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Background: The administration of a psychiatric evaluation to determine guardianship entails the prerequisite of a full psychiatric examination of the patient. In psychogeriatrics, dementia is the common reason for measures to determine incompetence and guardianship and in general psychiatry it is applicable for the diagnosis of schizophrenia. Legal guardianship is determined by the court and can apply to aspects involving confidentiality such as the patient's assets or body or both, and its duration can be temporary or permanent. This is a case study of a 30 year old man who had never undergone a psychiatric examination. His parents reported behavior that was suggestive of a prolonged paranoid psychotic state for the past 8 years with deterioration in the last year. All attempts by his parents to bring him to a medical or psychiatric examination were refused by the patient. In order to prevent further deterioration of the situation, the family was advised to request legal guardianship for him. Due to his refusal to be examined and the lack of indication for a forced examination, a long taped phone conversation was conducted with the patient and later validated to ensure that this was the patient in question. This conversation together with heteroanamnesis, provided the basis for writing a psychiatric evaluation recommending the appointment of a legal guardian for the patient. To the best of our knowledge, the court's decision to appoint a legal guardian based on a telephone conversation is a precedent.

Benzodiazepines are among the most often prescribed drugs worldwide, and are mostly prescribed by general practitioners and family physicians. Their side-effects include tolerance, dependence, intoxication, withdrawal syndrome, retrograde amnesia, paradoxical agitation (frequent in the elderly) and disinhibition. A 32-year-old woman is presented. She was brought to the emergency room because of psychotic-like behavior. It was caused by severe disinhibition due to a single 5 mg dose of diazepam prescribed during uncomplicated bereavement. 14 hours later all symptoms had subsided and she was discharged.

Depression in the elderly is characterized by a prolonged course and resistance to pharmacological treatment. Moreover, in old age sensitivity to the anticholinergic and cardiac side-effects of tricyclic antidepressants (TCA) increases. Recently new antidepressants with fewer side-effects have been developed. Of these, trazodone and mianserin have been particularly recommended for the treatment of depression in older patients. However, the effects of these new compounds on depression are similar to those of the older TCA's, leaving a substantial number of elderly patients with resistant depression. While there are many publications on the potentiation of the effect of TCA's by lithium carbonate, there is little data on the potentiation of the effects of trazodone and of mianserin by lithium, and no reports of their combined use in elderly patients. Birkhimer et al. reported a case of successful treatment of refractory depression with trazodone and lithium in a 45-year-old man. Heninger et al. successfully treated 2 treatment-refractory patients (aged 52 and 58 years, respectively) with a combination of mianserin and lithium. Price et al. reported that 85% of 12 drug-resistant patients improved when treated with lithium and mianserin, but only 22% of 9 patients treated with lithium and trazodone. We report a 73-year-old man with resistant depression whose physical condition contraindicated tricyclic antidepressants, in whom the combination of mianserin and lithium was both safe and effective.