Victor Ajluni, MD

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

The second-generation antipsychotic quetiapine is commonly used to treat several psychiatric disorders, including bipolar disorder (BD) and insomnia. In this case report, we discuss a patient with a history of unipolar depression and initial signs of mania who experienced an exacerbation of manic symptoms following administration of low-dose quetiapine. This case underscores the need for careful monitoring of patients receiving quetiapine, especially at lower doses, and the potential limitations of its efficacy in controlling manic symptoms.

Depressed with racing thoughts

Mr. X, age 58, is an Army veteran who lives with his wife of 29 years and works as a contractor. He has a history of depression and a suicide attempt 10 years ago by self-inflicted gunshot wound to the head, which left him with a bullet lodged in his sinus cavity and residual dysarthria after tongue surgery. After the suicide attempt, Mr. X was medically hospitalized, but not psychiatrically hospitalized. Shortly after, he self-discontinued all psychotropic medications and follow-up.

Mr. X has no other medical history and takes no other medications or supplements. His family history includes a mother with schizoaffective disorder, 1 brother with BD, and another brother with developmental delay.

Mr. X remained euthymic until his brother died. Soon after, he began to experience low mood, heightened anxiety, racing thoughts, tearfulness, and mild insomnia. He was prescribed quetiapine 25 mg/d at bedtime and instructed to titrate up to 50 mg/d.

Ten days later, Mr. X was brought to the hospital by his wife, who reported that after starting quetiapine, her husband began to act erratically. He had disorganized and racing thoughts, loose associations, labile affect, hyperactivity/restlessness, and was not sleeping. In the morning before presenting to the hospital, Mr. X had gone to work, laid down on the floor, began mumbling to himself, and would not respond to coworkers. Upon evaluation, Mr. X was noted to have pressured speech, disorganized speech, delusions, anxiety, and hallucinations. A CT scan of his head was normal, and a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, B12, folate, and hemoglobin A1c were within normal limits. Mr. X’s vitamin D level was low at 22 ng/mL, and a syphilis screen was negative.

Mr. X was admitted to the hospital for his safety. The treatment team discontinued quetiapine and started risperidone 3 mg twice a day for psychotic symptoms and mood stabilization. At the time of discharge 7 days later, Mr. X was no longer experiencing any hallucinations or delusions, his thought process was linear and goal-directed, his mood was stable, and his insomnia had improved. Based on the temporal relationship between the initiation of quetiapine and the onset of Mr. X’s manic symptoms, along with an absence of organic causes, the treatment team suspected Mr. X had experienced a worsening of manic symptoms induced by quetiapine. Before starting quetiapine, he had presented with an initial manic symptom of racing thoughts.

At his next outpatient appointment, Mr. X exhibited significant akathisia. The treatment team initiated propranolol 20 mg twice a day but Mr. X did not experience much improvement. Risperidone was reduced to 1 mg twice a day and Mr. X was started on clonazepam 0.5 mg twice a day. The akathisia resolved. The treatment team decided to discontinue all medications and observe Mr. X for any recurrence of symptoms. One year after his manic episode. Mr. X remained euthymic. He was able to resume full-time work and began psychotherapy to process the grief over the loss of his brother.

Quetiapine’s unique profile

This case sheds light on the potential limitations of quetiapine, especially at lower doses, for managing manic symptoms. Quetiapine exhibits antidepressant effects, even at doses as low as 50 mg/d.¹ At higher doses, quetiapine acts as an antagonist at serotonin (5-HT1A and 5-HT2A), dopamine (D1 and D2), histamine H1, and adrenergic receptors.² At doses <300 mg/d, there is an absence of dopamine receptor blockade and a higher affinity for 5-HT2A receptors, which could explain why higher doses are generally necessary for treating mania and psychotic symptoms.^3-5 High 5-HT2A antagonism may disinhibit the dopaminergic system and paradoxically increase dopaminergic activity, which could be the mechanism responsible for lack of control of manic symptoms with low doses of quetiapine.² Another possible explanation is that the metabolite of quetiapine, N-desalkylquetiapine, acts as a norepine­phrine reuptake blocker and partial 5-HT1Aantagonist, which acts as an antidepressant, and antidepressants are known to induce mania in vulnerable patients.⁴

The antimanic property of most antipsychotics (except possibly clozapine) is attributed to their D2 antagonistic potency. Because quetiapine is among the weaker D2 antagonists, its inability to prevent the progression of mania, especially at 50 mg/d, is not unexpected. Mr. X’s subsequent need for a stronger D2 antagonist—risperidone—at a significant dose further supports this observation. A common misconception is that quetiapine’s sedating effects make it effective for treating mania, but that is not the case. Clinicians should be cautious when prescribing quetiapine, especially at lower doses, to patients who exhibit signs of mania. Given the potential risk, clinicians should consider alternative treatments before resorting to low-dose quetiapine for insomnia. Regular monitoring for manic symptoms is crucial for all patients receiving quetiapine. If patients present with signs of mania or hypomania, a therapeutic dose range of 600 to 800 mg/d is recommended.⁶

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

The second-generation antipsychotic quetiapine is commonly used to treat several psychiatric disorders, including bipolar disorder (BD) and insomnia. In this case report, we discuss a patient with a history of unipolar depression and initial signs of mania who experienced an exacerbation of manic symptoms following administration of low-dose quetiapine. This case underscores the need for careful monitoring of patients receiving quetiapine, especially at lower doses, and the potential limitations of its efficacy in controlling manic symptoms.

Depressed with racing thoughts

Mr. X, age 58, is an Army veteran who lives with his wife of 29 years and works as a contractor. He has a history of depression and a suicide attempt 10 years ago by self-inflicted gunshot wound to the head, which left him with a bullet lodged in his sinus cavity and residual dysarthria after tongue surgery. After the suicide attempt, Mr. X was medically hospitalized, but not psychiatrically hospitalized. Shortly after, he self-discontinued all psychotropic medications and follow-up.

Mr. X has no other medical history and takes no other medications or supplements. His family history includes a mother with schizoaffective disorder, 1 brother with BD, and another brother with developmental delay.

Mr. X remained euthymic until his brother died. Soon after, he began to experience low mood, heightened anxiety, racing thoughts, tearfulness, and mild insomnia. He was prescribed quetiapine 25 mg/d at bedtime and instructed to titrate up to 50 mg/d.

Ten days later, Mr. X was brought to the hospital by his wife, who reported that after starting quetiapine, her husband began to act erratically. He had disorganized and racing thoughts, loose associations, labile affect, hyperactivity/restlessness, and was not sleeping. In the morning before presenting to the hospital, Mr. X had gone to work, laid down on the floor, began mumbling to himself, and would not respond to coworkers. Upon evaluation, Mr. X was noted to have pressured speech, disorganized speech, delusions, anxiety, and hallucinations. A CT scan of his head was normal, and a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, B12, folate, and hemoglobin A1c were within normal limits. Mr. X’s vitamin D level was low at 22 ng/mL, and a syphilis screen was negative.

Mr. X was admitted to the hospital for his safety. The treatment team discontinued quetiapine and started risperidone 3 mg twice a day for psychotic symptoms and mood stabilization. At the time of discharge 7 days later, Mr. X was no longer experiencing any hallucinations or delusions, his thought process was linear and goal-directed, his mood was stable, and his insomnia had improved. Based on the temporal relationship between the initiation of quetiapine and the onset of Mr. X’s manic symptoms, along with an absence of organic causes, the treatment team suspected Mr. X had experienced a worsening of manic symptoms induced by quetiapine. Before starting quetiapine, he had presented with an initial manic symptom of racing thoughts.

At his next outpatient appointment, Mr. X exhibited significant akathisia. The treatment team initiated propranolol 20 mg twice a day but Mr. X did not experience much improvement. Risperidone was reduced to 1 mg twice a day and Mr. X was started on clonazepam 0.5 mg twice a day. The akathisia resolved. The treatment team decided to discontinue all medications and observe Mr. X for any recurrence of symptoms. One year after his manic episode. Mr. X remained euthymic. He was able to resume full-time work and began psychotherapy to process the grief over the loss of his brother.

Quetiapine’s unique profile

This case sheds light on the potential limitations of quetiapine, especially at lower doses, for managing manic symptoms. Quetiapine exhibits antidepressant effects, even at doses as low as 50 mg/d.¹ At higher doses, quetiapine acts as an antagonist at serotonin (5-HT1A and 5-HT2A), dopamine (D1 and D2), histamine H1, and adrenergic receptors.² At doses <300 mg/d, there is an absence of dopamine receptor blockade and a higher affinity for 5-HT2A receptors, which could explain why higher doses are generally necessary for treating mania and psychotic symptoms.^3-5 High 5-HT2A antagonism may disinhibit the dopaminergic system and paradoxically increase dopaminergic activity, which could be the mechanism responsible for lack of control of manic symptoms with low doses of quetiapine.² Another possible explanation is that the metabolite of quetiapine, N-desalkylquetiapine, acts as a norepine­phrine reuptake blocker and partial 5-HT1Aantagonist, which acts as an antidepressant, and antidepressants are known to induce mania in vulnerable patients.⁴

The antimanic property of most antipsychotics (except possibly clozapine) is attributed to their D2 antagonistic potency. Because quetiapine is among the weaker D2 antagonists, its inability to prevent the progression of mania, especially at 50 mg/d, is not unexpected. Mr. X’s subsequent need for a stronger D2 antagonist—risperidone—at a significant dose further supports this observation. A common misconception is that quetiapine’s sedating effects make it effective for treating mania, but that is not the case. Clinicians should be cautious when prescribing quetiapine, especially at lower doses, to patients who exhibit signs of mania. Given the potential risk, clinicians should consider alternative treatments before resorting to low-dose quetiapine for insomnia. Regular monitoring for manic symptoms is crucial for all patients receiving quetiapine. If patients present with signs of mania or hypomania, a therapeutic dose range of 600 to 800 mg/d is recommended.⁶

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

The second-generation antipsychotic quetiapine is commonly used to treat several psychiatric disorders, including bipolar disorder (BD) and insomnia. In this case report, we discuss a patient with a history of unipolar depression and initial signs of mania who experienced an exacerbation of manic symptoms following administration of low-dose quetiapine. This case underscores the need for careful monitoring of patients receiving quetiapine, especially at lower doses, and the potential limitations of its efficacy in controlling manic symptoms.

Depressed with racing thoughts

Mr. X, age 58, is an Army veteran who lives with his wife of 29 years and works as a contractor. He has a history of depression and a suicide attempt 10 years ago by self-inflicted gunshot wound to the head, which left him with a bullet lodged in his sinus cavity and residual dysarthria after tongue surgery. After the suicide attempt, Mr. X was medically hospitalized, but not psychiatrically hospitalized. Shortly after, he self-discontinued all psychotropic medications and follow-up.

Mr. X has no other medical history and takes no other medications or supplements. His family history includes a mother with schizoaffective disorder, 1 brother with BD, and another brother with developmental delay.

Mr. X remained euthymic until his brother died. Soon after, he began to experience low mood, heightened anxiety, racing thoughts, tearfulness, and mild insomnia. He was prescribed quetiapine 25 mg/d at bedtime and instructed to titrate up to 50 mg/d.

Ten days later, Mr. X was brought to the hospital by his wife, who reported that after starting quetiapine, her husband began to act erratically. He had disorganized and racing thoughts, loose associations, labile affect, hyperactivity/restlessness, and was not sleeping. In the morning before presenting to the hospital, Mr. X had gone to work, laid down on the floor, began mumbling to himself, and would not respond to coworkers. Upon evaluation, Mr. X was noted to have pressured speech, disorganized speech, delusions, anxiety, and hallucinations. A CT scan of his head was normal, and a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, B12, folate, and hemoglobin A1c were within normal limits. Mr. X’s vitamin D level was low at 22 ng/mL, and a syphilis screen was negative.

Mr. X was admitted to the hospital for his safety. The treatment team discontinued quetiapine and started risperidone 3 mg twice a day for psychotic symptoms and mood stabilization. At the time of discharge 7 days later, Mr. X was no longer experiencing any hallucinations or delusions, his thought process was linear and goal-directed, his mood was stable, and his insomnia had improved. Based on the temporal relationship between the initiation of quetiapine and the onset of Mr. X’s manic symptoms, along with an absence of organic causes, the treatment team suspected Mr. X had experienced a worsening of manic symptoms induced by quetiapine. Before starting quetiapine, he had presented with an initial manic symptom of racing thoughts.

At his next outpatient appointment, Mr. X exhibited significant akathisia. The treatment team initiated propranolol 20 mg twice a day but Mr. X did not experience much improvement. Risperidone was reduced to 1 mg twice a day and Mr. X was started on clonazepam 0.5 mg twice a day. The akathisia resolved. The treatment team decided to discontinue all medications and observe Mr. X for any recurrence of symptoms. One year after his manic episode. Mr. X remained euthymic. He was able to resume full-time work and began psychotherapy to process the grief over the loss of his brother.

Quetiapine’s unique profile

This case sheds light on the potential limitations of quetiapine, especially at lower doses, for managing manic symptoms. Quetiapine exhibits antidepressant effects, even at doses as low as 50 mg/d.¹ At higher doses, quetiapine acts as an antagonist at serotonin (5-HT1A and 5-HT2A), dopamine (D1 and D2), histamine H1, and adrenergic receptors.² At doses <300 mg/d, there is an absence of dopamine receptor blockade and a higher affinity for 5-HT2A receptors, which could explain why higher doses are generally necessary for treating mania and psychotic symptoms.^3-5 High 5-HT2A antagonism may disinhibit the dopaminergic system and paradoxically increase dopaminergic activity, which could be the mechanism responsible for lack of control of manic symptoms with low doses of quetiapine.² Another possible explanation is that the metabolite of quetiapine, N-desalkylquetiapine, acts as a norepine­phrine reuptake blocker and partial 5-HT1Aantagonist, which acts as an antidepressant, and antidepressants are known to induce mania in vulnerable patients.⁴

The antimanic property of most antipsychotics (except possibly clozapine) is attributed to their D2 antagonistic potency. Because quetiapine is among the weaker D2 antagonists, its inability to prevent the progression of mania, especially at 50 mg/d, is not unexpected. Mr. X’s subsequent need for a stronger D2 antagonist—risperidone—at a significant dose further supports this observation. A common misconception is that quetiapine’s sedating effects make it effective for treating mania, but that is not the case. Clinicians should be cautious when prescribing quetiapine, especially at lower doses, to patients who exhibit signs of mania. Given the potential risk, clinicians should consider alternative treatments before resorting to low-dose quetiapine for insomnia. Regular monitoring for manic symptoms is crucial for all patients receiving quetiapine. If patients present with signs of mania or hypomania, a therapeutic dose range of 600 to 800 mg/d is recommended.⁶

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

Working closely with individuals with substance use disorders (SUDs), we’ve observed a worrisome trend of patients leaving the hospital against medical advice (AMA). This issue is not only prevalent in psychiatric settings, but also in emergency departments, medical and surgical floors, and even intensive care units.¹

Compared to individuals without such disorders, individuals with SUDs—particularly those with opioid use disorders—are up to 3 times more likely to leave the hospital AMA.^1,2 Leaving AMA can lead to multiple complications, including an increased risk of readmission, suboptimal treatment outcomes, and an increased use of health care resources.^1-3

It is critical to understand why patients elect to leave a hospital AMA. In a qualitative study, Simon et al¹ found that individuals with SUDs often leave AMA due to uncontrolled withdrawal symptoms and pain, perceived stigma and discrimination, and dissatisfaction with care. Predictors of patients leaving the hospital AMA include the severity of their drug dependence and previous negative treatment experiences.⁴ A systematic review found housing instability and a lack of social support influence an individual’s decision to leave AMA.⁵

Recommendations for managing patients who leave AMA

Enhancing your understanding of withdrawal symptoms may allow you to offer patients more effective symptom control, possibly with methadone or buprenorphine.² Injectable opioid agonist treatment may also help to retain a patient in care. In a case report, a 47-year-old man with a severe opioid use disorder who had left the hospital AMA due to uncontrolled opioid withdrawal was readmitted, treated with IV hydromorphone, and enrolled in ongoing community injectable opioid agonist treatment.⁶

Clinicians must address the stigma and discrimination patients with SUDs often face in health care institutions. Additional training for clinicians to improve their understanding of these disorders and foster a more compassionate and nonjudgmental approach to care may be beneficial.

Like most medicolegal conflicts, leaving AMA is often a clinical and interpersonal problem disguised as a legal one. When assessing these patients’ decision-making capacity, we often find they are angry and dissatisfied with the care they have (or have not) received. The most useful intervention may be to restore communication between the patient and their treatment team.

Even after a patient leaves AMA, the treatment team may experience countertransference issues, such as heightened emotional reactions or biases, that could compromise their clinical judgment. Addressing these dynamics may require team debriefings, supervision, or further training in managing transference and countertransference, particularly since patients who leave AMA may return for subsequent care.⁷

Integrated care models, which feature close collaboration between clinicians from different specialties, can help ensure that a patient’s diverse health needs are met and reduce the likelihood of them leaving AMA. Integrated care models may be particularly effective for patients with co-occurring conditions such as HIV and SUDs.⁸

Implementing these recommendations can be challenging. Barriers to addressing AMA departures span several domains, including patient-specific barriers (eg, stigma and discrimination), clinical barriers (eg, lack of resources and training for clinicians), institutional hurdles (eg, systemic inefficiencies), and broader social barriers (eg, housing instability and inadequate social support). Overcoming these barriers requires a multifaceted approach involving clinicians, policymakers, and the community that considers medical, psychological, and social factors.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

Working closely with individuals with substance use disorders (SUDs), we’ve observed a worrisome trend of patients leaving the hospital against medical advice (AMA). This issue is not only prevalent in psychiatric settings, but also in emergency departments, medical and surgical floors, and even intensive care units.¹

Compared to individuals without such disorders, individuals with SUDs—particularly those with opioid use disorders—are up to 3 times more likely to leave the hospital AMA.^1,2 Leaving AMA can lead to multiple complications, including an increased risk of readmission, suboptimal treatment outcomes, and an increased use of health care resources.^1-3

It is critical to understand why patients elect to leave a hospital AMA. In a qualitative study, Simon et al¹ found that individuals with SUDs often leave AMA due to uncontrolled withdrawal symptoms and pain, perceived stigma and discrimination, and dissatisfaction with care. Predictors of patients leaving the hospital AMA include the severity of their drug dependence and previous negative treatment experiences.⁴ A systematic review found housing instability and a lack of social support influence an individual’s decision to leave AMA.⁵

Recommendations for managing patients who leave AMA

Enhancing your understanding of withdrawal symptoms may allow you to offer patients more effective symptom control, possibly with methadone or buprenorphine.² Injectable opioid agonist treatment may also help to retain a patient in care. In a case report, a 47-year-old man with a severe opioid use disorder who had left the hospital AMA due to uncontrolled opioid withdrawal was readmitted, treated with IV hydromorphone, and enrolled in ongoing community injectable opioid agonist treatment.⁶

Clinicians must address the stigma and discrimination patients with SUDs often face in health care institutions. Additional training for clinicians to improve their understanding of these disorders and foster a more compassionate and nonjudgmental approach to care may be beneficial.

Like most medicolegal conflicts, leaving AMA is often a clinical and interpersonal problem disguised as a legal one. When assessing these patients’ decision-making capacity, we often find they are angry and dissatisfied with the care they have (or have not) received. The most useful intervention may be to restore communication between the patient and their treatment team.

Even after a patient leaves AMA, the treatment team may experience countertransference issues, such as heightened emotional reactions or biases, that could compromise their clinical judgment. Addressing these dynamics may require team debriefings, supervision, or further training in managing transference and countertransference, particularly since patients who leave AMA may return for subsequent care.⁷

Integrated care models, which feature close collaboration between clinicians from different specialties, can help ensure that a patient’s diverse health needs are met and reduce the likelihood of them leaving AMA. Integrated care models may be particularly effective for patients with co-occurring conditions such as HIV and SUDs.⁸

Implementing these recommendations can be challenging. Barriers to addressing AMA departures span several domains, including patient-specific barriers (eg, stigma and discrimination), clinical barriers (eg, lack of resources and training for clinicians), institutional hurdles (eg, systemic inefficiencies), and broader social barriers (eg, housing instability and inadequate social support). Overcoming these barriers requires a multifaceted approach involving clinicians, policymakers, and the community that considers medical, psychological, and social factors.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

Working closely with individuals with substance use disorders (SUDs), we’ve observed a worrisome trend of patients leaving the hospital against medical advice (AMA). This issue is not only prevalent in psychiatric settings, but also in emergency departments, medical and surgical floors, and even intensive care units.¹

Compared to individuals without such disorders, individuals with SUDs—particularly those with opioid use disorders—are up to 3 times more likely to leave the hospital AMA.^1,2 Leaving AMA can lead to multiple complications, including an increased risk of readmission, suboptimal treatment outcomes, and an increased use of health care resources.^1-3

It is critical to understand why patients elect to leave a hospital AMA. In a qualitative study, Simon et al¹ found that individuals with SUDs often leave AMA due to uncontrolled withdrawal symptoms and pain, perceived stigma and discrimination, and dissatisfaction with care. Predictors of patients leaving the hospital AMA include the severity of their drug dependence and previous negative treatment experiences.⁴ A systematic review found housing instability and a lack of social support influence an individual’s decision to leave AMA.⁵

Recommendations for managing patients who leave AMA

Enhancing your understanding of withdrawal symptoms may allow you to offer patients more effective symptom control, possibly with methadone or buprenorphine.² Injectable opioid agonist treatment may also help to retain a patient in care. In a case report, a 47-year-old man with a severe opioid use disorder who had left the hospital AMA due to uncontrolled opioid withdrawal was readmitted, treated with IV hydromorphone, and enrolled in ongoing community injectable opioid agonist treatment.⁶

Clinicians must address the stigma and discrimination patients with SUDs often face in health care institutions. Additional training for clinicians to improve their understanding of these disorders and foster a more compassionate and nonjudgmental approach to care may be beneficial.

Like most medicolegal conflicts, leaving AMA is often a clinical and interpersonal problem disguised as a legal one. When assessing these patients’ decision-making capacity, we often find they are angry and dissatisfied with the care they have (or have not) received. The most useful intervention may be to restore communication between the patient and their treatment team.

Even after a patient leaves AMA, the treatment team may experience countertransference issues, such as heightened emotional reactions or biases, that could compromise their clinical judgment. Addressing these dynamics may require team debriefings, supervision, or further training in managing transference and countertransference, particularly since patients who leave AMA may return for subsequent care.⁷

Integrated care models, which feature close collaboration between clinicians from different specialties, can help ensure that a patient’s diverse health needs are met and reduce the likelihood of them leaving AMA. Integrated care models may be particularly effective for patients with co-occurring conditions such as HIV and SUDs.⁸

Implementing these recommendations can be challenging. Barriers to addressing AMA departures span several domains, including patient-specific barriers (eg, stigma and discrimination), clinical barriers (eg, lack of resources and training for clinicians), institutional hurdles (eg, systemic inefficiencies), and broader social barriers (eg, housing instability and inadequate social support). Overcoming these barriers requires a multifaceted approach involving clinicians, policymakers, and the community that considers medical, psychological, and social factors.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

Creating an optimal learning environment for medical students studying psychiatry is essential for their growth and development. Over the last 25 years, I have worked with hundreds of medical students in a busy urban emergency department (ED), and I have developed a style that has worked well for them and for me. A supportive, engaging atmosphere can significantly enhance students’ understanding of psychiatric conditions, therapeutic approaches, and patient care. To ensure a productive and inspiring learning experience, educators should consider several key factors.

The educators

Faculty physicians should invest themselves in the students’ individual growth and aspirations by providing personalized guidance that caters to each student’s goals and challenges.¹ Educators must also embody a passion for psychiatry. I’ve found that integrating a lighthearted and humorous approach to my teaching style can relieve stress and enhance learning. I’ve also found it crucial to demonstrate empathy and effective communication skills that students can emulate in their professional development.² Encourage students to take an active role in their learning process by engaging in clinical discussions and decision-making. Lastly, providing regular assessments and constructive feedback in a supportive manner allows students to better understand their strengths and weaknesses, and to continually improve their knowledge and skills.³

The students

Encourage students to fully express their unique personalities, perspectives, and learning styles. This diversity can fuel creativity and promote an atmosphere of inclusivity and enhanced learning. Teach students to recognize the value in each patient encounter, because each offers a unique opportunity to deepen their understanding of psychiatric conditions.⁴ Instead of being mere observers, students should actively participate in their education by involving themselves in clinical discussions, treatment planning, and decision-making.

The environment

A supportive, inclusive learning environment should foster diversity, inclusivity, and collaborative learning by creating an engaging atmosphere in which students can express themselves. In my experience, a sense of relaxed focus can help alleviate stress and enhance creativity. Emphasize a patient-centered approach to instill empathy and compassion in students and enrich their understanding of psychiatric conditions.⁴

The peers

Encourage students to engage in peer feedback, which will provide their fellow trainees additional perspective on their performance and offer an avenue for constructive criticism and improvement.³ Promoting collaborative learning will foster a sense of camaraderie, help students share their diverse perspectives, and enhance the learning experience. Peers also play a crucial role in reinforcing positive behaviors and attitudes.

My extensive experience educating medical students studying psychiatry in a busy ED has taught me that creating an exceptional learning environment requires understanding the role of educators, students, the environment, and peers. By implementing these principles, educators can contribute to their students’ professional growth, equipping them with the skills and mindset necessary to become a compassionate, competent, effective physician.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

Creating an optimal learning environment for medical students studying psychiatry is essential for their growth and development. Over the last 25 years, I have worked with hundreds of medical students in a busy urban emergency department (ED), and I have developed a style that has worked well for them and for me. A supportive, engaging atmosphere can significantly enhance students’ understanding of psychiatric conditions, therapeutic approaches, and patient care. To ensure a productive and inspiring learning experience, educators should consider several key factors.

The educators

Faculty physicians should invest themselves in the students’ individual growth and aspirations by providing personalized guidance that caters to each student’s goals and challenges.¹ Educators must also embody a passion for psychiatry. I’ve found that integrating a lighthearted and humorous approach to my teaching style can relieve stress and enhance learning. I’ve also found it crucial to demonstrate empathy and effective communication skills that students can emulate in their professional development.² Encourage students to take an active role in their learning process by engaging in clinical discussions and decision-making. Lastly, providing regular assessments and constructive feedback in a supportive manner allows students to better understand their strengths and weaknesses, and to continually improve their knowledge and skills.³

The students

Encourage students to fully express their unique personalities, perspectives, and learning styles. This diversity can fuel creativity and promote an atmosphere of inclusivity and enhanced learning. Teach students to recognize the value in each patient encounter, because each offers a unique opportunity to deepen their understanding of psychiatric conditions.⁴ Instead of being mere observers, students should actively participate in their education by involving themselves in clinical discussions, treatment planning, and decision-making.

The environment

A supportive, inclusive learning environment should foster diversity, inclusivity, and collaborative learning by creating an engaging atmosphere in which students can express themselves. In my experience, a sense of relaxed focus can help alleviate stress and enhance creativity. Emphasize a patient-centered approach to instill empathy and compassion in students and enrich their understanding of psychiatric conditions.⁴

The peers

Encourage students to engage in peer feedback, which will provide their fellow trainees additional perspective on their performance and offer an avenue for constructive criticism and improvement.³ Promoting collaborative learning will foster a sense of camaraderie, help students share their diverse perspectives, and enhance the learning experience. Peers also play a crucial role in reinforcing positive behaviors and attitudes.

My extensive experience educating medical students studying psychiatry in a busy ED has taught me that creating an exceptional learning environment requires understanding the role of educators, students, the environment, and peers. By implementing these principles, educators can contribute to their students’ professional growth, equipping them with the skills and mindset necessary to become a compassionate, competent, effective physician.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

Creating an optimal learning environment for medical students studying psychiatry is essential for their growth and development. Over the last 25 years, I have worked with hundreds of medical students in a busy urban emergency department (ED), and I have developed a style that has worked well for them and for me. A supportive, engaging atmosphere can significantly enhance students’ understanding of psychiatric conditions, therapeutic approaches, and patient care. To ensure a productive and inspiring learning experience, educators should consider several key factors.

The educators

Faculty physicians should invest themselves in the students’ individual growth and aspirations by providing personalized guidance that caters to each student’s goals and challenges.¹ Educators must also embody a passion for psychiatry. I’ve found that integrating a lighthearted and humorous approach to my teaching style can relieve stress and enhance learning. I’ve also found it crucial to demonstrate empathy and effective communication skills that students can emulate in their professional development.² Encourage students to take an active role in their learning process by engaging in clinical discussions and decision-making. Lastly, providing regular assessments and constructive feedback in a supportive manner allows students to better understand their strengths and weaknesses, and to continually improve their knowledge and skills.³

The students

Encourage students to fully express their unique personalities, perspectives, and learning styles. This diversity can fuel creativity and promote an atmosphere of inclusivity and enhanced learning. Teach students to recognize the value in each patient encounter, because each offers a unique opportunity to deepen their understanding of psychiatric conditions.⁴ Instead of being mere observers, students should actively participate in their education by involving themselves in clinical discussions, treatment planning, and decision-making.

The environment

A supportive, inclusive learning environment should foster diversity, inclusivity, and collaborative learning by creating an engaging atmosphere in which students can express themselves. In my experience, a sense of relaxed focus can help alleviate stress and enhance creativity. Emphasize a patient-centered approach to instill empathy and compassion in students and enrich their understanding of psychiatric conditions.⁴

The peers

Encourage students to engage in peer feedback, which will provide their fellow trainees additional perspective on their performance and offer an avenue for constructive criticism and improvement.³ Promoting collaborative learning will foster a sense of camaraderie, help students share their diverse perspectives, and enhance the learning experience. Peers also play a crucial role in reinforcing positive behaviors and attitudes.

My extensive experience educating medical students studying psychiatry in a busy ED has taught me that creating an exceptional learning environment requires understanding the role of educators, students, the environment, and peers. By implementing these principles, educators can contribute to their students’ professional growth, equipping them with the skills and mindset necessary to become a compassionate, competent, effective physician.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

As an emergency department (ED) psychiatrist with 25 years of experience working in a large city, I am growing increasingly concerned about the escalating number of individuals experiencing homelessness in urban areas.

Homelessness remains a critical issue across the United States. The news reports from major urban areas are startling. In my own practice, I encounter approximately 10,000 patients annually, and at least one-half of them are homeless. Additionally, 75% of these patients who are homeless experience addiction, and many have lost all social support. Due to overcrowding at our area’s shelters, they resort to using the ED as a shelter because most of our shelters are overcrowded. This situation has caused an overwhelming overload in the ED and left staff disheartened and difficult to retain.

The relationship between mental illness and homelessness is complex and multifaceted. Research suggests that up to one-third of individuals who are homeless have serious mental illness.¹ Mental illness can contribute to homelessness by impeding individuals’ ability to maintain employment, housing, and social relationships. Conversely, homelessness can worsen mental illness (especially in younger individuals, who are most vulnerable) by exposing individuals to traumatic experiences, substance abuse, and other stressors.²

One approach to effectively address homelessness in urban areas is provide supportive housing that incorporates access to mental health services. Research has demonstrated that offering stable housing and mental health services to individuals experiencing homelessness can significantly improve their mental and physical health and reduce their reliance on costly emergency services.^3,4

Collaboration between the health care system and government is also essential. By working together, the health care system and government can develop comprehensive strategies, allocate resources, and implement interventions that address the physical and mental health needs of individuals who are homeless and provide them with the necessary support and services. This collaboration is essential to create sustainable solutions and make a meaningful impact in combating homelessness.⁵

Addressing homelessness in urban areas requires a comprehensive approach that recognizes the critical role of mental illness and necessity for collaborative solutions. While our ED has implemented certain measures, such as allowing patients to remain on 23-hour holds to prevent immediate re-admission, additional interventions are needed. These include expanding shelters and transitional housing programs, which are currently in short supply, and developing street medicine programs to meet individuals where they are and improve compliance with medications. By implementing these strategies, we can help minimize the impact of homelessness on individuals with mental illness and enhance the health and well-being of individuals experiencing homelessness.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

As an emergency department (ED) psychiatrist with 25 years of experience working in a large city, I am growing increasingly concerned about the escalating number of individuals experiencing homelessness in urban areas.

Homelessness remains a critical issue across the United States. The news reports from major urban areas are startling. In my own practice, I encounter approximately 10,000 patients annually, and at least one-half of them are homeless. Additionally, 75% of these patients who are homeless experience addiction, and many have lost all social support. Due to overcrowding at our area’s shelters, they resort to using the ED as a shelter because most of our shelters are overcrowded. This situation has caused an overwhelming overload in the ED and left staff disheartened and difficult to retain.

The relationship between mental illness and homelessness is complex and multifaceted. Research suggests that up to one-third of individuals who are homeless have serious mental illness.¹ Mental illness can contribute to homelessness by impeding individuals’ ability to maintain employment, housing, and social relationships. Conversely, homelessness can worsen mental illness (especially in younger individuals, who are most vulnerable) by exposing individuals to traumatic experiences, substance abuse, and other stressors.²

One approach to effectively address homelessness in urban areas is provide supportive housing that incorporates access to mental health services. Research has demonstrated that offering stable housing and mental health services to individuals experiencing homelessness can significantly improve their mental and physical health and reduce their reliance on costly emergency services.^3,4

Collaboration between the health care system and government is also essential. By working together, the health care system and government can develop comprehensive strategies, allocate resources, and implement interventions that address the physical and mental health needs of individuals who are homeless and provide them with the necessary support and services. This collaboration is essential to create sustainable solutions and make a meaningful impact in combating homelessness.⁵

Addressing homelessness in urban areas requires a comprehensive approach that recognizes the critical role of mental illness and necessity for collaborative solutions. While our ED has implemented certain measures, such as allowing patients to remain on 23-hour holds to prevent immediate re-admission, additional interventions are needed. These include expanding shelters and transitional housing programs, which are currently in short supply, and developing street medicine programs to meet individuals where they are and improve compliance with medications. By implementing these strategies, we can help minimize the impact of homelessness on individuals with mental illness and enhance the health and well-being of individuals experiencing homelessness.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

As an emergency department (ED) psychiatrist with 25 years of experience working in a large city, I am growing increasingly concerned about the escalating number of individuals experiencing homelessness in urban areas.

Homelessness remains a critical issue across the United States. The news reports from major urban areas are startling. In my own practice, I encounter approximately 10,000 patients annually, and at least one-half of them are homeless. Additionally, 75% of these patients who are homeless experience addiction, and many have lost all social support. Due to overcrowding at our area’s shelters, they resort to using the ED as a shelter because most of our shelters are overcrowded. This situation has caused an overwhelming overload in the ED and left staff disheartened and difficult to retain.

The relationship between mental illness and homelessness is complex and multifaceted. Research suggests that up to one-third of individuals who are homeless have serious mental illness.¹ Mental illness can contribute to homelessness by impeding individuals’ ability to maintain employment, housing, and social relationships. Conversely, homelessness can worsen mental illness (especially in younger individuals, who are most vulnerable) by exposing individuals to traumatic experiences, substance abuse, and other stressors.²

One approach to effectively address homelessness in urban areas is provide supportive housing that incorporates access to mental health services. Research has demonstrated that offering stable housing and mental health services to individuals experiencing homelessness can significantly improve their mental and physical health and reduce their reliance on costly emergency services.^3,4

Collaboration between the health care system and government is also essential. By working together, the health care system and government can develop comprehensive strategies, allocate resources, and implement interventions that address the physical and mental health needs of individuals who are homeless and provide them with the necessary support and services. This collaboration is essential to create sustainable solutions and make a meaningful impact in combating homelessness.⁵

Addressing homelessness in urban areas requires a comprehensive approach that recognizes the critical role of mental illness and necessity for collaborative solutions. While our ED has implemented certain measures, such as allowing patients to remain on 23-hour holds to prevent immediate re-admission, additional interventions are needed. These include expanding shelters and transitional housing programs, which are currently in short supply, and developing street medicine programs to meet individuals where they are and improve compliance with medications. By implementing these strategies, we can help minimize the impact of homelessness on individuals with mental illness and enhance the health and well-being of individuals experiencing homelessness.