COST OF NEUROSIS Much has been said and written about the expense of medical treatment and the burden thereby placed on the economy. However, untreated illness also makes financial demands on the community-for example, in provisions for social security and via lost industrial production. Both the direct costs of treatment and the indirect costs to the community are difficult to quantify precisely and figures have to be interpreted cautiously. Nevertheless, they can suggest important questions about health care. Croft-Jeffries and Wilkinson! lately examined the costs associated with the treatment of neurosis in general practices in the UK in the year 1985 and, for comparison, similarly derived costs of hypertension. The overall estimated expenses of the two disorders were substantial and not very different from one another-about C370 million for neurosis and about z337 million for hypertension. However, the proportion of direct to indirect costs differed between the two conditions. For hypertension, almost two-thirds of the total sum was the direct cost of treatment, and only a third the indirect cost of lost production. For neurosis, the proportions were reversed-a third for treatment and two-thirds in lost production. More of the treatment costs for neurosis (60%) were for consultations with the general practitioner (GP) than for drugs (40%); for hypertension, drugs amounted to 80% of the total. As the researchers point out, these estimates include several uncertainties. The treatment costs are incomplete because it was not possible to obtain accurate estimates of expenditure on hospital care and social services. The total expenditure on hospital services for minor psychiatric disorder in 1985 was C220 million,! but how much of this sum was spent on neurosis is unknown. Similarly, social service costs for neurotic disorders cannot be separated easily from those for other conditions. If health and social services are to be judged more by financial criteria in future, accounting systems will need to be capable of producing comparable data about expenditure in general practice, hospitals, and social services. Croft-Jeffries and Wilkinson also recognise that the estimated costs of lost production can be questioned. Such calculations take into account only days away from work certified as due to neurosis and it is known that neurosis is the cause of much uncertified, as well as certified, absence from work.2 Moreover, no estimate was made of loss of working days by patients’ relatives. However, the estimate includes a costing of days lost by housewives, whose time was priced at the average female wage. Despite the uncertainties, the study adds to other evidence3that neurosis is an important cause of lost production, as well as a major source of health service
expenditure. Thus there are good reasons for ensuring that the of neurosis is as effective and as economical as possible. Much progress has been made in improving the treatment of these conditions. For minor neurotic disorders, counselling has been shown to be as effective as routine treatment with drugs.4,sFor more severe and persistent neuroses, behavioural treatments produce lasting improvement in anxiety, phobic, and obsessional disorders.6-9 Moreover, behavioural treatment can lead to a reduction in consultations with general practitioners over the ensuing months.1O Concern about benzodiazepine dependency has encouraged renewed interest in the value of tricyclic antidepressants and monoamine oxidase inhibitors in neuroses,’1°’2 and has stimulated the development of new
anxiolytic drugs acting on 5-hydroxytryptamine receptors. 13 There have been attempts to compare the effects of different kinds of treatment of neurosis on economic indices;14,15 no substantial differences were found, but groups were small. Despite these useful advances, research is still needed to develop more effective and economical treatment for neurosis, including the group of disorders, commonly seen in general practice, characterised by complaints of physical rather than psychological symptoms, and to compare specialist treatment with care provided by GPs. The costs of this work would be repaid quickly if better treatment were to lead to even a modest reduction in the estimated /J250 million worth of production lost each year in the UK as a result of neurotic illness. The latest results were generated by the General Practice Research Unit at the Institute of Psychiatry in London, in which many important studies of neurosis have been carried out. The unit has now been closed by the Department of Health; the need for research into the causes and treatment of neurotic disorders is as strong as ever. Croft-Jeffries C, Wilkinson G. Costs of neurotic illness in UK general practice in 1985. Psychol Med 1989; 19: 549-58. 2. Jenkins R. Minor psychiatric morbidity in employed young men and women and its contribution to sickness absence. Br J Indust Med 1985; 1.
42: 147-54. 3. Hertzman P. The economic costs of mental illness in Sweden in 1975. Acta Psychiatr Scand 1983; 68: 359-67.
4. Ballestieri M, Williams P, Wilkinson G. Specialist mental health treatment in general practice: a meta-analysis. Psychol Med 1988; 18: 711-17.
Catalan J, Gath DH, Edmonds G, Ennis J. The effects of non-prescribing of anxiolytics in general practice I. Controlled evaluation of psychiatric and social outcome. Br J Psychiatry 1984; 144: 593-602. 6. Butler G, Cullington A, Munby M, Amies P, Gelder MG. Exposure and anxiety management in the treatment of social phobia. J Consult Clin Psychol 1984; 52: 642-50. 7. Butler G, Cullington A, Hibbert G, Klimes I, Gelder MG. Anxiety management for persistent generalised anxiety. Br J Psychiatry 1987; 5.
151: 535-42. 8. Marks IM. Phobic disorders 4 years after treatment. Br J Psychiatry 1971; 118: 683-88. 9. Marks IM, Hodgson R, Rachman S. Treatment of chronic obsessive compulsive neurosis by in vivo exposure. Br J Psychiatry 1975; 127: 349-64. 10. Butler G, Cullington A, Munby M, Amies PL, Gelder MG. Exposure and anxiety management in the treatment of social phobia. J Consult Clin Psychol 1984; 52: 642-50. 11. Kahn RJ, McNair DM, Frankenthaler LM. Tricyclic treatment of generalised anxiety disorder. J Affect Disord 1987; 13: 145-51. 12. Modigh K. Antidepressant drugs in anxiety disorders. Acta Psychiatr Scand 1987; 335: 57-71. 13. Ortiz A, Pohl R, Gershon S. Azaspirodecanediones in generalized anxiety disorder: buspirone. J Affect Dis 1987; 13: 131-43. 14. Ginsberg G, Marks IM, Waters H. Cost-benefit analysis of a controlled trial of nurse therapy for neuroses in primary care. Psychol Med 1984; 14: 683-90. 15. Mangen SP, Paykel ES, Griffith JH, Burchell A, Mancini P. Costeffectiveness of community psychiatric nurse or out-patient psychiatrist care of neurotic patients. Psychol Med 1983; 13: 407-16.
ROUTINE IMMUNISATION OF PRETERM INFANTS The
World Health Organisation, recognising the importance of the routine immunisation of children, has set a target that, by the year 2000, all children should be protected by immunisation. For countries within Europe the aim is to achieve a primary immunisation coverage rate of 90% by 1990 for all children under two years of age. 1 The WHO further recommends that, in an eligible child, the decision
immunisation should not be taken lightly.2 Preterm infants are more vulnerable than term infants because they have less IgG.3 The fetus obtains most of its IgG transplacentally from the mother, and there is a linear relation between IgG levels and gestational age. Very preterm babies have especially low levels of protective antibodies against pertussis4 so this group are most likely to have had respiratory difficulties in the neonatal period, which makes them more susceptible to the effects of whooping cough. The timing of immunisation in any infant represents a compromise between the need to achieve early effective protection against disease, especially for infants at high risk, and the knowledge that the ability to mount an adequate immune response improves with age. Advice about the timing of immunisation varies from country to country, since this decision is influenced by the prevalence of the diseases concerned. The WHO recommends that immunisation with oral poliovaccine (OPV) and BCG vaccine should start at birth in developing countries, because this policy offers better early protection; immunisation with diphtheria/pertussis/tetanus vaccine (DPT) should be delayed until six weeks of age, by which time most infants are able to mount an adequate immunological response to the pertussis component of the vaccine.5 In the past, immunisation of preterm infants was often delayed, especially in those of very low birthweight, because of concern that the immune system was not sufficiently mature to mount an
and fears that preterm infants might be more prone to adverse reactions.6A growing body of evidence now indicates that the ability to mount an immune response is related not to gestational age but to the length of time the infant has been exposed to extrauterine life. An early study showed that the immune response to diphtheria toxoid administered at birth was as good in preterm infants of 35 weeks gestation as in term infants.7 Moreover, preterm infants immunised at their expected date of delivery mounted a better response than did term infants immunised at birth, the response being similar to that achieved in term infants immunised at the same chronological age. Other studies in preterm infants have documented adequate specific antibody responses to diphtheria, pertussis, tetanus, and polio antigens, after a completed primary course of immunisation, when this is started at the recommended chronological age for term infants.4.8-10 Pullan and Hull lately showed that preterm infants as young as 26 weeks gestation who were immunised as soon as possible after the recommended age of three months had adequate antibody responses.1o Adverse reactions to immunisation, started in preterm infants at ages as young as two months, are less common than in term infants immunised at the same chronological age.1,10 Thus there is no reason to defer the immunisation of preterm infants on the grounds of safety. All the evidence therefore supports the recommendations of the American Academy of Pediatrics," the British Paediatric Association,12 and the UK Joint Committee on Immunisation and Vaccination, 13 that immunisation should begin at the chronological age recommended for term infants, provided there are no contraindications to its use. Satisfactory antibody responses are achieved and the frequency of side-effects is low. Even though this recommendation has been in force in the UK since 1985, it remains common for the immunisation of preterm infants to be delayed unnecessarily. 15 This attitude can partly be
a lack of experience in dealing with preterm infants among those in the community who advise on and administer immunisation.10,15 It is also in this group of infants that pertussiss vaccine is frequently omitted from the immunisation programme, as a result of uncertainty about the contraindications to its use. The American Academy of Pediatrics states that prematurity per se does not constitute a contraindication to pertussis immunisation,"the same contraindications apply to preterm infants as to term infants.11,14 It is therefore important for neonatal units to give unambiguous advice about the timing of, and the presence or absence of contraindications to, routine immunisation in preterm infants.1O.1U4,15 If the baby is still in hospital at the time immunisation is due to start, DPT should be given as soon as possible after this recommended age. Immunisation with OPV should be delayed until the day of discharge from hospital, to avoid cross-infection in the nursery.6.11
Begg NT, Noah ND. Immunisation targets in Europe and Britain. Br Med J 1985; 291: 1370-71. 2. Galazka AM, Lauer BA, Henderson RH, Keja J. Indications and contraindications for vaccines used in the Expanded Programme on 1.
Immunisation. Bull WHO 1984; 62: 357-66. 3. Bernbaum, J, Anolik R, Polin RA, Douglas SD. Development of the premature infant’s host defence system and its relationship to routine immunizations. Clin Perinatol 1984; 11: 7384. 4. Bernbaum JC, Daft A, Anolik R, et al. Response of preterm infants to diphtheria-tetanus/pertussis immunizations. J Pediatr 1985; 107: 184-88. 5. World Health Organisation: Expanded Programme on Immunization. Immunization Policy. WHO/EPI/GEN/86/7 REVI. Geneva: WHO, 1986. 6. Lingman S, Miller C, Pateman J, et al. Immunisation of preterm infants. Br Med J 1986; 292: 1183-85. 7. Dancis J, Osborn JJ, Kunz HW. Studies of the immunology of the newborn infant, IV. Antibody formation in the premature infant. Pediatrics 1953; 12: 151-57. 8. Smolen P, Bland R, Heiligenstein E, Lawless MR, Dillard R, Abramson J. Antibody response to oral polio vaccine in premature infants. J Pediatr 1983; 103: 917-19. 9. Conway SP, James JR, Smithells RW, Melville-Smith M, Magrath D. Immunisation of the preterm baby. Lancet 1987; ii: 1326. 10. Pullan CR, Hull D. Routine immunisation of preterm infants. Arch Dis Child 1989; 64: 1438-41. 11. Report of the Committee on Infectious Diseases. 21st ed. The 1988 red book. Elk Grove Village: American Academy of Pediatrics, 1988. 12. Nicoll A, Rudd P. British Paediatric Association. Manual on infections and immunizations in children. Oxford: Oxford Medical Publications, 1989. 13. Joint Committee on Immunisation and Vaccination. Immunisation against infectious disease. London: HM Stationery Office, 1988. 14. First Report of the British Paediatric Association/Joint Committee on Vaccination and Immunisation Liaison Group. London: British Paediatric Association, 1985. 15. Roper J, Day S. Uptake of immunisations in low birthweight infants. Arch Dis Child 1988; 63: 518-21.
THE LANCET AROUND THE WORLD Not all our readers may know that selections of material from the London edition of The Lancet are published at monthly intervals in Spanish, Italian, German and French. The editorial content of the weekly North American edition, however, is identical to the international edition published in London. We are pleased to announce that, with effect from this issue, publication of the North American Lancet transfers to Williams and Wilkins in Baltimore.* All editorial material submitted for publication should still be sent to our London office, the details of which are found on our second contents page. * 428 East Preston St, Baltimore, MD 21202-3993, USA (telephone: