Ronald W. Pies, MD

Suppose your new patient, Mr. Jones, tells you he is feeling “really down.” He meets all DSMIV symptomatic and duration criteria for a major depressive episode (MDE) after having lost his wife to cancer 2 weeks ago. Should you diagnose major depressive disorder?

A 52-year-old female college professor was referred to a psychiatrist by a nurse practitioner at the college health clinic. The referring diagnosis was “adjustment disorder with depressed mood versus atypical depression with somatization; rule out fibromyalgia.”

In our own time, many so-called conflicts of interest (COI) boil down to temptation, as James DuBois,3 professor and department chair of health care ethics at Saint Louis University, notes in his excellent chapter on this subject. A physician-researcher is tempted to slant the results of his or her study in order to maintain funding from a medical technology company.

It's often said that the word "crisis" is expressed in Chinese by two characters representing "danger" and "opportunity." In truth, the Chinese word for "crisis" (weiji) is better translated as "danger" (wei) and "crucial moment" (ji).

The adage has it that the road to hell is paved with good intentions. It is evident from this revealing portrait of neurologist Walter Freeman--the originator of the infamous "ice pick" lobotomy--that good intentions without sober analysis can indeed have hellish consequences.

Here is the conundrum: You have completed treatment with a fascinating and complex patient. Mr A has bipolar depression, Marfan syndrome, and hypothyroidism. You not only managed to navigate around the rocks of his medical problems, but you also managed to stabilize Mr A's bipolar disorder using a combination of lithium (Eskalith, Lithobid), thyroxine, and interpersonal therapy. You would now like to share your experience with colleagues, so you write up the case history; then suddenly, you are seized with misgivings.

In part 1 of this essay, I argued that individual freedom is not only compatible with determinism but dependent on it. I also argued that freedom is not an "either/or" condition. Rather, actions may be more or less free, and therefore, more or less "responsible," depending on a number of contingent factors, yielding various degrees of freedom. Psychiatrists, I suggested, can be most helpful in so far as we can describe, study, and categorize these degrees of freedom and the psychopathological conditions that undermine them. In part 2, I elaborate on the "naturalistic" model of freedom and autonomy and suggest how it may be applied to psychiatric disorders and medico-legal determinations of culpability.

Book review

Up Against the Wall

There were only 3 Jewish students in my high school, and I was one of them. In the small, western New York town where I grew up, most people were tolerant. But a small clique of anti-Semites made life tough for us Jewish kids. Most of the time, we just shrugged off the jokes and insults or came right back at these louts with a snappy retort. Sometimes, the bigotry grew more menacing.

The construct of bipolar spectrum disorder remains a work in progress. Its precise boundaries are still a matter of considerable debate. Some psychiatrists are convinced that it is widely overdiagnosed. It is possible that depending on the clinician and the clinical setting both views are correct.

On Taking the Helm

Psychiatrists certainly do not know all the answers when it comes to the recent spate of school shootings, but we do know some of the most pressing questions. For example, is there a difference in the psychological makeup of adult shooters versus student, or juvenile, shooters? To what degree does untreated psychosis or depression play a part in the shooter's seemingly inexplicable behavior? How important is bullying in motivating some students to seek revenge on their peers? What are the earliest warning signs of an impending attack by an assailant of any age?

Typically, delirium worsens at night ("sundowning"), with lucid intervals often present in the morning. It is important to realize that delirium may appear before any abnormal laboratory values are detected and may persist after the resolution of these abnormalities.

A young mother has just learned from her gynecologist that she is 2 months pregnant. She has had 7 major depressive episodes over the past 8 years, 3 of which were accompanied by serious suicide attempts. She is asking you if she should stop taking the antidepressant at this time. What do you advise?

What does the term “polypharmacy” actually mean? Dr Pies likens polypharmacy to fire: just as the latter may either heat your house or burn it down, polypharmacy may either help or harm the patient.

How does the difference between objective evidence and subjective evidence relate to the practice of psychiatry?

An overview of the articles in this Special Report on psychopharmacology.

Attempts have been made to integrate psychiatry and medicine as far back as Benjamin Rush, a physician and signer of the Declaration of Independence. Recent advances in research, clinical practice and organizational makeup, however, now make integration seem more plausible than ever. Find out what's happening to bring these two fields closer together.

In the second part of this series, read about the special issues psychiatrists face when treating women, children and adolescents, and elderly people with bipolar disorder and dementia. What are the recommendations for care and monitoring strategies to maintain patients on effective, long-term treatment regimens?

What special issues do psychiatrists face when treating women, children and adolescents, and elderly people with schizophrenia? Are there recommendations for care and monitoring strategies to maintain patients on effective, long-term treatment regimens?