Randy Hillard, MD

How do you feel about the state, insurance companies, or professional societies telling you how to practice medicine? Most of us would take strong exception to that idea, almost as if we had been asked, “How do you feel about the butcher of Baghdad?” One reason we became doctors—in addition to wanting to heal the sick—was that we do not like anyone telling us what to do.

Let me rephrase the question: “How do you feel about evidence-based guidelines that could help you make increasingly complex decisions about which medications to use under which circumstances?” At worst, most of us would respond, “Well, I don’t really need them, but I refer to them from time to time. And I certainly know a lot of practitioners who could benefit from them.”

Two ways to ask the same question, with a big difference in response. I resist anyone’s attempts to write a “cookbook” for my clinical practice, but I am interested in anything that helps me practice rationally.

This year, Trisha Suppes, MD, PhD, and the other the Texas Medication Algorithm Project (TMAP) collaborators will update their treatment algorithms to include evidence published since 2000. In this issue, Dr. Suppes and Geetha Shivakumar, MD, of the University of Texas/Southwestern Medical Center’s department of psychiatry preview potential updates in the TMAP bipolar mania and bipolar depression algorithms. They make it clear that algorithms can be valuable tools when carefully designed and implemented.

Despite my wariness about practice guidelines, I found this article quite palatable and—I must admit—useful. I hope you do, too.

How do you feel about the state, insurance companies, or professional societies telling you how to practice medicine? Most of us would take strong exception to that idea, almost as if we had been asked, “How do you feel about the butcher of Baghdad?” One reason we became doctors—in addition to wanting to heal the sick—was that we do not like anyone telling us what to do.

Let me rephrase the question: “How do you feel about evidence-based guidelines that could help you make increasingly complex decisions about which medications to use under which circumstances?” At worst, most of us would respond, “Well, I don’t really need them, but I refer to them from time to time. And I certainly know a lot of practitioners who could benefit from them.”

Two ways to ask the same question, with a big difference in response. I resist anyone’s attempts to write a “cookbook” for my clinical practice, but I am interested in anything that helps me practice rationally.

This year, Trisha Suppes, MD, PhD, and the other the Texas Medication Algorithm Project (TMAP) collaborators will update their treatment algorithms to include evidence published since 2000. In this issue, Dr. Suppes and Geetha Shivakumar, MD, of the University of Texas/Southwestern Medical Center’s department of psychiatry preview potential updates in the TMAP bipolar mania and bipolar depression algorithms. They make it clear that algorithms can be valuable tools when carefully designed and implemented.

Despite my wariness about practice guidelines, I found this article quite palatable and—I must admit—useful. I hope you do, too.

How do you feel about the state, insurance companies, or professional societies telling you how to practice medicine? Most of us would take strong exception to that idea, almost as if we had been asked, “How do you feel about the butcher of Baghdad?” One reason we became doctors—in addition to wanting to heal the sick—was that we do not like anyone telling us what to do.

Let me rephrase the question: “How do you feel about evidence-based guidelines that could help you make increasingly complex decisions about which medications to use under which circumstances?” At worst, most of us would respond, “Well, I don’t really need them, but I refer to them from time to time. And I certainly know a lot of practitioners who could benefit from them.”

Two ways to ask the same question, with a big difference in response. I resist anyone’s attempts to write a “cookbook” for my clinical practice, but I am interested in anything that helps me practice rationally.

This year, Trisha Suppes, MD, PhD, and the other the Texas Medication Algorithm Project (TMAP) collaborators will update their treatment algorithms to include evidence published since 2000. In this issue, Dr. Suppes and Geetha Shivakumar, MD, of the University of Texas/Southwestern Medical Center’s department of psychiatry preview potential updates in the TMAP bipolar mania and bipolar depression algorithms. They make it clear that algorithms can be valuable tools when carefully designed and implemented.

Despite my wariness about practice guidelines, I found this article quite palatable and—I must admit—useful. I hope you do, too.

In 1981, I wrote an article called, “Christmas and psychopathology” (Arch Gen Psychiatry 1981;38[Dec]:1377-81). In the Readers’ Guide to Periodical Literature, I found 103 magazine articles across 8 years under “Depression, Mental.” Sixteen dealt with Christmas depression.

This week, I did a Google search for “Christmas” (13,700,000 hits) and “depression” (237,000 hits). This weighty body of Web lore suggests that the popular press assumes many people get depressed before Christmas.

Why is there such an interest in Christmas depression? I think it’s because few of us feel as happy as we think we ought to over the holidays. Given the stresses of shopping, family obligations, and emotional baggage from previous years, I’m surprised that more people do not get depressed.

The fact is, however, that fewer people report to psychiatric emergency rooms just before Christmas than at other times of the year. My study in 1981 and most similar studies show that hospital admissions, suicide attempts and completions, and even letters to advice columnists go down just before Christmas, then go back up immediately afterwards. When you average the pre- and post-holiday statistics, Christmas is not one of the busiest seasons for psychiatric emergencies.

Maybe depression doesn’t increase before Christmas because people use their best coping strategies to get through the holiday. And maybe there is a little Christmas magic after all.

In 1981, I wrote an article called, “Christmas and psychopathology” (Arch Gen Psychiatry 1981;38[Dec]:1377-81). In the Readers’ Guide to Periodical Literature, I found 103 magazine articles across 8 years under “Depression, Mental.” Sixteen dealt with Christmas depression.

This week, I did a Google search for “Christmas” (13,700,000 hits) and “depression” (237,000 hits). This weighty body of Web lore suggests that the popular press assumes many people get depressed before Christmas.

Why is there such an interest in Christmas depression? I think it’s because few of us feel as happy as we think we ought to over the holidays. Given the stresses of shopping, family obligations, and emotional baggage from previous years, I’m surprised that more people do not get depressed.

The fact is, however, that fewer people report to psychiatric emergency rooms just before Christmas than at other times of the year. My study in 1981 and most similar studies show that hospital admissions, suicide attempts and completions, and even letters to advice columnists go down just before Christmas, then go back up immediately afterwards. When you average the pre- and post-holiday statistics, Christmas is not one of the busiest seasons for psychiatric emergencies.

Maybe depression doesn’t increase before Christmas because people use their best coping strategies to get through the holiday. And maybe there is a little Christmas magic after all.

In 1981, I wrote an article called, “Christmas and psychopathology” (Arch Gen Psychiatry 1981;38[Dec]:1377-81). In the Readers’ Guide to Periodical Literature, I found 103 magazine articles across 8 years under “Depression, Mental.” Sixteen dealt with Christmas depression.

This week, I did a Google search for “Christmas” (13,700,000 hits) and “depression” (237,000 hits). This weighty body of Web lore suggests that the popular press assumes many people get depressed before Christmas.

Why is there such an interest in Christmas depression? I think it’s because few of us feel as happy as we think we ought to over the holidays. Given the stresses of shopping, family obligations, and emotional baggage from previous years, I’m surprised that more people do not get depressed.

The fact is, however, that fewer people report to psychiatric emergency rooms just before Christmas than at other times of the year. My study in 1981 and most similar studies show that hospital admissions, suicide attempts and completions, and even letters to advice columnists go down just before Christmas, then go back up immediately afterwards. When you average the pre- and post-holiday statistics, Christmas is not one of the busiest seasons for psychiatric emergencies.

Maybe depression doesn’t increase before Christmas because people use their best coping strategies to get through the holiday. And maybe there is a little Christmas magic after all.

“If I’m ever angry at a psychiatrist, I will refer that doctor a patient with a first episode of psychosis.”

A psychiatrist whose brother suffers from a psychotic disorder once said this to me. She was joking, but—in a way—she was totally serious. The serious part relates to her experience as the loving family member of someone who suddenly and inexplicably became devastatingly ill. She and her family wanted to know the diagnosis, yet were afraid to find out. They alternately wanted to—and didn’t want to—discover a physical cause behind the illness. They blamed themselves, then resolved not to blame themselves.

They were educated and reasonably well informed; they thought they understood what serious mental illness was about. But when it came to confronting it in a loved one, they ultimately realized they knew nothing. In retrospect, they viewed their psychiatrist as pretty good, but at the time they had nothing good to say about him. Patients and their families often feel unhappy with the psychiatrist who treats a first episode of psychosis.

All physicians have the burden of helping patients and families come to terms with terrible, unexpected, and incomprehensible illnesses. That task is doubly difficult for psychiatrists, because of:

• the stigma attached to the illnesses we treat
• the subtlety of some early symptoms
• and peoples’ belief that a psychiatric illness cannot happen to them or to their loved ones.

First-episode psychoses may pose our greatest challenge as clinicians. In “First psychotic episode—a window of opportunity”, Christoph Correll, MD, and Alan Mendelowitz, MD, adeptly describe the many challenges we face in this clinical scenario: differential diagnosis, communicating the diagnosis, encouraging the family and patient to engage constructively in treatment, and getting the patient, attendants, and externals on the same page.

Nowhere in medicine is Hippocrates’ first aphorism more relevant: “Life is short, the art is long; the occasion is fleeting; experience fallacious, and judgment difficult.” I would probably say “help the patient … cooperate,” rather than “make the patient … cooperate,” but other than that, despite everything we have learned in medicine in the last few millennia, I would not change a thing.

“If I’m ever angry at a psychiatrist, I will refer that doctor a patient with a first episode of psychosis.”

A psychiatrist whose brother suffers from a psychotic disorder once said this to me. She was joking, but—in a way—she was totally serious. The serious part relates to her experience as the loving family member of someone who suddenly and inexplicably became devastatingly ill. She and her family wanted to know the diagnosis, yet were afraid to find out. They alternately wanted to—and didn’t want to—discover a physical cause behind the illness. They blamed themselves, then resolved not to blame themselves.

They were educated and reasonably well informed; they thought they understood what serious mental illness was about. But when it came to confronting it in a loved one, they ultimately realized they knew nothing. In retrospect, they viewed their psychiatrist as pretty good, but at the time they had nothing good to say about him. Patients and their families often feel unhappy with the psychiatrist who treats a first episode of psychosis.

All physicians have the burden of helping patients and families come to terms with terrible, unexpected, and incomprehensible illnesses. That task is doubly difficult for psychiatrists, because of:

• the stigma attached to the illnesses we treat
• the subtlety of some early symptoms
• and peoples’ belief that a psychiatric illness cannot happen to them or to their loved ones.

First-episode psychoses may pose our greatest challenge as clinicians. In “First psychotic episode—a window of opportunity”, Christoph Correll, MD, and Alan Mendelowitz, MD, adeptly describe the many challenges we face in this clinical scenario: differential diagnosis, communicating the diagnosis, encouraging the family and patient to engage constructively in treatment, and getting the patient, attendants, and externals on the same page.

Nowhere in medicine is Hippocrates’ first aphorism more relevant: “Life is short, the art is long; the occasion is fleeting; experience fallacious, and judgment difficult.” I would probably say “help the patient … cooperate,” rather than “make the patient … cooperate,” but other than that, despite everything we have learned in medicine in the last few millennia, I would not change a thing.

“If I’m ever angry at a psychiatrist, I will refer that doctor a patient with a first episode of psychosis.”

A psychiatrist whose brother suffers from a psychotic disorder once said this to me. She was joking, but—in a way—she was totally serious. The serious part relates to her experience as the loving family member of someone who suddenly and inexplicably became devastatingly ill. She and her family wanted to know the diagnosis, yet were afraid to find out. They alternately wanted to—and didn’t want to—discover a physical cause behind the illness. They blamed themselves, then resolved not to blame themselves.

They were educated and reasonably well informed; they thought they understood what serious mental illness was about. But when it came to confronting it in a loved one, they ultimately realized they knew nothing. In retrospect, they viewed their psychiatrist as pretty good, but at the time they had nothing good to say about him. Patients and their families often feel unhappy with the psychiatrist who treats a first episode of psychosis.

All physicians have the burden of helping patients and families come to terms with terrible, unexpected, and incomprehensible illnesses. That task is doubly difficult for psychiatrists, because of:

• the stigma attached to the illnesses we treat
• the subtlety of some early symptoms
• and peoples’ belief that a psychiatric illness cannot happen to them or to their loved ones.

First-episode psychoses may pose our greatest challenge as clinicians. In “First psychotic episode—a window of opportunity”, Christoph Correll, MD, and Alan Mendelowitz, MD, adeptly describe the many challenges we face in this clinical scenario: differential diagnosis, communicating the diagnosis, encouraging the family and patient to engage constructively in treatment, and getting the patient, attendants, and externals on the same page.

Nowhere in medicine is Hippocrates’ first aphorism more relevant: “Life is short, the art is long; the occasion is fleeting; experience fallacious, and judgment difficult.” I would probably say “help the patient … cooperate,” rather than “make the patient … cooperate,” but other than that, despite everything we have learned in medicine in the last few millennia, I would not change a thing.

Hippocrates’ first aphorism about the practice of medicine is as true today as it was 2,500 years ago: Life is short, the art is long, the occasion fleeting, experience fallacious, and judgment difficult.¹

Life is still short, although not as short as it was in Hippocrates’ day, but the art of medicine—what physicians are expected to know—may be hundreds of times longer. Greater life expectancy and knowledge allow us to offer more help than ever to patients with psychiatric disorders. Yet how can we possibly learn everything we are expected to know and improve the way we practice?

The occasion—the time during which we make clinical decisions—continues to be brief. In fact, patient contacts are more fleeting than ever, given the financial pressures of managed care.

Experience remains fallacious. Our clinical experience can lead us to believe that every condition has a more negative prognosis than it does. Patients who respond well to treatment return much less often than those who respond poorly and require more complicated care. Similarly, patients who get well may stop coming to see us, but those who do not get well may stay with us indefinitely.

Moreover, none of us sees a random sample of patients, so our perceptions of various psychiatric disorders may be warped by one or two dramatic experiences. It’s human nature to remember our most interesting or horrifying cases, rather than the more routine.

Based on my own experience, I was surprised by the low prevalence (13 to 18%) of conversion to mania in bipolar depressed patients treated with antidepressants, which is described by Robert M. Post, MD, in his special report on the Stanley Foundation Bipolar Network. I had assumed the conversion rate was much higher because I vividly recall an awful conversion to mania with catastrophic results that happened early in my career.

Of course I recommend all articles in this issue of, but I especially urge you to read the report by Dr. Post and his Stanley Foundation-funded team. What I like about these studies of bipolar disorder is that they:

• include patients similar to those I treat (i.e., a general population of bipolar patients, rather than one selected with criteria that excluded all but the most uncomplicated patients)
• are long-term (up to 6 years). It is frustrating when studies follow patients for weeks, while I have to treat them for years.
• offer lessons I can use in my practice this week (e.g., adjunctive lamotrigine can lead to a good response in previously unresponsive patients).

That, as I have mentioned before, is the goal of—to provide news you can use in your practice this week. In psychiatry, so many articles are published every day that it’s impossible to keep up with them. Reading reviews written by practitioners who can interpret that volume and comparing their conclusions with our own experience is one way we learn useful new material.

As Hippocrates observed, judgment is difficult in medical practice, and the same is true of medical editing. To help us exercise good judgment in the editing of, please continue to send me your comments and suggestions ([email protected]).

Hippocrates’ first aphorism about the practice of medicine is as true today as it was 2,500 years ago: Life is short, the art is long, the occasion fleeting, experience fallacious, and judgment difficult.¹

Life is still short, although not as short as it was in Hippocrates’ day, but the art of medicine—what physicians are expected to know—may be hundreds of times longer. Greater life expectancy and knowledge allow us to offer more help than ever to patients with psychiatric disorders. Yet how can we possibly learn everything we are expected to know and improve the way we practice?

The occasion—the time during which we make clinical decisions—continues to be brief. In fact, patient contacts are more fleeting than ever, given the financial pressures of managed care.

Experience remains fallacious. Our clinical experience can lead us to believe that every condition has a more negative prognosis than it does. Patients who respond well to treatment return much less often than those who respond poorly and require more complicated care. Similarly, patients who get well may stop coming to see us, but those who do not get well may stay with us indefinitely.

Moreover, none of us sees a random sample of patients, so our perceptions of various psychiatric disorders may be warped by one or two dramatic experiences. It’s human nature to remember our most interesting or horrifying cases, rather than the more routine.

Based on my own experience, I was surprised by the low prevalence (13 to 18%) of conversion to mania in bipolar depressed patients treated with antidepressants, which is described by Robert M. Post, MD, in his special report on the Stanley Foundation Bipolar Network. I had assumed the conversion rate was much higher because I vividly recall an awful conversion to mania with catastrophic results that happened early in my career.

Of course I recommend all articles in this issue of, but I especially urge you to read the report by Dr. Post and his Stanley Foundation-funded team. What I like about these studies of bipolar disorder is that they:

• include patients similar to those I treat (i.e., a general population of bipolar patients, rather than one selected with criteria that excluded all but the most uncomplicated patients)
• are long-term (up to 6 years). It is frustrating when studies follow patients for weeks, while I have to treat them for years.
• offer lessons I can use in my practice this week (e.g., adjunctive lamotrigine can lead to a good response in previously unresponsive patients).

That, as I have mentioned before, is the goal of—to provide news you can use in your practice this week. In psychiatry, so many articles are published every day that it’s impossible to keep up with them. Reading reviews written by practitioners who can interpret that volume and comparing their conclusions with our own experience is one way we learn useful new material.

As Hippocrates observed, judgment is difficult in medical practice, and the same is true of medical editing. To help us exercise good judgment in the editing of, please continue to send me your comments and suggestions ([email protected]).

Hippocrates’ first aphorism about the practice of medicine is as true today as it was 2,500 years ago: Life is short, the art is long, the occasion fleeting, experience fallacious, and judgment difficult.¹

Life is still short, although not as short as it was in Hippocrates’ day, but the art of medicine—what physicians are expected to know—may be hundreds of times longer. Greater life expectancy and knowledge allow us to offer more help than ever to patients with psychiatric disorders. Yet how can we possibly learn everything we are expected to know and improve the way we practice?

The occasion—the time during which we make clinical decisions—continues to be brief. In fact, patient contacts are more fleeting than ever, given the financial pressures of managed care.

Experience remains fallacious. Our clinical experience can lead us to believe that every condition has a more negative prognosis than it does. Patients who respond well to treatment return much less often than those who respond poorly and require more complicated care. Similarly, patients who get well may stop coming to see us, but those who do not get well may stay with us indefinitely.

Moreover, none of us sees a random sample of patients, so our perceptions of various psychiatric disorders may be warped by one or two dramatic experiences. It’s human nature to remember our most interesting or horrifying cases, rather than the more routine.

Based on my own experience, I was surprised by the low prevalence (13 to 18%) of conversion to mania in bipolar depressed patients treated with antidepressants, which is described by Robert M. Post, MD, in his special report on the Stanley Foundation Bipolar Network. I had assumed the conversion rate was much higher because I vividly recall an awful conversion to mania with catastrophic results that happened early in my career.

Of course I recommend all articles in this issue of, but I especially urge you to read the report by Dr. Post and his Stanley Foundation-funded team. What I like about these studies of bipolar disorder is that they:

• include patients similar to those I treat (i.e., a general population of bipolar patients, rather than one selected with criteria that excluded all but the most uncomplicated patients)
• are long-term (up to 6 years). It is frustrating when studies follow patients for weeks, while I have to treat them for years.
• offer lessons I can use in my practice this week (e.g., adjunctive lamotrigine can lead to a good response in previously unresponsive patients).

That, as I have mentioned before, is the goal of—to provide news you can use in your practice this week. In psychiatry, so many articles are published every day that it’s impossible to keep up with them. Reading reviews written by practitioners who can interpret that volume and comparing their conclusions with our own experience is one way we learn useful new material.

As Hippocrates observed, judgment is difficult in medical practice, and the same is true of medical editing. To help us exercise good judgment in the editing of, please continue to send me your comments and suggestions ([email protected]).

When I was in college I worried I would get bad grades if I didn’t learn everything in my courses. Grades meant a lot to me, as they did to most of us who eventually got into medical school. I hoped that I wouldn’t have to worry so much about grades once I was in medical school because, after all, I would already be in.

In fact, during medical school and residency, I stopped worrying about getting a bad grade if I didn’t learn enough. My new worry was: What if I don’t learn enough and accidentally kill somebody? Fortunately, everything in medical school got repeated multiple times until I learned what I needed to know.

Now that I am in practice, I am not as worried as I used to be that I might actually kill someone, although that is still in the back of my mind. What worries me today is learning all I need to know to help patients to the extent now possible. The faster the science of medicine changes, the more this concerns me.

We really do need to keep up with an amazing amount of information, don’t we? Almost any illness that affects a major organ system can lead to psychiatric symptoms. Pretty much any drug we give to treat psychiatric symptoms can affect other organ systems. Many psychiatric disorders can lead directly or indirectly to some somatic pathology. We need to keep up with general medicine, with new developments in diagnosis and treatment in psychiatry, and with the myriad interactions between medical and psychiatric conditions and treatments.

In this month’s issue of, Shaila Misri, MD, and Xanthoula Kostaras, BSc, bring us new insights into postpartum depression, a psychiatric disorder that in its most severe form can be fatal to the sufferer or her child, as recent headlines have reminded us all. I have distributed copies of “Postpartum depression: Is there an Andrea Yates in your practice?” to all the Ob/Gyns I’ve ever consulted to, and I have gotten much positive feedback (and more consultation requests) from them.

We also can learn about thyroid disorders and medication-induced cardiac arrhythmias, two medical conditions that also could kill our patients. I have incorporated into my practice the recommendations of W. Victor R. Vieweg, MD, on when to get an ECG on patients starting medications. And thanks to the insights of Richard Bermudes, MD, on thyroid disorders, I now feel more confident in interpreting minor elevations in physical hormone levels. In the past, I tended to order too many tests after detecting low-grade elevations, thus increasing my costs, turning up more false-positive results to follow up on, and unnecessarily frightening both myself and my patient.

The article by Dean Schuyler, MD, on cognitive therapy, lets us hone a potentially lifesaving tool for patients struggling with the chronic misery of dysthymia. Finally, the article on child and adolescent ADHD by Timothy Wilens, MD, Joseph Biederman, MD, and Thomas Spencer, MD, has been particularly helpful to me. After studying it, I concluded that I may have been underdiagnosing and undertreating this problem—in the process allowing patients to develop secondary morbidity. While to my knowledge my underdiagnosis and undertreatment of ADHD has not led to mortality among my patients, I am sure that depression and despair at getting inadequate answers and treatment could lead to a fatal outcome for some.

So welcome to another potentially lifesaving issue of. And keep those cards and letters (and emails) coming and let us know how we can help you. Write to, Quadrant HealthCom Inc., 110 Summit Ave., Montvale, NJ 07645, or e-mail us at [email protected].

When I was in college I worried I would get bad grades if I didn’t learn everything in my courses. Grades meant a lot to me, as they did to most of us who eventually got into medical school. I hoped that I wouldn’t have to worry so much about grades once I was in medical school because, after all, I would already be in.

In fact, during medical school and residency, I stopped worrying about getting a bad grade if I didn’t learn enough. My new worry was: What if I don’t learn enough and accidentally kill somebody? Fortunately, everything in medical school got repeated multiple times until I learned what I needed to know.

Now that I am in practice, I am not as worried as I used to be that I might actually kill someone, although that is still in the back of my mind. What worries me today is learning all I need to know to help patients to the extent now possible. The faster the science of medicine changes, the more this concerns me.

We really do need to keep up with an amazing amount of information, don’t we? Almost any illness that affects a major organ system can lead to psychiatric symptoms. Pretty much any drug we give to treat psychiatric symptoms can affect other organ systems. Many psychiatric disorders can lead directly or indirectly to some somatic pathology. We need to keep up with general medicine, with new developments in diagnosis and treatment in psychiatry, and with the myriad interactions between medical and psychiatric conditions and treatments.

In this month’s issue of, Shaila Misri, MD, and Xanthoula Kostaras, BSc, bring us new insights into postpartum depression, a psychiatric disorder that in its most severe form can be fatal to the sufferer or her child, as recent headlines have reminded us all. I have distributed copies of “Postpartum depression: Is there an Andrea Yates in your practice?” to all the Ob/Gyns I’ve ever consulted to, and I have gotten much positive feedback (and more consultation requests) from them.

We also can learn about thyroid disorders and medication-induced cardiac arrhythmias, two medical conditions that also could kill our patients. I have incorporated into my practice the recommendations of W. Victor R. Vieweg, MD, on when to get an ECG on patients starting medications. And thanks to the insights of Richard Bermudes, MD, on thyroid disorders, I now feel more confident in interpreting minor elevations in physical hormone levels. In the past, I tended to order too many tests after detecting low-grade elevations, thus increasing my costs, turning up more false-positive results to follow up on, and unnecessarily frightening both myself and my patient.

The article by Dean Schuyler, MD, on cognitive therapy, lets us hone a potentially lifesaving tool for patients struggling with the chronic misery of dysthymia. Finally, the article on child and adolescent ADHD by Timothy Wilens, MD, Joseph Biederman, MD, and Thomas Spencer, MD, has been particularly helpful to me. After studying it, I concluded that I may have been underdiagnosing and undertreating this problem—in the process allowing patients to develop secondary morbidity. While to my knowledge my underdiagnosis and undertreatment of ADHD has not led to mortality among my patients, I am sure that depression and despair at getting inadequate answers and treatment could lead to a fatal outcome for some.

So welcome to another potentially lifesaving issue of. And keep those cards and letters (and emails) coming and let us know how we can help you. Write to, Quadrant HealthCom Inc., 110 Summit Ave., Montvale, NJ 07645, or e-mail us at [email protected].

When I was in college I worried I would get bad grades if I didn’t learn everything in my courses. Grades meant a lot to me, as they did to most of us who eventually got into medical school. I hoped that I wouldn’t have to worry so much about grades once I was in medical school because, after all, I would already be in.

In fact, during medical school and residency, I stopped worrying about getting a bad grade if I didn’t learn enough. My new worry was: What if I don’t learn enough and accidentally kill somebody? Fortunately, everything in medical school got repeated multiple times until I learned what I needed to know.

Now that I am in practice, I am not as worried as I used to be that I might actually kill someone, although that is still in the back of my mind. What worries me today is learning all I need to know to help patients to the extent now possible. The faster the science of medicine changes, the more this concerns me.

We really do need to keep up with an amazing amount of information, don’t we? Almost any illness that affects a major organ system can lead to psychiatric symptoms. Pretty much any drug we give to treat psychiatric symptoms can affect other organ systems. Many psychiatric disorders can lead directly or indirectly to some somatic pathology. We need to keep up with general medicine, with new developments in diagnosis and treatment in psychiatry, and with the myriad interactions between medical and psychiatric conditions and treatments.

In this month’s issue of, Shaila Misri, MD, and Xanthoula Kostaras, BSc, bring us new insights into postpartum depression, a psychiatric disorder that in its most severe form can be fatal to the sufferer or her child, as recent headlines have reminded us all. I have distributed copies of “Postpartum depression: Is there an Andrea Yates in your practice?” to all the Ob/Gyns I’ve ever consulted to, and I have gotten much positive feedback (and more consultation requests) from them.

We also can learn about thyroid disorders and medication-induced cardiac arrhythmias, two medical conditions that also could kill our patients. I have incorporated into my practice the recommendations of W. Victor R. Vieweg, MD, on when to get an ECG on patients starting medications. And thanks to the insights of Richard Bermudes, MD, on thyroid disorders, I now feel more confident in interpreting minor elevations in physical hormone levels. In the past, I tended to order too many tests after detecting low-grade elevations, thus increasing my costs, turning up more false-positive results to follow up on, and unnecessarily frightening both myself and my patient.

The article by Dean Schuyler, MD, on cognitive therapy, lets us hone a potentially lifesaving tool for patients struggling with the chronic misery of dysthymia. Finally, the article on child and adolescent ADHD by Timothy Wilens, MD, Joseph Biederman, MD, and Thomas Spencer, MD, has been particularly helpful to me. After studying it, I concluded that I may have been underdiagnosing and undertreating this problem—in the process allowing patients to develop secondary morbidity. While to my knowledge my underdiagnosis and undertreatment of ADHD has not led to mortality among my patients, I am sure that depression and despair at getting inadequate answers and treatment could lead to a fatal outcome for some.

So welcome to another potentially lifesaving issue of. And keep those cards and letters (and emails) coming and let us know how we can help you. Write to, Quadrant HealthCom Inc., 110 Summit Ave., Montvale, NJ 07645, or e-mail us at [email protected].