Current Psychiatry

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

I explained to them that schizophrenia is a neurodevelopmental syndrome that comprises hundreds of different disorders of genetic or non-genetic etiology, all of which share a similar psychotic phenotype. Although the various genetic causes of schizophre­nia are difficult to prevent—but may be prevented in the future with epi­genetic techniques—the many non-genetic (environmental) pathways to schizophrenia can be avoided to significantly reduce the incidence of schizophrenia by 40% to 50%, accord­ing to some estimates.

I will share what I told this couple, because even couples without any family history of psychosis may have a child who develops schizophrenia because of a variety of environmental risk factors.

Genetic risk factors
One-half of the 20,000 genes in the 23 chromosomes of the human genome participate in constructing and sculpt­ing the extremely intricate and com­plex human brain. There are many ways that genetic factors can increase the risk of schizophrenia,¹ and only some are transmitted by parents:

Risk genes. More than 30 risk genes have been identified as heritable in schizophrenia. They are spread over many chromosomes and more are likely to be discovered. Most of those risk genes regulate glutamate— not dopamine—pathways, and each increases the risk by 2% to 4%.

Copy number variations (CNVs) are pro­duced via meiosis mishaps, where 1 or 3 alleles of certain genes are formed instead of the usual 2. A high frequency of CNVs have been found in schizophrenia com­pared with the general population—but also are found in autism and bipolar disorders—and are believed to disrupt brain development in various ways.

De novo mutations. Recent studies on large samples of people with schizo­phrenia (50,000 to 100,000) uncovered a much higher rate of mutations (some code for proteins while others are non­sense mutations that code for noth­ing). Obviously, these mutations led to anomalous neurodevelopment.

There are hundreds, maybe thou­sands, of genetic subtypes within the schizophrenia syndrome. Advances in epigenetics, which allow silencing of culprit genes or overexpression of protective genes, one day may enable psychiatric geneticists to prevent schizo­phrenia in fetuses at risk.

Non-genetic risk factors
Just as with the genetic patho-genic heterogeneity, the schizo­phrenia syndrome can be caused by numerous environmental adverse events,² many of which can be avoided, including:

Older paternal age (>45) at time of conception doubles or triples the risk of schizophrenia³ as well as autism and bipolar disorder. Aging sperm are associated with a higher rate of DNA fragmentation and genetic mutations.

Prenatal complications, especially during the second trimester when CNS development takes place. These adverse prenatal events skew fetal brain development to produce psy­chosis in adulthood and can be mini­mized with optimal prenatal care, which sadly is lacking among the poor. These include:
   • Vaginal infections before preg­nancy,⁴ such as herpes simplex virus, can cause fetal brain inflammation and increased risk of schizophrenia.
   • Infections during pregnancy— whether bacterial, viral, or proto­zoan (Toxoplasma gondii)—have been shown to significantly increase the risk of schizophrenia in offspring.⁵ An increase in serum C-reactive protein during pregnancy also is a biomarker of increased risk.
   • Poor diet, especially starva­tion, can double or triple the risk of schizophrenia.
   • Vitamin deficiency, especially folate and vitamin D, are critical for normal brain development.⁶ Vitamin D is vital to mitigate neuroinflammation.
   • Smoking before and during pregnancy.⁴
   • Medical illness during preg­nancy, especially gestational diabetes, increases the risk of schizophrenia in the fetus by 800%.⁷
   • Severe stress during pregnancy, such as the death of the spouse, dou­bles the risk of schizophrenia.²
   • Schizophrenia risk is 400% to 500% higher among those born and raised in an urban area, compared with a rural area.⁸
   • Babies born in northern latitudes, such as in Sweden, Norway, or Canada, have a 10-fold risk of schizophrenia in adulthood compared with babies born near the equator.⁶ This has been attrib­uted to lack of sunshine and the risk of severe vitamin D deficiency in north­ern latitudes.
   • High maternal body mass index during the first trimester⁷ increases the child’s risk of schizophrenia.
   • Low number of prenatal vis­its is associated with higher risk of schizophrenia.
   • Obstetric complications that cause hypoxia and a low Apgar score after birth increase the risk of schizophrenia. This includes long labor, cord around the neck, meco­nium spillage into the amniotic fluid, and mechanical injury with forceps delivery.
   • Infection in the newborn shortly after birth.

Severe physical or sexual abuse before age 5 is associated with increased risk of schizophrenia in adulthood.² This may be because of stress-induced epigenetic mechanisms (silencing or overexpressing certain genes).

Migration has been shown to increase the risk of schizophrenia by 3 to 5 fold. The exact reason is unclear, but it could be a combination of social stress, exposure to new types of germs, less sunshine, and even a different diet.

My advice to the couple? Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids); take ade­quate doses of folate and vitamin D, per­haps even choline⁹; avoid smoking before and during pregnancy; adopt a healthy, balanced diet; avoid excessive weight gain and/or gestational diabetes; avoid contact with people with infections; avoid expo­sure to cat feces (toxoplasmosis); sched­ule frequent prenatal visits; and hope for a smooth and uneventful delivery and a newborn with an Apgar score of 9 or 10. All this will greatly reduce the non-genetic risks of schizophrenia, but is unlikely to modify the genetic risks. However, it has been shown that a combination of both genetic and non-genetic risk factors is associated with a more severe form of schizophrenia.¹⁰

Optimal prenatal and postnatal care can be helpful for couples with a family history of schizophrenia (without mov­ing to deliver their baby in a rural village near the equator). However, if their child starts using marijuana during adolescence, all bets are off. The risk of schizophrenia and serious cortical tissue loss increases dramatically when a carrier of risk genes use Cannabis. But that’s another editorial, to be read by clinicians in states where marijuana has been (foolishly, I believe) legalized.

I explained to them that schizophrenia is a neurodevelopmental syndrome that comprises hundreds of different disorders of genetic or non-genetic etiology, all of which share a similar psychotic phenotype. Although the various genetic causes of schizophre­nia are difficult to prevent—but may be prevented in the future with epi­genetic techniques—the many non-genetic (environmental) pathways to schizophrenia can be avoided to significantly reduce the incidence of schizophrenia by 40% to 50%, accord­ing to some estimates.

I will share what I told this couple, because even couples without any family history of psychosis may have a child who develops schizophrenia because of a variety of environmental risk factors.

Genetic risk factors
One-half of the 20,000 genes in the 23 chromosomes of the human genome participate in constructing and sculpt­ing the extremely intricate and com­plex human brain. There are many ways that genetic factors can increase the risk of schizophrenia,¹ and only some are transmitted by parents:

Risk genes. More than 30 risk genes have been identified as heritable in schizophrenia. They are spread over many chromosomes and more are likely to be discovered. Most of those risk genes regulate glutamate— not dopamine—pathways, and each increases the risk by 2% to 4%.

Copy number variations (CNVs) are pro­duced via meiosis mishaps, where 1 or 3 alleles of certain genes are formed instead of the usual 2. A high frequency of CNVs have been found in schizophrenia com­pared with the general population—but also are found in autism and bipolar disorders—and are believed to disrupt brain development in various ways.

De novo mutations. Recent studies on large samples of people with schizo­phrenia (50,000 to 100,000) uncovered a much higher rate of mutations (some code for proteins while others are non­sense mutations that code for noth­ing). Obviously, these mutations led to anomalous neurodevelopment.

There are hundreds, maybe thou­sands, of genetic subtypes within the schizophrenia syndrome. Advances in epigenetics, which allow silencing of culprit genes or overexpression of protective genes, one day may enable psychiatric geneticists to prevent schizo­phrenia in fetuses at risk.

Non-genetic risk factors
Just as with the genetic patho-genic heterogeneity, the schizo­phrenia syndrome can be caused by numerous environmental adverse events,² many of which can be avoided, including:

Older paternal age (>45) at time of conception doubles or triples the risk of schizophrenia³ as well as autism and bipolar disorder. Aging sperm are associated with a higher rate of DNA fragmentation and genetic mutations.

Prenatal complications, especially during the second trimester when CNS development takes place. These adverse prenatal events skew fetal brain development to produce psy­chosis in adulthood and can be mini­mized with optimal prenatal care, which sadly is lacking among the poor. These include:
   • Vaginal infections before preg­nancy,⁴ such as herpes simplex virus, can cause fetal brain inflammation and increased risk of schizophrenia.
   • Infections during pregnancy— whether bacterial, viral, or proto­zoan (Toxoplasma gondii)—have been shown to significantly increase the risk of schizophrenia in offspring.⁵ An increase in serum C-reactive protein during pregnancy also is a biomarker of increased risk.
   • Poor diet, especially starva­tion, can double or triple the risk of schizophrenia.
   • Vitamin deficiency, especially folate and vitamin D, are critical for normal brain development.⁶ Vitamin D is vital to mitigate neuroinflammation.
   • Smoking before and during pregnancy.⁴
   • Medical illness during preg­nancy, especially gestational diabetes, increases the risk of schizophrenia in the fetus by 800%.⁷
   • Severe stress during pregnancy, such as the death of the spouse, dou­bles the risk of schizophrenia.²
   • Schizophrenia risk is 400% to 500% higher among those born and raised in an urban area, compared with a rural area.⁸
   • Babies born in northern latitudes, such as in Sweden, Norway, or Canada, have a 10-fold risk of schizophrenia in adulthood compared with babies born near the equator.⁶ This has been attrib­uted to lack of sunshine and the risk of severe vitamin D deficiency in north­ern latitudes.
   • High maternal body mass index during the first trimester⁷ increases the child’s risk of schizophrenia.
   • Low number of prenatal vis­its is associated with higher risk of schizophrenia.
   • Obstetric complications that cause hypoxia and a low Apgar score after birth increase the risk of schizophrenia. This includes long labor, cord around the neck, meco­nium spillage into the amniotic fluid, and mechanical injury with forceps delivery.
   • Infection in the newborn shortly after birth.

Severe physical or sexual abuse before age 5 is associated with increased risk of schizophrenia in adulthood.² This may be because of stress-induced epigenetic mechanisms (silencing or overexpressing certain genes).

Migration has been shown to increase the risk of schizophrenia by 3 to 5 fold. The exact reason is unclear, but it could be a combination of social stress, exposure to new types of germs, less sunshine, and even a different diet.

My advice to the couple? Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids); take ade­quate doses of folate and vitamin D, per­haps even choline⁹; avoid smoking before and during pregnancy; adopt a healthy, balanced diet; avoid excessive weight gain and/or gestational diabetes; avoid contact with people with infections; avoid expo­sure to cat feces (toxoplasmosis); sched­ule frequent prenatal visits; and hope for a smooth and uneventful delivery and a newborn with an Apgar score of 9 or 10. All this will greatly reduce the non-genetic risks of schizophrenia, but is unlikely to modify the genetic risks. However, it has been shown that a combination of both genetic and non-genetic risk factors is associated with a more severe form of schizophrenia.¹⁰

Optimal prenatal and postnatal care can be helpful for couples with a family history of schizophrenia (without mov­ing to deliver their baby in a rural village near the equator). However, if their child starts using marijuana during adolescence, all bets are off. The risk of schizophrenia and serious cortical tissue loss increases dramatically when a carrier of risk genes use Cannabis. But that’s another editorial, to be read by clinicians in states where marijuana has been (foolishly, I believe) legalized.

I explained to them that schizophrenia is a neurodevelopmental syndrome that comprises hundreds of different disorders of genetic or non-genetic etiology, all of which share a similar psychotic phenotype. Although the various genetic causes of schizophre­nia are difficult to prevent—but may be prevented in the future with epi­genetic techniques—the many non-genetic (environmental) pathways to schizophrenia can be avoided to significantly reduce the incidence of schizophrenia by 40% to 50%, accord­ing to some estimates.

I will share what I told this couple, because even couples without any family history of psychosis may have a child who develops schizophrenia because of a variety of environmental risk factors.

Genetic risk factors
One-half of the 20,000 genes in the 23 chromosomes of the human genome participate in constructing and sculpt­ing the extremely intricate and com­plex human brain. There are many ways that genetic factors can increase the risk of schizophrenia,¹ and only some are transmitted by parents:

Risk genes. More than 30 risk genes have been identified as heritable in schizophrenia. They are spread over many chromosomes and more are likely to be discovered. Most of those risk genes regulate glutamate— not dopamine—pathways, and each increases the risk by 2% to 4%.

Copy number variations (CNVs) are pro­duced via meiosis mishaps, where 1 or 3 alleles of certain genes are formed instead of the usual 2. A high frequency of CNVs have been found in schizophrenia com­pared with the general population—but also are found in autism and bipolar disorders—and are believed to disrupt brain development in various ways.

De novo mutations. Recent studies on large samples of people with schizo­phrenia (50,000 to 100,000) uncovered a much higher rate of mutations (some code for proteins while others are non­sense mutations that code for noth­ing). Obviously, these mutations led to anomalous neurodevelopment.

There are hundreds, maybe thou­sands, of genetic subtypes within the schizophrenia syndrome. Advances in epigenetics, which allow silencing of culprit genes or overexpression of protective genes, one day may enable psychiatric geneticists to prevent schizo­phrenia in fetuses at risk.

Non-genetic risk factors
Just as with the genetic patho-genic heterogeneity, the schizo­phrenia syndrome can be caused by numerous environmental adverse events,² many of which can be avoided, including:

Older paternal age (>45) at time of conception doubles or triples the risk of schizophrenia³ as well as autism and bipolar disorder. Aging sperm are associated with a higher rate of DNA fragmentation and genetic mutations.

Prenatal complications, especially during the second trimester when CNS development takes place. These adverse prenatal events skew fetal brain development to produce psy­chosis in adulthood and can be mini­mized with optimal prenatal care, which sadly is lacking among the poor. These include:
   • Vaginal infections before preg­nancy,⁴ such as herpes simplex virus, can cause fetal brain inflammation and increased risk of schizophrenia.
   • Infections during pregnancy— whether bacterial, viral, or proto­zoan (Toxoplasma gondii)—have been shown to significantly increase the risk of schizophrenia in offspring.⁵ An increase in serum C-reactive protein during pregnancy also is a biomarker of increased risk.
   • Poor diet, especially starva­tion, can double or triple the risk of schizophrenia.
   • Vitamin deficiency, especially folate and vitamin D, are critical for normal brain development.⁶ Vitamin D is vital to mitigate neuroinflammation.
   • Smoking before and during pregnancy.⁴
   • Medical illness during preg­nancy, especially gestational diabetes, increases the risk of schizophrenia in the fetus by 800%.⁷
   • Severe stress during pregnancy, such as the death of the spouse, dou­bles the risk of schizophrenia.²
   • Schizophrenia risk is 400% to 500% higher among those born and raised in an urban area, compared with a rural area.⁸
   • Babies born in northern latitudes, such as in Sweden, Norway, or Canada, have a 10-fold risk of schizophrenia in adulthood compared with babies born near the equator.⁶ This has been attrib­uted to lack of sunshine and the risk of severe vitamin D deficiency in north­ern latitudes.
   • High maternal body mass index during the first trimester⁷ increases the child’s risk of schizophrenia.
   • Low number of prenatal vis­its is associated with higher risk of schizophrenia.
   • Obstetric complications that cause hypoxia and a low Apgar score after birth increase the risk of schizophrenia. This includes long labor, cord around the neck, meco­nium spillage into the amniotic fluid, and mechanical injury with forceps delivery.
   • Infection in the newborn shortly after birth.

Severe physical or sexual abuse before age 5 is associated with increased risk of schizophrenia in adulthood.² This may be because of stress-induced epigenetic mechanisms (silencing or overexpressing certain genes).

Migration has been shown to increase the risk of schizophrenia by 3 to 5 fold. The exact reason is unclear, but it could be a combination of social stress, exposure to new types of germs, less sunshine, and even a different diet.

My advice to the couple? Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids); take ade­quate doses of folate and vitamin D, per­haps even choline⁹; avoid smoking before and during pregnancy; adopt a healthy, balanced diet; avoid excessive weight gain and/or gestational diabetes; avoid contact with people with infections; avoid expo­sure to cat feces (toxoplasmosis); sched­ule frequent prenatal visits; and hope for a smooth and uneventful delivery and a newborn with an Apgar score of 9 or 10. All this will greatly reduce the non-genetic risks of schizophrenia, but is unlikely to modify the genetic risks. However, it has been shown that a combination of both genetic and non-genetic risk factors is associated with a more severe form of schizophrenia.¹⁰

Optimal prenatal and postnatal care can be helpful for couples with a family history of schizophrenia (without mov­ing to deliver their baby in a rural village near the equator). However, if their child starts using marijuana during adolescence, all bets are off. The risk of schizophrenia and serious cortical tissue loss increases dramatically when a carrier of risk genes use Cannabis. But that’s another editorial, to be read by clinicians in states where marijuana has been (foolishly, I believe) legalized.

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making. 

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.² 

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk. 

Impusivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be aware of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings—2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess important risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making. 

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.² 

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk. 

Impusivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be aware of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings—2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess important risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making. 

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.² 

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk. 

Impusivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be aware of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings—2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess important risk factors for violence.

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

For a busy clinician, learning that a prescription pad has been stolen, sub-mitted with a counterfeit signature, and used to acquire a controlled substance comes as a shock. It evokes a sense of betrayal and raises a number of medico-legal issues that can be avoided if you know how to protect yourself.

Prescription pad security
One of the simplest ways to reduce prescrip­tion pad theft is to lock the pads in a secure location when the office is closed.1 Establish and maintain an inventory of prescription pads; you should number and count pads weekly. For Schedule-II controlled substance prescription pads, document the control number on each new pad.¹ The best way to ensure that all pads are accounted for is by using sequential numbering similar to bank check numbers.

Do not allow staff to sign your prescrip­tion pad. Limit access to prescription pads to authorized personnel; be sure that they keep the prescription pad in their pocket, not on their desk or a counter, and not in examining rooms, where they could be stolen. For elec­tronic prescribing, always lock the drawer where the computer prescription paper sits.¹

Some physicians might find it helpful to invest in tamper-resistant prescription pads. As of April 2008, the Centers for Medicare and Medicaid Services mandates that for a prescription pad to be considered tamper-resistant it must include 1 or more industry-recognized features designed to prevent unauthorized copying, erasure, or modifica­tion of prescriptions.²

When you order prescription pads, do not print your Drug Enforcement Administration (DEA) number on the pads. Also, check that your printer maintains strict process controls over prescription pad production, storage, and delivery.¹

Other ways to prevent fraudulent pre­scriptions include using a gel pen to write prescriptions, because these pens contain pigments that are quickly absorbed, prevent­ing ink from being washed away with chemi­cal solvents.¹ Never leave blank space on a written prescription and do not sign blank prescription pads beforehand.³ Write instruc­tions clearly on each prescription, informing pharmacists of ways to verify the prescrip­tion’s authenticity.

Legal responsibilities
In case your prescription pads are stolen, even after taking precautionary measures, make the following actions to report and record fraudulent charges:
   • If your prescription pads for Schedule-II medications—known as “triplicates”— are missing, give the control number of the first and last prescription in the pad to your state’s pharmacy organization. Some states have an electronic alert system to aid with filing a fraud claim (eg, the Texas Pharmacy Association has a section on its Web site for reporting prescription fraud and theft).
   • Immediately inform the local police department and local DEA office of the theft.³ Keep a copy of all communications for future reference.
   • If a pharmacy alerts you that a fraudu­lent prescription has been filled using one of your pads, request a copy of each filled pre­scription. Keep these records and file a copy with the police department and DEA.

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

For a busy clinician, learning that a prescription pad has been stolen, sub-mitted with a counterfeit signature, and used to acquire a controlled substance comes as a shock. It evokes a sense of betrayal and raises a number of medico-legal issues that can be avoided if you know how to protect yourself.

Prescription pad security
One of the simplest ways to reduce prescrip­tion pad theft is to lock the pads in a secure location when the office is closed.1 Establish and maintain an inventory of prescription pads; you should number and count pads weekly. For Schedule-II controlled substance prescription pads, document the control number on each new pad.¹ The best way to ensure that all pads are accounted for is by using sequential numbering similar to bank check numbers.

Do not allow staff to sign your prescrip­tion pad. Limit access to prescription pads to authorized personnel; be sure that they keep the prescription pad in their pocket, not on their desk or a counter, and not in examining rooms, where they could be stolen. For elec­tronic prescribing, always lock the drawer where the computer prescription paper sits.¹

Some physicians might find it helpful to invest in tamper-resistant prescription pads. As of April 2008, the Centers for Medicare and Medicaid Services mandates that for a prescription pad to be considered tamper-resistant it must include 1 or more industry-recognized features designed to prevent unauthorized copying, erasure, or modifica­tion of prescriptions.²

When you order prescription pads, do not print your Drug Enforcement Administration (DEA) number on the pads. Also, check that your printer maintains strict process controls over prescription pad production, storage, and delivery.¹

Other ways to prevent fraudulent pre­scriptions include using a gel pen to write prescriptions, because these pens contain pigments that are quickly absorbed, prevent­ing ink from being washed away with chemi­cal solvents.¹ Never leave blank space on a written prescription and do not sign blank prescription pads beforehand.³ Write instruc­tions clearly on each prescription, informing pharmacists of ways to verify the prescrip­tion’s authenticity.

Legal responsibilities
In case your prescription pads are stolen, even after taking precautionary measures, make the following actions to report and record fraudulent charges:
   • If your prescription pads for Schedule-II medications—known as “triplicates”— are missing, give the control number of the first and last prescription in the pad to your state’s pharmacy organization. Some states have an electronic alert system to aid with filing a fraud claim (eg, the Texas Pharmacy Association has a section on its Web site for reporting prescription fraud and theft).
   • Immediately inform the local police department and local DEA office of the theft.³ Keep a copy of all communications for future reference.
   • If a pharmacy alerts you that a fraudu­lent prescription has been filled using one of your pads, request a copy of each filled pre­scription. Keep these records and file a copy with the police department and DEA.

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

For a busy clinician, learning that a prescription pad has been stolen, sub-mitted with a counterfeit signature, and used to acquire a controlled substance comes as a shock. It evokes a sense of betrayal and raises a number of medico-legal issues that can be avoided if you know how to protect yourself.

Prescription pad security
One of the simplest ways to reduce prescrip­tion pad theft is to lock the pads in a secure location when the office is closed.1 Establish and maintain an inventory of prescription pads; you should number and count pads weekly. For Schedule-II controlled substance prescription pads, document the control number on each new pad.¹ The best way to ensure that all pads are accounted for is by using sequential numbering similar to bank check numbers.

Do not allow staff to sign your prescrip­tion pad. Limit access to prescription pads to authorized personnel; be sure that they keep the prescription pad in their pocket, not on their desk or a counter, and not in examining rooms, where they could be stolen. For elec­tronic prescribing, always lock the drawer where the computer prescription paper sits.¹

Some physicians might find it helpful to invest in tamper-resistant prescription pads. As of April 2008, the Centers for Medicare and Medicaid Services mandates that for a prescription pad to be considered tamper-resistant it must include 1 or more industry-recognized features designed to prevent unauthorized copying, erasure, or modifica­tion of prescriptions.²

When you order prescription pads, do not print your Drug Enforcement Administration (DEA) number on the pads. Also, check that your printer maintains strict process controls over prescription pad production, storage, and delivery.¹

Other ways to prevent fraudulent pre­scriptions include using a gel pen to write prescriptions, because these pens contain pigments that are quickly absorbed, prevent­ing ink from being washed away with chemi­cal solvents.¹ Never leave blank space on a written prescription and do not sign blank prescription pads beforehand.³ Write instruc­tions clearly on each prescription, informing pharmacists of ways to verify the prescrip­tion’s authenticity.

Legal responsibilities
In case your prescription pads are stolen, even after taking precautionary measures, make the following actions to report and record fraudulent charges:
   • If your prescription pads for Schedule-II medications—known as “triplicates”— are missing, give the control number of the first and last prescription in the pad to your state’s pharmacy organization. Some states have an electronic alert system to aid with filing a fraud claim (eg, the Texas Pharmacy Association has a section on its Web site for reporting prescription fraud and theft).
   • Immediately inform the local police department and local DEA office of the theft.³ Keep a copy of all communications for future reference.
   • If a pharmacy alerts you that a fraudu­lent prescription has been filled using one of your pads, request a copy of each filled pre­scription. Keep these records and file a copy with the police department and DEA.

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

In this article, we highlight key steps that were needed to integrate clinical pharmacy specialists at an academic ambulatory psychiatric and addiction treatment center that serves pediatric and adult populations. Academic stakeholders identified addition of pharmacy services as a strategic goal in an effort to maximize services offered by the center and increase patient access to care while aligning with the standards set out by the patient-centered medical home (PCMH) model.

We outline the role of clinical pharmacists in the care of adult patients in ambulatory psychiatry, illustrate opportu­nities to enhance patient care, point out possible challenges with implementation, and propose future initiatives to optimize the practitioner-pharmacist partnership.

Background: Role of ambulatory pharmacists in psychiatry
Clinical pharmacists’ role in the psychiatric ambulatory care setting generally is associated with positive outcomes. One study looking at a collaborative care model that uti­lized clinical pharmacist follow-up in managing major depressive disorder found that patients who received phar­macist intervention in the collaborative care model had, on average, a significantly higher adherence rate and patient satisfaction score than the “usual care” group.¹ Within this study, patients in both groups experienced global clini­cal improvement with no significant difference; however, pharmacist interventions had a posi­tive impact on several aspects of the care model, suggesting that pharmacists can be used effectively in ambulatory psychiatry.

Furthermore, a systematic study evalu­ating pharmacists’ impact on clinical and functional mental health outcomes iden­tified 8 relevant studies conducted in the outpatient setting.² Although interven­tions varied widely, most studies focused on pharmacists’ providing a combination of drug monitoring, treatment recommen­dations, and patient education. Outcomes were largely positive, including an overall reduction in number and dosage of psy­chiatric drugs, inferred cost savings, and significant improvements in the safe and efficacious use of antidepressant and anti­psychotic medications.

These preliminary positive results require replication in larger, random­ized cohorts. Additionally, the role of the pharmacist as medication manager in the collaborative care model requires further study. Results so far, however, indicate that pharmacists can have a positive impact on the care of ambulatory psychiatry patients. Nevertheless, there is still considerable need for ongoing exploration in this field.

Pre-implementation
The need for pharmacy services. Various initiatives and existing practices within our health care system have underscored the need for a psychiatric pharmacist in the outpatient setting (Table 1).

A board-certified psychiatric pharma­cist (BCPP) possesses specialized knowl­edge about treating patients affected by psychiatric illnesses. BCPPs work with prescribers and members of other disci­plines, such as nurses and social workers, to optimize drug treatment by making pharmacotherapeutic recommendations and providing appropriate monitoring to enhance patient satisfaction and quality of life.^3,4

Existing relationship with pharmacy. Along with evidence to support the posi­tive impact clinical pharmacists can have in caring for patients with mental illness in the outpatient setting, a strong existing relationship between the Department of Psychiatry and our adult inpatient psychi­atric pharmacist helped make it possible to develop an ambulatory psychiatric phar­macist position.

Each day, the inpatient psychiatric pharmacist works closely with the attend­ing psychiatrists and psychiatry residents to provide treatment recommendations and counseling services for patients on the unit. The psychiatry residents highly valued their experiences with the pharmacist in the inpatient setting and expressed disappointment that this col­laborative relationship was no longer available after they transitioned into the ambulatory setting.

Further, by being involved in initia­tives that were relevant to both inpa­tient and outpatient psychiatry, such as metabolic monitoring for patients taking atypical antipsychotics, the clini­cal pharmacist in inpatient psychiatry had the opportunity to interact with key stakeholders in both settings. As a result of these pre-existing collabora­tive relationships, many clinicians were eager to have pharmacists available as a resource for patient care in the outpatient setting.

Pharmacist perspective: Outreach to psychiatry leadershipRecognizing the incentives and oppor­tunities inherent in our emerging health care system, pharmacists became integral members of the patient care team in the PCMH model. Thanks to this effort, we now have PCMH pharmacists at every primary care health center in our health system (14 sites), providing disease man­agement programs and polypharmacy services.

PCMH pharmacists’ role in the primary care setting fueled interest from specialty services and created opportunities to extend our existing partnership in inpa­tient psychiatry. One such opportunity to demonstrate the expertise of a psychi­atric pharmacist was fueled by the FDA’s citalopram dosing alert⁵ at a system-wide level. This warning emerged as a chance to showcase the skill set of psychiatric phar­macists and the pharmacists’ successes in our PCMH model. The partnership was extended to include the buy-in of ambula­tory pharmacy leadership and key stake­holders in ambulatory psychiatry.

Initial meetings included ambula­tory care site leadership in psychiatry to increase awareness and understanding of pharmacists’ potential role in direct patient care. Achieving site leadership support was critical to successful implementation of pharmacist services in psychiatry. We also obtained approval from the Chair of the Department of Psychiatry to elicit sup­port from faculty group practice.

Psychiatry leadership perspective
As fiscal pressures intensify at academic health centers, it becomes increasingly important for resources to be used as efficiently and effectively as possible. As a greater percentage of mental health patients with more “straightforward,” less complex conditions are being managed by their primary care providers or non­prescribing psychotherapists, or both, the acuity and complexity of cases in patients who present to psychiatric clinics have intensified. This intensification of patient needs and clinical acuity is in heightened conflict with the ongoing demand for clini­cian productivity and efficiency.

Additionally, the need to provide care to a seemingly ever-growing number of moderately or severely ill patients dur­ing shorter, less frequent visits presents a daunting task for clinicians and clinical leaders. Collaborative care models appear to offer the best hope for managing the seemingly overwhelming demand for services.

In this model, the patient, who is the critical member of the team, is expected to become an “expert” on his or her ill­ness and to partner with members of the multidisciplinary team; with this support, patients are encouraged to develop a broad range of self-management skills and strat­egies to manage their illness. We believe that clinical pharmacists can and should play a critical role, not only in deliver­ing direct clinical services to patients but also in developing and devising the care models that will most effectively apply each team member’s unique set of knowl­edge, skills, and experience. Given the large percentage of our patients who have multiple medical comorbidities and who require complex medical and psychiat­ric medication regimens, the role of the pharmacist in reviewing, educating, and advising patients and other team members on these crucial pharmacy concerns will be paramount.

In light of these complex medication issues, pharmacists are uniquely posi­tioned to serve as a liaison among the patient, the primary care provider, and other members of their treatment team. We anticipate that our ambulatory psychiatry pharmacists will greatly enhance the com­fort and confidence of patients and their primary care providers during periods of care transition.

Potential roles for pharmacists in ambulatory psychiatry
One potential role for pharmacists in ambulatory psychiatry is to perform polypharmacy assessments of patients receiving complex medication regimens, prompted by physician referral. The poly­ pharmacy intake interview, performed to obtain an accurate medication list and to identify patients’ concerns about their medications, can be conducted in per­son or by telephone. Patients’ knowledge about medications and medication adher­ence are discussed, as are their perceptions of effectiveness and adverse effects.

After initial data gathering, pharma­cists complete a review of the medications, identifying any problems associated with medication indication, efficacy, tolerance, or adverse effects, drug-drug interactions, drug-nutrient interactions, and nonadher­ence. Pharmacists work to reduce medica­tion costs if that is a concern of the patient, because nonadherence can result. A medi­cation care plan is then developed in con­sultation with the primary care provider; here, the medication list is reconciled, the electronic medical record is updated, and actions to address any medication-related problems are prioritized.

Other services that might be offered include:• group education classes, based on patient motivational interviewing strate­gies, to address therapeutic nonadherence and to improve understanding of their dis­ease and treatment regimens• medication safety and monitoring• treatment intensification, as needed, following established protocols.

These are a few of the ways in which pharmacists can be relied on to expand and improve access to patient care ser­vices within ambulatory psychiatry. Key stakeholders anticipate development of newer ideas as the pharmacist’s role in ambulatory psychiatry is increasingly clarified.

Reimbursement model
In creating a role for pharmacy in ambu­latory psychiatry, it was essential that the model be financially viable and appeal­ing. Alongside its clinical model, our insti­tution has developed a financial model to support the pharmacist’s role. The lump-sum payment to the health centers from Blue Cross Blue Shield of Michigan afforded the ambulatory care clinics an opportunity to invest in PCMH pharma­cists. This funding, and the reimbursement based on T-code billing (face-to-face visits and phone consultation) for depression and other conditions requiring chronic care, provides ongoing support. From our experience, understanding physician reimbursement models and identifying relevant changes in health care reform are necessary to integrate new providers, including pharmacists, into a team-based care model.

Implementation
Promoting pharmacy services. To fos­ter anticipated collaboration with clini­cal pharmacists, the medical director of outpatient psychiatry disseminated an announcement to all providers regard­ing the investiture of clinical pharmacists to support patient care activities, educa­tion, and research. Clinicians were edu­cated about the pharmacists’ potential roles and about guidelines and methods for referral. Use of our electronic health record system enabled us to establish a relatively simple referral process involv­ing sharing electronic messages with our pharmacists.

Further, as part of the planned integra­tion of clinical pharmacists in the ambula­tory psychiatry setting, pharmacists met strategically with members of various disciplines, clinical programs, specialty clinic programs, and teams throughout the center. In addition to answering questions about the referral process, they empha­sized the role of pharmacy and opportuni­ties for collaboration.

Collaborating with others. Because the involvement of clinical pharmacists is unfamiliar to some practitioners in outpa­tient psychiatry, it is important to develop services without infringing on the roles other disciplines play. Indeed, a survey by Wheeler et al6 identified many concerns and potential boundaries among pharmacists, other providers, and patients. Concerns included confusion of practitioner roles and boundaries, a too-traditional percep­tion of the pharmacist, and demonstration of competence.⁶

Early on, we developed a structured forum to discuss ongoing challenges and address issues related to the rapidly changing clinical landscape. During these discussions we conveyed that adding pharmacists to psychiatric services would be collaborative in nature and intended to augment existing services. This commu­nication was pivotal to maintain the psy­chiatrist’s role as the ultimate prescriber and authority in the care of their patients; however, the pharmacist’s expertise, when sought, would help spur clinical and aca­demic discussion that will benefit the patient. These discussions are paramount to achieving a productive, team-based approach, to overcome challenges, and to identify opportunities of value to our pro­viders and patients (Box).

Work in progress
Implementing change in any clinical set­ting invariably creates challenges, and our endeavors to integrate clinical phar­macists into ambulatory psychiatry are no exception. We have identified several factors that we believe will optimize suc­cessful collaboration between pharmacy and ambulatory psychiatry (Table 2). Our primary challenge has been changing cli­nician behavior. Clinical practitioners can become too comfortable, wedded to their routines, and often are understandably resistant to change. Additionally, clinical systems often are inadvertently designed to obstruct change in ways that are not readily apparent. Efforts must be focused on behaviors and practices the clinical cul­ture should encourage.

The prospect of access to clinical phar­macist expertise in the outpatient setting was heralded with excitement, but the flow of referrals and consultations has been uneven. However simple the path for referral is, clinicians’ use of the system has been inconsistent—perhaps because of referrals’ passive, clinician-dependent nature. Educational outreach efforts often prompt a brief spike in referrals, only to be followed over time by a slow, steady drop-off. More active strategies will be needed, such as embedding the pharma­cists as regular, active, visible members of the various clinical teams, and imple­menting a system in which patient record reviews are assigned to the pharmacists according to agreed-upon clusters of clin­ical criteria.

One of these tactics has, in the short term, showed success. Embedded in one of our newer clinics, which were designed to bridge primary and psychiatric care, clinical pharmacists are helping manage medically complicated patients. They assist with medication selection in light of drug interactions and medical comor­bidities, conduct detailed medication his­tories, schedule follow-up visits to assess medication adherence and tolerability, and counsel patients experiencing insur­ance changes that make their medications less affordable. Integrating pharmacists in the new clinics has resulted in a steady flow of patient referrals and collaborative care work.

Clinical pharmacists are brainstorming with outpatient psychiatry leadership to build on these early successes. Ongoing communication and enhanced collabora­tion are essential, and can only improve the lives of our psychiatric patients.

For the future
Our partnership in ambulatory psychiatry was timed to occur during implementa­tion of our health system’s new electronic health record initiative. Clinical pharma­cists can play a key role in demonstrating use of the system to provide consistently accurate drug information to patients and to monitor patients receiving specific medications.

Development of ambulatory patient medication education groups, which has proved useful on the inpatient side, is another endeavor in the works. Integrating the clinical pharmacist with psychiatrists, psychologists, nurse prac­titioners, social workers, and trainees on specific teams devoted to depression, bipolar disorder, anxiety, perinatal men­tal health, and personality disorders also might prove to be a wide-ranging and promising strategy.

Enhancing the education and training experiences of residents, fellows, medical students, pharmacy students, and allied health professional learners present in our clinics is another exciting prospect. This cross-disciplinary training will yield a new generation of providers who will be more comfortable collaborating with colleagues from other disciplines, all intent on pro­viding high-quality, efficient care. We hope that, as these initiatives take root, we will recognize many opportunities to dissemi­nate our collaborative efforts in scholarly venues, documenting and sharing the pos­itive impact of our partnership.

Bottom Line
Because psychiatric outpatients present with challenging medical comorbidities and increasingly complex medication regimens, specialized clinical pharmacists can enrich the management team by offering essential monitoring and polypharmacy services, patient education and counseling, and cross-discipline training. At one academic treatment center, psychiatric and non-psychiatric practitioners are gradually buying in to these promising collaborative efforts.


Related Resources
• Board of Pharmacy Specialties. www.bpsweb.org/specialties/psychiatric.cfm.
• Abramowitz P. Ambulatory care pharmacy practice: The future is now. www.connect.ashp.org/blogs/paul-abramowitz/2014/05/14/ambulatory-care-pharmacy-practice-the-future-is-now.

Drug Brand Name
Citalopram • Celexa

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

In this article, we highlight key steps that were needed to integrate clinical pharmacy specialists at an academic ambulatory psychiatric and addiction treatment center that serves pediatric and adult populations. Academic stakeholders identified addition of pharmacy services as a strategic goal in an effort to maximize services offered by the center and increase patient access to care while aligning with the standards set out by the patient-centered medical home (PCMH) model.

We outline the role of clinical pharmacists in the care of adult patients in ambulatory psychiatry, illustrate opportu­nities to enhance patient care, point out possible challenges with implementation, and propose future initiatives to optimize the practitioner-pharmacist partnership.

Background: Role of ambulatory pharmacists in psychiatry
Clinical pharmacists’ role in the psychiatric ambulatory care setting generally is associated with positive outcomes. One study looking at a collaborative care model that uti­lized clinical pharmacist follow-up in managing major depressive disorder found that patients who received phar­macist intervention in the collaborative care model had, on average, a significantly higher adherence rate and patient satisfaction score than the “usual care” group.¹ Within this study, patients in both groups experienced global clini­cal improvement with no significant difference; however, pharmacist interventions had a posi­tive impact on several aspects of the care model, suggesting that pharmacists can be used effectively in ambulatory psychiatry.

Furthermore, a systematic study evalu­ating pharmacists’ impact on clinical and functional mental health outcomes iden­tified 8 relevant studies conducted in the outpatient setting.² Although interven­tions varied widely, most studies focused on pharmacists’ providing a combination of drug monitoring, treatment recommen­dations, and patient education. Outcomes were largely positive, including an overall reduction in number and dosage of psy­chiatric drugs, inferred cost savings, and significant improvements in the safe and efficacious use of antidepressant and anti­psychotic medications.

These preliminary positive results require replication in larger, random­ized cohorts. Additionally, the role of the pharmacist as medication manager in the collaborative care model requires further study. Results so far, however, indicate that pharmacists can have a positive impact on the care of ambulatory psychiatry patients. Nevertheless, there is still considerable need for ongoing exploration in this field.

Pre-implementation
The need for pharmacy services. Various initiatives and existing practices within our health care system have underscored the need for a psychiatric pharmacist in the outpatient setting (Table 1).

A board-certified psychiatric pharma­cist (BCPP) possesses specialized knowl­edge about treating patients affected by psychiatric illnesses. BCPPs work with prescribers and members of other disci­plines, such as nurses and social workers, to optimize drug treatment by making pharmacotherapeutic recommendations and providing appropriate monitoring to enhance patient satisfaction and quality of life.^3,4

Existing relationship with pharmacy. Along with evidence to support the posi­tive impact clinical pharmacists can have in caring for patients with mental illness in the outpatient setting, a strong existing relationship between the Department of Psychiatry and our adult inpatient psychi­atric pharmacist helped make it possible to develop an ambulatory psychiatric phar­macist position.

Each day, the inpatient psychiatric pharmacist works closely with the attend­ing psychiatrists and psychiatry residents to provide treatment recommendations and counseling services for patients on the unit. The psychiatry residents highly valued their experiences with the pharmacist in the inpatient setting and expressed disappointment that this col­laborative relationship was no longer available after they transitioned into the ambulatory setting.

Further, by being involved in initia­tives that were relevant to both inpa­tient and outpatient psychiatry, such as metabolic monitoring for patients taking atypical antipsychotics, the clini­cal pharmacist in inpatient psychiatry had the opportunity to interact with key stakeholders in both settings. As a result of these pre-existing collabora­tive relationships, many clinicians were eager to have pharmacists available as a resource for patient care in the outpatient setting.

Pharmacist perspective: Outreach to psychiatry leadershipRecognizing the incentives and oppor­tunities inherent in our emerging health care system, pharmacists became integral members of the patient care team in the PCMH model. Thanks to this effort, we now have PCMH pharmacists at every primary care health center in our health system (14 sites), providing disease man­agement programs and polypharmacy services.

PCMH pharmacists’ role in the primary care setting fueled interest from specialty services and created opportunities to extend our existing partnership in inpa­tient psychiatry. One such opportunity to demonstrate the expertise of a psychi­atric pharmacist was fueled by the FDA’s citalopram dosing alert⁵ at a system-wide level. This warning emerged as a chance to showcase the skill set of psychiatric phar­macists and the pharmacists’ successes in our PCMH model. The partnership was extended to include the buy-in of ambula­tory pharmacy leadership and key stake­holders in ambulatory psychiatry.

Initial meetings included ambula­tory care site leadership in psychiatry to increase awareness and understanding of pharmacists’ potential role in direct patient care. Achieving site leadership support was critical to successful implementation of pharmacist services in psychiatry. We also obtained approval from the Chair of the Department of Psychiatry to elicit sup­port from faculty group practice.

Psychiatry leadership perspective
As fiscal pressures intensify at academic health centers, it becomes increasingly important for resources to be used as efficiently and effectively as possible. As a greater percentage of mental health patients with more “straightforward,” less complex conditions are being managed by their primary care providers or non­prescribing psychotherapists, or both, the acuity and complexity of cases in patients who present to psychiatric clinics have intensified. This intensification of patient needs and clinical acuity is in heightened conflict with the ongoing demand for clini­cian productivity and efficiency.

Additionally, the need to provide care to a seemingly ever-growing number of moderately or severely ill patients dur­ing shorter, less frequent visits presents a daunting task for clinicians and clinical leaders. Collaborative care models appear to offer the best hope for managing the seemingly overwhelming demand for services.

In this model, the patient, who is the critical member of the team, is expected to become an “expert” on his or her ill­ness and to partner with members of the multidisciplinary team; with this support, patients are encouraged to develop a broad range of self-management skills and strat­egies to manage their illness. We believe that clinical pharmacists can and should play a critical role, not only in deliver­ing direct clinical services to patients but also in developing and devising the care models that will most effectively apply each team member’s unique set of knowl­edge, skills, and experience. Given the large percentage of our patients who have multiple medical comorbidities and who require complex medical and psychiat­ric medication regimens, the role of the pharmacist in reviewing, educating, and advising patients and other team members on these crucial pharmacy concerns will be paramount.

In light of these complex medication issues, pharmacists are uniquely posi­tioned to serve as a liaison among the patient, the primary care provider, and other members of their treatment team. We anticipate that our ambulatory psychiatry pharmacists will greatly enhance the com­fort and confidence of patients and their primary care providers during periods of care transition.

Potential roles for pharmacists in ambulatory psychiatry
One potential role for pharmacists in ambulatory psychiatry is to perform polypharmacy assessments of patients receiving complex medication regimens, prompted by physician referral. The poly­ pharmacy intake interview, performed to obtain an accurate medication list and to identify patients’ concerns about their medications, can be conducted in per­son or by telephone. Patients’ knowledge about medications and medication adher­ence are discussed, as are their perceptions of effectiveness and adverse effects.

After initial data gathering, pharma­cists complete a review of the medications, identifying any problems associated with medication indication, efficacy, tolerance, or adverse effects, drug-drug interactions, drug-nutrient interactions, and nonadher­ence. Pharmacists work to reduce medica­tion costs if that is a concern of the patient, because nonadherence can result. A medi­cation care plan is then developed in con­sultation with the primary care provider; here, the medication list is reconciled, the electronic medical record is updated, and actions to address any medication-related problems are prioritized.

Other services that might be offered include:• group education classes, based on patient motivational interviewing strate­gies, to address therapeutic nonadherence and to improve understanding of their dis­ease and treatment regimens• medication safety and monitoring• treatment intensification, as needed, following established protocols.

These are a few of the ways in which pharmacists can be relied on to expand and improve access to patient care ser­vices within ambulatory psychiatry. Key stakeholders anticipate development of newer ideas as the pharmacist’s role in ambulatory psychiatry is increasingly clarified.

Reimbursement model
In creating a role for pharmacy in ambu­latory psychiatry, it was essential that the model be financially viable and appeal­ing. Alongside its clinical model, our insti­tution has developed a financial model to support the pharmacist’s role. The lump-sum payment to the health centers from Blue Cross Blue Shield of Michigan afforded the ambulatory care clinics an opportunity to invest in PCMH pharma­cists. This funding, and the reimbursement based on T-code billing (face-to-face visits and phone consultation) for depression and other conditions requiring chronic care, provides ongoing support. From our experience, understanding physician reimbursement models and identifying relevant changes in health care reform are necessary to integrate new providers, including pharmacists, into a team-based care model.

Implementation
Promoting pharmacy services. To fos­ter anticipated collaboration with clini­cal pharmacists, the medical director of outpatient psychiatry disseminated an announcement to all providers regard­ing the investiture of clinical pharmacists to support patient care activities, educa­tion, and research. Clinicians were edu­cated about the pharmacists’ potential roles and about guidelines and methods for referral. Use of our electronic health record system enabled us to establish a relatively simple referral process involv­ing sharing electronic messages with our pharmacists.

Further, as part of the planned integra­tion of clinical pharmacists in the ambula­tory psychiatry setting, pharmacists met strategically with members of various disciplines, clinical programs, specialty clinic programs, and teams throughout the center. In addition to answering questions about the referral process, they empha­sized the role of pharmacy and opportuni­ties for collaboration.

Collaborating with others. Because the involvement of clinical pharmacists is unfamiliar to some practitioners in outpa­tient psychiatry, it is important to develop services without infringing on the roles other disciplines play. Indeed, a survey by Wheeler et al6 identified many concerns and potential boundaries among pharmacists, other providers, and patients. Concerns included confusion of practitioner roles and boundaries, a too-traditional percep­tion of the pharmacist, and demonstration of competence.⁶

Early on, we developed a structured forum to discuss ongoing challenges and address issues related to the rapidly changing clinical landscape. During these discussions we conveyed that adding pharmacists to psychiatric services would be collaborative in nature and intended to augment existing services. This commu­nication was pivotal to maintain the psy­chiatrist’s role as the ultimate prescriber and authority in the care of their patients; however, the pharmacist’s expertise, when sought, would help spur clinical and aca­demic discussion that will benefit the patient. These discussions are paramount to achieving a productive, team-based approach, to overcome challenges, and to identify opportunities of value to our pro­viders and patients (Box).

Work in progress
Implementing change in any clinical set­ting invariably creates challenges, and our endeavors to integrate clinical phar­macists into ambulatory psychiatry are no exception. We have identified several factors that we believe will optimize suc­cessful collaboration between pharmacy and ambulatory psychiatry (Table 2). Our primary challenge has been changing cli­nician behavior. Clinical practitioners can become too comfortable, wedded to their routines, and often are understandably resistant to change. Additionally, clinical systems often are inadvertently designed to obstruct change in ways that are not readily apparent. Efforts must be focused on behaviors and practices the clinical cul­ture should encourage.

The prospect of access to clinical phar­macist expertise in the outpatient setting was heralded with excitement, but the flow of referrals and consultations has been uneven. However simple the path for referral is, clinicians’ use of the system has been inconsistent—perhaps because of referrals’ passive, clinician-dependent nature. Educational outreach efforts often prompt a brief spike in referrals, only to be followed over time by a slow, steady drop-off. More active strategies will be needed, such as embedding the pharma­cists as regular, active, visible members of the various clinical teams, and imple­menting a system in which patient record reviews are assigned to the pharmacists according to agreed-upon clusters of clin­ical criteria.

One of these tactics has, in the short term, showed success. Embedded in one of our newer clinics, which were designed to bridge primary and psychiatric care, clinical pharmacists are helping manage medically complicated patients. They assist with medication selection in light of drug interactions and medical comor­bidities, conduct detailed medication his­tories, schedule follow-up visits to assess medication adherence and tolerability, and counsel patients experiencing insur­ance changes that make their medications less affordable. Integrating pharmacists in the new clinics has resulted in a steady flow of patient referrals and collaborative care work.

Clinical pharmacists are brainstorming with outpatient psychiatry leadership to build on these early successes. Ongoing communication and enhanced collabora­tion are essential, and can only improve the lives of our psychiatric patients.

For the future
Our partnership in ambulatory psychiatry was timed to occur during implementa­tion of our health system’s new electronic health record initiative. Clinical pharma­cists can play a key role in demonstrating use of the system to provide consistently accurate drug information to patients and to monitor patients receiving specific medications.

Development of ambulatory patient medication education groups, which has proved useful on the inpatient side, is another endeavor in the works. Integrating the clinical pharmacist with psychiatrists, psychologists, nurse prac­titioners, social workers, and trainees on specific teams devoted to depression, bipolar disorder, anxiety, perinatal men­tal health, and personality disorders also might prove to be a wide-ranging and promising strategy.

Enhancing the education and training experiences of residents, fellows, medical students, pharmacy students, and allied health professional learners present in our clinics is another exciting prospect. This cross-disciplinary training will yield a new generation of providers who will be more comfortable collaborating with colleagues from other disciplines, all intent on pro­viding high-quality, efficient care. We hope that, as these initiatives take root, we will recognize many opportunities to dissemi­nate our collaborative efforts in scholarly venues, documenting and sharing the pos­itive impact of our partnership.

Bottom Line
Because psychiatric outpatients present with challenging medical comorbidities and increasingly complex medication regimens, specialized clinical pharmacists can enrich the management team by offering essential monitoring and polypharmacy services, patient education and counseling, and cross-discipline training. At one academic treatment center, psychiatric and non-psychiatric practitioners are gradually buying in to these promising collaborative efforts.


Related Resources
• Board of Pharmacy Specialties. www.bpsweb.org/specialties/psychiatric.cfm.
• Abramowitz P. Ambulatory care pharmacy practice: The future is now. www.connect.ashp.org/blogs/paul-abramowitz/2014/05/14/ambulatory-care-pharmacy-practice-the-future-is-now.

Drug Brand Name
Citalopram • Celexa

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

In this article, we highlight key steps that were needed to integrate clinical pharmacy specialists at an academic ambulatory psychiatric and addiction treatment center that serves pediatric and adult populations. Academic stakeholders identified addition of pharmacy services as a strategic goal in an effort to maximize services offered by the center and increase patient access to care while aligning with the standards set out by the patient-centered medical home (PCMH) model.

We outline the role of clinical pharmacists in the care of adult patients in ambulatory psychiatry, illustrate opportu­nities to enhance patient care, point out possible challenges with implementation, and propose future initiatives to optimize the practitioner-pharmacist partnership.

Background: Role of ambulatory pharmacists in psychiatry
Clinical pharmacists’ role in the psychiatric ambulatory care setting generally is associated with positive outcomes. One study looking at a collaborative care model that uti­lized clinical pharmacist follow-up in managing major depressive disorder found that patients who received phar­macist intervention in the collaborative care model had, on average, a significantly higher adherence rate and patient satisfaction score than the “usual care” group.¹ Within this study, patients in both groups experienced global clini­cal improvement with no significant difference; however, pharmacist interventions had a posi­tive impact on several aspects of the care model, suggesting that pharmacists can be used effectively in ambulatory psychiatry.

Furthermore, a systematic study evalu­ating pharmacists’ impact on clinical and functional mental health outcomes iden­tified 8 relevant studies conducted in the outpatient setting.² Although interven­tions varied widely, most studies focused on pharmacists’ providing a combination of drug monitoring, treatment recommen­dations, and patient education. Outcomes were largely positive, including an overall reduction in number and dosage of psy­chiatric drugs, inferred cost savings, and significant improvements in the safe and efficacious use of antidepressant and anti­psychotic medications.

These preliminary positive results require replication in larger, random­ized cohorts. Additionally, the role of the pharmacist as medication manager in the collaborative care model requires further study. Results so far, however, indicate that pharmacists can have a positive impact on the care of ambulatory psychiatry patients. Nevertheless, there is still considerable need for ongoing exploration in this field.

Pre-implementation
The need for pharmacy services. Various initiatives and existing practices within our health care system have underscored the need for a psychiatric pharmacist in the outpatient setting (Table 1).

A board-certified psychiatric pharma­cist (BCPP) possesses specialized knowl­edge about treating patients affected by psychiatric illnesses. BCPPs work with prescribers and members of other disci­plines, such as nurses and social workers, to optimize drug treatment by making pharmacotherapeutic recommendations and providing appropriate monitoring to enhance patient satisfaction and quality of life.^3,4

Existing relationship with pharmacy. Along with evidence to support the posi­tive impact clinical pharmacists can have in caring for patients with mental illness in the outpatient setting, a strong existing relationship between the Department of Psychiatry and our adult inpatient psychi­atric pharmacist helped make it possible to develop an ambulatory psychiatric phar­macist position.

Each day, the inpatient psychiatric pharmacist works closely with the attend­ing psychiatrists and psychiatry residents to provide treatment recommendations and counseling services for patients on the unit. The psychiatry residents highly valued their experiences with the pharmacist in the inpatient setting and expressed disappointment that this col­laborative relationship was no longer available after they transitioned into the ambulatory setting.

Further, by being involved in initia­tives that were relevant to both inpa­tient and outpatient psychiatry, such as metabolic monitoring for patients taking atypical antipsychotics, the clini­cal pharmacist in inpatient psychiatry had the opportunity to interact with key stakeholders in both settings. As a result of these pre-existing collabora­tive relationships, many clinicians were eager to have pharmacists available as a resource for patient care in the outpatient setting.

Pharmacist perspective: Outreach to psychiatry leadershipRecognizing the incentives and oppor­tunities inherent in our emerging health care system, pharmacists became integral members of the patient care team in the PCMH model. Thanks to this effort, we now have PCMH pharmacists at every primary care health center in our health system (14 sites), providing disease man­agement programs and polypharmacy services.

PCMH pharmacists’ role in the primary care setting fueled interest from specialty services and created opportunities to extend our existing partnership in inpa­tient psychiatry. One such opportunity to demonstrate the expertise of a psychi­atric pharmacist was fueled by the FDA’s citalopram dosing alert⁵ at a system-wide level. This warning emerged as a chance to showcase the skill set of psychiatric phar­macists and the pharmacists’ successes in our PCMH model. The partnership was extended to include the buy-in of ambula­tory pharmacy leadership and key stake­holders in ambulatory psychiatry.

Initial meetings included ambula­tory care site leadership in psychiatry to increase awareness and understanding of pharmacists’ potential role in direct patient care. Achieving site leadership support was critical to successful implementation of pharmacist services in psychiatry. We also obtained approval from the Chair of the Department of Psychiatry to elicit sup­port from faculty group practice.

Psychiatry leadership perspective
As fiscal pressures intensify at academic health centers, it becomes increasingly important for resources to be used as efficiently and effectively as possible. As a greater percentage of mental health patients with more “straightforward,” less complex conditions are being managed by their primary care providers or non­prescribing psychotherapists, or both, the acuity and complexity of cases in patients who present to psychiatric clinics have intensified. This intensification of patient needs and clinical acuity is in heightened conflict with the ongoing demand for clini­cian productivity and efficiency.

Additionally, the need to provide care to a seemingly ever-growing number of moderately or severely ill patients dur­ing shorter, less frequent visits presents a daunting task for clinicians and clinical leaders. Collaborative care models appear to offer the best hope for managing the seemingly overwhelming demand for services.

In this model, the patient, who is the critical member of the team, is expected to become an “expert” on his or her ill­ness and to partner with members of the multidisciplinary team; with this support, patients are encouraged to develop a broad range of self-management skills and strat­egies to manage their illness. We believe that clinical pharmacists can and should play a critical role, not only in deliver­ing direct clinical services to patients but also in developing and devising the care models that will most effectively apply each team member’s unique set of knowl­edge, skills, and experience. Given the large percentage of our patients who have multiple medical comorbidities and who require complex medical and psychiat­ric medication regimens, the role of the pharmacist in reviewing, educating, and advising patients and other team members on these crucial pharmacy concerns will be paramount.

In light of these complex medication issues, pharmacists are uniquely posi­tioned to serve as a liaison among the patient, the primary care provider, and other members of their treatment team. We anticipate that our ambulatory psychiatry pharmacists will greatly enhance the com­fort and confidence of patients and their primary care providers during periods of care transition.

Potential roles for pharmacists in ambulatory psychiatry
One potential role for pharmacists in ambulatory psychiatry is to perform polypharmacy assessments of patients receiving complex medication regimens, prompted by physician referral. The poly­ pharmacy intake interview, performed to obtain an accurate medication list and to identify patients’ concerns about their medications, can be conducted in per­son or by telephone. Patients’ knowledge about medications and medication adher­ence are discussed, as are their perceptions of effectiveness and adverse effects.

After initial data gathering, pharma­cists complete a review of the medications, identifying any problems associated with medication indication, efficacy, tolerance, or adverse effects, drug-drug interactions, drug-nutrient interactions, and nonadher­ence. Pharmacists work to reduce medica­tion costs if that is a concern of the patient, because nonadherence can result. A medi­cation care plan is then developed in con­sultation with the primary care provider; here, the medication list is reconciled, the electronic medical record is updated, and actions to address any medication-related problems are prioritized.

Other services that might be offered include:• group education classes, based on patient motivational interviewing strate­gies, to address therapeutic nonadherence and to improve understanding of their dis­ease and treatment regimens• medication safety and monitoring• treatment intensification, as needed, following established protocols.

These are a few of the ways in which pharmacists can be relied on to expand and improve access to patient care ser­vices within ambulatory psychiatry. Key stakeholders anticipate development of newer ideas as the pharmacist’s role in ambulatory psychiatry is increasingly clarified.

Reimbursement model
In creating a role for pharmacy in ambu­latory psychiatry, it was essential that the model be financially viable and appeal­ing. Alongside its clinical model, our insti­tution has developed a financial model to support the pharmacist’s role. The lump-sum payment to the health centers from Blue Cross Blue Shield of Michigan afforded the ambulatory care clinics an opportunity to invest in PCMH pharma­cists. This funding, and the reimbursement based on T-code billing (face-to-face visits and phone consultation) for depression and other conditions requiring chronic care, provides ongoing support. From our experience, understanding physician reimbursement models and identifying relevant changes in health care reform are necessary to integrate new providers, including pharmacists, into a team-based care model.

Implementation
Promoting pharmacy services. To fos­ter anticipated collaboration with clini­cal pharmacists, the medical director of outpatient psychiatry disseminated an announcement to all providers regard­ing the investiture of clinical pharmacists to support patient care activities, educa­tion, and research. Clinicians were edu­cated about the pharmacists’ potential roles and about guidelines and methods for referral. Use of our electronic health record system enabled us to establish a relatively simple referral process involv­ing sharing electronic messages with our pharmacists.

Further, as part of the planned integra­tion of clinical pharmacists in the ambula­tory psychiatry setting, pharmacists met strategically with members of various disciplines, clinical programs, specialty clinic programs, and teams throughout the center. In addition to answering questions about the referral process, they empha­sized the role of pharmacy and opportuni­ties for collaboration.

Collaborating with others. Because the involvement of clinical pharmacists is unfamiliar to some practitioners in outpa­tient psychiatry, it is important to develop services without infringing on the roles other disciplines play. Indeed, a survey by Wheeler et al6 identified many concerns and potential boundaries among pharmacists, other providers, and patients. Concerns included confusion of practitioner roles and boundaries, a too-traditional percep­tion of the pharmacist, and demonstration of competence.⁶

Early on, we developed a structured forum to discuss ongoing challenges and address issues related to the rapidly changing clinical landscape. During these discussions we conveyed that adding pharmacists to psychiatric services would be collaborative in nature and intended to augment existing services. This commu­nication was pivotal to maintain the psy­chiatrist’s role as the ultimate prescriber and authority in the care of their patients; however, the pharmacist’s expertise, when sought, would help spur clinical and aca­demic discussion that will benefit the patient. These discussions are paramount to achieving a productive, team-based approach, to overcome challenges, and to identify opportunities of value to our pro­viders and patients (Box).

Work in progress
Implementing change in any clinical set­ting invariably creates challenges, and our endeavors to integrate clinical phar­macists into ambulatory psychiatry are no exception. We have identified several factors that we believe will optimize suc­cessful collaboration between pharmacy and ambulatory psychiatry (Table 2). Our primary challenge has been changing cli­nician behavior. Clinical practitioners can become too comfortable, wedded to their routines, and often are understandably resistant to change. Additionally, clinical systems often are inadvertently designed to obstruct change in ways that are not readily apparent. Efforts must be focused on behaviors and practices the clinical cul­ture should encourage.

The prospect of access to clinical phar­macist expertise in the outpatient setting was heralded with excitement, but the flow of referrals and consultations has been uneven. However simple the path for referral is, clinicians’ use of the system has been inconsistent—perhaps because of referrals’ passive, clinician-dependent nature. Educational outreach efforts often prompt a brief spike in referrals, only to be followed over time by a slow, steady drop-off. More active strategies will be needed, such as embedding the pharma­cists as regular, active, visible members of the various clinical teams, and imple­menting a system in which patient record reviews are assigned to the pharmacists according to agreed-upon clusters of clin­ical criteria.

One of these tactics has, in the short term, showed success. Embedded in one of our newer clinics, which were designed to bridge primary and psychiatric care, clinical pharmacists are helping manage medically complicated patients. They assist with medication selection in light of drug interactions and medical comor­bidities, conduct detailed medication his­tories, schedule follow-up visits to assess medication adherence and tolerability, and counsel patients experiencing insur­ance changes that make their medications less affordable. Integrating pharmacists in the new clinics has resulted in a steady flow of patient referrals and collaborative care work.

Clinical pharmacists are brainstorming with outpatient psychiatry leadership to build on these early successes. Ongoing communication and enhanced collabora­tion are essential, and can only improve the lives of our psychiatric patients.

For the future
Our partnership in ambulatory psychiatry was timed to occur during implementa­tion of our health system’s new electronic health record initiative. Clinical pharma­cists can play a key role in demonstrating use of the system to provide consistently accurate drug information to patients and to monitor patients receiving specific medications.

Development of ambulatory patient medication education groups, which has proved useful on the inpatient side, is another endeavor in the works. Integrating the clinical pharmacist with psychiatrists, psychologists, nurse prac­titioners, social workers, and trainees on specific teams devoted to depression, bipolar disorder, anxiety, perinatal men­tal health, and personality disorders also might prove to be a wide-ranging and promising strategy.

Enhancing the education and training experiences of residents, fellows, medical students, pharmacy students, and allied health professional learners present in our clinics is another exciting prospect. This cross-disciplinary training will yield a new generation of providers who will be more comfortable collaborating with colleagues from other disciplines, all intent on pro­viding high-quality, efficient care. We hope that, as these initiatives take root, we will recognize many opportunities to dissemi­nate our collaborative efforts in scholarly venues, documenting and sharing the pos­itive impact of our partnership.

Bottom Line
Because psychiatric outpatients present with challenging medical comorbidities and increasingly complex medication regimens, specialized clinical pharmacists can enrich the management team by offering essential monitoring and polypharmacy services, patient education and counseling, and cross-discipline training. At one academic treatment center, psychiatric and non-psychiatric practitioners are gradually buying in to these promising collaborative efforts.


Related Resources
• Board of Pharmacy Specialties. www.bpsweb.org/specialties/psychiatric.cfm.
• Abramowitz P. Ambulatory care pharmacy practice: The future is now. www.connect.ashp.org/blogs/paul-abramowitz/2014/05/14/ambulatory-care-pharmacy-practice-the-future-is-now.

Drug Brand Name
Citalopram • Celexa

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

Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.¹ Poor oral hygiene is a significant problem because it results in dental pathol­ogy that has an adverse influence on the whole body.

Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.² In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.³ Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.⁴

Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.⁵ The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental ero­sions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leu­koplakia, and oral papilloma or other can­cers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.⁵

Alcohol consumption increases the risk of oral cancer. Long-term alcohol use sup­presses bone marrow function, causing leukopenia and resulting in immunosup­pression and an increased incidence of dental infections.⁶ Excessive alcohol con­sumption also can cause thrombocytope­nia and bleeding, which can complicate dental procedures.

Smoking cigarettes increases the inci­dence of periodontal disease, especially necrotizing gingivitis and candidiasis.⁷ Ninety percent of patients with schizo­phrenia smoke—compared with up to 70% of patients with other psychiatric disor­ders, and 19% of the general population.^7,8 Physiologic aspects of schizophrenia rein­force the smoking habit.⁷

Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obe­sity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.

Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that peri­odontal disease will progress.⁹ Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque for­mation.¹⁰ Depression, anxiety, and substance abuse can lead to temporomandibular disor­ders that cause pain and restrict jaw move­ment.¹¹ Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.

Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.

Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.¹¹ Misdiagnosis can result in extractions or procedures without an appropriate indica­tion and failure to alleviate the pain. 

Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candi­diasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyski­nesia, dystonia) may cause tooth damage and make managing dentures difficult.⁶

What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting sub­stances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of den­tal caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.

From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.

A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physi­cian, facilitates health care and works to offer the patient access to global medical services.

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

Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.¹ Poor oral hygiene is a significant problem because it results in dental pathol­ogy that has an adverse influence on the whole body.

Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.² In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.³ Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.⁴

Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.⁵ The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental ero­sions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leu­koplakia, and oral papilloma or other can­cers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.⁵

Alcohol consumption increases the risk of oral cancer. Long-term alcohol use sup­presses bone marrow function, causing leukopenia and resulting in immunosup­pression and an increased incidence of dental infections.⁶ Excessive alcohol con­sumption also can cause thrombocytope­nia and bleeding, which can complicate dental procedures.

Smoking cigarettes increases the inci­dence of periodontal disease, especially necrotizing gingivitis and candidiasis.⁷ Ninety percent of patients with schizo­phrenia smoke—compared with up to 70% of patients with other psychiatric disor­ders, and 19% of the general population.^7,8 Physiologic aspects of schizophrenia rein­force the smoking habit.⁷

Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obe­sity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.

Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that peri­odontal disease will progress.⁹ Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque for­mation.¹⁰ Depression, anxiety, and substance abuse can lead to temporomandibular disor­ders that cause pain and restrict jaw move­ment.¹¹ Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.

Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.

Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.¹¹ Misdiagnosis can result in extractions or procedures without an appropriate indica­tion and failure to alleviate the pain. 

Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candi­diasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyski­nesia, dystonia) may cause tooth damage and make managing dentures difficult.⁶

What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting sub­stances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of den­tal caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.

From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.

A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physi­cian, facilitates health care and works to offer the patient access to global medical services.

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

Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.¹ Poor oral hygiene is a significant problem because it results in dental pathol­ogy that has an adverse influence on the whole body.

Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.² In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.³ Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.⁴

Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.⁵ The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental ero­sions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leu­koplakia, and oral papilloma or other can­cers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.⁵

Alcohol consumption increases the risk of oral cancer. Long-term alcohol use sup­presses bone marrow function, causing leukopenia and resulting in immunosup­pression and an increased incidence of dental infections.⁶ Excessive alcohol con­sumption also can cause thrombocytope­nia and bleeding, which can complicate dental procedures.

Smoking cigarettes increases the inci­dence of periodontal disease, especially necrotizing gingivitis and candidiasis.⁷ Ninety percent of patients with schizo­phrenia smoke—compared with up to 70% of patients with other psychiatric disor­ders, and 19% of the general population.^7,8 Physiologic aspects of schizophrenia rein­force the smoking habit.⁷

Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obe­sity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.

Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that peri­odontal disease will progress.⁹ Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque for­mation.¹⁰ Depression, anxiety, and substance abuse can lead to temporomandibular disor­ders that cause pain and restrict jaw move­ment.¹¹ Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.

Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.

Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.¹¹ Misdiagnosis can result in extractions or procedures without an appropriate indica­tion and failure to alleviate the pain. 

Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candi­diasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyski­nesia, dystonia) may cause tooth damage and make managing dentures difficult.⁶

What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting sub­stances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of den­tal caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.

From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.

A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physi­cian, facilitates health care and works to offer the patient access to global medical services.

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