LEITERS TO THE EDITOR
bulimina, depression, and suicidal behavior. She was administered fluoxetine, 60 mg/day, starting with a dose of 20 mg/day. Two weeks after her treatment began, she developed galactorrhea and hyperprolactinemia of 50 ng/ml. The fluoxetine dosage was reduced to 40 mg/ day. The galactorrhea stopped, and blood prolactin levels decreased to normal. Fluoxetine treatment was continued, and she remained in remission; she even served in the army. In fluoxetine advertisements, hyperprolactinemia is listed under the heading of "post-introduction reports"-adverse effects that have been observed since market introduction and that may have no causal relationship with the drug. However, the serotoninergic regulation of prolactin release was investigated recently in postmenopausal women (Urban an Veldhuis, 1991). Mean 24-hour serum prolactin concentrations increased significantly in women treated with fluoxetine. After communicating with the company center in Geneva, we were told that hyperprolactinemia in patients treated with high fluoxetine dosages does appear in the company database (Dr. Ben Amo, Pers. Commun.). As we are unaware of any reports of fluoxetine-induced hyperprolactinemia in children and adolescents, we thought it might be useful to report our experience. Our diagnosis must remain presumptive, however, as we were unable to perform a rechallenge test because of the family's reluctance. We assume that fluoxetine joins an entire line of psychotropic drugs in the causation of hyperprolactinemia (phenothiazines, tricyclic antidepressants, butyrophenones, benzamides, etc). Clearly, additional reports and controlled studies are in order to better establish the specific serotonin reuptake inhibitor induced hyperprolactinemia in children and adolescents. Iulian Iancu, M.D. Gideon Ratzoni, M.D. Avi Weitzman, M.D. Alan Apter, M.D. Geha Psychiatric Hospital Petah Tikva, Israel
REFERENCES
Liebowitz, M. R., Hollander, E., Fairbanks, J. & Campeas, R. (1990), Fluoxetine for adolescents with obsessive-compulsive disorder (letter). Am. J. Psychiatry, 147:370-371. Riddle, M. A., Hardin, M. T., King, R., Scahill, L., Woolston, J. L. (1990), Fluoxetine treatment of children and adolescents with Tourette's and obsessive-compulsive disorders: preliminary clinical experience. J. Am. Acad. Child Adolesc. Psychiatry, 29:45-48. Urban, R. J. & Veldhuis, J. D. (1991), A selective serotonin reuptake inhibitor, fluoxetine hydrochloride, modulates the pulsatile release of prolactin in post-menopausal women. Am. J. Obstet. Gynecol., 164:147-152.
What is a Control Group? To the Editor:
I am concerned about headlines and titles that promise too much. In journals, as elsewhere, they mislead and create confusion and disappointment. The November 1991 issue had an "In This Issue" headline on its cover saying, ,'Controlled Study of Psychoanalytic Treatment," by Moran et al. "Excellent!" I thought. Rare, hard to do, and much needed! I was eager to read the study.
756
I then found the title of the study on the Contents page, "A Controlled Study of the Psychoanalytic Treatment of Brittle Diabetes." This was still powerful and attractive (although less powerful because it was far less broad than the cover headline). I then read the article. It is useful in many ways, but does not justify its title. The article reports on two groups of diabetic children. One group was hospitalized for an average of 15 weeks, including 3 to 5 hours per week of dynamic psychotherapy or analysis; the other group was hospitalized, it seems, for an average of 3 weeks, without dynamic psychotherapy or analysis. To call the result a controlled study of psychoanalytic treatment, as the title does far more than the article does, is misleading. A more modest, careful, accurate title would have served your readers better. Lawrence Hartmann, M.D. Cambridge, Massachusetts REFERENCE
Moran, G., Fonagy, P., Kurtz, A., Bolton, A. & Brook, C. (1991), A controlled study of the psychoanalytic treatment of brittle diabetes. J. Am. Acad. Child Adolesc. Psychiatry, 30:926-935. Dr. Fonagy replies:
Dr. Hartmann appropriately calls us to task about misleading our potential readers by including the word "control" in the title of our article. In Britain, he would have recourse to the "Trade Descriptions Act" that prevents companies from advertising their products in a manner likely to mislead potential purchasers. The term "control" in evaluation research is a poorly defined one. It does little more than give an indication of the researcher's intention to hold some relevant factors constant while examining the influence of the independent variable. Even pharmacotherapeutic studies rarely use placebo controls that produce side effects comparable to the active drug. In the vast majority of psychotherapy outcome investigations, an adequate control group is impossible to find and no treatment control groups are frequently used. Our study used a partial no treatment control. The medical management of the patients was comparable in the psychotherapy and no therapy groups. As Dr. Hartmann points out, and as we were scrupulous to indicate in the article, differences between the groups may have been due to attention placebo, milieu-therapy effects, or indeed a myriad of other uncontrolled differences. Thus, a more accurate title might have been: "A Poorly Controlled Study of the Psychoanalytic Treatment of Brittle Diabetes." Peter Fonagy, Ph.D. University College, London
Letters to the Editor are welcome. They will be considered for publication but may not necessarily be published, nor will their receipt be acknowledged. Letters should, in general, not exceed 750 words, including a maximum of five references. They must be submitted in duplicate and typed double-spaced. All letters are subject to editing and shortening; the contents are the sole responsibility of the author. The Editor reserves the right to publish replies and solicit responses. Opinions expressed in this column are those of the authors of the letters and do not reflect opinions of the Journa!. Please direct your letters to John F. McDermott, Jr., M.D., Editor, Journal of the American Academy of Child and Adolescent Psychiatry, University of Hawaii School of Medicine at Kapiolani Medical Center, 1319 Punahou St., Honolulu, HI 96826-1032.
J. Am. Acad. Child Adolesc. Psychiatry, 31:4, July 1992
bulimina, depression, and suicidal behavior. She was administered fluoxetine, 60 mg/day, starting with a dose of 20 mg/day. Two weeks after her treatment began, she developed galactorrhea and hyperprolactinemia of 50 ng/ml. The fluoxetine dosage was reduced to 40 mg/ day. The galactorrhea stopped, and blood prolactin levels decreased to normal. Fluoxetine treatment was continued, and she remained in remission; she even served in the army. In fluoxetine advertisements, hyperprolactinemia is listed under the heading of "post-introduction reports"-adverse effects that have been observed since market introduction and that may have no causal relationship with the drug. However, the serotoninergic regulation of prolactin release was investigated recently in postmenopausal women (Urban an Veldhuis, 1991). Mean 24-hour serum prolactin concentrations increased significantly in women treated with fluoxetine. After communicating with the company center in Geneva, we were told that hyperprolactinemia in patients treated with high fluoxetine dosages does appear in the company database (Dr. Ben Amo, Pers. Commun.). As we are unaware of any reports of fluoxetine-induced hyperprolactinemia in children and adolescents, we thought it might be useful to report our experience. Our diagnosis must remain presumptive, however, as we were unable to perform a rechallenge test because of the family's reluctance. We assume that fluoxetine joins an entire line of psychotropic drugs in the causation of hyperprolactinemia (phenothiazines, tricyclic antidepressants, butyrophenones, benzamides, etc). Clearly, additional reports and controlled studies are in order to better establish the specific serotonin reuptake inhibitor induced hyperprolactinemia in children and adolescents. Iulian Iancu, M.D. Gideon Ratzoni, M.D. Avi Weitzman, M.D. Alan Apter, M.D. Geha Psychiatric Hospital Petah Tikva, Israel
REFERENCES
Liebowitz, M. R., Hollander, E., Fairbanks, J. & Campeas, R. (1990), Fluoxetine for adolescents with obsessive-compulsive disorder (letter). Am. J. Psychiatry, 147:370-371. Riddle, M. A., Hardin, M. T., King, R., Scahill, L., Woolston, J. L. (1990), Fluoxetine treatment of children and adolescents with Tourette's and obsessive-compulsive disorders: preliminary clinical experience. J. Am. Acad. Child Adolesc. Psychiatry, 29:45-48. Urban, R. J. & Veldhuis, J. D. (1991), A selective serotonin reuptake inhibitor, fluoxetine hydrochloride, modulates the pulsatile release of prolactin in post-menopausal women. Am. J. Obstet. Gynecol., 164:147-152.
What is a Control Group? To the Editor:
I am concerned about headlines and titles that promise too much. In journals, as elsewhere, they mislead and create confusion and disappointment. The November 1991 issue had an "In This Issue" headline on its cover saying, ,'Controlled Study of Psychoanalytic Treatment," by Moran et al. "Excellent!" I thought. Rare, hard to do, and much needed! I was eager to read the study.
756
I then found the title of the study on the Contents page, "A Controlled Study of the Psychoanalytic Treatment of Brittle Diabetes." This was still powerful and attractive (although less powerful because it was far less broad than the cover headline). I then read the article. It is useful in many ways, but does not justify its title. The article reports on two groups of diabetic children. One group was hospitalized for an average of 15 weeks, including 3 to 5 hours per week of dynamic psychotherapy or analysis; the other group was hospitalized, it seems, for an average of 3 weeks, without dynamic psychotherapy or analysis. To call the result a controlled study of psychoanalytic treatment, as the title does far more than the article does, is misleading. A more modest, careful, accurate title would have served your readers better. Lawrence Hartmann, M.D. Cambridge, Massachusetts REFERENCE
Moran, G., Fonagy, P., Kurtz, A., Bolton, A. & Brook, C. (1991), A controlled study of the psychoanalytic treatment of brittle diabetes. J. Am. Acad. Child Adolesc. Psychiatry, 30:926-935. Dr. Fonagy replies:
Dr. Hartmann appropriately calls us to task about misleading our potential readers by including the word "control" in the title of our article. In Britain, he would have recourse to the "Trade Descriptions Act" that prevents companies from advertising their products in a manner likely to mislead potential purchasers. The term "control" in evaluation research is a poorly defined one. It does little more than give an indication of the researcher's intention to hold some relevant factors constant while examining the influence of the independent variable. Even pharmacotherapeutic studies rarely use placebo controls that produce side effects comparable to the active drug. In the vast majority of psychotherapy outcome investigations, an adequate control group is impossible to find and no treatment control groups are frequently used. Our study used a partial no treatment control. The medical management of the patients was comparable in the psychotherapy and no therapy groups. As Dr. Hartmann points out, and as we were scrupulous to indicate in the article, differences between the groups may have been due to attention placebo, milieu-therapy effects, or indeed a myriad of other uncontrolled differences. Thus, a more accurate title might have been: "A Poorly Controlled Study of the Psychoanalytic Treatment of Brittle Diabetes." Peter Fonagy, Ph.D. University College, London
Letters to the Editor are welcome. They will be considered for publication but may not necessarily be published, nor will their receipt be acknowledged. Letters should, in general, not exceed 750 words, including a maximum of five references. They must be submitted in duplicate and typed double-spaced. All letters are subject to editing and shortening; the contents are the sole responsibility of the author. The Editor reserves the right to publish replies and solicit responses. Opinions expressed in this column are those of the authors of the letters and do not reflect opinions of the Journa!. Please direct your letters to John F. McDermott, Jr., M.D., Editor, Journal of the American Academy of Child and Adolescent Psychiatry, University of Hawaii School of Medicine at Kapiolani Medical Center, 1319 Punahou St., Honolulu, HI 96826-1032.
J. Am. Acad. Child Adolesc. Psychiatry, 31:4, July 1992
