1492

De Wit et al,19 in a randomised prospective double-blindstudy, compared ketoconazole (200 mg) daily withfluconazole (50 mg daily) in 37 patients with AIDS orAIDS-related complex and showed that fluconazole wasmore effective in the treatment of oral thrush but that

post-treatment relapses were common with both drugs.These results were confirmed in a subsequent prospectiverandomised study.2O Fluconazole 50 mg a day (single dose)for 2-3 weeks seems to prevent or suppress oral candidosis inHIV-infected patients, but either intermittent therapy ormaintenance therapy is essential to prevent relapses,although De Wit et a119 suggest that maintenance therapy isunnecessary. Itroconazole 100 mg orally once or twice dailyproduced a similar clinical response in HIV-positivepatients.21

Resistance to these antifungal agents has been reported inCandida isolates from HIV-infected patients. In one study, 3of patients undergoing treatment with ketoconazole theorganisms exhibited cross-resistance to other antifungalsincluding flucytosine and itroconazole.3

DYING WITH THEIR RIGHTS ON

SCHIZOPHRENIA is not an illness.1 Mental illness does notexist.2 Non-mental illnesses, including psychoses, are

profound reactions to family stresses, which it is

inappropriate to treat with drugs.3 If these views soundfamiliar it must be because they have dominated publicperceptions and have even been given academic credenceand respectability in sociology courses. However, theevidence for such seductive notions is unscientific and hasnot stood up to replication. Adoption studies4 and studies ofkibbutz and urban raised children5 have provided objectiveevidence that points in the opposite direction.

Nevertheless, false assumptions are interwoven, explicitlyor implicitly, into the arguments for the closure of

psychiatric hospitals in Britain. 55 such hospitals in Englandand Wales are designated for imminent closure.

Psychiatrists are depicted as "coercive ... agents of socialcontrol"6 and the word "release" is commonly applied to thedischarge of long-stay patients as if to imply that inmates arebeing detained against their will. Yet the closures are takingplace alongside the building of 26 new prisons, the first ofwhich is already in operation on the site of Banstead

Psychiatric Hospital. Over 90% of the increase in the prisonpopulation since 1950 to the present day can be directlyrelated to the declining number of psychiatric hospital bedsoccupied during this period;’ of the 95 000 people

19. De Wit S, Weerts D, Goossens H, Clumeck N. Comparison of fluconazole andketaconazole for oropharyngeal candidiasis in AIDS. Lancet 1989; i: 746-48.

20. Esposito R, Ulberti FC, Cernuschi M. Treatment of HIV positive patients withoropharyngeal and/or oesophageal candidsis: the results of a double blind study.Proceedings of the Fifth International Conference on AIDS, Montreal, 1989: 474(abstr ThBP348).

21. Smith DE, Allan M, Connelly GM, Migley J, Gazzard BG. Itroconazole andketoconazole in the treatment of mucocutaneous candidiasis. Proceedings of theFifth International Conference on AIDS, Montreal, 1989: 470 (abstr ThBP328).

1. Szasz TS, Schizophrenia: the sacred symbol of psychiatry. Br J Psychiatry 1976; 129:308-16.

2. Szasz TS. The myth of mental illness. New York: Hoeber, 1962. Reprinted. London:Paladin, 1972.

3. Laing RD, Esterson A. Sanity, madness and the family. London: TavistockPublications, 1964. Republished. Harmondsworth, Middlesex: Penguin, 1971.

4. Kety S, Rosenthal D, Wender P, Schulsinger F. Mental illness in biological andadoptive families of adoptive schizophrenics. Am J Psychiatry 1971; 128: 302-06.

5. Mirsky AF, Silberman EK, eds. The Israeli high risk study. Schizophrenia Bull 1985;11.

6. Ramon S. Psychiatry in Britain: meaning and policy London Croom Helm, 1985.7. Weller MPI, Weller BGA, Badenoch D. Mentally abnormal prisoners on remand.

Br Med J 1988; 297: 559-60.

discharged since 1950, local authorities are looking after amere 6800. s

In this week’s issue (p 1509), Dr Weller and his colleaguesreport that about 40% of homeless people in London are, orhad been, actively psychotic. These same individuals areespecially liable to imprisonment for various crimes and it isintensely difficult to arrange transfers from police custody topsychiatric hospitals,9 and even more so to psychiatric unitsin district general hospitals. 10The future remains bleak. We should not assume that

untested, key assumptions will be fulfilled: that few patientswill henceforth become psychiatrically handicapped, thatthose who do can be adequately cared for by social services,and that such a system, with less skilled and poorly trainedstaff," will be free of the difficulties inherent in the systemthat is being replaced. Precariously funded temporaryshelters, and "tea runs" undertaken by voluntaryorganisations are far better than nothing for the deludedhallucinated destitute, but such stop-gap measures shouldnot serve to postpone the funding and implementation of acoordinated national policy that includes asylum facilitiesfor voluntary patients who would rather find a refuge thanlive on the streets and die "with their rights on".

LOOKING UP WHILE GOING FULL CIRCLE

AFTER a miserable few years, prospects for the strife-torn

Department of Obstetrics and Gynaecology at the LondonHospital look distinctly better. The epic that began with thesummary suspension of the obstetrician Mrs Wendy Savagein April, 1985,1 now seems to be approaching a conclusionacceptable to all parties. The District Health Authority hasagreed (subject to negotiation with the London HospitalMedical College about funding) a package ofrecommendations from the District Medical Council andthe District General Manager. The plan is to appoint a sixthconsultant obstetrician and gynaecologist, and a

replacement for Mr J. C. Hartgill when he retires next year.This level of staffing will permit a bipartite operation withinthe department-ie, there will be two firms, of hospital-based and community-based obstetrics. Mrs Savage willcontinue to do research in the Faculty of General Practiceunder Prof Mal Salkind.

Three and a half years ago the Beaumont inquiry thatexonerated Mrs Savage chose to comment on severalmatters that were outside their strict terms of reference.

Among these "further observations" they noted "A

practical solution could be to separate the obstetric units atWhitechapel and Mile End. This could be achieved by MrsSavage and another consultant (perhaps a new appointment)being responsible for Mile End, whilst the other presentobstetric consultants would be responsible for

Whitechapel".2 It is therefore hard to distinguish the 1986prologue from the 1989 denouement. We hope that

everyone at the London Hospital will benefit from a

satisfactory outcome of this pitiful affair and that the medicalprofession as a whole will never again resort to bruisingconflict to resolve a professional disagreement.

8. Audit Commission for Local Authorities in England and Wales. Making a reality ofcommunity care. London. HM Stationery Office, 1986.

9 Cheadle J, Ditchfield J Sentencing mental ill offenders. London: Home OfficeResearch and Planning Unit, 1982.

10. Coid JW. Mentally abnormal prisoners on remand: I. Rejected or accepted by theNHS? Br Med J 1988; 296: 1779-82

11. Barclay PM. Social workers: their role and tasks. London: Bedford Square Press, 1982.1. Editorial Bitter reinstatement. Lancet 1989; ii: 308-09.2. Anon. Inquiry into obstetric practice of Mrs Savage. Lancet 1986; ii: 297.