Current Psychiatry

I enjoy the intellectual insights in Dr. Nasrallah’s From the Editor essays in Current Psychiatry. For future editorials, I suggest a few top­ics for him to discuss:
     • There is poor concordance between diagnosis and treatment by psychiatrists, compared with other medical specialties, because we do not have tests or measures to employ both before and after treatment. In other words, we have not standard­ized our evaluation or treatment. Despite my 4 videos on YouTube and an e-book, Standardizing psychiatric care, I have not received an enthusi­astic response or discussion from the American Psychiatric Association (APA) or academic psychiatrists— knowing that this step is crucial to integration of care with primary care physicians (PCPs) and other physi­cians. We must be a leader in training PCPs and other clinicians about how we care for our patients.
   • The practice of medicine is local. In this region of North Carolina, how­ever, the private practice of psychiatry is disappearing. It is almost impossi­ble to start a successful practice, pri­marily because of managed care.
    • The goals of psychiatric treat­ment have not been adopted by all professionals. This includes return­ing patients to optimal functioning at no less than 80% to 90% of their capacity in self care and professional, school, social, and home settings, and to having at least 85% of psychi­atric symptoms under control, with the least possible number of medica­tion side effects.
   • Treatment of psychiatric symp­toms is highly individual, and there­fore the dosage of each medication must be titrated carefully. This important aspect of treatment has not been well-emphasized in train­ing or by the leadership of the APA.
   • Treatment in psychiatry is a com­bination of the right medication and lowest effective dosage to minimize side effects. Therefore it is a poly­pharmacy, and we must accept it and educate patients accordingly.

I hope that Dr. Nasrallah’s influ­ential editorials will shed light on these topics, and begin a national and international debate on these issues.

V. Sagar Sethi, MD, PhD
Carmel Psychiatric Associates, PA
Charlotte, North Carolina

I enjoy the intellectual insights in Dr. Nasrallah’s From the Editor essays in Current Psychiatry. For future editorials, I suggest a few top­ics for him to discuss:
     • There is poor concordance between diagnosis and treatment by psychiatrists, compared with other medical specialties, because we do not have tests or measures to employ both before and after treatment. In other words, we have not standard­ized our evaluation or treatment. Despite my 4 videos on YouTube and an e-book, Standardizing psychiatric care, I have not received an enthusi­astic response or discussion from the American Psychiatric Association (APA) or academic psychiatrists— knowing that this step is crucial to integration of care with primary care physicians (PCPs) and other physi­cians. We must be a leader in training PCPs and other clinicians about how we care for our patients.
   • The practice of medicine is local. In this region of North Carolina, how­ever, the private practice of psychiatry is disappearing. It is almost impossi­ble to start a successful practice, pri­marily because of managed care.
    • The goals of psychiatric treat­ment have not been adopted by all professionals. This includes return­ing patients to optimal functioning at no less than 80% to 90% of their capacity in self care and professional, school, social, and home settings, and to having at least 85% of psychi­atric symptoms under control, with the least possible number of medica­tion side effects.
   • Treatment of psychiatric symp­toms is highly individual, and there­fore the dosage of each medication must be titrated carefully. This important aspect of treatment has not been well-emphasized in train­ing or by the leadership of the APA.
   • Treatment in psychiatry is a com­bination of the right medication and lowest effective dosage to minimize side effects. Therefore it is a poly­pharmacy, and we must accept it and educate patients accordingly.

I hope that Dr. Nasrallah’s influ­ential editorials will shed light on these topics, and begin a national and international debate on these issues.

V. Sagar Sethi, MD, PhD
Carmel Psychiatric Associates, PA
Charlotte, North Carolina

I enjoy the intellectual insights in Dr. Nasrallah’s From the Editor essays in Current Psychiatry. For future editorials, I suggest a few top­ics for him to discuss:
     • There is poor concordance between diagnosis and treatment by psychiatrists, compared with other medical specialties, because we do not have tests or measures to employ both before and after treatment. In other words, we have not standard­ized our evaluation or treatment. Despite my 4 videos on YouTube and an e-book, Standardizing psychiatric care, I have not received an enthusi­astic response or discussion from the American Psychiatric Association (APA) or academic psychiatrists— knowing that this step is crucial to integration of care with primary care physicians (PCPs) and other physi­cians. We must be a leader in training PCPs and other clinicians about how we care for our patients.
   • The practice of medicine is local. In this region of North Carolina, how­ever, the private practice of psychiatry is disappearing. It is almost impossi­ble to start a successful practice, pri­marily because of managed care.
    • The goals of psychiatric treat­ment have not been adopted by all professionals. This includes return­ing patients to optimal functioning at no less than 80% to 90% of their capacity in self care and professional, school, social, and home settings, and to having at least 85% of psychi­atric symptoms under control, with the least possible number of medica­tion side effects.
   • Treatment of psychiatric symp­toms is highly individual, and there­fore the dosage of each medication must be titrated carefully. This important aspect of treatment has not been well-emphasized in train­ing or by the leadership of the APA.
   • Treatment in psychiatry is a com­bination of the right medication and lowest effective dosage to minimize side effects. Therefore it is a poly­pharmacy, and we must accept it and educate patients accordingly.

I hope that Dr. Nasrallah’s influ­ential editorials will shed light on these topics, and begin a national and international debate on these issues.

V. Sagar Sethi, MD, PhD
Carmel Psychiatric Associates, PA
Charlotte, North Carolina

In Dr. Nasrallah’s Editorial on reduc­ing the risk of schizophrenia in a child (For couples seeking to conceive, offer advice on reducing the risk of schizo­phrenia, Current Psychiatry, From the Editor, August 2014, p. 11-12, 44; [http://bit.ly/1zAcnUq]), he advised a couple to “Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids)…”

Some people are concerned about mercury levels in fish and suggest limiting fish consumption during pregnancy. I do not follow this litera­ture and do not know which fish to recommend and avoid and the cur­rent status of the evidence. If people still believe this, should I suggest omega-3 fatty acid supplements instead of eating a lot of fish?

Oommen Mammen, MD
Western Psychiatric Institute and Clinic
Pittsburgh, Pennsylvania

Dr. Nasrallah responds
I recommend wild salmon as the best source of omega-3 fatty acids from fish. I avoid farmed salmon because that’s where some contamination has been reported. Absent the availability of wild salmon, I rec­ommend omega-3 fatty acid supplements.

Henry A. Nasrallah, MD
Professor and Chair Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri

In Dr. Nasrallah’s Editorial on reduc­ing the risk of schizophrenia in a child (For couples seeking to conceive, offer advice on reducing the risk of schizo­phrenia, Current Psychiatry, From the Editor, August 2014, p. 11-12, 44; [http://bit.ly/1zAcnUq]), he advised a couple to “Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids)…”

Some people are concerned about mercury levels in fish and suggest limiting fish consumption during pregnancy. I do not follow this litera­ture and do not know which fish to recommend and avoid and the cur­rent status of the evidence. If people still believe this, should I suggest omega-3 fatty acid supplements instead of eating a lot of fish?

Oommen Mammen, MD
Western Psychiatric Institute and Clinic
Pittsburgh, Pennsylvania

Dr. Nasrallah responds
I recommend wild salmon as the best source of omega-3 fatty acids from fish. I avoid farmed salmon because that’s where some contamination has been reported. Absent the availability of wild salmon, I rec­ommend omega-3 fatty acid supplements.

Henry A. Nasrallah, MD
Professor and Chair Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri

In Dr. Nasrallah’s Editorial on reduc­ing the risk of schizophrenia in a child (For couples seeking to conceive, offer advice on reducing the risk of schizo­phrenia, Current Psychiatry, From the Editor, August 2014, p. 11-12, 44; [http://bit.ly/1zAcnUq]), he advised a couple to “Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids)…”

Some people are concerned about mercury levels in fish and suggest limiting fish consumption during pregnancy. I do not follow this litera­ture and do not know which fish to recommend and avoid and the cur­rent status of the evidence. If people still believe this, should I suggest omega-3 fatty acid supplements instead of eating a lot of fish?

Oommen Mammen, MD
Western Psychiatric Institute and Clinic
Pittsburgh, Pennsylvania

Dr. Nasrallah responds
I recommend wild salmon as the best source of omega-3 fatty acids from fish. I avoid farmed salmon because that’s where some contamination has been reported. Absent the availability of wild salmon, I rec­ommend omega-3 fatty acid supplements.

Henry A. Nasrallah, MD
Professor and Chair Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri

When treating patients who abuse substances, it is important to watch for underlying clinical conditions that have been sup­pressed, relieved, or muted by alcohol or drugs. Many of these conditions can be mistaken for signs of withdrawal, drug-seeking, or new conditions arising from loss of euphoria from the drug. Prompt recogni­tion of these disorders and use of appropriate non-addictive treatments can prevent “against medical advice” discharges, relapses, and unneeded suffering in many cases.

Because the brain is the target organ, these conditions are either neuro­logic or psychiatric in nosology. Although psychiatric clinicians might not be familiar with neurologic conditions, quick recognition and treatment is necessary.

Restless legs syndrome and periodic limb movements of sleep
Restless legs syndrome (RLS) has 2 key components: paresthesia and akathisia. Although primarily involving the lower extremities, involve­ment also can include the upper extremities, torso, and head.

Paresthesia differs from typical neuropathies in that it usually is not pain­ful; rather, patients describe an odd sensation using terms such as ticklish, “creepy-crawly,” and other uncomfortable sensations.

Akathisia is a motor restlessness and need to move. The patient might feel momentary relief by moving or rubbing the extremities, only to have the paresthesia return quickly followed by the akathisia. Generally, reclining is the most prominent position that produces symptoms, but they can occur while sitting.

The cause of RLS is an abnormality of central dopamine or iron, or both, in the sub­stantia nigra; iron is a cofactor in dopamine synthesis. All RLS patients should have a serum ferritin level drawn and if <50 μg/dL, be treated with iron supplementation. Dopamine agonists, such as ropinirole, pramipexole, and carbidopa/levodopa, are effective (Table 1); other useful agents include benzodiazepines such as clonaz­epam and opioids such as hydrocodone.

Gabapentin is not significantly metabo­lized by the liver, has a 3% rate of protein bind­ing, and is excreted by the kidneys—making it safe for patients who abuse alcohol or opi­oids and have impaired hepatic function. Typical starting dosages of IR gabapentin are 100 to 300 mg, 3 times daily, if symptoms are present in the daytime. Asymmetric dosing can be helpful, with larger or single dosages given at bedtime (eg, 100 mg in morning, 100 mg in afternoon, 300 mg at bedtime). Dosing varies from patient to patient, from 300 mg to 3,600 mg/d. Increasing dosages produce lower bioavailability because of saturation in absorption or at the blood-brain barrier. At 100 mg every 8 hours, bioavail­ability is 80% but at 1,600 mg every 8 hours it drops to 27%.³

Periodic limb movements of sleep (PLMS) essentially is akathisia during sleep, and occurs in most patients with RLS. The patient feels tired in the morning because of lack of deep stage-N3 sleep. Because of the inverse relationship between serotonin and dopamine, most selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors can exacerbate RLS and PLMS.^4,5 Other culprits include antipsychot­ics, antiemetics, and antihistamines. The differential diagnosis includes withdrawal from opioids and attention-deficit/hyper­activity disorder (ADHD), which may be comorbid with RLS. There are many causes of secondary RLS including renal failure, pregnancy, varicose veins, and neuropathy.

Tremor
Benign familial, or essential, tremor is a fine intention tremor that can be suppressed by alcohol or benzodiazepines. After detoxifica­tion from either of these substances, persis­tent tremor can re-emerge; often, it is benign, although cerebellar and parkinsonian trem­ors must be ruled out. Essential tremor can be treated with gabapentin or beta blockers such as propranolol or metoprolol (Table 2).

Anxiety and panic disorder
Social anxiety often presents in addiction treatment centers in the context of group therapy, speaking in 12-step meetings, and having the patient describe his (her) autobi­ography and history of addiction. Because social anxiety disorder is the third most com­mon psychiatric disorder after simple pho­bia and major depressive disorder,⁶ it is not surprising that it emerges after withdrawal.

Patients with social anxiety disorder might self-medicate with alcohol or drugs, especially benzodiazepines (Box). Residential treatment presents an excellent environment for desensitization to fears of public speaking; early recognition is key. Apprehension about group therapy, present­ing a substance abuse history, or speaking at a 12-step meeting can lead to premature or “against medical advice” discharge.

Panic disorder commonly is comorbid with substance abuse. Many patients will arrive at treatment with a prescription for benzodiaz­epines. Because the risk of cross-addiction is high among recovering addicts, benzodiaze­pines should be avoided. Treating underlying anxiety is crucial for fostering sobriety. Generalized anxiety disorder is common among patients with an addiction, and can lead to relapse if not addressed. Use of non-addictive medications and cognitive therapy is useful in addressing this condition.

A quandary might arise in states where medical marijuana is legal, because Cannabis can be prescribed for anxiety disorders and posttraumatic stress disorder (PTSD). Promoting abstinence from all substances can present a challenge in patients with anxi­ety disorders who live in these states.

Medications for anxiety and panic dis­order include gabapentin, buspirone, hydroxyzine, beta blockers, and atypical antipsychotics (Table 2). Only buspirone and hydroxyzine are FDA-approved for anxiety; buspirone monotherapy generally is ineffec­tive for panic disorder.

Explaining to patients how anxiety arises, such as how classical conditioning leads to specific phobias, can be therapeu­tic. Describing Klein’s false suffocation alarm theory of panic attacks can illustrate the importance of practicing slow, deep breathing to prevent hyperventilation.⁷ Also, relabeling a panic attack with self-talk state­ments such as “I know what this is. It’s just a panic attack” can be helpful. Smartphone apps are available to help patients cope with anxiety and acute panic.⁸

Mood disorders
Many patients with bipolar disorder expe­rience substance abuse at some point; esti­mates are that up to 57% of patients have a comorbid addiction.^6,9 Persons with a mood disorder are at high risk of substance abuse because of genetic factors; patients also might self-medicate their mood symptoms.

After alcohol or drugs are withdrawn, mood disorders can emerge or resurge. Often, patients enter treatment taking antidepressants and mood stabilizers and usually haven’t been truthful with their treatment provider about their substance abuse. Care must be taken to ascertain whether mood symptoms are secondary to substance abuse. Asking “What’s the longest period of abstinence you’ve had in 2 years and how did you feel emotionally?” often will help you identify a secondary mood disorder. For example, a response of “6 months and I felt really depressed the entire time” would indicate a primary depressive disorder.

Because CNS depressants, such as alco­hol and benzodiazepines, can exacerbate a mood disorder, consider continuing or resuming a mood stabilizer or antidepres­sant during substance abuse treatment. When meeting a new patient, perform an independent evaluation, because substance use can mimic bipolar and depressive dis­orders. Careful assessment of suicidal ide­ation is necessary for all patients.

Sleep disorders
Insomnia—as a primary or secondary disorder—is common among patients with a substance use disorder. Insomnia always needs to be addressed. Not sleeping well interferes with cognition and energy and makes depression and bipolar disorder worse. Some experts recommend “waiting out” the insomnia, hoping that sobriety will resolve it—but it might not.

Initial insomnia can be treated with mela­tonin, 3 to 6 mg at bedtime or earlier in the evening.^10-12 Melatonin acts by regulating circadian rhythms, but can cause increased dreaming and nightmares; therefore, it should be avoided in patients who struggle with nightmares. Trazodone, 50 to 150 mg at bedtime, is an inexpensive sleep aid for initial insomnia and doesn’t cause weight gain, which many drugs with antihistaminic properties can. Prazosin, 1 to 2 mg initially, for nightmares in PTSD is effective.¹³

Antipsychotics might be necessary if nothing else works; quetiapine is effective for sleep and the ER form is FDA-approved as an add-on agent in major depression. Low-dose doxepin (≤10 mg) is effective for middle insomnia.¹⁴ At these low dosages, troublesome side effects of tricyclic antide­pressants can be avoided.

As many as 40% of adults with ADHD have a delayed sleep-phase disorder. Ask your patient if she is a “night owl,” how chronic the condition is, and when her best sleep occurs.15-17 Morning light and evening melatonin can help, but often are insufficient. Many patients present with undiagnosed or untreated sleep apnea, which can cause excessive daytime sleepiness. Referral to a sleep center is prudent; use of the Epworth Sleepiness Scale is a quick way to assess excessive daytime sleepiness.¹⁸

ADHD
ADHD commonly is comorbid with a sub­stance use disorder. Patients might pres­ent with an earlier diagnosis, including treatment. Several drugs of abuse can alle­viate ADHD symptoms, including amphet­amines, opioids, cocaine, and Cannabis; self-medicating is common. Because opi­oids increase dopamine release, a report of improved work and school performance while taking opioids early in addiction can be a clue to an ADHD diagnosis.

Explaining ADHD as a syndrome of “interest-based attention” helps. If a resi­dential treatment program uses reading and writing assignments, a patient with ADHD might struggle and will need extra help and time and a quiet place to do assignments.^19,20 A non-addictive medication, such as ato­moxetine, can help, but has an antidepres­sant-like delay of 3 to 5 weeks until onset of symptom relief. Using a long-acting stimu­lant can be effective and quick, with an effect size 3 to 4 times higher than atomoxetine; such agents should be avoided in patients who abuse amphetamines.

Studies show that treating ADHD, even with stimulants, neither helps nor hurts out­comes in substance use. Lisdexamfetamine is difficult to abuse and is an inactive prodrug (a bond of lysine and dextroamphetamine) that requires enzymatic cleavage and activa­tion by red blood cells; these characteristics creates a long-acting medication that has a lower abuse liability than other drugs for ADHD. However, abuse can occur and the drug must be used cautiously. Earley’s medi­cation guide referenced below recommends that lisdexamfetamine and other stimulants should be avoided if possible in patients in recovery. However, it adds that special­ists in treating ADHD in substance-abusing patients should weigh the potential benefits of stimulant use against the risk of relapse.¹⁷ Many patients enter treatment with a diag­nosis of bipolar disorder that might, in fact, be comorbid with ADHD.

Chronic pain
Many substance abuse patients began taking opioids for acute, then chronic, pain before their use escalated to addiction. These are challenging patients; often, they are referred for treatment without true addiction.

Keep in mind that dependence is not addiction. Pseudo-addiction is a condition in which pain is undertreated and the patient takes more medication to obtain relief, calls for early refills, and displays drug-seeking behavior but is not using drugs to achieve euphoria. A thorough history and physical and referrals to specialists such as orthopedic surgeons and pain specialists are necessary. Explaining opioid-induced hyperalgesia is important to help the patient understand that (1) pain can be made worse by increas­ing the dosage of an opioid because of supersensitivity and (2) many patients who are weaned off these drugs will experience a decrease or complete relief of pain.²¹

Gabapentin, duloxetine, or amitriptyline can be beneficial for chronic pain, as well as mindfulness techniques, physical therapy, and complementary and alternative medi­cine. Pregabalin can produce euphoria and often should be avoided.

A medication guide for recovery
Paul Earley, MD, former medical director at Talbott Recovery in Atlanta, Georgia, pub­lishes an online guide that classifies medica­tions into categories:
   • A: safe
   • B: use only under the supervision of an addiction medicine specialist or doctor
   • C: completely avoid if the patient is in recovery.¹⁷

The Talbott guide lists all stimulants in category C, (except for atomoxetine, which is category A). Hydroxyzine is listed under category B. Many programs for impaired professionals and state medical boards use the Guide, and will question the prescribing of any medication from categories B and C.¹⁷

Related Resources
• Spiegel DR, Kumari N, Petri JD. Safer use of benzodiaz­epines for alcohol detoxification. Current Psychiatry. 2012;11(10):10-15.
• Kelly TM, Daley DC, Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. Addict Behav. 2012;37(1):11-24.

Drug Brand Names
Amitriptyline • Elavil                                     Hydrocodone • Vicodin
Atenolol • Tenormin                                      Hydroxyzine • Vistaril, Atarax
Atomoxetine • Strattera                                Lisdexamfetamine • Vyvanse
Buprenorphine/ naloxone • Suboxone             Metoprolol • Lopressor, Toprol
Buspirone • BuSpar                                       Paroxetine • Paxil
Carbidopa-levodopa • Sinemet                       Pramipexole • Mirapex
Clonazepam • Klonopin                                  Prazosin • Minipress
Diazepam • Valium                                        Pregabalin • Lyrica
Doxepin • Silenor, Adapin, Sinequan               Propranolol • Inderal
Duloxetine • Cymbalta                                   Quetiapine • Seroquel
Escitalopram • Lexapro                                  Ropinirole • Requip
Gabapentin • Neurontin, Horizant                   Sertraline • Zoloft
                                                                   Trazodone • Desyrel

Disclosure
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

When treating patients who abuse substances, it is important to watch for underlying clinical conditions that have been sup­pressed, relieved, or muted by alcohol or drugs. Many of these conditions can be mistaken for signs of withdrawal, drug-seeking, or new conditions arising from loss of euphoria from the drug. Prompt recogni­tion of these disorders and use of appropriate non-addictive treatments can prevent “against medical advice” discharges, relapses, and unneeded suffering in many cases.

Because the brain is the target organ, these conditions are either neuro­logic or psychiatric in nosology. Although psychiatric clinicians might not be familiar with neurologic conditions, quick recognition and treatment is necessary.

Restless legs syndrome and periodic limb movements of sleep
Restless legs syndrome (RLS) has 2 key components: paresthesia and akathisia. Although primarily involving the lower extremities, involve­ment also can include the upper extremities, torso, and head.

Paresthesia differs from typical neuropathies in that it usually is not pain­ful; rather, patients describe an odd sensation using terms such as ticklish, “creepy-crawly,” and other uncomfortable sensations.

Akathisia is a motor restlessness and need to move. The patient might feel momentary relief by moving or rubbing the extremities, only to have the paresthesia return quickly followed by the akathisia. Generally, reclining is the most prominent position that produces symptoms, but they can occur while sitting.

The cause of RLS is an abnormality of central dopamine or iron, or both, in the sub­stantia nigra; iron is a cofactor in dopamine synthesis. All RLS patients should have a serum ferritin level drawn and if <50 μg/dL, be treated with iron supplementation. Dopamine agonists, such as ropinirole, pramipexole, and carbidopa/levodopa, are effective (Table 1); other useful agents include benzodiazepines such as clonaz­epam and opioids such as hydrocodone.

Gabapentin is not significantly metabo­lized by the liver, has a 3% rate of protein bind­ing, and is excreted by the kidneys—making it safe for patients who abuse alcohol or opi­oids and have impaired hepatic function. Typical starting dosages of IR gabapentin are 100 to 300 mg, 3 times daily, if symptoms are present in the daytime. Asymmetric dosing can be helpful, with larger or single dosages given at bedtime (eg, 100 mg in morning, 100 mg in afternoon, 300 mg at bedtime). Dosing varies from patient to patient, from 300 mg to 3,600 mg/d. Increasing dosages produce lower bioavailability because of saturation in absorption or at the blood-brain barrier. At 100 mg every 8 hours, bioavail­ability is 80% but at 1,600 mg every 8 hours it drops to 27%.³

Periodic limb movements of sleep (PLMS) essentially is akathisia during sleep, and occurs in most patients with RLS. The patient feels tired in the morning because of lack of deep stage-N3 sleep. Because of the inverse relationship between serotonin and dopamine, most selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors can exacerbate RLS and PLMS.^4,5 Other culprits include antipsychot­ics, antiemetics, and antihistamines. The differential diagnosis includes withdrawal from opioids and attention-deficit/hyper­activity disorder (ADHD), which may be comorbid with RLS. There are many causes of secondary RLS including renal failure, pregnancy, varicose veins, and neuropathy.

Tremor
Benign familial, or essential, tremor is a fine intention tremor that can be suppressed by alcohol or benzodiazepines. After detoxifica­tion from either of these substances, persis­tent tremor can re-emerge; often, it is benign, although cerebellar and parkinsonian trem­ors must be ruled out. Essential tremor can be treated with gabapentin or beta blockers such as propranolol or metoprolol (Table 2).

Anxiety and panic disorder
Social anxiety often presents in addiction treatment centers in the context of group therapy, speaking in 12-step meetings, and having the patient describe his (her) autobi­ography and history of addiction. Because social anxiety disorder is the third most com­mon psychiatric disorder after simple pho­bia and major depressive disorder,⁶ it is not surprising that it emerges after withdrawal.

Patients with social anxiety disorder might self-medicate with alcohol or drugs, especially benzodiazepines (Box). Residential treatment presents an excellent environment for desensitization to fears of public speaking; early recognition is key. Apprehension about group therapy, present­ing a substance abuse history, or speaking at a 12-step meeting can lead to premature or “against medical advice” discharge.

Panic disorder commonly is comorbid with substance abuse. Many patients will arrive at treatment with a prescription for benzodiaz­epines. Because the risk of cross-addiction is high among recovering addicts, benzodiaze­pines should be avoided. Treating underlying anxiety is crucial for fostering sobriety. Generalized anxiety disorder is common among patients with an addiction, and can lead to relapse if not addressed. Use of non-addictive medications and cognitive therapy is useful in addressing this condition.

A quandary might arise in states where medical marijuana is legal, because Cannabis can be prescribed for anxiety disorders and posttraumatic stress disorder (PTSD). Promoting abstinence from all substances can present a challenge in patients with anxi­ety disorders who live in these states.

Medications for anxiety and panic dis­order include gabapentin, buspirone, hydroxyzine, beta blockers, and atypical antipsychotics (Table 2). Only buspirone and hydroxyzine are FDA-approved for anxiety; buspirone monotherapy generally is ineffec­tive for panic disorder.

Explaining to patients how anxiety arises, such as how classical conditioning leads to specific phobias, can be therapeu­tic. Describing Klein’s false suffocation alarm theory of panic attacks can illustrate the importance of practicing slow, deep breathing to prevent hyperventilation.⁷ Also, relabeling a panic attack with self-talk state­ments such as “I know what this is. It’s just a panic attack” can be helpful. Smartphone apps are available to help patients cope with anxiety and acute panic.⁸

Mood disorders
Many patients with bipolar disorder expe­rience substance abuse at some point; esti­mates are that up to 57% of patients have a comorbid addiction.^6,9 Persons with a mood disorder are at high risk of substance abuse because of genetic factors; patients also might self-medicate their mood symptoms.

After alcohol or drugs are withdrawn, mood disorders can emerge or resurge. Often, patients enter treatment taking antidepressants and mood stabilizers and usually haven’t been truthful with their treatment provider about their substance abuse. Care must be taken to ascertain whether mood symptoms are secondary to substance abuse. Asking “What’s the longest period of abstinence you’ve had in 2 years and how did you feel emotionally?” often will help you identify a secondary mood disorder. For example, a response of “6 months and I felt really depressed the entire time” would indicate a primary depressive disorder.

Because CNS depressants, such as alco­hol and benzodiazepines, can exacerbate a mood disorder, consider continuing or resuming a mood stabilizer or antidepres­sant during substance abuse treatment. When meeting a new patient, perform an independent evaluation, because substance use can mimic bipolar and depressive dis­orders. Careful assessment of suicidal ide­ation is necessary for all patients.

Sleep disorders
Insomnia—as a primary or secondary disorder—is common among patients with a substance use disorder. Insomnia always needs to be addressed. Not sleeping well interferes with cognition and energy and makes depression and bipolar disorder worse. Some experts recommend “waiting out” the insomnia, hoping that sobriety will resolve it—but it might not.

Initial insomnia can be treated with mela­tonin, 3 to 6 mg at bedtime or earlier in the evening.^10-12 Melatonin acts by regulating circadian rhythms, but can cause increased dreaming and nightmares; therefore, it should be avoided in patients who struggle with nightmares. Trazodone, 50 to 150 mg at bedtime, is an inexpensive sleep aid for initial insomnia and doesn’t cause weight gain, which many drugs with antihistaminic properties can. Prazosin, 1 to 2 mg initially, for nightmares in PTSD is effective.¹³

Antipsychotics might be necessary if nothing else works; quetiapine is effective for sleep and the ER form is FDA-approved as an add-on agent in major depression. Low-dose doxepin (≤10 mg) is effective for middle insomnia.¹⁴ At these low dosages, troublesome side effects of tricyclic antide­pressants can be avoided.

As many as 40% of adults with ADHD have a delayed sleep-phase disorder. Ask your patient if she is a “night owl,” how chronic the condition is, and when her best sleep occurs.15-17 Morning light and evening melatonin can help, but often are insufficient. Many patients present with undiagnosed or untreated sleep apnea, which can cause excessive daytime sleepiness. Referral to a sleep center is prudent; use of the Epworth Sleepiness Scale is a quick way to assess excessive daytime sleepiness.¹⁸

ADHD
ADHD commonly is comorbid with a sub­stance use disorder. Patients might pres­ent with an earlier diagnosis, including treatment. Several drugs of abuse can alle­viate ADHD symptoms, including amphet­amines, opioids, cocaine, and Cannabis; self-medicating is common. Because opi­oids increase dopamine release, a report of improved work and school performance while taking opioids early in addiction can be a clue to an ADHD diagnosis.

Explaining ADHD as a syndrome of “interest-based attention” helps. If a resi­dential treatment program uses reading and writing assignments, a patient with ADHD might struggle and will need extra help and time and a quiet place to do assignments.^19,20 A non-addictive medication, such as ato­moxetine, can help, but has an antidepres­sant-like delay of 3 to 5 weeks until onset of symptom relief. Using a long-acting stimu­lant can be effective and quick, with an effect size 3 to 4 times higher than atomoxetine; such agents should be avoided in patients who abuse amphetamines.

Studies show that treating ADHD, even with stimulants, neither helps nor hurts out­comes in substance use. Lisdexamfetamine is difficult to abuse and is an inactive prodrug (a bond of lysine and dextroamphetamine) that requires enzymatic cleavage and activa­tion by red blood cells; these characteristics creates a long-acting medication that has a lower abuse liability than other drugs for ADHD. However, abuse can occur and the drug must be used cautiously. Earley’s medi­cation guide referenced below recommends that lisdexamfetamine and other stimulants should be avoided if possible in patients in recovery. However, it adds that special­ists in treating ADHD in substance-abusing patients should weigh the potential benefits of stimulant use against the risk of relapse.¹⁷ Many patients enter treatment with a diag­nosis of bipolar disorder that might, in fact, be comorbid with ADHD.

Chronic pain
Many substance abuse patients began taking opioids for acute, then chronic, pain before their use escalated to addiction. These are challenging patients; often, they are referred for treatment without true addiction.

Keep in mind that dependence is not addiction. Pseudo-addiction is a condition in which pain is undertreated and the patient takes more medication to obtain relief, calls for early refills, and displays drug-seeking behavior but is not using drugs to achieve euphoria. A thorough history and physical and referrals to specialists such as orthopedic surgeons and pain specialists are necessary. Explaining opioid-induced hyperalgesia is important to help the patient understand that (1) pain can be made worse by increas­ing the dosage of an opioid because of supersensitivity and (2) many patients who are weaned off these drugs will experience a decrease or complete relief of pain.²¹

Gabapentin, duloxetine, or amitriptyline can be beneficial for chronic pain, as well as mindfulness techniques, physical therapy, and complementary and alternative medi­cine. Pregabalin can produce euphoria and often should be avoided.

A medication guide for recovery
Paul Earley, MD, former medical director at Talbott Recovery in Atlanta, Georgia, pub­lishes an online guide that classifies medica­tions into categories:
   • A: safe
   • B: use only under the supervision of an addiction medicine specialist or doctor
   • C: completely avoid if the patient is in recovery.¹⁷

The Talbott guide lists all stimulants in category C, (except for atomoxetine, which is category A). Hydroxyzine is listed under category B. Many programs for impaired professionals and state medical boards use the Guide, and will question the prescribing of any medication from categories B and C.¹⁷

Related Resources
• Spiegel DR, Kumari N, Petri JD. Safer use of benzodiaz­epines for alcohol detoxification. Current Psychiatry. 2012;11(10):10-15.
• Kelly TM, Daley DC, Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. Addict Behav. 2012;37(1):11-24.

Drug Brand Names
Amitriptyline • Elavil                                     Hydrocodone • Vicodin
Atenolol • Tenormin                                      Hydroxyzine • Vistaril, Atarax
Atomoxetine • Strattera                                Lisdexamfetamine • Vyvanse
Buprenorphine/ naloxone • Suboxone             Metoprolol • Lopressor, Toprol
Buspirone • BuSpar                                       Paroxetine • Paxil
Carbidopa-levodopa • Sinemet                       Pramipexole • Mirapex
Clonazepam • Klonopin                                  Prazosin • Minipress
Diazepam • Valium                                        Pregabalin • Lyrica
Doxepin • Silenor, Adapin, Sinequan               Propranolol • Inderal
Duloxetine • Cymbalta                                   Quetiapine • Seroquel
Escitalopram • Lexapro                                  Ropinirole • Requip
Gabapentin • Neurontin, Horizant                   Sertraline • Zoloft
                                                                   Trazodone • Desyrel

Disclosure
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

When treating patients who abuse substances, it is important to watch for underlying clinical conditions that have been sup­pressed, relieved, or muted by alcohol or drugs. Many of these conditions can be mistaken for signs of withdrawal, drug-seeking, or new conditions arising from loss of euphoria from the drug. Prompt recogni­tion of these disorders and use of appropriate non-addictive treatments can prevent “against medical advice” discharges, relapses, and unneeded suffering in many cases.

Because the brain is the target organ, these conditions are either neuro­logic or psychiatric in nosology. Although psychiatric clinicians might not be familiar with neurologic conditions, quick recognition and treatment is necessary.

Restless legs syndrome and periodic limb movements of sleep
Restless legs syndrome (RLS) has 2 key components: paresthesia and akathisia. Although primarily involving the lower extremities, involve­ment also can include the upper extremities, torso, and head.

Paresthesia differs from typical neuropathies in that it usually is not pain­ful; rather, patients describe an odd sensation using terms such as ticklish, “creepy-crawly,” and other uncomfortable sensations.

Akathisia is a motor restlessness and need to move. The patient might feel momentary relief by moving or rubbing the extremities, only to have the paresthesia return quickly followed by the akathisia. Generally, reclining is the most prominent position that produces symptoms, but they can occur while sitting.

The cause of RLS is an abnormality of central dopamine or iron, or both, in the sub­stantia nigra; iron is a cofactor in dopamine synthesis. All RLS patients should have a serum ferritin level drawn and if <50 μg/dL, be treated with iron supplementation. Dopamine agonists, such as ropinirole, pramipexole, and carbidopa/levodopa, are effective (Table 1); other useful agents include benzodiazepines such as clonaz­epam and opioids such as hydrocodone.

Gabapentin is not significantly metabo­lized by the liver, has a 3% rate of protein bind­ing, and is excreted by the kidneys—making it safe for patients who abuse alcohol or opi­oids and have impaired hepatic function. Typical starting dosages of IR gabapentin are 100 to 300 mg, 3 times daily, if symptoms are present in the daytime. Asymmetric dosing can be helpful, with larger or single dosages given at bedtime (eg, 100 mg in morning, 100 mg in afternoon, 300 mg at bedtime). Dosing varies from patient to patient, from 300 mg to 3,600 mg/d. Increasing dosages produce lower bioavailability because of saturation in absorption or at the blood-brain barrier. At 100 mg every 8 hours, bioavail­ability is 80% but at 1,600 mg every 8 hours it drops to 27%.³

Periodic limb movements of sleep (PLMS) essentially is akathisia during sleep, and occurs in most patients with RLS. The patient feels tired in the morning because of lack of deep stage-N3 sleep. Because of the inverse relationship between serotonin and dopamine, most selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors can exacerbate RLS and PLMS.^4,5 Other culprits include antipsychot­ics, antiemetics, and antihistamines. The differential diagnosis includes withdrawal from opioids and attention-deficit/hyper­activity disorder (ADHD), which may be comorbid with RLS. There are many causes of secondary RLS including renal failure, pregnancy, varicose veins, and neuropathy.

Tremor
Benign familial, or essential, tremor is a fine intention tremor that can be suppressed by alcohol or benzodiazepines. After detoxifica­tion from either of these substances, persis­tent tremor can re-emerge; often, it is benign, although cerebellar and parkinsonian trem­ors must be ruled out. Essential tremor can be treated with gabapentin or beta blockers such as propranolol or metoprolol (Table 2).

Anxiety and panic disorder
Social anxiety often presents in addiction treatment centers in the context of group therapy, speaking in 12-step meetings, and having the patient describe his (her) autobi­ography and history of addiction. Because social anxiety disorder is the third most com­mon psychiatric disorder after simple pho­bia and major depressive disorder,⁶ it is not surprising that it emerges after withdrawal.

Patients with social anxiety disorder might self-medicate with alcohol or drugs, especially benzodiazepines (Box). Residential treatment presents an excellent environment for desensitization to fears of public speaking; early recognition is key. Apprehension about group therapy, present­ing a substance abuse history, or speaking at a 12-step meeting can lead to premature or “against medical advice” discharge.

Panic disorder commonly is comorbid with substance abuse. Many patients will arrive at treatment with a prescription for benzodiaz­epines. Because the risk of cross-addiction is high among recovering addicts, benzodiaze­pines should be avoided. Treating underlying anxiety is crucial for fostering sobriety. Generalized anxiety disorder is common among patients with an addiction, and can lead to relapse if not addressed. Use of non-addictive medications and cognitive therapy is useful in addressing this condition.

A quandary might arise in states where medical marijuana is legal, because Cannabis can be prescribed for anxiety disorders and posttraumatic stress disorder (PTSD). Promoting abstinence from all substances can present a challenge in patients with anxi­ety disorders who live in these states.

Medications for anxiety and panic dis­order include gabapentin, buspirone, hydroxyzine, beta blockers, and atypical antipsychotics (Table 2). Only buspirone and hydroxyzine are FDA-approved for anxiety; buspirone monotherapy generally is ineffec­tive for panic disorder.

Explaining to patients how anxiety arises, such as how classical conditioning leads to specific phobias, can be therapeu­tic. Describing Klein’s false suffocation alarm theory of panic attacks can illustrate the importance of practicing slow, deep breathing to prevent hyperventilation.⁷ Also, relabeling a panic attack with self-talk state­ments such as “I know what this is. It’s just a panic attack” can be helpful. Smartphone apps are available to help patients cope with anxiety and acute panic.⁸

Mood disorders
Many patients with bipolar disorder expe­rience substance abuse at some point; esti­mates are that up to 57% of patients have a comorbid addiction.^6,9 Persons with a mood disorder are at high risk of substance abuse because of genetic factors; patients also might self-medicate their mood symptoms.

After alcohol or drugs are withdrawn, mood disorders can emerge or resurge. Often, patients enter treatment taking antidepressants and mood stabilizers and usually haven’t been truthful with their treatment provider about their substance abuse. Care must be taken to ascertain whether mood symptoms are secondary to substance abuse. Asking “What’s the longest period of abstinence you’ve had in 2 years and how did you feel emotionally?” often will help you identify a secondary mood disorder. For example, a response of “6 months and I felt really depressed the entire time” would indicate a primary depressive disorder.

Because CNS depressants, such as alco­hol and benzodiazepines, can exacerbate a mood disorder, consider continuing or resuming a mood stabilizer or antidepres­sant during substance abuse treatment. When meeting a new patient, perform an independent evaluation, because substance use can mimic bipolar and depressive dis­orders. Careful assessment of suicidal ide­ation is necessary for all patients.

Sleep disorders
Insomnia—as a primary or secondary disorder—is common among patients with a substance use disorder. Insomnia always needs to be addressed. Not sleeping well interferes with cognition and energy and makes depression and bipolar disorder worse. Some experts recommend “waiting out” the insomnia, hoping that sobriety will resolve it—but it might not.

Initial insomnia can be treated with mela­tonin, 3 to 6 mg at bedtime or earlier in the evening.^10-12 Melatonin acts by regulating circadian rhythms, but can cause increased dreaming and nightmares; therefore, it should be avoided in patients who struggle with nightmares. Trazodone, 50 to 150 mg at bedtime, is an inexpensive sleep aid for initial insomnia and doesn’t cause weight gain, which many drugs with antihistaminic properties can. Prazosin, 1 to 2 mg initially, for nightmares in PTSD is effective.¹³

Antipsychotics might be necessary if nothing else works; quetiapine is effective for sleep and the ER form is FDA-approved as an add-on agent in major depression. Low-dose doxepin (≤10 mg) is effective for middle insomnia.¹⁴ At these low dosages, troublesome side effects of tricyclic antide­pressants can be avoided.

As many as 40% of adults with ADHD have a delayed sleep-phase disorder. Ask your patient if she is a “night owl,” how chronic the condition is, and when her best sleep occurs.15-17 Morning light and evening melatonin can help, but often are insufficient. Many patients present with undiagnosed or untreated sleep apnea, which can cause excessive daytime sleepiness. Referral to a sleep center is prudent; use of the Epworth Sleepiness Scale is a quick way to assess excessive daytime sleepiness.¹⁸

ADHD
ADHD commonly is comorbid with a sub­stance use disorder. Patients might pres­ent with an earlier diagnosis, including treatment. Several drugs of abuse can alle­viate ADHD symptoms, including amphet­amines, opioids, cocaine, and Cannabis; self-medicating is common. Because opi­oids increase dopamine release, a report of improved work and school performance while taking opioids early in addiction can be a clue to an ADHD diagnosis.

Explaining ADHD as a syndrome of “interest-based attention” helps. If a resi­dential treatment program uses reading and writing assignments, a patient with ADHD might struggle and will need extra help and time and a quiet place to do assignments.^19,20 A non-addictive medication, such as ato­moxetine, can help, but has an antidepres­sant-like delay of 3 to 5 weeks until onset of symptom relief. Using a long-acting stimu­lant can be effective and quick, with an effect size 3 to 4 times higher than atomoxetine; such agents should be avoided in patients who abuse amphetamines.

Studies show that treating ADHD, even with stimulants, neither helps nor hurts out­comes in substance use. Lisdexamfetamine is difficult to abuse and is an inactive prodrug (a bond of lysine and dextroamphetamine) that requires enzymatic cleavage and activa­tion by red blood cells; these characteristics creates a long-acting medication that has a lower abuse liability than other drugs for ADHD. However, abuse can occur and the drug must be used cautiously. Earley’s medi­cation guide referenced below recommends that lisdexamfetamine and other stimulants should be avoided if possible in patients in recovery. However, it adds that special­ists in treating ADHD in substance-abusing patients should weigh the potential benefits of stimulant use against the risk of relapse.¹⁷ Many patients enter treatment with a diag­nosis of bipolar disorder that might, in fact, be comorbid with ADHD.

Chronic pain
Many substance abuse patients began taking opioids for acute, then chronic, pain before their use escalated to addiction. These are challenging patients; often, they are referred for treatment without true addiction.

Keep in mind that dependence is not addiction. Pseudo-addiction is a condition in which pain is undertreated and the patient takes more medication to obtain relief, calls for early refills, and displays drug-seeking behavior but is not using drugs to achieve euphoria. A thorough history and physical and referrals to specialists such as orthopedic surgeons and pain specialists are necessary. Explaining opioid-induced hyperalgesia is important to help the patient understand that (1) pain can be made worse by increas­ing the dosage of an opioid because of supersensitivity and (2) many patients who are weaned off these drugs will experience a decrease or complete relief of pain.²¹

Gabapentin, duloxetine, or amitriptyline can be beneficial for chronic pain, as well as mindfulness techniques, physical therapy, and complementary and alternative medi­cine. Pregabalin can produce euphoria and often should be avoided.

A medication guide for recovery
Paul Earley, MD, former medical director at Talbott Recovery in Atlanta, Georgia, pub­lishes an online guide that classifies medica­tions into categories:
   • A: safe
   • B: use only under the supervision of an addiction medicine specialist or doctor
   • C: completely avoid if the patient is in recovery.¹⁷

The Talbott guide lists all stimulants in category C, (except for atomoxetine, which is category A). Hydroxyzine is listed under category B. Many programs for impaired professionals and state medical boards use the Guide, and will question the prescribing of any medication from categories B and C.¹⁷

Related Resources
• Spiegel DR, Kumari N, Petri JD. Safer use of benzodiaz­epines for alcohol detoxification. Current Psychiatry. 2012;11(10):10-15.
• Kelly TM, Daley DC, Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. Addict Behav. 2012;37(1):11-24.

Drug Brand Names
Amitriptyline • Elavil                                     Hydrocodone • Vicodin
Atenolol • Tenormin                                      Hydroxyzine • Vistaril, Atarax
Atomoxetine • Strattera                                Lisdexamfetamine • Vyvanse
Buprenorphine/ naloxone • Suboxone             Metoprolol • Lopressor, Toprol
Buspirone • BuSpar                                       Paroxetine • Paxil
Carbidopa-levodopa • Sinemet                       Pramipexole • Mirapex
Clonazepam • Klonopin                                  Prazosin • Minipress
Diazepam • Valium                                        Pregabalin • Lyrica
Doxepin • Silenor, Adapin, Sinequan               Propranolol • Inderal
Duloxetine • Cymbalta                                   Quetiapine • Seroquel
Escitalopram • Lexapro                                  Ropinirole • Requip
Gabapentin • Neurontin, Horizant                   Sertraline • Zoloft
                                                                   Trazodone • Desyrel

Disclosure
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

As part of a general trend among all medical spe­cialty boards, the American Board of Psychiatry and Neurology (ABPN) instituted a recertification process for all new general psychiatry certifications on October 1, 1994.¹ In 2000, the individual specialties that constitute the American Board of Medical Specialties (ABMS) subsequently agreed to develop a comprehensive maintenance of certification (MOC) pro­cess to demonstrate ongoing learning and competency beyond what could be captured by a recertification examination alone.

All ABMS member boards now use a 4-part process for recertification. For ABPN, those 4 core components are listed in the Table.^1,2

ABPN component 1 (maintaining an unrestricted medical license) and component 4 (passing the recertification examina­tion) are straightforward; however, requirements for continu­ing medical education (CME), including the specific need to accrue ABPN-approved self-assessment (SA) CME hours, and the Improvement in Medical Practice (performance in prac­tice, or PIP) module, have stoked significant commentary and confusion.

Based on feedback,^3,4 ABPN in 2014:
   • modified the SA and PIP requirements for physicians who certified or recertified between 2005 and 2011
   • changed the specific requirement for the PIP feedback component.

These modifications only added to feelings of uncertainty about the MOC process among many psychiatrists.⁵ 

Given the professional and personal importance attached to maintaining one’s general and subspecialty certifications, the 2 parts of this article—here and in the January 2015 issue—have been constructed to highlight current ABPN MOC require­ments and provide resources for understand­ing, tracking, and completing the SA and PIP portions.

In addition to this review, I urge all phy­sicians who are subject to MOC to read the 20-page revised MOC Program booklet^a (ver­sion 2.1, May 2014).⁵

^aDownload the booklet at www.abpn.com/downloads/moc/ moc_web_doc.pdf.

Who must recertify?
As of October 1, 1994, all physicians who achieve ABPN certifications in general psy­chiatry are issued a 10-year, time-limited certificate that expires on December 31 of the 10th year.³ Note that the 10-year, time-limited certificate in child and adolescent psychiatry began in 1995 and expires 10 years later on December 31.

Certificates in the subspecialties (addic­tion psychiatry, forensic psychiatry, geriat­ric psychiatry, etc.), including those issued before October 1, 1994, are 10-year, time-limited certificates that expire on December 31.³ This expiration date often is overlooked by physicians who are exempt from the MOC process for their general psychiatry, or child and adolescent psychiatry certifi­cation. There is no exemption for any sub­specialty certificate (aside from child and adolescent psychiatry before 1995), regard­less of the date of issue.

Moreover, physicians who hold a cer­tificate in a subspecialty also must maintain certification in their specialty (general psychi­atry) to apply for recertification in their sub­specialization. One exception: Diplomates in child and adolescent psychiatry do not need to maintain current certification in general psychiatry for their subspecialty certification to remain valid or to recertify in child and adolescent psychiatry.

The need to maintain multiple certifica­tions can seem onerous, but note that CME, SA, and PIP activities that have been com­pleted in one area of specialization or sub­specialization accrue and count for multiple certifications for diplomates certified in 2 or more areas.⁵

Get started!
Tracking your progress is critical to keep­ing up with MOC requirements. You can do this with a personal spreadsheet or by using online resources. Although it is not required, ABPN has established a system that allows diplomates to create and main­tain, at no cost, a physician folio on the ABPN server that facilitates documentation of CME hours, including specific SA hours, and PIP module completion.⁶ All diplomates are required to maintain records of SA activi­ties, CME activities, and PIP units; the ABPN will audit approximately 5% of examination applications.⁵

Regardless of what documentation method you choose, you should establish an active profile on the ABPN site (www.abpn. com/folios), confirm your contact infor­mation, and, if you are not active clinically, update your clinical status. ABPN requires that diplomates self-report their clinical sta­tus every 24 months—information that is available to the public. Clinical status also identifies to ABPN those PIP modules that you must complete.

ABPN recognizes 3 categories of clinical status⁵:
1. Clinically active. Provided any amount of direct or consultative care, or both, in the preceding 24 months, includ­ing supervision of residents.  
   a) Engaged in direct or consultative care, or both, sufficient to complete Improvement in Medical Practice (PIP) units.  
   b) Engaged in direct or consultative care, or both, that is insufficient to complete PIP units.

2. Clinically inactive. Did not provide direct or consultative care in the preceding 24 months.

3. Status unknown. No information is available on clinical activity.

Based on these definitions, physicians in Category 1a are required to complete all com­ponents of the MOC program, including PIP units; physicians in Category 1b or Category 2 are required to complete all components of the MOC program except PIP units.

A change in status from Category 1b or 2 to Category 1a (eg, moving from a purely administrative position to one with clinical duties) requires completion of ≥1 PIP unit.

The easy parts
Licenses. Maintaining your unrestricted professional license(s) is mandatory; the language of this requirement is unambigu­ous (Table).⁵ The plural form of license is intentional: Some physicians have medi­cal licenses in multiple states and, in some jurisdictions, licenses are required to super­vise physician assistants and other person­nel or to prescribe controlled substances. Any restriction on a professional license should be discussed with ABPN and resolved to prevent rejection of the exami­nation application.⁵

Examinations. For physicians who are not yet enrolled in the continuous-MOC (C-MOC) process (to be discussed in Part 2 of this article), an application to take the examination in Year 10 can be filed in Year 9 of the cycle—after the CME, SA, and PIP requirements are completed. Once a diplo­mate becomes subject to the C-MOC pro­cess by certifying or recertifying from 2012 onwards, completion of each 3-year module of CME, SA, and PIP will not coincide with the 10-year time frame of the examination.

The application deadline for all MOC examinations typically is the year before the examination; the examination should be taken in the year the certificate expires, although it can be taken earlier if desired.7 The examinations are computer-based and administered at a certified testing cen­ter. For diplomates who have more than 1 ABPN certificate and want to combine multiple examinations into 1 test session, a reduced fee structure applies.

The general psychiatry examination com­prises 220 single-answer, multiple-choice questions that must be completed within 290 minutes, with 10 extra minutes allotted to read on-screen instructions, sign in, and complete a post-examination survey.⁸ The combined examinations comprise 100 ques­tions from each ABPN specialty or subspe­cialty area.⁵

The content of the 2015 general psychiatry examination^b is available on the ABPN Web site.⁷ Note that the recertification examination in general psychiatry does not cover neurol­ogy topics.

^bDownload the outline of the examination at www.abpn.com/ downloads/content_outlines/MOC/2015-MOC-Psych-blueprint-060314-EWM-MR.pdf.

Examinations administered in 2015 and 2016 will use only diagnostic criteria that have not changed from DSM-IV-TR⁹: Neither obsolete diagnoses or subtypes from DSM-IV-TR nor new diagnoses or subtypes in DSM-5 (eg, hoarding disorder) will be tested.⁹ Diagnoses that are exactly or substantially the same will be tested; these include diagnoses:  
   • with a name change only (eg, “phono­logical disorder” in DSM-IV-TR is “speech sound disorder” in DSM-5)  
   • expanded into >1 new diagnosis (eg, hypochondriasis was expanded to 2 new diagnoses: somatic symptom disorder and ill­ness anxiety disorder)  
    • subsumed or combined into a new diag­nosis (eg, substance use and dependence are now combined into substance use disorder in DSM-5).⁹

For these diagnoses, both DSM-IV-TR and DSM-5 diagnoses will be provided on examinations.

Beginning in 2017, all examinations will use DSM-5 classifications and diagnostic criteria.⁹

Part 2 of this article in the January 2015 issue reviews other key aspects of MOC: continu­ing medical education (CME), including self-assessment requirements; performance in practice (PIP); and continuous maintenance of certification (C-MOC).

BOTTOM LINE
Maintenance of certification (MOC) is a manageable process, although it requires you to be familiar with its various elements, including the duration of certification, licensing requirements, and the examination. Start the process by (1) establishing a login on the ABPN Web site and (2) reviewing the MOC program booklet.

Related Resources
• ABPN MOC home page. www.abpn.com/moc.html
• ABPN-approved products for SA, CME, and PIP modules. www.abpn.com/moc_products.asp
• Peer and patient feedback forms– Peer feedback form v1. www.abpn.com/downloads/moc/PIP-peer-feedback-v1-051914.pdf
   – Patient feedback form v1. www.abpn.com/downloads/moc/PIP-patient-feedback-v1-051914.pdf
   – Patient feedback form v2. www.abpn.com/downloads/moc/PIP-patient-feedback-v2-051914.pdf
• ABPN physician folio page. https://application.abpn.com/webclient/folios.aspx

Disclosure
Dr. Meyer reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

As part of a general trend among all medical spe­cialty boards, the American Board of Psychiatry and Neurology (ABPN) instituted a recertification process for all new general psychiatry certifications on October 1, 1994.¹ In 2000, the individual specialties that constitute the American Board of Medical Specialties (ABMS) subsequently agreed to develop a comprehensive maintenance of certification (MOC) pro­cess to demonstrate ongoing learning and competency beyond what could be captured by a recertification examination alone.

All ABMS member boards now use a 4-part process for recertification. For ABPN, those 4 core components are listed in the Table.^1,2

ABPN component 1 (maintaining an unrestricted medical license) and component 4 (passing the recertification examina­tion) are straightforward; however, requirements for continu­ing medical education (CME), including the specific need to accrue ABPN-approved self-assessment (SA) CME hours, and the Improvement in Medical Practice (performance in prac­tice, or PIP) module, have stoked significant commentary and confusion.

Based on feedback,^3,4 ABPN in 2014:
   • modified the SA and PIP requirements for physicians who certified or recertified between 2005 and 2011
   • changed the specific requirement for the PIP feedback component.

These modifications only added to feelings of uncertainty about the MOC process among many psychiatrists.⁵ 

Given the professional and personal importance attached to maintaining one’s general and subspecialty certifications, the 2 parts of this article—here and in the January 2015 issue—have been constructed to highlight current ABPN MOC require­ments and provide resources for understand­ing, tracking, and completing the SA and PIP portions.

In addition to this review, I urge all phy­sicians who are subject to MOC to read the 20-page revised MOC Program booklet^a (ver­sion 2.1, May 2014).⁵

^aDownload the booklet at www.abpn.com/downloads/moc/ moc_web_doc.pdf.

Who must recertify?
As of October 1, 1994, all physicians who achieve ABPN certifications in general psy­chiatry are issued a 10-year, time-limited certificate that expires on December 31 of the 10th year.³ Note that the 10-year, time-limited certificate in child and adolescent psychiatry began in 1995 and expires 10 years later on December 31.

Certificates in the subspecialties (addic­tion psychiatry, forensic psychiatry, geriat­ric psychiatry, etc.), including those issued before October 1, 1994, are 10-year, time-limited certificates that expire on December 31.³ This expiration date often is overlooked by physicians who are exempt from the MOC process for their general psychiatry, or child and adolescent psychiatry certifi­cation. There is no exemption for any sub­specialty certificate (aside from child and adolescent psychiatry before 1995), regard­less of the date of issue.

Moreover, physicians who hold a cer­tificate in a subspecialty also must maintain certification in their specialty (general psychi­atry) to apply for recertification in their sub­specialization. One exception: Diplomates in child and adolescent psychiatry do not need to maintain current certification in general psychiatry for their subspecialty certification to remain valid or to recertify in child and adolescent psychiatry.

The need to maintain multiple certifica­tions can seem onerous, but note that CME, SA, and PIP activities that have been com­pleted in one area of specialization or sub­specialization accrue and count for multiple certifications for diplomates certified in 2 or more areas.⁵

Get started!
Tracking your progress is critical to keep­ing up with MOC requirements. You can do this with a personal spreadsheet or by using online resources. Although it is not required, ABPN has established a system that allows diplomates to create and main­tain, at no cost, a physician folio on the ABPN server that facilitates documentation of CME hours, including specific SA hours, and PIP module completion.⁶ All diplomates are required to maintain records of SA activi­ties, CME activities, and PIP units; the ABPN will audit approximately 5% of examination applications.⁵

Regardless of what documentation method you choose, you should establish an active profile on the ABPN site (www.abpn. com/folios), confirm your contact infor­mation, and, if you are not active clinically, update your clinical status. ABPN requires that diplomates self-report their clinical sta­tus every 24 months—information that is available to the public. Clinical status also identifies to ABPN those PIP modules that you must complete.

ABPN recognizes 3 categories of clinical status⁵:
1. Clinically active. Provided any amount of direct or consultative care, or both, in the preceding 24 months, includ­ing supervision of residents.  
   a) Engaged in direct or consultative care, or both, sufficient to complete Improvement in Medical Practice (PIP) units.  
   b) Engaged in direct or consultative care, or both, that is insufficient to complete PIP units.

2. Clinically inactive. Did not provide direct or consultative care in the preceding 24 months.

3. Status unknown. No information is available on clinical activity.

Based on these definitions, physicians in Category 1a are required to complete all com­ponents of the MOC program, including PIP units; physicians in Category 1b or Category 2 are required to complete all components of the MOC program except PIP units.

A change in status from Category 1b or 2 to Category 1a (eg, moving from a purely administrative position to one with clinical duties) requires completion of ≥1 PIP unit.

The easy parts
Licenses. Maintaining your unrestricted professional license(s) is mandatory; the language of this requirement is unambigu­ous (Table).⁵ The plural form of license is intentional: Some physicians have medi­cal licenses in multiple states and, in some jurisdictions, licenses are required to super­vise physician assistants and other person­nel or to prescribe controlled substances. Any restriction on a professional license should be discussed with ABPN and resolved to prevent rejection of the exami­nation application.⁵

Examinations. For physicians who are not yet enrolled in the continuous-MOC (C-MOC) process (to be discussed in Part 2 of this article), an application to take the examination in Year 10 can be filed in Year 9 of the cycle—after the CME, SA, and PIP requirements are completed. Once a diplo­mate becomes subject to the C-MOC pro­cess by certifying or recertifying from 2012 onwards, completion of each 3-year module of CME, SA, and PIP will not coincide with the 10-year time frame of the examination.

The application deadline for all MOC examinations typically is the year before the examination; the examination should be taken in the year the certificate expires, although it can be taken earlier if desired.7 The examinations are computer-based and administered at a certified testing cen­ter. For diplomates who have more than 1 ABPN certificate and want to combine multiple examinations into 1 test session, a reduced fee structure applies.

The general psychiatry examination com­prises 220 single-answer, multiple-choice questions that must be completed within 290 minutes, with 10 extra minutes allotted to read on-screen instructions, sign in, and complete a post-examination survey.⁸ The combined examinations comprise 100 ques­tions from each ABPN specialty or subspe­cialty area.⁵

The content of the 2015 general psychiatry examination^b is available on the ABPN Web site.⁷ Note that the recertification examination in general psychiatry does not cover neurol­ogy topics.

^bDownload the outline of the examination at www.abpn.com/ downloads/content_outlines/MOC/2015-MOC-Psych-blueprint-060314-EWM-MR.pdf.

Examinations administered in 2015 and 2016 will use only diagnostic criteria that have not changed from DSM-IV-TR⁹: Neither obsolete diagnoses or subtypes from DSM-IV-TR nor new diagnoses or subtypes in DSM-5 (eg, hoarding disorder) will be tested.⁹ Diagnoses that are exactly or substantially the same will be tested; these include diagnoses:  
   • with a name change only (eg, “phono­logical disorder” in DSM-IV-TR is “speech sound disorder” in DSM-5)  
   • expanded into >1 new diagnosis (eg, hypochondriasis was expanded to 2 new diagnoses: somatic symptom disorder and ill­ness anxiety disorder)  
    • subsumed or combined into a new diag­nosis (eg, substance use and dependence are now combined into substance use disorder in DSM-5).⁹

For these diagnoses, both DSM-IV-TR and DSM-5 diagnoses will be provided on examinations.

Beginning in 2017, all examinations will use DSM-5 classifications and diagnostic criteria.⁹

Part 2 of this article in the January 2015 issue reviews other key aspects of MOC: continu­ing medical education (CME), including self-assessment requirements; performance in practice (PIP); and continuous maintenance of certification (C-MOC).

BOTTOM LINE
Maintenance of certification (MOC) is a manageable process, although it requires you to be familiar with its various elements, including the duration of certification, licensing requirements, and the examination. Start the process by (1) establishing a login on the ABPN Web site and (2) reviewing the MOC program booklet.

Related Resources
• ABPN MOC home page. www.abpn.com/moc.html
• ABPN-approved products for SA, CME, and PIP modules. www.abpn.com/moc_products.asp
• Peer and patient feedback forms– Peer feedback form v1. www.abpn.com/downloads/moc/PIP-peer-feedback-v1-051914.pdf
   – Patient feedback form v1. www.abpn.com/downloads/moc/PIP-patient-feedback-v1-051914.pdf
   – Patient feedback form v2. www.abpn.com/downloads/moc/PIP-patient-feedback-v2-051914.pdf
• ABPN physician folio page. https://application.abpn.com/webclient/folios.aspx

Disclosure
Dr. Meyer reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

As part of a general trend among all medical spe­cialty boards, the American Board of Psychiatry and Neurology (ABPN) instituted a recertification process for all new general psychiatry certifications on October 1, 1994.¹ In 2000, the individual specialties that constitute the American Board of Medical Specialties (ABMS) subsequently agreed to develop a comprehensive maintenance of certification (MOC) pro­cess to demonstrate ongoing learning and competency beyond what could be captured by a recertification examination alone.

All ABMS member boards now use a 4-part process for recertification. For ABPN, those 4 core components are listed in the Table.^1,2

ABPN component 1 (maintaining an unrestricted medical license) and component 4 (passing the recertification examina­tion) are straightforward; however, requirements for continu­ing medical education (CME), including the specific need to accrue ABPN-approved self-assessment (SA) CME hours, and the Improvement in Medical Practice (performance in prac­tice, or PIP) module, have stoked significant commentary and confusion.

Based on feedback,^3,4 ABPN in 2014:
   • modified the SA and PIP requirements for physicians who certified or recertified between 2005 and 2011
   • changed the specific requirement for the PIP feedback component.

These modifications only added to feelings of uncertainty about the MOC process among many psychiatrists.⁵ 

Given the professional and personal importance attached to maintaining one’s general and subspecialty certifications, the 2 parts of this article—here and in the January 2015 issue—have been constructed to highlight current ABPN MOC require­ments and provide resources for understand­ing, tracking, and completing the SA and PIP portions.

In addition to this review, I urge all phy­sicians who are subject to MOC to read the 20-page revised MOC Program booklet^a (ver­sion 2.1, May 2014).⁵

^aDownload the booklet at www.abpn.com/downloads/moc/ moc_web_doc.pdf.

Who must recertify?
As of October 1, 1994, all physicians who achieve ABPN certifications in general psy­chiatry are issued a 10-year, time-limited certificate that expires on December 31 of the 10th year.³ Note that the 10-year, time-limited certificate in child and adolescent psychiatry began in 1995 and expires 10 years later on December 31.

Certificates in the subspecialties (addic­tion psychiatry, forensic psychiatry, geriat­ric psychiatry, etc.), including those issued before October 1, 1994, are 10-year, time-limited certificates that expire on December 31.³ This expiration date often is overlooked by physicians who are exempt from the MOC process for their general psychiatry, or child and adolescent psychiatry certifi­cation. There is no exemption for any sub­specialty certificate (aside from child and adolescent psychiatry before 1995), regard­less of the date of issue.

Moreover, physicians who hold a cer­tificate in a subspecialty also must maintain certification in their specialty (general psychi­atry) to apply for recertification in their sub­specialization. One exception: Diplomates in child and adolescent psychiatry do not need to maintain current certification in general psychiatry for their subspecialty certification to remain valid or to recertify in child and adolescent psychiatry.

The need to maintain multiple certifica­tions can seem onerous, but note that CME, SA, and PIP activities that have been com­pleted in one area of specialization or sub­specialization accrue and count for multiple certifications for diplomates certified in 2 or more areas.⁵

Get started!
Tracking your progress is critical to keep­ing up with MOC requirements. You can do this with a personal spreadsheet or by using online resources. Although it is not required, ABPN has established a system that allows diplomates to create and main­tain, at no cost, a physician folio on the ABPN server that facilitates documentation of CME hours, including specific SA hours, and PIP module completion.⁶ All diplomates are required to maintain records of SA activi­ties, CME activities, and PIP units; the ABPN will audit approximately 5% of examination applications.⁵

Regardless of what documentation method you choose, you should establish an active profile on the ABPN site (www.abpn. com/folios), confirm your contact infor­mation, and, if you are not active clinically, update your clinical status. ABPN requires that diplomates self-report their clinical sta­tus every 24 months—information that is available to the public. Clinical status also identifies to ABPN those PIP modules that you must complete.

ABPN recognizes 3 categories of clinical status⁵:
1. Clinically active. Provided any amount of direct or consultative care, or both, in the preceding 24 months, includ­ing supervision of residents.  
   a) Engaged in direct or consultative care, or both, sufficient to complete Improvement in Medical Practice (PIP) units.  
   b) Engaged in direct or consultative care, or both, that is insufficient to complete PIP units.

2. Clinically inactive. Did not provide direct or consultative care in the preceding 24 months.

3. Status unknown. No information is available on clinical activity.

Based on these definitions, physicians in Category 1a are required to complete all com­ponents of the MOC program, including PIP units; physicians in Category 1b or Category 2 are required to complete all components of the MOC program except PIP units.

A change in status from Category 1b or 2 to Category 1a (eg, moving from a purely administrative position to one with clinical duties) requires completion of ≥1 PIP unit.

The easy parts
Licenses. Maintaining your unrestricted professional license(s) is mandatory; the language of this requirement is unambigu­ous (Table).⁵ The plural form of license is intentional: Some physicians have medi­cal licenses in multiple states and, in some jurisdictions, licenses are required to super­vise physician assistants and other person­nel or to prescribe controlled substances. Any restriction on a professional license should be discussed with ABPN and resolved to prevent rejection of the exami­nation application.⁵

Examinations. For physicians who are not yet enrolled in the continuous-MOC (C-MOC) process (to be discussed in Part 2 of this article), an application to take the examination in Year 10 can be filed in Year 9 of the cycle—after the CME, SA, and PIP requirements are completed. Once a diplo­mate becomes subject to the C-MOC pro­cess by certifying or recertifying from 2012 onwards, completion of each 3-year module of CME, SA, and PIP will not coincide with the 10-year time frame of the examination.

The application deadline for all MOC examinations typically is the year before the examination; the examination should be taken in the year the certificate expires, although it can be taken earlier if desired.7 The examinations are computer-based and administered at a certified testing cen­ter. For diplomates who have more than 1 ABPN certificate and want to combine multiple examinations into 1 test session, a reduced fee structure applies.

The general psychiatry examination com­prises 220 single-answer, multiple-choice questions that must be completed within 290 minutes, with 10 extra minutes allotted to read on-screen instructions, sign in, and complete a post-examination survey.⁸ The combined examinations comprise 100 ques­tions from each ABPN specialty or subspe­cialty area.⁵

The content of the 2015 general psychiatry examination^b is available on the ABPN Web site.⁷ Note that the recertification examination in general psychiatry does not cover neurol­ogy topics.

^bDownload the outline of the examination at www.abpn.com/ downloads/content_outlines/MOC/2015-MOC-Psych-blueprint-060314-EWM-MR.pdf.

Examinations administered in 2015 and 2016 will use only diagnostic criteria that have not changed from DSM-IV-TR⁹: Neither obsolete diagnoses or subtypes from DSM-IV-TR nor new diagnoses or subtypes in DSM-5 (eg, hoarding disorder) will be tested.⁹ Diagnoses that are exactly or substantially the same will be tested; these include diagnoses:  
   • with a name change only (eg, “phono­logical disorder” in DSM-IV-TR is “speech sound disorder” in DSM-5)  
   • expanded into >1 new diagnosis (eg, hypochondriasis was expanded to 2 new diagnoses: somatic symptom disorder and ill­ness anxiety disorder)  
    • subsumed or combined into a new diag­nosis (eg, substance use and dependence are now combined into substance use disorder in DSM-5).⁹

For these diagnoses, both DSM-IV-TR and DSM-5 diagnoses will be provided on examinations.

Beginning in 2017, all examinations will use DSM-5 classifications and diagnostic criteria.⁹

Part 2 of this article in the January 2015 issue reviews other key aspects of MOC: continu­ing medical education (CME), including self-assessment requirements; performance in practice (PIP); and continuous maintenance of certification (C-MOC).

BOTTOM LINE
Maintenance of certification (MOC) is a manageable process, although it requires you to be familiar with its various elements, including the duration of certification, licensing requirements, and the examination. Start the process by (1) establishing a login on the ABPN Web site and (2) reviewing the MOC program booklet.

Related Resources
• ABPN MOC home page. www.abpn.com/moc.html
• ABPN-approved products for SA, CME, and PIP modules. www.abpn.com/moc_products.asp
• Peer and patient feedback forms– Peer feedback form v1. www.abpn.com/downloads/moc/PIP-peer-feedback-v1-051914.pdf
   – Patient feedback form v1. www.abpn.com/downloads/moc/PIP-patient-feedback-v1-051914.pdf
   – Patient feedback form v2. www.abpn.com/downloads/moc/PIP-patient-feedback-v2-051914.pdf
• ABPN physician folio page. https://application.abpn.com/webclient/folios.aspx

Disclosure
Dr. Meyer reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Millions of people suffer because they lack access to psychiatric care that they desperately need. The shortage of psychiatrists grows worse every day.

As a result of this anemic supply of psychiatrists, the mental health of the country’s populace is in jeopardy.

The facts paint the picture
The landmark National Institutes of Health-funded Epidemiologic Catchment Area (ECA) study, pub­lished a quarter of a century ago, found that 25% of the population suf­fered from a psychiatric disorder at some point in their life.¹ In 1990, that translated to 62 million people; today, the number would be 82 million.

Regrettably, the findings of the ECA were not followed by necessary action—simply, ensuring sufficient psychiatrists to meet the significant mental health needs of the nation.

Signs and symptoms
Manifestations of psychiatrynemia continue unabated:
   • frustration by primary care providers when they try to refer a patient to a psychiatrist—with appointments often unavailable for 4 to 6 months
   • lack of access to a psychiatrist within 100 miles in many rural areas
   • a large number of unfilled posi­tions for psychiatrists in many health care settings nationwide, which has created a thriving locum tenens industry
   • emergency rooms packed with psychiatric patients
   • a huge patient load in commu­nity mental health centers
   • a large increase in the percent­age of seriously mentally ill people in jails and prisons because of a lack of psychiatrists and psychiatric beds; according to Torrey et al,² the percentage of mentally ill patients incarcerated in the United States today is the same as it was in 1840, the pre-asylum era—shameful for a civilized country
   • an escalation of cash-only prac­tices and concierge psychiatry
   • a suicide rate that continues to rise (one wonders how many of the 40,600 deaths by suicide and 650,000 suicide attempts in 2012³ could have been prevented by prompt access to psychiatric care)
    • a severe shortage of psychiatric subspecialists (child, geriatric, addic­tion, psychosomatic); their numbers need to rise by 200% to 300% to meet the needs of those populations
    • an alarming overreliance on absurdly brief 15-minute med-checks as a way to cope with a large patient load.

What can be done?
To boost the number of psychiatric clini­cians and provide better access to care, I offer several prescriptions in the Box.⁴ (Yes, polytherapy is needed.)

Curing psychiatrynemia requires bold action on multiple fronts by differ­ent stakeholders. Considering the failure to act over the past 25 years, however, prospects for a quick remission are low.

We’re past needing an ounce of pre­vention; we need many pounds.

Millions of people suffer because they lack access to psychiatric care that they desperately need. The shortage of psychiatrists grows worse every day.

As a result of this anemic supply of psychiatrists, the mental health of the country’s populace is in jeopardy.

The facts paint the picture
The landmark National Institutes of Health-funded Epidemiologic Catchment Area (ECA) study, pub­lished a quarter of a century ago, found that 25% of the population suf­fered from a psychiatric disorder at some point in their life.¹ In 1990, that translated to 62 million people; today, the number would be 82 million.

Regrettably, the findings of the ECA were not followed by necessary action—simply, ensuring sufficient psychiatrists to meet the significant mental health needs of the nation.

Signs and symptoms
Manifestations of psychiatrynemia continue unabated:
   • frustration by primary care providers when they try to refer a patient to a psychiatrist—with appointments often unavailable for 4 to 6 months
   • lack of access to a psychiatrist within 100 miles in many rural areas
   • a large number of unfilled posi­tions for psychiatrists in many health care settings nationwide, which has created a thriving locum tenens industry
   • emergency rooms packed with psychiatric patients
   • a huge patient load in commu­nity mental health centers
   • a large increase in the percent­age of seriously mentally ill people in jails and prisons because of a lack of psychiatrists and psychiatric beds; according to Torrey et al,² the percentage of mentally ill patients incarcerated in the United States today is the same as it was in 1840, the pre-asylum era—shameful for a civilized country
   • an escalation of cash-only prac­tices and concierge psychiatry
   • a suicide rate that continues to rise (one wonders how many of the 40,600 deaths by suicide and 650,000 suicide attempts in 2012³ could have been prevented by prompt access to psychiatric care)
    • a severe shortage of psychiatric subspecialists (child, geriatric, addic­tion, psychosomatic); their numbers need to rise by 200% to 300% to meet the needs of those populations
    • an alarming overreliance on absurdly brief 15-minute med-checks as a way to cope with a large patient load.

What can be done?
To boost the number of psychiatric clini­cians and provide better access to care, I offer several prescriptions in the Box.⁴ (Yes, polytherapy is needed.)

Curing psychiatrynemia requires bold action on multiple fronts by differ­ent stakeholders. Considering the failure to act over the past 25 years, however, prospects for a quick remission are low.

We’re past needing an ounce of pre­vention; we need many pounds.

Millions of people suffer because they lack access to psychiatric care that they desperately need. The shortage of psychiatrists grows worse every day.

As a result of this anemic supply of psychiatrists, the mental health of the country’s populace is in jeopardy.

The facts paint the picture
The landmark National Institutes of Health-funded Epidemiologic Catchment Area (ECA) study, pub­lished a quarter of a century ago, found that 25% of the population suf­fered from a psychiatric disorder at some point in their life.¹ In 1990, that translated to 62 million people; today, the number would be 82 million.

Regrettably, the findings of the ECA were not followed by necessary action—simply, ensuring sufficient psychiatrists to meet the significant mental health needs of the nation.

Signs and symptoms
Manifestations of psychiatrynemia continue unabated:
   • frustration by primary care providers when they try to refer a patient to a psychiatrist—with appointments often unavailable for 4 to 6 months
   • lack of access to a psychiatrist within 100 miles in many rural areas
   • a large number of unfilled posi­tions for psychiatrists in many health care settings nationwide, which has created a thriving locum tenens industry
   • emergency rooms packed with psychiatric patients
   • a huge patient load in commu­nity mental health centers
   • a large increase in the percent­age of seriously mentally ill people in jails and prisons because of a lack of psychiatrists and psychiatric beds; according to Torrey et al,² the percentage of mentally ill patients incarcerated in the United States today is the same as it was in 1840, the pre-asylum era—shameful for a civilized country
   • an escalation of cash-only prac­tices and concierge psychiatry
   • a suicide rate that continues to rise (one wonders how many of the 40,600 deaths by suicide and 650,000 suicide attempts in 2012³ could have been prevented by prompt access to psychiatric care)
    • a severe shortage of psychiatric subspecialists (child, geriatric, addic­tion, psychosomatic); their numbers need to rise by 200% to 300% to meet the needs of those populations
    • an alarming overreliance on absurdly brief 15-minute med-checks as a way to cope with a large patient load.

What can be done?
To boost the number of psychiatric clini­cians and provide better access to care, I offer several prescriptions in the Box.⁴ (Yes, polytherapy is needed.)

Curing psychiatrynemia requires bold action on multiple fronts by differ­ent stakeholders. Considering the failure to act over the past 25 years, however, prospects for a quick remission are low.

We’re past needing an ounce of pre­vention; we need many pounds.

Patients with chronic illness, such as diabetes, are expected, and taught how, to participate in managing their disease. On the other hand, patients with serious mental illness historically have been thought of as passive recipients of care. Attitudes of care providers, patients, and family members are changing, how­ever, and, in the last decade, the Illness Management and Recovery (IMR) program has been developed for treating patients with serious mental illness, such as schizo­phrenia, using principles of chronic disease management.¹ Consider using this evi­dence-based psychosocial treatment modal­ity for your patients with schizophrenia.

Basic philosophy
A core assumption of IMR is realistic opti­mism that recovery is possible. Recovery, in this context, means that a patient can have a meaningful life despite having a serious illness. In IMR, patients engage in developing and tracking their prog­ress toward personally meaningful goals; that progress is broken down into small steps and worked on over the course of the program.

Critical components
IMR addresses practical matters of living with schizophrenia, including coping with symptoms and collaborating with provid­ers. The program combines elements from 6 areas:
   • psychoeducation
   • cognitive-behavioral approaches to medication management and other treatment targets
   • motivational interviewing
   • relapse prevention planning
   • social skills training
   • coping skills to manage persistent symptoms.

The original curriculum, which is avail­able free of charge, comprises 10 topics (Table).² Of note, the newest version, IMR-3, includes an additional module focused on healthy lifestyles.³

Implementation
Although typically delivered as a struc­tured weekly group intervention for 9 to 12 months, IMR can be taught individually. Involving a supportive person such as a family member, case manager, or residen­tial staff member can be useful. Physicians can select modules tailored to the patient’s needs. Any physician who wants to bring IMR to her (his) patient can download the SAMHSA Illness Management and Recovery Evidence-Based Practices KIT (Knowledge Informing Transformation).² This free down­load provides the full curriculum with hand­outs, and tips and training tools related to implementation and evaluation of IMR in a typical mental health care setting.

IMR is well-accepted by most participants; studies report a median 63% of patients com­plete IMR.⁴ Attendance for the intervention appears to be better in a group, rather than an individual, format. A number of patient characteristics, including older age, lower hostility, fewer psychotic symptoms, and more education, have been identified as pre­dictors of better attendance to manualized psychosocial treatments, such as IMR.⁵

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

Patients with chronic illness, such as diabetes, are expected, and taught how, to participate in managing their disease. On the other hand, patients with serious mental illness historically have been thought of as passive recipients of care. Attitudes of care providers, patients, and family members are changing, how­ever, and, in the last decade, the Illness Management and Recovery (IMR) program has been developed for treating patients with serious mental illness, such as schizo­phrenia, using principles of chronic disease management.¹ Consider using this evi­dence-based psychosocial treatment modal­ity for your patients with schizophrenia.

Basic philosophy
A core assumption of IMR is realistic opti­mism that recovery is possible. Recovery, in this context, means that a patient can have a meaningful life despite having a serious illness. In IMR, patients engage in developing and tracking their prog­ress toward personally meaningful goals; that progress is broken down into small steps and worked on over the course of the program.

Critical components
IMR addresses practical matters of living with schizophrenia, including coping with symptoms and collaborating with provid­ers. The program combines elements from 6 areas:
   • psychoeducation
   • cognitive-behavioral approaches to medication management and other treatment targets
   • motivational interviewing
   • relapse prevention planning
   • social skills training
   • coping skills to manage persistent symptoms.

The original curriculum, which is avail­able free of charge, comprises 10 topics (Table).² Of note, the newest version, IMR-3, includes an additional module focused on healthy lifestyles.³

Implementation
Although typically delivered as a struc­tured weekly group intervention for 9 to 12 months, IMR can be taught individually. Involving a supportive person such as a family member, case manager, or residen­tial staff member can be useful. Physicians can select modules tailored to the patient’s needs. Any physician who wants to bring IMR to her (his) patient can download the SAMHSA Illness Management and Recovery Evidence-Based Practices KIT (Knowledge Informing Transformation).² This free down­load provides the full curriculum with hand­outs, and tips and training tools related to implementation and evaluation of IMR in a typical mental health care setting.

IMR is well-accepted by most participants; studies report a median 63% of patients com­plete IMR.⁴ Attendance for the intervention appears to be better in a group, rather than an individual, format. A number of patient characteristics, including older age, lower hostility, fewer psychotic symptoms, and more education, have been identified as pre­dictors of better attendance to manualized psychosocial treatments, such as IMR.⁵

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

Patients with chronic illness, such as diabetes, are expected, and taught how, to participate in managing their disease. On the other hand, patients with serious mental illness historically have been thought of as passive recipients of care. Attitudes of care providers, patients, and family members are changing, how­ever, and, in the last decade, the Illness Management and Recovery (IMR) program has been developed for treating patients with serious mental illness, such as schizo­phrenia, using principles of chronic disease management.¹ Consider using this evi­dence-based psychosocial treatment modal­ity for your patients with schizophrenia.

Basic philosophy
A core assumption of IMR is realistic opti­mism that recovery is possible. Recovery, in this context, means that a patient can have a meaningful life despite having a serious illness. In IMR, patients engage in developing and tracking their prog­ress toward personally meaningful goals; that progress is broken down into small steps and worked on over the course of the program.

Critical components
IMR addresses practical matters of living with schizophrenia, including coping with symptoms and collaborating with provid­ers. The program combines elements from 6 areas:
   • psychoeducation
   • cognitive-behavioral approaches to medication management and other treatment targets
   • motivational interviewing
   • relapse prevention planning
   • social skills training
   • coping skills to manage persistent symptoms.

The original curriculum, which is avail­able free of charge, comprises 10 topics (Table).² Of note, the newest version, IMR-3, includes an additional module focused on healthy lifestyles.³

Implementation
Although typically delivered as a struc­tured weekly group intervention for 9 to 12 months, IMR can be taught individually. Involving a supportive person such as a family member, case manager, or residen­tial staff member can be useful. Physicians can select modules tailored to the patient’s needs. Any physician who wants to bring IMR to her (his) patient can download the SAMHSA Illness Management and Recovery Evidence-Based Practices KIT (Knowledge Informing Transformation).² This free down­load provides the full curriculum with hand­outs, and tips and training tools related to implementation and evaluation of IMR in a typical mental health care setting.

IMR is well-accepted by most participants; studies report a median 63% of patients com­plete IMR.⁴ Attendance for the intervention appears to be better in a group, rather than an individual, format. A number of patient characteristics, including older age, lower hostility, fewer psychotic symptoms, and more education, have been identified as pre­dictors of better attendance to manualized psychosocial treatments, such as IMR.⁵

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

Let me begin with a story.

A few years ago, when I was hop­ing to get into a psychiatry residency program, I did a month-long rotation in the intensive care unit (ICU) of a local hospital. One of our patients was a long-term resident of a nearby assisted living facility, who was treated for exacerbation of a chronic medical illness. Eventually this patient was stabilized to the point at which he could be discharged.

When the ICU physician decided to dis­charge this patient, he told the team that the man would need to be “sent back to a nurs­ing home.” The social worker, assuming that the physician wanted to place the patient in a skilled nursing facility, spent several hours trying to place the man in one of the local facilities. When the patient’s daughter arrived to visit her father and began asking questions about why he was being placed in a nursing home, staff immediately realized that the physician had simply meant for him to go back “home”—that is, to the facility from which he had come and where he had been living for several years.

Being the only person in the ICU who was a licensed nursing home administra­tor, with more than 10 years experience in a long-term care, I should have pointed out this miscommunication or, at least, should have raised the question to clarify the physi­cian’s intent. At the time, however, I wasn’t comfortable expressing my concern because I was “just an FMG observer” trying to stay on the attending’s good side.

I made a commitment to myself, however, to always talk about patients’ long-term care options and discharge planning algorithm with medical students, fellow residents, and other medical professionals I meet in my work. The following is an expression of that commitment.

Why focus on discharge when care is still underway?
Discharge planning usually begins on the first day of hospitalization. Before we are ready to discharge any patient, we, the physicians, usually have had many con­versations with members of the multidisci­plinary team and, always, with the patient and his (her) guardian(s). Why do we do all of this? The answer is simple: Physicians make the ultimate decision about what kind of environment (clinical, social, etc.) the patient is safe to be discharged to; after that decision is made, everything else is the patient’s choice. Our decision should be based on, first, global assessment of functioning—the ability to perform activities of daily living (ADL) and instrumental (non-essential) ADL—and, second, essential input from members of multidisciplinary team.

Here is an example to illustrate this point: If we (the multidisciplinary team) believe that a patient who has lived alone and, up to this point, was able to handle his own affairs, will not be safe if he is discharged to his home (based on observation of his over­all daily functioning) but he refuses to be institutionalized, we can evaluate his com­petency and initiate a motion to obtain a temporary guardianship.

If, on the other hand, we think that a patient needs to be placed in a skilled nursing facility and he, being fully aware of his condition, agrees with the decision of the multidisciplinary team, we cannot place him in a facility of our choosing (if it is against his will). Rather, we must give him options of facilities with similar ser­vices that meet his needs and let him or his guardian select the facility in which he’s to be placed.


How do we decide on the best course?
To choose what kind of environment a patient needs to be placed in after discharge, we can apply a simple algorithm (Box):
 

The patient does not need 24-hour pro­tective oversight or needs some, but not 24-hour, care. Discharge him to a home-and community-based care setting—with arrangements for home health agency services or a home-modification program. The patient would either live indepen­dently or in a group home setting, depend­ing on how much assistance he requires.

The patient does need 24-hour protective oversight and more than minimal assis­tance with ADL but doesn’t need 24-hour care, IV medication, etc.). In this case, the patient can be discharged to an assisted living or residential care facility, assuming that he is able to 1) find a so-called path to safety in an emergency (this why facilities are required to perform 1 fire drill per shift per month) and 2) afford rent, because Medicaid, Medicare, and many private insurance policies do not cover housing expenses (see “Keep financing in mind,” in the next section).

The patient is bed-bound or needs 24-hour treatment (eg, receives IV medi­cation or needs total nursing care) or is not bed-bound but is unable to find a path to safety (eg, a person with dementia). This kind of patient must be placed in a skilled nursing facility

Keep financing in mind
The patient’s ability to pay, as well as hav­ing access to insurance or a financial assis­tance program, is a major contributing factor in discharge planning. All financial options need to be considered by the physi­cians leading the discharge planning team.

Neither Medicaid nor Medicare ben­efits are available to pay rent; these insur­ance programs pay for medical services only. Medicaid does provide some money for assistance with ADL in home- and community-based settings (such assistance is arranged through, and provided by, home health care agencies) and to Medicaid-eligible residents of an assisted living facility.

Medicaid covers 100% of a nursing home stay for an eligible resident. Medicare might cover the cost of skilled-nursing facility care if the placement falls under the criterion of an “episode of care.”

It is worth mentioning that some Veterans’ Administration money might be available to a veteran or his (her) sur­viving spouse for assistance with ADL in home- and community-based settings or if he (she) is institutionalized. Other local programs might provide eligible recipients with long-term care services; discharge social workers, as members of the multi­disciplinary team, usually are resourceful at identifying such programs.

All in all, a complex project
Discharge planning is almost as important as the treatment given to the patient. It can be difficult to put all the pieces of the discharge plan together; sometimes, unclear disposition is the only reason a patient is kept in the hospital after being stabilized.

Above all, our ability to work with the multidisciplinary team and our knowledge of these simple steps will help us navigate our patients’ care plan successfully.


Disclosure
Dr. Graypel reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Let me begin with a story.

A few years ago, when I was hop­ing to get into a psychiatry residency program, I did a month-long rotation in the intensive care unit (ICU) of a local hospital. One of our patients was a long-term resident of a nearby assisted living facility, who was treated for exacerbation of a chronic medical illness. Eventually this patient was stabilized to the point at which he could be discharged.

When the ICU physician decided to dis­charge this patient, he told the team that the man would need to be “sent back to a nurs­ing home.” The social worker, assuming that the physician wanted to place the patient in a skilled nursing facility, spent several hours trying to place the man in one of the local facilities. When the patient’s daughter arrived to visit her father and began asking questions about why he was being placed in a nursing home, staff immediately realized that the physician had simply meant for him to go back “home”—that is, to the facility from which he had come and where he had been living for several years.

Being the only person in the ICU who was a licensed nursing home administra­tor, with more than 10 years experience in a long-term care, I should have pointed out this miscommunication or, at least, should have raised the question to clarify the physi­cian’s intent. At the time, however, I wasn’t comfortable expressing my concern because I was “just an FMG observer” trying to stay on the attending’s good side.

I made a commitment to myself, however, to always talk about patients’ long-term care options and discharge planning algorithm with medical students, fellow residents, and other medical professionals I meet in my work. The following is an expression of that commitment.

Why focus on discharge when care is still underway?
Discharge planning usually begins on the first day of hospitalization. Before we are ready to discharge any patient, we, the physicians, usually have had many con­versations with members of the multidisci­plinary team and, always, with the patient and his (her) guardian(s). Why do we do all of this? The answer is simple: Physicians make the ultimate decision about what kind of environment (clinical, social, etc.) the patient is safe to be discharged to; after that decision is made, everything else is the patient’s choice. Our decision should be based on, first, global assessment of functioning—the ability to perform activities of daily living (ADL) and instrumental (non-essential) ADL—and, second, essential input from members of multidisciplinary team.

Here is an example to illustrate this point: If we (the multidisciplinary team) believe that a patient who has lived alone and, up to this point, was able to handle his own affairs, will not be safe if he is discharged to his home (based on observation of his over­all daily functioning) but he refuses to be institutionalized, we can evaluate his com­petency and initiate a motion to obtain a temporary guardianship.

If, on the other hand, we think that a patient needs to be placed in a skilled nursing facility and he, being fully aware of his condition, agrees with the decision of the multidisciplinary team, we cannot place him in a facility of our choosing (if it is against his will). Rather, we must give him options of facilities with similar ser­vices that meet his needs and let him or his guardian select the facility in which he’s to be placed.


How do we decide on the best course?
To choose what kind of environment a patient needs to be placed in after discharge, we can apply a simple algorithm (Box):
 

The patient does not need 24-hour pro­tective oversight or needs some, but not 24-hour, care. Discharge him to a home-and community-based care setting—with arrangements for home health agency services or a home-modification program. The patient would either live indepen­dently or in a group home setting, depend­ing on how much assistance he requires.

The patient does need 24-hour protective oversight and more than minimal assis­tance with ADL but doesn’t need 24-hour care, IV medication, etc.). In this case, the patient can be discharged to an assisted living or residential care facility, assuming that he is able to 1) find a so-called path to safety in an emergency (this why facilities are required to perform 1 fire drill per shift per month) and 2) afford rent, because Medicaid, Medicare, and many private insurance policies do not cover housing expenses (see “Keep financing in mind,” in the next section).

The patient is bed-bound or needs 24-hour treatment (eg, receives IV medi­cation or needs total nursing care) or is not bed-bound but is unable to find a path to safety (eg, a person with dementia). This kind of patient must be placed in a skilled nursing facility

Keep financing in mind
The patient’s ability to pay, as well as hav­ing access to insurance or a financial assis­tance program, is a major contributing factor in discharge planning. All financial options need to be considered by the physi­cians leading the discharge planning team.

Neither Medicaid nor Medicare ben­efits are available to pay rent; these insur­ance programs pay for medical services only. Medicaid does provide some money for assistance with ADL in home- and community-based settings (such assistance is arranged through, and provided by, home health care agencies) and to Medicaid-eligible residents of an assisted living facility.

Medicaid covers 100% of a nursing home stay for an eligible resident. Medicare might cover the cost of skilled-nursing facility care if the placement falls under the criterion of an “episode of care.”

It is worth mentioning that some Veterans’ Administration money might be available to a veteran or his (her) sur­viving spouse for assistance with ADL in home- and community-based settings or if he (she) is institutionalized. Other local programs might provide eligible recipients with long-term care services; discharge social workers, as members of the multi­disciplinary team, usually are resourceful at identifying such programs.

All in all, a complex project
Discharge planning is almost as important as the treatment given to the patient. It can be difficult to put all the pieces of the discharge plan together; sometimes, unclear disposition is the only reason a patient is kept in the hospital after being stabilized.

Above all, our ability to work with the multidisciplinary team and our knowledge of these simple steps will help us navigate our patients’ care plan successfully.


Disclosure
Dr. Graypel reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Let me begin with a story.

A few years ago, when I was hop­ing to get into a psychiatry residency program, I did a month-long rotation in the intensive care unit (ICU) of a local hospital. One of our patients was a long-term resident of a nearby assisted living facility, who was treated for exacerbation of a chronic medical illness. Eventually this patient was stabilized to the point at which he could be discharged.

When the ICU physician decided to dis­charge this patient, he told the team that the man would need to be “sent back to a nurs­ing home.” The social worker, assuming that the physician wanted to place the patient in a skilled nursing facility, spent several hours trying to place the man in one of the local facilities. When the patient’s daughter arrived to visit her father and began asking questions about why he was being placed in a nursing home, staff immediately realized that the physician had simply meant for him to go back “home”—that is, to the facility from which he had come and where he had been living for several years.

Being the only person in the ICU who was a licensed nursing home administra­tor, with more than 10 years experience in a long-term care, I should have pointed out this miscommunication or, at least, should have raised the question to clarify the physi­cian’s intent. At the time, however, I wasn’t comfortable expressing my concern because I was “just an FMG observer” trying to stay on the attending’s good side.

I made a commitment to myself, however, to always talk about patients’ long-term care options and discharge planning algorithm with medical students, fellow residents, and other medical professionals I meet in my work. The following is an expression of that commitment.

Why focus on discharge when care is still underway?
Discharge planning usually begins on the first day of hospitalization. Before we are ready to discharge any patient, we, the physicians, usually have had many con­versations with members of the multidisci­plinary team and, always, with the patient and his (her) guardian(s). Why do we do all of this? The answer is simple: Physicians make the ultimate decision about what kind of environment (clinical, social, etc.) the patient is safe to be discharged to; after that decision is made, everything else is the patient’s choice. Our decision should be based on, first, global assessment of functioning—the ability to perform activities of daily living (ADL) and instrumental (non-essential) ADL—and, second, essential input from members of multidisciplinary team.

Here is an example to illustrate this point: If we (the multidisciplinary team) believe that a patient who has lived alone and, up to this point, was able to handle his own affairs, will not be safe if he is discharged to his home (based on observation of his over­all daily functioning) but he refuses to be institutionalized, we can evaluate his com­petency and initiate a motion to obtain a temporary guardianship.

If, on the other hand, we think that a patient needs to be placed in a skilled nursing facility and he, being fully aware of his condition, agrees with the decision of the multidisciplinary team, we cannot place him in a facility of our choosing (if it is against his will). Rather, we must give him options of facilities with similar ser­vices that meet his needs and let him or his guardian select the facility in which he’s to be placed.


How do we decide on the best course?
To choose what kind of environment a patient needs to be placed in after discharge, we can apply a simple algorithm (Box):
 

The patient does not need 24-hour pro­tective oversight or needs some, but not 24-hour, care. Discharge him to a home-and community-based care setting—with arrangements for home health agency services or a home-modification program. The patient would either live indepen­dently or in a group home setting, depend­ing on how much assistance he requires.

The patient does need 24-hour protective oversight and more than minimal assis­tance with ADL but doesn’t need 24-hour care, IV medication, etc.). In this case, the patient can be discharged to an assisted living or residential care facility, assuming that he is able to 1) find a so-called path to safety in an emergency (this why facilities are required to perform 1 fire drill per shift per month) and 2) afford rent, because Medicaid, Medicare, and many private insurance policies do not cover housing expenses (see “Keep financing in mind,” in the next section).

The patient is bed-bound or needs 24-hour treatment (eg, receives IV medi­cation or needs total nursing care) or is not bed-bound but is unable to find a path to safety (eg, a person with dementia). This kind of patient must be placed in a skilled nursing facility

Keep financing in mind
The patient’s ability to pay, as well as hav­ing access to insurance or a financial assis­tance program, is a major contributing factor in discharge planning. All financial options need to be considered by the physi­cians leading the discharge planning team.

Neither Medicaid nor Medicare ben­efits are available to pay rent; these insur­ance programs pay for medical services only. Medicaid does provide some money for assistance with ADL in home- and community-based settings (such assistance is arranged through, and provided by, home health care agencies) and to Medicaid-eligible residents of an assisted living facility.

Medicaid covers 100% of a nursing home stay for an eligible resident. Medicare might cover the cost of skilled-nursing facility care if the placement falls under the criterion of an “episode of care.”

It is worth mentioning that some Veterans’ Administration money might be available to a veteran or his (her) sur­viving spouse for assistance with ADL in home- and community-based settings or if he (she) is institutionalized. Other local programs might provide eligible recipients with long-term care services; discharge social workers, as members of the multi­disciplinary team, usually are resourceful at identifying such programs.

All in all, a complex project
Discharge planning is almost as important as the treatment given to the patient. It can be difficult to put all the pieces of the discharge plan together; sometimes, unclear disposition is the only reason a patient is kept in the hospital after being stabilized.

Above all, our ability to work with the multidisciplinary team and our knowledge of these simple steps will help us navigate our patients’ care plan successfully.


Disclosure
Dr. Graypel reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.