LETTERS

TO

THE

Am

EDITOR

The patient was hospitalized after opment of hyperactivity, religiosity,

the progressive

paranoia,

devel-

rifying fear that others were trying to embarrass and harm her. On admission, she appeared mildly depressed but claimed to be ‘high.’ Her speech was very circumstantial and nonstop but not pressured. Her thoughts were marked

ment elect

by paranoid

precious

‘

examination.

were

On

loose,

without

hallucinations.

and exhibited the

no deficits

She

was

on formal

alert,

cent

she

was

memory

cognitive

found

deficits

testing.

to be disoriented,

and

Her

noticeable

paranoia

with

marked

impairment

was

Our patient

is similar

in many

schizo-affective

ed by Drs. tial

disorder,

West

hypomanic

and paranoia. the observation chotic

to those

as did

four

of the

and Meltzer.

Furthermore, was

Thus, that and

anxiety

by

case lends states with

may

to lithium

cases

confirmation prominent

to psy-

with

‘ ‘

cal training, vant to this

which

can

12 years

from

come studies of therapy administered analysts. How is it that graduate

1482

is also

the issue

and thousands a patient fails

when

of to

There

is a medical

analysis

it seems

that

dictum

that therapy

which

be discontinued and another mode However, in the case of psychoan

assessment

of progress

and

out-

come can take years and thus may not identify patients are not obtaining optimum results from therapy.

Many thanks to Dr. Gedo for an interesting ten article and for his candor in evaluating sharing

that

evaluation

with

who

and well-writhis career and

his colleagues.

G. SOLOMON,

JONATHAN

M.D.

Hampton,

Va.

Dr. Gedo Replies

clear

atric training or that those who used my services did not get their money’s worth. In either case, I can assure him that everyone involved has been satisfied with the arrangements.

seems

arduous,

the

in living Is this

in order

unwise. and

analysts attitude

costly,

to treat

Is medirele-

may obtain toward psy-

consideration

in out-

by such inexperienced analysts who have com-

results?

There

years

N.C.

Hill,

pleted a lengthy training program are inadequately prepared to practice their profession? Or does the author mean that more experienced therapists tend to obtain better therapeutic

reim-

M.D.

in training

of 20 years

arise

for

ineligible

W. GARNER,

‘

is so lengthy,

then

spend happens

whether

he means

that

I was foolish

I have based my psychoanalytic and medical roots, but I certainly

kind of elitism? Dr. Gedo stated that inexperienced unsatisfactory results, and a negative choanalysis

their

have than

SIR: Dr. Solomon implies that the professional described in my report were not ‘ ‘cost effective.

with characterologic problems or problems rather than medical patients with medical disorders. spend

What

proves ineffective should of therapy administered.

In Psychoanalysis

a period

it seems

with

who rather

M.D.

uals

To

patients

treatment.

appropriate?

‘ ‘

over

case

of people and coping

benefit, especially when the analyst later determinesthrough his own growing ability as a maturing, experienced therapist-that his efforts were unwisely spent, his patient selection was poor, or his treatment techniques were in-

an in-

SIR: A Psychoanalyst Reports at Mid-Career” by John E. Gedo, M.D. (May 1979 issue) raised several issues. Dr. Gedo said he has treated a total of 36 people during his 20year career. The term people’ suggests he treats individ-

36 patients

then

Dr. Gedo’s for

mifear

Chapel

cost-effective?

se,

is the

EVANS,

L.

BENNET

Ratio

this

have

is on psy-

neurotoxicity. DWIGHT

The Cost-Benefit

that

individuals

the onus

report-

terrifying

be associated

per

such

I think

training.

dollars

by

our patient’s

marked

our patient’s acute manic

vulnerability

five

but

diseases.

surgery or reamounts of

‘

Finally,

car-

reported

therapy

medical

acute organic brain syndrome lithium carbonate therapy and discontinuation is suggestive therapeutic serum lithium 1evfalls within the broad range of

presentation

symptoms

creased

ways

professionals

,

bonate was discontinued and trifluoperazine, 10 mg h.s., was started. Her sensorium cleared within 36 hours. Formal neuropsychological testing done 48 hours after the lithium was discontinued was within normal limits. An EEG the following week was also normal. Drs. West and Meltzer. An developing after initiation of resolving rapidly after lithium of lithium neurotoxicity (at els). We believe our patient

resources,

demonstrate

‘

re-

Lithium

among

1979

bursement under any medical insurance program. Perhaps such ‘reeducation’ should be administered by lay therapists, e.g. educators, social workers, and others without

on formal

unchanged.

to

medical

,

time,

care

medical

patients. If analysis is a reeducation faulty patterns in living, relating,

mood was expansive and elated, and her motor activity increased. She was started on lithium carbonate, 300 mg q.i.d., and had a serum lithium level of 1.2 mEq/liter 3 days later. She was still quite paranoid, although her expansiveness and moton activity had decreased significantly. Her lithium carbonate dosage was decreased to 300 mg t.i.d. and a serum lithium level 2 days later (hospital day 7) was 1. 1 mEq/liter. At this

health

choanalysts

second hospital day, her associations grandiose and more paranoid. Her

and she was

the consensus

November

that patients who require cardiac require similarly disproportionate

life-threatening

cognitive

/36:/i,

should not be included in medical reimbursebecause a tiny percentage of patients can a disproportionate amount of resources. One

programs to utilize

could assert nal dialysis

‘

delusions

fully oriented,

I think

psychoanalysis. is that analysis

and the ter-

J Psychiatry

of third-party

reimbursement

for

,

activities ‘ ‘

to invest

I

It is un-

in psychi-

development on scientific believe that it is possible to

become an effective psychoanalyst without that specific background. Unfortunately, the work is so complex and demanding that most people who attempt it fail to achieve mastery. Dr. Solomon’s suggestion that we should abandon the field to educators and social workers therefore strikes me as wrong-headed. We need to raise our standards of admission, not lower them. Whether one chooses to regard psychoanalysis as a branch of medicine or not may well be a matter of taste, but as a physician aims of our

agreement.

I cannot profession

Medicine

of the effort behavior

to study

by means

allow Dr. Solomon’s version to pass without registering

is not only

nature.

a healing

My decision

of the psychoanalytic

art,

of the my dis-

it is also

to study instrument

part

human aligns

me with physicians pects of medicine. averting

death;

primarily interested in the scientific asThe physician does not confine himseff to his therapeutic responsibilities include the al-

leviation of suffering. My concentration on problems that seldom threaten life directly does not distinguish me from most of my medical colleagues. Dr. Solomon’s implication

Am

J Psychiatry

136:/i,

November

that I am less sensitive effectiveness

Medicine

than

than

is (or should

patients (dare have broader professionals

LETTERS

to the limitations

a physician

with cure.

1979

should

be) more

The results

of my therapeutic

be is simply

concerned

with

of my efforts

I claim that cherished status for them?) effects, especially in the case of mental or of parents.

in intellectual

who

should

In that

decisions profession

receive

may

how

much

of the

well

pie. M.D.

Chicago,

and

Breast

SIR: We read

be

I think

E. GEDO,

Ill.

Feeding

with great

interest

and Desipramine in Human M.D., and Paul J. Orsulak,

‘ ‘

Breast Ph.D.

Excretion

of imipramine and amitriptyline that in breast milk, it seems unwarranted

categorically

discontinue

that a nursing

breast

woman

taking

STEVE GARY

Milk” by Robert Sovner, (April 1979 issue). Their

therapy.” Sovner

drug

Drs.

and Orsulak

if they

require

reported

that

Drs.

antidepressant

the concentrations

of imipramine and desipramine found in breast milk approximate those found in plasma. Their patient did not achieve a therapeutic ifwe assume

level

of imipramine

a therapeutic

plus

serum

desipramine.

level

However,

of200

ng/ml,

Orsulak

and

of 200 ng/ml, and a 5-kg infant who consumes about 1 ,000 ml of breast milk a day, the infant would ingest about 0.2 mg of imipramine plus desipramine. This represents only .04 mg/kg. Although no dosing recommendation is available for infants, the initial dose ofimipramine for enuresis in a six-year-old child is 25 mg/day, or approximately 1 mg/kg (1). Unfortunately, els

the

in the infant’s of amitriptyline

month-old

nursing

of amitriptyline tions

were

triptyline

authors

serum.

did

not

measure

We recently

and

nortriptyline

infant.

After

the

per day for 3 weeks,

serum

assay

1evher

for

(2).

The

breast

nor-

could be found milk

specwas

not

as-

sayed.

A given low serum apparent in adults

liter/kg plasma

dose of imipramine or amitriptyline yields concentrations compared with most drugs. volume

of distribution

is very

large-850

liters

for amitriptyline protein binding

it is conjectured larger in infants than (5),

the tricyclics

undergo

oral administration, available for systemic

for tricyclic for

(3) and

extensive only

distribution

first pass about

33

infants have decreased extravascular volume

that volumes of distribution are in adults. It should also be noted

and

very The

antidepressants

imipramine

(4). Because and increased

45%

metabolism of an oral

Reply

Sovner

psychoactive

ingested

is

(3).

Given the desirability of breast feeding for the infant and for the mother with depression and the extremely low con-

such

will

or behavioral

maturation,

echolamine

concentrations

at one

At the such

present

factors

time,

as the

we have

neonate’s

as a tricyclic

accumulate

neurologic

and

perhaps or more

antidepressubtly

CNS

cat-

sites.

no information

maturity

affect

by altering concerning

of drug

metabolizing

enzymes, gastrointestinal permeability, and CNS sensitivity to tricyclic antidepressants. Consequently, we do not feel that the comparison between drug dosage in an adult or a sixyear-old child and in a newborn infant is valid. The case cxample reported by Levy and Wisniewski (1), in which a newborn infant whose mother had ingested chlorpromazine throughout her pregnancy manifested a parkinsonian syndrome at birth that persisted for 6 months, suggests that the nervous

system

reacts

very

differently

to chronic

exposure to psychoactive compounds. Based on these considerations, we still feel it recommend, as did Ananth (2) in his recent women taking tricyclic antidepressants refrain feeding until some evidence is presented that

not adversely

affected

by chronic

exposure

ratio

and the pediatrician in each

case

before

should making

is prudent review,

to that

from breast neonates are

to low doses

tricyclic antidepressants. However, because logical and psychological benefits of breast desirability of breast feeding for the mother

benefit

after

agent

chronically,

the psychiatrist

even that

dose

sant,

immature

amount

by the gas chromatography/mass

employed

2-

150 mg

concentra-

and 146 ng/ml No detectable

of drug (less than 28 ng/ml of total tricyclics) trometry

and

had taken

her serum

of

serum

in a mother

the mother

90 ng/ml for amitriptyline (236 ng/ml total tricyclics).

in the infant’s

amount

measured

Wash.

SIR: Dr. Erickson and associates state that women receiving tricyclic antidepressant therapy should be allowed to breast feed because the infant is likely to ingest negligible amounts ofthe drug. The unresolved issue, which Dr. Erickson and associates do not discuss, is whether very low doses

of a potent

a breast

milk concentration

drug

drugs

H. ERICKSON, R.Pu. H. SMITH, PHARM.D. FRED HEIDRICH, M.D.

Seattle,

‘ ‘

feeding

these

1. Shirkey HC: Pediatric Drug Handbook. Philadelphia, WB Saunders Co. 1977 2. Wilson JN, Williamson U, Raisys VA: Simultaneous measurement of secondary and tertiary tricyclic antidepressants by GC/ MS chemical factors ionization mass fragmentozyphy. Clin Chem 23:1012-1017, 1977 3. Gram LF: Factors influencing the metabolism of tricyclic antidepressants. Dan Med Bull 24:81-89, 1977 4. Ziegler VE, Briggs JT, Ardekani AB, et al: Contribution to the pharmacokinetics of amitriptyline. J Clin Pharmacol 18:462467, 1978 5. Morselli PC: Clinical pharmacokinetics in neonates. Clin Phar. macokinetics 1:81-98, 1976

of Imipramine

are important because of the prevalence of postpartum depression and the need to use tricyclic antidepressants in some cases. We disagree, however, with their conclusion that it would be prudent to advise nursing women

breast

are likely to to recom-

feeding.

findings

to discontinue

EDITOR

REFERENCES

arrangements

regard,

THE

should health

actually

He may

JOHN

Tricycics

of

it would be to the consumer: we can only damthrough unseemly quarrels about

issues.

wisest to leave age the medical

mend

prevention

with a handful

I am afraid these obvious considerations miss the point of Dr. Solomon’s argument. more interested in financial-administrative than

centrations be present

impudent.

TO

of

of the physiofeeding and the with depression,

weigh

the risk-

a decision.

REFERENCES 1. Levy W, Wisniewski K: Chiorpromazine causing pyramidal dysfunction in newborn infant of psychotic NY State J Med 74:684-685, 1974

extramother.

1483