Psychiatric illness in the medical profession In view of the increasing attention to "preventive psychiatry", Canada's medical profession should see what can be done to lower the morbidity and mortality of psychiatric illnesses in physicians. In this issue (page 311) Watterson reports an important study done in British Columbia. He has analysed data for 247 physician-patients to determine the incidence and severity of their psychiatric illnesses in relation to age, sex, level of training and field of practice. Many of the results corroborate previous work done in Great Britain, Denmark and the United States. Watterson found that the incidence of psychiatric illness was not dependent on sex or age but was related to field of practice - ophthalmologists and psychiatrists had the highest rate, with psychiatry residents heading the list. The psychiatry residents had the same problems as other hospital residents but at a greater incidence. Suicide rates paralleled the morbidity pattern. Seven physicians (all men) committed suicide in the 5 years of the study - four general practitioners, one ophthalmologist, one psychiatrist and a senior resident in medicine. The average age of the seven at the time of psychiatric referral was startlingly low (39 years). Two were manic-depressives, four had neurotic depression and one had a sociopathic personality associated with alcoholism and narcotic addiction. Might the two manic-depressives have been saved by early use of lithium carbonate? All the neurotic and sociopathic victims in Watterson's study had problems compounded by the use of alcohol or drugs; might a different approach in medical school or earlier intervention by fellow physicians have helped? Drug addiction rates are higher for physicians than for comparable
groups of nonphysicians and there is to accept Watterson's belief that "a evidence that alcoholism may be more degree of neurotic vulnerability is a common in physicians than in their prerequisite for the would-be psychononmedical social peers.14 Chafetz therapist". Watterson's survey is only a start stated that the percentage of alcoholics among the United States' 356 000 phy- and in only one province, to which sicians was estimated conservatively at many physicians have migrated for 18% - three times the percentage of various reasons. In addition to his study alcoholics in the general population of of the incidence and severity of psythat country.. In British Columbia chiatric illness as related to age, sex, the rate of physician-suicides (36.5/ level of training and field of practice, 100 000) is well above the national further study should be done in regard average for a socioeconomically com- to the following: the age at onset of parable nonphysician group. Is this psychiatric training; whether the consimply a reflection that deeply dis- tent and nature of childhood stresses turbed physicians have no outside interfere with the practice of medicine; resource to which they can turn or are the philosophy of life of the physicianmore of them deeply disturbed than patient, including religious faith and members of the "outside" population? its importance; and the ethnic background of the physician-patient. The If so, why? Why are ophthalmologists so prone results of such studies might indicate to psychiatric ills? Watterson proffers what type of physician should be disthe usual suggestions that the North couraged from entering the fields of American ophthalmologist (who does ophthalmology or psychiatry - and his own refractions) may be unduly some day we may have enough data frustrated by the lack of challenge and to know what type of practice is best by an excessively full and rigid work- suited for varying personalities. If a physician does become mentally load. More interesting is his speculation that "the eye... carries profound sym- ill, where can he turn? There are few bolic connotations" - might we infer treatment resources available to menthat ophthalmology and psychiatry deal tally ill physicians. The doctor with a with "outsight" and "insight"? Perhaps mental illness may seek an "asylum", there is extra stress in having either a refuge remote from his practice. Only one.s mind on the eye or one.s eye by leaving his area of practice can he ensure confidentiality. We need better on the mind. If further studies throughout Canada recognition of the need for available show these findings to be statistically treatment sources for physicians, with significant, further queries arise: Should effective temporary takeover of their those responsible for residency training workload by other competent phyprograms in ophthalmology and psy- sicians. Watterson has shown that, although chiatry make a more strenuous attempt to screen the psychologic profile of po- the incidence of psychiatric illness is tential trainees? Should their mentors the same in family physicians as in provide more support for the trainee? specialists, the illnesses tend to be more Although some psychiatry residents are severe and to have a poorer prognosis drawn into psychiatry in part to solve in the family physicians. Because of the their own problems, we are inclined not location and nature of their practices, CMA JOURNAL/AUGUST 21, 1976/VOL. 115 293
general practitioners carry on longer until they are sicker. Ought we, as physicians, to try to devise some network of mutual help for each other, so that we give ourselves at least the care we would offer our patients? There is a danger in concluding that there are so many gaps in our knowledge that there is nothing we can do. Enough evidence has been gathered to make it apparent that we should do something, even before all the final answers are available. Prevention begins with the difficult decision about who is to be admitted to medical school. Academic ability alone does not make a good physician, but a minimum academic ability is essential. Perhaps mental health alone does not make a good physician, but perhaps minimum standards of mental health are essential. There are no clear criteria, yet Vaillant and colleagues1 have shown that insecurity in childhood is related to vulnerability to stress in the practice of medicine. Is there a minimum of security necessary in childhood for the individual to be a good physician and, if so, can we measure it? Can we distinguish the insecurity that drives some people to great success from the insecurity that causes some people to fail? In medical schools openness about emotional problems in patients and physicians may be healthy and encourage earlier recognition of difficulties and acceptance of treatment both for the student and subsequently for the physician. Increasingly the content of the teaching must include more understanding of the physicians' potential lifestyles, stresses and patterns of morbidity. Medical school often convinces the young physician that his role is to stamp out disease, suffering and death, but he soon finds himself surrounded by disease and suffering. The result is often despair, guilt and fatigue, which can lead to overwork, compensated for by depression, excessive use of alcohol, drugs or even suicide. It seems important that it be made clear in medical school that our role is not to stamp out disease, suffering and death. Present efforts to clarify the role of the physician in helping dying patients and their families and in helping relatives through bereavement are good steps in this direction. Do some of the other situations with which the physician is frequently confronted make him uncertain about his own role and purpose? Secondary prevention, or early diagnosis and treatment, are also important. At the personal level, each of us must be willing to become involved with physicians in our practice or in our com-
munity who are facing difficulties. If they are our patients we should be honest and give them a factual diagnosis that doesn't overemphasize pylorospasm and de-emphasize anxiety, or emphasize overwork and ignore overdrinking. History-taking of the physician-patient should be detailed, with enquiries into personal and social areas; it should be done, when possible, by a physician who is respected by the patient but who is not a close friend. Each of us has a personal responsibility to reach out to the physician when we notice a change in his behaviour. It is better to be rebuffed by a colleague for interfering than to avoid this risk, only to have the physician commit suicide. Frequently the physician who is depressed or abusing drugs or alcohol deceives himself that no one else knows, and he is as likely to be relieved as to be angry if a colleague enquires and offers a helping hand. In 1973 the American Medical Association council on mental health stated categorically that it is "a physician's ethical responsibility" to recognize and take action when a colleague is unable to practise medicine adequately by reason of a physical or mental illness.7 At the level of the local hospital or medical society, it is suggested there should be a committee on physicians. health to serve in an advisory and nondisciplinary capacity. Such a committee should comprise respected physicians in the community. Both the provincial medical associations and the provincial colleges of physicians and surgeons should also consider innovative programs of early diagnosis and treatment. One possible means would be to have more physicians as field workers - competent to assess the danger signals noted by patients, colleagues or spouses, and empowered to provide professional pressure for the ill physician to obtain treatment - reinforced by a core of physicians able to do a locum tenens where needed. Finally, there is rehabilitation. The physician who has required psychiatric hospitalization often finds rehabilitation difficult. Reasons are many. Most of these physicians face insecurity aggravated by the realization that their medical knowledge is no longer up to date. More short courses should be available in specific areas to help physicians reenter practice with confidence. Some physicians need 3, 6 or 12 months' experience as interns or residents on specific services in order to regain their confidence and appropriate acumen. Some would benefit from a period of preceptorship with willing physicians in
294 CMA JOURNAL/AUGUST 21, 1976/VOL. 115
wStelabid® comprehensive and continuous control of gastrointestinal problems. COMPOSITION: Each 'Stelabid' Tablet No. 1 provides 1 mg of STELAZINE (trifluoperazinet SK&F) and 5mg of DARBID (isopropamide SK&F). Each 'Stelabid' Tablet No. 2 provides 2 mg of 'Stelazine' and 5 mg of'Darbid'. Each 'Stelabid' Forte Tablet provides 2 mg of 'Stelazine' and 7.5 mg of'Darbid'. Each 'Stelabid' Ultra Tablet provides 2 mg of 'Stelazine' and 10 mg of'Darbid'. Each 5 ml (1 teaspoonful) of'Stelabid' Elixir provides 1 mgof'Stelazine' and 5 mgof'Darbid'. INDICATIONS: 'Stelabid' is effective in the treatment of a wide range of gastrointestinal disorders - particularly where anxiety, tension, worry or other emotional factors are present including peptic ulcer, hyperchlorhydria, gastritis, duodenitis, pylorospasm, gastrointestinal spasm, biliary dyskinesia, chronic cholelithiasis, irritable colon, functional diarrhea. CONTRAINDICATIONS: 'Stelabid' is contraindicated in comatose states and in the presence of glaucoma, pyloric obstruction of organic origin, prostatic hypertrophy, bladder neck obstruction, obstructive intestinal lesions and/or ileus. ADVERSE REACTIONS: Possible anticholinergic side effects are constipation, dryness of the mouth, blurred vision and urinary hesitancy. Because of the low dosage of the 'Stelazine' component, neuromuscular (extrapyramidal) symptoms are not to be expected, but such reactions may occur in patients sensitive to phenothiazine compounds. Iodine skin rash may occur rarely. PRECAUTIONS: Use with caution in elderly patients, in patients with cardiac impairment, hyperthyroidism, or hiatal hernia; in pregnant patients, especially during the first trimester. Since the iodine in isopropamide iodide may alter PBI test results, and will suppress 1131 uptake, discontinue therapy one week prior to tests. Trifluoperazine has a wide margin of safety, however,blood or liver toxicity are possible occurrences. Trifluoperazine therapy may result in an increase in mental and physical activity. The potent antiemetic effect of 'Stelabid' may mask signs of overdosage of toxic drugs and may obscure diagnosis of such conditions as intestinal obstruction and brain tumour. ADULT DOSAGE: Tablets-One 'Stelabid' tablet b.i.d. (every 12 hours) Elixir - One teaspoonful (each 5 ml teaspoonful is equivalent to one 'Stelabid' Tablet No. 1) b.i.d. (every 12 hours). SUPPLY: Tablets - Maize-coloured, monogrammed tablets No. 1 and No. 2, available in bottles of 100, 500, and 1000. Forte available in bottles of 100 and 500, Ultra available in bottles of 100. Elixir available in 6 fi oz (170 ml) bottles. Monogrammed: Tablets No. 1 -SKF P90; No. 2- SKF P91; Forte - SKF P92; Ultra - SKF P93 Full information available on request or by consulting the Compendium of Pharmaceuticals and Specialties. tPat. 612,204- trifluoperazine
S K Smith Kline & French Canada Ltd. &I. Montreal (Quebec) H4M 2L6
the same type of practice. A few physicians on leaving a psychiatric hospital are faced with a limited licence. The need is for more individual physicians, clinics, hospitals and medical schools to provide supportive supervision for physicians at this stage of rehabilitation, which is often the most difficult phase of treatment because so few such opportunities are currently available. The advice "Physician, heal thyself" has not worked. We need an expanded
outlook and network for physicians with psychiatric illnesses. MERVILLE 0. VINCENT, BA, MD, CM, MRC PSYCH, FRCP[C] Executive director M. RUTH TATHAM, MD Staff physician Homewood Sanitarium of Guciph Guciph, ON
References 1. VAILLANT GE, SOBOWALE NC, MCARTHUR C:
Some psychologic vulnerabilities of physicians.
N Engi I Med 287: 372, 1972 Physicians' use of mood-altering drugs. A 20-year follow-up report. N Engi I Med 282: 365, 1970 3. VINCENT MO: Physicians and alcoholism. Rep Alcohol 27: 5, 1969 4. Pa.itso. M: Drug and alcohol problems in physicians. Psychiatr Opinion 12: 14, 1975 5. JONES RE: Do psychiatrists cover up addiction of physicians? Ibid, p 36
2. VAILLANT GE, BRIGHTON JR, MCARTHUR C:
6. SHAPIRO
ET,
PINSKER
H,
SHALE
JH
III:
Mentally ill physician as practitioner. JAMA 232: 725, 1975 7. American Medical Association, council on mental health: The sick physician: impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA 223: 684, 1973
Clinical application of triiodothyronine measurement Recent availability of the radioimmunoassay method for the measurement of serum triiodothyronine (T3) has increased our knowledge of the role of T3 in normal and abnormal thyroid function. Some established facts are: approximately 50 ,.g of T3 is secreted daily, compared with 80 .g of thyroxine (T4); blood concentrations of T3 approximate 100 ng/dl and of T4, 4 to 8 p.g/dl; in metabolic activity T3 is three times more potent than T4; and the biologic half-life of T3 is 2 days v. 7 days for T4. Thus T3 may be extremely important in metabolism. It has been suggested1 that T4 be viewed as a prohormone for T3, while T3 has two sources - direct secretion from the thyroid gland and peripheral monodeiodination of T4. The prohormone view has been challenged, however, by Chopra, Solomon and Chua Teco,2 who found normal values of T3 in clinically hypothyroid patients with an elevated value of serum thyroid stimLilating hormone (TSH) and subnormal values of free T4. They concluded that a normal concentration of free serum T3 in the absence of a normal concentration of free serum T4 is not sufficient to sustain euthyroidism. The measurement of T3 concentration in the blood presents problems: the cost will probably be higher than for T4 and T3 resin uptake determinations, and will not eliminate the need for these two standard tests. Assay for Ti must be sensitive enough to allow quantitative distinction between T3 and T4. Another methodologic variable is the degree of in vivo binding of T3 to thyroxine-binding globulin (TBG). Fortunately T3 is bound weakly to serum albumin and not at all to thyroxine-binding prealbumin. The most disturbing aspect of these considerations is the conclusion reached by Gharib, Ryan and Mayberry3 that certain local factors, perhaps dietary io-
dide, influence serum T3 values. Since the technical aspects of the assay method restrict its use to large centres, the problem of deriving information on normal values is of paramount importance and limits its usefulness. Even within a geographically localized population the intake of dietary iodide and exposure to iodine-containing compounds may not be uniform. Increased concentrations of serum T3 have been found in thyrotoxicosis (with or without concomitant increase in T4), in multinodular goitre, in autonomously functioning thyroid adenomas, in the early stages of development of Graves disease, after operation or iodine-13 1 (1311) therapy for thyrotoxicosis and as a compensatory mechanism in a failing thyroid gland. Determination of T3 is of greatest clinical assistance in patients who appear to be hyperthyroid but have normal concentrations of serum T4 and TBG and a normal 1311 uptake value, and in patients who appear euthyroid despite low concentrations of L and normal values of TBG, 1311 uptake and TSH. In the former, obtaining a T3 concentration that is abnormally high may obviate the need for a T3 suppression test. In the latter, the normal serum TSH value may indicate a euthyroid state or secondary hypothyroidism, so that the finding of a normal T3 concentration is crucial in establishing the true status of the thyroid gland. Patients with goitres from iodine deficiency or with enzymatic defects may have a normal concentration of T3 but a low concentration of T4 as a result of the selective stimulation of T3 production by elevated serum TSH levels. A recent study,4 although reporting on a limited number of subjects, indicated that serial estimations of T3 may provide the most reliable method of monitoring relapse in hyperthyroidism after discontinuation of antithyroid drug therapy. Elsewhere in this issue (page
Z96 CMA JOURNAL/AUGUST 21, 1976/VOL. 115
338) Walfish reviews these and other aspects of T3 and T4 interrelations. The practising physician need not yet order serum T3 measurement routinely; much information may be derived from the T4 value and T3 resin uptake or the free thyroxine index, coupled with 131J uptake (for hyperthyroidism) and with serum TSH value (for hypothyroidism). The basal metabolic rate, used to distinguish apparent hypo- or hyperthyroidism from true dysfunction, is no longer available in most centres. The recent interest in T3 metabolism does not mean that administration of T3 preparations will provide better therapy in situations where T4 preparations are now useful. Pure synthetic T4 is the preparation of choice because it is converted to T3 even in athyrotic patients, and because the serum concentration is conveniently measured in most laboratories. The use of pure T3 would impose the serious limitation that the T3 assay is not widely available as a check on appropriateness of dosage. Suppression of serum TSH applies only in the treatment of hypothyroidism, and the serum TSH assay is not universally available. C. REYNOLDS, MD, CM, MS, FRcP[C] Department of medicine St. Paul's Hospital Faculty of medicine University of British Columbia Vancouver, BC
References 1. OPPENHEIMER JH, SCHWARtZ HL, SURKs MI:
Propylthiouracil inhibits conversion of Lthyroxine to L-triiodothyronine. An explanation of the antithyroxine effect of propylthiouracil and evidence supporting the concept that triiodothyronine is the active, thyroid hormone. J Clin Invest 51: 2493, 1972 2. CHOPRA II, SOLOMON DH, CHUA Taco ON: Thyroxine. Just a prohormone or a hormone too? J Clin Endocrinol Metab 36: 1050, 1973 3. GHARIB H, RYAN RS. MAYBERRY WE: Tniodothyronine (T3) radioimmunoassay: a critical evaluation. Mayo Clin Proc 47: 934, 1972 4. MARSOEN
P.
HOWORTH
PJN,
CHALKLEY
5,
et al: Hormonal pattern of relapse in hyperthyroidism. Lancet 1: 944, 1975
groups of nonphysicians and there is to accept Watterson's belief that "a evidence that alcoholism may be more degree of neurotic vulnerability is a common in physicians than in their prerequisite for the would-be psychononmedical social peers.14 Chafetz therapist". Watterson's survey is only a start stated that the percentage of alcoholics among the United States' 356 000 phy- and in only one province, to which sicians was estimated conservatively at many physicians have migrated for 18% - three times the percentage of various reasons. In addition to his study alcoholics in the general population of of the incidence and severity of psythat country.. In British Columbia chiatric illness as related to age, sex, the rate of physician-suicides (36.5/ level of training and field of practice, 100 000) is well above the national further study should be done in regard average for a socioeconomically com- to the following: the age at onset of parable nonphysician group. Is this psychiatric training; whether the consimply a reflection that deeply dis- tent and nature of childhood stresses turbed physicians have no outside interfere with the practice of medicine; resource to which they can turn or are the philosophy of life of the physicianmore of them deeply disturbed than patient, including religious faith and members of the "outside" population? its importance; and the ethnic background of the physician-patient. The If so, why? Why are ophthalmologists so prone results of such studies might indicate to psychiatric ills? Watterson proffers what type of physician should be disthe usual suggestions that the North couraged from entering the fields of American ophthalmologist (who does ophthalmology or psychiatry - and his own refractions) may be unduly some day we may have enough data frustrated by the lack of challenge and to know what type of practice is best by an excessively full and rigid work- suited for varying personalities. If a physician does become mentally load. More interesting is his speculation that "the eye... carries profound sym- ill, where can he turn? There are few bolic connotations" - might we infer treatment resources available to menthat ophthalmology and psychiatry deal tally ill physicians. The doctor with a with "outsight" and "insight"? Perhaps mental illness may seek an "asylum", there is extra stress in having either a refuge remote from his practice. Only one.s mind on the eye or one.s eye by leaving his area of practice can he ensure confidentiality. We need better on the mind. If further studies throughout Canada recognition of the need for available show these findings to be statistically treatment sources for physicians, with significant, further queries arise: Should effective temporary takeover of their those responsible for residency training workload by other competent phyprograms in ophthalmology and psy- sicians. Watterson has shown that, although chiatry make a more strenuous attempt to screen the psychologic profile of po- the incidence of psychiatric illness is tential trainees? Should their mentors the same in family physicians as in provide more support for the trainee? specialists, the illnesses tend to be more Although some psychiatry residents are severe and to have a poorer prognosis drawn into psychiatry in part to solve in the family physicians. Because of the their own problems, we are inclined not location and nature of their practices, CMA JOURNAL/AUGUST 21, 1976/VOL. 115 293
general practitioners carry on longer until they are sicker. Ought we, as physicians, to try to devise some network of mutual help for each other, so that we give ourselves at least the care we would offer our patients? There is a danger in concluding that there are so many gaps in our knowledge that there is nothing we can do. Enough evidence has been gathered to make it apparent that we should do something, even before all the final answers are available. Prevention begins with the difficult decision about who is to be admitted to medical school. Academic ability alone does not make a good physician, but a minimum academic ability is essential. Perhaps mental health alone does not make a good physician, but perhaps minimum standards of mental health are essential. There are no clear criteria, yet Vaillant and colleagues1 have shown that insecurity in childhood is related to vulnerability to stress in the practice of medicine. Is there a minimum of security necessary in childhood for the individual to be a good physician and, if so, can we measure it? Can we distinguish the insecurity that drives some people to great success from the insecurity that causes some people to fail? In medical schools openness about emotional problems in patients and physicians may be healthy and encourage earlier recognition of difficulties and acceptance of treatment both for the student and subsequently for the physician. Increasingly the content of the teaching must include more understanding of the physicians' potential lifestyles, stresses and patterns of morbidity. Medical school often convinces the young physician that his role is to stamp out disease, suffering and death, but he soon finds himself surrounded by disease and suffering. The result is often despair, guilt and fatigue, which can lead to overwork, compensated for by depression, excessive use of alcohol, drugs or even suicide. It seems important that it be made clear in medical school that our role is not to stamp out disease, suffering and death. Present efforts to clarify the role of the physician in helping dying patients and their families and in helping relatives through bereavement are good steps in this direction. Do some of the other situations with which the physician is frequently confronted make him uncertain about his own role and purpose? Secondary prevention, or early diagnosis and treatment, are also important. At the personal level, each of us must be willing to become involved with physicians in our practice or in our com-
munity who are facing difficulties. If they are our patients we should be honest and give them a factual diagnosis that doesn't overemphasize pylorospasm and de-emphasize anxiety, or emphasize overwork and ignore overdrinking. History-taking of the physician-patient should be detailed, with enquiries into personal and social areas; it should be done, when possible, by a physician who is respected by the patient but who is not a close friend. Each of us has a personal responsibility to reach out to the physician when we notice a change in his behaviour. It is better to be rebuffed by a colleague for interfering than to avoid this risk, only to have the physician commit suicide. Frequently the physician who is depressed or abusing drugs or alcohol deceives himself that no one else knows, and he is as likely to be relieved as to be angry if a colleague enquires and offers a helping hand. In 1973 the American Medical Association council on mental health stated categorically that it is "a physician's ethical responsibility" to recognize and take action when a colleague is unable to practise medicine adequately by reason of a physical or mental illness.7 At the level of the local hospital or medical society, it is suggested there should be a committee on physicians. health to serve in an advisory and nondisciplinary capacity. Such a committee should comprise respected physicians in the community. Both the provincial medical associations and the provincial colleges of physicians and surgeons should also consider innovative programs of early diagnosis and treatment. One possible means would be to have more physicians as field workers - competent to assess the danger signals noted by patients, colleagues or spouses, and empowered to provide professional pressure for the ill physician to obtain treatment - reinforced by a core of physicians able to do a locum tenens where needed. Finally, there is rehabilitation. The physician who has required psychiatric hospitalization often finds rehabilitation difficult. Reasons are many. Most of these physicians face insecurity aggravated by the realization that their medical knowledge is no longer up to date. More short courses should be available in specific areas to help physicians reenter practice with confidence. Some physicians need 3, 6 or 12 months' experience as interns or residents on specific services in order to regain their confidence and appropriate acumen. Some would benefit from a period of preceptorship with willing physicians in
294 CMA JOURNAL/AUGUST 21, 1976/VOL. 115
wStelabid® comprehensive and continuous control of gastrointestinal problems. COMPOSITION: Each 'Stelabid' Tablet No. 1 provides 1 mg of STELAZINE (trifluoperazinet SK&F) and 5mg of DARBID (isopropamide SK&F). Each 'Stelabid' Tablet No. 2 provides 2 mg of 'Stelazine' and 5 mg of'Darbid'. Each 'Stelabid' Forte Tablet provides 2 mg of 'Stelazine' and 7.5 mg of'Darbid'. Each 'Stelabid' Ultra Tablet provides 2 mg of 'Stelazine' and 10 mg of'Darbid'. Each 5 ml (1 teaspoonful) of'Stelabid' Elixir provides 1 mgof'Stelazine' and 5 mgof'Darbid'. INDICATIONS: 'Stelabid' is effective in the treatment of a wide range of gastrointestinal disorders - particularly where anxiety, tension, worry or other emotional factors are present including peptic ulcer, hyperchlorhydria, gastritis, duodenitis, pylorospasm, gastrointestinal spasm, biliary dyskinesia, chronic cholelithiasis, irritable colon, functional diarrhea. CONTRAINDICATIONS: 'Stelabid' is contraindicated in comatose states and in the presence of glaucoma, pyloric obstruction of organic origin, prostatic hypertrophy, bladder neck obstruction, obstructive intestinal lesions and/or ileus. ADVERSE REACTIONS: Possible anticholinergic side effects are constipation, dryness of the mouth, blurred vision and urinary hesitancy. Because of the low dosage of the 'Stelazine' component, neuromuscular (extrapyramidal) symptoms are not to be expected, but such reactions may occur in patients sensitive to phenothiazine compounds. Iodine skin rash may occur rarely. PRECAUTIONS: Use with caution in elderly patients, in patients with cardiac impairment, hyperthyroidism, or hiatal hernia; in pregnant patients, especially during the first trimester. Since the iodine in isopropamide iodide may alter PBI test results, and will suppress 1131 uptake, discontinue therapy one week prior to tests. Trifluoperazine has a wide margin of safety, however,blood or liver toxicity are possible occurrences. Trifluoperazine therapy may result in an increase in mental and physical activity. The potent antiemetic effect of 'Stelabid' may mask signs of overdosage of toxic drugs and may obscure diagnosis of such conditions as intestinal obstruction and brain tumour. ADULT DOSAGE: Tablets-One 'Stelabid' tablet b.i.d. (every 12 hours) Elixir - One teaspoonful (each 5 ml teaspoonful is equivalent to one 'Stelabid' Tablet No. 1) b.i.d. (every 12 hours). SUPPLY: Tablets - Maize-coloured, monogrammed tablets No. 1 and No. 2, available in bottles of 100, 500, and 1000. Forte available in bottles of 100 and 500, Ultra available in bottles of 100. Elixir available in 6 fi oz (170 ml) bottles. Monogrammed: Tablets No. 1 -SKF P90; No. 2- SKF P91; Forte - SKF P92; Ultra - SKF P93 Full information available on request or by consulting the Compendium of Pharmaceuticals and Specialties. tPat. 612,204- trifluoperazine
S K Smith Kline & French Canada Ltd. &I. Montreal (Quebec) H4M 2L6
the same type of practice. A few physicians on leaving a psychiatric hospital are faced with a limited licence. The need is for more individual physicians, clinics, hospitals and medical schools to provide supportive supervision for physicians at this stage of rehabilitation, which is often the most difficult phase of treatment because so few such opportunities are currently available. The advice "Physician, heal thyself" has not worked. We need an expanded
outlook and network for physicians with psychiatric illnesses. MERVILLE 0. VINCENT, BA, MD, CM, MRC PSYCH, FRCP[C] Executive director M. RUTH TATHAM, MD Staff physician Homewood Sanitarium of Guciph Guciph, ON
References 1. VAILLANT GE, SOBOWALE NC, MCARTHUR C:
Some psychologic vulnerabilities of physicians.
N Engi I Med 287: 372, 1972 Physicians' use of mood-altering drugs. A 20-year follow-up report. N Engi I Med 282: 365, 1970 3. VINCENT MO: Physicians and alcoholism. Rep Alcohol 27: 5, 1969 4. Pa.itso. M: Drug and alcohol problems in physicians. Psychiatr Opinion 12: 14, 1975 5. JONES RE: Do psychiatrists cover up addiction of physicians? Ibid, p 36
2. VAILLANT GE, BRIGHTON JR, MCARTHUR C:
6. SHAPIRO
ET,
PINSKER
H,
SHALE
JH
III:
Mentally ill physician as practitioner. JAMA 232: 725, 1975 7. American Medical Association, council on mental health: The sick physician: impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA 223: 684, 1973
Clinical application of triiodothyronine measurement Recent availability of the radioimmunoassay method for the measurement of serum triiodothyronine (T3) has increased our knowledge of the role of T3 in normal and abnormal thyroid function. Some established facts are: approximately 50 ,.g of T3 is secreted daily, compared with 80 .g of thyroxine (T4); blood concentrations of T3 approximate 100 ng/dl and of T4, 4 to 8 p.g/dl; in metabolic activity T3 is three times more potent than T4; and the biologic half-life of T3 is 2 days v. 7 days for T4. Thus T3 may be extremely important in metabolism. It has been suggested1 that T4 be viewed as a prohormone for T3, while T3 has two sources - direct secretion from the thyroid gland and peripheral monodeiodination of T4. The prohormone view has been challenged, however, by Chopra, Solomon and Chua Teco,2 who found normal values of T3 in clinically hypothyroid patients with an elevated value of serum thyroid stimLilating hormone (TSH) and subnormal values of free T4. They concluded that a normal concentration of free serum T3 in the absence of a normal concentration of free serum T4 is not sufficient to sustain euthyroidism. The measurement of T3 concentration in the blood presents problems: the cost will probably be higher than for T4 and T3 resin uptake determinations, and will not eliminate the need for these two standard tests. Assay for Ti must be sensitive enough to allow quantitative distinction between T3 and T4. Another methodologic variable is the degree of in vivo binding of T3 to thyroxine-binding globulin (TBG). Fortunately T3 is bound weakly to serum albumin and not at all to thyroxine-binding prealbumin. The most disturbing aspect of these considerations is the conclusion reached by Gharib, Ryan and Mayberry3 that certain local factors, perhaps dietary io-
dide, influence serum T3 values. Since the technical aspects of the assay method restrict its use to large centres, the problem of deriving information on normal values is of paramount importance and limits its usefulness. Even within a geographically localized population the intake of dietary iodide and exposure to iodine-containing compounds may not be uniform. Increased concentrations of serum T3 have been found in thyrotoxicosis (with or without concomitant increase in T4), in multinodular goitre, in autonomously functioning thyroid adenomas, in the early stages of development of Graves disease, after operation or iodine-13 1 (1311) therapy for thyrotoxicosis and as a compensatory mechanism in a failing thyroid gland. Determination of T3 is of greatest clinical assistance in patients who appear to be hyperthyroid but have normal concentrations of serum T4 and TBG and a normal 1311 uptake value, and in patients who appear euthyroid despite low concentrations of L and normal values of TBG, 1311 uptake and TSH. In the former, obtaining a T3 concentration that is abnormally high may obviate the need for a T3 suppression test. In the latter, the normal serum TSH value may indicate a euthyroid state or secondary hypothyroidism, so that the finding of a normal T3 concentration is crucial in establishing the true status of the thyroid gland. Patients with goitres from iodine deficiency or with enzymatic defects may have a normal concentration of T3 but a low concentration of T4 as a result of the selective stimulation of T3 production by elevated serum TSH levels. A recent study,4 although reporting on a limited number of subjects, indicated that serial estimations of T3 may provide the most reliable method of monitoring relapse in hyperthyroidism after discontinuation of antithyroid drug therapy. Elsewhere in this issue (page
Z96 CMA JOURNAL/AUGUST 21, 1976/VOL. 115
338) Walfish reviews these and other aspects of T3 and T4 interrelations. The practising physician need not yet order serum T3 measurement routinely; much information may be derived from the T4 value and T3 resin uptake or the free thyroxine index, coupled with 131J uptake (for hyperthyroidism) and with serum TSH value (for hypothyroidism). The basal metabolic rate, used to distinguish apparent hypo- or hyperthyroidism from true dysfunction, is no longer available in most centres. The recent interest in T3 metabolism does not mean that administration of T3 preparations will provide better therapy in situations where T4 preparations are now useful. Pure synthetic T4 is the preparation of choice because it is converted to T3 even in athyrotic patients, and because the serum concentration is conveniently measured in most laboratories. The use of pure T3 would impose the serious limitation that the T3 assay is not widely available as a check on appropriateness of dosage. Suppression of serum TSH applies only in the treatment of hypothyroidism, and the serum TSH assay is not universally available. C. REYNOLDS, MD, CM, MS, FRcP[C] Department of medicine St. Paul's Hospital Faculty of medicine University of British Columbia Vancouver, BC
References 1. OPPENHEIMER JH, SCHWARtZ HL, SURKs MI:
Propylthiouracil inhibits conversion of Lthyroxine to L-triiodothyronine. An explanation of the antithyroxine effect of propylthiouracil and evidence supporting the concept that triiodothyronine is the active, thyroid hormone. J Clin Invest 51: 2493, 1972 2. CHOPRA II, SOLOMON DH, CHUA Taco ON: Thyroxine. Just a prohormone or a hormone too? J Clin Endocrinol Metab 36: 1050, 1973 3. GHARIB H, RYAN RS. MAYBERRY WE: Tniodothyronine (T3) radioimmunoassay: a critical evaluation. Mayo Clin Proc 47: 934, 1972 4. MARSOEN
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