Combining structured interviewing with a review of the medical record appears to produce more accurate primary diagnoses and to identify more secondary diagnoses than routine clinical methods. The patients' knowledge of their diagnoses was limited, suggesting a need for patient education in this setting. Whether use of structured interviewing in routine practice improves patient outcomes deserves further study.

PCCs have used and value a statewide system that provides access to teams of psychiatric consultants. Access to child mental health care may be substantially improved through public health interventions that promote collaboration between PCCs and child mental health specialists.

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The objective of this study was to evaluate pharmacological approaches for attention deficit hyperactivity disorder (ADHD) in children with bioplar disorder and comorbid ADHD. The medical charts of 38 patients with diagnoses of both Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., revised ADHD and bipolar disorder were reviewed over multiple visits to assess improvement and prescription patterns. Logistic regression was used to model the probability of improvement at each visit, and robust standard errors were estimated in order to account for correlation among individuals using Huber's correction for clustered data. The proportion of visits at which ADHD symptoms were rated as improved following initial improvement in manic symptoms was 7.5 times greater than before initial improvement of manic symptoms. The recurrence of manic symptoms following their initial stabilization significantly inhibited ADHD response to medication. Although tricyclic antidepressants (TCAs) significantly increased the probability of ADHD improvement following mood stabilization, there was also a significant association between treatment with TCAs and relapse of manic symptoms. Our results support the hypothesis that mood stabilization is a prerequisite for the successful pharmacologic treatment of ADHD in children with both ADHD and manic symptoms. Although TCAs can be helpful in the management of ADHD children with manic symptoms, these drugs should be used with caution since they can also have a destabilizing effect on manic symptoms.

This study assessed the effectiveness and tolerability of the selective serotonin reuptake inhibitor citalopram in the treatment of patients with pervasive developmental disorders (PDDs). The medical charts of 15 children and adolescents (aged 6-16 yr) with Asperger syndrome, autism, or PDD not otherwise specified treated with citalopram were retrospectively reviewed. The final dose of citalopram was 16.9 +/- 12.1 mg/day with a treatment duration of 218.8 +/- 167.2 days. Independent ratings of the Clinical Global Impression (CGI) Severity and Improvement scales allowed comparison between baseline and PDD symptoms at the last visit. Eleven adolescents (73%) exhibited significant improvement in PDD, anxiety, or mood CGI score (z = 2.95; p =.003). Anxiety symptoms associated with PDDs improved significantly in 66% of patients (z = 2.83, p =.005), and mood symptoms improved significantly in 47% of patients (z = 2.78, p =.005). Mild side effects were reported by five patients (33%). These data suggest citalopram may be effective, safe, and well tolerated as part of the treatment of PDDs.

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Forced terminations are a powerful experience for both patients and for residents. Such terminations often resemble earlier losses to patients, who may react with particular defense constellations, changes in symptoms, and profound reactions to the therapist. Similarly, prominent countertransference may manifest in attempts by residents to deny their importance to patients, to project reactions onto their patients, and to alter the therapy relationship. More intense therapy relationships usually require termination announcements months in advance. How much will be revealed to patients may best be determined prior to the announcement. Payments, gifts, subsequent contact, transfer to another therapist, and concluding therapy comments need evaluation of what is in the patient's best interest and may require creative approaches deviating from traditional therapy practices. This discussion reviewed reactions of patients and residents to forced termination, addressed the pragmatic issues confronting the resident, provided clinical vignettes illustrating peculiarities of forced terminations, and listed recommendations to assist the departing resident. Forced terminations afford powerful opportunities for contending with abandonment, disappointment, and loss directly in the therapy. While these experiences are certainly not comfortable, they can be used constructively to benefit patients if the issues surrounding the forced termination are carefully considered and addressed within the therapy.