Photoscreening for amblyogenic factors by public health personnel: the Eyecor Camera System.

OBJECTIVES: This pilot study was designed to assess the ability of a photoscreening camera to detect amblyogenic factors such as high refractive error, anisometropia, media opacities and strabismus in children, compared to the standard vision screening techniques employed by the local state public health screening personnel. METHODS: Public health personnel in Illinois used the Eyecor prototype to the current commercially available MTI PS-100 photoscreening camera (manufactured by Medical Technology Inc.) to screen 127 non-dilated subjects, ages 7 months to 20 years (mean age, 6 years), for amblyogenic factors. All participants were concurrently subjected to the "standard" vision screening employed routinely by state public health personnel. The study participants included a group of normal inner-city children and one group of special-needs children. The normal children came from both a public school and a private school. The special-needs children included a group of children from a state-run school for the deaf and hard-of-hearing and a separate group of children attending a multi-disciplinary Easter Seals clinic. RESULTS: In the population of normal children, the mean sensitivity and specificity for the observers using the Eyecor Camera system was 81% and 83% with a mean positive predictive value of 83%, and a mean negative predictive value of 55%. Standard vision screening techniques employed by public health service certified vision screeners had a sensitivity of 88%, a specificity of 91%, a positive predictive value of 67% and a negative predictive value of 97% in the same subjects. In the population of special-needs children with hearing impairment and developmental delay, the mean sensitivity and specificity for the observers using the Eyecor Camera system was 74% and 82% with a mean positive predictive value of 69% and a mean negative predictive value of 85%. Standard vision screening techniques employed by public health service certified vision screeners had a sensitivity of 100%, a specificity of 55%, a positive predictive value of 62% and a negative predictive value of 100% in the same subjects. (See Table 1) CONCLUSIONS: This study shows that the Eyecor Photoscreening Camera is useful in screening normal children for amblyogenic factors. Photoscreening was at least as effective as standard screening methodologies performed by certified vision screeners as required by state public health policy. In addition, photoscreening is particularly useful in testing those children "unscreenable" by conventional vision screening procedures.

Advantages and limitations of the concept of antidepressant therapy.

The current availability of a range of effective treatments make it more than ever necessary for depression to be recognised. The emphasis of treatment has moved from acute episodes to the longitudinal course of affective disorders. In addition to Major Depressive Disorder, the need for treatment is now established in less severe variants, particularly Dysthymia; the same drugs are applicable, but should be part of a global strategy. In general, antidepressants have to be considered in relation to non-pharmacological treatment methods, of which the most important is ECT. A great variety of new drugs have been found to have antidepressant efficacy, but pharmacologically this action is not a specific or exclusive one. Side-effects have on the whole not been studied for long enough, or in depressed patients rather than healthy volunteers; there are marked variations between individuals in their reactions to different drugs. Co-morbidity is a frequent issue in the treatment of depression, particularly for the elderly. Since overall suicide rates have not fallen in many countries, the treatment particularly of Major Depressive Disorder and Bipolar Disorder needs to be strengthened.

Amisulpride compared with standard neuroleptics in acute exacerbations of schizophrenia: three efficacy studies.

Three double-blind studies that included acutely ill schizophrenic patients were undertaken to assess the efficacy of amisulpride, an atypical antipsychotic with a selective affinity for dopamine D2, and D3, receptors. In the first study fixed doses of amisulpride (400, 800 and 1200 mg/day) and 16 mg/day of haloperidol were compared with 100 mg/day of amisulpride for a 4-week period. Efficacy was assessed using the Brief Psychiatric Rating Scale (BPRS), subscales of the Positive and Negative Symptom Scales (PANSS) and the Clinical Global Evaluation (CGI). Data were obtained on 319 subjects with the revised third-edition Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria for schizophrenia. The highest improvement, in terms of BPRS total scores, occurred in the two groups taking 400 mg or 800 mg amisulpride. These doses also induced less extrapyramidal disturbance compared with haloperidol. The second study compared amisulpride with haloperidol: 95 patients were treated for 6 weeks with 800 mg/day of amisulpride and 96 patients with 20 mg/day of haloperidol. Efficacy criteria were the same as in the first study. Amisulpride at 800 mg/day was at least as efficacious as 20 mg haloperidol for the positive symptoms of schizophrenia, but was significantly more effective against negative symptoms (PANSS negative subscale, P = 0.038). There was also a significantly lower incidence of parkisonism in the amisulpride group. The third study compared amisulpride with flupenthixol: 70 patients were treated with 1000 mg/day of amisulpride and 62 patients with 25 mg/day of flupenthixol for a 6-week period. The mean improvement in the BPRS total score was greater in the amisulpride group, although this difference just failed to reach statistical significance (P = 0.059). Both drugs improved negative symptoms (Scale for the Assessment of Negative Symptoms), but the effect was more marked with amisulpride. Differences were statistically different in favour of amisulpride for positive symptoms. These studies show that amisulpride has optimal efficacy at doses of between 400 and 800 mg/day. It was at least as effective as reference drugs in the treatment of positive symptoms, and also reduced negative symptoms. Furthermore, amisulpride provoked fewer extrapyramidal side effects than standard reference drugs.

The general hospital and mental health care: a British perspective.

For over a century, the specialist mental hospital was the basis of psychiatric care in all industrialized countries. Britain was among the first to establish national requirements for asylum care, although these institutions were financed and managed locally. Psychiatric treatment in general hospitals began in the later eighteenth century, but, except for some outpatient clinics, this practice ended prematurely in the mid-nineteenth century, not to resume until after World War II. The National Health Service (NHS) provided the framework within which general hospital psychiatry was re-created, forming the nucleus for district services. Although the intent of NHS reform in the 1980s was to establish a reduced market hospital system that would continue to offer long-term care, this service seems likely to continue for only a few more years. ¿Reforms¿ in the NHS and social services have placed the whole of British mental health care in a situation of uncertainty.

Towards more effective antipsychotic treatment.

The development of antipsychotic drugs has followed two complementary approaches, either towards highly specific actions (e.g. on the dopamine receptor) or targeting a broad range of receptors. The properties of 'atypical' agents challenge the original dopamine hypothesis and suggest roles for a variety of dopamine receptors and for other pathways, such as serotonin. Older drugs, despite their proven efficacy in relieving many schizophrenic symptoms, have several drawbacks, being ineffective in some patients, relatively ineffective against negative symptoms, and causing adverse neurological effects which may, in turn, be associated with poor compliance. Among newer agents, currently available ones, such as clozapine and risperidone, offer the possibility of more effective control of negative symptoms and an improved side-effect profile, while others are in earlier stages of development. However, much still remains to be understood about their mechanisms of action.

Historical and nosological aspects of dysthymia.

From the time of Hippocrates, the problem of persistently depressed mood has been recognised clinically. The first modern description of dysthymia was by Kahlbaum, who distinguished it from the fluctuating mood of cyclothymia. However, there has been continuous difficulty in separating low-grade depressive disorder from an abnormal personality trait. DSM-II defined chronic depression as a personality disorder, but Akiskal subsequently reclassified it as a mood disorder. In DSM-III, all chronic depression lasting more than two years was defined as 'Dysthymic disorder'. DSM-III-R brought together dysthymic and cyclothymic disorders into an affective category. ICD-10 dysthymia subsumes a number of categories which include recurrent depression of mood. The primary distinction between Dysthymia and Major Depressive Disorder is that Dysthymia is chronic, but symptomatically less severe. A number of unresolved problems remain in relation to its nosological status.

Epidemiology of schizophrenia in Salford, 1974-84. Changes in an urban community over ten years.

The prevalence and inception rates of treated schizophrenia in the population of inner-city Salford were compared with those from a similar survey, ten years earlier. Data were obtained from a computerised case register and a postal questionnaire sent to GPs, and case notes rated on the SCL and screened using ICD-9. The point-prevalence rate of 6.26 per 1000 adult population was higher than that previously reported (4.56), despite decreases in total inception rate and in the general population. Changes in rates are presumed to be related primarily to population movements and ageing of the schizophrenic sample. Compared with 1974, the numbers of in-patient days and long-stay in-patients had fallen substantially by 1984, although annual admissions increased over the decade; day-patient and out-patient attendances, and extramural contacts with psychiatrists, community psychiatric nurses, and social workers had also increased. Almost 62% of cases were maintained on depot injections as out-patients in 1984. Over 75% of identified schizophrenic patients were in contact with psychiatrists, but only 7 out of 557 were solely in contact with their GP. In spite of the emphasis on community care, responsibility for schizophrenic patients was still carried overwhelmingly by hospital psychiatric services.

Assessing the functional value of relatives' knowledge about schizophrenia: a preliminary report.

An instrument for assessing and evaluating what relatives know about schizophrenia was evaluated as both a pre- and a post-test for an educational programme. The Knowledge About Schizophrenia Interview (KASI) places emphasis on the functional value of the reported knowledge rather than on the recall of information; it is quick, easy to administer, can be rated reliably, and has face-validity for the relative. The educational programme increased scores from pre-test to a post-test one week after the programme. Relatives with high criticism ratings on the Camberwell Family Interview had lower scores at both tests. Relatives of less chronic patients showed lower scores at pre-test and acquired significantly more information from the programme, while relatives of more chronic patients were less influenced by the information sessions.

Oxypertine in tardive dyskinesia: a long-term controlled study.

A 6-month, double-blind, placebo-controlled study of oxypertine in tardive dyskinesia is described. Results suggest that any beneficial effect noticed initially is not sustained. When this effect is compared with the time course of development of supersensitivity after neuroleptics as reported in the literature, it becomes apparent that the drug, despite its different mechanism of action, behaves like any other conventional neuroleptic. On the basis of the findings, the authors feel that all proposed anti-dyskinetic drugs should be subjected to longer, controlled trials to prove their clinical efficacy.

Clovoxamine and doxepin in major depressive disorder: a double-blind controlled trial.

Clovoxamine, an inhibitor of neuronal uptake of both serotin and noradrenaline, was compared with doxepin in depressed patients over four weeks. Antidepressant efficacy was comparable for both drugs, but clovoxamine might have a special degree of efficacy for patients with more severe depressive illnesses.

Zetidoline, a new antipsychotic. First controlled trial in acute schizophrenia.

Zetidoline (ZTD), a compound chemically unrelated to any available antipsychotic, with selective dopamine receptor-blocking properties, was compared with haloperidol (HLP) in a double-blind study on 56 in-patients who had either first episodes or acute relapses of schizophrenia. ZTD was found to be safe, as effective as HLP, and to produce significantly fewer extrapyramidal side-effects (EPS).

Oxypertine in tardive dyskinesia: an 8-week controlled study.

In a double-blind placebo controlled trial of oxypertine in the treatment of tardive dyskinesia, 33 patients with chronic schizophrenia received either oxypertine or placebo. At the end of eight weeks, the results showed that oxypertine was superior to placebo at a statistically significant level.

Psychiatric service use in Salford. A comparison of point-prevalence ratios 1968 and 1978.

Using data from the Salford Psychiatric Case Register, point-prevalence patterns of service use in Salford County Borough are compared for 1968 and 1978 with respect to type of care, age and diagnosis. In a declining population, overall point-prevalence ratios increased from 9.52 to 13.44/1,000 adults, due almost entirely to two extensive new services--"injection-only" nurse contact with out-patients, and community psychiatric nurse domiciliary contact. Their development has apparently hardly affected use of other services. The increase was similar in most age-groups and in the predominating diagnostic groups (schizophrenia and depression). Prevalence ratios for long-stay patients barely changed in total, and increased for those accumulated in a ten-year period, but there was an upward shift in age. Day care increased, but its contribution remained relatively small. The diagnostic distribution of social work contact changed, as community psychiatric nurses (CPNs) assumed domiciliary care of people with schizophrenia.