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With the philosophy of community care and implementation of resettlement programmes the large mental handicap hospitals have discharged the majority . . of their patients into thelocal communities. ~ e f i Barnes Hospital in St. Albans, Herts. is one of these hospitals where active resettlement programmes are going on at present, and some of its long stay patients have been in the community for some time now.

Although a rare form of ‘lethal’ catatonia, involving high temperature and rigidity, was first described long before the advent of neuroleptic drugs, Delay's description of a syndrome malin in 1960 is usually regarded as the first recognition of this syndrome. Over the next 20 years the number of case reports grew and the appearance of reviews such as Caroff's in 1980 marked the birth of the neuroleptic malignant syndrome (NMS). Reports of its incidence give variation rates of up to fiftyfold, possibly due to differences in diagnostic criteria, and mortality reports are similarly variable. Although it is debatable whether it is a rare, severe idiosyncrasy or one of many neuromuscular side-effects of dopamine antagonists (Levinson & Simpson, 1986), most clinicians nowadays regard it as a serious but recognisable risk of neuroleptic treatment which merits further attention.

The efficacy of eltoprazine, a mixed 5-HT1 agonist, in treating aggressive behaviour in mentally handicapped patients was evaluated in a double-blind, placebo- and baseline-controlled study. In the total sample of 160 patients who entered the 8 week double-blind treatment phase, efficacy was not demonstrated. Also in a 28 week double-blind follow-up study, efficacy could not be demonstrated. Post-hoc exploratory analyses suggested eltoprazine was significantly better than placebo in reducing aggression scores of a subgroup of severely aggressive patients. There was no evident relationship between the plasma level of eltoprazine and therapeutic effect or safety and tolerance. The overall safety and tolerance of chronic eltoprazine treatment was good. In the discussion, several issues and pitfalls of aggression research are dealt with.

The populations in the large mental handicap hospitals arc known to be diverse, ranging from elderly non-psychiatric residential groups to acutely psychotic and behaviourally disturbed patients. At present demographic variables, medical and psychi atric characteristics of populations in these hospitals are changing in parallel with implementation of community care and resettlement programmes. In resettlement programmes, discharge priorities have been given to the easy to manage and less dependent residents while new challenging behavioural units and admission assessment wards are being opened to care for the multi-handicapped population. The use of psychotropic medication in this population has been under constant debate. While some drugs have probably been over prescribed, others have followed current trends in adult general psychiatry and fluctuated accordingly. The Cell Barnes Hospital Psychiatric Database (CBH-PD) was established in 1990 to evaluate, among other variables, the psychotropic medication usage in the total population of this large mental handicap hospital before closure and to form a basis in comparison with future surveys of the same population in the community.

Recent papers have again highlighted the consistently high use of neuroleptic agents among people with a learning disability, despite the lack of good evidence to support their role in this population for behaviour management and despite the risks of such medication. Evidence suggests, however, that prescribing habits have remained relatively unchanged; the reasons for this are poorly understood. Given the lack of understanding about the factors contributing to such drug use, and the possibility that use of neuroleptics will increase as people with learning disabilities move into the community, there seems a clear need for clinical guidelines to cover the prescribing and monitoring of neuroleptics within this group. Such guidelines should also ensure that reviews, using reliable measures of treatment efficacy, are carried out regularly.

EDITOR,—Some readers may be unaware that on 1 April an amendment to the 1983 Mental Health Act came into force. This gives to psychiatrists—known in legislative parlance as the responsible medical officer or, more alarmingly, the community responsible medical officer—new powers for the “supervisions” of mentally ill patients, termed supervised discharge. This act, however, confers no additional therapeutic powers for treating people with an illness. On the contrary, it gives powers that might …

Sixty-four eyes of 57 elderly patients with pigment epithelial detachments (PEDs) were studied with the aim of describing their morphological features and identifying prognostic factors. They were classified into four groups according to the following characteristics: early fluorescence, late fluorescence, shallow detachment with limited fluorescence ('drusen type'), irregular fluorescence. The following conclusions were drawn: 30% developed demonstrable subretinal new vessels; all groups except the drusen type were susceptible, the irregular group being particularly prone. 10% developed retinal pigment epithelial tears, and these occurred almost exclusively in the slow fluorescent group. Flattening of PEDs was a feature of drusen type and early fluorescent groups. Most patients lost vision. RPE tears occurred within a few months of presentation with immediate loss of vision; likewise rapid loss of vision followed the development of demonstrable new vessels, though not necessarily in those with changes thought to imply the presence of new vessels. Flattening after prolonged detachment was associated with pigment epithelial atrophy and invariable loss of vision. Visual acuity was maintained consistently only in those eyes with persistent detachment.