456

T.R.H. IN PSYCHOSES

Snt,—We were interested to note Dr Drayson’s letter(Feb. 23, p. 312) on the ineffectiveness of thyrotrophin-releasing hormone (T.R.H.) in cyclical psychoses. We hopeyou might allow us to add further negative findings. Ourresults, like his, are by themselves necessarily of limitedsignificance.We too were stimulated by Prange et al.,l who reported

a prompt improvement in the symptoms of depressionafter a single intravenous injection of T.R.H. They sug-gested that the antidepressant effect of T.R.H. need not bethyroid-mediated and that T.R.H. has a direct central effect.Kastin et awl. and Van Der Vis-Melsen et awl. report similarfindings. Such an approach to the treatment and xtiologyof the depression could obviously be of theoretical impor-tance. Hence we designed a double-blind experiment toinvestigate this possibility. We decided to study the effectof T.R.H. on patients presenting with so-called endogenousdepressive illness.The patients were assessed by a " Newcastle rating ".4 Two

male patients were selected on this basis. The first patient,aged 41, had no previous history of psychiatric illness. He wasadmitted to the hospital having had depression for 5 months.The second patient, aged 34, had a history of 12 years of severalrecurrent depressive episodes, each successfully treated withelectroconvulsive treatment. He had had only one spontaneousmanic phase. The third patient was a 62-year-old woman whohad had in the past 3 years 3 episodes of endogenous depression.On admission she was almost stuporous and therefore the

application of the rating scale was impossible. None of thepatients had received any medication for at least 7 days. The

patients were euthyroid.The Hamilton rating scale 11 was used for assessment of the

degree of depression at 8 A.M. and 4 P.M. The 100 mm. line testwas selected as a self-rating scale. 6 The patient was asked tomark the line from 9 A.M. to 4 P.M. inclusive, at hourly intervals.On the experimental days breakfast was withheld, the Hamilton

and self-rating scales were applied, then a slow intravenoussaline infusion was begun. At 9 A.M., 2 ml. (0-6 mg.) of T.R.H.or 2 ml. of saline was injected into the infusion tubing. At aninterval of 3 days each patient received both the active materialand the placebo.A psychiatrist, always the same one, interviewed the

patient at hourly intervals. The patient was continuouslyattended by an experienced nurse, who also made anassessment of his mental state as part of the normal routineof the clinic. Though for 5 hours after the injection therewas a fluctuation of mood in patients 1 and 2, with maxi-mum improvement shown on the 100 mm. line test atabout 2 P.M., the same changes occurred with the placebo(P>0-1). These effects presumably reflect the diurnalchanges of mood in these patients. On the third patientwe were not able to observe any change in her mental state.None of our patients reported any side-effects. Thyroid-stimulating-hormone responses to T.R.H. studied in thesecond and third patients were normal.From the study of these 3 patients we have not been

able to confirm any antidepressant properties of T.R.H.reported by the other authors.

Unit for Metabolic Studies inPsychiatry,

University Department of Psychiatry,Middlewood Hospital,

Sheffield S6 1TP.

M. DIMITRIKOUDIE. HANSON-NORTYF. A. JENNER.

1. Prange, A. J., Jr., Wilson, I. C., Lara, P. P., Alltop, L. B., Breese,G. R. Lancet, 1972, ii, 999.

2. Kastin, A. J., Ehrensing, R. H., Schalch, D. S., Anderson, M. S.ibid. p. 740.

3. Van Der Vis-Melsen, M. J. E., Wiener, J. D. ibid. p. 1415.4. Gurney, C., Roth, M., Garside, R. F. Proc. R. Soc. Med. 1970,

63, 232.5. Hamilton, M. J. Neurol. Neurosurg. Psychiat. 1960, 23, 56.6. Zealley, A. K., Aitken, R. C. B. Proc. R. Soc. Med. 1969, 62, 993.

SUBNORMALITY AT THE CROSSROADS

SiR,—Your editorial (Feb. 2, p. 156) decrying the lackof a unified approach to treating the mentally handicappedis interesting and noteworthy for its basic omission.You might as well whistle in the wind as suggest that

the young student and doctor can be attracted to caring forthe mentally handicapped by working in an " excitingclinical area ", well-funded and with challenging researchand teaching potential, which will be highly respected inthe medical profession. Who will inspire them ? And onwhat basis ? Exactly how will you recruit " workers whoare strongly motivated to help this underprivilegedcommunity group " ?Contemporary medicine exudes the objective philosophy

that immediate results are imperative and rewarded. Yetyou ask intelligent workers to put aside what they havebeen informally taught and enter a field in which meaningfulresults can be a long time in coming.There is another approach to this problem, and the

discussion would involve words like love, responsibility,devotion, obligation, and charity. Not once in youreditorial did you imply such a relationship. Obviously, incaring for inarticulate and generally helpless patients,more than scientific objectivism or normal medical interestis necessary.

If you really want to get this message across, you mayas well " bite the bullet " and point out that human beingsshould, and do, care for others for a higher reason thanmedicine alone.

675 Brown Road,Hazelwood, Missouri 63042, U.S.A. DANIEL R. SHIPLEY.

SiR,-While supporting strongly your aim (Feb. 2,p. 156) in bringing this area of work to the attention ofacademic institutions with the proposal of encouraginguniversity research-based units, this, I feel, may wellreceive a disproportionate priority. Those working in thearea will know only too well that effective methods of

therapy and training already exist and have been provedin high staff/patient ratio settings. It is not always thelack of information concerning the behaviourdl sciencesthat hampers the service-it is the lack of ward-based

personnel to perform the therapeutic work already withintheir area of expertise.The current priority must surely be to provide a setting

in which educational expertise can be practised by skillednurses and teachers in developing self-help and socialbehaviours in the patients in their direct care.The respectability offered by an academic unit must

not supersede this direct action based upon practical andnot intellectual sophistication. The emphasis on clinicalmedicine in mental handicap may only serve to cloudfurther the day-to-day problems faced by a ward staff oftwo nurses caring for thirty handicapped individuals inpoorly designed living units.

Lea Hospital,Stourbridge Road,

Bromsgrove, Worcs. B61 OAX.

C. WILLIAMS,Senior ClinicalPsychologist.

COLONIC BLEEDING

SIR,—Your editorial (Jan. 19, p. 85) stated that, oncecolonic bleeding has stopped, a double-contrast bariumenema should form an essential part of the thoroughinvestigation into the cause.However, many of the patients involved are elderly, and

it has been our experience that in such patients bowelpreparation for a barium enema may be badly toleratedand of limited success. The barium-enema examinationitself is strenuous for the patient and often diagnostically