Saeed Ahmed, MD

Alcohol withdrawal syndrome (AWS) occurs when an individual who is alcohol-dependent suddenly stops or significantly reduces his/her alcohol intake.¹ Symptoms of AWS, which can be fatal, include anxiety, restlessness, seizures, confusion, and delirium.¹ Because benzodiazepines have been proven effective in improving symptoms of AWS, they are considered the first-line treatment, but they also carry the risk of abuse, psychomotor sedation, cognitive impairment, and interactions with alcohol.¹

Non-benzodiazepine anticonvulsants (NBACs) such as valproic acid (VPA) and carbamazepine may offer benefit as alternatives or adjuncts to benzodiazepines.¹ Many NBACs affect the functioning of glutamate and gamma-aminobutyric acid (GABA) neurotransmitters,² which are particularly dysregulated in patients with AWS. Because NBACs help stabilize this imbalance, they may be useful for managing AWS and preventing relapse without the risks associated with benzodiazepines.²

Valproic acid: A better choice than carbamazepine

Compared with other NBACs, VPA and carbamazepine have been studied more extensively for treating patients with AWS, and their clinical effectiveness has been well documented.¹ For mild-to-moderate AWS, VPA and carbamazepine may be as effective as benzodiazepines in reducing the severity of symptoms, and more potent for preventing withdrawal seizures.¹

Increasing data suggests that compared with VPA, adjunctive treatment with carbamazepine for AWS may be more frequently associated with intolerable adverse effects such as ataxia, orthostatic hypotension, vertigo, nausea, and vomiting.¹ The rapid onset of AWS requires rapid-acting pharmacotherapy.¹ In attempting to rapidly achieve the desired plasma concentrations of carbamazepine, clinicians may risk inducing adverse effects. Compared with carbamazepine, VPA is associated with faster symptom resolution, a shorter duration of pharmacologic treatment, fewer transfers to the ICU, fewer withdrawal seizures, and a more favorable adverse effect profile.¹ Likely due to its shorter half-life, VPA delivers its therapeutic effects without producing significant adverse effects.¹

Early and aggressive treatment of AWS is needed to block kindling,³ which is characterized by the worsening of withdrawal symptoms each time an individual attempts to quit drinking alcohol. Compared with carbamazepine, VPA may be more helpful for blocking kindling.³

More data is needed

Due to ethical concerns, few studies have compared anticonvulsant medications with placebo for treating AWS.² Most studies examining NBACs for AWS have either used the anticonvulsant as an adjunct to a benzodiazepine to examine improvement in withdrawal symptoms, or compared the anticonvulsant with placebo or another intervention to assess the amount of a benzodiazepine required for safe detoxification.^2,4 Additionally, most studies examining NBACs have been short, and few followed patients after the active medication period, which limits our knowledge of the long-term effectiveness of NBACs.² Before NBACs can replace benzodiazepines for managing AWS, further evidence from clinical trials is needed to assess their efficiency as a stand-alone treatment.

Alcohol withdrawal syndrome (AWS) occurs when an individual who is alcohol-dependent suddenly stops or significantly reduces his/her alcohol intake.¹ Symptoms of AWS, which can be fatal, include anxiety, restlessness, seizures, confusion, and delirium.¹ Because benzodiazepines have been proven effective in improving symptoms of AWS, they are considered the first-line treatment, but they also carry the risk of abuse, psychomotor sedation, cognitive impairment, and interactions with alcohol.¹

Non-benzodiazepine anticonvulsants (NBACs) such as valproic acid (VPA) and carbamazepine may offer benefit as alternatives or adjuncts to benzodiazepines.¹ Many NBACs affect the functioning of glutamate and gamma-aminobutyric acid (GABA) neurotransmitters,² which are particularly dysregulated in patients with AWS. Because NBACs help stabilize this imbalance, they may be useful for managing AWS and preventing relapse without the risks associated with benzodiazepines.²

Valproic acid: A better choice than carbamazepine

Compared with other NBACs, VPA and carbamazepine have been studied more extensively for treating patients with AWS, and their clinical effectiveness has been well documented.¹ For mild-to-moderate AWS, VPA and carbamazepine may be as effective as benzodiazepines in reducing the severity of symptoms, and more potent for preventing withdrawal seizures.¹

Increasing data suggests that compared with VPA, adjunctive treatment with carbamazepine for AWS may be more frequently associated with intolerable adverse effects such as ataxia, orthostatic hypotension, vertigo, nausea, and vomiting.¹ The rapid onset of AWS requires rapid-acting pharmacotherapy.¹ In attempting to rapidly achieve the desired plasma concentrations of carbamazepine, clinicians may risk inducing adverse effects. Compared with carbamazepine, VPA is associated with faster symptom resolution, a shorter duration of pharmacologic treatment, fewer transfers to the ICU, fewer withdrawal seizures, and a more favorable adverse effect profile.¹ Likely due to its shorter half-life, VPA delivers its therapeutic effects without producing significant adverse effects.¹

Early and aggressive treatment of AWS is needed to block kindling,³ which is characterized by the worsening of withdrawal symptoms each time an individual attempts to quit drinking alcohol. Compared with carbamazepine, VPA may be more helpful for blocking kindling.³

More data is needed

Due to ethical concerns, few studies have compared anticonvulsant medications with placebo for treating AWS.² Most studies examining NBACs for AWS have either used the anticonvulsant as an adjunct to a benzodiazepine to examine improvement in withdrawal symptoms, or compared the anticonvulsant with placebo or another intervention to assess the amount of a benzodiazepine required for safe detoxification.^2,4 Additionally, most studies examining NBACs have been short, and few followed patients after the active medication period, which limits our knowledge of the long-term effectiveness of NBACs.² Before NBACs can replace benzodiazepines for managing AWS, further evidence from clinical trials is needed to assess their efficiency as a stand-alone treatment.

Alcohol withdrawal syndrome (AWS) occurs when an individual who is alcohol-dependent suddenly stops or significantly reduces his/her alcohol intake.¹ Symptoms of AWS, which can be fatal, include anxiety, restlessness, seizures, confusion, and delirium.¹ Because benzodiazepines have been proven effective in improving symptoms of AWS, they are considered the first-line treatment, but they also carry the risk of abuse, psychomotor sedation, cognitive impairment, and interactions with alcohol.¹

Non-benzodiazepine anticonvulsants (NBACs) such as valproic acid (VPA) and carbamazepine may offer benefit as alternatives or adjuncts to benzodiazepines.¹ Many NBACs affect the functioning of glutamate and gamma-aminobutyric acid (GABA) neurotransmitters,² which are particularly dysregulated in patients with AWS. Because NBACs help stabilize this imbalance, they may be useful for managing AWS and preventing relapse without the risks associated with benzodiazepines.²

Valproic acid: A better choice than carbamazepine

Compared with other NBACs, VPA and carbamazepine have been studied more extensively for treating patients with AWS, and their clinical effectiveness has been well documented.¹ For mild-to-moderate AWS, VPA and carbamazepine may be as effective as benzodiazepines in reducing the severity of symptoms, and more potent for preventing withdrawal seizures.¹

Increasing data suggests that compared with VPA, adjunctive treatment with carbamazepine for AWS may be more frequently associated with intolerable adverse effects such as ataxia, orthostatic hypotension, vertigo, nausea, and vomiting.¹ The rapid onset of AWS requires rapid-acting pharmacotherapy.¹ In attempting to rapidly achieve the desired plasma concentrations of carbamazepine, clinicians may risk inducing adverse effects. Compared with carbamazepine, VPA is associated with faster symptom resolution, a shorter duration of pharmacologic treatment, fewer transfers to the ICU, fewer withdrawal seizures, and a more favorable adverse effect profile.¹ Likely due to its shorter half-life, VPA delivers its therapeutic effects without producing significant adverse effects.¹

Early and aggressive treatment of AWS is needed to block kindling,³ which is characterized by the worsening of withdrawal symptoms each time an individual attempts to quit drinking alcohol. Compared with carbamazepine, VPA may be more helpful for blocking kindling.³

More data is needed

Due to ethical concerns, few studies have compared anticonvulsant medications with placebo for treating AWS.² Most studies examining NBACs for AWS have either used the anticonvulsant as an adjunct to a benzodiazepine to examine improvement in withdrawal symptoms, or compared the anticonvulsant with placebo or another intervention to assess the amount of a benzodiazepine required for safe detoxification.^2,4 Additionally, most studies examining NBACs have been short, and few followed patients after the active medication period, which limits our knowledge of the long-term effectiveness of NBACs.² Before NBACs can replace benzodiazepines for managing AWS, further evidence from clinical trials is needed to assess their efficiency as a stand-alone treatment.

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Addiction Psychiatry Fellow at Boston University, talked with William Pirl, MD, MPH, FACLP, FAPOS. Dr. Pirl is Associate Professor, Psychiatry, Harvard Medical School. He joined Dana-Farber Cancer Institute in 2018 as Vice Chair for Psychosocial Oncology, Department of Psychosocial Oncology and Palliative Care. He is a past president of the American Psychosocial Oncology Society and North American Associate Editor for the journal Psycho-Oncology.

Dr. Ahmed: What made you choose the psychiatric oncology track, and how did your training lead you towards this path?

Dr. Pirl: I went to medical school thinking that I wanted to be a psychiatrist. However, I was really drawn to internal medicine, especially the process of sorting through medical differential diagnoses. I was deciding between applying for residency in medicine or psychiatry when I did an elective rotation in consultation-liaison (CL) psychiatry. Consultation-liaison psychiatry combined both medicine and psychiatry, which is exactly what I wanted to do. After residency, I wanted to do a CL fellowship outside of Boston, which is where I had done all of my medical education and training. One of my residency advisors suggested Memorial Sloan-Kettering Cancer Center, and I ended up going there. On the first day of fellowship, I realized that I’d only be working with cancer over that year, which I had not really thought about beforehand. Luckily, I loved it, and over the year I realized that the work had tremendous impact and meaning.

Dr. Ahmed: What are some of the pros and cons of working in psychiatric oncology?

Dr. Pirl: Things that I think are pros might be cons for some people. Consults in psychiatric oncology tend to be more relationship-based than they might be in other CL subspecialties. Oncology clinicians want to know who they are referring their patients to, and they are used to team-based care. If you like practicing as part of a multidisciplinary team, this is a pro.

Psychiatric oncology has more focus on existential issues, which interests me more than some other things in psychiatry. Bearing witness to so much tragedy can be a con at times, but psychiatrists who do this work learn ways to manage this within themselves. Psychiatric oncology also offers many experiences where you can see how much impact you make. It’s rewarding to see results and get positive feedback from patients and their families.

Continue to: Lastly, this is...

Lastly, this is a historic time in oncology. Over the last 15 years, things are happening that I never thought I would live to see. Some patients who 10 or 15 years ago would have had an expected survival of 6 to 9 months are now living years. We are now at a point where we might not actually know a patient’s prognosis, which introduces a whole other layer of uncertainty in cancer. Working as a psychiatrist during this time of rapidly evolving care is amazing. Cancer care will look very different over the next decade.

Dr. Ahmed: Based on your personal experience, what should one consider when choosing a psychiatric oncology program?

Dr. Pirl: I trained in a time before CL was a certified subspecialty of psychiatry. At that time, programs could focus solely on cancer, which cannot be done now. Trainees need to have broader training in certified fellowships. If someone knows that they are interested in psychiatric oncology, there are 2 programs that they should consider: the Dana-Farber Cancer Institute track of the Brigham and Women’s Hospital CL fellowship, and the Memorial Sloan-Kettering Cancer Center/New York Hospital CL fellowship. However, completing a CL fellowship will give someone the skills to do this work, even though they may not know all of the cancer content yet.

Dr. Ahmed: What are some of the career options and work settings in psychiatric oncology?

Dr. Pirl: There are many factors that make it difficult for psychiatrist to have a psychiatric oncology private practice. The amount of late cancellations and no-shows because of illness makes it hard to do this work without some institutional subsidy. Also, being able to communicate and work as a team with oncology providers is much easier if you are in the same place. Most psychiatrists who do psychiatric oncology work in a cancer center or hospital. Practice settings at those places include both inpatient and outpatient work. There is also a shortage of psychiatrists doing this work, which makes it easier to get a job and to advance into leadership roles.

Continue to: Dr. Ahmed...

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Pirl: One challenge is figuring out how to make sure you have income doing something that is not financially viable on its own. This is why most people work for cancer centers or hospitals and have some institutional subsidy for their work. Another challenge is access to care. There are not enough psychiatric resources for all the people with cancer who need them. Traditional referral-based models are getting harder and harder to manage. I think the emotional aspects of the work can also be challenging at times.

Dr. Ahmed: Where do you see the field going?

Dr. Pirl: Psychosocial care is now considered part of quality cancer care, and regulations require cancer centers to do certain aspects of it. This is leading to clinical growth and more integration into oncology. However, I am worried that we are not having enough psychiatry residents choose to do CL and/or psychiatric oncology. Some trainees are choosing to do a palliative care fellowship instead. When those trainees tell me why they want to do palliative care, I say that I do all of that and actually have much more time to do it because I am not managing constipation and vent settings. We need to do a better job of making trainees more aware of psychiatric oncology.

Dr. Ahmed: What advice do you have for those contemplating a career in psychiatric oncology?

Dr. Pirl: Please join the field. There is a shortage of psychiatrists who do this work, which is ironically one of the best and most meaningful jobs in psychiatry.

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Addiction Psychiatry Fellow at Boston University, talked with William Pirl, MD, MPH, FACLP, FAPOS. Dr. Pirl is Associate Professor, Psychiatry, Harvard Medical School. He joined Dana-Farber Cancer Institute in 2018 as Vice Chair for Psychosocial Oncology, Department of Psychosocial Oncology and Palliative Care. He is a past president of the American Psychosocial Oncology Society and North American Associate Editor for the journal Psycho-Oncology.

Dr. Ahmed: What made you choose the psychiatric oncology track, and how did your training lead you towards this path?

Dr. Pirl: I went to medical school thinking that I wanted to be a psychiatrist. However, I was really drawn to internal medicine, especially the process of sorting through medical differential diagnoses. I was deciding between applying for residency in medicine or psychiatry when I did an elective rotation in consultation-liaison (CL) psychiatry. Consultation-liaison psychiatry combined both medicine and psychiatry, which is exactly what I wanted to do. After residency, I wanted to do a CL fellowship outside of Boston, which is where I had done all of my medical education and training. One of my residency advisors suggested Memorial Sloan-Kettering Cancer Center, and I ended up going there. On the first day of fellowship, I realized that I’d only be working with cancer over that year, which I had not really thought about beforehand. Luckily, I loved it, and over the year I realized that the work had tremendous impact and meaning.

Dr. Ahmed: What are some of the pros and cons of working in psychiatric oncology?

Dr. Pirl: Things that I think are pros might be cons for some people. Consults in psychiatric oncology tend to be more relationship-based than they might be in other CL subspecialties. Oncology clinicians want to know who they are referring their patients to, and they are used to team-based care. If you like practicing as part of a multidisciplinary team, this is a pro.

Psychiatric oncology has more focus on existential issues, which interests me more than some other things in psychiatry. Bearing witness to so much tragedy can be a con at times, but psychiatrists who do this work learn ways to manage this within themselves. Psychiatric oncology also offers many experiences where you can see how much impact you make. It’s rewarding to see results and get positive feedback from patients and their families.

Continue to: Lastly, this is...

Lastly, this is a historic time in oncology. Over the last 15 years, things are happening that I never thought I would live to see. Some patients who 10 or 15 years ago would have had an expected survival of 6 to 9 months are now living years. We are now at a point where we might not actually know a patient’s prognosis, which introduces a whole other layer of uncertainty in cancer. Working as a psychiatrist during this time of rapidly evolving care is amazing. Cancer care will look very different over the next decade.

Dr. Ahmed: Based on your personal experience, what should one consider when choosing a psychiatric oncology program?

Dr. Pirl: I trained in a time before CL was a certified subspecialty of psychiatry. At that time, programs could focus solely on cancer, which cannot be done now. Trainees need to have broader training in certified fellowships. If someone knows that they are interested in psychiatric oncology, there are 2 programs that they should consider: the Dana-Farber Cancer Institute track of the Brigham and Women’s Hospital CL fellowship, and the Memorial Sloan-Kettering Cancer Center/New York Hospital CL fellowship. However, completing a CL fellowship will give someone the skills to do this work, even though they may not know all of the cancer content yet.

Dr. Ahmed: What are some of the career options and work settings in psychiatric oncology?

Dr. Pirl: There are many factors that make it difficult for psychiatrist to have a psychiatric oncology private practice. The amount of late cancellations and no-shows because of illness makes it hard to do this work without some institutional subsidy. Also, being able to communicate and work as a team with oncology providers is much easier if you are in the same place. Most psychiatrists who do psychiatric oncology work in a cancer center or hospital. Practice settings at those places include both inpatient and outpatient work. There is also a shortage of psychiatrists doing this work, which makes it easier to get a job and to advance into leadership roles.

Continue to: Dr. Ahmed...

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Pirl: One challenge is figuring out how to make sure you have income doing something that is not financially viable on its own. This is why most people work for cancer centers or hospitals and have some institutional subsidy for their work. Another challenge is access to care. There are not enough psychiatric resources for all the people with cancer who need them. Traditional referral-based models are getting harder and harder to manage. I think the emotional aspects of the work can also be challenging at times.

Dr. Ahmed: Where do you see the field going?

Dr. Pirl: Psychosocial care is now considered part of quality cancer care, and regulations require cancer centers to do certain aspects of it. This is leading to clinical growth and more integration into oncology. However, I am worried that we are not having enough psychiatry residents choose to do CL and/or psychiatric oncology. Some trainees are choosing to do a palliative care fellowship instead. When those trainees tell me why they want to do palliative care, I say that I do all of that and actually have much more time to do it because I am not managing constipation and vent settings. We need to do a better job of making trainees more aware of psychiatric oncology.

Dr. Ahmed: What advice do you have for those contemplating a career in psychiatric oncology?

Dr. Pirl: Please join the field. There is a shortage of psychiatrists who do this work, which is ironically one of the best and most meaningful jobs in psychiatry.

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Addiction Psychiatry Fellow at Boston University, talked with William Pirl, MD, MPH, FACLP, FAPOS. Dr. Pirl is Associate Professor, Psychiatry, Harvard Medical School. He joined Dana-Farber Cancer Institute in 2018 as Vice Chair for Psychosocial Oncology, Department of Psychosocial Oncology and Palliative Care. He is a past president of the American Psychosocial Oncology Society and North American Associate Editor for the journal Psycho-Oncology.

Dr. Ahmed: What made you choose the psychiatric oncology track, and how did your training lead you towards this path?

Dr. Pirl: I went to medical school thinking that I wanted to be a psychiatrist. However, I was really drawn to internal medicine, especially the process of sorting through medical differential diagnoses. I was deciding between applying for residency in medicine or psychiatry when I did an elective rotation in consultation-liaison (CL) psychiatry. Consultation-liaison psychiatry combined both medicine and psychiatry, which is exactly what I wanted to do. After residency, I wanted to do a CL fellowship outside of Boston, which is where I had done all of my medical education and training. One of my residency advisors suggested Memorial Sloan-Kettering Cancer Center, and I ended up going there. On the first day of fellowship, I realized that I’d only be working with cancer over that year, which I had not really thought about beforehand. Luckily, I loved it, and over the year I realized that the work had tremendous impact and meaning.

Dr. Ahmed: What are some of the pros and cons of working in psychiatric oncology?

Dr. Pirl: Things that I think are pros might be cons for some people. Consults in psychiatric oncology tend to be more relationship-based than they might be in other CL subspecialties. Oncology clinicians want to know who they are referring their patients to, and they are used to team-based care. If you like practicing as part of a multidisciplinary team, this is a pro.

Psychiatric oncology has more focus on existential issues, which interests me more than some other things in psychiatry. Bearing witness to so much tragedy can be a con at times, but psychiatrists who do this work learn ways to manage this within themselves. Psychiatric oncology also offers many experiences where you can see how much impact you make. It’s rewarding to see results and get positive feedback from patients and their families.

Continue to: Lastly, this is...

Lastly, this is a historic time in oncology. Over the last 15 years, things are happening that I never thought I would live to see. Some patients who 10 or 15 years ago would have had an expected survival of 6 to 9 months are now living years. We are now at a point where we might not actually know a patient’s prognosis, which introduces a whole other layer of uncertainty in cancer. Working as a psychiatrist during this time of rapidly evolving care is amazing. Cancer care will look very different over the next decade.

Dr. Ahmed: Based on your personal experience, what should one consider when choosing a psychiatric oncology program?

Dr. Pirl: I trained in a time before CL was a certified subspecialty of psychiatry. At that time, programs could focus solely on cancer, which cannot be done now. Trainees need to have broader training in certified fellowships. If someone knows that they are interested in psychiatric oncology, there are 2 programs that they should consider: the Dana-Farber Cancer Institute track of the Brigham and Women’s Hospital CL fellowship, and the Memorial Sloan-Kettering Cancer Center/New York Hospital CL fellowship. However, completing a CL fellowship will give someone the skills to do this work, even though they may not know all of the cancer content yet.

Dr. Ahmed: What are some of the career options and work settings in psychiatric oncology?

Dr. Pirl: There are many factors that make it difficult for psychiatrist to have a psychiatric oncology private practice. The amount of late cancellations and no-shows because of illness makes it hard to do this work without some institutional subsidy. Also, being able to communicate and work as a team with oncology providers is much easier if you are in the same place. Most psychiatrists who do psychiatric oncology work in a cancer center or hospital. Practice settings at those places include both inpatient and outpatient work. There is also a shortage of psychiatrists doing this work, which makes it easier to get a job and to advance into leadership roles.

Continue to: Dr. Ahmed...

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Pirl: One challenge is figuring out how to make sure you have income doing something that is not financially viable on its own. This is why most people work for cancer centers or hospitals and have some institutional subsidy for their work. Another challenge is access to care. There are not enough psychiatric resources for all the people with cancer who need them. Traditional referral-based models are getting harder and harder to manage. I think the emotional aspects of the work can also be challenging at times.

Dr. Ahmed: Where do you see the field going?

Dr. Pirl: Psychosocial care is now considered part of quality cancer care, and regulations require cancer centers to do certain aspects of it. This is leading to clinical growth and more integration into oncology. However, I am worried that we are not having enough psychiatry residents choose to do CL and/or psychiatric oncology. Some trainees are choosing to do a palliative care fellowship instead. When those trainees tell me why they want to do palliative care, I say that I do all of that and actually have much more time to do it because I am not managing constipation and vent settings. We need to do a better job of making trainees more aware of psychiatric oncology.

Dr. Ahmed: What advice do you have for those contemplating a career in psychiatric oncology?

Dr. Pirl: Please join the field. There is a shortage of psychiatrists who do this work, which is ironically one of the best and most meaningful jobs in psychiatry.

Editor’s note:  Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Addiction Psychiatry Fellow at Boston University Medical Center/Boston University School of Medicine, talked with Paul S. Appelbaum, MD, Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law, and Director, Center for Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons. Dr. Appelbaum is currently Chair of the DSM Steering Committee for the American Psychiatric Association, and Co-chair of the Standing Committee on Ethics of the World Psychiatric Association. He performs forensic evaluations in civil and criminal cases, and treats patients with a broad variety of illnesses, including depression, anxiety, and adjustment problems.

Dr. Ahmed: What made you pick the forensic psychiatry track, and how did your training lead you towards this path?

Dr. Appelbaum: I was a debater in high school and college, and a fair number of our topics dealt with legal issues, which I’d always found intriguing. However, on entering medical school, I had assumed that I would need to leave those interests behind me. During the first week of medical school, though, we were all asked to select a behavioral science elective for the semester, and on the list was “Law and Psychiatry.” I didn’t know what it involved, but it sounded interesting, so I signed up. The class was taught by Dr. Alan Stone, a professor at Harvard Law School and the most important figure in the academic study of legal issues in psychiatry. By the end of the first class—on the Friday afternoon of my first week in medical school—I was so excited by the things we were discussing that I pretty much decided this was what I wanted to focus on in my career.

Later in medical school, I joined a research project looking at violence on the inpatient psychiatric units, as a way of broadening my knowledge of the field. During residency—we’re talking about the late 1970s, which was a time of great legal ferment about regulation of psychiatric practice—I persuaded my attending psychiatrist to join me in studying patients who were exercising their newly granted right to refuse treatment. That’s how Dr. Tom Gutheil and I started working together, a collaboration that continues today, with the publication of the 5th edition of our text, Clinical Handbook of Psychiatry and Law. I was also able to get foundation funding to do a study of patients’ decision-making capacities, a topic that has remained a focus of my research to the present day. During my final year of residency, I was able to create a chief residency in legal psychiatry, which allowed me to take law school courses, pursue my research, and supervise the more junior residents in their forensic evaluations.

Today, most people headed toward careers in forensic psychiatry take a fellowship after residency, but [such fellowships] were few and far between in 1980. So I went to Alan Stone for advice, and he said, “Go work with Loren Roth in Pittsburgh for 5 years, and you’ll be able to do anything you want after that.” I tracked down Loren Roth, then the leading empirical researcher on issues related to law and psychiatry, explained that Alan Stone had said I should go work with him, and somehow it all worked out. My first faculty job was with his Law and Psychiatry Program at the University of Pittsburgh.

Dr. Ahmed: What are some of the pros and cons of working in forensic psychiatry?

Continue to: Dr. Appelbaum...

Dr. Appelbaum: It may sound at first as though forensic psychiatry is a narrow subspecialty of psychiatry. But the field is actually immense, and the diversity of experiences that it provides is one of the big pros of a career in forensic psychiatry. On the academic side of the field, topics of research interest include prediction and management of violence, involuntary commitment and treatment, informed consent and decisional capacity, privacy and confidentiality of psychiatric treatment, criminal responsibility, and correctional treatment. Clinically, forensic psychiatrists perform a variety of evaluations, ranging from competence to consent to treatment, testamentary capacity, emotional harms in tort cases, psychiatric malpractice, sexual harassment and work-related disability, to competence to stand trial, voluntariness of confessions, insanity defense, and pre-sentencing assessments. Indeed, after nearly 40 years in the field, I still occasionally get asked to do evaluations of a type that I’ve never done before. Increasingly, forensic psychiatrists are involved in treating offenders, both in correctional facilities and in outpatient settings. Most people trained in forensic psychiatry mix their forensic work with general clinical work, whether inpatient or outpatient. So the flexibility that the field offers to craft a career is one of its great advantages.

On the cons side, a career in forensic psychiatry can mean a life of what Alan Stone called “moral peril.” By that he meant that forensic psychiatrists face constant ethical challenges as they perform evaluations and provide testimony. One challenge is to stay grounded in the evidence base of psychiatry and resist the temptation to draw conclusions that may seem “right” but that go beyond what psychiatric knowledge can actually support. Making that challenge even more difficult in private forensic practice is knowing that the party for whom one is working has specific interests that they are hoping you will support, and very definite ideas about what they want your conclusions to be. It may be in your financial interest to accommodate them, but in the long run, your reputation is your most valuable asset. Staying honest both to one’s beliefs and to the broader evidence base in psychiatry is an ongoing challenge, but a critical necessity.

Dr. Ahmed: Based on your personal experience, what should one consider when choosing a forensic psychiatry program?

Dr. Appelbaum: Having supervised forensic psychiatry fellowships for roughly 30 years, I think one of the most important aspects of a training program is its breadth. Given the diversity of the field, a program with a limited number of training sites that focuses on a restricted set of evaluations (usually related to criminal law) will not offer a fellow an optimal training experience. Diverse placements with a variety of evaluations to be performed under the supervision of experienced forensic psychiatrists, and without excessive service demands, are key aspects of a top-notch program. In addition, not everything can be learned hands-on; didactic training is indispensable. Fellows should be offered sufficient background on legal issues and the research base in forensic psychiatry to ground their subsequent work. Finally, for many fellows their time in fellowship is the last opportunity they may have to engage in research or other scholarly projects under supervision, another valuable component of a training program. A good question to ask of any program: What are your former fellows doing now? If the answers don’t reflect the career path you hope to pursue, that’s not the program for you.

Dr. Ahmed: What are some of the career options and work settings for forensic psychiatrists?

Continue to: Dr. Appelbaum...

Dr. Appelbaum: One of the advantages of forensic psychiatry is the plethora of work settings available. People headed to private practice can often combine clinical practice with forensic work, a necessity when starting one’s career and waiting to establish steady referral pipelines. Psychiatrists with forensic training are in demand in correctional facilities (which often pay higher salaries than comparable jobs in psychiatric facilities), forensic hospitals, and court clinics. Opportunities for academic involvement include directing fellowship programs, teaching residents, and conducting research. With regard to research, although funding is harder to come by than, for example, for studies of the biology of major psychiatric syndromes, determined psychiatrists can often find ways of framing questions related to forensic issues so that they appeal to funders’ priorities. As one gains experience, opportunities for consultation for law enforcement agencies, intelligence agencies, and federal and state mental health agencies may be available. It is rare for a forensic psychiatrist to do just one of these things; most forensic psychiatrists engage in a mix of types of work, including general clinical work. The possibilities are manifold.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Appelbaum: I talked already about some of the ethical challenges in forensic psychiatry. In addition, as a subspecialty that applies psychiatric knowledge to legal questions, forensic psychiatry requires its practitioners to stay up-to-date with both advances in psychiatry and changes in the law, not to mention variations across jurisdictions. This is not an area of specialization in which one can pay attention during fellowship and then coast through a career. In my view, it’s also critical for a good forensic psychiatrist to be an excellent clinician; forensic cases frequently offer diagnostic challenges that require the highest level of clinical skills to address. Finally, for people early in their careers, it can take a few years before they are well-enough known to get a steady flow of private forensic cases. So having a plan B during that career phase will be essential.

Dr. Ahmed: Where do you see forensic psychiatry going?

Dr. Appelbaum: Forensic evaluations will need to incorporate new assessment techniques and new knowledge—although not before they have been demonstrated to be valid and reliable. I can foresee increased use of specialized neuroimaging assessments, genomic and other “omic” testing, and measurement of other neurophysiologic parameters. As we know more about the etiology of psychiatric disorders, that will impact everything from evaluations of causation in emotional harms cases to conclusions about which divorcing parent may be better able to handle primary custody of a child. I think there will be exciting opportunities in the coming decades to integrate growing scientific knowledge about psychiatric illnesses into forensic psychiatry.

Continue to: Dr. Ahmed...

Dr. Ahmed: What advice do you have for those contemplating a career in forensic psychiatry?

Dr. Appelbaum: Residents thinking about undertaking training in forensic psychiatry should come to one of the annual meetings of the American Academy of Psychiatry and the Law, the major professional organization of forensic psychiatrists, which takes place every October. That will give them a good feel for the scope of the field and the types of work available. Many residencies offer rotations in forensic psychiatry, another opportunity to learn about the field, and even in programs that don’t, highly motivated residents are often able to arrange electives working with forensic psychiatrists in the community. Doing a research project in the area is another great way to learn more about the field. The more you know before you make a decision, the better that decision will be.

Editor’s note:  Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Addiction Psychiatry Fellow at Boston University Medical Center/Boston University School of Medicine, talked with Paul S. Appelbaum, MD, Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law, and Director, Center for Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons. Dr. Appelbaum is currently Chair of the DSM Steering Committee for the American Psychiatric Association, and Co-chair of the Standing Committee on Ethics of the World Psychiatric Association. He performs forensic evaluations in civil and criminal cases, and treats patients with a broad variety of illnesses, including depression, anxiety, and adjustment problems.

Dr. Ahmed: What made you pick the forensic psychiatry track, and how did your training lead you towards this path?

Dr. Appelbaum: I was a debater in high school and college, and a fair number of our topics dealt with legal issues, which I’d always found intriguing. However, on entering medical school, I had assumed that I would need to leave those interests behind me. During the first week of medical school, though, we were all asked to select a behavioral science elective for the semester, and on the list was “Law and Psychiatry.” I didn’t know what it involved, but it sounded interesting, so I signed up. The class was taught by Dr. Alan Stone, a professor at Harvard Law School and the most important figure in the academic study of legal issues in psychiatry. By the end of the first class—on the Friday afternoon of my first week in medical school—I was so excited by the things we were discussing that I pretty much decided this was what I wanted to focus on in my career.

Later in medical school, I joined a research project looking at violence on the inpatient psychiatric units, as a way of broadening my knowledge of the field. During residency—we’re talking about the late 1970s, which was a time of great legal ferment about regulation of psychiatric practice—I persuaded my attending psychiatrist to join me in studying patients who were exercising their newly granted right to refuse treatment. That’s how Dr. Tom Gutheil and I started working together, a collaboration that continues today, with the publication of the 5th edition of our text, Clinical Handbook of Psychiatry and Law. I was also able to get foundation funding to do a study of patients’ decision-making capacities, a topic that has remained a focus of my research to the present day. During my final year of residency, I was able to create a chief residency in legal psychiatry, which allowed me to take law school courses, pursue my research, and supervise the more junior residents in their forensic evaluations.

Today, most people headed toward careers in forensic psychiatry take a fellowship after residency, but [such fellowships] were few and far between in 1980. So I went to Alan Stone for advice, and he said, “Go work with Loren Roth in Pittsburgh for 5 years, and you’ll be able to do anything you want after that.” I tracked down Loren Roth, then the leading empirical researcher on issues related to law and psychiatry, explained that Alan Stone had said I should go work with him, and somehow it all worked out. My first faculty job was with his Law and Psychiatry Program at the University of Pittsburgh.

Dr. Ahmed: What are some of the pros and cons of working in forensic psychiatry?

Continue to: Dr. Appelbaum...

Dr. Appelbaum: It may sound at first as though forensic psychiatry is a narrow subspecialty of psychiatry. But the field is actually immense, and the diversity of experiences that it provides is one of the big pros of a career in forensic psychiatry. On the academic side of the field, topics of research interest include prediction and management of violence, involuntary commitment and treatment, informed consent and decisional capacity, privacy and confidentiality of psychiatric treatment, criminal responsibility, and correctional treatment. Clinically, forensic psychiatrists perform a variety of evaluations, ranging from competence to consent to treatment, testamentary capacity, emotional harms in tort cases, psychiatric malpractice, sexual harassment and work-related disability, to competence to stand trial, voluntariness of confessions, insanity defense, and pre-sentencing assessments. Indeed, after nearly 40 years in the field, I still occasionally get asked to do evaluations of a type that I’ve never done before. Increasingly, forensic psychiatrists are involved in treating offenders, both in correctional facilities and in outpatient settings. Most people trained in forensic psychiatry mix their forensic work with general clinical work, whether inpatient or outpatient. So the flexibility that the field offers to craft a career is one of its great advantages.

On the cons side, a career in forensic psychiatry can mean a life of what Alan Stone called “moral peril.” By that he meant that forensic psychiatrists face constant ethical challenges as they perform evaluations and provide testimony. One challenge is to stay grounded in the evidence base of psychiatry and resist the temptation to draw conclusions that may seem “right” but that go beyond what psychiatric knowledge can actually support. Making that challenge even more difficult in private forensic practice is knowing that the party for whom one is working has specific interests that they are hoping you will support, and very definite ideas about what they want your conclusions to be. It may be in your financial interest to accommodate them, but in the long run, your reputation is your most valuable asset. Staying honest both to one’s beliefs and to the broader evidence base in psychiatry is an ongoing challenge, but a critical necessity.

Dr. Ahmed: Based on your personal experience, what should one consider when choosing a forensic psychiatry program?

Dr. Appelbaum: Having supervised forensic psychiatry fellowships for roughly 30 years, I think one of the most important aspects of a training program is its breadth. Given the diversity of the field, a program with a limited number of training sites that focuses on a restricted set of evaluations (usually related to criminal law) will not offer a fellow an optimal training experience. Diverse placements with a variety of evaluations to be performed under the supervision of experienced forensic psychiatrists, and without excessive service demands, are key aspects of a top-notch program. In addition, not everything can be learned hands-on; didactic training is indispensable. Fellows should be offered sufficient background on legal issues and the research base in forensic psychiatry to ground their subsequent work. Finally, for many fellows their time in fellowship is the last opportunity they may have to engage in research or other scholarly projects under supervision, another valuable component of a training program. A good question to ask of any program: What are your former fellows doing now? If the answers don’t reflect the career path you hope to pursue, that’s not the program for you.

Dr. Ahmed: What are some of the career options and work settings for forensic psychiatrists?

Continue to: Dr. Appelbaum...

Dr. Appelbaum: One of the advantages of forensic psychiatry is the plethora of work settings available. People headed to private practice can often combine clinical practice with forensic work, a necessity when starting one’s career and waiting to establish steady referral pipelines. Psychiatrists with forensic training are in demand in correctional facilities (which often pay higher salaries than comparable jobs in psychiatric facilities), forensic hospitals, and court clinics. Opportunities for academic involvement include directing fellowship programs, teaching residents, and conducting research. With regard to research, although funding is harder to come by than, for example, for studies of the biology of major psychiatric syndromes, determined psychiatrists can often find ways of framing questions related to forensic issues so that they appeal to funders’ priorities. As one gains experience, opportunities for consultation for law enforcement agencies, intelligence agencies, and federal and state mental health agencies may be available. It is rare for a forensic psychiatrist to do just one of these things; most forensic psychiatrists engage in a mix of types of work, including general clinical work. The possibilities are manifold.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Appelbaum: I talked already about some of the ethical challenges in forensic psychiatry. In addition, as a subspecialty that applies psychiatric knowledge to legal questions, forensic psychiatry requires its practitioners to stay up-to-date with both advances in psychiatry and changes in the law, not to mention variations across jurisdictions. This is not an area of specialization in which one can pay attention during fellowship and then coast through a career. In my view, it’s also critical for a good forensic psychiatrist to be an excellent clinician; forensic cases frequently offer diagnostic challenges that require the highest level of clinical skills to address. Finally, for people early in their careers, it can take a few years before they are well-enough known to get a steady flow of private forensic cases. So having a plan B during that career phase will be essential.

Dr. Ahmed: Where do you see forensic psychiatry going?

Dr. Appelbaum: Forensic evaluations will need to incorporate new assessment techniques and new knowledge—although not before they have been demonstrated to be valid and reliable. I can foresee increased use of specialized neuroimaging assessments, genomic and other “omic” testing, and measurement of other neurophysiologic parameters. As we know more about the etiology of psychiatric disorders, that will impact everything from evaluations of causation in emotional harms cases to conclusions about which divorcing parent may be better able to handle primary custody of a child. I think there will be exciting opportunities in the coming decades to integrate growing scientific knowledge about psychiatric illnesses into forensic psychiatry.

Continue to: Dr. Ahmed...

Dr. Ahmed: What advice do you have for those contemplating a career in forensic psychiatry?

Dr. Appelbaum: Residents thinking about undertaking training in forensic psychiatry should come to one of the annual meetings of the American Academy of Psychiatry and the Law, the major professional organization of forensic psychiatrists, which takes place every October. That will give them a good feel for the scope of the field and the types of work available. Many residencies offer rotations in forensic psychiatry, another opportunity to learn about the field, and even in programs that don’t, highly motivated residents are often able to arrange electives working with forensic psychiatrists in the community. Doing a research project in the area is another great way to learn more about the field. The more you know before you make a decision, the better that decision will be.

Editor’s note:  Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Addiction Psychiatry Fellow at Boston University Medical Center/Boston University School of Medicine, talked with Paul S. Appelbaum, MD, Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law, and Director, Center for Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons. Dr. Appelbaum is currently Chair of the DSM Steering Committee for the American Psychiatric Association, and Co-chair of the Standing Committee on Ethics of the World Psychiatric Association. He performs forensic evaluations in civil and criminal cases, and treats patients with a broad variety of illnesses, including depression, anxiety, and adjustment problems.

Dr. Ahmed: What made you pick the forensic psychiatry track, and how did your training lead you towards this path?

Dr. Appelbaum: I was a debater in high school and college, and a fair number of our topics dealt with legal issues, which I’d always found intriguing. However, on entering medical school, I had assumed that I would need to leave those interests behind me. During the first week of medical school, though, we were all asked to select a behavioral science elective for the semester, and on the list was “Law and Psychiatry.” I didn’t know what it involved, but it sounded interesting, so I signed up. The class was taught by Dr. Alan Stone, a professor at Harvard Law School and the most important figure in the academic study of legal issues in psychiatry. By the end of the first class—on the Friday afternoon of my first week in medical school—I was so excited by the things we were discussing that I pretty much decided this was what I wanted to focus on in my career.

Later in medical school, I joined a research project looking at violence on the inpatient psychiatric units, as a way of broadening my knowledge of the field. During residency—we’re talking about the late 1970s, which was a time of great legal ferment about regulation of psychiatric practice—I persuaded my attending psychiatrist to join me in studying patients who were exercising their newly granted right to refuse treatment. That’s how Dr. Tom Gutheil and I started working together, a collaboration that continues today, with the publication of the 5th edition of our text, Clinical Handbook of Psychiatry and Law. I was also able to get foundation funding to do a study of patients’ decision-making capacities, a topic that has remained a focus of my research to the present day. During my final year of residency, I was able to create a chief residency in legal psychiatry, which allowed me to take law school courses, pursue my research, and supervise the more junior residents in their forensic evaluations.

Today, most people headed toward careers in forensic psychiatry take a fellowship after residency, but [such fellowships] were few and far between in 1980. So I went to Alan Stone for advice, and he said, “Go work with Loren Roth in Pittsburgh for 5 years, and you’ll be able to do anything you want after that.” I tracked down Loren Roth, then the leading empirical researcher on issues related to law and psychiatry, explained that Alan Stone had said I should go work with him, and somehow it all worked out. My first faculty job was with his Law and Psychiatry Program at the University of Pittsburgh.

Dr. Ahmed: What are some of the pros and cons of working in forensic psychiatry?

Continue to: Dr. Appelbaum...

Dr. Appelbaum: It may sound at first as though forensic psychiatry is a narrow subspecialty of psychiatry. But the field is actually immense, and the diversity of experiences that it provides is one of the big pros of a career in forensic psychiatry. On the academic side of the field, topics of research interest include prediction and management of violence, involuntary commitment and treatment, informed consent and decisional capacity, privacy and confidentiality of psychiatric treatment, criminal responsibility, and correctional treatment. Clinically, forensic psychiatrists perform a variety of evaluations, ranging from competence to consent to treatment, testamentary capacity, emotional harms in tort cases, psychiatric malpractice, sexual harassment and work-related disability, to competence to stand trial, voluntariness of confessions, insanity defense, and pre-sentencing assessments. Indeed, after nearly 40 years in the field, I still occasionally get asked to do evaluations of a type that I’ve never done before. Increasingly, forensic psychiatrists are involved in treating offenders, both in correctional facilities and in outpatient settings. Most people trained in forensic psychiatry mix their forensic work with general clinical work, whether inpatient or outpatient. So the flexibility that the field offers to craft a career is one of its great advantages.

On the cons side, a career in forensic psychiatry can mean a life of what Alan Stone called “moral peril.” By that he meant that forensic psychiatrists face constant ethical challenges as they perform evaluations and provide testimony. One challenge is to stay grounded in the evidence base of psychiatry and resist the temptation to draw conclusions that may seem “right” but that go beyond what psychiatric knowledge can actually support. Making that challenge even more difficult in private forensic practice is knowing that the party for whom one is working has specific interests that they are hoping you will support, and very definite ideas about what they want your conclusions to be. It may be in your financial interest to accommodate them, but in the long run, your reputation is your most valuable asset. Staying honest both to one’s beliefs and to the broader evidence base in psychiatry is an ongoing challenge, but a critical necessity.

Dr. Ahmed: Based on your personal experience, what should one consider when choosing a forensic psychiatry program?

Dr. Appelbaum: Having supervised forensic psychiatry fellowships for roughly 30 years, I think one of the most important aspects of a training program is its breadth. Given the diversity of the field, a program with a limited number of training sites that focuses on a restricted set of evaluations (usually related to criminal law) will not offer a fellow an optimal training experience. Diverse placements with a variety of evaluations to be performed under the supervision of experienced forensic psychiatrists, and without excessive service demands, are key aspects of a top-notch program. In addition, not everything can be learned hands-on; didactic training is indispensable. Fellows should be offered sufficient background on legal issues and the research base in forensic psychiatry to ground their subsequent work. Finally, for many fellows their time in fellowship is the last opportunity they may have to engage in research or other scholarly projects under supervision, another valuable component of a training program. A good question to ask of any program: What are your former fellows doing now? If the answers don’t reflect the career path you hope to pursue, that’s not the program for you.

Dr. Ahmed: What are some of the career options and work settings for forensic psychiatrists?

Continue to: Dr. Appelbaum...

Dr. Appelbaum: One of the advantages of forensic psychiatry is the plethora of work settings available. People headed to private practice can often combine clinical practice with forensic work, a necessity when starting one’s career and waiting to establish steady referral pipelines. Psychiatrists with forensic training are in demand in correctional facilities (which often pay higher salaries than comparable jobs in psychiatric facilities), forensic hospitals, and court clinics. Opportunities for academic involvement include directing fellowship programs, teaching residents, and conducting research. With regard to research, although funding is harder to come by than, for example, for studies of the biology of major psychiatric syndromes, determined psychiatrists can often find ways of framing questions related to forensic issues so that they appeal to funders’ priorities. As one gains experience, opportunities for consultation for law enforcement agencies, intelligence agencies, and federal and state mental health agencies may be available. It is rare for a forensic psychiatrist to do just one of these things; most forensic psychiatrists engage in a mix of types of work, including general clinical work. The possibilities are manifold.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Appelbaum: I talked already about some of the ethical challenges in forensic psychiatry. In addition, as a subspecialty that applies psychiatric knowledge to legal questions, forensic psychiatry requires its practitioners to stay up-to-date with both advances in psychiatry and changes in the law, not to mention variations across jurisdictions. This is not an area of specialization in which one can pay attention during fellowship and then coast through a career. In my view, it’s also critical for a good forensic psychiatrist to be an excellent clinician; forensic cases frequently offer diagnostic challenges that require the highest level of clinical skills to address. Finally, for people early in their careers, it can take a few years before they are well-enough known to get a steady flow of private forensic cases. So having a plan B during that career phase will be essential.

Dr. Ahmed: Where do you see forensic psychiatry going?

Dr. Appelbaum: Forensic evaluations will need to incorporate new assessment techniques and new knowledge—although not before they have been demonstrated to be valid and reliable. I can foresee increased use of specialized neuroimaging assessments, genomic and other “omic” testing, and measurement of other neurophysiologic parameters. As we know more about the etiology of psychiatric disorders, that will impact everything from evaluations of causation in emotional harms cases to conclusions about which divorcing parent may be better able to handle primary custody of a child. I think there will be exciting opportunities in the coming decades to integrate growing scientific knowledge about psychiatric illnesses into forensic psychiatry.

Continue to: Dr. Ahmed...

Dr. Ahmed: What advice do you have for those contemplating a career in forensic psychiatry?

Dr. Appelbaum: Residents thinking about undertaking training in forensic psychiatry should come to one of the annual meetings of the American Academy of Psychiatry and the Law, the major professional organization of forensic psychiatrists, which takes place every October. That will give them a good feel for the scope of the field and the types of work available. Many residencies offer rotations in forensic psychiatry, another opportunity to learn about the field, and even in programs that don’t, highly motivated residents are often able to arrange electives working with forensic psychiatrists in the community. Doing a research project in the area is another great way to learn more about the field. The more you know before you make a decision, the better that decision will be.

Editor’s note:  Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Chief Resident at Nassau University Medical Center, East Meadow, New York, talked with Donald W. Black, MD, Professor of Psychiatry, Department of Psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa. Dr. Black is also Editor-in-Chief of Annals of Clinical Psychiatry, and Secretary/Treasurer and former President of the American Academy of Clinical Psychiatrists. He is a clinical and translational researcher with more than 300 publications. His work has focused on the course and treatment of severe personality disorders, including researching the effectiveness of the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program for borderline personality disorder. He also conducts family and follow-up studies of behavioral addictions, including gambling disorder.

Dr. Ahmed: What made you choose the academic track, and how did your training lead you towards this path?

Dr. Black: I had always been interested in the idea of working at a medical school, and enjoyed writing and speaking. I was exposed to clinical research as a resident, and that confirmed my interest in academia, because I could envision combining all my interests, along with patient care. I always thought that patients were a major source of ideas for research and writing.

Dr. Ahmed: What are some of the pros and cons of working in academia?

Dr. Black: The pros include being able to influence future physicians through my teaching and writing; being able to pursue important research; and not being isolated from peers. Other advantages are being largely protected from utilization review; having more free time than peers in the private sector, who have difficulty finding coverage; and having defined benefits and a steady salary. I also share call with many peers.

When it comes to the cons, salaries are lower than in the private sector. The cons also include not being my own boss, and sometimes having to bend to the whims of an institution or supervisor.

Continue to: Dr. Ahmed...

Dr. Ahmed: Are you required to conduct research?

Dr. Black: Yes. This is one of the best aspects of my job: being able to make clinical discoveries that I can disseminate through writing and speaking. Over time, this has become increasingly challenging due to the difficulty of obtaining research funding from foundations or the federal government. This has become highly problematic, particularly for clinical researchers, because the National Institutes of Health has clearly been favoring neuroscience.

Dr. Ahmed: What is your typical day like?

Dr. Black: Because of the many hats I wear (or have worn), each day is different from the other. I combine patient care with research, writing, speaking, teaching, and administration. As a tenure-track faculty member, I am expected to write grants, conduct research, and publish. My clinical-track peers primarily provide patient care and teach students and residents.

Dr. Ahmed: What is unique about working in a training institute vs private practice?

Continue to: Dr. Black...

Dr. Black: As an academic psychiatrist, I feel I have the best of both worlds: patient care combined with opportunities my private practice colleagues do not have. Because I have published widely, and have developed a reputation, I am frequently invited to speak at meetings throughout the United States, and sometimes internationally. Travel is a perk of academia, and as someone who loves travel, that is important.

Dr. Ahmed: Where do you see psychiatry going?

Dr. Black: Psychiatry will always be an important specialty because no one else truly cares about patients with psychiatric illnesses. Mental illness will not go away, and society needs highly trained individuals to provide care. There are many “me too” clinicians who now share in caring for patients with psychiatric illnesses, but psychiatrists will always have the most training, and are in a position to provide supervision to others and to direct mental health care teams.

Dr. Ahmed: What advice do you have for residents contemplating a career in academic psychiatry?

Dr. Black: Because most medical schools now have both tenure and clinical tracks, no one needs to feel left out. Those who are interested in scholarly activities will gravitate to the tenure tract, and all that requires in terms of grants and papers, while those who are primarily interested in patient care and teaching will choose the clinical track.

Editor’s note:  Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Chief Resident at Nassau University Medical Center, East Meadow, New York, talked with Donald W. Black, MD, Professor of Psychiatry, Department of Psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa. Dr. Black is also Editor-in-Chief of Annals of Clinical Psychiatry, and Secretary/Treasurer and former President of the American Academy of Clinical Psychiatrists. He is a clinical and translational researcher with more than 300 publications. His work has focused on the course and treatment of severe personality disorders, including researching the effectiveness of the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program for borderline personality disorder. He also conducts family and follow-up studies of behavioral addictions, including gambling disorder.

Dr. Ahmed: What made you choose the academic track, and how did your training lead you towards this path?

Dr. Black: I had always been interested in the idea of working at a medical school, and enjoyed writing and speaking. I was exposed to clinical research as a resident, and that confirmed my interest in academia, because I could envision combining all my interests, along with patient care. I always thought that patients were a major source of ideas for research and writing.

Dr. Ahmed: What are some of the pros and cons of working in academia?

Dr. Black: The pros include being able to influence future physicians through my teaching and writing; being able to pursue important research; and not being isolated from peers. Other advantages are being largely protected from utilization review; having more free time than peers in the private sector, who have difficulty finding coverage; and having defined benefits and a steady salary. I also share call with many peers.

When it comes to the cons, salaries are lower than in the private sector. The cons also include not being my own boss, and sometimes having to bend to the whims of an institution or supervisor.

Continue to: Dr. Ahmed...

Dr. Ahmed: Are you required to conduct research?

Dr. Black: Yes. This is one of the best aspects of my job: being able to make clinical discoveries that I can disseminate through writing and speaking. Over time, this has become increasingly challenging due to the difficulty of obtaining research funding from foundations or the federal government. This has become highly problematic, particularly for clinical researchers, because the National Institutes of Health has clearly been favoring neuroscience.

Dr. Ahmed: What is your typical day like?

Dr. Black: Because of the many hats I wear (or have worn), each day is different from the other. I combine patient care with research, writing, speaking, teaching, and administration. As a tenure-track faculty member, I am expected to write grants, conduct research, and publish. My clinical-track peers primarily provide patient care and teach students and residents.

Dr. Ahmed: What is unique about working in a training institute vs private practice?

Continue to: Dr. Black...

Dr. Black: As an academic psychiatrist, I feel I have the best of both worlds: patient care combined with opportunities my private practice colleagues do not have. Because I have published widely, and have developed a reputation, I am frequently invited to speak at meetings throughout the United States, and sometimes internationally. Travel is a perk of academia, and as someone who loves travel, that is important.

Dr. Ahmed: Where do you see psychiatry going?

Dr. Black: Psychiatry will always be an important specialty because no one else truly cares about patients with psychiatric illnesses. Mental illness will not go away, and society needs highly trained individuals to provide care. There are many “me too” clinicians who now share in caring for patients with psychiatric illnesses, but psychiatrists will always have the most training, and are in a position to provide supervision to others and to direct mental health care teams.

Dr. Ahmed: What advice do you have for residents contemplating a career in academic psychiatry?

Dr. Black: Because most medical schools now have both tenure and clinical tracks, no one needs to feel left out. Those who are interested in scholarly activities will gravitate to the tenure tract, and all that requires in terms of grants and papers, while those who are primarily interested in patient care and teaching will choose the clinical track.

Editor’s note:  Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Chief Resident at Nassau University Medical Center, East Meadow, New York, talked with Donald W. Black, MD, Professor of Psychiatry, Department of Psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa. Dr. Black is also Editor-in-Chief of Annals of Clinical Psychiatry, and Secretary/Treasurer and former President of the American Academy of Clinical Psychiatrists. He is a clinical and translational researcher with more than 300 publications. His work has focused on the course and treatment of severe personality disorders, including researching the effectiveness of the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program for borderline personality disorder. He also conducts family and follow-up studies of behavioral addictions, including gambling disorder.

Dr. Ahmed: What made you choose the academic track, and how did your training lead you towards this path?

Dr. Black: I had always been interested in the idea of working at a medical school, and enjoyed writing and speaking. I was exposed to clinical research as a resident, and that confirmed my interest in academia, because I could envision combining all my interests, along with patient care. I always thought that patients were a major source of ideas for research and writing.

Dr. Ahmed: What are some of the pros and cons of working in academia?

Dr. Black: The pros include being able to influence future physicians through my teaching and writing; being able to pursue important research; and not being isolated from peers. Other advantages are being largely protected from utilization review; having more free time than peers in the private sector, who have difficulty finding coverage; and having defined benefits and a steady salary. I also share call with many peers.

When it comes to the cons, salaries are lower than in the private sector. The cons also include not being my own boss, and sometimes having to bend to the whims of an institution or supervisor.

Continue to: Dr. Ahmed...

Dr. Ahmed: Are you required to conduct research?

Dr. Black: Yes. This is one of the best aspects of my job: being able to make clinical discoveries that I can disseminate through writing and speaking. Over time, this has become increasingly challenging due to the difficulty of obtaining research funding from foundations or the federal government. This has become highly problematic, particularly for clinical researchers, because the National Institutes of Health has clearly been favoring neuroscience.

Dr. Ahmed: What is your typical day like?

Dr. Black: Because of the many hats I wear (or have worn), each day is different from the other. I combine patient care with research, writing, speaking, teaching, and administration. As a tenure-track faculty member, I am expected to write grants, conduct research, and publish. My clinical-track peers primarily provide patient care and teach students and residents.

Dr. Ahmed: What is unique about working in a training institute vs private practice?

Continue to: Dr. Black...

Dr. Black: As an academic psychiatrist, I feel I have the best of both worlds: patient care combined with opportunities my private practice colleagues do not have. Because I have published widely, and have developed a reputation, I am frequently invited to speak at meetings throughout the United States, and sometimes internationally. Travel is a perk of academia, and as someone who loves travel, that is important.

Dr. Ahmed: Where do you see psychiatry going?

Dr. Black: Psychiatry will always be an important specialty because no one else truly cares about patients with psychiatric illnesses. Mental illness will not go away, and society needs highly trained individuals to provide care. There are many “me too” clinicians who now share in caring for patients with psychiatric illnesses, but psychiatrists will always have the most training, and are in a position to provide supervision to others and to direct mental health care teams.

Dr. Ahmed: What advice do you have for residents contemplating a career in academic psychiatry?

Dr. Black: Because most medical schools now have both tenure and clinical tracks, no one needs to feel left out. Those who are interested in scholarly activities will gravitate to the tenure tract, and all that requires in terms of grants and papers, while those who are primarily interested in patient care and teaching will choose the clinical track.

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.

Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?

Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.

Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?

Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is unlikely to be gleaned simply though residency training. There are 2 routes to specialization after residency: addiction psychiatry, and addiction medicine. The American Board of Psychiatry and Neurology (ABPN) recognized addiction psychiatry as a subspecialty in 1993. Since 1998, completion of a fellowship recognized through the Accreditation Council for Graduate Medical Education has been required for board certification. There are almost 50 programs nationwide with approximately 150 spots. There is no match process for admissions; acceptance is based on a review of application documents and a personal interview. Upon completion of this 1 year of training, candidates sit for the certification exam, which is offered every other year.

Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.

Continue to: What was your fellowship experience link...

Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?

Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.

Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?

Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.

Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?

Continue to: Dr. Stanciu's response...

Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.

Dr. Ahmed: In what direction do you believe the subspecialty is headed?

Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.

Continue to: Another exciting possibility...

Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.

Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.

Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?

Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.

Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?

Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.

Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?

Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is unlikely to be gleaned simply though residency training. There are 2 routes to specialization after residency: addiction psychiatry, and addiction medicine. The American Board of Psychiatry and Neurology (ABPN) recognized addiction psychiatry as a subspecialty in 1993. Since 1998, completion of a fellowship recognized through the Accreditation Council for Graduate Medical Education has been required for board certification. There are almost 50 programs nationwide with approximately 150 spots. There is no match process for admissions; acceptance is based on a review of application documents and a personal interview. Upon completion of this 1 year of training, candidates sit for the certification exam, which is offered every other year.

Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.

Continue to: What was your fellowship experience link...

Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?

Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.

Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?

Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.

Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?

Continue to: Dr. Stanciu's response...

Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.

Dr. Ahmed: In what direction do you believe the subspecialty is headed?

Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.

Continue to: Another exciting possibility...

Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.

Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.

Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?

Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.

Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?

Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.

Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?

Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is unlikely to be gleaned simply though residency training. There are 2 routes to specialization after residency: addiction psychiatry, and addiction medicine. The American Board of Psychiatry and Neurology (ABPN) recognized addiction psychiatry as a subspecialty in 1993. Since 1998, completion of a fellowship recognized through the Accreditation Council for Graduate Medical Education has been required for board certification. There are almost 50 programs nationwide with approximately 150 spots. There is no match process for admissions; acceptance is based on a review of application documents and a personal interview. Upon completion of this 1 year of training, candidates sit for the certification exam, which is offered every other year.

Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.

Continue to: What was your fellowship experience link...

Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?

Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.

Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?

Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.

Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?

Continue to: Dr. Stanciu's response...

Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.

Dr. Ahmed: In what direction do you believe the subspecialty is headed?

Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.

Continue to: Another exciting possibility...

Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.

Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.

Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?

Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!

Psychiatrists often fail to adequately address their patients’ smoking, and often underestimate the impact of ongoing tobacco use. Evidence suggests that heavy smoking is a risk factor for major depressive disorder; it also is associated with increased suicidal ideations and attempts.^1,2 Tobacco use also has a mood-altering impact that can change the trajectory of mental illness, and alters the metabolism of most psychotropics.

Previously, psychiatrists may have been reluctant to prescribe the most effective interventions for smoking cessation—varenicline and bupropion—because these medications carried an FDA “black-box” warning of neuropsychiatric adverse effects, including increased aggression and suicidality. However, a large study called the EAGLES trial³ found that the neuropsychiatric risks associated with these medications were lower than previously thought. Consequently, in December 2016, the FDA removed the black-box warning related to serious mental health adverse effects from the labeling of varenicline and bupropion.⁴

The EAGLES trial was a large, multi-site global trial that included patients with and without mental illness. Its primary objective was to assess the risk of “clinically significant” adverse effects for individuals receiving varenicline, bupropion, nicotine replacement therapy (NRT), or placebo, and whether having a history of psychiatric conditions increased the risk of developing adverse effects when taking these therapies. Overall, 2% of smokers without mental illness experienced adverse effects, compared with 5% to 7% in the psychiatric cohort, regardless of treatment arm. The rate of neuropsychiatric events and scores on suicide severity scales were similar across treatment arms in both cohorts.³

We should take lessons from the EAGLES trial. We propose that clinicians ask themselves the following 6 questions when forming a treatment plan to address their patients’ tobacco use:

1. Does the patient meet DSM-5 criteria for nicotine use disorder and, if yes, what is the severity of his or her nicotine dependence? The Fagerstrom Test for Nicotine Dependence (FTND)⁵ is a 6-question instrument for evaluating the quantity of cigarette consumption, compulsion to use, and dependence. It provides clinicians with guidelines on preventing withdrawal by implementing NRTs, such as lozenges, an inhaler, patches, and/or gum. A score of 1 to 2 (low dependence) indicates that no NRT is needed; a score of 3 to 4 (low to moderate dependence) requires 1 NRT; and scores of 5 to 7 (moderate dependence) and ≥8 (high dependence) require a combination of NRTs.

In the EAGLES trial, all participants smoked at least 10 cigarettes per day, and had moderate dependence, with an average FTND score of 5 to 6.

2. What stage of change is the patient in, and how many times has he or she attempted to quit? Based on the answers, motivational interviewing may be appropriate.

Continue to: In the EAGLES trial...

In the EAGLES trial, the participants were motivated individuals who had on average 3 past quit attempts. Research suggests that even patients who have a serious mental illness can be motivated to quit (Box).^6-9

Box
Mental illness and motivation to quit smoking

3. What is the patient’s mental health status? What is the patient’s psychi­atric diagnosis and how clinically stable is he or she? What is his or her suicide risk? Consider using the Columbia Suicide Severity Rating Scale (C-SSRS).¹⁰

In the EAGLES trial, the psychiatric cohort included only patients who had been clinically stable for the past 6 months and had received the same medication regimen for at least the past 3 months, with no expected changes for 12 weeks. Patients with certain diagnoses were excluded (eg, delusional disorder, schizophreniform disorder, impulse control disorders), and only 1% had a personality disorder, which increases mood lability and likelihood of suicidality behavior.

Continue to: Does the patient have another comorbid substance use disorder?

4. Does the patient have another comorbid substance use disorder? In the EAGLES trial, those who had active substance use in the past year or were receiving methadone or buprenorphine/naloxone were excluded.

5. Does the patient have any medical conditions? Does he or she have a history of seizures or eating disorders? It is important to determine if a patient has a seizure disorder or another medical condition that is a contraindication for using varenicline or bupropion.

In the EAGLES trial, most adverse effects related to the medications administered involved sleep (insomnia) or the gastrointestinal system (nausea). The psychiatric cohort reported some anxiety with bupropion.

6. Have you discussed smoking cessation and a treatment plan with the patient at every visit? In the EAGLES trial, participants received 10-minute cessation counseling at every outpatient visit.

Continue to: When it comes time to select a medication regimen...

When it comes time to select a medication regimen, for bupropion, consider starting the patient with 150 mg/d, and increasing the dose to 150 mg twice a day 4 days later. The target quit date should be 7 days after starting the medication. Monitor the patient for symptoms of anxiety and insomnia.

For varenicline, start the patient at 0.5 mg/d, and increase the dose to 0.5 mg twice a day 4 days later. After another 4 days, increase the dose to 1 mg twice a day. Set a target quit date for 7 days after starting medication. Monitor the patient for nausea, insomnia, and abnormal dreams.

Psychiatrists often fail to adequately address their patients’ smoking, and often underestimate the impact of ongoing tobacco use. Evidence suggests that heavy smoking is a risk factor for major depressive disorder; it also is associated with increased suicidal ideations and attempts.^1,2 Tobacco use also has a mood-altering impact that can change the trajectory of mental illness, and alters the metabolism of most psychotropics.

Previously, psychiatrists may have been reluctant to prescribe the most effective interventions for smoking cessation—varenicline and bupropion—because these medications carried an FDA “black-box” warning of neuropsychiatric adverse effects, including increased aggression and suicidality. However, a large study called the EAGLES trial³ found that the neuropsychiatric risks associated with these medications were lower than previously thought. Consequently, in December 2016, the FDA removed the black-box warning related to serious mental health adverse effects from the labeling of varenicline and bupropion.⁴

The EAGLES trial was a large, multi-site global trial that included patients with and without mental illness. Its primary objective was to assess the risk of “clinically significant” adverse effects for individuals receiving varenicline, bupropion, nicotine replacement therapy (NRT), or placebo, and whether having a history of psychiatric conditions increased the risk of developing adverse effects when taking these therapies. Overall, 2% of smokers without mental illness experienced adverse effects, compared with 5% to 7% in the psychiatric cohort, regardless of treatment arm. The rate of neuropsychiatric events and scores on suicide severity scales were similar across treatment arms in both cohorts.³

We should take lessons from the EAGLES trial. We propose that clinicians ask themselves the following 6 questions when forming a treatment plan to address their patients’ tobacco use:

1. Does the patient meet DSM-5 criteria for nicotine use disorder and, if yes, what is the severity of his or her nicotine dependence? The Fagerstrom Test for Nicotine Dependence (FTND)⁵ is a 6-question instrument for evaluating the quantity of cigarette consumption, compulsion to use, and dependence. It provides clinicians with guidelines on preventing withdrawal by implementing NRTs, such as lozenges, an inhaler, patches, and/or gum. A score of 1 to 2 (low dependence) indicates that no NRT is needed; a score of 3 to 4 (low to moderate dependence) requires 1 NRT; and scores of 5 to 7 (moderate dependence) and ≥8 (high dependence) require a combination of NRTs.

In the EAGLES trial, all participants smoked at least 10 cigarettes per day, and had moderate dependence, with an average FTND score of 5 to 6.

2. What stage of change is the patient in, and how many times has he or she attempted to quit? Based on the answers, motivational interviewing may be appropriate.

Continue to: In the EAGLES trial...

In the EAGLES trial, the participants were motivated individuals who had on average 3 past quit attempts. Research suggests that even patients who have a serious mental illness can be motivated to quit (Box).^6-9

Box
Mental illness and motivation to quit smoking

3. What is the patient’s mental health status? What is the patient’s psychi­atric diagnosis and how clinically stable is he or she? What is his or her suicide risk? Consider using the Columbia Suicide Severity Rating Scale (C-SSRS).¹⁰

In the EAGLES trial, the psychiatric cohort included only patients who had been clinically stable for the past 6 months and had received the same medication regimen for at least the past 3 months, with no expected changes for 12 weeks. Patients with certain diagnoses were excluded (eg, delusional disorder, schizophreniform disorder, impulse control disorders), and only 1% had a personality disorder, which increases mood lability and likelihood of suicidality behavior.

Continue to: Does the patient have another comorbid substance use disorder?

4. Does the patient have another comorbid substance use disorder? In the EAGLES trial, those who had active substance use in the past year or were receiving methadone or buprenorphine/naloxone were excluded.

5. Does the patient have any medical conditions? Does he or she have a history of seizures or eating disorders? It is important to determine if a patient has a seizure disorder or another medical condition that is a contraindication for using varenicline or bupropion.

In the EAGLES trial, most adverse effects related to the medications administered involved sleep (insomnia) or the gastrointestinal system (nausea). The psychiatric cohort reported some anxiety with bupropion.

6. Have you discussed smoking cessation and a treatment plan with the patient at every visit? In the EAGLES trial, participants received 10-minute cessation counseling at every outpatient visit.

Continue to: When it comes time to select a medication regimen...

When it comes time to select a medication regimen, for bupropion, consider starting the patient with 150 mg/d, and increasing the dose to 150 mg twice a day 4 days later. The target quit date should be 7 days after starting the medication. Monitor the patient for symptoms of anxiety and insomnia.

For varenicline, start the patient at 0.5 mg/d, and increase the dose to 0.5 mg twice a day 4 days later. After another 4 days, increase the dose to 1 mg twice a day. Set a target quit date for 7 days after starting medication. Monitor the patient for nausea, insomnia, and abnormal dreams.

Psychiatrists often fail to adequately address their patients’ smoking, and often underestimate the impact of ongoing tobacco use. Evidence suggests that heavy smoking is a risk factor for major depressive disorder; it also is associated with increased suicidal ideations and attempts.^1,2 Tobacco use also has a mood-altering impact that can change the trajectory of mental illness, and alters the metabolism of most psychotropics.

Previously, psychiatrists may have been reluctant to prescribe the most effective interventions for smoking cessation—varenicline and bupropion—because these medications carried an FDA “black-box” warning of neuropsychiatric adverse effects, including increased aggression and suicidality. However, a large study called the EAGLES trial³ found that the neuropsychiatric risks associated with these medications were lower than previously thought. Consequently, in December 2016, the FDA removed the black-box warning related to serious mental health adverse effects from the labeling of varenicline and bupropion.⁴

The EAGLES trial was a large, multi-site global trial that included patients with and without mental illness. Its primary objective was to assess the risk of “clinically significant” adverse effects for individuals receiving varenicline, bupropion, nicotine replacement therapy (NRT), or placebo, and whether having a history of psychiatric conditions increased the risk of developing adverse effects when taking these therapies. Overall, 2% of smokers without mental illness experienced adverse effects, compared with 5% to 7% in the psychiatric cohort, regardless of treatment arm. The rate of neuropsychiatric events and scores on suicide severity scales were similar across treatment arms in both cohorts.³

We should take lessons from the EAGLES trial. We propose that clinicians ask themselves the following 6 questions when forming a treatment plan to address their patients’ tobacco use:

1. Does the patient meet DSM-5 criteria for nicotine use disorder and, if yes, what is the severity of his or her nicotine dependence? The Fagerstrom Test for Nicotine Dependence (FTND)⁵ is a 6-question instrument for evaluating the quantity of cigarette consumption, compulsion to use, and dependence. It provides clinicians with guidelines on preventing withdrawal by implementing NRTs, such as lozenges, an inhaler, patches, and/or gum. A score of 1 to 2 (low dependence) indicates that no NRT is needed; a score of 3 to 4 (low to moderate dependence) requires 1 NRT; and scores of 5 to 7 (moderate dependence) and ≥8 (high dependence) require a combination of NRTs.

In the EAGLES trial, all participants smoked at least 10 cigarettes per day, and had moderate dependence, with an average FTND score of 5 to 6.

2. What stage of change is the patient in, and how many times has he or she attempted to quit? Based on the answers, motivational interviewing may be appropriate.

Continue to: In the EAGLES trial...

In the EAGLES trial, the participants were motivated individuals who had on average 3 past quit attempts. Research suggests that even patients who have a serious mental illness can be motivated to quit (Box).^6-9

Box
Mental illness and motivation to quit smoking

3. What is the patient’s mental health status? What is the patient’s psychi­atric diagnosis and how clinically stable is he or she? What is his or her suicide risk? Consider using the Columbia Suicide Severity Rating Scale (C-SSRS).¹⁰

In the EAGLES trial, the psychiatric cohort included only patients who had been clinically stable for the past 6 months and had received the same medication regimen for at least the past 3 months, with no expected changes for 12 weeks. Patients with certain diagnoses were excluded (eg, delusional disorder, schizophreniform disorder, impulse control disorders), and only 1% had a personality disorder, which increases mood lability and likelihood of suicidality behavior.

Continue to: Does the patient have another comorbid substance use disorder?

4. Does the patient have another comorbid substance use disorder? In the EAGLES trial, those who had active substance use in the past year or were receiving methadone or buprenorphine/naloxone were excluded.

5. Does the patient have any medical conditions? Does he or she have a history of seizures or eating disorders? It is important to determine if a patient has a seizure disorder or another medical condition that is a contraindication for using varenicline or bupropion.

In the EAGLES trial, most adverse effects related to the medications administered involved sleep (insomnia) or the gastrointestinal system (nausea). The psychiatric cohort reported some anxiety with bupropion.

6. Have you discussed smoking cessation and a treatment plan with the patient at every visit? In the EAGLES trial, participants received 10-minute cessation counseling at every outpatient visit.

Continue to: When it comes time to select a medication regimen...

When it comes time to select a medication regimen, for bupropion, consider starting the patient with 150 mg/d, and increasing the dose to 150 mg twice a day 4 days later. The target quit date should be 7 days after starting the medication. Monitor the patient for symptoms of anxiety and insomnia.

For varenicline, start the patient at 0.5 mg/d, and increase the dose to 0.5 mg twice a day 4 days later. After another 4 days, increase the dose to 1 mg twice a day. Set a target quit date for 7 days after starting medication. Monitor the patient for nausea, insomnia, and abnormal dreams.

Dextromethorphan (DXM) is commonly found in over-the-counter (OTC) cold and cough preparations. When used at the therapeutic doses DXM has cough-suppressant properties through its action on the medulla. However, OTC preparations containing DXM are being increasingly used recreationally for the drug’s psychoactive effects, a practice referred to as “robotripping.” Such use can result in a toxidrome of delirium with agitation, paranoia, and hallucinations.¹ Residents need to be able to recognize the signs of DXM abuse and manage its potentially serious complications.

How DXM works

DXM has a wide therapeutic window. A typical therapeutic dose for cough is up to 120 mg/d. The most common adverse effects are mild (fever, diaphoresis, dizziness, nausea). At higher dosages, it acts as a nonselective serotonin reuptake inhibitor, a sigma-1 receptor agonist, and an N-methyl-d-aspartate (NMDA) receptor antagonist. DXM produces psychoactive effects through its active metabolite, dextrorphan, which has high affinity for NMDA. In this way, it can produce dissociative and stimulant effects. Although the amount of DXM in commercially available cold and cough preparations is modest, instructions for extraction and purification are readily available on the Internet.

Adverse effects include hallucinations, disorientation, mania, and aggression with delusions of supernatural abilities and insensitivity to pain; these effects are similar to those produced by phencyclidine (PCP).^2-4 Physiologically, diaphoresis, hyperthermia, and tachycardia are often observed.^3,5 These presentations carry a significant risk of mortality, and appropriate recognition and management is needed.

4 Phases of intoxication

DXM users have described 4 progressive behavioral phases that vary with dosage.^3,6,7 First, at 1.5 to 2.5 mg/kg, users report stimulating effects with perceptual alterations similar to those produced by 3,4-methylenedioxymethamphetamine (“ecstasy”). The second phase, reached at 2.5 to 7.5 mg/kg, is similar to alcohol and marijuana intoxication but includes more pronounced dysfunction in motor, cognitive, and perceptual skills, and perhaps visual hallucinations.^3,6,7 The third phase, noted at 7.5 to 15 mg/kg, resembles ketamine intoxication, with strong dissociation and hallucinations.^3,6,7 At greater doses, out-of-body, trance-like experiences may occur. Delirious misperceptions often lead to violent behavior and limited perception of pain. Users may experience a long course of any of these phases, with presentations lasting for up to 1 to 2 weeks after discontinuing use.⁸

Management is mainly supportive

Early recognition of DXM use is essential for treatment. Unfortunately, without collateral reports, this can be challenging because specialized toxicology screens are needed to detect DXM. Basic screens sometimes show a false positive for PCP. Take an inventory of all substances in the patient’s possession, either by examining the patient’s belongings or by obtaining collateral information from the patient’s family or friends.

Supportive care should be implemented, with a primary goal of controlling agitation. Short-acting benzodiazepines are helpful. Low-dose, short-term antipsychotics have shown benefit when hallucinations and paranoia are prominent.³ Decreasing stimulation and avoiding physical restraints while attempting to control aggression and psychosis with these medications is recommended. Using physical restraints on an individual who is in a state of agitated delirium can lead to severe injuries, cardiac and respiratory arrest, and death.^9-11

Patients typically experience rapid and complete remission of symptoms after discontinuing DXM use. However, evidence suggests DXM users can develop tolerance as well as psychological and physiological dependence. DXM withdrawal can be quite protracted and may include anxiety, dysphoria, insomnia, and suicidality.

Dextromethorphan (DXM) is commonly found in over-the-counter (OTC) cold and cough preparations. When used at the therapeutic doses DXM has cough-suppressant properties through its action on the medulla. However, OTC preparations containing DXM are being increasingly used recreationally for the drug’s psychoactive effects, a practice referred to as “robotripping.” Such use can result in a toxidrome of delirium with agitation, paranoia, and hallucinations.¹ Residents need to be able to recognize the signs of DXM abuse and manage its potentially serious complications.

How DXM works

DXM has a wide therapeutic window. A typical therapeutic dose for cough is up to 120 mg/d. The most common adverse effects are mild (fever, diaphoresis, dizziness, nausea). At higher dosages, it acts as a nonselective serotonin reuptake inhibitor, a sigma-1 receptor agonist, and an N-methyl-d-aspartate (NMDA) receptor antagonist. DXM produces psychoactive effects through its active metabolite, dextrorphan, which has high affinity for NMDA. In this way, it can produce dissociative and stimulant effects. Although the amount of DXM in commercially available cold and cough preparations is modest, instructions for extraction and purification are readily available on the Internet.

Adverse effects include hallucinations, disorientation, mania, and aggression with delusions of supernatural abilities and insensitivity to pain; these effects are similar to those produced by phencyclidine (PCP).^2-4 Physiologically, diaphoresis, hyperthermia, and tachycardia are often observed.^3,5 These presentations carry a significant risk of mortality, and appropriate recognition and management is needed.

4 Phases of intoxication

DXM users have described 4 progressive behavioral phases that vary with dosage.^3,6,7 First, at 1.5 to 2.5 mg/kg, users report stimulating effects with perceptual alterations similar to those produced by 3,4-methylenedioxymethamphetamine (“ecstasy”). The second phase, reached at 2.5 to 7.5 mg/kg, is similar to alcohol and marijuana intoxication but includes more pronounced dysfunction in motor, cognitive, and perceptual skills, and perhaps visual hallucinations.^3,6,7 The third phase, noted at 7.5 to 15 mg/kg, resembles ketamine intoxication, with strong dissociation and hallucinations.^3,6,7 At greater doses, out-of-body, trance-like experiences may occur. Delirious misperceptions often lead to violent behavior and limited perception of pain. Users may experience a long course of any of these phases, with presentations lasting for up to 1 to 2 weeks after discontinuing use.⁸

Management is mainly supportive

Early recognition of DXM use is essential for treatment. Unfortunately, without collateral reports, this can be challenging because specialized toxicology screens are needed to detect DXM. Basic screens sometimes show a false positive for PCP. Take an inventory of all substances in the patient’s possession, either by examining the patient’s belongings or by obtaining collateral information from the patient’s family or friends.

Supportive care should be implemented, with a primary goal of controlling agitation. Short-acting benzodiazepines are helpful. Low-dose, short-term antipsychotics have shown benefit when hallucinations and paranoia are prominent.³ Decreasing stimulation and avoiding physical restraints while attempting to control aggression and psychosis with these medications is recommended. Using physical restraints on an individual who is in a state of agitated delirium can lead to severe injuries, cardiac and respiratory arrest, and death.^9-11

Patients typically experience rapid and complete remission of symptoms after discontinuing DXM use. However, evidence suggests DXM users can develop tolerance as well as psychological and physiological dependence. DXM withdrawal can be quite protracted and may include anxiety, dysphoria, insomnia, and suicidality.

Dextromethorphan (DXM) is commonly found in over-the-counter (OTC) cold and cough preparations. When used at the therapeutic doses DXM has cough-suppressant properties through its action on the medulla. However, OTC preparations containing DXM are being increasingly used recreationally for the drug’s psychoactive effects, a practice referred to as “robotripping.” Such use can result in a toxidrome of delirium with agitation, paranoia, and hallucinations.¹ Residents need to be able to recognize the signs of DXM abuse and manage its potentially serious complications.

How DXM works

DXM has a wide therapeutic window. A typical therapeutic dose for cough is up to 120 mg/d. The most common adverse effects are mild (fever, diaphoresis, dizziness, nausea). At higher dosages, it acts as a nonselective serotonin reuptake inhibitor, a sigma-1 receptor agonist, and an N-methyl-d-aspartate (NMDA) receptor antagonist. DXM produces psychoactive effects through its active metabolite, dextrorphan, which has high affinity for NMDA. In this way, it can produce dissociative and stimulant effects. Although the amount of DXM in commercially available cold and cough preparations is modest, instructions for extraction and purification are readily available on the Internet.

Adverse effects include hallucinations, disorientation, mania, and aggression with delusions of supernatural abilities and insensitivity to pain; these effects are similar to those produced by phencyclidine (PCP).^2-4 Physiologically, diaphoresis, hyperthermia, and tachycardia are often observed.^3,5 These presentations carry a significant risk of mortality, and appropriate recognition and management is needed.

4 Phases of intoxication

DXM users have described 4 progressive behavioral phases that vary with dosage.^3,6,7 First, at 1.5 to 2.5 mg/kg, users report stimulating effects with perceptual alterations similar to those produced by 3,4-methylenedioxymethamphetamine (“ecstasy”). The second phase, reached at 2.5 to 7.5 mg/kg, is similar to alcohol and marijuana intoxication but includes more pronounced dysfunction in motor, cognitive, and perceptual skills, and perhaps visual hallucinations.^3,6,7 The third phase, noted at 7.5 to 15 mg/kg, resembles ketamine intoxication, with strong dissociation and hallucinations.^3,6,7 At greater doses, out-of-body, trance-like experiences may occur. Delirious misperceptions often lead to violent behavior and limited perception of pain. Users may experience a long course of any of these phases, with presentations lasting for up to 1 to 2 weeks after discontinuing use.⁸

Management is mainly supportive

Early recognition of DXM use is essential for treatment. Unfortunately, without collateral reports, this can be challenging because specialized toxicology screens are needed to detect DXM. Basic screens sometimes show a false positive for PCP. Take an inventory of all substances in the patient’s possession, either by examining the patient’s belongings or by obtaining collateral information from the patient’s family or friends.

Supportive care should be implemented, with a primary goal of controlling agitation. Short-acting benzodiazepines are helpful. Low-dose, short-term antipsychotics have shown benefit when hallucinations and paranoia are prominent.³ Decreasing stimulation and avoiding physical restraints while attempting to control aggression and psychosis with these medications is recommended. Using physical restraints on an individual who is in a state of agitated delirium can lead to severe injuries, cardiac and respiratory arrest, and death.^9-11

Patients typically experience rapid and complete remission of symptoms after discontinuing DXM use. However, evidence suggests DXM users can develop tolerance as well as psychological and physiological dependence. DXM withdrawal can be quite protracted and may include anxiety, dysphoria, insomnia, and suicidality.

When I came to this country, even before my current residency, I launched my addiction psychiatry career by researching nicotine addiction in schizophrenia patients. Those early experiences gave me a greater understanding of the health concerns and life experiences of people with addictions – and those more likely to develop them.

So imagine my excitement when I first became acquainted with the American Academy of Addiction Psychiatry (AAAP). I first learned about the AAAP, its mission, and activities at the 2017 American Psychiatric Association’s annual meeting in San Diego.

Getting in and involved

After returning to New York, I took those next steps and joined up, which opened the AAAP gates so I could receive its newsletters and submission calls, gain access to resources such as The American Journal on Addictions, survey the various joinable task forces, as well as discover who might be available to me as a mentor as part of the AAAP’s mentor-mentee program.

Sometime during my third-year residency training, I received a member-email advertising the AAAP 28th Annual Meeting and Scientific Symposium, and soon after that, received another email calling for research submissions to be presented there, as well as an invitation to apply for a trainee travel scholarship that would defray the cost for and allow its fellows to attend the meeting in San Diego. That alone was enticing enough to apply. But even more enticing was the opportunity to showcase the addiction work I had been doing during my residency, as well as to meet other members at various levels of the AAAP to determine whether I wanted to become more involved.
 

Pursuing experiences

I did not think twice about applying for the poster presentation and the travel scholarship. The AAAP’s online application forms for both were easy to understand and very well structured, which greatly helped me with filling out and formatting my applications. Taking the initiative toward even these first AAAP offerings brought more positive echoes. I was thrilled when the poster I proposed was accepted, mostly because it would give me the chance to present my recent addiction psych work from a higher platform. A few weeks later, I was thrilled again when I received an AAAP email congratulating me on being awarded the San Diego 28th annual meeting travel scholarship, which would waive the annual membership and conference registration fees, in addition to defraying my travel costs. Pacific breezes, here I come. And there I went. (Thanks to my extremely supportive training director, who first nominated me for the award.)

On the ground at 2017 AAAP

The 28th AAAP annual meeting opened on a balmy December Thursday, and that’s the day I arrived. I attended many addiction workshops and symposiums, which featured premier figures in addiction psychiatry. Of the numerous trainee-specific events I attended, the most informative was the “Fellowship Forum: Exploring the Field of Addiction Psychiatry.” At this forum, I learned the true benefits of doing an addiction psychiatry fellowship, while meeting many of the fellowship program directors of top institutions. Having them all under one “roof” made it easy to compare and contrast the specific training they offered.

Then came what were, for me, major highlights of the AAAP 2017. After I delivered my poster presentation and shared my research, I was able to receive very close, constructive feedback from the field’s most experienced professionals. And, finally, I met my AAAP mentors face to face: Dr. Amy Yule of Harvard Medical School, Boston; Dr. Thomas Penders, of East Carolina University, Greenville, N.C.; and Dr. Cornel Stanciu of Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
 

One AAAP trainee’s takeaways

All AAAP trainees, fellows, presenters leave the meeting with their own conclusions, but my biggest takeaways were:

• Regarding barriers to buprenorphine, emerging research supports similar efficacy for long-acting injectable naltrexone.
• Various protocols for rapid implementation of naltrexone are being used, and these allow for smoother transition and shorter “washout” periods.
• We should not overlook the effects of tobacco use in our patient population – and should address it aggressively, regardless of psychiatric comorbidities.
• The cannabinoid CBD receptors that exist on the dopamine pathway strengthen and complicate their relationship with psychosis.
• Telehealth should be seen as a potential solution for the incredible demand for addiction specialists, especially in rural and remote settings. The body of evidence supporting its efficacy is expanding.
• Synthetic cannabinoids are prevalent, and toxidromes exist – yet, trainees are not current on these.

The challenges facing those of us dedicated to fighting addiction have never been greater. I would urge more trainees and psychiatrists to join the AAAP in light of the opioid crisis and the potential fallout tied to marijuana legalization. I am grateful to have the opportunity to join my colleagues in this fight. Becoming part of the AAAP has led to a highly rewarding, career-enriching experience.
 

This article was updated 1/17/17.

Dr. Ahmed is a third-year resident in the department of psychiatry at Nassau University Medical Center, East Meadow, New York. Besides addiction psychiatry, his interests include public social psychiatry, health care policy, health disparities, and mental health stigma. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

When I came to this country, even before my current residency, I launched my addiction psychiatry career by researching nicotine addiction in schizophrenia patients. Those early experiences gave me a greater understanding of the health concerns and life experiences of people with addictions – and those more likely to develop them.

So imagine my excitement when I first became acquainted with the American Academy of Addiction Psychiatry (AAAP). I first learned about the AAAP, its mission, and activities at the 2017 American Psychiatric Association’s annual meeting in San Diego.

Getting in and involved

After returning to New York, I took those next steps and joined up, which opened the AAAP gates so I could receive its newsletters and submission calls, gain access to resources such as The American Journal on Addictions, survey the various joinable task forces, as well as discover who might be available to me as a mentor as part of the AAAP’s mentor-mentee program.

Sometime during my third-year residency training, I received a member-email advertising the AAAP 28th Annual Meeting and Scientific Symposium, and soon after that, received another email calling for research submissions to be presented there, as well as an invitation to apply for a trainee travel scholarship that would defray the cost for and allow its fellows to attend the meeting in San Diego. That alone was enticing enough to apply. But even more enticing was the opportunity to showcase the addiction work I had been doing during my residency, as well as to meet other members at various levels of the AAAP to determine whether I wanted to become more involved.
 

Pursuing experiences

I did not think twice about applying for the poster presentation and the travel scholarship. The AAAP’s online application forms for both were easy to understand and very well structured, which greatly helped me with filling out and formatting my applications. Taking the initiative toward even these first AAAP offerings brought more positive echoes. I was thrilled when the poster I proposed was accepted, mostly because it would give me the chance to present my recent addiction psych work from a higher platform. A few weeks later, I was thrilled again when I received an AAAP email congratulating me on being awarded the San Diego 28th annual meeting travel scholarship, which would waive the annual membership and conference registration fees, in addition to defraying my travel costs. Pacific breezes, here I come. And there I went. (Thanks to my extremely supportive training director, who first nominated me for the award.)

On the ground at 2017 AAAP

The 28th AAAP annual meeting opened on a balmy December Thursday, and that’s the day I arrived. I attended many addiction workshops and symposiums, which featured premier figures in addiction psychiatry. Of the numerous trainee-specific events I attended, the most informative was the “Fellowship Forum: Exploring the Field of Addiction Psychiatry.” At this forum, I learned the true benefits of doing an addiction psychiatry fellowship, while meeting many of the fellowship program directors of top institutions. Having them all under one “roof” made it easy to compare and contrast the specific training they offered.

Then came what were, for me, major highlights of the AAAP 2017. After I delivered my poster presentation and shared my research, I was able to receive very close, constructive feedback from the field’s most experienced professionals. And, finally, I met my AAAP mentors face to face: Dr. Amy Yule of Harvard Medical School, Boston; Dr. Thomas Penders, of East Carolina University, Greenville, N.C.; and Dr. Cornel Stanciu of Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
 

One AAAP trainee’s takeaways

All AAAP trainees, fellows, presenters leave the meeting with their own conclusions, but my biggest takeaways were:

• Regarding barriers to buprenorphine, emerging research supports similar efficacy for long-acting injectable naltrexone.
• Various protocols for rapid implementation of naltrexone are being used, and these allow for smoother transition and shorter “washout” periods.
• We should not overlook the effects of tobacco use in our patient population – and should address it aggressively, regardless of psychiatric comorbidities.
• The cannabinoid CBD receptors that exist on the dopamine pathway strengthen and complicate their relationship with psychosis.
• Telehealth should be seen as a potential solution for the incredible demand for addiction specialists, especially in rural and remote settings. The body of evidence supporting its efficacy is expanding.
• Synthetic cannabinoids are prevalent, and toxidromes exist – yet, trainees are not current on these.

The challenges facing those of us dedicated to fighting addiction have never been greater. I would urge more trainees and psychiatrists to join the AAAP in light of the opioid crisis and the potential fallout tied to marijuana legalization. I am grateful to have the opportunity to join my colleagues in this fight. Becoming part of the AAAP has led to a highly rewarding, career-enriching experience.
 

This article was updated 1/17/17.

Dr. Ahmed is a third-year resident in the department of psychiatry at Nassau University Medical Center, East Meadow, New York. Besides addiction psychiatry, his interests include public social psychiatry, health care policy, health disparities, and mental health stigma. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

When I came to this country, even before my current residency, I launched my addiction psychiatry career by researching nicotine addiction in schizophrenia patients. Those early experiences gave me a greater understanding of the health concerns and life experiences of people with addictions – and those more likely to develop them.

So imagine my excitement when I first became acquainted with the American Academy of Addiction Psychiatry (AAAP). I first learned about the AAAP, its mission, and activities at the 2017 American Psychiatric Association’s annual meeting in San Diego.

Getting in and involved

After returning to New York, I took those next steps and joined up, which opened the AAAP gates so I could receive its newsletters and submission calls, gain access to resources such as The American Journal on Addictions, survey the various joinable task forces, as well as discover who might be available to me as a mentor as part of the AAAP’s mentor-mentee program.

Sometime during my third-year residency training, I received a member-email advertising the AAAP 28th Annual Meeting and Scientific Symposium, and soon after that, received another email calling for research submissions to be presented there, as well as an invitation to apply for a trainee travel scholarship that would defray the cost for and allow its fellows to attend the meeting in San Diego. That alone was enticing enough to apply. But even more enticing was the opportunity to showcase the addiction work I had been doing during my residency, as well as to meet other members at various levels of the AAAP to determine whether I wanted to become more involved.
 

Pursuing experiences

I did not think twice about applying for the poster presentation and the travel scholarship. The AAAP’s online application forms for both were easy to understand and very well structured, which greatly helped me with filling out and formatting my applications. Taking the initiative toward even these first AAAP offerings brought more positive echoes. I was thrilled when the poster I proposed was accepted, mostly because it would give me the chance to present my recent addiction psych work from a higher platform. A few weeks later, I was thrilled again when I received an AAAP email congratulating me on being awarded the San Diego 28th annual meeting travel scholarship, which would waive the annual membership and conference registration fees, in addition to defraying my travel costs. Pacific breezes, here I come. And there I went. (Thanks to my extremely supportive training director, who first nominated me for the award.)

On the ground at 2017 AAAP

The 28th AAAP annual meeting opened on a balmy December Thursday, and that’s the day I arrived. I attended many addiction workshops and symposiums, which featured premier figures in addiction psychiatry. Of the numerous trainee-specific events I attended, the most informative was the “Fellowship Forum: Exploring the Field of Addiction Psychiatry.” At this forum, I learned the true benefits of doing an addiction psychiatry fellowship, while meeting many of the fellowship program directors of top institutions. Having them all under one “roof” made it easy to compare and contrast the specific training they offered.

Then came what were, for me, major highlights of the AAAP 2017. After I delivered my poster presentation and shared my research, I was able to receive very close, constructive feedback from the field’s most experienced professionals. And, finally, I met my AAAP mentors face to face: Dr. Amy Yule of Harvard Medical School, Boston; Dr. Thomas Penders, of East Carolina University, Greenville, N.C.; and Dr. Cornel Stanciu of Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
 

One AAAP trainee’s takeaways

All AAAP trainees, fellows, presenters leave the meeting with their own conclusions, but my biggest takeaways were:

• Regarding barriers to buprenorphine, emerging research supports similar efficacy for long-acting injectable naltrexone.
• Various protocols for rapid implementation of naltrexone are being used, and these allow for smoother transition and shorter “washout” periods.
• We should not overlook the effects of tobacco use in our patient population – and should address it aggressively, regardless of psychiatric comorbidities.
• The cannabinoid CBD receptors that exist on the dopamine pathway strengthen and complicate their relationship with psychosis.
• Telehealth should be seen as a potential solution for the incredible demand for addiction specialists, especially in rural and remote settings. The body of evidence supporting its efficacy is expanding.
• Synthetic cannabinoids are prevalent, and toxidromes exist – yet, trainees are not current on these.

The challenges facing those of us dedicated to fighting addiction have never been greater. I would urge more trainees and psychiatrists to join the AAAP in light of the opioid crisis and the potential fallout tied to marijuana legalization. I am grateful to have the opportunity to join my colleagues in this fight. Becoming part of the AAAP has led to a highly rewarding, career-enriching experience.
 

This article was updated 1/17/17.

Dr. Ahmed is a third-year resident in the department of psychiatry at Nassau University Medical Center, East Meadow, New York. Besides addiction psychiatry, his interests include public social psychiatry, health care policy, health disparities, and mental health stigma. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

What I thought would be a typical morning at the major county hospital – if that were ever possible on a psychiatric emergency unit (EU) – quickly turned atypical when I encountered a patient whom I will call Olivia.

Olivia is a 51-year-old male-to-female transgender woman who has not yet undergone gender reassignment surgery. She was brought to the EU by police, after expressing suicidal ideation during a phone call with a tax accountant. This was Olivia’s third visit to the psychiatric emergency unit because of suicide threats within 2 months. Though she was chronically suicidal, her current visit was triggered by a tax audit, which led her to view herself as an unwanted burden on society.

Historical perspective

Societal views of transgendered people vary. On one end of the spectrum is acceptance; in the middle is perhaps tolerance or mild discomfort at perceived abnormality; and at the other extreme are virulent hatred, discrimination, and invalidation of these individuals’ gender-affirming efforts.

Awareness of these hostile attitudes creates a vicious cycle of marginalization and mental illness among many transgender individuals.

Controversies surrounding sexual minorities are rooted in societal perceptions of gender delineations, and prevailing societal norms surrounding ethical and moral conduct. Most societies have a narrow perspective on gender, and seek to maintain a strict delineation of male and female identities, which contributes to the rejection of those with gender identity issues.^1,2 This often results in the invalidation of or active opposition to transgender individuals’ transition efforts. The reasons behind the rejection of transgender men and women are multifactorial, and can include a lack of awareness, homophobia, religious dogma, social stigmatization, and perceived non-employability – all often stemming largely from the lack of awareness that sexual identity and orientation are not a choice, but rather are predetermined by biological mechanisms. The intensifying familial, societal, political, and financial pressures all contribute to increased mental health issues, including increased incidence of suicide among sexual minorities.

Globally, sexual minorities continue to be subjected to gross human rights violations. Against the backdrop of prevalent social discrimination, transgender people experience a roughly threefold increase in the risk of developing anxiety disorders, which impair self-esteem and interpersonal functioning.³ The lifetime risk of attempted suicide is four times higher among transgender men, and two times higher among transgender women, than it is among cisgender men and women, respectively. Institutional discrimination in the public and private sectors results from laws and policies that impose inequities, or fail to protect sexual minorities. Examples are current policies denying medical coverage for sex reassignment surgery, denying health care by a provider because of transgender identity and numerous obstacles to obtain health insurance coverage.⁴

Impact of low acceptance

Recall Olivia’s need to delay the vocal cord surgery that arguably would have had a positive impact on her self-esteem. The transgender population faces increased health risks and barriers to appropriate mental health evaluation and inclusive care, particularly individuals with low acceptance from family, friends, and partners.⁵

A century ago, changing one’s gender was considered both highly disreputable and an impossible feat.⁶ Today, sex reassignment is the focus of political debate, with activists seeking equal rights for transgender individuals, despite the high rate of mental disorders in the community. While there is some positive public perception of transgender people, most still hold religious or moral objections to sex reassignment. Olivia’s family, for example, is typical in their rejection of her gender-affirming efforts. One example of this rejection is forbidding her to wear women’s clothing, stating that it makes them feel ashamed and subjects them to social ridicule.

As a result, Olivia lacks the social support that could work to remedy, to some extent, her suicidal ideation. Efforts to alleviate financial burdens that result from workplace discrimination, impediments to the pursuit of health, security, and happiness and the bureaucratic hurdles to gender affirmation are needed.^7,8 According to research by Kristen Clements-Nolle, PhD, MPH, and her associates, suicidality may be largely a reaction to the absence of legally secure equal rights for transgender men and women.⁹ In Olivia’s case, financial struggles with her mortgage, medical expenses for her autistic son, and anxiety about potentially losing the disability benefits on which she depends have added to her insecurity.

Financial insecurity resulting from her unemployment likely has exacerbated her feelings of inadequacy and depression. For example, because of her lack of financial resources, she had to delay the vocal cord surgery she desired. What would her prognosis be if her legal rights, including employment protection, were firmly in place? Likewise, the demands of parenting an autistic son posed another significant stressor that likely contributes to reciprocal stress for the child, resulting in the worsening of his autism symptoms.

In summary, transgender individuals face bias and discrimination in response to their gender-affirming efforts, which creates a vicious cycle of mental illness, suicidality, and societal marginalization. Addressing these endemic issues requires a multifaceted approach. Preventive strategies, including identification of mental health issues, and integration of mental health service with primary health care, are needed. Case registration, as a research measure to help understand the prevalence and severity of suicide among the LGBT population, would be beneficial.

Monitoring and follow-up of identified cases for supportive care (for example, gatekeeper training similar to the World Health Organization’s Suicide Prevention Initiative) also are needed to identify protective factors, in order to foster resilience in LGBT individuals facing negative reactions to disclosure of their sexual minority status. Legislation aimed at better facilitating a seamless integration of transgender men and women into mainstream society also is necessary. Supportive measures, particularly social supports promoting better mental health in trans individuals, could help reduce suicide rates. Finally, governmental initiatives to protect the human and constitutional rights of transgender people are key to minimizing the incidence of mental health issues and suicides among this vulnerable sexual minority group.

The path to addressing the issues faced by transgender individuals begins with education, which then leads to understanding. From understanding comes acceptance. Acceptance leads to equality – social, legal, and thereby, economic. Ensuring acceptance of all sexes as equal could mitigate the marginalization – in all its forms – experienced by gender-affirming individuals, with the end result being less mental illness and reduced rates of suicidality in this vulnerable population.⁷

Dr. Ahmed is a second-year resident in the department of psychiatry at the Nassau University Medical Center, East Meadow, New York. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and addiction psychiatry. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

References

1. LGBT Health. 2014 Jun;1(2):98-106.

2. Signs: Journal of Women in Culture and Society. 2006;32(1):83-111.

3. Int J Transgenderism. 2016:18(1):16-26.

4. Am J Public Health. 2014 Mar;104(3):e31-8.

5. Int J Transgenderism. 2017;18(1):104-18.

6. “Suicide attempts among transgender and gender non-conforming adults,” American Foundation for Suicide Prevention, 2014.

7. “Injustice at every turn: A report of the national transgender discrimination survey,” National Center for Transgender Equality, 2011.

8. J Gay Lesbian Soc Serv. 2014;26(2):186-206.

9. J Homosex. 2006;51(3):53-69.

What I thought would be a typical morning at the major county hospital – if that were ever possible on a psychiatric emergency unit (EU) – quickly turned atypical when I encountered a patient whom I will call Olivia.

Olivia is a 51-year-old male-to-female transgender woman who has not yet undergone gender reassignment surgery. She was brought to the EU by police, after expressing suicidal ideation during a phone call with a tax accountant. This was Olivia’s third visit to the psychiatric emergency unit because of suicide threats within 2 months. Though she was chronically suicidal, her current visit was triggered by a tax audit, which led her to view herself as an unwanted burden on society.

Historical perspective

Societal views of transgendered people vary. On one end of the spectrum is acceptance; in the middle is perhaps tolerance or mild discomfort at perceived abnormality; and at the other extreme are virulent hatred, discrimination, and invalidation of these individuals’ gender-affirming efforts.

Awareness of these hostile attitudes creates a vicious cycle of marginalization and mental illness among many transgender individuals.

Controversies surrounding sexual minorities are rooted in societal perceptions of gender delineations, and prevailing societal norms surrounding ethical and moral conduct. Most societies have a narrow perspective on gender, and seek to maintain a strict delineation of male and female identities, which contributes to the rejection of those with gender identity issues.^1,2 This often results in the invalidation of or active opposition to transgender individuals’ transition efforts. The reasons behind the rejection of transgender men and women are multifactorial, and can include a lack of awareness, homophobia, religious dogma, social stigmatization, and perceived non-employability – all often stemming largely from the lack of awareness that sexual identity and orientation are not a choice, but rather are predetermined by biological mechanisms. The intensifying familial, societal, political, and financial pressures all contribute to increased mental health issues, including increased incidence of suicide among sexual minorities.

Globally, sexual minorities continue to be subjected to gross human rights violations. Against the backdrop of prevalent social discrimination, transgender people experience a roughly threefold increase in the risk of developing anxiety disorders, which impair self-esteem and interpersonal functioning.³ The lifetime risk of attempted suicide is four times higher among transgender men, and two times higher among transgender women, than it is among cisgender men and women, respectively. Institutional discrimination in the public and private sectors results from laws and policies that impose inequities, or fail to protect sexual minorities. Examples are current policies denying medical coverage for sex reassignment surgery, denying health care by a provider because of transgender identity and numerous obstacles to obtain health insurance coverage.⁴

Impact of low acceptance

Recall Olivia’s need to delay the vocal cord surgery that arguably would have had a positive impact on her self-esteem. The transgender population faces increased health risks and barriers to appropriate mental health evaluation and inclusive care, particularly individuals with low acceptance from family, friends, and partners.⁵

A century ago, changing one’s gender was considered both highly disreputable and an impossible feat.⁶ Today, sex reassignment is the focus of political debate, with activists seeking equal rights for transgender individuals, despite the high rate of mental disorders in the community. While there is some positive public perception of transgender people, most still hold religious or moral objections to sex reassignment. Olivia’s family, for example, is typical in their rejection of her gender-affirming efforts. One example of this rejection is forbidding her to wear women’s clothing, stating that it makes them feel ashamed and subjects them to social ridicule.

As a result, Olivia lacks the social support that could work to remedy, to some extent, her suicidal ideation. Efforts to alleviate financial burdens that result from workplace discrimination, impediments to the pursuit of health, security, and happiness and the bureaucratic hurdles to gender affirmation are needed.^7,8 According to research by Kristen Clements-Nolle, PhD, MPH, and her associates, suicidality may be largely a reaction to the absence of legally secure equal rights for transgender men and women.⁹ In Olivia’s case, financial struggles with her mortgage, medical expenses for her autistic son, and anxiety about potentially losing the disability benefits on which she depends have added to her insecurity.

Financial insecurity resulting from her unemployment likely has exacerbated her feelings of inadequacy and depression. For example, because of her lack of financial resources, she had to delay the vocal cord surgery she desired. What would her prognosis be if her legal rights, including employment protection, were firmly in place? Likewise, the demands of parenting an autistic son posed another significant stressor that likely contributes to reciprocal stress for the child, resulting in the worsening of his autism symptoms.

In summary, transgender individuals face bias and discrimination in response to their gender-affirming efforts, which creates a vicious cycle of mental illness, suicidality, and societal marginalization. Addressing these endemic issues requires a multifaceted approach. Preventive strategies, including identification of mental health issues, and integration of mental health service with primary health care, are needed. Case registration, as a research measure to help understand the prevalence and severity of suicide among the LGBT population, would be beneficial.

Monitoring and follow-up of identified cases for supportive care (for example, gatekeeper training similar to the World Health Organization’s Suicide Prevention Initiative) also are needed to identify protective factors, in order to foster resilience in LGBT individuals facing negative reactions to disclosure of their sexual minority status. Legislation aimed at better facilitating a seamless integration of transgender men and women into mainstream society also is necessary. Supportive measures, particularly social supports promoting better mental health in trans individuals, could help reduce suicide rates. Finally, governmental initiatives to protect the human and constitutional rights of transgender people are key to minimizing the incidence of mental health issues and suicides among this vulnerable sexual minority group.

The path to addressing the issues faced by transgender individuals begins with education, which then leads to understanding. From understanding comes acceptance. Acceptance leads to equality – social, legal, and thereby, economic. Ensuring acceptance of all sexes as equal could mitigate the marginalization – in all its forms – experienced by gender-affirming individuals, with the end result being less mental illness and reduced rates of suicidality in this vulnerable population.⁷

Dr. Ahmed is a second-year resident in the department of psychiatry at the Nassau University Medical Center, East Meadow, New York. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and addiction psychiatry. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

References

1. LGBT Health. 2014 Jun;1(2):98-106.

2. Signs: Journal of Women in Culture and Society. 2006;32(1):83-111.

3. Int J Transgenderism. 2016:18(1):16-26.

4. Am J Public Health. 2014 Mar;104(3):e31-8.

5. Int J Transgenderism. 2017;18(1):104-18.

6. “Suicide attempts among transgender and gender non-conforming adults,” American Foundation for Suicide Prevention, 2014.

7. “Injustice at every turn: A report of the national transgender discrimination survey,” National Center for Transgender Equality, 2011.

8. J Gay Lesbian Soc Serv. 2014;26(2):186-206.

9. J Homosex. 2006;51(3):53-69.

What I thought would be a typical morning at the major county hospital – if that were ever possible on a psychiatric emergency unit (EU) – quickly turned atypical when I encountered a patient whom I will call Olivia.

Olivia is a 51-year-old male-to-female transgender woman who has not yet undergone gender reassignment surgery. She was brought to the EU by police, after expressing suicidal ideation during a phone call with a tax accountant. This was Olivia’s third visit to the psychiatric emergency unit because of suicide threats within 2 months. Though she was chronically suicidal, her current visit was triggered by a tax audit, which led her to view herself as an unwanted burden on society.

Historical perspective

Societal views of transgendered people vary. On one end of the spectrum is acceptance; in the middle is perhaps tolerance or mild discomfort at perceived abnormality; and at the other extreme are virulent hatred, discrimination, and invalidation of these individuals’ gender-affirming efforts.

Awareness of these hostile attitudes creates a vicious cycle of marginalization and mental illness among many transgender individuals.

Controversies surrounding sexual minorities are rooted in societal perceptions of gender delineations, and prevailing societal norms surrounding ethical and moral conduct. Most societies have a narrow perspective on gender, and seek to maintain a strict delineation of male and female identities, which contributes to the rejection of those with gender identity issues.^1,2 This often results in the invalidation of or active opposition to transgender individuals’ transition efforts. The reasons behind the rejection of transgender men and women are multifactorial, and can include a lack of awareness, homophobia, religious dogma, social stigmatization, and perceived non-employability – all often stemming largely from the lack of awareness that sexual identity and orientation are not a choice, but rather are predetermined by biological mechanisms. The intensifying familial, societal, political, and financial pressures all contribute to increased mental health issues, including increased incidence of suicide among sexual minorities.

Globally, sexual minorities continue to be subjected to gross human rights violations. Against the backdrop of prevalent social discrimination, transgender people experience a roughly threefold increase in the risk of developing anxiety disorders, which impair self-esteem and interpersonal functioning.³ The lifetime risk of attempted suicide is four times higher among transgender men, and two times higher among transgender women, than it is among cisgender men and women, respectively. Institutional discrimination in the public and private sectors results from laws and policies that impose inequities, or fail to protect sexual minorities. Examples are current policies denying medical coverage for sex reassignment surgery, denying health care by a provider because of transgender identity and numerous obstacles to obtain health insurance coverage.⁴

Impact of low acceptance

Recall Olivia’s need to delay the vocal cord surgery that arguably would have had a positive impact on her self-esteem. The transgender population faces increased health risks and barriers to appropriate mental health evaluation and inclusive care, particularly individuals with low acceptance from family, friends, and partners.⁵

A century ago, changing one’s gender was considered both highly disreputable and an impossible feat.⁶ Today, sex reassignment is the focus of political debate, with activists seeking equal rights for transgender individuals, despite the high rate of mental disorders in the community. While there is some positive public perception of transgender people, most still hold religious or moral objections to sex reassignment. Olivia’s family, for example, is typical in their rejection of her gender-affirming efforts. One example of this rejection is forbidding her to wear women’s clothing, stating that it makes them feel ashamed and subjects them to social ridicule.

As a result, Olivia lacks the social support that could work to remedy, to some extent, her suicidal ideation. Efforts to alleviate financial burdens that result from workplace discrimination, impediments to the pursuit of health, security, and happiness and the bureaucratic hurdles to gender affirmation are needed.^7,8 According to research by Kristen Clements-Nolle, PhD, MPH, and her associates, suicidality may be largely a reaction to the absence of legally secure equal rights for transgender men and women.⁹ In Olivia’s case, financial struggles with her mortgage, medical expenses for her autistic son, and anxiety about potentially losing the disability benefits on which she depends have added to her insecurity.

Financial insecurity resulting from her unemployment likely has exacerbated her feelings of inadequacy and depression. For example, because of her lack of financial resources, she had to delay the vocal cord surgery she desired. What would her prognosis be if her legal rights, including employment protection, were firmly in place? Likewise, the demands of parenting an autistic son posed another significant stressor that likely contributes to reciprocal stress for the child, resulting in the worsening of his autism symptoms.

In summary, transgender individuals face bias and discrimination in response to their gender-affirming efforts, which creates a vicious cycle of mental illness, suicidality, and societal marginalization. Addressing these endemic issues requires a multifaceted approach. Preventive strategies, including identification of mental health issues, and integration of mental health service with primary health care, are needed. Case registration, as a research measure to help understand the prevalence and severity of suicide among the LGBT population, would be beneficial.

Monitoring and follow-up of identified cases for supportive care (for example, gatekeeper training similar to the World Health Organization’s Suicide Prevention Initiative) also are needed to identify protective factors, in order to foster resilience in LGBT individuals facing negative reactions to disclosure of their sexual minority status. Legislation aimed at better facilitating a seamless integration of transgender men and women into mainstream society also is necessary. Supportive measures, particularly social supports promoting better mental health in trans individuals, could help reduce suicide rates. Finally, governmental initiatives to protect the human and constitutional rights of transgender people are key to minimizing the incidence of mental health issues and suicides among this vulnerable sexual minority group.

The path to addressing the issues faced by transgender individuals begins with education, which then leads to understanding. From understanding comes acceptance. Acceptance leads to equality – social, legal, and thereby, economic. Ensuring acceptance of all sexes as equal could mitigate the marginalization – in all its forms – experienced by gender-affirming individuals, with the end result being less mental illness and reduced rates of suicidality in this vulnerable population.⁷

Dr. Ahmed is a second-year resident in the department of psychiatry at the Nassau University Medical Center, East Meadow, New York. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and addiction psychiatry. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

References

1. LGBT Health. 2014 Jun;1(2):98-106.

2. Signs: Journal of Women in Culture and Society. 2006;32(1):83-111.

3. Int J Transgenderism. 2016:18(1):16-26.

4. Am J Public Health. 2014 Mar;104(3):e31-8.

5. Int J Transgenderism. 2017;18(1):104-18.

6. “Suicide attempts among transgender and gender non-conforming adults,” American Foundation for Suicide Prevention, 2014.

7. “Injustice at every turn: A report of the national transgender discrimination survey,” National Center for Transgender Equality, 2011.

8. J Gay Lesbian Soc Serv. 2014;26(2):186-206.

9. J Homosex. 2006;51(3):53-69.

Do we stand by our Hippocratic Oath when providing physician-assisted suicide?

Physician-assisted suicide (PAS) is a form of euthanasia in which a physician provides the patient with the pertinent information, and, in certain cases, a prescription for the necessary lethal drugs, so that the individual can willingly and successfully terminate his or her own life. The justification for PAS is the compassionate relief of intractable human suffering. Euthanasia and PAS are accepted practices in European countries such as the Netherlands, Belgium, and Luxembourg.

Critical role of mental health workers

Although PAS has been legalized in those five U.S. states, its support and cases have stalled in recent years, indicating serious ethical concerns, mostly because of multileveled challenges of combating and delineating cultural stereotypes, quantifying mental capacity, gauging quality of life, and deciding where to situate psychiatrists in the PAS decision.

The psychiatrist’s role is being debated. In the United States, opponents take issue with current PAS-legal state’s legislation regarding psychiatric evaluations. For example, Oregon stipulates a psychiatrist referral only in cases where a physician other than a psychiatrist believes the patient’s judgment is impaired. It’s agreed that psychiatrists have the best skill set to assess a patient’s perceptions. Other PAS-legal states require a psychiatrist or psychologist assessment before making the decision. Unfortunately, though, physicians have rarely referred these patients to psychiatrists before offering PAS as an option.

PAS opponents target standards by which concepts like “quality of life” or “contributing member of society” are judged – specifically, that “unbearable suffering” and its ramifications are ill defined – people whose lives are deemed “not worth living” (including the terminally ill) would be susceptible to “sympathetic death” via PAS that might result from PAS legalization. Opponents also argue that recognizing a suicide “right” contradicts that a significant number of suicide attempters have mental illness and need help. They say that legalizing PAS would enable mentally incapacitated people to commit the irreversible act based on their distorted perceptions without providing them the expected assistance from their profession.¹

The use of euthanasia or PAS gradually is trending from physically terminally ill patients toward psychiatrically complex patients. There are cases in which euthanasia or PAS was requested by psychiatric patients who had chronic psychiatric, medical, and psychosocial histories rather than purely physical ailment histories. In one study, Scott Y. H. Kim, MD, PhD, and his associates reviewed cases in the Netherlands in which either euthanasia or PAS for psychiatric disorders was deployed. The granted PAS requests appeared to involve physician judgment without psychiatric input.

The study reviewed 66 cases: 55% of patients had chronic severe conditions with extensive histories of attempted suicides and psychiatric hospitalizations, demonstrating that the granted euthanasia and PAS requests had involved extensive evaluations. However, 11% of cases had no independent psychiatric input, and 24% involved disagreement among the physicians.² PAS proponents and opponents support the involvement and expertise of psychiatrists in all of this.

Psychiatrists have long contended that suicide attempts are often a “cry for help,” not an earnest act to end one’s life. Legalizing PAS tells suicidal individuals that society does not care whether they live or die – a truly un-Hippocratic stance. The stereotypes tossed around in the PAS debate, which could mean life or death, need to be unpacked with specific criteria attached, rather than preconceptions.
 

Autonomy of patients and implications of PAS

In the PAS debate, there are serious life concerns exhibited by terminally ill/psychiatrically ill patients over losing their autonomy and becoming a burden to their families and caregivers. Stereotypes must be deconstructed, yes, but such patients generally have been considered to be rendered, by the sum effect of their illnesses, mentally incapable of making the decision to end their lives. Addressing this order of patient life concerns generally has been the realm of social workers, psychologists, and, in the most desirable cases, psychiatrists. Therefore, even in keeping with established practice, some form of competent psychiatric evaluation should be required before considering PAS as a viable option.

The call for this requirement is backed up by a study, which reported that 47% of patients who had considered or committed suicide previously were diagnosed with psychiatric disorders, and 15% had undiagnosed psychiatric disorders.³ Also, inventories of thwarted suicide attempters reveal that most lack the conviction to end their lives, and this obverse phenomenon is backed by a study that revealed that 75% of 96 suicidal patients were found to be ambivalent in their intent to end their lives. Suicide attempters simply may be trying to communicate with people in their lives in order to test their love and care.⁴ This indicates that those who attempt suicide are predominantly psychiatrically ill and prone to distorted perceptions, impaired judgment, frustration, escapism, and manipulative guilt.

Suicide is abhorrent to most human beings’ sensibilities, because humanity has an innate will to live.⁵ It is wrong to offer patients life-ending options when they might rejuvenate or ease into death naturally. With the debilitated or elderly, PAS could violate their human rights. If the attitude that they are a burden to society persists, then a certain segment of society might be tempted to avoid their intergenerational obligations to elders, particularly those elders presenting with concurrent mental illnesses. PAS would additionally fuel that problem. This would represent a profound injustice and gross violation of human dignity, while also serving as a denial of basic human rights, particularly the right to life and care.⁶

Conclusion

The complex physical, psychological, and social challenges associated with PAS and the difficulty in enforcing its laws necessitate more adept alternatives. Instead of conditionally legalizing suicide, we should ease patient suffering with compassion and calibrated treatment.^6,7

Terminally ill patients often suffer from depression, affecting their rationality. Adequate counseling, medical care, and psychological care should be the response to terminally ill patients considering suicide. If society accepts that ending a life is a reasonable response to human suffering that could otherwise be treated or reversed, then those with the most serious psychiatric conditions are destined to become more vulnerable. Therefore, physicians and psychiatrists should instead work harder to help patients recover, rather than participating in their quest for death.

Simplistic legal and regulatory oversight is insufficient, because the questions evoked by PAS are complicated by life, death, and ethics. Further research is needed to look into the mechanisms and morality of how psychiatrists and other physicians will make judgments and recommendations that are vital elements in developing regulatory oversight on PAS. Finally, future studies should look at which practices have been successful and which might be deemed unethical.
 

References

1. Clin Med (Lond). 2010 Aug;109(4):323-5.

2. JAMA Psychiatry. 2016;73(4):362-8.

3. “The Final Months: A Study of the Lives of 134 Persons Who Committed Suicide,” New York: Oxford University Press, 1981.

4. “Why We Shouldn’t Legalize Assisting Suicide, Part I.” Department of Medical Ethics, National Right to Life Committee.

5. “Working with Suicidal Individuals: A Guide to Providing Understanding, Assessment and Support,” Philadelphia: Jessica Kingsley Publishers, 2010.

6. “Always Care, Never Kill: How Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises the Family, and Violates Human Dignity and Equality,” Washington: The Heritage Foundation, 2015.

7. Ann Intern Med. 2012 Jan 3;156(1 Pt 2):73-104.

Dr. Ahmed is a 2nd-year resident in the psychiatry & behavioral sciences department at the Nassau University Medical Center, New York. Over the last 3 years, he has published and presented papers at national and international forums. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and undiagnosed and overdiagnosed psychiatric illnesses in children. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

Do we stand by our Hippocratic Oath when providing physician-assisted suicide?

Physician-assisted suicide (PAS) is a form of euthanasia in which a physician provides the patient with the pertinent information, and, in certain cases, a prescription for the necessary lethal drugs, so that the individual can willingly and successfully terminate his or her own life. The justification for PAS is the compassionate relief of intractable human suffering. Euthanasia and PAS are accepted practices in European countries such as the Netherlands, Belgium, and Luxembourg.

Critical role of mental health workers

Although PAS has been legalized in those five U.S. states, its support and cases have stalled in recent years, indicating serious ethical concerns, mostly because of multileveled challenges of combating and delineating cultural stereotypes, quantifying mental capacity, gauging quality of life, and deciding where to situate psychiatrists in the PAS decision.

The psychiatrist’s role is being debated. In the United States, opponents take issue with current PAS-legal state’s legislation regarding psychiatric evaluations. For example, Oregon stipulates a psychiatrist referral only in cases where a physician other than a psychiatrist believes the patient’s judgment is impaired. It’s agreed that psychiatrists have the best skill set to assess a patient’s perceptions. Other PAS-legal states require a psychiatrist or psychologist assessment before making the decision. Unfortunately, though, physicians have rarely referred these patients to psychiatrists before offering PAS as an option.

PAS opponents target standards by which concepts like “quality of life” or “contributing member of society” are judged – specifically, that “unbearable suffering” and its ramifications are ill defined – people whose lives are deemed “not worth living” (including the terminally ill) would be susceptible to “sympathetic death” via PAS that might result from PAS legalization. Opponents also argue that recognizing a suicide “right” contradicts that a significant number of suicide attempters have mental illness and need help. They say that legalizing PAS would enable mentally incapacitated people to commit the irreversible act based on their distorted perceptions without providing them the expected assistance from their profession.¹

The use of euthanasia or PAS gradually is trending from physically terminally ill patients toward psychiatrically complex patients. There are cases in which euthanasia or PAS was requested by psychiatric patients who had chronic psychiatric, medical, and psychosocial histories rather than purely physical ailment histories. In one study, Scott Y. H. Kim, MD, PhD, and his associates reviewed cases in the Netherlands in which either euthanasia or PAS for psychiatric disorders was deployed. The granted PAS requests appeared to involve physician judgment without psychiatric input.

The study reviewed 66 cases: 55% of patients had chronic severe conditions with extensive histories of attempted suicides and psychiatric hospitalizations, demonstrating that the granted euthanasia and PAS requests had involved extensive evaluations. However, 11% of cases had no independent psychiatric input, and 24% involved disagreement among the physicians.² PAS proponents and opponents support the involvement and expertise of psychiatrists in all of this.

Psychiatrists have long contended that suicide attempts are often a “cry for help,” not an earnest act to end one’s life. Legalizing PAS tells suicidal individuals that society does not care whether they live or die – a truly un-Hippocratic stance. The stereotypes tossed around in the PAS debate, which could mean life or death, need to be unpacked with specific criteria attached, rather than preconceptions.
 

Autonomy of patients and implications of PAS

In the PAS debate, there are serious life concerns exhibited by terminally ill/psychiatrically ill patients over losing their autonomy and becoming a burden to their families and caregivers. Stereotypes must be deconstructed, yes, but such patients generally have been considered to be rendered, by the sum effect of their illnesses, mentally incapable of making the decision to end their lives. Addressing this order of patient life concerns generally has been the realm of social workers, psychologists, and, in the most desirable cases, psychiatrists. Therefore, even in keeping with established practice, some form of competent psychiatric evaluation should be required before considering PAS as a viable option.

The call for this requirement is backed up by a study, which reported that 47% of patients who had considered or committed suicide previously were diagnosed with psychiatric disorders, and 15% had undiagnosed psychiatric disorders.³ Also, inventories of thwarted suicide attempters reveal that most lack the conviction to end their lives, and this obverse phenomenon is backed by a study that revealed that 75% of 96 suicidal patients were found to be ambivalent in their intent to end their lives. Suicide attempters simply may be trying to communicate with people in their lives in order to test their love and care.⁴ This indicates that those who attempt suicide are predominantly psychiatrically ill and prone to distorted perceptions, impaired judgment, frustration, escapism, and manipulative guilt.

Suicide is abhorrent to most human beings’ sensibilities, because humanity has an innate will to live.⁵ It is wrong to offer patients life-ending options when they might rejuvenate or ease into death naturally. With the debilitated or elderly, PAS could violate their human rights. If the attitude that they are a burden to society persists, then a certain segment of society might be tempted to avoid their intergenerational obligations to elders, particularly those elders presenting with concurrent mental illnesses. PAS would additionally fuel that problem. This would represent a profound injustice and gross violation of human dignity, while also serving as a denial of basic human rights, particularly the right to life and care.⁶

Conclusion

The complex physical, psychological, and social challenges associated with PAS and the difficulty in enforcing its laws necessitate more adept alternatives. Instead of conditionally legalizing suicide, we should ease patient suffering with compassion and calibrated treatment.^6,7

Terminally ill patients often suffer from depression, affecting their rationality. Adequate counseling, medical care, and psychological care should be the response to terminally ill patients considering suicide. If society accepts that ending a life is a reasonable response to human suffering that could otherwise be treated or reversed, then those with the most serious psychiatric conditions are destined to become more vulnerable. Therefore, physicians and psychiatrists should instead work harder to help patients recover, rather than participating in their quest for death.

Simplistic legal and regulatory oversight is insufficient, because the questions evoked by PAS are complicated by life, death, and ethics. Further research is needed to look into the mechanisms and morality of how psychiatrists and other physicians will make judgments and recommendations that are vital elements in developing regulatory oversight on PAS. Finally, future studies should look at which practices have been successful and which might be deemed unethical.
 

References

1. Clin Med (Lond). 2010 Aug;109(4):323-5.

2. JAMA Psychiatry. 2016;73(4):362-8.

3. “The Final Months: A Study of the Lives of 134 Persons Who Committed Suicide,” New York: Oxford University Press, 1981.

4. “Why We Shouldn’t Legalize Assisting Suicide, Part I.” Department of Medical Ethics, National Right to Life Committee.

5. “Working with Suicidal Individuals: A Guide to Providing Understanding, Assessment and Support,” Philadelphia: Jessica Kingsley Publishers, 2010.

6. “Always Care, Never Kill: How Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises the Family, and Violates Human Dignity and Equality,” Washington: The Heritage Foundation, 2015.

7. Ann Intern Med. 2012 Jan 3;156(1 Pt 2):73-104.

Dr. Ahmed is a 2nd-year resident in the psychiatry & behavioral sciences department at the Nassau University Medical Center, New York. Over the last 3 years, he has published and presented papers at national and international forums. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and undiagnosed and overdiagnosed psychiatric illnesses in children. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

Do we stand by our Hippocratic Oath when providing physician-assisted suicide?

Physician-assisted suicide (PAS) is a form of euthanasia in which a physician provides the patient with the pertinent information, and, in certain cases, a prescription for the necessary lethal drugs, so that the individual can willingly and successfully terminate his or her own life. The justification for PAS is the compassionate relief of intractable human suffering. Euthanasia and PAS are accepted practices in European countries such as the Netherlands, Belgium, and Luxembourg.

Critical role of mental health workers

Although PAS has been legalized in those five U.S. states, its support and cases have stalled in recent years, indicating serious ethical concerns, mostly because of multileveled challenges of combating and delineating cultural stereotypes, quantifying mental capacity, gauging quality of life, and deciding where to situate psychiatrists in the PAS decision.

The psychiatrist’s role is being debated. In the United States, opponents take issue with current PAS-legal state’s legislation regarding psychiatric evaluations. For example, Oregon stipulates a psychiatrist referral only in cases where a physician other than a psychiatrist believes the patient’s judgment is impaired. It’s agreed that psychiatrists have the best skill set to assess a patient’s perceptions. Other PAS-legal states require a psychiatrist or psychologist assessment before making the decision. Unfortunately, though, physicians have rarely referred these patients to psychiatrists before offering PAS as an option.

PAS opponents target standards by which concepts like “quality of life” or “contributing member of society” are judged – specifically, that “unbearable suffering” and its ramifications are ill defined – people whose lives are deemed “not worth living” (including the terminally ill) would be susceptible to “sympathetic death” via PAS that might result from PAS legalization. Opponents also argue that recognizing a suicide “right” contradicts that a significant number of suicide attempters have mental illness and need help. They say that legalizing PAS would enable mentally incapacitated people to commit the irreversible act based on their distorted perceptions without providing them the expected assistance from their profession.¹

The use of euthanasia or PAS gradually is trending from physically terminally ill patients toward psychiatrically complex patients. There are cases in which euthanasia or PAS was requested by psychiatric patients who had chronic psychiatric, medical, and psychosocial histories rather than purely physical ailment histories. In one study, Scott Y. H. Kim, MD, PhD, and his associates reviewed cases in the Netherlands in which either euthanasia or PAS for psychiatric disorders was deployed. The granted PAS requests appeared to involve physician judgment without psychiatric input.

The study reviewed 66 cases: 55% of patients had chronic severe conditions with extensive histories of attempted suicides and psychiatric hospitalizations, demonstrating that the granted euthanasia and PAS requests had involved extensive evaluations. However, 11% of cases had no independent psychiatric input, and 24% involved disagreement among the physicians.² PAS proponents and opponents support the involvement and expertise of psychiatrists in all of this.

Psychiatrists have long contended that suicide attempts are often a “cry for help,” not an earnest act to end one’s life. Legalizing PAS tells suicidal individuals that society does not care whether they live or die – a truly un-Hippocratic stance. The stereotypes tossed around in the PAS debate, which could mean life or death, need to be unpacked with specific criteria attached, rather than preconceptions.
 

Autonomy of patients and implications of PAS

In the PAS debate, there are serious life concerns exhibited by terminally ill/psychiatrically ill patients over losing their autonomy and becoming a burden to their families and caregivers. Stereotypes must be deconstructed, yes, but such patients generally have been considered to be rendered, by the sum effect of their illnesses, mentally incapable of making the decision to end their lives. Addressing this order of patient life concerns generally has been the realm of social workers, psychologists, and, in the most desirable cases, psychiatrists. Therefore, even in keeping with established practice, some form of competent psychiatric evaluation should be required before considering PAS as a viable option.

The call for this requirement is backed up by a study, which reported that 47% of patients who had considered or committed suicide previously were diagnosed with psychiatric disorders, and 15% had undiagnosed psychiatric disorders.³ Also, inventories of thwarted suicide attempters reveal that most lack the conviction to end their lives, and this obverse phenomenon is backed by a study that revealed that 75% of 96 suicidal patients were found to be ambivalent in their intent to end their lives. Suicide attempters simply may be trying to communicate with people in their lives in order to test their love and care.⁴ This indicates that those who attempt suicide are predominantly psychiatrically ill and prone to distorted perceptions, impaired judgment, frustration, escapism, and manipulative guilt.

Suicide is abhorrent to most human beings’ sensibilities, because humanity has an innate will to live.⁵ It is wrong to offer patients life-ending options when they might rejuvenate or ease into death naturally. With the debilitated or elderly, PAS could violate their human rights. If the attitude that they are a burden to society persists, then a certain segment of society might be tempted to avoid their intergenerational obligations to elders, particularly those elders presenting with concurrent mental illnesses. PAS would additionally fuel that problem. This would represent a profound injustice and gross violation of human dignity, while also serving as a denial of basic human rights, particularly the right to life and care.⁶

Conclusion

The complex physical, psychological, and social challenges associated with PAS and the difficulty in enforcing its laws necessitate more adept alternatives. Instead of conditionally legalizing suicide, we should ease patient suffering with compassion and calibrated treatment.^6,7

Terminally ill patients often suffer from depression, affecting their rationality. Adequate counseling, medical care, and psychological care should be the response to terminally ill patients considering suicide. If society accepts that ending a life is a reasonable response to human suffering that could otherwise be treated or reversed, then those with the most serious psychiatric conditions are destined to become more vulnerable. Therefore, physicians and psychiatrists should instead work harder to help patients recover, rather than participating in their quest for death.

Simplistic legal and regulatory oversight is insufficient, because the questions evoked by PAS are complicated by life, death, and ethics. Further research is needed to look into the mechanisms and morality of how psychiatrists and other physicians will make judgments and recommendations that are vital elements in developing regulatory oversight on PAS. Finally, future studies should look at which practices have been successful and which might be deemed unethical.
 

References

1. Clin Med (Lond). 2010 Aug;109(4):323-5.

2. JAMA Psychiatry. 2016;73(4):362-8.

3. “The Final Months: A Study of the Lives of 134 Persons Who Committed Suicide,” New York: Oxford University Press, 1981.

4. “Why We Shouldn’t Legalize Assisting Suicide, Part I.” Department of Medical Ethics, National Right to Life Committee.

5. “Working with Suicidal Individuals: A Guide to Providing Understanding, Assessment and Support,” Philadelphia: Jessica Kingsley Publishers, 2010.

6. “Always Care, Never Kill: How Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises the Family, and Violates Human Dignity and Equality,” Washington: The Heritage Foundation, 2015.

7. Ann Intern Med. 2012 Jan 3;156(1 Pt 2):73-104.

Dr. Ahmed is a 2nd-year resident in the psychiatry & behavioral sciences department at the Nassau University Medical Center, New York. Over the last 3 years, he has published and presented papers at national and international forums. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and undiagnosed and overdiagnosed psychiatric illnesses in children. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.