groupti@iU@its the need for a prospective controlled trial looking at the effective nessof lithiumIn minimisingpuerperalbipolarrelapse.
neuroleptic following early symptoms of mania three days post-partum), had been considered for and/or placed on
British Journal of Psychiatry (1992), 161, 692—694
the time of birth wasrecorded, as weresteady-stateserum
lithium prophylaxis. Case notes were examined to determine
that patients fulfilled the ResearchDiagnosticCriteria (RDC) for bipolar disorder (Spitzer et a!, 1978). The frequency, type and severity of episodes, previous treatment
with lithium and its efficacy as a prophylactic agent were noted. The date of commencement of lithium relative to lithium levels, the duration of treatment and the occurrence
In women with a history of manic-depressive or
(of anytype),duration,andseverityof anyrelapseduring
puerperal
this time.
affective psychosis the risk of developing
a psychotic illness following a subsequent pregnancy is between 1 in 5 and 1 in 2 (Bratfos & Haug, 1966;
‘¿Lithium prophylaxis' was defmed as a minimum of three months of lithium treatment after delivery with serum levels
of0.4 mmol/l or more.‘¿Puerperal relapse'wasdefmedas
Reich & Winokur, 1970; Abou-Saleh & Coppen, 1983). This is an almost 500-fold increase from the
readmission with either depression or mania within three months of childbirth.
base rate of 1—2per 1000 deliveries (Kendell et a!, 1987). Despite this uniquely high risk and the recent evidence indicating that most puerperal psychoses are
Results
affective (Kendell et a!, 1987), there is no agreed
A total of 17 women fulfilling RDC criteria for bipolar
prophylactic
strategy
in this group
of patients.
Most psychiatrists are reluctant to prescribe lithium during pregnancy because of the risk of congenital abnormality,
and very few would prescribe
it to
disorderor puerperalaffectivepsychosiswereidentified.Of these, 11werecommencedon lithiumbut two discontinued it in the early puerperium. Thus the two groups were
identifiedas follows: nine patients(threeof whom were also included in the Stewart eta!, 1991 study) in the lithium
breast-feeding mothers, as the concentration of lithium in breast milk is up to half of that in the mother's serum (Schou & Weinstein, 1980). Reich & Winokur (1970) were the first to support the use of lithium prophylaxis for bipolar women in the puerperium. Stewart eta! (1991) reported on 21 women at high risk of puerperal affective psychosis
treatment group and eight in the non-treatment group.
given prophylactic
womenin eachgroup.Obstetriccomplicationsoccurring
lithium late in the third trimester
or immediately after delivery. Only l0°loof the women had a recurrence
of their psychotic
illness
within six months of parturition. This paper describes the use and effectiveness of prophylactic medication in a group of women at risk for affective psychosis in the puerperium and compares the rate of puerperal relapse in treatment and non-treatment groups.
Demographic, obstetric and clinical data for the two groups were as follows: mean age was 26.5 years (range
20—32years) for the lithium group and 28.5 years (range
21-39years)forthenon-lithiumgroup.Allthewomenwere married
except for two who were single (one per group).
There was a similar distribution of socioeconomic class (Classes II to IV) and an equal proportion
of primiparous
with the index births were as follows: two Caesarian sections (both in the untreated group), one stillbirth and one post
partumhaemorrhage(thelattertwo in thetreatedgroup). Sixwomen(threeper group) had a past historyof mania occurring in the puerperium alone çrable1). Six of the treat ment group had been on lithium in the past with apparently
goodeffect,whileoneofthepatientsfromthenon-treatment grouphadpreviouslyreceivedlithiumwithlittlesuccessdue to non-compliance. In six of the nine patients in the treatment group, lithium
Method All consultant psychiatrists at the Royal Edinburgh Hospital
was commencedin the secondor thirdtrimesterof preg nancy,inonepatientitwascontinuedthroughoutpregnancy andintheothertwopatientslithiumwascommencedwithin
were asked to recallthose of their patientswith a past history of bipolar disorderor puerperalaffectivepsychosis 48 hours of parturition. Prophylaxis was continued for who between1978and 1988had beenconsideredfor, or between three months and two or more years (Table 2). 692
LITHIUM
IN PUERPERAL
Table 1 Pasthistoryof affectiveillnessand responseto lithium
AFFECTIVE
693
PSYCHOSIS
1959). All relapsers were admitted
to hospital with moderate
to severe episodes of mama (5 out of the 8 relapserswere psychotic at the time of admission) and all except two (in Pasthistoryof affectiveillness Pastlithium the untreated group) relapsed within three weeks of bipolar puerperal “¿responders― parturition. Average duration of in-patient stay was seven (episodes)
weeks(range5—12 weeks)andfourout of thesixrelapsers from the untreated group were subsequently commenced
Uthiumgroup @n =9)
2 3 4 5 6 7
8
mania mania mania mania mania(3)
+
on lithiumprophylaxis. Discussion
+
mania mania(2)
mania
mania(2)
mania
What led clinicians to consider this group of patients +
for
:
these patients had clear-cut and often recurrent
+
lithium
therapy
particular
and
women?
A
what
led
possible
them
to
recall
explanation
these is
that
9 mania(3) manic episodes and were therefore ‘¿memorable'. As Untreatedgroup(n= 8) 10 mania(3) depression/manianon-compliant a consequence of their bipolar history they were 11 mania likely to be considered potential lithium responders. mania 12 Why were certain patients given lithium prophylaxis 13 mania (2) and others not? Two-thirds ofwomen in the treatment 14 mania group had been successfully treated with lithium in mania 15 the past and were thus recommenced on it. While mania 16 the reasons for not using lithium in the untreated 17 mania
group were not given, three possibilities have to be
considered: refusal by the patient to accept treatment, Twooutof ninepatientson lithiumrelapsed,althoughtheir breakdown in communication between the psychiatrist symptoms
were milder than in previous episodes,
and six
and general practitioner/obstetrician
at the time of
outof eightpatientsnoton lithiumrelapsed.Thedifference the planned start of treatment (e.g. at birth) and the in outcome between the two groups was statistically significant (j@= 4.48, P3
= 8)10 -12 weeksmania-11 -3 weeksmania—12 weeksmania-13-8 -3 weeksmania-14 -2 weeksmania-15 weekmania-16 -1 ----17 ---P-P= post-partum;T =trimester.
did not relapse. Reported annual rates of relapse in bipolar patients
on and off lithium are 20% and 70% per annum respectively
(Schou
& Weinstein,
1980). This is
similar to the proportion of treated and untreated patients
relapsing
over
the
three-month
‘¿post
partum' period alone. Such a high rate of relapse further emphasises the need for intervention particular group of patients. A case could
be made
for offering
lithium
in this to all
patients with a bipolar illness for the period of 3—6 months post-partum during which they are at greatest
694
AUSTIN
risk of relapse (Kendell et a!, 1987; McNeil, 1986). However, nursing mothers would haveto be convinced of the need to commence lithium and hence forego breast-feeding in order to diminish the risk of relapse. Evidence in favour of such a therapeutic strategy is emerging but needs to be more compelling in order to alter both the clinician's and patient's attitudes
to the use of lithium in the puerperium. While the ethical considerations of potentially withholding lithium during this high-risk period need to be carefully assessed for each patient, the benefits of prophylaxis can be assessed conclusively only by a prospective controlled trial. A multicentre trial is likely to be necessary since these patients are difficult to recruit in sufficient numbers from one
centre alone. Alternatively small trials using similar methods could be conducted and the combined results assessed by means of a quantitative analysis
(Rosenthal, 1984).
thanks
are due to Professor
manic—depressivefemales. AcM Psychiatrica Scandinavica, 42, 285—294.
K&sisu.,R. E., Citauims, J. C. & PlAn, C. (1987)Epidemiology of puerperalpsychosis.BritishJournalof Psychiatry,150, 662—673.
McNan,,T. F. (1986)A prospective studyof post-partum psychoses in a highriskgroup.I: Clinicalcharacteristicsof thecurrentpost partumepisodes.ActaPsychlatncaScandinavica,74,205-216. M*wrm, N. & HAENSZEL, W. (1959)Statistical aspects of the analysisof data from retrospectivestudiesof disease.Journal of National Cancer Institute, 22, 719-748. Rmas, T. & WiNolnin, 0. (1970) Post-partum psychoses in patients
withmanic-depressivedisease.Journal of Nervousand Mental Dlso,ders, 151, 60—68.
Ro@mw@,R. (1984)Meta-analyticProceduresfor SocialR@rch (2nd prInting).BeverlyHills: Sage. Scuou,M. &Wmmnmi,M. R. (1980)Problemsof lithiummainten ance and treatment during pregnancy, delivery and lactation. Agremologle, 21A, 7-9. SPIT7.ER,I. R., ENoIconr, J. & ROBB1NS,E. (1978) Research Diagnostic Criteriafora Selected Group of Functional Disorders
(3rdedn). New York:New YorkStatePsychiatricInstitute. Siew4@iti, D. E., KLoP,n'ENIlouwEit, J. L., KENDaLL, R. E., ci a! (1991)Prophylacticlihium in puerperalpsychosis.Theexperience of three centres. British Journal of Psychiatry, 15*, 393-397.
Acknowledgements Many
Baxz@s,0. & HAuo,J. 0. (1966)Puerperalmental disordersin
R. E. Kendell
and
Dr
K. P. Ebmeier for their helpful comments on earlier drafts of this paper.
Marie-Paule
Veronique
Austin,
MBBS, FRANZCP,
Honorary Lecturer Department of Psychiatry, University of NSW and Staff Speciallst, Mood Disorder Unit, Prince Henry Hospital, Little Bay, Rfernces NSW 2036, Australia; formerly Clinical Research [email protected], M. & C0PPEN, A. (1983)Puerperalaffectivedisorder Fellow, MRC Brian Brain MetabolismUnit, Royal and responseto lithium.BritLchJournal of Psychiatry,142,539. EdinburghHospital, Edinburgh
Obsessive—Compulsive Disorder and Paraphiia
in a Monozygotic Twin Pair
ELIZABETH M. J. CRYAN, GERARD J. BUTCHER and MARCUS G. T. WEBB We reportOCD and paraphiNaIn two male membersof triplets (the two males being monozygotic twins), and discuss the posaible aetlologlcal factors for this prevIously
unreported
occurrence.
We suggest
that
1990). There may also be a higher concordance for OCD
among
suggesting
monozygotic
than
a genetic component
dizygotic
twins,
to the disorder,
patients presenting with paraphilla should be examined for OCD and that a detailed sexual history should be obtained In all patients wIth OCD. British Journal of Psychiatry (1992), 161, 694—698
but further studies are necessary to confirm this (Jenike, 1989). The most frequently encountered obsession in OCD is a fear of contamination. However, sexual obsessions also occur and were
Obsessive-compulsive
of acting on sexual impulse, or fears of sexual
disorder (OCD) is now con
reported in 32% of the patients studied by Rasmussen & Tsuang (1986), where they were most often fears
sidered to be more common in the general population
perversions.
than panic disorder or schizophrenia,
attitudes, and functioning of obsessive-compulsive
with a lifetime
In
a
study
of
the
sexual
history,
prevalence of 2.5% (Robins et a!, 1984). There is a
patients,
recognised association between OCD and depression, and these patients also have an increased vulnerability
engaging in sexually deviant behaviour although 73% of the 44 subjects reported themselves as not being
to other anxiety disorders (Rasmussen & Eisen,
satisfied
none of the patients
were reported
with their sex lives (Freund
as
& Steketee,
Puerperal affective psychosis: is there a case for lithium prophylaxis? M P Austin BJP 1992, 161:692-694. Access the most recent version at DOI: 10.1192/bjp.161.5.692
References Reprints/ permissions You can respond to this article at Downloaded from
This article cites 0 articles, 0 of which you can access for free at: http://bjp.rcpsych.org/content/161/5/692#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] /letters/submit/bjprcpsych;161/5/692 http://bjp.rcpsych.org/ on June 12, 2017 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/site/subscriptions/
it Is wall known that women with a history of manic depressive or puorperal affective psychosis are at particularly
high risk of relapse
in the puneperlum.
This
actually placed on, prophylactic
medication
either during
pregnancy or within 48 hours of childbirth. All the patients (except one who was given low-dose
paper describes the use of lithium given during or after pregnancy to women with a history of bipolar Illness or puerperal affective psychosis. The rate of puerperal relapse In these subjects was compared with that In a similar group of women not on lithium. The significantly better outcome ofthe vestment groupti@iU@its the need for a prospective controlled trial looking at the effective nessof lithiumIn minimisingpuerperalbipolarrelapse.
neuroleptic following early symptoms of mania three days post-partum), had been considered for and/or placed on
British Journal of Psychiatry (1992), 161, 692—694
the time of birth wasrecorded, as weresteady-stateserum
lithium prophylaxis. Case notes were examined to determine
that patients fulfilled the ResearchDiagnosticCriteria (RDC) for bipolar disorder (Spitzer et a!, 1978). The frequency, type and severity of episodes, previous treatment
with lithium and its efficacy as a prophylactic agent were noted. The date of commencement of lithium relative to lithium levels, the duration of treatment and the occurrence
In women with a history of manic-depressive or
(of anytype),duration,andseverityof anyrelapseduring
puerperal
this time.
affective psychosis the risk of developing
a psychotic illness following a subsequent pregnancy is between 1 in 5 and 1 in 2 (Bratfos & Haug, 1966;
‘¿Lithium prophylaxis' was defmed as a minimum of three months of lithium treatment after delivery with serum levels
of0.4 mmol/l or more.‘¿Puerperal relapse'wasdefmedas
Reich & Winokur, 1970; Abou-Saleh & Coppen, 1983). This is an almost 500-fold increase from the
readmission with either depression or mania within three months of childbirth.
base rate of 1—2per 1000 deliveries (Kendell et a!, 1987). Despite this uniquely high risk and the recent evidence indicating that most puerperal psychoses are
Results
affective (Kendell et a!, 1987), there is no agreed
A total of 17 women fulfilling RDC criteria for bipolar
prophylactic
strategy
in this group
of patients.
Most psychiatrists are reluctant to prescribe lithium during pregnancy because of the risk of congenital abnormality,
and very few would prescribe
it to
disorderor puerperalaffectivepsychosiswereidentified.Of these, 11werecommencedon lithiumbut two discontinued it in the early puerperium. Thus the two groups were
identifiedas follows: nine patients(threeof whom were also included in the Stewart eta!, 1991 study) in the lithium
breast-feeding mothers, as the concentration of lithium in breast milk is up to half of that in the mother's serum (Schou & Weinstein, 1980). Reich & Winokur (1970) were the first to support the use of lithium prophylaxis for bipolar women in the puerperium. Stewart eta! (1991) reported on 21 women at high risk of puerperal affective psychosis
treatment group and eight in the non-treatment group.
given prophylactic
womenin eachgroup.Obstetriccomplicationsoccurring
lithium late in the third trimester
or immediately after delivery. Only l0°loof the women had a recurrence
of their psychotic
illness
within six months of parturition. This paper describes the use and effectiveness of prophylactic medication in a group of women at risk for affective psychosis in the puerperium and compares the rate of puerperal relapse in treatment and non-treatment groups.
Demographic, obstetric and clinical data for the two groups were as follows: mean age was 26.5 years (range
20—32years) for the lithium group and 28.5 years (range
21-39years)forthenon-lithiumgroup.Allthewomenwere married
except for two who were single (one per group).
There was a similar distribution of socioeconomic class (Classes II to IV) and an equal proportion
of primiparous
with the index births were as follows: two Caesarian sections (both in the untreated group), one stillbirth and one post
partumhaemorrhage(thelattertwo in thetreatedgroup). Sixwomen(threeper group) had a past historyof mania occurring in the puerperium alone çrable1). Six of the treat ment group had been on lithium in the past with apparently
goodeffect,whileoneofthepatientsfromthenon-treatment grouphadpreviouslyreceivedlithiumwithlittlesuccessdue to non-compliance. In six of the nine patients in the treatment group, lithium
Method All consultant psychiatrists at the Royal Edinburgh Hospital
was commencedin the secondor thirdtrimesterof preg nancy,inonepatientitwascontinuedthroughoutpregnancy andintheothertwopatientslithiumwascommencedwithin
were asked to recallthose of their patientswith a past history of bipolar disorderor puerperalaffectivepsychosis 48 hours of parturition. Prophylaxis was continued for who between1978and 1988had beenconsideredfor, or between three months and two or more years (Table 2). 692
LITHIUM
IN PUERPERAL
Table 1 Pasthistoryof affectiveillnessand responseto lithium
AFFECTIVE
693
PSYCHOSIS
1959). All relapsers were admitted
to hospital with moderate
to severe episodes of mama (5 out of the 8 relapserswere psychotic at the time of admission) and all except two (in Pasthistoryof affectiveillness Pastlithium the untreated group) relapsed within three weeks of bipolar puerperal “¿responders― parturition. Average duration of in-patient stay was seven (episodes)
weeks(range5—12 weeks)andfourout of thesixrelapsers from the untreated group were subsequently commenced
Uthiumgroup @n =9)
2 3 4 5 6 7
8
mania mania mania mania mania(3)
+
on lithiumprophylaxis. Discussion
+
mania mania(2)
mania
mania(2)
mania
What led clinicians to consider this group of patients +
for
:
these patients had clear-cut and often recurrent
+
lithium
therapy
particular
and
women?
A
what
led
possible
them
to
recall
explanation
these is
that
9 mania(3) manic episodes and were therefore ‘¿memorable'. As Untreatedgroup(n= 8) 10 mania(3) depression/manianon-compliant a consequence of their bipolar history they were 11 mania likely to be considered potential lithium responders. mania 12 Why were certain patients given lithium prophylaxis 13 mania (2) and others not? Two-thirds ofwomen in the treatment 14 mania group had been successfully treated with lithium in mania 15 the past and were thus recommenced on it. While mania 16 the reasons for not using lithium in the untreated 17 mania
group were not given, three possibilities have to be
considered: refusal by the patient to accept treatment, Twooutof ninepatientson lithiumrelapsed,althoughtheir breakdown in communication between the psychiatrist symptoms
were milder than in previous episodes,
and six
and general practitioner/obstetrician
at the time of
outof eightpatientsnoton lithiumrelapsed.Thedifference the planned start of treatment (e.g. at birth) and the in outcome between the two groups was statistically significant (j@= 4.48, P3
= 8)10 -12 weeksmania-11 -3 weeksmania—12 weeksmania-13-8 -3 weeksmania-14 -2 weeksmania-15 weekmania-16 -1 ----17 ---P-P= post-partum;T =trimester.
did not relapse. Reported annual rates of relapse in bipolar patients
on and off lithium are 20% and 70% per annum respectively
(Schou
& Weinstein,
1980). This is
similar to the proportion of treated and untreated patients
relapsing
over
the
three-month
‘¿post
partum' period alone. Such a high rate of relapse further emphasises the need for intervention particular group of patients. A case could
be made
for offering
lithium
in this to all
patients with a bipolar illness for the period of 3—6 months post-partum during which they are at greatest
694
AUSTIN
risk of relapse (Kendell et a!, 1987; McNeil, 1986). However, nursing mothers would haveto be convinced of the need to commence lithium and hence forego breast-feeding in order to diminish the risk of relapse. Evidence in favour of such a therapeutic strategy is emerging but needs to be more compelling in order to alter both the clinician's and patient's attitudes
to the use of lithium in the puerperium. While the ethical considerations of potentially withholding lithium during this high-risk period need to be carefully assessed for each patient, the benefits of prophylaxis can be assessed conclusively only by a prospective controlled trial. A multicentre trial is likely to be necessary since these patients are difficult to recruit in sufficient numbers from one
centre alone. Alternatively small trials using similar methods could be conducted and the combined results assessed by means of a quantitative analysis
(Rosenthal, 1984).
thanks
are due to Professor
manic—depressivefemales. AcM Psychiatrica Scandinavica, 42, 285—294.
K&sisu.,R. E., Citauims, J. C. & PlAn, C. (1987)Epidemiology of puerperalpsychosis.BritishJournalof Psychiatry,150, 662—673.
McNan,,T. F. (1986)A prospective studyof post-partum psychoses in a highriskgroup.I: Clinicalcharacteristicsof thecurrentpost partumepisodes.ActaPsychlatncaScandinavica,74,205-216. M*wrm, N. & HAENSZEL, W. (1959)Statistical aspects of the analysisof data from retrospectivestudiesof disease.Journal of National Cancer Institute, 22, 719-748. Rmas, T. & WiNolnin, 0. (1970) Post-partum psychoses in patients
withmanic-depressivedisease.Journal of Nervousand Mental Dlso,ders, 151, 60—68.
Ro@mw@,R. (1984)Meta-analyticProceduresfor SocialR@rch (2nd prInting).BeverlyHills: Sage. Scuou,M. &Wmmnmi,M. R. (1980)Problemsof lithiummainten ance and treatment during pregnancy, delivery and lactation. Agremologle, 21A, 7-9. SPIT7.ER,I. R., ENoIconr, J. & ROBB1NS,E. (1978) Research Diagnostic Criteriafora Selected Group of Functional Disorders
(3rdedn). New York:New YorkStatePsychiatricInstitute. Siew4@iti, D. E., KLoP,n'ENIlouwEit, J. L., KENDaLL, R. E., ci a! (1991)Prophylacticlihium in puerperalpsychosis.Theexperience of three centres. British Journal of Psychiatry, 15*, 393-397.
Acknowledgements Many
Baxz@s,0. & HAuo,J. 0. (1966)Puerperalmental disordersin
R. E. Kendell
and
Dr
K. P. Ebmeier for their helpful comments on earlier drafts of this paper.
Marie-Paule
Veronique
Austin,
MBBS, FRANZCP,
Honorary Lecturer Department of Psychiatry, University of NSW and Staff Speciallst, Mood Disorder Unit, Prince Henry Hospital, Little Bay, Rfernces NSW 2036, Australia; formerly Clinical Research [email protected], M. & C0PPEN, A. (1983)Puerperalaffectivedisorder Fellow, MRC Brian Brain MetabolismUnit, Royal and responseto lithium.BritLchJournal of Psychiatry,142,539. EdinburghHospital, Edinburgh
Obsessive—Compulsive Disorder and Paraphiia
in a Monozygotic Twin Pair
ELIZABETH M. J. CRYAN, GERARD J. BUTCHER and MARCUS G. T. WEBB We reportOCD and paraphiNaIn two male membersof triplets (the two males being monozygotic twins), and discuss the posaible aetlologlcal factors for this prevIously
unreported
occurrence.
We suggest
that
1990). There may also be a higher concordance for OCD
among
suggesting
monozygotic
than
a genetic component
dizygotic
twins,
to the disorder,
patients presenting with paraphilla should be examined for OCD and that a detailed sexual history should be obtained In all patients wIth OCD. British Journal of Psychiatry (1992), 161, 694—698
but further studies are necessary to confirm this (Jenike, 1989). The most frequently encountered obsession in OCD is a fear of contamination. However, sexual obsessions also occur and were
Obsessive-compulsive
of acting on sexual impulse, or fears of sexual
disorder (OCD) is now con
reported in 32% of the patients studied by Rasmussen & Tsuang (1986), where they were most often fears
sidered to be more common in the general population
perversions.
than panic disorder or schizophrenia,
attitudes, and functioning of obsessive-compulsive
with a lifetime
In
a
study
of
the
sexual
history,
prevalence of 2.5% (Robins et a!, 1984). There is a
patients,
recognised association between OCD and depression, and these patients also have an increased vulnerability
engaging in sexually deviant behaviour although 73% of the 44 subjects reported themselves as not being
to other anxiety disorders (Rasmussen & Eisen,
satisfied
none of the patients
were reported
with their sex lives (Freund
as
& Steketee,
Puerperal affective psychosis: is there a case for lithium prophylaxis? M P Austin BJP 1992, 161:692-694. Access the most recent version at DOI: 10.1192/bjp.161.5.692
References Reprints/ permissions You can respond to this article at Downloaded from
This article cites 0 articles, 0 of which you can access for free at: http://bjp.rcpsych.org/content/161/5/692#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] /letters/submit/bjprcpsych;161/5/692 http://bjp.rcpsych.org/ on June 12, 2017 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/site/subscriptions/
