Gordon Harper

Amitriptyline in the Treatment of Anorexia Nervosa: A Double-blind, Placebo-controlled Study

The tricyclic antidepressant drug amitriptyline was evaluated as a short-term treatment of anorexia nervosa patients. In a 5-week double-blind, placebo-controlled study 11 patients were given amitriptyline and 14 received placebo. In addition, 18 patients who refused to participate in the drug trial and received only psychosocial treatment were used as an additional comparison group. Overall, patients in the three groups showed little improvement. No statistically significant differences favoring amitriptyline were found in any of the outcome variables. Plasma levels varied widely among patients receiving similar doses. No association was found between plasma levels and improvement in either psychiatric symptomatology or weight. Amitriptyline patients did not manifest any tendency for a reduction of depressive symptomatology. In addition, amitriptyline treatment was associated with substantial discomfort and adverse affects.

Child and Adolescent Inpatient Restraint Reduction: A State Initiative to Promote Strength-Based Care

OBJECTIVE To reduce the use of restraint and seclusion with children and adolescents in psychiatric inpatient units by promoting a preventive, strength-based model of care. METHOD The State Mental Health Authority used data analysis, quality improvement strategies, regulatory oversight, and technical assistance to develop and implement system change over a 22-month period. No changes in regulation or policy were undertaken. RESULTS Comparative data collected before and after the interventions demonstrated substantial reductions in the use of restraint and seclusion. Child units (age 5-12) decreased from 84.03 to 22.78 episodes per 1,000 patient days (72.9%), adolescent units from 72.22 to 37.99 episodes (47.4%), and mixed child/adolescent units from 73.37 to 30.08 episodes (59%). CONCLUSIONS The use of restraint and seclusion in child and adolescent inpatient settings can be reduced through a systems approach, which may have applicability to other settings and systems.

A New educational approach for supporting the professional development of third-year medical students

This paper describes a new course designed to support the professional development of third-year medical students. The course runs through the clinical clerkships, and has several additional features: it includes a multidisciplinary faculty; it is centrally based in the medical school; it addresses students’ values and attitudes in addition to their knowledge and skills; and it makes use of small-group learning methods, and faculty, student, and group continuity during the year. The curriculum, which addresses ethical, social, and communicative issues in medicine, plus the evaluation of students and of the course, are described.

Focal inpatient treatment planning.

Focal Inpatient Treatment Planning (FITP) is a new method of organizing and choosing among the many data available to the inpatient clinician. FITP emphasizes one Focal Problem, provides criteria for defining it, makes it possible to formulate the problem in operational language, channels free-ranging case discussion into workaday terms, invites the clinician to make explicit a sophisticated view of pathogenesis; including developmental, dynamic, and contextual factors, and ties formulation to intervention through explicit objectives. By requiring language that is jargon-free and accessible to patients and parents, FITP fosters empathy and alliance between the treatment community and the domain of the patient. This paper describes and illustrates FITP and provides guidelines for its implementation by an inpatient child and adolescent psychiatry service.

ALLIANCE FORMATION WITH PARENTS: Limit-Setting and the Effect of Mandated Reporting

The ability of parents to cooperate in their childrens treatment is not fixed, but is a potential that evolves in a clinical relationship. Such clinical work includes a hierarchy of limit-setting, ranging from education to legal intervention. The experience of an inpatient child psychosomatic service indicates that such limit-setting was relevant in more than 50% of cases, and served to enhance the alliance with parents and children.

Urinary MHPG in anorexia nervosa patients with and without a concomitant major depressive disorder

Twenty-four hour urinary MHPG excretion was measured in a group of anorexia nervosa patients before and after five weeks of treatment and in matched normal control subjects. A sub-group of anorexia nervosa patients who met research diagnostic criteria (RDC) for a concomitant major depressive disorder (AN-RDC +) was found to have, both initially and after treatment, significantly lower mean urinary MHPG levels than the normal control subjects. In contrast, mean urinary MHPG levels in anorexia nervosa patients who did not meet criteria for major depressive disorder (AN-RDC +) were similar to values in normal controls. Utilizing the median value of all urinary MHPG samples as the cut-off point, it was found that significantly more AN-RDC + patients excreted low MHPG compared with AN-RDC-patients and normal control subjects. The manifestation of a major depressive disorder according to RDC was found to be more important than body size variables in predicting the variance of MHPG. It is suggested that urinary MHPG levels may be useful in discriminating between sub-types of anorexia nervosa patients.

Varieties of Parenting Failure in Anorexia Nervosa: Protection and Parentectomy, Revisited

This paper discusses family treatment in anorexia nervosa from the perspective of parenting failure and the childs need for protection. Data are presented from a series of 150 hospitalized patients and a chart review of 25 cases. The data illustrate the frequency with which patients lose weight on contact with parents and the varieties of parenting failure observed: provision of harmful unprescribed medication, maliganant denial, breakdown of householding, ***etc. A hierarchy of parenting stabilizing interventions leading from the educational to the legal-administrative is presented and examples given. Advantages and dangers in this approach and the ways it contrast with the family therapy appraoch are spelled out.

Child and adolescent mental health policy: Promise to provision

Mental health policy enables the translation of the knowledge base of ‘how’ to help children and families into the actual ‘provision’ of help. Amid competing pressures to leave the allocation of services to the market, policy is required to define needs, select priorities, match resources with need, and to measure what has been accomplished. Crafting policy requires balancing contrasting goals and approaches, here spelled out. Public mental health policy can be compared to other forms of continuous quality improvement (CQI).

Diagnostic Dilemmas and Principles of Management

Unexplained disability in childhood challenges the physician diagnostically and therapeutically. Clinical presentation is typically that of a chronically ill and increasingly disabled child, often with positive physical findings and erratic response to usual medical management. The physician experiences great pressure to diagnose, to counsel, and to cure. Family characteristics include an inability to speak in psychological terms, denial of the familys involvement in the childs symptoms, and an emphasis on equivocal bio medical findings. Diagnostic and therapeutic tools specific to these disabilities are defined, with clinical illustrations provided.

Case Study: The Internet as a Developmental Tool in an Adolescent Boy With Psychosis

The Internet has become an increasingly important part of teen culture; however, there still remains little in the medical/psychiatric literature pertaining to the impact of the Internet on adolescent development. Despite the potential problems associated with communication online, the Internet offers a variety of positive opportunities for teens. In this report, we present a case study that illustrates the Internet as a helpful tool in a 15-year-old adolescent boy with a history of chronic neurological illness accompanied by refractory psychosis. Although the case emphasizes some of the ways in which the Internet may have a positive impact on adolescent development, further research is indicated to evaluate the contexts in which the Internet serves healthy developmental processes and those in which its influence is potentially deleterious.