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October 2012 Volume 7 Issue 10 October 2012 Volume 7 Issue 10 Inside In This Issue Contents 2 Writer’s Block Monifa Seawell, M.D. 3 Psychotherapy in the Medical Clinic David Hsu, M.D. 4 Prolonged QTc in a Hemodialysis Patient on Citalopram and Olanzapine for Bipolar Disorder Kristopher Keith Klem, B.A. 6 Prenatal and Postpartum Depression Harita Raja, M.D. 8 Factitious Acute Right Hemiplegia: Challenges of Treating Patients Without Universal Electronic Medical Records Hector Diez-Caballero, M.D. This issue of the Residents’ Journal highlights articles on the theme of psychosomatic Shirley Sostre-Oquendo, medicine. In a commentary, David Hsu, M.D., describes his experiences in a dual M.D. residency program focusing on psychiatry and internal medicine. Kristopher Klem, 10 Management of B.A., presents a case report on prolonged QTc in a hemodialysis patient receiving Psychosis With Comorbid antidepressant treatment for bipolar disorder. Harita Raja, M.D., discusses prena- Prolactinoma Neevon Esmaili, M.D. tal and postpartum depression and provides information on epidemiology, screening Daniel Newman, M.D. tools, and treatment. Lastly, Dr. Hsu contributes a book review of Why Psychiatry Is a Dawn Ueda, M.D. Branch of Medicine. 12 Why Psychiatry Is a Branch of Medicine Editor-in-Chief Guest Section Editor David Hsu, M.D. Monifa Seawell, M.D. David Hsu, M.D. Senior Editor Editors Emeriti 13 Test Your Knowledge Sarah M. Fayad, M.D. Sarah B. Johnson, M.D. Molly McVoy, M.D. Associate Editor Author Information and 14 Arshya Vahabzadeh, M.D. Joseph M. Cerimele, M.D. Upcoming Issue Themes Staff Editor Angela Moore Editorial Writer’s Block Monifa Seawell, M.D. Editor-in-Chief I am often contacted by trainees who Look to the Residents’ tion to their selected topic, as well as help want to author a manuscript but who Journal for Ideas guide you in authoring an article. find themselves stuck in trying to decide what to write about. I provide them with Readers who are interested in author- Ask Us for Advice the following advice to alleviate writer’s ing a manuscript can find suggestions on At the Residents’ Journal, we are com- block. what to write about in several places in mitted to author development. Feel free Write About What the Journal. In many issues, we include a to contact us to discuss any manuscript Call For Papers, which highlights a spe- ideas you may have. We can assist you in Interests You cific topic. narrowing broad ideas down to a focused I frequently advise trainees that when At the end of each issue, you will find the plan. We can also assist you in deter- they are having difficulty determining themes of our upcoming guest sections. If mining what type of manuscript would what to write about, they should think there is an upcoming guest section theme be most appropriate for your topic(s) of about topics that interest them, and then that interests you and you would like to interest. write about that. The Residents’ Journal contribute a manuscript to that section, If you follow this advice, I am confi- seeks to feature manuscripts covering a you should contact the Guest Section dent that you can successfully overcome diverse range of topics. Your unique inter- Editor for that issue. The Guest Section writer’s block and be on your way to con- ests and experiences can serve as excellent Editors can inform you about the types tributing to the Residents’ Journal. material for a manuscript. of manuscripts they are seeking in rela- The Residents’ Journal 2 Commentary Psychotherapy in the Medical Clinic David Hsu, M.D. “To be able to listen and to gather in- are no randomized controlled trials my approach of honing in on patients’ formation from another person in this for the duration of silence required at deepest concerns through active listening other person’s own right … is an art of the beginning of sessions, the timing has been effective in my practice. interpersonal exchange which few peo- of interpretations, or the pithiness of Psychiatrists do not have a monopoly on ple are able to practice without special follow-up questions. Everyone has a the term “countertransference.” Internists training. To be in command of this art different story to tell, and the job of the use it too, likely because transference is by no means tantamount to actually therapist is to capture and validate the dynamics are pervasive in all of medicine. being a good psychiatrist, but is the pre- uniqueness of the patient’s narrative. In When treating patients, it is universally requisite of all intensive psychotherapy.” empathic interviewing, the physician important to be aware of one’s own –Frieda Fromm-Reichmann, M.D., seeks to view situations from another feelings as a doctor, and these feelings Principles of Intensive Psychotherapy person’s perspective, to feel what the can develop when working with a patient patient feels, and to differentiate between in the short-term, as well as long-term, the patient’s needs and wishes. Physicians setting. As I look into the last year of Training to be both an internist and a trained in this type of interviewing can residency, my realization of potentially psychiatrist is a phenomenon that has use empathy skills to build therapeutic working with these patients for 5 years occurred over the past two decades. Dual alliances that are essential in every clinical is humbling. They have given me the residency programs are resource intensive, encounter. opportunity to care for them in the most and the compression of two specialty The psychiatry clinic is no different personal sense and to witness my own training programs into 5 years has its own from the medical clinic. In both clinics, personal growth as a doctor as reflected developmental challenges. In the third patients talk about their back pain, in my relationship with them. They have year of the internal medicine/psychiatry operations, cancers, liver disease, tremors, been my best teachers. training program, residents have the and sleep problems, in addition to their Dr. Hsu is a fifth-year resident in the opportunity to work the entire year in the psychosocial concerns, such as depression, outpatient psychiatry clinic, where they Departments of Internal Medicine and Psy- anxiety, or substance abuse. Patients state chiatry and Behavioral Sciences, University learn intensive psychotherapy. Strangely, that they come simply to see a doctor. I have discovered that my background of California Davis Medical Center, Sacra- My medical clinic on Friday afternoons mento, Calif. in internal medicine has affected my is across campus, and recently I realized psychiatric practice, and vice versa. that the patient I bring into the room— Learning psychotherapy is challenging in both contexts—does not change. because it is essentially an art. There Psychodynamic issues still resonate, and If you will be completing your residency this year, we would like your help in recruiting new subscribers by encouraging an incoming resident or fellow to subscribe to our monthly e-publication. Also, if you'd like to continue receiving e-mail notification alerts when each issue of the AJP Residents' Journal is published, send your new e-mail address to [email protected] with the subject line "New e-mail address post-residency." The Residents’ Journal 3 Treatment in Psychiatry Prolonged QTc in a Hemodialysis Patient on Citalopram and Olanzapine for Bipolar Disorder Kristopher Keith Klem, B.A. Citalopram is a selective serotonin The patient had a long history of recal- been associated with torsades de pointes reuptake inhibitor used in the treat- citrant bipolar disorder, which was being in patients with abnormal electrolyte ment of depression. Olanzapine is an treated successfully with citalopram (40 levels and end-stage renal disease (4, 5). atypical antipsychotic with U.S. Food mg once daily) and olanzapine (20 mg Concomitant antipsychotic and anti- and Drug Administration approval for taken at night). A mental status exami- depressant therapy has been shown to the treatment of bipolar disorder and nation revealed an affable yet exhausted prolong QTc more than antipsychotic schizophrenia. Corrected QT (QTc) in- woman with a concerned affect, articulate monotherapy; synergistic blockade of terval prolongation has been reported speech, and cogent thought process. Her potassium channels is the proposed with use of both medications, but few overall mood was apprehensive, reflected mechanism (6). Electrolyte disturbances studies have examined the differential by her thought content being predomi- also influence QT interval prolongation. role of these medications in prolonging nantly focused on having another infected Frequent cardiac arrhythmias in pa- QTc. The present report is of a case of dialysis site. Both olanzapine and cita- tients with chronic kidney disease have prolonged QTc in a 50-year-old woman lopram were discontinued following the prompted studies investigating the role of with chronic kidney disease who was re- ECG results, and the patient was closely hemodialysis on QT prolongation. Rapid ceiving hemodialysis as well as citalopram monitored using telemetry. One day fol- changes in electrolyte concentrations and olanzapine for bipolar disorder. Dis- lowing discontinuation of olanzapine and during dialysis are thought to contribute continuing both medications resulted in citalopram, the patient’s QTc interval fell to arrhythmias, and changes in plasma improved QTc, and restarting olanzapine from 644 msec to 531 msec. The next day, electrolyte concentration during hemo- without citalopram resulted in no in- the QTc interval fell again to 493 msec. dialysis have been correlated with QT crease in QTc. It was then decided to restart olanzapine prolongation (7). at a reduced dosage of 10 mg nightly. An Case Several mechanisms could account for the ECG performed the next day revealed prolonged QTc in the above case.
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