Current Psychiatry

Asenapine an atypical antipsychotic sold under the brand name Saphris, was granted a second, pediatric indi­cation by the FDA in March 2015 as mono­therapy for acute treatment of manic or mixed episodes of bipolar I disorder in chil­dren and adolescents age 10 to 17 (Table 1).¹ (Asenapine was first approved in August 2009 as monotherapy or adjunctive therapy to lithium or valproate in adults for schizo­phrenia and bipolar I disorder.^1,2)

Dosage and administration
Asenapine is available as 2.5-, 5-, and 10-mg sublingual tablets, the only atypical anti­psychotic with this formulation.¹ The rec­ommended dosage for the new indication is 2.5 mg twice daily for 3 days, titrated to 5 mg twice daily, titrated again to 10 mg twice daily after 3 days.³ In a phase I study, pedi­atric patients appeared to be more sensitive to dystonia when the recommended dosage escalation schedule was not followed.³

In clinical trials, drinking water 2 to 5 minutes after taking asenapine decreased exposure to the drug. Instruct patients not to swallow the tablet and to avoid eating and drinking for 10 minutes after administration.³

For full prescribing information for pediat­ric and adult patients, see Reference 3.

Safety and efficacy
In a 3-week, placebo-controlled, double-blind trial of 403 patients, 302 children and adolescents age 10 to 17 received asenap­ine at fixed dosages of 2.5 to 10 mg twice daily; the remainder were given placebo. The Young Mania Rating Scale (YMRS) total score and Clinical Global Impressions Severity of Illness scores of patients who received asenapine improved significantly compared with those who received placebo, as measured by change from baseline to week 3 (Table 2).¹

Asenapine was not shown to be effective in pediatric patients with schizophrenia in an 8-week, placebo-controlled, double-blind trial.

The pharmacokinetics of asenapine in pediatric patients are similar to those seen in adults.

Adverse effects
In pediatric patients, the most common reported adverse effects of asenapine are:
   • dizziness
   • dysgeusia
   • fatigue
   • increased appetite
   • increased weight
   • nausea
   • oral paresthesia
   • somnolence.

Similar adverse effects were reported in the pediatric bipolar disorder and adult bipolar disorder clinical trials (Table 3).³ A complete list of reported adverse effects is given in the package insert.³

When treating pediatric patients, moni­tor the child’s weight gain against expected normal weight gain.

Asenapine is contraindicated in patients with hepatic impairment and those who have a hypersensitivity to asenapine or any components in its formulation.³

Asenapine an atypical antipsychotic sold under the brand name Saphris, was granted a second, pediatric indi­cation by the FDA in March 2015 as mono­therapy for acute treatment of manic or mixed episodes of bipolar I disorder in chil­dren and adolescents age 10 to 17 (Table 1).¹ (Asenapine was first approved in August 2009 as monotherapy or adjunctive therapy to lithium or valproate in adults for schizo­phrenia and bipolar I disorder.^1,2)

Dosage and administration
Asenapine is available as 2.5-, 5-, and 10-mg sublingual tablets, the only atypical anti­psychotic with this formulation.¹ The rec­ommended dosage for the new indication is 2.5 mg twice daily for 3 days, titrated to 5 mg twice daily, titrated again to 10 mg twice daily after 3 days.³ In a phase I study, pedi­atric patients appeared to be more sensitive to dystonia when the recommended dosage escalation schedule was not followed.³

In clinical trials, drinking water 2 to 5 minutes after taking asenapine decreased exposure to the drug. Instruct patients not to swallow the tablet and to avoid eating and drinking for 10 minutes after administration.³

For full prescribing information for pediat­ric and adult patients, see Reference 3.

Safety and efficacy
In a 3-week, placebo-controlled, double-blind trial of 403 patients, 302 children and adolescents age 10 to 17 received asenap­ine at fixed dosages of 2.5 to 10 mg twice daily; the remainder were given placebo. The Young Mania Rating Scale (YMRS) total score and Clinical Global Impressions Severity of Illness scores of patients who received asenapine improved significantly compared with those who received placebo, as measured by change from baseline to week 3 (Table 2).¹

Asenapine was not shown to be effective in pediatric patients with schizophrenia in an 8-week, placebo-controlled, double-blind trial.

The pharmacokinetics of asenapine in pediatric patients are similar to those seen in adults.

Adverse effects
In pediatric patients, the most common reported adverse effects of asenapine are:
   • dizziness
   • dysgeusia
   • fatigue
   • increased appetite
   • increased weight
   • nausea
   • oral paresthesia
   • somnolence.

Similar adverse effects were reported in the pediatric bipolar disorder and adult bipolar disorder clinical trials (Table 3).³ A complete list of reported adverse effects is given in the package insert.³

When treating pediatric patients, moni­tor the child’s weight gain against expected normal weight gain.

Asenapine is contraindicated in patients with hepatic impairment and those who have a hypersensitivity to asenapine or any components in its formulation.³

Asenapine an atypical antipsychotic sold under the brand name Saphris, was granted a second, pediatric indi­cation by the FDA in March 2015 as mono­therapy for acute treatment of manic or mixed episodes of bipolar I disorder in chil­dren and adolescents age 10 to 17 (Table 1).¹ (Asenapine was first approved in August 2009 as monotherapy or adjunctive therapy to lithium or valproate in adults for schizo­phrenia and bipolar I disorder.^1,2)

Dosage and administration
Asenapine is available as 2.5-, 5-, and 10-mg sublingual tablets, the only atypical anti­psychotic with this formulation.¹ The rec­ommended dosage for the new indication is 2.5 mg twice daily for 3 days, titrated to 5 mg twice daily, titrated again to 10 mg twice daily after 3 days.³ In a phase I study, pedi­atric patients appeared to be more sensitive to dystonia when the recommended dosage escalation schedule was not followed.³

In clinical trials, drinking water 2 to 5 minutes after taking asenapine decreased exposure to the drug. Instruct patients not to swallow the tablet and to avoid eating and drinking for 10 minutes after administration.³

For full prescribing information for pediat­ric and adult patients, see Reference 3.

Safety and efficacy
In a 3-week, placebo-controlled, double-blind trial of 403 patients, 302 children and adolescents age 10 to 17 received asenap­ine at fixed dosages of 2.5 to 10 mg twice daily; the remainder were given placebo. The Young Mania Rating Scale (YMRS) total score and Clinical Global Impressions Severity of Illness scores of patients who received asenapine improved significantly compared with those who received placebo, as measured by change from baseline to week 3 (Table 2).¹

Asenapine was not shown to be effective in pediatric patients with schizophrenia in an 8-week, placebo-controlled, double-blind trial.

The pharmacokinetics of asenapine in pediatric patients are similar to those seen in adults.

Adverse effects
In pediatric patients, the most common reported adverse effects of asenapine are:
   • dizziness
   • dysgeusia
   • fatigue
   • increased appetite
   • increased weight
   • nausea
   • oral paresthesia
   • somnolence.

Similar adverse effects were reported in the pediatric bipolar disorder and adult bipolar disorder clinical trials (Table 3).³ A complete list of reported adverse effects is given in the package insert.³

When treating pediatric patients, moni­tor the child’s weight gain against expected normal weight gain.

Asenapine is contraindicated in patients with hepatic impairment and those who have a hypersensitivity to asenapine or any components in its formulation.³

CASE A fainting spell
Ms. A, age 13, is admitted to a pediatric unit after fainting and losing consciousness for 5 minutes in the shower, during which time she was non-responsive. She reports feeling nause­ated and having blurry vision before dropping to the floor.

Ms. A reports intentional self-restriction of calories, self-induced vomiting, and other purg­ing behaviors, such as laxative abuse and exces­sive exercising.

During the mental status examination, Ms. A is lying in bed wearing hospital clothes, legs flexed at the knee, hands on her side, and a fixed gaze at the ceiling with poor eye con­tact. She is of slender stature and tall, seems slightly older than her stated age, and is poorly groomed.

Throughout the interview, Ms. A has sig­nificant psychomotor retardation, reports her mood as tired, and has a blunted affect. She speaks at a low volume and has poverty of speech; she takes deep sighs before answer­ing questions. Her thought process is linear and she cooperates with the interview. She has poor recall, including delayed 3-minute recall and poor sustained attention. Her abstraction capacity is fair and her intellect is average and comparable with her age group. Ms. A is pre­occupied that eating will cause weight gain. She denies hallucinations but reports passive death wishes with self-harm by scratching.

What is the differential diagnosis to explain Ms. A’s presentation?
   a) syncope
   b) seizures
   c) dehydration
   d) hypotension

HISTORY Preoccupied with weight
Ms. A reports vomiting twice a day, while show­ering and at night when no one is around, every day for 2 months. She stopped eating and taking in fluids 3 days before admission to the medical unit. Also, she reports restricting her diet to 700 to 1,000 calories a day, skipping lunch at school, and eating minimally at night. Ms. A uses raspberry ketones and green coffee beans, which are adver­tised to aid weight loss, and laxative pills from her mother’s medicine cabinet once or twice a week when her throat is sore from vomiting. She reports exercising excessively, which includes running, crunches, and lifting weights. She has lost approximately 30 lb in the last 2 months.

Ms. A says she fears gaining weight and feels increased guilt after eating a meal. She said that looking at food induced “anxiety attack” symptoms of increased heart rate, sweaty palms, feeling of choking, nervousness, and shakiness. She adds that she does not want to be “bigger” than her classmates. Her under­standing of the consequences of not eating is, “It will get worse, I will shut down and die. I do not fear death, I only fear getting bigger than others.”

She reports that her fixation on avoiding food started when she realized that she was the tallest girl in her class and the only girl in her class running on the track team, after which she quit athletics. She reports that depression symptoms pre-dated her eating disorder symp­toms; onset of significant depression likely was precipitated by her grandfather’s death a year earlier, and then exacerbated by the recent death of a family pet.

Ms. A’s depressive symptoms are described as anhedonia (avoiding being outside and not enjoying drawing anymore), decreased energy, tearfulness, sadness, decreased con­centration, and passive suicidal thoughts. Her mother is supportive and motivates her daughter to “get better.” Ms. A denies any symptoms of psychosis, other anxiety symp­toms, other mood disorder symptoms, sub­stance abuse, or homicidality.

Ms. A’s mother says she felt that, recently, her daughter has been having some difficulty with confused thoughts and significantly delayed responses. However, the mother reports that her daughter always had some­what delayed responses from what she felt is typical. Her mother adds that Ms. A’s suicidal thoughts have worsened since her daughter started restricting her diet.

Which diagnosis likely accounts for Ms. A’s presentation?
   a) major depressive disorder (MDD)
   b) eating disorder, not otherwise specified (NOS)
   c) anorexia nervosa, purging type
   d) catatonia, unspecified
   e) anxiety disorder NOS
   f) cognitive disorder
   g) psychosis NOS

The authors’ observations
There are many reported causes of catatonia in children and adolescents, including those that are psychiatric, medical, or neurological, as well as drugs (Table 1).^1,2 Affective disor­ders have been associated with catatonia in adults, but has not been widely reported in children and adolescents.^1,3 Organic and neu­rologic causes, such as neurological tumors and cerebral hemorrhage, should be ruled out first because, although rare, they can be fatal (Table 2).² If the cause of catatonia is not recognized quickly (Figure,^1,2) effective treatment could be delayed.⁴

Presentation in adults and adolescents is similar.

An eating disorder could be comorbid with another psychiatric disorder, such as MDD, dysthymia, or panic disorder.⁵ Ms. A’s report of depression before she began restricting food favored a primary diagnosis of MDD. Her depressive symptoms of low appetite or low self-worth could have led to her preoccupation with body image.

There has been evidence that negative self-image and eating disorders are associ­ated, but data are limited and the connection remains unclear.⁶ Ms. A’s self-esteem was very low. Her fixation on restricting food could have been perpetuated by her self-criticism and by being excluded from her peer group in school. Her weight loss could have brought anxiety symptoms to the fore­front because of physiologic changes that accompany extreme weight loss.

The treatment team was concerned about her delayed responses, which could be explained by the catatonic features that reflected the severity of her depression. She had no obvious symptoms of psychosis, but her intrusive thoughts and obsessions with avoiding food did not completely rule out psychosis.

Childhood-onset schizophrenia, although rare, has been associated with catatonia; fol­lowing up with a catatonia rating scale, such as the Catatonia Rating Scale or the Bush- Francis Catatonia Rating Scale (BFCRS), would be useful for tracking symptom prog­ress. In Ms. A’s case, her mood disorder was primary, but did not rule out psychosis-like prodromal symptoms.⁷

Ms. A is diagnosed with MDD, single episode, severe, with catatonic features, and without psychosis, and eating disorder, NOS.

EVALUATION Mostly normal
Ms. A does not have a history of mental ill­ness and was not seeing a psychiatrist or therapist, nor did she have any prior psychi­atric admissions. She denies suicide attempts, but reports self-injurious behavior involving scratching her skin, which started during the current mood episode. She has never taken any psychotropic medications. Ms. A lives at home with her biological mother and father and 17-year-old brother. She attends middle school with average grades and has no his­tory of disciplinary actions. She has no his­tory of bullying or teasing, although she did report some previous difficulty with relational aggression toward her peers in the 5th grade. Her mother has a history of anorexia nervosa that began when she was a teenager, but these symptoms are stable and under control. There is additionally a family history of bipolar disorder.

Ms. A has a family history of coronary artery disease and diabetes in the mother and maternal relatives. Her grandfather died from liver cancer. She was allergic to sulfa drugs and was taking a multivitamin and minocycline for acne.

Physical examination reveals some super­ficial scratches but otherwise was within normal limits. Initial lab results reveal a nor­mal complete blood count and differential. Thyroid-stimulating hormone is 1.29 mIU/L and free T4 is 0.96 mg/dL, both within normal limits. Urinalysis is within normal limits and urine pregnancy test is negative. A compre­hensive metabolic panel shows mild elevation in aspartate aminotransferase (AST) at 60 U/L and alanine aminotransferase (ALT) at 92 U/L, respectively. Phosphorus level is within nor­mal limits. Prealbumin level is slightly low at 15.1 mg/dL.

Which treatment plan would you recommend for Ms. A?
   a) discharge with outpatient psychiatric treatment
   b) recommend medical stabilization with follow-up from the psychosomatic team and then outpatient psychiatric follow-up
   c) admit her to the psychiatric acute inpa­tient hospital with psychiatric outpatient discharge follow-up plan
   d) discharge her home with follow-up with her primary care physician
   e) recommend follow-up from the psycho­somatic team while on medical floor with acute inpatient admission and psychiatric outpatient follow-up at discharge

The authors’ observations
Scarcity of data and reporting of cases of ado­lescent catatonia limits guidance for diagno­sis and treatment.⁸ There are several rating scales with variability in definition, but that overall provide a guiding tool for detecting catatonia. The Brief Cognitive Rating Scale is considered the most versatile because it is more valid, reliable, and requires less time to complete than other rating scales.⁹

Ms. A’s symptoms were a combination of depressive symptoms with severity defined by catatonic features, eating disorder with worsening course, anxiety symptoms, and genetic loading of eating disorder in her mother. The challenge of this case was making an accurate diagnosis and treating Ms. A, which required continuous obser­vation following an eating disorder proto­col, resolution of her catatonia, resuming a normal diet, and decreasing her suicidality. Retrospectively, her scores on the BFCRS were high on screening items 1 to 14, which measure presence or absence and severity of symptoms.

The best option was to admit Ms. A to an inpatient psychiatric facility after she is cleared medically with outpatient services to follow up.

How would you treat Ms. A’s symptoms?
   a) aggressively treat catatonia
   b) address her eating disorder
   c) work to resolve her depression

The authors’ observations
The challenge was to choose the psycho­tropic medication that would target her depression, obsessive, rigid thoughts, and catatonia. Administering an antidepressant with an antipsychotic would have relieved her depressive and obsessive symptoms but would not have improved her catato­nia. The psychosomatic medicine team rec­ommended starting a selective serotonin reuptake inhibitor and a benzodiazepine to target both the depression and the cata­tonic symptoms. Ms. A received sertraline, 12.5 mg/d, which was increased to 25 mg/d on the third day. IV lorazepam, 1 mg, 3 times a day, was recommended but the pediatric team prescribed an oral formulation. The hospital’s eating disorder protocol was insti­tuted on the day of admission.

Treatment options for catatonia
Benzodiazepines are the first line of treat­ment for catatonia and other neurolep­tics, specifically antipsychotics, have been considered dangerous.¹⁰ Benzodiazepine-resistant catatonia, which is sometimes seen in patients with autism, might respond to electroconvulsive therapy (ECT),¹¹ although in some states it cannot be administered to children age <18.¹² Benzodiazepines have shown dramatic improvement within hours, as has ECT.^8,13 Additionally, if patients do not respond to a benzodiazepine or ECT, con­sider other options such as zolpidem, olan­zapine,¹⁴ or sensory integration system (in adolescents with autism).¹⁵

Ms. A did not need ECT or an alternative treatment because she responded well to 3 doses of oral lorazepam. Her amotivation, negativism, and rigidity with prolonged posturing improved. Her psychomotor retardation improved overall, although she reported some dizziness and had some pos­tural hypotension, which was attributed to her eating issues and dehydration.

OUTCOME Feeling motivated
Ms. A is transferred to psychiatric inpatient unit. She tolerates sertraline, which is titrated to 50 mg/d. She is placed on the hospital’s standard eating disorder protocol. She con­tinues to eat well with adequate intake of solids and liquid and exhibits only some anxi­ety associated with meals. During the course of hospitalization, she attends group therapy and her catatonic symptoms completely resolve. She says she thinks that her thoughts are improving and that she is not longer feel­ing confused. She reports being motivated to continue to improve her eating disorder symptoms.

The treatment team holds a family session during which family dynamic issues that are stressful to Ms. A are discussed, such as some conflict with her parents as well as some nega­tive interactions between Ms. A and her father. Repeat comprehensive metabolic panel on admission to the inpatient psychiatric hospital reveals persistent elevation of AST at 92 U/L and ALT at 143 U/L. Ms. A is discharged home with follow-up with a psychiatrist and a thera­pist. The treatment team also recommends that she follow up in a program that special­izes in eating disorders.

4-month follow-up. Ms. A returns to inpa­tient psychiatric hospital after overdose of ser­traline and aripiprazole, which were started by an outpatient psychiatrist. She reports severe depressive symptoms because of school stressors. She denies any problems eating and did not show any symptoms of catato­nia. In her chart, there is a mention of “cloudy thoughts” and quietness. At this admission, her ALT is 17 U/L and AST is 19 U/L. Sertraline is increased to 150 mg/d and aripiprazole is reduced to 2 mg/d and then later increased to 5 mg/d, after which she is discharged home with an outpatient psychiatric follow-up.

1-year follow-up. Ms. A has been follow­ing up with an outpatient psychiatrist and is receiving sertraline, 150 mg/d, aripiprazole, 2.5 mg/d, and extended-release methylphe­nidate, 36 mg/d, along with L-methylfolate, multivitamins, and omega-3 fish oil as adju­vants for her depressive symptoms. Ms. A does not show symptoms of an eating disorder or catatonia, and her depression and psychomo­tor activity have improved, with better overall functionality, after adding the stimulant and adjunctives to the antidepressant.

The authors’ observations
The importance of including catatonia NOS with its various specifiers, such as medi­cal, metabolic, toxic, affective, etc., has been discussed.^16,17 In Ms. A’s case, instead of treating the specific symptoms—affective or eating disorder or obsessive quality of thought content, mimicking psychotic-like symptoms—addressing the catatonia ini­tially had a better outcome. More studies related to chronic and acute catatonia in adolescents are needed because of the risk of increased morbidity and premature death.¹⁸ Early recognition of catatonia is needed¹⁹ because it often is underdiagnosed.²⁰

Eating disorders often become worse over the first 5 years, and close monitoring and assessment is needed for adolescents.²¹ Also, prodromal psychotic symptoms require follow-up because techniques for early detection and intervention for children and adolescents are still in their infancy.²²

Bottom Line
Catatonia in adolescents should be addressed early, when it is treatable and the outcome is favorable. It is important to recognize catatonia in an emergency department or inpatient medical unit setting in a hospital because it is often underdiagnosed or misdiagnosed. The presentation of catatonia is similar in adolescents and adults. Benzodiazepines are first-line treatment for catatonia; consider electroconvulsive therapy if patients do not respond to drug therapy.

Related Resources
• Roberto AJ, Pinnaka S, Mohan A, et al. Adolescent catatonia successfully treated with lorazepam and aripiprazole. Case Rep Psychiatry. 2014;2014:309517. doi: 10.1155/2014/309517.
• Raffin M, Zugaj-Bensaou L, Bodeau N, et al. Treatment use in a prospective naturalistic cohort of children and adolescents with catatonia. Eur Child Adolesc Psychiatry. 2015;24(4):441-449.

Drug Brand Names
Aripiprazole • Abilify                                  Minocycline • Minocin
L-methylfolate • Deplin                              Olanzapine • Zyprexa
Lorazepam • Ativan                                   Sertraline • Zoloft
Methylphenidate • Ritalin,  Concerta          Zolpidem • Ambien, Intermezzo

Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE A fainting spell
Ms. A, age 13, is admitted to a pediatric unit after fainting and losing consciousness for 5 minutes in the shower, during which time she was non-responsive. She reports feeling nause­ated and having blurry vision before dropping to the floor.

Ms. A reports intentional self-restriction of calories, self-induced vomiting, and other purg­ing behaviors, such as laxative abuse and exces­sive exercising.

During the mental status examination, Ms. A is lying in bed wearing hospital clothes, legs flexed at the knee, hands on her side, and a fixed gaze at the ceiling with poor eye con­tact. She is of slender stature and tall, seems slightly older than her stated age, and is poorly groomed.

Throughout the interview, Ms. A has sig­nificant psychomotor retardation, reports her mood as tired, and has a blunted affect. She speaks at a low volume and has poverty of speech; she takes deep sighs before answer­ing questions. Her thought process is linear and she cooperates with the interview. She has poor recall, including delayed 3-minute recall and poor sustained attention. Her abstraction capacity is fair and her intellect is average and comparable with her age group. Ms. A is pre­occupied that eating will cause weight gain. She denies hallucinations but reports passive death wishes with self-harm by scratching.

What is the differential diagnosis to explain Ms. A’s presentation?
   a) syncope
   b) seizures
   c) dehydration
   d) hypotension

HISTORY Preoccupied with weight
Ms. A reports vomiting twice a day, while show­ering and at night when no one is around, every day for 2 months. She stopped eating and taking in fluids 3 days before admission to the medical unit. Also, she reports restricting her diet to 700 to 1,000 calories a day, skipping lunch at school, and eating minimally at night. Ms. A uses raspberry ketones and green coffee beans, which are adver­tised to aid weight loss, and laxative pills from her mother’s medicine cabinet once or twice a week when her throat is sore from vomiting. She reports exercising excessively, which includes running, crunches, and lifting weights. She has lost approximately 30 lb in the last 2 months.

Ms. A says she fears gaining weight and feels increased guilt after eating a meal. She said that looking at food induced “anxiety attack” symptoms of increased heart rate, sweaty palms, feeling of choking, nervousness, and shakiness. She adds that she does not want to be “bigger” than her classmates. Her under­standing of the consequences of not eating is, “It will get worse, I will shut down and die. I do not fear death, I only fear getting bigger than others.”

She reports that her fixation on avoiding food started when she realized that she was the tallest girl in her class and the only girl in her class running on the track team, after which she quit athletics. She reports that depression symptoms pre-dated her eating disorder symp­toms; onset of significant depression likely was precipitated by her grandfather’s death a year earlier, and then exacerbated by the recent death of a family pet.

Ms. A’s depressive symptoms are described as anhedonia (avoiding being outside and not enjoying drawing anymore), decreased energy, tearfulness, sadness, decreased con­centration, and passive suicidal thoughts. Her mother is supportive and motivates her daughter to “get better.” Ms. A denies any symptoms of psychosis, other anxiety symp­toms, other mood disorder symptoms, sub­stance abuse, or homicidality.

Ms. A’s mother says she felt that, recently, her daughter has been having some difficulty with confused thoughts and significantly delayed responses. However, the mother reports that her daughter always had some­what delayed responses from what she felt is typical. Her mother adds that Ms. A’s suicidal thoughts have worsened since her daughter started restricting her diet.

Which diagnosis likely accounts for Ms. A’s presentation?
   a) major depressive disorder (MDD)
   b) eating disorder, not otherwise specified (NOS)
   c) anorexia nervosa, purging type
   d) catatonia, unspecified
   e) anxiety disorder NOS
   f) cognitive disorder
   g) psychosis NOS

The authors’ observations
There are many reported causes of catatonia in children and adolescents, including those that are psychiatric, medical, or neurological, as well as drugs (Table 1).^1,2 Affective disor­ders have been associated with catatonia in adults, but has not been widely reported in children and adolescents.^1,3 Organic and neu­rologic causes, such as neurological tumors and cerebral hemorrhage, should be ruled out first because, although rare, they can be fatal (Table 2).² If the cause of catatonia is not recognized quickly (Figure,^1,2) effective treatment could be delayed.⁴

Presentation in adults and adolescents is similar.

An eating disorder could be comorbid with another psychiatric disorder, such as MDD, dysthymia, or panic disorder.⁵ Ms. A’s report of depression before she began restricting food favored a primary diagnosis of MDD. Her depressive symptoms of low appetite or low self-worth could have led to her preoccupation with body image.

There has been evidence that negative self-image and eating disorders are associ­ated, but data are limited and the connection remains unclear.⁶ Ms. A’s self-esteem was very low. Her fixation on restricting food could have been perpetuated by her self-criticism and by being excluded from her peer group in school. Her weight loss could have brought anxiety symptoms to the fore­front because of physiologic changes that accompany extreme weight loss.

The treatment team was concerned about her delayed responses, which could be explained by the catatonic features that reflected the severity of her depression. She had no obvious symptoms of psychosis, but her intrusive thoughts and obsessions with avoiding food did not completely rule out psychosis.

Childhood-onset schizophrenia, although rare, has been associated with catatonia; fol­lowing up with a catatonia rating scale, such as the Catatonia Rating Scale or the Bush- Francis Catatonia Rating Scale (BFCRS), would be useful for tracking symptom prog­ress. In Ms. A’s case, her mood disorder was primary, but did not rule out psychosis-like prodromal symptoms.⁷

Ms. A is diagnosed with MDD, single episode, severe, with catatonic features, and without psychosis, and eating disorder, NOS.

EVALUATION Mostly normal
Ms. A does not have a history of mental ill­ness and was not seeing a psychiatrist or therapist, nor did she have any prior psychi­atric admissions. She denies suicide attempts, but reports self-injurious behavior involving scratching her skin, which started during the current mood episode. She has never taken any psychotropic medications. Ms. A lives at home with her biological mother and father and 17-year-old brother. She attends middle school with average grades and has no his­tory of disciplinary actions. She has no his­tory of bullying or teasing, although she did report some previous difficulty with relational aggression toward her peers in the 5th grade. Her mother has a history of anorexia nervosa that began when she was a teenager, but these symptoms are stable and under control. There is additionally a family history of bipolar disorder.

Ms. A has a family history of coronary artery disease and diabetes in the mother and maternal relatives. Her grandfather died from liver cancer. She was allergic to sulfa drugs and was taking a multivitamin and minocycline for acne.

Physical examination reveals some super­ficial scratches but otherwise was within normal limits. Initial lab results reveal a nor­mal complete blood count and differential. Thyroid-stimulating hormone is 1.29 mIU/L and free T4 is 0.96 mg/dL, both within normal limits. Urinalysis is within normal limits and urine pregnancy test is negative. A compre­hensive metabolic panel shows mild elevation in aspartate aminotransferase (AST) at 60 U/L and alanine aminotransferase (ALT) at 92 U/L, respectively. Phosphorus level is within nor­mal limits. Prealbumin level is slightly low at 15.1 mg/dL.

Which treatment plan would you recommend for Ms. A?
   a) discharge with outpatient psychiatric treatment
   b) recommend medical stabilization with follow-up from the psychosomatic team and then outpatient psychiatric follow-up
   c) admit her to the psychiatric acute inpa­tient hospital with psychiatric outpatient discharge follow-up plan
   d) discharge her home with follow-up with her primary care physician
   e) recommend follow-up from the psycho­somatic team while on medical floor with acute inpatient admission and psychiatric outpatient follow-up at discharge

The authors’ observations
Scarcity of data and reporting of cases of ado­lescent catatonia limits guidance for diagno­sis and treatment.⁸ There are several rating scales with variability in definition, but that overall provide a guiding tool for detecting catatonia. The Brief Cognitive Rating Scale is considered the most versatile because it is more valid, reliable, and requires less time to complete than other rating scales.⁹

Ms. A’s symptoms were a combination of depressive symptoms with severity defined by catatonic features, eating disorder with worsening course, anxiety symptoms, and genetic loading of eating disorder in her mother. The challenge of this case was making an accurate diagnosis and treating Ms. A, which required continuous obser­vation following an eating disorder proto­col, resolution of her catatonia, resuming a normal diet, and decreasing her suicidality. Retrospectively, her scores on the BFCRS were high on screening items 1 to 14, which measure presence or absence and severity of symptoms.

The best option was to admit Ms. A to an inpatient psychiatric facility after she is cleared medically with outpatient services to follow up.

How would you treat Ms. A’s symptoms?
   a) aggressively treat catatonia
   b) address her eating disorder
   c) work to resolve her depression

The authors’ observations
The challenge was to choose the psycho­tropic medication that would target her depression, obsessive, rigid thoughts, and catatonia. Administering an antidepressant with an antipsychotic would have relieved her depressive and obsessive symptoms but would not have improved her catato­nia. The psychosomatic medicine team rec­ommended starting a selective serotonin reuptake inhibitor and a benzodiazepine to target both the depression and the cata­tonic symptoms. Ms. A received sertraline, 12.5 mg/d, which was increased to 25 mg/d on the third day. IV lorazepam, 1 mg, 3 times a day, was recommended but the pediatric team prescribed an oral formulation. The hospital’s eating disorder protocol was insti­tuted on the day of admission.

Treatment options for catatonia
Benzodiazepines are the first line of treat­ment for catatonia and other neurolep­tics, specifically antipsychotics, have been considered dangerous.¹⁰ Benzodiazepine-resistant catatonia, which is sometimes seen in patients with autism, might respond to electroconvulsive therapy (ECT),¹¹ although in some states it cannot be administered to children age <18.¹² Benzodiazepines have shown dramatic improvement within hours, as has ECT.^8,13 Additionally, if patients do not respond to a benzodiazepine or ECT, con­sider other options such as zolpidem, olan­zapine,¹⁴ or sensory integration system (in adolescents with autism).¹⁵

Ms. A did not need ECT or an alternative treatment because she responded well to 3 doses of oral lorazepam. Her amotivation, negativism, and rigidity with prolonged posturing improved. Her psychomotor retardation improved overall, although she reported some dizziness and had some pos­tural hypotension, which was attributed to her eating issues and dehydration.

OUTCOME Feeling motivated
Ms. A is transferred to psychiatric inpatient unit. She tolerates sertraline, which is titrated to 50 mg/d. She is placed on the hospital’s standard eating disorder protocol. She con­tinues to eat well with adequate intake of solids and liquid and exhibits only some anxi­ety associated with meals. During the course of hospitalization, she attends group therapy and her catatonic symptoms completely resolve. She says she thinks that her thoughts are improving and that she is not longer feel­ing confused. She reports being motivated to continue to improve her eating disorder symptoms.

The treatment team holds a family session during which family dynamic issues that are stressful to Ms. A are discussed, such as some conflict with her parents as well as some nega­tive interactions between Ms. A and her father. Repeat comprehensive metabolic panel on admission to the inpatient psychiatric hospital reveals persistent elevation of AST at 92 U/L and ALT at 143 U/L. Ms. A is discharged home with follow-up with a psychiatrist and a thera­pist. The treatment team also recommends that she follow up in a program that special­izes in eating disorders.

4-month follow-up. Ms. A returns to inpa­tient psychiatric hospital after overdose of ser­traline and aripiprazole, which were started by an outpatient psychiatrist. She reports severe depressive symptoms because of school stressors. She denies any problems eating and did not show any symptoms of catato­nia. In her chart, there is a mention of “cloudy thoughts” and quietness. At this admission, her ALT is 17 U/L and AST is 19 U/L. Sertraline is increased to 150 mg/d and aripiprazole is reduced to 2 mg/d and then later increased to 5 mg/d, after which she is discharged home with an outpatient psychiatric follow-up.

1-year follow-up. Ms. A has been follow­ing up with an outpatient psychiatrist and is receiving sertraline, 150 mg/d, aripiprazole, 2.5 mg/d, and extended-release methylphe­nidate, 36 mg/d, along with L-methylfolate, multivitamins, and omega-3 fish oil as adju­vants for her depressive symptoms. Ms. A does not show symptoms of an eating disorder or catatonia, and her depression and psychomo­tor activity have improved, with better overall functionality, after adding the stimulant and adjunctives to the antidepressant.

The authors’ observations
The importance of including catatonia NOS with its various specifiers, such as medi­cal, metabolic, toxic, affective, etc., has been discussed.^16,17 In Ms. A’s case, instead of treating the specific symptoms—affective or eating disorder or obsessive quality of thought content, mimicking psychotic-like symptoms—addressing the catatonia ini­tially had a better outcome. More studies related to chronic and acute catatonia in adolescents are needed because of the risk of increased morbidity and premature death.¹⁸ Early recognition of catatonia is needed¹⁹ because it often is underdiagnosed.²⁰

Eating disorders often become worse over the first 5 years, and close monitoring and assessment is needed for adolescents.²¹ Also, prodromal psychotic symptoms require follow-up because techniques for early detection and intervention for children and adolescents are still in their infancy.²²

Bottom Line
Catatonia in adolescents should be addressed early, when it is treatable and the outcome is favorable. It is important to recognize catatonia in an emergency department or inpatient medical unit setting in a hospital because it is often underdiagnosed or misdiagnosed. The presentation of catatonia is similar in adolescents and adults. Benzodiazepines are first-line treatment for catatonia; consider electroconvulsive therapy if patients do not respond to drug therapy.

Related Resources
• Roberto AJ, Pinnaka S, Mohan A, et al. Adolescent catatonia successfully treated with lorazepam and aripiprazole. Case Rep Psychiatry. 2014;2014:309517. doi: 10.1155/2014/309517.
• Raffin M, Zugaj-Bensaou L, Bodeau N, et al. Treatment use in a prospective naturalistic cohort of children and adolescents with catatonia. Eur Child Adolesc Psychiatry. 2015;24(4):441-449.

Drug Brand Names
Aripiprazole • Abilify                                  Minocycline • Minocin
L-methylfolate • Deplin                              Olanzapine • Zyprexa
Lorazepam • Ativan                                   Sertraline • Zoloft
Methylphenidate • Ritalin,  Concerta          Zolpidem • Ambien, Intermezzo

Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE A fainting spell
Ms. A, age 13, is admitted to a pediatric unit after fainting and losing consciousness for 5 minutes in the shower, during which time she was non-responsive. She reports feeling nause­ated and having blurry vision before dropping to the floor.

Ms. A reports intentional self-restriction of calories, self-induced vomiting, and other purg­ing behaviors, such as laxative abuse and exces­sive exercising.

During the mental status examination, Ms. A is lying in bed wearing hospital clothes, legs flexed at the knee, hands on her side, and a fixed gaze at the ceiling with poor eye con­tact. She is of slender stature and tall, seems slightly older than her stated age, and is poorly groomed.

Throughout the interview, Ms. A has sig­nificant psychomotor retardation, reports her mood as tired, and has a blunted affect. She speaks at a low volume and has poverty of speech; she takes deep sighs before answer­ing questions. Her thought process is linear and she cooperates with the interview. She has poor recall, including delayed 3-minute recall and poor sustained attention. Her abstraction capacity is fair and her intellect is average and comparable with her age group. Ms. A is pre­occupied that eating will cause weight gain. She denies hallucinations but reports passive death wishes with self-harm by scratching.

What is the differential diagnosis to explain Ms. A’s presentation?
   a) syncope
   b) seizures
   c) dehydration
   d) hypotension

HISTORY Preoccupied with weight
Ms. A reports vomiting twice a day, while show­ering and at night when no one is around, every day for 2 months. She stopped eating and taking in fluids 3 days before admission to the medical unit. Also, she reports restricting her diet to 700 to 1,000 calories a day, skipping lunch at school, and eating minimally at night. Ms. A uses raspberry ketones and green coffee beans, which are adver­tised to aid weight loss, and laxative pills from her mother’s medicine cabinet once or twice a week when her throat is sore from vomiting. She reports exercising excessively, which includes running, crunches, and lifting weights. She has lost approximately 30 lb in the last 2 months.

Ms. A says she fears gaining weight and feels increased guilt after eating a meal. She said that looking at food induced “anxiety attack” symptoms of increased heart rate, sweaty palms, feeling of choking, nervousness, and shakiness. She adds that she does not want to be “bigger” than her classmates. Her under­standing of the consequences of not eating is, “It will get worse, I will shut down and die. I do not fear death, I only fear getting bigger than others.”

She reports that her fixation on avoiding food started when she realized that she was the tallest girl in her class and the only girl in her class running on the track team, after which she quit athletics. She reports that depression symptoms pre-dated her eating disorder symp­toms; onset of significant depression likely was precipitated by her grandfather’s death a year earlier, and then exacerbated by the recent death of a family pet.

Ms. A’s depressive symptoms are described as anhedonia (avoiding being outside and not enjoying drawing anymore), decreased energy, tearfulness, sadness, decreased con­centration, and passive suicidal thoughts. Her mother is supportive and motivates her daughter to “get better.” Ms. A denies any symptoms of psychosis, other anxiety symp­toms, other mood disorder symptoms, sub­stance abuse, or homicidality.

Ms. A’s mother says she felt that, recently, her daughter has been having some difficulty with confused thoughts and significantly delayed responses. However, the mother reports that her daughter always had some­what delayed responses from what she felt is typical. Her mother adds that Ms. A’s suicidal thoughts have worsened since her daughter started restricting her diet.

Which diagnosis likely accounts for Ms. A’s presentation?
   a) major depressive disorder (MDD)
   b) eating disorder, not otherwise specified (NOS)
   c) anorexia nervosa, purging type
   d) catatonia, unspecified
   e) anxiety disorder NOS
   f) cognitive disorder
   g) psychosis NOS

The authors’ observations
There are many reported causes of catatonia in children and adolescents, including those that are psychiatric, medical, or neurological, as well as drugs (Table 1).^1,2 Affective disor­ders have been associated with catatonia in adults, but has not been widely reported in children and adolescents.^1,3 Organic and neu­rologic causes, such as neurological tumors and cerebral hemorrhage, should be ruled out first because, although rare, they can be fatal (Table 2).² If the cause of catatonia is not recognized quickly (Figure,^1,2) effective treatment could be delayed.⁴

Presentation in adults and adolescents is similar.

An eating disorder could be comorbid with another psychiatric disorder, such as MDD, dysthymia, or panic disorder.⁵ Ms. A’s report of depression before she began restricting food favored a primary diagnosis of MDD. Her depressive symptoms of low appetite or low self-worth could have led to her preoccupation with body image.

There has been evidence that negative self-image and eating disorders are associ­ated, but data are limited and the connection remains unclear.⁶ Ms. A’s self-esteem was very low. Her fixation on restricting food could have been perpetuated by her self-criticism and by being excluded from her peer group in school. Her weight loss could have brought anxiety symptoms to the fore­front because of physiologic changes that accompany extreme weight loss.

The treatment team was concerned about her delayed responses, which could be explained by the catatonic features that reflected the severity of her depression. She had no obvious symptoms of psychosis, but her intrusive thoughts and obsessions with avoiding food did not completely rule out psychosis.

Childhood-onset schizophrenia, although rare, has been associated with catatonia; fol­lowing up with a catatonia rating scale, such as the Catatonia Rating Scale or the Bush- Francis Catatonia Rating Scale (BFCRS), would be useful for tracking symptom prog­ress. In Ms. A’s case, her mood disorder was primary, but did not rule out psychosis-like prodromal symptoms.⁷

Ms. A is diagnosed with MDD, single episode, severe, with catatonic features, and without psychosis, and eating disorder, NOS.

EVALUATION Mostly normal
Ms. A does not have a history of mental ill­ness and was not seeing a psychiatrist or therapist, nor did she have any prior psychi­atric admissions. She denies suicide attempts, but reports self-injurious behavior involving scratching her skin, which started during the current mood episode. She has never taken any psychotropic medications. Ms. A lives at home with her biological mother and father and 17-year-old brother. She attends middle school with average grades and has no his­tory of disciplinary actions. She has no his­tory of bullying or teasing, although she did report some previous difficulty with relational aggression toward her peers in the 5th grade. Her mother has a history of anorexia nervosa that began when she was a teenager, but these symptoms are stable and under control. There is additionally a family history of bipolar disorder.

Ms. A has a family history of coronary artery disease and diabetes in the mother and maternal relatives. Her grandfather died from liver cancer. She was allergic to sulfa drugs and was taking a multivitamin and minocycline for acne.

Physical examination reveals some super­ficial scratches but otherwise was within normal limits. Initial lab results reveal a nor­mal complete blood count and differential. Thyroid-stimulating hormone is 1.29 mIU/L and free T4 is 0.96 mg/dL, both within normal limits. Urinalysis is within normal limits and urine pregnancy test is negative. A compre­hensive metabolic panel shows mild elevation in aspartate aminotransferase (AST) at 60 U/L and alanine aminotransferase (ALT) at 92 U/L, respectively. Phosphorus level is within nor­mal limits. Prealbumin level is slightly low at 15.1 mg/dL.

Which treatment plan would you recommend for Ms. A?
   a) discharge with outpatient psychiatric treatment
   b) recommend medical stabilization with follow-up from the psychosomatic team and then outpatient psychiatric follow-up
   c) admit her to the psychiatric acute inpa­tient hospital with psychiatric outpatient discharge follow-up plan
   d) discharge her home with follow-up with her primary care physician
   e) recommend follow-up from the psycho­somatic team while on medical floor with acute inpatient admission and psychiatric outpatient follow-up at discharge

The authors’ observations
Scarcity of data and reporting of cases of ado­lescent catatonia limits guidance for diagno­sis and treatment.⁸ There are several rating scales with variability in definition, but that overall provide a guiding tool for detecting catatonia. The Brief Cognitive Rating Scale is considered the most versatile because it is more valid, reliable, and requires less time to complete than other rating scales.⁹

Ms. A’s symptoms were a combination of depressive symptoms with severity defined by catatonic features, eating disorder with worsening course, anxiety symptoms, and genetic loading of eating disorder in her mother. The challenge of this case was making an accurate diagnosis and treating Ms. A, which required continuous obser­vation following an eating disorder proto­col, resolution of her catatonia, resuming a normal diet, and decreasing her suicidality. Retrospectively, her scores on the BFCRS were high on screening items 1 to 14, which measure presence or absence and severity of symptoms.

The best option was to admit Ms. A to an inpatient psychiatric facility after she is cleared medically with outpatient services to follow up.

How would you treat Ms. A’s symptoms?
   a) aggressively treat catatonia
   b) address her eating disorder
   c) work to resolve her depression

The authors’ observations
The challenge was to choose the psycho­tropic medication that would target her depression, obsessive, rigid thoughts, and catatonia. Administering an antidepressant with an antipsychotic would have relieved her depressive and obsessive symptoms but would not have improved her catato­nia. The psychosomatic medicine team rec­ommended starting a selective serotonin reuptake inhibitor and a benzodiazepine to target both the depression and the cata­tonic symptoms. Ms. A received sertraline, 12.5 mg/d, which was increased to 25 mg/d on the third day. IV lorazepam, 1 mg, 3 times a day, was recommended but the pediatric team prescribed an oral formulation. The hospital’s eating disorder protocol was insti­tuted on the day of admission.

Treatment options for catatonia
Benzodiazepines are the first line of treat­ment for catatonia and other neurolep­tics, specifically antipsychotics, have been considered dangerous.¹⁰ Benzodiazepine-resistant catatonia, which is sometimes seen in patients with autism, might respond to electroconvulsive therapy (ECT),¹¹ although in some states it cannot be administered to children age <18.¹² Benzodiazepines have shown dramatic improvement within hours, as has ECT.^8,13 Additionally, if patients do not respond to a benzodiazepine or ECT, con­sider other options such as zolpidem, olan­zapine,¹⁴ or sensory integration system (in adolescents with autism).¹⁵

Ms. A did not need ECT or an alternative treatment because she responded well to 3 doses of oral lorazepam. Her amotivation, negativism, and rigidity with prolonged posturing improved. Her psychomotor retardation improved overall, although she reported some dizziness and had some pos­tural hypotension, which was attributed to her eating issues and dehydration.

OUTCOME Feeling motivated
Ms. A is transferred to psychiatric inpatient unit. She tolerates sertraline, which is titrated to 50 mg/d. She is placed on the hospital’s standard eating disorder protocol. She con­tinues to eat well with adequate intake of solids and liquid and exhibits only some anxi­ety associated with meals. During the course of hospitalization, she attends group therapy and her catatonic symptoms completely resolve. She says she thinks that her thoughts are improving and that she is not longer feel­ing confused. She reports being motivated to continue to improve her eating disorder symptoms.

The treatment team holds a family session during which family dynamic issues that are stressful to Ms. A are discussed, such as some conflict with her parents as well as some nega­tive interactions between Ms. A and her father. Repeat comprehensive metabolic panel on admission to the inpatient psychiatric hospital reveals persistent elevation of AST at 92 U/L and ALT at 143 U/L. Ms. A is discharged home with follow-up with a psychiatrist and a thera­pist. The treatment team also recommends that she follow up in a program that special­izes in eating disorders.

4-month follow-up. Ms. A returns to inpa­tient psychiatric hospital after overdose of ser­traline and aripiprazole, which were started by an outpatient psychiatrist. She reports severe depressive symptoms because of school stressors. She denies any problems eating and did not show any symptoms of catato­nia. In her chart, there is a mention of “cloudy thoughts” and quietness. At this admission, her ALT is 17 U/L and AST is 19 U/L. Sertraline is increased to 150 mg/d and aripiprazole is reduced to 2 mg/d and then later increased to 5 mg/d, after which she is discharged home with an outpatient psychiatric follow-up.

1-year follow-up. Ms. A has been follow­ing up with an outpatient psychiatrist and is receiving sertraline, 150 mg/d, aripiprazole, 2.5 mg/d, and extended-release methylphe­nidate, 36 mg/d, along with L-methylfolate, multivitamins, and omega-3 fish oil as adju­vants for her depressive symptoms. Ms. A does not show symptoms of an eating disorder or catatonia, and her depression and psychomo­tor activity have improved, with better overall functionality, after adding the stimulant and adjunctives to the antidepressant.

The authors’ observations
The importance of including catatonia NOS with its various specifiers, such as medi­cal, metabolic, toxic, affective, etc., has been discussed.^16,17 In Ms. A’s case, instead of treating the specific symptoms—affective or eating disorder or obsessive quality of thought content, mimicking psychotic-like symptoms—addressing the catatonia ini­tially had a better outcome. More studies related to chronic and acute catatonia in adolescents are needed because of the risk of increased morbidity and premature death.¹⁸ Early recognition of catatonia is needed¹⁹ because it often is underdiagnosed.²⁰

Eating disorders often become worse over the first 5 years, and close monitoring and assessment is needed for adolescents.²¹ Also, prodromal psychotic symptoms require follow-up because techniques for early detection and intervention for children and adolescents are still in their infancy.²²

Bottom Line
Catatonia in adolescents should be addressed early, when it is treatable and the outcome is favorable. It is important to recognize catatonia in an emergency department or inpatient medical unit setting in a hospital because it is often underdiagnosed or misdiagnosed. The presentation of catatonia is similar in adolescents and adults. Benzodiazepines are first-line treatment for catatonia; consider electroconvulsive therapy if patients do not respond to drug therapy.

Related Resources
• Roberto AJ, Pinnaka S, Mohan A, et al. Adolescent catatonia successfully treated with lorazepam and aripiprazole. Case Rep Psychiatry. 2014;2014:309517. doi: 10.1155/2014/309517.
• Raffin M, Zugaj-Bensaou L, Bodeau N, et al. Treatment use in a prospective naturalistic cohort of children and adolescents with catatonia. Eur Child Adolesc Psychiatry. 2015;24(4):441-449.

Drug Brand Names
Aripiprazole • Abilify                                  Minocycline • Minocin
L-methylfolate • Deplin                              Olanzapine • Zyprexa
Lorazepam • Ativan                                   Sertraline • Zoloft
Methylphenidate • Ritalin,  Concerta          Zolpidem • Ambien, Intermezzo

Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Pulling up charts. Phone tag. Prior authorizations. Rinse, repeat.

Reminiscent of the movie Groundhog Day, the daily grind in running a practice rarely gives way. Some days there are more faxes to process or paperwork to push than other days but, on the whole, there’s no escaping the tedium and time sink that these gloomy chores engender. In some practices, an assistant is hired to absorb the barrage; if not, it is left to the clinician to handle at the expense of time for patient care or life out­side practice.

Compounding matters, creating new systems to assuage these tasks can feel like a sisyphean endeavor, because the energy required to start likely will be more than what is already being expended. For example, switching from paper-based to electronic systems is tantalizing but incurs its own learning curve and has a financial cost. Likewise, hiring administrative help demands a significant investment in train­ing and, if patient contact is part of the job description, even more preparation is nec­essary because she (he) becomes the public face of the practice. Fortunately, both of these options pay dividends in the long run.

Yet, even with some basic strategies, what seems like the inevitability of inertia can be reshaped into a more efficient, less quotid­ian experience. Consider the following ways to streamline processes and eliminate time wasted and not spent on providing care.

Patient-specific tasks
Prior authorizations. The typical process is to have to call the insurance company to have the paperwork faxed, burning 5 to 15 minutes by being placed on hold or being transferred between departments. Instead, ask the patient to call the insurance com­pany (she [he] should get the phone num­ber from the pharmacist and have your fax number handy) and request the paper­work, with her (his) demographic informa­tion pre-filled in, be faxed to your office. If she is told by the insurance company that the doctor has to call, instruct the patient to explain it is merely a request to have forms faxed and to call again and speak with a different agent if necessary. If the patient pushes back, explaining that this helps keeps your rates lower or from having to bill for this specific time usually smooths things over.

Voicemails. Listening (and re-listening) to a long voicemail takes time. Although using a professional transcription service might be costly, it may be less expensive than your time if you get lots of long voicemails. Or, consider using a service that provides com­puter-generated transcriptions. Although less accurate, it often allows you to skim and is more affordable.

Scheduling. Booking follow-up appoint­ments during a session uses valuable clini­cal care time, but booking them outside of session can be laborious. As an alter­native, offer online scheduling through your electronic medical record (EMR) or a stand-alone service that allows you to retain control over what times you are available and how soon and far out patients can book. Be sure that only your current patients and, perhaps, colleagues (for scheduling phone calls) have access to your calendar, and make your cancellation policy explicitly clear.

Refill requests. Patients routinely opt-in for automatic prescription refill requests at their pharmacy, believing it is a no-brainer for convenience’s sake. However, for psychiatrists who prescribe only enough refills to last until the patient’s next appointment, these requests can become a burden because they can’t be ignored, but shouldn’t necessarily be acted upon either. Often, time is spent clarifying with the patient if a refill is really needed, and some­times—consciously or unconsciously— patients use automatic requests to bypass having to come in for an appointment. As an alternative, ask your patients to opt-out of auto-refill programs and to contact you directly if they are about to run out of medication.

Prescreening. An inordinate amount of time can be spent ensuring that a pro­spective patient is a good fit from a clini­cal, scheduling, and payment perspective. Save time by having a simple prescreen­ing process that conveys that you care, yet want to make sure certain criteria are met before you accept a patient into the prac­tice. This is where having a trained assis­tant or an electronic prescreening option can be useful.

Practice at large
Electronic charts. Common complaints about EMRs among users are they are clunky, convoluted, and slow, and the EMR “flow” does not match the provider’s. Although each extra click might only take a few sec­onds, the loss of rhythm is draining and leads to a dissatisfying, tired feeling. Be sure when selecting an EMR that the user experience is considered as important as functionality.

Billing statements. Write or print, fold, place in an envelope, put a stamp on the envelope, address the envelope, take it to the mailbox. Need more be said about how inefficient this is? Use your EMR, a biller, or billing software to send statements automatically.

Of course, make sure that any method that employs technology or outsourc­ing to a service has appropriate Health Insurance Portability and Accountability Act safeguards.

Nothing to lose but your chains
Although running a practice gives you some freedom in your schedule, with that comes the shackles of processing adminis­trative tasks that accompany clinical care. Finding ways to handle them more effi­ciently leads to improved job satisfaction and more time for patient care. You and your patients will both benefit.

Disclosure
Dr. Braslow is the founder of Luminello.com.

Pulling up charts. Phone tag. Prior authorizations. Rinse, repeat.

Reminiscent of the movie Groundhog Day, the daily grind in running a practice rarely gives way. Some days there are more faxes to process or paperwork to push than other days but, on the whole, there’s no escaping the tedium and time sink that these gloomy chores engender. In some practices, an assistant is hired to absorb the barrage; if not, it is left to the clinician to handle at the expense of time for patient care or life out­side practice.

Compounding matters, creating new systems to assuage these tasks can feel like a sisyphean endeavor, because the energy required to start likely will be more than what is already being expended. For example, switching from paper-based to electronic systems is tantalizing but incurs its own learning curve and has a financial cost. Likewise, hiring administrative help demands a significant investment in train­ing and, if patient contact is part of the job description, even more preparation is nec­essary because she (he) becomes the public face of the practice. Fortunately, both of these options pay dividends in the long run.

Yet, even with some basic strategies, what seems like the inevitability of inertia can be reshaped into a more efficient, less quotid­ian experience. Consider the following ways to streamline processes and eliminate time wasted and not spent on providing care.

Patient-specific tasks
Prior authorizations. The typical process is to have to call the insurance company to have the paperwork faxed, burning 5 to 15 minutes by being placed on hold or being transferred between departments. Instead, ask the patient to call the insurance com­pany (she [he] should get the phone num­ber from the pharmacist and have your fax number handy) and request the paper­work, with her (his) demographic informa­tion pre-filled in, be faxed to your office. If she is told by the insurance company that the doctor has to call, instruct the patient to explain it is merely a request to have forms faxed and to call again and speak with a different agent if necessary. If the patient pushes back, explaining that this helps keeps your rates lower or from having to bill for this specific time usually smooths things over.

Voicemails. Listening (and re-listening) to a long voicemail takes time. Although using a professional transcription service might be costly, it may be less expensive than your time if you get lots of long voicemails. Or, consider using a service that provides com­puter-generated transcriptions. Although less accurate, it often allows you to skim and is more affordable.

Scheduling. Booking follow-up appoint­ments during a session uses valuable clini­cal care time, but booking them outside of session can be laborious. As an alter­native, offer online scheduling through your electronic medical record (EMR) or a stand-alone service that allows you to retain control over what times you are available and how soon and far out patients can book. Be sure that only your current patients and, perhaps, colleagues (for scheduling phone calls) have access to your calendar, and make your cancellation policy explicitly clear.

Refill requests. Patients routinely opt-in for automatic prescription refill requests at their pharmacy, believing it is a no-brainer for convenience’s sake. However, for psychiatrists who prescribe only enough refills to last until the patient’s next appointment, these requests can become a burden because they can’t be ignored, but shouldn’t necessarily be acted upon either. Often, time is spent clarifying with the patient if a refill is really needed, and some­times—consciously or unconsciously— patients use automatic requests to bypass having to come in for an appointment. As an alternative, ask your patients to opt-out of auto-refill programs and to contact you directly if they are about to run out of medication.

Prescreening. An inordinate amount of time can be spent ensuring that a pro­spective patient is a good fit from a clini­cal, scheduling, and payment perspective. Save time by having a simple prescreen­ing process that conveys that you care, yet want to make sure certain criteria are met before you accept a patient into the prac­tice. This is where having a trained assis­tant or an electronic prescreening option can be useful.

Practice at large
Electronic charts. Common complaints about EMRs among users are they are clunky, convoluted, and slow, and the EMR “flow” does not match the provider’s. Although each extra click might only take a few sec­onds, the loss of rhythm is draining and leads to a dissatisfying, tired feeling. Be sure when selecting an EMR that the user experience is considered as important as functionality.

Billing statements. Write or print, fold, place in an envelope, put a stamp on the envelope, address the envelope, take it to the mailbox. Need more be said about how inefficient this is? Use your EMR, a biller, or billing software to send statements automatically.

Of course, make sure that any method that employs technology or outsourc­ing to a service has appropriate Health Insurance Portability and Accountability Act safeguards.

Nothing to lose but your chains
Although running a practice gives you some freedom in your schedule, with that comes the shackles of processing adminis­trative tasks that accompany clinical care. Finding ways to handle them more effi­ciently leads to improved job satisfaction and more time for patient care. You and your patients will both benefit.

Disclosure
Dr. Braslow is the founder of Luminello.com.

Pulling up charts. Phone tag. Prior authorizations. Rinse, repeat.

Reminiscent of the movie Groundhog Day, the daily grind in running a practice rarely gives way. Some days there are more faxes to process or paperwork to push than other days but, on the whole, there’s no escaping the tedium and time sink that these gloomy chores engender. In some practices, an assistant is hired to absorb the barrage; if not, it is left to the clinician to handle at the expense of time for patient care or life out­side practice.

Compounding matters, creating new systems to assuage these tasks can feel like a sisyphean endeavor, because the energy required to start likely will be more than what is already being expended. For example, switching from paper-based to electronic systems is tantalizing but incurs its own learning curve and has a financial cost. Likewise, hiring administrative help demands a significant investment in train­ing and, if patient contact is part of the job description, even more preparation is nec­essary because she (he) becomes the public face of the practice. Fortunately, both of these options pay dividends in the long run.

Yet, even with some basic strategies, what seems like the inevitability of inertia can be reshaped into a more efficient, less quotid­ian experience. Consider the following ways to streamline processes and eliminate time wasted and not spent on providing care.

Patient-specific tasks
Prior authorizations. The typical process is to have to call the insurance company to have the paperwork faxed, burning 5 to 15 minutes by being placed on hold or being transferred between departments. Instead, ask the patient to call the insurance com­pany (she [he] should get the phone num­ber from the pharmacist and have your fax number handy) and request the paper­work, with her (his) demographic informa­tion pre-filled in, be faxed to your office. If she is told by the insurance company that the doctor has to call, instruct the patient to explain it is merely a request to have forms faxed and to call again and speak with a different agent if necessary. If the patient pushes back, explaining that this helps keeps your rates lower or from having to bill for this specific time usually smooths things over.

Voicemails. Listening (and re-listening) to a long voicemail takes time. Although using a professional transcription service might be costly, it may be less expensive than your time if you get lots of long voicemails. Or, consider using a service that provides com­puter-generated transcriptions. Although less accurate, it often allows you to skim and is more affordable.

Scheduling. Booking follow-up appoint­ments during a session uses valuable clini­cal care time, but booking them outside of session can be laborious. As an alter­native, offer online scheduling through your electronic medical record (EMR) or a stand-alone service that allows you to retain control over what times you are available and how soon and far out patients can book. Be sure that only your current patients and, perhaps, colleagues (for scheduling phone calls) have access to your calendar, and make your cancellation policy explicitly clear.

Refill requests. Patients routinely opt-in for automatic prescription refill requests at their pharmacy, believing it is a no-brainer for convenience’s sake. However, for psychiatrists who prescribe only enough refills to last until the patient’s next appointment, these requests can become a burden because they can’t be ignored, but shouldn’t necessarily be acted upon either. Often, time is spent clarifying with the patient if a refill is really needed, and some­times—consciously or unconsciously— patients use automatic requests to bypass having to come in for an appointment. As an alternative, ask your patients to opt-out of auto-refill programs and to contact you directly if they are about to run out of medication.

Prescreening. An inordinate amount of time can be spent ensuring that a pro­spective patient is a good fit from a clini­cal, scheduling, and payment perspective. Save time by having a simple prescreen­ing process that conveys that you care, yet want to make sure certain criteria are met before you accept a patient into the prac­tice. This is where having a trained assis­tant or an electronic prescreening option can be useful.

Practice at large
Electronic charts. Common complaints about EMRs among users are they are clunky, convoluted, and slow, and the EMR “flow” does not match the provider’s. Although each extra click might only take a few sec­onds, the loss of rhythm is draining and leads to a dissatisfying, tired feeling. Be sure when selecting an EMR that the user experience is considered as important as functionality.

Billing statements. Write or print, fold, place in an envelope, put a stamp on the envelope, address the envelope, take it to the mailbox. Need more be said about how inefficient this is? Use your EMR, a biller, or billing software to send statements automatically.

Of course, make sure that any method that employs technology or outsourc­ing to a service has appropriate Health Insurance Portability and Accountability Act safeguards.

Nothing to lose but your chains
Although running a practice gives you some freedom in your schedule, with that comes the shackles of processing adminis­trative tasks that accompany clinical care. Finding ways to handle them more effi­ciently leads to improved job satisfaction and more time for patient care. You and your patients will both benefit.

Disclosure
Dr. Braslow is the founder of Luminello.com.

Many college students suffer from mental illness (Table 1),¹ which can have a negative impact on academic performance. Although psychotropic medications are an important part of treat­ment for many college students, the potential for misuse always is present. Drug misuse occurs when patients use medications for reasons inconsistent with legal or medical guidelines.² For example, patients may take a medica­tion that has not been prescribed for them or in a manner that is inconsis­tent with the prescriber’s instructions, including administration with other substances.³

Misuse of psychotropic drugs is prevalent among college students. A study of 14,175 students from 26 campuses reported that 14.7% of students taking a psychotropic are doing so without a prescription, including stimu­lants (52.6%), anxiolytics (38.4%), and antidepressants (17.4%).⁴ Another study states that more than one-third of responders reported misuse of >1 class of medication.⁵

Psychotropic misuse is concerning because it increases the risk of adverse events. Nearly one-half of medication errors are associated with writing and dispensing the prescription, which means that prescribers can work to reduce these errors.⁶ However, nonadherence, prescription misuse, and failure to disclose use of over-the-counter drugs, illicit drugs, and herbal products makes preventing most adverse events difficult, if not impossible, for prescribers.^7,8

Psychotropic drug misuse among college students is highly variable and unpredictable. Students misuse medications, including stimulants, ben­zodiazepines, and antidepressants, for a variety of reasons, such as study enhancement, experimentation, intoxication, self-medication, relaxation, and stress management.⁸ One survey reported that >70% of students taking a psychotropic medication took it with alcohol or another illicit drug.⁹

However, <20% of those using a psy­chotropic medication with alcohol or other illicit drugs told their health care provider(s),⁹ making it impossible for cli­nicians to predict a patient’s risk of drug− drug interactions and subsequent adverse events. Additionally, additive effects could occur¹⁰ and changes in a patient’s presenta­tion could be caused by a reaction to a com­bination of medications, rather than a new symptom of mental illness.

This article will examine common issues associated with drug misuse among col­lege-age students and review prevention strategies (Table 2).

Stimulants
Stimulants have the highest rate of diver­sion; 61.7% of college students prescribed stimulants have shared or sold their medi­cation.¹¹ A survey of 115 students from 2 universities reported that the most common reason for stimulant misuse was to enhance academic performance.¹² The same survey showed that some students take stimulants with Cannabis (17%) and alcohol (30%).¹² As a result, in addition to lowering grade point average (GPA) and other academic difficul­ties,¹³ students misusing stimulants are at risk of drug interactions.¹⁴

It is critical to ascertain the route of drug administration, because non-oral routes, including crushing then snorting or inject­ing, are associated with additional health concerns, such as accidental death or blood-borne illnesses.^15,16 Cardiac adverse effects of stimulants include hypertension, vasospasm, tachycardia, and dysrhythmia; psychiatric and other effects include sero­tonin syndrome, hallucinations, anxiety, paranoia, seizures, tics, hyperthermia, and tremor.¹⁷ Health care providers prescrib­ing or caring for people taking a stimulant should monitor for these potential effects.

The risk of switch to mania might not be apparent to those who prescribe stimulants or to young people who take non-prescribed stimulants for academic enhancement or to achieve medication-induced euphoria. Adolescent stimulant use is associated with symptoms of early-onset bipolar disorder in patients who have attention-deficit/ hyperactivity disorder (ADHD) and undi­agnosed bipolarity.¹⁸

The cardiovascular risk associated with stimulant use is debatable. Although sev­eral studies have been conducted,^19-21 meth­odological factors limit their applicability. To minimize potential risks, several precau­tions should be taken before prescribing a stimulant to treat ADHD.

First, obtain a detailed personal and family medical history, asking about pos­sible cardiovascular disease. Second, care­fully scrutinize the patient’s cardiovascular system during the physical exam. Third, consider additional testing, such as an elec­trocardiogram, if the patient’s history or physical exam indicates possible risk.²²

As a prescriber, you should be aware of the prevalence of stimulant use among students with and without ADHD, includ­ing those who could be feigning ADHD symptoms.¹⁵ Diversion could occur through sharing medications or selling them to friends and family.¹¹ It also is possible that these medications may be used with other illicit substances, such as Cannabis, ecstasy, cocaine, and opiates.²³ Students also could misuse stimulants by taking more than the prescribed dosage.²⁴

Risk factors for misuse of stimulants include: heavy alcohol use, previous illicit drug use, white race, fraternity or sorority membership, low GPA, increased hyperac­tivity symptoms, and attendance at a com­petitive college or university.^25-27

Benzodiazepines
Misuse of benzodiazepine is a significant component of prescription drug abuse and often occurs with other medications and alcohol.²⁸ Additional methods of mis­use include increased dosage and non-oral routes of administration.²⁹

A 2001 national survey reported that 7.8% of college students have misused benzodiaz­epines.²³ Common characteristics of benzo­diazepine abusers include young age, male sex, personality characteristics of impulsiv­ity and hopelessness, and abuse of other drugs, including cocaine and methadone.^28,29

Benzodiazepines are prescribed for their anxiolytic and hypnotic properties and stu­dents could use these drugs with other agents to augment the euphoric effects or diminish withdrawal symptoms.³⁰ Patients taking ben­zodiazepines for anxiety might self-medicate with alcohol, which increases sedation and depression, and can contribute to the risk for respiratory depression.¹⁰ Misuse of benzodi­azepines can result in cognitive and psycho­motor impairment and increase the risk of accidents and overdose.^29,31

Although overdose with monotherapy is rare, the risk increases when a benzodiaz­epine is used with alcohol¹⁰ or another respi­ratory depressants, such as opioids, because combination use can produce additive effects.²⁸ You should therefore avoid prescrib­ing benzodiazepines to patients who have a history of significant substance abuse and consider using alternative, non-addictive agents, such as selective serotonin reuptake inhibitors, or non-pharmaceutical treatment when such patients present with an anxiety disorder. The risk of adverse effects of ben­zodiazepines can be reduced by limiting the dosing and the duration of the treatment, and by using longer-acting rather than the more addictive, shorter-acting, agents.

Antidepressants
Health care providers should be aware that, despite the relative absence of physically addictive properties, antidepressants from most classes are abusable agents sought by young people for non-medical use. In particular, the literature highlights mono­amine oxidase inhibitors (MAOIs), tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and bupropion as the antidepressants most likely to be misused for their amphetamine-like euphoric effects or serotonin-induced dissociative effects.³² However, compared with other drug classes discussed in this article, the rate of antide­pressant misuse is relatively low among col­lege students.

Regardless of the antidepressant selected, clinicians should be concerned about alcohol use among college-age patients. Persons with depression are at increased risk of alcohol­ism compared with the general population.³³ This combination can increase depressive symptoms and sedation, and decrease coor­dination, judgment, and reaction time.³³

Excessive alcohol use can increase the risk of seizures in patients taking antidepressants such as buproprion.³⁴ Employ caution when prescribing bupropion to patients who have a predisposing clini­cal factor that increases seizure risk, such as excessive alcohol use and abrupt ces­sation, use of other medications that may lower seizure threshold (eg, theophylline, amphetamines, phenothiazines), and a his­tory of head trauma.³⁴

To minimize the risk of seizures with bupropion, titrate up the dosage slowly. Furthermore, using a low dosage during dual therapy for antidepressant augmenta­tion further decreases the risk of seizure.³⁵ For these reasons, we recommend that you avoid bupropion in patients who are at risk of binge drinking, and give careful consid­eration to providing alternative therapies for them.

Prescribers and patients should also keep in mind that hypertensive crisis could occur if MAOIs are combined with certain types of alcoholic beverages containing tyramine, including some wines and draft beer.³³

How you can identify and prevent misuse
Careful communication between health care provider and patient that is necessary to minimize the risk of adverse drug events with psychotropic medications often is lack­ing. For example, 24% of study college-age participants did not remember if their physi­cian provided a diagnosis and 28.8% could not recall being informed about side effects and, perhaps as a result, many students did not take their medications as prescribed.⁹

Further, prescribers should ask college-age patients who are undergoing stimulant treatment if they believe that they are being adequately treated. They should inquire about how they are taking their medica­tions.¹¹ These questions can lead to discus­sion of the need for these medications and reevaluation of their perceived indication.¹¹

Remind patients to take their medication only as directed.³⁶ Highlight the need to:
   • store medications in a discreet location
   • properly dispose of unused medications
   • keep tabs on the quantity of pills
   • know how to resist requests for diver­sion from peers.

The Substance Abuse and Mental Health Services Administration offers additional useful strategies,³⁷ and pharmacists also can be partners in substance use education and prevention.³⁸ These are examples of how health care providers can take an active role in providing patients with a thorough and detailed understanding of (1) their condi­tions and (2) their prescribed medications to improve efficacy and safety while pre­venting misuse.⁸

A study found that the most common method of obtaining these medications without a prescription is acquiring them from peers; 54% of undergraduate patients with stimulant prescriptions have been approached by peers to give, trade, or sell their drugs.²⁵ Other methods include pur­chasing medications online or faking pre­scriptions.³⁹ Health care providers should remind patients of the legal ramifications of sharing or selling their prescribed medi­cations. Finally, providers must be vigilant for students who may feign symptoms to obtain a prescription:
   • be wary if symptom presentation sounds too “textbook”
   • seek collateral history from family. Adults with ADHD should have shown symptoms during childhood
   • use external verification such as neuropsychological testing for ADHD. A neuropsychologist can detect deception by analyzing the pattern of responses to questions.

Patient assessment is a key step to in pre­venting abuse of psychotropic medications. Gentle inquiry about school-related stress and other risk factors for misuse can help practitioners determine if students are at risk of diversion and if additional screening is necessary.

In response to these issues, Stone and Merlo⁸ have suggested that, in addition to the educational programs held on col­lege campuses on alcohol, illicit drugs, and prescription painkillers, patients should be better informed on the appropriate use of prescription psychiatric medications, instructed to avoid sharing with family and friends, and assessed for abuse risk at regu­lar intervals.

To further protect patients from adverse outcomes during treatment, you can employ conservative and safe prescribing techniques. One strategy might be to keep a personal formulary that lists key medica­tions you use in everyday practice, includ­ing knowledge about each drug’s dosage, potential adverse effects, key warnings, and drug−drug interactions.⁴⁰

Furthermore, maintain healthy caution about newly approved medications and carefully consider how they measure up to existing agents—in other words, prac­tice evidence-based medicine, particu­larly when students request a particular agent.^40,41 Prescribers should evaluate the risk of abuse before prescribing and attempt to prevent misuse by limiting quantities and minimizing polypharmacy.

Last, pharmacists can be key allies for consultation and appropriate medication selection.

 
Bottom Line
Psychotropic medications are necessary to treat the variety of conditions—anxiety, attention-deficit/hyperactivity disorder, depression, and panic disorder—common among college students. However, students are at risk of combining their prescribed medications with other medications, drugs, and alcohol or could sell or share their medication with peers. Proper counseling and identification of risk factors can be important tools for preventing such events.

Related Resources
• American College Health Association-National College Health Assessment. www.acha-ncha.org.
• Schwartz VI. College mental health: How to provide care for students in need. Current Psychiatry. 2011;10(12):22-29.

Drug Brand Names
Bupropion • Wellbutrin, Zyban
Methadone • Methadose, Dolophine
Theophylline • Theo-24, Theolair, Uniphyl

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Many college students suffer from mental illness (Table 1),¹ which can have a negative impact on academic performance. Although psychotropic medications are an important part of treat­ment for many college students, the potential for misuse always is present. Drug misuse occurs when patients use medications for reasons inconsistent with legal or medical guidelines.² For example, patients may take a medica­tion that has not been prescribed for them or in a manner that is inconsis­tent with the prescriber’s instructions, including administration with other substances.³

Misuse of psychotropic drugs is prevalent among college students. A study of 14,175 students from 26 campuses reported that 14.7% of students taking a psychotropic are doing so without a prescription, including stimu­lants (52.6%), anxiolytics (38.4%), and antidepressants (17.4%).⁴ Another study states that more than one-third of responders reported misuse of >1 class of medication.⁵

Psychotropic misuse is concerning because it increases the risk of adverse events. Nearly one-half of medication errors are associated with writing and dispensing the prescription, which means that prescribers can work to reduce these errors.⁶ However, nonadherence, prescription misuse, and failure to disclose use of over-the-counter drugs, illicit drugs, and herbal products makes preventing most adverse events difficult, if not impossible, for prescribers.^7,8

Psychotropic drug misuse among college students is highly variable and unpredictable. Students misuse medications, including stimulants, ben­zodiazepines, and antidepressants, for a variety of reasons, such as study enhancement, experimentation, intoxication, self-medication, relaxation, and stress management.⁸ One survey reported that >70% of students taking a psychotropic medication took it with alcohol or another illicit drug.⁹

However, <20% of those using a psy­chotropic medication with alcohol or other illicit drugs told their health care provider(s),⁹ making it impossible for cli­nicians to predict a patient’s risk of drug− drug interactions and subsequent adverse events. Additionally, additive effects could occur¹⁰ and changes in a patient’s presenta­tion could be caused by a reaction to a com­bination of medications, rather than a new symptom of mental illness.

This article will examine common issues associated with drug misuse among col­lege-age students and review prevention strategies (Table 2).

Stimulants
Stimulants have the highest rate of diver­sion; 61.7% of college students prescribed stimulants have shared or sold their medi­cation.¹¹ A survey of 115 students from 2 universities reported that the most common reason for stimulant misuse was to enhance academic performance.¹² The same survey showed that some students take stimulants with Cannabis (17%) and alcohol (30%).¹² As a result, in addition to lowering grade point average (GPA) and other academic difficul­ties,¹³ students misusing stimulants are at risk of drug interactions.¹⁴

It is critical to ascertain the route of drug administration, because non-oral routes, including crushing then snorting or inject­ing, are associated with additional health concerns, such as accidental death or blood-borne illnesses.^15,16 Cardiac adverse effects of stimulants include hypertension, vasospasm, tachycardia, and dysrhythmia; psychiatric and other effects include sero­tonin syndrome, hallucinations, anxiety, paranoia, seizures, tics, hyperthermia, and tremor.¹⁷ Health care providers prescrib­ing or caring for people taking a stimulant should monitor for these potential effects.

The risk of switch to mania might not be apparent to those who prescribe stimulants or to young people who take non-prescribed stimulants for academic enhancement or to achieve medication-induced euphoria. Adolescent stimulant use is associated with symptoms of early-onset bipolar disorder in patients who have attention-deficit/ hyperactivity disorder (ADHD) and undi­agnosed bipolarity.¹⁸

The cardiovascular risk associated with stimulant use is debatable. Although sev­eral studies have been conducted,^19-21 meth­odological factors limit their applicability. To minimize potential risks, several precau­tions should be taken before prescribing a stimulant to treat ADHD.

First, obtain a detailed personal and family medical history, asking about pos­sible cardiovascular disease. Second, care­fully scrutinize the patient’s cardiovascular system during the physical exam. Third, consider additional testing, such as an elec­trocardiogram, if the patient’s history or physical exam indicates possible risk.²²

As a prescriber, you should be aware of the prevalence of stimulant use among students with and without ADHD, includ­ing those who could be feigning ADHD symptoms.¹⁵ Diversion could occur through sharing medications or selling them to friends and family.¹¹ It also is possible that these medications may be used with other illicit substances, such as Cannabis, ecstasy, cocaine, and opiates.²³ Students also could misuse stimulants by taking more than the prescribed dosage.²⁴

Risk factors for misuse of stimulants include: heavy alcohol use, previous illicit drug use, white race, fraternity or sorority membership, low GPA, increased hyperac­tivity symptoms, and attendance at a com­petitive college or university.^25-27

Benzodiazepines
Misuse of benzodiazepine is a significant component of prescription drug abuse and often occurs with other medications and alcohol.²⁸ Additional methods of mis­use include increased dosage and non-oral routes of administration.²⁹

A 2001 national survey reported that 7.8% of college students have misused benzodiaz­epines.²³ Common characteristics of benzo­diazepine abusers include young age, male sex, personality characteristics of impulsiv­ity and hopelessness, and abuse of other drugs, including cocaine and methadone.^28,29

Benzodiazepines are prescribed for their anxiolytic and hypnotic properties and stu­dents could use these drugs with other agents to augment the euphoric effects or diminish withdrawal symptoms.³⁰ Patients taking ben­zodiazepines for anxiety might self-medicate with alcohol, which increases sedation and depression, and can contribute to the risk for respiratory depression.¹⁰ Misuse of benzodi­azepines can result in cognitive and psycho­motor impairment and increase the risk of accidents and overdose.^29,31

Although overdose with monotherapy is rare, the risk increases when a benzodiaz­epine is used with alcohol¹⁰ or another respi­ratory depressants, such as opioids, because combination use can produce additive effects.²⁸ You should therefore avoid prescrib­ing benzodiazepines to patients who have a history of significant substance abuse and consider using alternative, non-addictive agents, such as selective serotonin reuptake inhibitors, or non-pharmaceutical treatment when such patients present with an anxiety disorder. The risk of adverse effects of ben­zodiazepines can be reduced by limiting the dosing and the duration of the treatment, and by using longer-acting rather than the more addictive, shorter-acting, agents.

Antidepressants
Health care providers should be aware that, despite the relative absence of physically addictive properties, antidepressants from most classes are abusable agents sought by young people for non-medical use. In particular, the literature highlights mono­amine oxidase inhibitors (MAOIs), tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and bupropion as the antidepressants most likely to be misused for their amphetamine-like euphoric effects or serotonin-induced dissociative effects.³² However, compared with other drug classes discussed in this article, the rate of antide­pressant misuse is relatively low among col­lege students.

Regardless of the antidepressant selected, clinicians should be concerned about alcohol use among college-age patients. Persons with depression are at increased risk of alcohol­ism compared with the general population.³³ This combination can increase depressive symptoms and sedation, and decrease coor­dination, judgment, and reaction time.³³

Excessive alcohol use can increase the risk of seizures in patients taking antidepressants such as buproprion.³⁴ Employ caution when prescribing bupropion to patients who have a predisposing clini­cal factor that increases seizure risk, such as excessive alcohol use and abrupt ces­sation, use of other medications that may lower seizure threshold (eg, theophylline, amphetamines, phenothiazines), and a his­tory of head trauma.³⁴

To minimize the risk of seizures with bupropion, titrate up the dosage slowly. Furthermore, using a low dosage during dual therapy for antidepressant augmenta­tion further decreases the risk of seizure.³⁵ For these reasons, we recommend that you avoid bupropion in patients who are at risk of binge drinking, and give careful consid­eration to providing alternative therapies for them.

Prescribers and patients should also keep in mind that hypertensive crisis could occur if MAOIs are combined with certain types of alcoholic beverages containing tyramine, including some wines and draft beer.³³

How you can identify and prevent misuse
Careful communication between health care provider and patient that is necessary to minimize the risk of adverse drug events with psychotropic medications often is lack­ing. For example, 24% of study college-age participants did not remember if their physi­cian provided a diagnosis and 28.8% could not recall being informed about side effects and, perhaps as a result, many students did not take their medications as prescribed.⁹

Further, prescribers should ask college-age patients who are undergoing stimulant treatment if they believe that they are being adequately treated. They should inquire about how they are taking their medica­tions.¹¹ These questions can lead to discus­sion of the need for these medications and reevaluation of their perceived indication.¹¹

Remind patients to take their medication only as directed.³⁶ Highlight the need to:
   • store medications in a discreet location
   • properly dispose of unused medications
   • keep tabs on the quantity of pills
   • know how to resist requests for diver­sion from peers.

The Substance Abuse and Mental Health Services Administration offers additional useful strategies,³⁷ and pharmacists also can be partners in substance use education and prevention.³⁸ These are examples of how health care providers can take an active role in providing patients with a thorough and detailed understanding of (1) their condi­tions and (2) their prescribed medications to improve efficacy and safety while pre­venting misuse.⁸

A study found that the most common method of obtaining these medications without a prescription is acquiring them from peers; 54% of undergraduate patients with stimulant prescriptions have been approached by peers to give, trade, or sell their drugs.²⁵ Other methods include pur­chasing medications online or faking pre­scriptions.³⁹ Health care providers should remind patients of the legal ramifications of sharing or selling their prescribed medi­cations. Finally, providers must be vigilant for students who may feign symptoms to obtain a prescription:
   • be wary if symptom presentation sounds too “textbook”
   • seek collateral history from family. Adults with ADHD should have shown symptoms during childhood
   • use external verification such as neuropsychological testing for ADHD. A neuropsychologist can detect deception by analyzing the pattern of responses to questions.

Patient assessment is a key step to in pre­venting abuse of psychotropic medications. Gentle inquiry about school-related stress and other risk factors for misuse can help practitioners determine if students are at risk of diversion and if additional screening is necessary.

In response to these issues, Stone and Merlo⁸ have suggested that, in addition to the educational programs held on col­lege campuses on alcohol, illicit drugs, and prescription painkillers, patients should be better informed on the appropriate use of prescription psychiatric medications, instructed to avoid sharing with family and friends, and assessed for abuse risk at regu­lar intervals.

To further protect patients from adverse outcomes during treatment, you can employ conservative and safe prescribing techniques. One strategy might be to keep a personal formulary that lists key medica­tions you use in everyday practice, includ­ing knowledge about each drug’s dosage, potential adverse effects, key warnings, and drug−drug interactions.⁴⁰

Furthermore, maintain healthy caution about newly approved medications and carefully consider how they measure up to existing agents—in other words, prac­tice evidence-based medicine, particu­larly when students request a particular agent.^40,41 Prescribers should evaluate the risk of abuse before prescribing and attempt to prevent misuse by limiting quantities and minimizing polypharmacy.

Last, pharmacists can be key allies for consultation and appropriate medication selection.

 
Bottom Line
Psychotropic medications are necessary to treat the variety of conditions—anxiety, attention-deficit/hyperactivity disorder, depression, and panic disorder—common among college students. However, students are at risk of combining their prescribed medications with other medications, drugs, and alcohol or could sell or share their medication with peers. Proper counseling and identification of risk factors can be important tools for preventing such events.

Related Resources
• American College Health Association-National College Health Assessment. www.acha-ncha.org.
• Schwartz VI. College mental health: How to provide care for students in need. Current Psychiatry. 2011;10(12):22-29.

Drug Brand Names
Bupropion • Wellbutrin, Zyban
Methadone • Methadose, Dolophine
Theophylline • Theo-24, Theolair, Uniphyl

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Many college students suffer from mental illness (Table 1),¹ which can have a negative impact on academic performance. Although psychotropic medications are an important part of treat­ment for many college students, the potential for misuse always is present. Drug misuse occurs when patients use medications for reasons inconsistent with legal or medical guidelines.² For example, patients may take a medica­tion that has not been prescribed for them or in a manner that is inconsis­tent with the prescriber’s instructions, including administration with other substances.³

Misuse of psychotropic drugs is prevalent among college students. A study of 14,175 students from 26 campuses reported that 14.7% of students taking a psychotropic are doing so without a prescription, including stimu­lants (52.6%), anxiolytics (38.4%), and antidepressants (17.4%).⁴ Another study states that more than one-third of responders reported misuse of >1 class of medication.⁵

Psychotropic misuse is concerning because it increases the risk of adverse events. Nearly one-half of medication errors are associated with writing and dispensing the prescription, which means that prescribers can work to reduce these errors.⁶ However, nonadherence, prescription misuse, and failure to disclose use of over-the-counter drugs, illicit drugs, and herbal products makes preventing most adverse events difficult, if not impossible, for prescribers.^7,8

Psychotropic drug misuse among college students is highly variable and unpredictable. Students misuse medications, including stimulants, ben­zodiazepines, and antidepressants, for a variety of reasons, such as study enhancement, experimentation, intoxication, self-medication, relaxation, and stress management.⁸ One survey reported that >70% of students taking a psychotropic medication took it with alcohol or another illicit drug.⁹

However, <20% of those using a psy­chotropic medication with alcohol or other illicit drugs told their health care provider(s),⁹ making it impossible for cli­nicians to predict a patient’s risk of drug− drug interactions and subsequent adverse events. Additionally, additive effects could occur¹⁰ and changes in a patient’s presenta­tion could be caused by a reaction to a com­bination of medications, rather than a new symptom of mental illness.

This article will examine common issues associated with drug misuse among col­lege-age students and review prevention strategies (Table 2).

Stimulants
Stimulants have the highest rate of diver­sion; 61.7% of college students prescribed stimulants have shared or sold their medi­cation.¹¹ A survey of 115 students from 2 universities reported that the most common reason for stimulant misuse was to enhance academic performance.¹² The same survey showed that some students take stimulants with Cannabis (17%) and alcohol (30%).¹² As a result, in addition to lowering grade point average (GPA) and other academic difficul­ties,¹³ students misusing stimulants are at risk of drug interactions.¹⁴

It is critical to ascertain the route of drug administration, because non-oral routes, including crushing then snorting or inject­ing, are associated with additional health concerns, such as accidental death or blood-borne illnesses.^15,16 Cardiac adverse effects of stimulants include hypertension, vasospasm, tachycardia, and dysrhythmia; psychiatric and other effects include sero­tonin syndrome, hallucinations, anxiety, paranoia, seizures, tics, hyperthermia, and tremor.¹⁷ Health care providers prescrib­ing or caring for people taking a stimulant should monitor for these potential effects.

The risk of switch to mania might not be apparent to those who prescribe stimulants or to young people who take non-prescribed stimulants for academic enhancement or to achieve medication-induced euphoria. Adolescent stimulant use is associated with symptoms of early-onset bipolar disorder in patients who have attention-deficit/ hyperactivity disorder (ADHD) and undi­agnosed bipolarity.¹⁸

The cardiovascular risk associated with stimulant use is debatable. Although sev­eral studies have been conducted,^19-21 meth­odological factors limit their applicability. To minimize potential risks, several precau­tions should be taken before prescribing a stimulant to treat ADHD.

First, obtain a detailed personal and family medical history, asking about pos­sible cardiovascular disease. Second, care­fully scrutinize the patient’s cardiovascular system during the physical exam. Third, consider additional testing, such as an elec­trocardiogram, if the patient’s history or physical exam indicates possible risk.²²

As a prescriber, you should be aware of the prevalence of stimulant use among students with and without ADHD, includ­ing those who could be feigning ADHD symptoms.¹⁵ Diversion could occur through sharing medications or selling them to friends and family.¹¹ It also is possible that these medications may be used with other illicit substances, such as Cannabis, ecstasy, cocaine, and opiates.²³ Students also could misuse stimulants by taking more than the prescribed dosage.²⁴

Risk factors for misuse of stimulants include: heavy alcohol use, previous illicit drug use, white race, fraternity or sorority membership, low GPA, increased hyperac­tivity symptoms, and attendance at a com­petitive college or university.^25-27

Benzodiazepines
Misuse of benzodiazepine is a significant component of prescription drug abuse and often occurs with other medications and alcohol.²⁸ Additional methods of mis­use include increased dosage and non-oral routes of administration.²⁹

A 2001 national survey reported that 7.8% of college students have misused benzodiaz­epines.²³ Common characteristics of benzo­diazepine abusers include young age, male sex, personality characteristics of impulsiv­ity and hopelessness, and abuse of other drugs, including cocaine and methadone.^28,29

Benzodiazepines are prescribed for their anxiolytic and hypnotic properties and stu­dents could use these drugs with other agents to augment the euphoric effects or diminish withdrawal symptoms.³⁰ Patients taking ben­zodiazepines for anxiety might self-medicate with alcohol, which increases sedation and depression, and can contribute to the risk for respiratory depression.¹⁰ Misuse of benzodi­azepines can result in cognitive and psycho­motor impairment and increase the risk of accidents and overdose.^29,31

Although overdose with monotherapy is rare, the risk increases when a benzodiaz­epine is used with alcohol¹⁰ or another respi­ratory depressants, such as opioids, because combination use can produce additive effects.²⁸ You should therefore avoid prescrib­ing benzodiazepines to patients who have a history of significant substance abuse and consider using alternative, non-addictive agents, such as selective serotonin reuptake inhibitors, or non-pharmaceutical treatment when such patients present with an anxiety disorder. The risk of adverse effects of ben­zodiazepines can be reduced by limiting the dosing and the duration of the treatment, and by using longer-acting rather than the more addictive, shorter-acting, agents.

Antidepressants
Health care providers should be aware that, despite the relative absence of physically addictive properties, antidepressants from most classes are abusable agents sought by young people for non-medical use. In particular, the literature highlights mono­amine oxidase inhibitors (MAOIs), tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and bupropion as the antidepressants most likely to be misused for their amphetamine-like euphoric effects or serotonin-induced dissociative effects.³² However, compared with other drug classes discussed in this article, the rate of antide­pressant misuse is relatively low among col­lege students.

Regardless of the antidepressant selected, clinicians should be concerned about alcohol use among college-age patients. Persons with depression are at increased risk of alcohol­ism compared with the general population.³³ This combination can increase depressive symptoms and sedation, and decrease coor­dination, judgment, and reaction time.³³

Excessive alcohol use can increase the risk of seizures in patients taking antidepressants such as buproprion.³⁴ Employ caution when prescribing bupropion to patients who have a predisposing clini­cal factor that increases seizure risk, such as excessive alcohol use and abrupt ces­sation, use of other medications that may lower seizure threshold (eg, theophylline, amphetamines, phenothiazines), and a his­tory of head trauma.³⁴

To minimize the risk of seizures with bupropion, titrate up the dosage slowly. Furthermore, using a low dosage during dual therapy for antidepressant augmenta­tion further decreases the risk of seizure.³⁵ For these reasons, we recommend that you avoid bupropion in patients who are at risk of binge drinking, and give careful consid­eration to providing alternative therapies for them.

Prescribers and patients should also keep in mind that hypertensive crisis could occur if MAOIs are combined with certain types of alcoholic beverages containing tyramine, including some wines and draft beer.³³

How you can identify and prevent misuse
Careful communication between health care provider and patient that is necessary to minimize the risk of adverse drug events with psychotropic medications often is lack­ing. For example, 24% of study college-age participants did not remember if their physi­cian provided a diagnosis and 28.8% could not recall being informed about side effects and, perhaps as a result, many students did not take their medications as prescribed.⁹

Further, prescribers should ask college-age patients who are undergoing stimulant treatment if they believe that they are being adequately treated. They should inquire about how they are taking their medica­tions.¹¹ These questions can lead to discus­sion of the need for these medications and reevaluation of their perceived indication.¹¹

Remind patients to take their medication only as directed.³⁶ Highlight the need to:
   • store medications in a discreet location
   • properly dispose of unused medications
   • keep tabs on the quantity of pills
   • know how to resist requests for diver­sion from peers.

The Substance Abuse and Mental Health Services Administration offers additional useful strategies,³⁷ and pharmacists also can be partners in substance use education and prevention.³⁸ These are examples of how health care providers can take an active role in providing patients with a thorough and detailed understanding of (1) their condi­tions and (2) their prescribed medications to improve efficacy and safety while pre­venting misuse.⁸

A study found that the most common method of obtaining these medications without a prescription is acquiring them from peers; 54% of undergraduate patients with stimulant prescriptions have been approached by peers to give, trade, or sell their drugs.²⁵ Other methods include pur­chasing medications online or faking pre­scriptions.³⁹ Health care providers should remind patients of the legal ramifications of sharing or selling their prescribed medi­cations. Finally, providers must be vigilant for students who may feign symptoms to obtain a prescription:
   • be wary if symptom presentation sounds too “textbook”
   • seek collateral history from family. Adults with ADHD should have shown symptoms during childhood
   • use external verification such as neuropsychological testing for ADHD. A neuropsychologist can detect deception by analyzing the pattern of responses to questions.

Patient assessment is a key step to in pre­venting abuse of psychotropic medications. Gentle inquiry about school-related stress and other risk factors for misuse can help practitioners determine if students are at risk of diversion and if additional screening is necessary.

In response to these issues, Stone and Merlo⁸ have suggested that, in addition to the educational programs held on col­lege campuses on alcohol, illicit drugs, and prescription painkillers, patients should be better informed on the appropriate use of prescription psychiatric medications, instructed to avoid sharing with family and friends, and assessed for abuse risk at regu­lar intervals.

To further protect patients from adverse outcomes during treatment, you can employ conservative and safe prescribing techniques. One strategy might be to keep a personal formulary that lists key medica­tions you use in everyday practice, includ­ing knowledge about each drug’s dosage, potential adverse effects, key warnings, and drug−drug interactions.⁴⁰

Furthermore, maintain healthy caution about newly approved medications and carefully consider how they measure up to existing agents—in other words, prac­tice evidence-based medicine, particu­larly when students request a particular agent.^40,41 Prescribers should evaluate the risk of abuse before prescribing and attempt to prevent misuse by limiting quantities and minimizing polypharmacy.

Last, pharmacists can be key allies for consultation and appropriate medication selection.

 
Bottom Line
Psychotropic medications are necessary to treat the variety of conditions—anxiety, attention-deficit/hyperactivity disorder, depression, and panic disorder—common among college students. However, students are at risk of combining their prescribed medications with other medications, drugs, and alcohol or could sell or share their medication with peers. Proper counseling and identification of risk factors can be important tools for preventing such events.

Related Resources
• American College Health Association-National College Health Assessment. www.acha-ncha.org.
• Schwartz VI. College mental health: How to provide care for students in need. Current Psychiatry. 2011;10(12):22-29.

Drug Brand Names
Bupropion • Wellbutrin, Zyban
Methadone • Methadose, Dolophine
Theophylline • Theo-24, Theolair, Uniphyl

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Little is known about people who write to criminals incar­cerated for a violent crime. However, existence of Web sites such as WriteAPrisoner.com, Meet-An-Inmate.com, and PrisonPenPals.com suggests some appetite among the public for corresponding with the incarcerated. Writers of letters might be drawn to the “bad boy” image of prison­ers. Furthermore, much has been written of the willingness of some battered women to remain in an abusive domestic relationship, leading them to correspond with their abusers even after those abusers are incarcerated.^1,2

To our knowledge, no examination of letters written to a mass murderer has been published. Therefore, we catego­rized and analyzed 784 letters sent to a high-profile male mass murderer whose crime was committed during the past decade. Here is a description of the study and what we found, as well as discussion of how our findings might offer utility in a psychiatric practice.

Goals of the study
We hypothesized that a large percentage of those letters could be classified as “Romantic,” given the lay percep­tion that it is women who write to mass murderers. We also sought to evaluate follow-up letters sent by these writers to test the assumption that their individual goals would be con­stant over time.

We performed this study in the hope that the research could assist psychiatric practitioners in treating patients who seek to associate with a violent person (see “Treatment considerations,”). We thought it might be helpful for practitioners to get a better understanding of the nature of people who write to a violent offender or express a desire to do so.

Methods of study
Two authors (R.S.J. and D.P.G.) evaluated 819 letters that had been written by non-incarcerated, non-family adults to 1 mass murderer. The initial letter and follow-up letters written by each unique writer (n = 333) were categorized as follows:
   • state or country from which the letter was sent
   • age
   • sex
   • number of letters sent by each writer
   • whether a photograph was enclosed
   • whether additional items were enclosed (eg, gifts, drawings)
   • whether the letter was rejected by prison authorities
   • the writer’s purpose.

The study was approved by the insti­tutional review board of Baylor College of Medicine.

Letters were assigned to 1 of 5 categories:

Acquaintance letters sought ongoing cor­respondence relationship with the murderer. They focused largely on conveying informa­tion about the writer.

Show of support letters also sought an ongoing correspondence relationship with the murderer, but instead focused on him, not the writer.

Romance letters used words that conveyed romantic or non-platonic affection.

Spiritual letters gave advice to the mur­derer with a religious tone.

Words of wisdom letters offered advice but lacked a religious tone.

Given the nonstandardized nature of categorization and the lack of a formal questionnaire, we were unable to perform an exploratory factor analysis on our cat­egorizations. Inter-rater reliability of letter categorization was 0.79.

Results: Writer profiles, purpose for writing
In all, we reviewed 819 letters:
   • Thirty-five letters were excluded because they were written by family mem­bers, children, or other prisoners
   • Of the remaining 784 letters, there were 333 unique writers
   • Two-hundred sixty letters were writ­ten by women, 61 by men; 2 were co-written by both sexes; sex could not be determined for 10.

Women were more likely than men to write a letter (P = .014) and to write ≥3 letters (P = .001). The age of the writer was deter­mined for 117 (35.1%) letters; mean age was 27.8 (± 8.9) years (range, 18 to 59 years).

The purpose of the letters differed by sex (P < .001) but not by the writer’s age (P = .058). Women were more likely than men to write letters categorized as “Acquaintance,” “Romance,” and “Show of support”; in con­trast, men were more likely than women to write a letter categorized as “Spiritual”  (Table 1). Approximately 95% of let­ters were handwritten. Letters averaged 3 pages (range, 1 to 16 pages).

Two-hundred sixteen writers wrote a single letter; 53 wrote 2 letters; 18 wrote 3 let­ters; 11 wrote 4 letters; 30 wrote 5 to 10 let­ters; and 9 wrote 11 to 43 letters. The purpose of follow-up letters was associated with the age of the writer (P < .001) and with the writ­er’s sex (P < .001). Women were more likely to write “Show of support” and “Romance” follow-up letters; men were more likely to write “Spiritual” follow-up letters (Table 2).

Results suggested that the purpose of the initial letter was a reasonable predictor of the purpose of follow-up letters (P < .001) (Table 3). The murderer never responded to any letters. Letters were most often writ­ten from his state of incarceration; next, from contiguous states; then, from non-contiguous states; and, last, from interna­tional locations (P < .001).

Of the initial letters from writers who wrote ≥10, 60% were categorized as “Acquaintance” and 20% as “Romance.” The writer who wrote the most letters (43) moved during the course of her letter-writing to live in the same state as the murderer; she stated in her letters that she did so to be closer to him and to be able to attend his court hearings. Four other writers, each of whom wrote >5 letters, stated that they had traveled to the murderer’s state of incarcera­tion to attend some of his hearings in person.

Composite examples of more common categories of letters
Names and other pertinent identifying information have been changed.

Acquaintance. Hi, Steve. I’ve been follow­ing your case and just wanted to write you so that maybe we could be friends or keep in touch since you’re probably pretty bored. I’m a 27-year-old college student studying market­ing and working at Applebee’s as a waitress (for now) until I can land my dream job. I’ve enclosed a picture of me and my dachshund along with a photo of my favorite beach in the world. Write me back if you want. Jenny.

Show of support. Steve: I’ve been really wor­ried about you since first seeing you on TV. You look different lately and I hope they’re treating you OK and feeding you decent food. In case they’re not, I’ve enclosed a little something to buy yourself a treat. Just know that there are many of us that care about you and are really pulling for you to be strong in this tough situ­ation you’re in. Yours truly, Karen.

Romance. Dearest Steven: My mind has been filled with thoughts of you and of us since I last saw you in my dreams! Be strong, because you are going to beat this once they understand that you are not responsible for what happened! Don’t you see, sweetie, the system failed you, and now you’re caught up in something that you will soon overcome. When I think of the day that you get released, and how we’ll be able to settle down some­where together, it gets me incredibly excited. You and I are meant to be together, because I understand you and can help you get better. I love you, Steven! Please write me back so that I know we’re on the same page about our plans for the future. Love, ♥ Your sweetie, Rachel.

Spiritual. Dear Child of God: The Lord has a plan for you. I know that things right now might be confusing, and you’re in a black place, but He is there right beside you. If you need some reading materials to give you com­fort, just let me know and I can get a Bible to you along with some other books to give you solace and strengthen your walk with Him. God forgives you and he loves you so much! Much love in Christ, Mary.

Discussion
Given that the mass murderer in this study was a young man, it is not surpris­ing that 78% of writers of initial letters were women. However, it is interesting that, among women’s initial letters, 44% were “Acquaintance” letters and only 15% were categorized as “Romance.”

Given the severity of the murderer’s crime, it is remarkable that he received only 1 “Hate mail” letter.

Initial “Spiritual” letters were more likely to be followed by letters of the same category than any other category; “Romance” letters were a close second. This demonstrates the consistent efforts of writers in these 2 categories. Highly persis­tent writers (≥10 letters) were most likely to fall into “Acquaintance” and “Romance” categories. The persistence of these writers is remarkable, in view of the fact that none of their letters were answered. We hypoth­esize that the killer did not reply because he had no interest in correspondence.

Similarities to stalking. Given that 9 writ­ers wrote >10 letters each and 2 wrote >20 each, elements of their behavior are not unlike what is seen in stalkers.³ Consistent with the stalking literature and Mullen et al4 stalker typology, many writers in this study appeared to seek intimacy with the perpetrator through “Romance” or “Show of support” letters, and might be akin to Mullen’s so-called intimacy-seeking stalker. Such stalkers’ behavior arises out of loneliness, with a strong desire for a rela­tionship with the target; a significant per­centage of such stalkers suffer a delusional disorder.

Mullen’s so-called incompetent suitor stalker is similar to the intimacy-seeking type but, instead, has an interest in a short-term relationship and is far less persistent in his (her) stalking behavior⁴; this type might apply to the writers in this study who wrote >1 but <10 letters.

Two additional observations also are notable when trying to characterize people who write letters: (1) A high percentage of people who stalk a celebrity suffer a psy­chotic disorder^5,6; (2) 4 letter-writers trav­eled, and 1 relocated, to the murderer’s state of incarceration to attend his hearings and be closer to him.

This study has limitations:
   • categorization of letters is inherently subjective and the categories themselves were created by the researchers
   • the nature and categorization of such letters might vary considerably with the age and sex of the violent criminal; our findings in this case are not generalizable.

Last, researchers who plan to study writers of letters to incarcerated criminals should consider sending a personality test and other questionnaires to those writers to understand this population better.

Treatment considerations
Psychiatrists treating patients who seek a romantic attachment with a violent person should consider psychotherapy as a means of treating possible character pathology. The desire for romance with a violent crimi­nal was greater among repeat writers (20%) than in initial letters (15%), suggesting that people who have a strong inclination to associate with a violent person might benefit from exploring romantic feelings in therapy. Specifically, therapists would be wise to explore with such patients the possibility that they experienced violence or verbal abuse in childhood or adulthood.

To the extent that evidence of prior abuse exists, a diagnosis of posttraumatic stress disorder (PTSD) might be appro­priate; specialized therapy for men and women with a history of abuse might be indicated. It is important to provide vali­dation for patients who are victims when they describe their abuse, and to stress that they did nothing to provoke the violence. Furthermore, investigation of why the patient feels drawn romantically toward a violent criminal is helpful, as well as an examination of how such behavior is self-defeating.

There might be value in having patients keep a journal in lieu of actually sending letters; there is evidence that “journaling” can reduce substance use recidivism.⁷ This work can be performed in conjunction with group or individual psychotherapy that addresses any history of abuse and subse­quent PTSD.

Many patients are reluctant to discuss their romantic feelings toward a violent criminal until the psychiatrist has estab­lished a strong doctor−patient relationship. Last, clinicians should not hesitate to refer these patients to a therapist who specializes in domestic violence.

Related Resource
• Marazziti D, Falaschi V, Lombardi A, et al. Stalking: a neuro­biological perspective. Riv Psichiatr. 2015;50(1):12-18.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Little is known about people who write to criminals incar­cerated for a violent crime. However, existence of Web sites such as WriteAPrisoner.com, Meet-An-Inmate.com, and PrisonPenPals.com suggests some appetite among the public for corresponding with the incarcerated. Writers of letters might be drawn to the “bad boy” image of prison­ers. Furthermore, much has been written of the willingness of some battered women to remain in an abusive domestic relationship, leading them to correspond with their abusers even after those abusers are incarcerated.^1,2

To our knowledge, no examination of letters written to a mass murderer has been published. Therefore, we catego­rized and analyzed 784 letters sent to a high-profile male mass murderer whose crime was committed during the past decade. Here is a description of the study and what we found, as well as discussion of how our findings might offer utility in a psychiatric practice.

Goals of the study
We hypothesized that a large percentage of those letters could be classified as “Romantic,” given the lay percep­tion that it is women who write to mass murderers. We also sought to evaluate follow-up letters sent by these writers to test the assumption that their individual goals would be con­stant over time.

We performed this study in the hope that the research could assist psychiatric practitioners in treating patients who seek to associate with a violent person (see “Treatment considerations,”). We thought it might be helpful for practitioners to get a better understanding of the nature of people who write to a violent offender or express a desire to do so.

Methods of study
Two authors (R.S.J. and D.P.G.) evaluated 819 letters that had been written by non-incarcerated, non-family adults to 1 mass murderer. The initial letter and follow-up letters written by each unique writer (n = 333) were categorized as follows:
   • state or country from which the letter was sent
   • age
   • sex
   • number of letters sent by each writer
   • whether a photograph was enclosed
   • whether additional items were enclosed (eg, gifts, drawings)
   • whether the letter was rejected by prison authorities
   • the writer’s purpose.

The study was approved by the insti­tutional review board of Baylor College of Medicine.

Letters were assigned to 1 of 5 categories:

Acquaintance letters sought ongoing cor­respondence relationship with the murderer. They focused largely on conveying informa­tion about the writer.

Show of support letters also sought an ongoing correspondence relationship with the murderer, but instead focused on him, not the writer.

Romance letters used words that conveyed romantic or non-platonic affection.

Spiritual letters gave advice to the mur­derer with a religious tone.

Words of wisdom letters offered advice but lacked a religious tone.

Given the nonstandardized nature of categorization and the lack of a formal questionnaire, we were unable to perform an exploratory factor analysis on our cat­egorizations. Inter-rater reliability of letter categorization was 0.79.

Results: Writer profiles, purpose for writing
In all, we reviewed 819 letters:
   • Thirty-five letters were excluded because they were written by family mem­bers, children, or other prisoners
   • Of the remaining 784 letters, there were 333 unique writers
   • Two-hundred sixty letters were writ­ten by women, 61 by men; 2 were co-written by both sexes; sex could not be determined for 10.

Women were more likely than men to write a letter (P = .014) and to write ≥3 letters (P = .001). The age of the writer was deter­mined for 117 (35.1%) letters; mean age was 27.8 (± 8.9) years (range, 18 to 59 years).

The purpose of the letters differed by sex (P < .001) but not by the writer’s age (P = .058). Women were more likely than men to write letters categorized as “Acquaintance,” “Romance,” and “Show of support”; in con­trast, men were more likely than women to write a letter categorized as “Spiritual”  (Table 1). Approximately 95% of let­ters were handwritten. Letters averaged 3 pages (range, 1 to 16 pages).

Two-hundred sixteen writers wrote a single letter; 53 wrote 2 letters; 18 wrote 3 let­ters; 11 wrote 4 letters; 30 wrote 5 to 10 let­ters; and 9 wrote 11 to 43 letters. The purpose of follow-up letters was associated with the age of the writer (P < .001) and with the writ­er’s sex (P < .001). Women were more likely to write “Show of support” and “Romance” follow-up letters; men were more likely to write “Spiritual” follow-up letters (Table 2).

Results suggested that the purpose of the initial letter was a reasonable predictor of the purpose of follow-up letters (P < .001) (Table 3). The murderer never responded to any letters. Letters were most often writ­ten from his state of incarceration; next, from contiguous states; then, from non-contiguous states; and, last, from interna­tional locations (P < .001).

Of the initial letters from writers who wrote ≥10, 60% were categorized as “Acquaintance” and 20% as “Romance.” The writer who wrote the most letters (43) moved during the course of her letter-writing to live in the same state as the murderer; she stated in her letters that she did so to be closer to him and to be able to attend his court hearings. Four other writers, each of whom wrote >5 letters, stated that they had traveled to the murderer’s state of incarcera­tion to attend some of his hearings in person.

Composite examples of more common categories of letters
Names and other pertinent identifying information have been changed.

Acquaintance. Hi, Steve. I’ve been follow­ing your case and just wanted to write you so that maybe we could be friends or keep in touch since you’re probably pretty bored. I’m a 27-year-old college student studying market­ing and working at Applebee’s as a waitress (for now) until I can land my dream job. I’ve enclosed a picture of me and my dachshund along with a photo of my favorite beach in the world. Write me back if you want. Jenny.

Show of support. Steve: I’ve been really wor­ried about you since first seeing you on TV. You look different lately and I hope they’re treating you OK and feeding you decent food. In case they’re not, I’ve enclosed a little something to buy yourself a treat. Just know that there are many of us that care about you and are really pulling for you to be strong in this tough situ­ation you’re in. Yours truly, Karen.

Romance. Dearest Steven: My mind has been filled with thoughts of you and of us since I last saw you in my dreams! Be strong, because you are going to beat this once they understand that you are not responsible for what happened! Don’t you see, sweetie, the system failed you, and now you’re caught up in something that you will soon overcome. When I think of the day that you get released, and how we’ll be able to settle down some­where together, it gets me incredibly excited. You and I are meant to be together, because I understand you and can help you get better. I love you, Steven! Please write me back so that I know we’re on the same page about our plans for the future. Love, ♥ Your sweetie, Rachel.

Spiritual. Dear Child of God: The Lord has a plan for you. I know that things right now might be confusing, and you’re in a black place, but He is there right beside you. If you need some reading materials to give you com­fort, just let me know and I can get a Bible to you along with some other books to give you solace and strengthen your walk with Him. God forgives you and he loves you so much! Much love in Christ, Mary.

Discussion
Given that the mass murderer in this study was a young man, it is not surpris­ing that 78% of writers of initial letters were women. However, it is interesting that, among women’s initial letters, 44% were “Acquaintance” letters and only 15% were categorized as “Romance.”

Given the severity of the murderer’s crime, it is remarkable that he received only 1 “Hate mail” letter.

Initial “Spiritual” letters were more likely to be followed by letters of the same category than any other category; “Romance” letters were a close second. This demonstrates the consistent efforts of writers in these 2 categories. Highly persis­tent writers (≥10 letters) were most likely to fall into “Acquaintance” and “Romance” categories. The persistence of these writers is remarkable, in view of the fact that none of their letters were answered. We hypoth­esize that the killer did not reply because he had no interest in correspondence.

Similarities to stalking. Given that 9 writ­ers wrote >10 letters each and 2 wrote >20 each, elements of their behavior are not unlike what is seen in stalkers.³ Consistent with the stalking literature and Mullen et al4 stalker typology, many writers in this study appeared to seek intimacy with the perpetrator through “Romance” or “Show of support” letters, and might be akin to Mullen’s so-called intimacy-seeking stalker. Such stalkers’ behavior arises out of loneliness, with a strong desire for a rela­tionship with the target; a significant per­centage of such stalkers suffer a delusional disorder.

Mullen’s so-called incompetent suitor stalker is similar to the intimacy-seeking type but, instead, has an interest in a short-term relationship and is far less persistent in his (her) stalking behavior⁴; this type might apply to the writers in this study who wrote >1 but <10 letters.

Two additional observations also are notable when trying to characterize people who write letters: (1) A high percentage of people who stalk a celebrity suffer a psy­chotic disorder^5,6; (2) 4 letter-writers trav­eled, and 1 relocated, to the murderer’s state of incarceration to attend his hearings and be closer to him.

This study has limitations:
   • categorization of letters is inherently subjective and the categories themselves were created by the researchers
   • the nature and categorization of such letters might vary considerably with the age and sex of the violent criminal; our findings in this case are not generalizable.

Last, researchers who plan to study writers of letters to incarcerated criminals should consider sending a personality test and other questionnaires to those writers to understand this population better.

Treatment considerations
Psychiatrists treating patients who seek a romantic attachment with a violent person should consider psychotherapy as a means of treating possible character pathology. The desire for romance with a violent crimi­nal was greater among repeat writers (20%) than in initial letters (15%), suggesting that people who have a strong inclination to associate with a violent person might benefit from exploring romantic feelings in therapy. Specifically, therapists would be wise to explore with such patients the possibility that they experienced violence or verbal abuse in childhood or adulthood.

To the extent that evidence of prior abuse exists, a diagnosis of posttraumatic stress disorder (PTSD) might be appro­priate; specialized therapy for men and women with a history of abuse might be indicated. It is important to provide vali­dation for patients who are victims when they describe their abuse, and to stress that they did nothing to provoke the violence. Furthermore, investigation of why the patient feels drawn romantically toward a violent criminal is helpful, as well as an examination of how such behavior is self-defeating.

There might be value in having patients keep a journal in lieu of actually sending letters; there is evidence that “journaling” can reduce substance use recidivism.⁷ This work can be performed in conjunction with group or individual psychotherapy that addresses any history of abuse and subse­quent PTSD.

Many patients are reluctant to discuss their romantic feelings toward a violent criminal until the psychiatrist has estab­lished a strong doctor−patient relationship. Last, clinicians should not hesitate to refer these patients to a therapist who specializes in domestic violence.

Related Resource
• Marazziti D, Falaschi V, Lombardi A, et al. Stalking: a neuro­biological perspective. Riv Psichiatr. 2015;50(1):12-18.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Little is known about people who write to criminals incar­cerated for a violent crime. However, existence of Web sites such as WriteAPrisoner.com, Meet-An-Inmate.com, and PrisonPenPals.com suggests some appetite among the public for corresponding with the incarcerated. Writers of letters might be drawn to the “bad boy” image of prison­ers. Furthermore, much has been written of the willingness of some battered women to remain in an abusive domestic relationship, leading them to correspond with their abusers even after those abusers are incarcerated.^1,2

To our knowledge, no examination of letters written to a mass murderer has been published. Therefore, we catego­rized and analyzed 784 letters sent to a high-profile male mass murderer whose crime was committed during the past decade. Here is a description of the study and what we found, as well as discussion of how our findings might offer utility in a psychiatric practice.

Goals of the study
We hypothesized that a large percentage of those letters could be classified as “Romantic,” given the lay percep­tion that it is women who write to mass murderers. We also sought to evaluate follow-up letters sent by these writers to test the assumption that their individual goals would be con­stant over time.

We performed this study in the hope that the research could assist psychiatric practitioners in treating patients who seek to associate with a violent person (see “Treatment considerations,”). We thought it might be helpful for practitioners to get a better understanding of the nature of people who write to a violent offender or express a desire to do so.

Methods of study
Two authors (R.S.J. and D.P.G.) evaluated 819 letters that had been written by non-incarcerated, non-family adults to 1 mass murderer. The initial letter and follow-up letters written by each unique writer (n = 333) were categorized as follows:
   • state or country from which the letter was sent
   • age
   • sex
   • number of letters sent by each writer
   • whether a photograph was enclosed
   • whether additional items were enclosed (eg, gifts, drawings)
   • whether the letter was rejected by prison authorities
   • the writer’s purpose.

The study was approved by the insti­tutional review board of Baylor College of Medicine.

Letters were assigned to 1 of 5 categories:

Acquaintance letters sought ongoing cor­respondence relationship with the murderer. They focused largely on conveying informa­tion about the writer.

Show of support letters also sought an ongoing correspondence relationship with the murderer, but instead focused on him, not the writer.

Romance letters used words that conveyed romantic or non-platonic affection.

Spiritual letters gave advice to the mur­derer with a religious tone.

Words of wisdom letters offered advice but lacked a religious tone.

Given the nonstandardized nature of categorization and the lack of a formal questionnaire, we were unable to perform an exploratory factor analysis on our cat­egorizations. Inter-rater reliability of letter categorization was 0.79.

Results: Writer profiles, purpose for writing
In all, we reviewed 819 letters:
   • Thirty-five letters were excluded because they were written by family mem­bers, children, or other prisoners
   • Of the remaining 784 letters, there were 333 unique writers
   • Two-hundred sixty letters were writ­ten by women, 61 by men; 2 were co-written by both sexes; sex could not be determined for 10.

Women were more likely than men to write a letter (P = .014) and to write ≥3 letters (P = .001). The age of the writer was deter­mined for 117 (35.1%) letters; mean age was 27.8 (± 8.9) years (range, 18 to 59 years).

The purpose of the letters differed by sex (P < .001) but not by the writer’s age (P = .058). Women were more likely than men to write letters categorized as “Acquaintance,” “Romance,” and “Show of support”; in con­trast, men were more likely than women to write a letter categorized as “Spiritual”  (Table 1). Approximately 95% of let­ters were handwritten. Letters averaged 3 pages (range, 1 to 16 pages).

Two-hundred sixteen writers wrote a single letter; 53 wrote 2 letters; 18 wrote 3 let­ters; 11 wrote 4 letters; 30 wrote 5 to 10 let­ters; and 9 wrote 11 to 43 letters. The purpose of follow-up letters was associated with the age of the writer (P < .001) and with the writ­er’s sex (P < .001). Women were more likely to write “Show of support” and “Romance” follow-up letters; men were more likely to write “Spiritual” follow-up letters (Table 2).

Results suggested that the purpose of the initial letter was a reasonable predictor of the purpose of follow-up letters (P < .001) (Table 3). The murderer never responded to any letters. Letters were most often writ­ten from his state of incarceration; next, from contiguous states; then, from non-contiguous states; and, last, from interna­tional locations (P < .001).

Of the initial letters from writers who wrote ≥10, 60% were categorized as “Acquaintance” and 20% as “Romance.” The writer who wrote the most letters (43) moved during the course of her letter-writing to live in the same state as the murderer; she stated in her letters that she did so to be closer to him and to be able to attend his court hearings. Four other writers, each of whom wrote >5 letters, stated that they had traveled to the murderer’s state of incarcera­tion to attend some of his hearings in person.

Composite examples of more common categories of letters
Names and other pertinent identifying information have been changed.

Acquaintance. Hi, Steve. I’ve been follow­ing your case and just wanted to write you so that maybe we could be friends or keep in touch since you’re probably pretty bored. I’m a 27-year-old college student studying market­ing and working at Applebee’s as a waitress (for now) until I can land my dream job. I’ve enclosed a picture of me and my dachshund along with a photo of my favorite beach in the world. Write me back if you want. Jenny.

Show of support. Steve: I’ve been really wor­ried about you since first seeing you on TV. You look different lately and I hope they’re treating you OK and feeding you decent food. In case they’re not, I’ve enclosed a little something to buy yourself a treat. Just know that there are many of us that care about you and are really pulling for you to be strong in this tough situ­ation you’re in. Yours truly, Karen.

Romance. Dearest Steven: My mind has been filled with thoughts of you and of us since I last saw you in my dreams! Be strong, because you are going to beat this once they understand that you are not responsible for what happened! Don’t you see, sweetie, the system failed you, and now you’re caught up in something that you will soon overcome. When I think of the day that you get released, and how we’ll be able to settle down some­where together, it gets me incredibly excited. You and I are meant to be together, because I understand you and can help you get better. I love you, Steven! Please write me back so that I know we’re on the same page about our plans for the future. Love, ♥ Your sweetie, Rachel.

Spiritual. Dear Child of God: The Lord has a plan for you. I know that things right now might be confusing, and you’re in a black place, but He is there right beside you. If you need some reading materials to give you com­fort, just let me know and I can get a Bible to you along with some other books to give you solace and strengthen your walk with Him. God forgives you and he loves you so much! Much love in Christ, Mary.

Discussion
Given that the mass murderer in this study was a young man, it is not surpris­ing that 78% of writers of initial letters were women. However, it is interesting that, among women’s initial letters, 44% were “Acquaintance” letters and only 15% were categorized as “Romance.”

Given the severity of the murderer’s crime, it is remarkable that he received only 1 “Hate mail” letter.

Initial “Spiritual” letters were more likely to be followed by letters of the same category than any other category; “Romance” letters were a close second. This demonstrates the consistent efforts of writers in these 2 categories. Highly persis­tent writers (≥10 letters) were most likely to fall into “Acquaintance” and “Romance” categories. The persistence of these writers is remarkable, in view of the fact that none of their letters were answered. We hypoth­esize that the killer did not reply because he had no interest in correspondence.

Similarities to stalking. Given that 9 writ­ers wrote >10 letters each and 2 wrote >20 each, elements of their behavior are not unlike what is seen in stalkers.³ Consistent with the stalking literature and Mullen et al4 stalker typology, many writers in this study appeared to seek intimacy with the perpetrator through “Romance” or “Show of support” letters, and might be akin to Mullen’s so-called intimacy-seeking stalker. Such stalkers’ behavior arises out of loneliness, with a strong desire for a rela­tionship with the target; a significant per­centage of such stalkers suffer a delusional disorder.

Mullen’s so-called incompetent suitor stalker is similar to the intimacy-seeking type but, instead, has an interest in a short-term relationship and is far less persistent in his (her) stalking behavior⁴; this type might apply to the writers in this study who wrote >1 but <10 letters.

Two additional observations also are notable when trying to characterize people who write letters: (1) A high percentage of people who stalk a celebrity suffer a psy­chotic disorder^5,6; (2) 4 letter-writers trav­eled, and 1 relocated, to the murderer’s state of incarceration to attend his hearings and be closer to him.

This study has limitations:
   • categorization of letters is inherently subjective and the categories themselves were created by the researchers
   • the nature and categorization of such letters might vary considerably with the age and sex of the violent criminal; our findings in this case are not generalizable.

Last, researchers who plan to study writers of letters to incarcerated criminals should consider sending a personality test and other questionnaires to those writers to understand this population better.

Treatment considerations
Psychiatrists treating patients who seek a romantic attachment with a violent person should consider psychotherapy as a means of treating possible character pathology. The desire for romance with a violent crimi­nal was greater among repeat writers (20%) than in initial letters (15%), suggesting that people who have a strong inclination to associate with a violent person might benefit from exploring romantic feelings in therapy. Specifically, therapists would be wise to explore with such patients the possibility that they experienced violence or verbal abuse in childhood or adulthood.

To the extent that evidence of prior abuse exists, a diagnosis of posttraumatic stress disorder (PTSD) might be appro­priate; specialized therapy for men and women with a history of abuse might be indicated. It is important to provide vali­dation for patients who are victims when they describe their abuse, and to stress that they did nothing to provoke the violence. Furthermore, investigation of why the patient feels drawn romantically toward a violent criminal is helpful, as well as an examination of how such behavior is self-defeating.

There might be value in having patients keep a journal in lieu of actually sending letters; there is evidence that “journaling” can reduce substance use recidivism.⁷ This work can be performed in conjunction with group or individual psychotherapy that addresses any history of abuse and subse­quent PTSD.

Many patients are reluctant to discuss their romantic feelings toward a violent criminal until the psychiatrist has estab­lished a strong doctor−patient relationship. Last, clinicians should not hesitate to refer these patients to a therapist who specializes in domestic violence.

Related Resource
• Marazziti D, Falaschi V, Lombardi A, et al. Stalking: a neuro­biological perspective. Riv Psichiatr. 2015;50(1):12-18.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Brief cognitive screening is essential for assessing neurocognitive disor­ders. Such screening can give clini­cians a snapshot of patients’ cognitive abilities across a range of disorders and help tailor interventions to yield better outcomes. Appropriate administration of a brief cognitive screening using telehealth technology can improve access to care and treatment planning.

Neurocognitive decline can be a barrier to treatment
Persons with neurocognitive impairment, regardless of the cause, often face barriers when they seek treatment. Memory and attention difficulties often interfere with attending appointments; driving restric­tions, smaller social networks, caregiver burden, and medical conditions limit access to care. For such patients, tele­health assessment is a tool that physicians can use to help patients overcome these barriers.

Cognitive screening tools
Brief cognitive assessments need to dem­onstrate (1) consistent and accurate scores over time (reliability) and (2) that they are measuring the intended cognitive domain (validity). The Mini-Mental State Examination is used often; the Montreal Cognitive Assessment and the Short Blessed Test are additional cognitive screeners that have support in the literature for use with telehealth technology.¹

Telehealth assessment modalities
Modalities for telehealth assessment² include:
   • Audio-based systems. Pro: Telephone-based telehealth screening usually does not require extra equipment or advanced planning. Con: Visual information is absent and there is overreliance on verbal tasks.
   • Video-based systems. Pro: Using video­phones or video conferencing systems allow physicians to observe patients’ behaviors and their ability to complete tasks on paper. Con: A video system often requires more planning and effort to set up than other types of systems.
   • Web-based systems. Pro: Web sites on which patient and provider can interact in real time—through a combination of audio, video, and programmed applications—offer immediate access to a patient’s responses and test results, thus providing a wealth of clinical information such as exact timing and calculation of patients’ responses, abil­ity to record and review patients’ approach to construction tasks, and the capability to adapt test batteries in real-time based on patients’ ongoing performance. Con: Such systems require specialized software and infrastructure.

Support for telehealth screening
Our patients report feeling comfortable with telehealth screening; they overwhelmingly report that they prefer telehealth services to in-person services that require travel. Studies on the reliability and validity of using cog­nitive screeners have shown that telehealth screening is a feasible and acceptable prac­tice.³ Although the telehealth approaches mentioned here can all be used effectively, we have found that video-based cognitive screening might offer the best balance of flexibility, accessibility, and ease of use at this time.

Our recommendations
Consider your resources, patient popula­tion, and the scope of available telehealth services to guide your approach. Use vali­dated measures that fit the limitations of the modality you have chosen:
   • Telephone-based screenings should use verbally based measures (eg, the Short Blessed Test and the Telephone Interview for Cognitive Status).
   • Video-based screenings can include visual elements, but you need to decide how to best administer, record, and score the patient’s written responses. You might need to mail portions of tests along with a writing utensil and paper to their home. Patients can hold up their responses to the camera or send back the completed tests for scoring.
   • Adapt testing to the constraints of a particular situation, but modifications to tests should be limited as much as possible to minimize decreases in reliability and validity.
   • Have a clear policy for dealing with unexpected events, such as technological malfunctions, patient privacy concerns, and mental health emergencies.

Acknowledgement
This article was supported by the facilities and resources of the Salem VA Medical Center. The views expressed in this article are those of the authors and not necessarily those of the Department of Veterans Affairs.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or wiith manufacturers of competing products.

Brief cognitive screening is essential for assessing neurocognitive disor­ders. Such screening can give clini­cians a snapshot of patients’ cognitive abilities across a range of disorders and help tailor interventions to yield better outcomes. Appropriate administration of a brief cognitive screening using telehealth technology can improve access to care and treatment planning.

Neurocognitive decline can be a barrier to treatment
Persons with neurocognitive impairment, regardless of the cause, often face barriers when they seek treatment. Memory and attention difficulties often interfere with attending appointments; driving restric­tions, smaller social networks, caregiver burden, and medical conditions limit access to care. For such patients, tele­health assessment is a tool that physicians can use to help patients overcome these barriers.

Cognitive screening tools
Brief cognitive assessments need to dem­onstrate (1) consistent and accurate scores over time (reliability) and (2) that they are measuring the intended cognitive domain (validity). The Mini-Mental State Examination is used often; the Montreal Cognitive Assessment and the Short Blessed Test are additional cognitive screeners that have support in the literature for use with telehealth technology.¹

Telehealth assessment modalities
Modalities for telehealth assessment² include:
   • Audio-based systems. Pro: Telephone-based telehealth screening usually does not require extra equipment or advanced planning. Con: Visual information is absent and there is overreliance on verbal tasks.
   • Video-based systems. Pro: Using video­phones or video conferencing systems allow physicians to observe patients’ behaviors and their ability to complete tasks on paper. Con: A video system often requires more planning and effort to set up than other types of systems.
   • Web-based systems. Pro: Web sites on which patient and provider can interact in real time—through a combination of audio, video, and programmed applications—offer immediate access to a patient’s responses and test results, thus providing a wealth of clinical information such as exact timing and calculation of patients’ responses, abil­ity to record and review patients’ approach to construction tasks, and the capability to adapt test batteries in real-time based on patients’ ongoing performance. Con: Such systems require specialized software and infrastructure.

Support for telehealth screening
Our patients report feeling comfortable with telehealth screening; they overwhelmingly report that they prefer telehealth services to in-person services that require travel. Studies on the reliability and validity of using cog­nitive screeners have shown that telehealth screening is a feasible and acceptable prac­tice.³ Although the telehealth approaches mentioned here can all be used effectively, we have found that video-based cognitive screening might offer the best balance of flexibility, accessibility, and ease of use at this time.

Our recommendations
Consider your resources, patient popula­tion, and the scope of available telehealth services to guide your approach. Use vali­dated measures that fit the limitations of the modality you have chosen:
   • Telephone-based screenings should use verbally based measures (eg, the Short Blessed Test and the Telephone Interview for Cognitive Status).
   • Video-based screenings can include visual elements, but you need to decide how to best administer, record, and score the patient’s written responses. You might need to mail portions of tests along with a writing utensil and paper to their home. Patients can hold up their responses to the camera or send back the completed tests for scoring.
   • Adapt testing to the constraints of a particular situation, but modifications to tests should be limited as much as possible to minimize decreases in reliability and validity.
   • Have a clear policy for dealing with unexpected events, such as technological malfunctions, patient privacy concerns, and mental health emergencies.

Acknowledgement
This article was supported by the facilities and resources of the Salem VA Medical Center. The views expressed in this article are those of the authors and not necessarily those of the Department of Veterans Affairs.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or wiith manufacturers of competing products.

Brief cognitive screening is essential for assessing neurocognitive disor­ders. Such screening can give clini­cians a snapshot of patients’ cognitive abilities across a range of disorders and help tailor interventions to yield better outcomes. Appropriate administration of a brief cognitive screening using telehealth technology can improve access to care and treatment planning.

Neurocognitive decline can be a barrier to treatment
Persons with neurocognitive impairment, regardless of the cause, often face barriers when they seek treatment. Memory and attention difficulties often interfere with attending appointments; driving restric­tions, smaller social networks, caregiver burden, and medical conditions limit access to care. For such patients, tele­health assessment is a tool that physicians can use to help patients overcome these barriers.

Cognitive screening tools
Brief cognitive assessments need to dem­onstrate (1) consistent and accurate scores over time (reliability) and (2) that they are measuring the intended cognitive domain (validity). The Mini-Mental State Examination is used often; the Montreal Cognitive Assessment and the Short Blessed Test are additional cognitive screeners that have support in the literature for use with telehealth technology.¹

Telehealth assessment modalities
Modalities for telehealth assessment² include:
   • Audio-based systems. Pro: Telephone-based telehealth screening usually does not require extra equipment or advanced planning. Con: Visual information is absent and there is overreliance on verbal tasks.
   • Video-based systems. Pro: Using video­phones or video conferencing systems allow physicians to observe patients’ behaviors and their ability to complete tasks on paper. Con: A video system often requires more planning and effort to set up than other types of systems.
   • Web-based systems. Pro: Web sites on which patient and provider can interact in real time—through a combination of audio, video, and programmed applications—offer immediate access to a patient’s responses and test results, thus providing a wealth of clinical information such as exact timing and calculation of patients’ responses, abil­ity to record and review patients’ approach to construction tasks, and the capability to adapt test batteries in real-time based on patients’ ongoing performance. Con: Such systems require specialized software and infrastructure.

Support for telehealth screening
Our patients report feeling comfortable with telehealth screening; they overwhelmingly report that they prefer telehealth services to in-person services that require travel. Studies on the reliability and validity of using cog­nitive screeners have shown that telehealth screening is a feasible and acceptable prac­tice.³ Although the telehealth approaches mentioned here can all be used effectively, we have found that video-based cognitive screening might offer the best balance of flexibility, accessibility, and ease of use at this time.

Our recommendations
Consider your resources, patient popula­tion, and the scope of available telehealth services to guide your approach. Use vali­dated measures that fit the limitations of the modality you have chosen:
   • Telephone-based screenings should use verbally based measures (eg, the Short Blessed Test and the Telephone Interview for Cognitive Status).
   • Video-based screenings can include visual elements, but you need to decide how to best administer, record, and score the patient’s written responses. You might need to mail portions of tests along with a writing utensil and paper to their home. Patients can hold up their responses to the camera or send back the completed tests for scoring.
   • Adapt testing to the constraints of a particular situation, but modifications to tests should be limited as much as possible to minimize decreases in reliability and validity.
   • Have a clear policy for dealing with unexpected events, such as technological malfunctions, patient privacy concerns, and mental health emergencies.

Acknowledgement
This article was supported by the facilities and resources of the Salem VA Medical Center. The views expressed in this article are those of the authors and not necessarily those of the Department of Veterans Affairs.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or wiith manufacturers of competing products.