RT is a 30-year-old auto mechanic whom I have been treating for over 3 years. About 5 months ago, after many discussions, we elected to begin treatment for symptoms of depression. He initially did well with fluoxetine, but after several months he returned to tell me that the effect had “worn off” and that he wanted to try sertraline because it worked for his brother. I acceded, and at his 3-week follow-up, he noted that he had felt great within days, but experienced excessive grumpiness and even rage. At this time he admitted to me that his father was an alcoholic but denied any substance abuse himself. After he scored 9 strongly affirmative responses on Hirschfeld's Mood Disorder Questionnaire, we discussed the possibility that he may suffer from bipolar depression. He agreed, so I switched him to combination fluoxetine/olanzapine. Today, at his 10-day follow-up, he tells me, “For the first time in my life, I feel happy and even-keeled.”

After I was through silently congratulating myself on making the correct diagnosis in 5 months instead of the customary 8 years, I made a follow-up appointment for him in 3 weeks.

KD is a 40-year-old woman whom I have been reluctantly treating with methylphenidate for adult ADD. I had tried atomoxetine (Strattera) with her, but she took it upon herself to try her child's medication and ran back telling me that she preferred the stimulant. Now, since I frown on it, I generally don't reward that behavior with a prescription. This time, though, since I have been caring for the entire family for 5 years, I succumbed to her pleas. Well, she's called back twice for higher doses and is irritated that I won't increase the dose without an office visit.

What a pain in the tuchus! I have visions of turning this parent into a stimulant addict, so I have referred her to my local psychiatrist friend for “further evaluation.” Fortunately, he doesn't mind being the bad guy if he sniffs out misuse of medication.

Next time, I'm sticking to my guns….

Ahh, a day off. A chance to rest my brain. I take my car to the local garage for some routine maintenance and take advantage of the quiet time to read my American Academy of Family Physicians journal. To my dismay, there is a woman in the waiting area who recognizes a medication advertised on a folded-over page and initiates a conversation about her brother's depression. On the one hand, I'm glad to give her some insight into the disease that may help her assist her brother, but on the other, I'm taking the newspaper next time.

BY is a 65-year-old woman whose husband has just surprised her with a vacation home at the beach. To reach it, though, requires crossing a very tall bridge over the intracoastal waterway, and BY has developed a severe case of agoraphobia relating specifically to that bridge alone. Now, I'm wondering, is her issue really agoraphobia, or is her issue with her husband buying a vacation home without her input? We're going to start with a pinch of alprazolam as needed and see if a little sensitization therapy works. I guess whether she sensitized to the bridge or the house doesn't matter.

I'm surprised to see RT back on my schedule this morning after his amazing recovery. I'm wondering: Relapse? Weight gain? What?

What I failed to anticipate was the angry spouse. RT's wife consulted the Internet and now challenges my diagnosis. Hmm. After giving her a brief primer about the varied presentation of the illness, I turn to RT and he confirms that he feels great and is without untoward side effects. He restates his prior testimonial. But the wife, quite sniffy at this point, raises her voice to tell me that no husband of hers could ever be bipolar.

Alas, the real problem surfaces. She is clearly not to be convinced. I tell her she can call it irritable grumpy depression if she wants, that her husband's outcome is what matters to me. Still no progress. So, my old friend the psychiatrist gets a chance to speak with this couple. In cases like this I contact him personally to relate the background history because I'm sure Mrs. RT will browbeat him into changing his story.

I feel bad for RT. But I'm glad it's Friday.