LET TERS TO THE EDI TOR

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1 LET TERS TO THE EDI TOR Re: Neuroleptic Malignant Syndrome Associated With Quetiapine We wish to com ment upon the case of neu ro lep tic ma lig nant syn drome (NMS) as so ci ated with queti apine that was re - ported in the Oc to ber is sue of the Jour - nal (1). The author re ported queti apine use that was fol lowed by 13 days of rest - less ness, agi ta tion, and dia pho re sis. Loxap ine was then added to the regi men, and the next day the pa tient de vel oped the full ful mi nant syn drome of NMS, meet ing the cri te ria of Leven son (2), Ad - don izio and oth ers (3), DSM- IV (4), Ca - roff and oth ers (5), and, proba bly, Pope and oth ers (6). There have been sev eral cases of NMS as so ci ated with the use of atypi cal neu ro lep tics, par ticu larly clo - zap ine (7). It is strik ing how often the pres en ta tion is less ful mi nant with atypi - cal neu ro lep tic use; ex tra py ra mi dal symp toms (EPS), in par ticu lar, are less promi nent. This is not sur pris ing, con - sid er ing the side- effects pro file of the atypi cals, which show fewer EPS than do classic agents. Given the above, we won der whether the author might com ment on the pos si bil ity of loxapine be ing also a sig nifi cant con - trib ut ing cause of the NMS. Loxap ine is a clas sic neu ro lep tic that has been as so - ci ated with NMS of the more ful mi nant va ri ety (8) more like the case de - scribed by Al- Waneen (1), with promi - nent EPS and very high cre atine ki nase (CK). We be lieve that, with con comi tant use of loxap ine, it is in cor rect to con - clude that queti apine in duced NMS in this case. It is also worth noting that NMS de vel oped in spite of the use of lo - raze pam which Fink (9) rec om mends as a treatment for NMS. 1. Al- Waneen R. Neu ro lep tic ma lig nant syn drome as - so ci ated with queti apine. Can J Psy chia try 2000;45: Leven son J. Neu ro lep tic ma lig nant syn drome. Am J Psy chia try 1985;142: Ad don izio G, Susman VL, Roth SD. Symp toms of neu ro lep tic ma lig nant syn drome in 82 con secu tive in pa tients. Am J Psy chia try 1986;143: Ameri can Psy chi at ric As so cia tion. Di ag nos tic and sta tis ti cal man ual of mental dis or ders. 4th ed. Wash - ing ton (DC): APA; Ca roff SN, Mann SC, Laza rus A, Sul li van KL, Macfad den W. Neu ro lep tic ma lig nant syn drome: di - ag nos tic is sues. Psy chi at ric Ann 1991;21 (3): Pope HG, Keck PE, McEl roy SL. Fre quency and pres en ta tion of neu ro lep tic ma lig nant syn drome in a large psy chi at ric hos pi tal. Am J Psy chia try 1986;143: Karagi anis J, Phil lips L, Ho gan K, Le drew K. Clo - zap ine as so ci ated neu ro lep tic ma lig nant syn drome: two new cases and a re view of the lit era ture. Ann Phar ma co ther 1999;33: Chong LS, Abbott PM. Neu ro lep tic ma lig nant syn - drome sec on dary to loxap ine. Br J Psy chia try 1991;159: Fink M. Toxic se ro tonin syn drome or neu ro lep tic ma - lig nant syn drome? Phar ma cop sy chia try 1996;29: James Karagianis, MD, FRCPC Leslie Phillips, PharmD Kevin Hogan, MD, FRCPC Kellie LeDrew, MD, FRCPC St John s, Newfoundland Neuroleptic Malignant Syndrome Associated With Quetiapine: A Response In their re view of 32 case re ports of neu - ro lep tic ma lig nant syn drome (NMS) re - lated to clo zap ine or risperidone, Hasan and Buck ley (1) iden ti fied 20 of those cases as being NMS, ap ply ing DSM- IV cri te ria. The clini cal picture of NMS in those pa tients re sem bled that usu ally at - trib ut able to con ven tional an tipsy chot - ics. They found that no suf fi cient evi dence ex ists cur rently to sup port the con cept of atypi cal NMS with novel an tipsy chot ics. With re gard to the case of Mr D that I de - scribed in my origi nal let ter (2), I would like to high light a few points. First, the pa ti ent s pro gres sive symp toms of rest - less ness, agi ta tion, trem ors, pro fuse sweat ing, and al tered mental state (the pa tient was alert but ap peared dazed and dis or gan ized in his speech) be gan to de - velop 13 days into the queti apine trial at a dos age level of 250 mg twice daily. Those fea tures that were ret ro spec tively viewed as early mani fes ta tions of NMS pre ceded the use of loxap ine and loraze - pam (taken as needed a few times over the next sev eral hours), during which time the full syn dro mal pic ture evolved. Those 2 agents were ad min is tered to ad - dress the mis tak enly di ag nosed in - creased psy cho sis. Vi tal signs were not checked at the time. Of note, the pa tient re ceived no de pot medi ca tion or an tipsy - chot ics other than those I have de scribed. Al though it is pos si ble that the oc ca - sional use of loxap ine may have contrib - uted to the pro gres sion of the already- evolving NMS in this case, it is un likely that this agent was a di rect cause of it. Sec ond, as far as phar ma co ther apy of NMS, Leven son (3) and Laza rus, Ca - roff, and Mann (4) pointed out in their elo quent re views of this syn drome that there is to date no clear evi dence for the value of any sin gle spe cific treat ment. Ben zo di azepines, and es pe cially loraze - pam, may use fully pre vent ex haus tion by con trol ling agi ta tion and tar get ing cata to nia (if present) (5). En dur ing re - sponses have not, how ever, been achieved (4). Fur ther, since I sub mit ted my letter for pub li ca tion, an other case re port of possi - ble NMS with queti apine has been pub - lished (6). Fi nally, I have also been made aware that a similar re port by Whalley, Diaz, and How ard ap peared in late 1999 (7). Can J Psychiatry, Vol 46, May

2 May 2001 Letters to the Editor Hasan S, Buck ley P. Novel an tipsy chot ics and the neu ro lep tic ma lig nant syn drome, a re view and cri - tique. Am J Psy chia try1998;155: Al- Waneen R. Neu ro lep tic ma lig nant syn drome as - so ci ated with queti apine. Can J Psy chia try 2000;45: Leven son J. Neu ro lep tic ma lig nant syn drome. Am J Psy chia try 1985:142: Laza rus A, Mann SC, Ca roff SN. The neu ro lep tic ma - lig nant syn drome and re lated con di tions. Wash ing - ton (DC): Ameri can Psy chi at ric Press Inc; Korn hu ber J, Wel ler M. Neu ro lep tic ma lig nant syn - drome. Cur rent Opin ion in Neu rol ogy 1994:7; Stan ley A.K., Hunter J. Pos si ble neu ro lep tic ma lig - nant syn drome with queti apine. Br J Psy chia try 2000;176: Whal ley N, Diaz P, How ard J. Neu ro lep tic ma lig nant syn drome as so ci ated with the use of queti apine [ab - stract]. Can J Hos pi tal Phar macy 1999;52:112. Riyadh Al-Waneen, MD, FRCPC Riyadh, Saudi Arabia Neurobiology of the Use of Selective Serotonin Reuptake Inhibitors During Pregnancy Jer ome (1) dis cusses a re cent clini cal situa tion in volv ing a mother with de - pres sion who is cur rently re fus ing anti - de pres sants for fear of harm ing her un born sec ond child. A re port that in - fants ex posed to fluoxet ine in the third tri mes ter had higher rates of pre ma ture de liv ery, res pi ra tory dif fi culty, jit teri - ness, cya no sis, and lower birth weight sup ports her con cern (2). Neu ro bio logi - cal fea tures are sug gested by stud ies link ing sub clini cal im pair ment of lung air ways in panic dis or der, uter ine ir ri ta - bil ity in preterm la bour, and dys regu la - tion of mood (3,4). Simi larly, an other study in di cates that anxi ety dis or ders in fe male chil dren pre dict rela tively short stat ure in early adult hood due to inhibi - tion of growth hor mone by do pa mine ab nor mali ties lat er al ized to the right hemi sphere, for which the meta bolic rate is higher in girls and women (5). This hy pothe sis is sup ported by 2 re - ports. The first re port ob serves that sero - to ner gic in hi bi tion of do pa mine in mice, caused by pre na tal ex po sure to a clini - cally rele vant dose of par oxet ine, may have height ened the per form ance on se lect anxi ety tests of infant off spring, as evi denced by more sepa ra tion vo cali za - tion among both male and fe male pups (6). The sec ond re port con cludes that ciga rette smoking in creases the risk of cer tain anxi ety dis or ders dur ing late ado les cence and early adult hood (7). These find ings prompt neu ro chemi cal and phar ma co thera peu tic in ves ti ga tion of the dys regu la tion of an cient neuro - modu la tory sys tems in evolving brains (4). 1. Jer ome L, Misri S. The use of se lec tive se ro tonin re - up take in hibi tors dur ing preg nancy and lac ta tion: Cur rent knowl edge [let ter and re ply]. Can J Psy chia - try 2000;45: Misri S, Kostares D, Kostares X. The use of se lec tive se ro tonin re up take in hibi tors dur ing preg nancy and lac ta tion: Cur rent knowl edge. Can J Psy chia try 2000;45: Fried man EH, Rob erts WE, Mor ri son JC. Neu ro bi ol - ogy of uter ine ir ri ta bil ity in pre term labor [letter and re ply]. Am J Ob stet Gy ne col 1995;173: Fried man EH, Bryan T. Neu ro bi ol ogy of the in flu - ence of af fect on social- information proc ess ing [let - ter and re sponse]. J Learn Disabil 2000;33: Fried man EH, Cizza G, Chrousos GP, Pine D, Co hen P, Brook J. Anxi ety and short stature [let ters and re - ply]. Pe di at rics 1997;99: Fried man EH. Neu ro bi ol ogy of be hav ioral changes af ter pre na tal ex po sure to par oxet ine (Paxil) [let ter]. Am J Ob stet Gy ne col 2000;183: John son JG, Co hen P, Pine DS, Klein DF, Kasen S, Brook JS. As so cia tion be tween ciga rette smoking and anxi ety dis or ders in early adult hood. JAMA 2000;284: Ernest H Friedman, MD Cleveland, Ohio Ondansetron Rather Than Metoclopramide for Bupropion-Induced Nausea Bupropion, once only an an ti de pres sant pre scribed by psy chia trists, is now rou - tinely in di cated by any phy si cian to help pa tients stop smok ing (1). Al though usu ally well tol er ated, bupropion may cause nau sea (1,2), a side ef fect con sis - tent with do pa min er gic stimulation that might af fect treat ment ad her ence and ef - fec tive ness. It might at first ap pear that this prob lem could be han dled eas ily by pre scrib ing the an tie metic me to clo pra - mide, a do pa mine D 2 an tago nist (3), or by re duc ing the dos age. This strategy, how ever, could in the ory in ter fere with the ef fi cacy of bupropion, be cause its pro posed mecha nism of ac tion is pre - cisely the en hance ment of do pa min er gic ac tiv ity (4). We re port the case of a 38- year- old woman who ex pe ri enced mod er ate nau - sea as she ini ti ated treat ment with 300 mg daily of bupropion (Zy ban), taken for de pres sion. This side ef fect was only par tially re lieved by the his ta mine H 1 an tago nist di men hy dri nate. It was, how - ever, suc cess fully treated with the sero - tonin 5-HT 3 an tago nist on dan setron (3) (8 mg orally as needed). Af ter 8 days of treat ment, the pa tient was able to dis con - tinue this medi ca tion with out needing to re duce the bupropion dos age. We there - fore sug gest that on dan setron can be con sid ered be fore treat ment with meto - clo pra mide to mini mize pu ta tive re - duced ef fi cacy. 1. Jorenby DE, Leis chow SJ, Nides MA, Rennard SI, John ston JA, Hughes AR, and others. A con trolled trial of sustained-release bupropion, a nico tine patch, or both for smok ing ces sa tion. N Engl J Med 1999;340: Settle EC Jr. Bupropion sus tained re lease: side ef fect pro file. J Clin Psy chia try 1998;59 (suppl 4):S32 S Roila F, Del Favero A. An tie met ics re vis ited. Curr Opin On col 1997;9: Feighner JP. Mecha nism of ac tion of an ti de pres sant medi ca tions. J Clin Psy chia try 1999;60:S4 S11. Diogo R Lara MD PhD Ellis D Busnello, MD PhD Diogo O Souza MD PhD Porto Alegre, Brazil The Use of Intravenous Valproate in Psychiatry In re cent years, the util ity of the anticon - vul sant medi ca tions for pa tients who have bi po lar ill ness has been ap pre ci - ated. This is es pe cially the case for pa - tients who have mixed or rapid- cycling bi po lar ill ness (1,2) and for pa tients with ma nia com pli cated by sub stance de - pend ence or neu ro logi cal ill ness (3,4).

3 372 The Canadian Journal of Psychiatry Vol 46, No 4 Medi ca tions in clud ing val proic acid, car ba mazepine, la mo trogine, and ga - bap en tin have all been the sub ject of case re ports, at least, de scrib ing their ef - fec tive ness in treat ing bi po lar illness. The oral form of the medi ca tion may take sev eral days to achieve steady- state lev els. Oral load ing of val proic acid has been used to shorten this time, but nau - sea may limit this route of ad mini stra - tion. Pa tients may also ref use to take their medi ca tion or be un able to con trol their air way, which makes them vul ner - able to as pi ra tion pneu mo nia. In these situa tions, pa tients with bi po lar ill ness may be ex posed to high doses of par - enteral ben zo di azepines or neu ro lep tics to treat their agi ta tion, which may have un de sired side ef fects. For many years, neu rolo gists have used in tra ve nous (IV) medi ca tions to treat sei zures. Un til re cently, this treat ment in volved pheny toin or phe no bar bi tol. Re cently, val proic acid has been avail - able in an IV for mu la tion called Depa - con (Ab bott Labo ra to ries, Ab bot Park, IL). This for mu la tion can be given in dex trose, sa line, or Ring ers lac tated so - lu tion, pre pared by add ing 1 gram of De - pa con to 500 cc of so lu tion. This should not be in fused at more than 20 mg per minute. The dose of IV val proate varies ac cord ing to the pa ti ent s age and clini - cal con di tion. We often start with a dose of 500 to 1000 mg and judge clini cal re - sponse. The daily dos age varies be tween 1 to 3 grams for most of our adult popu - la tion and one-half of this for the eld erly. We meas ure lev els on the morn ing of the sec ond day of treat ment. While it is rec om mended that IV val - proate be in fused at a rate not to ex ceed 1 gram per hour, doses up to 200 mg per minute have been given with no ad verse side ef fects. The in fu sion does not re - quire cardiac moni tor ing and causes no sig nifi cant or thostatic hy poten sion. It pro duces less nau sea than the other forms of the agent, and ad di tional risk in volves only the typi cal ef fects seen with IV use, such as lo cal skin in fec tion (3). In the last 2 years we have used IV val - proate to treat pa tients with various neu - ro logic and psy chi at ric ill nesses, in clud ing ma nia, de men tia with agi ta - tion, status mi graine, and even trigemi - nal neu ral gia. IV val proate has been es pe cially help ful in the acutely agi tated pa tient or those who ref use or, due to as - pi ra tion risk, can not take medi ca tion orally. Pa tients with agi tated ma nia may re ceive a full loading dose over a pe riod of 1 hour. In most pa tients, we have found this helpful in di min ish ing agi - tated symp toms. This strat egy mini - mizes the ad junc tive agents that need to be given. While many psy chia trists ini - tially feel less com fort able with IV medi ca tions, the wide spread ac cep tance of other forms of val proic acid should mod ify this hesi ta tion. Fur ther, as psy - chi at ric care moves to gen eral medi cal hos pi tal set tings, IV medi ca tions are be - com ing more eas ily ac ces si ble. 1. Good win FK, Ja mi son KR. Manic de pres sive ill ness. New York (NY): Ox ford Uni ver sity Press; Hilty DM, Brady KT, Hales RE. A re view of bi po lar ill ness among adults. Psy chi atr Serv 1999;30: Bauer MS, Why brow PC. Rapid cy cling bi po lar af - fec tive dis or der. Arch Gen Psy chi atr 1990;47: Co ryell W, En di cott J, Kel ler M. Rapid cycling af fec - trive dis or der. Arch Gen Psy chi atr 1992;49: Nor ton J, Qualrles E. In tra ve nous val proate in neu - rop sy chia try. Phar ma co ther apy 1000;20: John Norton, MD Jackson, Mississippi Sudden Death Following Neuroleptic Administration Due to Hemoperitoneum Resulting From Physical Restraint Sud den deaths have been re ported in pre vi ously healthy pa tients fol low ing neu ro lep tic ad mini stra tion (1 3). In many such cases the causes of these deaths have been un clear and autop sies un help ful. Of ten, such deaths are as - sumed to be due to neuroleptic- induced car dio tox ic ity (ar ryth mias) (4), with other less com mon causes be ing neuro - lep tic ma lig nant syn drome (NMS), sei - zures, acute la ryn geal dysto nia, ma lig nant hy per ther mia, and overdos - age (5). In di vidu als at risk are elderly, physi cally de bili tated, and agi tated pa - tients (5). Rarely, other causes re sult in sud den death and are often ig nored. The fol low ing case re port, how ever, high - lights the im por tance of thorough in ves - ti ga tion of the causes of such deaths. A 19- year- old, pre vi ously healthy man pre sented to our emer gency in a physi - cally re strained state, with a 10- day his - tory of ag gres sive be hav iour, ir rele vant talk, and dis tur bances in bio logi cal, so - cial, and oc cu pa tional func tion ing. There was no other con tribu tory his tory of medi cal or neu ro logi cal ill ness, sub - stance use, or drug sen si tiv ity. A mental status ex ami na tion re vealed motor rest - less ness, de lu sions of per se cu tion, and hal lu ci na tory be hav iour. The pa tient was un co op era tive in re gard to a de tailed physi cal ex ami na tion but had sta ble vital pa rame ters, and grossly, all the sys tems (car dio vas cu lar, res pi ra tory, gas tro in - tes ti nal, and neu ro logi cal) were nor mal. There were, how ever, mul ti ple abra - sions over the pa ti ent s face, trunk, and limbs. A di ag no sis was made of acute poly mor phic psy chotic dis or der without symp toms of schizo phre nia, as per ICD- 10 cri te ria (6). Bio chemi cal in ves - ti ga tions, in clud ing re nal and liver func - tion tests, were nor mal. The pa tient was freed from re straints and 10 mg IM of ha loperi dol was ad min is tered immedi - ately, and re peated af ter 8 hours, to calm the pa tient. The pa tient de vel oped breath ing dif fi culty 1 hour af ter the sec - ond dose, and on ex ami na tion he had marked pal lor, hy poten sion, tachycar - dia, and tachyp noea. There were no signs of NMS. Emer gency bio chemi cal pa rame ters, in clud ing re nal and liver func tions, glu cose, and cre atine phos - phoki nase were nor mal. The pa tient died of cardio- respiratory fail ure within 45

4 May 2001 Letters to the Editor 373 min utes of de vel op ing dysp noea, de - spite all re sus ci ta tory meas ures. An autopsy re vealed 1.5 li tres of un clot ted blood in the peri to neal cav ity and a small tear in the liver cap sule near the porta he pa tis. The cause of sud den death in this case was hy po vo lemic shock due to hemo - peri to neum re sult ing from trauma to the liver sus tained dur ing physi cal re straint used by the pa ti ent s at tenders. If an autopsy had not been con ducted, the death might have been as sumed to be due to neuroleptic- induced tox ic ity. A thor ough in ves ti ga tion is there fore rec - om mended for such deaths be fore they are as sumed to be due to neuroleptics. 1. Do lan M, Boyd C, Shetty G. Neu ro lep tic in duced sud den death- a case re port and a criti cal re view. Med Sci Law 1995;35: Ku mar A. Sud den un ex plained death in a psy chi at ric pa tient a case re port: the role of phe nothi azi nes and physi cal re straint. Med Sci Law 1997;37: Mod es tin J, Krapf R, Boker W. A fa tal ity during ha - loperi dol treat ment: mecha nism of sud den death. Am J Psy chia try 1981;38: Warner JP, Bar nes TR, Henry JA. Elec tro car dio - graphic changes in pa tients re ceiv ing neu ro lep tic medi ca tion. Acta Psy chi atr Scand 1996;93: Marder RS, van Kam men DP. In: Sa dock BJ, Sa dock VA, edi tors. Com pre hen sive text book of psy chia try. Phila del phia: Lip pin cott Wil liams and Wilk ins; p World Health Or gani za tion: The ICD-10 clas si fi ca - tion of mental and be hav ioural dis or ders: clini cal de - scrip tions and di ag nos tic guide lines. Ge neva: World Health Or gani za tion; GVL Raju, MBBS TC Ramesh Kumar, MD S Khanna, MD, MRCPsych Bangalore, India Does the Cellular Phone Help to Communicate When Face-to-Face Contacts are Difficult? So cial con tacts, which have been found to be posi tively re lated to per ceived so - cial sup port (1), of ten de crease with de - pres sion (2). The cellular phone makes com mu ni ca tion pos si ble al most any - where and does not re quire face- to- face con tact. It is not known, how ever, whether there are any as so cia tions be - tween the use of cellular phones and de - pres sion. Thus, we sought to in ves ti gate this question us ing a sam ple from the Fin nish gen eral popu la tion. Our sam ple in cluded 2945 sub jects be - tween the ages of 26 and 65 years who were ran domly se lected from the Na - tional Popu la tion Reg is ter and liv ing in the Dis trict of Ku opio, Fin land. Study ques tion naires were mailed in May June 1999, and a total of 1767 ques tion naires were re turned, re sult ing in a re sponse rate of 60%. The sub jects were ques tioned about their so cio de mo - graphic back ground and their use of the cel lu lar phone. In ad di tion, the re spon - dents were pre sented with 4 state ments elic it ing their per sonal views re gard ing the value of cel lu lar phone use (1 2 agree; 3 4 dis agree). De pres sion was screened using the 21- item Beck De - pres sion In ven tory (BDI) (3). The statis - ti cal meth ods used in cluded the Pear son chi- square test, Fish er s 2- tailed ex act test, and lo gis tic re gres sion analyses. State ments evok ing re sponses of no opin ion were ex cluded from all analy - ses. A to tal of 66.7% (n = 1178) re ported own ing a cel lu lar phone. Al though sub - jects with de pres sion (BDI score 9) (n = 358, 20.3%) were found to use a cell phone as fre quently ( 2 calls daily) as the other sub jects (54.9% vs. 58.1%, ns.), they re ported re ceiv ing fewer calls than did sub jects with out de pres sion ( 2 calls daily) (45.1% vs. 33.6%, χ 2 = 10.1, df 1, P < 0.01). Lo gis tic re gres sion analy sis in di cated that using a cel lu lar phone had dif fer ent val ues for subjects with de pres sion. Af - ter ad just ment for sex (men: 40% vs. 43%), age (45 vs. 49 years), mari tal status (sin gle : 25% vs. 32%), and fi nan - cial status (poor: 13% vs. 43%), these as - so cia tions per sisted for 2 state ments: It is easier for me to talk with other peo ple by cel lu lar phone than face- to- face (OR = 2.3; 95%CI, 1.1 to 5.1), and My cellu - lar phone is like a friend to me and it re - places my miss ing re la tion ships with other people (OR = 3.2; 95%CI, 1.3 to 8.3). In this study, subjects with de pres sion at tached more per sonal sig nifi cance to the use of the cellular phone than did the sub jects with out de pres sion, and it is there fore pos si ble that the use of cel lu lar phones might of fer sub jec tive so cial sup port and also positively in flu ence the size of the us ers so cial net work, both of which fac tors have been found to pre dict re cov ery from de pres sion (2). Be cause our study de sign was cross- sectional, it was not pos si ble to con clude whether regu lar use of the cel lu lar phone might con trib ute to main tain ing per sonal con - tacts over the long term. Cel lu lar phones do, how ever, seem to make com mu ni ca - tion pos si ble when de pres sive symp - toms make face- to- face con tacts dif fi cult. 1. Peirce RS, Frone MR, Rus sell M, Cooper ML, Mu dar P. A lon gi tu di nal model of so cial contact, so cial sup - port, de pres sion and al co hol use. Health Psy chol 2000;19: George LK, Blazer DG, Hughes DC, Fowler N. So - cial sup port and the out come of ma jor de pres sion. Br J Psy chia try 1989;154: Beck AT, Steer RA, Garbin MG. Psy cho met ric prop - er ties of the Beck De pres sion In ven tory: twenty-five years of evalua tion. Clin Psy chol Rev 1988;8: Kirsi Honkalampi, Lic Psych Antti Tanskanen, MD, PhD Jukka Hintikka, MD, PhD Kaisa Haatainen, MHSc, RN Heimo Viinamäki, Professor Kuopio, Finland What Factors Contribute to Senior Psychiatry Residents Interest in Geriatric Psychiatry? The study by Lieff and Clarke (1) con - firms the find ings of pre vi ous work. Prior to 1987, there was no com pul sory train ing in geri at ric psy chia try (2). If a

5 374 The Canadian Journal of Psychiatry Vol 46, No 4 resi dent were to de velop an in ter est in this field, it had to be as a re sult of per - sonal choice. Based on a sam ple of 1 it was found that... psy cho ge ri at rics (was) in tel lec tu ally chal leng ing, emo - tion ally sat is fy ing, but in credi bly frus - trat ing (3). En thu si as tic or char is matic su per vi sors hardly en tered the pic ture, al though there was a great deal of sup - port from the Unit Di rec tor at the Lon - don Psy chi at ric Hos pi tal for the resi dent wish ing to de velop a novel treatment ap - proach (4). As in the cur rent study, com fort with the medi cal psy chi at ric na ture of the spe cialty was an im por tant fac tor be cause the resi dent had had 8 years of pre vi ous ex pe ri ence in gen eral prac tice. I agree with Lieff and Clarke that... in ter est of sen ior psy chia try resi dents in the prac tice of geri at ric psy - chia try may be an ac quired taste. To add to the in trin sic in ter est of work ing with eld erly psy chi at ric pa tients, resi - dents need to be en cour aged to de velop their own re search proj ects, pref era bly in col labo ra tion with other dis ci plines. The low rating for avail abil ity of re - search op por tu ni ties re ported by Lieff and Clarke may re flect more on the pro - gram than the resi dents lack of in ter est. 1. Lieff SJ, Clarke D. What fac tors con trib ute to sen ior psy chia try resi dents in ter est in geri at ric psy chia try? Can J Psy chia try 2000;45; Royal Col lege of Phy si cians and Sur geons of Canada. Ob jec tives of train ing and spe cialty re quire ments in psy chia try. City?: Royal Col lege of Phy si cians and Sur geons of Can ada; Rei chen feld HF. Im prov ing psy cho ge ri at ric care: aban don ing the im age of Cin der ella. Hu mane Medi - cine 1995;11: Rei chen feld HF, Car ri ere L, Csapo KG, Gard ner RC. Evalu at ing the ef fects of ac tiv ity pro grams on a geri - at ric ward. Ger on tolo gist 1973;13: Hans F Reichenfeld, MB, FRCPC Ottawa, Ontario