Current Psychiatry

Cognitive-behavioral therapy for insomnia (CBT-I) can be effective, regardless of whether chronic insomnia is primary or secondary to psychiatric, substance dependence, or psychophysiologic causes.¹ In fact, with a response rate of 70% to 80%,² CBT-I can be as effective as medication in the short term and even more effective in the long term.³

Delivered in 4 to 10 sessions, CBT-I typically includes assessment and monitoring of insomnia and sleep patterns, sleep restriction, stimulus control, sleep hygiene education, relaxation training, cognitive therapy, and relapse prevention. Goals are to:

• decrease the time spent awake in bed, thereby increasing sleep efficiency
  
• strengthen the association between the bedroom and sleep
  
• address maladaptive sleep habits and lifestyle factors that affect sleep
  
• remove extraneous stimuli from the bedroom.
  

Group therapy with CBT-I

At our clinic, we have modified standard CBT-I techniques into a group format that includes patients with other sleep disorders, medical conditions, or psychiatric diagnoses. Also, CBT-I can benefit mentally ill out-patients with persistent secondary insomnia despite adequate hypnotic dosages.

Challenges to a CBT-I format include: member dropout, inconsistent attendance, disparate psychiatric diagnoses, and different forms of insomnia. In addition, motivating patients to change poor sleep habits that have been in place for decades can be difficult. Finally, CBT-I—although simple in concept—can be difficult to employ, particularly the behavioral components of stimulus control and sleep restriction. Many patients resist these behavioral interventions because they do not experience relief in the short term. Because improved sleep quality frequently is experienced toward the end of treatment, patient motivation and consistency are crucial for success.

For optimal results when leading group CBT-I, be consistent when teaching skills, checking homework, and gaining treatment compliance. Educate patients about CBT-I principles, and help them understand the rationale for what may seem like counterintuitive treatments, such as decreasing time spent in bed. Inform patients that they must practice these skills consistently and stick with the protocol until treatment ends. When patients know the treatment is time-limited and see others in the group begin to benefit, this commitment can seem less daunting.

Cognitive-behavioral therapy for insomnia (CBT-I) can be effective, regardless of whether chronic insomnia is primary or secondary to psychiatric, substance dependence, or psychophysiologic causes.¹ In fact, with a response rate of 70% to 80%,² CBT-I can be as effective as medication in the short term and even more effective in the long term.³

Delivered in 4 to 10 sessions, CBT-I typically includes assessment and monitoring of insomnia and sleep patterns, sleep restriction, stimulus control, sleep hygiene education, relaxation training, cognitive therapy, and relapse prevention. Goals are to:

• decrease the time spent awake in bed, thereby increasing sleep efficiency
  
• strengthen the association between the bedroom and sleep
  
• address maladaptive sleep habits and lifestyle factors that affect sleep
  
• remove extraneous stimuli from the bedroom.
  

Group therapy with CBT-I

At our clinic, we have modified standard CBT-I techniques into a group format that includes patients with other sleep disorders, medical conditions, or psychiatric diagnoses. Also, CBT-I can benefit mentally ill out-patients with persistent secondary insomnia despite adequate hypnotic dosages.

Challenges to a CBT-I format include: member dropout, inconsistent attendance, disparate psychiatric diagnoses, and different forms of insomnia. In addition, motivating patients to change poor sleep habits that have been in place for decades can be difficult. Finally, CBT-I—although simple in concept—can be difficult to employ, particularly the behavioral components of stimulus control and sleep restriction. Many patients resist these behavioral interventions because they do not experience relief in the short term. Because improved sleep quality frequently is experienced toward the end of treatment, patient motivation and consistency are crucial for success.

For optimal results when leading group CBT-I, be consistent when teaching skills, checking homework, and gaining treatment compliance. Educate patients about CBT-I principles, and help them understand the rationale for what may seem like counterintuitive treatments, such as decreasing time spent in bed. Inform patients that they must practice these skills consistently and stick with the protocol until treatment ends. When patients know the treatment is time-limited and see others in the group begin to benefit, this commitment can seem less daunting.

Cognitive-behavioral therapy for insomnia (CBT-I) can be effective, regardless of whether chronic insomnia is primary or secondary to psychiatric, substance dependence, or psychophysiologic causes.¹ In fact, with a response rate of 70% to 80%,² CBT-I can be as effective as medication in the short term and even more effective in the long term.³

Delivered in 4 to 10 sessions, CBT-I typically includes assessment and monitoring of insomnia and sleep patterns, sleep restriction, stimulus control, sleep hygiene education, relaxation training, cognitive therapy, and relapse prevention. Goals are to:

• decrease the time spent awake in bed, thereby increasing sleep efficiency
  
• strengthen the association between the bedroom and sleep
  
• address maladaptive sleep habits and lifestyle factors that affect sleep
  
• remove extraneous stimuli from the bedroom.
  

Group therapy with CBT-I

At our clinic, we have modified standard CBT-I techniques into a group format that includes patients with other sleep disorders, medical conditions, or psychiatric diagnoses. Also, CBT-I can benefit mentally ill out-patients with persistent secondary insomnia despite adequate hypnotic dosages.

Challenges to a CBT-I format include: member dropout, inconsistent attendance, disparate psychiatric diagnoses, and different forms of insomnia. In addition, motivating patients to change poor sleep habits that have been in place for decades can be difficult. Finally, CBT-I—although simple in concept—can be difficult to employ, particularly the behavioral components of stimulus control and sleep restriction. Many patients resist these behavioral interventions because they do not experience relief in the short term. Because improved sleep quality frequently is experienced toward the end of treatment, patient motivation and consistency are crucial for success.

For optimal results when leading group CBT-I, be consistent when teaching skills, checking homework, and gaining treatment compliance. Educate patients about CBT-I principles, and help them understand the rationale for what may seem like counterintuitive treatments, such as decreasing time spent in bed. Inform patients that they must practice these skills consistently and stick with the protocol until treatment ends. When patients know the treatment is time-limited and see others in the group begin to benefit, this commitment can seem less daunting.

I note with some dismay an increasing trend in Current Psychiatry to identify almost any mood disorder as bipolar disorder. I found the clinical logic expressed in the supplement “Diagnosing and managing psychotic and mood disorders” (Current Psychiatry, December 2008) especially confounding.

In the case “Bipolar depression and anxiety,” a clinician is implicitly criticized for “focusing on symptoms without giving due consideration to a patient’s history and family history (leading) to a snap misjudgment and inappropriate treatment.” These are harsh words. However, the only possible bipolar symptoms reported in the case study are “feeling over-stimulated and…tremendously irritable.” There also is a family history that “suggested” bipolar disorder. Although this history in the context of a poorly responsive, agitated depression certainly makes bipolar disorder a reasonable diagnosis, assuming that a patient is bipolar and starting mood stabilizers from treatment onset given the data seems like a leap of faith. If I diagnosed bipolar disorder in all my irritable, depressed patients with a vague family history of possible bipolar illness, then my rate of unipolar depression would drop to around 5%.

In addition, Dr. Henry Nasrallah’s suggestion that the chronically and severely psychotic man in “Treatment-resistant psychosis and schizophrenia” has bipolar disorder seems dubious. There is no history of lack of need for sleep, excessive psychomotor activity, grandiosity, or a stated episodic nature to his disturbance. Yes, he has been severely ill, psychotic, and violent, but all these factors are consistent with severe schizophrenia. Finally, to suggest that his tardive dyskinesia adds credibility to the bipolar argument is illogical. Almost all cats have fur but this does not mean that because a newly discovered species is furry, it must be a cat.

One would wonder if clinical judgment has been influenced in any way by the large number of pharmaceutical grants received by the expert panel.

Joshua O. Zimmerman, MD
Minneapolis, MN

Dr. Nasrallah responds

I thank Dr. Zimmerman for his letter regarding the December 2008 supplement to Current Psychiatry, which was based on a roundtable discussion of 4 cases from the 4 participating faculty’s clinical practices. Both diagnostic and treatment issues were discussed in a spontaneous and unrehearsed manner. The faculty submitted their challenging cases before they knew who sponsored the CME activity, so it is not fair to assume the clinicians were influenced by pharmaceutical industry involvement.

Whether or not you agree, studies have shown that bipolar depression is frequently misdiagnosed as unipolar depression if a patient has never had a manic episode.^1,2 This is an important diagnostic issue because antidepressants—all approved by the FDA for unipolar depression only—may cause a switch to hypomania, mania, mixed states, or rapid cycling when used as monotherapy in some patients. The faculty agreed that the patient with bipolar depression and anxiety was 1 of those misdiagnosed bipolar depression cases that switched to a mixed state (irritable depression) when given venlafaxine, which was shown in a recent meta-analysis to have the highest switching rate among antidepressants.³

It would be an egregious oversight if a psychiatrist did not have a high index of suspicion about the possibility of a bipolar depression in a patient who presented with:

• early-onset depression (in her early 20s in this case)
  
• a first-degree family member diagnosed with bipolar disorder (her father)
  
• a description of her depressed mood as “tremendously irritable.”
  

I also would add that about a dozen published, controlled studies report significant improvement with the addition of lithium in “treatment-resistant depression” after numerous failures or worsening with antidepressants. Many of those cases likely are bipolar depression that worsened with antidepressant monotherapy because a mood stabilizer was needed.

As for the second case of “Treatment-resistant psychosis and schizophrenia,” numerous clues in the patient’s history point to severe psychotic bipolar disorder:

• initial psychotic symptoms appeared in high school after age 17, but he completed his college degree, which is more typical of bipolar disorder than schizophrenia
  
• very frequent hospitalizations (>50 admissions), which is consistent with bipolar cyclicity
  
• assaultiveness, which is more consistent with irritable mania than schizophrenia
  
• past and current treatment with mood stabilizers, which suggests that his psychiatrist noted manic symptoms
  
• ability to get married early in his illness even after hospitalization
  
• advanced vocabulary, which is characteristic of mania rather than schizophrenia
  
• history of episodic depression and suicidal ideas
  
• episodes of excitement, rapid speech, hypersexuality, and grandiose delusions, which can be found in schizophrenia but are consistent with psychotic mania in the context of these other bipolar disorder features.
  

I welcome Dr. Zimmerman’s disagreement on diagnostic issues and hope that he sees that the faculty’s diagnostic formulations were driven by the historical facts in the presented cases as well as research findings, not due to any other reason or motive. All of the participants would have given the same diagnostic discussion to our medical students and residents on any morning rounds.

Henry A. Nasrallah, MD
Editor-in-Chief

I note with some dismay an increasing trend in Current Psychiatry to identify almost any mood disorder as bipolar disorder. I found the clinical logic expressed in the supplement “Diagnosing and managing psychotic and mood disorders” (Current Psychiatry, December 2008) especially confounding.

In the case “Bipolar depression and anxiety,” a clinician is implicitly criticized for “focusing on symptoms without giving due consideration to a patient’s history and family history (leading) to a snap misjudgment and inappropriate treatment.” These are harsh words. However, the only possible bipolar symptoms reported in the case study are “feeling over-stimulated and…tremendously irritable.” There also is a family history that “suggested” bipolar disorder. Although this history in the context of a poorly responsive, agitated depression certainly makes bipolar disorder a reasonable diagnosis, assuming that a patient is bipolar and starting mood stabilizers from treatment onset given the data seems like a leap of faith. If I diagnosed bipolar disorder in all my irritable, depressed patients with a vague family history of possible bipolar illness, then my rate of unipolar depression would drop to around 5%.

In addition, Dr. Henry Nasrallah’s suggestion that the chronically and severely psychotic man in “Treatment-resistant psychosis and schizophrenia” has bipolar disorder seems dubious. There is no history of lack of need for sleep, excessive psychomotor activity, grandiosity, or a stated episodic nature to his disturbance. Yes, he has been severely ill, psychotic, and violent, but all these factors are consistent with severe schizophrenia. Finally, to suggest that his tardive dyskinesia adds credibility to the bipolar argument is illogical. Almost all cats have fur but this does not mean that because a newly discovered species is furry, it must be a cat.

One would wonder if clinical judgment has been influenced in any way by the large number of pharmaceutical grants received by the expert panel.

Joshua O. Zimmerman, MD
Minneapolis, MN

Dr. Nasrallah responds

I thank Dr. Zimmerman for his letter regarding the December 2008 supplement to Current Psychiatry, which was based on a roundtable discussion of 4 cases from the 4 participating faculty’s clinical practices. Both diagnostic and treatment issues were discussed in a spontaneous and unrehearsed manner. The faculty submitted their challenging cases before they knew who sponsored the CME activity, so it is not fair to assume the clinicians were influenced by pharmaceutical industry involvement.

Whether or not you agree, studies have shown that bipolar depression is frequently misdiagnosed as unipolar depression if a patient has never had a manic episode.^1,2 This is an important diagnostic issue because antidepressants—all approved by the FDA for unipolar depression only—may cause a switch to hypomania, mania, mixed states, or rapid cycling when used as monotherapy in some patients. The faculty agreed that the patient with bipolar depression and anxiety was 1 of those misdiagnosed bipolar depression cases that switched to a mixed state (irritable depression) when given venlafaxine, which was shown in a recent meta-analysis to have the highest switching rate among antidepressants.³

It would be an egregious oversight if a psychiatrist did not have a high index of suspicion about the possibility of a bipolar depression in a patient who presented with:

• early-onset depression (in her early 20s in this case)
  
• a first-degree family member diagnosed with bipolar disorder (her father)
  
• a description of her depressed mood as “tremendously irritable.”
  

I also would add that about a dozen published, controlled studies report significant improvement with the addition of lithium in “treatment-resistant depression” after numerous failures or worsening with antidepressants. Many of those cases likely are bipolar depression that worsened with antidepressant monotherapy because a mood stabilizer was needed.

As for the second case of “Treatment-resistant psychosis and schizophrenia,” numerous clues in the patient’s history point to severe psychotic bipolar disorder:

• initial psychotic symptoms appeared in high school after age 17, but he completed his college degree, which is more typical of bipolar disorder than schizophrenia
  
• very frequent hospitalizations (>50 admissions), which is consistent with bipolar cyclicity
  
• assaultiveness, which is more consistent with irritable mania than schizophrenia
  
• past and current treatment with mood stabilizers, which suggests that his psychiatrist noted manic symptoms
  
• ability to get married early in his illness even after hospitalization
  
• advanced vocabulary, which is characteristic of mania rather than schizophrenia
  
• history of episodic depression and suicidal ideas
  
• episodes of excitement, rapid speech, hypersexuality, and grandiose delusions, which can be found in schizophrenia but are consistent with psychotic mania in the context of these other bipolar disorder features.
  

I welcome Dr. Zimmerman’s disagreement on diagnostic issues and hope that he sees that the faculty’s diagnostic formulations were driven by the historical facts in the presented cases as well as research findings, not due to any other reason or motive. All of the participants would have given the same diagnostic discussion to our medical students and residents on any morning rounds.

Henry A. Nasrallah, MD
Editor-in-Chief

I note with some dismay an increasing trend in Current Psychiatry to identify almost any mood disorder as bipolar disorder. I found the clinical logic expressed in the supplement “Diagnosing and managing psychotic and mood disorders” (Current Psychiatry, December 2008) especially confounding.

In the case “Bipolar depression and anxiety,” a clinician is implicitly criticized for “focusing on symptoms without giving due consideration to a patient’s history and family history (leading) to a snap misjudgment and inappropriate treatment.” These are harsh words. However, the only possible bipolar symptoms reported in the case study are “feeling over-stimulated and…tremendously irritable.” There also is a family history that “suggested” bipolar disorder. Although this history in the context of a poorly responsive, agitated depression certainly makes bipolar disorder a reasonable diagnosis, assuming that a patient is bipolar and starting mood stabilizers from treatment onset given the data seems like a leap of faith. If I diagnosed bipolar disorder in all my irritable, depressed patients with a vague family history of possible bipolar illness, then my rate of unipolar depression would drop to around 5%.

In addition, Dr. Henry Nasrallah’s suggestion that the chronically and severely psychotic man in “Treatment-resistant psychosis and schizophrenia” has bipolar disorder seems dubious. There is no history of lack of need for sleep, excessive psychomotor activity, grandiosity, or a stated episodic nature to his disturbance. Yes, he has been severely ill, psychotic, and violent, but all these factors are consistent with severe schizophrenia. Finally, to suggest that his tardive dyskinesia adds credibility to the bipolar argument is illogical. Almost all cats have fur but this does not mean that because a newly discovered species is furry, it must be a cat.

One would wonder if clinical judgment has been influenced in any way by the large number of pharmaceutical grants received by the expert panel.

Joshua O. Zimmerman, MD
Minneapolis, MN

Dr. Nasrallah responds

I thank Dr. Zimmerman for his letter regarding the December 2008 supplement to Current Psychiatry, which was based on a roundtable discussion of 4 cases from the 4 participating faculty’s clinical practices. Both diagnostic and treatment issues were discussed in a spontaneous and unrehearsed manner. The faculty submitted their challenging cases before they knew who sponsored the CME activity, so it is not fair to assume the clinicians were influenced by pharmaceutical industry involvement.

Whether or not you agree, studies have shown that bipolar depression is frequently misdiagnosed as unipolar depression if a patient has never had a manic episode.^1,2 This is an important diagnostic issue because antidepressants—all approved by the FDA for unipolar depression only—may cause a switch to hypomania, mania, mixed states, or rapid cycling when used as monotherapy in some patients. The faculty agreed that the patient with bipolar depression and anxiety was 1 of those misdiagnosed bipolar depression cases that switched to a mixed state (irritable depression) when given venlafaxine, which was shown in a recent meta-analysis to have the highest switching rate among antidepressants.³

It would be an egregious oversight if a psychiatrist did not have a high index of suspicion about the possibility of a bipolar depression in a patient who presented with:

• early-onset depression (in her early 20s in this case)
  
• a first-degree family member diagnosed with bipolar disorder (her father)
  
• a description of her depressed mood as “tremendously irritable.”
  

I also would add that about a dozen published, controlled studies report significant improvement with the addition of lithium in “treatment-resistant depression” after numerous failures or worsening with antidepressants. Many of those cases likely are bipolar depression that worsened with antidepressant monotherapy because a mood stabilizer was needed.

As for the second case of “Treatment-resistant psychosis and schizophrenia,” numerous clues in the patient’s history point to severe psychotic bipolar disorder:

• initial psychotic symptoms appeared in high school after age 17, but he completed his college degree, which is more typical of bipolar disorder than schizophrenia
  
• very frequent hospitalizations (>50 admissions), which is consistent with bipolar cyclicity
  
• assaultiveness, which is more consistent with irritable mania than schizophrenia
  
• past and current treatment with mood stabilizers, which suggests that his psychiatrist noted manic symptoms
  
• ability to get married early in his illness even after hospitalization
  
• advanced vocabulary, which is characteristic of mania rather than schizophrenia
  
• history of episodic depression and suicidal ideas
  
• episodes of excitement, rapid speech, hypersexuality, and grandiose delusions, which can be found in schizophrenia but are consistent with psychotic mania in the context of these other bipolar disorder features.
  

I welcome Dr. Zimmerman’s disagreement on diagnostic issues and hope that he sees that the faculty’s diagnostic formulations were driven by the historical facts in the presented cases as well as research findings, not due to any other reason or motive. All of the participants would have given the same diagnostic discussion to our medical students and residents on any morning rounds.

Henry A. Nasrallah, MD
Editor-in-Chief

Comment on this article

Can you imagine an internist starting insulin for a patient with diabetes without obtaining a baseline glucose level? How would that internist know from visit to visit whether treatment was working and to what extent? How would he or she know how and when to adjust the dose to achieve hyperglycemia remission and a normal serum level?

If our medical colleagues wouldn’t dream of treating patients without measuring the symptoms of illness, why should psychiatric practice be different? Why aren’t psychiatrists measuring patients’ depression, anxiety, mania, or psychosis before and after starting psychopharmacologic agents?

Standardized tools unused

I recently surveyed a sample of Current Psychiatry readers, asking about their use of standard measurement instruments in clinical practice. I conducted this online survey as part of the needs assessment for a CME workshop I am planning at the University of Cincinnati. As I expected, most of the respondents indicated that they do not utilize any of 4 clinical rating scales routinely used in the evidence-based controlled trials required for FDA approval of psychiatric medications. These scales—which most said they had heard of or read about—include:

• Positive and Negative Syndrome Scale (PANSS) for schizophrenia
• Young Mania Rating Scale (YMRS) for bipolar mania
• Hamilton Depression Rating Scale (HAM-D) for unipolar depression
• Montgomery-Åsberg Depression Rating Scale (MADRS) for bipolar depression.

Lack of time was the most common reason respondents cited for not using these tools. Many preferred that their patients complete self-rating scales instead. Although I agree that patient self-ratings can be useful, they lack the objectivity and comprehensiveness of a clinician’s observation.

Many good reasons

One of the most important goals in modern psychiatric practice is to achieve remission, not just partial symptomatic response. Remission of depression, bipolar disorder, or schizophrenia is defined by a quantitative threshold measured on a standard rating scale. Therefore, we must use the pertinent rating scales if we wish to document that our patients achieve remission, which is the gateway to recovery and return to social and vocational functioning.

I believe psychiatrists should use standardized clinical rating scales because it is good medical practice that our patients need. Standardized measurements would enable all psychiatrists to use the same language relating to severity of illness, response, or remission. Then, when we read records of patients referred to us or cover while a colleague is on vacation, the numerical assessment combined with clinical impressions in the notes will facilitate continuity of care and guide ongoing treatment.

Let’s face it: the contents of many psychiatric charts are too general (“patient is doing better”) or vague (“patient partially improved”). Very few practitioners have time to cite whether or not every sign and symptom persists at a mild, moderate, or severe degree. By adopting standard rating scales, busy practitioners could do more (through better documentation) in less time (such as by circling the severity number corresponding to the symptoms listed on the scale).

Coming soon: Electronic medical records

The Obama administration’s economic stimulus package includes $19 billion to incentivize the adoption of universal electronic medical records (a 10-year goal set in 2004 by President Bush). Clinicians in facilities that have adopted e-medical records can enter clinical ratings with the click of a mouse. Issues beyond symptoms—such as functioning, quality of life, relationships, coping with stresses, etc.—can be addressed in the handwritten progress note text. (By the way, standard rating scales exist for those issues, too.)

Let us not wait for the time when reimbursement may become linked to documenting PANSS, YMRS, or MADRS scores at initial evaluations and follow-up visits. The time has come for psychiatrists—like our medical colleagues—to upgrade to objective, measurement-based practice and documentation. Improving the quality of inadequately informative or outright deficient medical records would be good for the patient and the practitioner. The quality of psychiatric treatment in the clinical setting should be no less rigorous than the controlled research trials that led to approval of the treatments.

Comment on this article

Can you imagine an internist starting insulin for a patient with diabetes without obtaining a baseline glucose level? How would that internist know from visit to visit whether treatment was working and to what extent? How would he or she know how and when to adjust the dose to achieve hyperglycemia remission and a normal serum level?

If our medical colleagues wouldn’t dream of treating patients without measuring the symptoms of illness, why should psychiatric practice be different? Why aren’t psychiatrists measuring patients’ depression, anxiety, mania, or psychosis before and after starting psychopharmacologic agents?

Standardized tools unused

I recently surveyed a sample of Current Psychiatry readers, asking about their use of standard measurement instruments in clinical practice. I conducted this online survey as part of the needs assessment for a CME workshop I am planning at the University of Cincinnati. As I expected, most of the respondents indicated that they do not utilize any of 4 clinical rating scales routinely used in the evidence-based controlled trials required for FDA approval of psychiatric medications. These scales—which most said they had heard of or read about—include:

• Positive and Negative Syndrome Scale (PANSS) for schizophrenia
• Young Mania Rating Scale (YMRS) for bipolar mania
• Hamilton Depression Rating Scale (HAM-D) for unipolar depression
• Montgomery-Åsberg Depression Rating Scale (MADRS) for bipolar depression.

Lack of time was the most common reason respondents cited for not using these tools. Many preferred that their patients complete self-rating scales instead. Although I agree that patient self-ratings can be useful, they lack the objectivity and comprehensiveness of a clinician’s observation.

Many good reasons

One of the most important goals in modern psychiatric practice is to achieve remission, not just partial symptomatic response. Remission of depression, bipolar disorder, or schizophrenia is defined by a quantitative threshold measured on a standard rating scale. Therefore, we must use the pertinent rating scales if we wish to document that our patients achieve remission, which is the gateway to recovery and return to social and vocational functioning.

I believe psychiatrists should use standardized clinical rating scales because it is good medical practice that our patients need. Standardized measurements would enable all psychiatrists to use the same language relating to severity of illness, response, or remission. Then, when we read records of patients referred to us or cover while a colleague is on vacation, the numerical assessment combined with clinical impressions in the notes will facilitate continuity of care and guide ongoing treatment.

Let’s face it: the contents of many psychiatric charts are too general (“patient is doing better”) or vague (“patient partially improved”). Very few practitioners have time to cite whether or not every sign and symptom persists at a mild, moderate, or severe degree. By adopting standard rating scales, busy practitioners could do more (through better documentation) in less time (such as by circling the severity number corresponding to the symptoms listed on the scale).

Coming soon: Electronic medical records

The Obama administration’s economic stimulus package includes $19 billion to incentivize the adoption of universal electronic medical records (a 10-year goal set in 2004 by President Bush). Clinicians in facilities that have adopted e-medical records can enter clinical ratings with the click of a mouse. Issues beyond symptoms—such as functioning, quality of life, relationships, coping with stresses, etc.—can be addressed in the handwritten progress note text. (By the way, standard rating scales exist for those issues, too.)

Let us not wait for the time when reimbursement may become linked to documenting PANSS, YMRS, or MADRS scores at initial evaluations and follow-up visits. The time has come for psychiatrists—like our medical colleagues—to upgrade to objective, measurement-based practice and documentation. Improving the quality of inadequately informative or outright deficient medical records would be good for the patient and the practitioner. The quality of psychiatric treatment in the clinical setting should be no less rigorous than the controlled research trials that led to approval of the treatments.

Comment on this article

Can you imagine an internist starting insulin for a patient with diabetes without obtaining a baseline glucose level? How would that internist know from visit to visit whether treatment was working and to what extent? How would he or she know how and when to adjust the dose to achieve hyperglycemia remission and a normal serum level?

If our medical colleagues wouldn’t dream of treating patients without measuring the symptoms of illness, why should psychiatric practice be different? Why aren’t psychiatrists measuring patients’ depression, anxiety, mania, or psychosis before and after starting psychopharmacologic agents?

Standardized tools unused

I recently surveyed a sample of Current Psychiatry readers, asking about their use of standard measurement instruments in clinical practice. I conducted this online survey as part of the needs assessment for a CME workshop I am planning at the University of Cincinnati. As I expected, most of the respondents indicated that they do not utilize any of 4 clinical rating scales routinely used in the evidence-based controlled trials required for FDA approval of psychiatric medications. These scales—which most said they had heard of or read about—include:

• Positive and Negative Syndrome Scale (PANSS) for schizophrenia
• Young Mania Rating Scale (YMRS) for bipolar mania
• Hamilton Depression Rating Scale (HAM-D) for unipolar depression
• Montgomery-Åsberg Depression Rating Scale (MADRS) for bipolar depression.

Lack of time was the most common reason respondents cited for not using these tools. Many preferred that their patients complete self-rating scales instead. Although I agree that patient self-ratings can be useful, they lack the objectivity and comprehensiveness of a clinician’s observation.

Many good reasons

One of the most important goals in modern psychiatric practice is to achieve remission, not just partial symptomatic response. Remission of depression, bipolar disorder, or schizophrenia is defined by a quantitative threshold measured on a standard rating scale. Therefore, we must use the pertinent rating scales if we wish to document that our patients achieve remission, which is the gateway to recovery and return to social and vocational functioning.

I believe psychiatrists should use standardized clinical rating scales because it is good medical practice that our patients need. Standardized measurements would enable all psychiatrists to use the same language relating to severity of illness, response, or remission. Then, when we read records of patients referred to us or cover while a colleague is on vacation, the numerical assessment combined with clinical impressions in the notes will facilitate continuity of care and guide ongoing treatment.

Let’s face it: the contents of many psychiatric charts are too general (“patient is doing better”) or vague (“patient partially improved”). Very few practitioners have time to cite whether or not every sign and symptom persists at a mild, moderate, or severe degree. By adopting standard rating scales, busy practitioners could do more (through better documentation) in less time (such as by circling the severity number corresponding to the symptoms listed on the scale).

Coming soon: Electronic medical records

The Obama administration’s economic stimulus package includes $19 billion to incentivize the adoption of universal electronic medical records (a 10-year goal set in 2004 by President Bush). Clinicians in facilities that have adopted e-medical records can enter clinical ratings with the click of a mouse. Issues beyond symptoms—such as functioning, quality of life, relationships, coping with stresses, etc.—can be addressed in the handwritten progress note text. (By the way, standard rating scales exist for those issues, too.)

Let us not wait for the time when reimbursement may become linked to documenting PANSS, YMRS, or MADRS scores at initial evaluations and follow-up visits. The time has come for psychiatrists—like our medical colleagues—to upgrade to objective, measurement-based practice and documentation. Improving the quality of inadequately informative or outright deficient medical records would be good for the patient and the practitioner. The quality of psychiatric treatment in the clinical setting should be no less rigorous than the controlled research trials that led to approval of the treatments.

Case: Worsening memory

Mrs. K, age 46, is being treated by a neurologist for stable relapsing-remitting multiple sclerosis (MS) and migraine headaches when she complains of worsening memory over the past 5 years. She reports having difficulty recalling details of recent events and conversations. She describes occasional word-finding difficulties and problems maintaining her train of thought. She forgets where she places things and has gotten lost while driving, even on familiar routes. Her husband reports she takes more time to process things in general.

Mrs. K’s cognitive decline has affected her daily life and ability to work. For 4 years, she has been an office assistant at a campground, where she takes phone reservations and keeps a site schedule. Formerly simple tasks—such as taking a phone number—have become increasingly difficult, and she cannot recall a list of 3 things to buy at the supermarket without writing them down.

As a teenager, Mrs. K suffered migraines but did not seek treatment, and her headaches remitted for about 10 years. At age 29, she started to experience tunnel vision. Three years later she reported bilateral foot numbness and was diagnosed with MS. She responded well to interferon beta-1b but her migraines returned, occurring several times a week. Her migraines are successfully treated with topiramate, 75 mg/d, for prophylactic therapy and rizatriptan, 10 mg, as needed for abortive therapy. Her medication regimen also includes:

• eszopiclone, 2 mg/d, and amitriptyline, 10 mg/d, for insomnia
  
• butalbital/aspirin/caffeine, 50/325/40 mg, as needed for tension headaches
  
• fexofenadine, 12 mg/d, and budesonide, 32 mcg, 4 sprays/d, for allergy symptoms
  
• esomeprazole, 80 mg/d, and famotidine, 20 mg/d, as needed for dyspepsia
  
• propranolol, 120 mg/d, for hypertension
  
• levothyroxine, 75 mcg/d, for hypothyroidism
  
• conjugatedestrogens, 0.45 mg/d, for hypoestrogenemia
  
• alprazolam, 0.25 mg/d, aspirin, 81 mg/d, vitamin E, 800 IU/d, and a multivitamin.
  

The neurologist orders neuropsychological testing. Mrs. K demonstrates some depressive symptoms but is within normal limits across all aspects of neurocognition, including basic and complex attention, memory, bilateral motor functioning, expressive and receptive language, visuospatial/constructional function, and self-regulatory/executive functioning. The neurologist refers Mrs. K for psychiatric evaluation of her depressive symptoms.

The author’s observations

Many neuropsychiatric abnormalities may accompany MS (Table).¹ These can be classified as cognitive dysfunction or disturbances in mood, affect, and behavior.

Although the cause of cognitive impairment in patients with MS is unclear, its extent and profound impact on functioning has become widely recognized over the past 20 years.²

An estimated 40% to 65% of patients with MS suffer from cognitive dysfunction.^1,3 Testing indicates deficiencies most often in:

• attention
  
• information processing speed
  
• working memory
  
• verbal memory
  
• visuospatial function
  
• executive functions.⁴
  

• reduced social interactions
  
• increased sexual dysfunction
  
• greater difficulty with household tasks.⁶
  

Long-term interferon beta-1b treatment prevents MS relapses, but a recent study found that interferon beta-1b had a negative impact on patients’ mental health composite score and in most quality-of-life subscales over 2 years.⁸ Nevertheless, Mrs. K received interferon beta-1b therapy for at least 9 years without noticing cognitive decline.

Table

Neuropsychiatric conditions associated with MS

EVALUATION: Dysthymia

Mrs. K reports memory problems as her chief complaint. She also complains of a depressed mood, irritability, distractibility, and insomnia since her memory problems began, and admits being readily tearful. Mrs. K has difficulty “turning off her thinking” at night, which leads to delayed sleep onset, but denies sleeplessness, racing thoughts, or feelings of euphoria.

Her thought process is coherent and goal-directed, and she denies having auditory or visual hallucinations or active or passive suicidal or homicidal ideation. She scores 29/30 on the Mini-Mental State Exam, but by interview she appears to have impaired remote memory. Mrs. K demonstrates unimpaired judgment and good insight.

The author’s observations

Mrs. K meets DSM-IV-TR criteria for dysthymic disorder and agrees to start mirtazapine, 15 mg at bedtime. I chose this antidepressant because Mrs. K continues to complain of difficulty falling asleep, and mirtazapine is known to significantly decrease sleep latency and increase total sleep time. Approximately one-half of patients with MS will experience depression.^1,9 In a recent study of 245 MS patients followed in a neurology clinic, two-thirds of those who met criteria for major depressive disorder did not receive antidepressants.¹⁰

TREATMENT: A new strategy

After 2 more months Mrs. K’s mood is euthymic and she demonstrates a bright affect, but she experiences continued decline in short- and long-term memory and reports increasing frustration with simple tasks. The rest of her mental status exam is unremarkable. I instruct her to reduce the mirtazapine dosage to 15 mg/d.

At the next visit 10 weeks later, she again presents with a euthymic mood and a bright affect. She says she attempted to decrease mirtazapine but experienced increased irritability so she remained on the 30-mg dose, with a positive effect on her mood and reduced irritability. Unfortunately, her memory problems persist.

Approximately 2 years after Mrs. K’s first visit, I devise a new pharmacologic strategy. Mrs. K believes that she no longer is depressed and that her only problem is her inability to recall events. To address this, I decide to try memantine, which has been shown to cause modest improvement in clinical symptoms in severe stages of Alzheimer’s disease¹¹ and also has been reported to be useful in the treatment of cognitive impairment in some bipolar disorder patients.¹² I start memantine at 10 mg/d and titrate up to 20 mg/d in 3 months.

The author’s observations

Mrs. K’s substantial memory improvement while receiving memantine warrants considering the drug for patients with cognitive dysfunction attributable to MS. Memantine is an uncompetitive NMDA receptor antagonist that the FDA approved in 2003 to treat moderate-to-severe Alzheimer’s disease (Box).^11,13 It is generally well tolerated and safe, with a low potential for drug-drug interactions. In clinical trials of patients receiving memantine for Alzheimer’s disease and vascular dementia, the most commonly reported side effects were dizziness, headache, constipation, and confusion.¹⁴

A recent trial of memantine therapy for MS at the University of Navarra was suspended for reversible mild-to-moderate neurologic side effects.¹⁵ A phase II/phase III double-blind placebo-controlled trial at the University of Oregon designed to determine whether memantine is an effective treatment for memory and cognitive problems associated with MS is recruiting participants.¹⁶

Memantine has been reported to successfully treat other MS symptoms. A 1997 retrospective study found that 11 patients with acquired pendular nystagmus (APN) secondary to MS experienced complete resolution of APN when given memantine.¹⁷

Box

• Parsons CG, Stöffler A, Danysz W. Memantine: a NMDA receptor antagonist that improves memory by restoration of homeostasis in the glutamatergic system—too little activation is bad, too much is even worse. Neuropharmacology. 2007;53(6):699-723.
  

• Alprazolam • Xanax
  
• Amitriptyline • Elavil
  
• Budesonide • Rhinocort
  
• Butalbital/Aspirin/Caffeine • Fiorinal
  
• Conjugated Estrogens • Premarin
  
• Esomeprazole • Nexium
  
• Eszopiclone • Lunesta
  
• Famotidine • Pepcid
  
• Fexofenadine • Allegra
  
• Interferon beta-1b • Betaseron
  
• Levothyroxine • Synthroid
  
• Memantine • Namenda
  
• Propranolol • Inderal
  
• Rizatriptan • Maxalt
  
• Topiramate • Topamax
  

Dr. Rao is a speaker for Forest Pharmaceuticals.

Acknowledgement

The author thanks Alexander M. Timchak, MS-IV, Stritch School of Medicine, Loyola University, Chicago, for his assistance with this article.

Case: Worsening memory

Mrs. K, age 46, is being treated by a neurologist for stable relapsing-remitting multiple sclerosis (MS) and migraine headaches when she complains of worsening memory over the past 5 years. She reports having difficulty recalling details of recent events and conversations. She describes occasional word-finding difficulties and problems maintaining her train of thought. She forgets where she places things and has gotten lost while driving, even on familiar routes. Her husband reports she takes more time to process things in general.

Mrs. K’s cognitive decline has affected her daily life and ability to work. For 4 years, she has been an office assistant at a campground, where she takes phone reservations and keeps a site schedule. Formerly simple tasks—such as taking a phone number—have become increasingly difficult, and she cannot recall a list of 3 things to buy at the supermarket without writing them down.

As a teenager, Mrs. K suffered migraines but did not seek treatment, and her headaches remitted for about 10 years. At age 29, she started to experience tunnel vision. Three years later she reported bilateral foot numbness and was diagnosed with MS. She responded well to interferon beta-1b but her migraines returned, occurring several times a week. Her migraines are successfully treated with topiramate, 75 mg/d, for prophylactic therapy and rizatriptan, 10 mg, as needed for abortive therapy. Her medication regimen also includes:

• eszopiclone, 2 mg/d, and amitriptyline, 10 mg/d, for insomnia
  
• butalbital/aspirin/caffeine, 50/325/40 mg, as needed for tension headaches
  
• fexofenadine, 12 mg/d, and budesonide, 32 mcg, 4 sprays/d, for allergy symptoms
  
• esomeprazole, 80 mg/d, and famotidine, 20 mg/d, as needed for dyspepsia
  
• propranolol, 120 mg/d, for hypertension
  
• levothyroxine, 75 mcg/d, for hypothyroidism
  
• conjugatedestrogens, 0.45 mg/d, for hypoestrogenemia
  
• alprazolam, 0.25 mg/d, aspirin, 81 mg/d, vitamin E, 800 IU/d, and a multivitamin.
  

The neurologist orders neuropsychological testing. Mrs. K demonstrates some depressive symptoms but is within normal limits across all aspects of neurocognition, including basic and complex attention, memory, bilateral motor functioning, expressive and receptive language, visuospatial/constructional function, and self-regulatory/executive functioning. The neurologist refers Mrs. K for psychiatric evaluation of her depressive symptoms.

The author’s observations

Many neuropsychiatric abnormalities may accompany MS (Table).¹ These can be classified as cognitive dysfunction or disturbances in mood, affect, and behavior.

Although the cause of cognitive impairment in patients with MS is unclear, its extent and profound impact on functioning has become widely recognized over the past 20 years.²

An estimated 40% to 65% of patients with MS suffer from cognitive dysfunction.^1,3 Testing indicates deficiencies most often in:

• attention
  
• information processing speed
  
• working memory
  
• verbal memory
  
• visuospatial function
  
• executive functions.⁴
  

• reduced social interactions
  
• increased sexual dysfunction
  
• greater difficulty with household tasks.⁶
  

Long-term interferon beta-1b treatment prevents MS relapses, but a recent study found that interferon beta-1b had a negative impact on patients’ mental health composite score and in most quality-of-life subscales over 2 years.⁸ Nevertheless, Mrs. K received interferon beta-1b therapy for at least 9 years without noticing cognitive decline.

Table

Neuropsychiatric conditions associated with MS

EVALUATION: Dysthymia

Mrs. K reports memory problems as her chief complaint. She also complains of a depressed mood, irritability, distractibility, and insomnia since her memory problems began, and admits being readily tearful. Mrs. K has difficulty “turning off her thinking” at night, which leads to delayed sleep onset, but denies sleeplessness, racing thoughts, or feelings of euphoria.

Her thought process is coherent and goal-directed, and she denies having auditory or visual hallucinations or active or passive suicidal or homicidal ideation. She scores 29/30 on the Mini-Mental State Exam, but by interview she appears to have impaired remote memory. Mrs. K demonstrates unimpaired judgment and good insight.

The author’s observations

Mrs. K meets DSM-IV-TR criteria for dysthymic disorder and agrees to start mirtazapine, 15 mg at bedtime. I chose this antidepressant because Mrs. K continues to complain of difficulty falling asleep, and mirtazapine is known to significantly decrease sleep latency and increase total sleep time. Approximately one-half of patients with MS will experience depression.^1,9 In a recent study of 245 MS patients followed in a neurology clinic, two-thirds of those who met criteria for major depressive disorder did not receive antidepressants.¹⁰

TREATMENT: A new strategy

After 2 more months Mrs. K’s mood is euthymic and she demonstrates a bright affect, but she experiences continued decline in short- and long-term memory and reports increasing frustration with simple tasks. The rest of her mental status exam is unremarkable. I instruct her to reduce the mirtazapine dosage to 15 mg/d.

At the next visit 10 weeks later, she again presents with a euthymic mood and a bright affect. She says she attempted to decrease mirtazapine but experienced increased irritability so she remained on the 30-mg dose, with a positive effect on her mood and reduced irritability. Unfortunately, her memory problems persist.

Approximately 2 years after Mrs. K’s first visit, I devise a new pharmacologic strategy. Mrs. K believes that she no longer is depressed and that her only problem is her inability to recall events. To address this, I decide to try memantine, which has been shown to cause modest improvement in clinical symptoms in severe stages of Alzheimer’s disease¹¹ and also has been reported to be useful in the treatment of cognitive impairment in some bipolar disorder patients.¹² I start memantine at 10 mg/d and titrate up to 20 mg/d in 3 months.

The author’s observations

Mrs. K’s substantial memory improvement while receiving memantine warrants considering the drug for patients with cognitive dysfunction attributable to MS. Memantine is an uncompetitive NMDA receptor antagonist that the FDA approved in 2003 to treat moderate-to-severe Alzheimer’s disease (Box).^11,13 It is generally well tolerated and safe, with a low potential for drug-drug interactions. In clinical trials of patients receiving memantine for Alzheimer’s disease and vascular dementia, the most commonly reported side effects were dizziness, headache, constipation, and confusion.¹⁴

A recent trial of memantine therapy for MS at the University of Navarra was suspended for reversible mild-to-moderate neurologic side effects.¹⁵ A phase II/phase III double-blind placebo-controlled trial at the University of Oregon designed to determine whether memantine is an effective treatment for memory and cognitive problems associated with MS is recruiting participants.¹⁶

Memantine has been reported to successfully treat other MS symptoms. A 1997 retrospective study found that 11 patients with acquired pendular nystagmus (APN) secondary to MS experienced complete resolution of APN when given memantine.¹⁷

Box

• Parsons CG, Stöffler A, Danysz W. Memantine: a NMDA receptor antagonist that improves memory by restoration of homeostasis in the glutamatergic system—too little activation is bad, too much is even worse. Neuropharmacology. 2007;53(6):699-723.
  

• Alprazolam • Xanax
  
• Amitriptyline • Elavil
  
• Budesonide • Rhinocort
  
• Butalbital/Aspirin/Caffeine • Fiorinal
  
• Conjugated Estrogens • Premarin
  
• Esomeprazole • Nexium
  
• Eszopiclone • Lunesta
  
• Famotidine • Pepcid
  
• Fexofenadine • Allegra
  
• Interferon beta-1b • Betaseron
  
• Levothyroxine • Synthroid
  
• Memantine • Namenda
  
• Propranolol • Inderal
  
• Rizatriptan • Maxalt
  
• Topiramate • Topamax
  

Dr. Rao is a speaker for Forest Pharmaceuticals.

Acknowledgement

The author thanks Alexander M. Timchak, MS-IV, Stritch School of Medicine, Loyola University, Chicago, for his assistance with this article.

Case: Worsening memory

Mrs. K, age 46, is being treated by a neurologist for stable relapsing-remitting multiple sclerosis (MS) and migraine headaches when she complains of worsening memory over the past 5 years. She reports having difficulty recalling details of recent events and conversations. She describes occasional word-finding difficulties and problems maintaining her train of thought. She forgets where she places things and has gotten lost while driving, even on familiar routes. Her husband reports she takes more time to process things in general.

Mrs. K’s cognitive decline has affected her daily life and ability to work. For 4 years, she has been an office assistant at a campground, where she takes phone reservations and keeps a site schedule. Formerly simple tasks—such as taking a phone number—have become increasingly difficult, and she cannot recall a list of 3 things to buy at the supermarket without writing them down.

As a teenager, Mrs. K suffered migraines but did not seek treatment, and her headaches remitted for about 10 years. At age 29, she started to experience tunnel vision. Three years later she reported bilateral foot numbness and was diagnosed with MS. She responded well to interferon beta-1b but her migraines returned, occurring several times a week. Her migraines are successfully treated with topiramate, 75 mg/d, for prophylactic therapy and rizatriptan, 10 mg, as needed for abortive therapy. Her medication regimen also includes:

• eszopiclone, 2 mg/d, and amitriptyline, 10 mg/d, for insomnia
  
• butalbital/aspirin/caffeine, 50/325/40 mg, as needed for tension headaches
  
• fexofenadine, 12 mg/d, and budesonide, 32 mcg, 4 sprays/d, for allergy symptoms
  
• esomeprazole, 80 mg/d, and famotidine, 20 mg/d, as needed for dyspepsia
  
• propranolol, 120 mg/d, for hypertension
  
• levothyroxine, 75 mcg/d, for hypothyroidism
  
• conjugatedestrogens, 0.45 mg/d, for hypoestrogenemia
  
• alprazolam, 0.25 mg/d, aspirin, 81 mg/d, vitamin E, 800 IU/d, and a multivitamin.
  

The neurologist orders neuropsychological testing. Mrs. K demonstrates some depressive symptoms but is within normal limits across all aspects of neurocognition, including basic and complex attention, memory, bilateral motor functioning, expressive and receptive language, visuospatial/constructional function, and self-regulatory/executive functioning. The neurologist refers Mrs. K for psychiatric evaluation of her depressive symptoms.

The author’s observations

Many neuropsychiatric abnormalities may accompany MS (Table).¹ These can be classified as cognitive dysfunction or disturbances in mood, affect, and behavior.

Although the cause of cognitive impairment in patients with MS is unclear, its extent and profound impact on functioning has become widely recognized over the past 20 years.²

An estimated 40% to 65% of patients with MS suffer from cognitive dysfunction.^1,3 Testing indicates deficiencies most often in:

• attention
  
• information processing speed
  
• working memory
  
• verbal memory
  
• visuospatial function
  
• executive functions.⁴
  

• reduced social interactions
  
• increased sexual dysfunction
  
• greater difficulty with household tasks.⁶
  

Long-term interferon beta-1b treatment prevents MS relapses, but a recent study found that interferon beta-1b had a negative impact on patients’ mental health composite score and in most quality-of-life subscales over 2 years.⁸ Nevertheless, Mrs. K received interferon beta-1b therapy for at least 9 years without noticing cognitive decline.

Table

Neuropsychiatric conditions associated with MS

EVALUATION: Dysthymia

Mrs. K reports memory problems as her chief complaint. She also complains of a depressed mood, irritability, distractibility, and insomnia since her memory problems began, and admits being readily tearful. Mrs. K has difficulty “turning off her thinking” at night, which leads to delayed sleep onset, but denies sleeplessness, racing thoughts, or feelings of euphoria.

Her thought process is coherent and goal-directed, and she denies having auditory or visual hallucinations or active or passive suicidal or homicidal ideation. She scores 29/30 on the Mini-Mental State Exam, but by interview she appears to have impaired remote memory. Mrs. K demonstrates unimpaired judgment and good insight.

The author’s observations

Mrs. K meets DSM-IV-TR criteria for dysthymic disorder and agrees to start mirtazapine, 15 mg at bedtime. I chose this antidepressant because Mrs. K continues to complain of difficulty falling asleep, and mirtazapine is known to significantly decrease sleep latency and increase total sleep time. Approximately one-half of patients with MS will experience depression.^1,9 In a recent study of 245 MS patients followed in a neurology clinic, two-thirds of those who met criteria for major depressive disorder did not receive antidepressants.¹⁰

TREATMENT: A new strategy

After 2 more months Mrs. K’s mood is euthymic and she demonstrates a bright affect, but she experiences continued decline in short- and long-term memory and reports increasing frustration with simple tasks. The rest of her mental status exam is unremarkable. I instruct her to reduce the mirtazapine dosage to 15 mg/d.

At the next visit 10 weeks later, she again presents with a euthymic mood and a bright affect. She says she attempted to decrease mirtazapine but experienced increased irritability so she remained on the 30-mg dose, with a positive effect on her mood and reduced irritability. Unfortunately, her memory problems persist.

Approximately 2 years after Mrs. K’s first visit, I devise a new pharmacologic strategy. Mrs. K believes that she no longer is depressed and that her only problem is her inability to recall events. To address this, I decide to try memantine, which has been shown to cause modest improvement in clinical symptoms in severe stages of Alzheimer’s disease¹¹ and also has been reported to be useful in the treatment of cognitive impairment in some bipolar disorder patients.¹² I start memantine at 10 mg/d and titrate up to 20 mg/d in 3 months.

The author’s observations

Mrs. K’s substantial memory improvement while receiving memantine warrants considering the drug for patients with cognitive dysfunction attributable to MS. Memantine is an uncompetitive NMDA receptor antagonist that the FDA approved in 2003 to treat moderate-to-severe Alzheimer’s disease (Box).^11,13 It is generally well tolerated and safe, with a low potential for drug-drug interactions. In clinical trials of patients receiving memantine for Alzheimer’s disease and vascular dementia, the most commonly reported side effects were dizziness, headache, constipation, and confusion.¹⁴

A recent trial of memantine therapy for MS at the University of Navarra was suspended for reversible mild-to-moderate neurologic side effects.¹⁵ A phase II/phase III double-blind placebo-controlled trial at the University of Oregon designed to determine whether memantine is an effective treatment for memory and cognitive problems associated with MS is recruiting participants.¹⁶

Memantine has been reported to successfully treat other MS symptoms. A 1997 retrospective study found that 11 patients with acquired pendular nystagmus (APN) secondary to MS experienced complete resolution of APN when given memantine.¹⁷

Box

• Parsons CG, Stöffler A, Danysz W. Memantine: a NMDA receptor antagonist that improves memory by restoration of homeostasis in the glutamatergic system—too little activation is bad, too much is even worse. Neuropharmacology. 2007;53(6):699-723.
  

• Alprazolam • Xanax
  
• Amitriptyline • Elavil
  
• Budesonide • Rhinocort
  
• Butalbital/Aspirin/Caffeine • Fiorinal
  
• Conjugated Estrogens • Premarin
  
• Esomeprazole • Nexium
  
• Eszopiclone • Lunesta
  
• Famotidine • Pepcid
  
• Fexofenadine • Allegra
  
• Interferon beta-1b • Betaseron
  
• Levothyroxine • Synthroid
  
• Memantine • Namenda
  
• Propranolol • Inderal
  
• Rizatriptan • Maxalt
  
• Topiramate • Topamax
  

Dr. Rao is a speaker for Forest Pharmaceuticals.

Acknowledgement

The author thanks Alexander M. Timchak, MS-IV, Stritch School of Medicine, Loyola University, Chicago, for his assistance with this article.

Comment on this article

Mr. G, age 46, works for a large federal government agency in a middle-management position. He presents seeking treatment for insomnia. He says, “I just need a sleeping pill. I haven’t been able to sleep for the last 3 months because everybody at work is talking behind my back and spreading rumors about how I’m crazy. My boss is in on it, too. She is always trying to undermine me and makes a big deal out of every little mistake I make.”

Mr. G is suspicious, asking questions about the confidentiality of medical records. His speech is rapid, and he is anxious but exhibits a full range of affect and no pressured speech or flight of ideas. Mr. G describes early, middle, and late insomnia, decreased energy and interest, and gaining 10 pounds over the past 3 months.

He admits owning a gun and having frequent thoughts of suicide and fantasies of killing his boss, although Mr. G repeatedly affirms he would never act on these thoughts. A week ago, his wife moved in with her parents because, he says, “she just couldn’t stand to be around me any longer.”

I consider involuntary hospitalization for Mr. G. Ultimately I contact his wife, who agrees to pick him up, stay with him overnight, and return with him the next morning. Because the only medication Mr. G is willing to consider is sleeping pills, I prescribe flurazepam, 30 mg qhs.

Mr. G was apparently paranoid, thinking of killing his boss, and had a gun. If his wife had not answered the phone and been willing to stay with him, he might have been involuntarily committed. As it was, further interviews with him revealed that Mr. G had been a target of workplace “mobbing,” and that his insomnia and paranoia developed because of a deliberate campaign by coworkers.

This article discusses how to recognize symptoms of workplace mobbing, using Mr. G’s experience to illustrate the dynamics of this group behavior. An informed mental health professional can be of enormous help to a mobbing victim, but an uninformed professional can unwittingly make the situation much worse.

What is ‘mobbing’?

Initiated most often by a person in a position of power or influence, mobbing has been described as “a desperate urge to crush and eliminate the target…. As the campaign proceeds, a steadily larger range of hostile ploys and communications comes to be seen as legitimate.”¹ This behavior pattern has been recognized in Europe since the 1980s but is not well recognized in the United States.

Davenport et al² brought the phenomenon and its consequences to the U.S. public’s attention in 1999 with the publication of Mobbing: emotional abuse in the American workplace. Otherwise, little professional literature on workplace mobbing has been produced in the United States.

A PubMed search on the term “mobbing” limited to 1982 through October 2008 returned 95 listings, excluding those dealing purely with ethology, but only 1 report from the United States. Studies from outside the United States indicate that mobbing is relatively common (Box).

Mobbing, bullying, and harassment. The term “workplace mobbing” was coined by Leymann,³ an occupational psychologist who investigated the psychology of workers who had suffered severe trauma. He observed that some of the most severe reactions were among workers who had been the target of “an impassioned collective campaign by coworkers to exclude, punish, or humiliate” them.

Many researchers use the term mobbing to describe a negative work environment created by several individuals working together.^1–3 However, some researchers such as Namie et al⁴ use the term workplace bullying to describe the creation of a hostile work environment by either a single individual—usually a boss—or a number of individuals.

Box

CASE CONTINUED: Why I first thought ‘paranoia’

During our first interview, Mr. G said that 6 months before he sought treatment he had reported misuse of government property by his supervisor’s boss. The case was investigated and dismissed. Mr. G’s supervisor never confronted him about the complaint, but shortly afterwards Mr. G started to notice disturbing changes in the workplace.

His supervisor avoided Mr. G’s phone calls and e-mails and stopped meeting with him. Instead, she met with Mr. G’s subordinates. The subordinates started to ignore Mr. G’s instructions and would roll their eyes or be inattentive when he spoke. Coworkers stopped talking when Mr. G approached, and he started receiving anonymous e-mails questioning his ability and sanity. He was reprimanded in writing for having made a $9 mathematical error in an expense reimbursement request.

Mr. G said when he approached his superior about the work environment, she stated that he was “just paranoid” and needed to see a psychiatrist.

When Mr. G’s wife accompanies him to the second interview, she confirms his impressions of ostracism and gossip at work. She also relates her experiences with people from Mr. G’s office who previously had been friendly but now were distant or hostile. Mr. G shows me copies of harassing work e-mails and memos. I tell Mr. G I believe his story and diagnose him as suffering from posttraumatic stress disorder (PTSD). He begins supportive/cognitive therapy and continues flurazepam.

Mobbing syndrome

As it turns out, Mr. G was not paranoid; his coworkers really were trying to get him. Leymann⁵ divided 45 types of mobbing behaviors into 5 categories. These were organized as attacks on:

• self-expression and ability to communicate (victim is silenced, given no opportunity to communicate, subject to verbal attacks)
  
• social relationships (colleagues do not talk to the victim, victim is physically isolated from others)
  
• reputation (victim is the target of gossip and ridicule)
  
• occupational situation (victim is given meaningless tasks or no work at all)
  
• physical health (victim is assigned dangerous tasks, threatened with bodily harm, or physically attacked).
  

Table 1

Mobbing syndrome: 10 factors

• different ethnicity
  
• an “odd” personality
  
• high achievement.
  

Phases of mobbing

Secondary morbidity. Victims of workplace mobbing frequently suffer from:

• adjustment disorders
  
• somatic symptoms (eg, headaches or irritable bowel syndrome)
  
• PTSD^6,7
  
• major depression.⁸
  

Leymann³ estimated that 15% of suicides in Sweden could be directly attributed to workplace mobbing. Although no other researcher has reported such a dramatic proportion, others have reported increased risk of suicidal behavior among mobbing victims.¹⁰

Table 3

Degrees of mobbing

CASE CONTINUED: Redirecting energy into a job search

As I met with Mr. G over the next 3 months, the pattern of malicious communication and actions continued at his office. For example, he received a written reprimand for being 10 minutes late after having overslept when starting flurazepam, which he continued to take for about 6 weeks without further tardiness. I encouraged Mr. G to withdraw energy from work by keeping a low profile and trying not to react to provocations. Instead, I counseled him to put energy into family activities and try to find a new job.

Mr. G experienced relatively mild, first-degree workplace mobbing, but it had a substantial effect on his quality of life and that of his wife for almost 1 year. If I had followed my first impulse and had Mr. G involuntarily hospitalized after our first interview, it would have confirmed rumors at his office and probably would have escalated the mobbing behavior.

Diagnostic recommendations

Consider the possibility that seemingly paranoid individuals could be the target of mobbing at work, and don’t underestimate the psychological stress of being mobbed. Other forms of workplace harassment can be extremely stressful but do not have the “paranoidogenic” potential of mobbing. Patients may be so distressed that it is difficult to figure out what is going on in their work environment.

Ask patients to present physical evidence of conspiracy or harassment. Mobbing patients usually are willing to bring in large quantities of material. Keep in mind that when subjected to mobbing behavior over time, a person who is not initially paranoid is likely to develop some secondary suspiciousness and even frank paranoia.

Also consider the possibility of “pseudomobbing,” in which an individual falsely believes he or she is a mobbing victim. Cases of pseudomobbing have been reported in European literature¹¹ and may represent a negative side effect of greater public awareness of the mobbing phenomenon (and of legal remedies to mobbing available in various European countries).

Mobbing is a serious stressor that can lead to psychiatric and medical morbidity and even suicide. Major depressive disorder—often with suicidal ideation—is frequently associated with being mobbed.¹²

A diagnosis of PTSD can be missed if the mobbing victim does not seem to have been subjected to a severe enough stress to meet PTSD criteria.

Treatment recommendations

First, do no harm: Do not allow yourself to be used by the mob. This process can be direct—as in the Mr. G’s case, where the patient was almost involuntarily committed—or subtle. For example, a person you know may describe the behavior of “someone at work,” and you may be tempted to respond, “Well, I have not examined this person, but from what you say, it sounds like maybe…” You could then be quoted as a psychiatrist who agrees that the person is paranoid.

Giving your patient a name for what is happening to him or her may be the most therapeutic intervention. Generally, patients have not heard of mobbing. They typically are confused about what is happening and may blame themselves.

Treat secondary symptoms of depression, anxiety, PTSD, or other sequelae with pharmacotherapy, psychotherapy, or a combination as appropriate. Refer patients with somatic symptoms to primary care if you feel that they need further evaluation.

Encourage your patient to visualize choices and ways to escape the situation. Frequently, patients will be locked into “fighting for justice” or putting up with the situation because they see no options.

Encourage your patient to withdraw energy from work and invest it in family, social life, or anything else. At the appropriate time, encourage him or her to grieve losses experienced as a result of the mobbing.

Related resources

• Leymann H. The Mobbing Encyclopaedia. www.leymann.se.
  
• Westhues K. Workplace mobbing in academe. http://arts.uwaterloo.ca/~kwesthue/mobbing.htm.
  
• Namie R, Namie G. The Workplace Bullying Institute. www.bullyinginstitute.org.
  

• Flurazepam • Dalmane
  

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

Comment on this article

Mr. G, age 46, works for a large federal government agency in a middle-management position. He presents seeking treatment for insomnia. He says, “I just need a sleeping pill. I haven’t been able to sleep for the last 3 months because everybody at work is talking behind my back and spreading rumors about how I’m crazy. My boss is in on it, too. She is always trying to undermine me and makes a big deal out of every little mistake I make.”

Mr. G is suspicious, asking questions about the confidentiality of medical records. His speech is rapid, and he is anxious but exhibits a full range of affect and no pressured speech or flight of ideas. Mr. G describes early, middle, and late insomnia, decreased energy and interest, and gaining 10 pounds over the past 3 months.

He admits owning a gun and having frequent thoughts of suicide and fantasies of killing his boss, although Mr. G repeatedly affirms he would never act on these thoughts. A week ago, his wife moved in with her parents because, he says, “she just couldn’t stand to be around me any longer.”

I consider involuntary hospitalization for Mr. G. Ultimately I contact his wife, who agrees to pick him up, stay with him overnight, and return with him the next morning. Because the only medication Mr. G is willing to consider is sleeping pills, I prescribe flurazepam, 30 mg qhs.

Mr. G was apparently paranoid, thinking of killing his boss, and had a gun. If his wife had not answered the phone and been willing to stay with him, he might have been involuntarily committed. As it was, further interviews with him revealed that Mr. G had been a target of workplace “mobbing,” and that his insomnia and paranoia developed because of a deliberate campaign by coworkers.

This article discusses how to recognize symptoms of workplace mobbing, using Mr. G’s experience to illustrate the dynamics of this group behavior. An informed mental health professional can be of enormous help to a mobbing victim, but an uninformed professional can unwittingly make the situation much worse.

What is ‘mobbing’?

Initiated most often by a person in a position of power or influence, mobbing has been described as “a desperate urge to crush and eliminate the target…. As the campaign proceeds, a steadily larger range of hostile ploys and communications comes to be seen as legitimate.”¹ This behavior pattern has been recognized in Europe since the 1980s but is not well recognized in the United States.

Davenport et al² brought the phenomenon and its consequences to the U.S. public’s attention in 1999 with the publication of Mobbing: emotional abuse in the American workplace. Otherwise, little professional literature on workplace mobbing has been produced in the United States.

A PubMed search on the term “mobbing” limited to 1982 through October 2008 returned 95 listings, excluding those dealing purely with ethology, but only 1 report from the United States. Studies from outside the United States indicate that mobbing is relatively common (Box).

Mobbing, bullying, and harassment. The term “workplace mobbing” was coined by Leymann,³ an occupational psychologist who investigated the psychology of workers who had suffered severe trauma. He observed that some of the most severe reactions were among workers who had been the target of “an impassioned collective campaign by coworkers to exclude, punish, or humiliate” them.

Many researchers use the term mobbing to describe a negative work environment created by several individuals working together.^1–3 However, some researchers such as Namie et al⁴ use the term workplace bullying to describe the creation of a hostile work environment by either a single individual—usually a boss—or a number of individuals.

Box

CASE CONTINUED: Why I first thought ‘paranoia’

During our first interview, Mr. G said that 6 months before he sought treatment he had reported misuse of government property by his supervisor’s boss. The case was investigated and dismissed. Mr. G’s supervisor never confronted him about the complaint, but shortly afterwards Mr. G started to notice disturbing changes in the workplace.

His supervisor avoided Mr. G’s phone calls and e-mails and stopped meeting with him. Instead, she met with Mr. G’s subordinates. The subordinates started to ignore Mr. G’s instructions and would roll their eyes or be inattentive when he spoke. Coworkers stopped talking when Mr. G approached, and he started receiving anonymous e-mails questioning his ability and sanity. He was reprimanded in writing for having made a $9 mathematical error in an expense reimbursement request.

Mr. G said when he approached his superior about the work environment, she stated that he was “just paranoid” and needed to see a psychiatrist.

When Mr. G’s wife accompanies him to the second interview, she confirms his impressions of ostracism and gossip at work. She also relates her experiences with people from Mr. G’s office who previously had been friendly but now were distant or hostile. Mr. G shows me copies of harassing work e-mails and memos. I tell Mr. G I believe his story and diagnose him as suffering from posttraumatic stress disorder (PTSD). He begins supportive/cognitive therapy and continues flurazepam.

Mobbing syndrome

As it turns out, Mr. G was not paranoid; his coworkers really were trying to get him. Leymann⁵ divided 45 types of mobbing behaviors into 5 categories. These were organized as attacks on:

• self-expression and ability to communicate (victim is silenced, given no opportunity to communicate, subject to verbal attacks)
  
• social relationships (colleagues do not talk to the victim, victim is physically isolated from others)
  
• reputation (victim is the target of gossip and ridicule)
  
• occupational situation (victim is given meaningless tasks or no work at all)
  
• physical health (victim is assigned dangerous tasks, threatened with bodily harm, or physically attacked).
  

Table 1

Mobbing syndrome: 10 factors

• different ethnicity
  
• an “odd” personality
  
• high achievement.
  

Phases of mobbing

Secondary morbidity. Victims of workplace mobbing frequently suffer from:

• adjustment disorders
  
• somatic symptoms (eg, headaches or irritable bowel syndrome)
  
• PTSD^6,7
  
• major depression.⁸
  

Leymann³ estimated that 15% of suicides in Sweden could be directly attributed to workplace mobbing. Although no other researcher has reported such a dramatic proportion, others have reported increased risk of suicidal behavior among mobbing victims.¹⁰

Table 3

Degrees of mobbing

CASE CONTINUED: Redirecting energy into a job search

As I met with Mr. G over the next 3 months, the pattern of malicious communication and actions continued at his office. For example, he received a written reprimand for being 10 minutes late after having overslept when starting flurazepam, which he continued to take for about 6 weeks without further tardiness. I encouraged Mr. G to withdraw energy from work by keeping a low profile and trying not to react to provocations. Instead, I counseled him to put energy into family activities and try to find a new job.

Mr. G experienced relatively mild, first-degree workplace mobbing, but it had a substantial effect on his quality of life and that of his wife for almost 1 year. If I had followed my first impulse and had Mr. G involuntarily hospitalized after our first interview, it would have confirmed rumors at his office and probably would have escalated the mobbing behavior.

Diagnostic recommendations

Consider the possibility that seemingly paranoid individuals could be the target of mobbing at work, and don’t underestimate the psychological stress of being mobbed. Other forms of workplace harassment can be extremely stressful but do not have the “paranoidogenic” potential of mobbing. Patients may be so distressed that it is difficult to figure out what is going on in their work environment.

Ask patients to present physical evidence of conspiracy or harassment. Mobbing patients usually are willing to bring in large quantities of material. Keep in mind that when subjected to mobbing behavior over time, a person who is not initially paranoid is likely to develop some secondary suspiciousness and even frank paranoia.

Also consider the possibility of “pseudomobbing,” in which an individual falsely believes he or she is a mobbing victim. Cases of pseudomobbing have been reported in European literature¹¹ and may represent a negative side effect of greater public awareness of the mobbing phenomenon (and of legal remedies to mobbing available in various European countries).

Mobbing is a serious stressor that can lead to psychiatric and medical morbidity and even suicide. Major depressive disorder—often with suicidal ideation—is frequently associated with being mobbed.¹²

A diagnosis of PTSD can be missed if the mobbing victim does not seem to have been subjected to a severe enough stress to meet PTSD criteria.

Treatment recommendations

First, do no harm: Do not allow yourself to be used by the mob. This process can be direct—as in the Mr. G’s case, where the patient was almost involuntarily committed—or subtle. For example, a person you know may describe the behavior of “someone at work,” and you may be tempted to respond, “Well, I have not examined this person, but from what you say, it sounds like maybe…” You could then be quoted as a psychiatrist who agrees that the person is paranoid.

Giving your patient a name for what is happening to him or her may be the most therapeutic intervention. Generally, patients have not heard of mobbing. They typically are confused about what is happening and may blame themselves.

Treat secondary symptoms of depression, anxiety, PTSD, or other sequelae with pharmacotherapy, psychotherapy, or a combination as appropriate. Refer patients with somatic symptoms to primary care if you feel that they need further evaluation.

Encourage your patient to visualize choices and ways to escape the situation. Frequently, patients will be locked into “fighting for justice” or putting up with the situation because they see no options.

Encourage your patient to withdraw energy from work and invest it in family, social life, or anything else. At the appropriate time, encourage him or her to grieve losses experienced as a result of the mobbing.

Related resources

• Leymann H. The Mobbing Encyclopaedia. www.leymann.se.
  
• Westhues K. Workplace mobbing in academe. http://arts.uwaterloo.ca/~kwesthue/mobbing.htm.
  
• Namie R, Namie G. The Workplace Bullying Institute. www.bullyinginstitute.org.
  

• Flurazepam • Dalmane
  

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

Comment on this article

Mr. G, age 46, works for a large federal government agency in a middle-management position. He presents seeking treatment for insomnia. He says, “I just need a sleeping pill. I haven’t been able to sleep for the last 3 months because everybody at work is talking behind my back and spreading rumors about how I’m crazy. My boss is in on it, too. She is always trying to undermine me and makes a big deal out of every little mistake I make.”

Mr. G is suspicious, asking questions about the confidentiality of medical records. His speech is rapid, and he is anxious but exhibits a full range of affect and no pressured speech or flight of ideas. Mr. G describes early, middle, and late insomnia, decreased energy and interest, and gaining 10 pounds over the past 3 months.

He admits owning a gun and having frequent thoughts of suicide and fantasies of killing his boss, although Mr. G repeatedly affirms he would never act on these thoughts. A week ago, his wife moved in with her parents because, he says, “she just couldn’t stand to be around me any longer.”

I consider involuntary hospitalization for Mr. G. Ultimately I contact his wife, who agrees to pick him up, stay with him overnight, and return with him the next morning. Because the only medication Mr. G is willing to consider is sleeping pills, I prescribe flurazepam, 30 mg qhs.

Mr. G was apparently paranoid, thinking of killing his boss, and had a gun. If his wife had not answered the phone and been willing to stay with him, he might have been involuntarily committed. As it was, further interviews with him revealed that Mr. G had been a target of workplace “mobbing,” and that his insomnia and paranoia developed because of a deliberate campaign by coworkers.

This article discusses how to recognize symptoms of workplace mobbing, using Mr. G’s experience to illustrate the dynamics of this group behavior. An informed mental health professional can be of enormous help to a mobbing victim, but an uninformed professional can unwittingly make the situation much worse.

What is ‘mobbing’?

Initiated most often by a person in a position of power or influence, mobbing has been described as “a desperate urge to crush and eliminate the target…. As the campaign proceeds, a steadily larger range of hostile ploys and communications comes to be seen as legitimate.”¹ This behavior pattern has been recognized in Europe since the 1980s but is not well recognized in the United States.

Davenport et al² brought the phenomenon and its consequences to the U.S. public’s attention in 1999 with the publication of Mobbing: emotional abuse in the American workplace. Otherwise, little professional literature on workplace mobbing has been produced in the United States.

A PubMed search on the term “mobbing” limited to 1982 through October 2008 returned 95 listings, excluding those dealing purely with ethology, but only 1 report from the United States. Studies from outside the United States indicate that mobbing is relatively common (Box).

Mobbing, bullying, and harassment. The term “workplace mobbing” was coined by Leymann,³ an occupational psychologist who investigated the psychology of workers who had suffered severe trauma. He observed that some of the most severe reactions were among workers who had been the target of “an impassioned collective campaign by coworkers to exclude, punish, or humiliate” them.

Many researchers use the term mobbing to describe a negative work environment created by several individuals working together.^1–3 However, some researchers such as Namie et al⁴ use the term workplace bullying to describe the creation of a hostile work environment by either a single individual—usually a boss—or a number of individuals.

Box

CASE CONTINUED: Why I first thought ‘paranoia’

During our first interview, Mr. G said that 6 months before he sought treatment he had reported misuse of government property by his supervisor’s boss. The case was investigated and dismissed. Mr. G’s supervisor never confronted him about the complaint, but shortly afterwards Mr. G started to notice disturbing changes in the workplace.

His supervisor avoided Mr. G’s phone calls and e-mails and stopped meeting with him. Instead, she met with Mr. G’s subordinates. The subordinates started to ignore Mr. G’s instructions and would roll their eyes or be inattentive when he spoke. Coworkers stopped talking when Mr. G approached, and he started receiving anonymous e-mails questioning his ability and sanity. He was reprimanded in writing for having made a $9 mathematical error in an expense reimbursement request.

Mr. G said when he approached his superior about the work environment, she stated that he was “just paranoid” and needed to see a psychiatrist.

When Mr. G’s wife accompanies him to the second interview, she confirms his impressions of ostracism and gossip at work. She also relates her experiences with people from Mr. G’s office who previously had been friendly but now were distant or hostile. Mr. G shows me copies of harassing work e-mails and memos. I tell Mr. G I believe his story and diagnose him as suffering from posttraumatic stress disorder (PTSD). He begins supportive/cognitive therapy and continues flurazepam.

Mobbing syndrome

As it turns out, Mr. G was not paranoid; his coworkers really were trying to get him. Leymann⁵ divided 45 types of mobbing behaviors into 5 categories. These were organized as attacks on:

• self-expression and ability to communicate (victim is silenced, given no opportunity to communicate, subject to verbal attacks)
  
• social relationships (colleagues do not talk to the victim, victim is physically isolated from others)
  
• reputation (victim is the target of gossip and ridicule)
  
• occupational situation (victim is given meaningless tasks or no work at all)
  
• physical health (victim is assigned dangerous tasks, threatened with bodily harm, or physically attacked).
  

Table 1

Mobbing syndrome: 10 factors

• different ethnicity
  
• an “odd” personality
  
• high achievement.
  

Phases of mobbing

Secondary morbidity. Victims of workplace mobbing frequently suffer from:

• adjustment disorders
  
• somatic symptoms (eg, headaches or irritable bowel syndrome)
  
• PTSD^6,7
  
• major depression.⁸
  

Leymann³ estimated that 15% of suicides in Sweden could be directly attributed to workplace mobbing. Although no other researcher has reported such a dramatic proportion, others have reported increased risk of suicidal behavior among mobbing victims.¹⁰

Table 3

Degrees of mobbing

CASE CONTINUED: Redirecting energy into a job search

As I met with Mr. G over the next 3 months, the pattern of malicious communication and actions continued at his office. For example, he received a written reprimand for being 10 minutes late after having overslept when starting flurazepam, which he continued to take for about 6 weeks without further tardiness. I encouraged Mr. G to withdraw energy from work by keeping a low profile and trying not to react to provocations. Instead, I counseled him to put energy into family activities and try to find a new job.

Mr. G experienced relatively mild, first-degree workplace mobbing, but it had a substantial effect on his quality of life and that of his wife for almost 1 year. If I had followed my first impulse and had Mr. G involuntarily hospitalized after our first interview, it would have confirmed rumors at his office and probably would have escalated the mobbing behavior.

Diagnostic recommendations

Consider the possibility that seemingly paranoid individuals could be the target of mobbing at work, and don’t underestimate the psychological stress of being mobbed. Other forms of workplace harassment can be extremely stressful but do not have the “paranoidogenic” potential of mobbing. Patients may be so distressed that it is difficult to figure out what is going on in their work environment.

Ask patients to present physical evidence of conspiracy or harassment. Mobbing patients usually are willing to bring in large quantities of material. Keep in mind that when subjected to mobbing behavior over time, a person who is not initially paranoid is likely to develop some secondary suspiciousness and even frank paranoia.

Also consider the possibility of “pseudomobbing,” in which an individual falsely believes he or she is a mobbing victim. Cases of pseudomobbing have been reported in European literature¹¹ and may represent a negative side effect of greater public awareness of the mobbing phenomenon (and of legal remedies to mobbing available in various European countries).

Mobbing is a serious stressor that can lead to psychiatric and medical morbidity and even suicide. Major depressive disorder—often with suicidal ideation—is frequently associated with being mobbed.¹²

A diagnosis of PTSD can be missed if the mobbing victim does not seem to have been subjected to a severe enough stress to meet PTSD criteria.

Treatment recommendations

First, do no harm: Do not allow yourself to be used by the mob. This process can be direct—as in the Mr. G’s case, where the patient was almost involuntarily committed—or subtle. For example, a person you know may describe the behavior of “someone at work,” and you may be tempted to respond, “Well, I have not examined this person, but from what you say, it sounds like maybe…” You could then be quoted as a psychiatrist who agrees that the person is paranoid.

Giving your patient a name for what is happening to him or her may be the most therapeutic intervention. Generally, patients have not heard of mobbing. They typically are confused about what is happening and may blame themselves.

Treat secondary symptoms of depression, anxiety, PTSD, or other sequelae with pharmacotherapy, psychotherapy, or a combination as appropriate. Refer patients with somatic symptoms to primary care if you feel that they need further evaluation.

Encourage your patient to visualize choices and ways to escape the situation. Frequently, patients will be locked into “fighting for justice” or putting up with the situation because they see no options.

Encourage your patient to withdraw energy from work and invest it in family, social life, or anything else. At the appropriate time, encourage him or her to grieve losses experienced as a result of the mobbing.

Related resources

• Leymann H. The Mobbing Encyclopaedia. www.leymann.se.
  
• Westhues K. Workplace mobbing in academe. http://arts.uwaterloo.ca/~kwesthue/mobbing.htm.
  
• Namie R, Namie G. The Workplace Bullying Institute. www.bullyinginstitute.org.
  

• Flurazepam • Dalmane
  

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

Comment on this article

Mr. D, age 45 with a history of schizophrenia, is admitted to an inpatient psychiatric unit. The psychiatrist recommends an antipsychotic to help Mr. D with fears that the FBI has implanted a radio signal device into his tooth filling. She explains the risks and benefits of the proposed drug and alternate medications, as well as the risks of no treatment.

Mr. D calmly but consistently declines the treatment. He states that he recognizes the antipsychotic is used to treat psychotic symptoms, can help people who hear voices, and can have side effects such as tardive dyskinesia. His thoughts become disorganized and difficult to follow, however, as he explains that he does not believe the medication is needed for his situation because the FBI is involved in tracking his behavior.

Informed consent in clinical settings is designed to allow patients to make rational choices about their treatment before it begins. When a psychiatric patient such as Mr. D declines a treatment you recommend, how can you balance the 2 ethical principles in medicine: beneficence toward the patient and respect for individual autonomy?¹

Some authors have raised concerns that informed consent in physician-patient interactions are at times an empty exercise undertaken solely to satisfy a legal expectation.² If executed properly, however, informed consent can enhance the therapeutic alliance and help improve treatment adherence.

Patient-centered treatment

As patients have become more informed consumers, the “doctor knows best” model of care has given way to an expectation that patients know best what they would want done regarding their health. Lawsuits related to informed consent generally allege that physicians failed to provide appropriate informed consent for treatment the plaintiffs received. These complaints suggest that had the patient been more appropriately informed, he or she might have made a different choice and would not have suffered harm related to treatment.

In a patient-centered approach to treatment, informed consent allows the patient to make an autonomous decision with the appropriate information. Providing treatment without the patient’s expressed consent could be viewed more seriously, potentially even as battery.³ Recent informed consent cases tend to rely on negligence theories, however, rather than on claims of battery. Negligence cases helped set the stage of evolving expectations—first seen with surgical procedures, then medical interventions, then medication treatment, and now even with psychotherapy (Box 1)—that informed consent should be obtained in clinical settings.⁴

Box 1

3 components of informed consent

Informed consent includes 3 components: voluntariness, disclosure, and competence.⁵

Voluntariness implies that the patient must make treatment-related choices of his or her own free will and without coercion. In Kaimowitz v Michigan Department of Mental Health,⁶ the court ruled that involuntarily committed persons living in what was considered an inherently coercive institutional environment were not capable of providing voluntary consent to a high-risk experimental procedure. This case had a major impact on prison research.

In treatment settings as well, a patient’s circumstances might be considered coercive. Historically, civilly committed patients did not have the right to refuse treatment. A movement in the 1980s helped to separate civil commitment and the right to refuse treatment, which is well-established in most jurisdictions today.⁷ In psychiatric inpatient settings, even an involuntarily committed patient generally has a right to refuse recommended medications unless a legally permissible mechanism overrides the refusal.

Disclosure means that a person requires certain information to make a rational decision to accept or reject treatment. The question is: How much information needs to be disclosed for a patient to be adequately informed?

Disclosure requirements vary across jurisdictions. In 1960, Natanson v Kline supported the standard that disclosure required that which a “reasonable practitioner” might disclose to patients about their treatment in similar circumstances.⁸ Although some jurisdictions have maintained that standard,⁵ subsequent cases identified a more patient-centered approach to disclosure called the “reasonable person” standard (Box 2).^5,9

Competence. In many settings, clinicians use the construct of “capacity” rather than “competence” because competence is a legal term that can be determined only by a judge. When an individual is deemed incompetent, his or her right to make autonomous decisions can be overridden. Children are not competent by virtue of their status as minors, although exceptions may be made for certain older youth. Adults are presumed competent unless adjudicated otherwise.

Box 2

Competence can be broken down into 4 component capacities (Box 3).¹¹ The degree of incapacity required for a finding of incompetence is complicated and difficult to codify. Instruments designed to standardize competence assessment are available¹² but not routinely used in clinical settings. Even with these instruments, no threshold of capacity clearly defines competence. Some authors have argued for a sliding scale of competence, with standards becoming more stringent as the degree of risk related to the treatment decision increases.^13,14

Box 3

Exceptions to informed consent

Emergencies. Informed consent is not required under some circumstances.⁵ Consider the patient who is brought to the emergency room unconscious after a fall, with no family contact information. A neurosurgeon might need to intervene immediately to save the patient’s life, using the emergency exception to informed consent.

In an emergency, when a person is unable to give informed consent or time does not allow for a full informed consent process, the clinician generally follows the principle of doing no harm. Treatment may be started in an emergency without full informed consent on the assumption that most competent people would consent to treatment, especially where life or limb was at risk. If time and circumstances permit in an emergency, obtaining the consent of available family members may be prudent.

Incompetence. If a judge determines that a patient is incompetent to make his or her own treatment decisions, a substitute decision-maker—such as a guardian—could be appointed. In these cases, respect would suggest that to the extent possible and appropriate you would inform the incompetent ward about treatment in a way that he or she may understand.

In other circumstances, such as when a healthcare proxy has been invoked, previously designated surrogate decision-makers provide informed consent on behalf of the patient who clinically is found to lack the capacity to make healthcare decisions.

Waivers. Sometimes a competent patient decides to waive the right to further information and may turn the decision over to the clinician. To rely upon this exception, some documented assessment—even if brief—of the patient’s capacity to waive information may be important.

As noted, informing patients of their health situations is expected and accepted. Even in psychiatric settings, receiving information about potentially serious medication side effects has not necessarily led to patient harm or refusal of treatment.¹⁵ Therefore, use of this exception is only for very narrowly tailored circumstances, if used at all, and not simply because you believe a patient will refuse to consent if informed about a proposed treatment.

Some case law exists on the need to establish why the therapeutic privilege was justified as a rationale to not provide informed consent in a particular situation.¹⁶ Therefore, though it should be rarely invoked, if you use therapeutic privilege, document why you invoked this exception for that particular patient and in that particular circumstance.

Building the therapeutic alliance

Although it may meet policy or legal informed consent requirements, simply providing the patient with a form to sign before treatment begins does little to enhance patient-clinician communication.² Providing detailed written information also might not be adequate to ensure that the patient understands the complexity of a treatment you have asked him to consider.¹⁷ Instead, an informed consent model that relies on active, ongoing dialogue about treatment can maximize patient autonomy while working for the good of the patient (Table).

• the patient’s role is understood as that of an inquisitive consumer who may challenge the physician’s authority in the quest for information
  
• the clinician challenges the patient’s preconceived beliefs about his or her illness and educates the patient so that both parties approach the medical issue from common ground.
  

By engaging in ongoing informed consent, you may achieve greater gains within the therapeutic alliance and reduce the risk of liability.¹⁹ Where uncertainties are related to treatment, share these ambiguities as an aspect of informed consent, especially when the patient plays an active role in treatment.⁴ Similarly, an expanded informed consent process may be needed when:

• proposed treatments are particularly risky
  
• several treatment alternatives could be acceptable and effective
  
• evidence supports opposing views of a treatment’s effectiveness.^4,20
  

Using informed consent to build a therapeutic alliance

CASE CONTINUED: A question of competence

Mr. D is calm in his discussions with the psychiatrist, and the information she presents does not seem to cause him further harm. Thus, the emergency and therapeutic privilege exceptions do not eliminate the need for an ongoing informed consent process at this time.

Mr. D has a factual understanding of the risks and benefits of the recommended antipsychotic and is able to express a consistent choice about starting this treatment. He lacks, however, an ability to appreciate his situation and has difficulty manipulating information rationally. Overall, he has deficits in aspects of his decision-making competence, which could signal the need for an exception to obtaining informed consent.

Related resources

• Pinals DA, Appelbaum PS. The history and current status of competence and informed consent in psychiatric research. Isr J Psychiatry Relat Sci. 2000;37(2):82-94.
  
• American Medical Association. Legal issues/patient physician relationship topics. www.ama-assn.org/ama/pub/physician-resources/legal-topics.shtml.
  

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

Comment on this article

Mr. D, age 45 with a history of schizophrenia, is admitted to an inpatient psychiatric unit. The psychiatrist recommends an antipsychotic to help Mr. D with fears that the FBI has implanted a radio signal device into his tooth filling. She explains the risks and benefits of the proposed drug and alternate medications, as well as the risks of no treatment.

Mr. D calmly but consistently declines the treatment. He states that he recognizes the antipsychotic is used to treat psychotic symptoms, can help people who hear voices, and can have side effects such as tardive dyskinesia. His thoughts become disorganized and difficult to follow, however, as he explains that he does not believe the medication is needed for his situation because the FBI is involved in tracking his behavior.

Informed consent in clinical settings is designed to allow patients to make rational choices about their treatment before it begins. When a psychiatric patient such as Mr. D declines a treatment you recommend, how can you balance the 2 ethical principles in medicine: beneficence toward the patient and respect for individual autonomy?¹

Some authors have raised concerns that informed consent in physician-patient interactions are at times an empty exercise undertaken solely to satisfy a legal expectation.² If executed properly, however, informed consent can enhance the therapeutic alliance and help improve treatment adherence.

Patient-centered treatment

As patients have become more informed consumers, the “doctor knows best” model of care has given way to an expectation that patients know best what they would want done regarding their health. Lawsuits related to informed consent generally allege that physicians failed to provide appropriate informed consent for treatment the plaintiffs received. These complaints suggest that had the patient been more appropriately informed, he or she might have made a different choice and would not have suffered harm related to treatment.

In a patient-centered approach to treatment, informed consent allows the patient to make an autonomous decision with the appropriate information. Providing treatment without the patient’s expressed consent could be viewed more seriously, potentially even as battery.³ Recent informed consent cases tend to rely on negligence theories, however, rather than on claims of battery. Negligence cases helped set the stage of evolving expectations—first seen with surgical procedures, then medical interventions, then medication treatment, and now even with psychotherapy (Box 1)—that informed consent should be obtained in clinical settings.⁴

Box 1

3 components of informed consent

Informed consent includes 3 components: voluntariness, disclosure, and competence.⁵

Voluntariness implies that the patient must make treatment-related choices of his or her own free will and without coercion. In Kaimowitz v Michigan Department of Mental Health,⁶ the court ruled that involuntarily committed persons living in what was considered an inherently coercive institutional environment were not capable of providing voluntary consent to a high-risk experimental procedure. This case had a major impact on prison research.

In treatment settings as well, a patient’s circumstances might be considered coercive. Historically, civilly committed patients did not have the right to refuse treatment. A movement in the 1980s helped to separate civil commitment and the right to refuse treatment, which is well-established in most jurisdictions today.⁷ In psychiatric inpatient settings, even an involuntarily committed patient generally has a right to refuse recommended medications unless a legally permissible mechanism overrides the refusal.

Disclosure means that a person requires certain information to make a rational decision to accept or reject treatment. The question is: How much information needs to be disclosed for a patient to be adequately informed?

Disclosure requirements vary across jurisdictions. In 1960, Natanson v Kline supported the standard that disclosure required that which a “reasonable practitioner” might disclose to patients about their treatment in similar circumstances.⁸ Although some jurisdictions have maintained that standard,⁵ subsequent cases identified a more patient-centered approach to disclosure called the “reasonable person” standard (Box 2).^5,9

Competence. In many settings, clinicians use the construct of “capacity” rather than “competence” because competence is a legal term that can be determined only by a judge. When an individual is deemed incompetent, his or her right to make autonomous decisions can be overridden. Children are not competent by virtue of their status as minors, although exceptions may be made for certain older youth. Adults are presumed competent unless adjudicated otherwise.

Box 2

Competence can be broken down into 4 component capacities (Box 3).¹¹ The degree of incapacity required for a finding of incompetence is complicated and difficult to codify. Instruments designed to standardize competence assessment are available¹² but not routinely used in clinical settings. Even with these instruments, no threshold of capacity clearly defines competence. Some authors have argued for a sliding scale of competence, with standards becoming more stringent as the degree of risk related to the treatment decision increases.^13,14

Box 3

Exceptions to informed consent

Emergencies. Informed consent is not required under some circumstances.⁵ Consider the patient who is brought to the emergency room unconscious after a fall, with no family contact information. A neurosurgeon might need to intervene immediately to save the patient’s life, using the emergency exception to informed consent.

In an emergency, when a person is unable to give informed consent or time does not allow for a full informed consent process, the clinician generally follows the principle of doing no harm. Treatment may be started in an emergency without full informed consent on the assumption that most competent people would consent to treatment, especially where life or limb was at risk. If time and circumstances permit in an emergency, obtaining the consent of available family members may be prudent.

Incompetence. If a judge determines that a patient is incompetent to make his or her own treatment decisions, a substitute decision-maker—such as a guardian—could be appointed. In these cases, respect would suggest that to the extent possible and appropriate you would inform the incompetent ward about treatment in a way that he or she may understand.

In other circumstances, such as when a healthcare proxy has been invoked, previously designated surrogate decision-makers provide informed consent on behalf of the patient who clinically is found to lack the capacity to make healthcare decisions.

Waivers. Sometimes a competent patient decides to waive the right to further information and may turn the decision over to the clinician. To rely upon this exception, some documented assessment—even if brief—of the patient’s capacity to waive information may be important.

As noted, informing patients of their health situations is expected and accepted. Even in psychiatric settings, receiving information about potentially serious medication side effects has not necessarily led to patient harm or refusal of treatment.¹⁵ Therefore, use of this exception is only for very narrowly tailored circumstances, if used at all, and not simply because you believe a patient will refuse to consent if informed about a proposed treatment.

Some case law exists on the need to establish why the therapeutic privilege was justified as a rationale to not provide informed consent in a particular situation.¹⁶ Therefore, though it should be rarely invoked, if you use therapeutic privilege, document why you invoked this exception for that particular patient and in that particular circumstance.

Building the therapeutic alliance

Although it may meet policy or legal informed consent requirements, simply providing the patient with a form to sign before treatment begins does little to enhance patient-clinician communication.² Providing detailed written information also might not be adequate to ensure that the patient understands the complexity of a treatment you have asked him to consider.¹⁷ Instead, an informed consent model that relies on active, ongoing dialogue about treatment can maximize patient autonomy while working for the good of the patient (Table).

• the patient’s role is understood as that of an inquisitive consumer who may challenge the physician’s authority in the quest for information
  
• the clinician challenges the patient’s preconceived beliefs about his or her illness and educates the patient so that both parties approach the medical issue from common ground.
  

By engaging in ongoing informed consent, you may achieve greater gains within the therapeutic alliance and reduce the risk of liability.¹⁹ Where uncertainties are related to treatment, share these ambiguities as an aspect of informed consent, especially when the patient plays an active role in treatment.⁴ Similarly, an expanded informed consent process may be needed when:

• proposed treatments are particularly risky
  
• several treatment alternatives could be acceptable and effective
  
• evidence supports opposing views of a treatment’s effectiveness.^4,20
  

Using informed consent to build a therapeutic alliance

CASE CONTINUED: A question of competence

Mr. D is calm in his discussions with the psychiatrist, and the information she presents does not seem to cause him further harm. Thus, the emergency and therapeutic privilege exceptions do not eliminate the need for an ongoing informed consent process at this time.

Mr. D has a factual understanding of the risks and benefits of the recommended antipsychotic and is able to express a consistent choice about starting this treatment. He lacks, however, an ability to appreciate his situation and has difficulty manipulating information rationally. Overall, he has deficits in aspects of his decision-making competence, which could signal the need for an exception to obtaining informed consent.

Related resources

• Pinals DA, Appelbaum PS. The history and current status of competence and informed consent in psychiatric research. Isr J Psychiatry Relat Sci. 2000;37(2):82-94.
  
• American Medical Association. Legal issues/patient physician relationship topics. www.ama-assn.org/ama/pub/physician-resources/legal-topics.shtml.
  

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

Comment on this article

Mr. D, age 45 with a history of schizophrenia, is admitted to an inpatient psychiatric unit. The psychiatrist recommends an antipsychotic to help Mr. D with fears that the FBI has implanted a radio signal device into his tooth filling. She explains the risks and benefits of the proposed drug and alternate medications, as well as the risks of no treatment.

Mr. D calmly but consistently declines the treatment. He states that he recognizes the antipsychotic is used to treat psychotic symptoms, can help people who hear voices, and can have side effects such as tardive dyskinesia. His thoughts become disorganized and difficult to follow, however, as he explains that he does not believe the medication is needed for his situation because the FBI is involved in tracking his behavior.

Informed consent in clinical settings is designed to allow patients to make rational choices about their treatment before it begins. When a psychiatric patient such as Mr. D declines a treatment you recommend, how can you balance the 2 ethical principles in medicine: beneficence toward the patient and respect for individual autonomy?¹

Some authors have raised concerns that informed consent in physician-patient interactions are at times an empty exercise undertaken solely to satisfy a legal expectation.² If executed properly, however, informed consent can enhance the therapeutic alliance and help improve treatment adherence.

Patient-centered treatment

As patients have become more informed consumers, the “doctor knows best” model of care has given way to an expectation that patients know best what they would want done regarding their health. Lawsuits related to informed consent generally allege that physicians failed to provide appropriate informed consent for treatment the plaintiffs received. These complaints suggest that had the patient been more appropriately informed, he or she might have made a different choice and would not have suffered harm related to treatment.

In a patient-centered approach to treatment, informed consent allows the patient to make an autonomous decision with the appropriate information. Providing treatment without the patient’s expressed consent could be viewed more seriously, potentially even as battery.³ Recent informed consent cases tend to rely on negligence theories, however, rather than on claims of battery. Negligence cases helped set the stage of evolving expectations—first seen with surgical procedures, then medical interventions, then medication treatment, and now even with psychotherapy (Box 1)—that informed consent should be obtained in clinical settings.⁴

Box 1

3 components of informed consent

Informed consent includes 3 components: voluntariness, disclosure, and competence.⁵

Voluntariness implies that the patient must make treatment-related choices of his or her own free will and without coercion. In Kaimowitz v Michigan Department of Mental Health,⁶ the court ruled that involuntarily committed persons living in what was considered an inherently coercive institutional environment were not capable of providing voluntary consent to a high-risk experimental procedure. This case had a major impact on prison research.

In treatment settings as well, a patient’s circumstances might be considered coercive. Historically, civilly committed patients did not have the right to refuse treatment. A movement in the 1980s helped to separate civil commitment and the right to refuse treatment, which is well-established in most jurisdictions today.⁷ In psychiatric inpatient settings, even an involuntarily committed patient generally has a right to refuse recommended medications unless a legally permissible mechanism overrides the refusal.

Disclosure means that a person requires certain information to make a rational decision to accept or reject treatment. The question is: How much information needs to be disclosed for a patient to be adequately informed?

Disclosure requirements vary across jurisdictions. In 1960, Natanson v Kline supported the standard that disclosure required that which a “reasonable practitioner” might disclose to patients about their treatment in similar circumstances.⁸ Although some jurisdictions have maintained that standard,⁵ subsequent cases identified a more patient-centered approach to disclosure called the “reasonable person” standard (Box 2).^5,9

Competence. In many settings, clinicians use the construct of “capacity” rather than “competence” because competence is a legal term that can be determined only by a judge. When an individual is deemed incompetent, his or her right to make autonomous decisions can be overridden. Children are not competent by virtue of their status as minors, although exceptions may be made for certain older youth. Adults are presumed competent unless adjudicated otherwise.

Box 2

Competence can be broken down into 4 component capacities (Box 3).¹¹ The degree of incapacity required for a finding of incompetence is complicated and difficult to codify. Instruments designed to standardize competence assessment are available¹² but not routinely used in clinical settings. Even with these instruments, no threshold of capacity clearly defines competence. Some authors have argued for a sliding scale of competence, with standards becoming more stringent as the degree of risk related to the treatment decision increases.^13,14

Box 3

Exceptions to informed consent

Emergencies. Informed consent is not required under some circumstances.⁵ Consider the patient who is brought to the emergency room unconscious after a fall, with no family contact information. A neurosurgeon might need to intervene immediately to save the patient’s life, using the emergency exception to informed consent.

In an emergency, when a person is unable to give informed consent or time does not allow for a full informed consent process, the clinician generally follows the principle of doing no harm. Treatment may be started in an emergency without full informed consent on the assumption that most competent people would consent to treatment, especially where life or limb was at risk. If time and circumstances permit in an emergency, obtaining the consent of available family members may be prudent.

Incompetence. If a judge determines that a patient is incompetent to make his or her own treatment decisions, a substitute decision-maker—such as a guardian—could be appointed. In these cases, respect would suggest that to the extent possible and appropriate you would inform the incompetent ward about treatment in a way that he or she may understand.

In other circumstances, such as when a healthcare proxy has been invoked, previously designated surrogate decision-makers provide informed consent on behalf of the patient who clinically is found to lack the capacity to make healthcare decisions.

Waivers. Sometimes a competent patient decides to waive the right to further information and may turn the decision over to the clinician. To rely upon this exception, some documented assessment—even if brief—of the patient’s capacity to waive information may be important.

As noted, informing patients of their health situations is expected and accepted. Even in psychiatric settings, receiving information about potentially serious medication side effects has not necessarily led to patient harm or refusal of treatment.¹⁵ Therefore, use of this exception is only for very narrowly tailored circumstances, if used at all, and not simply because you believe a patient will refuse to consent if informed about a proposed treatment.

Some case law exists on the need to establish why the therapeutic privilege was justified as a rationale to not provide informed consent in a particular situation.¹⁶ Therefore, though it should be rarely invoked, if you use therapeutic privilege, document why you invoked this exception for that particular patient and in that particular circumstance.

Building the therapeutic alliance

Although it may meet policy or legal informed consent requirements, simply providing the patient with a form to sign before treatment begins does little to enhance patient-clinician communication.² Providing detailed written information also might not be adequate to ensure that the patient understands the complexity of a treatment you have asked him to consider.¹⁷ Instead, an informed consent model that relies on active, ongoing dialogue about treatment can maximize patient autonomy while working for the good of the patient (Table).

• the patient’s role is understood as that of an inquisitive consumer who may challenge the physician’s authority in the quest for information
  
• the clinician challenges the patient’s preconceived beliefs about his or her illness and educates the patient so that both parties approach the medical issue from common ground.
  

By engaging in ongoing informed consent, you may achieve greater gains within the therapeutic alliance and reduce the risk of liability.¹⁹ Where uncertainties are related to treatment, share these ambiguities as an aspect of informed consent, especially when the patient plays an active role in treatment.⁴ Similarly, an expanded informed consent process may be needed when:

• proposed treatments are particularly risky
  
• several treatment alternatives could be acceptable and effective
  
• evidence supports opposing views of a treatment’s effectiveness.^4,20
  

Using informed consent to build a therapeutic alliance

CASE CONTINUED: A question of competence

Mr. D is calm in his discussions with the psychiatrist, and the information she presents does not seem to cause him further harm. Thus, the emergency and therapeutic privilege exceptions do not eliminate the need for an ongoing informed consent process at this time.

Mr. D has a factual understanding of the risks and benefits of the recommended antipsychotic and is able to express a consistent choice about starting this treatment. He lacks, however, an ability to appreciate his situation and has difficulty manipulating information rationally. Overall, he has deficits in aspects of his decision-making competence, which could signal the need for an exception to obtaining informed consent.

Related resources

• Pinals DA, Appelbaum PS. The history and current status of competence and informed consent in psychiatric research. Isr J Psychiatry Relat Sci. 2000;37(2):82-94.
  
• American Medical Association. Legal issues/patient physician relationship topics. www.ama-assn.org/ama/pub/physician-resources/legal-topics.shtml.
  

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

WEB AUDIO
Listen to Dr. Muskin discuss the patient-physician dynamic

Two strangers meet in the hospital cafeteria. Mrs. R, an elderly woman, asks Dr. W, a first-year medical resident, for help in getting a bottle of soda from the cooler. Afterward, Dr. W comments to a colleague with whom she is having lunch, “That woman reminds me of my grandmother.”

What does that comment reflect about Dr. W? It is a statement about the doctor’s transference. That is, she is aware of elements about Mrs. R that evoke internal responses appropriate to a prior important relationship.

What if Mrs. R was to subsequently faint, require admission to the hospital, and become Dr. W’s patient? If Dr. W’s comment indicates transference, would the same reaction to Mrs. R now be countertransference? Does that change if the doctor is unaware of emotions Mrs. R evokes? Is it still countertransference whether Dr. W is caring and compassionate, overly involved with Mrs. R, or—unaware of negative feelings associated with “grandmothers”—avoids the patient?

This article explores how complex internal experiences play out in the general medical setting and discusses how psychiatric consultants can help medical/surgical colleagues understand and manage difficult patient-physician relationships.

The therapeutic dyad

Countertransference and transference are concepts embedded in psychodynamic thinking. They are part of how many people think about interpersonal relations, whether or not they use these terms. Countertransference and transference may be conscious, but they always have an unconscious component. Factors that influence what will be transference and countertransference in adult life have both:

• a biological component because part of personality is genetic
  
• a psychological component based upon experiences throughout life ( Box 1 ).¹
  

Countertransference is a dimensional concept, not an all-or-nothing experience. Some reactions to patients are based entirely upon their transference to us and have nothing to do with us (therapists) as people. Others derive mostly from psychodynamics within the therapist ( Box 2 ). Countertransference has evolved to incorporate responses evoked by a combination of:

• the patient’s transference
  
• the therapist’s unique psychodynamics
  
• the real relationship in the therapeutic dyad.²
  

Patients with medical illness

Psychiatrists think of countertransference as a psychological situation occurring in the office or on an inpatient psychiatric unit. We focus our attention on how we feel and what we think while working with patients. We talk about our reactions to patients in supervision, rounds, case conferences, and other situations where mental health professionals discuss patients.

Our medical/surgical colleagues’ reactions to patients often correlate with certain patient presentations and may have little to do with the actual person who is the patient.⁴ The medical setting provides an opportunity for countertransference to occur in the absence of apparent transference.

Somatic illness imposes on patients some degree of regression. This regression and attempts to cope with it are inherent to somatic illness and hospitalization. Several schemas⁵ describe basic coping mechanisms common to most patients ( Table ).^6,7 Recognizing a patient’s character style or personality type may help clinicians predict their countertransference when interacting with that patient. Uncooperative patients and those perceived as “difficult” are particularly likely to evoke negative countertransference.⁸

Table

Patients’ response to illness,
with common countertransference by medical staff

CASE CONTINUED: No longer ‘grandmotherly’

Mrs. R and Dr. W are now in a patient-physician relationship. Dr. W is no longer handing Mrs. R a bottle of soda but is inquiring about her life, use of alcohol and other drugs, intimate activities, etc. Mrs. R reacts with anger at the “personal questions.” In addition, Dr. W orders tests that are uncomfortable for Mrs. R, who refuses to cooperate with some procedures.

Dr. W’s memories of her grandmother (who was encouraging, supportive, and loving) color her experience of Mrs. R. She ignores nursing staff’s complaints about Mrs. R being demanding and difficult as the patient becomes aggressive and increasingly confused.

Unable to see the patient as she really is, Dr. W becomes angry and defends Mrs. R’s behavior. The nurses feel Dr. W is unrealistic and ignore her at the nursing station. Late on a Friday night, Mrs. R becomes paranoid, hallucinating that “demons” are in her room. She tries to elope from the hospital. Dr. W is off for the weekend, and the staff requests an emergency psychiatric consultation.

Mrs. R evokes a reaction from the nurses because of how she interacts with them. Dr. W’s response—based on her experience of her grandmother—has nothing to do with the way Mrs. R relates interpersonally but reflects a reaction to the patient’s gender and age. Both reactions would be countertransference, using the modern definition.

If reactions to a patient such as Mrs. R are positive, no one seems to notice and the reactions might or might not influence her care. If the reactions are negative, they might influence her care and generate a request for a psychiatric consultation.

Some patients cannot communicate because of neurologic disorders, intubation, language barriers, or because they are unconscious when admitted. Without information from the patient, medical staff may form ideas about the patient based on their unconscious fantasies. These fantasies may influence the patient’s care.⁹ Psychiatric consultants are not immune to countertransference, but we come into situations with the opportunity to experience all participants from the outside.

CASE CONTINUED: The psychiatric consultation

During the interview, the psychiatrist asks Mrs. R if she takes any medications. She retorts that she always takes “Centrum” at bed-time and demands to know why she is not getting her “vitamins.” She is given oxazepam and falls asleep.

The psychiatrist recommends benzodiazepine detoxification, suspecting Mrs. R is taking prazepam at home from an old prescription (when the medication was a brand called “Centrax”). This suspicion is confirmed when Mrs. R’s family brings in a large shopping bag of medications she has collected over decades, and Mrs. R identifies her nighttime “vitamin.”

Patients with particular character styles evoke predictable reactions from others, including psychotherapists. Discussing these reactions has been a part of psychiatric training for decades. A subset of patients has been described as “hateful,” as they routinely evoke extremely negative responses.¹⁰ Whether their primary disorder is psychiatric, medical, or some of both, these patients evoke strong countertransference reactions.

Psychiatrists may be comfortable discussing a “narcissistic patient, a dependent clinger with borderline features,” but our medical colleagues might not share our comfort with psychiatric jargon.¹¹ It may be more useful to say to medical staff that the patient “thinks of himself as very important, cannot accept his need to be taken care of, and tends to see things in black and white.”

Managing difficult patients

The characterizations that follow describe unconscious reactions to types of individuals who are routinely experienced as “difficult” patients. Some patients may exhibit a mixture of character styles ( Table ) and do not easily fall into 1 category. The concepts can be useful in clarifying the reactions that patients evoke in medical staff.

‘Dependent’ patients. Some patients demand continuous attention but are unaware of their insatiable neediness. Early in treatment, they may evoke positive countertransference because they are intensely grateful for attention. They can be enticing, unconsciously seductive, and gratifying to their doctors. Over time, they drain and exhaust their physicians, who resort to avoidance and wish to get rid of these patients.

Recommendation. Set limits to prevent the patient from feeling rejected or an actual rejection when he or she is transferred to another doctor’s care. Coach physicians to:

• ask patients to “Tell me what is most important for us to discuss today”
  
• be clear how long the visit will last.
  

‘Entitled’ patients. Another type of “difficult” patient projects an air of entitlement, which typically reflects an underlying insatiable neediness. They may use intimidation, guilt, and threats of punishment to get their doctors to provide the care they demand. These patients appear powerful (even though they may possess no special status), and they may be overtly devaluing of the physician while simultaneously demanding special attention.

The doctor resents the patient’s entitlement but develops an expectable countertransference fear that he or she will get in trouble if the demands are not met. Wishes to retaliate and “put the patient in his or her place” are common.

Recommendation. Saying, “It is understandable that you want the best care, and I plan to give you the best care,” makes it clear to the patient that the physician hears the patient’s concerns. Advise the physician to request the patient’s “understanding and compassion” for other patients who also need the physician’s time and attention.

‘Help-rejecting’ patients. “Help-rejecting” patients demand care but show little faith in treatment and do not follow treatment plans. The harder the physician tries to help, the less likely the plan will succeed. For these patients, treatment success evokes a fear of abandonment; thus, treatment must fail to maintain the relationship.

Common countertransference reactions are initial anxiety that the treatment plan was not adequate, followed by anger and depression as the physician feels stuck with a patient for whom nothing works.

When the patient adheres only partially to the plan and a psychiatric consultant is called for an “uncooperative” patient, help the doctor understand how the patient sees the world. It is the patient’s psychological needs—not the physician’s failure—that control the outcome of the care.

‘Self-destructive’ patients may appear unaware of their dangerous actions. They evoke malice from their doctors, who feel the patients are purposely engaging in life-threatening behaviors. The patients’ unconscious dependence remains unknown as their denial of the consequences of their behavior frightens and angers those involved in their care. Some of these patients cannot be stopped before their actions cause them permanent harm or death.

Recommendation. You might remind the physician that we all are entitled to live our lives as we choose. To decompress intense feelings, advise the physician to share, without blaming the patient, what medical staff can realistically do. Saying “We’ll do the best we can” (rather than “Treatment is useless for someone like you”) permits the patient to receive the degree of care he or she can accept without the physician feeling helpless. Understanding our limitations and obligations is part of using our countertransference to aid in patient care.

CASE CONTINUED: Feeling better

When Dr. W returns on Monday, she angrily calls the psychiatrist to complain that her patient has been placed on a benzodiazepine and at the “implication” that Mrs. R was abusing medication. When they talk in person, the psychiatrist explains the situation to Dr. W and suggests they meet with Mrs. R together.

Mrs. R is embarrassed when told about her behavior, identifies the pill, and admits taking prazepam for several weeks prior to hospitalization. She says she never understood how a vitamin could help her sleep so well. No longer delirious, Mrs. R is pleasant and asks many questions. She is surprised that “so young” a doctor was assigned to her case and asks if the chief of medicine could be brought in, as she is on the board of directors of another hospital. “No offense, dear,” she says to Dr. W; “I’m sure you did an excellent job, but usually only senior doctors take care of me.”

Dr. W accepts the psychiatrist’s suggestion to repair her relationship with the nurses with an apology. She now notes that Mrs. R is nothing like her grandmother and seems “pretty stuck up.” She is glad to be off the case and accepts the psychiatrist’s idea that Mrs. R’s need to feel important should not make Dr. W feel bad about herself.

Related resources

• Gabbard GO, ed. Countertransference issues in psychiatric treatment. In: Oldham JM, Riba MB, eds. Review of psychiatry series. Washington, DC: American Psychiatric Publishing, Inc.; 1999.
  
• Blumenfield M, Strain JJ, Grossman S. Psychodynamic approach. In: Blumenfield M, Strain JJ, eds. Psychosomatic medicine. Philadelphia, PA: Lippincott, Williams and Wilkins; 2006:817-828.
  

• Oxazepam • Serax
  
• Prazepam • Centrax
  

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

WEB AUDIO
Listen to Dr. Muskin discuss the patient-physician dynamic

Two strangers meet in the hospital cafeteria. Mrs. R, an elderly woman, asks Dr. W, a first-year medical resident, for help in getting a bottle of soda from the cooler. Afterward, Dr. W comments to a colleague with whom she is having lunch, “That woman reminds me of my grandmother.”

What does that comment reflect about Dr. W? It is a statement about the doctor’s transference. That is, she is aware of elements about Mrs. R that evoke internal responses appropriate to a prior important relationship.

What if Mrs. R was to subsequently faint, require admission to the hospital, and become Dr. W’s patient? If Dr. W’s comment indicates transference, would the same reaction to Mrs. R now be countertransference? Does that change if the doctor is unaware of emotions Mrs. R evokes? Is it still countertransference whether Dr. W is caring and compassionate, overly involved with Mrs. R, or—unaware of negative feelings associated with “grandmothers”—avoids the patient?

This article explores how complex internal experiences play out in the general medical setting and discusses how psychiatric consultants can help medical/surgical colleagues understand and manage difficult patient-physician relationships.

The therapeutic dyad

Countertransference and transference are concepts embedded in psychodynamic thinking. They are part of how many people think about interpersonal relations, whether or not they use these terms. Countertransference and transference may be conscious, but they always have an unconscious component. Factors that influence what will be transference and countertransference in adult life have both:

• a biological component because part of personality is genetic
  
• a psychological component based upon experiences throughout life ( Box 1 ).¹
  

Countertransference is a dimensional concept, not an all-or-nothing experience. Some reactions to patients are based entirely upon their transference to us and have nothing to do with us (therapists) as people. Others derive mostly from psychodynamics within the therapist ( Box 2 ). Countertransference has evolved to incorporate responses evoked by a combination of:

• the patient’s transference
  
• the therapist’s unique psychodynamics
  
• the real relationship in the therapeutic dyad.²
  

Patients with medical illness

Psychiatrists think of countertransference as a psychological situation occurring in the office or on an inpatient psychiatric unit. We focus our attention on how we feel and what we think while working with patients. We talk about our reactions to patients in supervision, rounds, case conferences, and other situations where mental health professionals discuss patients.

Our medical/surgical colleagues’ reactions to patients often correlate with certain patient presentations and may have little to do with the actual person who is the patient.⁴ The medical setting provides an opportunity for countertransference to occur in the absence of apparent transference.

Somatic illness imposes on patients some degree of regression. This regression and attempts to cope with it are inherent to somatic illness and hospitalization. Several schemas⁵ describe basic coping mechanisms common to most patients ( Table ).^6,7 Recognizing a patient’s character style or personality type may help clinicians predict their countertransference when interacting with that patient. Uncooperative patients and those perceived as “difficult” are particularly likely to evoke negative countertransference.⁸

Table

Patients’ response to illness,
with common countertransference by medical staff

CASE CONTINUED: No longer ‘grandmotherly’

Mrs. R and Dr. W are now in a patient-physician relationship. Dr. W is no longer handing Mrs. R a bottle of soda but is inquiring about her life, use of alcohol and other drugs, intimate activities, etc. Mrs. R reacts with anger at the “personal questions.” In addition, Dr. W orders tests that are uncomfortable for Mrs. R, who refuses to cooperate with some procedures.

Dr. W’s memories of her grandmother (who was encouraging, supportive, and loving) color her experience of Mrs. R. She ignores nursing staff’s complaints about Mrs. R being demanding and difficult as the patient becomes aggressive and increasingly confused.

Unable to see the patient as she really is, Dr. W becomes angry and defends Mrs. R’s behavior. The nurses feel Dr. W is unrealistic and ignore her at the nursing station. Late on a Friday night, Mrs. R becomes paranoid, hallucinating that “demons” are in her room. She tries to elope from the hospital. Dr. W is off for the weekend, and the staff requests an emergency psychiatric consultation.

Mrs. R evokes a reaction from the nurses because of how she interacts with them. Dr. W’s response—based on her experience of her grandmother—has nothing to do with the way Mrs. R relates interpersonally but reflects a reaction to the patient’s gender and age. Both reactions would be countertransference, using the modern definition.

If reactions to a patient such as Mrs. R are positive, no one seems to notice and the reactions might or might not influence her care. If the reactions are negative, they might influence her care and generate a request for a psychiatric consultation.

Some patients cannot communicate because of neurologic disorders, intubation, language barriers, or because they are unconscious when admitted. Without information from the patient, medical staff may form ideas about the patient based on their unconscious fantasies. These fantasies may influence the patient’s care.⁹ Psychiatric consultants are not immune to countertransference, but we come into situations with the opportunity to experience all participants from the outside.

CASE CONTINUED: The psychiatric consultation

During the interview, the psychiatrist asks Mrs. R if she takes any medications. She retorts that she always takes “Centrum” at bed-time and demands to know why she is not getting her “vitamins.” She is given oxazepam and falls asleep.

The psychiatrist recommends benzodiazepine detoxification, suspecting Mrs. R is taking prazepam at home from an old prescription (when the medication was a brand called “Centrax”). This suspicion is confirmed when Mrs. R’s family brings in a large shopping bag of medications she has collected over decades, and Mrs. R identifies her nighttime “vitamin.”

Patients with particular character styles evoke predictable reactions from others, including psychotherapists. Discussing these reactions has been a part of psychiatric training for decades. A subset of patients has been described as “hateful,” as they routinely evoke extremely negative responses.¹⁰ Whether their primary disorder is psychiatric, medical, or some of both, these patients evoke strong countertransference reactions.

Psychiatrists may be comfortable discussing a “narcissistic patient, a dependent clinger with borderline features,” but our medical colleagues might not share our comfort with psychiatric jargon.¹¹ It may be more useful to say to medical staff that the patient “thinks of himself as very important, cannot accept his need to be taken care of, and tends to see things in black and white.”

Managing difficult patients

The characterizations that follow describe unconscious reactions to types of individuals who are routinely experienced as “difficult” patients. Some patients may exhibit a mixture of character styles ( Table ) and do not easily fall into 1 category. The concepts can be useful in clarifying the reactions that patients evoke in medical staff.

‘Dependent’ patients. Some patients demand continuous attention but are unaware of their insatiable neediness. Early in treatment, they may evoke positive countertransference because they are intensely grateful for attention. They can be enticing, unconsciously seductive, and gratifying to their doctors. Over time, they drain and exhaust their physicians, who resort to avoidance and wish to get rid of these patients.

Recommendation. Set limits to prevent the patient from feeling rejected or an actual rejection when he or she is transferred to another doctor’s care. Coach physicians to:

• ask patients to “Tell me what is most important for us to discuss today”
  
• be clear how long the visit will last.
  

‘Entitled’ patients. Another type of “difficult” patient projects an air of entitlement, which typically reflects an underlying insatiable neediness. They may use intimidation, guilt, and threats of punishment to get their doctors to provide the care they demand. These patients appear powerful (even though they may possess no special status), and they may be overtly devaluing of the physician while simultaneously demanding special attention.

The doctor resents the patient’s entitlement but develops an expectable countertransference fear that he or she will get in trouble if the demands are not met. Wishes to retaliate and “put the patient in his or her place” are common.

Recommendation. Saying, “It is understandable that you want the best care, and I plan to give you the best care,” makes it clear to the patient that the physician hears the patient’s concerns. Advise the physician to request the patient’s “understanding and compassion” for other patients who also need the physician’s time and attention.

‘Help-rejecting’ patients. “Help-rejecting” patients demand care but show little faith in treatment and do not follow treatment plans. The harder the physician tries to help, the less likely the plan will succeed. For these patients, treatment success evokes a fear of abandonment; thus, treatment must fail to maintain the relationship.

Common countertransference reactions are initial anxiety that the treatment plan was not adequate, followed by anger and depression as the physician feels stuck with a patient for whom nothing works.

When the patient adheres only partially to the plan and a psychiatric consultant is called for an “uncooperative” patient, help the doctor understand how the patient sees the world. It is the patient’s psychological needs—not the physician’s failure—that control the outcome of the care.

‘Self-destructive’ patients may appear unaware of their dangerous actions. They evoke malice from their doctors, who feel the patients are purposely engaging in life-threatening behaviors. The patients’ unconscious dependence remains unknown as their denial of the consequences of their behavior frightens and angers those involved in their care. Some of these patients cannot be stopped before their actions cause them permanent harm or death.

Recommendation. You might remind the physician that we all are entitled to live our lives as we choose. To decompress intense feelings, advise the physician to share, without blaming the patient, what medical staff can realistically do. Saying “We’ll do the best we can” (rather than “Treatment is useless for someone like you”) permits the patient to receive the degree of care he or she can accept without the physician feeling helpless. Understanding our limitations and obligations is part of using our countertransference to aid in patient care.

CASE CONTINUED: Feeling better

When Dr. W returns on Monday, she angrily calls the psychiatrist to complain that her patient has been placed on a benzodiazepine and at the “implication” that Mrs. R was abusing medication. When they talk in person, the psychiatrist explains the situation to Dr. W and suggests they meet with Mrs. R together.

Mrs. R is embarrassed when told about her behavior, identifies the pill, and admits taking prazepam for several weeks prior to hospitalization. She says she never understood how a vitamin could help her sleep so well. No longer delirious, Mrs. R is pleasant and asks many questions. She is surprised that “so young” a doctor was assigned to her case and asks if the chief of medicine could be brought in, as she is on the board of directors of another hospital. “No offense, dear,” she says to Dr. W; “I’m sure you did an excellent job, but usually only senior doctors take care of me.”

Dr. W accepts the psychiatrist’s suggestion to repair her relationship with the nurses with an apology. She now notes that Mrs. R is nothing like her grandmother and seems “pretty stuck up.” She is glad to be off the case and accepts the psychiatrist’s idea that Mrs. R’s need to feel important should not make Dr. W feel bad about herself.

Related resources

• Gabbard GO, ed. Countertransference issues in psychiatric treatment. In: Oldham JM, Riba MB, eds. Review of psychiatry series. Washington, DC: American Psychiatric Publishing, Inc.; 1999.
  
• Blumenfield M, Strain JJ, Grossman S. Psychodynamic approach. In: Blumenfield M, Strain JJ, eds. Psychosomatic medicine. Philadelphia, PA: Lippincott, Williams and Wilkins; 2006:817-828.
  

• Oxazepam • Serax
  
• Prazepam • Centrax
  

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

WEB AUDIO
Listen to Dr. Muskin discuss the patient-physician dynamic

Two strangers meet in the hospital cafeteria. Mrs. R, an elderly woman, asks Dr. W, a first-year medical resident, for help in getting a bottle of soda from the cooler. Afterward, Dr. W comments to a colleague with whom she is having lunch, “That woman reminds me of my grandmother.”

What does that comment reflect about Dr. W? It is a statement about the doctor’s transference. That is, she is aware of elements about Mrs. R that evoke internal responses appropriate to a prior important relationship.

What if Mrs. R was to subsequently faint, require admission to the hospital, and become Dr. W’s patient? If Dr. W’s comment indicates transference, would the same reaction to Mrs. R now be countertransference? Does that change if the doctor is unaware of emotions Mrs. R evokes? Is it still countertransference whether Dr. W is caring and compassionate, overly involved with Mrs. R, or—unaware of negative feelings associated with “grandmothers”—avoids the patient?

This article explores how complex internal experiences play out in the general medical setting and discusses how psychiatric consultants can help medical/surgical colleagues understand and manage difficult patient-physician relationships.

The therapeutic dyad

Countertransference and transference are concepts embedded in psychodynamic thinking. They are part of how many people think about interpersonal relations, whether or not they use these terms. Countertransference and transference may be conscious, but they always have an unconscious component. Factors that influence what will be transference and countertransference in adult life have both:

• a biological component because part of personality is genetic
  
• a psychological component based upon experiences throughout life ( Box 1 ).¹
  

Countertransference is a dimensional concept, not an all-or-nothing experience. Some reactions to patients are based entirely upon their transference to us and have nothing to do with us (therapists) as people. Others derive mostly from psychodynamics within the therapist ( Box 2 ). Countertransference has evolved to incorporate responses evoked by a combination of:

• the patient’s transference
  
• the therapist’s unique psychodynamics
  
• the real relationship in the therapeutic dyad.²
  

Patients with medical illness

Psychiatrists think of countertransference as a psychological situation occurring in the office or on an inpatient psychiatric unit. We focus our attention on how we feel and what we think while working with patients. We talk about our reactions to patients in supervision, rounds, case conferences, and other situations where mental health professionals discuss patients.

Our medical/surgical colleagues’ reactions to patients often correlate with certain patient presentations and may have little to do with the actual person who is the patient.⁴ The medical setting provides an opportunity for countertransference to occur in the absence of apparent transference.

Somatic illness imposes on patients some degree of regression. This regression and attempts to cope with it are inherent to somatic illness and hospitalization. Several schemas⁵ describe basic coping mechanisms common to most patients ( Table ).^6,7 Recognizing a patient’s character style or personality type may help clinicians predict their countertransference when interacting with that patient. Uncooperative patients and those perceived as “difficult” are particularly likely to evoke negative countertransference.⁸

Table

Patients’ response to illness,
with common countertransference by medical staff

CASE CONTINUED: No longer ‘grandmotherly’

Mrs. R and Dr. W are now in a patient-physician relationship. Dr. W is no longer handing Mrs. R a bottle of soda but is inquiring about her life, use of alcohol and other drugs, intimate activities, etc. Mrs. R reacts with anger at the “personal questions.” In addition, Dr. W orders tests that are uncomfortable for Mrs. R, who refuses to cooperate with some procedures.

Dr. W’s memories of her grandmother (who was encouraging, supportive, and loving) color her experience of Mrs. R. She ignores nursing staff’s complaints about Mrs. R being demanding and difficult as the patient becomes aggressive and increasingly confused.

Unable to see the patient as she really is, Dr. W becomes angry and defends Mrs. R’s behavior. The nurses feel Dr. W is unrealistic and ignore her at the nursing station. Late on a Friday night, Mrs. R becomes paranoid, hallucinating that “demons” are in her room. She tries to elope from the hospital. Dr. W is off for the weekend, and the staff requests an emergency psychiatric consultation.

Mrs. R evokes a reaction from the nurses because of how she interacts with them. Dr. W’s response—based on her experience of her grandmother—has nothing to do with the way Mrs. R relates interpersonally but reflects a reaction to the patient’s gender and age. Both reactions would be countertransference, using the modern definition.

If reactions to a patient such as Mrs. R are positive, no one seems to notice and the reactions might or might not influence her care. If the reactions are negative, they might influence her care and generate a request for a psychiatric consultation.

Some patients cannot communicate because of neurologic disorders, intubation, language barriers, or because they are unconscious when admitted. Without information from the patient, medical staff may form ideas about the patient based on their unconscious fantasies. These fantasies may influence the patient’s care.⁹ Psychiatric consultants are not immune to countertransference, but we come into situations with the opportunity to experience all participants from the outside.

CASE CONTINUED: The psychiatric consultation

During the interview, the psychiatrist asks Mrs. R if she takes any medications. She retorts that she always takes “Centrum” at bed-time and demands to know why she is not getting her “vitamins.” She is given oxazepam and falls asleep.

The psychiatrist recommends benzodiazepine detoxification, suspecting Mrs. R is taking prazepam at home from an old prescription (when the medication was a brand called “Centrax”). This suspicion is confirmed when Mrs. R’s family brings in a large shopping bag of medications she has collected over decades, and Mrs. R identifies her nighttime “vitamin.”

Patients with particular character styles evoke predictable reactions from others, including psychotherapists. Discussing these reactions has been a part of psychiatric training for decades. A subset of patients has been described as “hateful,” as they routinely evoke extremely negative responses.¹⁰ Whether their primary disorder is psychiatric, medical, or some of both, these patients evoke strong countertransference reactions.

Psychiatrists may be comfortable discussing a “narcissistic patient, a dependent clinger with borderline features,” but our medical colleagues might not share our comfort with psychiatric jargon.¹¹ It may be more useful to say to medical staff that the patient “thinks of himself as very important, cannot accept his need to be taken care of, and tends to see things in black and white.”

Managing difficult patients

The characterizations that follow describe unconscious reactions to types of individuals who are routinely experienced as “difficult” patients. Some patients may exhibit a mixture of character styles ( Table ) and do not easily fall into 1 category. The concepts can be useful in clarifying the reactions that patients evoke in medical staff.

‘Dependent’ patients. Some patients demand continuous attention but are unaware of their insatiable neediness. Early in treatment, they may evoke positive countertransference because they are intensely grateful for attention. They can be enticing, unconsciously seductive, and gratifying to their doctors. Over time, they drain and exhaust their physicians, who resort to avoidance and wish to get rid of these patients.

Recommendation. Set limits to prevent the patient from feeling rejected or an actual rejection when he or she is transferred to another doctor’s care. Coach physicians to:

• ask patients to “Tell me what is most important for us to discuss today”
  
• be clear how long the visit will last.
  

‘Entitled’ patients. Another type of “difficult” patient projects an air of entitlement, which typically reflects an underlying insatiable neediness. They may use intimidation, guilt, and threats of punishment to get their doctors to provide the care they demand. These patients appear powerful (even though they may possess no special status), and they may be overtly devaluing of the physician while simultaneously demanding special attention.

The doctor resents the patient’s entitlement but develops an expectable countertransference fear that he or she will get in trouble if the demands are not met. Wishes to retaliate and “put the patient in his or her place” are common.

Recommendation. Saying, “It is understandable that you want the best care, and I plan to give you the best care,” makes it clear to the patient that the physician hears the patient’s concerns. Advise the physician to request the patient’s “understanding and compassion” for other patients who also need the physician’s time and attention.

‘Help-rejecting’ patients. “Help-rejecting” patients demand care but show little faith in treatment and do not follow treatment plans. The harder the physician tries to help, the less likely the plan will succeed. For these patients, treatment success evokes a fear of abandonment; thus, treatment must fail to maintain the relationship.

Common countertransference reactions are initial anxiety that the treatment plan was not adequate, followed by anger and depression as the physician feels stuck with a patient for whom nothing works.

When the patient adheres only partially to the plan and a psychiatric consultant is called for an “uncooperative” patient, help the doctor understand how the patient sees the world. It is the patient’s psychological needs—not the physician’s failure—that control the outcome of the care.

‘Self-destructive’ patients may appear unaware of their dangerous actions. They evoke malice from their doctors, who feel the patients are purposely engaging in life-threatening behaviors. The patients’ unconscious dependence remains unknown as their denial of the consequences of their behavior frightens and angers those involved in their care. Some of these patients cannot be stopped before their actions cause them permanent harm or death.

Recommendation. You might remind the physician that we all are entitled to live our lives as we choose. To decompress intense feelings, advise the physician to share, without blaming the patient, what medical staff can realistically do. Saying “We’ll do the best we can” (rather than “Treatment is useless for someone like you”) permits the patient to receive the degree of care he or she can accept without the physician feeling helpless. Understanding our limitations and obligations is part of using our countertransference to aid in patient care.

CASE CONTINUED: Feeling better

When Dr. W returns on Monday, she angrily calls the psychiatrist to complain that her patient has been placed on a benzodiazepine and at the “implication” that Mrs. R was abusing medication. When they talk in person, the psychiatrist explains the situation to Dr. W and suggests they meet with Mrs. R together.

Mrs. R is embarrassed when told about her behavior, identifies the pill, and admits taking prazepam for several weeks prior to hospitalization. She says she never understood how a vitamin could help her sleep so well. No longer delirious, Mrs. R is pleasant and asks many questions. She is surprised that “so young” a doctor was assigned to her case and asks if the chief of medicine could be brought in, as she is on the board of directors of another hospital. “No offense, dear,” she says to Dr. W; “I’m sure you did an excellent job, but usually only senior doctors take care of me.”

Dr. W accepts the psychiatrist’s suggestion to repair her relationship with the nurses with an apology. She now notes that Mrs. R is nothing like her grandmother and seems “pretty stuck up.” She is glad to be off the case and accepts the psychiatrist’s idea that Mrs. R’s need to feel important should not make Dr. W feel bad about herself.

Related resources

• Gabbard GO, ed. Countertransference issues in psychiatric treatment. In: Oldham JM, Riba MB, eds. Review of psychiatry series. Washington, DC: American Psychiatric Publishing, Inc.; 1999.
  
• Blumenfield M, Strain JJ, Grossman S. Psychodynamic approach. In: Blumenfield M, Strain JJ, eds. Psychosomatic medicine. Philadelphia, PA: Lippincott, Williams and Wilkins; 2006:817-828.
  

• Oxazepam • Serax
  
• Prazepam • Centrax
  

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

Comment on this article

Mr. B, age 35, is admitted for the fourth time to the inpatient service with hallucinations and delusions related to chronic schizophrenia. After appropriate attempts to control his symptoms, he has begun to respond to usual treatment with an atypical antipsychotic. He remains a “partial responder,” however, at the maximum FDA-approved dosage listed in the package insert (PI). What do you do next?

Because of this author’s (NSK) dual training in medicine and forensic psychiatry, other clinicians often ask me about patients such as Mr. B. Prescribing for patients who do not respond to standard dosages can create anxiety about going “off-label.” This article describes how to manage potential risk to yourself and your patient by communicating effectively and documenting informed consent.

What are the options?

To effectively treat Mr. B’s symptoms, you could:

• change medications and start over
  
• augment with a second atypical antipsychotic
  
• stay with the antipsychotic to which he has shown partial response, but go above the PI dosing.
  

Changing medications is attractive, but the choice of an atypical antipsychotic with relative metabolic neutrality is limited, and “switching” is time-consuming. When a drug begins to show efficacy, most clinicians won’t opt to “change horses midstream”—especially if managed care is pressuring for rapid discharge.

Only a few case reports have described combining atypical antipsychotics.^1-4 Moreover, many managed care providers and governmental payers/regulators will not pay for polypharmacy with 2 atypical antipsychotics or will allow it only during cross-tapering from one agent to another.

‘High-dose’ monotherapy is the choice most often taken by clinicians and experts. Pharmaceutical manufacturers study a wide range of doses during medication development. Two pivotal trials form the basis of the New Drug Application for FDA approval and largely dictate the PI language.

Don’t misconstrue the PI dosing as optimal for a specific medication or patient. Historically, FDA-approved dosing for atypical antipsychotics has been too high (risperidone, aripiprazole) or too low (ziprasidone, quetiapine) for many patients we treat, even when the medications are used as indicated. This problem is magnified when clinicians try to make individual patients (N=1) resemble the average pooled analysis of the clinical trial group (N>200) and find that the individual patient may be a low-dose, average-dose, or high-dose responder (Table 1).

Informed prescribing. Polypharmacy is a complex issue because essentially no pharmacokinetic or pharmacodynamic studies have examined the simultaneous use of ≥3 psychotropics. When a pharmacist or drug interaction computer alerts you to a potential drug-drug interaction, the warning is almost always theoretical. No real data exist about coadministering most medications.

Physicians may query a manufacturer about off-label, above-PI dosing data by contacting the company’s medical information department or asking a pharmaceutical representative. What you receive will vary by manufacturer, but in almost every case you will get the safety data you want. Occasionally you also will get efficacy data, which is nice but not crucial. An online literature search of MEDLINE is another way to obtain this information.

Table 1

Patient factors that influence response to medication

Liability risk?

Every clinician I’ve met prescribes drugs off-label, whether in terms of dose, indication, or age limits in the PI as published in the Physicians’ Desk Reference (PDR).⁵ Still, nearly all describe to me the following nightmare, in which they “violated” the PI and “something bad” happens.

They are sitting in court on the witness stand, white-knuckled and sweaty, as a plaintiff’s attorney strolls up to them, PDR in hand, and says: “Doctor, isn’t this the Bible, and you violated the Bible?” And thus is born the fear of a malpractice claim, predicated on off-label dosing.

Off-label prescribing is rarely the only issue in a lawsuit, according to Denny Rodriguez, assistant vice president, claims, Professional Risk Management Services (PRMS), Inc.—manager of The Psychiatrists’ Program endorsed by the American Psychiatric Association. When raised, allegations related to off-label prescribing are among many presented by the plaintiff under the rubric of treatment that violated the standard of care.

Contrary to the plaintiff’s allegations, off-label prescribing rarely violates the standard of care because it has valid clinical and scientific bases. And don’t acknowledge the PDR as “the Bible,” which it is not; it’s a compilation of PIs. The FDA affirms that once a product is approved for marketing, a physician may choose to prescribe it for off-label use (Box).⁵

Box

Standard of care

The real issue for practitioners is the “standard of care.” Violating the standard of care—what a similarly trained clinician would do under similar circumstances—is the first step on the slippery slope to malpractice. Here we can be quite sure that the standard of care and evidence-based medicine are in sync and support the use of off-label, high-dose monotherapy.

Properly documenting your reasoning helps to demonstrate that your prescribing meets the standard of care. Always document and obtain informed consent. Also stay up-to-date about:

• medications you prescribe
  
• emerging evidence and safety information
  
• appropriate patient monitoring for clinical response and adverse effects.⁸
  

Black boxes and bold lettering

The FDA may mandate that a manufacturer highlight certain information on a PI in 3 ways—bold lettering, black-box warning, and red lettering, in order of presumed increasing seriousness. This system is meant to draw prescribers’ attention to potential safety problems with pharmaceutical agents. No psychiatric medications carry red-letter warnings, a classification usually reserved for antineoplastic agents.

The FDA’s action appears to “level the playing field,” giving patients the misperception that any treatment would carry an equal risk. Therefore, when you prescribe a drug that carries a class-wide warning in its PI, present the evidence in a balanced, objective manner so that the patient can make an informed decision.

Managing risk

Your best protection against liability is to communicate effectively with the patient and document that communication—including informed consent—in the medical record.⁸ Obtain and document informed consent whenever:

• you initiate a drug or other treatment
  
• treatment extends beyond the PI-recommended maximum dose.
  

• changes in medications or dosages based on the new information
  
• closer monitoring of potential side effects and other actions
  
• empowerment to make decisions about stopping a medication or trying alternate medications or treatments.
  

Documenting informed consent

What to include. View informed consent as an ongoing discussion, not a document that needs to be put into a chart to comply with a legal mandate. Documenting informed consent may be as simple as going through the process and then including pertinent points in the medical record (Table 2). The following is an example of a medical record entry used by one author (NSK) to document an initial informed consent discussion:

“I have explained to the patient the reasons for prescribing the above medication, the expected benefits and potential side effects, the treatment alternatives and possible risks and benefits of the alternatives, and the expected course w/o treatment. The patient asked appropriate questions and appeared to understand the answers. (I discussed off-label use.) I provided information from the manufacturer (or some other source). The patient has decided to try this medication and to be followed.”

Caveats. Avoid “cutting and pasting” language for each informed consent discussion into each medical record. Make your discussion and its documentation reflect each individual’s treatment plan. If you use a preprinted consent/medications side-effect form (as required by many institutions and clinics), consider entering a personalized notation into the progress notes as needed, such as when:

• you prescribe medications with high risk for serious side effects
  
• you use off-label prescribing that is not customary
  
• a patient needs extra assistance to follow the treatment plan.⁸
  

Table 2

Informed consent: Pertinent points to document

• include all significant and material risks on the form
  
• state on the form that the risks “include, but are not limited to” those listed on the form
  
• have thorough informed consent discussions with patients
  
• enter into the medical record your discussion and a copy of the form signed by the patient.
  

• What information would I want a physician to disclose to my loved one (parent, child, spouse, etc.) if I was not present and my loved one needed to give consent to a treatment recommendation?
  
• Is this information of the type that a reasonable person could say: “I wouldn’t have consented if the doctor had told me that”? If you think so, then provide this information to your patient.
  

Related resources

• Food and Drug Administration (FDA). Information sheets on hundreds of FDA-approved drugs, listed alphabetically. www.fda.gov/cder/drug/DrugSafety/DrugIndex.htm.
  
• FDA. Drug safety information for consumers and healthcare professionals. www.fda.gov/cder/index.html.
  

• Aripiprazole • Abilify
  
• Olanzapine • Zyprexa
  
• Quetiapine • Seroquel
  
• Risperidone • Risperdal
  
• Ziprasidone • Geodon
  

Dr. Kaye receives research support from Pfizer Inc. and Takeda Pharmaceutical and is a consultant to and speaker for Pfizer Inc., AstraZeneca, and GlaxoSmithKline.

Jacqueline Melonas is a full-time employee of PRMS, Inc. PRMS, Inc. contracts with Eli Lilly and Company to provide risk management content related to the management of medical malpractice liability.

Comment on this article

Mr. B, age 35, is admitted for the fourth time to the inpatient service with hallucinations and delusions related to chronic schizophrenia. After appropriate attempts to control his symptoms, he has begun to respond to usual treatment with an atypical antipsychotic. He remains a “partial responder,” however, at the maximum FDA-approved dosage listed in the package insert (PI). What do you do next?

Because of this author’s (NSK) dual training in medicine and forensic psychiatry, other clinicians often ask me about patients such as Mr. B. Prescribing for patients who do not respond to standard dosages can create anxiety about going “off-label.” This article describes how to manage potential risk to yourself and your patient by communicating effectively and documenting informed consent.

What are the options?

To effectively treat Mr. B’s symptoms, you could:

• change medications and start over
  
• augment with a second atypical antipsychotic
  
• stay with the antipsychotic to which he has shown partial response, but go above the PI dosing.
  

Changing medications is attractive, but the choice of an atypical antipsychotic with relative metabolic neutrality is limited, and “switching” is time-consuming. When a drug begins to show efficacy, most clinicians won’t opt to “change horses midstream”—especially if managed care is pressuring for rapid discharge.

Only a few case reports have described combining atypical antipsychotics.^1-4 Moreover, many managed care providers and governmental payers/regulators will not pay for polypharmacy with 2 atypical antipsychotics or will allow it only during cross-tapering from one agent to another.

‘High-dose’ monotherapy is the choice most often taken by clinicians and experts. Pharmaceutical manufacturers study a wide range of doses during medication development. Two pivotal trials form the basis of the New Drug Application for FDA approval and largely dictate the PI language.

Don’t misconstrue the PI dosing as optimal for a specific medication or patient. Historically, FDA-approved dosing for atypical antipsychotics has been too high (risperidone, aripiprazole) or too low (ziprasidone, quetiapine) for many patients we treat, even when the medications are used as indicated. This problem is magnified when clinicians try to make individual patients (N=1) resemble the average pooled analysis of the clinical trial group (N>200) and find that the individual patient may be a low-dose, average-dose, or high-dose responder (Table 1).

Informed prescribing. Polypharmacy is a complex issue because essentially no pharmacokinetic or pharmacodynamic studies have examined the simultaneous use of ≥3 psychotropics. When a pharmacist or drug interaction computer alerts you to a potential drug-drug interaction, the warning is almost always theoretical. No real data exist about coadministering most medications.

Physicians may query a manufacturer about off-label, above-PI dosing data by contacting the company’s medical information department or asking a pharmaceutical representative. What you receive will vary by manufacturer, but in almost every case you will get the safety data you want. Occasionally you also will get efficacy data, which is nice but not crucial. An online literature search of MEDLINE is another way to obtain this information.

Table 1

Patient factors that influence response to medication

Liability risk?

Every clinician I’ve met prescribes drugs off-label, whether in terms of dose, indication, or age limits in the PI as published in the Physicians’ Desk Reference (PDR).⁵ Still, nearly all describe to me the following nightmare, in which they “violated” the PI and “something bad” happens.

They are sitting in court on the witness stand, white-knuckled and sweaty, as a plaintiff’s attorney strolls up to them, PDR in hand, and says: “Doctor, isn’t this the Bible, and you violated the Bible?” And thus is born the fear of a malpractice claim, predicated on off-label dosing.

Off-label prescribing is rarely the only issue in a lawsuit, according to Denny Rodriguez, assistant vice president, claims, Professional Risk Management Services (PRMS), Inc.—manager of The Psychiatrists’ Program endorsed by the American Psychiatric Association. When raised, allegations related to off-label prescribing are among many presented by the plaintiff under the rubric of treatment that violated the standard of care.

Contrary to the plaintiff’s allegations, off-label prescribing rarely violates the standard of care because it has valid clinical and scientific bases. And don’t acknowledge the PDR as “the Bible,” which it is not; it’s a compilation of PIs. The FDA affirms that once a product is approved for marketing, a physician may choose to prescribe it for off-label use (Box).⁵

Box

Standard of care

The real issue for practitioners is the “standard of care.” Violating the standard of care—what a similarly trained clinician would do under similar circumstances—is the first step on the slippery slope to malpractice. Here we can be quite sure that the standard of care and evidence-based medicine are in sync and support the use of off-label, high-dose monotherapy.

Properly documenting your reasoning helps to demonstrate that your prescribing meets the standard of care. Always document and obtain informed consent. Also stay up-to-date about:

• medications you prescribe
  
• emerging evidence and safety information
  
• appropriate patient monitoring for clinical response and adverse effects.⁸
  

Black boxes and bold lettering

The FDA may mandate that a manufacturer highlight certain information on a PI in 3 ways—bold lettering, black-box warning, and red lettering, in order of presumed increasing seriousness. This system is meant to draw prescribers’ attention to potential safety problems with pharmaceutical agents. No psychiatric medications carry red-letter warnings, a classification usually reserved for antineoplastic agents.

The FDA’s action appears to “level the playing field,” giving patients the misperception that any treatment would carry an equal risk. Therefore, when you prescribe a drug that carries a class-wide warning in its PI, present the evidence in a balanced, objective manner so that the patient can make an informed decision.

Managing risk

Your best protection against liability is to communicate effectively with the patient and document that communication—including informed consent—in the medical record.⁸ Obtain and document informed consent whenever:

• you initiate a drug or other treatment
  
• treatment extends beyond the PI-recommended maximum dose.
  

• changes in medications or dosages based on the new information
  
• closer monitoring of potential side effects and other actions
  
• empowerment to make decisions about stopping a medication or trying alternate medications or treatments.
  

Documenting informed consent

What to include. View informed consent as an ongoing discussion, not a document that needs to be put into a chart to comply with a legal mandate. Documenting informed consent may be as simple as going through the process and then including pertinent points in the medical record (Table 2). The following is an example of a medical record entry used by one author (NSK) to document an initial informed consent discussion:

“I have explained to the patient the reasons for prescribing the above medication, the expected benefits and potential side effects, the treatment alternatives and possible risks and benefits of the alternatives, and the expected course w/o treatment. The patient asked appropriate questions and appeared to understand the answers. (I discussed off-label use.) I provided information from the manufacturer (or some other source). The patient has decided to try this medication and to be followed.”

Caveats. Avoid “cutting and pasting” language for each informed consent discussion into each medical record. Make your discussion and its documentation reflect each individual’s treatment plan. If you use a preprinted consent/medications side-effect form (as required by many institutions and clinics), consider entering a personalized notation into the progress notes as needed, such as when:

• you prescribe medications with high risk for serious side effects
  
• you use off-label prescribing that is not customary
  
• a patient needs extra assistance to follow the treatment plan.⁸
  

Table 2

Informed consent: Pertinent points to document

• include all significant and material risks on the form
  
• state on the form that the risks “include, but are not limited to” those listed on the form
  
• have thorough informed consent discussions with patients
  
• enter into the medical record your discussion and a copy of the form signed by the patient.
  

• What information would I want a physician to disclose to my loved one (parent, child, spouse, etc.) if I was not present and my loved one needed to give consent to a treatment recommendation?
  
• Is this information of the type that a reasonable person could say: “I wouldn’t have consented if the doctor had told me that”? If you think so, then provide this information to your patient.
  

Related resources

• Food and Drug Administration (FDA). Information sheets on hundreds of FDA-approved drugs, listed alphabetically. www.fda.gov/cder/drug/DrugSafety/DrugIndex.htm.
  
• FDA. Drug safety information for consumers and healthcare professionals. www.fda.gov/cder/index.html.
  

• Aripiprazole • Abilify
  
• Olanzapine • Zyprexa
  
• Quetiapine • Seroquel
  
• Risperidone • Risperdal
  
• Ziprasidone • Geodon
  

Dr. Kaye receives research support from Pfizer Inc. and Takeda Pharmaceutical and is a consultant to and speaker for Pfizer Inc., AstraZeneca, and GlaxoSmithKline.

Jacqueline Melonas is a full-time employee of PRMS, Inc. PRMS, Inc. contracts with Eli Lilly and Company to provide risk management content related to the management of medical malpractice liability.

Comment on this article

Mr. B, age 35, is admitted for the fourth time to the inpatient service with hallucinations and delusions related to chronic schizophrenia. After appropriate attempts to control his symptoms, he has begun to respond to usual treatment with an atypical antipsychotic. He remains a “partial responder,” however, at the maximum FDA-approved dosage listed in the package insert (PI). What do you do next?

Because of this author’s (NSK) dual training in medicine and forensic psychiatry, other clinicians often ask me about patients such as Mr. B. Prescribing for patients who do not respond to standard dosages can create anxiety about going “off-label.” This article describes how to manage potential risk to yourself and your patient by communicating effectively and documenting informed consent.

What are the options?

To effectively treat Mr. B’s symptoms, you could:

• change medications and start over
  
• augment with a second atypical antipsychotic
  
• stay with the antipsychotic to which he has shown partial response, but go above the PI dosing.
  

Changing medications is attractive, but the choice of an atypical antipsychotic with relative metabolic neutrality is limited, and “switching” is time-consuming. When a drug begins to show efficacy, most clinicians won’t opt to “change horses midstream”—especially if managed care is pressuring for rapid discharge.

Only a few case reports have described combining atypical antipsychotics.^1-4 Moreover, many managed care providers and governmental payers/regulators will not pay for polypharmacy with 2 atypical antipsychotics or will allow it only during cross-tapering from one agent to another.

‘High-dose’ monotherapy is the choice most often taken by clinicians and experts. Pharmaceutical manufacturers study a wide range of doses during medication development. Two pivotal trials form the basis of the New Drug Application for FDA approval and largely dictate the PI language.

Don’t misconstrue the PI dosing as optimal for a specific medication or patient. Historically, FDA-approved dosing for atypical antipsychotics has been too high (risperidone, aripiprazole) or too low (ziprasidone, quetiapine) for many patients we treat, even when the medications are used as indicated. This problem is magnified when clinicians try to make individual patients (N=1) resemble the average pooled analysis of the clinical trial group (N>200) and find that the individual patient may be a low-dose, average-dose, or high-dose responder (Table 1).

Informed prescribing. Polypharmacy is a complex issue because essentially no pharmacokinetic or pharmacodynamic studies have examined the simultaneous use of ≥3 psychotropics. When a pharmacist or drug interaction computer alerts you to a potential drug-drug interaction, the warning is almost always theoretical. No real data exist about coadministering most medications.

Physicians may query a manufacturer about off-label, above-PI dosing data by contacting the company’s medical information department or asking a pharmaceutical representative. What you receive will vary by manufacturer, but in almost every case you will get the safety data you want. Occasionally you also will get efficacy data, which is nice but not crucial. An online literature search of MEDLINE is another way to obtain this information.

Table 1

Patient factors that influence response to medication

Liability risk?

Every clinician I’ve met prescribes drugs off-label, whether in terms of dose, indication, or age limits in the PI as published in the Physicians’ Desk Reference (PDR).⁵ Still, nearly all describe to me the following nightmare, in which they “violated” the PI and “something bad” happens.

They are sitting in court on the witness stand, white-knuckled and sweaty, as a plaintiff’s attorney strolls up to them, PDR in hand, and says: “Doctor, isn’t this the Bible, and you violated the Bible?” And thus is born the fear of a malpractice claim, predicated on off-label dosing.

Off-label prescribing is rarely the only issue in a lawsuit, according to Denny Rodriguez, assistant vice president, claims, Professional Risk Management Services (PRMS), Inc.—manager of The Psychiatrists’ Program endorsed by the American Psychiatric Association. When raised, allegations related to off-label prescribing are among many presented by the plaintiff under the rubric of treatment that violated the standard of care.

Contrary to the plaintiff’s allegations, off-label prescribing rarely violates the standard of care because it has valid clinical and scientific bases. And don’t acknowledge the PDR as “the Bible,” which it is not; it’s a compilation of PIs. The FDA affirms that once a product is approved for marketing, a physician may choose to prescribe it for off-label use (Box).⁵

Box

Standard of care

The real issue for practitioners is the “standard of care.” Violating the standard of care—what a similarly trained clinician would do under similar circumstances—is the first step on the slippery slope to malpractice. Here we can be quite sure that the standard of care and evidence-based medicine are in sync and support the use of off-label, high-dose monotherapy.

Properly documenting your reasoning helps to demonstrate that your prescribing meets the standard of care. Always document and obtain informed consent. Also stay up-to-date about:

• medications you prescribe
  
• emerging evidence and safety information
  
• appropriate patient monitoring for clinical response and adverse effects.⁸
  

Black boxes and bold lettering

The FDA may mandate that a manufacturer highlight certain information on a PI in 3 ways—bold lettering, black-box warning, and red lettering, in order of presumed increasing seriousness. This system is meant to draw prescribers’ attention to potential safety problems with pharmaceutical agents. No psychiatric medications carry red-letter warnings, a classification usually reserved for antineoplastic agents.

The FDA’s action appears to “level the playing field,” giving patients the misperception that any treatment would carry an equal risk. Therefore, when you prescribe a drug that carries a class-wide warning in its PI, present the evidence in a balanced, objective manner so that the patient can make an informed decision.

Managing risk

Your best protection against liability is to communicate effectively with the patient and document that communication—including informed consent—in the medical record.⁸ Obtain and document informed consent whenever:

• you initiate a drug or other treatment
  
• treatment extends beyond the PI-recommended maximum dose.
  

• changes in medications or dosages based on the new information
  
• closer monitoring of potential side effects and other actions
  
• empowerment to make decisions about stopping a medication or trying alternate medications or treatments.
  

Documenting informed consent

What to include. View informed consent as an ongoing discussion, not a document that needs to be put into a chart to comply with a legal mandate. Documenting informed consent may be as simple as going through the process and then including pertinent points in the medical record (Table 2). The following is an example of a medical record entry used by one author (NSK) to document an initial informed consent discussion:

“I have explained to the patient the reasons for prescribing the above medication, the expected benefits and potential side effects, the treatment alternatives and possible risks and benefits of the alternatives, and the expected course w/o treatment. The patient asked appropriate questions and appeared to understand the answers. (I discussed off-label use.) I provided information from the manufacturer (or some other source). The patient has decided to try this medication and to be followed.”

Caveats. Avoid “cutting and pasting” language for each informed consent discussion into each medical record. Make your discussion and its documentation reflect each individual’s treatment plan. If you use a preprinted consent/medications side-effect form (as required by many institutions and clinics), consider entering a personalized notation into the progress notes as needed, such as when:

• you prescribe medications with high risk for serious side effects
  
• you use off-label prescribing that is not customary
  
• a patient needs extra assistance to follow the treatment plan.⁸
  

Table 2

Informed consent: Pertinent points to document

• include all significant and material risks on the form
  
• state on the form that the risks “include, but are not limited to” those listed on the form
  
• have thorough informed consent discussions with patients
  
• enter into the medical record your discussion and a copy of the form signed by the patient.
  

• What information would I want a physician to disclose to my loved one (parent, child, spouse, etc.) if I was not present and my loved one needed to give consent to a treatment recommendation?
  
• Is this information of the type that a reasonable person could say: “I wouldn’t have consented if the doctor had told me that”? If you think so, then provide this information to your patient.
  

Related resources

• Food and Drug Administration (FDA). Information sheets on hundreds of FDA-approved drugs, listed alphabetically. www.fda.gov/cder/drug/DrugSafety/DrugIndex.htm.
  
• FDA. Drug safety information for consumers and healthcare professionals. www.fda.gov/cder/index.html.
  

• Aripiprazole • Abilify
  
• Olanzapine • Zyprexa
  
• Quetiapine • Seroquel
  
• Risperidone • Risperdal
  
• Ziprasidone • Geodon
  

Dr. Kaye receives research support from Pfizer Inc. and Takeda Pharmaceutical and is a consultant to and speaker for Pfizer Inc., AstraZeneca, and GlaxoSmithKline.

Jacqueline Melonas is a full-time employee of PRMS, Inc. PRMS, Inc. contracts with Eli Lilly and Company to provide risk management content related to the management of medical malpractice liability.