LETTERS
TO THE
competency-based model to psychiatric education for medical students. Medical educators have applied many of the principles of competency-based instruction to various aspects of the medical school curriculum. Although more sophisticated methods of evaluation and instruction have been developed (1 , 2), most of this work has been carried out in
overdose patient in perspective. A systematic management of consecutive overdose cases the reader with a better idea of the frequency
the teaching
been
of medical
specialties
other
than
psychiatry
and
in the allied health professions. Some of this work has involved the teaching of psychological principles to nonpsychiatric health professionals (3, 4). More recently, there have been attempts to apply principles of instructional design (including the specification of performance objectives and objective evaluation measures) to psychiatric teaching. Examples of this include the teaching of interviewing techniques (5), psychopathology (6), and clinical clerkship experiences (7). Unfortunately, we know of no fully integrated four-year psychiatry curriculum in a medical school wherein formative and summative evaluation is carried out. We are presently involved in the development of a competencybased psychiatric clerkship at the University of California School of Medicine, with the goal of achieving such an integrated model.
We hope
that
as more
programs
attempt
to apply
the corn-
petency-based model to psychiatric education, more definitive work will be carried out in the critical areas of medical student education and teaching competency.
REFERENCES 1. Barrows H: Simulated Patients. Springfield, Ill, Charles C Thomas, 1972 2. Harless WG, Drennan CG, Marxer JJ, et al: Case: a computeraided simulation of the clinical encounter. J Med Educ 46:443448, 1971 3. Weinstein HM, Gould BG, Russell ML: Interviewing skills for respiratory therapists: a teaching module, 1976 (unpublished manuscript) 4. Bland C, Houge D, Filiatrault L, et al: Developing an objective based curriculum for family practice residency. J Family Practice (in press) 5. Endow Al, Adler LM, Wexler M: Programmed instruction in interviewing: an experiment in medical education. JAMA 212:1843-1846, 1970 6. Randels PM, Kilpatrick DG, McCurdy L, et al: Comparison of the psychiatry learning system and traditional teaching of psychiatry. J Med Educ 51:751-757, 1976 7. Meyerson A, Wachtel A: Utilization of a videotape based test to evaluate competence of psychiatric clerks and aspects of a teaching program. Paper presented at the Conference on Research in Medical Education, American Association of Medical Colleges, San Francisco, Nov 13-14, 1976
ic clinical agement.
findings and In addition,
overdose
with
of the
MICHAEL
Overdosing
the Tricyclic
Overdose
M.
WEINSTEIN,
L. RUSSELL, San Francisco,
tricyclic with
would
measurements adverse
provide
(which
effects,
evidence
manof the
have
contrary
to one
of a tricyclic
over-
regarding the treatment of tri(1). We have studied a group of 45 consecutively hospitalized patients with tricyclic antidepressant overdose, using serial plasma determinations and documentation of physical findings for up to 144 hours. In our experience, the prompt use of respiratory support, which avoids hypoxia that may prompt cardiac arrhythmias, has been adequate in most cases. Overzealous use of drugs in treating the overdose patient may create medical emergencies rather than solve them.
The following
conclusions overdoses
is a list of findings
from
our own
experience
and the literature that are contrary to points raised in the two papers referred to above. 1 . The use of ipecac rather than gastric lavage may stimulate seizures and result in the aspiration ofgastric contents. 2. Treatment of tricyclic overdose patients with adrenal corticosteroids is contraindicated, since these drugs have been reported to inhibit tricyclic metabolism in animals (2) and have inhibited tricyclic metabolism in 1 patient in our series who had a concurrent neurological illness. 3. Overhydration of the patient is to be avoided because
the
direct
pressants
myocardial makes
depressant
the
patient
ure (3). Antiarrhythmic
effect
prone
drugs
must
of tricyclic
to congestive
be used
with
antideheart
fail-
caution
be-
cause many of them are cardiac depressants. 4. The casual use of physostigmine to arouse a tricyclic overdose patient (even if the patient has not been further overdosed with hypnotics) is certainly not diagnostic of a tncyclic overdose and is seldom of any sustained clinical value in patients with severe tnicyclic overdoses that have been documented by plasma measurements. That the patient descnbed by Dns. Holinger and Klawans remained in the intensive care unit for 10 days prior to extubation indicated physostigmine did not produce an immediate recovery. The clinician must also be aware that physostigmine can be lethal
if the patient
has
a junctional
rhythmia. 5. Major tricyclic absence of emergency es in our series have
100 or more ingestion
We agree
M.D. PH.D.
plasma
and justify antidepressant
report of the would provide of such dramat-
the need for such drastic clinical documentation of the severity
to correlate
reports)
dose cyclic
drug HARVEY
found
EDITOR
or idioventricular
cardiac
drug ingestions can be diagnosed room tnicyclic plasma assays; had QRS durations on routine
milliseconds
within
the first
24 hours
ar-
in the all casECGs of
after
the
(4).
that the use of 74 mg of physostigmine
in one
patient in a 6-hour period and 193 mg in another who remained in coma for several days is worth reporting; however, we question whether either report will decrease medical complications after tricyclic antidepressant overdose.
Calif
Patient REFERENCES
SIR:
We
read
‘ ‘
Reversal
of Tricyclic-Overdosage-Induced
Central Anticholinergic Syndrome by Physostigmine’ by Paul C. Holinger, M.D., and Harold L. Klawans, M.D., and ‘
“Treatment
noz,
M.D.
of Tricyclic
(September
Intoxication”
1976 issue)
by
with
Rodrigo
initial
A.
interest
Mu-
and
subsequent dismay. The findings in the single case presented in each paper are so different from our own that we think they deserve comment in order to keep management of the
1. Petit JM, Spiker DO, Ruwitch JF, et al: Tricyclic antidepressant plasma levels and adverse effects in 40 overdose cases. Clin Pharmacol Ther (in press) 2. Von Bahr C, Sjoqvist F, Orrenius 5: The inhibitory effect of hydrocortisone and testosterone on plasma disappearance of nortriptyline in the dog and profused rat liver. Eur J Pharmacol 9:106-110, 1970 3. Laddu AR, Lomani P: Desipramine toxicity and its treatment.
Am J Psychiatry
134:4,
April
1977
461
LETTERS
TO THE
Toxicol
EDITOR
Appl Pharmacol
4. Spiker
DG,
Weiss
AN,
overdose:
clinical
col Ther
18:539-546,
15:287-294, Chang
1969
2. Kline
55, et al: Tricyclic
presentation
and plasma
antidepressant
levels.
Clin Pharma-
T. BIGG5,
JOHN
A.
M.D.
E.
VINCENT
4.
M.D.
RIESENBERG,
M.D.
ZIEGLER,
St.
Louis,
5.
Mo.
6.
Dr.
Munoz SIR:
Dr.
carefully its
and
Biggs
or they
content,
Holinger
Drs.
and
purpose,
and
proposals
cyclic
any that
outlined
by
of the
‘
My paper
1 1 supportive
for emergency
and
treatment
antidepressants.
Dr.
Biggs
criticizing
short
it as
paragraph
and
associates
offers
three
criticisms
with do not
trioffer
they indicate has been useful
that merit
consideration.
First, without reference or clinical data, the authors reject the induction ofemesis with ipecac because they are worried about seizures and aspiration. They advocate exclusive use
of stomach lavage, tory complications state of knowledge reference
alert
which is also known to produce respiraand to trigger seizures (1). The present does not favor a dogmatic attitude (e.g.,
2). Induction
patient
of vomiting
who has just
patient who is becoming stomach lavage, which tubation.
Second, sostigmine,’
taken
which
to be ideal
an overdose,
for the
whereas
the
progressively obtunded may require is safer if preceded by tracheal in-
the letter complains ‘
seems
no one
about has
‘
‘the casual
advocated.
use of phy-
As stated
in step
1 1 of my schedule, physostigmine is used for cardiovascular and central nervous system effects ofanticholinergic medication. Until Dr. Biggs and associates produce evidence to refute the findings of those who have advocated these selective ofphysostigmine (3-6), their position appears uncritical and prejudicial. If they are withholding this effective treatment for the specific manifestations outlined in my paper, they should clarify their medical, legal, and logical justifications. Third, the letter decries the use of physostigmine as a diagnostic tool, something I have not suggested. On the other hand, in order to prevent readers of their letter from thinking that the clinician should wait for blood level studies before treating the patient for tricyclic overdose, I should mention that the evidence on the value of blood levels in tricyclic intoxication, even that provided by the St. Louis group (7), is still equivocal; most hospitals do not have the technique available, and many patients have been successfully treated uses
on the basis of clinical observations. learned (at the same center where have their laboratory) that chances tory tion.
measurement
can
ever
replace
careful
clinical
RH:
ment,
7th ed. Los
Handbook
Altos,
Lange
Diagnosis
Medical
1971
462
Am J Psychiatry
134:4,
April
1977
and
Treat-
NJ.
A.
M.D.
MUNOZ,
Wis.
SIR: The purpose of our paper was to draw attention to the central anticholingeric syndrome caused by phenothiazines and antiparkinson medication in addition to tricyclic antidepressants, with a focus on two manifestations of the syndrome, coma and movement abnormalities (myoclonus and choreoathetosis), and their reversal by physostigmine. The clinical efficacy and theoretical implications of reversal of
the central been
well
anticholinergic
syndrome
documented
in the
by physostigmine
anesthesia
have
general medical literature as well as in psychiatric journals (1-6). This documentation has included several hundred patients in investigations ranging from controlled double-blind studies to reports
and
on consecutive cases. Dr. Biggs and associates’ letter is also directed Munoz’ article, which may confuse the issues. like
to distinguish
Munoz.
our
In particular,
purpose
and
findings
we reiterate
of diazepam, barbiturates, tion for seizure-like activity scribed as myoclonic jerks
toward Dr. We would
from
our caution
those
about
of Dr.
the use
or other anticonvulsive medicathat may be more accurately deand choreoathetosis.
REFERENCES 1. Greene LT: Physostigmine treatment ofanticholinergic drug depression in postoperative patients. Anesth Analg (Cleve) 50:222-226, 1971 2. Duvoisin RC, Katz R: Reversal of central anticholinergic syndrome in man by physostigmine. JAMA 206:1963-1965, 1968 3. El-Yousef M, Janowsky DS, Davis JM, et al: Reversal of antiparkinsonian drug toxicity by physostigmine: a controlled study. Am J Psychiatry 130:141-145, 1973 4. Burks JS, Walker JE, Rumack BH, et al: Tricyclic antidepressant poisoning: reversal of coma, choreoathetosis, and myoclonus by physostigmine. JAMA 230: 1405-1407, 1974 5. Bernards W: Case history number 74: reversal of phenothiazineinduced coma with physostigmine. Anesth Analg (Cleve) 52:938-941, 1973 6. Snyder BD: Physostigmine and anticholinergic poisoning.
JAMA
233:1165-1166,
1975 PAUL
C.
M.D.
HOLINGER,
L. KLAWANS,
HAROLD
observa-
Publications,
Drugs:
Oradell,
Sheboygan,
M.D. Ill.
Chicago, Criteria
of Poisoning:
Calif.
A:Psychotropic
of Overdose.
RODRIGO
I am glad to note that I Dr. Biggs and associates are slim that any labora-
REFERENCES
I. Dreisbach
Chamberlain
Management
“a
experience.
The letter
SF,
de-
symptom-specific
of intoxication
criticism of 9 of the measures, although the first (establishing proper ventilation)
in their
7.
and associates either did not read my paper drastically misunderstood it. They ignored
case presentation’ on the basis voted to 1 of 15 cases discussed. measures
Reply
Klawans
Alexander
for Emergency
Medical Economics Co. 1974 Burks iS, Walker JE, Rumack BH, et al: Tricyclic antidepressant poisoning: reversal of coma, choreoathetosis, and myoclonus by physostigmine. JAMA 230: 1405-1407, 1974 Duvoisin RC, Katz R: Reversal of central anticholinergic syndrome in man by physostigmine. JAMA 206:1963-1965, 1968 Snyder BD, Blonde L, McWhirter WR: Reversal of amitriptyline intoxication by physostigmine. JAMA 230:1433-1434, 1974 Granacher RP, Baldessarini RJ: Physostigmine. Arch Gen Psychiatry 32:375-380, 1975 Spiker DG, Weiss AN, Chang 55, et al: Tricyclic antidepressant overdose: clinical presentation and plasma levels. Clin Pharmacol 18:539-546, 1975
3.
1975
ROBERT
NS,
Manual
SIR:
for
the
I heartily
tonia: Prediction Richard Abrams,
of Catatonia
Diagnosis concur
with
of Response M.D. and ,
the
thesis
presented
in “Cata-
to Somatic Treatments’ Michael Alan Taylor,
‘
by
M.D.
TO THE
competency-based model to psychiatric education for medical students. Medical educators have applied many of the principles of competency-based instruction to various aspects of the medical school curriculum. Although more sophisticated methods of evaluation and instruction have been developed (1 , 2), most of this work has been carried out in
overdose patient in perspective. A systematic management of consecutive overdose cases the reader with a better idea of the frequency
the teaching
been
of medical
specialties
other
than
psychiatry
and
in the allied health professions. Some of this work has involved the teaching of psychological principles to nonpsychiatric health professionals (3, 4). More recently, there have been attempts to apply principles of instructional design (including the specification of performance objectives and objective evaluation measures) to psychiatric teaching. Examples of this include the teaching of interviewing techniques (5), psychopathology (6), and clinical clerkship experiences (7). Unfortunately, we know of no fully integrated four-year psychiatry curriculum in a medical school wherein formative and summative evaluation is carried out. We are presently involved in the development of a competencybased psychiatric clerkship at the University of California School of Medicine, with the goal of achieving such an integrated model.
We hope
that
as more
programs
attempt
to apply
the corn-
petency-based model to psychiatric education, more definitive work will be carried out in the critical areas of medical student education and teaching competency.
REFERENCES 1. Barrows H: Simulated Patients. Springfield, Ill, Charles C Thomas, 1972 2. Harless WG, Drennan CG, Marxer JJ, et al: Case: a computeraided simulation of the clinical encounter. J Med Educ 46:443448, 1971 3. Weinstein HM, Gould BG, Russell ML: Interviewing skills for respiratory therapists: a teaching module, 1976 (unpublished manuscript) 4. Bland C, Houge D, Filiatrault L, et al: Developing an objective based curriculum for family practice residency. J Family Practice (in press) 5. Endow Al, Adler LM, Wexler M: Programmed instruction in interviewing: an experiment in medical education. JAMA 212:1843-1846, 1970 6. Randels PM, Kilpatrick DG, McCurdy L, et al: Comparison of the psychiatry learning system and traditional teaching of psychiatry. J Med Educ 51:751-757, 1976 7. Meyerson A, Wachtel A: Utilization of a videotape based test to evaluate competence of psychiatric clerks and aspects of a teaching program. Paper presented at the Conference on Research in Medical Education, American Association of Medical Colleges, San Francisco, Nov 13-14, 1976
ic clinical agement.
findings and In addition,
overdose
with
of the
MICHAEL
Overdosing
the Tricyclic
Overdose
M.
WEINSTEIN,
L. RUSSELL, San Francisco,
tricyclic with
would
measurements adverse
provide
(which
effects,
evidence
manof the
have
contrary
to one
of a tricyclic
over-
regarding the treatment of tri(1). We have studied a group of 45 consecutively hospitalized patients with tricyclic antidepressant overdose, using serial plasma determinations and documentation of physical findings for up to 144 hours. In our experience, the prompt use of respiratory support, which avoids hypoxia that may prompt cardiac arrhythmias, has been adequate in most cases. Overzealous use of drugs in treating the overdose patient may create medical emergencies rather than solve them.
The following
conclusions overdoses
is a list of findings
from
our own
experience
and the literature that are contrary to points raised in the two papers referred to above. 1 . The use of ipecac rather than gastric lavage may stimulate seizures and result in the aspiration ofgastric contents. 2. Treatment of tricyclic overdose patients with adrenal corticosteroids is contraindicated, since these drugs have been reported to inhibit tricyclic metabolism in animals (2) and have inhibited tricyclic metabolism in 1 patient in our series who had a concurrent neurological illness. 3. Overhydration of the patient is to be avoided because
the
direct
pressants
myocardial makes
depressant
the
patient
ure (3). Antiarrhythmic
effect
prone
drugs
must
of tricyclic
to congestive
be used
with
antideheart
fail-
caution
be-
cause many of them are cardiac depressants. 4. The casual use of physostigmine to arouse a tricyclic overdose patient (even if the patient has not been further overdosed with hypnotics) is certainly not diagnostic of a tncyclic overdose and is seldom of any sustained clinical value in patients with severe tnicyclic overdoses that have been documented by plasma measurements. That the patient descnbed by Dns. Holinger and Klawans remained in the intensive care unit for 10 days prior to extubation indicated physostigmine did not produce an immediate recovery. The clinician must also be aware that physostigmine can be lethal
if the patient
has
a junctional
rhythmia. 5. Major tricyclic absence of emergency es in our series have
100 or more ingestion
We agree
M.D. PH.D.
plasma
and justify antidepressant
report of the would provide of such dramat-
the need for such drastic clinical documentation of the severity
to correlate
reports)
dose cyclic
drug HARVEY
found
EDITOR
or idioventricular
cardiac
drug ingestions can be diagnosed room tnicyclic plasma assays; had QRS durations on routine
milliseconds
within
the first
24 hours
ar-
in the all casECGs of
after
the
(4).
that the use of 74 mg of physostigmine
in one
patient in a 6-hour period and 193 mg in another who remained in coma for several days is worth reporting; however, we question whether either report will decrease medical complications after tricyclic antidepressant overdose.
Calif
Patient REFERENCES
SIR:
We
read
‘ ‘
Reversal
of Tricyclic-Overdosage-Induced
Central Anticholinergic Syndrome by Physostigmine’ by Paul C. Holinger, M.D., and Harold L. Klawans, M.D., and ‘
“Treatment
noz,
M.D.
of Tricyclic
(September
Intoxication”
1976 issue)
by
with
Rodrigo
initial
A.
interest
Mu-
and
subsequent dismay. The findings in the single case presented in each paper are so different from our own that we think they deserve comment in order to keep management of the
1. Petit JM, Spiker DO, Ruwitch JF, et al: Tricyclic antidepressant plasma levels and adverse effects in 40 overdose cases. Clin Pharmacol Ther (in press) 2. Von Bahr C, Sjoqvist F, Orrenius 5: The inhibitory effect of hydrocortisone and testosterone on plasma disappearance of nortriptyline in the dog and profused rat liver. Eur J Pharmacol 9:106-110, 1970 3. Laddu AR, Lomani P: Desipramine toxicity and its treatment.
Am J Psychiatry
134:4,
April
1977
461
LETTERS
TO THE
Toxicol
EDITOR
Appl Pharmacol
4. Spiker
DG,
Weiss
AN,
overdose:
clinical
col Ther
18:539-546,
15:287-294, Chang
1969
2. Kline
55, et al: Tricyclic
presentation
and plasma
antidepressant
levels.
Clin Pharma-
T. BIGG5,
JOHN
A.
M.D.
E.
VINCENT
4.
M.D.
RIESENBERG,
M.D.
ZIEGLER,
St.
Louis,
5.
Mo.
6.
Dr.
Munoz SIR:
Dr.
carefully its
and
Biggs
or they
content,
Holinger
Drs.
and
purpose,
and
proposals
cyclic
any that
outlined
by
of the
‘
My paper
1 1 supportive
for emergency
and
treatment
antidepressants.
Dr.
Biggs
criticizing
short
it as
paragraph
and
associates
offers
three
criticisms
with do not
trioffer
they indicate has been useful
that merit
consideration.
First, without reference or clinical data, the authors reject the induction ofemesis with ipecac because they are worried about seizures and aspiration. They advocate exclusive use
of stomach lavage, tory complications state of knowledge reference
alert
which is also known to produce respiraand to trigger seizures (1). The present does not favor a dogmatic attitude (e.g.,
2). Induction
patient
of vomiting
who has just
patient who is becoming stomach lavage, which tubation.
Second, sostigmine,’
taken
which
to be ideal
an overdose,
for the
whereas
the
progressively obtunded may require is safer if preceded by tracheal in-
the letter complains ‘
seems
no one
about has
‘
‘the casual
advocated.
use of phy-
As stated
in step
1 1 of my schedule, physostigmine is used for cardiovascular and central nervous system effects ofanticholinergic medication. Until Dr. Biggs and associates produce evidence to refute the findings of those who have advocated these selective ofphysostigmine (3-6), their position appears uncritical and prejudicial. If they are withholding this effective treatment for the specific manifestations outlined in my paper, they should clarify their medical, legal, and logical justifications. Third, the letter decries the use of physostigmine as a diagnostic tool, something I have not suggested. On the other hand, in order to prevent readers of their letter from thinking that the clinician should wait for blood level studies before treating the patient for tricyclic overdose, I should mention that the evidence on the value of blood levels in tricyclic intoxication, even that provided by the St. Louis group (7), is still equivocal; most hospitals do not have the technique available, and many patients have been successfully treated uses
on the basis of clinical observations. learned (at the same center where have their laboratory) that chances tory tion.
measurement
can
ever
replace
careful
clinical
RH:
ment,
7th ed. Los
Handbook
Altos,
Lange
Diagnosis
Medical
1971
462
Am J Psychiatry
134:4,
April
1977
and
Treat-
NJ.
A.
M.D.
MUNOZ,
Wis.
SIR: The purpose of our paper was to draw attention to the central anticholingeric syndrome caused by phenothiazines and antiparkinson medication in addition to tricyclic antidepressants, with a focus on two manifestations of the syndrome, coma and movement abnormalities (myoclonus and choreoathetosis), and their reversal by physostigmine. The clinical efficacy and theoretical implications of reversal of
the central been
well
anticholinergic
syndrome
documented
in the
by physostigmine
anesthesia
have
general medical literature as well as in psychiatric journals (1-6). This documentation has included several hundred patients in investigations ranging from controlled double-blind studies to reports
and
on consecutive cases. Dr. Biggs and associates’ letter is also directed Munoz’ article, which may confuse the issues. like
to distinguish
Munoz.
our
In particular,
purpose
and
findings
we reiterate
of diazepam, barbiturates, tion for seizure-like activity scribed as myoclonic jerks
toward Dr. We would
from
our caution
those
about
of Dr.
the use
or other anticonvulsive medicathat may be more accurately deand choreoathetosis.
REFERENCES 1. Greene LT: Physostigmine treatment ofanticholinergic drug depression in postoperative patients. Anesth Analg (Cleve) 50:222-226, 1971 2. Duvoisin RC, Katz R: Reversal of central anticholinergic syndrome in man by physostigmine. JAMA 206:1963-1965, 1968 3. El-Yousef M, Janowsky DS, Davis JM, et al: Reversal of antiparkinsonian drug toxicity by physostigmine: a controlled study. Am J Psychiatry 130:141-145, 1973 4. Burks JS, Walker JE, Rumack BH, et al: Tricyclic antidepressant poisoning: reversal of coma, choreoathetosis, and myoclonus by physostigmine. JAMA 230: 1405-1407, 1974 5. Bernards W: Case history number 74: reversal of phenothiazineinduced coma with physostigmine. Anesth Analg (Cleve) 52:938-941, 1973 6. Snyder BD: Physostigmine and anticholinergic poisoning.
JAMA
233:1165-1166,
1975 PAUL
C.
M.D.
HOLINGER,
L. KLAWANS,
HAROLD
observa-
Publications,
Drugs:
Oradell,
Sheboygan,
M.D. Ill.
Chicago, Criteria
of Poisoning:
Calif.
A:Psychotropic
of Overdose.
RODRIGO
I am glad to note that I Dr. Biggs and associates are slim that any labora-
REFERENCES
I. Dreisbach
Chamberlain
Management
“a
experience.
The letter
SF,
de-
symptom-specific
of intoxication
criticism of 9 of the measures, although the first (establishing proper ventilation)
in their
7.
and associates either did not read my paper drastically misunderstood it. They ignored
case presentation’ on the basis voted to 1 of 15 cases discussed. measures
Reply
Klawans
Alexander
for Emergency
Medical Economics Co. 1974 Burks iS, Walker JE, Rumack BH, et al: Tricyclic antidepressant poisoning: reversal of coma, choreoathetosis, and myoclonus by physostigmine. JAMA 230: 1405-1407, 1974 Duvoisin RC, Katz R: Reversal of central anticholinergic syndrome in man by physostigmine. JAMA 206:1963-1965, 1968 Snyder BD, Blonde L, McWhirter WR: Reversal of amitriptyline intoxication by physostigmine. JAMA 230:1433-1434, 1974 Granacher RP, Baldessarini RJ: Physostigmine. Arch Gen Psychiatry 32:375-380, 1975 Spiker DG, Weiss AN, Chang 55, et al: Tricyclic antidepressant overdose: clinical presentation and plasma levels. Clin Pharmacol 18:539-546, 1975
3.
1975
ROBERT
NS,
Manual
SIR:
for
the
I heartily
tonia: Prediction Richard Abrams,
of Catatonia
Diagnosis concur
with
of Response M.D. and ,
the
thesis
presented
in “Cata-
to Somatic Treatments’ Michael Alan Taylor,
‘
by
M.D.
