James Randolph Hillard, MD

We in psychiatry have often gotten it wrong about menopause. We have “pathologized” normal perimenopause experience, at times ascribing its mood symptoms to DSM-II’s “involutional melancholia,” or to change of life or empty nest syndrome. At other times we have “normalized” pathological experience, dismissing women’s complaints of depression and anxiety and referring them too quickly to Ob/Gyns.

Sometimes we have relied too heavily on hormonal treatments and at other times have not used them enough. Hormone replacement therapies clearly do benefit many women with psychiatric symptoms ranging from mild to severe. But hormonal treatments do not help all women and they can have harmful side effects, as the Women’s Health Initiative studies of estrogen with progesterone have shown. We clearly need to understand more about hormonal treatments and not just leave their understanding and management to Ob/Gyns.

A step in that direction is “Minding menopause,” by Louann Brizendine, MD. This article presents the current approach to diagnosis and treatment of menopause-related psychiatric symptoms, based on the latest evidence and Dr. Brizendine’s experience as director of the Women’s Mood and Hormone Clinic at Langley Porter Psychiatric Clinic, San Francisco.

Dr. Brizendine’s article portrays psychiatry at its best, changing its approaches to coincide with new data and experience—until we get it right.

We in psychiatry have often gotten it wrong about menopause. We have “pathologized” normal perimenopause experience, at times ascribing its mood symptoms to DSM-II’s “involutional melancholia,” or to change of life or empty nest syndrome. At other times we have “normalized” pathological experience, dismissing women’s complaints of depression and anxiety and referring them too quickly to Ob/Gyns.

Sometimes we have relied too heavily on hormonal treatments and at other times have not used them enough. Hormone replacement therapies clearly do benefit many women with psychiatric symptoms ranging from mild to severe. But hormonal treatments do not help all women and they can have harmful side effects, as the Women’s Health Initiative studies of estrogen with progesterone have shown. We clearly need to understand more about hormonal treatments and not just leave their understanding and management to Ob/Gyns.

A step in that direction is “Minding menopause,” by Louann Brizendine, MD. This article presents the current approach to diagnosis and treatment of menopause-related psychiatric symptoms, based on the latest evidence and Dr. Brizendine’s experience as director of the Women’s Mood and Hormone Clinic at Langley Porter Psychiatric Clinic, San Francisco.

Dr. Brizendine’s article portrays psychiatry at its best, changing its approaches to coincide with new data and experience—until we get it right.

We in psychiatry have often gotten it wrong about menopause. We have “pathologized” normal perimenopause experience, at times ascribing its mood symptoms to DSM-II’s “involutional melancholia,” or to change of life or empty nest syndrome. At other times we have “normalized” pathological experience, dismissing women’s complaints of depression and anxiety and referring them too quickly to Ob/Gyns.

Sometimes we have relied too heavily on hormonal treatments and at other times have not used them enough. Hormone replacement therapies clearly do benefit many women with psychiatric symptoms ranging from mild to severe. But hormonal treatments do not help all women and they can have harmful side effects, as the Women’s Health Initiative studies of estrogen with progesterone have shown. We clearly need to understand more about hormonal treatments and not just leave their understanding and management to Ob/Gyns.

A step in that direction is “Minding menopause,” by Louann Brizendine, MD. This article presents the current approach to diagnosis and treatment of menopause-related psychiatric symptoms, based on the latest evidence and Dr. Brizendine’s experience as director of the Women’s Mood and Hormone Clinic at Langley Porter Psychiatric Clinic, San Francisco.

Dr. Brizendine’s article portrays psychiatry at its best, changing its approaches to coincide with new data and experience—until we get it right.

I’m suffering from congestive work failure. I’m sure you understand, as many of you probably are suffering from it, too, as you struggle to keep up with your work.

When I studied cardiovascular physiology in medical school, I learned about the Starling curve. Increasing work increases cardiac muscle efficiency up to a point, after which adding more work decreases cardiac output and leads to congestive heart failure. Miraculously, it seems, digitalis helps the failing heart regain its efficiency.

Congestive work failure also follows a Starling curve. I work more efficiently as my workload increases up to a point, after which more work makes me lessefficient. As I fall behind and miss deadlines, I become anxious and unhappy just thinking about all the work I have to do. So I go into work avoidance—going out for coffee, surfing the Internet, or even reading journals—to escape from thinking about how far behind I am. Of course, avoiding my work puts me even further behind.

Someday I hope the pharmaceutical industry invents a “digitalis for the mind” to treat my condition. Meanwhile, reading Current Psychiatry is the best treatment I know. It helps me to efficiently keep up with new developments in clinical practice—and sometimes provides a medium to productively channel my work avoidance.

I’m suffering from congestive work failure. I’m sure you understand, as many of you probably are suffering from it, too, as you struggle to keep up with your work.

When I studied cardiovascular physiology in medical school, I learned about the Starling curve. Increasing work increases cardiac muscle efficiency up to a point, after which adding more work decreases cardiac output and leads to congestive heart failure. Miraculously, it seems, digitalis helps the failing heart regain its efficiency.

Congestive work failure also follows a Starling curve. I work more efficiently as my workload increases up to a point, after which more work makes me lessefficient. As I fall behind and miss deadlines, I become anxious and unhappy just thinking about all the work I have to do. So I go into work avoidance—going out for coffee, surfing the Internet, or even reading journals—to escape from thinking about how far behind I am. Of course, avoiding my work puts me even further behind.

Someday I hope the pharmaceutical industry invents a “digitalis for the mind” to treat my condition. Meanwhile, reading Current Psychiatry is the best treatment I know. It helps me to efficiently keep up with new developments in clinical practice—and sometimes provides a medium to productively channel my work avoidance.

I’m suffering from congestive work failure. I’m sure you understand, as many of you probably are suffering from it, too, as you struggle to keep up with your work.

When I studied cardiovascular physiology in medical school, I learned about the Starling curve. Increasing work increases cardiac muscle efficiency up to a point, after which adding more work decreases cardiac output and leads to congestive heart failure. Miraculously, it seems, digitalis helps the failing heart regain its efficiency.

Congestive work failure also follows a Starling curve. I work more efficiently as my workload increases up to a point, after which more work makes me lessefficient. As I fall behind and miss deadlines, I become anxious and unhappy just thinking about all the work I have to do. So I go into work avoidance—going out for coffee, surfing the Internet, or even reading journals—to escape from thinking about how far behind I am. Of course, avoiding my work puts me even further behind.

Someday I hope the pharmaceutical industry invents a “digitalis for the mind” to treat my condition. Meanwhile, reading Current Psychiatry is the best treatment I know. It helps me to efficiently keep up with new developments in clinical practice—and sometimes provides a medium to productively channel my work avoidance.

Where do you learn about new psychotropics? One source is the drug reps who come to see us all the time, but their educational materials have a marketing objective.

Current Psychiatry’s “Out of the Pipeline” offers an alernative—a source of early, unbiased information about new medications for psychiatric practice.

This month’s “Out of the Pipeline” examines sodium oxybate (Xyrem), indicated for treating cataplexy in patients with narcolepsy. Sodium oxybate is a legally manufactured form of an illegal “date rape” drug. As an orphan drug, sodium oxybate has undergone less clinical testing than is required for conventional FDA approvals. I want to know as much as possible about this medication before I prescribe it, and the article by Lois E. Krahn, MD—one of Current Psychiatry’s associate editors—is a good start.

Frankly, it is difficult to find qualified “Out of the Pipeline” authors who don’t have apparent conflicts of interest. Almost anyone who could write knowledgeably about premarket experience with a drug has participated in its clinical trials, most of which are supported by pharmaceutical companies. To address this concern, we:

• identify and invite the authors ourselves (without input from pharmaceutical companies)
• emphasize to authors the need for balance and objectivity
• disclose authors’ financial relationships with any companies whose products are mentioned or with manufacturers of competing products
• subject each article to peer review and revision before publication.

I expect more drugs will be developed with novel mechanisms of action and very specific indications. This trend will benefit our patients but increase our need for trusted advice, as in Current Psychiatry.

Where do you learn about new psychotropics? One source is the drug reps who come to see us all the time, but their educational materials have a marketing objective.

Current Psychiatry’s “Out of the Pipeline” offers an alernative—a source of early, unbiased information about new medications for psychiatric practice.

This month’s “Out of the Pipeline” examines sodium oxybate (Xyrem), indicated for treating cataplexy in patients with narcolepsy. Sodium oxybate is a legally manufactured form of an illegal “date rape” drug. As an orphan drug, sodium oxybate has undergone less clinical testing than is required for conventional FDA approvals. I want to know as much as possible about this medication before I prescribe it, and the article by Lois E. Krahn, MD—one of Current Psychiatry’s associate editors—is a good start.

Frankly, it is difficult to find qualified “Out of the Pipeline” authors who don’t have apparent conflicts of interest. Almost anyone who could write knowledgeably about premarket experience with a drug has participated in its clinical trials, most of which are supported by pharmaceutical companies. To address this concern, we:

• identify and invite the authors ourselves (without input from pharmaceutical companies)
• emphasize to authors the need for balance and objectivity
• disclose authors’ financial relationships with any companies whose products are mentioned or with manufacturers of competing products
• subject each article to peer review and revision before publication.

I expect more drugs will be developed with novel mechanisms of action and very specific indications. This trend will benefit our patients but increase our need for trusted advice, as in Current Psychiatry.

Where do you learn about new psychotropics? One source is the drug reps who come to see us all the time, but their educational materials have a marketing objective.

Current Psychiatry’s “Out of the Pipeline” offers an alernative—a source of early, unbiased information about new medications for psychiatric practice.

This month’s “Out of the Pipeline” examines sodium oxybate (Xyrem), indicated for treating cataplexy in patients with narcolepsy. Sodium oxybate is a legally manufactured form of an illegal “date rape” drug. As an orphan drug, sodium oxybate has undergone less clinical testing than is required for conventional FDA approvals. I want to know as much as possible about this medication before I prescribe it, and the article by Lois E. Krahn, MD—one of Current Psychiatry’s associate editors—is a good start.

Frankly, it is difficult to find qualified “Out of the Pipeline” authors who don’t have apparent conflicts of interest. Almost anyone who could write knowledgeably about premarket experience with a drug has participated in its clinical trials, most of which are supported by pharmaceutical companies. To address this concern, we:

• identify and invite the authors ourselves (without input from pharmaceutical companies)
• emphasize to authors the need for balance and objectivity
• disclose authors’ financial relationships with any companies whose products are mentioned or with manufacturers of competing products
• subject each article to peer review and revision before publication.

I expect more drugs will be developed with novel mechanisms of action and very specific indications. This trend will benefit our patients but increase our need for trusted advice, as in Current Psychiatry.

To me, the main difference between MDs and PhDs* is that MDs—at some point—must stop gathering data and make decisions.

I once heard Dr. Albert (Mickey) Stunkard say that when he was a physician fellow at Stanford University’s Center for Advanced Studies in the Behavioral Sciences he was at first energized—and a little intimidated—by the scintillating conversations taking place around him. Eventually, though, all the discourse reminded him of those long, philosophical discussions he and his classmates had had in their college dorms (“Well, on one hand you have communism, and on the other hand you have fascism… ”).

Physicians do not have the luxury of endless debate. At some point, we need to do something or else let our patients die of old age while waiting. One issue about which I have had to make decisions over the years—and which has troubled me the most—is whether to treat pregnant patients with psychotropics. Generally, I try to avoid using drugs in these cases, but sometimes I decide that the mother’s need for drug therapy outweighs the potential risks to her offspring.

Dr. Lori Altshuler and colleagues’ article in this issue is the best summary I have seen of what is known about the risks of using psychotropics in pregnant bipolar women. Each time I treat a woman with bipolar disorder, I will remember this discussion and the algorithm these authors suggest for making therapeutic decisions.

This excellent article may not be the final word on the subject. It can, however, help us with an important clinical decision we often have to make—and that is what Current Psychiatry is all about.

To me, the main difference between MDs and PhDs* is that MDs—at some point—must stop gathering data and make decisions.

I once heard Dr. Albert (Mickey) Stunkard say that when he was a physician fellow at Stanford University’s Center for Advanced Studies in the Behavioral Sciences he was at first energized—and a little intimidated—by the scintillating conversations taking place around him. Eventually, though, all the discourse reminded him of those long, philosophical discussions he and his classmates had had in their college dorms (“Well, on one hand you have communism, and on the other hand you have fascism… ”).

Physicians do not have the luxury of endless debate. At some point, we need to do something or else let our patients die of old age while waiting. One issue about which I have had to make decisions over the years—and which has troubled me the most—is whether to treat pregnant patients with psychotropics. Generally, I try to avoid using drugs in these cases, but sometimes I decide that the mother’s need for drug therapy outweighs the potential risks to her offspring.

Dr. Lori Altshuler and colleagues’ article in this issue is the best summary I have seen of what is known about the risks of using psychotropics in pregnant bipolar women. Each time I treat a woman with bipolar disorder, I will remember this discussion and the algorithm these authors suggest for making therapeutic decisions.

This excellent article may not be the final word on the subject. It can, however, help us with an important clinical decision we often have to make—and that is what Current Psychiatry is all about.

To me, the main difference between MDs and PhDs* is that MDs—at some point—must stop gathering data and make decisions.

I once heard Dr. Albert (Mickey) Stunkard say that when he was a physician fellow at Stanford University’s Center for Advanced Studies in the Behavioral Sciences he was at first energized—and a little intimidated—by the scintillating conversations taking place around him. Eventually, though, all the discourse reminded him of those long, philosophical discussions he and his classmates had had in their college dorms (“Well, on one hand you have communism, and on the other hand you have fascism… ”).

Physicians do not have the luxury of endless debate. At some point, we need to do something or else let our patients die of old age while waiting. One issue about which I have had to make decisions over the years—and which has troubled me the most—is whether to treat pregnant patients with psychotropics. Generally, I try to avoid using drugs in these cases, but sometimes I decide that the mother’s need for drug therapy outweighs the potential risks to her offspring.

Dr. Lori Altshuler and colleagues’ article in this issue is the best summary I have seen of what is known about the risks of using psychotropics in pregnant bipolar women. Each time I treat a woman with bipolar disorder, I will remember this discussion and the algorithm these authors suggest for making therapeutic decisions.

This excellent article may not be the final word on the subject. It can, however, help us with an important clinical decision we often have to make—and that is what Current Psychiatry is all about.

Yesterday I tried to explain electroconvulsive therapy (ECT) to my 15-year-old son. Of my three children, he comes closest to idealizing me and is most likely to consider medical school. Still, he was a tough sell. His initial reaction to ECT was “that sounds sort of primitive.”

Dr. Max Fink’s article in this issue reviews the overwhelming evidence for ECT’s efficacy in major depressive disorder and the obstacles that prevent ECT from being used as widely as research suggests it should be. Two obstacles are limited availability (few psychiatrists make it part of their practice) and social stigma. The stigma leads to low availability, which makes ECT available only as a last resort, which in turn increases the stigma.

Dr. Fink identifies a third obstacle as “academic low regard,” meaning that academic psychiatrists relegate ECT to a third- or fourth-line therapy and neglect to teach about it. ECT was introduced before psychodynamic therapies and effective medications revolutionized psychiatry. Consequently, psychiatrists trained in psychodynamics and psychopharmacology pay less attention to ECT than the data warrant.

Repetitive transcranial magnetic stimulation (rTMS)—ably reviewed in this issue by Drs. Sheila Dowd and Philip Janicak—has an advantage over ECT in being new and therefore perceived as exciting. It also is less aesthetically problematic because most people have a more positive attitude towards magnets than electric shocks.

Time will tell where rTMS might fit into our treatment algorithms for major depressive disorder. Taken together, however, ECT and rTMS illustrate how psychiatry can advance by keeping established treatments of proven efficacy while embracing new treatments.

Either because I convinced my son of the benefits of ECT—or because he wanted to avoid conflict—he eventually said, “Well, I guess you have to use whatever works, even if you don’t know exactly how it works.” So true.

Yesterday I tried to explain electroconvulsive therapy (ECT) to my 15-year-old son. Of my three children, he comes closest to idealizing me and is most likely to consider medical school. Still, he was a tough sell. His initial reaction to ECT was “that sounds sort of primitive.”

Dr. Max Fink’s article in this issue reviews the overwhelming evidence for ECT’s efficacy in major depressive disorder and the obstacles that prevent ECT from being used as widely as research suggests it should be. Two obstacles are limited availability (few psychiatrists make it part of their practice) and social stigma. The stigma leads to low availability, which makes ECT available only as a last resort, which in turn increases the stigma.

Dr. Fink identifies a third obstacle as “academic low regard,” meaning that academic psychiatrists relegate ECT to a third- or fourth-line therapy and neglect to teach about it. ECT was introduced before psychodynamic therapies and effective medications revolutionized psychiatry. Consequently, psychiatrists trained in psychodynamics and psychopharmacology pay less attention to ECT than the data warrant.

Repetitive transcranial magnetic stimulation (rTMS)—ably reviewed in this issue by Drs. Sheila Dowd and Philip Janicak—has an advantage over ECT in being new and therefore perceived as exciting. It also is less aesthetically problematic because most people have a more positive attitude towards magnets than electric shocks.

Time will tell where rTMS might fit into our treatment algorithms for major depressive disorder. Taken together, however, ECT and rTMS illustrate how psychiatry can advance by keeping established treatments of proven efficacy while embracing new treatments.

Either because I convinced my son of the benefits of ECT—or because he wanted to avoid conflict—he eventually said, “Well, I guess you have to use whatever works, even if you don’t know exactly how it works.” So true.

Yesterday I tried to explain electroconvulsive therapy (ECT) to my 15-year-old son. Of my three children, he comes closest to idealizing me and is most likely to consider medical school. Still, he was a tough sell. His initial reaction to ECT was “that sounds sort of primitive.”

Dr. Max Fink’s article in this issue reviews the overwhelming evidence for ECT’s efficacy in major depressive disorder and the obstacles that prevent ECT from being used as widely as research suggests it should be. Two obstacles are limited availability (few psychiatrists make it part of their practice) and social stigma. The stigma leads to low availability, which makes ECT available only as a last resort, which in turn increases the stigma.

Dr. Fink identifies a third obstacle as “academic low regard,” meaning that academic psychiatrists relegate ECT to a third- or fourth-line therapy and neglect to teach about it. ECT was introduced before psychodynamic therapies and effective medications revolutionized psychiatry. Consequently, psychiatrists trained in psychodynamics and psychopharmacology pay less attention to ECT than the data warrant.

Repetitive transcranial magnetic stimulation (rTMS)—ably reviewed in this issue by Drs. Sheila Dowd and Philip Janicak—has an advantage over ECT in being new and therefore perceived as exciting. It also is less aesthetically problematic because most people have a more positive attitude towards magnets than electric shocks.

Time will tell where rTMS might fit into our treatment algorithms for major depressive disorder. Taken together, however, ECT and rTMS illustrate how psychiatry can advance by keeping established treatments of proven efficacy while embracing new treatments.

Either because I convinced my son of the benefits of ECT—or because he wanted to avoid conflict—he eventually said, “Well, I guess you have to use whatever works, even if you don’t know exactly how it works.” So true.

I’m sure we’ve all asked ourselves that question. Psychiatrists spend a lot of time observing hospitals. Our training requires us to work in hospitals, and many of us practice in hospitals after training.

You probably have ideas that could save your hospital thousands—even millions—of dollars, but the powers that be are not interested. You also, undoubtedly, have ideas to improve patient safety and satisfaction, but they are not interested in those, either.

Before anyone takes offense, I want to distinguish between hospitals—which tend to be stupid—and hospital administrators—who tend to be bright. I would guess that hospital administrators are even more frustrated than we are about how difficult it is for hospitals to make good decisions. Hospitals have this problem because they are big, complex systems with nobody in charge.

Years of “cost-based pricing”—when insurers paid whatever hospitals reported as t heir costs—contributed to hospital stupidity. This free-lunch reimbursement system may well have caused hospitals irreversible brain damage. It certainly made it difficult for them to adjust to “price-based costing”—having to bring costs in line with predetermined prices dictated by the payer.

I think, though, that the main reason hospitals became stupid was because they could get away with it. Hospitals had so much money and power that they did not need to be rational or responsive. Increased competition has eroded hospitals’ supremacy in the health-care market, but old habits die hard.

What can psychiatry learn from hospitals’ mistakes? If our profession could become more powerful without becoming stupid, we could rule the world—or, at least, the mental health care delivery system.

I’m sure we’ve all asked ourselves that question. Psychiatrists spend a lot of time observing hospitals. Our training requires us to work in hospitals, and many of us practice in hospitals after training.

You probably have ideas that could save your hospital thousands—even millions—of dollars, but the powers that be are not interested. You also, undoubtedly, have ideas to improve patient safety and satisfaction, but they are not interested in those, either.

Before anyone takes offense, I want to distinguish between hospitals—which tend to be stupid—and hospital administrators—who tend to be bright. I would guess that hospital administrators are even more frustrated than we are about how difficult it is for hospitals to make good decisions. Hospitals have this problem because they are big, complex systems with nobody in charge.

Years of “cost-based pricing”—when insurers paid whatever hospitals reported as t heir costs—contributed to hospital stupidity. This free-lunch reimbursement system may well have caused hospitals irreversible brain damage. It certainly made it difficult for them to adjust to “price-based costing”—having to bring costs in line with predetermined prices dictated by the payer.

I think, though, that the main reason hospitals became stupid was because they could get away with it. Hospitals had so much money and power that they did not need to be rational or responsive. Increased competition has eroded hospitals’ supremacy in the health-care market, but old habits die hard.

What can psychiatry learn from hospitals’ mistakes? If our profession could become more powerful without becoming stupid, we could rule the world—or, at least, the mental health care delivery system.

I’m sure we’ve all asked ourselves that question. Psychiatrists spend a lot of time observing hospitals. Our training requires us to work in hospitals, and many of us practice in hospitals after training.

You probably have ideas that could save your hospital thousands—even millions—of dollars, but the powers that be are not interested. You also, undoubtedly, have ideas to improve patient safety and satisfaction, but they are not interested in those, either.

Before anyone takes offense, I want to distinguish between hospitals—which tend to be stupid—and hospital administrators—who tend to be bright. I would guess that hospital administrators are even more frustrated than we are about how difficult it is for hospitals to make good decisions. Hospitals have this problem because they are big, complex systems with nobody in charge.

Years of “cost-based pricing”—when insurers paid whatever hospitals reported as t heir costs—contributed to hospital stupidity. This free-lunch reimbursement system may well have caused hospitals irreversible brain damage. It certainly made it difficult for them to adjust to “price-based costing”—having to bring costs in line with predetermined prices dictated by the payer.

I think, though, that the main reason hospitals became stupid was because they could get away with it. Hospitals had so much money and power that they did not need to be rational or responsive. Increased competition has eroded hospitals’ supremacy in the health-care market, but old habits die hard.

What can psychiatry learn from hospitals’ mistakes? If our profession could become more powerful without becoming stupid, we could rule the world—or, at least, the mental health care delivery system.

Several years ago, I read an article explaining that Japanese communication has at least three and probably six distinct “politeness levels.” English, of course, has no explicit politeness levels, but the article got me thinking about English communica-tion’s implicit politeness levels.

Since then, my most important discovery in the field of politeness studies is related to memos. Almost nobody remembers the content of my memos for more than 24 hours, but they remember their tone for years. This, of course, is consistent with Freud’s observation that certain emotional reactions remain forever alive in the subconscious.

Based on my discovery, I developed a rating scale called the Cincinnati Politeness Scale for Memos (CPS-m). When writing memos in my department, I generally try for about a 5.0—stupid and bureaucratic—although I believe that everything over 2.5 has its place in some context or other. Editorials can probably be rated on the same scale, as they resemble memos from the editor to the reader. For my editorials, I usually try for about a 7.0— polite—while most medical journal editors seem to try for about a 6.0—formal and reserved—and others seem to aim considerably lower.

For memos, and probably for all other forms of human communication, the politeness level is at least as important as the content. So let me know if you approve of the style, content, and politeness level of this monthÙs editorial (hillarjr@email.uc.edu). Feel free to offer constructive criticism of anything else in CURRENTPSYCHIATRY, but please keep it to a level of at least 4.0. Thanks.

Several years ago, I read an article explaining that Japanese communication has at least three and probably six distinct “politeness levels.” English, of course, has no explicit politeness levels, but the article got me thinking about English communica-tion’s implicit politeness levels.

Since then, my most important discovery in the field of politeness studies is related to memos. Almost nobody remembers the content of my memos for more than 24 hours, but they remember their tone for years. This, of course, is consistent with Freud’s observation that certain emotional reactions remain forever alive in the subconscious.

Based on my discovery, I developed a rating scale called the Cincinnati Politeness Scale for Memos (CPS-m). When writing memos in my department, I generally try for about a 5.0—stupid and bureaucratic—although I believe that everything over 2.5 has its place in some context or other. Editorials can probably be rated on the same scale, as they resemble memos from the editor to the reader. For my editorials, I usually try for about a 7.0— polite—while most medical journal editors seem to try for about a 6.0—formal and reserved—and others seem to aim considerably lower.

For memos, and probably for all other forms of human communication, the politeness level is at least as important as the content. So let me know if you approve of the style, content, and politeness level of this monthÙs editorial (hillarjr@email.uc.edu). Feel free to offer constructive criticism of anything else in CURRENTPSYCHIATRY, but please keep it to a level of at least 4.0. Thanks.

Several years ago, I read an article explaining that Japanese communication has at least three and probably six distinct “politeness levels.” English, of course, has no explicit politeness levels, but the article got me thinking about English communica-tion’s implicit politeness levels.

Since then, my most important discovery in the field of politeness studies is related to memos. Almost nobody remembers the content of my memos for more than 24 hours, but they remember their tone for years. This, of course, is consistent with Freud’s observation that certain emotional reactions remain forever alive in the subconscious.

Based on my discovery, I developed a rating scale called the Cincinnati Politeness Scale for Memos (CPS-m). When writing memos in my department, I generally try for about a 5.0—stupid and bureaucratic—although I believe that everything over 2.5 has its place in some context or other. Editorials can probably be rated on the same scale, as they resemble memos from the editor to the reader. For my editorials, I usually try for about a 7.0— polite—while most medical journal editors seem to try for about a 6.0—formal and reserved—and others seem to aim considerably lower.

For memos, and probably for all other forms of human communication, the politeness level is at least as important as the content. So let me know if you approve of the style, content, and politeness level of this monthÙs editorial (hillarjr@email.uc.edu). Feel free to offer constructive criticism of anything else in CURRENTPSYCHIATRY, but please keep it to a level of at least 4.0. Thanks.

When prescribing medications, I’m confident that few of us behave unethically. But I’m also confident that none of us goes through a full day practicing only evidence-based medicine.

I would like to use medications only in ways that have been proven in double-blind, placebo-controlled studies—the gold standard of evidence-based medicine. However, most of my patients (and I’m sure most of yours) have too many psychiatric, chemical dependency, and medical diagnoses or are too young or too old to meet the inclusion criteria for most double-blind studies. And of those few patients with just one diagnosis, many do not achieve complete remission on the drugs that are supposed to work for them.

What do we do then? I usually try a single medication that has not been thoroughly researched for the diagnoses I’m treating, or I use multiple medications.

Yes, I am a polypharmacist, and Drs. Sheldon Preskorn and Steven Werder have become my new heroes. Their article in this issue reviews the literature on use of multiple medications and suggests general principles for going beyond the literature.

Maybe that’s a better way to think about it: going beyond the literature. Where there are good scientific studies to guide us, we should certainly follow them. But we need to admit that there are not studies to justify everything we do. The practice of medicine would be ineffectual if we had to tell suffering patients, “I’m sorry, you’ll have to come back in a few years when maybe we will have completed some more studies.”

The practice of medicine in psychiatry—and in all other specialties—combines proven treatments and those for which there is evidence but not proof. Frequently, we try treatments that lack solid evidence but whose potential for efficacy exceeds their potential for harm.

Most medical research arises from clinical practice. If we prescribed only what is proven, we would never generate—or test—new hypotheses. We would not be using all of the available evidence, and we would not be helping as many patients. The purpose of Current Psychiatry is to keep us informed of the latest evidence, so that we can use it—or go beyond it—as each case dictates.

I am proud to be a polypharmacist. There, I’ve said it, and I really do feel better.

When prescribing medications, I’m confident that few of us behave unethically. But I’m also confident that none of us goes through a full day practicing only evidence-based medicine.

I would like to use medications only in ways that have been proven in double-blind, placebo-controlled studies—the gold standard of evidence-based medicine. However, most of my patients (and I’m sure most of yours) have too many psychiatric, chemical dependency, and medical diagnoses or are too young or too old to meet the inclusion criteria for most double-blind studies. And of those few patients with just one diagnosis, many do not achieve complete remission on the drugs that are supposed to work for them.

What do we do then? I usually try a single medication that has not been thoroughly researched for the diagnoses I’m treating, or I use multiple medications.

Yes, I am a polypharmacist, and Drs. Sheldon Preskorn and Steven Werder have become my new heroes. Their article in this issue reviews the literature on use of multiple medications and suggests general principles for going beyond the literature.

Maybe that’s a better way to think about it: going beyond the literature. Where there are good scientific studies to guide us, we should certainly follow them. But we need to admit that there are not studies to justify everything we do. The practice of medicine would be ineffectual if we had to tell suffering patients, “I’m sorry, you’ll have to come back in a few years when maybe we will have completed some more studies.”

The practice of medicine in psychiatry—and in all other specialties—combines proven treatments and those for which there is evidence but not proof. Frequently, we try treatments that lack solid evidence but whose potential for efficacy exceeds their potential for harm.

Most medical research arises from clinical practice. If we prescribed only what is proven, we would never generate—or test—new hypotheses. We would not be using all of the available evidence, and we would not be helping as many patients. The purpose of Current Psychiatry is to keep us informed of the latest evidence, so that we can use it—or go beyond it—as each case dictates.

I am proud to be a polypharmacist. There, I’ve said it, and I really do feel better.

When prescribing medications, I’m confident that few of us behave unethically. But I’m also confident that none of us goes through a full day practicing only evidence-based medicine.

I would like to use medications only in ways that have been proven in double-blind, placebo-controlled studies—the gold standard of evidence-based medicine. However, most of my patients (and I’m sure most of yours) have too many psychiatric, chemical dependency, and medical diagnoses or are too young or too old to meet the inclusion criteria for most double-blind studies. And of those few patients with just one diagnosis, many do not achieve complete remission on the drugs that are supposed to work for them.

What do we do then? I usually try a single medication that has not been thoroughly researched for the diagnoses I’m treating, or I use multiple medications.

Yes, I am a polypharmacist, and Drs. Sheldon Preskorn and Steven Werder have become my new heroes. Their article in this issue reviews the literature on use of multiple medications and suggests general principles for going beyond the literature.

Maybe that’s a better way to think about it: going beyond the literature. Where there are good scientific studies to guide us, we should certainly follow them. But we need to admit that there are not studies to justify everything we do. The practice of medicine would be ineffectual if we had to tell suffering patients, “I’m sorry, you’ll have to come back in a few years when maybe we will have completed some more studies.”

The practice of medicine in psychiatry—and in all other specialties—combines proven treatments and those for which there is evidence but not proof. Frequently, we try treatments that lack solid evidence but whose potential for efficacy exceeds their potential for harm.

Most medical research arises from clinical practice. If we prescribed only what is proven, we would never generate—or test—new hypotheses. We would not be using all of the available evidence, and we would not be helping as many patients. The purpose of Current Psychiatry is to keep us informed of the latest evidence, so that we can use it—or go beyond it—as each case dictates.

I am proud to be a polypharmacist. There, I’ve said it, and I really do feel better.

This month we welcome to our circulation 500 geriatric psychiatrists and 125 psychiatrists who chair academic departments at U.S. medical schools. Look for two articles in this issue on diagnosing and treating mental disorders in older patients:

• John W. Kasckow, MD, and colleagues from the University of Cincinnati College of Medicine discuss when and how to use selective serotonin reuptake inhibitors to treat late-life depression.
• Sumer Verma, MD, explains how uninformed treatment decisions led to an unfortunate outcome in an 85-year-old with dementia and depression in his “Cases That Test Your Skills” article.

I learned a lot from these articles, and I think they will be useful to both general and geriatric psychiatrists.

At the other end of the age spectrum, Elizabeth Weller, MD, and colleagues at Children’s Hospital of Philadelphia review new evidence on assessing and managing posttraumatic stress disorder in children and adolescents exposed to violence and abuse.

Schizoaffective disorder, which can plague adults at various stages of life, comprises a complex mix of psychotic and affective symptoms that confound rational treatment. Dr. Stephen Strakowski’s thoughtful cover article has convinced me that this construct does have validity, something I have long wondered about.

Christopher Pelic, MD, and Hugh Myrick, MD, of the Medical University of South Carolina, address alcohol withdrawal and delirium tremens—a problem that cuts across a wide age spectrum. Their well-documented answer to the question “Which patients are at highest risk?” may surprise you.

As we begin our second year of publication, one thing that hasn’t changed is the need for your feedback. Please continue to send me your comments and suggestions (hillarjr@email.uc.edu).

This month we welcome to our circulation 500 geriatric psychiatrists and 125 psychiatrists who chair academic departments at U.S. medical schools. Look for two articles in this issue on diagnosing and treating mental disorders in older patients:

• John W. Kasckow, MD, and colleagues from the University of Cincinnati College of Medicine discuss when and how to use selective serotonin reuptake inhibitors to treat late-life depression.
• Sumer Verma, MD, explains how uninformed treatment decisions led to an unfortunate outcome in an 85-year-old with dementia and depression in his “Cases That Test Your Skills” article.

I learned a lot from these articles, and I think they will be useful to both general and geriatric psychiatrists.

At the other end of the age spectrum, Elizabeth Weller, MD, and colleagues at Children’s Hospital of Philadelphia review new evidence on assessing and managing posttraumatic stress disorder in children and adolescents exposed to violence and abuse.

Schizoaffective disorder, which can plague adults at various stages of life, comprises a complex mix of psychotic and affective symptoms that confound rational treatment. Dr. Stephen Strakowski’s thoughtful cover article has convinced me that this construct does have validity, something I have long wondered about.

Christopher Pelic, MD, and Hugh Myrick, MD, of the Medical University of South Carolina, address alcohol withdrawal and delirium tremens—a problem that cuts across a wide age spectrum. Their well-documented answer to the question “Which patients are at highest risk?” may surprise you.

As we begin our second year of publication, one thing that hasn’t changed is the need for your feedback. Please continue to send me your comments and suggestions (hillarjr@email.uc.edu).

This month we welcome to our circulation 500 geriatric psychiatrists and 125 psychiatrists who chair academic departments at U.S. medical schools. Look for two articles in this issue on diagnosing and treating mental disorders in older patients:

• John W. Kasckow, MD, and colleagues from the University of Cincinnati College of Medicine discuss when and how to use selective serotonin reuptake inhibitors to treat late-life depression.
• Sumer Verma, MD, explains how uninformed treatment decisions led to an unfortunate outcome in an 85-year-old with dementia and depression in his “Cases That Test Your Skills” article.

I learned a lot from these articles, and I think they will be useful to both general and geriatric psychiatrists.

At the other end of the age spectrum, Elizabeth Weller, MD, and colleagues at Children’s Hospital of Philadelphia review new evidence on assessing and managing posttraumatic stress disorder in children and adolescents exposed to violence and abuse.

Schizoaffective disorder, which can plague adults at various stages of life, comprises a complex mix of psychotic and affective symptoms that confound rational treatment. Dr. Stephen Strakowski’s thoughtful cover article has convinced me that this construct does have validity, something I have long wondered about.

Christopher Pelic, MD, and Hugh Myrick, MD, of the Medical University of South Carolina, address alcohol withdrawal and delirium tremens—a problem that cuts across a wide age spectrum. Their well-documented answer to the question “Which patients are at highest risk?” may surprise you.

As we begin our second year of publication, one thing that hasn’t changed is the need for your feedback. Please continue to send me your comments and suggestions (hillarjr@email.uc.edu).