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OBJECTIVE: Since the 1970s the number of women physicians has steadily increased and is expected to continue to climb into the next century. Psychiatry is a medical specialty that has been successful in attracting women. As more young women enter psychiatry, more colleagues will be pregnant in the workplace. This paper explores some of the practical issues that pregnancy poses for the early-career psychiatrist, her colleagues, and her patients. METHODS: A MEDLINE search was conducted. Literature on the pregnant physician, the pregnant therapist, and the pregnant resident was reviewed. Recommendations found in these resources were combined with the author's observations to create a single resource paper that outlines common problems and practical strategies for the psychiatrist who is pregnant. RESULTS: The integration of the psychiatrist's maternal identity with her professional identity is a task that often begins during pregnancy. The fear of abandonment is a common theme for patients under her care. Relationships with colleagues are sometimes strained. The medical workplace has been slow to accommodate the needs of women, who make up a growing percentage of professional employees. CONCLUSIONS: The reproductive years and the early years of practice overlap for a growing number of women in psychiatry. The life experience of motherhood can be an important part of one's growth as a psychiatrist. Relationships with coworkers and patients can be eased if potential problems are recognized and dealt with early on. Employers and medical organizations are challenged to make an investment in women professionals through the development of family-oriented policies.

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The use of medicinal herbs has increased over the past few years, and psychotropic herbs are among the most popular on the market. Patients and physicians may assume these products are safe; however, dietary supplements are not subject to the rigorous testing required for prescription medications. Problems that may occur with the use of psychotropic herbs include overuse or abuse, side effects, and herb-drug interactions. Ma huang, St. John's wort, and kava are examples of readily available herbs with the potential for negative effects. Physicians should improve their knowledge of these products so they can provide reliable information to their patients.

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UNLABELLED: Nine patients with bipolar mood disorder and concurrent substance dependence were treated in an 18-bed inpatient addiction unit over a 3-month period. A multidisciplinary team approach used a medicalized Minnesota model and stressed the establishment of a positive diagnosis and individualization of management strategies for each patient. Clinically significant affective symptoms that required acute psychiatric intervention developed in several patients during hospitalization. Manic symptoms developed in three patients during sedative withdrawal, requiring the team to differentiate manic symptoms from physiologic withdrawal; and two patients became severely depressed, requiring pharmacologic management and suicide-prevention strategies. SUMMARY: Our experience with the patients in this case series supports the contention that there is no simple, uniform approach to the substance-dependent patient with bipolar disorder. Treatment teams must be prepared to differentiate complex syndromes and to manage manic, depressive, and addictive behaviors.

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The purpose of this study was to compare the psychotropic prescribing practices of family physicians and psychiatric physicians, and to assess their satisfaction with education about psychotropic prescribing. A survey was mailed to 461 active members of the Minnesota Psychiatric Society and to a randomized sample of 461 active members of the Minnesota Academy of Family Physicians. Major depression, panic disorder, and dementia with behavioral disturbance were selected for study. For each disorder, we asked for the estimated number of patients seen and treated as well as a list in order of preference of the three medications they most commonly use. Those surveyed were also asked about their level of satisfaction with the training they received in medical school, residency, and continuing medical education (CME) courses on the topic of psychotropic prescribing. The two physician groups reported similar prescribing practices for the single-drug treatment of depression. Family physicians more frequently prescribed minor tranquilizers and older generation psychotropics than did psychiatrists when treating panic disorder and dementia with behavioral disturbance. Patients with depression were the least likely to be referred to other health professionals. Neither physician group was satisfied with medical school education in this area; family physicians were less satisfied with residency training and in related CME courses than were psychiatric physicians. Additional study is needed to better understand interspecialty practice variation for commonly encountered psychiatric disorders. Medical education programs at all levels could better meet the reported needs of their graduates by providing more attention to prescribing psychotropic agents.

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A widely held belief is that amphetamine-like stimulants have abuse potential, but addiction to these drugs is seldom mentioned. We describe seven patients who fulfilled criteria for amphetamine-like abuse or dependence, based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. This case series lends clinical support to the research findings that amphetamine-like drugs are reinforcing and therefore can be addictive. The use of standardized criteria to classify excessive over-the-counter stimulant use as abuse or dependence distinguishes these case reports from others in the medical literature. Public concern about the misuse of this class of drugs is discussed. We propose that clinicians use standardized criteria to diagnose accurately abuse of or dependence on over-the-counter stimulants for a better understanding of the extent of this problem.

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The treatment of alcoholism has changed during the past 2 decades. Notable developments have occurred in pharmacotherapy, psychotherapy, and health-care delivery. A better understanding of the biologic basis for addiction has led to clinical trials of medications that target neuroreceptors. One such medication is the opiate antagonist naltrexone, which decreases the craving for alcohol. Psychosocial interventions continue to be the mainstay of alcohol treatment programs. The efficacy of three different therapies was demonstrated in a study called Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). This study, however, did not prove the patient-treatment "matching" hypothesis. In addition to therapies provided by addiction specialists, interest is growing in the use of brief motivational techniques in primary-care settings. As the field of addiction responds to an unfolding health-care delivery system, a broader range of treatment options in conjunction with a greater opportunity to individualize patient care is evolving.

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Thirteen patients with stiff-man syndrome (SMS) were studied with the Minnesota Multiphasic Personality Inventory (MMPI), the Self-Administered Alcoholism Screening Test (SAAST), the State-Trait Anxiety Inventory (STAI) profiles, and by telephone interviews. The mean MMPI, SAAST, and STAI were within normal limits; however, several patients had abnormal profiles. The results of telephone interviews revealed that 8 patients (62%) had been given at least 1 psychiatric diagnosis and 4 (31%) abused alcohol or were dependent on it. Two patients had a psychiatric diagnosis that preceded the onset of symptoms of SMS. The authors hypothesize that SMS patients have a gamma-aminobutyric acid deficiency or GABAergic neuron dysfunction that leads to psychiatric symptoms, including depression and chemical abuse. Clinicians treating patients with SMS must be alert to the possible presence of comorbid psychiatric illnesses in this patient population.

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BACKGROUND: Stiff-man syndrome is a rare central nervous system disease first described nearly 40 years ago. Its cause has been attributed to both neurologic and psychiatric processes. In recent years, it has been accepted as a neurologic condition in which the gamma-aminobutyric acid (GABA) system malfunctions, probably because of an autoimmune process. Published reports that have described psychiatric manifestations of the disease have relied on descriptions of one or two cases and literature reviews. METHOD: We reviewed the medical records of 24 patients with confirmed stiff-man syndrome, 12 of whom had received psychiatric consultation. This review was done to better determine the psychiatric manifestations of stiff-man syndrome. RESULTS: Retrospective analysis of these 12 cases showed that the most common psychiatric symptoms were anxiety, depression, and alcohol abuse. CONCLUSION: We speculate that the GABA system is involved in both the neurologic and psychiatric symptoms of these patients. Psychiatrists have a significant role in the management of patients with stiff-man syndrome and may be expected to manage anxiety, depression, and substance misuse.

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OBJECTIVE: In this report, we describe the abuse of fluoxetine (an antidepressant) in two patients who had histories of substance abuse. MATERIAL AND METHODS: Specific details of the stimulant effects of fluoxetine, used in excessive dosages and in conjunction with other drugs, are discussed. RESULTS: After hospitalization, our two patients were able to discontinue use of fluoxetine and had improved mentation. CONCLUSION: Although the mechanism for this phenomenon is unknown, we postulate that drug craving and behavioral factors are involved.

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