Systematic errors are caused by flaws in the hospital system or in the transfer of information. The failure is in the health care delivery system as a whole rather than in the individual doctor. An example is an inability to retrieve a patient’s medical records. Individual errors are attributed to a particular physician or to a specific member of the treatment team. The physician bears the responsibility even if the error is made by a person under his or her supervision. Examples include prescribing the wrong medication or operating on the wrong leg. It is appropriate to use email that contains patient information providing all releases have been obtained. Systematic errors are more common in institutions where many people have to interact. Solo practices have few people, so there is less chance for errors to occur.

Melatonin is the substance that has been implicated in mood disorders with a seasonal pattern. Melatonin’s exact mechanism of action is unknown, but its production is stimulated in the dark, and it may affect the sleep–wake cycle. Melatonin is synthesized from serotonin, an active neurotransmitter. Decreased nocturnal secretion of melatonin has been associated with depression. A number of other substances also affect behavior, and some known endocrine diseases (e.g., Cushing’s disease) have associated psychiatric signs such as psychosis. Symptoms of anxiety or depression may also be explained in some patients by changes in endocrine function.

Luteotropic hormone (LTH) is an anterior pituitary hormone whose action maintains the function of the corpus luteum. Gonadotropin-releasing hormone (GnRH), produced by the hypothalamus, increases the pituitary secretion of LTH and follicle-stimulating hormone (FSH).

Testosterone is the hormone responsible for secondary sex characteristics in men. A decreased testosterone level has been associated with erectile dysfunction and depression. Testosterone is also formed in small amounts by the ovaries and the adrenal cortex.

Estrogen is the hormone responsible for pubertal changes in girls. Exogenous estrogen replacement therapy has been associated with depression.

A patient who shows a WBC of 2,000 while taking clozapine (Clozaril) is at high risk for agranulocytosis. If agranulocytosis develops (i.e., if the WBC is less than 1,000) and there is evidence of severe infection (e.g., skin ulcerations), the patient should be placed in protective isolation on a medical unit. The clinician should stop the administration of clozapine at once, not increase the dosage of clozapine. The patient may or may not have clinical symptoms, such as fever and sore throat. If the patient does have such symptoms, antibiotic therapy may be necessary. Depending on the severity of the condition, the physician should monitor the patient’s WBC every 2 days, not 10 days, or institute daily, not weekly, CBC tests with differential.

Somatizing patients pose a number of difficulties for the consulting and the treating psychiatrist because they may be reluctant to engage in self-reflection and psychological exploration. Many somatizing patients live with the fear that their symptoms are not being taken seriously and the parallel fear that something medically serious may be overlooked. The psychiatrist’s main task is to acknowledge the suffering conveyed by the patient without necessarily accepting the patient’s explanation for symptoms. Clinicians should be curious about both the nature of the psychiatric complaint and the impact of those complaints on the patient’s life. While pain may be a complaint, it is not a major impediment to treatment.

Severely depressed patients may have difficulty concentrating, thinking clearly, and speaking spontaneously. The psychiatrist evaluating a depressed patient may need to be more forceful and directive than usual. Although depressed patients should not be badgered, long silences are seldom useful, and the examiner may need to repeat questions more than once.

Narcissistic patients act as though they are superior to everyone around them, including the doctor. They may initially idealize the doctor out of a need to have their doctor be as perfect as they are, but idealization can quickly turn to disdain when they realize that the doctor is only human. Underneath their surface arrogance, narcissistic patients feel desperately inadequate and fear that others will see through them.

The common lithium pretreatment tests include serum electrolytes, blood urea nitrogen (BUN), serum creatinine, urinalysis, thyroid function tests (TFTs) (e.g., thyroid-stimulating hormone, thyroxine [T₄], T₃ resin uptake [T₃RU]), and an electrocardiogram (ECG). In patients with a history suggestive of possible kidney problems, a 24-hour urine test for creatinine and protein clearance is recommended.

Lithium has effects on a number of organ systems of which the clinician should be aware. Lithium therapy is associated with a benign elevation of the white blood cell count (WBC), which may reach 15,000 cells per mm³. This WBC elevation can sometimes be mistaken for signs of infection or wrongly attributed to lithium in the context of other signs of infection. Furthermore, lithium can have adverse effects on electrolyte balance (especially in patients taking thiazide diuretics), thyroid function, the kidney, and the heart. Its levels may also be altered by nonsteroidal antiinflammatory drugs and aspirin.

Lithium may also lead to nephrogenic diabetes insipidus. Its levels can increase with dehydration. It has been argued that antithyroid antibody testing is helpful in assessing the possibility of lithium-induced hypothyroidism. Because of the potential cardiac teratogenicity of lithium, a pregnancy test in women of childbearing age should be ordered. Periodic follow-up of serum electrolytes, BUN, creatinine, glomerular filtration rate, TFTs, ECG, and 24-hour urine for creatinine and protein clearance are recommended. The frequency and exact makeup of the follow-up testing battery should be dictated by the patient’s medical condition.

Patients have a legal right to access their medical records. This right derives from the belief that medical care is a collaborative process between doctor and patient. The medical record is a narrative that documents all events that occur during the course of treatment. It is used not only by the treating team but also by regulatory agencies and managed care companies. It is also crucial in malpractice litigation. Although in theory it is accessible to authorized persons only and is safeguarded for confidentiality, absolute confidentiality cannot be guaranteed.

Psychiatrists often encounter violent patients in a hospital setting. Frequently, the police bring a patient into the emergency department in some type of physical restraint (e.g., handcuffs). The psychiatrist must establish whether effective verbal contact can be made with the patient or whether the patient’s sense of reality is so impaired that productive interviewing is impossible. If impaired reality testing is an issue, the psychiatrist may have to medicate a violent patient before taking a history.

With or without restraints, a violent patient should not be interviewed alone to establish a patient–doctor relationship. At least one other person should always be present; in some situations, that other person should be a security guard or a police officer. Other precautions include leaving the interview room’s door open and sitting between the patient and the door so the interviewer has unrestricted access to an exit if it becomes necessary. The psychiatrist must make it clear, in a firm but calm manner, that the patient may say or feel anything but is not free to act in a violent way. Delusions should never be directly challenged. Delusions are fixed false ideas that may be thought of as a patient’s defensive and self-protective, albeit maladaptive, strategy against overwhelming anxiety, low self-esteem, and confusion. Challenging a delusion by insisting that it is not true or possible only increases the patient’s anxiety and often leads the patient to defend the belief desperately. However, clinicians should not pretend that they believe patients’ delusions. Often, the best approach is for clinicians to indicate they understand that the patient believes the delusion to be true but he or she does not hold the same belief.

The patient’s history and physical examination typically dictate which tests are ordered. Laboratory abnormalities are typically useful when they optimize outcomes, that is, if the test results will contribute to the detection of a previously unrecognized medical condition or otherwise influence treatment. Diagnostic testing can also serve a therapeutic function by reassuring the patient or family that other serious medical problems do not appear to be present.

Serum amylase may be increased in patients with bulimia nervosa. Serum bicarbonate may be decreased in patients with panic disorder and may be elevated in patients with bulimia nervosa. Serum calcium may be increased in patients with depression in addition to hyperparathyroidism and bone metastases.

Electroencephalography (EEG) obtained during sleep is a potentially powerful biological marker of psychiatric illness. In schizophrenia (not major depressive disorder), increased sleep latency

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