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Provide your patients with a DEFENSE against age-related cognitive decline
Psychiatric providers often encounter older adult patients who report difficulty with memory and express the fear they are “developing dementia.” Often, after a thorough evaluation of the reported deficits and history, we find that a serious or progressive neurocognitive disorder is unlikely. However, such occasions are an opportunity to discuss lifestyle changes that may help prevent, or at least slow, development of later-life cognitive decline.
Although I inform my patients that the body of evidence supporting many of these preventive measures still is evolving, I suggest the following approach that may provide a DEFENSE against future cognitive disability.
Diet options that are “heart healthy” seem to be “brain healthy” as well. This may be due, in part, to the antioxidant and anti-inflammatory effects of particular foods.1 Therefore, I suggest patients try to implement a Mediterranean-type diet that emphasizes fish (especially those rich in omega-3 fats, such as salmon and tuna), poultry, fresh fruit, and vegetables, as well as legumes.
ETOH has been shown, in a moderate amount (eg, 1 drink a day for women and 1 to 2 drinks for men), to be brain protective because of the antioxidants found in the alcohol or the direct relaxation effects that are produced—or both. Although red wine often is recommended, recent studies have shown that those who enjoyed an active life into their 70s and 80s had consumed a moderate amount of alcohol over their lifetime regardless of the type of spirit (eg, 12 oz of beer, 4 oz of wine, 1 oz of hard liquor).2
Friends contribute to an active, stimulating, and emotionally supported life. Having a strong social network, an antidote to loneliness and depression, has been shown to reduce the risk of “turning on” specific genes that stimulate an inflammatory process that can lead to brain cell death and neural damage.3
Exercise might be the most important ingredient for a longer, healthier, and more cognitively intact life. Moderate exercise, several times a week, increases blood flow to the brain and, subsequently, stimulates neuronal synapses and the hippocampus.4 The forms of exercise include walking, biking, swimming, resistance training, and even gardening.
No tobacco! It is known that smoking leads to accelerated aging for the heart and brain, so it is our responsibility to remain vigilant in promoting smoking cessation strategies.
Sleep has received increased attention, with recent studies providing evidence that the brain uses that time to “flush out” neurotoxic by-products of cognitive activity that have accumulated throughout the day.5 As evidence continues to be examined on this process, it is reasonable to recommend adequate sleep and a consistent sleep pattern as possible defenses against brain cell insult.
Engagement in tasks that are cognitively stimulating has been promoted as potential “brain exercises” to stave off future memory loss. For example, computer games that are mentally challenging; lively and frequent conversations; and learning a language all appear to increase neural activation and communication throughout the brain.6
As brain research continues to expand, providers will become more knowledgeable and aware of the steps our patients can take when they discuss concerns about their risk of progressive cognitive disability and memory loss. For now, however, it is important to describe what we do know based on current research and help our patients develop the best defense they can against age-related cognitive decline.
Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Gu Y, Nieves JW, Stern Y, et al. Food combination and Alzheimer disease risk: a protective diet. Arch Neurol. 2010;67(6):699-706.
2. Paganini-Hill A, Kawas CH, Corrada MM. Type of alcohol consumed, changes in intake over time, and mortality: the Leisure World Cohort Study. Age Ageing. 2007;36(2):203-209.
3. Cole SW, Hawkley LC, Arevelo JM, et al. Transcript origin analysis identifies antigen-presenting cells as primary targets of socially regulated gene expression in leukocytes. Proc Natl Acad Sci U S A. 2011;108(7):3080-3085.
4. Small G, Vorgan G. The Alzheimer’s Prevention Program: keep your brain healthy for the rest of your life. New York, NY: Workman Publishing Company, Inc; 2011:71.
5. Xie L, Kang H, Xu Q, et al. Sleep drives metabolite clearance from the adult brain. Science. 2013;342(6156):373-377.
6. Hall CB, Liptor RB, Sliwinski M, et al. Cognitive activities delay onset of memory decline in persons who develop dementia. Neurology. 2009;73(5):356-361.
Psychiatric providers often encounter older adult patients who report difficulty with memory and express the fear they are “developing dementia.” Often, after a thorough evaluation of the reported deficits and history, we find that a serious or progressive neurocognitive disorder is unlikely. However, such occasions are an opportunity to discuss lifestyle changes that may help prevent, or at least slow, development of later-life cognitive decline.
Although I inform my patients that the body of evidence supporting many of these preventive measures still is evolving, I suggest the following approach that may provide a DEFENSE against future cognitive disability.
Diet options that are “heart healthy” seem to be “brain healthy” as well. This may be due, in part, to the antioxidant and anti-inflammatory effects of particular foods.1 Therefore, I suggest patients try to implement a Mediterranean-type diet that emphasizes fish (especially those rich in omega-3 fats, such as salmon and tuna), poultry, fresh fruit, and vegetables, as well as legumes.
ETOH has been shown, in a moderate amount (eg, 1 drink a day for women and 1 to 2 drinks for men), to be brain protective because of the antioxidants found in the alcohol or the direct relaxation effects that are produced—or both. Although red wine often is recommended, recent studies have shown that those who enjoyed an active life into their 70s and 80s had consumed a moderate amount of alcohol over their lifetime regardless of the type of spirit (eg, 12 oz of beer, 4 oz of wine, 1 oz of hard liquor).2
Friends contribute to an active, stimulating, and emotionally supported life. Having a strong social network, an antidote to loneliness and depression, has been shown to reduce the risk of “turning on” specific genes that stimulate an inflammatory process that can lead to brain cell death and neural damage.3
Exercise might be the most important ingredient for a longer, healthier, and more cognitively intact life. Moderate exercise, several times a week, increases blood flow to the brain and, subsequently, stimulates neuronal synapses and the hippocampus.4 The forms of exercise include walking, biking, swimming, resistance training, and even gardening.
No tobacco! It is known that smoking leads to accelerated aging for the heart and brain, so it is our responsibility to remain vigilant in promoting smoking cessation strategies.
Sleep has received increased attention, with recent studies providing evidence that the brain uses that time to “flush out” neurotoxic by-products of cognitive activity that have accumulated throughout the day.5 As evidence continues to be examined on this process, it is reasonable to recommend adequate sleep and a consistent sleep pattern as possible defenses against brain cell insult.
Engagement in tasks that are cognitively stimulating has been promoted as potential “brain exercises” to stave off future memory loss. For example, computer games that are mentally challenging; lively and frequent conversations; and learning a language all appear to increase neural activation and communication throughout the brain.6
As brain research continues to expand, providers will become more knowledgeable and aware of the steps our patients can take when they discuss concerns about their risk of progressive cognitive disability and memory loss. For now, however, it is important to describe what we do know based on current research and help our patients develop the best defense they can against age-related cognitive decline.
Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Psychiatric providers often encounter older adult patients who report difficulty with memory and express the fear they are “developing dementia.” Often, after a thorough evaluation of the reported deficits and history, we find that a serious or progressive neurocognitive disorder is unlikely. However, such occasions are an opportunity to discuss lifestyle changes that may help prevent, or at least slow, development of later-life cognitive decline.
Although I inform my patients that the body of evidence supporting many of these preventive measures still is evolving, I suggest the following approach that may provide a DEFENSE against future cognitive disability.
Diet options that are “heart healthy” seem to be “brain healthy” as well. This may be due, in part, to the antioxidant and anti-inflammatory effects of particular foods.1 Therefore, I suggest patients try to implement a Mediterranean-type diet that emphasizes fish (especially those rich in omega-3 fats, such as salmon and tuna), poultry, fresh fruit, and vegetables, as well as legumes.
ETOH has been shown, in a moderate amount (eg, 1 drink a day for women and 1 to 2 drinks for men), to be brain protective because of the antioxidants found in the alcohol or the direct relaxation effects that are produced—or both. Although red wine often is recommended, recent studies have shown that those who enjoyed an active life into their 70s and 80s had consumed a moderate amount of alcohol over their lifetime regardless of the type of spirit (eg, 12 oz of beer, 4 oz of wine, 1 oz of hard liquor).2
Friends contribute to an active, stimulating, and emotionally supported life. Having a strong social network, an antidote to loneliness and depression, has been shown to reduce the risk of “turning on” specific genes that stimulate an inflammatory process that can lead to brain cell death and neural damage.3
Exercise might be the most important ingredient for a longer, healthier, and more cognitively intact life. Moderate exercise, several times a week, increases blood flow to the brain and, subsequently, stimulates neuronal synapses and the hippocampus.4 The forms of exercise include walking, biking, swimming, resistance training, and even gardening.
No tobacco! It is known that smoking leads to accelerated aging for the heart and brain, so it is our responsibility to remain vigilant in promoting smoking cessation strategies.
Sleep has received increased attention, with recent studies providing evidence that the brain uses that time to “flush out” neurotoxic by-products of cognitive activity that have accumulated throughout the day.5 As evidence continues to be examined on this process, it is reasonable to recommend adequate sleep and a consistent sleep pattern as possible defenses against brain cell insult.
Engagement in tasks that are cognitively stimulating has been promoted as potential “brain exercises” to stave off future memory loss. For example, computer games that are mentally challenging; lively and frequent conversations; and learning a language all appear to increase neural activation and communication throughout the brain.6
As brain research continues to expand, providers will become more knowledgeable and aware of the steps our patients can take when they discuss concerns about their risk of progressive cognitive disability and memory loss. For now, however, it is important to describe what we do know based on current research and help our patients develop the best defense they can against age-related cognitive decline.
Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Gu Y, Nieves JW, Stern Y, et al. Food combination and Alzheimer disease risk: a protective diet. Arch Neurol. 2010;67(6):699-706.
2. Paganini-Hill A, Kawas CH, Corrada MM. Type of alcohol consumed, changes in intake over time, and mortality: the Leisure World Cohort Study. Age Ageing. 2007;36(2):203-209.
3. Cole SW, Hawkley LC, Arevelo JM, et al. Transcript origin analysis identifies antigen-presenting cells as primary targets of socially regulated gene expression in leukocytes. Proc Natl Acad Sci U S A. 2011;108(7):3080-3085.
4. Small G, Vorgan G. The Alzheimer’s Prevention Program: keep your brain healthy for the rest of your life. New York, NY: Workman Publishing Company, Inc; 2011:71.
5. Xie L, Kang H, Xu Q, et al. Sleep drives metabolite clearance from the adult brain. Science. 2013;342(6156):373-377.
6. Hall CB, Liptor RB, Sliwinski M, et al. Cognitive activities delay onset of memory decline in persons who develop dementia. Neurology. 2009;73(5):356-361.
1. Gu Y, Nieves JW, Stern Y, et al. Food combination and Alzheimer disease risk: a protective diet. Arch Neurol. 2010;67(6):699-706.
2. Paganini-Hill A, Kawas CH, Corrada MM. Type of alcohol consumed, changes in intake over time, and mortality: the Leisure World Cohort Study. Age Ageing. 2007;36(2):203-209.
3. Cole SW, Hawkley LC, Arevelo JM, et al. Transcript origin analysis identifies antigen-presenting cells as primary targets of socially regulated gene expression in leukocytes. Proc Natl Acad Sci U S A. 2011;108(7):3080-3085.
4. Small G, Vorgan G. The Alzheimer’s Prevention Program: keep your brain healthy for the rest of your life. New York, NY: Workman Publishing Company, Inc; 2011:71.
5. Xie L, Kang H, Xu Q, et al. Sleep drives metabolite clearance from the adult brain. Science. 2013;342(6156):373-377.
6. Hall CB, Liptor RB, Sliwinski M, et al. Cognitive activities delay onset of memory decline in persons who develop dementia. Neurology. 2009;73(5):356-361.
Is He DISTRACTED? Tool for Assessing ADHD in an Adult
Adult attention deficit/hyperactivity disorder (ADHD) can be challenging to assess accurately. Adult ADHD differs significantly from childhood ADHD in that hyperactivity often is absent or greatly diminished, comorbid disorders (depression or substance use) are common, and previously compensated attention deficits in school can manifest in the patient’s personal and professional life.1
The mnemonic DISTRACTED can help when recalling key components in assessing adult ADHD.2 Because ADHD is a developmental disorder—there are signs of onset in childhood—it is important to maintain a longitudinal view when asking about patterns of behavior or thinking.
DISTRACTIBILITY
Is there a pattern of the patient getting “off track” in conversations or in school/work situations because of straying thoughts or daydreams? Is there a tendency to overrespond to extraneous stimuli (eg, cell phones, computers, television) that impedes the patient’s ability to converse, receive information, or follow directions?
IMPULSIVITY
Does the patient have a history of saying things “off the cuff,” interrupting others, or “walking on” someone else’s words in a conversation? Is impulsivity evident in the person’s substance use or spending patterns?
SCHOOL HISTORY
This domain is important in diagnosing ADHD in adults because there needs to be evidence that the disorder was present from an early age. How did the patient perform in school (ie, grades, organization, completion of homework assignments)? Was there a behavioral pattern that reflected hyperactivity (could not stay seated) or emotional dysregulation (frequent outbursts)?
TASK COMPLETION
Does the patient have trouble finishing assignments at work, staying focused on a project that is considered boring, or completing a home project (eg, fixing a leaky faucet) in a timely fashion?
RATING SCALES
Rating scales should be used to help support the diagnosis, based on the patient’s history and life story. There are more than 12 scales that can be utilized in a clinical setting3; the ADHD/Hyperactivity Disorder Self-Report Scale is a brief and easy measure of core ADHD symptoms.
ACCIDENTS
Adults with ADHD often are accident-prone because of inattention, hyperactivity, or impulsivity. Does the patient have a history of unintentionally hurting himself because he “wasn’t paying attention” (falls, burns), or was too impatient (traffic accidents or citations)?
COMMITMENTS
Does the patient fail to fulfill verbal obligations (by arriving late, forgetting to run errands)? Has this difficulty to commit created problems in relationships over time?
TIME MANAGEMENT
How difficult is it for the patient to stay organized while balancing work expectations, social obligations, and family needs? Is there a pattern of chaotic scheduling with regard to meals, work, or sleeping?
EMPLOYMENT
Has the patient changed jobs because the work becomes “too boring” or “uninteresting”? Is there a pattern of being terminated because of poor work quality based on time management or job performance?
DECISIONS
Adults with ADHD often make hasty, ill-informed choices or procrastinate so that they do not have to make a decision. Does the patient’s decision-making reveal a pattern of being too distracted to hear the information needed or too impatient to consider all the details?
Remember: No single component of this mnemonic suffices to diagnose adult ADHD. However, these considerations will help clarify what lies behind your DISTRACTED patient’s search for self-understanding and appropriate medical care.
REFERENCES
1. Barkley RA, Brown TE. Unrecognized attention-deficit/hyperactivity disorder in adults presenting with other psychiatric disorders. CNS Spectr. 2008;13(11):977-984.
2. Barkley R. Taking Charge of Adult ADHD. New York, NY: Guilford Press; 2010.
3. Attwell C. ADHD, rating scales, and your practice today. The Carlat Psychiatry Report. 2012;10(12):1,3,5-8.
Adult attention deficit/hyperactivity disorder (ADHD) can be challenging to assess accurately. Adult ADHD differs significantly from childhood ADHD in that hyperactivity often is absent or greatly diminished, comorbid disorders (depression or substance use) are common, and previously compensated attention deficits in school can manifest in the patient’s personal and professional life.1
The mnemonic DISTRACTED can help when recalling key components in assessing adult ADHD.2 Because ADHD is a developmental disorder—there are signs of onset in childhood—it is important to maintain a longitudinal view when asking about patterns of behavior or thinking.
DISTRACTIBILITY
Is there a pattern of the patient getting “off track” in conversations or in school/work situations because of straying thoughts or daydreams? Is there a tendency to overrespond to extraneous stimuli (eg, cell phones, computers, television) that impedes the patient’s ability to converse, receive information, or follow directions?
IMPULSIVITY
Does the patient have a history of saying things “off the cuff,” interrupting others, or “walking on” someone else’s words in a conversation? Is impulsivity evident in the person’s substance use or spending patterns?
SCHOOL HISTORY
This domain is important in diagnosing ADHD in adults because there needs to be evidence that the disorder was present from an early age. How did the patient perform in school (ie, grades, organization, completion of homework assignments)? Was there a behavioral pattern that reflected hyperactivity (could not stay seated) or emotional dysregulation (frequent outbursts)?
TASK COMPLETION
Does the patient have trouble finishing assignments at work, staying focused on a project that is considered boring, or completing a home project (eg, fixing a leaky faucet) in a timely fashion?
RATING SCALES
Rating scales should be used to help support the diagnosis, based on the patient’s history and life story. There are more than 12 scales that can be utilized in a clinical setting3; the ADHD/Hyperactivity Disorder Self-Report Scale is a brief and easy measure of core ADHD symptoms.
ACCIDENTS
Adults with ADHD often are accident-prone because of inattention, hyperactivity, or impulsivity. Does the patient have a history of unintentionally hurting himself because he “wasn’t paying attention” (falls, burns), or was too impatient (traffic accidents or citations)?
COMMITMENTS
Does the patient fail to fulfill verbal obligations (by arriving late, forgetting to run errands)? Has this difficulty to commit created problems in relationships over time?
TIME MANAGEMENT
How difficult is it for the patient to stay organized while balancing work expectations, social obligations, and family needs? Is there a pattern of chaotic scheduling with regard to meals, work, or sleeping?
EMPLOYMENT
Has the patient changed jobs because the work becomes “too boring” or “uninteresting”? Is there a pattern of being terminated because of poor work quality based on time management or job performance?
DECISIONS
Adults with ADHD often make hasty, ill-informed choices or procrastinate so that they do not have to make a decision. Does the patient’s decision-making reveal a pattern of being too distracted to hear the information needed or too impatient to consider all the details?
Remember: No single component of this mnemonic suffices to diagnose adult ADHD. However, these considerations will help clarify what lies behind your DISTRACTED patient’s search for self-understanding and appropriate medical care.
REFERENCES
1. Barkley RA, Brown TE. Unrecognized attention-deficit/hyperactivity disorder in adults presenting with other psychiatric disorders. CNS Spectr. 2008;13(11):977-984.
2. Barkley R. Taking Charge of Adult ADHD. New York, NY: Guilford Press; 2010.
3. Attwell C. ADHD, rating scales, and your practice today. The Carlat Psychiatry Report. 2012;10(12):1,3,5-8.
Adult attention deficit/hyperactivity disorder (ADHD) can be challenging to assess accurately. Adult ADHD differs significantly from childhood ADHD in that hyperactivity often is absent or greatly diminished, comorbid disorders (depression or substance use) are common, and previously compensated attention deficits in school can manifest in the patient’s personal and professional life.1
The mnemonic DISTRACTED can help when recalling key components in assessing adult ADHD.2 Because ADHD is a developmental disorder—there are signs of onset in childhood—it is important to maintain a longitudinal view when asking about patterns of behavior or thinking.
DISTRACTIBILITY
Is there a pattern of the patient getting “off track” in conversations or in school/work situations because of straying thoughts or daydreams? Is there a tendency to overrespond to extraneous stimuli (eg, cell phones, computers, television) that impedes the patient’s ability to converse, receive information, or follow directions?
IMPULSIVITY
Does the patient have a history of saying things “off the cuff,” interrupting others, or “walking on” someone else’s words in a conversation? Is impulsivity evident in the person’s substance use or spending patterns?
SCHOOL HISTORY
This domain is important in diagnosing ADHD in adults because there needs to be evidence that the disorder was present from an early age. How did the patient perform in school (ie, grades, organization, completion of homework assignments)? Was there a behavioral pattern that reflected hyperactivity (could not stay seated) or emotional dysregulation (frequent outbursts)?
TASK COMPLETION
Does the patient have trouble finishing assignments at work, staying focused on a project that is considered boring, or completing a home project (eg, fixing a leaky faucet) in a timely fashion?
RATING SCALES
Rating scales should be used to help support the diagnosis, based on the patient’s history and life story. There are more than 12 scales that can be utilized in a clinical setting3; the ADHD/Hyperactivity Disorder Self-Report Scale is a brief and easy measure of core ADHD symptoms.
ACCIDENTS
Adults with ADHD often are accident-prone because of inattention, hyperactivity, or impulsivity. Does the patient have a history of unintentionally hurting himself because he “wasn’t paying attention” (falls, burns), or was too impatient (traffic accidents or citations)?
COMMITMENTS
Does the patient fail to fulfill verbal obligations (by arriving late, forgetting to run errands)? Has this difficulty to commit created problems in relationships over time?
TIME MANAGEMENT
How difficult is it for the patient to stay organized while balancing work expectations, social obligations, and family needs? Is there a pattern of chaotic scheduling with regard to meals, work, or sleeping?
EMPLOYMENT
Has the patient changed jobs because the work becomes “too boring” or “uninteresting”? Is there a pattern of being terminated because of poor work quality based on time management or job performance?
DECISIONS
Adults with ADHD often make hasty, ill-informed choices or procrastinate so that they do not have to make a decision. Does the patient’s decision-making reveal a pattern of being too distracted to hear the information needed or too impatient to consider all the details?
Remember: No single component of this mnemonic suffices to diagnose adult ADHD. However, these considerations will help clarify what lies behind your DISTRACTED patient’s search for self-understanding and appropriate medical care.
REFERENCES
1. Barkley RA, Brown TE. Unrecognized attention-deficit/hyperactivity disorder in adults presenting with other psychiatric disorders. CNS Spectr. 2008;13(11):977-984.
2. Barkley R. Taking Charge of Adult ADHD. New York, NY: Guilford Press; 2010.
3. Attwell C. ADHD, rating scales, and your practice today. The Carlat Psychiatry Report. 2012;10(12):1,3,5-8.
Is he DISTRACTED? Considerations when diagnosing ADHD in an adult
Adult attention-deficit/hyperactivity disorder (ADHD) can be challenging to assess accurately. Adult ADHD differs significantly from childhood ADHD, in that hyperactivity often is absent or greatly diminished, comorbid disorders (depression or substance use) are common, and previously compensated attention deficits in school can manifest in the patient’s personal and professional life.1
The mnemonic DISTRACTED can help when recalling key components in assessing adult ADHD.2 Because ADHD is a developmental disorder—there are signs of onset in childhood—it is important to maintain a longitudinal view when asking about patterns of behavior or thinking.
Distractibility. Is there a pattern of getting “off track” in conversations or in school or work situations because of straying thoughts or daydreams? Is there a tendency to over-respond to extraneous stimuli (eg, cell phones, computers, television) that impedes the patient’s ability to converse, receive information, or follow directions?
Impulsivity. Does the patient have a history of saying things “off the cuff,” interrupting others, or “walking on” someone else’s words in a conversation? Is impulsivity evident in the person’s substance use or spending patterns?
School history. This domain is important in diagnosing ADHD in adults because there needs to be evidence that the disorder was present from an early age. How did the patient perform in school (ie, grades, organization, completion of homework assignments)? Was there a behavioral pattern that reflected hyperactivity (could not stay seated) or emotional dysregulation (frequent outbursts)?
Task completion. Does the patient have trouble finishing assignments at work, staying focused on a project that is considered boring, or completing a home project (eg, fixing a leaky faucet) in a timely fashion?
Rating scales. Rating scales should be used to help support the diagnosis, based on the patient’s history and life story. There are >12 scales that can be utilized in a
clinical setting3; the ADHD/Hyperactivity Disorder Self-Report Scale is a brief and easy measure of core ADHD symptoms.
Accidents. Adults with ADHD often are accident-prone because of inattention, hyperactivity, or impulsivity. Does the patient have a history of unintentionally hurting himself because he “wasn’t paying attention” (falls, burns), or was too impatient (traffic accidents or citations)?
Commitments. Does the patient fail to fulfill verbal obligations (by arriving late, forgetting to run errands)? Has this difficulty to commit created problems in relationships over time?
Time management. How difficult is it for the patient to stay organized while balancing work expectations, social obligations, and family needs? Is there a pattern of chaotic scheduling with regard to meals, work, or sleeping?
Employment. Has the patient changed jobs because the work becomes “too boring” or “uninteresting”? Is there a pattern of being terminated because of poor work quality based on time management or job performance?
Decisions. Adults with ADHD often make hasty, ill-informed choices or procrastinate so that they do not have to make a decision. Does the patient’s decision-making reveal a pattern of being too distracted to hear the information needed, or too impatient to consider all the details?
Remember: No single component of this mnemonic alone suffices to make a diagnosis of adult ADHD. However, these considerations will help clarify what lies behind your DISTRACTED patient’s search for self-understanding and appropriate medical care.
Disclosure
Dr. Christensen reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Barkley RA, Brown TE. Unrecognized attention-deficit/hyperactivity disorder in adults presenting with other psychiatric disorders. CNS Spectr. 2008;13(11):977-984.
2. Barkley R. Taking charge of adult ADHD. New York, NY: Guilford Press; 2010.
3. Attwell C. ADHD, rating scales, and your practice today. The Carlat Psychiatry Report. 2012;10(12):1,3,5-8.
Adult attention-deficit/hyperactivity disorder (ADHD) can be challenging to assess accurately. Adult ADHD differs significantly from childhood ADHD, in that hyperactivity often is absent or greatly diminished, comorbid disorders (depression or substance use) are common, and previously compensated attention deficits in school can manifest in the patient’s personal and professional life.1
The mnemonic DISTRACTED can help when recalling key components in assessing adult ADHD.2 Because ADHD is a developmental disorder—there are signs of onset in childhood—it is important to maintain a longitudinal view when asking about patterns of behavior or thinking.
Distractibility. Is there a pattern of getting “off track” in conversations or in school or work situations because of straying thoughts or daydreams? Is there a tendency to over-respond to extraneous stimuli (eg, cell phones, computers, television) that impedes the patient’s ability to converse, receive information, or follow directions?
Impulsivity. Does the patient have a history of saying things “off the cuff,” interrupting others, or “walking on” someone else’s words in a conversation? Is impulsivity evident in the person’s substance use or spending patterns?
School history. This domain is important in diagnosing ADHD in adults because there needs to be evidence that the disorder was present from an early age. How did the patient perform in school (ie, grades, organization, completion of homework assignments)? Was there a behavioral pattern that reflected hyperactivity (could not stay seated) or emotional dysregulation (frequent outbursts)?
Task completion. Does the patient have trouble finishing assignments at work, staying focused on a project that is considered boring, or completing a home project (eg, fixing a leaky faucet) in a timely fashion?
Rating scales. Rating scales should be used to help support the diagnosis, based on the patient’s history and life story. There are >12 scales that can be utilized in a
clinical setting3; the ADHD/Hyperactivity Disorder Self-Report Scale is a brief and easy measure of core ADHD symptoms.
Accidents. Adults with ADHD often are accident-prone because of inattention, hyperactivity, or impulsivity. Does the patient have a history of unintentionally hurting himself because he “wasn’t paying attention” (falls, burns), or was too impatient (traffic accidents or citations)?
Commitments. Does the patient fail to fulfill verbal obligations (by arriving late, forgetting to run errands)? Has this difficulty to commit created problems in relationships over time?
Time management. How difficult is it for the patient to stay organized while balancing work expectations, social obligations, and family needs? Is there a pattern of chaotic scheduling with regard to meals, work, or sleeping?
Employment. Has the patient changed jobs because the work becomes “too boring” or “uninteresting”? Is there a pattern of being terminated because of poor work quality based on time management or job performance?
Decisions. Adults with ADHD often make hasty, ill-informed choices or procrastinate so that they do not have to make a decision. Does the patient’s decision-making reveal a pattern of being too distracted to hear the information needed, or too impatient to consider all the details?
Remember: No single component of this mnemonic alone suffices to make a diagnosis of adult ADHD. However, these considerations will help clarify what lies behind your DISTRACTED patient’s search for self-understanding and appropriate medical care.
Disclosure
Dr. Christensen reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Adult attention-deficit/hyperactivity disorder (ADHD) can be challenging to assess accurately. Adult ADHD differs significantly from childhood ADHD, in that hyperactivity often is absent or greatly diminished, comorbid disorders (depression or substance use) are common, and previously compensated attention deficits in school can manifest in the patient’s personal and professional life.1
The mnemonic DISTRACTED can help when recalling key components in assessing adult ADHD.2 Because ADHD is a developmental disorder—there are signs of onset in childhood—it is important to maintain a longitudinal view when asking about patterns of behavior or thinking.
Distractibility. Is there a pattern of getting “off track” in conversations or in school or work situations because of straying thoughts or daydreams? Is there a tendency to over-respond to extraneous stimuli (eg, cell phones, computers, television) that impedes the patient’s ability to converse, receive information, or follow directions?
Impulsivity. Does the patient have a history of saying things “off the cuff,” interrupting others, or “walking on” someone else’s words in a conversation? Is impulsivity evident in the person’s substance use or spending patterns?
School history. This domain is important in diagnosing ADHD in adults because there needs to be evidence that the disorder was present from an early age. How did the patient perform in school (ie, grades, organization, completion of homework assignments)? Was there a behavioral pattern that reflected hyperactivity (could not stay seated) or emotional dysregulation (frequent outbursts)?
Task completion. Does the patient have trouble finishing assignments at work, staying focused on a project that is considered boring, or completing a home project (eg, fixing a leaky faucet) in a timely fashion?
Rating scales. Rating scales should be used to help support the diagnosis, based on the patient’s history and life story. There are >12 scales that can be utilized in a
clinical setting3; the ADHD/Hyperactivity Disorder Self-Report Scale is a brief and easy measure of core ADHD symptoms.
Accidents. Adults with ADHD often are accident-prone because of inattention, hyperactivity, or impulsivity. Does the patient have a history of unintentionally hurting himself because he “wasn’t paying attention” (falls, burns), or was too impatient (traffic accidents or citations)?
Commitments. Does the patient fail to fulfill verbal obligations (by arriving late, forgetting to run errands)? Has this difficulty to commit created problems in relationships over time?
Time management. How difficult is it for the patient to stay organized while balancing work expectations, social obligations, and family needs? Is there a pattern of chaotic scheduling with regard to meals, work, or sleeping?
Employment. Has the patient changed jobs because the work becomes “too boring” or “uninteresting”? Is there a pattern of being terminated because of poor work quality based on time management or job performance?
Decisions. Adults with ADHD often make hasty, ill-informed choices or procrastinate so that they do not have to make a decision. Does the patient’s decision-making reveal a pattern of being too distracted to hear the information needed, or too impatient to consider all the details?
Remember: No single component of this mnemonic alone suffices to make a diagnosis of adult ADHD. However, these considerations will help clarify what lies behind your DISTRACTED patient’s search for self-understanding and appropriate medical care.
Disclosure
Dr. Christensen reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Barkley RA, Brown TE. Unrecognized attention-deficit/hyperactivity disorder in adults presenting with other psychiatric disorders. CNS Spectr. 2008;13(11):977-984.
2. Barkley R. Taking charge of adult ADHD. New York, NY: Guilford Press; 2010.
3. Attwell C. ADHD, rating scales, and your practice today. The Carlat Psychiatry Report. 2012;10(12):1,3,5-8.
1. Barkley RA, Brown TE. Unrecognized attention-deficit/hyperactivity disorder in adults presenting with other psychiatric disorders. CNS Spectr. 2008;13(11):977-984.
2. Barkley R. Taking charge of adult ADHD. New York, NY: Guilford Press; 2010.
3. Attwell C. ADHD, rating scales, and your practice today. The Carlat Psychiatry Report. 2012;10(12):1,3,5-8.
Help patients SLEEP without medication
Some of patients’ most common complaints involve sleep: too little, too late, never enough. Although sleep disruptions often are related to the psychiatric disorder for which the person seeks treatment, cognitive and behavioral factors play significant roles.1 Unfortunately, quite often patients expect to be given “something” to foster sleep.
Before writing a prescription, be prepared to evaluate sleep disturbances and educate patients about sleep and how it can be facilitated without medication. The mnemonic SLEEP can help you readily access a basic set of nonpharmacologic aids to assess and treat uncomplicated sleep disturbances.
Schedule. Ask patients about their sleep-wake schedule. Is their pattern routine and regular, or unpredictable? Are they “in synch” with the sleep/activity patterns of those with whom they live, or is their schedule “off track” and disrupted by household noise and activities? Consistency is key to normalizing sleep.
Limit. Sensible limits on caffeinated beverages need to be addressed. Strongly encourage patients to limit nicotine and alcohol in-take. Assess the amount as well as timing of their use of these substances. Remind your patient that alcohol and smoking have a direct impact on sleep initiation and can disrupt sleep because of nocturnal withdrawal.
Eliminate. Removing noxious environmental stimuli is critical. Ask patients about the level of nighttime noise, excessive light, and ventilation and temperature of their sleeping area (cooler is better). Eliminate factors that create a “hostile” sleep environment.
Exercise. Regular exercise performed during the day (but not immediately before going to bed) may be an effective antidote to the psychic stress and physical tension that often contribute to insomnia.2 A several-times-per-week routine of brisk walking, riding a bicycle, swimming, or yoga can reduce sleep-onset latency and improve sleep maintenance. An exercise routine can enhance a patient’s overall health and knock out a daytime sleep habit.
Psychotherapy. Cognitive-behavioral therapy for insomnia has demonstrated efficacy in treating sleep disorders.3 Learning how to “catch, check, and change” distorted and negative cognitions regarding sleep onset can be a valuable tool for persons who are motivated to alter their thoughts and behaviors that contribute to sleep complaints, and may simultaneously improve associated anxiety and/or depression.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep. 2006;9:1398-1414.
2. Passos GS, Povares D, Santana MG, et al. Effect of acute physical exercise on patients with chronic primary insomnia. J Clin Sleep Med. 2010;6:270-275.
3. Edinger JD, Olsen MK, Stechuchak KM, et al. Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical trial. Sleep. 2009;32:499-510.
Some of patients’ most common complaints involve sleep: too little, too late, never enough. Although sleep disruptions often are related to the psychiatric disorder for which the person seeks treatment, cognitive and behavioral factors play significant roles.1 Unfortunately, quite often patients expect to be given “something” to foster sleep.
Before writing a prescription, be prepared to evaluate sleep disturbances and educate patients about sleep and how it can be facilitated without medication. The mnemonic SLEEP can help you readily access a basic set of nonpharmacologic aids to assess and treat uncomplicated sleep disturbances.
Schedule. Ask patients about their sleep-wake schedule. Is their pattern routine and regular, or unpredictable? Are they “in synch” with the sleep/activity patterns of those with whom they live, or is their schedule “off track” and disrupted by household noise and activities? Consistency is key to normalizing sleep.
Limit. Sensible limits on caffeinated beverages need to be addressed. Strongly encourage patients to limit nicotine and alcohol in-take. Assess the amount as well as timing of their use of these substances. Remind your patient that alcohol and smoking have a direct impact on sleep initiation and can disrupt sleep because of nocturnal withdrawal.
Eliminate. Removing noxious environmental stimuli is critical. Ask patients about the level of nighttime noise, excessive light, and ventilation and temperature of their sleeping area (cooler is better). Eliminate factors that create a “hostile” sleep environment.
Exercise. Regular exercise performed during the day (but not immediately before going to bed) may be an effective antidote to the psychic stress and physical tension that often contribute to insomnia.2 A several-times-per-week routine of brisk walking, riding a bicycle, swimming, or yoga can reduce sleep-onset latency and improve sleep maintenance. An exercise routine can enhance a patient’s overall health and knock out a daytime sleep habit.
Psychotherapy. Cognitive-behavioral therapy for insomnia has demonstrated efficacy in treating sleep disorders.3 Learning how to “catch, check, and change” distorted and negative cognitions regarding sleep onset can be a valuable tool for persons who are motivated to alter their thoughts and behaviors that contribute to sleep complaints, and may simultaneously improve associated anxiety and/or depression.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Some of patients’ most common complaints involve sleep: too little, too late, never enough. Although sleep disruptions often are related to the psychiatric disorder for which the person seeks treatment, cognitive and behavioral factors play significant roles.1 Unfortunately, quite often patients expect to be given “something” to foster sleep.
Before writing a prescription, be prepared to evaluate sleep disturbances and educate patients about sleep and how it can be facilitated without medication. The mnemonic SLEEP can help you readily access a basic set of nonpharmacologic aids to assess and treat uncomplicated sleep disturbances.
Schedule. Ask patients about their sleep-wake schedule. Is their pattern routine and regular, or unpredictable? Are they “in synch” with the sleep/activity patterns of those with whom they live, or is their schedule “off track” and disrupted by household noise and activities? Consistency is key to normalizing sleep.
Limit. Sensible limits on caffeinated beverages need to be addressed. Strongly encourage patients to limit nicotine and alcohol in-take. Assess the amount as well as timing of their use of these substances. Remind your patient that alcohol and smoking have a direct impact on sleep initiation and can disrupt sleep because of nocturnal withdrawal.
Eliminate. Removing noxious environmental stimuli is critical. Ask patients about the level of nighttime noise, excessive light, and ventilation and temperature of their sleeping area (cooler is better). Eliminate factors that create a “hostile” sleep environment.
Exercise. Regular exercise performed during the day (but not immediately before going to bed) may be an effective antidote to the psychic stress and physical tension that often contribute to insomnia.2 A several-times-per-week routine of brisk walking, riding a bicycle, swimming, or yoga can reduce sleep-onset latency and improve sleep maintenance. An exercise routine can enhance a patient’s overall health and knock out a daytime sleep habit.
Psychotherapy. Cognitive-behavioral therapy for insomnia has demonstrated efficacy in treating sleep disorders.3 Learning how to “catch, check, and change” distorted and negative cognitions regarding sleep onset can be a valuable tool for persons who are motivated to alter their thoughts and behaviors that contribute to sleep complaints, and may simultaneously improve associated anxiety and/or depression.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep. 2006;9:1398-1414.
2. Passos GS, Povares D, Santana MG, et al. Effect of acute physical exercise on patients with chronic primary insomnia. J Clin Sleep Med. 2010;6:270-275.
3. Edinger JD, Olsen MK, Stechuchak KM, et al. Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical trial. Sleep. 2009;32:499-510.
1. Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep. 2006;9:1398-1414.
2. Passos GS, Povares D, Santana MG, et al. Effect of acute physical exercise on patients with chronic primary insomnia. J Clin Sleep Med. 2010;6:270-275.
3. Edinger JD, Olsen MK, Stechuchak KM, et al. Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical trial. Sleep. 2009;32:499-510.
How to approach your patient’s RELAPSE
Relapse is common during recovery from alcohol or substance abuse. It’s estimated that >90% of patients will experience a relapse with 1 year of initiating abstinence.1 How clinicians approach relapse may make the difference between a prolonged relapse or a brief one, and whether the patient has multiple occurrences or infrequent “slips.” We use the mnemonic RELAPSE to teach our medical students and residents the key components involved in addressing and preventing relapse in our patients.
Reconnection. After a relapse, patients often feel shame and guilt. They may be hesitant to talk about it and may skip appointments. It is critical to reconnect with patients through a clinical posture that is welcoming, accepting, and nonjudgmental.
Education. When a patient relapses, you have the opportunity to educate the patient, family, and significant others about substance use disorders and how they effect the “3 B’s” (brain, body, and behavior), and also the availability of treatment options.
Linkage. One possible reason behind a relapse is the lack or loss of ties to a support group, recovery program, faith community, or family. After an assessment, help your patient establish links to specific support systems needed to foster recovery.
Anticipation. It is important to assess with the patient precipitating events that led to the relapse and anticipate warning signs. Anticipating future triggers (eg, stress, loss, relationship difficulties, etc.) will allow patients to be proactive in maintaining recovery.
Psychiatric. The presence of co-occurring psychiatric disorders is the expectation rather than the exception. After a patient has relapsed, we strongly emphasize reevaluating whether unaddressed mood, anxiety, or psychotic symptoms have contributed to the relapse.
Social. Relapse does not occur within a vacuum. Social issues clearly impact one’s ability to abstain from substances. A clinician who assesses a patient’s social milieu (eg, finances, friends, and employment) and social skills (eg, ability to communicate, ask for help, and assertively say no) likely will be able to identify key factors that led to relapse.
Empowerment. Resuming recovery is based on hope, cultivation of a healthy self-esteem, and sense of control over one’s life. After a relapse, strive to use a person-centered, strength-based approach that supports the patient’s commitment to change and self-determination.
1. Hales RE, Yudofsky SC. Essentials of clinical psychiatry. 2nd ed. Arlington, VA: American Psychiatric Publishing Inc.; 2004:149.
Relapse is common during recovery from alcohol or substance abuse. It’s estimated that >90% of patients will experience a relapse with 1 year of initiating abstinence.1 How clinicians approach relapse may make the difference between a prolonged relapse or a brief one, and whether the patient has multiple occurrences or infrequent “slips.” We use the mnemonic RELAPSE to teach our medical students and residents the key components involved in addressing and preventing relapse in our patients.
Reconnection. After a relapse, patients often feel shame and guilt. They may be hesitant to talk about it and may skip appointments. It is critical to reconnect with patients through a clinical posture that is welcoming, accepting, and nonjudgmental.
Education. When a patient relapses, you have the opportunity to educate the patient, family, and significant others about substance use disorders and how they effect the “3 B’s” (brain, body, and behavior), and also the availability of treatment options.
Linkage. One possible reason behind a relapse is the lack or loss of ties to a support group, recovery program, faith community, or family. After an assessment, help your patient establish links to specific support systems needed to foster recovery.
Anticipation. It is important to assess with the patient precipitating events that led to the relapse and anticipate warning signs. Anticipating future triggers (eg, stress, loss, relationship difficulties, etc.) will allow patients to be proactive in maintaining recovery.
Psychiatric. The presence of co-occurring psychiatric disorders is the expectation rather than the exception. After a patient has relapsed, we strongly emphasize reevaluating whether unaddressed mood, anxiety, or psychotic symptoms have contributed to the relapse.
Social. Relapse does not occur within a vacuum. Social issues clearly impact one’s ability to abstain from substances. A clinician who assesses a patient’s social milieu (eg, finances, friends, and employment) and social skills (eg, ability to communicate, ask for help, and assertively say no) likely will be able to identify key factors that led to relapse.
Empowerment. Resuming recovery is based on hope, cultivation of a healthy self-esteem, and sense of control over one’s life. After a relapse, strive to use a person-centered, strength-based approach that supports the patient’s commitment to change and self-determination.
Relapse is common during recovery from alcohol or substance abuse. It’s estimated that >90% of patients will experience a relapse with 1 year of initiating abstinence.1 How clinicians approach relapse may make the difference between a prolonged relapse or a brief one, and whether the patient has multiple occurrences or infrequent “slips.” We use the mnemonic RELAPSE to teach our medical students and residents the key components involved in addressing and preventing relapse in our patients.
Reconnection. After a relapse, patients often feel shame and guilt. They may be hesitant to talk about it and may skip appointments. It is critical to reconnect with patients through a clinical posture that is welcoming, accepting, and nonjudgmental.
Education. When a patient relapses, you have the opportunity to educate the patient, family, and significant others about substance use disorders and how they effect the “3 B’s” (brain, body, and behavior), and also the availability of treatment options.
Linkage. One possible reason behind a relapse is the lack or loss of ties to a support group, recovery program, faith community, or family. After an assessment, help your patient establish links to specific support systems needed to foster recovery.
Anticipation. It is important to assess with the patient precipitating events that led to the relapse and anticipate warning signs. Anticipating future triggers (eg, stress, loss, relationship difficulties, etc.) will allow patients to be proactive in maintaining recovery.
Psychiatric. The presence of co-occurring psychiatric disorders is the expectation rather than the exception. After a patient has relapsed, we strongly emphasize reevaluating whether unaddressed mood, anxiety, or psychotic symptoms have contributed to the relapse.
Social. Relapse does not occur within a vacuum. Social issues clearly impact one’s ability to abstain from substances. A clinician who assesses a patient’s social milieu (eg, finances, friends, and employment) and social skills (eg, ability to communicate, ask for help, and assertively say no) likely will be able to identify key factors that led to relapse.
Empowerment. Resuming recovery is based on hope, cultivation of a healthy self-esteem, and sense of control over one’s life. After a relapse, strive to use a person-centered, strength-based approach that supports the patient’s commitment to change and self-determination.
1. Hales RE, Yudofsky SC. Essentials of clinical psychiatry. 2nd ed. Arlington, VA: American Psychiatric Publishing Inc.; 2004:149.
1. Hales RE, Yudofsky SC. Essentials of clinical psychiatry. 2nd ed. Arlington, VA: American Psychiatric Publishing Inc.; 2004:149.
Teaching the STEPs of clinical psychopharmacology
Teaching medical students and psychiatry residents the principles of safe, effective clinical psychopharmacology can be challenging. Psychotropic agents from the same category often possess different mechanisms of action, cause various side effects, and have distinct safety profiles. Moreover, similar agents can be differentiated by the amount of evidence supporting their efficacy in treating particular disorders.
To help, I encourage prescribers to add a “STEP”—Safety, Tolerability, Efficacy, and Practicality—to their clinical decision-making. This is an invaluable “pearl” I learned nearly a decade ago and present here in a slightly modified form.1
Safety. Know the psychotropic’s safety profile, especially regarding comorbid medical illness and potential drug-drug interactions. Bupropion, for instance, may be an excellent choice for a depressed patient who recently had a myocardial infarction, but research shows the drug is risky for a person with a comorbid seizure disorder.
Tolerability. Evaluate the short- and long-term effects of each medication. Haloperidol, for example, is a reasonable choice for acute treatment of psychotic agitation in the emergency department, but a young woman struggling to manage her schizophrenia may not tolerate the drug as a maintenance therapy.
Efficacy. Familiarize yourself with the clinical evidence supporting a drug’s use for a particular disorder. Evidence strongly supports lithium carbonate for treating bipolar affective disorder, but current evidence-based clinical guidelines do not endorse gabapentin as a first choice for mood stabilization.
Practicality. Consider cost, adherence, and monitoring issues. A medication will certainly fail if the patient never fills the prescription because of cost or cannot adhere to a multiple daily dosing regimen or routine serum chemistries. This aspect may be the most essential to dispensing psychotropics because the student or resident must have a thoughtful grasp of the patient’s life circumstances, deficits, strengths, and motivation. Such understanding can be achieved only through careful, empathic listening and active involvement in the patient’s care and well-being.
Reference
1. Preskorn SH. Selection of an antidepressant: mirtazapine. J Clin Psychiatry 1997;58(suppl 6):3-8.
Dr. Christensen is associate professor of psychiatry, University of Florida College of Medicine, Jacksonville, and director of the university’s community psychiatry program.
Teaching medical students and psychiatry residents the principles of safe, effective clinical psychopharmacology can be challenging. Psychotropic agents from the same category often possess different mechanisms of action, cause various side effects, and have distinct safety profiles. Moreover, similar agents can be differentiated by the amount of evidence supporting their efficacy in treating particular disorders.
To help, I encourage prescribers to add a “STEP”—Safety, Tolerability, Efficacy, and Practicality—to their clinical decision-making. This is an invaluable “pearl” I learned nearly a decade ago and present here in a slightly modified form.1
Safety. Know the psychotropic’s safety profile, especially regarding comorbid medical illness and potential drug-drug interactions. Bupropion, for instance, may be an excellent choice for a depressed patient who recently had a myocardial infarction, but research shows the drug is risky for a person with a comorbid seizure disorder.
Tolerability. Evaluate the short- and long-term effects of each medication. Haloperidol, for example, is a reasonable choice for acute treatment of psychotic agitation in the emergency department, but a young woman struggling to manage her schizophrenia may not tolerate the drug as a maintenance therapy.
Efficacy. Familiarize yourself with the clinical evidence supporting a drug’s use for a particular disorder. Evidence strongly supports lithium carbonate for treating bipolar affective disorder, but current evidence-based clinical guidelines do not endorse gabapentin as a first choice for mood stabilization.
Practicality. Consider cost, adherence, and monitoring issues. A medication will certainly fail if the patient never fills the prescription because of cost or cannot adhere to a multiple daily dosing regimen or routine serum chemistries. This aspect may be the most essential to dispensing psychotropics because the student or resident must have a thoughtful grasp of the patient’s life circumstances, deficits, strengths, and motivation. Such understanding can be achieved only through careful, empathic listening and active involvement in the patient’s care and well-being.
Teaching medical students and psychiatry residents the principles of safe, effective clinical psychopharmacology can be challenging. Psychotropic agents from the same category often possess different mechanisms of action, cause various side effects, and have distinct safety profiles. Moreover, similar agents can be differentiated by the amount of evidence supporting their efficacy in treating particular disorders.
To help, I encourage prescribers to add a “STEP”—Safety, Tolerability, Efficacy, and Practicality—to their clinical decision-making. This is an invaluable “pearl” I learned nearly a decade ago and present here in a slightly modified form.1
Safety. Know the psychotropic’s safety profile, especially regarding comorbid medical illness and potential drug-drug interactions. Bupropion, for instance, may be an excellent choice for a depressed patient who recently had a myocardial infarction, but research shows the drug is risky for a person with a comorbid seizure disorder.
Tolerability. Evaluate the short- and long-term effects of each medication. Haloperidol, for example, is a reasonable choice for acute treatment of psychotic agitation in the emergency department, but a young woman struggling to manage her schizophrenia may not tolerate the drug as a maintenance therapy.
Efficacy. Familiarize yourself with the clinical evidence supporting a drug’s use for a particular disorder. Evidence strongly supports lithium carbonate for treating bipolar affective disorder, but current evidence-based clinical guidelines do not endorse gabapentin as a first choice for mood stabilization.
Practicality. Consider cost, adherence, and monitoring issues. A medication will certainly fail if the patient never fills the prescription because of cost or cannot adhere to a multiple daily dosing regimen or routine serum chemistries. This aspect may be the most essential to dispensing psychotropics because the student or resident must have a thoughtful grasp of the patient’s life circumstances, deficits, strengths, and motivation. Such understanding can be achieved only through careful, empathic listening and active involvement in the patient’s care and well-being.
Reference
1. Preskorn SH. Selection of an antidepressant: mirtazapine. J Clin Psychiatry 1997;58(suppl 6):3-8.
Dr. Christensen is associate professor of psychiatry, University of Florida College of Medicine, Jacksonville, and director of the university’s community psychiatry program.
Reference
1. Preskorn SH. Selection of an antidepressant: mirtazapine. J Clin Psychiatry 1997;58(suppl 6):3-8.
Dr. Christensen is associate professor of psychiatry, University of Florida College of Medicine, Jacksonville, and director of the university’s community psychiatry program.
‘Prescribing’ behavioral and lifestyle changes
Psychiatrists commonly treat persons whose first words during an office visit are: “I need something for…”—usually sleep problems, obesity, anxiety, or low energy.
Although these difficulties could point to a psychiatric or medical disorder, unhealthy behaviors such as poor sleep hygiene, substance abuse, lack of exercise, or inadequate diet often are to blame. Despite the patient’s expectations, medication might not be therapeutic or clinically indicated.
For such cases, I use my prescription pad to “prescribe” problem-focused, medically appropriate, nondrug treatments. Handwritten prescriptions reinforce the targeted behavioral change or lifestyle modification discussed during our session.
A written prescription doesn’t replace verbal recommendations, but I believe it provides concrete treatment instructions that lead to positive behavioral changes.
How behavioral ‘prescriptions’ work
Suppose a person with insomnia who drinks coffee and caffeinated sodas throughout the day requests sleep medication. I write a prescription for “doses” of coffee (“Drink no more than three cups a day”) and when the doses should be taken (“Do not take coffee or soda after 4 PM”).
If a patient is sedentary and gaining weight, I write a prescription to reduce calories (“Avoid eating cookies, cake, and ‘junk food’”) and to begin an easy, graded exercise program (“Start walking 30 minutes per day, four times per week”). For a patient whose anxiety symptoms do not improve after therapeutic medication trials, I prescribe relaxation techniques (“Practice deep-breathing exercises twice daily for the next 14 days”).
These written prescriptions include the date, patient’s name, and my signature. To guard against forgeries, I leave no blank spaces. I hand the prescription to the patient and instruct him or her to post it in a conspicuous place, such as the refrigerator door, coffee maker, or bathroom mirror. Most patients respond positively even though the prescription is not for medication, because it directly addresses their stated problem.
As with written orders for medications, I keep copies of behavioral/lifestyle prescriptions in the patient’s chart and refer to them when discussing adherence, to reinforce progress, and to adjust behavior modifications.
The prescription pad holds therapeutic power, but not all prescriptions we hand our patients need to be for medicine.
Dr. Christensen is associate professor of psychiatry, University of Florida College of Medicine, Jacksonville, and director of the university’s community psychiatry program.
Psychiatrists commonly treat persons whose first words during an office visit are: “I need something for…”—usually sleep problems, obesity, anxiety, or low energy.
Although these difficulties could point to a psychiatric or medical disorder, unhealthy behaviors such as poor sleep hygiene, substance abuse, lack of exercise, or inadequate diet often are to blame. Despite the patient’s expectations, medication might not be therapeutic or clinically indicated.
For such cases, I use my prescription pad to “prescribe” problem-focused, medically appropriate, nondrug treatments. Handwritten prescriptions reinforce the targeted behavioral change or lifestyle modification discussed during our session.
A written prescription doesn’t replace verbal recommendations, but I believe it provides concrete treatment instructions that lead to positive behavioral changes.
How behavioral ‘prescriptions’ work
Suppose a person with insomnia who drinks coffee and caffeinated sodas throughout the day requests sleep medication. I write a prescription for “doses” of coffee (“Drink no more than three cups a day”) and when the doses should be taken (“Do not take coffee or soda after 4 PM”).
If a patient is sedentary and gaining weight, I write a prescription to reduce calories (“Avoid eating cookies, cake, and ‘junk food’”) and to begin an easy, graded exercise program (“Start walking 30 minutes per day, four times per week”). For a patient whose anxiety symptoms do not improve after therapeutic medication trials, I prescribe relaxation techniques (“Practice deep-breathing exercises twice daily for the next 14 days”).
These written prescriptions include the date, patient’s name, and my signature. To guard against forgeries, I leave no blank spaces. I hand the prescription to the patient and instruct him or her to post it in a conspicuous place, such as the refrigerator door, coffee maker, or bathroom mirror. Most patients respond positively even though the prescription is not for medication, because it directly addresses their stated problem.
As with written orders for medications, I keep copies of behavioral/lifestyle prescriptions in the patient’s chart and refer to them when discussing adherence, to reinforce progress, and to adjust behavior modifications.
The prescription pad holds therapeutic power, but not all prescriptions we hand our patients need to be for medicine.
Psychiatrists commonly treat persons whose first words during an office visit are: “I need something for…”—usually sleep problems, obesity, anxiety, or low energy.
Although these difficulties could point to a psychiatric or medical disorder, unhealthy behaviors such as poor sleep hygiene, substance abuse, lack of exercise, or inadequate diet often are to blame. Despite the patient’s expectations, medication might not be therapeutic or clinically indicated.
For such cases, I use my prescription pad to “prescribe” problem-focused, medically appropriate, nondrug treatments. Handwritten prescriptions reinforce the targeted behavioral change or lifestyle modification discussed during our session.
A written prescription doesn’t replace verbal recommendations, but I believe it provides concrete treatment instructions that lead to positive behavioral changes.
How behavioral ‘prescriptions’ work
Suppose a person with insomnia who drinks coffee and caffeinated sodas throughout the day requests sleep medication. I write a prescription for “doses” of coffee (“Drink no more than three cups a day”) and when the doses should be taken (“Do not take coffee or soda after 4 PM”).
If a patient is sedentary and gaining weight, I write a prescription to reduce calories (“Avoid eating cookies, cake, and ‘junk food’”) and to begin an easy, graded exercise program (“Start walking 30 minutes per day, four times per week”). For a patient whose anxiety symptoms do not improve after therapeutic medication trials, I prescribe relaxation techniques (“Practice deep-breathing exercises twice daily for the next 14 days”).
These written prescriptions include the date, patient’s name, and my signature. To guard against forgeries, I leave no blank spaces. I hand the prescription to the patient and instruct him or her to post it in a conspicuous place, such as the refrigerator door, coffee maker, or bathroom mirror. Most patients respond positively even though the prescription is not for medication, because it directly addresses their stated problem.
As with written orders for medications, I keep copies of behavioral/lifestyle prescriptions in the patient’s chart and refer to them when discussing adherence, to reinforce progress, and to adjust behavior modifications.
The prescription pad holds therapeutic power, but not all prescriptions we hand our patients need to be for medicine.
Dr. Christensen is associate professor of psychiatry, University of Florida College of Medicine, Jacksonville, and director of the university’s community psychiatry program.
Dr. Christensen is associate professor of psychiatry, University of Florida College of Medicine, Jacksonville, and director of the university’s community psychiatry program.
Get serotonin syndrome down cold with SHIVERS
Critical initial treatment of serotonin syndrome (SS) depends on its swift and accurate identification. But the diagnosis can be complicated by nonspecific laboratory markers and physical symptoms similar to other hyperthermic disorders, such as neuroleptic malignant syndrome and anticholinergic toxicity.
You can recall SS’s hallmark physical symptoms with the acronym SHIVERS (Box).
Differentiating SS from other hyperthermic states requires a thorough review of the patient’s medical and drug history, clinical findings, and laboratory results. If diagnosed shortly after symptom onset and before muscular hypertonicity and hyperthermia develop, most uncomplicated SS cases resolve uneventfully over 24 hours. The key is to discontinue the causative agents, monitor vital signs, and administer IV fluids.1
Cyproheptadine, 4 mg every 4 hours as needed, is the recommended therapy, but further investigation is needed to confirm its effectiveness in alleviating SS or preventing a more-severe, potentially fatal course.2 Try benzodiazepines such as lorazepam (1 to 2 mg slow IV push) to moderate temperature, control agitation, and blunt the syndrome’s hyperadrenergic component. Intensive care is warranted in severe cases involving hypertonicity, rhabdomyolosis, and hyperthermia (temperature >41°C).
S hivering, one of the neuromuscular symptoms unique to SS, helps distinguish it from other hyperthermic syndromes
H yperreflexia and myoclonus are frequently seen in mild to moderate cases and are especially notable in the lower extremities; muscular rigidity occurs only in more severe cases
I ncreased temperature, although variable in SS and usually observed in severe cases, is likely caused by muscular hypertonicity
V ital sign instability can present as tachycardia, tachypnea, and/or labile blood pressure
E ncephalopathy—characterized by mental status changes such as agitation, delirium, confusion, and to a lesser extent obtundation—can develop from hyperthermia
R estlessness and incoordination are common because of excess serotonin activity
S weating (diaphoresis) is an autonomic response to excessive serotonin stimulation; by comparison, anticholinergic toxicity usually manifests with hot, dry skin
1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005;353(11):1112-20.
2. Sternbach H. Serotonin syndrome: How to avoid, identify and treat dangerous drug interactions. Current Psychiatry 2003;2(5):15-24.
Dr. Christensen is associate professor of psychiatry, University of Florida College of Medicine, Jacksonville, and director of the university’s community psychiatry program.
Critical initial treatment of serotonin syndrome (SS) depends on its swift and accurate identification. But the diagnosis can be complicated by nonspecific laboratory markers and physical symptoms similar to other hyperthermic disorders, such as neuroleptic malignant syndrome and anticholinergic toxicity.
You can recall SS’s hallmark physical symptoms with the acronym SHIVERS (Box).
Differentiating SS from other hyperthermic states requires a thorough review of the patient’s medical and drug history, clinical findings, and laboratory results. If diagnosed shortly after symptom onset and before muscular hypertonicity and hyperthermia develop, most uncomplicated SS cases resolve uneventfully over 24 hours. The key is to discontinue the causative agents, monitor vital signs, and administer IV fluids.1
Cyproheptadine, 4 mg every 4 hours as needed, is the recommended therapy, but further investigation is needed to confirm its effectiveness in alleviating SS or preventing a more-severe, potentially fatal course.2 Try benzodiazepines such as lorazepam (1 to 2 mg slow IV push) to moderate temperature, control agitation, and blunt the syndrome’s hyperadrenergic component. Intensive care is warranted in severe cases involving hypertonicity, rhabdomyolosis, and hyperthermia (temperature >41°C).
S hivering, one of the neuromuscular symptoms unique to SS, helps distinguish it from other hyperthermic syndromes
H yperreflexia and myoclonus are frequently seen in mild to moderate cases and are especially notable in the lower extremities; muscular rigidity occurs only in more severe cases
I ncreased temperature, although variable in SS and usually observed in severe cases, is likely caused by muscular hypertonicity
V ital sign instability can present as tachycardia, tachypnea, and/or labile blood pressure
E ncephalopathy—characterized by mental status changes such as agitation, delirium, confusion, and to a lesser extent obtundation—can develop from hyperthermia
R estlessness and incoordination are common because of excess serotonin activity
S weating (diaphoresis) is an autonomic response to excessive serotonin stimulation; by comparison, anticholinergic toxicity usually manifests with hot, dry skin
Critical initial treatment of serotonin syndrome (SS) depends on its swift and accurate identification. But the diagnosis can be complicated by nonspecific laboratory markers and physical symptoms similar to other hyperthermic disorders, such as neuroleptic malignant syndrome and anticholinergic toxicity.
You can recall SS’s hallmark physical symptoms with the acronym SHIVERS (Box).
Differentiating SS from other hyperthermic states requires a thorough review of the patient’s medical and drug history, clinical findings, and laboratory results. If diagnosed shortly after symptom onset and before muscular hypertonicity and hyperthermia develop, most uncomplicated SS cases resolve uneventfully over 24 hours. The key is to discontinue the causative agents, monitor vital signs, and administer IV fluids.1
Cyproheptadine, 4 mg every 4 hours as needed, is the recommended therapy, but further investigation is needed to confirm its effectiveness in alleviating SS or preventing a more-severe, potentially fatal course.2 Try benzodiazepines such as lorazepam (1 to 2 mg slow IV push) to moderate temperature, control agitation, and blunt the syndrome’s hyperadrenergic component. Intensive care is warranted in severe cases involving hypertonicity, rhabdomyolosis, and hyperthermia (temperature >41°C).
S hivering, one of the neuromuscular symptoms unique to SS, helps distinguish it from other hyperthermic syndromes
H yperreflexia and myoclonus are frequently seen in mild to moderate cases and are especially notable in the lower extremities; muscular rigidity occurs only in more severe cases
I ncreased temperature, although variable in SS and usually observed in severe cases, is likely caused by muscular hypertonicity
V ital sign instability can present as tachycardia, tachypnea, and/or labile blood pressure
E ncephalopathy—characterized by mental status changes such as agitation, delirium, confusion, and to a lesser extent obtundation—can develop from hyperthermia
R estlessness and incoordination are common because of excess serotonin activity
S weating (diaphoresis) is an autonomic response to excessive serotonin stimulation; by comparison, anticholinergic toxicity usually manifests with hot, dry skin
1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005;353(11):1112-20.
2. Sternbach H. Serotonin syndrome: How to avoid, identify and treat dangerous drug interactions. Current Psychiatry 2003;2(5):15-24.
Dr. Christensen is associate professor of psychiatry, University of Florida College of Medicine, Jacksonville, and director of the university’s community psychiatry program.
1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005;353(11):1112-20.
2. Sternbach H. Serotonin syndrome: How to avoid, identify and treat dangerous drug interactions. Current Psychiatry 2003;2(5):15-24.
Dr. Christensen is associate professor of psychiatry, University of Florida College of Medicine, Jacksonville, and director of the university’s community psychiatry program.