James Randolph Hillard, MD

Comment on this article

Mr. G, age 46, works for a large federal government agency in a middle-management position. He presents seeking treatment for insomnia. He says, “I just need a sleeping pill. I haven’t been able to sleep for the last 3 months because everybody at work is talking behind my back and spreading rumors about how I’m crazy. My boss is in on it, too. She is always trying to undermine me and makes a big deal out of every little mistake I make.”

Mr. G is suspicious, asking questions about the confidentiality of medical records. His speech is rapid, and he is anxious but exhibits a full range of affect and no pressured speech or flight of ideas. Mr. G describes early, middle, and late insomnia, decreased energy and interest, and gaining 10 pounds over the past 3 months.

He admits owning a gun and having frequent thoughts of suicide and fantasies of killing his boss, although Mr. G repeatedly affirms he would never act on these thoughts. A week ago, his wife moved in with her parents because, he says, “she just couldn’t stand to be around me any longer.”

I consider involuntary hospitalization for Mr. G. Ultimately I contact his wife, who agrees to pick him up, stay with him overnight, and return with him the next morning. Because the only medication Mr. G is willing to consider is sleeping pills, I prescribe flurazepam, 30 mg qhs.

Mr. G was apparently paranoid, thinking of killing his boss, and had a gun. If his wife had not answered the phone and been willing to stay with him, he might have been involuntarily committed. As it was, further interviews with him revealed that Mr. G had been a target of workplace “mobbing,” and that his insomnia and paranoia developed because of a deliberate campaign by coworkers.

This article discusses how to recognize symptoms of workplace mobbing, using Mr. G’s experience to illustrate the dynamics of this group behavior. An informed mental health professional can be of enormous help to a mobbing victim, but an uninformed professional can unwittingly make the situation much worse.

What is ‘mobbing’?

Initiated most often by a person in a position of power or influence, mobbing has been described as “a desperate urge to crush and eliminate the target…. As the campaign proceeds, a steadily larger range of hostile ploys and communications comes to be seen as legitimate.”¹ This behavior pattern has been recognized in Europe since the 1980s but is not well recognized in the United States.

Davenport et al² brought the phenomenon and its consequences to the U.S. public’s attention in 1999 with the publication of Mobbing: emotional abuse in the American workplace. Otherwise, little professional literature on workplace mobbing has been produced in the United States.

A PubMed search on the term “mobbing” limited to 1982 through October 2008 returned 95 listings, excluding those dealing purely with ethology, but only 1 report from the United States. Studies from outside the United States indicate that mobbing is relatively common (Box).

Mobbing, bullying, and harassment. The term “workplace mobbing” was coined by Leymann,³ an occupational psychologist who investigated the psychology of workers who had suffered severe trauma. He observed that some of the most severe reactions were among workers who had been the target of “an impassioned collective campaign by coworkers to exclude, punish, or humiliate” them.

Many researchers use the term mobbing to describe a negative work environment created by several individuals working together.^1–3 However, some researchers such as Namie et al⁴ use the term workplace bullying to describe the creation of a hostile work environment by either a single individual—usually a boss—or a number of individuals.

Box

CASE CONTINUED: Why I first thought ‘paranoia’

During our first interview, Mr. G said that 6 months before he sought treatment he had reported misuse of government property by his supervisor’s boss. The case was investigated and dismissed. Mr. G’s supervisor never confronted him about the complaint, but shortly afterwards Mr. G started to notice disturbing changes in the workplace.

His supervisor avoided Mr. G’s phone calls and e-mails and stopped meeting with him. Instead, she met with Mr. G’s subordinates. The subordinates started to ignore Mr. G’s instructions and would roll their eyes or be inattentive when he spoke. Coworkers stopped talking when Mr. G approached, and he started receiving anonymous e-mails questioning his ability and sanity. He was reprimanded in writing for having made a $9 mathematical error in an expense reimbursement request.

Mr. G said when he approached his superior about the work environment, she stated that he was “just paranoid” and needed to see a psychiatrist.

When Mr. G’s wife accompanies him to the second interview, she confirms his impressions of ostracism and gossip at work. She also relates her experiences with people from Mr. G’s office who previously had been friendly but now were distant or hostile. Mr. G shows me copies of harassing work e-mails and memos. I tell Mr. G I believe his story and diagnose him as suffering from posttraumatic stress disorder (PTSD). He begins supportive/cognitive therapy and continues flurazepam.

Mobbing syndrome

As it turns out, Mr. G was not paranoid; his coworkers really were trying to get him. Leymann⁵ divided 45 types of mobbing behaviors into 5 categories. These were organized as attacks on:

• self-expression and ability to communicate (victim is silenced, given no opportunity to communicate, subject to verbal attacks)
  
• social relationships (colleagues do not talk to the victim, victim is physically isolated from others)
  
• reputation (victim is the target of gossip and ridicule)
  
• occupational situation (victim is given meaningless tasks or no work at all)
  
• physical health (victim is assigned dangerous tasks, threatened with bodily harm, or physically attacked).
  

Table 1

Mobbing syndrome: 10 factors

• different ethnicity
  
• an “odd” personality
  
• high achievement.
  

Phases of mobbing

Secondary morbidity. Victims of workplace mobbing frequently suffer from:

• adjustment disorders
  
• somatic symptoms (eg, headaches or irritable bowel syndrome)
  
• PTSD^6,7
  
• major depression.⁸
  

Leymann³ estimated that 15% of suicides in Sweden could be directly attributed to workplace mobbing. Although no other researcher has reported such a dramatic proportion, others have reported increased risk of suicidal behavior among mobbing victims.¹⁰

Table 3

Degrees of mobbing

CASE CONTINUED: Redirecting energy into a job search

As I met with Mr. G over the next 3 months, the pattern of malicious communication and actions continued at his office. For example, he received a written reprimand for being 10 minutes late after having overslept when starting flurazepam, which he continued to take for about 6 weeks without further tardiness. I encouraged Mr. G to withdraw energy from work by keeping a low profile and trying not to react to provocations. Instead, I counseled him to put energy into family activities and try to find a new job.

Mr. G experienced relatively mild, first-degree workplace mobbing, but it had a substantial effect on his quality of life and that of his wife for almost 1 year. If I had followed my first impulse and had Mr. G involuntarily hospitalized after our first interview, it would have confirmed rumors at his office and probably would have escalated the mobbing behavior.

Diagnostic recommendations

Consider the possibility that seemingly paranoid individuals could be the target of mobbing at work, and don’t underestimate the psychological stress of being mobbed. Other forms of workplace harassment can be extremely stressful but do not have the “paranoidogenic” potential of mobbing. Patients may be so distressed that it is difficult to figure out what is going on in their work environment.

Ask patients to present physical evidence of conspiracy or harassment. Mobbing patients usually are willing to bring in large quantities of material. Keep in mind that when subjected to mobbing behavior over time, a person who is not initially paranoid is likely to develop some secondary suspiciousness and even frank paranoia.

Also consider the possibility of “pseudomobbing,” in which an individual falsely believes he or she is a mobbing victim. Cases of pseudomobbing have been reported in European literature¹¹ and may represent a negative side effect of greater public awareness of the mobbing phenomenon (and of legal remedies to mobbing available in various European countries).

Mobbing is a serious stressor that can lead to psychiatric and medical morbidity and even suicide. Major depressive disorder—often with suicidal ideation—is frequently associated with being mobbed.¹²

A diagnosis of PTSD can be missed if the mobbing victim does not seem to have been subjected to a severe enough stress to meet PTSD criteria.

Treatment recommendations

First, do no harm: Do not allow yourself to be used by the mob. This process can be direct—as in the Mr. G’s case, where the patient was almost involuntarily committed—or subtle. For example, a person you know may describe the behavior of “someone at work,” and you may be tempted to respond, “Well, I have not examined this person, but from what you say, it sounds like maybe…” You could then be quoted as a psychiatrist who agrees that the person is paranoid.

Giving your patient a name for what is happening to him or her may be the most therapeutic intervention. Generally, patients have not heard of mobbing. They typically are confused about what is happening and may blame themselves.

Treat secondary symptoms of depression, anxiety, PTSD, or other sequelae with pharmacotherapy, psychotherapy, or a combination as appropriate. Refer patients with somatic symptoms to primary care if you feel that they need further evaluation.

Encourage your patient to visualize choices and ways to escape the situation. Frequently, patients will be locked into “fighting for justice” or putting up with the situation because they see no options.

Encourage your patient to withdraw energy from work and invest it in family, social life, or anything else. At the appropriate time, encourage him or her to grieve losses experienced as a result of the mobbing.

Related resources

• Leymann H. The Mobbing Encyclopaedia. www.leymann.se.
  
• Westhues K. Workplace mobbing in academe. http://arts.uwaterloo.ca/~kwesthue/mobbing.htm.
  
• Namie R, Namie G. The Workplace Bullying Institute. www.bullyinginstitute.org.
  

• Flurazepam • Dalmane
  

Dr. Hillard reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Comment on this article

Mr. G, age 46, works for a large federal government agency in a middle-management position. He presents seeking treatment for insomnia. He says, “I just need a sleeping pill. I haven’t been able to sleep for the last 3 months because everybody at work is talking behind my back and spreading rumors about how I’m crazy. My boss is in on it, too. She is always trying to undermine me and makes a big deal out of every little mistake I make.”

Mr. G is suspicious, asking questions about the confidentiality of medical records. His speech is rapid, and he is anxious but exhibits a full range of affect and no pressured speech or flight of ideas. Mr. G describes early, middle, and late insomnia, decreased energy and interest, and gaining 10 pounds over the past 3 months.

He admits owning a gun and having frequent thoughts of suicide and fantasies of killing his boss, although Mr. G repeatedly affirms he would never act on these thoughts. A week ago, his wife moved in with her parents because, he says, “she just couldn’t stand to be around me any longer.”

I consider involuntary hospitalization for Mr. G. Ultimately I contact his wife, who agrees to pick him up, stay with him overnight, and return with him the next morning. Because the only medication Mr. G is willing to consider is sleeping pills, I prescribe flurazepam, 30 mg qhs.

Mr. G was apparently paranoid, thinking of killing his boss, and had a gun. If his wife had not answered the phone and been willing to stay with him, he might have been involuntarily committed. As it was, further interviews with him revealed that Mr. G had been a target of workplace “mobbing,” and that his insomnia and paranoia developed because of a deliberate campaign by coworkers.

This article discusses how to recognize symptoms of workplace mobbing, using Mr. G’s experience to illustrate the dynamics of this group behavior. An informed mental health professional can be of enormous help to a mobbing victim, but an uninformed professional can unwittingly make the situation much worse.

What is ‘mobbing’?

Initiated most often by a person in a position of power or influence, mobbing has been described as “a desperate urge to crush and eliminate the target…. As the campaign proceeds, a steadily larger range of hostile ploys and communications comes to be seen as legitimate.”¹ This behavior pattern has been recognized in Europe since the 1980s but is not well recognized in the United States.

Davenport et al² brought the phenomenon and its consequences to the U.S. public’s attention in 1999 with the publication of Mobbing: emotional abuse in the American workplace. Otherwise, little professional literature on workplace mobbing has been produced in the United States.

A PubMed search on the term “mobbing” limited to 1982 through October 2008 returned 95 listings, excluding those dealing purely with ethology, but only 1 report from the United States. Studies from outside the United States indicate that mobbing is relatively common (Box).

Mobbing, bullying, and harassment. The term “workplace mobbing” was coined by Leymann,³ an occupational psychologist who investigated the psychology of workers who had suffered severe trauma. He observed that some of the most severe reactions were among workers who had been the target of “an impassioned collective campaign by coworkers to exclude, punish, or humiliate” them.

Many researchers use the term mobbing to describe a negative work environment created by several individuals working together.^1–3 However, some researchers such as Namie et al⁴ use the term workplace bullying to describe the creation of a hostile work environment by either a single individual—usually a boss—or a number of individuals.

Box

CASE CONTINUED: Why I first thought ‘paranoia’

During our first interview, Mr. G said that 6 months before he sought treatment he had reported misuse of government property by his supervisor’s boss. The case was investigated and dismissed. Mr. G’s supervisor never confronted him about the complaint, but shortly afterwards Mr. G started to notice disturbing changes in the workplace.

His supervisor avoided Mr. G’s phone calls and e-mails and stopped meeting with him. Instead, she met with Mr. G’s subordinates. The subordinates started to ignore Mr. G’s instructions and would roll their eyes or be inattentive when he spoke. Coworkers stopped talking when Mr. G approached, and he started receiving anonymous e-mails questioning his ability and sanity. He was reprimanded in writing for having made a $9 mathematical error in an expense reimbursement request.

Mr. G said when he approached his superior about the work environment, she stated that he was “just paranoid” and needed to see a psychiatrist.

When Mr. G’s wife accompanies him to the second interview, she confirms his impressions of ostracism and gossip at work. She also relates her experiences with people from Mr. G’s office who previously had been friendly but now were distant or hostile. Mr. G shows me copies of harassing work e-mails and memos. I tell Mr. G I believe his story and diagnose him as suffering from posttraumatic stress disorder (PTSD). He begins supportive/cognitive therapy and continues flurazepam.

Mobbing syndrome

As it turns out, Mr. G was not paranoid; his coworkers really were trying to get him. Leymann⁵ divided 45 types of mobbing behaviors into 5 categories. These were organized as attacks on:

• self-expression and ability to communicate (victim is silenced, given no opportunity to communicate, subject to verbal attacks)
  
• social relationships (colleagues do not talk to the victim, victim is physically isolated from others)
  
• reputation (victim is the target of gossip and ridicule)
  
• occupational situation (victim is given meaningless tasks or no work at all)
  
• physical health (victim is assigned dangerous tasks, threatened with bodily harm, or physically attacked).
  

Table 1

Mobbing syndrome: 10 factors

• different ethnicity
  
• an “odd” personality
  
• high achievement.
  

Phases of mobbing

Secondary morbidity. Victims of workplace mobbing frequently suffer from:

• adjustment disorders
  
• somatic symptoms (eg, headaches or irritable bowel syndrome)
  
• PTSD^6,7
  
• major depression.⁸
  

Leymann³ estimated that 15% of suicides in Sweden could be directly attributed to workplace mobbing. Although no other researcher has reported such a dramatic proportion, others have reported increased risk of suicidal behavior among mobbing victims.¹⁰

Table 3

Degrees of mobbing

CASE CONTINUED: Redirecting energy into a job search

As I met with Mr. G over the next 3 months, the pattern of malicious communication and actions continued at his office. For example, he received a written reprimand for being 10 minutes late after having overslept when starting flurazepam, which he continued to take for about 6 weeks without further tardiness. I encouraged Mr. G to withdraw energy from work by keeping a low profile and trying not to react to provocations. Instead, I counseled him to put energy into family activities and try to find a new job.

Mr. G experienced relatively mild, first-degree workplace mobbing, but it had a substantial effect on his quality of life and that of his wife for almost 1 year. If I had followed my first impulse and had Mr. G involuntarily hospitalized after our first interview, it would have confirmed rumors at his office and probably would have escalated the mobbing behavior.

Diagnostic recommendations

Consider the possibility that seemingly paranoid individuals could be the target of mobbing at work, and don’t underestimate the psychological stress of being mobbed. Other forms of workplace harassment can be extremely stressful but do not have the “paranoidogenic” potential of mobbing. Patients may be so distressed that it is difficult to figure out what is going on in their work environment.

Ask patients to present physical evidence of conspiracy or harassment. Mobbing patients usually are willing to bring in large quantities of material. Keep in mind that when subjected to mobbing behavior over time, a person who is not initially paranoid is likely to develop some secondary suspiciousness and even frank paranoia.

Also consider the possibility of “pseudomobbing,” in which an individual falsely believes he or she is a mobbing victim. Cases of pseudomobbing have been reported in European literature¹¹ and may represent a negative side effect of greater public awareness of the mobbing phenomenon (and of legal remedies to mobbing available in various European countries).

Mobbing is a serious stressor that can lead to psychiatric and medical morbidity and even suicide. Major depressive disorder—often with suicidal ideation—is frequently associated with being mobbed.¹²

A diagnosis of PTSD can be missed if the mobbing victim does not seem to have been subjected to a severe enough stress to meet PTSD criteria.

Treatment recommendations

First, do no harm: Do not allow yourself to be used by the mob. This process can be direct—as in the Mr. G’s case, where the patient was almost involuntarily committed—or subtle. For example, a person you know may describe the behavior of “someone at work,” and you may be tempted to respond, “Well, I have not examined this person, but from what you say, it sounds like maybe…” You could then be quoted as a psychiatrist who agrees that the person is paranoid.

Giving your patient a name for what is happening to him or her may be the most therapeutic intervention. Generally, patients have not heard of mobbing. They typically are confused about what is happening and may blame themselves.

Treat secondary symptoms of depression, anxiety, PTSD, or other sequelae with pharmacotherapy, psychotherapy, or a combination as appropriate. Refer patients with somatic symptoms to primary care if you feel that they need further evaluation.

Encourage your patient to visualize choices and ways to escape the situation. Frequently, patients will be locked into “fighting for justice” or putting up with the situation because they see no options.

Encourage your patient to withdraw energy from work and invest it in family, social life, or anything else. At the appropriate time, encourage him or her to grieve losses experienced as a result of the mobbing.

Related resources

• Leymann H. The Mobbing Encyclopaedia. www.leymann.se.
  
• Westhues K. Workplace mobbing in academe. http://arts.uwaterloo.ca/~kwesthue/mobbing.htm.
  
• Namie R, Namie G. The Workplace Bullying Institute. www.bullyinginstitute.org.
  

• Flurazepam • Dalmane
  

Dr. Hillard reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Comment on this article

Mr. G, age 46, works for a large federal government agency in a middle-management position. He presents seeking treatment for insomnia. He says, “I just need a sleeping pill. I haven’t been able to sleep for the last 3 months because everybody at work is talking behind my back and spreading rumors about how I’m crazy. My boss is in on it, too. She is always trying to undermine me and makes a big deal out of every little mistake I make.”

Mr. G is suspicious, asking questions about the confidentiality of medical records. His speech is rapid, and he is anxious but exhibits a full range of affect and no pressured speech or flight of ideas. Mr. G describes early, middle, and late insomnia, decreased energy and interest, and gaining 10 pounds over the past 3 months.

He admits owning a gun and having frequent thoughts of suicide and fantasies of killing his boss, although Mr. G repeatedly affirms he would never act on these thoughts. A week ago, his wife moved in with her parents because, he says, “she just couldn’t stand to be around me any longer.”

I consider involuntary hospitalization for Mr. G. Ultimately I contact his wife, who agrees to pick him up, stay with him overnight, and return with him the next morning. Because the only medication Mr. G is willing to consider is sleeping pills, I prescribe flurazepam, 30 mg qhs.

Mr. G was apparently paranoid, thinking of killing his boss, and had a gun. If his wife had not answered the phone and been willing to stay with him, he might have been involuntarily committed. As it was, further interviews with him revealed that Mr. G had been a target of workplace “mobbing,” and that his insomnia and paranoia developed because of a deliberate campaign by coworkers.

This article discusses how to recognize symptoms of workplace mobbing, using Mr. G’s experience to illustrate the dynamics of this group behavior. An informed mental health professional can be of enormous help to a mobbing victim, but an uninformed professional can unwittingly make the situation much worse.

What is ‘mobbing’?

Initiated most often by a person in a position of power or influence, mobbing has been described as “a desperate urge to crush and eliminate the target…. As the campaign proceeds, a steadily larger range of hostile ploys and communications comes to be seen as legitimate.”¹ This behavior pattern has been recognized in Europe since the 1980s but is not well recognized in the United States.

Davenport et al² brought the phenomenon and its consequences to the U.S. public’s attention in 1999 with the publication of Mobbing: emotional abuse in the American workplace. Otherwise, little professional literature on workplace mobbing has been produced in the United States.

A PubMed search on the term “mobbing” limited to 1982 through October 2008 returned 95 listings, excluding those dealing purely with ethology, but only 1 report from the United States. Studies from outside the United States indicate that mobbing is relatively common (Box).

Mobbing, bullying, and harassment. The term “workplace mobbing” was coined by Leymann,³ an occupational psychologist who investigated the psychology of workers who had suffered severe trauma. He observed that some of the most severe reactions were among workers who had been the target of “an impassioned collective campaign by coworkers to exclude, punish, or humiliate” them.

Many researchers use the term mobbing to describe a negative work environment created by several individuals working together.^1–3 However, some researchers such as Namie et al⁴ use the term workplace bullying to describe the creation of a hostile work environment by either a single individual—usually a boss—or a number of individuals.

Box

CASE CONTINUED: Why I first thought ‘paranoia’

During our first interview, Mr. G said that 6 months before he sought treatment he had reported misuse of government property by his supervisor’s boss. The case was investigated and dismissed. Mr. G’s supervisor never confronted him about the complaint, but shortly afterwards Mr. G started to notice disturbing changes in the workplace.

His supervisor avoided Mr. G’s phone calls and e-mails and stopped meeting with him. Instead, she met with Mr. G’s subordinates. The subordinates started to ignore Mr. G’s instructions and would roll their eyes or be inattentive when he spoke. Coworkers stopped talking when Mr. G approached, and he started receiving anonymous e-mails questioning his ability and sanity. He was reprimanded in writing for having made a $9 mathematical error in an expense reimbursement request.

Mr. G said when he approached his superior about the work environment, she stated that he was “just paranoid” and needed to see a psychiatrist.

When Mr. G’s wife accompanies him to the second interview, she confirms his impressions of ostracism and gossip at work. She also relates her experiences with people from Mr. G’s office who previously had been friendly but now were distant or hostile. Mr. G shows me copies of harassing work e-mails and memos. I tell Mr. G I believe his story and diagnose him as suffering from posttraumatic stress disorder (PTSD). He begins supportive/cognitive therapy and continues flurazepam.

Mobbing syndrome

As it turns out, Mr. G was not paranoid; his coworkers really were trying to get him. Leymann⁵ divided 45 types of mobbing behaviors into 5 categories. These were organized as attacks on:

• self-expression and ability to communicate (victim is silenced, given no opportunity to communicate, subject to verbal attacks)
  
• social relationships (colleagues do not talk to the victim, victim is physically isolated from others)
  
• reputation (victim is the target of gossip and ridicule)
  
• occupational situation (victim is given meaningless tasks or no work at all)
  
• physical health (victim is assigned dangerous tasks, threatened with bodily harm, or physically attacked).
  

Table 1

Mobbing syndrome: 10 factors

• different ethnicity
  
• an “odd” personality
  
• high achievement.
  

Phases of mobbing

Secondary morbidity. Victims of workplace mobbing frequently suffer from:

• adjustment disorders
  
• somatic symptoms (eg, headaches or irritable bowel syndrome)
  
• PTSD^6,7
  
• major depression.⁸
  

Leymann³ estimated that 15% of suicides in Sweden could be directly attributed to workplace mobbing. Although no other researcher has reported such a dramatic proportion, others have reported increased risk of suicidal behavior among mobbing victims.¹⁰

Table 3

Degrees of mobbing

CASE CONTINUED: Redirecting energy into a job search

As I met with Mr. G over the next 3 months, the pattern of malicious communication and actions continued at his office. For example, he received a written reprimand for being 10 minutes late after having overslept when starting flurazepam, which he continued to take for about 6 weeks without further tardiness. I encouraged Mr. G to withdraw energy from work by keeping a low profile and trying not to react to provocations. Instead, I counseled him to put energy into family activities and try to find a new job.

Mr. G experienced relatively mild, first-degree workplace mobbing, but it had a substantial effect on his quality of life and that of his wife for almost 1 year. If I had followed my first impulse and had Mr. G involuntarily hospitalized after our first interview, it would have confirmed rumors at his office and probably would have escalated the mobbing behavior.

Diagnostic recommendations

Consider the possibility that seemingly paranoid individuals could be the target of mobbing at work, and don’t underestimate the psychological stress of being mobbed. Other forms of workplace harassment can be extremely stressful but do not have the “paranoidogenic” potential of mobbing. Patients may be so distressed that it is difficult to figure out what is going on in their work environment.

Ask patients to present physical evidence of conspiracy or harassment. Mobbing patients usually are willing to bring in large quantities of material. Keep in mind that when subjected to mobbing behavior over time, a person who is not initially paranoid is likely to develop some secondary suspiciousness and even frank paranoia.

Also consider the possibility of “pseudomobbing,” in which an individual falsely believes he or she is a mobbing victim. Cases of pseudomobbing have been reported in European literature¹¹ and may represent a negative side effect of greater public awareness of the mobbing phenomenon (and of legal remedies to mobbing available in various European countries).

Mobbing is a serious stressor that can lead to psychiatric and medical morbidity and even suicide. Major depressive disorder—often with suicidal ideation—is frequently associated with being mobbed.¹²

A diagnosis of PTSD can be missed if the mobbing victim does not seem to have been subjected to a severe enough stress to meet PTSD criteria.

Treatment recommendations

First, do no harm: Do not allow yourself to be used by the mob. This process can be direct—as in the Mr. G’s case, where the patient was almost involuntarily committed—or subtle. For example, a person you know may describe the behavior of “someone at work,” and you may be tempted to respond, “Well, I have not examined this person, but from what you say, it sounds like maybe…” You could then be quoted as a psychiatrist who agrees that the person is paranoid.

Giving your patient a name for what is happening to him or her may be the most therapeutic intervention. Generally, patients have not heard of mobbing. They typically are confused about what is happening and may blame themselves.

Treat secondary symptoms of depression, anxiety, PTSD, or other sequelae with pharmacotherapy, psychotherapy, or a combination as appropriate. Refer patients with somatic symptoms to primary care if you feel that they need further evaluation.

Encourage your patient to visualize choices and ways to escape the situation. Frequently, patients will be locked into “fighting for justice” or putting up with the situation because they see no options.

Encourage your patient to withdraw energy from work and invest it in family, social life, or anything else. At the appropriate time, encourage him or her to grieve losses experienced as a result of the mobbing.

Related resources

• Leymann H. The Mobbing Encyclopaedia. www.leymann.se.
  
• Westhues K. Workplace mobbing in academe. http://arts.uwaterloo.ca/~kwesthue/mobbing.htm.
  
• Namie R, Namie G. The Workplace Bullying Institute. www.bullyinginstitute.org.
  

• Flurazepam • Dalmane
  

Dr. Hillard reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Valedictory: a statement of farewell or leave taking. From pp. stem of L. valedicere “bid farewell,” from vale, imperative of valere “be well” + dicere “to say”

Dear Readers,

I am graduating from my position as editor-in-chief of Current Psychiatry. Four years is enough for high school, college, medical school, or residency training (at least in psychiatry). It is also the right amount of time to have been editor of this journal (although it has taken me closer to 5 years to finish).

Since January 2002, Current Psychiatry has become one of the most widely read journals in its field. It is the only journal I read cover to cover, and I know that is the case for many of you as well. Wherever I go, I hear extremely positive comments from psychiatrists and psychiatric nurse practitioners. I like to think that Current Psychiatry—more than other journals—has put our readers at the center and has always tried to give you “news you can use this week” in your clinical practices.

I am very happy that our editor, Alice Luddington, and the rest of the excellent Quadrant HealthCom Inc. staff will continue to work with you on this journal. I am also happy that my good friend, Henry A. Nasrallah, MD, is assuming the role of editor-in-chief as of next month’s issue.

I plan to work on several exciting new projects this summer. I also plan to read Current Psychiatry for a long time to come. Be well!

Valedictory: a statement of farewell or leave taking. From pp. stem of L. valedicere “bid farewell,” from vale, imperative of valere “be well” + dicere “to say”

Dear Readers,

I am graduating from my position as editor-in-chief of Current Psychiatry. Four years is enough for high school, college, medical school, or residency training (at least in psychiatry). It is also the right amount of time to have been editor of this journal (although it has taken me closer to 5 years to finish).

Since January 2002, Current Psychiatry has become one of the most widely read journals in its field. It is the only journal I read cover to cover, and I know that is the case for many of you as well. Wherever I go, I hear extremely positive comments from psychiatrists and psychiatric nurse practitioners. I like to think that Current Psychiatry—more than other journals—has put our readers at the center and has always tried to give you “news you can use this week” in your clinical practices.

I am very happy that our editor, Alice Luddington, and the rest of the excellent Quadrant HealthCom Inc. staff will continue to work with you on this journal. I am also happy that my good friend, Henry A. Nasrallah, MD, is assuming the role of editor-in-chief as of next month’s issue.

I plan to work on several exciting new projects this summer. I also plan to read Current Psychiatry for a long time to come. Be well!

Valedictory: a statement of farewell or leave taking. From pp. stem of L. valedicere “bid farewell,” from vale, imperative of valere “be well” + dicere “to say”

Dear Readers,

I am graduating from my position as editor-in-chief of Current Psychiatry. Four years is enough for high school, college, medical school, or residency training (at least in psychiatry). It is also the right amount of time to have been editor of this journal (although it has taken me closer to 5 years to finish).

Since January 2002, Current Psychiatry has become one of the most widely read journals in its field. It is the only journal I read cover to cover, and I know that is the case for many of you as well. Wherever I go, I hear extremely positive comments from psychiatrists and psychiatric nurse practitioners. I like to think that Current Psychiatry—more than other journals—has put our readers at the center and has always tried to give you “news you can use this week” in your clinical practices.

I am very happy that our editor, Alice Luddington, and the rest of the excellent Quadrant HealthCom Inc. staff will continue to work with you on this journal. I am also happy that my good friend, Henry A. Nasrallah, MD, is assuming the role of editor-in-chief as of next month’s issue.

I plan to work on several exciting new projects this summer. I also plan to read Current Psychiatry for a long time to come. Be well!

The 1960s’ catecholamine hypothesis—that depression is caused by deficiencies in neurotransmitters such as serotonin and norepinephrine—has greatly influenced how doctors, patients, and the public regard depression. On the positive side, this “chemical imbalance” concept helped reduce the stigma of depression; the illness could be seen as something other than the patient’s fault.

More subtly, though, the imbalance idea is overly simplistic: Antidepressants work in depression the way insulin does in diabetes. When patients don’t have enough of a chemical, just replace it and you have managed the disease. Consequently, some health insurers cover medication management of depression but not psychotherapy, and patients come into the office saying, “I don’t want to talk about my feelings; just give me a pill.”

A recent study suggests that depression and its treatment are more complicated than a simple chemical imbalance. In “Neuroscience News”, Dr. Edmund Higgins reviews research suggesting that scarred DNA strands cause depression.

Thus, science is catching up with what psychiatrists have learned first-hand from clinical practice:

• depression is caused by a complex interaction among neurotransmitters, genetics, and environment
• treating depression successfully is usually complex, too.

The 1960s’ catecholamine hypothesis—that depression is caused by deficiencies in neurotransmitters such as serotonin and norepinephrine—has greatly influenced how doctors, patients, and the public regard depression. On the positive side, this “chemical imbalance” concept helped reduce the stigma of depression; the illness could be seen as something other than the patient’s fault.

More subtly, though, the imbalance idea is overly simplistic: Antidepressants work in depression the way insulin does in diabetes. When patients don’t have enough of a chemical, just replace it and you have managed the disease. Consequently, some health insurers cover medication management of depression but not psychotherapy, and patients come into the office saying, “I don’t want to talk about my feelings; just give me a pill.”

A recent study suggests that depression and its treatment are more complicated than a simple chemical imbalance. In “Neuroscience News”, Dr. Edmund Higgins reviews research suggesting that scarred DNA strands cause depression.

Thus, science is catching up with what psychiatrists have learned first-hand from clinical practice:

• depression is caused by a complex interaction among neurotransmitters, genetics, and environment
• treating depression successfully is usually complex, too.

The 1960s’ catecholamine hypothesis—that depression is caused by deficiencies in neurotransmitters such as serotonin and norepinephrine—has greatly influenced how doctors, patients, and the public regard depression. On the positive side, this “chemical imbalance” concept helped reduce the stigma of depression; the illness could be seen as something other than the patient’s fault.

More subtly, though, the imbalance idea is overly simplistic: Antidepressants work in depression the way insulin does in diabetes. When patients don’t have enough of a chemical, just replace it and you have managed the disease. Consequently, some health insurers cover medication management of depression but not psychotherapy, and patients come into the office saying, “I don’t want to talk about my feelings; just give me a pill.”

A recent study suggests that depression and its treatment are more complicated than a simple chemical imbalance. In “Neuroscience News”, Dr. Edmund Higgins reviews research suggesting that scarred DNA strands cause depression.

Thus, science is catching up with what psychiatrists have learned first-hand from clinical practice:

• depression is caused by a complex interaction among neurotransmitters, genetics, and environment
• treating depression successfully is usually complex, too.

Jane Pauley is well-known for hosting NBC television’s Today Show but also for developing manic symptoms from corticosteroid therapy. Dr. Michael Cerullo (page 43) mentions her case in his excellent discussion of how to treat steroid-induced mania or mixed bipolar symptoms and reduce the risk in patients who require sustained corticosteroids.

Jane (we are on a first-name basis, aren’t we?) revealed in her autobiography¹ that she developed mania after taking corticosteroids for urticaria. In this case, a widely admired broadcaster’s revelation probably helped reduce the stigma of psychiatric illness.

But last year Hollywood celebs Tom Cruise and Brooke Shields debated the merits of antidepressant therapy for postpartum depression. That highly publicized exchange—he on the “con” side, she on the “pro”—certainly raised public awareness of depression in new mothers, but its effects on psychiatry’s image might have been more negative than positive.

And what do we make of actress Lorraine Bracco, who plays a psychiatrist on the HBO TV series, The Sopranos? Her character, Dr. Jennifer Melfi, treats mobster Tony Soprano’s panic attacks but not his, well, antisocial traits. Speaking at last year’s American Psychiatric Association meeting, Bracco stated that “in real life, I’m actually someone who has suffered from depression and had to seek the help of a psychiatrist.”

So we have a real patient portraying a psychiatrist treating an imaginary patient and then lecturing to real psychiatrists. That seems ironic, but I think The Sopranos’ popularity and Bracco’s acknowledgment that she sought treatment for depression make psychiatry look pretty good.

Jane Pauley is well-known for hosting NBC television’s Today Show but also for developing manic symptoms from corticosteroid therapy. Dr. Michael Cerullo (page 43) mentions her case in his excellent discussion of how to treat steroid-induced mania or mixed bipolar symptoms and reduce the risk in patients who require sustained corticosteroids.

Jane (we are on a first-name basis, aren’t we?) revealed in her autobiography¹ that she developed mania after taking corticosteroids for urticaria. In this case, a widely admired broadcaster’s revelation probably helped reduce the stigma of psychiatric illness.

But last year Hollywood celebs Tom Cruise and Brooke Shields debated the merits of antidepressant therapy for postpartum depression. That highly publicized exchange—he on the “con” side, she on the “pro”—certainly raised public awareness of depression in new mothers, but its effects on psychiatry’s image might have been more negative than positive.

And what do we make of actress Lorraine Bracco, who plays a psychiatrist on the HBO TV series, The Sopranos? Her character, Dr. Jennifer Melfi, treats mobster Tony Soprano’s panic attacks but not his, well, antisocial traits. Speaking at last year’s American Psychiatric Association meeting, Bracco stated that “in real life, I’m actually someone who has suffered from depression and had to seek the help of a psychiatrist.”

So we have a real patient portraying a psychiatrist treating an imaginary patient and then lecturing to real psychiatrists. That seems ironic, but I think The Sopranos’ popularity and Bracco’s acknowledgment that she sought treatment for depression make psychiatry look pretty good.

Jane Pauley is well-known for hosting NBC television’s Today Show but also for developing manic symptoms from corticosteroid therapy. Dr. Michael Cerullo (page 43) mentions her case in his excellent discussion of how to treat steroid-induced mania or mixed bipolar symptoms and reduce the risk in patients who require sustained corticosteroids.

Jane (we are on a first-name basis, aren’t we?) revealed in her autobiography¹ that she developed mania after taking corticosteroids for urticaria. In this case, a widely admired broadcaster’s revelation probably helped reduce the stigma of psychiatric illness.

But last year Hollywood celebs Tom Cruise and Brooke Shields debated the merits of antidepressant therapy for postpartum depression. That highly publicized exchange—he on the “con” side, she on the “pro”—certainly raised public awareness of depression in new mothers, but its effects on psychiatry’s image might have been more negative than positive.

And what do we make of actress Lorraine Bracco, who plays a psychiatrist on the HBO TV series, The Sopranos? Her character, Dr. Jennifer Melfi, treats mobster Tony Soprano’s panic attacks but not his, well, antisocial traits. Speaking at last year’s American Psychiatric Association meeting, Bracco stated that “in real life, I’m actually someone who has suffered from depression and had to seek the help of a psychiatrist.”

So we have a real patient portraying a psychiatrist treating an imaginary patient and then lecturing to real psychiatrists. That seems ironic, but I think The Sopranos’ popularity and Bracco’s acknowledgment that she sought treatment for depression make psychiatry look pretty good.

Three years after the U.S.-led invasion of Iraq, psychiatrists on the home front are dealing with the war’s neuropsychiatric casualties. We are seeing veterans, their families, friends, and acquaintances, whether we practice in VA medical centers, military medicine, or the community.

To help us, Drs. Timothy Lineberry, Sriram Ramaswamy, J. Michael Bostwick, and James Rundell offer tools to screen for and treat combat-related posttraumatic stress disorder, including PTSD of military sexual trauma. Dr. John Daniels tells which medications may do more harm than good for patients with traumatic brain injury.

World War II brought psychiatric disorders home, showing that not just “crazy people” develop psychiatric symptoms. A half-million U.S. troops were admitted for psychiatric care in overseas hospitals alone.¹ Americans began to accept that anyone under extreme conditions could become psychiatrically ill.

Today, there are many ways to feel about our involvement in “Operation Iraqi Freedom” but only one way to feel about the dedicated men and women serving there. They deserve our respect, our love, and all our knowledge and skill to help them deal with the trauma they have endured for us all.

Three years after the U.S.-led invasion of Iraq, psychiatrists on the home front are dealing with the war’s neuropsychiatric casualties. We are seeing veterans, their families, friends, and acquaintances, whether we practice in VA medical centers, military medicine, or the community.

To help us, Drs. Timothy Lineberry, Sriram Ramaswamy, J. Michael Bostwick, and James Rundell offer tools to screen for and treat combat-related posttraumatic stress disorder, including PTSD of military sexual trauma. Dr. John Daniels tells which medications may do more harm than good for patients with traumatic brain injury.

World War II brought psychiatric disorders home, showing that not just “crazy people” develop psychiatric symptoms. A half-million U.S. troops were admitted for psychiatric care in overseas hospitals alone.¹ Americans began to accept that anyone under extreme conditions could become psychiatrically ill.

Today, there are many ways to feel about our involvement in “Operation Iraqi Freedom” but only one way to feel about the dedicated men and women serving there. They deserve our respect, our love, and all our knowledge and skill to help them deal with the trauma they have endured for us all.

Three years after the U.S.-led invasion of Iraq, psychiatrists on the home front are dealing with the war’s neuropsychiatric casualties. We are seeing veterans, their families, friends, and acquaintances, whether we practice in VA medical centers, military medicine, or the community.

To help us, Drs. Timothy Lineberry, Sriram Ramaswamy, J. Michael Bostwick, and James Rundell offer tools to screen for and treat combat-related posttraumatic stress disorder, including PTSD of military sexual trauma. Dr. John Daniels tells which medications may do more harm than good for patients with traumatic brain injury.

World War II brought psychiatric disorders home, showing that not just “crazy people” develop psychiatric symptoms. A half-million U.S. troops were admitted for psychiatric care in overseas hospitals alone.¹ Americans began to accept that anyone under extreme conditions could become psychiatrically ill.

Today, there are many ways to feel about our involvement in “Operation Iraqi Freedom” but only one way to feel about the dedicated men and women serving there. They deserve our respect, our love, and all our knowledge and skill to help them deal with the trauma they have endured for us all.

What do you do when a patient with major depressive disorder who is being successfully maintained on medication wants to become pregnant or has just learned she is pregnant?

If you’re like me, you worry—a lot. If you stop maintenance antidepressants, the chance of depressive relapse is substantial. If you continue the medication and the child has congenital anomalies, the chance of you being blamed is substantial. Either way, you can be sued for malpractice.

Two articles this month address this dilemma: an evidence-based review on use of SSRIs in pregnancy by Caitlin Hasser, MD, Louann Brizendine, MD, and Anna Spielvogel, MD, PhD, from the University of California, San Francisco, and a commentary on the FDA’s paroxetine advisory by Lawson Wulsin, MD, of the University of Cincinnati.

FDA categorizes most drugs we prescribe as pregnancy risk category C, “Risk cannot be ruled out.” Paroxetine has recently been moved to category D, “Evidence of risk to the fetus in human studies.” About 3% of births involve anomalies; a recent study of women who took paroxetine during pregnancy showed a 4% rate. If you treat 30 or more pregnant, depressed patients during your career, odds are that at least one of them will have a child with birth defects, purely by chance.

If we continue antidepressant therapy during pregnancy, the best we can do is study the literature, document that we discussed risks and benefits with the patient, and avoid paroxetine if possible. If we discontinue the medication, the best we can do is document that we discussed risks and benefits with the patient and follow her closely for depressive relapse.

Nobody said this job would be easy.

What do you do when a patient with major depressive disorder who is being successfully maintained on medication wants to become pregnant or has just learned she is pregnant?

If you’re like me, you worry—a lot. If you stop maintenance antidepressants, the chance of depressive relapse is substantial. If you continue the medication and the child has congenital anomalies, the chance of you being blamed is substantial. Either way, you can be sued for malpractice.

Two articles this month address this dilemma: an evidence-based review on use of SSRIs in pregnancy by Caitlin Hasser, MD, Louann Brizendine, MD, and Anna Spielvogel, MD, PhD, from the University of California, San Francisco, and a commentary on the FDA’s paroxetine advisory by Lawson Wulsin, MD, of the University of Cincinnati.

FDA categorizes most drugs we prescribe as pregnancy risk category C, “Risk cannot be ruled out.” Paroxetine has recently been moved to category D, “Evidence of risk to the fetus in human studies.” About 3% of births involve anomalies; a recent study of women who took paroxetine during pregnancy showed a 4% rate. If you treat 30 or more pregnant, depressed patients during your career, odds are that at least one of them will have a child with birth defects, purely by chance.

If we continue antidepressant therapy during pregnancy, the best we can do is study the literature, document that we discussed risks and benefits with the patient, and avoid paroxetine if possible. If we discontinue the medication, the best we can do is document that we discussed risks and benefits with the patient and follow her closely for depressive relapse.

Nobody said this job would be easy.

What do you do when a patient with major depressive disorder who is being successfully maintained on medication wants to become pregnant or has just learned she is pregnant?

If you’re like me, you worry—a lot. If you stop maintenance antidepressants, the chance of depressive relapse is substantial. If you continue the medication and the child has congenital anomalies, the chance of you being blamed is substantial. Either way, you can be sued for malpractice.

Two articles this month address this dilemma: an evidence-based review on use of SSRIs in pregnancy by Caitlin Hasser, MD, Louann Brizendine, MD, and Anna Spielvogel, MD, PhD, from the University of California, San Francisco, and a commentary on the FDA’s paroxetine advisory by Lawson Wulsin, MD, of the University of Cincinnati.

FDA categorizes most drugs we prescribe as pregnancy risk category C, “Risk cannot be ruled out.” Paroxetine has recently been moved to category D, “Evidence of risk to the fetus in human studies.” About 3% of births involve anomalies; a recent study of women who took paroxetine during pregnancy showed a 4% rate. If you treat 30 or more pregnant, depressed patients during your career, odds are that at least one of them will have a child with birth defects, purely by chance.

If we continue antidepressant therapy during pregnancy, the best we can do is study the literature, document that we discussed risks and benefits with the patient, and avoid paroxetine if possible. If we discontinue the medication, the best we can do is document that we discussed risks and benefits with the patient and follow her closely for depressive relapse.

Nobody said this job would be easy.

This issue of Current Psychiatry poses the question: “Does schizophrenia exist?” Isn’t it shocking that we are still asking this in 2006? After all, our specialty treats a sizable proportion of patients diagnosed with schizophrenia.

I have been trying to think of analogous questions other Quadrant HealthCom Inc. specialty journals might consider:

• Would Contemporary Surgery ask “Does appendicitis exist?”
• Would The Journal of Family Practice ask “Does the common cold exist?”
• Would OBG Management ask “Does pregnancy exist?” (Well, maybe our question about schizophrenia is not quite that extreme.)

C. Raymond Lake, MD, PhD, professor of psychiatry at the University of Kansas School of Medicine, and Nathaniel Hurwitz, MD, assistant professor of psychiatry at Yale University School of Medicine, make a strong case that psychiatrists frequently fail to recognize severe bipolar disorder by assuming that psychosis means schizophrenia. These authors then examine recent evidence that schizophrenia may not exist as an independent disorder.

Because Drs. Lake and Hurwitz acknowledge that their view is a minority opinion, we asked Henry A. Nasrallah, MD, editor of Schizophrenia Research, for his perspective. He argues persuasively for a fundamental distinction between schizophrenia and bipolar disorder.

Discussions such as this reinforce my belief that psychiatry continues to evolve as a medical specialty. What do you think? To voice your opinion, click here. We will publish selected letters in Current Psychiatry.

This issue of Current Psychiatry poses the question: “Does schizophrenia exist?” Isn’t it shocking that we are still asking this in 2006? After all, our specialty treats a sizable proportion of patients diagnosed with schizophrenia.

I have been trying to think of analogous questions other Quadrant HealthCom Inc. specialty journals might consider:

• Would Contemporary Surgery ask “Does appendicitis exist?”
• Would The Journal of Family Practice ask “Does the common cold exist?”
• Would OBG Management ask “Does pregnancy exist?” (Well, maybe our question about schizophrenia is not quite that extreme.)

C. Raymond Lake, MD, PhD, professor of psychiatry at the University of Kansas School of Medicine, and Nathaniel Hurwitz, MD, assistant professor of psychiatry at Yale University School of Medicine, make a strong case that psychiatrists frequently fail to recognize severe bipolar disorder by assuming that psychosis means schizophrenia. These authors then examine recent evidence that schizophrenia may not exist as an independent disorder.

Because Drs. Lake and Hurwitz acknowledge that their view is a minority opinion, we asked Henry A. Nasrallah, MD, editor of Schizophrenia Research, for his perspective. He argues persuasively for a fundamental distinction between schizophrenia and bipolar disorder.

Discussions such as this reinforce my belief that psychiatry continues to evolve as a medical specialty. What do you think? To voice your opinion, click here. We will publish selected letters in Current Psychiatry.

This issue of Current Psychiatry poses the question: “Does schizophrenia exist?” Isn’t it shocking that we are still asking this in 2006? After all, our specialty treats a sizable proportion of patients diagnosed with schizophrenia.

I have been trying to think of analogous questions other Quadrant HealthCom Inc. specialty journals might consider:

• Would Contemporary Surgery ask “Does appendicitis exist?”
• Would The Journal of Family Practice ask “Does the common cold exist?”
• Would OBG Management ask “Does pregnancy exist?” (Well, maybe our question about schizophrenia is not quite that extreme.)

C. Raymond Lake, MD, PhD, professor of psychiatry at the University of Kansas School of Medicine, and Nathaniel Hurwitz, MD, assistant professor of psychiatry at Yale University School of Medicine, make a strong case that psychiatrists frequently fail to recognize severe bipolar disorder by assuming that psychosis means schizophrenia. These authors then examine recent evidence that schizophrenia may not exist as an independent disorder.

Because Drs. Lake and Hurwitz acknowledge that their view is a minority opinion, we asked Henry A. Nasrallah, MD, editor of Schizophrenia Research, for his perspective. He argues persuasively for a fundamental distinction between schizophrenia and bipolar disorder.

Discussions such as this reinforce my belief that psychiatry continues to evolve as a medical specialty. What do you think? To voice your opinion, click here. We will publish selected letters in Current Psychiatry.

Six years in the making, phase 1 results of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) in schizophrenia have confirmed my clinical observations:

• One was the 74% discontinuation rate (though I admit I take some comfort in knowing I am not the only one who has trouble keeping patients with schizophrenia in treatment).
• Another was that 42% of the patients had metabolic syndrome, and most were not being treated for diabetes, hyperlipidemia, and hypertension. I believe individuals with schizophrenia deserve better than that.

The first reported CATIE finding was that four tested atypical antipsychotics were similar in effectiveness to perphenazine, as measured by the discontinuation rate. How can this be? My experience—and probably yours, too—is that atypical antipsychotics are more effective and better tolerated than the older ones. Dr. Henry Nasrallah, a CATIE investigator, offers some explanations.

The CATIE study is sponsored by the National Institute of Mental Health. As Dr. Nasrallah describes, CATIE differs from FDA-required efficacy trials in its longer duration (18 months), larger size (nearly 1,500 patients), and less-stringent inclusion/exclusion criteria. Just about anyone with a diagnosis of schizophrenia, regardless of comorbidities, was eligible so that CATIE would reflect "real world" schizophrenia. And in that regard it succeeded; the study’s patients are much like those you and I treat.

I’m worried that this mega-study showed no agent to be clearly superior, but payers can clearly demonstrate higher costs for the newer agents. A study as huge and expensive as CATIE probably will never be repeated, so we may never have a comparable study to challenge its results.

Will our patients be deprived of treatments that our clinical experience shows are best for them? Not if we can help it; there is a lot to be learned from CATIE, and we need to be informed about its results.

Six years in the making, phase 1 results of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) in schizophrenia have confirmed my clinical observations:

• One was the 74% discontinuation rate (though I admit I take some comfort in knowing I am not the only one who has trouble keeping patients with schizophrenia in treatment).
• Another was that 42% of the patients had metabolic syndrome, and most were not being treated for diabetes, hyperlipidemia, and hypertension. I believe individuals with schizophrenia deserve better than that.

The first reported CATIE finding was that four tested atypical antipsychotics were similar in effectiveness to perphenazine, as measured by the discontinuation rate. How can this be? My experience—and probably yours, too—is that atypical antipsychotics are more effective and better tolerated than the older ones. Dr. Henry Nasrallah, a CATIE investigator, offers some explanations.

The CATIE study is sponsored by the National Institute of Mental Health. As Dr. Nasrallah describes, CATIE differs from FDA-required efficacy trials in its longer duration (18 months), larger size (nearly 1,500 patients), and less-stringent inclusion/exclusion criteria. Just about anyone with a diagnosis of schizophrenia, regardless of comorbidities, was eligible so that CATIE would reflect "real world" schizophrenia. And in that regard it succeeded; the study’s patients are much like those you and I treat.

I’m worried that this mega-study showed no agent to be clearly superior, but payers can clearly demonstrate higher costs for the newer agents. A study as huge and expensive as CATIE probably will never be repeated, so we may never have a comparable study to challenge its results.

Will our patients be deprived of treatments that our clinical experience shows are best for them? Not if we can help it; there is a lot to be learned from CATIE, and we need to be informed about its results.

Six years in the making, phase 1 results of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) in schizophrenia have confirmed my clinical observations:

• One was the 74% discontinuation rate (though I admit I take some comfort in knowing I am not the only one who has trouble keeping patients with schizophrenia in treatment).
• Another was that 42% of the patients had metabolic syndrome, and most were not being treated for diabetes, hyperlipidemia, and hypertension. I believe individuals with schizophrenia deserve better than that.

The first reported CATIE finding was that four tested atypical antipsychotics were similar in effectiveness to perphenazine, as measured by the discontinuation rate. How can this be? My experience—and probably yours, too—is that atypical antipsychotics are more effective and better tolerated than the older ones. Dr. Henry Nasrallah, a CATIE investigator, offers some explanations.

The CATIE study is sponsored by the National Institute of Mental Health. As Dr. Nasrallah describes, CATIE differs from FDA-required efficacy trials in its longer duration (18 months), larger size (nearly 1,500 patients), and less-stringent inclusion/exclusion criteria. Just about anyone with a diagnosis of schizophrenia, regardless of comorbidities, was eligible so that CATIE would reflect "real world" schizophrenia. And in that regard it succeeded; the study’s patients are much like those you and I treat.

I’m worried that this mega-study showed no agent to be clearly superior, but payers can clearly demonstrate higher costs for the newer agents. A study as huge and expensive as CATIE probably will never be repeated, so we may never have a comparable study to challenge its results.

Will our patients be deprived of treatments that our clinical experience shows are best for them? Not if we can help it; there is a lot to be learned from CATIE, and we need to be informed about its results.

Do you make New Year’s resolutions? At least 60% of Americans do, according to a Kaiser Permanente “New Year’s and Health Issues Survey” of 1,000 U.S. adults. Rather depressingly, the survey also found that for every 10 respondents who kept their resolutions all year, 99 did not.

Going online to learn more, my Google search for “new year resolutions” yielded 1,360,000 results (by comparison, a search for “alien abduction” found 711,000). The U.S. government Web portal FirstGov.gov lists as the “most popular” resolutions: drink less alcohol, eat right, get a better education, get a better job, get fit, lose weight, quit smoking, reduce stress, save money, take a trip, and volunteer to help others.

Is it mentally healthy to make New Year’s resolutions? I suppose so, if they motivate you to make positive changes. For example, in this issue, Drs. Phil Bohnert and Anne O’Connell describe how to make changes in your life to prevent or recover from burnout. But the 10% New Year’s resolution “compliance rate” in the Kaiser Permanente survey suggests that fundamental lifestyle changes are uncommon, despite our good intentions.

If we make resolutions but don’t keep them, how could that be good? Maybe taking on health and moral issues once a year is countertherapeutic. Making resolutions, not keeping them, and then feeling guilty probably does more harm than good.

My resolution for 2005 was not to let anything drive me crazy during the year. That clearly proved overly ambitious. For 2006, I have resolved to try to watch more TV and to gain a few pounds. At least these resolutions should not leave me feeling guilty.

Best wishes for a healthy and happy new year from me and the Current Psychiatry family!

Do you make New Year’s resolutions? At least 60% of Americans do, according to a Kaiser Permanente “New Year’s and Health Issues Survey” of 1,000 U.S. adults. Rather depressingly, the survey also found that for every 10 respondents who kept their resolutions all year, 99 did not.

Going online to learn more, my Google search for “new year resolutions” yielded 1,360,000 results (by comparison, a search for “alien abduction” found 711,000). The U.S. government Web portal FirstGov.gov lists as the “most popular” resolutions: drink less alcohol, eat right, get a better education, get a better job, get fit, lose weight, quit smoking, reduce stress, save money, take a trip, and volunteer to help others.

Is it mentally healthy to make New Year’s resolutions? I suppose so, if they motivate you to make positive changes. For example, in this issue, Drs. Phil Bohnert and Anne O’Connell describe how to make changes in your life to prevent or recover from burnout. But the 10% New Year’s resolution “compliance rate” in the Kaiser Permanente survey suggests that fundamental lifestyle changes are uncommon, despite our good intentions.

If we make resolutions but don’t keep them, how could that be good? Maybe taking on health and moral issues once a year is countertherapeutic. Making resolutions, not keeping them, and then feeling guilty probably does more harm than good.

My resolution for 2005 was not to let anything drive me crazy during the year. That clearly proved overly ambitious. For 2006, I have resolved to try to watch more TV and to gain a few pounds. At least these resolutions should not leave me feeling guilty.

Best wishes for a healthy and happy new year from me and the Current Psychiatry family!

Do you make New Year’s resolutions? At least 60% of Americans do, according to a Kaiser Permanente “New Year’s and Health Issues Survey” of 1,000 U.S. adults. Rather depressingly, the survey also found that for every 10 respondents who kept their resolutions all year, 99 did not.

Going online to learn more, my Google search for “new year resolutions” yielded 1,360,000 results (by comparison, a search for “alien abduction” found 711,000). The U.S. government Web portal FirstGov.gov lists as the “most popular” resolutions: drink less alcohol, eat right, get a better education, get a better job, get fit, lose weight, quit smoking, reduce stress, save money, take a trip, and volunteer to help others.

Is it mentally healthy to make New Year’s resolutions? I suppose so, if they motivate you to make positive changes. For example, in this issue, Drs. Phil Bohnert and Anne O’Connell describe how to make changes in your life to prevent or recover from burnout. But the 10% New Year’s resolution “compliance rate” in the Kaiser Permanente survey suggests that fundamental lifestyle changes are uncommon, despite our good intentions.

If we make resolutions but don’t keep them, how could that be good? Maybe taking on health and moral issues once a year is countertherapeutic. Making resolutions, not keeping them, and then feeling guilty probably does more harm than good.

My resolution for 2005 was not to let anything drive me crazy during the year. That clearly proved overly ambitious. For 2006, I have resolved to try to watch more TV and to gain a few pounds. At least these resolutions should not leave me feeling guilty.

Best wishes for a healthy and happy new year from me and the Current Psychiatry family!

Like it or not, we deal with psychiatric emergencies. Emergencies—by definition—come at inconvenient times. Everybody is upset. None of the so-called “community resources” are available when we need them. And we usually have trouble getting paid for responding.

On the other hand, being asked to evaluate and treat patients with emergency psychiatric problems enables us to use all of our training and experience. In the adrenaline-charged emergency department (ED), our informed decisions can make a tremendous difference in the lives of patients and their families.

In this issue, Drs. Gabrielle Melin and Kristin Vickers-Douglas describe a practical workup of patients who arrive at the ED with acute psychiatric illness (page 14). They emphasize how to:

• conduct a sufficient workup for medical and psychiatric illness
• develop a therapeutic alliance with patients under trying circumstances
• protect staff and ourselves, as well as patients, from harm.

As Drs. Melin and Vickers-Douglas explain, “In the high-pressure ED, a sufficient workup for complicated medical conditions lies somewhere between extensive/unnecessary and inadequate. Thus, determining an exact diagnosis is not as important as establishing a diagnostic category to guide emergency treatment.” Similarly, adopting a pragmatic attitude can help us balance emergencies’ frustrations with their opportunities.

P. S. Last month I announced a contest asking for creative ideas for the Craig and Frances Lindner Center of HOPE, a psychiatric treatment center to be built in Cincinnati. Suggestions can be clinical, architectural, financial, or anything else. We will award $1,000 for the best idea.

The entry deadline is midnight Dec. 31, 2005. Send your suggestions to paul.keck@uc.edu.

Like it or not, we deal with psychiatric emergencies. Emergencies—by definition—come at inconvenient times. Everybody is upset. None of the so-called “community resources” are available when we need them. And we usually have trouble getting paid for responding.

On the other hand, being asked to evaluate and treat patients with emergency psychiatric problems enables us to use all of our training and experience. In the adrenaline-charged emergency department (ED), our informed decisions can make a tremendous difference in the lives of patients and their families.

In this issue, Drs. Gabrielle Melin and Kristin Vickers-Douglas describe a practical workup of patients who arrive at the ED with acute psychiatric illness (page 14). They emphasize how to:

• conduct a sufficient workup for medical and psychiatric illness
• develop a therapeutic alliance with patients under trying circumstances
• protect staff and ourselves, as well as patients, from harm.

As Drs. Melin and Vickers-Douglas explain, “In the high-pressure ED, a sufficient workup for complicated medical conditions lies somewhere between extensive/unnecessary and inadequate. Thus, determining an exact diagnosis is not as important as establishing a diagnostic category to guide emergency treatment.” Similarly, adopting a pragmatic attitude can help us balance emergencies’ frustrations with their opportunities.

P. S. Last month I announced a contest asking for creative ideas for the Craig and Frances Lindner Center of HOPE, a psychiatric treatment center to be built in Cincinnati. Suggestions can be clinical, architectural, financial, or anything else. We will award $1,000 for the best idea.

The entry deadline is midnight Dec. 31, 2005. Send your suggestions to paul.keck@uc.edu.

Like it or not, we deal with psychiatric emergencies. Emergencies—by definition—come at inconvenient times. Everybody is upset. None of the so-called “community resources” are available when we need them. And we usually have trouble getting paid for responding.

On the other hand, being asked to evaluate and treat patients with emergency psychiatric problems enables us to use all of our training and experience. In the adrenaline-charged emergency department (ED), our informed decisions can make a tremendous difference in the lives of patients and their families.

In this issue, Drs. Gabrielle Melin and Kristin Vickers-Douglas describe a practical workup of patients who arrive at the ED with acute psychiatric illness (page 14). They emphasize how to:

• conduct a sufficient workup for medical and psychiatric illness
• develop a therapeutic alliance with patients under trying circumstances
• protect staff and ourselves, as well as patients, from harm.

As Drs. Melin and Vickers-Douglas explain, “In the high-pressure ED, a sufficient workup for complicated medical conditions lies somewhere between extensive/unnecessary and inadequate. Thus, determining an exact diagnosis is not as important as establishing a diagnostic category to guide emergency treatment.” Similarly, adopting a pragmatic attitude can help us balance emergencies’ frustrations with their opportunities.

P. S. Last month I announced a contest asking for creative ideas for the Craig and Frances Lindner Center of HOPE, a psychiatric treatment center to be built in Cincinnati. Suggestions can be clinical, architectural, financial, or anything else. We will award $1,000 for the best idea.

The entry deadline is midnight Dec. 31, 2005. Send your suggestions to paul.keck@uc.edu.