Am

J Psychiatry

/35:10,

October

/978

the person who did the videotaping the raters, since he had already decided that

LETTERS

might have ‘tipped” whether the patient ‘

had dyskinesia. We doubt that this was the case. The technician who recorded the evaluation did not know which patients had dyskinesia and recorded every subject in a standandized way. Most dyskinetic patients had dyskinetic movements not only during the structured part of the exam but also during the 1- to 2-minute observation period, when only the patient was present and videotaped, and all raters concurred on dyskinesia during the latter period. The point is highlighted by the fact that one patient with tardive dyskinesia demonstrated dyskinetic symptoms only during the obsenvation period in which all three raters independently concurred. Finally, Dr. Mattes is concerned about psychiatrists being alarmed ‘ ‘ unnecessarily’ ‘ by our report. We found that 10% ofthe dyskinetic population, on 4% ofthe survey population, had moderately severe dyskinesia; the remaining cases of dyskinesia were ofminimal or mild severity. It has been sug-

gested that dyskinesia of possible recent onset tinuing 4). For

antipsychotic this reason,

of dyskinesia

of minimal on mild severity and may be readily reversed by discon-

medication on lowering the dosage (3, careful examinations to detect early signs

should

be a routine

part

of psychiatric

evalua-

tions of patients treated with neunoleptics. Until the clinician has more guidelines as to which patients are most vulnerable, every patient taking neuroleptic medication must be viewed as susceptible to tardive dyskinesia. Part of good patient care should be an ‘ ‘overconcern’ ‘ for the development ofthis syndrome.

REFERENCES

1. Mardsen CD, Tarsy D, Baldessarini Ri: Spontaneous and druginduced movement disorders in psychotic patients, in Psychiatnc Aspects of Neurologic Disease. Edited by Benson DF, Blumer D. New York, Grune & Stratton, 1975 2. Casey DE, Denny D: Pharmacological characterizations of tardive dyskinesia. Psychopharmacology 54:1-8, 1977 3 . American College of Neuropsychopharmacology-Food and Drug Administration Task Force: Neurological syndromes associated with antipsychotic drug use. Arch Gen Psychiatry 28:463-467,

1973

4. Quitkin F, Rifkin A, Gochfeld L, et al: Tardive dyskinesia: first signs reversible? Am i Psychiatry 134:84-87, 1977 GREGORY

Positive SIR:

Side

M. AsNI5, M.D. New York, N.Y.

of Lithium?

by Sahayl J. Nasr, M.D. , and Robert W. ‘ ‘Coincidental Improvement in Asthma Treatment’ ‘ (September 1977 issue) in association with the observations of Peter L. Putnam, M.D. (Letten to the Editor, March 1978 issue) concerning remission of dermatologic symptoms in two patients with eczematoid denmatitis treated with lithium prompted us to report another possible ‘ ‘positive’ ‘ side effect of lithium observed in two patients with seborrheic dermatitis.

Atkins, During

The

The

Effects

are

article

M.D. Lithium

,

on

dermatologic

pressive man cleared prophylactic lithium ing a 5-year follow-up. year-old schizophrenic

symptoms

of a 63-year

old

manic-dc-

completely 1 month after initiation of treatment and have not reappeared dunA similar effect was observed in a 32woman with severe seborrheic der-

TO

THE

EDITOR

matitis who was treated successfully with low doses of lithium for her premenstrual tension syndrome. It is worth noting that remission of both premenstrual and dermatologic symptoms was achieved with a lithium dose of only 300 mg/ day, for one week before expected day of menstruation.

We are currently a double-blind ium carbonate matitis.

pursuing

investigation on nonpsychotic

the issue

further

on the effect patients

G.N.

by conducting

of low doses with seborrheic

CHRISTODOULOU, AG.

M.D.

M.D. Greece

VARELTZIDES,

Athens,

Mental

Health

Services

of lithden-

in HMOs

SIR: In ‘ ‘The External Provision of Health Maintenance Organization Mental Health Services’ ‘ (June 1978 issue) David J. Muller, M.D. , offers unsubstantiated opinions about

HMOs. health

My

experience

services

(HCHP)

since

at

as a director the

1969 leads

Harvard

of integrated

Community

me to believe

that

Health

mental Plan

the comparison

of alternative

models must be addressed objectively. ‘quality,’ ‘ “flexibility,’ ‘ and “personal care” superior in Dr. Mullen’s clinic? He does not cite norms of staff training or experience, individual or group performance standards, supervisory practices, evaluation of treatment outcome, quality control mechanisms, on organized consumer input-features of many HMOs. Contract negotiations seem an insufficient substitute. Although I find many statements in the article objectionable, two oversimplifications require response. The first relates to cost: If “cost to the HMO” is less (no numbers are given), what about cost to the member? In stating, ‘ ‘ When the benefits are used up, there may be insufficient motivation to pay out of pocket and continue therapy.” and “The initial sessions may therefore have been wasted,’ ‘ Dr. Mullen ignores the vast literature demonstrating effectiveness of brief treatment. With staff motivation, treatment can be planned so that most patients can be treated within insurable limits. At HCHP, where extended psychotherapy is available, less than 1% of patients seen require treatment beyond the benefit limit of 20 sessions a year. A system using prepaid benefits to introduce patients to fee-for-service treatment will be inexpensive to the HMO and profitable to the clinic but expensive for the member. Capitation payments go farther iffewer “heads” show up. Current estimates suggest that l0%-15% of the population may require psychiatric services (I). A cost/benefit assessment should include numbers referred and seen, cancellations, and no-show rates. At HCHP, 12% of members who use health services in a year come to the mental health service. Combined cancellation and no-show rates are less than 10%, and over 82% of patients referred show up. Other internal services report similar experience (2). Comparison figures from Dr. Mullen would be of interest. The second area I would like to address is liaison. A number of authors have urged shared responsibility for mental health care (1). In a medical setting, where doctors and nurses see many psychological problems, this must include willingness to diagnose and treat common disturbances as well as readiness to refer when necessary. The notion that “at least monthly conferences’ ‘ with HMO physicians will adequately support such efforts is na#{239}ve.At HCHP, approximately 30% of medical patients receive a diagnosis of emo-

How

are

‘

1249

LETTERS

TO

THE

Am

EDITOR

dilemma one of

tional disturbance during a year; half are treated by the mcdical provider, half are referred. Mental health staff support this function by spending l0%-20% of their time in liaison activities and joint programs. Physical contiguity facilitates this. Dr. Muller’s

arguments

for an autonomous,

cohesive

In summary, HMOs should

I believe be withheld

that generic pending data

conclusions that permit

about meaning-

ful comparisons. REFERENCES

1. Mechanic D: Considerations in the design of mental efits under national health insurance. Am I Public 482-488, 1978 2. Spoerl 0: Treatment patterns in prepaid psychiatric Psychiatry 131:56-59, 1974

health benHealth 68: care.

Boston, Dr.

Muller

Am J

M.D.

J. BENNETT,

MICHAEL

Mass.

Replies

SIR: I would like to reemphasize a major point of my paper. Any feature that the HMO wants in its mental health services can either be incorporated into its own internal department on specified in the contract with an external group. This could include many of the considerations Dr. Bennett emphasizes in his letter, such as staff training and expenience, supervisory practices, evaluation and outcome studies, quality control, organized consumer input, extensive Iiaison services, and as much presence, visibility, and influence as desired. With these and other features equalized, I feel the autonomy and incentive of the external group give it a real advantage. Having been on both sides of the fence, I can state this definitely. Cost to the member is the same with an internal or an external group. When the HMO coverage is exhausted, the member must pay out of pocket regardless. I thank Dr. Bennett for his comments. DAVID

J. MULLER, Denver,

Using

Phylogenetic

Mechanisms

to an environmental of a target organ.

We propose

tal health group, with control over staff appointments and training, programmatic decision making, and a portion of the budget, are compelling. These factors characterize our systern and are essential. I agree with his concern about softening the medical model. Insofar as mental health professionals can make such a contribution, this calls for a greaten presence, visibility, and influence in the medical setting, not for leaving it.

M.D. Cob.

in Classification

We

would

like

to comment

Classification for Psychophysiologic Looney, M.D., and associates

1250

on

“A

New

Disorders” (March 1978

Method

of

by John G. issue). The

situation

an alternative

solution.

and

the

resulting

In our attempts

to es-

tablish the biological underpinnings of psychophysiologic disorders, we have been concerned with the phylogenetic mechanisms that underlie their emergence. We see these as innate responses that are now inappropriate but were once adaptive. For example, an irritable bowel syndrome becomes flight reaction, abortive and partial, manifested by increased evacuation of large bowel and bladder; spasms of the neck musdes become dominance/submission conflict, manifested by spasms of the muscles that raise and lower the head; angina pectonis becomes mock death reflex, abortive and partial, manifested by spasms of coronary arteries; and chronic mdigestion becomes flight reaction, inhibited, resulting in chronic anxiety and manifested by impaired secretions of the upper alimentary tract.

We even

have

a place

for

the

hypochondriac

within

this

schema: impaired filtering of vegetative sensory stimulation (target organs are skin, heart, abdomen, etc.), cognitively elaborated as ‘ ‘cancer,’ ‘ ‘ ‘tuberculosis,’ ‘ or unspecified illness. This is but a sampling. We are aware that this novel approach could be considered too controversial to use as a classificatory scheme; nonetheless it permits the use of ethologically verifiable instinctual response systems, placing the symptoms into a biological context, alludes to an openended stressor that sets the mechanism into action, and allows the avoidance or inclusion of metapsychological concepts depending on whether the emphasis is on a medical or psychological model. A.

DAVID

JONAS, DoRIs

London

,

M.D. F. JONAS England

Correction In the

August

1978

issue

there

was

an

error

in

‘

‘The

Prevalence of Schizophrenia: A Reassessment Using Modcnn Diagnostic Criteria’ ‘ by Michael Alan Taylor, M.D., and Richard Abrams, M.D. The reference to the study by Weissman and associates (cited as reference 14) in the last sentence of the first paragraph of the Inpatient and Outpatient Studies section (p. 946) should appear in the Population Studies section. The last sentence of Inpatient and

Outpatient SIR:

1978

of classifying psychophysiologic disorders has been choosing between a characterologic determinant

responding dysfunction

men-

135:10, October

J Psychiatry

mission changed).

The

Studies prevalence

staff

regrets

should

therefore

figures

this error.

(range

refer of

to 8 different 0.6%-6.7%

adis

un-