BRITISH MEDICAL JOURNAL
25 JANUARY 1975
working party2 make it clear what sort of
people it is intended to detain in these places
or what objectives will be attained by doing
The proposed units are not to be used for
problem with discharge from special hos-
given why discharge from a regional security
unit should be any easier. Faith is placed in
the possibilities for "therapy" in the pro-
posed units (Butler Report, para. 9; D.H.S.S.
Report, paras. 23, 28, 29(3), and 50) but its
nature is not discussed. The Butler Com-
crowding in special hospitals, but if this is
due to the number of people there who have
"dangerous, violent, or crirrinal propensities"
provision of units which are not to house
people who would be an inmediate danger
to the public (para. 12). This can be achieved
people that many of those now in special
hospitals are less dangerous than they have
hitherto thought them to be. Otherwise the
security at regional units cannot be less strict
(D.H.S.S. Report, para. 8) than at special
The working party states (paras. 28 and
that "the meaning of
longer well understood," but neither report
clarifies the important issues involved. They
mention the difficulties experienced by staff
in ordinary psychliatric hospitals when deal-
ing with clients whose behaviour presents
(Butler Report, para. 9; D.H.S.S. Report,
19, 20, and
regional security units will clearly be from
ruptive. However, no indication is given of
any help likely to be provided to staff in
existing psychiatric hospitals to develop rich
and sophisticated rehabilitation progranmnes
which could decrease the frequency of dis-
ruptive behaviour and avoid the need for
restraint. Without such help it seems likely
security units could soon fill the new places
created and merely regionalize
lems now faced in the State security units.
We are concerned that akternative w;ays of
veloped before new units are created.
We have every sympathy with the points
made by Dr. D. Tidmarsh (2 November, p.
286) but we cannot see how, in the absence
stated admission policy and
goals of treatment,
the proposed regional
units can be prevented from beconing as
badly blocked as the existing special hos-
pitals.-We are, etc.,
44). But a major
5). No reasons are
is justifiably concerned about over-
is going to be relieved by the
is not made clear how over-
should be de-
JOHN W. PALMER
Health Care Evaluation Research Team,
1 Home Office and Department of Health and Social
Security, Interim Report of the Committee on
London, H.M.S.O., 1974.
London, D.H.S.S.. 1974.
World Medical Association
financial climate the question is being asked
whether the B.M.A. can afford to continue
its membership of the W.M.A. I believe the
B.M.A. can and must because never before
has there been such a need for those who
together-not only in Britain but through-
against Government interference in Britain
but the position of our colleagues in many
Governments, for compelling reasons, often
"honour and dignity" of the profession can
be sustained only when there is a free and
strong medical association. If this is essential
on a national level it is just as essential on
an international level. International agencies,
course W.H.O. in particular, are involved in
matters which often have a direct impact on
the way medicine is practised. It is there-
fore essential for the voice of the profession
to be heard at this level. Just as the B.M.A.
is the voice of the medical profession vis-a-
equally important that a similar authoritative
body should exist at international level.
members of the W.M.A. and has been a
highly respected and staunch supporter ever
since. Its subscription to the W.M.A. costs
two Swiss francs per U.K. member, roughly
30p each, a very small contribution to make
to a very important task.
May I take this opportunity to remind
B.M.A. mnembers that they are entitled to
members? Not only does this help to sup-
port the work of the W.M.A., but such
membership can be useful to those who do
bers are also entitled to take part in the
annual assembly. The subscription rate is at
present £6 per annum, iincluding subscrip-
tion to the World Medical 7ournal. Anyone
interested should contact the B.M.A.-I am,
travel. Associate mem-
H. A. CONSTABLE
British Supporting Group ofW.M.A.
Effective Dosage of Tricyclic
SIR,-Gontinuing the debate on the clinical
significance of tricyclic antidepressant plasma
peutic range," ito which Drs. A. J. Coppen
and S. A. Montgomery refer (11 January,
p. 91), we feel that further ddtailed comment
may not be out of place.
There are now quite a number of pub-
between tricyclic antidepressant plasma con-
centrations and clinical response has been
examined. The findings, however, are by no
means in concordance for the simple reason
that the design of these studies conforms to
no single pattern. Generalizations fxom the
results of one study are therefore fa}lacious.
Firstly, there is little clinical consistency in the
type of patients investigated. Some workers have
considered only patients with "severe endogenous"
"moderate" depression, and one study specifically
included patients with personality or environ-
mental problems. It would seem illogical, if not
foolish, to expect any sort of clear relationship
between drug plasma concentrations and thera-
peutic response among such a diagnostic diversity
Secondly, not all of the studies have been
devoted to the same drugs, some having been
concerned with nortriptyline, others with imipra-
mine, and yet another with amitriptyline. Since
there are important pharmacological differences
between the tricyclic antidepressants
always valid to compare the findings of studies
conducted on different drugs.12
Thirdly, the analysis of tricyclic antidepressant
plasma concentrations is difficult to perform and
the same techniques have not always been followed
throughout. Thus the plasma nortriptyline levels
reported in one particular study are quite
variance with the accumulated data on the pharma-
cokinetics of this drug in man.3-6
depression is a complex and biochemically hetero-
geneous disease, probably with a deficiency of at
least two important neurotransmitter amines.7 9
"endogenous depressives" in various studies need
universally to antidepressive medication.
For many reasons, therefore, we at least
would hesitate to propound a "therapeutic
range" of plasma levels for all tricyclic anti-
depressant drugs that might be used in a
diversity of patients superficially diagnosed
as suffering from "depression." From our ex-
perience over a number of years now in
offering a service for the measurement of
tricyclic antidepressant drugs in plasma we
in this unit would agree with the views of
Asberg2 that in patienfts who do not respond
depressant drugs and in those who suffer
from serious side effects the measurement of
efficacy of treatment. In addition, the regular
monitoring of tihese levels may also prove
useful in those patients receiving long-term
medication for the prophylaxis of recurrent
properly diagnosed endogenous depression,
distinguished from that vast population of
people prescribed antidepressant medication
aetiology, for whom, we would admit, the
performing of plasma level analyses
doubtful value.-We are, ewc.,
is a way of increasing the
tbhis way, must be
1raithwaite,R. A., et al., Lancet, 1973, 1, 556.
2 Asberg, M.,Clinical Pharmacology
peutics, 1974, 16, 215.
Pharmacology, 1972, 4, 82.
4 Alexanderson, B., M.D. Thesis,
of Linkoping, Sweden.
Pharmacology, 1973, 6. 44.
6 Braithwaite, R. A., Ph.D. Thesis, 1974. University
1971, 6, 147.
Therapeutics, 1973, 14, 277.
Praag, H. M., Pharnakopsychiatrie
Psychopharmakologie, 1974, 7, 88.
10Kragh-Sorensen,P., et al., Psychological Medicine,
1974, 4, 174.
Fluorescent Drumsticks in Human Female
SIR,-The presence of a sex specific nuclear
appendage, called "drumstick," was first re-
ported in human polymorphonuclear leuco-
cytes by Davidson and Smith.1 In normal