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This article addresses several practical issues related to beginning psychotherapy: telephone contact, the initial session, referral to another therapist, discussion of arrangements, charging for missed sessions, guidelines for the patient and interactions outside the therapy hours. It takes a question-and-answer form, dealing with with questions a neophyte psychotherapist might ask. Although the article specifically relates to treatment that is dynamically oriented, it is also relevant to other forms of psychotherapy.

Myron Liptzin, M.D., is a respected psychiatrist who specialized in the treatment of university students. Liptzin retired last year as chief of psychiatry of student health at the University of North Carolina at Chapel Hill, where he had earned a reputation as a skillful clinician who was particularly adept at crisis intervention. If Liptzin had hoped to go on to a less hectic and stressful life, his expectations were shattered when he found himself accused of negligence in one of the most unusual cases of psychiatric malpractice of this century. A former patient went on a rampage-killing two people-and then blamed Liptzin. The verdict against the psychiatrist was front-page news, and CBS's "60 Minutes" went to North Carolina to do a story that aired mid-November 1998. Like a bolt out of the blue, Liptzin had gotten his 15 minutes of unwanted fame.

DeAndra's story: I came into the rooms and realized after a while that I had the attitudes and behaviors of an addict way before I ever picked up a drug. I remember growing up and being at my family's parties, [where] my aunts and uncles would give me and my brothers beer. There are pictures in our photo albums of us, all under 6 or 7, with cans of beer in our hands. At an early age I learned to manipulate to get what I wanted.

Psychiatrists, like the rest of America, continue to have trouble with alcoholic and other addicted patients. We are comfortable when patients want to get better, tell us the truth and come to treatment of their own free will, but alcoholics often don't fit this profile. We respond angrily when patients manipulate us. We are surprised when their sincere desire for help evaporates after we suggest a plan that will bring about real change.

Nearly 25 years ago, the National Institute on Alcohol Abuse and Alcoholism hailed couple and family therapy as "one of the most outstanding current advances in the area of psychotherapy of alcoholism" and called for controlled studies to test these promising methods. Currently behavioral couples therapy (BCT) is the family therapy method with the strongest research support for its effectiveness in substance abuse.

It is now customary psychiatric practice to think of a patient's illness as primarily biological in origin-so much so that, for many illnesses, published practice guidelines almost exclusively describe medication strategies.

This is the first in a series of articles summarizing research presented at the 1998 American College of Neuropsychopharmacology Annual Meeting.

Migration - Poetry of the Times

Lately, things have not been going well for some of the nation's largest health plans. Lawsuits have managed care organizations around the country worried that their cost-cutting measures may end up penalizing them with liabilities in the hundreds of millions of dollars.

Efforts are underway to persuade the Health Care Financing Administration (HCFA) to expand Medicare coverage for positron emission tomography, popularly known as PET scanning. At present, the government only reimburses charges for PET scans in connection with the diagnosis of lung cancer.

Concerned about increasing medical costs, Congress began to tinker with physicians' fees under Medicare with the Omnibus Budget Reconciliation Act of 1989. The result, the Resource-Based Relative Value Scale (RBRVS), altered our fees in the Medicare system.

Daniel F. Kripke, M.D. has studied the relationship between biological rhythms and depression since the early 1970s. He states that seasonal responses in many mammals are controlled by the photoperiod. Therefore, it seemed that depression might be analogous to winter responses and that light might be an effective treatment.

Despite the development of better-tolerated antidepressants and more effective applications of nondrug modalities like cognitive-behavioral therapy, depressive disorders are often chronic or recurrent. The researchers point out that there has been relatively little evaluation of chronic depression, with most studies addressing short-term treatment of acute episodes.

Given that passion, opinion, opportunism and inertia have shaped much of managed care's evolution, there is an increasing need for the systematic gathering and rational application of facts. Outcome evaluations and insights into what facilitates and what impedes efficient and effective care are now avidly sought, not only for improving care delivery and treatment effectiveness but also for regulatory functions and commercial promotion.

Insomnia, the subjective sense of having inadequate quantity or quality of sleep, occurs in 20% to 35% of the general population. Not surprisingly, many insomniacs describe a variety of difficulties in their personal and professional lives.

In recent years, melatonin has been touted in the media as a "hot sleeping pill, natural and cheap" and as the drug that "may help ease insomnia, combat jet lag...and extend life." Trials are finally being conducted. Across the United States, some 30 medical centers are studying melatonin as a potential treatment for sleep disturbances.

Warning of declining resources for mental health, Nelba Chavez, Ph.D., administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), said mental health must become a top priority in public policy, health care services and coverage, training of health care professionals and community education.

Putting Kevorkian on trial is not the same as developing a rational health care policy for those who are terminally ill. Kevorkian needs to be checked, but too much significance should not be given to his case. Our concern with the care for those who are seriously or terminally ill is too important to relegate to the trial of someone who is so narrowly fixed on being the instrument of his own death or that of others.

The Mental Health Parity Act of 1996-the long sought after federal law that was supposed to discourage health benefits discrimination against the mentally ill-was described as having "failed" to achieve parity because insurers and employers take advantage of loopholes. Despite the critical nature of the report, however, no one from the American Psychiatric Association, not a single psychiatrist for that matter, is quoted in the article.

Woman With a Finger Stuck in Her Nose - Poetry of the Times

A physician asks, via the Internet, for help in locating a resource to evaluate possible interactions between herbal remedies and Western medications. A Stanford researcher surveys 1,035 randomly selected people and reports that 40% of them have used such alternative health care as chiropractic, acupuncture or homeopathy during the past year (Astin, 1998). A survey of U.S. medical schools indicates nearly two-thirds of those responding (64%) now offer courses that include alternative medicine (Wetzel et al., 1998).

Alternative medicine was the theme of this issue of JAMA and in each of the other nine American Medical Association journals published in November. The editors of these scientific journals made an effort to provide physicians and other health care professionals with clinically relevant, reliable, fresh scientific information on alternative therapies.

It is more cost-effective for psychiatrists to provide medication and psychotherapy to depressed patients than it is to split treatment between medical doctors and other mental health care providers

Considered a "fringe" therapy 25 years ago, biofeedback has matured today to a modality much closer to mainstream treatment. Its value is accepted by a growing number of professionals, and it is covered by Medicare for some conditions, as well as by most health insurers.

Faced with the trend toward shorter length of stay in inpatient psychiatric units, practitioners and patients in need of care face dramatic changes in treatment.

Culture has been identified as one of the etiological factors leading to the development of eating disorders. Rates of these disorders appear to vary among different cultures and to change across time as cultures evolve. Additionally, eating disorders appear to be more widespread among contemporary cultural groups than was previously believed.

Although the majority of American households includes a pet, it is only recently that we have begun to explore the relationship between people and their pets and the possible physical and emotional benefits of that relationship.

Although evidence shows that selective serotonin reuptake inhibitor (SSRI) antidepressants cause less orthostasis and interfere less with psychomotor function than do tricyclic antidepressants (TCAs), a recent pharmacoepidemiologic study found them comparable in increasing elderly patients' risk for falling.

Hospital Food - Poetry of the Times

For decades, physicians have railed against the inequities of malpractice laws, lobbying for statutory changes that would insulate them from injustices, both real and perceived. In an ironic twist, extending tort liability has become the latest weapon against managed care companies and the medical directors who often make utilization review determinations. As a result, managed care companies are now rushing to embrace the once scorned external review and independent appeals processes in a last-ditch effort to stave off reforms requiring them to justify health care decisions in front of judges and juries.