LETTERS
TO
THE
Am
EDITOR
ment. Further, rebutted that
we noted that Brunswick and associates (3), statement on the basis of high stability in pa-
benefited’ since it
tients
whose
ratio
theoretical
period All lithium after dence isfied
for the plasma lithium levels to stabilize. of our measures were taken at least one week after was started, and many were taken several months initiation
that that
lithium
was
of
measured
lithium
10 times
therapy.
Although
multiple measurements the ratio was obtained
levels
had
been
after
a sufficient
there
are necessary, only after
reached.
‘
or
was
simply
.
.
of the
.
patients
likelihood
to stay
with
the
drug”
a speculation, as other explanations would be at this point (e.g. the 2 patients may have been markedly dependent on their therapist, very compulsive and compliant, ,
and their sampling
RBC/plasma error).
lithium
ratios
high
by
be with
more
formulations
simple
random
M.D. M.D. M.D. Tex.
FLEMENBAUM,
L.
RICHARD
WEDDIGE,
JOHN
MILLER,
Lubbock,
The
paper
‘
‘Violent
apeutic
agent
The patient mitted that tory
for a small
group
to a state
hospital
abuse
of his wife,
Imipramine,
and
Responsive
to d-Am-
and associates (March a patient I have treated; can be an important ther-
of adults.
married
verger
in 1972 after
time, anger and irritability included numerous episodes
who was ad-
a suicide
threat.
At
were prominent, and his hisof loss of temper, physical
frequent
fist fights
chlordiazepoxide,
with
thionidazine,
other and
men. a combi-
nation of perphenazine and amitriptyline were all without benefit and made the patient feel too “drugged’ to work effectively after he was released from the hospital. Like the ‘
patient cited in the paper by himself suggested amphetamine experience. He has done very
erance,
weight
used the drug the Harnington
work
and
loss,
or sleep
during the Memorial
Richmond and associates, he on the basis of his previous well, without developing tol-
disturbance,
6 years Hospital
and
has not over-
that he has been attending Mental Health Clinic. His
domestic
life are satisfactory. This man was an ‘average student’ in childhood, and resuits of a neurologic examination were normal. The diagnosis “adult brain damage” probably would have to be twisted a bit to apply to him. Perhaps the phrase “amphetamine‘
1000
will
would
be
avoid
revised.
H. PENTLARGE,
M.D. Mass.
Southhridge,
Addiction
to Placebo
SIR: I would like to comment on the interesting paper ‘ ‘ A Note on the Addictive Personality: Addiction to Placebos” by Ira Mintz, M.D. (March 1977 issue). Dependence on placebo might not be rare. As far as I know, I published the first case report nine years ago (1). Similar descriptions by Czech authors followed (2, 3). Dr. Mintz’ patients and my patient
were
schizophrenic,
but
the other
patients
never
have
been
I . Vinai’ 0: Dependence on a placebo: a case report. Br i Psychiatry 115:1189-1190, 1969 2. Boleloucky Z: A contribution to the problem of placebo dependence: case report. Activ Nerv Super(Prague) 13:190-191, 1971 3. Honz#{225}kR, Hor#{225}kov#{225} E, CulIk A: Our experience with the effect of placebo in some functional and psychosomatic disorders. Activ Nerv Super(Prague) 14:184-185. 1972 OLDiICH Prague.
Sleep
Patients
Dyscontrol
was a 46-year-old
of patients,
and
undoubtedly VICTOR
Deprivation
Since
SIR:
SIR:
group
1978
REFERENCES
ABRAHAM
phetamine’ ‘ by Janet S. Richmond 1978 issue) prompts me to describe as the authors noted, amphetamine
this
August
psychotic.
1. Mendels J, Frazer A: Intracellular lithium concentration and clinical response: towards a membrane theory of depression. J Psychiatr Res 10:9-18, 1973 2. Lee C, Jenner E: The relationship of plasma to erythrocyte lithium levels in patients taking lithium carbonate. Br J Psychiatry 127:596-598, 1975 3. Brunswick D, Frazer A, Mendels J: Lithium ratio and clinical response in manic-depressive illness (ltr to ed). Lancet 1:41, 1977
Adult
for
observations
that
REFERENCES
“Amphetamine-Benefited”
useful
empirical
135:8,
is cvi-
we are satsteady-state
Regarding the two patients who stayed with the medication for a long time despite lack of response, our statement that the ratio is ‘either indicative of probable lithium success
would
‘
accords
J Psychiatry
‘
VINAk, M.D. Czechoslovakia
in Depression
Pflug
and
Tolle’s
original
report
(I) of the anti-
depressant effects of sleep deprivation in endogenous depression, our research group has maintained an interest in this phenomenon. At the National Institute of Mental Health 10 of 19 hospitalized patients with major depressions experienced transient, moderate improvement after one night’s sleep deprivation (2). Since the procedure has been primarily regarded as a research tool, we were particularly interested in the report by G.N. Christodoulou. M.D.. and associates (March 1978 issue) of a ‘ ‘Possible Prophylactic Effect of Sleep Deprivation’ ‘ in a woman with rapidly cycling recur-
rent depressive illness. We are interested imipramine,
which
continued We raise
when she this question
tion
(3)
that
in
had
knowing
been
given
whether to the
maintenance patient,
was
began her sleep deprivation because of our own recent
maintenance
tricyclic
dis-
regimen. observa-
antidepressants
caused
rapid cycling between mania and depression in 6 bipolar women (we have not seen this response in bipolar men). Till and
Vuckovic
also
reported
treated with maintenance hypomania and depression cycled rapidly on tricyclics
that
a
subgroup
lactic responses to lithium alone. Perhaps the authors would comment think it is plausible that tricyclics induced
their tients
patient. We have studied only but would like to alert clinicians
continuous pressants
or intermittent may cause rapid
of
patients
tricyclics rapidly cycled between (4). Three of our patients who subsequently had good prophy-
administration mood cycles
on whether they the rapid cycles in
a small number to the possibility of tricyclic in a subgroup
of pathat antideof pa-
Am
J Psychiatry
135:8,
August
1978
LETTERS
tients (possibly only women) with recurrent affective disorder. The possibility that tricyclics in effect accelerate the natural course of manic-depressive illness in all of its phases has theoretical implications for understanding their mechanism of action and the pathophysiology of the illness.
REFERENCES I. Pflug nous
B, Tolle
sleep 2.
and
deprivation.
the
ofthe
treatment
24-hour
rhythm
ofendogenous
Int Pharmacopsychiatry
Psychiatry
Wehr
TA,
33:627-632,
Goodwin
pression caused Bull (in press) 4. Till E. Vuckovic handlung aufden copsychiatry
in endoge-
depression
6: 187-196,
Post RM, Kotin J, Goodwin FK: Effects ofsleep mood and central amine metabolism in depressed
Gen 3.
R: Disturbance
depression
by
1971
deprivation
on
patients.
Arch
1976
FK:
Rapid
by maintenance
between
tricyclics.
mania
and
de-
Psychopharmacol
5: uber den Einfluss der thymoleptischen BeVerlaufendogener Depressionen. Int Pharma-
4:210-219,
1970
THOMAS
A.
WEI-IR.
K. GOODwIN. Bethesda,
FREDERICK
M.D. M.D.
Md.
SIR: I welcomed the contribution by Dr. Christodoulou and associates in the March 1978 issue because genuinely effective prophylactic interventions are so hard to come by in our field. However, I wonder whether a biopsychosocial approach is not indicated to explain their interesting results.
For
example.
I note
that
the
sleep
deprivation
treatments
took place in nightclubs or tavernas where the patient was accompanied by her husband. Have the authors considered the possible psychopharmacologic effects of ouzo or retsina. which might well have been introduced into the experiment on those occasions? And what about dancing in groups or in solo (with or without ouzo)? A study of these inputs in a controlled hospital setting would seem advisable. It is interesting that the patient’s husband, who shared her sleep deprivation experiences, displayed no obvious psychologic changes. This suggests that the husband was exposed, perhaps even habituated, to this procedure before his wife’s deprivation therapy began. If my hunch is correct, then one might inquire of the mental health of any former companmight
have
night activities pression in that
ion(s)
who
in the quarter
The
authors
state
been
part
past. Has recently?
that
when
of
the
there
the
husband’s
been
patient
EDITOR
We agree
with
Drs.
Wehr
and Goodwin
that
tricyclic
that
maintenance
tricyclics
recurrent depression sive relapses (2).
We enjoyed mour
Dr.
as well
may
slow
by preventing
Linn’s
the
letter
as his expert
and
down
the
course
occurrence
of Greek
his hu-
drinking
and
Associates
hab-
its. Our patient had a strong dislike for both ouzo and retsina but she did like kokkineli, which she consumed in moderate amounts during her sleep deprivation sessions. However, as was stated in our paper, sleep deprivation was found to be prophylactically effective not only when it was practiced in nightclubs or tavernas but also during our patient’s sojourn in the hospital, where nocturnal drinking (or dancing) would have caused a stroke in our Matron (whose health condition has not changed). It appears, therefore, that sleep deprivation is effective not only in association with alcohol but also ‘
‘in solo.” Dr. Linn’s
suggestion
that
our
case
report
should
be
viewed from a biopsychosocial angle prompted us to consider Greek nocturnal recreation patterns in the light of a possible nonconscious mechanism aiming at prophylaxis from depression. Although epidemiological evidence is lacking, it is generally
believed
that
Greeks
are
characterized
by
more
or less cyclothymic temperaments and are possibly prone to developing affective disorders. In view of this, could their habit of staying awake late at night (at home or, more often, outdoors) be interpreted as a nonconscious depressionavoidance maneuver? It is worth noting in this respect that popular Greek music performed in tavernas often reflects basically depressive emotions, ranging from nostalgia and frustration to despair.
was
of de-
advised
to
REFERENCES I. Janowsky depression. 2.
DS, El-Yousef MK, Davis Psychosom Med 36:248-257,
Prien RF, imipramine
chiatry
Klett CJ, in prevention
29:420-425,
LINN, York,
JM: Acetylcholine 1974
Caffey EM Jr: Lithium of affective episodes.
and
carbonate Arch Gen
and Psy-
1973 G.N.
CHRISTODOULOU,
M.D.
D.E.
MALLIARAS,
M.D.
G.N.
M.D. N.Y.
LYKOURAS,
M.D. M.D.
PAPADIMITRIOU.
C.N.
STEFANIS,
M.D.
Athens, Christodoulou
of
of depres-
we appreciated
knowledge
E.P.
Dr.
drugs
may precipitate manic bouts in patients with recurrent affective disorders. Such a view would be compatible with the induction by tricyclic antidepressants of a shift in the adrenergic-cholinergic balance toward adrenergic predominance (I). However, in the case we described (a case of recurrent depression), no manic attacks occurred during or after administration of tricyclics, and it is unlikely that prophylactic tricyclic antidepressants produced an acceleration of our patient’s depressive relapses. Also, there is evidence suggest-
Saturday
evidence
discontinue sleep deprivation, she agreed ‘ ‘reluctantly.” Looking at the matter from a biopsychosocial point of view, I can understand her reluctance. I am glad that the patient remains symptom-free two months after termination of treatment. One more question occurs to me: Is her husband with her on Saturday nights or has he continued sleep deprivation on his own? LOUIS New
THE
the onset of sleep deprivation; otherwise, one would have been entitled to consider only “a possible prophylactic effect of a combination of sleep deprivation and tnicyclic medicatlon.”
ing cycling
TO
Greece
Reply Psychiatric
SIR: We thank Drs. Wehr and Goodwin for their interest in our paper and for their constructive comments. Maintenance tricyclic antidepressants were of course discontinued before
SIR: leagues
Symptoms The on
report Mitral
‘ ‘
and by Dr. Valve
Mitral Stephen Prolapse
Valve
Prolapse
F. Pariser Syndrome
Syndrome and and
his colAnxiety
1001
TO
THE
Am
EDITOR
ment. Further, rebutted that
we noted that Brunswick and associates (3), statement on the basis of high stability in pa-
benefited’ since it
tients
whose
ratio
theoretical
period All lithium after dence isfied
for the plasma lithium levels to stabilize. of our measures were taken at least one week after was started, and many were taken several months initiation
that that
lithium
was
of
measured
lithium
10 times
therapy.
Although
multiple measurements the ratio was obtained
levels
had
been
after
a sufficient
there
are necessary, only after
reached.
‘
or
was
simply
.
.
of the
.
patients
likelihood
to stay
with
the
drug”
a speculation, as other explanations would be at this point (e.g. the 2 patients may have been markedly dependent on their therapist, very compulsive and compliant, ,
and their sampling
RBC/plasma error).
lithium
ratios
high
by
be with
more
formulations
simple
random
M.D. M.D. M.D. Tex.
FLEMENBAUM,
L.
RICHARD
WEDDIGE,
JOHN
MILLER,
Lubbock,
The
paper
‘
‘Violent
apeutic
agent
The patient mitted that tory
for a small
group
to a state
hospital
abuse
of his wife,
Imipramine,
and
Responsive
to d-Am-
and associates (March a patient I have treated; can be an important ther-
of adults.
married
verger
in 1972 after
time, anger and irritability included numerous episodes
who was ad-
a suicide
threat.
At
were prominent, and his hisof loss of temper, physical
frequent
fist fights
chlordiazepoxide,
with
thionidazine,
other and
men. a combi-
nation of perphenazine and amitriptyline were all without benefit and made the patient feel too “drugged’ to work effectively after he was released from the hospital. Like the ‘
patient cited in the paper by himself suggested amphetamine experience. He has done very
erance,
weight
used the drug the Harnington
work
and
loss,
or sleep
during the Memorial
Richmond and associates, he on the basis of his previous well, without developing tol-
disturbance,
6 years Hospital
and
has not over-
that he has been attending Mental Health Clinic. His
domestic
life are satisfactory. This man was an ‘average student’ in childhood, and resuits of a neurologic examination were normal. The diagnosis “adult brain damage” probably would have to be twisted a bit to apply to him. Perhaps the phrase “amphetamine‘
1000
will
would
be
avoid
revised.
H. PENTLARGE,
M.D. Mass.
Southhridge,
Addiction
to Placebo
SIR: I would like to comment on the interesting paper ‘ ‘ A Note on the Addictive Personality: Addiction to Placebos” by Ira Mintz, M.D. (March 1977 issue). Dependence on placebo might not be rare. As far as I know, I published the first case report nine years ago (1). Similar descriptions by Czech authors followed (2, 3). Dr. Mintz’ patients and my patient
were
schizophrenic,
but
the other
patients
never
have
been
I . Vinai’ 0: Dependence on a placebo: a case report. Br i Psychiatry 115:1189-1190, 1969 2. Boleloucky Z: A contribution to the problem of placebo dependence: case report. Activ Nerv Super(Prague) 13:190-191, 1971 3. Honz#{225}kR, Hor#{225}kov#{225} E, CulIk A: Our experience with the effect of placebo in some functional and psychosomatic disorders. Activ Nerv Super(Prague) 14:184-185. 1972 OLDiICH Prague.
Sleep
Patients
Dyscontrol
was a 46-year-old
of patients,
and
undoubtedly VICTOR
Deprivation
Since
SIR:
SIR:
group
1978
REFERENCES
ABRAHAM
phetamine’ ‘ by Janet S. Richmond 1978 issue) prompts me to describe as the authors noted, amphetamine
this
August
psychotic.
1. Mendels J, Frazer A: Intracellular lithium concentration and clinical response: towards a membrane theory of depression. J Psychiatr Res 10:9-18, 1973 2. Lee C, Jenner E: The relationship of plasma to erythrocyte lithium levels in patients taking lithium carbonate. Br J Psychiatry 127:596-598, 1975 3. Brunswick D, Frazer A, Mendels J: Lithium ratio and clinical response in manic-depressive illness (ltr to ed). Lancet 1:41, 1977
Adult
for
observations
that
REFERENCES
“Amphetamine-Benefited”
useful
empirical
135:8,
is cvi-
we are satsteady-state
Regarding the two patients who stayed with the medication for a long time despite lack of response, our statement that the ratio is ‘either indicative of probable lithium success
would
‘
accords
J Psychiatry
‘
VINAk, M.D. Czechoslovakia
in Depression
Pflug
and
Tolle’s
original
report
(I) of the anti-
depressant effects of sleep deprivation in endogenous depression, our research group has maintained an interest in this phenomenon. At the National Institute of Mental Health 10 of 19 hospitalized patients with major depressions experienced transient, moderate improvement after one night’s sleep deprivation (2). Since the procedure has been primarily regarded as a research tool, we were particularly interested in the report by G.N. Christodoulou. M.D.. and associates (March 1978 issue) of a ‘ ‘Possible Prophylactic Effect of Sleep Deprivation’ ‘ in a woman with rapidly cycling recur-
rent depressive illness. We are interested imipramine,
which
continued We raise
when she this question
tion
(3)
that
in
had
knowing
been
given
whether to the
maintenance patient,
was
began her sleep deprivation because of our own recent
maintenance
tricyclic
dis-
regimen. observa-
antidepressants
caused
rapid cycling between mania and depression in 6 bipolar women (we have not seen this response in bipolar men). Till and
Vuckovic
also
reported
treated with maintenance hypomania and depression cycled rapidly on tricyclics
that
a
subgroup
lactic responses to lithium alone. Perhaps the authors would comment think it is plausible that tricyclics induced
their tients
patient. We have studied only but would like to alert clinicians
continuous pressants
or intermittent may cause rapid
of
patients
tricyclics rapidly cycled between (4). Three of our patients who subsequently had good prophy-
administration mood cycles
on whether they the rapid cycles in
a small number to the possibility of tricyclic in a subgroup
of pathat antideof pa-
Am
J Psychiatry
135:8,
August
1978
LETTERS
tients (possibly only women) with recurrent affective disorder. The possibility that tricyclics in effect accelerate the natural course of manic-depressive illness in all of its phases has theoretical implications for understanding their mechanism of action and the pathophysiology of the illness.
REFERENCES I. Pflug nous
B, Tolle
sleep 2.
and
deprivation.
the
ofthe
treatment
24-hour
rhythm
ofendogenous
Int Pharmacopsychiatry
Psychiatry
Wehr
TA,
33:627-632,
Goodwin
pression caused Bull (in press) 4. Till E. Vuckovic handlung aufden copsychiatry
in endoge-
depression
6: 187-196,
Post RM, Kotin J, Goodwin FK: Effects ofsleep mood and central amine metabolism in depressed
Gen 3.
R: Disturbance
depression
by
1971
deprivation
on
patients.
Arch
1976
FK:
Rapid
by maintenance
between
tricyclics.
mania
and
de-
Psychopharmacol
5: uber den Einfluss der thymoleptischen BeVerlaufendogener Depressionen. Int Pharma-
4:210-219,
1970
THOMAS
A.
WEI-IR.
K. GOODwIN. Bethesda,
FREDERICK
M.D. M.D.
Md.
SIR: I welcomed the contribution by Dr. Christodoulou and associates in the March 1978 issue because genuinely effective prophylactic interventions are so hard to come by in our field. However, I wonder whether a biopsychosocial approach is not indicated to explain their interesting results.
For
example.
I note
that
the
sleep
deprivation
treatments
took place in nightclubs or tavernas where the patient was accompanied by her husband. Have the authors considered the possible psychopharmacologic effects of ouzo or retsina. which might well have been introduced into the experiment on those occasions? And what about dancing in groups or in solo (with or without ouzo)? A study of these inputs in a controlled hospital setting would seem advisable. It is interesting that the patient’s husband, who shared her sleep deprivation experiences, displayed no obvious psychologic changes. This suggests that the husband was exposed, perhaps even habituated, to this procedure before his wife’s deprivation therapy began. If my hunch is correct, then one might inquire of the mental health of any former companmight
have
night activities pression in that
ion(s)
who
in the quarter
The
authors
state
been
part
past. Has recently?
that
when
of
the
there
the
husband’s
been
patient
EDITOR
We agree
with
Drs.
Wehr
and Goodwin
that
tricyclic
that
maintenance
tricyclics
recurrent depression sive relapses (2).
We enjoyed mour
Dr.
as well
may
slow
by preventing
Linn’s
the
letter
as his expert
and
down
the
course
occurrence
of Greek
his hu-
drinking
and
Associates
hab-
its. Our patient had a strong dislike for both ouzo and retsina but she did like kokkineli, which she consumed in moderate amounts during her sleep deprivation sessions. However, as was stated in our paper, sleep deprivation was found to be prophylactically effective not only when it was practiced in nightclubs or tavernas but also during our patient’s sojourn in the hospital, where nocturnal drinking (or dancing) would have caused a stroke in our Matron (whose health condition has not changed). It appears, therefore, that sleep deprivation is effective not only in association with alcohol but also ‘
‘in solo.” Dr. Linn’s
suggestion
that
our
case
report
should
be
viewed from a biopsychosocial angle prompted us to consider Greek nocturnal recreation patterns in the light of a possible nonconscious mechanism aiming at prophylaxis from depression. Although epidemiological evidence is lacking, it is generally
believed
that
Greeks
are
characterized
by
more
or less cyclothymic temperaments and are possibly prone to developing affective disorders. In view of this, could their habit of staying awake late at night (at home or, more often, outdoors) be interpreted as a nonconscious depressionavoidance maneuver? It is worth noting in this respect that popular Greek music performed in tavernas often reflects basically depressive emotions, ranging from nostalgia and frustration to despair.
was
of de-
advised
to
REFERENCES I. Janowsky depression. 2.
DS, El-Yousef MK, Davis Psychosom Med 36:248-257,
Prien RF, imipramine
chiatry
Klett CJ, in prevention
29:420-425,
LINN, York,
JM: Acetylcholine 1974
Caffey EM Jr: Lithium of affective episodes.
and
carbonate Arch Gen
and Psy-
1973 G.N.
CHRISTODOULOU,
M.D.
D.E.
MALLIARAS,
M.D.
G.N.
M.D. N.Y.
LYKOURAS,
M.D. M.D.
PAPADIMITRIOU.
C.N.
STEFANIS,
M.D.
Athens, Christodoulou
of
of depres-
we appreciated
knowledge
E.P.
Dr.
drugs
may precipitate manic bouts in patients with recurrent affective disorders. Such a view would be compatible with the induction by tricyclic antidepressants of a shift in the adrenergic-cholinergic balance toward adrenergic predominance (I). However, in the case we described (a case of recurrent depression), no manic attacks occurred during or after administration of tricyclics, and it is unlikely that prophylactic tricyclic antidepressants produced an acceleration of our patient’s depressive relapses. Also, there is evidence suggest-
Saturday
evidence
discontinue sleep deprivation, she agreed ‘ ‘reluctantly.” Looking at the matter from a biopsychosocial point of view, I can understand her reluctance. I am glad that the patient remains symptom-free two months after termination of treatment. One more question occurs to me: Is her husband with her on Saturday nights or has he continued sleep deprivation on his own? LOUIS New
THE
the onset of sleep deprivation; otherwise, one would have been entitled to consider only “a possible prophylactic effect of a combination of sleep deprivation and tnicyclic medicatlon.”
ing cycling
TO
Greece
Reply Psychiatric
SIR: We thank Drs. Wehr and Goodwin for their interest in our paper and for their constructive comments. Maintenance tricyclic antidepressants were of course discontinued before
SIR: leagues
Symptoms The on
report Mitral
‘ ‘
and by Dr. Valve
Mitral Stephen Prolapse
Valve
Prolapse
F. Pariser Syndrome
Syndrome and and
his colAnxiety
1001
