Mr. B, age 35, is admitted for the fourth time to the inpatient service with hallucinations and delusions related to chronic schizophrenia. After appropriate attempts control his symptoms, he has begun to respond to usual treatment with an atypical antipsychotic. He remains a “partial responder,” however, at the maximum FDA-approved dosage listed in the package
insert (PI). What do you do next?
Because of this author’s (NSK) dual training in medicine and forensic psychiatry, other clinicians often ask me about patients such as Mr. B. Prescribing for patients who do not respond to standard dosages can create anxiety about going “off-label.” This article describes how to manage potential risk to yourself and your patient by communicating effectively and documenting informed consent.

-  Is Your Depressed Patient Bipolar? (original text)
- Is your Depressed Patient Bipolar (June 2005, with charts and revisions)
Abstract:  Accurate diagnosis of mood disorders is critical to their effective treatment. Distinguishing
between major depression and bipolar disorders, especially the depressed phase of a bipolar
disorder, is essential, since they differ substantially in their genetics, clinical course, outcomes, prognosis, and treatment. In current practice, bipolar disorders, especially bipolar II disorder, are underdiagnosed. Misdiagnosing bipolar disorders deprives patients of timely and potentially lifesaving treatment, particularly considering the development of newer and possibly more effective medications for both depressive features and the maintenance treatment (prevention of
recurrence/relapse). This article focuses specifically on how to recognize the identifying features suggestive of a bipolar disorder in patients who present with depressive symptoms or who have previously been diagnosed with major depression or dysthymia. This task is not especially time-consuming, and the interested primary care or family physician can easily perform this assessment. Tools to assist the physician in daily practice with the evaluation and recognition of bipolar disorders and bipolar depression are presented and discussed.
Key Words: bipolar disorders, bipolar II, depression, bipolar depression

A Primary Care Approach to Bipolar Disorder
Many patients with bipolar disorder can be successfully managed in primary care if the physician uses the tools and information available. Bipolar disorder treatment encompasses far more than pharmacotherapy. Non-pharmacologic interventions are vital. Numerous medications are effective in treating this disorder but they do not exhibit class effects. Anticonvulsants and antipsychotic drugs, in particular, have very different efficacy and safety profiles. This article discusses the types of non-pharmacologic therapies that have shown success in bipolar disorder management, pharmacotherapy goals and options, clinical pearls for using atypical antipsychotics in bipolar disorder (including off-label usage), and medical comorbidities as potential treatment confounders (namely obesity and diabetes). With messages of hope, direction, and the importance of adherence, PCPs can have a dramatic impact on the outcomes of their patients with bipolar disorder.

Families, Murder, and Insanity: A Psychiatric Review of Paternal Neonaticide
Abstract:  Neonaticide is the killing of a newborn within the first 24 hours of life. Although relatively uncommon, numerous cases of maternal neonaticide have been reported. To date, only two cases of paternal neonaticide have appeared in the literature. The authors review neonaticide and present two new case reports of paternal neonaticide. A psychodynamic explanation of paternal neonaticide is formulated. A new definition for neonaticide, more consistent with biological and psychological determinants is suggested.

When Your Patient Commits Suicide The Psychiatrist's Role, Responses, and Responsibilities
Abstract:  Suicides constitute a not infrequent event in a psychiatrist's practice and have a major impact upon the clinician as well as the family and the staff. Many psychiatrists especially those in residency are never taught how to manage a patient's suicide. The authors share their experiences in this area and make clear recommendations for interventions with staff, family, and other patients. Careful attention to the physician's own needs are suggested. It is suggested that this material be made part of psychiatry residents training.

Feigned Insanity in Nineteenth Century America Legal Cases
Abstract:  Today, it is only out of necessity that lawyers bring physicians into the courtroom. Indeed, it is only the ability of an expert witness to give opinion testimony and to answer hypothetical questions that makes his attendance attractive to the bar at all. In reviewing the cases of feigned insanity during the 1800's it becomes clear that the same sentiments existed then as well. Indeed, little has changed during the intervening century.

The Pharmacological Treatment of Sexual Offenders
Abstract:  As a result of the Kansas v Hendricks decision in the US Supreme Court, upholding the civil committal of sexual offenders under sexual predator statutes, the treatment of sexual deviation has become a focus of considerable national interest. The effective treatment of sexual deviants is a complicated issue that involves psychological and pharmacological treatment approaches. Psychiatrists because of their training in medicine and skills in psychotherapy should be ideally suited to treat these individuals as there is general agreement among experts that a combined psychological and pharmacological treatment approach is most effective. Biological treatments, specifically surgical castration and stereotaxic neurosurgery have been used historically in the treatment of sexual offenders to reduce their sexual drive and to prevent recidivism.

LaLonde v. Eissner
 Massachusetts Protects Court  Appointed Expert Witnesses
Abstract: Previously, I have reported on two important cases involving the relationship of the judiciary and expert witnesses. In Tolisano v Texon, the New York State Court of Appeals, the State's highest court, ruled that there existed no doctor-patient relationship when a forensic evaluation is performed. In so doing, the court acted to protect expert witnesses and finally reaffirmed a concept which experts have consistently maintained. In McNamara v. Honeyman the Massachusetts Supreme Judicial Court, that State's highest court, ruled that if a physician defendant was a public employee then he/she would be protected from not only negligence but from gross negligence as well.

I am pleased to add the case of LaLonde v. Eissner to this growing list of case law which helps to articulate the role of a forensic psychiatrist and the protection's to be afforded in the conduct of our work. This may be the first time a State's highest court has granted judicial immunity to a forensic psychiatrist performing an evaluation in the absence of a specific court order for the evaluation.

Tolisano v Texon:
 New York States Protects Expert Witnesses
Abstract:  Every expert witness is familiar with the four D's of tort law: a Dereliction of a Duty Directly causing Damages. In order for a tort claim to be successful all four of these elements must be proven. The professions, medicine in particular, have long held that when examining and rendering an opinion for a third party, no malpractice could be charged as clearly there was no patient/physician relationship and hence no Duty to the individual.

This reasoning allows for participation by psychiatrists in insurance examinations, competency hearings and a host of other forensic examinations. Although this reasoning may seem clear to A.A.P.L. members, until the New York State Court of Appeals (the State's highest court) overturned a New York State Supreme Court Appellate Division ruling  this issue was in doubt.

American Psychiatric Publishing Inc.
0895-0172 EN RC4867 Letters
An Open Label Trial of Donepezil (Aricept) in the Treatment of Persons with Mild Traumatic Brain Injury.

We read with interest, the review by Griffin et. al.1 on the use of cholinergic agents in the treatment of persons who sustained traumatic brain injury (TBI). As early as 1997 (Poster session at the joint meeting of the American Neuropsychiatric Association and the British Neuropsychiatry Association. Cambridge, England.), we too suspected that these medications might be beneficial in treating cognitive dysfunction, memory deficits, and emotional instability, all observed in TBI.

Psychic Akathisia
Use of atypical antipsychotics has become the standard of care in the treatment of psychosis. As newer agents enter the marketplace, clinicians have a choice of medications with significantly different receptor binding profiles. Ziprasidone, the newest agent on the market, is notable for its ability to act as a 5HT1-A agonist. In addition, ziprasidone is thought to bind almost exclusively in the A10 mesolimbic/mesocortical pathway and to avoid the A9 nigrostriatal pathway in the brain. Thus, akathisia would not be expected to be a frequent occurrence with this medication.

www.currentpsychiatry.com

Challenges in Recognition, Clinical Management, and Treatment of Bipolar Disorders at the Interface of Psychiatric Medicine and Primary Care
- Defining the challenge: Recognizing and treating bipolar disorders wherever patients present
- Challenges in diagnosing bipolar disorder: Identifying Mixed Episodes . . . . . . . . . . .
- Clinical management of bipolar disorder: Achieving best outcomes through a Role of the primary care provider
- Treatment by phase: Pharmacologic management of bipolar disorder
- Recognizing bipolar disorder on initial presentation: A case study with decision points

www.jfponline.com

Challenges in Recognition, Clinical Management, and Treatment of Bipolar Disorders at the Interface of Psychiatric Medicine and Primary Care
- Defining the challenge: Recognizing and treating bipolar disorders wherever patients present
-  Challenges in diagnosing bipolar disorder: Identifying Mixed Episodes
- Clinical management of bipolar disorder: Achieving best outcomes through a Role of the primary care provider.
- Treatment by phase: Pharmacologic management of bipolar disorder
- Recognizing bipolar disorder on initial presentation: A case study with decision points

Effect of Open-Label Lamotrigine as Monotherapy
and Adjunctive Therapy on the Self-Assessed Cognitive (August 2007)
Abstract: Cognitive deficits in patients with bipolar disorder are likely to impair occupational and social functioning. In a post hoc analysis of data from a prospective, open-label study of lamotrigine in 1175 patients 13 years or older with bipolar I disorder, changes in the self-rated cognitive function scores of patients receiving
lamotrigine as monotherapy or as adjunctive therapy were evaluated. Lamotrigine was given for 12 weeks, with a target dosage of 200 mg/d.

Alleged Sexual Abuse in the Context of Divorce
Abstract: Alleged sexual abuse looms as one of the most difficult, controversial and challenging issues facing society. In almost all cases, it is one person's word against another's in a crime that is not witnessed. Assuming we have a special ability to discern truth, society often calls upon psychiatrists to either substantiate or to invalidate such a claim. This task is complicated enough in the course of normal therapy and without the threat of litigation. In the context of divorce, the allegation by one party that a child has been abused poses a question that would cross Solomon's eyes.

Sexual Deviancy
Abstract: Sexual deviancy is a rather broad and vague term. Its usage connotes that there are recognized norms of sexual behavior which are accepted by society in general. In fact, "normal" sexual behavior has never been well categorized. Rather, aberrant behaviors, sufficiently unacceptable to most persons, have been lumped together to comprise sexual deviancy. These of course may vary over time and across different cultures, although there are probably some behaviors which almost everyone would label deviant.

Tardive Dyskinesia: Tremors in Law and Medicine
Abstract:  Although debate exists as to the incidence and prevalence of antipsychotic induced tardive dyskinesia (TD), it is readily accepted that antipsychotics can and often do induce this potentially irreversible movement disorder. Prevalence rates of 25%-40% and incidence rates of 1-3% annually are commonly reported. Ongoing and controversial research shows tardive dyskinesia may in fact be part of the normal aging process occurring in up to 32% of persons never exposed to an antipsychotic. Despite this, if a person has ever been exposed to an antipsychotic and later develops TD, the chance that the drug will be blamed is high. In this article, I review the various legal theories that may be invoked in a case involving TD, including relevant case law to illustrate each of the theories. This is the first article published in a peer reviewed scientific journal to suggest that all patients should be offered the opportunity to try the newer "atypical" antipsychotics which may be much safer agents.

Rand v. Miller:
Can Record Review Constitute a  Doctor-Patient Relationship?
Abstract: In 1987, A.A.P.L. issued Ethical Guidelines for the Practice of Forensic Psychiatry. These were revised in 1989 and again in 1991. One of the most generally held concepts is the need to examine an individual, if at all possible, prior to rendering an opinion as to their psychiatric condition, if any. This stems from the controversial "Goldwater Rule" issued by the A.P.A. Nonetheless, there are circumstances where physicians, psychiatrists and even forensic psychiatrists continue to, on a regular basis, issue written opinions without even the slightest of efforts to interview the individual in question.
Recently, in Rand v. Miller, the Supreme Court of West Virginia shared with us its opinion on this pressing issue. It is one of a series of cases on which I have reported which deal with the relationship between a forensic psychiatrist and an evaluee. Clearly, the Miller case continues the trend of decisions affirming the lack of a doctor patient relationship in a forensic setting.

State v. Szemple:
Marital-Communication  and the Priest-Penitent Privilege
Abstract: On May 12, 1994, the Supreme Court of New Jersey handed down one of the most interesting decisions of the decade. In daring to tread where few have had the courage, the court addressed the confidential relationship between a priest and a penitent and in so doing, has changed the thinking of at least the last 500 years. In addition, an important ruling on the marital-communication privilege was made.

McNamara v. Honeyman:
Massachusetts Protects Psychiatrist
Abstract:  One of the greatest problems encountered by State Hospitals is the difficulty they have attracting well-trained psychiatrists to work with the chronically mentally ill. In particular, the potential liability that attends to working with this population has been a concern of many. Until Honeyman, the leading case in Massachusetts was Florio v. Kennedy. Florio held that if a physician were a "public employee" he/she would be held immune from liability under the Tort Claims Act 

In Honeyman, the court went well beyond the Florio standard and indeed may now be on the cutting edge in this regard. Here, the Supreme Judicial Court (Massachusetts's highest court) ruled that "For purposes of the Massachusetts Tort Claims Act, it is not material whether the conduct of an employee constitutes gross negligence or merely simply negligence.

The Journal of Clinical Psychiatry
Ziprasidone augmentation of clozapine

Clozapine, the oldest atypical antipsychotic remains the "gold standard" in the treatment of Schizophrenia and associated psychotic disorders (1). However, the side effects of this treatment are well known and include significant weight gain and an anticholinergic profile (2). The concept of adding quetiapine to clozapine with the potential to lower the dose of clozapine, and thus reduce the side effect profile of the clozapine has been supported clinically and in the literature (3,4).