Current Psychiatry

“Corticosteroid psychosis: Stop therapy or add psychotropics?” (Med/Psych Update, Current Psychiatry, January 2010) provided excellent information, especially for consultation-liaison psychiatrists. I understand studies have been funded to show efficacy for atypicals, but can the authors point to studies that show efficacy for perphenazine, haloperidol, or other typical antipsychotics? My guess is that typicals and atypicals essentially are equivalent in corticosteroid-induced acute mania.

Corey Yilmaz, MD
Adult and child psychiatrist
Buckeye, AZ

The authors respond

Dr. Yilmaz is correct that typical antipsychotics would be useful for off-label treatment of corticosteroid-induced psychosis. Three publications provide further detail about using these medications for corticosteroid-induced psychosis. A case series by Wada et al¹ and a case report by Ahmad and Rasul² report on the efficacy of low-dose (1 mg/d to 4 mg/d) haloperidol in treating patients who developed acute psychosis following initiation of a corticosteroid. These patients showed a rapid and marked improvement with haloperidol. A brief report by Bloch et al³ describes a patient prophylactically treated with chlorpromazine, 150 mg, before receiving high-dose methylprednisone, initiated at 1 g and titrated over 10 days. The patient did not exhibit any psychiatric symptoms but did develop hypomania when chlorpromazine was stopped, which resolved with readministration of this medication. We did not find any case reports on perphenazine.

Andrew J. Muzyk, PharmD
Assistant professor
Campbell University School of Pharmacy
Clinical specialist in internal medicine/psychiatry
Department of pharmacy, Duke University Hospital

Shannon Holt, PharmD
Clinical pharmacist

Jane P. Gagliardi, MD
Assistant professor of psychiatry and behavioral sciences
Assistant professor of medicine
Duke University School of Medicine
Durham, NC

“Corticosteroid psychosis: Stop therapy or add psychotropics?” (Med/Psych Update, Current Psychiatry, January 2010) provided excellent information, especially for consultation-liaison psychiatrists. I understand studies have been funded to show efficacy for atypicals, but can the authors point to studies that show efficacy for perphenazine, haloperidol, or other typical antipsychotics? My guess is that typicals and atypicals essentially are equivalent in corticosteroid-induced acute mania.

Corey Yilmaz, MD
Adult and child psychiatrist
Buckeye, AZ

The authors respond

Dr. Yilmaz is correct that typical antipsychotics would be useful for off-label treatment of corticosteroid-induced psychosis. Three publications provide further detail about using these medications for corticosteroid-induced psychosis. A case series by Wada et al¹ and a case report by Ahmad and Rasul² report on the efficacy of low-dose (1 mg/d to 4 mg/d) haloperidol in treating patients who developed acute psychosis following initiation of a corticosteroid. These patients showed a rapid and marked improvement with haloperidol. A brief report by Bloch et al³ describes a patient prophylactically treated with chlorpromazine, 150 mg, before receiving high-dose methylprednisone, initiated at 1 g and titrated over 10 days. The patient did not exhibit any psychiatric symptoms but did develop hypomania when chlorpromazine was stopped, which resolved with readministration of this medication. We did not find any case reports on perphenazine.

Andrew J. Muzyk, PharmD
Assistant professor
Campbell University School of Pharmacy
Clinical specialist in internal medicine/psychiatry
Department of pharmacy, Duke University Hospital

Shannon Holt, PharmD
Clinical pharmacist

Jane P. Gagliardi, MD
Assistant professor of psychiatry and behavioral sciences
Assistant professor of medicine
Duke University School of Medicine
Durham, NC

“Corticosteroid psychosis: Stop therapy or add psychotropics?” (Med/Psych Update, Current Psychiatry, January 2010) provided excellent information, especially for consultation-liaison psychiatrists. I understand studies have been funded to show efficacy for atypicals, but can the authors point to studies that show efficacy for perphenazine, haloperidol, or other typical antipsychotics? My guess is that typicals and atypicals essentially are equivalent in corticosteroid-induced acute mania.

Corey Yilmaz, MD
Adult and child psychiatrist
Buckeye, AZ

The authors respond

Dr. Yilmaz is correct that typical antipsychotics would be useful for off-label treatment of corticosteroid-induced psychosis. Three publications provide further detail about using these medications for corticosteroid-induced psychosis. A case series by Wada et al¹ and a case report by Ahmad and Rasul² report on the efficacy of low-dose (1 mg/d to 4 mg/d) haloperidol in treating patients who developed acute psychosis following initiation of a corticosteroid. These patients showed a rapid and marked improvement with haloperidol. A brief report by Bloch et al³ describes a patient prophylactically treated with chlorpromazine, 150 mg, before receiving high-dose methylprednisone, initiated at 1 g and titrated over 10 days. The patient did not exhibit any psychiatric symptoms but did develop hypomania when chlorpromazine was stopped, which resolved with readministration of this medication. We did not find any case reports on perphenazine.

Andrew J. Muzyk, PharmD
Assistant professor
Campbell University School of Pharmacy
Clinical specialist in internal medicine/psychiatry
Department of pharmacy, Duke University Hospital

Shannon Holt, PharmD
Clinical pharmacist

Jane P. Gagliardi, MD
Assistant professor of psychiatry and behavioral sciences
Assistant professor of medicine
Duke University School of Medicine
Durham, NC

When treating deaf psychiatric patients, appropriate psychiatric care is possible when you maintain an awareness of deaf culture and language. Consider these 10 points:

1. Certified American Sign Language (ASL) interpreters are necessary. The Americans with Disabilities Act requires that all health care providers offer “auxiliary aids and services to provide effective communication.” For deaf patients, often this means an interpreter. Certified interpreters:

• have passed fluency examinations
• are culturally competent
• follow standards of practice
• have a code of ethics
• are required to pursue continuing education to keep their skills sharp and up to date.

Visit the Registry of Interpreters for the Deaf at www.rid.org to search by state for freelance qualified ASL interpreters and interpreting agencies. Be aware that clinicians must pay for the interpreting service, which is not reimbursed by insurance. Rates vary by region.

2. ASL fluency levels vary. Approximately 90% of deaf children are born to hearing parents, and exposure to ASL may be delayed or minimal. As a result, the presence of a fluent ASL interpreter does not guarantee patient comprehension. The patient may not understand the questions being asked resulting in incorrect endorsement or denial of symptoms. Dysfluent patients’ language may mimic that of a patient with a thought disorder or intellectual disability, resulting in misdiagnosis.¹

3. Meet the interpreter before the session. Discuss your goals and explain the meaning of psychiatric terms and symptoms to help him or her communicate your message and interpret the patient’s response.²

ASL is not visual English. Some concepts do not translate into ASL and need to be modified or omitted by interpreters. English idioms often used in diagnostic interviews, such as “feeling blue” or “feeling keyed up or on edge,” do not have exact ASL translations.

An interpreter has to use his or her judgment on how to translate these concepts in ASL. Some symptoms such as “panic attack” and “auditory hallucination” do not have corresponding signs in ASL.

Interpreters may convey these concepts by describing or even acting them out. Ambiguity is difficult to maintain in ASL. Interpreters often have to give examples or lists of possible choices to communicate a concept. Some open-ended questions must be transformed into multiple-choice questions, which can be leading or narrow potential responses.

4. Be aware of privacy. Certified interpreters are required to maintain confidentiality. However, a deaf patient might not have the same interpreter over the course of treatment. The deaf community is close-knit, and a patient using multiple interpreters may worry about confidentiality. Deaf people are likely to use interpreters in a variety of settings and may feel uncomfortable working with the same interpreter in a psychiatric setting and other social situations. The deaf patient always has final say over whether or not to work with a particular interpreter.

5. Avoid using families as interpreters. Even if they are fluent in ASL, family members can distort examination findings and will eliminate confidentiality. If a family member insists on serving as an interpreter, discuss his or her reasons. For example, some families use a form of idiosyncratic gestures often called “home signs” instead of ASL. In this case, you would need a family member present because an ASL interpreter would not be familiar with these. In other situations, you may have to educate family members about why a certified interpreter is more appropriate.

6. Don’t rely on written English. A typical deaf person of normal intelligence has a fourth-grade reading level. Self-report measures of symptoms often are written for an eighth-grade reading or higher level. In psychiatry, subtle nuances in communication are critical, and relying on written English could cause misunderstandings.

Do not use written notes passed back and forth with your patient to avoid the expense of an ASL interpreter. Physicians have been successfully sued for refusing to hire interpreters in the hope of “getting by” with written notes. In these cases the judgments against the physicians were not covered by malpractice insurance.

7. Don’t overpathologize. ASL is an expressive and dramatic language. In addition, deaf persons may have different personal space boundaries than hearing persons. Don’t mistake these cultural norms as evidence of a mood disorder or character pathology.

8. Be cautious when assessing a deaf person for psychosis and “hearing-based” phenomena such as auditory hallucinations. Psychotic disorders historically have been overdiagnosed in deaf patients when clinicians rely solely on subjective reports of symptoms. Instead, err on the side of caution unless you identify objective, observable evidence (such as bizarre behavior or clearly stated delusional beliefs).¹

9. Clarify. Deaf persons—just like hearing persons—do not like to appear unknowledgeable. A patient may “nod along,” leading you to inaccurate conclusions and misdiagnosis. Use open-ended questions to elicit a full description of symptoms.

10. Be patient and plan ahead. Schedule longer sessions—as much as twice as long—to allow extra time for interpretation and double-checking comprehension. Remember that each question has to be asked, interpreted, answered, and interpreted again. Follow-up questions may be necessary to ensure comprehension.

When treating deaf psychiatric patients, appropriate psychiatric care is possible when you maintain an awareness of deaf culture and language. Consider these 10 points:

1. Certified American Sign Language (ASL) interpreters are necessary. The Americans with Disabilities Act requires that all health care providers offer “auxiliary aids and services to provide effective communication.” For deaf patients, often this means an interpreter. Certified interpreters:

• have passed fluency examinations
• are culturally competent
• follow standards of practice
• have a code of ethics
• are required to pursue continuing education to keep their skills sharp and up to date.

Visit the Registry of Interpreters for the Deaf at www.rid.org to search by state for freelance qualified ASL interpreters and interpreting agencies. Be aware that clinicians must pay for the interpreting service, which is not reimbursed by insurance. Rates vary by region.

2. ASL fluency levels vary. Approximately 90% of deaf children are born to hearing parents, and exposure to ASL may be delayed or minimal. As a result, the presence of a fluent ASL interpreter does not guarantee patient comprehension. The patient may not understand the questions being asked resulting in incorrect endorsement or denial of symptoms. Dysfluent patients’ language may mimic that of a patient with a thought disorder or intellectual disability, resulting in misdiagnosis.¹

3. Meet the interpreter before the session. Discuss your goals and explain the meaning of psychiatric terms and symptoms to help him or her communicate your message and interpret the patient’s response.²

ASL is not visual English. Some concepts do not translate into ASL and need to be modified or omitted by interpreters. English idioms often used in diagnostic interviews, such as “feeling blue” or “feeling keyed up or on edge,” do not have exact ASL translations.

An interpreter has to use his or her judgment on how to translate these concepts in ASL. Some symptoms such as “panic attack” and “auditory hallucination” do not have corresponding signs in ASL.

Interpreters may convey these concepts by describing or even acting them out. Ambiguity is difficult to maintain in ASL. Interpreters often have to give examples or lists of possible choices to communicate a concept. Some open-ended questions must be transformed into multiple-choice questions, which can be leading or narrow potential responses.

4. Be aware of privacy. Certified interpreters are required to maintain confidentiality. However, a deaf patient might not have the same interpreter over the course of treatment. The deaf community is close-knit, and a patient using multiple interpreters may worry about confidentiality. Deaf people are likely to use interpreters in a variety of settings and may feel uncomfortable working with the same interpreter in a psychiatric setting and other social situations. The deaf patient always has final say over whether or not to work with a particular interpreter.

5. Avoid using families as interpreters. Even if they are fluent in ASL, family members can distort examination findings and will eliminate confidentiality. If a family member insists on serving as an interpreter, discuss his or her reasons. For example, some families use a form of idiosyncratic gestures often called “home signs” instead of ASL. In this case, you would need a family member present because an ASL interpreter would not be familiar with these. In other situations, you may have to educate family members about why a certified interpreter is more appropriate.

6. Don’t rely on written English. A typical deaf person of normal intelligence has a fourth-grade reading level. Self-report measures of symptoms often are written for an eighth-grade reading or higher level. In psychiatry, subtle nuances in communication are critical, and relying on written English could cause misunderstandings.

Do not use written notes passed back and forth with your patient to avoid the expense of an ASL interpreter. Physicians have been successfully sued for refusing to hire interpreters in the hope of “getting by” with written notes. In these cases the judgments against the physicians were not covered by malpractice insurance.

7. Don’t overpathologize. ASL is an expressive and dramatic language. In addition, deaf persons may have different personal space boundaries than hearing persons. Don’t mistake these cultural norms as evidence of a mood disorder or character pathology.

8. Be cautious when assessing a deaf person for psychosis and “hearing-based” phenomena such as auditory hallucinations. Psychotic disorders historically have been overdiagnosed in deaf patients when clinicians rely solely on subjective reports of symptoms. Instead, err on the side of caution unless you identify objective, observable evidence (such as bizarre behavior or clearly stated delusional beliefs).¹

9. Clarify. Deaf persons—just like hearing persons—do not like to appear unknowledgeable. A patient may “nod along,” leading you to inaccurate conclusions and misdiagnosis. Use open-ended questions to elicit a full description of symptoms.

10. Be patient and plan ahead. Schedule longer sessions—as much as twice as long—to allow extra time for interpretation and double-checking comprehension. Remember that each question has to be asked, interpreted, answered, and interpreted again. Follow-up questions may be necessary to ensure comprehension.

When treating deaf psychiatric patients, appropriate psychiatric care is possible when you maintain an awareness of deaf culture and language. Consider these 10 points:

1. Certified American Sign Language (ASL) interpreters are necessary. The Americans with Disabilities Act requires that all health care providers offer “auxiliary aids and services to provide effective communication.” For deaf patients, often this means an interpreter. Certified interpreters:

• have passed fluency examinations
• are culturally competent
• follow standards of practice
• have a code of ethics
• are required to pursue continuing education to keep their skills sharp and up to date.

Visit the Registry of Interpreters for the Deaf at www.rid.org to search by state for freelance qualified ASL interpreters and interpreting agencies. Be aware that clinicians must pay for the interpreting service, which is not reimbursed by insurance. Rates vary by region.

2. ASL fluency levels vary. Approximately 90% of deaf children are born to hearing parents, and exposure to ASL may be delayed or minimal. As a result, the presence of a fluent ASL interpreter does not guarantee patient comprehension. The patient may not understand the questions being asked resulting in incorrect endorsement or denial of symptoms. Dysfluent patients’ language may mimic that of a patient with a thought disorder or intellectual disability, resulting in misdiagnosis.¹

3. Meet the interpreter before the session. Discuss your goals and explain the meaning of psychiatric terms and symptoms to help him or her communicate your message and interpret the patient’s response.²

ASL is not visual English. Some concepts do not translate into ASL and need to be modified or omitted by interpreters. English idioms often used in diagnostic interviews, such as “feeling blue” or “feeling keyed up or on edge,” do not have exact ASL translations.

An interpreter has to use his or her judgment on how to translate these concepts in ASL. Some symptoms such as “panic attack” and “auditory hallucination” do not have corresponding signs in ASL.

Interpreters may convey these concepts by describing or even acting them out. Ambiguity is difficult to maintain in ASL. Interpreters often have to give examples or lists of possible choices to communicate a concept. Some open-ended questions must be transformed into multiple-choice questions, which can be leading or narrow potential responses.

4. Be aware of privacy. Certified interpreters are required to maintain confidentiality. However, a deaf patient might not have the same interpreter over the course of treatment. The deaf community is close-knit, and a patient using multiple interpreters may worry about confidentiality. Deaf people are likely to use interpreters in a variety of settings and may feel uncomfortable working with the same interpreter in a psychiatric setting and other social situations. The deaf patient always has final say over whether or not to work with a particular interpreter.

5. Avoid using families as interpreters. Even if they are fluent in ASL, family members can distort examination findings and will eliminate confidentiality. If a family member insists on serving as an interpreter, discuss his or her reasons. For example, some families use a form of idiosyncratic gestures often called “home signs” instead of ASL. In this case, you would need a family member present because an ASL interpreter would not be familiar with these. In other situations, you may have to educate family members about why a certified interpreter is more appropriate.

6. Don’t rely on written English. A typical deaf person of normal intelligence has a fourth-grade reading level. Self-report measures of symptoms often are written for an eighth-grade reading or higher level. In psychiatry, subtle nuances in communication are critical, and relying on written English could cause misunderstandings.

Do not use written notes passed back and forth with your patient to avoid the expense of an ASL interpreter. Physicians have been successfully sued for refusing to hire interpreters in the hope of “getting by” with written notes. In these cases the judgments against the physicians were not covered by malpractice insurance.

7. Don’t overpathologize. ASL is an expressive and dramatic language. In addition, deaf persons may have different personal space boundaries than hearing persons. Don’t mistake these cultural norms as evidence of a mood disorder or character pathology.

8. Be cautious when assessing a deaf person for psychosis and “hearing-based” phenomena such as auditory hallucinations. Psychotic disorders historically have been overdiagnosed in deaf patients when clinicians rely solely on subjective reports of symptoms. Instead, err on the side of caution unless you identify objective, observable evidence (such as bizarre behavior or clearly stated delusional beliefs).¹

9. Clarify. Deaf persons—just like hearing persons—do not like to appear unknowledgeable. A patient may “nod along,” leading you to inaccurate conclusions and misdiagnosis. Use open-ended questions to elicit a full description of symptoms.

10. Be patient and plan ahead. Schedule longer sessions—as much as twice as long—to allow extra time for interpretation and double-checking comprehension. Remember that each question has to be asked, interpreted, answered, and interpreted again. Follow-up questions may be necessary to ensure comprehension.

In the United States >33,000 people take their lives each year.¹ Depression is involved in 65% to 90% of all suicides;² however, some patients may not appear acutely depressed or might minimize suicidal thoughts to avoid treatment or hospitalization.

Having direct patient contact, information from collateral sources, and available medical records will guide you in developing a treatment plan, but also consider these 3 areas using the mnemonic PPD:

Past suicide attempts. One of the best predictors of future suicidal behavior is past attempts.³ Ask your patient if he or she has engaged in suicidal behaviors of increasing lethality, such as overdosing, cutting, or unintentional firearm injury. Patients who engage in “escalating attempts” are at a higher risk of harming themselves.⁴

Psychosis. Actively psychotic patients have difficulty contracting for safety. They may report hearing voices telling them to harm themselves or others. Ask patients about hallucinations and how they respond to these experiences even if the hallucinations do not involve suicidal content. For example, a patient with a delusion of having a deadly infectious disease may ingest an entire bottle of medication to eradicate the infection. This might seem like a suicide attempt, but the patient’s intent was not to die, but to “treat” himself or herself.

Drugs and alcohol. One-third of those who commit suicide test positive for alcohol and nearly 1 in 5 have evidence of opiates.⁵ Patients may abuse substances to regulate their moods; however, they are prone to suicidal behavior under the influence of drugs or alcohol. Ask your patient about substances he or she uses and how they impact suicidal thoughts.

Positive findings for ≥1 of the above criteria place a patient at higher risk for suicidal behavior.⁶ By incorporating these 3 factors into your suicide assessment, you will be better equipped to justify the level of care and treatment you recommend.

In the United States >33,000 people take their lives each year.¹ Depression is involved in 65% to 90% of all suicides;² however, some patients may not appear acutely depressed or might minimize suicidal thoughts to avoid treatment or hospitalization.

Having direct patient contact, information from collateral sources, and available medical records will guide you in developing a treatment plan, but also consider these 3 areas using the mnemonic PPD:

Past suicide attempts. One of the best predictors of future suicidal behavior is past attempts.³ Ask your patient if he or she has engaged in suicidal behaviors of increasing lethality, such as overdosing, cutting, or unintentional firearm injury. Patients who engage in “escalating attempts” are at a higher risk of harming themselves.⁴

Psychosis. Actively psychotic patients have difficulty contracting for safety. They may report hearing voices telling them to harm themselves or others. Ask patients about hallucinations and how they respond to these experiences even if the hallucinations do not involve suicidal content. For example, a patient with a delusion of having a deadly infectious disease may ingest an entire bottle of medication to eradicate the infection. This might seem like a suicide attempt, but the patient’s intent was not to die, but to “treat” himself or herself.

Drugs and alcohol. One-third of those who commit suicide test positive for alcohol and nearly 1 in 5 have evidence of opiates.⁵ Patients may abuse substances to regulate their moods; however, they are prone to suicidal behavior under the influence of drugs or alcohol. Ask your patient about substances he or she uses and how they impact suicidal thoughts.

Positive findings for ≥1 of the above criteria place a patient at higher risk for suicidal behavior.⁶ By incorporating these 3 factors into your suicide assessment, you will be better equipped to justify the level of care and treatment you recommend.

In the United States >33,000 people take their lives each year.¹ Depression is involved in 65% to 90% of all suicides;² however, some patients may not appear acutely depressed or might minimize suicidal thoughts to avoid treatment or hospitalization.

Having direct patient contact, information from collateral sources, and available medical records will guide you in developing a treatment plan, but also consider these 3 areas using the mnemonic PPD:

Past suicide attempts. One of the best predictors of future suicidal behavior is past attempts.³ Ask your patient if he or she has engaged in suicidal behaviors of increasing lethality, such as overdosing, cutting, or unintentional firearm injury. Patients who engage in “escalating attempts” are at a higher risk of harming themselves.⁴

Psychosis. Actively psychotic patients have difficulty contracting for safety. They may report hearing voices telling them to harm themselves or others. Ask patients about hallucinations and how they respond to these experiences even if the hallucinations do not involve suicidal content. For example, a patient with a delusion of having a deadly infectious disease may ingest an entire bottle of medication to eradicate the infection. This might seem like a suicide attempt, but the patient’s intent was not to die, but to “treat” himself or herself.

Drugs and alcohol. One-third of those who commit suicide test positive for alcohol and nearly 1 in 5 have evidence of opiates.⁵ Patients may abuse substances to regulate their moods; however, they are prone to suicidal behavior under the influence of drugs or alcohol. Ask your patient about substances he or she uses and how they impact suicidal thoughts.

Positive findings for ≥1 of the above criteria place a patient at higher risk for suicidal behavior.⁶ By incorporating these 3 factors into your suicide assessment, you will be better equipped to justify the level of care and treatment you recommend.

In “Children with tic disorders: How to match treatment with symptoms” (Current Psychiatry, March 2010), the authors describe Sammy, who developed symptoms of Tourette syndrome. However, we should not forget that children with allergies often experience itching or irritation of the eyelids, nostrils, and throat that causes them to blink, sniff, touch their nose, or clear their throat. The presence of sneezing, runny, or congested nose may help distinguish allergies, but there is an interesting overlap.

I was intrigued by the authors’ suggestion to tell parents “you typically do not treat children with antipsychotics for more than one year continuously.” I thought the decision to continue or discontinue depended on an individualized risk and benefit approach. Are the authors referring to Tourette syndrome specifically or all indications including psychosis and/or mania?

Ian T. Webber, MD
Community Psychiatry Associates
San Francisco, CA

The authors respond

Children with allergies may receive a diagnosis of a tic disorder, but it has been our experience that the tic disorder initially is mislabeled as an allergy. We recommend asking about premonitory urge or sensation, whether the symptom can be temporarily suppressed, and whether there is a sense of relief after the action. Noting a seasonal pattern also may help make the correct diagnosis.

We recommend not planning antipsychotic treatment for longer than 1 year because the risks of metabolic side effects may outweigh benefit for a tic disorder with a waxing and waning course. The decision to continue medication is based on the individual’s risk-benefit ratio. Our article focused on treatment of tic disorders; psychosis and mania are extremely rare in children. If a child presents with out-of-control behavior, we recommend a behavior plan and parental guidance over antipsychotics if possible. Short-term antipsychotic use may be indicated, although most are off-label in the pediatric population. Tapering the medication periodically to determine whether it is still necessary can help limit side effects, such as diabetes.

Jeste et al¹ note that with each year of antipsychotic use, 5% of patients will show signs of tardive dyskinesia. In a retrospective study of 60 adolescents treated with risperidone, typical antipsychotics, or no antipsychotic, the risperidone-treated group gained significantly more body mass than those receiving a conventional antipsychotic over 6 months.² Degrauw et al³ reported that weight gain is not always excessive in pediatric patients treated with antipsychotics for >1 year.

Elena Harris, MD, PhD
Assistant professor
Division of child and adolescent psychiatry

Steve W. Wu, MD
Assistant professor
Division of child neurology
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH

In “Children with tic disorders: How to match treatment with symptoms” (Current Psychiatry, March 2010), the authors describe Sammy, who developed symptoms of Tourette syndrome. However, we should not forget that children with allergies often experience itching or irritation of the eyelids, nostrils, and throat that causes them to blink, sniff, touch their nose, or clear their throat. The presence of sneezing, runny, or congested nose may help distinguish allergies, but there is an interesting overlap.

I was intrigued by the authors’ suggestion to tell parents “you typically do not treat children with antipsychotics for more than one year continuously.” I thought the decision to continue or discontinue depended on an individualized risk and benefit approach. Are the authors referring to Tourette syndrome specifically or all indications including psychosis and/or mania?

Ian T. Webber, MD
Community Psychiatry Associates
San Francisco, CA

The authors respond

Children with allergies may receive a diagnosis of a tic disorder, but it has been our experience that the tic disorder initially is mislabeled as an allergy. We recommend asking about premonitory urge or sensation, whether the symptom can be temporarily suppressed, and whether there is a sense of relief after the action. Noting a seasonal pattern also may help make the correct diagnosis.

We recommend not planning antipsychotic treatment for longer than 1 year because the risks of metabolic side effects may outweigh benefit for a tic disorder with a waxing and waning course. The decision to continue medication is based on the individual’s risk-benefit ratio. Our article focused on treatment of tic disorders; psychosis and mania are extremely rare in children. If a child presents with out-of-control behavior, we recommend a behavior plan and parental guidance over antipsychotics if possible. Short-term antipsychotic use may be indicated, although most are off-label in the pediatric population. Tapering the medication periodically to determine whether it is still necessary can help limit side effects, such as diabetes.

Jeste et al¹ note that with each year of antipsychotic use, 5% of patients will show signs of tardive dyskinesia. In a retrospective study of 60 adolescents treated with risperidone, typical antipsychotics, or no antipsychotic, the risperidone-treated group gained significantly more body mass than those receiving a conventional antipsychotic over 6 months.² Degrauw et al³ reported that weight gain is not always excessive in pediatric patients treated with antipsychotics for >1 year.

Elena Harris, MD, PhD
Assistant professor
Division of child and adolescent psychiatry

Steve W. Wu, MD
Assistant professor
Division of child neurology
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH

In “Children with tic disorders: How to match treatment with symptoms” (Current Psychiatry, March 2010), the authors describe Sammy, who developed symptoms of Tourette syndrome. However, we should not forget that children with allergies often experience itching or irritation of the eyelids, nostrils, and throat that causes them to blink, sniff, touch their nose, or clear their throat. The presence of sneezing, runny, or congested nose may help distinguish allergies, but there is an interesting overlap.

I was intrigued by the authors’ suggestion to tell parents “you typically do not treat children with antipsychotics for more than one year continuously.” I thought the decision to continue or discontinue depended on an individualized risk and benefit approach. Are the authors referring to Tourette syndrome specifically or all indications including psychosis and/or mania?

Ian T. Webber, MD
Community Psychiatry Associates
San Francisco, CA

The authors respond

Children with allergies may receive a diagnosis of a tic disorder, but it has been our experience that the tic disorder initially is mislabeled as an allergy. We recommend asking about premonitory urge or sensation, whether the symptom can be temporarily suppressed, and whether there is a sense of relief after the action. Noting a seasonal pattern also may help make the correct diagnosis.

We recommend not planning antipsychotic treatment for longer than 1 year because the risks of metabolic side effects may outweigh benefit for a tic disorder with a waxing and waning course. The decision to continue medication is based on the individual’s risk-benefit ratio. Our article focused on treatment of tic disorders; psychosis and mania are extremely rare in children. If a child presents with out-of-control behavior, we recommend a behavior plan and parental guidance over antipsychotics if possible. Short-term antipsychotic use may be indicated, although most are off-label in the pediatric population. Tapering the medication periodically to determine whether it is still necessary can help limit side effects, such as diabetes.

Jeste et al¹ note that with each year of antipsychotic use, 5% of patients will show signs of tardive dyskinesia. In a retrospective study of 60 adolescents treated with risperidone, typical antipsychotics, or no antipsychotic, the risperidone-treated group gained significantly more body mass than those receiving a conventional antipsychotic over 6 months.² Degrauw et al³ reported that weight gain is not always excessive in pediatric patients treated with antipsychotics for >1 year.

Elena Harris, MD, PhD
Assistant professor
Division of child and adolescent psychiatry

Steve W. Wu, MD
Assistant professor
Division of child neurology
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH

Dr. Henry A. Nasrallah’s “A psychiatric manifesto” (From the Editor, Current Psychiatry, April 2010; available at http://bit.ly/9tOuvi) is a precise description of the beauty and hardships unique to our ever-evolving specialty. I am proud to share this description with medical students, psychiatry residents, and fellows and urge others to consider doing the same. I find myself reflecting on each of these core themes during the day. It is true that as we stand on the brink of great neuroscience discoveries with potential to benefit millions of our patients, we simultaneously face “more detractors and self-appointed critics than any other medical specialty.” I am hopeful that this living manifesto will bolster collective adhesion within our field while also helping to educate non-psychiatrists of “who we are and what we do.”

James G. MacKenzie, DO
Medical director, consultation and emergency services
Department of child and adolescent psychiatry
Children’s Memorial Hospital
Chicago, IL

Dr. Henry A. Nasrallah’s “A psychiatric manifesto” (From the Editor, Current Psychiatry, April 2010; available at http://bit.ly/9tOuvi) is a precise description of the beauty and hardships unique to our ever-evolving specialty. I am proud to share this description with medical students, psychiatry residents, and fellows and urge others to consider doing the same. I find myself reflecting on each of these core themes during the day. It is true that as we stand on the brink of great neuroscience discoveries with potential to benefit millions of our patients, we simultaneously face “more detractors and self-appointed critics than any other medical specialty.” I am hopeful that this living manifesto will bolster collective adhesion within our field while also helping to educate non-psychiatrists of “who we are and what we do.”

James G. MacKenzie, DO
Medical director, consultation and emergency services
Department of child and adolescent psychiatry
Children’s Memorial Hospital
Chicago, IL

Dr. Henry A. Nasrallah’s “A psychiatric manifesto” (From the Editor, Current Psychiatry, April 2010; available at http://bit.ly/9tOuvi) is a precise description of the beauty and hardships unique to our ever-evolving specialty. I am proud to share this description with medical students, psychiatry residents, and fellows and urge others to consider doing the same. I find myself reflecting on each of these core themes during the day. It is true that as we stand on the brink of great neuroscience discoveries with potential to benefit millions of our patients, we simultaneously face “more detractors and self-appointed critics than any other medical specialty.” I am hopeful that this living manifesto will bolster collective adhesion within our field while also helping to educate non-psychiatrists of “who we are and what we do.”

James G. MacKenzie, DO
Medical director, consultation and emergency services
Department of child and adolescent psychiatry
Children’s Memorial Hospital
Chicago, IL

Do lawyers understand psychiatry? To answer that semi-rhetorical question, I imagined the following conversation between 2 friends, Barry the barrister and Harry the psychiatrist.

Barry: Harry, I think psychiatry is a politically incorrect discipline.

Harry: How so, my dear friend?

Barry: Well, psychiatrists hospitalize people against their will, strip them of their civil liberties, and force them to take powerful, mind-altering drugs.

Harry: Barry, when you think about it objectively, involuntary hospitalization is a compassionate and legal act for people suffering from a brain disease that makes them suicidal or homicidal and a danger to themselves and others with no insight that they are sick. Once treated and improved, patients regain their civil liberties and often thank us for providing care against their will. And a person needs a healthy brain to properly exercise one’s civil liberties.

Barry: What about electroconvulsive therapy (ECT)? Why would you subject people to such a primitive procedure?

Harry: For your information, when used for treating severely depressed persons who do not respond to multiple medications, ECT is one of the most effective procedures.¹ It saves the lives of suicidal patients and restores their functioning. Published studies show that ECT stimulates neurogenesis and helps regenerate brain tissue by stimulating the production of new brain cells in the hippocampus, a critical structure that loses tissue during depression.² Other neurostimulation techniques, including repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS), recently have been FDA-approved for severe depression. Deep brain stimulation (DBS) also is emerging as a promising treatment.³

Barry: But Harry, you psychiatrists medicalize normal emotions such as sadness or grief and pathologize high energy in children, transforming them into diagnostic labels like attention-deficit/hyperactivity disorder.

Harry: Normal sadness or grief is not a psychiatric diagnosis. People seek psychiatric help on their own or are brought in by their loved ones when an emotional tsunami devastates their lives, causing them to stop functioning, demonstrate unusual behavior, or express suicidal thoughts. Children referred for treatment because of uncontrollable behaviors at home and school are afflicted by neurobiologic disorders and FDA-approved medications help them to lead normal lives. Do you really believe children are incapable of having a psychiatric illness?

Barry: OK, but isn’t it irresponsible for psychiatrists to administer powerful antipsychotics to elderly persons in nursing homes when the FDA has issued a “black-box” warning that this practice may be fatal?

Harry: I wish that one day you would visit a facility for older persons with Alzheimer’s disease to see that as many as half of these individuals become psychotic, extremely agitated and assaultive, or a risk to themselves, the staff, and other patients.⁴ Would you like to advise physicians about how to manage serious dementia-related delusions and hallucinations without using antipsychotics?

Barry: You keep throwing the ball in my court, but psychiatrists violate the law daily by using psychiatric medications for conditions other than their approved use. Some studies show that up to 60% of psychotropic drugs are being used off-label.⁵

Harry: Less than 20% of DSM-IV diagnoses have an FDA-approved medication.⁶ What do you expect psychiatrists to tell the other 80%—“Sorry, come back in a decade or 2 when a drug is finally developed and approved for your condition”? Psychiatrists are compassionate when they select a medication the FDA has already deemed safe for a certain psychiatric illness and prescribe it for other ailments that have some of the same symptoms. Thanks to judiciously implemented off-label practices, many patients obtain some relief instead of continuing to suffer. And there is no law against off-label prescribing. It is left up to the physician’s discretion to use existing tools when there are no other options.

Barry: Harry, your responses have led me to view psychiatry more positively. I urge you write an editorial in a legal journal to debunk the myths.

Harry: Thanks for the suggestion, Barry. I think I will write an editorial in a widely read psychiatry journal called Current Psychiatry and avail it to all attorneys via CurrentPsychiatry.com.

Do lawyers understand psychiatry? To answer that semi-rhetorical question, I imagined the following conversation between 2 friends, Barry the barrister and Harry the psychiatrist.

Barry: Harry, I think psychiatry is a politically incorrect discipline.

Harry: How so, my dear friend?

Barry: Well, psychiatrists hospitalize people against their will, strip them of their civil liberties, and force them to take powerful, mind-altering drugs.

Harry: Barry, when you think about it objectively, involuntary hospitalization is a compassionate and legal act for people suffering from a brain disease that makes them suicidal or homicidal and a danger to themselves and others with no insight that they are sick. Once treated and improved, patients regain their civil liberties and often thank us for providing care against their will. And a person needs a healthy brain to properly exercise one’s civil liberties.

Barry: What about electroconvulsive therapy (ECT)? Why would you subject people to such a primitive procedure?

Harry: For your information, when used for treating severely depressed persons who do not respond to multiple medications, ECT is one of the most effective procedures.¹ It saves the lives of suicidal patients and restores their functioning. Published studies show that ECT stimulates neurogenesis and helps regenerate brain tissue by stimulating the production of new brain cells in the hippocampus, a critical structure that loses tissue during depression.² Other neurostimulation techniques, including repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS), recently have been FDA-approved for severe depression. Deep brain stimulation (DBS) also is emerging as a promising treatment.³

Barry: But Harry, you psychiatrists medicalize normal emotions such as sadness or grief and pathologize high energy in children, transforming them into diagnostic labels like attention-deficit/hyperactivity disorder.

Harry: Normal sadness or grief is not a psychiatric diagnosis. People seek psychiatric help on their own or are brought in by their loved ones when an emotional tsunami devastates their lives, causing them to stop functioning, demonstrate unusual behavior, or express suicidal thoughts. Children referred for treatment because of uncontrollable behaviors at home and school are afflicted by neurobiologic disorders and FDA-approved medications help them to lead normal lives. Do you really believe children are incapable of having a psychiatric illness?

Barry: OK, but isn’t it irresponsible for psychiatrists to administer powerful antipsychotics to elderly persons in nursing homes when the FDA has issued a “black-box” warning that this practice may be fatal?

Harry: I wish that one day you would visit a facility for older persons with Alzheimer’s disease to see that as many as half of these individuals become psychotic, extremely agitated and assaultive, or a risk to themselves, the staff, and other patients.⁴ Would you like to advise physicians about how to manage serious dementia-related delusions and hallucinations without using antipsychotics?

Barry: You keep throwing the ball in my court, but psychiatrists violate the law daily by using psychiatric medications for conditions other than their approved use. Some studies show that up to 60% of psychotropic drugs are being used off-label.⁵

Harry: Less than 20% of DSM-IV diagnoses have an FDA-approved medication.⁶ What do you expect psychiatrists to tell the other 80%—“Sorry, come back in a decade or 2 when a drug is finally developed and approved for your condition”? Psychiatrists are compassionate when they select a medication the FDA has already deemed safe for a certain psychiatric illness and prescribe it for other ailments that have some of the same symptoms. Thanks to judiciously implemented off-label practices, many patients obtain some relief instead of continuing to suffer. And there is no law against off-label prescribing. It is left up to the physician’s discretion to use existing tools when there are no other options.

Barry: Harry, your responses have led me to view psychiatry more positively. I urge you write an editorial in a legal journal to debunk the myths.

Harry: Thanks for the suggestion, Barry. I think I will write an editorial in a widely read psychiatry journal called Current Psychiatry and avail it to all attorneys via CurrentPsychiatry.com.

Do lawyers understand psychiatry? To answer that semi-rhetorical question, I imagined the following conversation between 2 friends, Barry the barrister and Harry the psychiatrist.

Barry: Harry, I think psychiatry is a politically incorrect discipline.

Harry: How so, my dear friend?

Barry: Well, psychiatrists hospitalize people against their will, strip them of their civil liberties, and force them to take powerful, mind-altering drugs.

Harry: Barry, when you think about it objectively, involuntary hospitalization is a compassionate and legal act for people suffering from a brain disease that makes them suicidal or homicidal and a danger to themselves and others with no insight that they are sick. Once treated and improved, patients regain their civil liberties and often thank us for providing care against their will. And a person needs a healthy brain to properly exercise one’s civil liberties.

Barry: What about electroconvulsive therapy (ECT)? Why would you subject people to such a primitive procedure?

Harry: For your information, when used for treating severely depressed persons who do not respond to multiple medications, ECT is one of the most effective procedures.¹ It saves the lives of suicidal patients and restores their functioning. Published studies show that ECT stimulates neurogenesis and helps regenerate brain tissue by stimulating the production of new brain cells in the hippocampus, a critical structure that loses tissue during depression.² Other neurostimulation techniques, including repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS), recently have been FDA-approved for severe depression. Deep brain stimulation (DBS) also is emerging as a promising treatment.³

Barry: But Harry, you psychiatrists medicalize normal emotions such as sadness or grief and pathologize high energy in children, transforming them into diagnostic labels like attention-deficit/hyperactivity disorder.

Harry: Normal sadness or grief is not a psychiatric diagnosis. People seek psychiatric help on their own or are brought in by their loved ones when an emotional tsunami devastates their lives, causing them to stop functioning, demonstrate unusual behavior, or express suicidal thoughts. Children referred for treatment because of uncontrollable behaviors at home and school are afflicted by neurobiologic disorders and FDA-approved medications help them to lead normal lives. Do you really believe children are incapable of having a psychiatric illness?

Barry: OK, but isn’t it irresponsible for psychiatrists to administer powerful antipsychotics to elderly persons in nursing homes when the FDA has issued a “black-box” warning that this practice may be fatal?

Harry: I wish that one day you would visit a facility for older persons with Alzheimer’s disease to see that as many as half of these individuals become psychotic, extremely agitated and assaultive, or a risk to themselves, the staff, and other patients.⁴ Would you like to advise physicians about how to manage serious dementia-related delusions and hallucinations without using antipsychotics?

Barry: You keep throwing the ball in my court, but psychiatrists violate the law daily by using psychiatric medications for conditions other than their approved use. Some studies show that up to 60% of psychotropic drugs are being used off-label.⁵

Harry: Less than 20% of DSM-IV diagnoses have an FDA-approved medication.⁶ What do you expect psychiatrists to tell the other 80%—“Sorry, come back in a decade or 2 when a drug is finally developed and approved for your condition”? Psychiatrists are compassionate when they select a medication the FDA has already deemed safe for a certain psychiatric illness and prescribe it for other ailments that have some of the same symptoms. Thanks to judiciously implemented off-label practices, many patients obtain some relief instead of continuing to suffer. And there is no law against off-label prescribing. It is left up to the physician’s discretion to use existing tools when there are no other options.

Barry: Harry, your responses have led me to view psychiatry more positively. I urge you write an editorial in a legal journal to debunk the myths.

Harry: Thanks for the suggestion, Barry. I think I will write an editorial in a widely read psychiatry journal called Current Psychiatry and avail it to all attorneys via CurrentPsychiatry.com.

Discuss this article

From all outward appearances Dr. S, a part-time psychiatrist at an inpatient psychiatric facility and in private practice for 12 years, is living the “perfect life,” with a wife, children, and successful practice.

In retrospect, his drug addiction began insidiously. In college, Dr. S continued to use oxycodone/acetaminophen prescribed for a shoulder injury long after his pain had resolved. He began to use cocaine in residency to help him “get through” the 36-hour call days, and it “helped” him earn the chief resident position because of his heightened energy and concentration. Dr. S’ primary care physician initially prescribed him benzodiazepines for anxiety and to help him sleep. Opiates were prescribed for a musculoskeletal injury. Dr. S obtained prescriptions for these medications from multiple providers. This ultimately escalated to self-prescription using aliases. Dr. S also began to drink heavily each evening.

Dr. S disregards colleagues’ comment about his obvious mood swings, which he attributes to his stressful job and “nagging” wife, despite having a family history of bipolar disorder. He becomes enraged when his wife or friends suggest he seek help. His colleagues whisper behind his back, but for years, no one confronts him about his unpredictable and frequently inappropriate behavior. Eventually, a nurse files a sexual harassment suit against Dr. S, and a patient complains to the medical board that Dr. S exhibited sexually inappropriate behavior during a therapy session.

As physicians, recognizing impairment in our colleagues or ourselves can be difficult. The American Medical Association defines an impaired physician as one who is unable to fulfill personal or professional responsibilities because of psychiatric illness, alcoholism, or drug dependence.¹ Impairment is present when a physician is unable to perform in a manner that conforms to acceptable standards of practice, exhibits serious flaws in judgment, and provides incompetent care.^1-3

Recognizing when a physician is impaired, deciding whether to report him or her to the state medical board, and referring a colleague for treatment can be challenging. This article will:

• review substance abuse, cognitive decline, and other causes of impairment
• address legal and ethical issues involved in reporting a colleague to the state medical board
• provide resources for physician treatment and assistance.

Physicians and addiction

Chemical dependence is the most frequent disabling illness among physicians,⁴ and substance abuse is the most common form of impairment that results in discipline by a state medical board.⁵ An estimated 6% to 8% of physicians abuse drugs, and approximately 14% develop alcohol use disorders; these rates are comparable to those of the general population.⁵ Psychiatrists, emergency room physicians, and solo practitioners are 3 times more likely to abuse substances than other doctors.⁶ An obsessive-compulsive personality and other factors may predispose physicians to substance abuse (Table 1).^7,8

Alcohol is the most commonly abused substance, followed by opiates, cocaine, and other stimulants.⁹ Physicians are estimated to use opiates and benzodiazepines at a rate 5 times greater than that of the general public.^10,11

An often-hidden problem. Physicians frequently deny substance abuse and many are able to conceal the problem from coworkers, even as their personal lives disintegrate.^1,12 Marital and relationship problems may be the first indication of impairment, which gradually spreads to other aspects of their lives (Table 2).^1,2,5 A doctor’s professional performance often is the last area to be affected.^1,12

Substance abuse in physicians may long go unreported. The clinician’s family may want to protect the physician’s reputation, career, and income. Colleagues may be intimidated, uncertain of their concerns, or fearful for their jobs if they report the physician’s impairment. Patients may be reluctant to report their concerns because they depend on their provider for health care, respect the physician, or deny that a doctor could have a drug or alcohol problem.⁵

Table 1

Physicians and substance abuse: Predisposing factors

Table 2

Signs of substance abuse

Screening for cognitive decline

Many people with cognitive impairment lack insight into their problem and may minimize or deny the degree of their impairment.¹³ The prevalence of dementia in individuals age ≥65 is 3% to 11%,¹⁴ and 18% of physicians are in this age group.¹⁵

Ethical, legal, and practical issues arise in determining who, when, and how to screen physicians for cognitive problems. Standard screening exams may not be adequately sensitive for a well-educated physician, and neuropsychological testing may be necessary to detect mild cognitive impairment.¹³ In addition, the cognitive, visual-spacial, reactivity, reasoning, and calculation skills required for capable medical practice vary among specialties.¹⁶

One screening option is a “360-degree review” of information obtained from peers, patients, and non-physician colleagues that the College of Physicians and Surgeons in Alberta, Canada, has incorporated into its Physician’s Achievement Review (PAR) for physicians age ≥65.¹⁷ Compiled in a confidential manner and shared with the physician, the 360-degree survey assesses his or her:

• skill and knowledge
• psychosocial functioning
• management skills
• performance
• collegiality.

In Alberta, physicians who score in the lower one-third of the survey are assessed with an on-site evaluation by physicians from his or her specialty appointed by the PAR Director of Practice Improvement.

Alternately, physicians age ≥65 could be required to undergo annual or biannual neuropsychological testing to screen for mild cognitive impairment or other evidence of cognitive decline. In the United States, any screening requirement must be structured to comply with the Age Discrimination in Employment Act.¹⁸

If a physician shows evidence of cognitive impairment, the state medical board should initiate closer scrutiny and modify or revoke privileges if indicated. Remediation programs designed to assist impaired physicians may not be effective for those with cognitive impairment because the decline in cognitive functioning associated with illnesses such as Alzheimer’s disease often is progressive.¹³

‘Disruptive’ physicians

Mental illnesses such as personality or affective disorders, interpersonal problems within or outside the workplace, or other stressors could lead a physician to disrupt the workplace or patient care. Numerous programs have been established across the United States to help evaluate and treat disruptive physicians. Remediation programs can help identify and offer education for “dyscompetent” physicians (see Related Resources).¹³

To report, or not to report

In a national survey of physicians, only 45% of respondents indicated that they had notified the state licensing board of a colleague they felt was impaired or incompetent, yet almost all (96%) indicated that these individuals should be reported.¹⁹ Any duty to report requires, at minimum, that the physician be affected by an illness that impairs his or her cognition, concentration, rapid decision making, and ability to handle emergencies or perform work functions safely.²⁰

Shouten²⁰ cautions that someone who is considering filing a report because of fear of liability if they don’t should balance this concern against potential liability for breaching confidentiality. If there is evidence of an imminent risk or serious harm to the physician or patients, you may be legally required to breach confidentiality. Some states require licensed health practitioners to report acts of professional misconduct, unless the information is obtained solely from directly treating the physician. These requirements apply only within the state, and only to that state’s licensees.^20-22

An ethical requirement to report also must be balanced against the obligation to maintain confidentiality. Ethics are largely a matter of individual standards, and individuals’ perceived ethical duties vary.

If you are considering reporting an impaired colleague, learn the laws in your state. If the physician is from another jurisdiction, the law provides little definitive guidance. Shouten recommends focusing on clinical outcomes for the doctor and his or her patients rather than on legal liability.²⁰

Physician health programs

Nationwide directories of physician health programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Some programs are affiliated with state licensing boards, some are branches of state medical societies, and some are independent. These programs provide confidential treatment and assistance to practitioners experiencing substance or alcohol abuse, mental illness, or disruptive behavior. Some institutions may offer physicians an employee assistance program.

State medical societies may provide information about accessing a physician health program. Programs sponsored by medical societies almost always are independent of state licensing boards. This arrangement allows physicians to seek help without fear of punishment or censure or revocation of their license. Noncompliance with a physician health program, however, likely will result in being reported to the medical board.

Physician health programs typically employ a rehabilitative approach. Punitive measures such as reporting physicians to the medical board usually are not pursued unless the individual does not comply with treatment and monitoring guidelines. A physician who abuses substances, for example, may be required to complete a residential treatment program, attend support group meetings such as 12-step programs, participate in individual therapy, and undergo random screening for alcohol and illicit drug use.⁵

Abstinence is the goal of treating clinicians who abuse substances. Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment;^23,24 75% to 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.^24,25 Acceptance of recovery as a lifelong process, monitoring, and self-vigilance often are necessary to achieve and maintain abstinence.⁵

Risk factors for relapse include:

• denial of illness
• poor stress-coping and relationship skills
• social and professional isolation
• inability to accept feedback
• complacency and overconfidence
• failure to attend support group meetings
• dysfunctional family dynamics
• feelings of self-pity, blame, and guilt.⁵

Treating an impaired colleague. Reid²⁶ recommends that psychiatrists should not evaluate or treat a self-referred, potentially impaired physician unless the relationship is strictly clinical. A physician may withhold symptoms, behaviors, or problems because his or her license, malpractice case, or career are at stake.

Advise a physician who requests evaluation or treatment related to license concerns or any legal matter to seek legal counsel. Working with such physician/patients only upon referral by a lawyer, licensing board, or physicians’ health committee provides treating psychiatrists with a clear professional role, allowing them to focus solely on the physician/patient’s treatment needs.

CASE CONTINUED: Extensive help, then success

The medical director of the hospital where Dr. S works refers him to his state’s impaired physician program. After investigating the complaints by the nurse and patient, the medical board suspends Dr. S’ license and requires him to enter a substance abuse treatment program. He completes an intensive residential program for impaired physicians and achieves sobriety from drugs and alcohol. His mood disorder is successfully treated with medications and psychotherapy. The medical board requires Dr. S to have a chaperone present for all visits with patients and submit random urine drug screens once his license is provisionally restored. The medical board also requires Dr. S to undergo ongoing psychiatric care and medication monitoring. He remains abstinent from alcohol and drugs, complies with the medical board’s requirements, and enjoys a productive practice and improved relationship with his family.

Related Resources

Disruptive physicians

• Samenow C, Swiggart W, Spickard A Jr. Consequence of physician disruptive behavior. Tenn Med. 2007;100(11):38-40.
• Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144(2):107-115.
• Linney BJ. Confronting the disruptive physician. Physician Exec. 1997;23:55-59.

Physician evaluation

• Anfang SA, Faulkner LR, Fromson JA, et al. The American Psychiatric Association’s resource document on guidelines for psychiatric fitness-for-duty evaluations of physicians. J Am Acad Psychiatry Law. 2005;33:85-88.
• Harmon L, Pomm R. Evaluation, treatment, and monitoring of disruptive physicians’ behavior. Psychiatr Ann. 2004; 34:770-774.

Other resources

• Federation of State Physician Health Programs. www.fsphp.org.
• Federation of State Medical Boards: Directory of Physician Assessment and Remedial Education Programs. www.fsmb.org/pdf/RemEdProg.pdf.
• The Center for Professional Health, Vanderbilt University Medical Center. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.
• Alcoholics Anonymous. www.aa.org.
• Narcotics Anonymous. www.na.org.

Drug Brand Name

• Oxycodone/acetaminophen • Percocet

Disclosure

The authors report no financial relationship with the manufacturer of any product mentioned in this article or with manufacturers of competing products.

Discuss this article

From all outward appearances Dr. S, a part-time psychiatrist at an inpatient psychiatric facility and in private practice for 12 years, is living the “perfect life,” with a wife, children, and successful practice.

In retrospect, his drug addiction began insidiously. In college, Dr. S continued to use oxycodone/acetaminophen prescribed for a shoulder injury long after his pain had resolved. He began to use cocaine in residency to help him “get through” the 36-hour call days, and it “helped” him earn the chief resident position because of his heightened energy and concentration. Dr. S’ primary care physician initially prescribed him benzodiazepines for anxiety and to help him sleep. Opiates were prescribed for a musculoskeletal injury. Dr. S obtained prescriptions for these medications from multiple providers. This ultimately escalated to self-prescription using aliases. Dr. S also began to drink heavily each evening.

Dr. S disregards colleagues’ comment about his obvious mood swings, which he attributes to his stressful job and “nagging” wife, despite having a family history of bipolar disorder. He becomes enraged when his wife or friends suggest he seek help. His colleagues whisper behind his back, but for years, no one confronts him about his unpredictable and frequently inappropriate behavior. Eventually, a nurse files a sexual harassment suit against Dr. S, and a patient complains to the medical board that Dr. S exhibited sexually inappropriate behavior during a therapy session.

As physicians, recognizing impairment in our colleagues or ourselves can be difficult. The American Medical Association defines an impaired physician as one who is unable to fulfill personal or professional responsibilities because of psychiatric illness, alcoholism, or drug dependence.¹ Impairment is present when a physician is unable to perform in a manner that conforms to acceptable standards of practice, exhibits serious flaws in judgment, and provides incompetent care.^1-3

Recognizing when a physician is impaired, deciding whether to report him or her to the state medical board, and referring a colleague for treatment can be challenging. This article will:

• review substance abuse, cognitive decline, and other causes of impairment
• address legal and ethical issues involved in reporting a colleague to the state medical board
• provide resources for physician treatment and assistance.

Physicians and addiction

Chemical dependence is the most frequent disabling illness among physicians,⁴ and substance abuse is the most common form of impairment that results in discipline by a state medical board.⁵ An estimated 6% to 8% of physicians abuse drugs, and approximately 14% develop alcohol use disorders; these rates are comparable to those of the general population.⁵ Psychiatrists, emergency room physicians, and solo practitioners are 3 times more likely to abuse substances than other doctors.⁶ An obsessive-compulsive personality and other factors may predispose physicians to substance abuse (Table 1).^7,8

Alcohol is the most commonly abused substance, followed by opiates, cocaine, and other stimulants.⁹ Physicians are estimated to use opiates and benzodiazepines at a rate 5 times greater than that of the general public.^10,11

An often-hidden problem. Physicians frequently deny substance abuse and many are able to conceal the problem from coworkers, even as their personal lives disintegrate.^1,12 Marital and relationship problems may be the first indication of impairment, which gradually spreads to other aspects of their lives (Table 2).^1,2,5 A doctor’s professional performance often is the last area to be affected.^1,12

Substance abuse in physicians may long go unreported. The clinician’s family may want to protect the physician’s reputation, career, and income. Colleagues may be intimidated, uncertain of their concerns, or fearful for their jobs if they report the physician’s impairment. Patients may be reluctant to report their concerns because they depend on their provider for health care, respect the physician, or deny that a doctor could have a drug or alcohol problem.⁵

Table 1

Physicians and substance abuse: Predisposing factors

Table 2

Signs of substance abuse

Screening for cognitive decline

Many people with cognitive impairment lack insight into their problem and may minimize or deny the degree of their impairment.¹³ The prevalence of dementia in individuals age ≥65 is 3% to 11%,¹⁴ and 18% of physicians are in this age group.¹⁵

Ethical, legal, and practical issues arise in determining who, when, and how to screen physicians for cognitive problems. Standard screening exams may not be adequately sensitive for a well-educated physician, and neuropsychological testing may be necessary to detect mild cognitive impairment.¹³ In addition, the cognitive, visual-spacial, reactivity, reasoning, and calculation skills required for capable medical practice vary among specialties.¹⁶

One screening option is a “360-degree review” of information obtained from peers, patients, and non-physician colleagues that the College of Physicians and Surgeons in Alberta, Canada, has incorporated into its Physician’s Achievement Review (PAR) for physicians age ≥65.¹⁷ Compiled in a confidential manner and shared with the physician, the 360-degree survey assesses his or her:

• skill and knowledge
• psychosocial functioning
• management skills
• performance
• collegiality.

In Alberta, physicians who score in the lower one-third of the survey are assessed with an on-site evaluation by physicians from his or her specialty appointed by the PAR Director of Practice Improvement.

Alternately, physicians age ≥65 could be required to undergo annual or biannual neuropsychological testing to screen for mild cognitive impairment or other evidence of cognitive decline. In the United States, any screening requirement must be structured to comply with the Age Discrimination in Employment Act.¹⁸

If a physician shows evidence of cognitive impairment, the state medical board should initiate closer scrutiny and modify or revoke privileges if indicated. Remediation programs designed to assist impaired physicians may not be effective for those with cognitive impairment because the decline in cognitive functioning associated with illnesses such as Alzheimer’s disease often is progressive.¹³

‘Disruptive’ physicians

Mental illnesses such as personality or affective disorders, interpersonal problems within or outside the workplace, or other stressors could lead a physician to disrupt the workplace or patient care. Numerous programs have been established across the United States to help evaluate and treat disruptive physicians. Remediation programs can help identify and offer education for “dyscompetent” physicians (see Related Resources).¹³

To report, or not to report

In a national survey of physicians, only 45% of respondents indicated that they had notified the state licensing board of a colleague they felt was impaired or incompetent, yet almost all (96%) indicated that these individuals should be reported.¹⁹ Any duty to report requires, at minimum, that the physician be affected by an illness that impairs his or her cognition, concentration, rapid decision making, and ability to handle emergencies or perform work functions safely.²⁰

Shouten²⁰ cautions that someone who is considering filing a report because of fear of liability if they don’t should balance this concern against potential liability for breaching confidentiality. If there is evidence of an imminent risk or serious harm to the physician or patients, you may be legally required to breach confidentiality. Some states require licensed health practitioners to report acts of professional misconduct, unless the information is obtained solely from directly treating the physician. These requirements apply only within the state, and only to that state’s licensees.^20-22

An ethical requirement to report also must be balanced against the obligation to maintain confidentiality. Ethics are largely a matter of individual standards, and individuals’ perceived ethical duties vary.

If you are considering reporting an impaired colleague, learn the laws in your state. If the physician is from another jurisdiction, the law provides little definitive guidance. Shouten recommends focusing on clinical outcomes for the doctor and his or her patients rather than on legal liability.²⁰

Physician health programs

Nationwide directories of physician health programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Some programs are affiliated with state licensing boards, some are branches of state medical societies, and some are independent. These programs provide confidential treatment and assistance to practitioners experiencing substance or alcohol abuse, mental illness, or disruptive behavior. Some institutions may offer physicians an employee assistance program.

State medical societies may provide information about accessing a physician health program. Programs sponsored by medical societies almost always are independent of state licensing boards. This arrangement allows physicians to seek help without fear of punishment or censure or revocation of their license. Noncompliance with a physician health program, however, likely will result in being reported to the medical board.

Physician health programs typically employ a rehabilitative approach. Punitive measures such as reporting physicians to the medical board usually are not pursued unless the individual does not comply with treatment and monitoring guidelines. A physician who abuses substances, for example, may be required to complete a residential treatment program, attend support group meetings such as 12-step programs, participate in individual therapy, and undergo random screening for alcohol and illicit drug use.⁵

Abstinence is the goal of treating clinicians who abuse substances. Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment;^23,24 75% to 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.^24,25 Acceptance of recovery as a lifelong process, monitoring, and self-vigilance often are necessary to achieve and maintain abstinence.⁵

Risk factors for relapse include:

• denial of illness
• poor stress-coping and relationship skills
• social and professional isolation
• inability to accept feedback
• complacency and overconfidence
• failure to attend support group meetings
• dysfunctional family dynamics
• feelings of self-pity, blame, and guilt.⁵

Treating an impaired colleague. Reid²⁶ recommends that psychiatrists should not evaluate or treat a self-referred, potentially impaired physician unless the relationship is strictly clinical. A physician may withhold symptoms, behaviors, or problems because his or her license, malpractice case, or career are at stake.

Advise a physician who requests evaluation or treatment related to license concerns or any legal matter to seek legal counsel. Working with such physician/patients only upon referral by a lawyer, licensing board, or physicians’ health committee provides treating psychiatrists with a clear professional role, allowing them to focus solely on the physician/patient’s treatment needs.

CASE CONTINUED: Extensive help, then success

The medical director of the hospital where Dr. S works refers him to his state’s impaired physician program. After investigating the complaints by the nurse and patient, the medical board suspends Dr. S’ license and requires him to enter a substance abuse treatment program. He completes an intensive residential program for impaired physicians and achieves sobriety from drugs and alcohol. His mood disorder is successfully treated with medications and psychotherapy. The medical board requires Dr. S to have a chaperone present for all visits with patients and submit random urine drug screens once his license is provisionally restored. The medical board also requires Dr. S to undergo ongoing psychiatric care and medication monitoring. He remains abstinent from alcohol and drugs, complies with the medical board’s requirements, and enjoys a productive practice and improved relationship with his family.

Related Resources

Disruptive physicians

• Samenow C, Swiggart W, Spickard A Jr. Consequence of physician disruptive behavior. Tenn Med. 2007;100(11):38-40.
• Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144(2):107-115.
• Linney BJ. Confronting the disruptive physician. Physician Exec. 1997;23:55-59.

Physician evaluation

• Anfang SA, Faulkner LR, Fromson JA, et al. The American Psychiatric Association’s resource document on guidelines for psychiatric fitness-for-duty evaluations of physicians. J Am Acad Psychiatry Law. 2005;33:85-88.
• Harmon L, Pomm R. Evaluation, treatment, and monitoring of disruptive physicians’ behavior. Psychiatr Ann. 2004; 34:770-774.

Other resources

• Federation of State Physician Health Programs. www.fsphp.org.
• Federation of State Medical Boards: Directory of Physician Assessment and Remedial Education Programs. www.fsmb.org/pdf/RemEdProg.pdf.
• The Center for Professional Health, Vanderbilt University Medical Center. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.
• Alcoholics Anonymous. www.aa.org.
• Narcotics Anonymous. www.na.org.

Drug Brand Name

• Oxycodone/acetaminophen • Percocet

Disclosure

The authors report no financial relationship with the manufacturer of any product mentioned in this article or with manufacturers of competing products.

Discuss this article

From all outward appearances Dr. S, a part-time psychiatrist at an inpatient psychiatric facility and in private practice for 12 years, is living the “perfect life,” with a wife, children, and successful practice.

In retrospect, his drug addiction began insidiously. In college, Dr. S continued to use oxycodone/acetaminophen prescribed for a shoulder injury long after his pain had resolved. He began to use cocaine in residency to help him “get through” the 36-hour call days, and it “helped” him earn the chief resident position because of his heightened energy and concentration. Dr. S’ primary care physician initially prescribed him benzodiazepines for anxiety and to help him sleep. Opiates were prescribed for a musculoskeletal injury. Dr. S obtained prescriptions for these medications from multiple providers. This ultimately escalated to self-prescription using aliases. Dr. S also began to drink heavily each evening.

Dr. S disregards colleagues’ comment about his obvious mood swings, which he attributes to his stressful job and “nagging” wife, despite having a family history of bipolar disorder. He becomes enraged when his wife or friends suggest he seek help. His colleagues whisper behind his back, but for years, no one confronts him about his unpredictable and frequently inappropriate behavior. Eventually, a nurse files a sexual harassment suit against Dr. S, and a patient complains to the medical board that Dr. S exhibited sexually inappropriate behavior during a therapy session.

As physicians, recognizing impairment in our colleagues or ourselves can be difficult. The American Medical Association defines an impaired physician as one who is unable to fulfill personal or professional responsibilities because of psychiatric illness, alcoholism, or drug dependence.¹ Impairment is present when a physician is unable to perform in a manner that conforms to acceptable standards of practice, exhibits serious flaws in judgment, and provides incompetent care.^1-3

Recognizing when a physician is impaired, deciding whether to report him or her to the state medical board, and referring a colleague for treatment can be challenging. This article will:

• review substance abuse, cognitive decline, and other causes of impairment
• address legal and ethical issues involved in reporting a colleague to the state medical board
• provide resources for physician treatment and assistance.

Physicians and addiction

Chemical dependence is the most frequent disabling illness among physicians,⁴ and substance abuse is the most common form of impairment that results in discipline by a state medical board.⁵ An estimated 6% to 8% of physicians abuse drugs, and approximately 14% develop alcohol use disorders; these rates are comparable to those of the general population.⁵ Psychiatrists, emergency room physicians, and solo practitioners are 3 times more likely to abuse substances than other doctors.⁶ An obsessive-compulsive personality and other factors may predispose physicians to substance abuse (Table 1).^7,8

Alcohol is the most commonly abused substance, followed by opiates, cocaine, and other stimulants.⁹ Physicians are estimated to use opiates and benzodiazepines at a rate 5 times greater than that of the general public.^10,11

An often-hidden problem. Physicians frequently deny substance abuse and many are able to conceal the problem from coworkers, even as their personal lives disintegrate.^1,12 Marital and relationship problems may be the first indication of impairment, which gradually spreads to other aspects of their lives (Table 2).^1,2,5 A doctor’s professional performance often is the last area to be affected.^1,12

Substance abuse in physicians may long go unreported. The clinician’s family may want to protect the physician’s reputation, career, and income. Colleagues may be intimidated, uncertain of their concerns, or fearful for their jobs if they report the physician’s impairment. Patients may be reluctant to report their concerns because they depend on their provider for health care, respect the physician, or deny that a doctor could have a drug or alcohol problem.⁵

Table 1

Physicians and substance abuse: Predisposing factors

Table 2

Signs of substance abuse

Screening for cognitive decline

Many people with cognitive impairment lack insight into their problem and may minimize or deny the degree of their impairment.¹³ The prevalence of dementia in individuals age ≥65 is 3% to 11%,¹⁴ and 18% of physicians are in this age group.¹⁵

Ethical, legal, and practical issues arise in determining who, when, and how to screen physicians for cognitive problems. Standard screening exams may not be adequately sensitive for a well-educated physician, and neuropsychological testing may be necessary to detect mild cognitive impairment.¹³ In addition, the cognitive, visual-spacial, reactivity, reasoning, and calculation skills required for capable medical practice vary among specialties.¹⁶

One screening option is a “360-degree review” of information obtained from peers, patients, and non-physician colleagues that the College of Physicians and Surgeons in Alberta, Canada, has incorporated into its Physician’s Achievement Review (PAR) for physicians age ≥65.¹⁷ Compiled in a confidential manner and shared with the physician, the 360-degree survey assesses his or her:

• skill and knowledge
• psychosocial functioning
• management skills
• performance
• collegiality.

In Alberta, physicians who score in the lower one-third of the survey are assessed with an on-site evaluation by physicians from his or her specialty appointed by the PAR Director of Practice Improvement.

Alternately, physicians age ≥65 could be required to undergo annual or biannual neuropsychological testing to screen for mild cognitive impairment or other evidence of cognitive decline. In the United States, any screening requirement must be structured to comply with the Age Discrimination in Employment Act.¹⁸

If a physician shows evidence of cognitive impairment, the state medical board should initiate closer scrutiny and modify or revoke privileges if indicated. Remediation programs designed to assist impaired physicians may not be effective for those with cognitive impairment because the decline in cognitive functioning associated with illnesses such as Alzheimer’s disease often is progressive.¹³

‘Disruptive’ physicians

Mental illnesses such as personality or affective disorders, interpersonal problems within or outside the workplace, or other stressors could lead a physician to disrupt the workplace or patient care. Numerous programs have been established across the United States to help evaluate and treat disruptive physicians. Remediation programs can help identify and offer education for “dyscompetent” physicians (see Related Resources).¹³

To report, or not to report

In a national survey of physicians, only 45% of respondents indicated that they had notified the state licensing board of a colleague they felt was impaired or incompetent, yet almost all (96%) indicated that these individuals should be reported.¹⁹ Any duty to report requires, at minimum, that the physician be affected by an illness that impairs his or her cognition, concentration, rapid decision making, and ability to handle emergencies or perform work functions safely.²⁰

Shouten²⁰ cautions that someone who is considering filing a report because of fear of liability if they don’t should balance this concern against potential liability for breaching confidentiality. If there is evidence of an imminent risk or serious harm to the physician or patients, you may be legally required to breach confidentiality. Some states require licensed health practitioners to report acts of professional misconduct, unless the information is obtained solely from directly treating the physician. These requirements apply only within the state, and only to that state’s licensees.^20-22

An ethical requirement to report also must be balanced against the obligation to maintain confidentiality. Ethics are largely a matter of individual standards, and individuals’ perceived ethical duties vary.

If you are considering reporting an impaired colleague, learn the laws in your state. If the physician is from another jurisdiction, the law provides little definitive guidance. Shouten recommends focusing on clinical outcomes for the doctor and his or her patients rather than on legal liability.²⁰

Physician health programs

Nationwide directories of physician health programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Some programs are affiliated with state licensing boards, some are branches of state medical societies, and some are independent. These programs provide confidential treatment and assistance to practitioners experiencing substance or alcohol abuse, mental illness, or disruptive behavior. Some institutions may offer physicians an employee assistance program.

State medical societies may provide information about accessing a physician health program. Programs sponsored by medical societies almost always are independent of state licensing boards. This arrangement allows physicians to seek help without fear of punishment or censure or revocation of their license. Noncompliance with a physician health program, however, likely will result in being reported to the medical board.

Physician health programs typically employ a rehabilitative approach. Punitive measures such as reporting physicians to the medical board usually are not pursued unless the individual does not comply with treatment and monitoring guidelines. A physician who abuses substances, for example, may be required to complete a residential treatment program, attend support group meetings such as 12-step programs, participate in individual therapy, and undergo random screening for alcohol and illicit drug use.⁵

Abstinence is the goal of treating clinicians who abuse substances. Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment;^23,24 75% to 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.^24,25 Acceptance of recovery as a lifelong process, monitoring, and self-vigilance often are necessary to achieve and maintain abstinence.⁵

Risk factors for relapse include:

• denial of illness
• poor stress-coping and relationship skills
• social and professional isolation
• inability to accept feedback
• complacency and overconfidence
• failure to attend support group meetings
• dysfunctional family dynamics
• feelings of self-pity, blame, and guilt.⁵

Treating an impaired colleague. Reid²⁶ recommends that psychiatrists should not evaluate or treat a self-referred, potentially impaired physician unless the relationship is strictly clinical. A physician may withhold symptoms, behaviors, or problems because his or her license, malpractice case, or career are at stake.

Advise a physician who requests evaluation or treatment related to license concerns or any legal matter to seek legal counsel. Working with such physician/patients only upon referral by a lawyer, licensing board, or physicians’ health committee provides treating psychiatrists with a clear professional role, allowing them to focus solely on the physician/patient’s treatment needs.

CASE CONTINUED: Extensive help, then success

The medical director of the hospital where Dr. S works refers him to his state’s impaired physician program. After investigating the complaints by the nurse and patient, the medical board suspends Dr. S’ license and requires him to enter a substance abuse treatment program. He completes an intensive residential program for impaired physicians and achieves sobriety from drugs and alcohol. His mood disorder is successfully treated with medications and psychotherapy. The medical board requires Dr. S to have a chaperone present for all visits with patients and submit random urine drug screens once his license is provisionally restored. The medical board also requires Dr. S to undergo ongoing psychiatric care and medication monitoring. He remains abstinent from alcohol and drugs, complies with the medical board’s requirements, and enjoys a productive practice and improved relationship with his family.

Related Resources

Disruptive physicians

• Samenow C, Swiggart W, Spickard A Jr. Consequence of physician disruptive behavior. Tenn Med. 2007;100(11):38-40.
• Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144(2):107-115.
• Linney BJ. Confronting the disruptive physician. Physician Exec. 1997;23:55-59.

Physician evaluation

• Anfang SA, Faulkner LR, Fromson JA, et al. The American Psychiatric Association’s resource document on guidelines for psychiatric fitness-for-duty evaluations of physicians. J Am Acad Psychiatry Law. 2005;33:85-88.
• Harmon L, Pomm R. Evaluation, treatment, and monitoring of disruptive physicians’ behavior. Psychiatr Ann. 2004; 34:770-774.

Other resources

• Federation of State Physician Health Programs. www.fsphp.org.
• Federation of State Medical Boards: Directory of Physician Assessment and Remedial Education Programs. www.fsmb.org/pdf/RemEdProg.pdf.
• The Center for Professional Health, Vanderbilt University Medical Center. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.
• Alcoholics Anonymous. www.aa.org.
• Narcotics Anonymous. www.na.org.

Drug Brand Name

• Oxycodone/acetaminophen • Percocet

Disclosure

The authors report no financial relationship with the manufacturer of any product mentioned in this article or with manufacturers of competing products.