Ephedra, a psychoactive substance with stimulant properties, is found in many herbal products. Often perceived by the lay public as benign, the potential health-related dangers of using these products are beginning to be recognized. We review four cases associated with ephedra-containing herbal products and report three additional cases. Unlike the previously reported cases, the patients presented in this report developed persistent psychosis that required psychopharmaceutical management.

A case formulation summarises and integrates the important information regarding a patient and their problems. It provides a shared understanding of these problems between patient and professional, which can improve the therapeutic relationship and help identify useful interventions and potential difficulties. 1 The training curriculum of the Royal College of Psychiatrists in the UK describes the ability to construct formulations as a competency to be achieved in core training. 2Studies that have evaluated psychiatric case formulations have demonstrated poor standards in both clinical and academic settings. A US study rated case formulations in residents' portfolios as less than competent on average. 3Another US study showed that formulations contained mainly descriptive information, with little integration or inference of causes. 4 We are not aware of any published UK studies on this subject; however, in an unpublished British study, M.A. examined 150 new assessment letters, of which only 16% included any formulation, showing that case formulation is rarely attempted in routine psychiatric practice.There is evidence that teaching case formulation leads to improvement. Mental health professionals who received 2 h of training produced better formulations in clinical practice, 5 and medical students taught mechanistic case diagramming reported being more comfortable in writing a formulation. 6 An increased emphasis on case formulation within a psychiatric training scheme led to improvement in portfolio case formulation entries. 3There are many different approaches to case formulation, with most psychotherapies having formulations based on their models. [7][8][9] The most common generic approach is a biopsychosocial one, although this term has been used in a number of different ways. As described by Engel, it is a systemic focusing on the current time frame.10,11 Currently, the term usually refers to identifying predisposing, precipitating and perpetuating factors within biological, psychological and social domains. It is often represented as a 3 6 3 grid, which has been criticised for encouraging the listing of factors, rather than integrating them. 12 We were able to identify only two tools for assessing psychiatric case formulations, the case formulation content coding manual 4 and the biopsychosocial formulation scoring rubric. 3 The case formulation content coding manual is a theoretically neutral research tool, 4 which seems to be very detailed, time consuming and does not produce an easily interpretable score. The biopsychosocial formulation scoring rubric rates formulations on a scale from one to six, each with a descriptor, 3 giving potentially broad, subjective evaluations of formulations, with little information on where improvement is needed. Integrated case formulation approachThe integrated case formulation (ICF) approach was designed by M.A. and R.W. and is based on the standard psychiatric history. The aim is to provide a simple structure that can be used by professionals to integrate information Ai...

Although case-formulation is considered an important skill by various training bodies, it seems that this is rarely translated into daily clinical practice. The authors discuss the possible reasons for this deficiency and discuss potential solutions.