Greg Muirhead

WAIKOLOA, HAWAII — An infamous, deadly disease that killed a large portion of the population of Europe in medieval times can still make rare and disruptive appearances in the modern emergency department.

Speaking at a symposium on emergency medicine sponsored by Stanford University, Dr. Diku P. Mandavia recalled the case of a 30-year-old woman admitted to a special part of the emergency department where very ill patients were placed.

“She's intubated,” he recalled. “She's on three pressor agents. She's in frank sepsis. She's in shock. They're throwing the kitchen sink at her, as far as antibiotics—she's got four or five antibiotics. They still can't sort out what to do. Her chest and urine are clear. All the other suspects are clear.”

The woman had been in the emergency department for 10 hours before she came to his attention, explained Dr. Mandavia, attending staff physician at Cedars-Sinai Medical Center, Los Angeles. When he asked for the cause of the sepsis, a resident said that a deep abscess in the right axilla was suspected. The abscess had not yet been drained because of concerns about how deep it was, and that draining might cause injury.

Dr. Mandavia called for an axillary ultrasound to be done, after which he had the abscess drained and cultured.

“A lot of pus emerged,” he remembered. “After draining, the patient went to bed in the ICU. This all happened by 3 p.m., Wednesday afternoon. At about 10:30 p.m. on Friday night, I get a phone call at home, and it's from a faculty [member] who never calls me.”

The caller asked if he recalled the case of the septic woman whose abscess was drained; Dr Mandavia said he did.

“She said, 'Guess what? You've been exposed to the plague!'” he recalled.

“You may know nothing about the plague,” he said to his audience. “I knew nothing myself.” Dr. Mandavia started looking for information about it on the Internet, but “there's not a lot out there,” he commented. “It's not an everyday diagnosis.”

Dr. Mandavia called a couple of infectious disease experts who also didn't know much about it. Meanwhile, the hospital was in turmoil; the Centers for Disease Control and Prevention was involved, “and I'm an indexed case now,” he said.

Meanwhile, Dr. Mandavia learned a crucial piece of information: There's a critical difference between the bubonic plague and the highly contagious disease it can convert to, called the pneumonic plague.

“Thank God she had the bubonic plague because if she had had the pneumonic plague, I would have been dead in 24 hours,” Dr. Mandavia explained. “Everyone in the room would have been dead in 24 hours.”

How did the patient get the bubonic plague? “This was a patient who had very, very poor hygiene in the house, and there were dead rodents and fleas,” he explained.

WAIKOLOA, HAWAII — An infamous, deadly disease that killed a large portion of the population of Europe in medieval times can still make rare and disruptive appearances in the modern emergency department.

Speaking at a symposium on emergency medicine sponsored by Stanford University, Dr. Diku P. Mandavia recalled the case of a 30-year-old woman admitted to a special part of the emergency department where very ill patients were placed.

“She's intubated,” he recalled. “She's on three pressor agents. She's in frank sepsis. She's in shock. They're throwing the kitchen sink at her, as far as antibiotics—she's got four or five antibiotics. They still can't sort out what to do. Her chest and urine are clear. All the other suspects are clear.”

The woman had been in the emergency department for 10 hours before she came to his attention, explained Dr. Mandavia, attending staff physician at Cedars-Sinai Medical Center, Los Angeles. When he asked for the cause of the sepsis, a resident said that a deep abscess in the right axilla was suspected. The abscess had not yet been drained because of concerns about how deep it was, and that draining might cause injury.

Dr. Mandavia called for an axillary ultrasound to be done, after which he had the abscess drained and cultured.

“A lot of pus emerged,” he remembered. “After draining, the patient went to bed in the ICU. This all happened by 3 p.m., Wednesday afternoon. At about 10:30 p.m. on Friday night, I get a phone call at home, and it's from a faculty [member] who never calls me.”

The caller asked if he recalled the case of the septic woman whose abscess was drained; Dr Mandavia said he did.

“She said, 'Guess what? You've been exposed to the plague!'” he recalled.

“You may know nothing about the plague,” he said to his audience. “I knew nothing myself.” Dr. Mandavia started looking for information about it on the Internet, but “there's not a lot out there,” he commented. “It's not an everyday diagnosis.”

Dr. Mandavia called a couple of infectious disease experts who also didn't know much about it. Meanwhile, the hospital was in turmoil; the Centers for Disease Control and Prevention was involved, “and I'm an indexed case now,” he said.

Meanwhile, Dr. Mandavia learned a crucial piece of information: There's a critical difference between the bubonic plague and the highly contagious disease it can convert to, called the pneumonic plague.

“Thank God she had the bubonic plague because if she had had the pneumonic plague, I would have been dead in 24 hours,” Dr. Mandavia explained. “Everyone in the room would have been dead in 24 hours.”

How did the patient get the bubonic plague? “This was a patient who had very, very poor hygiene in the house, and there were dead rodents and fleas,” he explained.

WAIKOLOA, HAWAII — An infamous, deadly disease that killed a large portion of the population of Europe in medieval times can still make rare and disruptive appearances in the modern emergency department.

Speaking at a symposium on emergency medicine sponsored by Stanford University, Dr. Diku P. Mandavia recalled the case of a 30-year-old woman admitted to a special part of the emergency department where very ill patients were placed.

“She's intubated,” he recalled. “She's on three pressor agents. She's in frank sepsis. She's in shock. They're throwing the kitchen sink at her, as far as antibiotics—she's got four or five antibiotics. They still can't sort out what to do. Her chest and urine are clear. All the other suspects are clear.”

The woman had been in the emergency department for 10 hours before she came to his attention, explained Dr. Mandavia, attending staff physician at Cedars-Sinai Medical Center, Los Angeles. When he asked for the cause of the sepsis, a resident said that a deep abscess in the right axilla was suspected. The abscess had not yet been drained because of concerns about how deep it was, and that draining might cause injury.

Dr. Mandavia called for an axillary ultrasound to be done, after which he had the abscess drained and cultured.

“A lot of pus emerged,” he remembered. “After draining, the patient went to bed in the ICU. This all happened by 3 p.m., Wednesday afternoon. At about 10:30 p.m. on Friday night, I get a phone call at home, and it's from a faculty [member] who never calls me.”

The caller asked if he recalled the case of the septic woman whose abscess was drained; Dr Mandavia said he did.

“She said, 'Guess what? You've been exposed to the plague!'” he recalled.

“You may know nothing about the plague,” he said to his audience. “I knew nothing myself.” Dr. Mandavia started looking for information about it on the Internet, but “there's not a lot out there,” he commented. “It's not an everyday diagnosis.”

Dr. Mandavia called a couple of infectious disease experts who also didn't know much about it. Meanwhile, the hospital was in turmoil; the Centers for Disease Control and Prevention was involved, “and I'm an indexed case now,” he said.

Meanwhile, Dr. Mandavia learned a crucial piece of information: There's a critical difference between the bubonic plague and the highly contagious disease it can convert to, called the pneumonic plague.

“Thank God she had the bubonic plague because if she had had the pneumonic plague, I would have been dead in 24 hours,” Dr. Mandavia explained. “Everyone in the room would have been dead in 24 hours.”

How did the patient get the bubonic plague? “This was a patient who had very, very poor hygiene in the house, and there were dead rodents and fleas,” he explained.

KOLOA, HAWAII — The DSM-IV criteria for diagnosing premenstrual dysphoric disorder need to be improved, Dr. Meir Steiner said at the annual meeting of the American College of Psychiatrists.

“What is wrong with the DSM criteria for PMDD?” he asked rhetorically. The answer is that all of the questions listed have just yes or no answers, which indicates that the criteria are too rigid. As a result, in the 17 years since the DSM criteria were formed, the Food and Drug Administration has not allowed “any studies on PMS because they claim there are no criteria that define or identify PMS,” he said.

“I believe PMS and PMDD are on a spectrum.” PMDD is primarily what psychiatrists are dealing with, which are primarily the mood syndromes, whereas PMS is something obstetricians and gynecologists see more of, which are primarily physical symptoms, said Dr. Steiner, professor of psychiatry and behavioral neurosciences, and ob.gyn. at McMaster University in Hamilton, Ont.

Dr. Steiner and his colleagues decided to try assessing DSM-IV criteria on a spectrum. With this approach, the physician would look at the symptom irritability, for example, and ask patients, “Is it severe, is it moderate, is it mild, or does it not exist at all?”

“By doing that, you have actually taken the DSM-IV criteria and transformed them from a yes/no to a continuum,” he said. (See box.)

The investigators did the same with the DSM-IV questions with regard to the burden of illness.

Dr. Steiner and his associates then created the following formula: If at least one of the first four criteria is severe (which is what the DSM-IV requires); at least four of the questions from 1 to 14 is moderate to severe; and at least one of the burden criteria is severe, then a patient qualifies for PMDD.

Then they went a step further: “If you are missing one step on each of these [criteria], you will still qualify for what we have identified as severe PMS,” Dr. Steiner asserted.

The investigators tested their new instrument on women who were at least 18 years of age, asking them to fill out a questionnaire that listed the 14 DSM-IV criteria for PMDD and then to rate their symptoms as “not at all,” “mild,” “moderate,” or “severe.” (See box.) A total of 5.1% of women qualified as having PMDD, and 20.7% had severe PMS.

To fulfill the diagnosis of PMS, “[the women] had the burden of illness and they had symptoms of PMDD, but were short one severity criterion,” said Dr. Steiner, who is also with the department of psychiatry in the Institute of Medical Sciences at the University of Toronto.

Because the FDA was not convinced that these symptoms occurred in girls younger than 18 years of age, Dr. Steiner and his associates tried the questionnaire on girls aged 12-17 years.

They interviewed 604 girls from three high schools. Nine percent of those girls qualified as having PMDD and 31% of them had severe PMS.

Of the latter, “what was missing was the burden of illness,” he said, noting that “four of the girls eventually came to the clinic for treatment.”

Dr. Steiner disclosed that he has received grants from the Canadian Institutes of Health Research and Physician Services Inc. He has received research support from GlaxoSmithKline Inc., Wyeth, AstraZeneca Pharmaceuticals LP, and H. Lundbeck A/S.

In addition, he is a consultant for Wyeth, GlaxoSmithKline, AstraZeneca, Azevan Pharmaceuticals Inc., and Bayer Schering Pharma. He has received an honorarium from Azevan.

DSM Criteria forDiagnosing PMDD

A. Symptoms must occur during the week before menses and remit a few days after onset of menses. Five of the following symptoms must be present and at least one must be 1, 2, 3, or 4.

1. Depressed mood or dysphoria.

2. Anxiety or tension.

3. Affective lability.

4. Irritability.

5. Decreased interest in engaging in usual activities.

6. Concentration difficulties.

7. Marked lack of energy.

8. Marked change in appetite, overeating, or food cravings.

9. Hypersomnia or insomnia.

10. Feeling overwhelmed.

11. Other physical symptoms, such as breast tenderness or bloating.

B. Symptoms must interfere with work, school, usual activities, or relationships.

C. Symptoms must not be merely an exacerbation of another disorder.

D. Criteria A, B, and C must be confirmed by prospective daily ratings for at least two consecutive symptomatic menstrual cycles.

Source: DSM-IV, Text Revision

Symptoms Listed On Questionnaire

1. Anger/irritability.

2. Anxiety/tension.

3. Tearful/increased sensitivity to rejection.

4. Depressed mood/hopelessness.

5. Decreased interest in executing work activities.

6. Decreased interest in engaging in home activities.

7. Decreased interest in participating in social activities.

8. Difficulty concentrating.

9. Fatigue/lack of energy.

10. Overeating/food cravings.

11. Insomnia.

12. Hypersomnia.

13. Feeling overwhelmed or out of control.

14. Physical symptoms: breast tenderness, headaches, joint/muscle pain, bloating, weight gain.

Source: Dr. Steiner

KOLOA, HAWAII — The DSM-IV criteria for diagnosing premenstrual dysphoric disorder need to be improved, Dr. Meir Steiner said at the annual meeting of the American College of Psychiatrists.

“What is wrong with the DSM criteria for PMDD?” he asked rhetorically. The answer is that all of the questions listed have just yes or no answers, which indicates that the criteria are too rigid. As a result, in the 17 years since the DSM criteria were formed, the Food and Drug Administration has not allowed “any studies on PMS because they claim there are no criteria that define or identify PMS,” he said.

“I believe PMS and PMDD are on a spectrum.” PMDD is primarily what psychiatrists are dealing with, which are primarily the mood syndromes, whereas PMS is something obstetricians and gynecologists see more of, which are primarily physical symptoms, said Dr. Steiner, professor of psychiatry and behavioral neurosciences, and ob.gyn. at McMaster University in Hamilton, Ont.

Dr. Steiner and his colleagues decided to try assessing DSM-IV criteria on a spectrum. With this approach, the physician would look at the symptom irritability, for example, and ask patients, “Is it severe, is it moderate, is it mild, or does it not exist at all?”

“By doing that, you have actually taken the DSM-IV criteria and transformed them from a yes/no to a continuum,” he said. (See box.)

The investigators did the same with the DSM-IV questions with regard to the burden of illness.

Dr. Steiner and his associates then created the following formula: If at least one of the first four criteria is severe (which is what the DSM-IV requires); at least four of the questions from 1 to 14 is moderate to severe; and at least one of the burden criteria is severe, then a patient qualifies for PMDD.

Then they went a step further: “If you are missing one step on each of these [criteria], you will still qualify for what we have identified as severe PMS,” Dr. Steiner asserted.

The investigators tested their new instrument on women who were at least 18 years of age, asking them to fill out a questionnaire that listed the 14 DSM-IV criteria for PMDD and then to rate their symptoms as “not at all,” “mild,” “moderate,” or “severe.” (See box.) A total of 5.1% of women qualified as having PMDD, and 20.7% had severe PMS.

To fulfill the diagnosis of PMS, “[the women] had the burden of illness and they had symptoms of PMDD, but were short one severity criterion,” said Dr. Steiner, who is also with the department of psychiatry in the Institute of Medical Sciences at the University of Toronto.

Because the FDA was not convinced that these symptoms occurred in girls younger than 18 years of age, Dr. Steiner and his associates tried the questionnaire on girls aged 12-17 years.

They interviewed 604 girls from three high schools. Nine percent of those girls qualified as having PMDD and 31% of them had severe PMS.

Of the latter, “what was missing was the burden of illness,” he said, noting that “four of the girls eventually came to the clinic for treatment.”

Dr. Steiner disclosed that he has received grants from the Canadian Institutes of Health Research and Physician Services Inc. He has received research support from GlaxoSmithKline Inc., Wyeth, AstraZeneca Pharmaceuticals LP, and H. Lundbeck A/S.

In addition, he is a consultant for Wyeth, GlaxoSmithKline, AstraZeneca, Azevan Pharmaceuticals Inc., and Bayer Schering Pharma. He has received an honorarium from Azevan.

DSM Criteria forDiagnosing PMDD

A. Symptoms must occur during the week before menses and remit a few days after onset of menses. Five of the following symptoms must be present and at least one must be 1, 2, 3, or 4.

1. Depressed mood or dysphoria.

2. Anxiety or tension.

3. Affective lability.

4. Irritability.

5. Decreased interest in engaging in usual activities.

6. Concentration difficulties.

7. Marked lack of energy.

8. Marked change in appetite, overeating, or food cravings.

9. Hypersomnia or insomnia.

10. Feeling overwhelmed.

11. Other physical symptoms, such as breast tenderness or bloating.

B. Symptoms must interfere with work, school, usual activities, or relationships.

C. Symptoms must not be merely an exacerbation of another disorder.

D. Criteria A, B, and C must be confirmed by prospective daily ratings for at least two consecutive symptomatic menstrual cycles.

Source: DSM-IV, Text Revision

Symptoms Listed On Questionnaire

1. Anger/irritability.

2. Anxiety/tension.

3. Tearful/increased sensitivity to rejection.

4. Depressed mood/hopelessness.

5. Decreased interest in executing work activities.

6. Decreased interest in engaging in home activities.

7. Decreased interest in participating in social activities.

8. Difficulty concentrating.

9. Fatigue/lack of energy.

10. Overeating/food cravings.

11. Insomnia.

12. Hypersomnia.

13. Feeling overwhelmed or out of control.

14. Physical symptoms: breast tenderness, headaches, joint/muscle pain, bloating, weight gain.

Source: Dr. Steiner

KOLOA, HAWAII — The DSM-IV criteria for diagnosing premenstrual dysphoric disorder need to be improved, Dr. Meir Steiner said at the annual meeting of the American College of Psychiatrists.

“What is wrong with the DSM criteria for PMDD?” he asked rhetorically. The answer is that all of the questions listed have just yes or no answers, which indicates that the criteria are too rigid. As a result, in the 17 years since the DSM criteria were formed, the Food and Drug Administration has not allowed “any studies on PMS because they claim there are no criteria that define or identify PMS,” he said.

“I believe PMS and PMDD are on a spectrum.” PMDD is primarily what psychiatrists are dealing with, which are primarily the mood syndromes, whereas PMS is something obstetricians and gynecologists see more of, which are primarily physical symptoms, said Dr. Steiner, professor of psychiatry and behavioral neurosciences, and ob.gyn. at McMaster University in Hamilton, Ont.

Dr. Steiner and his colleagues decided to try assessing DSM-IV criteria on a spectrum. With this approach, the physician would look at the symptom irritability, for example, and ask patients, “Is it severe, is it moderate, is it mild, or does it not exist at all?”

“By doing that, you have actually taken the DSM-IV criteria and transformed them from a yes/no to a continuum,” he said. (See box.)

The investigators did the same with the DSM-IV questions with regard to the burden of illness.

Dr. Steiner and his associates then created the following formula: If at least one of the first four criteria is severe (which is what the DSM-IV requires); at least four of the questions from 1 to 14 is moderate to severe; and at least one of the burden criteria is severe, then a patient qualifies for PMDD.

Then they went a step further: “If you are missing one step on each of these [criteria], you will still qualify for what we have identified as severe PMS,” Dr. Steiner asserted.

The investigators tested their new instrument on women who were at least 18 years of age, asking them to fill out a questionnaire that listed the 14 DSM-IV criteria for PMDD and then to rate their symptoms as “not at all,” “mild,” “moderate,” or “severe.” (See box.) A total of 5.1% of women qualified as having PMDD, and 20.7% had severe PMS.

To fulfill the diagnosis of PMS, “[the women] had the burden of illness and they had symptoms of PMDD, but were short one severity criterion,” said Dr. Steiner, who is also with the department of psychiatry in the Institute of Medical Sciences at the University of Toronto.

Because the FDA was not convinced that these symptoms occurred in girls younger than 18 years of age, Dr. Steiner and his associates tried the questionnaire on girls aged 12-17 years.

They interviewed 604 girls from three high schools. Nine percent of those girls qualified as having PMDD and 31% of them had severe PMS.

Of the latter, “what was missing was the burden of illness,” he said, noting that “four of the girls eventually came to the clinic for treatment.”

Dr. Steiner disclosed that he has received grants from the Canadian Institutes of Health Research and Physician Services Inc. He has received research support from GlaxoSmithKline Inc., Wyeth, AstraZeneca Pharmaceuticals LP, and H. Lundbeck A/S.

In addition, he is a consultant for Wyeth, GlaxoSmithKline, AstraZeneca, Azevan Pharmaceuticals Inc., and Bayer Schering Pharma. He has received an honorarium from Azevan.

DSM Criteria forDiagnosing PMDD

A. Symptoms must occur during the week before menses and remit a few days after onset of menses. Five of the following symptoms must be present and at least one must be 1, 2, 3, or 4.

1. Depressed mood or dysphoria.

2. Anxiety or tension.

3. Affective lability.

4. Irritability.

5. Decreased interest in engaging in usual activities.

6. Concentration difficulties.

7. Marked lack of energy.

8. Marked change in appetite, overeating, or food cravings.

9. Hypersomnia or insomnia.

10. Feeling overwhelmed.

11. Other physical symptoms, such as breast tenderness or bloating.

B. Symptoms must interfere with work, school, usual activities, or relationships.

C. Symptoms must not be merely an exacerbation of another disorder.

D. Criteria A, B, and C must be confirmed by prospective daily ratings for at least two consecutive symptomatic menstrual cycles.

Source: DSM-IV, Text Revision

Symptoms Listed On Questionnaire

1. Anger/irritability.

2. Anxiety/tension.

3. Tearful/increased sensitivity to rejection.

4. Depressed mood/hopelessness.

5. Decreased interest in executing work activities.

6. Decreased interest in engaging in home activities.

7. Decreased interest in participating in social activities.

8. Difficulty concentrating.

9. Fatigue/lack of energy.

10. Overeating/food cravings.

11. Insomnia.

12. Hypersomnia.

13. Feeling overwhelmed or out of control.

14. Physical symptoms: breast tenderness, headaches, joint/muscle pain, bloating, weight gain.

Source: Dr. Steiner

KOLOA, HAWAII — Although labeling typically doesn't support the use of psychotropic drugs in pregnant women, the drugs might be needed during pregnancy, according to an observational study done at Emory University, Atlanta.

“What I want you to recognize is that you're going to expose the child to something, be it illness or treatment, and in the context of that, some decisions are far worse than others,” Dr. Zachary N. Stowe said at the annual meeting of the American College of Psychiatrists. “Abruptly stopping or changing treatment at knowledge of conception is an effort on your part to reduce your anxiety. It doesn't change outcome. In fact, it probably worsens outcome,” Dr. Stowe asserted.

The need for treatment cannot be ignored. A large number of women who become pregnant have a mental health problem.

“We're talking about [400,000] or 500,000 women every year with a neuropsychiatric illness that” begins before family planning, or that might have been treated or needed to be treated during family planning, said Dr. Stowe, who is director of the women's mental health program at Emory University.

And with 4 million U.S. deliveries per year, he pointed out, “over 50% of pregnancies are unplanned.”

Studies of antenatal depression and its consequences led the American College of Obstetricians and Gynecologists to issue the following guideline statement in November 2007:

“Maternal psychiatric illness, if inadequately treated or untreated, may result in poor compliance with prenatal care, inadequate nutrition, exposure to additional medications or herbal remedies, increased alcohol and tobacco use, deficits in mother-infant bonding, and disruptions within the family environment.”

Other antenatal depression study findings include increases in suicide, postpartum depression, premature birth, low birth weight, neonatal complications, and fetal demise, said Dr. Stowe.

In the observational study that he and his colleagues conducted, pregnant women who had depression decided for themselves whether to discontinue their antidepressant medication.

Of the women who discontinued, 68% became “sick” before delivery, said Dr. Stowe. The other 32% were able to stop taking their antidepressant safely, but 25% who stayed on their antidepressant still became sick.

For women with bipolar disorder who discontinued their mood-stabilizing medication, 85% became sick before delivery.

A big problem, of course, is the typical drug labeling statement that “use in pregnancy is not recommended unless the potential benefits justify the potential risks to the fetus,” which Dr. Stowe called “handwashing.”

There's no question that psychotropic drugs will reach the fetus. Psychotropic medicines are designed to get past the blood-brain barrier and reach the brain, which means they will likely pass through the placental barrier without any difficulty. His own unpublished research has supported this, but he wondered if it is always harmful.

“You can actually statistically argue that antidepressants reduce your risk of birth defects,” he said. “To date, we have no confirmed evidence of increased birth defects on our antidepressants.”

In some psychotropic categories, however, some drugs are better than others—or much worse.

“Valproate has consistently the highest placental passage of any medicine we've studied, and it has the worst outcome,” said Dr. Stowe. “It is worse than Accutane.”

“In my opinion, there is no justification for first-line use of valproic acid in women of reproductive years,” he continued. In babies whose mothers used valproic acid during pregnancy, “the mean IQ drop is 15 points. One in 10 children is mentally retarded,” he said.

On the other hand, “lamotrigine is the cleanest anticonvulsant we've seen. It is emerging as the number-one treatment for epilepsy during pregnancy. The overall malformation rate is lower than the national average,” he pointed out.

A recent, not-yet-published study of the use of lamotrigine in 26 women with bipolar disorder found that they did well if they continued the drug throughout pregnancy but not if they discontinued.

A higher dosage is needed for treatment of bipolar disorder, just as it is needed for epilepsy, Dr. Stowe said.

Another unpublished study found that pregnant women using olanzapine “failed their blood sugar test, independent of dose,” he said. “We should not trade gestational diabetes to treat mental illness during pregnancy, because what you're actually trading is the risk for adult-onset diabetes after pregnancy. Gestational diabetes is a well-known risk factor for that.”

Not much is known about the use of atypical antipsychotic drugs during pregnancy, he said.

As for pregnant women using lithium, be aware that dehydration at birth can cause lithium toxicity in the infant, he said (Am. J. Psychiatry 2005;162:2162–70).

Switching drugs during the course of pregnancy with the thought that drug B has more safety data than drug A is entering “the world of the unknown,” Dr. Stowe said, “because all the data for medicine B were not derived from babies that first got medicine A. Everything we know about teratology says two medicines are worse than one. And please remember, the later trimesters can be just as important as the first trimester.”

Given the uncertainties of sexual behavior and the possibility of undetected pregnancy in female patients, “you should treat all women as though they are pregnant, starting at age 9. From 9 to 49, they are pregnant until proven otherwise,” he said.

Regarding the possibility of passing medications to infants during breast-feeding, “the dose in pregnancy is huge compared to the dose in lactation. Worrying about the medicine in lactation, if you used it in pregnancy, is really a waste of time. Our medicines in the bloodstream for antidepressants are nanograms per milliliter; for anticonvulsants they are in micrograms per milliliter. That's what gets into breast milk,” he said.

Dr. Stowe is on advisory boards for Bristol-Myers Squibb Co. and GlaxoSmithKline Inc. He has received grants from GlaxoSmithKline, Pfizer Inc., and Wyeth Pharmaceuticals. He is on the speakers bureaus of Eli Lilly, GlaxoSmithKline, Pfizer, and Wyeth Pharmaceuticals.

KOLOA, HAWAII — Although labeling typically doesn't support the use of psychotropic drugs in pregnant women, the drugs might be needed during pregnancy, according to an observational study done at Emory University, Atlanta.

“What I want you to recognize is that you're going to expose the child to something, be it illness or treatment, and in the context of that, some decisions are far worse than others,” Dr. Zachary N. Stowe said at the annual meeting of the American College of Psychiatrists. “Abruptly stopping or changing treatment at knowledge of conception is an effort on your part to reduce your anxiety. It doesn't change outcome. In fact, it probably worsens outcome,” Dr. Stowe asserted.

The need for treatment cannot be ignored. A large number of women who become pregnant have a mental health problem.

“We're talking about [400,000] or 500,000 women every year with a neuropsychiatric illness that” begins before family planning, or that might have been treated or needed to be treated during family planning, said Dr. Stowe, who is director of the women's mental health program at Emory University.

And with 4 million U.S. deliveries per year, he pointed out, “over 50% of pregnancies are unplanned.”

Studies of antenatal depression and its consequences led the American College of Obstetricians and Gynecologists to issue the following guideline statement in November 2007:

“Maternal psychiatric illness, if inadequately treated or untreated, may result in poor compliance with prenatal care, inadequate nutrition, exposure to additional medications or herbal remedies, increased alcohol and tobacco use, deficits in mother-infant bonding, and disruptions within the family environment.”

Other antenatal depression study findings include increases in suicide, postpartum depression, premature birth, low birth weight, neonatal complications, and fetal demise, said Dr. Stowe.

In the observational study that he and his colleagues conducted, pregnant women who had depression decided for themselves whether to discontinue their antidepressant medication.

Of the women who discontinued, 68% became “sick” before delivery, said Dr. Stowe. The other 32% were able to stop taking their antidepressant safely, but 25% who stayed on their antidepressant still became sick.

For women with bipolar disorder who discontinued their mood-stabilizing medication, 85% became sick before delivery.

A big problem, of course, is the typical drug labeling statement that “use in pregnancy is not recommended unless the potential benefits justify the potential risks to the fetus,” which Dr. Stowe called “handwashing.”

There's no question that psychotropic drugs will reach the fetus. Psychotropic medicines are designed to get past the blood-brain barrier and reach the brain, which means they will likely pass through the placental barrier without any difficulty. His own unpublished research has supported this, but he wondered if it is always harmful.

“You can actually statistically argue that antidepressants reduce your risk of birth defects,” he said. “To date, we have no confirmed evidence of increased birth defects on our antidepressants.”

In some psychotropic categories, however, some drugs are better than others—or much worse.

“Valproate has consistently the highest placental passage of any medicine we've studied, and it has the worst outcome,” said Dr. Stowe. “It is worse than Accutane.”

“In my opinion, there is no justification for first-line use of valproic acid in women of reproductive years,” he continued. In babies whose mothers used valproic acid during pregnancy, “the mean IQ drop is 15 points. One in 10 children is mentally retarded,” he said.

On the other hand, “lamotrigine is the cleanest anticonvulsant we've seen. It is emerging as the number-one treatment for epilepsy during pregnancy. The overall malformation rate is lower than the national average,” he pointed out.

A recent, not-yet-published study of the use of lamotrigine in 26 women with bipolar disorder found that they did well if they continued the drug throughout pregnancy but not if they discontinued.

A higher dosage is needed for treatment of bipolar disorder, just as it is needed for epilepsy, Dr. Stowe said.

Another unpublished study found that pregnant women using olanzapine “failed their blood sugar test, independent of dose,” he said. “We should not trade gestational diabetes to treat mental illness during pregnancy, because what you're actually trading is the risk for adult-onset diabetes after pregnancy. Gestational diabetes is a well-known risk factor for that.”

Not much is known about the use of atypical antipsychotic drugs during pregnancy, he said.

As for pregnant women using lithium, be aware that dehydration at birth can cause lithium toxicity in the infant, he said (Am. J. Psychiatry 2005;162:2162–70).

Switching drugs during the course of pregnancy with the thought that drug B has more safety data than drug A is entering “the world of the unknown,” Dr. Stowe said, “because all the data for medicine B were not derived from babies that first got medicine A. Everything we know about teratology says two medicines are worse than one. And please remember, the later trimesters can be just as important as the first trimester.”

Given the uncertainties of sexual behavior and the possibility of undetected pregnancy in female patients, “you should treat all women as though they are pregnant, starting at age 9. From 9 to 49, they are pregnant until proven otherwise,” he said.

Regarding the possibility of passing medications to infants during breast-feeding, “the dose in pregnancy is huge compared to the dose in lactation. Worrying about the medicine in lactation, if you used it in pregnancy, is really a waste of time. Our medicines in the bloodstream for antidepressants are nanograms per milliliter; for anticonvulsants they are in micrograms per milliliter. That's what gets into breast milk,” he said.

Dr. Stowe is on advisory boards for Bristol-Myers Squibb Co. and GlaxoSmithKline Inc. He has received grants from GlaxoSmithKline, Pfizer Inc., and Wyeth Pharmaceuticals. He is on the speakers bureaus of Eli Lilly, GlaxoSmithKline, Pfizer, and Wyeth Pharmaceuticals.

KOLOA, HAWAII — Although labeling typically doesn't support the use of psychotropic drugs in pregnant women, the drugs might be needed during pregnancy, according to an observational study done at Emory University, Atlanta.

“What I want you to recognize is that you're going to expose the child to something, be it illness or treatment, and in the context of that, some decisions are far worse than others,” Dr. Zachary N. Stowe said at the annual meeting of the American College of Psychiatrists. “Abruptly stopping or changing treatment at knowledge of conception is an effort on your part to reduce your anxiety. It doesn't change outcome. In fact, it probably worsens outcome,” Dr. Stowe asserted.

The need for treatment cannot be ignored. A large number of women who become pregnant have a mental health problem.

“We're talking about [400,000] or 500,000 women every year with a neuropsychiatric illness that” begins before family planning, or that might have been treated or needed to be treated during family planning, said Dr. Stowe, who is director of the women's mental health program at Emory University.

And with 4 million U.S. deliveries per year, he pointed out, “over 50% of pregnancies are unplanned.”

Studies of antenatal depression and its consequences led the American College of Obstetricians and Gynecologists to issue the following guideline statement in November 2007:

“Maternal psychiatric illness, if inadequately treated or untreated, may result in poor compliance with prenatal care, inadequate nutrition, exposure to additional medications or herbal remedies, increased alcohol and tobacco use, deficits in mother-infant bonding, and disruptions within the family environment.”

Other antenatal depression study findings include increases in suicide, postpartum depression, premature birth, low birth weight, neonatal complications, and fetal demise, said Dr. Stowe.

In the observational study that he and his colleagues conducted, pregnant women who had depression decided for themselves whether to discontinue their antidepressant medication.

Of the women who discontinued, 68% became “sick” before delivery, said Dr. Stowe. The other 32% were able to stop taking their antidepressant safely, but 25% who stayed on their antidepressant still became sick.

For women with bipolar disorder who discontinued their mood-stabilizing medication, 85% became sick before delivery.

A big problem, of course, is the typical drug labeling statement that “use in pregnancy is not recommended unless the potential benefits justify the potential risks to the fetus,” which Dr. Stowe called “handwashing.”

There's no question that psychotropic drugs will reach the fetus. Psychotropic medicines are designed to get past the blood-brain barrier and reach the brain, which means they will likely pass through the placental barrier without any difficulty. His own unpublished research has supported this, but he wondered if it is always harmful.

“You can actually statistically argue that antidepressants reduce your risk of birth defects,” he said. “To date, we have no confirmed evidence of increased birth defects on our antidepressants.”

In some psychotropic categories, however, some drugs are better than others—or much worse.

“Valproate has consistently the highest placental passage of any medicine we've studied, and it has the worst outcome,” said Dr. Stowe. “It is worse than Accutane.”

“In my opinion, there is no justification for first-line use of valproic acid in women of reproductive years,” he continued. In babies whose mothers used valproic acid during pregnancy, “the mean IQ drop is 15 points. One in 10 children is mentally retarded,” he said.

On the other hand, “lamotrigine is the cleanest anticonvulsant we've seen. It is emerging as the number-one treatment for epilepsy during pregnancy. The overall malformation rate is lower than the national average,” he pointed out.

A recent, not-yet-published study of the use of lamotrigine in 26 women with bipolar disorder found that they did well if they continued the drug throughout pregnancy but not if they discontinued.

A higher dosage is needed for treatment of bipolar disorder, just as it is needed for epilepsy, Dr. Stowe said.

Another unpublished study found that pregnant women using olanzapine “failed their blood sugar test, independent of dose,” he said. “We should not trade gestational diabetes to treat mental illness during pregnancy, because what you're actually trading is the risk for adult-onset diabetes after pregnancy. Gestational diabetes is a well-known risk factor for that.”

Not much is known about the use of atypical antipsychotic drugs during pregnancy, he said.

As for pregnant women using lithium, be aware that dehydration at birth can cause lithium toxicity in the infant, he said (Am. J. Psychiatry 2005;162:2162–70).

Switching drugs during the course of pregnancy with the thought that drug B has more safety data than drug A is entering “the world of the unknown,” Dr. Stowe said, “because all the data for medicine B were not derived from babies that first got medicine A. Everything we know about teratology says two medicines are worse than one. And please remember, the later trimesters can be just as important as the first trimester.”

Given the uncertainties of sexual behavior and the possibility of undetected pregnancy in female patients, “you should treat all women as though they are pregnant, starting at age 9. From 9 to 49, they are pregnant until proven otherwise,” he said.

Regarding the possibility of passing medications to infants during breast-feeding, “the dose in pregnancy is huge compared to the dose in lactation. Worrying about the medicine in lactation, if you used it in pregnancy, is really a waste of time. Our medicines in the bloodstream for antidepressants are nanograms per milliliter; for anticonvulsants they are in micrograms per milliliter. That's what gets into breast milk,” he said.

Dr. Stowe is on advisory boards for Bristol-Myers Squibb Co. and GlaxoSmithKline Inc. He has received grants from GlaxoSmithKline, Pfizer Inc., and Wyeth Pharmaceuticals. He is on the speakers bureaus of Eli Lilly, GlaxoSmithKline, Pfizer, and Wyeth Pharmaceuticals.

HONOLULU — Bazedoxifene is effective in preventing osteoporosis in postmenopausal women, according to the results of a 2-year, phase III, placebo-controlled trial presented at the annual meeting of the American Society for Bone and Mineral Research.

“In relatively young, healthy, postmenopausal women with normal or low bone mineral density, bazedoxifene treatment prevented bone loss, reduced bone turnover, was generally well tolerated, had a neutral effect on endometrial tissue, and, for the primary end point, had similar BMD efficacy as raloxifene,” said Dr. Paul D. Miller, of the University of Colorado Medical Center, Denver. In addition, “bazedoxifene had a favorable risk-benefit profile, supporting its use for the prevention of postmenopausal early bone loss.”

A novel selective estrogen receptor modulator, bazedoxifene has been under development as monotherapy for the prevention and treatment of postmenopausal osteoporosis. In late April 2007, the Food and Drug Administration issued an approvable letter for bazedoxifene for the prevention of postmenopausal osteoporosis; this study was designed to assess the efficacy and safety of the drug for this purpose.

Study participants were healthy postmenopausal women aged 45 years, whose femoral neck bone or lumbar spine T scores were not less than -2.5. Women with vasomotor symptoms that required treatment, as well as those with bone diseases, previous vertebral fractures, or endometrial hyperplasia, were excluded.

In the trial, a total of 1,583 postmenopausal women were randomized to daily bazedoxifene regimens of 10 mg, 20 mg, or 40 mg, or to raloxifene (60 mg), or to placebo. In addition, all women received a daily calcium supplement of 600 mg.

Of 1,583 women enrolled, 1,113 (70%) completed the 2-year study. More than 90% of women in each treatment group were white. Mean body mass index (kg/m

The primary outcome was the percent change in the BMD of the lumbar spine after 24 months of treatment. BMD at other skeletal sites was a secondary outcome.

By month 24 of treatment, BMD loss was prevented in all treatment groups with the exception of women using placebo, who experienced a significant decline in BMD. More specifically, the percent change in lumbar spine BMD from baseline—relative to placebo—was 1.1%, 1.4%, and 1.5%, for bazedoxifene 10 mg, 20 mg, and 40 mg, respectively; it was 1.5% for raloxifene 60 mg (P less than .001). Similar dose-response results were found at other skeletal sites for women using bazedoxifene.

Adverse event rates were similar among treatment groups, as were serious adverse event rates and adverse event-caused discontinuations.

Vasodilation was found more often in patients using bazedoxifene 20 mg (20%) and 40 mg (23%) and raloxifene 60 mg (18%), compared with those using placebo (13%). Other cardiovascular adverse event rates were similarly low in all treatment groups. All treatment groups had a similar incidence of leg cramps, ranging from 9% to nearly 12%. All treatment groups had a low incidence of venous thrombotic adverse events, including fewer than 1% of patients using bazedoxifene at any dosage.

The study was supported by Wyeth Research and Wyeth Pharmaceuticals. Dr. Miller also disclosed various financial relationships to a number of research companies, including Wyeth.

HONOLULU — Bazedoxifene is effective in preventing osteoporosis in postmenopausal women, according to the results of a 2-year, phase III, placebo-controlled trial presented at the annual meeting of the American Society for Bone and Mineral Research.

“In relatively young, healthy, postmenopausal women with normal or low bone mineral density, bazedoxifene treatment prevented bone loss, reduced bone turnover, was generally well tolerated, had a neutral effect on endometrial tissue, and, for the primary end point, had similar BMD efficacy as raloxifene,” said Dr. Paul D. Miller, of the University of Colorado Medical Center, Denver. In addition, “bazedoxifene had a favorable risk-benefit profile, supporting its use for the prevention of postmenopausal early bone loss.”

A novel selective estrogen receptor modulator, bazedoxifene has been under development as monotherapy for the prevention and treatment of postmenopausal osteoporosis. In late April 2007, the Food and Drug Administration issued an approvable letter for bazedoxifene for the prevention of postmenopausal osteoporosis; this study was designed to assess the efficacy and safety of the drug for this purpose.

Study participants were healthy postmenopausal women aged 45 years, whose femoral neck bone or lumbar spine T scores were not less than -2.5. Women with vasomotor symptoms that required treatment, as well as those with bone diseases, previous vertebral fractures, or endometrial hyperplasia, were excluded.

In the trial, a total of 1,583 postmenopausal women were randomized to daily bazedoxifene regimens of 10 mg, 20 mg, or 40 mg, or to raloxifene (60 mg), or to placebo. In addition, all women received a daily calcium supplement of 600 mg.

Of 1,583 women enrolled, 1,113 (70%) completed the 2-year study. More than 90% of women in each treatment group were white. Mean body mass index (kg/m

The primary outcome was the percent change in the BMD of the lumbar spine after 24 months of treatment. BMD at other skeletal sites was a secondary outcome.

By month 24 of treatment, BMD loss was prevented in all treatment groups with the exception of women using placebo, who experienced a significant decline in BMD. More specifically, the percent change in lumbar spine BMD from baseline—relative to placebo—was 1.1%, 1.4%, and 1.5%, for bazedoxifene 10 mg, 20 mg, and 40 mg, respectively; it was 1.5% for raloxifene 60 mg (P less than .001). Similar dose-response results were found at other skeletal sites for women using bazedoxifene.

Adverse event rates were similar among treatment groups, as were serious adverse event rates and adverse event-caused discontinuations.

Vasodilation was found more often in patients using bazedoxifene 20 mg (20%) and 40 mg (23%) and raloxifene 60 mg (18%), compared with those using placebo (13%). Other cardiovascular adverse event rates were similarly low in all treatment groups. All treatment groups had a similar incidence of leg cramps, ranging from 9% to nearly 12%. All treatment groups had a low incidence of venous thrombotic adverse events, including fewer than 1% of patients using bazedoxifene at any dosage.

The study was supported by Wyeth Research and Wyeth Pharmaceuticals. Dr. Miller also disclosed various financial relationships to a number of research companies, including Wyeth.

HONOLULU — Bazedoxifene is effective in preventing osteoporosis in postmenopausal women, according to the results of a 2-year, phase III, placebo-controlled trial presented at the annual meeting of the American Society for Bone and Mineral Research.

“In relatively young, healthy, postmenopausal women with normal or low bone mineral density, bazedoxifene treatment prevented bone loss, reduced bone turnover, was generally well tolerated, had a neutral effect on endometrial tissue, and, for the primary end point, had similar BMD efficacy as raloxifene,” said Dr. Paul D. Miller, of the University of Colorado Medical Center, Denver. In addition, “bazedoxifene had a favorable risk-benefit profile, supporting its use for the prevention of postmenopausal early bone loss.”

A novel selective estrogen receptor modulator, bazedoxifene has been under development as monotherapy for the prevention and treatment of postmenopausal osteoporosis. In late April 2007, the Food and Drug Administration issued an approvable letter for bazedoxifene for the prevention of postmenopausal osteoporosis; this study was designed to assess the efficacy and safety of the drug for this purpose.

Study participants were healthy postmenopausal women aged 45 years, whose femoral neck bone or lumbar spine T scores were not less than -2.5. Women with vasomotor symptoms that required treatment, as well as those with bone diseases, previous vertebral fractures, or endometrial hyperplasia, were excluded.

In the trial, a total of 1,583 postmenopausal women were randomized to daily bazedoxifene regimens of 10 mg, 20 mg, or 40 mg, or to raloxifene (60 mg), or to placebo. In addition, all women received a daily calcium supplement of 600 mg.

Of 1,583 women enrolled, 1,113 (70%) completed the 2-year study. More than 90% of women in each treatment group were white. Mean body mass index (kg/m

The primary outcome was the percent change in the BMD of the lumbar spine after 24 months of treatment. BMD at other skeletal sites was a secondary outcome.

By month 24 of treatment, BMD loss was prevented in all treatment groups with the exception of women using placebo, who experienced a significant decline in BMD. More specifically, the percent change in lumbar spine BMD from baseline—relative to placebo—was 1.1%, 1.4%, and 1.5%, for bazedoxifene 10 mg, 20 mg, and 40 mg, respectively; it was 1.5% for raloxifene 60 mg (P less than .001). Similar dose-response results were found at other skeletal sites for women using bazedoxifene.

Adverse event rates were similar among treatment groups, as were serious adverse event rates and adverse event-caused discontinuations.

Vasodilation was found more often in patients using bazedoxifene 20 mg (20%) and 40 mg (23%) and raloxifene 60 mg (18%), compared with those using placebo (13%). Other cardiovascular adverse event rates were similarly low in all treatment groups. All treatment groups had a similar incidence of leg cramps, ranging from 9% to nearly 12%. All treatment groups had a low incidence of venous thrombotic adverse events, including fewer than 1% of patients using bazedoxifene at any dosage.

The study was supported by Wyeth Research and Wyeth Pharmaceuticals. Dr. Miller also disclosed various financial relationships to a number of research companies, including Wyeth.

WAIKOLOA, HAWAII — Calcium hydroxylapatite, injected as an implant for soft-tissue augmentation of the nasolabial folds and other facial areas, was safe after 4 years of follow-up in a two-center study of over 100 patients.

The investigators found that results lasted about 8 months for the majority of patients; results lasted longer (about 10–12 months) in patients who received multiple injections and touch-up sessions.

Dr. Bruce E. Katz of the department of dermatology at Mount Sinai School of Medicine, New York, described the findings (Dermatol. Surg. 2007;33:122–7) during a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The 113 patients in the study ranged in age from 26 to 78 years; 100 of them were women. The nasolabial folds were injected in 86 patients. A single injection was given at a single session to 75 patients (66%), and 38 (34%) had more than one session, said Dr. Katz. Most patients were given a 1-mL injection of calcium hydroxylapatite at a session; 12 were given a 2-mL injection.

Calcium hydroxylapatite (Radiesse) is a synthetically sourced, semipermanent, soft-tissue filler that comprises 25- to 45-mcm microspheres suspended in an aqueous gel. The microspheres "form a scaffold for tissue growth," he said. The calcium hydroxylapatite particles degrade over time to calcium particles and phosphate ions. "This material is highly biocompatible, it's durable, it does not migrate, it's not antigenic, and it's [radiopaque]."

Seven patients in the study reported adverse events, which were short term and minor, resolving within a month, according to Dr. Katz. These adverse events included three cases of transient ecchymoses, two patients with inflammation and edema, and two with nongranulomatous submucosal nodules of the lip.

A subset of 41 patients rated efficacy of treatment on a scale of 1 (satisfactory) to 5 (excellent), he said. The mean score of visual satisfaction after treatment was 4.6. The mean scores of those physicians who rated results using the same scale were 4.5 for visual satisfaction and 4.6 for the feel of the implant. At 6 months' follow-up, patients' mean scores were 4.8 for visual satisfaction and 4.9 for the feel of the treatment; physicians' mean scores were 4.5 for visual satisfaction and 4.9 for feel.

Dr. Katz has received compensation from BioForm Medical Inc. for making presentations on calcium hydroxylapatite.

SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

WAIKOLOA, HAWAII — Calcium hydroxylapatite, injected as an implant for soft-tissue augmentation of the nasolabial folds and other facial areas, was safe after 4 years of follow-up in a two-center study of over 100 patients.

The investigators found that results lasted about 8 months for the majority of patients; results lasted longer (about 10–12 months) in patients who received multiple injections and touch-up sessions.

Dr. Bruce E. Katz of the department of dermatology at Mount Sinai School of Medicine, New York, described the findings (Dermatol. Surg. 2007;33:122–7) during a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The 113 patients in the study ranged in age from 26 to 78 years; 100 of them were women. The nasolabial folds were injected in 86 patients. A single injection was given at a single session to 75 patients (66%), and 38 (34%) had more than one session, said Dr. Katz. Most patients were given a 1-mL injection of calcium hydroxylapatite at a session; 12 were given a 2-mL injection.

Calcium hydroxylapatite (Radiesse) is a synthetically sourced, semipermanent, soft-tissue filler that comprises 25- to 45-mcm microspheres suspended in an aqueous gel. The microspheres "form a scaffold for tissue growth," he said. The calcium hydroxylapatite particles degrade over time to calcium particles and phosphate ions. "This material is highly biocompatible, it's durable, it does not migrate, it's not antigenic, and it's [radiopaque]."

Seven patients in the study reported adverse events, which were short term and minor, resolving within a month, according to Dr. Katz. These adverse events included three cases of transient ecchymoses, two patients with inflammation and edema, and two with nongranulomatous submucosal nodules of the lip.

A subset of 41 patients rated efficacy of treatment on a scale of 1 (satisfactory) to 5 (excellent), he said. The mean score of visual satisfaction after treatment was 4.6. The mean scores of those physicians who rated results using the same scale were 4.5 for visual satisfaction and 4.6 for the feel of the implant. At 6 months' follow-up, patients' mean scores were 4.8 for visual satisfaction and 4.9 for the feel of the treatment; physicians' mean scores were 4.5 for visual satisfaction and 4.9 for feel.

Dr. Katz has received compensation from BioForm Medical Inc. for making presentations on calcium hydroxylapatite.

SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

WAIKOLOA, HAWAII — Calcium hydroxylapatite, injected as an implant for soft-tissue augmentation of the nasolabial folds and other facial areas, was safe after 4 years of follow-up in a two-center study of over 100 patients.

The investigators found that results lasted about 8 months for the majority of patients; results lasted longer (about 10–12 months) in patients who received multiple injections and touch-up sessions.

Dr. Bruce E. Katz of the department of dermatology at Mount Sinai School of Medicine, New York, described the findings (Dermatol. Surg. 2007;33:122–7) during a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The 113 patients in the study ranged in age from 26 to 78 years; 100 of them were women. The nasolabial folds were injected in 86 patients. A single injection was given at a single session to 75 patients (66%), and 38 (34%) had more than one session, said Dr. Katz. Most patients were given a 1-mL injection of calcium hydroxylapatite at a session; 12 were given a 2-mL injection.

Calcium hydroxylapatite (Radiesse) is a synthetically sourced, semipermanent, soft-tissue filler that comprises 25- to 45-mcm microspheres suspended in an aqueous gel. The microspheres "form a scaffold for tissue growth," he said. The calcium hydroxylapatite particles degrade over time to calcium particles and phosphate ions. "This material is highly biocompatible, it's durable, it does not migrate, it's not antigenic, and it's [radiopaque]."

Seven patients in the study reported adverse events, which were short term and minor, resolving within a month, according to Dr. Katz. These adverse events included three cases of transient ecchymoses, two patients with inflammation and edema, and two with nongranulomatous submucosal nodules of the lip.

A subset of 41 patients rated efficacy of treatment on a scale of 1 (satisfactory) to 5 (excellent), he said. The mean score of visual satisfaction after treatment was 4.6. The mean scores of those physicians who rated results using the same scale were 4.5 for visual satisfaction and 4.6 for the feel of the implant. At 6 months' follow-up, patients' mean scores were 4.8 for visual satisfaction and 4.9 for the feel of the treatment; physicians' mean scores were 4.5 for visual satisfaction and 4.9 for feel.

Dr. Katz has received compensation from BioForm Medical Inc. for making presentations on calcium hydroxylapatite.

SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

KOLOA, HAWAII — The DSM-IV criteria for diagnosing premenstrual dysphoric disorder need to be improved, Dr. Meir Steiner said at the annual meeting of the American College of Psychiatrists.

“What is wrong with the DSM criteria for PMDD?” he asked rhetorically. All the questions listed have just yes-or-no answers, indicating that the criteria are too rigid. As a result, in the 17 years since the DSM criteria were formed, the Food and Drug Administration has not allowed “any studies on PMS because they claim there are no criteria that define or identify PMS,” he said.

“I believe PMS and PMDD are on a spectrum. PMDD is primarily what we psychiatrists are dealing with, which are primarily the mood syndromes, whereas PMS is something [obstetricians and gynecologists] see more of, which are primarily physical symptoms,” said Dr. Steiner, professor of psychiatry and behavioral neurosciences, and ob.gyn. at McMaster University in Hamilton, Ont.

Dr. Steiner and his colleagues decided to try assessing DSM-IV criteria on a spectrum. With this approach, the physician would look at the symptom irritability, for example, and ask patients, “Is it severe, is it moderate, is it mild, or does it not exist at all?”

“By doing that, you have actually taken the DSM-IV criteria and transformed them from a yes/no to a continuum,” he said. (See box.) They did the same with the DSM-IV questions regarding the burden of illness.

The investigators then created the following formula: If at least one of the first four criteria is severe (which is what the DSM-IV requires); at least four of the questions from 1 to 14 is moderate to severe; and at least one of the burden criteria is severe, then a patient qualifies for PMDD. Then they went a step further: “If you are missing one step on each of these [criteria], you will still qualify for what we have identified as severe PMS,” he said.

They tested their new instrument on women who were at least 18 years of age, asking them to fill out a questionnaire that listed the 14 DSM-IV criteria for PMDD and to rate their symptoms as “not at all,” “mild,” “moderate,” or “severe.” A total of 5.1% of women qualified as having PMDD, and 20.7% had severe PMS.

To fulfill the diagnosis of PMS, “they had the burden of illness and they had symptoms of PMDD, but were short one severity criterion,” said Dr. Steiner, who is also founding director of the Women's Health Concerns Clinic for St. Joseph's Healthcare in Hamilton.

Because the FDA was not convinced that these symptoms occurred in girls younger than 18 years of age, Dr. Steiner and his associates tried the questionnaire on girls aged 12–17 years. They interviewed 604 girls from three high schools. Of those girls, 9% qualified as having PMDD and 31% had severe PMS. Of the latter, “what was missing was the burden of illness,” he said, noting that “four of the girls eventually came to the clinic for treatment.”

Premenstrual Symptoms Questionnaire

Anger/irritability.

Anxiety/tension.

Tearful/increased sensitivity to rejection.

Depressed mood/hopelessness.

Decreased interest in work activities.

Decreased interest in home activities.

Decreased interest in social activities.

Difficulty concentrating.

Fatigue/lack of energy.

Overeating/food cravings.

Insomnia.

Hypersomnia.

Feeling overwhelmed or out of control.

Physical symptoms: breast tenderness, headaches, joint/muscle pain, bloating, weight gain.

Source: Dr. Steiner

Diagnostic Criteria for PMDD

Symptoms must occur during the week before menses and remit a few days after onset of menses. Five of the following symptoms must be present and at least one must be 1, 2, 3, or 4.

Depressed mood or dysphoria.

Anxiety or tension.

Affective lability.

Irritability.

Decreased interest in usual activities.

Concentration difficulties.

Marked lack of energy.

Marked change in appetite, overeating, or food cravings.

Hypersomnia or insomnia.

Feeling overwhelmed.

Other physical symptoms, such as breast tenderness or bloating.

Symptoms must interfere with work, school, usual activities, or relationships.

Symptoms must not be merely an exacerbation of another disorder.

Criteria A, B, and C must be confirmed by prospective daily ratings for at least two consecutive symptomatic menstrual cycles.

Source: DSM-IV, Text Revision

KOLOA, HAWAII — The DSM-IV criteria for diagnosing premenstrual dysphoric disorder need to be improved, Dr. Meir Steiner said at the annual meeting of the American College of Psychiatrists.

“What is wrong with the DSM criteria for PMDD?” he asked rhetorically. All the questions listed have just yes-or-no answers, indicating that the criteria are too rigid. As a result, in the 17 years since the DSM criteria were formed, the Food and Drug Administration has not allowed “any studies on PMS because they claim there are no criteria that define or identify PMS,” he said.

“I believe PMS and PMDD are on a spectrum. PMDD is primarily what we psychiatrists are dealing with, which are primarily the mood syndromes, whereas PMS is something [obstetricians and gynecologists] see more of, which are primarily physical symptoms,” said Dr. Steiner, professor of psychiatry and behavioral neurosciences, and ob.gyn. at McMaster University in Hamilton, Ont.

Dr. Steiner and his colleagues decided to try assessing DSM-IV criteria on a spectrum. With this approach, the physician would look at the symptom irritability, for example, and ask patients, “Is it severe, is it moderate, is it mild, or does it not exist at all?”

“By doing that, you have actually taken the DSM-IV criteria and transformed them from a yes/no to a continuum,” he said. (See box.) They did the same with the DSM-IV questions regarding the burden of illness.

The investigators then created the following formula: If at least one of the first four criteria is severe (which is what the DSM-IV requires); at least four of the questions from 1 to 14 is moderate to severe; and at least one of the burden criteria is severe, then a patient qualifies for PMDD. Then they went a step further: “If you are missing one step on each of these [criteria], you will still qualify for what we have identified as severe PMS,” he said.

They tested their new instrument on women who were at least 18 years of age, asking them to fill out a questionnaire that listed the 14 DSM-IV criteria for PMDD and to rate their symptoms as “not at all,” “mild,” “moderate,” or “severe.” A total of 5.1% of women qualified as having PMDD, and 20.7% had severe PMS.

To fulfill the diagnosis of PMS, “they had the burden of illness and they had symptoms of PMDD, but were short one severity criterion,” said Dr. Steiner, who is also founding director of the Women's Health Concerns Clinic for St. Joseph's Healthcare in Hamilton.

Because the FDA was not convinced that these symptoms occurred in girls younger than 18 years of age, Dr. Steiner and his associates tried the questionnaire on girls aged 12–17 years. They interviewed 604 girls from three high schools. Of those girls, 9% qualified as having PMDD and 31% had severe PMS. Of the latter, “what was missing was the burden of illness,” he said, noting that “four of the girls eventually came to the clinic for treatment.”

Premenstrual Symptoms Questionnaire

Anger/irritability.

Anxiety/tension.

Tearful/increased sensitivity to rejection.

Depressed mood/hopelessness.

Decreased interest in work activities.

Decreased interest in home activities.

Decreased interest in social activities.

Difficulty concentrating.

Fatigue/lack of energy.

Overeating/food cravings.

Insomnia.

Hypersomnia.

Feeling overwhelmed or out of control.

Physical symptoms: breast tenderness, headaches, joint/muscle pain, bloating, weight gain.

Source: Dr. Steiner

Diagnostic Criteria for PMDD

Symptoms must occur during the week before menses and remit a few days after onset of menses. Five of the following symptoms must be present and at least one must be 1, 2, 3, or 4.

Depressed mood or dysphoria.

Anxiety or tension.

Affective lability.

Irritability.

Decreased interest in usual activities.

Concentration difficulties.

Marked lack of energy.

Marked change in appetite, overeating, or food cravings.

Hypersomnia or insomnia.

Feeling overwhelmed.

Other physical symptoms, such as breast tenderness or bloating.

Symptoms must interfere with work, school, usual activities, or relationships.

Symptoms must not be merely an exacerbation of another disorder.

Criteria A, B, and C must be confirmed by prospective daily ratings for at least two consecutive symptomatic menstrual cycles.

Source: DSM-IV, Text Revision

KOLOA, HAWAII — The DSM-IV criteria for diagnosing premenstrual dysphoric disorder need to be improved, Dr. Meir Steiner said at the annual meeting of the American College of Psychiatrists.

“What is wrong with the DSM criteria for PMDD?” he asked rhetorically. All the questions listed have just yes-or-no answers, indicating that the criteria are too rigid. As a result, in the 17 years since the DSM criteria were formed, the Food and Drug Administration has not allowed “any studies on PMS because they claim there are no criteria that define or identify PMS,” he said.

“I believe PMS and PMDD are on a spectrum. PMDD is primarily what we psychiatrists are dealing with, which are primarily the mood syndromes, whereas PMS is something [obstetricians and gynecologists] see more of, which are primarily physical symptoms,” said Dr. Steiner, professor of psychiatry and behavioral neurosciences, and ob.gyn. at McMaster University in Hamilton, Ont.

Dr. Steiner and his colleagues decided to try assessing DSM-IV criteria on a spectrum. With this approach, the physician would look at the symptom irritability, for example, and ask patients, “Is it severe, is it moderate, is it mild, or does it not exist at all?”

“By doing that, you have actually taken the DSM-IV criteria and transformed them from a yes/no to a continuum,” he said. (See box.) They did the same with the DSM-IV questions regarding the burden of illness.

The investigators then created the following formula: If at least one of the first four criteria is severe (which is what the DSM-IV requires); at least four of the questions from 1 to 14 is moderate to severe; and at least one of the burden criteria is severe, then a patient qualifies for PMDD. Then they went a step further: “If you are missing one step on each of these [criteria], you will still qualify for what we have identified as severe PMS,” he said.

They tested their new instrument on women who were at least 18 years of age, asking them to fill out a questionnaire that listed the 14 DSM-IV criteria for PMDD and to rate their symptoms as “not at all,” “mild,” “moderate,” or “severe.” A total of 5.1% of women qualified as having PMDD, and 20.7% had severe PMS.

To fulfill the diagnosis of PMS, “they had the burden of illness and they had symptoms of PMDD, but were short one severity criterion,” said Dr. Steiner, who is also founding director of the Women's Health Concerns Clinic for St. Joseph's Healthcare in Hamilton.

Because the FDA was not convinced that these symptoms occurred in girls younger than 18 years of age, Dr. Steiner and his associates tried the questionnaire on girls aged 12–17 years. They interviewed 604 girls from three high schools. Of those girls, 9% qualified as having PMDD and 31% had severe PMS. Of the latter, “what was missing was the burden of illness,” he said, noting that “four of the girls eventually came to the clinic for treatment.”

Premenstrual Symptoms Questionnaire

Anger/irritability.

Anxiety/tension.

Tearful/increased sensitivity to rejection.

Depressed mood/hopelessness.

Decreased interest in work activities.

Decreased interest in home activities.

Decreased interest in social activities.

Difficulty concentrating.

Fatigue/lack of energy.

Overeating/food cravings.

Insomnia.

Hypersomnia.

Feeling overwhelmed or out of control.

Physical symptoms: breast tenderness, headaches, joint/muscle pain, bloating, weight gain.

Source: Dr. Steiner

Diagnostic Criteria for PMDD

Symptoms must occur during the week before menses and remit a few days after onset of menses. Five of the following symptoms must be present and at least one must be 1, 2, 3, or 4.

Depressed mood or dysphoria.

Anxiety or tension.

Affective lability.

Irritability.

Decreased interest in usual activities.

Concentration difficulties.

Marked lack of energy.

Marked change in appetite, overeating, or food cravings.

Hypersomnia or insomnia.

Feeling overwhelmed.

Other physical symptoms, such as breast tenderness or bloating.

Symptoms must interfere with work, school, usual activities, or relationships.

Symptoms must not be merely an exacerbation of another disorder.

Criteria A, B, and C must be confirmed by prospective daily ratings for at least two consecutive symptomatic menstrual cycles.

Source: DSM-IV, Text Revision

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), said at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300–400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital. The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder. The film also includes interviews with two spouses who were survivors of husband physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May, although the date had not yet been set at press time.

In addition, a set of slides related to the topic of the film is being developed that can be used at medical schools, in residency programs, and at hospitals, according to Dr. Clayton. Those slides will be available over the next few months.

From the larger film, a 13-minute short about the medical student also has been under development. “We lose about an entire medical school class a year—of physicians—to suicide every year.” Dr. Clayton said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fund-raising walk held in Boston, she said.

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), said at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300–400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital. The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder. The film also includes interviews with two spouses who were survivors of husband physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May, although the date had not yet been set at press time.

In addition, a set of slides related to the topic of the film is being developed that can be used at medical schools, in residency programs, and at hospitals, according to Dr. Clayton. Those slides will be available over the next few months.

From the larger film, a 13-minute short about the medical student also has been under development. “We lose about an entire medical school class a year—of physicians—to suicide every year.” Dr. Clayton said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fund-raising walk held in Boston, she said.

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), said at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300–400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital. The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder. The film also includes interviews with two spouses who were survivors of husband physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May, although the date had not yet been set at press time.

In addition, a set of slides related to the topic of the film is being developed that can be used at medical schools, in residency programs, and at hospitals, according to Dr. Clayton. Those slides will be available over the next few months.

From the larger film, a 13-minute short about the medical student also has been under development. “We lose about an entire medical school class a year—of physicians—to suicide every year.” Dr. Clayton said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fund-raising walk held in Boston, she said.

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), said at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300–400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital. The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder. The film also includes interviews with two spouses who were survivors of husband physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May. In addition, a set of slides related to the topic of the film will be available over the next few months for use at medical schools, in residency programs, and at hospitals, according to Dr. Clayton.

From the larger film, a 13-minute short about the medical student also has been under development. “We lose about an entire medical school class a year—of physicians—to suicide every year.” Dr. Clayton said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fundraising walk held in Boston, she said.

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), said at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300–400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital. The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder. The film also includes interviews with two spouses who were survivors of husband physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May. In addition, a set of slides related to the topic of the film will be available over the next few months for use at medical schools, in residency programs, and at hospitals, according to Dr. Clayton.

From the larger film, a 13-minute short about the medical student also has been under development. “We lose about an entire medical school class a year—of physicians—to suicide every year.” Dr. Clayton said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fundraising walk held in Boston, she said.

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), said at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300–400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital. The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder. The film also includes interviews with two spouses who were survivors of husband physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May. In addition, a set of slides related to the topic of the film will be available over the next few months for use at medical schools, in residency programs, and at hospitals, according to Dr. Clayton.

From the larger film, a 13-minute short about the medical student also has been under development. “We lose about an entire medical school class a year—of physicians—to suicide every year.” Dr. Clayton said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fundraising walk held in Boston, she said.

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, which is titled “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, said Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300-400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital.

The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder.

The film also includes interviews with two spouses who were survivors of husband physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May, although the date had not yet been set at press time.

In addition, a set of slides related to the topic of the film is being developed that can be used at medical schools, in residency programs, and at hospitals, according to Dr. Clayton.

Those slides will be available over the next few months.

From the larger film, a 13-minute short about the medical student also has been under development.

“We lose about an entire medical school class a year—of physicians—to suicide,” Dr. Clayton said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fund-raising walk that was held in Boston, commented Dr. Clayton.

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, which is titled “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, said Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300-400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital.

The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder.

The film also includes interviews with two spouses who were survivors of husband physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May, although the date had not yet been set at press time.

In addition, a set of slides related to the topic of the film is being developed that can be used at medical schools, in residency programs, and at hospitals, according to Dr. Clayton.

Those slides will be available over the next few months.

From the larger film, a 13-minute short about the medical student also has been under development.

“We lose about an entire medical school class a year—of physicians—to suicide,” Dr. Clayton said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fund-raising walk that was held in Boston, commented Dr. Clayton.

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, which is titled “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, said Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300-400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital.

The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder.

The film also includes interviews with two spouses who were survivors of husband physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May, although the date had not yet been set at press time.

In addition, a set of slides related to the topic of the film is being developed that can be used at medical schools, in residency programs, and at hospitals, according to Dr. Clayton.

Those slides will be available over the next few months.

From the larger film, a 13-minute short about the medical student also has been under development.

“We lose about an entire medical school class a year—of physicians—to suicide,” Dr. Clayton said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fund-raising walk that was held in Boston, commented Dr. Clayton.

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), said at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300–400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital. The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder. The film includes interviews with two spouses of physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May, although the date had not yet been set at press time.

In addition, a set of slides related to the topic of the film is being developed that can be used at medical schools, in residency programs, and at hospitals, according to Dr. Clayton.

From the larger film, a 13-minute short about the medical student also has been under development. “We lose about an entire medical school class a year—of physicians—to suicide every year,” she said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fund-raising walk held in Boston, Dr. Clayton said.

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), said at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300–400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital. The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder. The film includes interviews with two spouses of physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May, although the date had not yet been set at press time.

In addition, a set of slides related to the topic of the film is being developed that can be used at medical schools, in residency programs, and at hospitals, according to Dr. Clayton.

From the larger film, a 13-minute short about the medical student also has been under development. “We lose about an entire medical school class a year—of physicians—to suicide every year,” she said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fund-raising walk held in Boston, Dr. Clayton said.

KAUAI, HAWAII — U.S. physicians have among the highest suicide rates of any occupation in this country, and a 1-hour documentary has been made to illuminate this problem, Dr. Paula Clayton reported.

The hope is that the documentary, “Struggling in Silence: Physician Depression and Suicide,” will foster a change in the practice and culture of medicine so that physicians begin to feel free to seek psychiatric help when they need it, Dr. Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), said at the annual meeting of the American College of Psychiatrists.

According to a clip from the film shown at the meeting, 300–400 physicians commit suicide each year. The clip showed interviews with a medical student in San Diego, a surgeon from Arkansas, and a physician at Massachusetts General Hospital. The first two described their struggles with depression, and in the third interview, the physician discussed her difficulties in dealing with bipolar disorder. The film includes interviews with two spouses of physicians who committed suicide, Dr. Clayton said.

The film is scheduled to be aired on PBS stations in May, although the date had not yet been set at press time.

In addition, a set of slides related to the topic of the film is being developed that can be used at medical schools, in residency programs, and at hospitals, according to Dr. Clayton.

From the larger film, a 13-minute short about the medical student also has been under development. “We lose about an entire medical school class a year—of physicians—to suicide every year,” she said.

“Struggling in Silence,” created by AFSP, was partly funded by the American College of Physicians, Wyeth Pharmaceuticals, and proceeds from a fund-raising walk held in Boston, Dr. Clayton said.