H&CP Hospital and Community Eating [)isorders: The Changing Population of Bulimia Patients A Journal of the PatientsвЂ™ Psychiatry Accounts of Stress and Coping in Schizophrenia American November 1989 Reports on APAвЂ™s 1989 Achievement Award Winners Psychiatric Association HALDOL ?.. DECANOATE #{149}#{149} tr Su tirвЂќ ul L ) th schzophreriic Ui Siflge 1T)Ofltfly it p13ter1t Th. following is a brief summary only. B&ors prescribing, se comp#{234}t pr..cribEng information in HALDOLand HALDOL Dscanoats PrOdUCtI.b&Ing. Contrainthcatlons: S1nce the phamiacoogic and cliniC& actions of HALDOL (hafoperidol) Decanoate are attributed to IIALDOL as the active mediCatiOn. COntraindiCatiOnS, Warnings, and addfhon& iformation are those of HALDOL. Some secons have been modified to reflect the prolongedaction of HALDOL Decanoate HALDOL is contraindicated m severe toxic centraf nervous system depression comatose states from any cause and m dividuafs who are hypersensitive to tPis drug have Parkuisons disease. Warninga Tardwe Dysafnesia rdtve dyskinesia, a syndrome consisting of POtentially wreversla Wwofuntary dyskinetic movements may deve#{234}op in patients treated with anbpsychotic drugs. Although the prevalenos of the syndrome appears to be highest among the elderly. especially ederty women. ft is imposafble to rely upon prevalence estimates to pedt. at the inception of antipsychotictreatment, which patients are Iikelytodevefopthesyndrome. Whether antipsychotic drug products differ in their potential to cause tardive dyskineSta is unknown. Both the risk of developing tardive dyskinesia and the likelihood that it will become wreversible are believed to crease as the duraon of treatment and the total cumulative dose of antipsychotic drugs adtThnistered to the patient ilicrease. However, the syndrome can devafop, although much tess commonly, after relathiely brief treatment peflods at low doses. There is no known treatment for establishedcasesoftardivedyskinesia. atthoughthe syndromemayremit, partiallyorcompletely, if anpsychotictreatment is wlthdrawrt AntipsychOtiCtreatment, itself, however, may suppress(or partially suppress)the signs and symptoms of the syndrome and thereby may possibfy mask the underlying procass. The effect that symptomatic suppression has upon the long-term course of the syndrome is unknown. Given these considerations, anpsychotic drugs should be prescribed k a manner that is most likely to minimize the occurrence of tardive dyskrneSia. Chronic anbpsychndctreatment ShOtidgenerally be reserved forpatlents WhOSUfIerfrOm achronicillness that 1) is known to respond to antipsychotic drugs. and 2) for whom aftemave, equally effecve, but potentially tess harmful treatments are not avadableor appropriate In patients whodo require chronic treatment, the smallest dose and the shortest duration of treatment producing a satisfactory cliniCaf response shouвЂ™d be sought. The need for conlinued treatment shou$d be reassessed periodically If signs and symptoms of tardive dyskinesia appear in a patient on arThpsychollcs drug discondnuation should be considered. However, some patients may require treatment despite the presence of the syndrome.(Forfurther mfOrTnaOn about the description of tardedysfoneafaand s cnicaf detectior please referto ADVERSE REPCT1ONS) Puro#tic M&igIeAt Syndroma (NMS) A potentially fataf symptom compfex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with antipsychotic drugs clinicaf manifestations of NMS are hyperpyrexia. muscfe hgidit altered mental status Qnctudkg catatonic signs) and evidence of autonomic wretability(Wregular pulse or blood pressure, tachycardsa diaphoresi and cardiac dysrhythmias). Additional signs may itdude elevated creatine phosphokinase. myoglobnuna(rhabdomyolysis)and acute renal fallure Thediagnosticevaluation ofpatients with tts syndrome is compficate In arriving atadiagnosis, it is important to entify cases where the dWiical presentation includes both serious medical flness(e, pneumonia, systemic infection, etc)and untreated or inadequately treated extrapyramidal signs and symptoms (EPS Other important considerations in the differentet diagnosis inctudecentral anticholinergic toxicity, heat stroke, drUgfeverand primary centralnervoussystem (NS) pathology. The management of NMS should idude 1) immediate discontinuation of antipsychotic drugs and otherdrugs notessentiaf toconcurrenttherapy, 2)intensive symptomatic treatment and medical monitoring, and 3)treatment of anyconcomitant serious medical problems for which specific treatments are available. There is no general agreement about specific pharmacological treatment regimens for uncomplicated NMS. If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. The patient should be carefully monitored, since recurrences of NMS have been reported. Hyperpyrexia and heat stroke, not associated with the above symptom complex, have also been reported with HALDOL. Usage at Pregnancy: (see PRECAUTIONS Usage in Pregnancy) Combined Use With Lithium: (see PRECAUTiONS Drug lnteracIions General: Bronchopneumonia, sometimes fata has followed use of antipsychotic drugs, including haloperidot Prompt remedial therapy should be instituted if dehydration, hemoconcentration or reduced pulmonary ventilation occur, especially in the elderly. Decreased serum cholesterol and/or cutaneous and ocular changes have been reported with chemically-related drugs, although not with haloperidol. SePRECAUTIONS lnforrnationforPatients formnformation on mental and/orphysicalabilitles and on concomitant usewith other substances Precautions: Administer cautiously to patiente (1) with severe cardiovascular disorders due to the possibility of transient hypotension and/or precipitation of anginal pain (if a vasopressor is required, epinephrine should not be used since HALDOL may block its vasopressor activity and paradoxical further lowering of blood pressure may occur; metaraminol, phenylephrine or norepinephnne should be used (2) receiving anticonvulsant medication with a history of seizures, or with EEG abnormalities, because 1-IALDOL. may lower the convulsive threshold. If indicated, adequate antbconvulsant therapy should be concomitantly maintained; (3) with known allergies or a history of allergic reactions to drugs (4) receiving anticoaguIant since an siolated instance of interference occurred with the effects of one anticoagulant (phenmndione Concomitent antiparkinson medication, if required, may have to be continued after HALDOL is discontinued because of different excretion rates; if both are discontinued simultaneously, extrapyramidal symptoms may occur. Intraocular pressure may increase when antichotnergic drugs, induding antiparkmnson drugs are administered concomitantly with HALDOL. When HALDOL is used for mania in bipolar disorders, there may baa rapid mood swing to depression. Severe neurotoxicity my occur in patients with thyrotoxicosis receiving antipsychoticmedicatior induding HALDOL. The 1, 5, 10 mg HALDOL tablets contain FD&C вЂ�hallow No. 5 (tartrazine) which may cause - - - allergic-type reactions(mduding bronchial asthma)in certain susceptible individuals, especiallyin thosewhohaveaspinn hypersensitivity. Information lbrPataints: Mental and/or physical abilities required for hazardous tasks or driving may be itnpaire Alcohol should beavoidedduetopossibleadditiveeffects and hypotension. Drug lnteraction& Patients receiving lithium plus haloperidol should be monitored dosely for early evidence of neurological toxicity and treatment discontinued promptly if such signs appear. As with other antipsychotic agents it should be noted that HALDOL may be capable of potentiatingONSdepressants such as anesthetics opiates, and alcohoL CarcinogenesI Mutagenesis andlmpairment olFertility: No mutagenic potential of haloperidol decanoatewasfound in theAmes Salmonella microsomal activation assay. Carcmnogenicity studies using oral haloperidol were COnduCted in Wistar rats (dosed at up to 5 mkg daily for 24 months)and in AJbmnoSwiss mice (dosed at up to 5 mqjkg daily for 18 months). lntheratstudysurvivalwaslessthanoptimal inaIIdosegroup reducingthenumbero( ratsatrisk fordevelopin9tumors. However, althougharelatlvelygreaternumberofratssurvlvedtotheendof the study in high dose male and female groups, these animals did nothave agreater incidenceof tumors than control animals. Therefore, although not optimal, this study does suggest the absence of a haloperidol related increase in the incidence of neoplasia in rats at doses up to 20 timestheusualdaily human doseforchronicorresistant patients. In femalemiceat5and20tlmes the highest initial daily dose for chronic or resistant patient there was a Statistically significant increase in mammary gland neoplasia and total tumor incidence; at 20 times the same daily dose there was a statistically significant increase in pituitary gland neoplasia. In male mice, no statistically significant differences in incidences of total tumors or specific tumor types were noted Antipsychotic drugs elevate prolactin leveI the elevation persists during chronic administration. Tissue culture experiments indicate that approximately one-third of human breast cancers are prolactin dependentin littr4 afactorof potential importanceifthe presaiptionofthesedrugsis contemplated in a patient with a previously detected breast cancer. Although disturbances such as galactorrhea, amenorrhea, gynecomastia, and impotence have been reported, the dinicaf significance of elevated serum prolactin levels is unknown for most patients. An increase in mammary neoplasms has been found in rodents after chronic administration of antipsychotic drugs. Neitherdinical studies norepidemiologicstudiesconductedtodate, however, haveshown an association between chronic administratiOn of these drugs and mammary tumorigenesis the availableevidenceisconsideredtoolimited tobecondusiveatthistime. Usage in Pregnancy: Pregnancy Category C. Sate use in pregnancy or in women likely to become pregnant has not been established, useonly if benefitclearlyjustifles potential hazardsto the fetus. MirsingMother Infants should not benursedduring drug treatment. Pediatric Usa Controlled trials to establish the safety and effectiveness of intramuscular administration in children have not been COnduCted Adv.rsi Reactions: Adverse reactions following the administratiOn of HALDOL (haloperidol) Decanoate are those of HALDOL. Since vast experience has accumulated with HALDOL,, the adverse reactions are reported for that compound as well as for HALDOL Decanoate. As with all injectablemedications, local tissuereactions havebeen reportedwith HALDOL. Decanoate. cNS fects Extrapparnkia! Reactions-Neuromuscular (extrapyramidal) reactions have been reported frequently, often during the first few days of treatment Generally they involved Parkinson-like symptoms which when first observed were usually mild to moderately severe and usually reversible. Other types of neuromuscular reactions (motor restlessness, dystonia, akathisia, hyperreflexia opisthotonos, oculogyric crises) have been reported far less frequently, but were often more severe. Severe extrapyramidai reactions have been reported at relatively low doses. Generally, extrapyramidal symptoms are dose-related since they occur at relatively high doses anddisappear or become less severe when thedOseis reduced. AntiparkirisOn drugs may berequired. Persistent extrapyramidal reactions have been reported and the drug may have to be discontinued in such cases. WtIidraWaIEmergent Neurological Sqis-Abrupt discontinuation of short-term antipsychotic therapyisgenerallyuneventful. However, some patientsonmamntenance treatment experience transient dysldnetlC signs after abrupt withdrawal In certain cases these are indistlngulshablefrom iardiveDysklnesiaвЂќ exceptforduration. It isunknownwhethergradual withdrawal will reduce the occurrence of these sign but until further evidence is available HALDOL should be gradually withdrawrt Tardtve Dysklflesia-As with all antipsyChOtiC agents HALDOL has been associated with persistent dyskinesia l#{228}rdivedyskinesia, a syndrome consisting of potentially wreversibI involuntary, dyskinetic movement may appear in some patients on long-term therapy or may occur after drug therapy has been discontinued. The risk appears to be greater in elderly patientson high-dose therapy, especially femalet The symptoms are persistent and in some patients appear Wreversibl The syndrome ia characterized by rhythmical involuntary movements of tongi* fa mouth or jaw (ag., protrusion of tongi* putting of cheeks, puckering of mouth, chewing movements). Sometimes these may be accompanied by involuntary movements of extremities and the trunk. There is no known effective treatment for tardlve dyskinesl antiparkinson agents usually do not alleviate the symptoms of this syndrome It is suggested that all antipsychotic agents be discontinued if these symptoms appear. Should it be necessary to reinstitute treatment, or increase the dosage of the agent, or switch toadifferent antipsychotic agent, this syndrome may bemasked. It has been reported that fine vermicular movement of the tongue may be an early sign of tardive dyskinesia and if the medication is stopped at that time the full syndrome may not deveIo Tardive DyStOnIa-4tbrdiVe dystonla, not associated with the above syndrome, has also been reported l#{228}rdive dystonia is characterized bydelayedonsetofchoreicordystonicmovements, isoften persistent, and hasthe potential ofbecoming irreversibla Other NS Effects-Insomnia, restIessnes anxiety, euphoria, agitation, drowsiness depression, lethargy, headach confusior vertiga grandmalSeLzUreS, and exacerbationofpsythoticsymptomstbiduding hallucinations, andcatatono-hkebehavioral states which mayberesponsive todrug withdrawal and/ortreatmentwithantichoIinergicdrug Body as a Wh Neuroleptic malignant syndrome (NMS hyperpyrexia and heat stroke have been reported with HALDOL. (See WARNINGS for further information concerning NMS)CardiovascularElfects l#{228}chycartha,hypotension, hypertension and ECG changes. Hei7tOibgicEffeCtS Reportsof mild, usuallytransientleukopenlaandleukocytosis, minimaldecreasesin redbIOOdCeII counts anemia, or a tendency toward tymphomonocytosis; a9ranulocytosis rarely reported and only in association with other medication. Liver fects Impaired liver function anti/or jaundice. Dermaibkiglc Reeotlore Maculopapular and acneiform reactions lsolated cases of photosensitivity, loss of hair. Endocrine Deorcfers Lactation, breast engorgement, mastalgia, menstrual irregularities, gynecomastia, impotence, increased libido, hyperglycemia, hypoglycemia and hyponatremia. GastrolntestlnalElfect&Anorexia,constipation,dlarthea, hypersaliVatiOn,dyspepwe, nausea and vomiting. Aubnomic Reactbns Dry moutt blurred visior urinary retention, diaphoresis, and priapism. Respkafory 8fects Laryngospasm, bronchospasm and increased depthof reapiratiort Speda!Senses Cataracts retinopathy andVISU&dIStUrbanCe Other: Cases of sudden and unexpected death have been reported in association with the administration of HALDOL Thenatureo(theevidenoemakes itimpossibletodeterrninedeflnitively whatrole, if any, HALDOL played in the outcomeof thereportedcases. The possibititythat HALDOLcaused death cannot, of cours beexduded, but it is tobekeptin mindthat sudden end unexpecteddeath may occur in psychotic patients when they go untreated or when they are treated with other antipsychotlcdrugt IMPOR1PJ4T: Full dlrectlonsforuseshouldb.r.adb.for.HALDOLorHALDOLDcanoa.js admlnlstersd orprescrlbed. For Information on symptoms and treatment of ov.rdosag., see full prescribing Informsdon The short-acting HALDOL injectable form is intended only for acutely agitated psychotic patients with moderately severetovery severesymptoms. 7 2088 1% MCNEIL PHARMACEUTICAL MCNEILAB INC SpnngHouse PA 19477 Sustained drug levels with a single monthly dose HALDOL DEANOATE (HALOPERIDOL) INJECTION Sustained _______ from protection relapse ________ Please see brief summary on next page. of Prescribing Information During dose adjustment or episodes of exacerbation of psychotic symptoms. HALDOL Decanoate therapy can be supplemented with short-acting forms of HALDOL (haloperidol) The side effects of HALDOL Decanoate are those of HALDOL.The prolonged action of HALDOL Decanoate should be considered in the management of side effects McNEIL PHARMACEUTICAL McNE1LAB NC SprngHousePA 9477 This calls With Asleep at the switch. for a switch in antidepressants. PAMELOR there is little Yet all the efficacy daytime sedation.16 of amitriptyline.7 1/F PAMELOR (nortriptyline HC1) The active metaboilte PAMEWR may impair the mental and/or physical abilities required for the performance of hazardous tasks, such as operating heavy machinery or driving a car; therefore, the patient should be warned accordingly. . References: I Thompson IL U, Thompson Wi.. Ileating depressIon tncvclics, tetracvclics. and other options. Modern Medicine August 1983:5187109 2. (;eorgota A Affectivedisorden pharmacotherap. In Kaplan HI. Sadock BJ, eds Cornprebensur Textbook of PsвЂ™cbsalr; IV Italtimore. Md WIlliams & Wilkins. 1985,1:821833. 3. ByeC, Clublev M, Peck 8W 1)rowsiness. mpairedper. lormance and tricvclic antidepressanidrugs llrJClEn Pbarmacol 1978.6 155 161 4. Kupler DJ. Spiker 15G. Rossi A. ColвЂ™le вЂ�A. Shaw 1, Illrich K. Nortriptline and KEG sleep in depressedpatients. BwlPsycbsatr 982.17 535546 5. Blackwell B, Peterson GR, Kuzma RJ, Ilosteiler RM. Adolph Alt The effect of five iricvclic antidepressanison salivary flowand mood in healih volunteers Cornrnurncalson.c in Psivbopbarmacol. 19110i:255-26l 6. hayes FE. Krisioff CA Adverse maclions to five new anlidepressanis C/rn Pbarrn 1986.5 471-480 7. Ziegler yE. Clavion I, Biggs JT A comparisoii siud of amiiriptvline and noriripivline with plasma levels Arch Ceo Psivhsalrs: May 1977:.ti607.b12. Contraindlcaiions: I) Concurrent use with a monoamine oxidase (MAO) inhibitor, since hyperpyretic crises. severe convulsions. and fatali. lies have occurred when similarlricyclic aolidepressantswere used in such combinations, MAO itihibilors should be discontinued for at least two weeks before treatment with Pamelor (nortriptyline HCI) is started 2) 1lpersensilivity to Pamelor (norlriptyline MCI) cross-sensitivity with other dibeiizazepines is a possibilits 3) The acute recovery period after myocardial infarction Warnings: Give only under close supervisioii to patients with cardiovascular disease, because of the tendency of the drug to produce sinus tachvcardia and to prolong conduction time. ms-ocardial infarction. arrhythmia. aiid strokes have occurred The atitihvpertensive action of guanelhidine and similar agents may be blocked. Itecause of its anlichohioergic activity; nortriptyline should be used with great caution in palieiitswho have glaucoma or a histor) of urinary reteiilion Patieotswith a history of seizures should be followed closely. sitice iiortriptIine is known to lower the convulsive threshold Great care is required in hyperthyroid palieiits or those receiving thyroid medication, since cardiac arrhythmias may develop Nortriptvliiie mas impair tie mental aiidinr phssical atuli- . (G 1989 Sandoz Pharmaceuticals Corporation of amitriptyline ties required for the performance of hazardous tasks. such as operating machinery or driving a car; therefore, the patient should be warned accordingly. Excessive consumption of alcohol may have a potentiating ctfed, which mas- lead to the danger of increased suicidal attempts or overdosage, especially in patientswith historiesof emotional disturbances or suicidal ideation. The concomitant administration of quinidine and nortriptyhine may result in a significantly longer plasma half-life, higher A.ti.C. and lower clearance of nortriptyline. Usein Pregnancy-Safe use duringpregtiancy andlactation has notbeen established. therefore, in pregnant patients, nursing mothers, or women ofchildbearing potetitial, the potential benefits must be weighed against the possible hazards (Ise in Children -Not recommended for use its children, since safety atid effectiveness in the pediatric age group have not been established. PrecautIons: Use in schizophrenic patients may result in an exacerba- lion of the psychosis or may activate latent schizophrenic symptoms; in nveractiveoragitatedpatients, increasedanxietv andagitation may occur; in manic-depressive patients, symptoms ofthe manic phase may emerge Administration ofreserpine during therapy with a tricychic antidepressant has been shown to produce a вЂ�stimulating effect in some depressed patients. Troublesome patient hostiliti- may be aroused. Epileptiform seizures may accompatly administration Close supervision and careful ad)ustment of dosage are required when used with other antichohinergic drugs and sympathomimetic drugs. Coticurrent administration of cimetidine can produce chitiically significant increases in the plasma concentralions ofthe tricvchic antidepressant. Patietits should be informed that the responseto alcohol may be exasserated. When essential, may be administered with electroconvulsive therapy, although the hazards may be in. creased t)iscontiiiue the drug for several days, ifpossible, prior to elective surgery The possibility of a suicidal attempt by a depressed patient re mains after the ititialion of treatment; in this regard, it is important that the least possiblequantits ofdrugbedispensed at any given lime Both dcnation and lowering of blood sugar levels have been reported. A case of significant hypoglycemia has beeii reported in a type II diabetic patient maintained oii chlorpropamide (250 mgiday), after the addition of nortriptyline (125 mWdav). Adverse Reactions: (.вЂ�ardioi-ascular-t-lypotension. hperteosion. tachycardia, palpitation, myocardial infarction, block, stroke. PsвЂ™cbialric-Confusional with hallucinations, disorientation, arrhythmias, heart stales (especially in the elderly) delusions; anxiety, restlessness, agitation, insomnia, panic, nightmares; hypomania; exacerbation of psychosis. Neurologic-Numhness, tingling, paresthesias of extremities; incoordination, ataxia, tremors, peripheral neuropathy; extrapyramidal symptoms, seizures, alteration in EEG patterns; tinnitus.Anlicbolinergic -E)ry mouth and, rarely, associated sublingual adenitis; blurred vision, disturbance of accommodation, mydriasis; constipation, paralytic leus; urinary retention, delayed micturition, dilation ofthe urinary tract.Allergic-Skin rash, petechiae, urticaria, itching, photosensitizatioti (avoid excessive exposure to sunlight): edema (general or offace and tongue), drug fever, cross-sensitivity with other tricychic drugs. HemalologicBone marrow depression, iticluditig agranulocylosis; eosinophihia; pur. pura; thrombocytopenia. Ga.sвЂ™lmmlestinal-Nausea and vomiting, anorexia, epigastric distress, diarrhea, peculiar taste, stomatitis, abdominal cramps, black-tongue. Endocriiw-Gynecomastia in the male, breast enlargement and galaclorrhea in the female; increased or decreased libido, impotence; testicular swellitig; elevation or depression ofblood sugar hendo; syndrome of inappropriate ADH (antidiuretic hormone) secretion. Other-Jaundice (simulalitig ohstructisвЂ™e(, altered liver function; weight gain or less; perspiration. flushing; urinary frequencs; nocturia; drowsi- hess, dizziness, weakness, fatigue; headache; parotid swelling; alopecia Wilhdrauejl SiвЂ™rn/itovns-Though these are not indicative of addiction, abrupt cessation oftreatmeot after prolonged therapy may produce nausea, headache, and malaise Overdosage: Toxic overdosage may result iii confusion, restlessness,ag itation, vomiting, hperpyrexia, muscle rigidits; hyperactive reflexes, tachscardia, ECG evidence of impaired conduction, shock, congestive heart failure, stupor. coma. atid CNS stimulation with consulsiotis (ohlowed by-respirators depressioti l)eaths have occurred with drugs of this antidote is known; general supportive measures are indicated, with gastric lavage (PAM-Z17-1/13/891 class. Nospecific SANDOZPHARMACEUTICALS Corporonon, #{163} Hanover, NJ 07936 i201 i 503-7500 PAM-289- 1 3R I had an important dream last night Therapist the Analysand premier was holding Fontainebleau Therapist The American interdisciplinary Orthopsychiatric Association organization Meeting in Miami, its Annual Hotel. in mental health Florida, at the -- Hmmm - TA It was spring, April 25-29, 1990. There were at least 150 educational events full-day institutes, workshops, panels, general sessions and poster groups. They covered over 80 subject areas, ranging from adolescence to womenвЂ™s issues. T Hmmm TA There were social events, too, so I got to network with lots of mental health professionals psychiatrists, psychologists, social workers, psychiatric nurses, counselors, educators, attorneys, and others. T Hmmm TA There was that ORTHO spirit of shared interdisciplinary learning and commitment to social issues. T Hmmm TA Best of all, I remembered that as an ORTHO member, I was entitled to free general registration by mail. That gave me free entry to general sessions and poster groups and reduced rates on those outstanding full-day institutes, workshops, and panels. Continuing Education Credits were available, too. What do you think it all means? It means you should sign up quickly. And by the way, where can Igeta preliminary program anda membership application? T - Contact: Dept. C ORTHO 19 West 44th Street Suite Whether American Heart Association The American Orthopsychiatric Association 1616 New York, NY 10036 1-212-354-5770 you a psychiatrist WEвЂ™RE FIGHTING FOR YOUR LIFE are seeking . . a new or opportunity an employer The professional recruitment Psychiatric Placement Service help meet your needs. The Psychiatric Placement trists and deals only with kind of specialized service We are experts efforts providing at a lower cost infbrrnation Placement anti Graeme 1400 a position staff of the American (PPS), Psychiatric serving clients currently available AssociationвЂ™s nationwide, can Service was developed by psychiatrists for psychiapsychiatric recruitment. As a result we give you the private search firms canвЂ™t match. in our profession, with continuous a comprehensive physician/employer than private physican search firms. The Psychiatric recruitment. For further with Service application Fergusson, is the firms APAвЂ™s marketing and recruitment database. Best of all, itвЂ™s answer to cost contact, Placement Coordinator Psychiatric Placement Service K Street N.W., Washington, D.C. (202) 682-6108 20005 effective The synapse-crossroads for serotonin ( IL /, ..-. .._._,., - .._) i..?; .:. - \ - - 2 . ./ / .- ./ In depression AC#{174} fluoxetine hydrochloride вЂњa potent Effectively serotonin reuptake inhibitor... represents a new class of antidepressantsвЂ™1 relieves depression* Unlike the tricyclics, Prozac specifically inhibits serotonin uptake. Its minimal action on other neurotransmitters may explain its favorable side-effect profile. Fewer side therapy effects Avoid using concomitantly to Prozac MAO inhibitors or in proximity Rash and/or urticaria occurred 4% of clinical trial patients A wide margin 20-mg once-a-day in of safety to disrupt Side effects are generally mild and manageable, and include nausea, anxiety/nervousness, insomnia, and drowsiness therapy PROZAC... A specifically different antidepressant I. CurrTherRes 1986;39:559-563. defined by DSMlll. *As See adjacent page for brief summary prescribing FL.4907.T-949301 of information. В©1989. DISTAPR000CTS COMNY Prozaca fluoxetine hydrochloride Brl.tSummmy: Coitths InformatIon. package Ifterature for complete ladicatlos: Prozac is indicated forthetreatmentof depression. Ceetrafadfcatfes: Prozac is contraindicated in patients known to be hypersen. sitiveto ii. Waralus: Monoamine Oxase Inhibitcws -Data on the effects of the cornblood use of fluoxetne and MAO intbitors are IThted. Thor cornbrned use shoufd be avoided. Based on experience with the cornbsned adlTdntstralion of MAOIs and tricycfcs, at east 14 days shoutd elapse between discontinuation of an MAO inttlbltorand initiation oftreatrnent wfthfluoxetine. Because of thelong hat-lives of fluoxetine and tis active metatiOtite, at least five weeks (approxirnatety five hat-lives of norfluoxetine) should ofapse between discontinuation of fluoxetine and initiation of therapy with an MAOI. Administration of an MAOI within five weeks of discontinuation of fluoxetine mayincreasethe hskofseciousevents.WhileacausalreiobonsNptofluoxetne has not been established, death has been reported to occur fofiosing the ioltiation of MA therapy shortly after discontinuation of fluoxetise. RashandAccampanyingEvents Durrng premarketingtestin of morethan 5,600 US patients givenfluoxetine. approximately 4% developed a rash and/or urticaiia Arnon9 these cases. almost a ttsrd were withdrawn from treatment because of the rash and/or systemic iopns or symptoms associated with the rash Ctnical findings reported in association with rash inctudefever, teikocytosis, arlhratgias. edema, carpat tunnel syndrome, respiratory distress, fymphadenopathy. proteinuria, and mOd transarninase elevation. Most patents snproved prornptty wftf discontinuation of fluoxetine and/or adiIsCtIVe treat. rnentwith anbtsstaminesorsteriods, and all patientsexperiencin9theseevents were reportedto recover completely. Two patients are known to have developed a serious cutaneous systemic dkiess. In neither patient was there an unequivocal diagnosis. but one was considered to have a koikOcytOctastic vascutitis, and the othe a severe desquamatlng srome that was considered variously to be a vascultis or erythema multiforme Several other patients have had systemic syndromes suggestive of serum sickness. Whether the association of rash and other events constitutes a true fluoxetine-induced syndrome. or a chance association of rash wfth the other signs and symptoms ofdifferentetioiogy orpathogenests, is uoknowabteatttss pont Hi the drugs development Reassuring io the knowledge, cted above. that no patient is repOrtedtO have sustained lasting injury. Even though almost two thirds of those developln a rash continued to take fluoxetine without any consequence, the physicas should discontinue Prozac upon appearance of rash. Precasitfess: Ger,eraI-.pgj..rj still lnapmr$a-Anxiety. nervousness. and insomnia were reported by 10% to 15% of patents treated with Proust. These symptoms lud to drug discontinuation in 5% of patients treated with Prozac. Metat.#{225}ppetleaistWeiufi-Significant weight loss. especially io urejerweight depressed patients. may be an undesirable result of treatment with Prozac. In controlled ckrdcal trials, approamatety 9% of patients treated with Prozac experienced anorexia. This incidence is approximately sixfold that seen in placebo controls. A weight loss of greaterthan 5% of body weight occurred in 13% of patients treated wfth Prozac compared to 4% of placebo- and 3% of thcycbc-antidepressant-treated patients. Howeve only rarely have patients been discontinued from treatmentwith Prozac because of weight loss. Acfl1aLg1Ma1aL1ty11ania-During premailteting testing, hypomania or masea occurred in approximately 1% of fIUOXetIne-treatedpatents. Actvation of rnaniaThypomarna has also been reported in a small proportion of patients with Major Affective tssorder treated with other marketed antidepressants. eliIim-Twetve patients among more than 6,000 evaluated worldwide in the course ofpremarketing developmentoffluoxetine expenencedconvutsions (or events described as possibly having been seeures). a rate of 0.2% that appears to be similar to that associated with other marketed antidepressants. Prozac should be lotroduced with care in patients witha ldstory of seizures. fl#{231}-The possibility of a suicide attempt is inherent io depression and may persist until signdlcant remission occurs. Close supervision of high-risk patents should accompany initial druf therapy. Prescriptions for Prozac should be written for the smallest quantity of capsulus consistent with good patient mana merit. Uiorderto reducethe risk of overdose. - m*r active metabolite (seven to nine days), changes in dose wilt not be fully reflected in plasma for several weeks. affecting both strategies for titration to finof dose and withdrawal from treatment (see Clinical Pharmacology and Dosage and Administration(. yse in PatientsWlth ConcomitarII(pess-Clinicalexperience with Prozac in patents with concomitant systemic illness is liMed. Caution is advisable in using Prozac in patients with diseases or conditions that could affect metabolism or hemodynannic responses. Ftuoxetine has Sll been evaluated or used to any appreciable extent in patents with a recent history of myocardiof infarction or unstable heart disease. Patents withthesediagnoses were systematically exckidedfrom chnical studies during the products premarket testing. However, the electrocarctograms of 312 patients who received Prozac in double-blind thalu were retrospectively evaluated; no conduction abnormalities that resulted in heart block were observed. The mean heart rate was reduced by approxrinately three beats/met. In sebects with cirrhosis of the hve the cluarances of fluoxetne arid fls active metabolite, norftuoxetine, were decreased, thus increasing the eliminalion hat-lives of these substances. A lower or iou frequent dose should be used In patients with cirrhosis. Since ftuoxetine is extensively metabolized, excretion of unchanged drug in urine is a minor route of ebmetation. However, until adequate numbers of patents with severe mel tinpeirment have been evaluated during chronic treatmerewith ftuoxetine, d should be used with caution io such patients. lt1erferpce Wh Coaatve l Motor Perfprnce-Any psychoactive drug may impair fudgment. thinfong, or motor skills, and patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that the drag treatment does not affect them adversely. !nfoimatkit for Patients Physicians are advised to discuss the following issues with patientstorwhoni they prescribe Prozac: Because Prozac may impan ient thinltmg, or motor skills, patients should be advised to avoid driving a car or operating hazardous macfunery untiltheyare reasonably cettainthattheir performance is nOtaffected. Patients should be advised to nformthofr physician Stay aretaldng or plan totalte any prescription or over-the-counter drugs oralcohol. Patients shoofd be advised to notify their physician il they become pregnant or intendto become pregnant during therapy. Patients should be advised to notifytheir physician rithey are breastfeedlng an infant. Patients should be advised to notifytheir physician if they develop a rash or hives. Laboratory Tests -There are no specitic IabOratOrytestS recommended. Drug Interactions -As with all drugs, the potential for interaction by a varietyofmechanisms (ie, pharmacodynamic, pharmacokinetic drug inhibition or enhancement etc( is a possdiilfty (see Accumulation and Slow Elimination - undeiвЂ™ClInical jpcesaaii-There have been greater than twofold increases of previouslystabte plasmatevelsofotherantidepressantswhen Prozac has been administered in combination with these agents (see Accumulation and Slow Elimination underClinicat Pharmacology). Qepiln&laaLs-The hall-We of concurrently administered diazepam may be prolonged in some patients (see Accumulation and Slow Ehmination underClinical Pharmacology). ecanseoxoonpilwad tration of ftuoxetne to a patient taking another drug that is tightly bound to protein (eg, Coumadin, digitotdn) may cause a shOt in plasma concentrations potentially resulting in an adverse effect Conversely, adverse effects may result from displacement of proteIn-bound fluoxetine by other tightly bound drugs (see Accumulation and Slow EIiminationunrCknicat Pharmacology). #{231}NS-Actlve Drpos-The nsk of using Prozac In combination with other CNS-acilve dru#{231}s has not been systematically evaluated. Consequently, canton is advised il the concomitant administration of Prozac and such drugs is requiced (see Accumulation and Slow Elimmation under Clliuicat Pharmacology). Electroconvulsive Ttaany-There are no chrilcat studies establishing the benefit of the combined use of ECT and fluoxetine. A single report of a prolonged seizure in a patlentonftuoxetine has been reported. Carcinogenesis, Mutagenesis. Impairment of Fortuity- There is no esidence of carcinogenicity, mutagenicty, orimpatrmentoffertikty with Prozac. The dietary administration of fluoxetine to rats and mice for two years at tevelsalentto approximately 7.5and9.Otimesthe maximum human dose (80 mg) respectively produced nOevidence of carcinogenicity. Ruoxetine and norftuoxetine have been shown to have no genotoxic effects based on the following assays: bacterial mutation assay, DNA repair assay in cultured rat hepatocytes, mouse tymplioma assay, and in vivo sisterchromatld exchange assay in Chinese hamster bone marrow cells. Twolertility studies conductedin ratsatdosesofapproeimatetyfiveandine times the maximum human dose (80 tog) indicated that fluoxetne had no adverseeffectsonfertkty. Askghtdecreaseinneonatal survivalwasnoted, but this was probably associated with depressed maternal food consumption and maximum daily human dose (80 mg) respectively and have revealed no esidence of harm to the fetus due to Prozac. There are, however, no adequate and well-controlled studies in pregnant women. Because animat reproduction sluclies are not always predictive of human response, lIds drug should be used du0 PregnanCyOOtYdCluartYneeded. on totoranii delnieryin humans is unknowr Nursing Mothers -ft is not known whether and, il so, in what amount this drug or its metabolites are excreted in human milk. Because many drugs are excreted in human mif#{231} caution shoutd be exercised when Prozac is admimsteredtoanursingwornan. Usage in Children- Safety and effectiveness in children have not been established. UsageintheEldertyProzac has not been systematically evaluated molder patients: however, severof hundred elderly patents have participated in dllnicat studies with Prozac, and no unusual adverse age-related phenomena have been elentified. However, these data are insuffIcient to rule out possible age-related differences during clwonic use, particularly in elderly patients who have concomitant systemic illnesses orwho are receiving concommtantdrugs. IM,onaimnofa -Severof cases of hyponatremia (some with serum sodium lowerthan 1 10 mmot/L)have beenrepOrted.The hyponatremiaappearedto be reversiblewhen Prozac was discontinued. Althoughthese cases were complex with varying possible etiologies, some were possibly duetOthe syndrome of inappropriate antidiuretic hormone secretion (StADH). The majority of these occurrences have been in older patients and in patientstaking diuretics orwho wereotherwise volume depleted. Adverse Reactiess: Coinv-nonty Observed -The most commonly observed adverse events associated wlththe useof Prozac and not seen atan equhialene incidence among placebo-treated patients were: nervous system complaints. including anxiety, nervousness, and insomnia; drowsiness and fatigue or astheisa; tremor; sweating; gastrointestinal complaints. including anorexia. nausea, and diarrhea; and dizziness orlightheadedness. Associated With Discontinuation ofTreatment -Fifteen percent of approximately 4,000 patients who received Prozac in US premartietin9 clinical trials discontinued treatment due to an adverse event. The more common events causing discontinuation included: psychiatric (5.3%), prImarily nervousness. anxiety, and insomnia; digestive (3.0%), primarily nausea; nervous system (1 .6%), primarily dimness; body as a whole (1.5%), primarIly asthensa and headache; and shin (1 .4%), primarily rash and pruritus. TAStE 1.TREATMB4T-EMERGENTAOVERSE E30вЂ™tRtNcE C Pt.AC080-CONTROILED I3JNICALTRLALS ian Body SynOnV Osms Headache LkWeu audey Petzac 5-1,7301 20.3 Prozac#{149} (fluoxetine hydrochloride, Dista) PliceSo IN-mel 1.9 15.5 0.5 7.1 6.3 5.5 2.4 3.3 1 1 1.3 1,7 2.0 14.9 13.u 11.6 9.4 7.9 5_7 4.2 16 16 Body 1.5 Prnz aвЂ™vers.rveвЂ™r N=i,73O Anthem Sitectluo,viral Pain.Snb Fuvw Pali.chenl Allergy k*iinza 4.4 3.4 1.6 1.4 1.3 12 1.2 вЂ� - Au-0 syndrona 2ngles - ranon Koadacte. OiiUS Dinrihea Muue 21 1 12.3 0 Hemere Tascharw GaiSciudedSo MaciSo 0-799) 1.9 3.1 1.1 - 1.1 11 15 llppw ConceiSiSo 10.1 70 Slnosaums Couofi Prwnu 0 6 2.8 2.7 19 1.3 2.6 2.3 2.1 16 14 18 2u I 6 9.5 8.7 64 4.5 6.0 15 Hntthusheu 3.3 Paliutatlons kJh1-U 18 13 34 2.4 18 1.6 1.0 2.9 13 Padi.back P5i1. Pad.nancle 2.0 1.2 1.2 1_i 10 1.9 14 84 27 24 3.8 1.8 1.4 4.3 - 1.1 14 10 14 4 tisul Mnnslruallun. - Swual 19 nausulion Lkinwyvact uweduon Vofon iSnftuteice Evmer-debyaBost - bocytopenia. Ovsrdesae: Human EApefience -As of December 1987, there were two deaths among approximately 38 reports of acute overdose with fluoxetine, either alone or in combination with other drugs and/or alcohol. One death OIVOIVOd a combined overdose with approximately 1,800 req of ftuoxetine and an undetermined amount of maprotfine. Plasma concentrations of fluoxetine and maprotiline were 4.57 mg/I and 4.18 mg,Q respectively. A second death involved three drugs yielding plasma concentrations as follows: ftuoxetine, 1.93 maJL; norfluoxetjne, 1.10 ng/L; codeine, 1.80 mg/i,; temazepam, 3.80 m other patient who reportedly took 3.000 mg of ftuoxetine experienced tWo grand mat seizures that remitted spontaneously without specifIc anticonvutsant treatment (see Management of Overdose). The actual amount of drug absorbed may have beer, less duetovomiting. Nausea and vomiting were prominent in overdoses involving higher fluoxetine doses. Other prominent symptoms of overdose included agitation, restlessness, hypomania, and other signs of CNS excitation. Except for the two deaths noted above, allotheroverdose cases recovered without residua. - PV24720PP 11117991 - Additiona!infornsationavallabietotheprofess,on 16 1.2 MN Pharmacology(. Jjypflai-Ftve patients receiving Prozac in combination with tryptophan experienced adverse reactions, including agitation, restlessness, and gastroritestinal distress. Monoamine Osidase trVtibitors-See Warnings. unset 14C1OENCE Incidence in Controlled Clinical Trials -Table 1 enumerates adverse events thatoccurred atafrequency of 1% or moreanong Prozac-treated patmentswho participated in controlledtrlals comparing Prozac with placebo. The prescriber should be aware that these figures cannot be used to predict the incidence of side effects in the course of usual medical practice where patent charactorls. tics and other factors differ from those that prevailed in the clinical trials. Similarty.the citedfrequencies cannot becompared withflgures obtainedfrom othercknical investigations invohang differenttreatments, uses, and mnvestigatots. The cited figures, however, do provide the prescribing physician with some basis forestimating the relative contribution ofdrug and nondrug factors tothe side-effectincidence rate iota pogulation studied. Other Events Observed During the Preinai*eting Evaiua.tioei of Prozac During clmnicaltesting in the US, multiple doses of Prozac were administereiltO approximately 5.600 subcts. Untoward events associated with thisexposure were recorded by clinical investigators using descriptive terminOlOgy of their ownchooslng. Consequently, itisnotpossibletoprov$dea meanlngfulestimate of the proportion of individuals experiencing adverse events without first grouping simllartypesofuntowardeventsintoahmited (ii, reduced) numberof standardized eventcategories. Inthetabulatlons which follow, a standard COSTARTDictionary terminology has been usedto classify reported adverseevents. ThefrequenCieS presented. therefore, representthe proportion ofthe 5.600 individuals exposed to Prozac who experienced an event of the type cited on at least one occasion while receiving Prozac. Af reported events are inckidedexceptthose afready listed in tables, those COSTART terms so general as to be uninformative, and those events where a drug cause was remote. It is important to emphasize that, althoughthe events reported did occurduringtreatmentwith Prozac, they were not necessarily caused by it Events arefurtherclassifled within body system categories and enumerated in order of decreasing frequency using the following definitions: frequent adverse events are defined as those occurring on one or mona occasions in at least 1/lOOpatients; infrequentadverse events arethose occurring in 1/bOb 1/1,000 patients; rare events arethose occurring in lessthan 1/1,000 patients. QthвЂ™ as a Whol-Frequent: ctdbs; Infrequent chills and fever. cyst, face edema. hangover effect pain, malaise, neck pain, neck rigldfty, andpehac pain; Rare: abdomen enlarged, celkifits, hydrocephafus, hypothermia, 11 syndrome, monhliasis, and serum sickness. Cvas#{231}til Sv-Mfre angina pectoris, arrhyThmia, homer. rhage, hypertenmon, hypotension, migraine. postural hypotension, syncope, and tachycardia; Rare: AV block (first-degree), bradycardl bundle-branch block, cerebral ischemia, myocardial infarct, thrombophlebitis, vascular headache, and ventriculararrhythmia. flyyg-Frequent increased appetite: Infrequent: aphihous stomatitis, dysphaa, eructation. esophagitis, gastrltis, gingivitis, glossitis, liver function tests abnormal, melons, stornathtis, and thirst Rare: bloody diarrhea. cholecystitls, chofelitlilasis, colitis, duodenal ulcer, intents, focal incontinence, hematemesis, hepatitis, hepatomegaly, hyperchlorhydrla, acreased salivation, ice, liver tenderness, mouth ulceration, salivary gland enlargement stomach utoer, tongue discoloration, andtongue edema. 5,fl5$,yste-!nfrequent: hypothyroidism; Rare: goiter and hyperthyroidism. jJfpjfJfJ,,ymtgbuSystecr-!nfroquent: anemia and lymphadenopathy; Rare: bleedIng time increased, blood dyscrasia. leukopenia, lymphocytosis, petechia, purpura. sedimentation rate increased, sod thrombocythemia. Metailotic Spd Nuytbon-Froquent: weight kiss; Infrequent: generalized edema. hypoglycemia, penpheral edema, and weight gain; Rare: dehydration, Qout hypercholesterenila, hyperglycemia, hyperlipenila, hypoglycemic riscton, hypokabemla, hyponatremla, and Iron deficiency anemia. Muscutpskeletal v.pj,ffl-Infrequent: arthritis, bone pain, bursitis, tenosynovitis, and twitching; flare: bone neCrOSIS, chondrodystrophy, muscle hemorrhage. myositis. osteoporosis, pathological fracture, and rheumatoid arthritis. ,jystetn-Frequent: abnormal dreams and agitation; Infrequent: abnormal gat, acute brain syndrome, aitattilsia. amnesia. apathy, stains, butcoglossal syndrome, CNS stimulation, convulsion, delusions, depersonalizalion, emotional lability, euphoria, hallucinations, hostility, hyperkinesia, hypesthesia, incoordmnation, libido increased, manic reaction, neuralgia, netsropathy, paranoid reaction, psychosis, and vertigo; Rare: abnormal electronscephalogram, antisocial reaction, chronic brain syndrome, circumoral paresthesia, OilS depression, coma, dysarthria, dystorila, extrapyramidal syndrome, hypertorila, hysteria, myodonus, nystagmus, paralysis, reflexes decreased, stupor. andtorhcollis. jj,pira.torJystsn-Frequent: bronchitis, rhmnitis, and yawn; Infrequent: asthma, epistasss, hiccup, hyperventilation, and pneumonia; Rare: apses, hemoptysis, hypoxia, larynx edema, lung edema, lung fibrosis/alveolitis, and pleural effusion. g.,ppeodaos-Infrequent: acne, alopecia, contact dermatitis, dry skin, herpes simplex maculopapular rash, and urticaria; Rare: eczema, erythema multiforme, fungal dermatitis, herpes zoster, hirsutism, psoriasis, perpuric rash, pustular rash, sebontiea, skin discoloration, skin hypertrophy, subcutaneous nodule, and vesicubobubous rash. ,peciaISens-Infrequent: amblyopia, conjunctivitis, ear pain, eye pain, mydnasis, photophobia, and tinnitus; Rare: blepharitis, cataract, corneal lesion, deafness, diplopia, eye hemorrhage, glaucoma, ribs, ptosis, strabismus, and taste kiss. Qjjy-Infrequent: abnormal e(aculation, amenorrhea. breast pain, cystltis, dysuna, fibrocystic breast. impotence, leukorrhea, menopause, menorrhagia. ovarian disordet urinary incontinence, urinary retention, urinary urgency, urination impaired, and vaginitis; Rare: abortion, albuminuria, breast enlargement, dyspareunia, epididymitis, female lactation, hematuria, hypeminorities, kidney calculus, metrorrhatma, orchitis, polyurla, pyelonephrlds, pytiria, salpingitis, urethral pain, urethritis, urinary tract disorder, urolithiasis, uterinehemorrtiage, uterine spasm, and vagesal hemorrhage. Mastintmductkjn Reports -Voluntary reports of adverse events temporally associated with Prozac that have been received since market introduction and which may have no causal relationship with the drug include the following: vagInal bleeding after drug withdrawal, hyperprolactinemia, and throm- 2.8 1%olMazac4e*dpadei99weiictidsd. вЂ� -Sindencahenflial 1%. Prozac#{176}(fiuoxetine hydrochloride, Dista) onrequesl from 1.0 Dleta Products Company Division of Eli Ully and Company Indiana 46285 ______________Indianapolis, Prozac#{149}(fluoxetine hydrochloride, Dista) BOYER MARIN PROFOUND CHANGE FOR THE REGRESSED BEHAVIORAL WINTER HEALTH CONFERENCE 1990 l,2&3, TIMBERLINE MT. HOOD, PATIENT Representing a mature tradition oftreatment grounded in results, Mann Programs for Mental Recovery and Boyer House Foundation have joined together to create a unique residential treatment center offering active, highly structured milieu treatment and intensive psychoanalytically-oriented individual psychotherapy to adults with severe mental disorders such as schizophrenia, major affective and personality disorders. SERVICES PSYCHIATRIC MARCH LODGE LODGE OREGON Near Portland, Timberline has one of the longest lift systems in N. America. The summer home of the U.S. and Canadian ski teams. (Beginner and advanced slopes.) THE 1990 ANNUAL MEETING includes: I Neuropsychiatric Manifestations of AIDS. I Serotonin Systems and Psychiatric Treatment I Pathogenesis and Treatment of Multiple Personality Disorder Ample time will be allowed to enjoy the slopes. Discount for early registration 1, 1989) and to student residents. December вЂ�ii !1I ! 1 503/230-8787. Space is limited. I H Conference offers 15 Catego,y I GslEHows Send for complete program to: Jan Cook, Registration Chair HOLLADAY PARK MEDICAL CENTER 1225 N.E. 2nd Ave., Portland, OR 97232 (by EXECUTIVE DIRECIвЂ™OR ADULT PRIVATE ROBBIE PSYCHIATRIST CENTRAL PRACTICE CONNECTICUT KINGSTON, MEDICAL MSW DIRECIOR ROBERTJONES,J.D., CLINICAL MD, DIRECIвЂ™OR NILES MEDDERS CLINICAL Does general consider the challenge of a private adult psychiatry appeal fee-for-.ervice to you? practice If so, then plea.e JAINIE BLJENAVEN1TRA, M.D.. ROCKVILLE, MARYlAND FERNANDO CESARMAN, M.D., MEXICO CITY, MEXICO RENA11вЂ™A (ADDINI DE BENEDE1TI, M.D., ROME, ITALY HEITOR F.B. DE PAOLA, M.D., RiO DEJANEIRO, BRAZIL DIETER EICKE, M.D., KASSEL, GERMANY RLID()LPII EKSTEIN, PH.D., LOS ANGELES, CALIFORNIA ABRAM EKSTERMAN, M.D., RIO DEJANEIRO, BRAZ1L PETER L. GIO4CCHINI, M.D., CHICAGO, ILLINOIS the following Our client, a progressive 240 bed community hospital located in a highly desirable suburb outside Hartford, Connecticutia actively seekingaBoard Certified/Board Prepared Psychiatrist to join an independent, private fee-for-service practice. Additional highlights include: .. Establlihed 26 bed inpatient unit; strong interdiaciplinary team . Modern, fully staffed outpatient counseling center with (35) clinical and support staff . Full of psychiatric spectrum . Ca_il sharing and coll CONSULTANTS L BRYCE BOYER, M.D., BERKELEY, CAUFORNIA in LEON GRINBERG. M.D., MADRID, SPAIN JAMES GRO1вЂ™STEIN, M.D., LOS ANGELES, CALIFORNIA JOHN G. GUNDERSON, M.D., BOSTON, MASSACHUSETFS SвЂ™EIN HAL)GSGJERD, M.D., OSLO, NORвЂ™AAY BARRY K. IIERMAN, M.D., AUSTIN, TEXAS JANE HEWITtвЂ™, D.M.H., BERKELE CALIFORNIA ALLEN KANNER, PH.D., PALO ALTO, CALIFORNIA diagnoses support Preferred candidates should have interest in a communitybased practice and demonstrate versatile skill. in general adult psychiatry. Attractive income potential for qualified ThEODORE LIDZ, M.D., NEW HAVEN, CONNECI1CLrF ThOMAS OGDEN, M.D., SAN FRANCISCO, CALIFORNIA RAYMOND G. POGGI, M.D., BERKELEY, CALIFORNIA CANS REAGAN, M.D., WASHINGTON, D.C. DAVID ROSENFELD, M.D., BUENOS AIRES, ARGENTINA candidates. For further detaila and immediate consideration, please call: Cheryl Freedman at (215) 363-5600; or remit credentiala to John Downing Associates, Inc., P.O. Box 452, Lionville, PA 19353, FAX (215) 363-5658. JOSE SCHECHTMANN, M.D., BUENOS AIRES, ARGENTINA HANS STEINER, M.D., PALO ALTO, CALIFORNIA ENDRE UGELSTAD, M.D.. OSLO. NORWAY \AMIK I). VOLKAN, M.D., CHARLOвЂ™IlвЂ™ESVILLE, VIRGINIA DAVID ZIMMERMAN, M.D., PORTO ALEGRE, BRAZIL John Thming Ph Lionvilk Ceasmoas, In Aiates, BOYER MARIN Seaivh 170 P.O. Bo, 452. tissiviete, PA 19353 San GeronimoValley LODGE Road, Woodacre, (1-415-488-4340) CA 94973 1 -- L - - .- HEAIJH E - -- ---- - -- - ----. - -- -- SERVICES ----.-.. .- . j SOLUTIONS ----- - ,---- -- ----- Taking Care Of The Person Instead Of The Paperwork Now thereвЂ™s right from your own keyboard. We realize keeping track of people, care plans and medications takes a way to get the information you need to help your clients, and have more time to see them. If you treat the developmentally disabled, mentally ill or people with ., : :, : more than just time. You also need вЂ� accuracy. With IBM system you substance abuse wonвЂ™t problems, whether about records youвЂ™re misfiled, a small community facility or a large we have hospital, a system that can help. The IBM Health Management Information your With it, tasks that took days can take minutes, your youвЂ™ll clientвЂ™s have complete being illegibly entire staff at all times. And can be accessible to multiple facilities. An IBM Health Management Information System System. because to worry written, or simply unavailable. The information will be current and accessible to based psychiatric have this instant medical access to records handles many administrative too. By automating your chores billing and _w1 . . . .. Lli#{224}i .1_ I LL.L. in ?.вЂ� . ,. I:, accounts collection . receivables, cycles youвЂ™ll shorten and minimize unre- imbursedfees. вЂ�. This system also lets you auto- mate client demographics, census and financial information.Which can reduce the burden of government reporting and increase administrative productivity. The IBM Health Management Information System can give you the time you need to help your clients. To learn more, mail in the coupon below, or call us: 1 800 IBM-2468, ext. 200. leasesendmemoredailsahouthow Health Management improve the quality anH3M Information System can of care in my institution. Clip and mail to: IBM 1)RM. Dept. 200 101 Paragon Drive Monivale, NJ 07645 Or call: 1 800 IBM-2t68. 200 ext. Company .ddress City .JLaвЂ™..._________ 7:.. _______ Phone L I LII .Li.i.. ,-..---i IBM is a registered trademark В©1989 IBM Corporation of International Business Machines Corporation. вЂњIT FEELS GOOD FEEL USEFUL AGAINвЂќ TO For the chronic schizophrenic patient, work performance smoother social help path improve a better towards the attitude ability toward recovery. can and a Navane may Navane mean more competent to concentrate and promote work and co-workers.вЂ™3 27% output compared to baseline switched to Navane2вЂќ rIse In work shown In patients 20 IMPROVEMENT 4IXENEGRP DETERIORATION Anticholinergic4 and cardiovascular5вЂ™6 patients treated with infrequently. Should occur, they usually side effects in 0 be controlled. (Adapted @1989, Pfizer Inc. 3 4 OF STUDY from DiMascio and Demirgian3) Forty-two psychotic mate and female patients under age 55 were entered in this study on a nonblind basis, and randomly assigned to their regular medication or switched to thiothixene. Patients were evaluated at baseline and on a daily basis, and periodically rated on the Global Improvement and Brief Psychiatric Rating Scales. In schizophrenia, Please see brief summary of NAVANE (thiothixene/thiothixene prescribing information on adjacent page. 2 MONTHS Navane are reported extrapyramidal symptoms can GURUETIONGMOUP 1 HCI) liothixene HC) CaPsu/ 1mg 20mg (thiothixene) (thiothixene HCI) Itfrels useful good again to feel References: 1 Bressler B. Friedel RO: A comparison between chiorpromazine and thiothixene in a Veterans Administration hospital population. Psychosomafics 1971 12:275-277 2. OiMascio A, Demirgian E: Study of the activating operhes of thiethixene. Psychosomatics 1972:13:105-108. 3. DiMaSCIO A, Demirgian E: Joti training in the rehabilitation of the chronic schizophrenic. Presented as a Scientific Exhibit at The Amercan Psychiatric Association. Washington, DC, May 3-6, 1971. 4. Goldstein B, Weiner D, Banas F: Clinical evaluation of thiothixene in chronic ambulatory schizophrenic patients. in Lehmann HE, Ban TA (ads): The Thioxanthenes: Morn Problems ofPharmacq,sych,atry Basal. Switzerland, S. Karger, 1969, vol 2, pp 45-52. 5 Ditenkoffer RI, Gallant DM, George RB, et at: Electrocardiographic evaluation of schizophrenic patients: A double-blind comparison. Presented as a Scientific Exhibit at The 125th Annual Meeting of the American Psychiatric Association, Dallas, May 1-4, 1972. 6. Data available on request from Roerig. BRIEF SUMMARY OF PRESCRIBING INFORMATiON Navau. (lMxeee) Capsades: 1 tag. 2 tag, 5 tag, 10 mg, 20mg (thlethlzeoe bydrochride) Couiceatrate: 5 mg/mI, kd,amvscvlar 2 mg/mI, 5 mg/mI Indlcitlees: Navane is effective in the management of manifestations of psychotic disorders. Navane has not been evaluated in the management of behaveral complications in patients with mental retardation. Contraladlcatlons: Contraindicated in patients with circulatory collapse, comatose states, central nervous system depression dueto any cause, and blood dyscrasias. Contraindicated in individuals who have shown hypersensitivityto the drug. It is not known whetherthere is a cross-sensitivity between the thioxanthenes and the phenothiazine derivatives, butthe possibility should be considered. Warnings: Tardive Oyskinessa.-Tardive dyskinesia, a syndrome consisting of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with neuroleptic (antipsychotic) drugs. Although the prevalence of the syndrome appears to be highestamongtheelderly, especiailyeldertywomen, itis impossibieto rely upon prevalenceestimatesto predict, atthe inception ofneuroleptictreatment, which patients are likely to develop the syndrome. Whether neuroleptic drug products ditier in their potential to cause tardive dyskinesia is unknown. Both the risk of developing the syndrome and the likelihood that it will become irreversible are believed to increase as the duration oftreatment and the total cumulative dose of neuroleptic drugs administered to the patent increase. However, the syndrome can develop, although much isss commonly, after relatively brieftreatment penods at low doses. There is no known treatment for established ses of tardive dyskinesia, although the syndrome may remit, partially or compistely, if neuroleptictreatment is withdrawn. Neuroieptictreatment, itself, however, may suppress (or partially suppress) the signs and symptoms of the syndrome and thereby may possibly mask the underlying disease process. The effect that symptomatic suppression has upon the long-term course of the syndrome is unknown. Given these considerations, neuroleptics should be prescribed in a mannerthat is most likely to minimize the occurrence of tardive dyskinesia. Chronic neuroleptic treatment should generally be reserved for paDents who sufferfrom a chronic illness that, 1) is known to respond to rieuroleptic drugs, and, 2) for whom alternative, equally effective, butpotentialty less harmfultreatments are notavailable or appropriate. In patients who do require chronictreatment, the smallestdose and the shortestduration oftreatment producing a satisfactory clinical response should be sought. The need for continued treatment should be reassessed periodically. It signs and symptoms of tardive dyskinesia appear in a patient on neuroleptics, drug discontinuation should be considered. However, some patients may require treatment despite the presence of the syndrome. (For further information about the description of tardive dyskinesia and its clinical detection, please refer to Information for Patients in the Precautions section, and to the Adverse Reactions section.) Netiro.вЂ™eptic Malignant Syndrome (NMS)-A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with antipsychotic drugs. Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythimas) The diagnostic evaluation of patients with this syndrome is complicated. In arriving at a diagnosis, it is importantto identity cases where the clinical presentation includes both serious medical illness(e.g. , pneumonia, systemic infection, etc.) and untreated or inadequatelytreated extrapyramidal signs arid symptoms (EPS) Other important considerations in the differential diagnosis include central anticholinergic toxicity, heat stroke, drug fever and primary central nervous system (CP4S) pathology. The management of NMS should include 1 immediate discontinuation of antipsychotic drugs and other drugs notessentialto concurrenttherapy, 2) intensive symptomatictreatmentand medical monitouing, and 3) treatment of any concomitant serious medical problemsforwhich specific treatmentsareavailable. There is no general agreement about specific pharmacological treatment regimens for uncomplicated NMS. It a patient requires antipsychotic drug treatment after recovery from NMS. the potential reintroduction of drug therapy should be carefully considered. The patient thoid be carefully monitored, since recurrences of NMS have been reported. Usage in Phegnancy-Safe use of Navane during pregnancy has not been established. Therefore, this drug should be given to pregnant patients onlywhen, in thejudgment of the physician, the expected benefits from the treatment exceed the possible risks to mother and fetus. Animal reproduction studies and clinical experience to date have not demonstrated any teratogenic effects. In the animal reproduction studies with Navane, there was some decrease in conception rate and litter size, and an increase in resorption rate in rats and rabbits, changes which have been similarly reported with other psychotropic agents. After repeated oral administration of Navane to rats (5 to 15 mg/kg/day), rabbits (3 to 50 mg/kg/day), and monkeys (1 to 3 mg/kg/day) before and during gestation, no teratogenic effects were seen. (See Precautions.) Usage in Chi!dren-The use of Navane in children under 12 years of age is not recommended because safety and efficacy in the pediatnc age group have not been established. As is true with many CNS drugs, Navane may impair the mental and/or physical abilities required br the performance of potentially hazardous tasks such as driving a car or operating machinery, especially during the first few days of therapy. Therefore, the patient should be cautioned accordingly. As in the case ofother CNS-acting drugs, patients receiving Navane should be cautioned aboutthe p05sible additive effects (which may include hypotension) with CNS depressants and with alcohol. Precavtlons: An antiemetic effect was observed in animal studies with Navane; since this effect may also occur in man, it is possible that Navane may mask signs of overdosage of toxic drugs and may obscure conditions such as intestinal obstruction and brain tumor. In consideration of the known capability of Navane and certain other psychotropic drugs to precipitate convulsions, extreme caution should be used in patients with a history of convulsie disorders or those in a state of alcohol withdrawal since it may lower the convulsive threshold. Although Navane potentiates the actions of the barbiturates, the dosage of the anticonvulsant therapy should not be reduced when Navane is administered concurrently. CautKin as weilas careful adtustmentofthe dosage is indicated when Navane is used in conjunction with other CNS depressants other than anticonvulsant drugs. Though exhibiting rather weak anticholinergic properties, Navane should be used with caution in patients who are known or suspected to have glaucoma, or who might be exposed to extreme heat, or who are receiving atropine or related drugs. Use with caution in patients with cardiovascular disease. Also, careful observation should be made for pigmentary retinopathy, and lenticular pigmentation (fine lenticular pigmentation has been noted in a small number of patients treated with Navane for prolonged ) Concentrate 5 mg/mI penods). Blood dyscrasias (agranulocytosis, pancytopema, thrombocytopenic purpura), and liver damage (jaundice, biliary stasis) have been reported with related druQs. Undue exposure to sunlight should be avoided. Photosensitive reactions have been reported in patients on Navane (thiothixene). lntramuscularAdministratjon-As with all intramuscular preparations, Navane Intramuscular should be injected well within the body of a relatively large muscle. The preferred sites are the upper outer quadrant of the buttock (i.e. gluteus maximus) and the mid-lateral thigh. The deltoid area should be used only if well developed, such as in certain adults and older children, and then only with caution to avold radial nerve inlury. Intramuscular inctions should not be made into the lower and mid-thirds of the upper arm. As with all intramuscular infections, aspiration is necessary to help avoid inadvertent injection into a blood vessel. Neuroleptic drugs elevate prolactin levels: the elevation persists during chronic administration. Tissue culture experiments indicate that approximately one third of human breast cancers are prolactin-dependent in vitro, a factor of potential importance it the prescription ofthese drugs is contemplated in a patient with a previously detected breast cancer. Although disturbances such as galactorrhea, amenorrhea, gynecomastia, and impotence have been reported, the dinical significance of elevated serum prolactin levels is unknown for most patients. An increase in mammary neoplasms has been found in rodents after chronic administration of neuroleptic drugs. Neither dinical studies nor epalemiologic studies conducted to date, howeve have shown an associahon between chronic administration ofthese drugs and mammary tumorgenesis; the available evidence is considered too limited to be conclusive at this tune. Information forPatients-Given the likelihoodthatsome patients exposed chronicallyto neurolepticswill develop tardive dyskinesia, it is advised that all patients in whom chronic use is contemplated be given, it possible, full information about this risk. The decision to inform patients and/or their guardians must obviously take into account the dinical drcumstances and the competency of the patient to understand the information provided. Adverse Reactlona: Note: Not all of the following adverse reactions have been reported with Navane (thiothixene). However, since Navane has certain chemical and pharmacoloqic similarities to the phenothiazines, all of the known side effects and toxicity associated with phenothiazine therapy should be borne in mind when Navane is used. Cardiovascular effects: Tachycardia, hypotension, lightheadedness, and syncope. In the event hypotension occurs, epinephrine should notbe used asa pressoragentsince a paradoxicalfurther lowering of blood pressure may result. Nonspecific EKG changes have been observed in some patients receiving Navane (thiothixene). These changes are usually reversible and frequently disappear on continued Navane therapy. The incidence of these changes is lower than that observed with some phenothiazines. The clinical significance ofthese changes is not known. CNS effects: Drowsiness, usually mild, may occur although it usually subsides with continuation of Navane therapy. The incidence of sedation appears similar to that ofthe piperazinegroup of phenothiazines, butlessthan that otcertain aliphatic phenothiazines. Restlessness, agitation and insomnia have been noted with Navane. Seizures and paradoxical exacerbation of psychotic symptoms have occurred with Navane infrequently. Hyperreftexia has been reported in infants delivered from mothers having received structurally related drugs. In addition, phenothiazine derivatives have been associated with cerebral edema and cerebrospinal fluid abnormalities. Extrapyramidal symptoms, such as pseudo-parkinsonism, akathisia, and dystonia have been reported Management of these extrapyramidal symptoms depends upon the type and severity. Rapid relief of acute symptoms may requirethe use of an injectable antiparkinson agent. More slowly emerging symptoms may be managed by reducing the dosage of Navane and/or administenng an oral antiparkinson agent Persistent Tardive Dyskinesia: As with all antipsychotic agents tardive dyskinesia may appear in some patents on long-term therapy or may occur after drug therapy has been discontinued. The syndrome is characterized by rhythmical involuntary movements ofthe tongue, face, mouth aw (e.g. , protrusion of tongue, puffing of cheeks, puckering of mouth, chewing movements). Sometimes these may be accompanied by involuntary movements of extremities. Since early detection of tardive dyskinesia is important, patients should be monitored on an ongoing hasis. It has been reported thatfine vermicular movementofthetorigue may bean early sign ofthe syndrome If this any other presentation of the syndrome is observed, the clinician should consider possible discoi-tinuation of neuroleptic medication. (See Warnin9s section.) Hepatic Effects: Elevations of serum transaminase and alkaline phosphatase, usually transient, ha been infrequently observed in some patients No clinically confirmed cases of laundice attributable to Navane have been reported. Hematologic Effects: As is true with certain other psychotropic drugs, leukopenia and eukocytosis, which are usually transient, can occur occasionally with Navane. Other antipsychotic drugs have been associated with agranulocytosis, eosinophilia, hemolytic anemia, thrombocytopenia and pancytopenia. Ailergic Reactions: Rash, prurifus, urticana, photosensitivity and rare cases of anaphylaxis have been reported with Navane. Undue exposure to sunliqht should be avoided. Although not experienced with Navane, exfoliative dermatitis and contact dermatitis (in nursing personnel) have been reported with certain phenothiazines. Endocrine Disorders: Lactation, moderate breast enlargementand amenorrhea have occurred in a small percentage of females receiving Navane. If persistent, this may necessitate a reduction in dosage or the discontinuation of therapy. Phenothiazines have been associated with false positive pregnancy tests, gynecomastia, hypoglycemia, hyperglycemia, and gfycosuna. Autonomic Effects: Dry mouth, blurred vision, nasal congestion, constipation, increased sweating, increased salivation, and impotence have occurred infrequently with Navane therapy. Phenothiazines have been associated with miosis, mydriasis, and adynamic dens Other Adverse Reactions: Hyperpyrexia, anorexia, nausea, vomiting, diarrhea, increase in appetite and weight, weakness or fatigue, pofydipsia and peripheral edema. Although not reported with Navane, evidence indicates there is a relationship between phenothiazine therapy and the occurrence of a systemic lupus erythematosus-like syndrome. Neuroleptic Malignant Syndrome (NMS): Please refer to the text regarding NMS in the WARNINGS section. NOTE: Sudden deaths have occasionally been reported in patients who have received certain phenothiazine derivatives. In some cases the cause of death was apparently cardiac arrest or asphyxia due to failure ofthe cough reflex. In others, the cause could not be determined nor cotud it be established that death was due to phenothiazine administration. Dosage: Dosage of Navane should be individually adjusted depending on the chronicity and severity of the condition. See full prescribing information. Overdesage: For information on signs and symptoms, and treatment of overdosage, see full prescribing information. RORIG A division of Pfizer Pharmaceuticals New York, New York 10017 Calendar To have afree ing in Hospital listing ofyour and Community meetPsychiatryвЂ™s monthly calendar, drop us a note giving the details of the meeting-sponsor(s), inclusive dates, locations, type of meeting (workshop, conference, annual meeting, etc.), theme or topic area (if applicable), and the name, address, and telephone number of the party to contact for more information. If continuing education credits are available, list the type and number. Because of space limitations, listings of only those meetings considered of most interest to H&CPвЂ™s readership will be included. All notices and changes must be received no later than two months before date ofpublication (for exampie, June 1 for August publication). Correspondence should be addressed to Calendar, Hospital and Community Psychiatry, American PsychiatricAssociation, 1400 K Street, N.W., Washington, D.C. 20005. November November 2-3, symposium and depression, Wasatch Canyons and University of Utah School of Social Work, Hospital Graduate Park City, rico, Wasatch South 84 123, on panic Utah. Contact Canyons 1 500 West, Peggy Hospital, Salt Lake City, Car5770 Utah 800-262-6199. November 3-5, symposium on FreudвЂ™s impact on 20th century thought, sponsored by University of South Carolina School of Medicine, Sheraton Hotel and Convention Center, Columbia, South Carolina. Contact Gerry Herron, Department of 1128 USC Box 5303, 29250, and Behavioral Sci- School of Medicine, Columbia, South P.O. try, 803-253-4250. November 5-8, 31st southern regional conference on mental health statistics, Bourbon Orleans Hotel, New Orleans. meyer, sion Ph.D., of Mental Contact North David Carolina LangDivi- Health, Mental Retar- dation, and Substance Abuse, North Salisbury Street, Raleigh, Carolina 2761 1, 919-733-3295. North November management office dependent York 9- 1 1 course on of the chemically , patient, November sponsored University 325 by New Medical 13-17, ference Carolina November 5-7, 6th annual conference on the chronic patient, sponsored by University Hospital of Jacksonville, Omni Hotel, Jacksonyule, Florida. Contact Ed R. Pant, M.S., University Hospital, Community Mental Health Center, 655 West 8th Street,Jacksonville, florida 32209, 904350-6806. Center, on Arusha, Psychiatry, tre, P.O. 2nd U.S. health psychi- congress, sponsored by Psychiatric Times, New York Hilton. Contact Andrea Crossetta, Conference Management Corporation, Box 200 4990, Connecticut Norwalk, tional Association of Rehabilitation Facilities, Holiday Inn 1-70 East, Denyen. Contact NARF, P.O. Box 17675, Washington, D.C. 2004 1 703-648, 9300. November gress fects 22-25, international conon mass media and their efon human behavior, sponsored by Center for ext. sored by the National Center for State Courts, Tucson. Contact Institute for Court Management, NCSC, 1331 Seventh Street, Suite 402, Denver, Colorado 80202, 800-253-2000. November 13-14, conference on sex offenders and their victims, Carlton Place Hotel, Toronto. Contact Suzanne Curnoe, Conference Coordinator, P.O. Box 7205, Oakville, Ontario, Canada L6J 6L5, 416-257-0184. 1989 Vol. Health Athens. CMHR, Contact 58 Notara Athens 106 Greece; 83, L. and VanStreet, telephone, 82-38-332. November 29-December sign, on health MarriottвЂ™s 2, 2nd sym- care interior de- Orlando World Cen- ter, Orlando, Florida. Contact National Symposium on Health Care Interior Design, 4550 Alhambra Way, Marti- 94533, 4 15-370-0345. December December 226. November 12-15, workshop on improving the interactions of the juslice and mental health systems, spon- November Mental Research, dorou, Avenue, Connecticut 203-852-0500, Medical CenDar Es Salaam, November 16-17, seminar on personnel management for rehabilitation facilities, sponsored by the Na- nez, California 10-12, mental Dr. of Tanzania. November and con- psychia- Tanzania. Contact Head, Department Muhimbili Box 65293, posium atric international rehabilitation G. P. Kilonzo, New York City. Contact NYU Medical Center, Postgraduate Medical School, 5 50 First Avenue, New York, New York 10016, 212-340-5295. 06856, November 2-5, 23rd annual conference, Association for Advancement of Behavior Therapy, Washington, D.C. Contact Program Chair, AABT, 15 West 36th Street, New York, New York 10018, 212-279-7970. Neuropsychiatry ence, 40 No. 11 1 1-15, international conference on general hospital psychiatry, Cerromar Beach, Puerto Rico. Contact E. Perez, M.D., do Joan Bradden, Department of Psychiatry, Ottawa Civic Hospital, 1053 Carling Ayenue, 4E9, Ottawa, Ontario, 613-725-4787. Canada K1Y December 18-19, annual conference, Society for Psychosomatic Research, Royal College of Physicians, London. Contact Dr. Michael Murphy, Department of Psychological Medicine, Kings College Hospital, Denmark Hill, London SE5 9RS, England, 01-326-3014. (continued Hospital and Community on page 1137) Psychiatry ) T7T7?i /1 NEW kT r_Id :)\4 (BURRORON HOD helps clear depression with few life-style disruptions. See brief summary of full prescribing on last pages of this advertisement. information Chemically unique WELLBUTRIN tricyclics/tetracyclics, monoamine or other known antidepressants. is unrelated to oxidase inhibitors, WELLBUTRIN relieves depression as effectively as amitriptyline. Clinical Global lmprovement* 1 very much 2 much 3 minimally improved \ improved - improved U) 0) C вЂ�-<_ Wellbutrin (n=62)t вЂ�I-. Amitriptyhne ($g)t minimally 5 Drug I * 0 Adapted tDosages 75 worse Day I I I 8 15 22 from Mendels were I 300 to 450 to 1 50 mg/day I 29 et al.1 mg/day 43 64 92 for WELLBUTRIN, for amitriptyline. Please review IMPORTANT CONSIDERATIONS BEFORE PRESCRIBING WELLBUTRIN on page 6 and brief summary on the last pages of this advertisement before prescribing WELLBUTRIN. ( WELLBUTRIN relieves depression with no clinically significant effect on cardiac conduction. Average Change in EKG Parameters from Baseline Values During Treatmentt j!, a) C 0 U Wellbutrin (n=23) C 0 * 0 1.0 Placebo baseline Adapted Amitriptyline (n=23) from вЂњBy contrast, Wenger 2.0 3.0 4.0 Milliseconds et al.2 the present results with bupropion support the in vitro data demonstrating that this antidepressant lacks these undesirable electro-physiologic properties, and imply that bupropion has a substantially wider margin of safety in man than amitriptyline with regard to cardiac conduction.вЂќ2 j /1 WELLBUTRIN relieves depression with no clinically significant orthostatic hypotension. Orthostatic Blood Pressure Wellbutrin Change Placebo 0 LJJ Hg)t I, Tricyclics I 133W U (mm +1 1 -6.5 -10 - 01 E - i1) > 0-c,) 2C-30 -32.4 -40 * Adapted from Farid et al.3 butri n#{174} (BURRORON Helps clear depression with HOD few life-style disruptions. See brief summary of full prescribing on last pages of this advertisement. information WELLBUTRIN relieves depression with few anticholinergic side effects. Percent Relative Difference in Anticholinergic to Placebot Effects Wellbutrin 27.6 26.0 (n=323) #{149} U) C a) 18.4 0 17.3 0 14.6 C a) 0 10.3 a) 1.9 Dry Constipation Blurred vision mouth * Data on file, Burroughs Weilcome 2.2 Urinary retention Co.вЂ™ sq WELLBUTRIN relieves depression with little or no weight gain. Change - in Body Weight (percent of patients; n=341)t - 62.8% 60 50 - 40 - - No weight - V - .. change 4 C 27.8% a) ea 30 - 0 Lost 20 6 lb - 9-4% - 10 Gained 6 lb LвЂ™.вЂ™ \4 - 90.6% gained * Data on file, Burroughs \ no weight Wellcome 4. Co.вЂ™ I Fr] .---вЂ� *L/J (I / WELLBUTRIN relieves depression with little or no daytime drowsiness. Percent of Patients Treatment-Related 50 Reporting Drowsinesst - U) C a) (13 0 0 C 20 15.3% a) a- 0 * Data Wellbutrin Amitriptyline (n=98) (n=49) on file, Burroughs Wellcome ., I Co.4 In placebo-controlled clinical trials, the incidence of drowsinesst treated with WELLBUTRIN was 1 9.8%, versus 1 9.5% for those for patients receiving placebo. Agitation and Insomnia: A substantial proportion of patients treated with WELLBUTRIN experience some degree of increased restlessness, agitation, anxiety, and insomnia, especially shortly after initiation of treatment. In clinical studies, these symptoms were sometimes of sufficient magnitude to require treatment with sedative/hypnotic drugs. In approximately 2% of patients, symptoms were sufficiently severe to require discontinuation of WELLBUTRIN treatment. вЂ�As with all drugs in this category, perform tasks requiring judgment patients should be cautioned that the ability NEW l-iвЂ™ (RURRORON Helps clear to or motor and cognitive skills may be impaired. depression with few F ;i-1#{128} HOD life-style disruptions. See brief summary on last pages of full prescribing of this advertisement. information /вЂ� Wellbutrin#{174} helps clear depression Important prescribing considerations Weilbutrin. before Treatment Day Patient Selection Criteria WELLBUTRIN is contraindicated in patients . with a seizure disorder . with a current or prior diagnosis of bulimia or anorexia nervosa . on monoamine oxidase (MAO) inhibitor therapy . who are allergic to it (See CONTRAINDICATIONS section of full prescribing information.) WELLBUTRIN should be administered with extreme caution to patients . with a history of seizure, cranial trauma, or other factors that predispose toward seizure . taking other agents or other treatment regimens that may lower seizure threshold (See WARNINGS section of full prescribing information.) Overdosage In 1 3 cases of overdose involving WELLBUTRIN, were no deaths or lasting sequelae. with few life-style disruptions. Dosing Regimen 1-3 4 Total T Tablet Daily Dose Strength 200 mg 300mg 100 mg 100mg Number of Tablets Morning Midday Evening 1 1 0 1 1 1 An increase in dosage, up to a maximum of 450 mg/ day, given in divided doses of not more than 1 50 mg each, may be considered for patients in whom no clinical improvement is noted after several weeks of treatment at 300 mg/day. Increases in dose should not exceed 1 00 mg/day in a three-day period. WELLBUTRIN is available in both 75 mg and 1 00 mg tablets. Important: No single dose of WELLBUTRIN should exceed 150 mg because a higher incidence of seizures has been observed in patients receiving higher individual doses of WELLBUTRIN. For this reason, too, patients should be reminded that they should not double up on any dose because they missed a previous one. Dosage should not exceed 450 mg per day (see WARNINGS). there Seizures A wide range of seizure rates have been reported with antidepressant therapy with some reports as low as 0.1 %. The incidence of seizures with WELLBUTRIN is approximately 0.4%, which may be as much as fourfold higher than some other antidepressants, although no direct comparative studies have been conducted. Dosage and Administration The recommended starting dose of WELLBUTRIN is 200 mg/day given as 100 mg b.i.d. Based on clinical response, this dose may be increased to 300 mg/day given as 100 mg t.i.d. no sooner than three days after beginning therapy. Clinical trials involving more than 7,000 depressed patients and over 200 investigators demonstrated that WELLBUTRIN relieves depression in a wide range of patients: - with no clinically significant effects on cardiac conduction - with no clinically significant orthostatic hypotension - with few anticholinergic side effects - with little or no weight gain - with little or no daytime drowsiness NEW WeHbutrin (BURRORON See brief summary of on last pages /pab1?31 HO) full prescribing of this advertisement. information WELLBUTRIN#{174}(BUPROPION HYDROCHLORIDE) Tablets Before prescribing, please consult complete product information, a summary of which follows: Use in Patients with Systemic Illness: There is no clinical experience establishing the satety of Wellbutrin in patients with a recent history of myocardial infarction or unstable heart INDICATIONS AND USAGE: Vllbutrin is indicated forthe treatment of depression. A physiclan considering the initiation of Wellbutrin should be aware that the drug may cause generalized seizures with an approximate incidence of 0.4% (4/1000). This incidence may exceed that of other antidepressants as much as fourfold. This relative risk is only an ap- disease. Therefore, care should be exercised if it is used in these groups. Wellbutrin was tolerated in Patients who had previously developed orthostatic hypotension while receiving tricyclic antidepressants. bupropion HCI and s metabolitesarealmost completelyexcretedthnugh the kidney proximation and metabolites are likelyto undergo conjugation inthe liver priorto urinary excretion, treatment of patients with renal or hepatic impairment should be initiated at reduced dosage as bupropion and its metabolites may accumulate in such patients beyond concentrations expected in patients without renal or hepatic impairment. The patient should be closely monitoredforpossibletoxiceffectsofelevated bloodandtissuelevelsofdrugandmetaboles. Information for Patients: since no direct comparative studies have been conducted. CONTRAINDICATIONS: Wellbutrin is contraindicated in patients: with a seizure disorder; with a current or prior diagnosis of bulimia or anorexia nervosa, because of a higher incidence of seizures noted in such patients; who have shown an allergic response to it; or who are currently being treated with an MAO inhibitor. At least 14 days should elapse between discontinuation of an MAO inhibitor and initiation of treatment with Wellbutrin. WARNINGS: SEIZURES: Wellbutnn is associated with seizures In approximately 04% (4/1000) of patients treated at doses up to 450 mg/day. This incidence of seizures may exceed that of other marketed antidepressants by as much as fourfold. This relative risk is only an approximate estimate because no direct comparative studies have been conducted. The estimated seizure incidence forWellbutrin increases almosttenfold between 450 and 600 mg/day, which is twice the usually required daily dose (300 mg) and one and one-third the maximum recommended daily dose (450 mg). Given the wide variability among individuals and their capacity to metabolize and eliminate drugs, this disproportionate increase in seizure incidence with dose incrementation calls for caution in dosing. Duringthe pro-approval evaluation period, 25 among approximately 2400 patients treated with Weilbutrin experienced seizures. Atthetimeofseizure, 7 patients were receivIng datly doses of4SO mg rn below, foran incidence of033% (3/1000) withinthe recommended dose range. Twelve (12) patients experienced seizures at600 mg perday (23% incidence); 6 additIonal patients had seizures at daily doses between 600 and 900 mg (28% Incidence). Aseparate, prospective studywas conductedto determinethe incidence ofseizure during an8weektreatmentexposureinapproximately3200addftionalpatientswhoreceiveddaily doses of up to 450 mg. Patients were permitted to continue treatment beyond 8 weeks if clinically indicated. Eight (8) seIzures occurred during the Initial 8 weektreatment period and 5 seizures were reported in patients continuing treatment beyond 8 weeks, resuffing in a total seizure incidence of 0.4%. The risk of seizure appears to be strongly associated with dose and the presence of predisposlng factors. Asignificant predisposing factor (e.g., history of head trauma prior seizure, CNStunw, concomitant medationsthater seizurethreshold, etc.)was present in approximately one-half ofthe patients experiencing a seizure. Sudden and large increments in dose may contribute to increased risk. While many seizures occurred early in the course of treatment, some seizures did occur after several weeks at fixed dose. Recommendations for reducing the risk otseizure: Retrospective analysis of clinical experience gained during the development ofWeflbutrin suggests thatthe risk of seizure may be minimized if (1) the total daily dose ofWellbutrin does notexceed 450 mg, (2) the daily dose is administered t.i.d. , with each single dose notto exceed 150 mg to avoid high peak concentrations of bupropion and/or its metaboiltes, and (3) the rate of incrementation of dose is very gradual. Extreme caution should be used when Wellbutrin is (1) administered to patients with a historyofseizure, cranialtrauma, orother predisposition(s) toward seizure, or (2) prescrIbed with other agents (e.g., antipsychotics, other antidepressants, etc.) or treatment regimens (e.g. , abrupt discontinuation ofa benzodlazepine)that lower seizure threshold. Potential for IвЂ™lepatotoxicity: In rats receiving large doses of bupropion chronically, there was an increase in incidence of hepatic hyperplastic nodulesand hepatocellular hypertrophy. In dogs receiving large doses of bupropion chronically, various histologic changes were seen inthe liver, and laboratorytests suggesting mild hepatocellular injury were noted. Although scattered abnormalities in liverfunctiontests were detected in patients participating in clinicaltrials, there is noclinicalevidencethatbupropion actsasa hepatotoxin in humans. PRECAUTIONS: General: Agitation and Insomnia: A substantial proportion of patients treated with Wellbutrin expenence some degree ofincreased restlessness, agitation, anxiety, and insomnia, especially shortly after initiation of treatment. In clinical studies, these symptoms were sometimes ofsufficientmagnitudeto requiretreatmentwith sedative/hypnotic drugs. In approximately 2% of patients, symptoms were sufficiently severeto require discontinuation ofWellbutrin вЂ�eatment. p. vchosis, Confusion, and Other Neuropsychiatric Phenomena: Patients treated with Wt Ibutrjn have been reported to show a variety of neuropsychiatric signs and symptoms inck ding delusions, hallucinations. psychotic episodes, confusion, and paranoia. Because ofthe uncontrolled nature of many studies, it is impossible to provide a precise estimate of the extent of risk imposed by treatment with Wellbutrin. In several cases, neuropsychiatric phenomena abated upon dose reduction and/or withdrawal of treatment. Activation ofPsychosisand/orMania: Antidepressants can precipitate manic episodes in Bipolar Manic Depressive patients during the depressed phase oftheir illness and may activate latent psychosis in other susceptible patients. Wellbutrin is expected to pose similar risks. AlteredAppetite and Weight: A weight loss of greater than 5 pounds occurred in 28% of Wellbutrin patients. This incidence is approximately double that seen in comparable patients treated with tricyclics or placebo. Furthermore, while 34.5% of patients receiving tricyclicantidepressantsgainedweight, only9.4% of patientstreated with Wellbutrin did. Consequently, if weight loss is a major presenting sign of a patientвЂ™s depressive illness, the anorectic and/or weight reducing potential of Wellbutrin should be considered. Suicide:The possibilityofa suicideattempt is inherent in depression and may persist until significant remission occurs. Accordingly, prescriptions for Wellbutrin should be written for the smallest number of tablets consistent with good patient management. Patients should be instructed to takeWellbutrin in equally divided doses three or fourtimes a day to minimize the risk of seizure. patients should be told that any CNS-active drug like Wellbutrin may impair their ability to perform tasks requiring judgment or motor and cognitive skills. Consequently, until they are reasonably certain that Wellbutrin does not adversely affect their performancethey should refrain from driving an automobile or operating complex, hazardous machinery. Patients should be told that the use and cessation of use of alcohol may alter the seizure threshold, and, therefore, thatthe consumption of alcohol should be minimized, and, if possible, avoided completely tients should be advised to inform their physician if they are taking or plan to take any prescription or over-the-counter drugs. patients should be advised to notify their physician if they become pregnant or intend to become pregnant during therapy Drug Interactions: No systematic data have been collected on the consequences of the concomitant administration of Wellbutrin and other drugs. However, animal data suggestthat Wellbutrin may be an inducer of drug metabolizing enzymes. This may be of potential clinical importance because the blood levels of co- administered drugs may be altered. Alternatively, because bupropion is extensively metabolized, the co-administration of 0ther drugs may affect its clinical activity. In particular, care should be exercised when administering drugs known to affect hepatic drug metabolizing enzyme systems (e.g ., carbamazepine, cimetidine, phenobarbital, phenytoin). Studies in animals demonstrate that the acutetoxicity of bupropion is enhanced by the MAO inhibitor phenelzine (see CONTRAINDICATIONS). Limited clinical data suggesta higher incidence ofadverse experiences in patients receiving concurrentadministration ofWellbutrin and L-dopa. Administration ofWellbutrinto patients receiving L-dopa concurrently should be undertaken with caution, using small initial doses and small gradual dose increases. Concurrent administration of Wellbutrin and agents which lower seizure threshold should be undertaken only with extreme caution (see WARNINGS) .Low initial dosing and small gradual dose increases should be employed. Carcinogenesis, Mutagenesis, Impairment of FertIlity: Lifetime carcinogenicity studies were performed in rats and mice at doses up to 300 and 150 mg/kg/day, respectively. In the rat study there was an increase in nodular proliferative lesions of the liver at doses of 100 to 300 mg/kg/day; lower doses were not tested. The question of whether or not such lesions may be precursors of neoplasms ofthe liver is currently unresolved. Similar liver lesions were not seen in the mouse study, and no increase in malignant tumors of the liver and other organs was seen in either study. Bupropion produced a borderline positive response (2-3 times control mutation rate) in some strains in the Ames bacterial mutagenicity test, and a high oral dose (300, but not 100 or 200 mg/kg) produced a low incidence of chromosomal aberrations in rats. The relevance ofthese results in estimatingthe risk ofhuman exposuretotherapeutic doses is unknown. Afertility study was performed in rats; no evidence ofimpairmentoffertilitywas encountered at oral doses up to 300 mg/kg/day. Pregnancy: Teratogenic Effects: Pregnancy Category B: Reproduction studies have been pertormed in rabbits and rats at doses up to 15-45 times the human daily dose and have revealed no definitive evidence of impaired fertility or harm tothe fetus due to bupropion. (In rabbits, a slightly increased incidence offetal abnormalities was seen in two studies, but there was no increase in any specific abnormality). There are no adequate and wellcontrolled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed. lJbor and Delivery: The effect of Wellbutrin on labor and delivery in humans is unknown. Nursing Mothers: Because ofthe potentialfor serious adverse reactions in nursing infants from Wellbutrin, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. Pediatric Use: The safety and effectiveness ofWellbutrin in individuals under 18 years old have not been established. Use in the Elderly: Wellbutrin has not been systematically evaluated in older patients. ADVERSE REACTIONS: (See also WARNINGS and PRECAUTIONS) Adverse events cornmonly encountered in patientstreated with Wellbutrin are agitation, dry mouth, insomnia, headache/migraine, nausea/vomiting, constipation, and tremor. Adverse events were sufficientlytroublesometo cause discontinuation ofWellbutrin treatment in approximately ten percent of the 2400 patients and volunteers who participated inthe productвЂ™s pre-approvalclinicaltnals. The morecommoneventscausing discontinuation include neuropsychiatric disturbances (3.0%), primarilyagitation and abnormalities in mental status; gastrointestinal disturbances (2.1%), primarily nauseaand vomiting; neurological disturbances (1 .7%), primarily seizures, headaches, and sleep disturbances; and dermatologic problems (1 .4%), primarily rashes. It is important to note, however, that many of these events occurred at doses that exceed the recommended daily dose. The table below is presented solely to indicate the relative frequency of adverse events reported in representative controlled clinical studies conducted to evaluate the safety and efficacy of fllbutrin under relatively similar conditions of daily dosage (300-600 mg), setting, and duration (3-4 weeks). The figures cited cannot be used to predict precisely the incidence of untoward events in the course of usual medical practice where patient characteristics and other factors must differ from those which prevailed in the clinical trials. These incidence figures also cannot be compared with those obtained from other clinical studies involving related drug products as each group of drug trials is conducted under a different set of conditions. Finally, it is important to emphasize that the tabulation does not reflect the relative severity and/or clinical importance ofthe events. A better perspective on the serious adverse events associated with the use of Wellbutrin is provided in the WARNINGS and PRECAUTIONS sections. EMERGENT ADVERSE EXPERIENCE INCIDENCE IN PLACEBO-CONTROLLED CUNICAL InIALsвЂ™ (Percent of Patients Reporting) CARDIOVASCULAR Cardiac Arrhylhmias Dizziness Hypertension Hypotension Palpitations Syncope l#{228}chycardia WsllbuhвЂ™In Patients (n = 323) Placebo Patients (n = 185) 5.3 22.3 4.3 4.3 16.2 1.6 2.5 2.2 3.7 2.2 1.2 10.8 0.5 8.6 DERMATOLOGIC Prunlus Rash GASTROINTESTiNAL Anorexia Appetite increase Constipalion Diarrhea Dyspepsia Nausea/\Aimiting ightGain WeighlLoss 2.2 0.0 8.0 6.5 18.3 18.4 3.7 26.0 2.2 17.3 6.8 3.1 22.9 13.6 23.2 8.6 2.2 18.9 22.7 23.2 3.4 4.7 2.5 1.9 3.1 1.1 2.2 2.2 GENiTOUR1NARY impolence Menstrual Complaints Urinary rrequency Urinary Retention 3.1 2.7 Akathisia 1.5 1.1 Akinesia/Bradykinesia 8.0 8.6 1.9 1.6 Cutaneous bnperatureDisturbance Excessive SweaIing Headache/Migraine impaired Sleep Ouaiity increased Salivary Flow insomnia Muscie Spasms Pseudoparkinsonism Sedation Sensory Disturbance Tremor Welbutrin Placebo PafteMs Patients (n = 323) (n = 185) 27.6 22.3 18.4 14.6 25.7 22.2 4.0 3.4 18.6 1.9 1.5 19.8 4.0 21.1 1.6 3.8 15.7 3.2 1.6 19.5 3.2 7.6 NEUROPSYCHiATRIC Agitation Anxiety 31.9 3.1 22.2 1.1 Confusion DecreasedLibido Delusions 8.4 3.1 1.2 4.9 1.6 Disturbed Concentration Euphoria 3.1 1.1 3.8 1.2 5.6 0.5 3.8 Fatigue 5.0 8.6 Fever/Chiiis 1.2 0.5 Hostility NONSPECIFIC and 300 mg of tranylcypromine and recovered further 5.0 11.4 SPECIALSENSES Auditory Disturbance Blurred Vision 5.3 14.6 3.2 10.3 Gustatory Disturbance 3.1 1.1 during the entire pro-approval evaluation of Wellbutrln: During its pre-approval assessment, Wellbutrin was evaluated in almost 2400 subjects. The condiOther events observed tions and duration of exposureto Wellbutrin varied greatly and a substantial proportion of the experience was gained in open and uncontrolled clinical settings. Duringthis experience, numerous adverse events were reported; however, without appropriate controls, it is rnpossibleto determine with certainty which events were or were not caused by Wellbutrin. The following enumeration is organized by organ system and describes events in terms of their relative frequency of reporting in the data base. Events of major clinical importance are also described in the WARNINGS and PRECAUTIONS sections of the labeling. The following definitions of frequency are used: Frequent adverse events are defined as those occurring in at least 1/100 patients. Infrequent adverse events are those occurring in 1/100 to 1/1000 patients, while rare events are those occurring in less than 1/1000 patients. Cardiovascular: Frequent was edema; infrequent were chest pain, EKG abnormalities (premature beats and nonspecific SiT changes), and shortness of breath/dyspnea; and rare were pallor and phlebitis. Dermatologic:Frequent were nonspecific rashes; infrequent were alopecia and dry skin; rare were change in hair color and hirsutism. Endocilne: Infrequent was gynecomastia; rare were glycosuria and hormone level change. Gastrointestinal: Infrequent were dysphagia, thirst disturbance, and liver damage/jauncolitis, G.I. bleeding, and intestinal without experienced a grand mal seizure sequelae. DOSAGE AND ADMINISTRATION: General Dosing Considerations: It is particularly important to administer Wellbutrin in a manner most likely to minimize the risk of seizure (see WARNINGS). Increases in dose should not exceed 100 mg/day in a 3 day period. Gradual escalation in dosage is also important if agitation, motor restlessness, and insomnia, often seen during the initial days of treatment, areto be minimized. Ifnecessary, these effects may be managed bytemporary reduction of dose or the short-term administration of an intermediate to long-acting sedative hypnotic. A sedative hypnotic usually is not required beyond the first week of treatment. Insomnia may also be minimized byavoiding bedtime doses. Ifdistressing, untoward effects supervene, dose escalation should be stopped. No single dose offIlbutrfn should exceed 150 mg. Wellbutnn should beadministered lid., preferably with at least 6 hours between successive doses. Usual Dosage for Adults: The usual adult dose is 300 mg/day, given t.i.d. Dosing should begin at 200 mg/day, given as 100 mg bid. Based on clinical response, this dose may be increased to 300 mg/day, given as 100 mg t.i.d. , no soonerthan 3 days after beginning therapy (see table below). Dosing Regimen Treatment Total Tablet Number of Tablets Day Daily Dose 1 вЂ�Events reported by at least 1% of Weiibutnn patients are inciuded. dice; rare were rectal complaints, embolism. 9000 mg of Wellbutrin RESPiRATORY Complaints and pulmonary ofWellbutrin. Thirteen overdoses occurred during clinical trials. Twelve patients ingested 850 to4200 mg and recovered without significant sequelae. Another patient who ingested Upper Respiratory MUSCUWSKELETAL Arthritis NEUROLOGICAL Adverse Experience Dry Mouth Pneumonia Respiratory: OVERDOSAGE: Human overdose experience: There has been limited clinical experience with overdosage TREATMENT AdverseExperlence Nonspecffic: Frequent were flu-like symptoms; infrequent was nonspecific pain; rare were body odor, surgically related pain, infection, medication reaction and overdose. Past-Approval Reports: The following additional events were rarely observed (less than 1/1000 patients) post-approval. Cardiovascular: Flushing and myocardial infarction. Dermatologic: Acne. Gastrointestinal: Stomach ulcer. Hematologic/Oncologic: Anemia and pancytopenia. Neurological: Aphasia. Musculoskeletal: Musculoskeletal chest pain. 200mg 300mg 4 Strength Morning Midday Evening 100mg 100mg 1 1 0 1 1 Increasing the Dosage Above 300 mg/Day: As with other antidepressants, the full antidepressant effect of Wellbutrin may not be evident until 4 weeks of treatment or longer. An increase in dosage, uptoa maximum of450 mg/day, given in divided doses of not more than 150 mg each, may be considered for patients in whom no clinical improvement is noted after several weeks of treatment at 300 mg/day. Dosing above 300 mg/day may be accomplished using the 75 or 100 mg tablets. The 100 mg tablet must beadministered q.i.d. with at least 4 hours between successive doses, in order notto exceed the limit of 150 mg in a single dose. Wellbutrin should be discontinued in patients who do not demonstrate an adequate response after an appropriate period of treatment at 450 mg/day. Elderly Patients: In general, older patients are knownto metabolize drugs more slowly and to be more sensitivetothe anticholinergic, sedative, and cardiovascular side effects of antidepressant drugs. References: 1. Mendels J, Amin MM, Chouinard G, et al, A comparative study of bupropion and amitriptyline in depressed outpatients, J Clin Psychiatry. 1983;44(5, sec 2):1 18-120. 2. Wenger TL, Cohn JB, Bustrack J. Comparison of the effects of bupropion and amitriptyline on cardiac conduction in depressed patients, J Clin Psychiatry. 1983;44(5, sec 2):1 74-1 75. 3. Farid FE, Wenger TL, Tsai SY, et al, Use of bupropion in patients who exhibit orthostatic hypotension on tricyclic antidepressants. J Clin Psychiatry. 1983:44 (5, sec 2):1 70-173, 4. Data on file, Burroughs Wellcome Co. perforation. Genitounnary: Frequent was nocturia; infrequent were vaginal irritation, testicular swelling, urinary tract infection, painful erection, and retarded ejaculation; rare were dysuria, enuresis, urinary incontinence, menopause, ovarian disorder, pelvic infection, cystitis, dyspareunia, and painful ejaculation. Hematologic/Oncologic: Rare was lymphadenopathy. Neunisogical: (see WARNINGS) Frequent were ataxia/incoordination, seizure, myoclonus, dyskinesia, and dystonia; infrequentwere mydriasis, vertigo, and dysarthria; and rare were EEG abnormality, abnormal neurological exam, impaired attention, and sciatica. (see PRECAUTIONS) Frequent were mania/hypomania, increased libido, hallucinations, decrease in sexualfunction, and depression; infrequentwere memory impairment, depersonalization, psychosis, dysphoria, mood instability, paranoia, formal thought disorder, and frigidity; rare was suicidal ideation. Oral Complaints: Frequent was stomatitis; infrequent were toothache, bruxism, gum irritation, and oral edema; rare was glossitis. Resp#{252}atoiy: Infrequentwere bronchitisand shortnessofbreath/dyspnea; rarewereepistaxis and rate or rhythm disorder. Special Senses: Infrequent was visual disturbance; rare was diplopia. вЂ�dUelibutrin hi NEW (RURRORON Newopsychiatiic: Copr - 1989 Burroughs Welicome Co Au r,ghts rese,ved W-141 Burroughs Wellcome Weilcome Co. Research Triangle Park, NC 27709 HO) (continuedfrom page 1128) Box 365, Greenbelt, Maryland Contact 20770, 301-345-3534. January January 5-7, seminar on therapeutic touch, sponsored by University of California, Los Angeles, Extension, Doubletree Hotel, Marina del Rey, California. Contact ExtensionвЂ™s Health Sciences Department, P.O. Box 24901, Los Angeles, California 90024, 2 1 3-825-670 1. February 15-16, regional congress, World Federation of Societies in Biological Psychiatry, Casablanca, Morocco. Contact Dr. M. Moussaoui, Moroccan Association of Biological Psychiatry, Centre sitaire, February American vancement Hilton, January 1 1-14, annual meeting, American Association of Directors of Psychiatric Residency Training, Inc., Royal Sonesta Hotel, New Orleans. Contact Peter M. Zeman, M.D., Executive Secretary, AADPRT, 400 Washington Street, Hartford, Connecticut 06106, 203-241-6856. 21-24, 57th annual meetNational Association of PriPsychiatric Hospitals, MarriOttвЂ™s Camelback Inn, Scottsdale, Anzona. Contact NAPPH, 1319 F Street, N.W., No. 1000, Washington, D.C. 20004, 202-393-6700. January ing, vate Psychiatnique Casablanca, Univer- Morocco. 15-20, annual meeting, Association for the Adof Science, New Orleans New Orleans. ings Office, AAAS, N.W., Washington, Contact Meet- 1333 H Street, D.C. 20005, 202- 326-6448. February 17-19, annual meeting, American Association for Geriatric Psychiatry, Le Menidien Hotel on Coronado Island, San Diego. Contact George T. Grossbeng, M.D., President, AAGP, P.O. Box 376A, Greenbelt, Maryland 20770, 301-220-0952. February 20-24, annual meeting, American Group Therapy Associa- tion, Place, Inc., Westin Hotel-Copley Boston. Contact Marsha Block, Chief AGPA, Executive New York, New York S. 6th Floor, 10010, 2 12- February 477-2677. February February 21-24, fourth national forum on AIDS and chemical dependency, sponsored by the American 2-3, conference on suicide, sponsored by Cambridge Hospital and Harvard Medical School, Boston. Contact Judy Reiner Plait, Ed.D., Director, Continuing Education Division, Department of Psychiatry, Cambridge Hospital, 1493 Street, Cambridge, 02139, 617-864-6165. Cambridge Suite 225, Rochester, 14624, 716-235-6910. New York 33612, 3rd 813-974-4500. February 14-18, annual meeting, American College of Psychiatrists, Wyndham Hotel, Palm Springs, California. Contact Alice Conde Martinez, Executive Director, ACP, P.O. Hospital and ference Travel on Alcoholism and Drug Dependencies, Hotel, Miami. Contact Coordinator, Services, Hyatt Con- Meeting Community Psychiatry Linda Hotel, Fort Tuchman, Service, VA Medical Kingsbnidge Road, 10468, 212-584-9000, March 1-3, annual can Psychopathological Lauderdale. Neurology Center, 130 West Bronx, New York ext. 1885. meeting, AmenAssociation, March 6-9, 8th annual symposium on forensic psychiatry, Desert Inn Country Club and Spa, Las Vegas. Vol. annual meeting, AssoAcademic Psychiatry, Seattle. Contact Department of Psychiatry, Mount Auburn Hospital, Cambridge, Massachusetts 02238, 617-4923500, ext. 4314. March 9-10, conference on treating the addictions, sponsored by Cambridge Hospital and Harvard Medical School, Boston. Contact Judy Reiner Plait, Ed.D., Director, Continuing Education chiatry, Division, Department Cambridge of Psy- Hospital, 1493 bridge Street, Cambridge, setts 02139, 617-864-6165. March 16-19, annual Cam- Massachu- meeting, Amen- McDonough, Ed.D., ton, AACD, Alexandria, Executive Direc- 5999 Stevenson Virginia 22304, Avenue, 703-823- 9800. March 21-23, can Medical Hyatt annual meeting, AmenStudent Association, Regency Crystal City, ton, Virginia. Contact Executive Director, Preston ginia Arling- Paul R. Wright, AMSA, 1890 White Drive, Reston, 22091, 703-620-6600. Vir- 40 No. Plaza, Boston. Contact K. Degnon, Executive 6728 McLean Old McLean, George Director, APS, Village Virginia 22101, Drive, 703-556- 9222. March 23-28, annual meeting, Amencan Society of Clinical Hypnosis, Sheraton World Resort, Orlando, Ronida. Jr., Contact Executive 2250 East Des Plaines, William F. Vice-President, Devon Illinois Avenue, 60018, Hoffmann, ASCH, Suite 336, 312-297- 3317. St. Moritz, New York City. Contact Nancy C. Andreasen, M.D., Ph.D., Department of Psychiatry, University of Iowa College of Medicine, 500 Newton Road, Iowa City, Iowa 52242, 3 19-356-1 5 53. 1989 7-10, for Stouffer Madison, Mary OвЂ™Loughlin, pley Marina November March ciation March 22-24, annual meeting, Amencan Psychosomatic Society, Inc., Co- March 1-3, symposium on nonepileptic seizures, sponsored by the Amencan Epilepsy Society and the Epilepsy Foundation of America, Marniott of Foren- and 404-458-3382. March Contact annual research conference, sponsored by Research and Training Center for ChildrenвЂ™s Mental Health of the Florida Mental Health Institute, Tampa, Florida. Contact Bob Friedman, Director, RTCCMH, FMHI, 13301 Bruce B. Downs Boulevard, Tampa, Florida 12-14, Society Other Regency Massachusetts February 4-7, annual meeting, Amencan Association of Psychiatric Services for Children, San Diego Hilton, San Diego. Contact Sydney Koret, Ph.D., Executive Director, AAPSC, 1200-C Scottsville Road, February Medical College can Association for Counseling and Development, Cincinnati Convention Center, Cincinnati. Contact Patrick J. Officer, 22 East 21st Street, American sic Psychiatry, 26701 Quail Creek, No. 295, Laguna Hills, California 92656, 714-831-0236. 11 March 28-April 1, 18th annual meeting, American Society for Psychosomatic Obstetrics and Gynecology, Waldorf Astoria Hotel, New York. Contact Patricia Stahn, Administrator, Liaison Activities, American College of Obstetricians and Gynecologists, 409 12th D.C. 20024, Street, S.W., Washington, 202-863-2514. 1137 Information Hospital and peer-reviewed nal Community Psychiatty, a interdisciplinary jour- published monthly can Psychiatric primarily to bers of agencies. for Contributors by the Association, professional mental H&CP Amen- is directed staff health mem- facilities and effectively, voice authors should and first person use active whenever possible, write short sentences, as specific as possible. Authors use gender-neutral language. and be should papers, review articles, commentary, and reports on legal, judicial, and eco- Authors must carefully protect patient anonymity, and must disguise identifying information. H&CP welcomes submission of papens from the American Psychiatric AssociationвЂ™s annual meeting. Papers nomic can of psychiatric publishes journal deals with all aspects service delivery. 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(If the not stated as a research purpose is question, it should be translatable into a research question.) 3) Also in the last paragraph of the introduction, indicate the type of study design. 4) Preferably in the methods section, describe the data analysis procedure con1989 Vol. section, 40 No. 11 including tables, report only the findings related directly to the research purpose or research question. Omit other data. 6) When reporting results of tests of significance, always report observed test statistic value, degrees of freedom, probability level, and, for t and F tests, whether вЂњrepeated measuresвЂќ were used. Reviewers will evaluate manuscripts for adherence to these guidelines. Literature reviews and special artides. Generally they are solicited by the editor and are 4,000 to 7,000 words plus a maximum of 100 references. 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Quality of Care INC. with a can QHRвЂќ A defense cancer be cooked up in your Q uality Joint Healthcare Commission maximize the We care Resources, on Accreditation value of your understand the providers. assistance And, quality unique a not-for-profit Organizations, improvement activities. of psychiatric individualized substance and programs . Alcohol/drug dependence services Community mental health centers Child/adolescent psychiatric services Adult psychiatric services Services for the mentally retarded/ developmentally disabled Forensic facilities . . WE PROVIDE further abuse technical hospitals WE _ help for: Psychiatric . For and . . can educational CAN information, Quality 875 A DIFFERENCEвЂ™ complete the attached Healthcare North Michigan Suite 2207 Chicago, Illinois or, call SOLUTIONS! MAKE Resources, form and send it to: flrcra cancer. Foods high in fats, salt- or nitrite-cured food,ssuch as ham, and fish and types of smoked by traditional should be eaten in Avenue 60611 us at: _______ firttвЂ™ Address _________ City/State/Zip Telephone Number H&CP 11/89 Note: QHRвЂ™s tion activities. advantage retained are entirely separate of QHR services should services consultation Any requestor nor receive QHR. sausages methods moderation. Be moderate in consumption of alcohol also. A good rule of thumb is cut down on fat and donвЂ™t be fat. Weight reduction may lower cancer risk. Our 12-year study of nearly a million Americans uncovered high cancer risks panicularly among people 40% or more overweight. Now, more than ever, we know you can cook up your own defense against cancer. So eat healthy and healthy. - _______ rti 7: There is evidence that diet and cancer are related, Some foods may promote cancer,while others may. protect you from it. Foods related to lowening the risk of cancer of the larynx and esophagus all have high amounts ofcarotene, a form of Vitamin A which is in cantaloupes, peaches, broccoli, spinach, all dark green leafy vegetables, sweet potatoes, carrots, pumpkin, winter squash, and tomatoes, citrus fruits and brussels sprouts. Foods that may help reduce the risk ofga.strointestinal and respiratory tract cancer are cabbage, broccoli, brussels sprouts, kohlrabi, cauliflower, Fruits, vegetables and whole;p-. ?grain cereals such as oatmeal, bran and wheat may help lower the risk of colorectal Inc. 312/642-9193 Name Title kitchen. of the them. tailors . subsidiary of Healthcare needs we provide to fulfill Q HR Inc., any special treatment from understand in the accreditation Joint Commission it will process derive because accredita- no special No it had one cancer q RIC4N faces alone. CANCER SOCIETY#{174} NORTH CAROUNA A of Opportunity Medical Opportunities State Immediate Excellent for PSYCHIATRISTS BIBE A вЂњwarm and friendly place to practice, a great place to live. Commumties exist thmughout the State, from over 300 miles of beautiful 2IaI)jI:]JВ©;:\1 beaches, across rolling hills of the Piedmont, America. North Carolina provides in Eastern tivities. mental Expanding ceflified/Board eligible services health psychiatrists offer highest mountains recreational ac- for Board health pro- opportunities with community Mental state supported psychiatric approved grams and withJCAH Salaries are competitive; deferred compensation. to the unlimited hospitals. excellent benefit package including on-call and Many programs are affiliated with one of four psychiathc residency programs in North Carolina; Univessity appointmean available. Full license to practice medicine in North Carolina a Vinfen Corporation is currently recruiting a Medical Director for a large psychiatric facility in Southeastern Mass. Salary negotiable. The must. Also, positions available for PSYCHOLOGISTS REGISTERED NURSES PHYSICAI Please send C.V. to: Shirley A. McKinney, Vice President, Professional Services, VINFEN CORPORATION, 28 Travis Street, Boston, MA 02134. (617) 254-7300. An Equal Opportunity/Affirmative Action Employer. THERAPISTS OCCUPATIONAL THERAPISTS SOCIAL WORKERS SPEECH & lANGUAGE PATHOLOGISTS information Forfurther Tom Lane, Recmitment Patsy ONea1, please contact: Director Recruitment NC. Department Division of Mental Coordinator of Human Health, & Substance Disabilities, 325 N. Salisbuzy Resources Developmental Abuse Services St., Raleigh, (919) N.C. 27611 733-5668 вЂњVIV c NFEN 0 R P 0 R A T I 0 N вЂ� . CHIEF OF PROFESSIONAL SERVICES Rewarding opportunity for an experienced Board Certified Psychiatrist to direct treatment services in an innovative public mental health system. Oversee all aspects of clinical services within the disciplines of Psychiatry, Nursing, Social Work, Psycho!ogy, Rehabilitation, and Chaplaincy. Position reports directly to the Superintendent and is actively involved with Q, UR, peer review and Residency Training. Connecticut Valley Hospital is a fully accredited hospital with a 451 bed inpatient and three community programs that are integral parts of regionalized managed care system. JCAHO Must have four yearsвЂ™ as staffpsychiatrist hospital or clinic, including one administrative or clinical supervision, licensure, and Board cialist in Psychiatry. and APA Administrative itation preferred. in in CT year certification as Academic Psychiatry affiliation accred- spe- Athrrnativc Action/Equal Comprehensive Oppoi-tunitv Employer. Regional opportunities ing for and include ment planning and in with has work- a variety of Outstanding and research time fringe benefit program. Medical Director and vitae to: Erickson St. Peter Regional 100 Freeman Drive iii and ofapplication D. For the both candidate. William Peter, in a gen- programs. salary letter treatutilizing approach appointment to qualified assessment, implementation team forensic Academic Send clinically psychiatric and multi-disciplinary able Center interested groups. Services eral Treatment psychiatrists administratively disability St. Salary range $72, 136 to $90,795 with libera! fringe benefits, including possibility of on-grounds housing. Send resume to Raymond Cioffi, Personnel Director, Connecticut Valley Hospital, Box 351, Middletown, CT 06457. An PSYCHIATRISTS Treatment Mn., 56082 more information: ST. Center (507) PETER TREATMENT 931-7127 REGIONAL CENTER avail- staff nurses had annual average increases of 7 5 5 percent and 7 5 3 percent, respectively; staff psychologists were earning an average of $42,725 in 1988, staff nurses $27,321. . Annual . rates ofincrease tors of nursing (7.38 for direc- percent) and directors of psychology (7.36 percent) outpaced the rate of increase for directors of social work (6.45 percent). In 1988 psychology directors earned an average salary of $57,4 17, nursing directors $44,605, and social work directors $37,024. Staff social workers earned an average of $28,455. The gap in salaries between staffnurses and staff social workers narrowed over the ten-year period, which may reflect the shortage ofnurses and the lack of problems hospitals experience in recruiting social workers according to the author of the survey report, Dan W. Pope, Ph.D. , Medical directors in private hospitals earned substantially more than teaching staff in medical colleges, whose salary averaged $82,284 in 1988, and medical directors of general hospital units, whose salary averaged S I 10,000. However, the average salary of private hospital medical directors fell below than that ofmedical school department chairs, who were paid an average of $147,IOOin 1988. Both administrators and nursing directors were paid lower salaries in private psychiatric hospitals than their counterparts in general hospitals. Salaries for general hospital administrators climbed at a higher annual rate (9.4 1 percent) over the 1979-88 period and averaged $96,400in 1988. The average salary ofa director of nursing in a general hospital was $52,300 in 1988 and had increased at a higher annual rate (8.84 percent) in the 1979-88 period than the average salary in a private psychiatric hospital. Dr. Pope said the fact that private psychiatric hospitals tend to have fewer beds than general hospitals may account for some of the difference in salary levels. On the other hand, social work directors in private psychiatric hos- Hospital and Community Psychiatry pitals earned more than social work directors in general hospitals, who were paid an average salary of $33,900 in 1988. Dr. Pope said the higher salary in private psychiatric hospitals may reflect the more direct role social work directors play in patient care in those settings. News Briefs Decade George of the Brain: President Bush has signed a congressional resolution declaring the 1990s the Decade ofthe Brain. The resolution, introduced in Congress by Representative Silvio 0. Conte (R.Mass.) and cosponsored by Senator Donald W. Riegle,Jr. (D.-Mich.), is designed to promote awareness of the technological advances that have been made in the last decade in the treatment ofbrain injuries and disorders and to emphasize the need for more research into the brain. Disorders and diseases associated with brain dysfunction include schizophrenia, depressive and manicdepressive illnesses, obsessive-cornpulsive disorder, substance abuse disorders, epilepsy, stroke, AlzheirnerвЂ™s disease, AIDS dementia complex, and ParkinsonвЂ™s disease. The resolution passed the House of Representatives last June 29 with 246 cosponsors and passed the Senate on July 13 with 56 cosponsors. It was signed by President Bush onjuly 25. NAMI training award: Departments of psychiatry, psychology social work, and nursing that are training students to work with the chronic mentally ill and their families are invited to apply for the Award for Excellence in Training presented annually by the National Alliance for the Mentally Ill. The deadline for applications is March 1 1 990. For more information, contact Kayla Bernheim, Ph.D., Livingston County Counseling Services, Building 1, , Stanley awards: The first seven recipients ofthe Stanley Foundation Awards for Research on Serious Mental Diseases have been announced by the National Alliance for the Mentally Ill. They areJ. A. Girault, M.D., of the College de France in Paris; S.J. Watson, Ph.D., M.D., ofthe University of Michigan in Ann Arbor;J. G. Knight, Ph.D., of the University of Otago, New Zealand; C. P. Reynolds, Ph.D., of QueenвЂ™s Medical Centre in Nottingham, England; K. L. OвЂ™Malley, Ph.D., of Washington University SchoolofMedicine in St. Louis; S.J. Peroutka, M.D., Ph.D., of Stanford (Calif.) University Medical Center; and S.J. Lolait, Ph.D., ofthe National Institute of Mental Health in Rockville, Maryland. Twenty senior scientists were also awarded grants through the Stanley Scholars program, which enables them to hire promising students to work with them on research on mental illness. The foundation has pledged to provide $1 million annually to support research on the causes of serious mental diseases. TO ADVERTISERS INDEX NOVEMBER EMPLOYMENT 1115, HALDOL McNeil 1989 OPPORTUNITIES 1204, 1208-1215,C3 DECANOATE Pharmaceutical IBM HEALTh MANAGEMENT SYSTEM MARIN . . . . C2-1 INFORMATION 1116-1117 LODGE MEETINGS NAVANE Roerig 105 1115 & SYMPOSiA 1108-1115 1123-1124 Pharmaceuticals QUALITY HEALThCARE 1140 PAMELOR 1106 Sandoz Pharmaceuticals PROZAC 1110-1112 , County New York 658-2834. November Campus, 14510; 1989 Mount Morris, telephone, Vol. 40 Products/Div. 1129-1136 Burrougha-Welicome The 11 of Eli Lilly & (k. WELLBUTRIN XANAX 716- No. Dista Co. C3-C4 Upjohn Company 1207 Clas sified Rates and Advertising CompHealth cum Tenens Deadlines staffing) Rates: $4.40 per line Classified sionable box rates are to agencies. service number noncommis- Absolute ad and copy changes for deadline for all cancellations issues and West, 84101. December 1 for January Issue January 2 for February Issue February 1 for March Issue March 1 for April Issue Correspondence Tiawana Pierce nationwide toll 532-1200). is: Address finest Lophysician Each . Or #300, we Utah (801) 300 City, UT Lake leader in and Staffing. a change are or just encourage you We currently have starting out to write or call us. openings in Ohio, H&CP Classified Advertising American Psychiatric Association 1400 K Street, NW. Washington, D.C. 20005 Pennsylvania, Virginia, sippi, Illinois, and offer competitive other salaries, community professional (202) 682-6124 (202) 682-6114 ronments, fulland part-time openings and the opportunity to establish a private practice. Contact: ANNASHAE (FAX) All advertisers in this section must employ without regard to race or sex, in accordance with law. Readers are urged to report any violations immediately to the Editor. Hospital Community Psychiatry CLINICAL CHIATRISTS: Management, specializing patient the management facilities, practice privately. the resources powered package of establish you need $100,000; a private stream c.v. to referrals, Director Dept. HC, 7601 200, 3589. 1208 You career: An with income excess in excess are available offers RECTORSHIP POSITIONS tal-based inpatient psychiatric and provides the opportunity to & of of McLean, the practice; 22102; all a highfinancial well freedom Rd., 1-800-368- in to a steady and more. of Recruitment, Lewinsville VA have to build excellent potential inDI- at hospiunits, for you will Send Suite Village, Mississtates. We pleasant Wilson OH 449-2662. confidence. envi- All Mills 44 143- inquiries THE PSYCHIATRIC PLACEMENT SERVICE of the American Psychiatric Association currently has DIRECTORS-PSYMental Health Inc., a nationwide firm in psychiatric 6593 Mayfield 3404; (216) are held in ______________ Nationwide settings, CORPORATION, Rd., Florida, of 1 30 vacancies. in many areas of Positions the coun- thriving underserved first year ongoing stipend sponsibilities. outpatient practice in community. Genercompensation includes for administrative reContact Pam Taylor at (800) 327-1585 or (305) 271-9213 Phoenix-FULL-TIME AND TIME PSYCHIATRISTS-needed for outpt. mental Ambulatory copa County Phoenix, health Care Arizona. Positions For information Munz, Ambulatory dinator, 1400 Fergusson, Psychiatric K Street, 20005; Placement NW, Placement Washington, $90K. ticipate atry Service. inpatient CoorService, DC (202) 682-6108. Carroll 44 1 1 5. 85040; (602) PSYCHIAOR OUTPA- multidisciplinary the AZ Fayetteville-STAFF ThIST-INPATIENT move Graeme available Arkansas Unusual in development exploring contact with children/acontractor provided. contact: Care, Phoenix, at V.A. in please services for work with adults and/or dolescents. Independent status. Malpractice coverage Broadway, 437-4453. PART- Division of ManHealth Department, to interested available, in Florida. TIENT are AL ASSISTANT MEDICAL DIRECTOR-Regional Medical Center seeking recently trained or experienced board-eligible/board-certified psychiatrist to assist in developing expanding inpatient program. Opportunity to de- try for STAFF PSYCHIATRISTS, ASSOCIATE MEDICAL DIRECTORS AND MEDICAL DIRECTORS. If you are seeking a career and positions Proof and Behavioral NeurobiolStation, Birmingham, velop this ous is Healthcare If you David L. Garver, M.D., and Chairman, Department Arizona South POSITIONSCORPORATION a recognized Management seeking (in 155 Salt PSYCHIATRIC ANNASHAE to: free write Contact lessor Psychiatry ogy, UAB 35294. oldest and largest supplier of temporary psychiatric staffing services at: 1800-453-3030 Deadline: the CompHealth Psychiatrist is carefully screened and referenced insuring you competent, reliable coverage. Have your practice covered or join us and cover other practices. Call CompHealth Physician Group, AmericaвЂ™s (approximately 36 characters) $35.20 minimum $ 12.00 extra for blind provides (temporary Medical Center. opportunity of unit new Outpatient team, Salary to parPsychi- clinic 25-bed for acute with open treatment. Me- 187 beds, exPsychiatry. ConM.D., Chief of orJim Williams, dical/Surgical hospital, cellent relations with tact Arthur Arnold, Staff(501) 444-5050, 444-5020. Alabama Birmingham-CO-DIRECTOR OF VA-UAB DAY HOSPITAL PROGRAM-with academic affiliation at University of Alabama at Birmingham (UAB) Department of Psychiatry and Behavioral Neurobiology. Position available immediately in pleasant working environment with cohesive staff on campus of major teaching hospital. Teaching responsibility for medical students and resident electives. November 1989 Vol. 40 No. 11 California Bakersfield-PSYCH IATRI MENTAL HEALTH-Psychiatrist $95,500 $98,000, pensation al benefits weekly. diagnostic patients Health Hospital STI- board eligible; Psychiatrist IIBoard Certified. Total comexceed $ 100,000 with liberpackage. Salaries paid biPosition provides psychiatric, and therapeutic services to of the Kern County Mental Department. A valid and Community license Psychiatry to practice medicine in the State of California is required. Apply immediately: Contact Don Ross, Personnel Analyst, Kern County Personnel Department, 1120 Golden CA 93301 State (805) Ave., Bakersfield, 871-8240. CENTRAL NO-Combine CALIFORNIA-FRESa QUALITY lifestyle with a QUALITY career opportunity as a Staff Psychiatrist. Central California and Fresno offer a unique metropolitan/rural atmosphere of cultural, professional and leisure activities. Yosemite National Park, Carmel, San Francisco, Los Angeles are all within easy reach. FresnoвЂ™s housing values are among the best in the state, with both urban and rural settings. Join our multidisciplinary teams in a variety of inpatient and outpatient settings. Contract salary $100,000 +, CME time, additional pay for specific assignments and malpractice coverage. Please send your Curriculum Vitae and a copy of your current terson, California license to: Paul Fresno County Department Health, 93775; P.O. Box 11867, Patof Fresno, CA (209) 445-3305. ARE YOU WAITING FOR? You now have the opportunity to enjoy an unencumbered psychiatric practice forty hours per week in a variety of clinical areas: Acute, Forensics, Resosonal Geropsychiatnic, Skills world-class Enjoy the Interper- Development. location-the collegiality Practice in a Napa Valley. and support of 80+ staff physicians, 80+ CME hours per year, psychiatric residency program, extensive library, good salary, and generous call. Minimal fringe benefits. No night weekend call. INTERESTED? To apply, send CV to Jeffrey Zwenin, D.O., Medical Director, Napa State Hospital, 2100 Napa-Vallejo Highway, Napa, CA 94558-6293. OR CALL NOW: (707) 253-5434. In California 800-42 1-0666. Equal Opportunity Employer, Affirmative Action, and Physicians psychiatry enal residency psychology Union. program ferred. and Duties will supervising include County. Send resume to: H.B. Kahn, MD, Medical Director, San Mateo County General Hospital, 222 W. 39th Ave., San Mateo, CA 94403. Hospital and Community Psychiatry sev- Po- teaching psychiatry residents, psychology trainees, dents, consultation and medical stuto the organ transplant service and service, development clinic and subspecialty inpatient pediatric of an outpatient clinics, working with the Family Therapy PPMC, and development liaison relationsurgical or medical units, and teach and supervise psychiatry resident and medical students who rotate on the service. Time, facilities and funding are available for research. A California license is repatient care, ships with quired. your CV If you terian Medical San Francisco, January accredited, 1, team. support work with Time, facilities, and are available to initi- ate on continue research projects. Must have, or be eligible for, a California license. Send CV to Robert E. Hales, M.D. , Chairman, Department of Psychiatry, Medical Francisco, Pacific Presbyterian Center, P0 Box CA 94120-7999. 7999, (415) San 923- 3624. San Francisco-CONSULTATION/LIAISON PSYCHIATRY SHIP-Position available Presbyterian Medical a 34 1-bed tal tertiary located Center care in the FELLOWat Pacific (PPMC), teaching Pacific hospi- Heights sec- Box 799, (4 15)923- eclectic ACGME general fulltrainee- psychiatry at a modern leading 340-bed Center, serving as both a corn- program Medical munity hospital ten with other tients a multi- Center, P0 CA 94120; 1990, in an competency-based classes, to send San Francisco-POSTGRADUATE YEAR III PSYCHIATRY RESIDENCY POSITION available on or before skill, ability interested, 3297. psychopathologies, and are and three references to George E. Becker, M.D., Director, Consultation Psychiatry Division, Department of Psychiatry, Pacific Presby- oriented, Clinic at of educa- develop particular tional programs for the community and medical center. Position requires leadership, initiative, administrative served are and tions are and tertiary care GME programs. representative socioeconomic ethic Clinical groups. coordinated conferences, and sion to maximize Strong professional among with rota- seminars, individual superviin-depth training. and teaching ties Psychiatry, nal Medicine, Social Work cenPaof all Neurology, Clinical provide Inter- Psychology, and a well-rounded interdisciplinary education. Competitive stipend and benefits. Eligibility for California license required. AAIEOE. Inquiries: James R. McCurdy, M.D., Director, Psychiatry Residency Training, or Larraine Decker, Training Coordinator, Department Pacific Presbyterian P.O. Box 7999, 94120-7999; of Psychiatry, Medical Center, San Francisco, CA (415) 923-3510. tion of San Francisco. This is an new fellowship to begin July 1, 1990. Stipend is at the PGY V level with opportunities Colorado lowships Denver-PSYCHIATRIST-Innovative team working with older adults. Medical evaluations, consultations. Some supervision. $78K to $ 104K to augment funding. PPMC is a major teaching center with residency programs in psychiatry, medicine, pathology, and ophthalmology, and felin cardiology, pulmonary ical care, gastroenterology, mology subspecialty San Francisco Bay Area-INPATIENT ADULT PSYCHIATRISTExellent opportunity for a creative inpatient ad ult psychiatrist involving training and supervision of Psychiatric Residents and working in a most progressive and innovative community mental health program with consultatiye/evaluative and treatment roles. Competitive salary with strong benefit package. Half-time to full-time position available in culturally rich, environmentally beautiful San Mateo and programs. training sition is part-time, with excellent salary and benefits. Full-time office available for private practice and secretarial support provided. Individual must be Board eligible. Board certified pre- disciplinary financial Napa-PSYCHIATRISTS-WHAT cialization, San Francisco-CHILD PSYCHIATRIST-Position available on or before January 1, 1990 at Pacific Presbytenian Medical (PPMC) a 34 1 bed tentiary care referral center located in the Pacific Heights section of San Francisco. The Department of Psychiatry is expanding the number of core faculty members. It has a four year approved transplant. The areas, hospital ing site for various and is also surgical ties (orthopedics, others) and other cnitophthal- plus liver a train- subspecial- general medical benefits for full-time. Part-time also available. National Institute Behavior Change, (303)296-2244. Ask for Lois Munson. for surgery and disciplines. PPMC is noted for its pioneering work in performing kidney, liver, bone marrow, and heart transplants. The hospital has a major commitment to oncology, kidney dialysis, and cardiac rehabihitation. New and expanded Jacksonville-PSYCHIATRIST-A comprehensive community programs license. Excellent benefits. Alberto Director, Center, Please respond with CV to: de ha Tome, M.D., Medical Mental Health Resource Inc., P.O. Box 19249, JackFL 32245-9249. EOE. in OB/GYN and pediatrics have recently Consultation multidisciplinary been established. The Fellow would serve on a Consultation Psychi- atry staffed Service psychologists, cialists. November and He/she 1989 by psychiatrists, clinical would Vol. nurse provide 40 spe- direct No. 11 Florida health he/certified sonville, M/F/H/V. center is seeking psychiatrist with salary mental a board-eligiba Florida plus other 1209. Commonwealth Indiana Logansport-STAFF TRIST-Logansport has immediate PSYCHIAState Hospital opening for Staff Psystart- chiatnist. Extremely ing salaries and ranges are negotiabhe experience and training. Ex- based of Kentucky. Inquir- fessionals Vitae be sub- 12-bed mitted to Vice President for Resource Development, Comprehensive Care Centers of Northern Kentucky, P.O. Box 1260, Covington, KY 41012. EOE. CMH. ies and on competitive cellent fringe for on-grounds benefits housing. with potential This hospital Curriculum Michigan is based upon a medical provides an atmosphere sional growth. Indiana completion of approved model and for profeslicense and psychiatric residency required. Contact W. Edward Smith, Human Resources Director, Logansport State Hospital, Logansport, IN 46947. (219) 722-4141. Equal Opportunity Employer. Male/Fernale. Alpena-STAFF Four county Health Clinic time PSYCHIATRISTCommunity Mental on Lake Huron has full- vacancy in well-established Clinical supervision and staff on outpatient 27-bed tal. sional inpatient matehy tating $102,000, on-call; and Charles dependency Central program, an ex- to work ty and in a peaceful, get that Knoxville just counseling center, services. If you want hometown feeling, then for you, located from Des Moines, include attractive re- minutes Benefits tirement tion, communi- is the place 45 Iowa. rustic plan, fifteen thirty days sick and mulate), health practice coverage. days paid vaca- leave (can accu- life insurance, Competitive malsalary and bonus depending upon quahifications. Require hicensure in any state. Equal opportunity Chief of Staff Center, 15 15 employer. Contact (1 1), D. V. West Pleasant A. Medical St. , Knox- ville, IA 50138; (515) 842-3101, ext. 6006. Kentucky Covington-CHILD LESCENT and AND ADO- PSYCHIATRIST-Varied stimulating serving full seriously chemically time, dependent olescents joint and/or children at a large JCAHO Community position disturbed Mental Health and ad- accredited Center and bed private, non-profit child and adolescent psychiatnic hospital. Progressive multi disciitвЂ™s associated phinary phasis tialed salary. within fifty-one atmosphere with strong maintaining convenient to a wide highly variety of cultural, educational, and suits. Candidates fled or eligible, must be Board and licensable 1210 em- credenprofessional staff. Competitive Located in Northern Kentucky the Greater Cincinnati area on recreational puncertiin the A. White, leave; Director, MenAve., Al- Community 49707; State (517) 356-2161. CHILD PSYCHIA- TRY SERVICES-Fellowship trained Child Psychiatrist needed for inpatient/outpatient practice. Area hospital has 15 bed adult unit and 18 bed child unit. Second Child Psychiatrist sought to assist on DRG exempt program. Excellent guarantee and benefits. Community mental health center attached to hospital. Large liberal arts and business university in town. Short driving distance to Lansing and De- troit. Send curriculum vitae or call: Durham Medical Search, Inc., 6300 Transit Rd., P.O. Box 478, Depew, NY 14043, 1-800-633-7724 (National), 1-800-367-2356 (NYS). Minnesota Fergus Falls-PSYCHIATRISTPosition available for psychiatrist in the beautiful lakes area of Minnesota with numerous cultural, educational, and recreational opportunities. Work with multidisciplinary team to provide outpatient services to varied clientele. Opportunity for clinical faculty appointment. Salary to $1 15,000.00. Excellent fringe benefits, including paid malpractice insurance. Please call (218) 736-6987, or send CV to Clinical Director, Lakeland Mental Health Center, Inc., 126 East Alcott Ave., Fergus Falls, MN 56537. Winona-PSYCHIATRIST-A established community system seeks mental a board well health certified-board eligible psychiatrist. Opportunity offers outpatient practice at a Mental Health Center with a staff of 45 pro- November 1989 Vol. 40 along beautiful miles south practice mental A community on a health unity of26,000 Mississippi of Numerous opportunities at located River, Minneapolis/St. educational 110 Paul. and cultural are provided by an expanding University with graduate programs and private liberal arts college. Excellent compensation and benefit package. Send CV in confidence or contact Rand Gettler, Community Memorial Hospital, 855 Mankato Ave., Winona, MN, 55987. Call collect (507) 457-4302. No. Jefferson An E.E.O. 11 City-CLINICAL NURSE SPECIALIST-Exciting, new position for RN to coordinate nursing function of adult psychiatric unit. Responsibihities include: standard of care, patient care delivery system, staff development, education. BSN required; minimum of two years recent acute mental health experience preferred. Colleges and from Michigan-ASSOCIATE OF inpatient Missouri ro- vacation/sick 1 13 South DIRECTOR tended alcohol rehabilitation program, a transitional care unit, a day treatment center, a clinical and consultation tal Health, pena, MI EOE. includes leave, disability, life, malpractice insurance. Michigan and certified hospi- for profesto approxi- which paid Contact Northeast in general opportunity Salary: Up Knoxville-CHIEF, PSYCHIATRY SERVICE-Knoxville Veterans Administration Medical Center is actively recruiting for a Chief, Psychiatry Service. Our medical center has four acute general psychiatry units, an alcohol Iowa clinic. of agency clients basis; access to unit Excellent growth. educational health, treatment may universities beautiful nearby; Lake of 45 minutes St. Marys Health the Ozarks. Competitive salary and benefits. Equal Opportunity Employer. Submit resume to: Kathy DeForest, Manager/Mental Health, ten, 100 St. Marys Medical ferson City, MO 65101. Kansas Cen- Plaza, Jef- City-STAFF PSYCHIAexists for a fulltime staff psychiatrist to serve in a new outpatient post-traumatic stress treatment program at this medical center. This is an opportunity to participate in the development of an innovative treatment program; playing an important role in shaping the program and the position. Involvement in a variety of treatment, research, educational, and administrative activities are possibhe, according to the incumbentвЂ™s interests. The Medical Center is a 470bed general medical/surgical/psychiaTRIST-A tnic vacancy facility affiliated with the University of Kansas Medical school and a number of other professional schools. Applicants will be eligible for an academic appointment to the University of Kansas Department of Psychiatry. The Kansas City area offers both one of the highest qualities of life and one of the lowest cost of housing and living of any major metropolitan area. Top flight recreational activities of all varieties are available, including theater, symphony, the arts, professional and collegiate sports, and many parks and outdoor recreational areas. Inquiries should be made to the Directon, PCT, VAMC, 4801 Linwood Blvd., Kansas City, MO 64128; (816)861-4700 extension 371, or FF5 754-1 37 1 Smoke-free facility. EOE. . Hospital and Community Psychiatry Nevada-PSYC RECTOR AND H I ATRIST-DISTAFF-JCAHO-ac- New credited mental health center located in scenic southwest Missouri seeks apphicants for a clinical director and a staff psychiatrist position. Our center provides both inpatient and outpatient services in adult psychiatry. Minimum qualifications include residency cornphetion and license eligibility with administrative experience preferred for the director position. Salary is negotiable with free legal liability coverage and excellent fringe benefits. Enjoy a relaxed lifestyle and lower cost of living near the scenic Missouri Ozarks region. Contact Personnel Office, Nevada State Hospital, Nevada, MO 64772; (417) 667-7833, ext. 2152. New Hampshire Manchester-Board-certified/boardeligible PSYCHIATRISTS for adult inpatient unit and a child and adolescent unit in a community hospital that serves an area of 240,000. This is a dynamic and aggressively expanding program of behavior medicine and psychiatry in an acute care setting located in beautiful tax-free New Hampshire! Only 45 minutes to Boston, Seacoast, lakes, and mountains region. Responsibilities revolve primarily around the provision of inpatient services, but the opportunity exists for outpatient salary/benefits quire or Sharon 80 care as well. package CV in send Dionne, Into: multispecialty going qualified group major tus, including income ten of Carol Group City FELLOWSHIP CHIATRY-Now IN the Fellowship Columbia York & Area PUBLIC in its ninth in Public University State PSYyear, Psychiatry and Psychiatric the of New Institute pre- pares junior psychiatrists for successful management and clinical roles in the most progressive aspects of public secton psychiatry. The training program includes teaching in strategic organizational management, advanced practice in social psychiatry and family therapy, and the scientific basis of public practice-evaluation ohogy. with research Didactic exercises on-site field model clinical for six full-time, will 1989. Direct are combined experience until inquiries M.D., 722 West 10032; 168th and in December to Director, Street, R. FellowBox 1 11, Institute, New York, (212) 960-2556. Community Psychiatry program. Send letand CV to Mrs. Sessa, Slocum-Dickson PC, 430 Court St., Medical Utica, NY North salary/benefit package awaits board-certified/boardeligible adult psychiatrist in large, progressive community mental health centen. Staff position currently available offers opportunity to work in academics, research, direct inpatient and outpatient care, administration, and program development. Rapidly growing city of 450,000 with low unemployment and thriving economy. Located 1 hours from the 3 mountains, 1/2 hours from the beaches, Charlotte is the largest city in the Carolinas. Send C.V. to: JoAnn sician land its Silver and from school. major Our cludes Crenshaw, Recruitment, Charlotte, NC Kaiser R.N., P.O. Box a seeks PSYCHIATRISTS and certified/board-eligible CHIATRISTS to medical board- CHILD PSYjoin multidis- mental health Durham/Chapel in board-cer- staff in Hill, our and Must have offices. psychopharmacology and therapy. Excellent salary/benefits including professional hiability and medical coverage, paid vacation and sick leave, holidays, continuing education, retirement plan, and shareholder opportunity. CV to Phyllis Kline, Recruitment Coordinator- HCP, Carolina Permanente Medical Group, P.A., 3 120 Highwoods Blvd., Raleigh, NC 27604-1018; (800) 277CPMG. AA/EOE. twenty miles and medical package in- competitive salary/benefits Wilson-PSYCH prehensive IATRIST-ComCommunity Center Mental east of Raleigh, NC, Health seeks the ofa board eligible psychiatrist. is well funded, well organized professional, congenial staff. Our Medical Records manager has a great disposition. City of Wilson is family oriented with excellent medical facihities. Drive to work in 1 5 minutes. Convenient to beach tans, metropolitan cehlent benefits We are resorts, moun- areas and 1-95. Exwith paid malpractice. a special program seeking a special doctor to provide psychiatric care and supervision. Call collectJohn White, Area Director, (919) 399802 Affirmative Employer. 1. portunity Action/Equal Op- Oregon Pendleton-CHIEF FICER-This 32861, 28232. Permanente ciphinary Raleigh, Phy- Lake; university compensation plan, including malpractice insurance. Please contact: Faye Rogers, Area Director, Tideland Mental Health Centen, 1308 Highland Drive, Washington, NC 27889; (919) 946-8061. with Carolina Charlotte-Excellent 1/2 to boating, fishing, and sailing Pamhico Sound to Ocracoke Is- services Program 13502. MEDICAL is an opportunity OFto lead an outstanding team of clinicians and to realize your vision for rural public psychiatry. The Chief Medical Officer must be a creative and skillful psychiatnc administrator who is committed to participative management and innovation. The Eastern Oregon Psychiatric center is a state-operated, sixty-bed general psychiatric inpatient component of a sixteen-county rural mental health network. The Center and its associated county mental health programs have a long history of close cooperation and coordination. This Iacihity is known for its teamwork, cornmitment to innovation, and high morale. It is associated with the Oregon Health land, Sciences and University a joint Department of in Port- appointment win the Psychiatry may be to the CMO. EOPC is located in a town of 15,000 at the foot of the Blue Mountains and in the center of world-class fishing, hunting, wind surfavailable Washington-PSYCHIATRISTTIDELAND MENTAL CENTER, a comprehensive ty program Coastal serving Plain opening portunities include and clinical HEALTH communi- five of North immediate fled/board-eligible ices 3 1, William in Public Psychiatry, York, State Psychiatric NY Hospital site epidemi- services. Applications one-year positions be accepted McFarlane, ship New and with proSta- incentive cost-accounted distribution introduction short-term York currently underis seeking a expansion ble psychiatrist. Salaried position excellent corporate fringe benefit gram. Two years to Shareholder skills New MED40-member board-certified/board-ehigi- Charlotte (603) 623-1321. access across State Utica-SLOCUM-DICKSON ICAL GROUP PC-A tifled attractive is offered. confidence do Health NorthEast, Rd., Manchester, NH Tarrytown 03103; An York counties Carolina, in the has an for a board-certipsychiatrist. direct patient supervision variety of outpatient peutic settings. and Op- serv- to staff special Experience in a thera- with 1989 Vol. 40 No. skiing, 11 and mountain climbing. PendletonвЂ™s schools are excellent, estate is exceptionally affordable, three major metropolitan areas within be three and hours drive. a board-eligible psychiatrist substance abuse and chronic mental illness a plus. We are located in a beautiful geographical area of coastal rivers, lakes, and sounds with headquarters in the City ofWashington, nestled on the navigable Pamhico River with ready November ing, or with You should board-certified inpatient administrative real and are experience training and/or experience. Salary to $72,204 with an excellent fringe benefits package. Contact Stephen penintendent, H. Feinstein, Eastern PH.D., Oregon Su- Psychi- atnic Center, 2575 Westgate, Pendleton, OR 97801; (503) 276-0810. 1211 Salem-STAFF PSYCHIATRIST- Are you interested in living one hour from the spectacular Oregon coast, the scenic Cascade Mountains, and the cuhtural pursuits of Portland? Oregon State Hospital is JCAHO-accredited with general adult psychiatry and these specialty areas: forensic, geriatric, child/adolescent, and correctional psychiatry. Several openings academic affiliation Health Sciences have possible with Oregon University land. Individuals ic appointment may spend one in Port- approved for academin forensic psychiatry day a week doing teaching/research with an ongoing fonensic research team. Onsite teaching and supervision is also possible. Salem is the state capital and is a small, familyoriented city. Medical staff may choose inexpensive, tractive housing like hospital spacious located on the at- park- campus. Housing else- area, including rural are where in housing, excellent health is inexpensive. including insurance, life tional and the deferred Benefits comprehensive insurance, compensation op- rise up Officer to $90,800 in July, of the day duties 1990. provide generous additional pay (up to $16,000) or vacation time. Contact Philip Shapiro, M.D., M.P.H., Chief Medical Officer at (503) 378-2374, Oregon State Hospital, 2600 Center St., N.E., Salem, OR are Department of Equal Opportunity ployers. Tennessee Knoxville-PSYCHIATRIST to join three full-time and two part-time psychiatnists for full- or part-time position. with private, non-profit, comprehensive ten. 97310. community Columbia-ACADEMIC CHILD PSYCHIATRISTS-Department Neunopsychiatry of and Behavioral Sci- ence, University of South Carolina School of Medicine. Challenging opportunity in child psychiatry programs including gram a psychiatry at the fellowship pro- S. Hall Psychiatric Institute. Requires a demonstrated competence and strong interest in clinical teaching and pursuit of scholarly activities. Level of appointment and salary depending upon candidates experience and qualifications. Salaries can be supplemented through the DepartmentвЂ™s Professional Practice plan. Excellent fringe benefits program. The Hall Psychiatric Institute is located in beautiful downtown Columbia, only capital a few of South miles affiliated blocks Carolina. Carolina from the University Approximately 100 Ocean and for write Don- M.D., the South Blue Ridge Mountains, excellent weekend trips. For information, or call the Chain, Alexander G. aid, from William of P.O. Atlantic Box 202, SC 29202; (803) 734-7113. versity South Carolina 1212 of mental Negotiable package salary health and full cenbenefit for board-ehigible/board-certi- fled M.D. AACP/APA Position Guidelines. patient community and inpatient meets/exceeds Includes out- services and and university hospi- services tal on grounds. Private practice permitted. Outdoor mountain/water necreation abound. Stable, quality cornmunity practice in metro area of 594,000 with University of Tennessee and Smoky Mountains. Contact Clif Tennison, M.D., Helen Ross McNabb Center, vilhe, 1 520 TN Cherokee 37920; Trail, (615) Knox- 637-9711. Columbia, The and UniSouth or of exceeds Beaumont-Psychiatrists highly developed, needed in JCAHO- 4-county accredited CMHC in process of expanding scope of operations. Innovative methods of delivering services to all segments of by-line. Primary mont area 250,000) my, highly the population service sites (Tn-City with and Great commu- recreational fresh/salt fishing 1 hour from 30 minutes from the hour drive to Houston. GulfCoast. Flexible uhe and the in our assignments and base econo- medical cultural residential, is our Beau- population a well-balanced developed many in lakes for work load: tient. Salary weeks inpatient American Asso- Psychiatrists psychiatric practice. Af- 80% outpatient, and fringe vacation, 20% inpa- benefits one week (three CME/year, etc.) over $100,000, depending sition and qualifications. Contact ent G. Denney, M.D., Medical ton, P.O. Box 4730, Tyler, TX on po- Rob- Dinec75712; (214) 597-135 1. EOE. Tyler is a beautiful place to live, 1 00 miles east of Dallas in the Piney Woods and Lake Country. El Paso-PSYCHIATRIST-New position division center. board in expanding medical services of a community mental health Requires board eligibility on certification and Texas license. A base salary depending fication. of upon Fringe plus $73,300-$95,700 experience benefit and certipackage of administrative and malpractice liability coverage. El PasoвЂ™s cost of living is considered one of the lowest in the nation. Average three bedroom house rents for average home Mountain $496.00 per month; sells for $65,000. resorts with skiing and fish- two hours away. A culturally diverse major metropolitan area, El Paso has a population ofover 500,000. Our claim is not one of putting more money into your life but we do proming are ise more Spanish/English water formation, region, Personnel Center, 1-1/2 sched- all Community fihiated with University of Texas Health Center at Tyler, we provide psychiatric rotation for their Family Practice Residency. Well-distributed 23% Texas opportunities. Carolina it meets ciation standards nity, South Mental Em- and outstanding state-paid retirement, for a total benefits package worth 42% of annual salary. Salary for a board-centifled psychiatrist is up to $84,500 and will Carolina Health 79990; life for your money. Bilingual required. For more incall or write W. M. Smith, Director, Life Management P.o. Box 9997, El Paso, TX (915) 594-1069. outpatient, Houston-PSYCH! psychiatric ATRISTS- adult crisis stabilization in a structured 40-bed residential facility and a 20-bed chemical dependency unit. Functional duties will include Lange, multi-program Psychiatry Service in major VA general hospital seeks two certified or eligible psychia- evaluations in hospital, & assessments, treatment team recommendations, evaluation and monitoring. qualifications: degree proved of medical 3-year. school Psychiatry gram, Texas medical Board certified and ence preferred. $ 102,000, DOE status; excellent Contact rector, John Adult medication Minimum from an ap- full-time and treatment leadership positions abuse affiliation outpatient programs. drug Strong and completion residency benefit post pro- required. board Salary and expeni- $80,000- board certified benefits EOE. TX, 77701; package includes bonuses subsidized 30 life no malpractice P. Ross, A.C.S.W., DiResidential Programs, MHMR of Southest St., Beaumont, TX 6203. for inpatient with Baylor College of Medicine ports opportunities for teaching research as well as clinical care. license and fringe tnists 2750 5. 8th (409) 838- new hospital ample days and health opens heave, insurance, Magnificent in autumn of 1990. Positions available January 1990. Send CV to William E. Fann, M.D. Department of Psychiatry, Baylor College of Medicine, One TX 77030. Baylor Plaza, Houston, Houston-PSYCHIATRIST East Texas/Tyler-PSYCHIATRIC POSITIONS available to join five other psychiatrists in a comprehensive community CMHC has November mental health strong medical 1989 Vol. center. leadership; 40 No. SERV- ICES-GENERALIST-CHILD/A- DOLESCENT-Mental Mental Retardation nis County, Houston, ditional 11 and Full salary annual premiums. sup- Hospital Physician and Health and Authority of HanTexas, seeks adservices. Community Two years Psychiatry experience in a psychiatric setting. Must be board-certified or board-ehigible. If you are interested in full-time or part-time services, contact Catherine Fine Art, collegiate International Henry, major Director, (713) Human 3737 683-4012, D, Houston, TX Resources, Dacoma, Suite clinical Texas. nestled a variety of evaluations, supervision, development in a flexible area of beautiful East Texas, 125 Northeast of Houston, 175 miles Southeast ofDallas, and 20 miles South of a 12,000 student population State university. Favorable cost-of-living area with a base salary of $100,000 plus travel pay of up to $12,000/year and an additional $ 1 ,000/week compensation if on-call duty is worked. Benefits include 1 3 paid holidays and vacation days/year, insurance. candidates may call or Dr., Lufkin, TX 75901; package expenses, holidays, and an paid or send (804) 23803. for a motivat- ehigi- Psychiatry additional call duty. benefits, and Eastern on- exists for faculty affiliation of Washington The hospital is situatfrom Spokane, in the Pacific Northwest. a wide range of cultural opportunities includ- civic theater, two fourtwo community colleges, Washington University. and an hourвЂ™s lakes, drive, lent skiing, fishing, ing. Several public, golfing facilities are vicinity. for possibility mountains less than ad- for continuing Salary: $85,740 to have University colleges, retireand compensation The year insur- compensation the heart of Spokane offers and educational vaca- life within offer excel- sailing, and huntas well as private in the immediate In addition, relocation costs are provided. Housing costs in the Spokane area are below the national average. Interested psychiatrists should contact Al Miller, M.D., col- Wisconsin eligible/board hospital. with the Medical and attractions of a the Medical College of Virginia with opportunities for teaching and research. Richmond, вЂњone of the most livable cities in the countryвЂќ is conveniently located within an easy two hour drive to the mountains, beaches, historic вЂ�Williamsburg, the nationвЂ™s capital, and affords a wide array of cultural, histonical, and recreational opportunities. In the greater Richmond area there are opportunities to enjoy the symphony, Community employer. Ft. Steilacoom-GENERAL CHIATRIST (Board hiking, ble or board certified psychiatrist to become a pant of our staff. Opportunity for practice with adult and forensic and State Petersburg, EEO/AA plus Nearby vi- Central 4030, deferred of paid leave, Washington The hospiUniversity of School nearby with skiing. include chini- sports. and the The State income CV plan. Send Professional Hospital, (206) Services, Fort 756-2349. Medical insurance, equivadeferred to Director, State WA 98494; STATE addition of cellent knowledge of psychopharmacology, the to working in an interdisciplinary and relate well be new setting, health recreational outlets An excellent November 40 Vol. Excellent include Door Winnebago and LawUniversity. Low overhead, exincome potential. Specialty inencouraged. Call Ken Olson, Lake County, Madison or write St., Suite 530, 1531 South Appleton, WI 54915. & Conferences AMERICAN GROUP PSYCHOTHERAPY ASSOCIATION ANNUAL MEETING, 34TH ANNUAL INSTITUTE, 47TH ANNUAL CONFERENCE, THE WESTIN No. PLACE, BOS- interest 11 sections geared toward experiential learning. Different modalities will be represented by top therapists. In conjunction the Conference with provides the Institute, stimulating papers, panels, demonstrations and workshops designed to broaden the scope of the participantвЂ™s area of expertise. Topics to be covered include: Hospital cen- tens and the community. 1989 nity in the hub ofWisconsin. cific comfortable to mental primo-oppontu- TON, FEBRUARY 20-24, 1990: The Institute is devoted to small group teaching and provides an array of spe- psychiatrist positions, the hospital has psychiatric vacancies in its adult, geniatnic, and forensic psychiatric programs. Applicants should have an exability hospital-affihiat- risk, HOTEL-COPLEY Lake-EASTERN to the private Low Meetings EOE. Due practice. seek psychiatrist an HOSPITAL is a 362-bed JCAHO-accredited facility serving Eastern Wash- ington. psychiatrists inchud- Western Steilacoom, to join thriving ed (414) 738-2727, and are is without estimated optional of or adolescent/child Seattle- benefits, ing hospitalization/medical retirement, vacation hence at 24%, plus group general theatre, cool summers housing costs tax. Excellent Appleton-PSYCHIATRIST-Pro- gressive rence cellent terest Additional symphony, professional income with the possibility appointment with liabil- insurance, cal faculty appointment possible. Located on Puget Sound, the area offers boating of all sorts, fishing, camping, (409) board 11 curriculum do Box An Washington Area-PSYCH!- is searching populations joint faculty their medical/dental ment, ing symphony, leave, health 524-7511, P.O. certified (HCFA) tal is associated send Hospital, sick professional Tacoma area enjoys temperate winters; professionally fringe relocation tax deferred cornInterested applicants plan. call to certified and with WA State license)-.Salary to $85,74 1. Western State Hospital is a fully accredited (JCAHO) and ing JCAHO accredited psychiatric hospital located on a beautiful 700acre campus twenty-five miles south of Richmond and ance, Medical School. ed twenty-minutes certi- Excellent consists sick holidays, psychiatrists with the upward board including annual reasonable stimulating Hospital or eligibility. and State nationally for package tion, lect, (509) 299-4351, or P.O. Box A, Medical Lake, WA 99022, for further information. Virginia Richmond a bonus benefit Hospital, . ATRIST-Central both and ranges plus fication son, 639- 1 14 1 EEO/AAE. Greater cities benefit ministrative leave medical education. Rich- taeвЂ™s to: Richard Elliott, M.D., Ph.D., Medical Director, (804) 524-7291 or John P. Kirby, Recruitment Supervi- their resume to: Mn. Tim Richenson, Director, Human Resources and Business Planning, Deep East Texas MHMR Services, 4101 South Medford linking The hospital has an active medical education program with experience, VA from of the area provides many opportunifor continuing education, includthe Medical College of Virginia. Salary is negotiable commensurate may approved medical school and completion of an approved three year psychiatnic residency required. Two years experience in a clinical management position following residency program preferred. Must have Texas license and Board Certification preferred. Qualified other pensation $8,000- Graduation closely ity and life insurance, paid retirement, and $ 1 0,000/year center contribution to your retirement plan, no social secunity taxes withheld, paid medical/dental/hife insurance, and paid professional liability Museum and ties ing paid miles 12 to $97,327, environment located in Lufkin, Lufkin (population 30,000) is in the non-urban pineywoods- /lakes airlines mond Mental Health Center to provide services including medical psychotherapy, clinical staff recognized and, both professional and sporting events. Richmond Airport is served by six and abroad. continuing 77092. Lufkin-PSYCHIATRIST-Staff psychiatrist for Community and a nationally Approach. Accreditation Settings AGPA and Group-Centered is accredited Council for by the Medical 1213 Education to cation also for sponsor credits continuing for meet the the American PhysicianвЂ™s Events criteria for Medical Category Association Recognition program contact: East 2 1st Street, NY 10010. 1 Award. information materials edu- physicians. and For registration AGPA, 6th Floor, Dept. New 4, 25 York, Premiering in the January 1990 issue, the Products and Services Directory CALL FOR PAPERS. SUICIDE IN THE 1990вЂ™S. American Association of Suicidology 23rd Annual Conference, New Orleans, Louisiana, April 25, 1990. Contact: AAS, 2459 5. Ash, Denver, CO 80222; (303) 692-0985. Books & Tapes HELP YOURSELF AND YOUR PATIENTS. Psychiatrist-produced VHS tapes save you patient compliance, ity by explaining and precautions time, improve and reduce liabilthe uses, side effects for Lithium, Neuro- leptics, and the medications used for treating Anxiety and Depression. Use them in the office, hospital, training, etc. Approximately each. One tape-$59; three-$145; four-$180. rency twenty or equivalent. minutes two-$ 100; U.S. cur- Send check, ey order, or Master Card/Visa, number to 2060 P55, Drive, Suite Houston, TX 1 597 for Money A Space Park 404, Department 77058. Call (713) information Back Mental mon- AMEX or to D, 335- order. Guarantee. Health classified Employers ad in COMMUNITY HOSPITAL PSYCHIATRY & adds a new dimension to your staff recruitment efforts. HereвЂ™s why: 1) A classi- fled ad in H&CP takes into a wide variety treatment settings, and administrative country. 2) ensures reach other 3)The in H&CP incorporated ment that your message psychologists, health cost means in program. your position available issue! 1214 the psychiatric nurses, activity therapists, mental low across interdisciplinary psychiatrists, administrators, cial workes, message agencies H&CPвЂ™s readership will your of mental health training programs, professionals. of classified that your Plan openings soand advertising it can current now easily be recruit- to advertise in the next November 1989 Vol. 40 No. 11 Hospital and Community Psychiatry .. PSYCHIATRIST POSITION FlED OR BOARD MUST BE LICENSABLE LENT SALARY CREDITED IN INDIANA. BENEFITS. AND FACILITY INDIANA. 1-2 TOWN ATMOSPHERE DRIVING NITIES INVESTIGATE HERE CENTER, AT SEND LEUERS THE AND PERSONNEL EQUAL BOWEN is the health members board eligible certified/board us keep up with Program rapid in growth Northeastern multispecialty group practice care services to the In the Cleveland-Akron more than of oven 40 plus Permanente a mature, Kaiser that 205,000 area. of experience makes years (25 in leader solId, in the managed care sector of the health care industry. The rewards of practice with us are substantial-excellent salary and benefit packages, company-paid retirement plan, full malpractice coverage. A stimulating, cine, Kaiser environment in which PermanenteвЂ™s of the dynamic, offers the best Please to practice Ohio Region resurgent, ofbig your living resume mcdl- may call us in the heart Midwest. The and culture area in an area. to: Ronald G. Potts, M.D. Medical Director Ohio Perinanente Medical 1300 E. 9th Street, Suite Cleveland, OH 44114 EMPLOYER Is located industrial city sophistication accessible send IN 46580 oryou quality more... and affordable, BOX 497 OPPORTUNITY for Permanente OPMG collegial TO: Ohio Permanente Group, Inc. to help Kaiser Ohio) OffICE WARSAW, looking Our wealth REFERENCE OF LICENSE COPY P.O. R. 3 are provides Kaiser OPPORTU- OTIS RESUME, the Medical the Ohio. SPORTING THE WeвЂ™re we of OFFERING MAJOR AND A LEADER PSYCHIATRISTS DISTANCE CITIES ARTS TO THE and METROPOLITAN EVENTS. IN IN NORTHERN HOURS THEATER, AC- REQION SMALL WITHIN JCAIIO PERMANEN1E JOIN EXCEL- LOCATED OF LAKES HEART OF KAiSER FOR BOARD CERTIELIQIBLE PSYCHIATRIST. AVAILABLE collect at Group, 1100 (216) Inc. 623-8780. BINGHAMTON g!!c ;51v,i fttiiiicic PSVCHIATRC CENTER Child Psychiatrist M[LICAI CERTiFIED BOARD DIRECTOR PSYCHIATRIST OF A 48.BED MEDICAL D1RECTOR AND MEDICAL HEALTH UNIT SERVICES POSITION AS MEDICAL COMPREHENSIVE WITHIN TO THE OF MEDICATION OF PROVIDED ASSURES AND REGULA11ONS BOARD OVERSEES APPROPRIATENESS CENTER, AGENCY BY MENTAL AS IN PROVIDES MANAGERIAL A DIRECTiON AND TO THE HAVE AN ALL LAWS. THE SERVES THE AS ADVI- DIRECTOR, CENTERвЂ™S CONSULTANT TO MENTAL WITH CUNICAL RELATION THE INDIRECT REPRESENTS COMMUNITY MEDICAL ASSURES AND COMMUNITY COMPUANCE DIRECTOR. DIRECTORS SERVES CUNIC, DIRECT REQUIREMENTS; MEDICAL EXECUTIVE ALL GARY MEDICAL FUNDING THE SERVICES; MUST INPATIENT FILL TO PHYSICIANS AND MEDICAL THERAPISTS; AND CUNI- DIRECTOR. BE BOARD CERTIFIED. COMPE1ThVE SALARY SEND OF APPUCATION LFflER LaNITA HUMAN GARY (219) AND MUST FRINGE BENEFIT AND VITAE INDIANA PROGRAM UCENSE OFFERED. TO: M. JAMES We are COMMUNITY core position as a Child Psychiatrist Psychiatric Center. a 535 bed JCAHO accredited awaits you at the New York State Hospital. We have a 15 bed Adolescent Unit consisting of adolescents ages 13-18 drawn from a 5 county catchment area. The Adolescent Service provides a full range of psychiatric services and is closely networked with community agencies and school systems. We are currently in the planning stages for a major capital expansion. Binghamton, New York is nestled in a valley of the Appalachian Foothills, an area of outstanding natural beauty which is centrally located and easily accesses New York City, Syracuse, etc., the Fingerlakes and Poconos. The Metropolitan area boasts a population of 250,000 with excellent school systems and a major university and many other cultural associations. We are seeking the right individual who is board certified in child psychiatry and is a dynamic leader, a team oriented individual and one who will guide our Adolescent Unit with vision as we continue to expand. Who CareвЂќ and grow with us. DEPARTMENT MENTAL 6th AVENUE INDIANA who Come and join the вЂњPeople RESOURCES I 00 WEST GARY, A fulfilling Binghamton Psychiatric QUAUTY CAL TO FACIUTY. HEALTh SOR I PopIe HEALTH CENTER, INC. Contact: Mr. Russell Jordan Director of Human (607) 46402 Resources 773-4012 881-2456 EOE/M/F , EW STATE Equal HEALTH 0punI/AffirmatIve FFICEYORK OF MENTAL ActIon Employer