LETTERS TO THE EDITOR
continued from page 970 ing Medical Education (ACCME). Policies and Procedures Manual. Chicago, III: ACCME; 1982. 2. Accreditation Council for Continuing Medical Education. Guidelines for Accreditation. Chicago, III: ACCME; 1982. 3. Davis D, Feldman E. The McMaster CME Society. Journal of Medicai Education. 1982;57:476-480. 4. Premi JN. Problem-based, selfdirected continuing medical education in a group of practicing family physicians. Journal of Medical Education. 1 988;63:484-486. 5. Felch WC. The case for hospitalbased continuing medical education. The Hospital Medical Staff 1977;6:12-13. 6. Rosser WW. A national selfevaluation program for Canadian family doctors. Can Med Assoc J. 1975;1 12:982-985. 7. Taylor MP. Continuing education for general practice-a learning system. Journal of the Royal College of General Practitioners. 1977;27:137-142. 8. Miller GE. Continuing education for what? Joumal of Medical Education. 1 967;42:321 -326. 9. Ashbaugh D, McKean R. Continuing medical education: the philosophy and use of audit. JAMA. 1976;236:14851488. 10. Meyer TC. Toward a continuum in medical education. Bull NY Acad Med. 1975;61 :719-726. 11. Koska MT. Tapping into quality data is next for hospital CME programs. Hospitals. 1990;64:30, 33.
Forensic Psychiatry To the Editor: This letter investigates the putative genetic predisposition of affective disorders and the need to elicit a comprehensive familial history in order to facilitate appropriate management.'-4 This approach could have important implications in the psychopharmacological management of such cases.
On October 2, 1990, a 25-yearold single, black male was admitted to our Forensic Unit on inconsequential legal charges for emergency treatment. He was a tall (6'5"), normally developed, slender individual, who was described as hostile with increased psychomotor activity and verbal productivity. Furthermore, he was experiencing command auditory hallucinations telling him to hurt people, and he was seeing birds in his cell with a cat outside his cell waiting to kill the bird. He was supposed to be taking lithium carbonate orally (300 mg four times a day), clonazepam (0.5 mg orally twice a day), and haloperidol (5 mg at bedtime). He refused to take the haloperidol because of extrapyrmidal symptoms, and he was taking the lithium and clonazepam only sporadically. Past history revealed a previous admission to the civil side of Central State Hospital, from March 16, 1989 to June 5, 1989, at which time he was given diagnoses of depressive disorder NOS and alcohol abuse. He was discharged on the above listed medications. Upon admission to the Forensic Unit, the patient was found to be in a manic phase of bipolar disorder with psychotic features for which he was stabilized on lithium carbonate (300 mg orally three times a day), clonazepam (0.5 mg twice a day), and thioridazine hydrochloride (100 mg orally at bedtime), which replaced the haloperidol he had been refusing. He made a rapid satisfactory response to these medications and was returned to the local jail in a state of remission. However, just prior to discharge, he revealed I had treated his mother on previous occasions and when given her surname
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 11
which was different from his, I recalled that I had indeed treated his mother at Medical College of Virginia in Richmond, Virginia, initially in 1969 while a resident a Medical College of Virginia, and subsequently on the civil side of Central State Hospital, as well as the Richmond Community Mental Health Clinic. I also recalled that her diagnosis was bipolar disorder with psychotic features. Her medication for several years had been lithium carbonate (300 mg orally three times a day) and thioridazine hydrochloride (100 mg orally at bedtime). In taking a comprehensive family history, the concept of genetic predisposition must be thoroughly investigated to the point that once this fact is established, further investigation should include the pharmacological management of the family member. In the case described here, the mother's pharmacological managment was similar to the son's, with the exception of clonazepam being added to the son's dosage regimen. Miller M. Ryans, MD Forensic Unit Central State Hospital Petersburg, Virginia Literature Cited 1. Gershon ES. Comprehensive Textbook of Psychiatry IV Vol 1. Baltimore, Md: Williams & Wilkins; 1985. 2. Bernstein JG. Clinical Psychopharmacology. Boston, Mass: Wright PSG Inc; 1984. 3. Goodwin FK, Jamison KR. ManicDepressive Illness. New York, NY: Oxford University Press; 1990. 4. Gershon ES. Recent developments in genetics of manic-depressive illness. J Clin Psychiatry 1 989;50(suppl): 4-7.
987
continued from page 970 ing Medical Education (ACCME). Policies and Procedures Manual. Chicago, III: ACCME; 1982. 2. Accreditation Council for Continuing Medical Education. Guidelines for Accreditation. Chicago, III: ACCME; 1982. 3. Davis D, Feldman E. The McMaster CME Society. Journal of Medicai Education. 1982;57:476-480. 4. Premi JN. Problem-based, selfdirected continuing medical education in a group of practicing family physicians. Journal of Medical Education. 1 988;63:484-486. 5. Felch WC. The case for hospitalbased continuing medical education. The Hospital Medical Staff 1977;6:12-13. 6. Rosser WW. A national selfevaluation program for Canadian family doctors. Can Med Assoc J. 1975;1 12:982-985. 7. Taylor MP. Continuing education for general practice-a learning system. Journal of the Royal College of General Practitioners. 1977;27:137-142. 8. Miller GE. Continuing education for what? Joumal of Medical Education. 1 967;42:321 -326. 9. Ashbaugh D, McKean R. Continuing medical education: the philosophy and use of audit. JAMA. 1976;236:14851488. 10. Meyer TC. Toward a continuum in medical education. Bull NY Acad Med. 1975;61 :719-726. 11. Koska MT. Tapping into quality data is next for hospital CME programs. Hospitals. 1990;64:30, 33.
Forensic Psychiatry To the Editor: This letter investigates the putative genetic predisposition of affective disorders and the need to elicit a comprehensive familial history in order to facilitate appropriate management.'-4 This approach could have important implications in the psychopharmacological management of such cases.
On October 2, 1990, a 25-yearold single, black male was admitted to our Forensic Unit on inconsequential legal charges for emergency treatment. He was a tall (6'5"), normally developed, slender individual, who was described as hostile with increased psychomotor activity and verbal productivity. Furthermore, he was experiencing command auditory hallucinations telling him to hurt people, and he was seeing birds in his cell with a cat outside his cell waiting to kill the bird. He was supposed to be taking lithium carbonate orally (300 mg four times a day), clonazepam (0.5 mg orally twice a day), and haloperidol (5 mg at bedtime). He refused to take the haloperidol because of extrapyrmidal symptoms, and he was taking the lithium and clonazepam only sporadically. Past history revealed a previous admission to the civil side of Central State Hospital, from March 16, 1989 to June 5, 1989, at which time he was given diagnoses of depressive disorder NOS and alcohol abuse. He was discharged on the above listed medications. Upon admission to the Forensic Unit, the patient was found to be in a manic phase of bipolar disorder with psychotic features for which he was stabilized on lithium carbonate (300 mg orally three times a day), clonazepam (0.5 mg twice a day), and thioridazine hydrochloride (100 mg orally at bedtime), which replaced the haloperidol he had been refusing. He made a rapid satisfactory response to these medications and was returned to the local jail in a state of remission. However, just prior to discharge, he revealed I had treated his mother on previous occasions and when given her surname
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 11
which was different from his, I recalled that I had indeed treated his mother at Medical College of Virginia in Richmond, Virginia, initially in 1969 while a resident a Medical College of Virginia, and subsequently on the civil side of Central State Hospital, as well as the Richmond Community Mental Health Clinic. I also recalled that her diagnosis was bipolar disorder with psychotic features. Her medication for several years had been lithium carbonate (300 mg orally three times a day) and thioridazine hydrochloride (100 mg orally at bedtime). In taking a comprehensive family history, the concept of genetic predisposition must be thoroughly investigated to the point that once this fact is established, further investigation should include the pharmacological management of the family member. In the case described here, the mother's pharmacological managment was similar to the son's, with the exception of clonazepam being added to the son's dosage regimen. Miller M. Ryans, MD Forensic Unit Central State Hospital Petersburg, Virginia Literature Cited 1. Gershon ES. Comprehensive Textbook of Psychiatry IV Vol 1. Baltimore, Md: Williams & Wilkins; 1985. 2. Bernstein JG. Clinical Psychopharmacology. Boston, Mass: Wright PSG Inc; 1984. 3. Goodwin FK, Jamison KR. ManicDepressive Illness. New York, NY: Oxford University Press; 1990. 4. Gershon ES. Recent developments in genetics of manic-depressive illness. J Clin Psychiatry 1 989;50(suppl): 4-7.
987
