LETTERS
TO
THE
Am
EDITOR
J Psychiatry
135:1/,
November
1978
We disagree with the notion that psychiatry’s returning to the mainstream of medicine would make biochemists and pillpushers of us all, for the greater glory of ‘science’ and the
impulse control that was worse when he drank alcohol, which he used to self-medicate for his subjective depression. Psychological testing showed that the patient had a verbal
detriment
of 124 and a performance IQ of 106. The Graham Kendall Memory Test reflected normal perceptual motor abilities. The Bender-Gestalt was normal. Neurological and physical examinations were within normal limits. All laboratory tests,
‘ ‘
stream
of our
patients.
of medicine
and
improved
ties.
The
standing
indications
biological
lead for
returning
rather
than
the
criteria
available
treatment
modali-
to our have
advanced
under-
immeasurably
to the detriment
of our
been
PETER
to
patients.
E. CASEY, Portland,
DANIEL
IQ
main-
diagnostic
our
illnesses
to
to better
contributions
of psychiatric
the benefit
Rather,
‘ ‘
should
RABINS,
Baltimore,
M.D.
Ore. M.D.
Md.
skull series, and CT scan were within normal limits except for a bromide level of 42 mg/100 ml. The patient was kept in the hospital (medication-free) for 1 month, with resolution of his episodes of depression. The bromide level gradually decreased to 30 over 2 weeks. The patient did not evince any of
the impulsivity that had been reported prior to admission, and his ability to concentrate appeared to return by the time of discharge. Short-term follow-up at 1 month has disclosed the
Generic SIR:
Versus
The
Brand
Name
spreading
legalization
of the
substitution
of ge-
nenic for brand-name drugs, including psychotropics, is responsible for an escalating number of patients receiving genenic rather than the prescribed brand-name drug from the dispensing pharmacist. In the case of tricyclic antidepres-
sants, this practice can be hazardous because, as the Food and Drug Administration has stated in the Federal Register of February 17, 1978, ‘available data suggest that the various marketed brands of the same oral tricyclic antidepressant may not have comparable therapeutic effects’ ‘ (due to bioequivalence differences) and “the substitution ofa poorly bioavailable form in the regimen of a patient controlled on a fully available form would result in reversion to the depressed state.” I am gathering instances of I) depressed patients who did not respond to initial treatment with a generic tricyclic anti-
depressant
but
did
respond
to a subsequently
administered
brand-name tricyclic antidepressant, and 2) depressed patients who responded to a brand-name tricyclic but relapsed when a generic form was substituted. I would be grateful if my fellow psychiatrists who have had patients adversely affected by treatment with a generic tricyclic antidepressant would share their data with me. FRANK
Bromism
from
Over-the-Counter
absence
The counter
Psychotropics
J. AYD, JR., M.D. Baltimore, Md.
Medications
SIR: In his article ‘Bromism: Alive in Well’ ‘ (July 1978 issue) Ira Brenner, M.D. , pointed out that neuropsychiatric symptoms can occur below the normally accepted cut-off point of 50 mg/lOO ml. We have reason to believe that bromism is not a rare disorder and have recently seen a case here.
of attempting
relief.
The
patient
reported
a his-
tory of diminished libido and decreased concentration over the previous 2 years, although he denied sleep or appetite disturbance, suicidality, delusions, or hallucinations. He was unable to perform his work as an engineer and was socially
1428
withdrawn
from
his
premorbid
life
style.
He
had
poor
on
no
medications.
of his anxiety.
This
behavior
had
they
evaluated
him,
but the patient
reports
that he
did not consider over-the-counter medications as the type of medication the physicians were asking about. This suggests that in all evaluations patients should be directed to inform
the
physician
about
all pills
over-the-counter medications etc.) since the patients may they went to see the physician.
they ,
are
ingesting
vitamins, not relate
Another
Reason
for
(including
oral contraceptives, these to the reason
ROBERT
H.
GERNER,
M.D.
Los
Angeles,
Calif.
Partial
Hospital-
Underutilization
of
ization?
SIR: I would like to comment on the article titled ‘ ‘The Paradoxical Underutilization of Partial Hospitalization” by Edward B. Fink, M.D. , Richard Longabaugh, Ed.D. , and Robert Stout, Ph.D. (June 1978 issue). The authors conclude
that the underutilization to be largely attributable
of partial to the
hospitalization ‘appears subjective discomforts of
physicians and ment setting. ‘
families
with
have
hospitalization important
group age
‘
enough
In a brief providers that Blue
patients’
The refusals
been
psychiatric
no
to get control
at the time
Ohio
with
symptoms
continued for 7 or 8 months before admission and had not been detected by previous psychiatrists or in previous hospitalizations over the six months before admission. Contact with the patient’s previous physicians revealed that they had appropriately asked him about any medication he was taking
antidepressants,
‘
previous
bromide probably came from this source. After his recovery, discussion with the patient revealed that he had been feeling anxious about his job performance and started taking these over-the-counter preparations, which did not initially relieve his anxiety ; he increased the frequency of ingestion as a way
The patient, a 33-year-old man, was admitted for treatment ofa depression that had been intermittent and manifested by sudden episodes of his feeling ‘very depressed,’ which lasted minutes to hours and occurred several times weekly. The patient had had these episodes for approximately 3 months and had been treated previously in a hospital. He is now an outpatient and has been given adequate doses of tnicyclic ‘
of his
patient reported that he had been taking an over-thesedative but was unable to remember the name; the
authors only of third-party
telephone
survey
ofhospital
Prudential
alternative
Department)
will pay
Blue bills
Shield and
depending
and Travelers some
percentage
treat-
mention that there to finance partial
of six major
federal medical Mutual, and
hospitalization:
policy,
this
briefly payers
treatment and do not seem to feel to include in their conclusions.
and state and Cross, Midland
Welfare
‘
health providers Medicaid
no percentage on
the
that
it is
insurance I found (State of
of partial individual
or
will pay no percentofphysicians’
bills;
will pay some percentage: and Aetna will pay 50%-80% but does not cover meals. Medicaid (U.S. government for patients over 65 or disabled for 2 years or longer)
Am
J Psychiatry
/35:1/,
November
will pay no percentage cians’ bills. The results companies, Prudential
that
cover
Cross,
of hospital costs of this survey and Aetna, will
a percentage
Travelers,
/978
of day
Midland,
and
LETTERS
but show write
will pay physithat only two some policies
hospital most
treatment.
Blue
Shield
will
not pay for partial
hospitalization.
I submit
that
conclusions that ization is attributable the physician and incomplete.
the
of discomfort alternative
partial hospitalon the part of treatment are
Another
underutilization to subjective patients to this
the authors’
There programs ones. state,
is no doubt that presents many Our experience however, has
ue to encourage
conclusion
might
it is an ethical
be that
for
hospital
services
been
with Blue successful.
the efforts
L.
the
help
TISHLER,
1cm in partial insurance
letter
hospital
partial portant
hospital reason
addresses
do not
ROBERT
lack
day
a very
important
namely,
pay
for
that
of third-party
problem. program
to the
in 1973,
tween land,
described payment
Prior
that than
health
treatment
in a
this is a more imthose we empha-
basis,
the
in our article,
for
extensive
insurance
well
as
to
the
now
is a permanent
come pital
study
feature
its
a
be-
Partial
the
clinicians,
coverage
Shield
completion
efforts
to
partial hospimembers, as
hospital
Cross/Blue
study
con-
of the
out-
on the part of the hosit was
judged
that
such
efforts were worthwhile. Other psychiatric institutions have followed our early example, and many hospitals in the surrounding area discussed their specific third-party payer problems with us and learned of our experience. Several of these
hospitals
have
bynow
successfully
negotiated
analo-
gous arrangements with insurance providers. In contrast to Dr. Tishler’s survey, our local Blue Cross/Blue Shield office reports that its affiliates in as many as 17 other states are providing coverage date. (A complete
Dr.
Tishler’s
clinicians
for partial hospital programs listing is available on request.)
letter
should
also
consider
suggests not
that
admitting
as of this
for ethical patients
best
interest
productive
contend
that
of patient than
Dr.
such
care. Tishler’s
a practice
would
Perhaps would
not
an alternative be
to
increase
partial
the cost to our and rebe
in the
more our
to explain
vulnerability
to neurotic
distress
symp-
forward another hypothesis to explain to neurotic distress symptoms. This
huhy-
pothesis is based on the notion that both adaptation and maladaptation are active processes which can be portrayed by the concept of adaptive and maladaptive cycles (1 , 2). The maladaptive cycle , whic h includes neurotic maladaptation, is based on the premise that failure may lead to further fail-
These
ideas
led to a hypothesis
about
the possible
role
ofneurotic maladaptation in prehistory. As natural selection operates on genetic differences, the two mechanisms would have magnified the impact of these genetic differences, thereby accelerating the weeding action of natural selection. This dual process would have accelerated the phylogenetic
adaptation of various animal species, including early man. Dr. Galanter’s hypothesis and mine differ in that whereas I refer to adaptive and maladaptive cycles, he appears to think in terms ofa single continuum, the adaptive. Another theory that overlaps with playing an adaptive
his is that biological
of Price, role (3).
ter view neurosis as promoting Dr. Galanter did not attempt formulation successful
explaining in contributing
One
that less cohesive
knows
crate neurotic ers: one can
why
distress differentiate
is the
sociobiological
saw Price
neurosis as and Galan-
social behavior. to provide a sociobiological
very cohesive groups to a decline in neurotic
families
symptoms between
are functional and those the support they provide
who Both
are more
prone
in their offspring peer or family
that are dysfunctional for the members ofthe
function
should be distress.
of
this
to gen-
than groups
oththat
in terms of group. What
differentiation?
It is
well known that when groups compete, those who are victorious tend to show euphoria and those who are defeated tend to exhibit depression and anxiety. This even applies when
reasons to
hospital programs if third-party payers do not cover of medical care. As documented in the introduction article (see references 1-4, p. 716), many clinicians searchers
R.I.
toms. He argued that because affiliation with a highly cohesive group engenders a significant decline in neurotic distress, the adaptive value of this vulnerability may lie in part in assuring effective integration with a larger social group, thereby leading to a more adaptive social unit.
ure.
subscribers
outcome documented,
Shield, that and family
and
and
completed
to offer
of Blue
extensive
administration
not
hospital
as an alternative to inpatient the hospital included the con-
payer.
Island. negotiations
required
was
partial
were
agreed
Cross/Blue to patients
third-party
tracts in Rhode Although the
of our
complete a treatment data. The study has
the satisfaction of Blue talization is beneficial
PH.D.
in Prehistory
I recently put man vulnerability
the
Cross/Blue Shield of Rhode Ispayer in the state. On a trial
carrier
hospital follow-up
however,
hospitalization
negotiations
partial hospitalization coverage coverage. The agreement with dition that the with 18-month
day
establishment
the hospital and Blue the major thirdparty
STOUT,
Providence,
Maladaptation
prob-
many
psychiatric
setting. He contends for underutilization hospital
M.D. ED.D.
Ohio
sized.
In the
in this contin-
SIR: In ‘ The ‘Relief Effect’ : A Sociobiological Model for Neurotic Distress and Large-Group Therapy’ ‘ (May 1978 issue) Marc Galanter, M.D., put forward a sociobiological
utilization;
providers
FINK,
LONGABAUGH,
of
model Tishler’s
B.
EDWARD
Dr. Fink and AssociatesReply Dr.
Shield it will
of others.
RICHARD
PH.D.
Columbus,
SIR:
Cross/Blue We hope
response
without
CARL
EDITOR
the development of partial hospital potential obstacles, including fiscal
on the part of psychiatrists and psychologists not to have patients admitted to psychiatric facilities when insurance and family resources cannot cover the accrued bills (and it is rare to see patients pay third-party payments).
THE
forts to educate the third-party carriers, as we do our patients and their families, regarding the advantages of treatment in the partial hospital setting. The development of alternative clinical services which meet the needs of our patients thereby would be fostered.
Blue plans
TO
ef-
representatives prehistoric
times
of groups compete. the morale or
I would cohesiveness
submit of
that in a group
would have been a rough index of the biological endowment of the members of the group. The well-integrated family or peer group would have been able to provide greater support to their members than would the less well-integrated group. 1429
TO
THE
Am
EDITOR
J Psychiatry
135:1/,
November
1978
We disagree with the notion that psychiatry’s returning to the mainstream of medicine would make biochemists and pillpushers of us all, for the greater glory of ‘science’ and the
impulse control that was worse when he drank alcohol, which he used to self-medicate for his subjective depression. Psychological testing showed that the patient had a verbal
detriment
of 124 and a performance IQ of 106. The Graham Kendall Memory Test reflected normal perceptual motor abilities. The Bender-Gestalt was normal. Neurological and physical examinations were within normal limits. All laboratory tests,
‘ ‘
stream
of our
patients.
of medicine
and
improved
ties.
The
standing
indications
biological
lead for
returning
rather
than
the
criteria
available
treatment
modali-
to our have
advanced
under-
immeasurably
to the detriment
of our
been
PETER
to
patients.
E. CASEY, Portland,
DANIEL
IQ
main-
diagnostic
our
illnesses
to
to better
contributions
of psychiatric
the benefit
Rather,
‘ ‘
should
RABINS,
Baltimore,
M.D.
Ore. M.D.
Md.
skull series, and CT scan were within normal limits except for a bromide level of 42 mg/100 ml. The patient was kept in the hospital (medication-free) for 1 month, with resolution of his episodes of depression. The bromide level gradually decreased to 30 over 2 weeks. The patient did not evince any of
the impulsivity that had been reported prior to admission, and his ability to concentrate appeared to return by the time of discharge. Short-term follow-up at 1 month has disclosed the
Generic SIR:
Versus
The
Brand
Name
spreading
legalization
of the
substitution
of ge-
nenic for brand-name drugs, including psychotropics, is responsible for an escalating number of patients receiving genenic rather than the prescribed brand-name drug from the dispensing pharmacist. In the case of tricyclic antidepres-
sants, this practice can be hazardous because, as the Food and Drug Administration has stated in the Federal Register of February 17, 1978, ‘available data suggest that the various marketed brands of the same oral tricyclic antidepressant may not have comparable therapeutic effects’ ‘ (due to bioequivalence differences) and “the substitution ofa poorly bioavailable form in the regimen of a patient controlled on a fully available form would result in reversion to the depressed state.” I am gathering instances of I) depressed patients who did not respond to initial treatment with a generic tricyclic anti-
depressant
but
did
respond
to a subsequently
administered
brand-name tricyclic antidepressant, and 2) depressed patients who responded to a brand-name tricyclic but relapsed when a generic form was substituted. I would be grateful if my fellow psychiatrists who have had patients adversely affected by treatment with a generic tricyclic antidepressant would share their data with me. FRANK
Bromism
from
Over-the-Counter
absence
The counter
Psychotropics
J. AYD, JR., M.D. Baltimore, Md.
Medications
SIR: In his article ‘Bromism: Alive in Well’ ‘ (July 1978 issue) Ira Brenner, M.D. , pointed out that neuropsychiatric symptoms can occur below the normally accepted cut-off point of 50 mg/lOO ml. We have reason to believe that bromism is not a rare disorder and have recently seen a case here.
of attempting
relief.
The
patient
reported
a his-
tory of diminished libido and decreased concentration over the previous 2 years, although he denied sleep or appetite disturbance, suicidality, delusions, or hallucinations. He was unable to perform his work as an engineer and was socially
1428
withdrawn
from
his
premorbid
life
style.
He
had
poor
on
no
medications.
of his anxiety.
This
behavior
had
they
evaluated
him,
but the patient
reports
that he
did not consider over-the-counter medications as the type of medication the physicians were asking about. This suggests that in all evaluations patients should be directed to inform
the
physician
about
all pills
over-the-counter medications etc.) since the patients may they went to see the physician.
they ,
are
ingesting
vitamins, not relate
Another
Reason
for
(including
oral contraceptives, these to the reason
ROBERT
H.
GERNER,
M.D.
Los
Angeles,
Calif.
Partial
Hospital-
Underutilization
of
ization?
SIR: I would like to comment on the article titled ‘ ‘The Paradoxical Underutilization of Partial Hospitalization” by Edward B. Fink, M.D. , Richard Longabaugh, Ed.D. , and Robert Stout, Ph.D. (June 1978 issue). The authors conclude
that the underutilization to be largely attributable
of partial to the
hospitalization ‘appears subjective discomforts of
physicians and ment setting. ‘
families
with
have
hospitalization important
group age
‘
enough
In a brief providers that Blue
patients’
The refusals
been
psychiatric
no
to get control
at the time
Ohio
with
symptoms
continued for 7 or 8 months before admission and had not been detected by previous psychiatrists or in previous hospitalizations over the six months before admission. Contact with the patient’s previous physicians revealed that they had appropriately asked him about any medication he was taking
antidepressants,
‘
previous
bromide probably came from this source. After his recovery, discussion with the patient revealed that he had been feeling anxious about his job performance and started taking these over-the-counter preparations, which did not initially relieve his anxiety ; he increased the frequency of ingestion as a way
The patient, a 33-year-old man, was admitted for treatment ofa depression that had been intermittent and manifested by sudden episodes of his feeling ‘very depressed,’ which lasted minutes to hours and occurred several times weekly. The patient had had these episodes for approximately 3 months and had been treated previously in a hospital. He is now an outpatient and has been given adequate doses of tnicyclic ‘
of his
patient reported that he had been taking an over-thesedative but was unable to remember the name; the
authors only of third-party
telephone
survey
ofhospital
Prudential
alternative
Department)
will pay
Blue bills
Shield and
depending
and Travelers some
percentage
treat-
mention that there to finance partial
of six major
federal medical Mutual, and
hospitalization:
policy,
this
briefly payers
treatment and do not seem to feel to include in their conclusions.
and state and Cross, Midland
Welfare
‘
health providers Medicaid
no percentage on
the
that
it is
insurance I found (State of
of partial individual
or
will pay no percentofphysicians’
bills;
will pay some percentage: and Aetna will pay 50%-80% but does not cover meals. Medicaid (U.S. government for patients over 65 or disabled for 2 years or longer)
Am
J Psychiatry
/35:1/,
November
will pay no percentage cians’ bills. The results companies, Prudential
that
cover
Cross,
of hospital costs of this survey and Aetna, will
a percentage
Travelers,
/978
of day
Midland,
and
LETTERS
but show write
will pay physithat only two some policies
hospital most
treatment.
Blue
Shield
will
not pay for partial
hospitalization.
I submit
that
conclusions that ization is attributable the physician and incomplete.
the
of discomfort alternative
partial hospitalon the part of treatment are
Another
underutilization to subjective patients to this
the authors’
There programs ones. state,
is no doubt that presents many Our experience however, has
ue to encourage
conclusion
might
it is an ethical
be that
for
hospital
services
been
with Blue successful.
the efforts
L.
the
help
TISHLER,
1cm in partial insurance
letter
hospital
partial portant
hospital reason
addresses
do not
ROBERT
lack
day
a very
important
namely,
pay
for
that
of third-party
problem. program
to the
in 1973,
tween land,
described payment
Prior
that than
health
treatment
in a
this is a more imthose we empha-
basis,
the
in our article,
for
extensive
insurance
well
as
to
the
now
is a permanent
come pital
study
feature
its
a
be-
Partial
the
clinicians,
coverage
Shield
completion
efforts
to
partial hospimembers, as
hospital
Cross/Blue
study
con-
of the
out-
on the part of the hosit was
judged
that
such
efforts were worthwhile. Other psychiatric institutions have followed our early example, and many hospitals in the surrounding area discussed their specific third-party payer problems with us and learned of our experience. Several of these
hospitals
have
bynow
successfully
negotiated
analo-
gous arrangements with insurance providers. In contrast to Dr. Tishler’s survey, our local Blue Cross/Blue Shield office reports that its affiliates in as many as 17 other states are providing coverage date. (A complete
Dr.
Tishler’s
clinicians
for partial hospital programs listing is available on request.)
letter
should
also
consider
suggests not
that
admitting
as of this
for ethical patients
best
interest
productive
contend
that
of patient than
Dr.
such
care. Tishler’s
a practice
would
Perhaps would
not
an alternative be
to
increase
partial
the cost to our and rebe
in the
more our
to explain
vulnerability
to neurotic
distress
symp-
forward another hypothesis to explain to neurotic distress symptoms. This
huhy-
pothesis is based on the notion that both adaptation and maladaptation are active processes which can be portrayed by the concept of adaptive and maladaptive cycles (1 , 2). The maladaptive cycle , whic h includes neurotic maladaptation, is based on the premise that failure may lead to further fail-
These
ideas
led to a hypothesis
about
the possible
role
ofneurotic maladaptation in prehistory. As natural selection operates on genetic differences, the two mechanisms would have magnified the impact of these genetic differences, thereby accelerating the weeding action of natural selection. This dual process would have accelerated the phylogenetic
adaptation of various animal species, including early man. Dr. Galanter’s hypothesis and mine differ in that whereas I refer to adaptive and maladaptive cycles, he appears to think in terms ofa single continuum, the adaptive. Another theory that overlaps with playing an adaptive
his is that biological
of Price, role (3).
ter view neurosis as promoting Dr. Galanter did not attempt formulation successful
explaining in contributing
One
that less cohesive
knows
crate neurotic ers: one can
why
distress differentiate
is the
sociobiological
saw Price
neurosis as and Galan-
social behavior. to provide a sociobiological
very cohesive groups to a decline in neurotic
families
symptoms between
are functional and those the support they provide
who Both
are more
prone
in their offspring peer or family
that are dysfunctional for the members ofthe
function
should be distress.
of
this
to gen-
than groups
oththat
in terms of group. What
differentiation?
It is
well known that when groups compete, those who are victorious tend to show euphoria and those who are defeated tend to exhibit depression and anxiety. This even applies when
reasons to
hospital programs if third-party payers do not cover of medical care. As documented in the introduction article (see references 1-4, p. 716), many clinicians searchers
R.I.
toms. He argued that because affiliation with a highly cohesive group engenders a significant decline in neurotic distress, the adaptive value of this vulnerability may lie in part in assuring effective integration with a larger social group, thereby leading to a more adaptive social unit.
ure.
subscribers
outcome documented,
Shield, that and family
and
and
completed
to offer
of Blue
extensive
administration
not
hospital
as an alternative to inpatient the hospital included the con-
payer.
Island. negotiations
required
was
partial
were
agreed
Cross/Blue to patients
third-party
tracts in Rhode Although the
of our
complete a treatment data. The study has
the satisfaction of Blue talization is beneficial
PH.D.
in Prehistory
I recently put man vulnerability
the
Cross/Blue Shield of Rhode Ispayer in the state. On a trial
carrier
hospital follow-up
however,
hospitalization
negotiations
partial hospitalization coverage coverage. The agreement with dition that the with 18-month
day
establishment
the hospital and Blue the major thirdparty
STOUT,
Providence,
Maladaptation
prob-
many
psychiatric
setting. He contends for underutilization hospital
M.D. ED.D.
Ohio
sized.
In the
in this contin-
SIR: In ‘ The ‘Relief Effect’ : A Sociobiological Model for Neurotic Distress and Large-Group Therapy’ ‘ (May 1978 issue) Marc Galanter, M.D., put forward a sociobiological
utilization;
providers
FINK,
LONGABAUGH,
of
model Tishler’s
B.
EDWARD
Dr. Fink and AssociatesReply Dr.
Shield it will
of others.
RICHARD
PH.D.
Columbus,
SIR:
Cross/Blue We hope
response
without
CARL
EDITOR
the development of partial hospital potential obstacles, including fiscal
on the part of psychiatrists and psychologists not to have patients admitted to psychiatric facilities when insurance and family resources cannot cover the accrued bills (and it is rare to see patients pay third-party payments).
THE
forts to educate the third-party carriers, as we do our patients and their families, regarding the advantages of treatment in the partial hospital setting. The development of alternative clinical services which meet the needs of our patients thereby would be fostered.
Blue plans
TO
ef-
representatives prehistoric
times
of groups compete. the morale or
I would cohesiveness
submit of
that in a group
would have been a rough index of the biological endowment of the members of the group. The well-integrated family or peer group would have been able to provide greater support to their members than would the less well-integrated group. 1429
