Current Psychiatry

Mrs. E, age 74, has been distraught for 6 months since the death of her husband of 45 years. She is brought for evaluation by her daughter, who is exasperated and worried about her mother’s sad mood, frequent tearfulness, weight loss (11 pounds), and social isolation.

Mrs. E says she feels lost and paralyzed, that she “sticks out like a sore thumb” when among couples “that still have each other.” She refuses to go to church, though she attended regularly in the past.

Unresolved grief appears to be linked to the onset and persistence of Mrs. E’s depressive symptoms. After a thorough evaluation confirms major depression, the psychiatrist explains the diagnosis to Mrs. E. She agrees to begin an antidepressant and interpersonal psychotherapy (IPT).

IPT is easy to use and well-suited to address abnormal grieving, role transitions, and role disputes in depressed older patients. In controlled trials, IPT has been shown effective as acute¹ and maintenance treatment^2,3 of depression. This article describes how IPT can work effectively for depressed older adults and their clinicians.

IPT and elder depression

New-onset or recurrent depression is common in older patients experiencing retirement, relocation, disabilities, or loss of important persons in their lives (Box 1) ⁴ IPT recognizes that depression, regardless of psychosocial stress or biologic vulnerability, is expressed in an interpersonal environment (Box 2).^5,6 The environment may have contributed to the depression, but it also can be a platform for intervention.

Depressed older adults who are verbal, nondemented, and engageable are candidates for IPT, with or without adjunctive antidepressant therapy. Psychotherapy is not indicated for patients with severe dementia, but this article will describe how IPT is being adapted for those with early dementia or mild cognitive impairment.

Box 1

Case continued: ‘he made all the decisions’

At Mrs. E’s first IPT session, the therapist assigns her the “sick role.” They contract to meet 12 to 16 weeks, and Mrs. E’s daughter agrees to drive her to sessions.

In the next few weeks, the therapist explains depression’s biopsychosocial model and explores dual strategies with Mrs. E: to ease her mourning and explore new interests or relationships. The therapist encourages her to express her feelings and seeks to understand the dynamics of her marriage.

Mrs. E said she was raised by nurturing parents and married soon after high school. She depended on her husband for almost every decision, including their social calendar. She describes their relationship as mutually loving. As part of an interpersonal inventory, her therapist encourages her to describe in detail all the ways she misses him.

The ‘sick role.’ The therapist assigned Mrs. E the “sick role” to emphasize that major depression can be a severe illness. A therapist might say: “If you had pneumonia, you wouldn’t think of trying to rake leaves. You would rest and take care of yourself to speed the healing. Persons with major depression should do the same.”

The contract. The therapist also explained to Mrs. E that contracting to meet weekly for 12 to 16 weeks is part of the treatment. A contract:

• encourages patients to commit to an IPT trial for a reasonable time
  
• presses patients to achieve adequate progress by the deadline
  
• discourages digression, avoidance of painful subjects, and dependence on the therapist.
  

IPT begins with a complete psychiatric evaluation, including the patient’s past, family, and social histories; alcohol and drug use; medical comorbidities; mental status exam; and sometimes blood screening to rule out metabolic abnormalities. Antidepressants are prescribed as needed to relieve vegetative symptoms and are used during IPT when indicated.

Interpersonal inventory. Each of the patient’s interpersonal relationships is then systematically reviewed. This inventory sets the stage for exploring relationships that may be linked to the depressive symptoms or offer opportunities for trying alternate coping trategies, such as learning to seek social support (Table 2).

Table 1

IPT’s understanding of depression comprises 3 component processes

‘How-to’ checklist of IPT procedures

IPT’S FOUR FOCI

IPT’s goal is to relieve depressive symptoms by identifying and focusing on problems that may have caused or are perpetuating those symptoms. Most of the reasons depressed patients give for seeking help fall into four foci: unresolved grief, role transition, role dispute, and interpersonal deficit (Table 3).^5,6 The therapist uses clarification, interpretation, confrontation, and testing of perceptions and performance to address each focus, as detailed in the IPT manual.⁶

The therapist acts as the patient’s advocate, and focuses treatment on interpersonal relationships in the “here and now,” not past traumas, childhood conflicts, cognitive-behavioral interventions, or intrapsychic themes. No attempt is made to restructure personality.

Progress in relieving depressive symptoms is reviewed regularly, and treatment ends within the contract’s time limits in many cases. Older patients may need additional sessions because they often take longer to respond to antidepressant trials (6 to 8 weeks, compared with 3 to 4 weeks for younger adults). We allow older patients to “catch up” with additional sessions if illness, lack of transportation, or other problems prevent them from receiving the “full dose” of IPT.

IPT does not work for all patients. Consider other types of treatment if a patient shows no discernable benefit.

Table 3

IPT’s 4 foci, specific to late-life depression

Case continued: stalled in grief

As the weeks pass, Mrs. E improves but remains hypoactive and reclusive. She seems afraid to take any action without her late husband’s approval. Thinking about making independent decisions overwhelms her, and she withdraws to her couch to hide.

Her therapist discerns that Mrs. E needs more-active confrontation to accept that her new life requires her to make choices, even though decision-making is difficult for her. They develop a game, hronicling all decisions Mrs. E has made for the first time, such as calling a repairman and planting the summer vegetable garden by herself.

The therapist applauds these “firsts” and points out that Mrs. E’s depressive symptoms have improved as her list of completed decisions has grown. Mrs. E holds the power to make decisions, the therapist stresses, and bears the consequences of not taking action.

Applying ipt to late-life depression

Our group has used IPT in research protocols for 15 years. We and others^7-11 have found that IPT is well-suited for treating late-life depression because:

• Older patients without psychotherapy experience or psychological sophistication can easily participate.
  
• Persons with limited education can understand IPT’s informal explanations of depression.
  
• Two foci of IPT—grief and role transition—address common themes of aging, such as spousal role disputes after retirement or caregiver stress when one partner becomes ill or shows signs of dementia.
  

Only minor IPT adaptations were required for older patients, such as:

• shorter sessions for those who reported physical discomfort
  
• accommodating for hearing loss, arranging transportation, and conducting sessions by telephone when patients were ill or shut in by inclement weather.
  

Case continued: more ‘firsts’ build confidence

Mrs. E makes slow, sometimes painful, but steady progress. Her therapist encourages her to keep trying more “firsts,”such as going back to church and attending her first social event alone, and to review her emotional reactions.

Mrs. E’s depressive symptoms wane as her confidence builds, and she readjusts her self-image to that of a widow who enjoyed a good marriage with a benevolent but overprotective husband. Her therapist links her progress to her string of successful “firsts” and to the contributing benefit of anti-depressant medication.

IPT As maintenance therapy

In the Maintenance Therapies for Late Life Depression (MTLLD) study—a randomized, double-blind, placebo-controlled trial¹²—we showed IPT to be effective as maintenance therapy for recurrent depression in patients age 60 and older. The 187 patients (mean age 67, one-third age ≥70) with nonpsychotic unipolar major depression were first treated to remission with IPT plus nortriptyline (80 to 120 ng/mL).

We then randomly assigned the 107 who achieved recovery to one of four maintenance therapies. After 3 years of monthly follow-up, relapse rates were:

• 20% with nortriptyline plus maintenance IPT
  
• 43% with nortriptyline plus medication clinic visits
  
• 64% with maintenance IPT plus placebo
  
• 90% with medication clinic plus placebo.
  

Further analysis showed that patients age ≥70 required combined treatment with nortriptyline and IPT to stay well, whereas those ages 60 to 69 stayed well with drug therapy alone. Patients age ≥70 also had a higher and more rapid relapse rate.

Recurrence by therapy focus. In patients who received placebo instead of nortriptyline:

• Time without a new depressive episode was similar for patients with a focus on grief or role transition, whether they received IPT or medication checkups.
  
• Recurrence rates were clearly lower in patients whose initial focus was role dispute if they received monthly maintenance IPT sessions instead of medication check visits.
  

Case continued: looking ahead

As the 12- to 16-week contracted period winds down, Mrs. E admits she still longs for her husband’s protection. She said she would gladly give up her independence to have that “safe” feeling back.

The therapist acknowledges that feeling but gently reminds her that she has the tools to face her new life realistically. During therapy, Mrs. E has shown she can assess life’s many decisions, make rational choices, and live with the consequences.

Their final discussion touches on the notion that Mrs. E could imagine having some kind of friendship with another man in the future.

Wrapping up. The last IPT sessions focus on reviewing any decline in depressive symptoms that may be linked to having learned new coping skills. With successful IPT, patients learn to appraise their strengths and remaining vulnerabilities and gain skills, self-confidence, and understanding to confront remaining obstacles after therapy ends.

Adapting ipt for special populations

Resistant depression. Researchers at the University of Pittsburgh are investigating whether adding IPT can achieve remission in depressed older patients who show partial response to a 6-week trial of escitalopram, 10 mg/d. In this ongoing trial, patients with Hamilton Depression Rating Scale scores of 11 to 14 after 6 weeks receive an increased escitalopram dosage (20 mg/d) and are randomly assigned to medication alone or medication plus 16 weeks of IPT.

Cognitive impairment. An unpublished follow-up to the MTLLD study enrolled 116 patients aged ≥70 and used a similar design, except that:

• patients were not required to have had recurrent depressive episodes
  
• paroxetine was used instead of nortriptyline
  
• patients with cognitive impairment (Mini-Mental Status Examination scores ?18/30) were included.
  

Cognitive impairment may have interfered with patients’ ability to benefit from traditional IPT. Thus, to improve the quality of life of depressed, cognitively-impaired elders, researchers are involving caregivers (usually a spouse or adult child) in modified forms of IPT couples therapy.^6,13-18 A team at the University of Pittsburgh is developing a flexible approach that includes meetings with the patient, the caregiver, or both. Two papers on IPT-CI (for cognitive impairment) are under review.

Related resources

• International Society for Interpersonal Psychotherapy. Accreditation, training, and research information. www.interpersonalpsychotherapy.org.
  
• Stuart S, Robertson M. Interpersonal psychotherapy: a clinician’s guide. London: Edward Arnold Ltd.; 2002.
  
• Miller MD, Reynolds CF. Interpersonal psychotherapy. In: Hepple J, Pierce J, Wilkinson P (eds). Psychological therapies with older people. East Sussex, UK: Brunner-Routledge; 2002:103-27.
  
• Miller MD, Reynolds CF. Living longer depression-free: a family guide to the recognition, treatment and prevention of depression in later life. Baltimore: Johns Hopkins University Press; 2002.
  

• Escitalopram • Lexapro
  
• Nortriptyline • Pamelor
  
• Paroxetine • Paxil
  

Dr. Miller is a consultant to Forest Laboratories and GlaxoSmithKline and is a speaker for Forest Laboratories, GlaxoSmithKline, and Wyeth Pharmaceuticals.

Mrs. E, age 74, has been distraught for 6 months since the death of her husband of 45 years. She is brought for evaluation by her daughter, who is exasperated and worried about her mother’s sad mood, frequent tearfulness, weight loss (11 pounds), and social isolation.

Mrs. E says she feels lost and paralyzed, that she “sticks out like a sore thumb” when among couples “that still have each other.” She refuses to go to church, though she attended regularly in the past.

Unresolved grief appears to be linked to the onset and persistence of Mrs. E’s depressive symptoms. After a thorough evaluation confirms major depression, the psychiatrist explains the diagnosis to Mrs. E. She agrees to begin an antidepressant and interpersonal psychotherapy (IPT).

IPT is easy to use and well-suited to address abnormal grieving, role transitions, and role disputes in depressed older patients. In controlled trials, IPT has been shown effective as acute¹ and maintenance treatment^2,3 of depression. This article describes how IPT can work effectively for depressed older adults and their clinicians.

IPT and elder depression

New-onset or recurrent depression is common in older patients experiencing retirement, relocation, disabilities, or loss of important persons in their lives (Box 1) ⁴ IPT recognizes that depression, regardless of psychosocial stress or biologic vulnerability, is expressed in an interpersonal environment (Box 2).^5,6 The environment may have contributed to the depression, but it also can be a platform for intervention.

Depressed older adults who are verbal, nondemented, and engageable are candidates for IPT, with or without adjunctive antidepressant therapy. Psychotherapy is not indicated for patients with severe dementia, but this article will describe how IPT is being adapted for those with early dementia or mild cognitive impairment.

Box 1

Case continued: ‘he made all the decisions’

At Mrs. E’s first IPT session, the therapist assigns her the “sick role.” They contract to meet 12 to 16 weeks, and Mrs. E’s daughter agrees to drive her to sessions.

In the next few weeks, the therapist explains depression’s biopsychosocial model and explores dual strategies with Mrs. E: to ease her mourning and explore new interests or relationships. The therapist encourages her to express her feelings and seeks to understand the dynamics of her marriage.

Mrs. E said she was raised by nurturing parents and married soon after high school. She depended on her husband for almost every decision, including their social calendar. She describes their relationship as mutually loving. As part of an interpersonal inventory, her therapist encourages her to describe in detail all the ways she misses him.

The ‘sick role.’ The therapist assigned Mrs. E the “sick role” to emphasize that major depression can be a severe illness. A therapist might say: “If you had pneumonia, you wouldn’t think of trying to rake leaves. You would rest and take care of yourself to speed the healing. Persons with major depression should do the same.”

The contract. The therapist also explained to Mrs. E that contracting to meet weekly for 12 to 16 weeks is part of the treatment. A contract:

• encourages patients to commit to an IPT trial for a reasonable time
  
• presses patients to achieve adequate progress by the deadline
  
• discourages digression, avoidance of painful subjects, and dependence on the therapist.
  

IPT begins with a complete psychiatric evaluation, including the patient’s past, family, and social histories; alcohol and drug use; medical comorbidities; mental status exam; and sometimes blood screening to rule out metabolic abnormalities. Antidepressants are prescribed as needed to relieve vegetative symptoms and are used during IPT when indicated.

Interpersonal inventory. Each of the patient’s interpersonal relationships is then systematically reviewed. This inventory sets the stage for exploring relationships that may be linked to the depressive symptoms or offer opportunities for trying alternate coping trategies, such as learning to seek social support (Table 2).

Table 1

IPT’s understanding of depression comprises 3 component processes

‘How-to’ checklist of IPT procedures

IPT’S FOUR FOCI

IPT’s goal is to relieve depressive symptoms by identifying and focusing on problems that may have caused or are perpetuating those symptoms. Most of the reasons depressed patients give for seeking help fall into four foci: unresolved grief, role transition, role dispute, and interpersonal deficit (Table 3).^5,6 The therapist uses clarification, interpretation, confrontation, and testing of perceptions and performance to address each focus, as detailed in the IPT manual.⁶

The therapist acts as the patient’s advocate, and focuses treatment on interpersonal relationships in the “here and now,” not past traumas, childhood conflicts, cognitive-behavioral interventions, or intrapsychic themes. No attempt is made to restructure personality.

Progress in relieving depressive symptoms is reviewed regularly, and treatment ends within the contract’s time limits in many cases. Older patients may need additional sessions because they often take longer to respond to antidepressant trials (6 to 8 weeks, compared with 3 to 4 weeks for younger adults). We allow older patients to “catch up” with additional sessions if illness, lack of transportation, or other problems prevent them from receiving the “full dose” of IPT.

IPT does not work for all patients. Consider other types of treatment if a patient shows no discernable benefit.

Table 3

IPT’s 4 foci, specific to late-life depression

Case continued: stalled in grief

As the weeks pass, Mrs. E improves but remains hypoactive and reclusive. She seems afraid to take any action without her late husband’s approval. Thinking about making independent decisions overwhelms her, and she withdraws to her couch to hide.

Her therapist discerns that Mrs. E needs more-active confrontation to accept that her new life requires her to make choices, even though decision-making is difficult for her. They develop a game, hronicling all decisions Mrs. E has made for the first time, such as calling a repairman and planting the summer vegetable garden by herself.

The therapist applauds these “firsts” and points out that Mrs. E’s depressive symptoms have improved as her list of completed decisions has grown. Mrs. E holds the power to make decisions, the therapist stresses, and bears the consequences of not taking action.

Applying ipt to late-life depression

Our group has used IPT in research protocols for 15 years. We and others^7-11 have found that IPT is well-suited for treating late-life depression because:

• Older patients without psychotherapy experience or psychological sophistication can easily participate.
  
• Persons with limited education can understand IPT’s informal explanations of depression.
  
• Two foci of IPT—grief and role transition—address common themes of aging, such as spousal role disputes after retirement or caregiver stress when one partner becomes ill or shows signs of dementia.
  

Only minor IPT adaptations were required for older patients, such as:

• shorter sessions for those who reported physical discomfort
  
• accommodating for hearing loss, arranging transportation, and conducting sessions by telephone when patients were ill or shut in by inclement weather.
  

Case continued: more ‘firsts’ build confidence

Mrs. E makes slow, sometimes painful, but steady progress. Her therapist encourages her to keep trying more “firsts,”such as going back to church and attending her first social event alone, and to review her emotional reactions.

Mrs. E’s depressive symptoms wane as her confidence builds, and she readjusts her self-image to that of a widow who enjoyed a good marriage with a benevolent but overprotective husband. Her therapist links her progress to her string of successful “firsts” and to the contributing benefit of anti-depressant medication.

IPT As maintenance therapy

In the Maintenance Therapies for Late Life Depression (MTLLD) study—a randomized, double-blind, placebo-controlled trial¹²—we showed IPT to be effective as maintenance therapy for recurrent depression in patients age 60 and older. The 187 patients (mean age 67, one-third age ≥70) with nonpsychotic unipolar major depression were first treated to remission with IPT plus nortriptyline (80 to 120 ng/mL).

We then randomly assigned the 107 who achieved recovery to one of four maintenance therapies. After 3 years of monthly follow-up, relapse rates were:

• 20% with nortriptyline plus maintenance IPT
  
• 43% with nortriptyline plus medication clinic visits
  
• 64% with maintenance IPT plus placebo
  
• 90% with medication clinic plus placebo.
  

Further analysis showed that patients age ≥70 required combined treatment with nortriptyline and IPT to stay well, whereas those ages 60 to 69 stayed well with drug therapy alone. Patients age ≥70 also had a higher and more rapid relapse rate.

Recurrence by therapy focus. In patients who received placebo instead of nortriptyline:

• Time without a new depressive episode was similar for patients with a focus on grief or role transition, whether they received IPT or medication checkups.
  
• Recurrence rates were clearly lower in patients whose initial focus was role dispute if they received monthly maintenance IPT sessions instead of medication check visits.
  

Case continued: looking ahead

As the 12- to 16-week contracted period winds down, Mrs. E admits she still longs for her husband’s protection. She said she would gladly give up her independence to have that “safe” feeling back.

The therapist acknowledges that feeling but gently reminds her that she has the tools to face her new life realistically. During therapy, Mrs. E has shown she can assess life’s many decisions, make rational choices, and live with the consequences.

Their final discussion touches on the notion that Mrs. E could imagine having some kind of friendship with another man in the future.

Wrapping up. The last IPT sessions focus on reviewing any decline in depressive symptoms that may be linked to having learned new coping skills. With successful IPT, patients learn to appraise their strengths and remaining vulnerabilities and gain skills, self-confidence, and understanding to confront remaining obstacles after therapy ends.

Adapting ipt for special populations

Resistant depression. Researchers at the University of Pittsburgh are investigating whether adding IPT can achieve remission in depressed older patients who show partial response to a 6-week trial of escitalopram, 10 mg/d. In this ongoing trial, patients with Hamilton Depression Rating Scale scores of 11 to 14 after 6 weeks receive an increased escitalopram dosage (20 mg/d) and are randomly assigned to medication alone or medication plus 16 weeks of IPT.

Cognitive impairment. An unpublished follow-up to the MTLLD study enrolled 116 patients aged ≥70 and used a similar design, except that:

• patients were not required to have had recurrent depressive episodes
  
• paroxetine was used instead of nortriptyline
  
• patients with cognitive impairment (Mini-Mental Status Examination scores ?18/30) were included.
  

Cognitive impairment may have interfered with patients’ ability to benefit from traditional IPT. Thus, to improve the quality of life of depressed, cognitively-impaired elders, researchers are involving caregivers (usually a spouse or adult child) in modified forms of IPT couples therapy.^6,13-18 A team at the University of Pittsburgh is developing a flexible approach that includes meetings with the patient, the caregiver, or both. Two papers on IPT-CI (for cognitive impairment) are under review.

Related resources

• International Society for Interpersonal Psychotherapy. Accreditation, training, and research information. www.interpersonalpsychotherapy.org.
  
• Stuart S, Robertson M. Interpersonal psychotherapy: a clinician’s guide. London: Edward Arnold Ltd.; 2002.
  
• Miller MD, Reynolds CF. Interpersonal psychotherapy. In: Hepple J, Pierce J, Wilkinson P (eds). Psychological therapies with older people. East Sussex, UK: Brunner-Routledge; 2002:103-27.
  
• Miller MD, Reynolds CF. Living longer depression-free: a family guide to the recognition, treatment and prevention of depression in later life. Baltimore: Johns Hopkins University Press; 2002.
  

• Escitalopram • Lexapro
  
• Nortriptyline • Pamelor
  
• Paroxetine • Paxil
  

Dr. Miller is a consultant to Forest Laboratories and GlaxoSmithKline and is a speaker for Forest Laboratories, GlaxoSmithKline, and Wyeth Pharmaceuticals.

Mrs. E, age 74, has been distraught for 6 months since the death of her husband of 45 years. She is brought for evaluation by her daughter, who is exasperated and worried about her mother’s sad mood, frequent tearfulness, weight loss (11 pounds), and social isolation.

Mrs. E says she feels lost and paralyzed, that she “sticks out like a sore thumb” when among couples “that still have each other.” She refuses to go to church, though she attended regularly in the past.

Unresolved grief appears to be linked to the onset and persistence of Mrs. E’s depressive symptoms. After a thorough evaluation confirms major depression, the psychiatrist explains the diagnosis to Mrs. E. She agrees to begin an antidepressant and interpersonal psychotherapy (IPT).

IPT is easy to use and well-suited to address abnormal grieving, role transitions, and role disputes in depressed older patients. In controlled trials, IPT has been shown effective as acute¹ and maintenance treatment^2,3 of depression. This article describes how IPT can work effectively for depressed older adults and their clinicians.

IPT and elder depression

New-onset or recurrent depression is common in older patients experiencing retirement, relocation, disabilities, or loss of important persons in their lives (Box 1) ⁴ IPT recognizes that depression, regardless of psychosocial stress or biologic vulnerability, is expressed in an interpersonal environment (Box 2).^5,6 The environment may have contributed to the depression, but it also can be a platform for intervention.

Depressed older adults who are verbal, nondemented, and engageable are candidates for IPT, with or without adjunctive antidepressant therapy. Psychotherapy is not indicated for patients with severe dementia, but this article will describe how IPT is being adapted for those with early dementia or mild cognitive impairment.

Box 1

Case continued: ‘he made all the decisions’

At Mrs. E’s first IPT session, the therapist assigns her the “sick role.” They contract to meet 12 to 16 weeks, and Mrs. E’s daughter agrees to drive her to sessions.

In the next few weeks, the therapist explains depression’s biopsychosocial model and explores dual strategies with Mrs. E: to ease her mourning and explore new interests or relationships. The therapist encourages her to express her feelings and seeks to understand the dynamics of her marriage.

Mrs. E said she was raised by nurturing parents and married soon after high school. She depended on her husband for almost every decision, including their social calendar. She describes their relationship as mutually loving. As part of an interpersonal inventory, her therapist encourages her to describe in detail all the ways she misses him.

The ‘sick role.’ The therapist assigned Mrs. E the “sick role” to emphasize that major depression can be a severe illness. A therapist might say: “If you had pneumonia, you wouldn’t think of trying to rake leaves. You would rest and take care of yourself to speed the healing. Persons with major depression should do the same.”

The contract. The therapist also explained to Mrs. E that contracting to meet weekly for 12 to 16 weeks is part of the treatment. A contract:

• encourages patients to commit to an IPT trial for a reasonable time
  
• presses patients to achieve adequate progress by the deadline
  
• discourages digression, avoidance of painful subjects, and dependence on the therapist.
  

IPT begins with a complete psychiatric evaluation, including the patient’s past, family, and social histories; alcohol and drug use; medical comorbidities; mental status exam; and sometimes blood screening to rule out metabolic abnormalities. Antidepressants are prescribed as needed to relieve vegetative symptoms and are used during IPT when indicated.

Interpersonal inventory. Each of the patient’s interpersonal relationships is then systematically reviewed. This inventory sets the stage for exploring relationships that may be linked to the depressive symptoms or offer opportunities for trying alternate coping trategies, such as learning to seek social support (Table 2).

Table 1

IPT’s understanding of depression comprises 3 component processes

‘How-to’ checklist of IPT procedures

IPT’S FOUR FOCI

IPT’s goal is to relieve depressive symptoms by identifying and focusing on problems that may have caused or are perpetuating those symptoms. Most of the reasons depressed patients give for seeking help fall into four foci: unresolved grief, role transition, role dispute, and interpersonal deficit (Table 3).^5,6 The therapist uses clarification, interpretation, confrontation, and testing of perceptions and performance to address each focus, as detailed in the IPT manual.⁶

The therapist acts as the patient’s advocate, and focuses treatment on interpersonal relationships in the “here and now,” not past traumas, childhood conflicts, cognitive-behavioral interventions, or intrapsychic themes. No attempt is made to restructure personality.

Progress in relieving depressive symptoms is reviewed regularly, and treatment ends within the contract’s time limits in many cases. Older patients may need additional sessions because they often take longer to respond to antidepressant trials (6 to 8 weeks, compared with 3 to 4 weeks for younger adults). We allow older patients to “catch up” with additional sessions if illness, lack of transportation, or other problems prevent them from receiving the “full dose” of IPT.

IPT does not work for all patients. Consider other types of treatment if a patient shows no discernable benefit.

Table 3

IPT’s 4 foci, specific to late-life depression

Case continued: stalled in grief

As the weeks pass, Mrs. E improves but remains hypoactive and reclusive. She seems afraid to take any action without her late husband’s approval. Thinking about making independent decisions overwhelms her, and she withdraws to her couch to hide.

Her therapist discerns that Mrs. E needs more-active confrontation to accept that her new life requires her to make choices, even though decision-making is difficult for her. They develop a game, hronicling all decisions Mrs. E has made for the first time, such as calling a repairman and planting the summer vegetable garden by herself.

The therapist applauds these “firsts” and points out that Mrs. E’s depressive symptoms have improved as her list of completed decisions has grown. Mrs. E holds the power to make decisions, the therapist stresses, and bears the consequences of not taking action.

Applying ipt to late-life depression

Our group has used IPT in research protocols for 15 years. We and others^7-11 have found that IPT is well-suited for treating late-life depression because:

• Older patients without psychotherapy experience or psychological sophistication can easily participate.
  
• Persons with limited education can understand IPT’s informal explanations of depression.
  
• Two foci of IPT—grief and role transition—address common themes of aging, such as spousal role disputes after retirement or caregiver stress when one partner becomes ill or shows signs of dementia.
  

Only minor IPT adaptations were required for older patients, such as:

• shorter sessions for those who reported physical discomfort
  
• accommodating for hearing loss, arranging transportation, and conducting sessions by telephone when patients were ill or shut in by inclement weather.
  

Case continued: more ‘firsts’ build confidence

Mrs. E makes slow, sometimes painful, but steady progress. Her therapist encourages her to keep trying more “firsts,”such as going back to church and attending her first social event alone, and to review her emotional reactions.

Mrs. E’s depressive symptoms wane as her confidence builds, and she readjusts her self-image to that of a widow who enjoyed a good marriage with a benevolent but overprotective husband. Her therapist links her progress to her string of successful “firsts” and to the contributing benefit of anti-depressant medication.

IPT As maintenance therapy

In the Maintenance Therapies for Late Life Depression (MTLLD) study—a randomized, double-blind, placebo-controlled trial¹²—we showed IPT to be effective as maintenance therapy for recurrent depression in patients age 60 and older. The 187 patients (mean age 67, one-third age ≥70) with nonpsychotic unipolar major depression were first treated to remission with IPT plus nortriptyline (80 to 120 ng/mL).

We then randomly assigned the 107 who achieved recovery to one of four maintenance therapies. After 3 years of monthly follow-up, relapse rates were:

• 20% with nortriptyline plus maintenance IPT
  
• 43% with nortriptyline plus medication clinic visits
  
• 64% with maintenance IPT plus placebo
  
• 90% with medication clinic plus placebo.
  

Further analysis showed that patients age ≥70 required combined treatment with nortriptyline and IPT to stay well, whereas those ages 60 to 69 stayed well with drug therapy alone. Patients age ≥70 also had a higher and more rapid relapse rate.

Recurrence by therapy focus. In patients who received placebo instead of nortriptyline:

• Time without a new depressive episode was similar for patients with a focus on grief or role transition, whether they received IPT or medication checkups.
  
• Recurrence rates were clearly lower in patients whose initial focus was role dispute if they received monthly maintenance IPT sessions instead of medication check visits.
  

Case continued: looking ahead

As the 12- to 16-week contracted period winds down, Mrs. E admits she still longs for her husband’s protection. She said she would gladly give up her independence to have that “safe” feeling back.

The therapist acknowledges that feeling but gently reminds her that she has the tools to face her new life realistically. During therapy, Mrs. E has shown she can assess life’s many decisions, make rational choices, and live with the consequences.

Their final discussion touches on the notion that Mrs. E could imagine having some kind of friendship with another man in the future.

Wrapping up. The last IPT sessions focus on reviewing any decline in depressive symptoms that may be linked to having learned new coping skills. With successful IPT, patients learn to appraise their strengths and remaining vulnerabilities and gain skills, self-confidence, and understanding to confront remaining obstacles after therapy ends.

Adapting ipt for special populations

Resistant depression. Researchers at the University of Pittsburgh are investigating whether adding IPT can achieve remission in depressed older patients who show partial response to a 6-week trial of escitalopram, 10 mg/d. In this ongoing trial, patients with Hamilton Depression Rating Scale scores of 11 to 14 after 6 weeks receive an increased escitalopram dosage (20 mg/d) and are randomly assigned to medication alone or medication plus 16 weeks of IPT.

Cognitive impairment. An unpublished follow-up to the MTLLD study enrolled 116 patients aged ≥70 and used a similar design, except that:

• patients were not required to have had recurrent depressive episodes
  
• paroxetine was used instead of nortriptyline
  
• patients with cognitive impairment (Mini-Mental Status Examination scores ?18/30) were included.
  

Cognitive impairment may have interfered with patients’ ability to benefit from traditional IPT. Thus, to improve the quality of life of depressed, cognitively-impaired elders, researchers are involving caregivers (usually a spouse or adult child) in modified forms of IPT couples therapy.^6,13-18 A team at the University of Pittsburgh is developing a flexible approach that includes meetings with the patient, the caregiver, or both. Two papers on IPT-CI (for cognitive impairment) are under review.

Related resources

• International Society for Interpersonal Psychotherapy. Accreditation, training, and research information. www.interpersonalpsychotherapy.org.
  
• Stuart S, Robertson M. Interpersonal psychotherapy: a clinician’s guide. London: Edward Arnold Ltd.; 2002.
  
• Miller MD, Reynolds CF. Interpersonal psychotherapy. In: Hepple J, Pierce J, Wilkinson P (eds). Psychological therapies with older people. East Sussex, UK: Brunner-Routledge; 2002:103-27.
  
• Miller MD, Reynolds CF. Living longer depression-free: a family guide to the recognition, treatment and prevention of depression in later life. Baltimore: Johns Hopkins University Press; 2002.
  

• Escitalopram • Lexapro
  
• Nortriptyline • Pamelor
  
• Paroxetine • Paxil
  

Dr. Miller is a consultant to Forest Laboratories and GlaxoSmithKline and is a speaker for Forest Laboratories, GlaxoSmithKline, and Wyeth Pharmaceuticals.

Reputed Cosa Nostra boss Vincent “The Chin” Gigante deceived “the most respected minds in forensic psychiatry” for years by malingering schizophrenia.¹ Ultimately, he admitted to maintaining his charade from 1990 to 1997 during evaluations of his competency to stand trial for racketeering.

A lesson from this case—said a psychiatrist who concluded Gigante was malingering—is, “When feigning is a consideration, we must be more critical and less accepting of our impressions when we conduct and interpret a psychiatric examination…than might be the case in a typical clinical situation.”²

Even in typical clinical situations, however, psychiatrists may be reluctant to diagnose malingering³ for fear of being sued, assaulted—or wrong. An inaccurate diagnosis of malingering may unjustly stigmatize a patient and deny him needed care.⁴

Because psychiatrists need a systematized approach to detect malingering,⁵ we offer specific clinical factors and approaches to help you recognize malingered psychosis.

What is Malingering?

No other syndrome is as easy to define yet so difficult to diagnose as malingering. Reliably diagnosing malingered mental illness is complex, requiring the psychiatrist to consider collateral data beyond the patient interview.

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.⁶ In practice, malingering commonly must be differentiated from factitious disorder, which also involves intentional production of symptoms. In factitious disorders, the patient’s motivation is to assume the sick role, which can be thought of as an internal or psychological incentive.

Three categories of malingering include:

• pure malingering (feigning a nonexistent disorder)
• partial malingering (consciously exaggerating real symptoms)
• false imputation (ascribing real symptoms to a cause the individual knows is unrelated to the symptoms).⁷

Motivations. Individuals usually malinger to avoid pain (such as difficult situations or punishment) or to seek pleasure (such as to obtain compensation or medications) (Table 1). In correctional settings, for example, inmates may malinger mental illness to do “easier time” or to obtain drugs. On the other hand, malingering in prison also may be an adaptive response by a mentally ill inmate to relatively sparse and difficult-to-obtain mental health resources.⁸

Table 1

Common motives of malingerers

Interview Style

When you suspect a patient is malingering, keep your suspicions to yourself and conduct an objective evaluation. Patients are likely to become defensive if you show annoyance or incredulity, and putting them on guard decreases your ability to uncover evidence of malingering.⁹

Begin by asking open-ended questions, which allow patients to report symptoms in their own words. To avoid hinting at correct responses, carefully phrase initial inquiries about symptoms. Later in the interview, you can proceed to more-detailed questions of specific symptoms, as discussed below.

If possible, review collateral data before the interview, when it is most helpful. Consider information that would support or refute the alleged symptoms, such as treatment and insurance records, police reports, and interviews of close friends or family.

The patient interview may be prolonged because fatigue may diminish a malingerer’s ability to maintain fake symptoms. In very difficult cases, consider monitoring during inpatient assessment because feigned psychosis is extremely difficult to maintain 24 hours a day.

Watch for individuals who endorse rare or improbable symptoms. Rare symptoms—by definition—occur very infrequently, and even severely disturbed patients almost never report improbable symptoms.¹⁰ Consider asking malingerers about improbable symptoms to see if they will endorse them. For example:

• “When people talk to you, do you see the words they speak spelled out?”¹¹
• “Have you ever believed that automobiles are members of an organized religion?”¹²

Watch closely for internal or external inconsistency in the suspected malingerer’s presentation (Table 2).

Table 2

Clues to identify malingering during patient evaluation

Malingered Psychotic Symptoms

Detecting malingered mental illness is considered an advanced psychiatric skill, partly because you must understand thoroughly how genuine psychotic symptoms manifest.

Hallucinations. If a patient alleges atypical hallucinations, ask about them in detail. Hallucinations are usually (88%) associated with delusions.¹³ Genuine hallucinations are typically intermittent rather than continuous.

Continue to: Auditory hallucinations

Auditory hallucinations are usually clear, not vague (7%) or inaudible. Both male and female voices are commonly heard (75%), and voices are usually perceived as originating outside the head (88%).¹⁴ In schizophrenia, the major themes are persecutory or instructive.¹⁵

Command auditory hallucinations are easy to fabricate. Persons experiencing genuine command hallucinations:

• do not always obey the voices, especially if doing so would be dangerous¹⁶
• usually present with noncommand hallucinations (85%) and delusions (75%) as well¹⁷

Thus, view with suspicion someone who alleges an isolated command hallucination without other psychotic symptoms.

Genuine schizophrenic hallucinations tend to diminish when patients are involved in activities. Thus, to deal with their hallucinations, persons with schizophrenia typically cope by:

• engaging in activities (working, listening to a radio, watching TV)
• changing posture (lying down, walking)
• seeking interpersonal contact
• taking medications.

If you suspect a person of malingered auditory hallucinations, ask what he or she does to make the voices go away or diminish in intensity. Patients with genuine schizophrenia often can stop their auditory hallucinations while in remission but not during acute illness.

Malingerers may report auditory hallucinations of stilted or implausible language. For example, we have evaluated:

• an individual charged with attempted rape who alleged that voices said, “Go commit a sex offense.”
• a bank robber who alleged that voices kept screaming, “Stick up, stick up, stick up!”

Both examples contain language that is very questionable for genuine hallucinations, while providing the patient with “psychotic justification” for an illegal act that has a rational alternative motive.

Visual hallucinations are experienced by an estimated 24% to 30% of psychotic individuals but are reported much more often by malingerers (46%) than by persons with genuine psychosis (4%).¹⁸

Genuine visual hallucinations are usually of normalsized people and are seen in color.¹⁴ On rare occasions, genuine visual hallucinations of small people (Lilliputian hallucinations) may be associated with alcohol use, organic disease, or toxic psychosis (such as anticholinergic toxicity) but are rarely seen by persons with schizophrenia.

Psychotic visual hallucinations do not typically change if the eyes are closed or open, whereas drug-induced hallucinations are more readily seen with eyes closed or in the dark. Unformed hallucinations—such as flashes of light, shadows, or moving objects—are typically associated with neurologic disease and substance use.¹⁹

Suspect malingering if the patient reports dramatic or atypical visual hallucinations. For example, one defendant charged with bank robbery calmly reported seeing “a 30-foot tall, red giant smashing down the walls” of the interview room. When he was asked detailed questions, he frequently replied, “I don’t know.” He eventually admitted to malingering.

Delusions. Genuine delusions vary in content, theme, degree of systemization, and relevance to the person’s life. The complexity and sophistication of delusional systems usually reflect the individual’s intelligence. Persecutory delusions are more likely to be acted upon than are other types of delusions.²⁰

Malingerers may claim that a delusion began or disappeared suddenly. In reality, systematized delusions usually take weeks to develop and much longer to disappear. Typically, the delusion will become somewhat less relevant, and the individual will gradually relinquish its importance over time after adequate treatment. In general, the more bizarre the delusion’s content, the more disorganized the individual’s thinking is likely to be (Table 3).

With genuine delusions, the individual’s behavior usually conforms to the delusions’ content. For example, Russell Weston—who suffered from schizophrenia—made a deadly assault on the U.S. Capitol in 1998 because he held a delusional belief that cannibalism was destroying Washington, DC. Before he shot and killed two U.S. Capitol security officers, he had gone to the Central Intelligence Agency several years before and voiced the same delusional concerns.

Suspect malingering if a patient alleges persecutory delusions without engaging in corresponding paranoid behaviors. One exception is the person with long-standing schizophrenia who has grown accustomed to the delusion and whose behavior is no longer consistent with it.

Table 3

Uncommon psychosis presentations that suggest malingering

Where Malingerers Trip Up

Malingerers may have inadequate or incomplete knowledge of the mental illness they are faking. Indeed, malingerers are like actors who can portray a role only as well as they understand it. They often overact their part or mistakenly believe the more bizarre their behavior, the more convincing they will be. Conversely, “successful” malingerers are more likely to endorse fewer symptoms and avoid endorsing overly bizarre or unusual symptoms.²¹

Continue to: Numerous clinical factors suggest malingering...

Numerous clinical factors suggest malingering (Table 4). Malingerers are more likely to eagerly “thrust forward” their illness, whereas patients with genuine schizophrenia are often reluctant to discuss their symptoms.²²

Malingerers may attempt to take control of the interview and behave in an intimidating or hostile manner. They may accuse the psychiatrist of inferring that they are faking. Such behavior is rare in genuinely psychotic individuals. Although DSM-IV-TR states that antisocial personality disorder should arouse suspicions of malingering, some studies have failed to show a relationship. One study has associated psychopathic traits with malingering.²³

Malingerers often believe that faking intellectual deficits, in addition to psychotic symptoms, will make them more believable. For example, a man who had completed several years of college alleged that he did not know the colors of the American flag.

Malingerers are more likely to give vague or hedging answers to straightforward questions. For example, when asked whether an alleged voice was male or female, one malingerer replied, “It was probably a man’s voice.” Malingerers may also answer, “I don’t know” to detailed questions about psychotic symptoms. Whereas a person with genuine psychotic symptoms could easily give an answer, the malingerer may have never experienced the symptoms and consequently “doesn’t know” the correct answer.

Psychotic symptoms such as derailment, neologisms, loose associations, and word salad are rarely simulated. This is because it is much more difficult for a malingerer to successfully imitate psychotic thought processes than psychotic thought content. Similarly, it is unusual for a malingerer to fake schizophrenia’s subtle signs, such as negative symptoms.

Table 4

Clinical factors that suggest malingering

Psychological Testing

Although many psychometric tests are available for detecting malingered psychosis, few have been validated. Among the more reliable are:

• Structured Interview of Reported Symptoms (SIRS)
• Minnesota Multiphasic Personality Inventory, Revised (MMPI-2)
• Miller Forensic Assessment of Symptoms Test (M-FAST).¹¹

SIRS includes questions about rare symptoms, uncommon symptom pairing, atypical symptoms, and other indices involving excessive symptom reporting. It takes 30 to 60 minutes to administer. Tested in inpatient, forensic, and correctional populations, the SIRS has shown consistently high accuracy in detecting malingered psychiatric illness.²⁴

Two MMPI-2 scales—F-scale and F-K Index—are the most frequently used test for evaluating suspected malingering. When using the MMPI-2 in this manner, consult the literature for appropriate cutoff scores (see Related resources). Although the MMPI-2 is the most validated psychometric method to detect malingering, a malingerer with high intelligence and previous knowledge of the test could evade detection.²⁵

M-FAST was developed to provide a brief, reliable screen for malingered mental illness. This test takes 10 to 15 minutes to administer and measures rare symptom combinations, excessive reporting, and atypical symptoms.¹¹ It has shown good validity and high correlation with the SIRS and MMPI-2.^26,27

Confronting the Malingerer

If a thorough investigation indicates that a patient is malingering psychosis, you may decide to confront the evaluee. Avoid direct accusations of lying,¹⁰ and give the suspected malingerer every opportunity to save face. For example, it is preferable to say, “You haven’t told me the whole truth.”

A thoughtful approach that asks the evaluee to clarify inconsistencies is more likely to be productive and safer for the examiner. When confronting individuals with a history of violence and aggression, have adequate security personnel with you.

Related resources

• Structured Interview of Reported Symptoms (SIRS). Available for purchase from Psychological Assessment Resources at www3.parinc.com (enter “SIRS” in search field).
• Graham JR. MMPI-2: Assessing personality and psychopathology. New York: Oxford Press; 2000. (Source of cutoff scores to use MMPI-2 scales [F-scale and F-K Index] to evaluate suspected malingering).
• Psychological Assessment Resources, Inc. Miller Forensic Assessment of Symptoms Test (M-FAST). Available at: www3.parinc.com (enter “M-FAST” in search field).

Reputed Cosa Nostra boss Vincent “The Chin” Gigante deceived “the most respected minds in forensic psychiatry” for years by malingering schizophrenia.¹ Ultimately, he admitted to maintaining his charade from 1990 to 1997 during evaluations of his competency to stand trial for racketeering.

A lesson from this case—said a psychiatrist who concluded Gigante was malingering—is, “When feigning is a consideration, we must be more critical and less accepting of our impressions when we conduct and interpret a psychiatric examination…than might be the case in a typical clinical situation.”²

Even in typical clinical situations, however, psychiatrists may be reluctant to diagnose malingering³ for fear of being sued, assaulted—or wrong. An inaccurate diagnosis of malingering may unjustly stigmatize a patient and deny him needed care.⁴

Because psychiatrists need a systematized approach to detect malingering,⁵ we offer specific clinical factors and approaches to help you recognize malingered psychosis.

What is Malingering?

No other syndrome is as easy to define yet so difficult to diagnose as malingering. Reliably diagnosing malingered mental illness is complex, requiring the psychiatrist to consider collateral data beyond the patient interview.

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.⁶ In practice, malingering commonly must be differentiated from factitious disorder, which also involves intentional production of symptoms. In factitious disorders, the patient’s motivation is to assume the sick role, which can be thought of as an internal or psychological incentive.

Three categories of malingering include:

• pure malingering (feigning a nonexistent disorder)
• partial malingering (consciously exaggerating real symptoms)
• false imputation (ascribing real symptoms to a cause the individual knows is unrelated to the symptoms).⁷

Motivations. Individuals usually malinger to avoid pain (such as difficult situations or punishment) or to seek pleasure (such as to obtain compensation or medications) (Table 1). In correctional settings, for example, inmates may malinger mental illness to do “easier time” or to obtain drugs. On the other hand, malingering in prison also may be an adaptive response by a mentally ill inmate to relatively sparse and difficult-to-obtain mental health resources.⁸

Table 1

Common motives of malingerers

Interview Style

When you suspect a patient is malingering, keep your suspicions to yourself and conduct an objective evaluation. Patients are likely to become defensive if you show annoyance or incredulity, and putting them on guard decreases your ability to uncover evidence of malingering.⁹

Begin by asking open-ended questions, which allow patients to report symptoms in their own words. To avoid hinting at correct responses, carefully phrase initial inquiries about symptoms. Later in the interview, you can proceed to more-detailed questions of specific symptoms, as discussed below.

If possible, review collateral data before the interview, when it is most helpful. Consider information that would support or refute the alleged symptoms, such as treatment and insurance records, police reports, and interviews of close friends or family.

The patient interview may be prolonged because fatigue may diminish a malingerer’s ability to maintain fake symptoms. In very difficult cases, consider monitoring during inpatient assessment because feigned psychosis is extremely difficult to maintain 24 hours a day.

Watch for individuals who endorse rare or improbable symptoms. Rare symptoms—by definition—occur very infrequently, and even severely disturbed patients almost never report improbable symptoms.¹⁰ Consider asking malingerers about improbable symptoms to see if they will endorse them. For example:

• “When people talk to you, do you see the words they speak spelled out?”¹¹
• “Have you ever believed that automobiles are members of an organized religion?”¹²

Watch closely for internal or external inconsistency in the suspected malingerer’s presentation (Table 2).

Table 2

Clues to identify malingering during patient evaluation

Malingered Psychotic Symptoms

Detecting malingered mental illness is considered an advanced psychiatric skill, partly because you must understand thoroughly how genuine psychotic symptoms manifest.

Hallucinations. If a patient alleges atypical hallucinations, ask about them in detail. Hallucinations are usually (88%) associated with delusions.¹³ Genuine hallucinations are typically intermittent rather than continuous.

Continue to: Auditory hallucinations

Auditory hallucinations are usually clear, not vague (7%) or inaudible. Both male and female voices are commonly heard (75%), and voices are usually perceived as originating outside the head (88%).¹⁴ In schizophrenia, the major themes are persecutory or instructive.¹⁵

Command auditory hallucinations are easy to fabricate. Persons experiencing genuine command hallucinations:

• do not always obey the voices, especially if doing so would be dangerous¹⁶
• usually present with noncommand hallucinations (85%) and delusions (75%) as well¹⁷

Thus, view with suspicion someone who alleges an isolated command hallucination without other psychotic symptoms.

Genuine schizophrenic hallucinations tend to diminish when patients are involved in activities. Thus, to deal with their hallucinations, persons with schizophrenia typically cope by:

• engaging in activities (working, listening to a radio, watching TV)
• changing posture (lying down, walking)
• seeking interpersonal contact
• taking medications.

If you suspect a person of malingered auditory hallucinations, ask what he or she does to make the voices go away or diminish in intensity. Patients with genuine schizophrenia often can stop their auditory hallucinations while in remission but not during acute illness.

Malingerers may report auditory hallucinations of stilted or implausible language. For example, we have evaluated:

• an individual charged with attempted rape who alleged that voices said, “Go commit a sex offense.”
• a bank robber who alleged that voices kept screaming, “Stick up, stick up, stick up!”

Both examples contain language that is very questionable for genuine hallucinations, while providing the patient with “psychotic justification” for an illegal act that has a rational alternative motive.

Visual hallucinations are experienced by an estimated 24% to 30% of psychotic individuals but are reported much more often by malingerers (46%) than by persons with genuine psychosis (4%).¹⁸

Genuine visual hallucinations are usually of normalsized people and are seen in color.¹⁴ On rare occasions, genuine visual hallucinations of small people (Lilliputian hallucinations) may be associated with alcohol use, organic disease, or toxic psychosis (such as anticholinergic toxicity) but are rarely seen by persons with schizophrenia.

Psychotic visual hallucinations do not typically change if the eyes are closed or open, whereas drug-induced hallucinations are more readily seen with eyes closed or in the dark. Unformed hallucinations—such as flashes of light, shadows, or moving objects—are typically associated with neurologic disease and substance use.¹⁹

Suspect malingering if the patient reports dramatic or atypical visual hallucinations. For example, one defendant charged with bank robbery calmly reported seeing “a 30-foot tall, red giant smashing down the walls” of the interview room. When he was asked detailed questions, he frequently replied, “I don’t know.” He eventually admitted to malingering.

Delusions. Genuine delusions vary in content, theme, degree of systemization, and relevance to the person’s life. The complexity and sophistication of delusional systems usually reflect the individual’s intelligence. Persecutory delusions are more likely to be acted upon than are other types of delusions.²⁰

Malingerers may claim that a delusion began or disappeared suddenly. In reality, systematized delusions usually take weeks to develop and much longer to disappear. Typically, the delusion will become somewhat less relevant, and the individual will gradually relinquish its importance over time after adequate treatment. In general, the more bizarre the delusion’s content, the more disorganized the individual’s thinking is likely to be (Table 3).

With genuine delusions, the individual’s behavior usually conforms to the delusions’ content. For example, Russell Weston—who suffered from schizophrenia—made a deadly assault on the U.S. Capitol in 1998 because he held a delusional belief that cannibalism was destroying Washington, DC. Before he shot and killed two U.S. Capitol security officers, he had gone to the Central Intelligence Agency several years before and voiced the same delusional concerns.

Suspect malingering if a patient alleges persecutory delusions without engaging in corresponding paranoid behaviors. One exception is the person with long-standing schizophrenia who has grown accustomed to the delusion and whose behavior is no longer consistent with it.

Table 3

Uncommon psychosis presentations that suggest malingering

Where Malingerers Trip Up

Malingerers may have inadequate or incomplete knowledge of the mental illness they are faking. Indeed, malingerers are like actors who can portray a role only as well as they understand it. They often overact their part or mistakenly believe the more bizarre their behavior, the more convincing they will be. Conversely, “successful” malingerers are more likely to endorse fewer symptoms and avoid endorsing overly bizarre or unusual symptoms.²¹

Continue to: Numerous clinical factors suggest malingering...

Numerous clinical factors suggest malingering (Table 4). Malingerers are more likely to eagerly “thrust forward” their illness, whereas patients with genuine schizophrenia are often reluctant to discuss their symptoms.²²

Malingerers may attempt to take control of the interview and behave in an intimidating or hostile manner. They may accuse the psychiatrist of inferring that they are faking. Such behavior is rare in genuinely psychotic individuals. Although DSM-IV-TR states that antisocial personality disorder should arouse suspicions of malingering, some studies have failed to show a relationship. One study has associated psychopathic traits with malingering.²³

Malingerers often believe that faking intellectual deficits, in addition to psychotic symptoms, will make them more believable. For example, a man who had completed several years of college alleged that he did not know the colors of the American flag.

Malingerers are more likely to give vague or hedging answers to straightforward questions. For example, when asked whether an alleged voice was male or female, one malingerer replied, “It was probably a man’s voice.” Malingerers may also answer, “I don’t know” to detailed questions about psychotic symptoms. Whereas a person with genuine psychotic symptoms could easily give an answer, the malingerer may have never experienced the symptoms and consequently “doesn’t know” the correct answer.

Psychotic symptoms such as derailment, neologisms, loose associations, and word salad are rarely simulated. This is because it is much more difficult for a malingerer to successfully imitate psychotic thought processes than psychotic thought content. Similarly, it is unusual for a malingerer to fake schizophrenia’s subtle signs, such as negative symptoms.

Table 4

Clinical factors that suggest malingering

Psychological Testing

Although many psychometric tests are available for detecting malingered psychosis, few have been validated. Among the more reliable are:

• Structured Interview of Reported Symptoms (SIRS)
• Minnesota Multiphasic Personality Inventory, Revised (MMPI-2)
• Miller Forensic Assessment of Symptoms Test (M-FAST).¹¹

SIRS includes questions about rare symptoms, uncommon symptom pairing, atypical symptoms, and other indices involving excessive symptom reporting. It takes 30 to 60 minutes to administer. Tested in inpatient, forensic, and correctional populations, the SIRS has shown consistently high accuracy in detecting malingered psychiatric illness.²⁴

Two MMPI-2 scales—F-scale and F-K Index—are the most frequently used test for evaluating suspected malingering. When using the MMPI-2 in this manner, consult the literature for appropriate cutoff scores (see Related resources). Although the MMPI-2 is the most validated psychometric method to detect malingering, a malingerer with high intelligence and previous knowledge of the test could evade detection.²⁵

M-FAST was developed to provide a brief, reliable screen for malingered mental illness. This test takes 10 to 15 minutes to administer and measures rare symptom combinations, excessive reporting, and atypical symptoms.¹¹ It has shown good validity and high correlation with the SIRS and MMPI-2.^26,27

Confronting the Malingerer

If a thorough investigation indicates that a patient is malingering psychosis, you may decide to confront the evaluee. Avoid direct accusations of lying,¹⁰ and give the suspected malingerer every opportunity to save face. For example, it is preferable to say, “You haven’t told me the whole truth.”

A thoughtful approach that asks the evaluee to clarify inconsistencies is more likely to be productive and safer for the examiner. When confronting individuals with a history of violence and aggression, have adequate security personnel with you.

Related resources

• Structured Interview of Reported Symptoms (SIRS). Available for purchase from Psychological Assessment Resources at www3.parinc.com (enter “SIRS” in search field).
• Graham JR. MMPI-2: Assessing personality and psychopathology. New York: Oxford Press; 2000. (Source of cutoff scores to use MMPI-2 scales [F-scale and F-K Index] to evaluate suspected malingering).
• Psychological Assessment Resources, Inc. Miller Forensic Assessment of Symptoms Test (M-FAST). Available at: www3.parinc.com (enter “M-FAST” in search field).

Reputed Cosa Nostra boss Vincent “The Chin” Gigante deceived “the most respected minds in forensic psychiatry” for years by malingering schizophrenia.¹ Ultimately, he admitted to maintaining his charade from 1990 to 1997 during evaluations of his competency to stand trial for racketeering.

A lesson from this case—said a psychiatrist who concluded Gigante was malingering—is, “When feigning is a consideration, we must be more critical and less accepting of our impressions when we conduct and interpret a psychiatric examination…than might be the case in a typical clinical situation.”²

Even in typical clinical situations, however, psychiatrists may be reluctant to diagnose malingering³ for fear of being sued, assaulted—or wrong. An inaccurate diagnosis of malingering may unjustly stigmatize a patient and deny him needed care.⁴

Because psychiatrists need a systematized approach to detect malingering,⁵ we offer specific clinical factors and approaches to help you recognize malingered psychosis.

What is Malingering?

No other syndrome is as easy to define yet so difficult to diagnose as malingering. Reliably diagnosing malingered mental illness is complex, requiring the psychiatrist to consider collateral data beyond the patient interview.

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.⁶ In practice, malingering commonly must be differentiated from factitious disorder, which also involves intentional production of symptoms. In factitious disorders, the patient’s motivation is to assume the sick role, which can be thought of as an internal or psychological incentive.

Three categories of malingering include:

• pure malingering (feigning a nonexistent disorder)
• partial malingering (consciously exaggerating real symptoms)
• false imputation (ascribing real symptoms to a cause the individual knows is unrelated to the symptoms).⁷

Motivations. Individuals usually malinger to avoid pain (such as difficult situations or punishment) or to seek pleasure (such as to obtain compensation or medications) (Table 1). In correctional settings, for example, inmates may malinger mental illness to do “easier time” or to obtain drugs. On the other hand, malingering in prison also may be an adaptive response by a mentally ill inmate to relatively sparse and difficult-to-obtain mental health resources.⁸

Table 1

Common motives of malingerers

Interview Style

When you suspect a patient is malingering, keep your suspicions to yourself and conduct an objective evaluation. Patients are likely to become defensive if you show annoyance or incredulity, and putting them on guard decreases your ability to uncover evidence of malingering.⁹

Begin by asking open-ended questions, which allow patients to report symptoms in their own words. To avoid hinting at correct responses, carefully phrase initial inquiries about symptoms. Later in the interview, you can proceed to more-detailed questions of specific symptoms, as discussed below.

If possible, review collateral data before the interview, when it is most helpful. Consider information that would support or refute the alleged symptoms, such as treatment and insurance records, police reports, and interviews of close friends or family.

The patient interview may be prolonged because fatigue may diminish a malingerer’s ability to maintain fake symptoms. In very difficult cases, consider monitoring during inpatient assessment because feigned psychosis is extremely difficult to maintain 24 hours a day.

Watch for individuals who endorse rare or improbable symptoms. Rare symptoms—by definition—occur very infrequently, and even severely disturbed patients almost never report improbable symptoms.¹⁰ Consider asking malingerers about improbable symptoms to see if they will endorse them. For example:

• “When people talk to you, do you see the words they speak spelled out?”¹¹
• “Have you ever believed that automobiles are members of an organized religion?”¹²

Watch closely for internal or external inconsistency in the suspected malingerer’s presentation (Table 2).

Table 2

Clues to identify malingering during patient evaluation

Malingered Psychotic Symptoms

Detecting malingered mental illness is considered an advanced psychiatric skill, partly because you must understand thoroughly how genuine psychotic symptoms manifest.

Hallucinations. If a patient alleges atypical hallucinations, ask about them in detail. Hallucinations are usually (88%) associated with delusions.¹³ Genuine hallucinations are typically intermittent rather than continuous.

Continue to: Auditory hallucinations

Auditory hallucinations are usually clear, not vague (7%) or inaudible. Both male and female voices are commonly heard (75%), and voices are usually perceived as originating outside the head (88%).¹⁴ In schizophrenia, the major themes are persecutory or instructive.¹⁵

Command auditory hallucinations are easy to fabricate. Persons experiencing genuine command hallucinations:

• do not always obey the voices, especially if doing so would be dangerous¹⁶
• usually present with noncommand hallucinations (85%) and delusions (75%) as well¹⁷

Thus, view with suspicion someone who alleges an isolated command hallucination without other psychotic symptoms.

Genuine schizophrenic hallucinations tend to diminish when patients are involved in activities. Thus, to deal with their hallucinations, persons with schizophrenia typically cope by:

• engaging in activities (working, listening to a radio, watching TV)
• changing posture (lying down, walking)
• seeking interpersonal contact
• taking medications.

If you suspect a person of malingered auditory hallucinations, ask what he or she does to make the voices go away or diminish in intensity. Patients with genuine schizophrenia often can stop their auditory hallucinations while in remission but not during acute illness.

Malingerers may report auditory hallucinations of stilted or implausible language. For example, we have evaluated:

• an individual charged with attempted rape who alleged that voices said, “Go commit a sex offense.”
• a bank robber who alleged that voices kept screaming, “Stick up, stick up, stick up!”

Both examples contain language that is very questionable for genuine hallucinations, while providing the patient with “psychotic justification” for an illegal act that has a rational alternative motive.

Visual hallucinations are experienced by an estimated 24% to 30% of psychotic individuals but are reported much more often by malingerers (46%) than by persons with genuine psychosis (4%).¹⁸

Genuine visual hallucinations are usually of normalsized people and are seen in color.¹⁴ On rare occasions, genuine visual hallucinations of small people (Lilliputian hallucinations) may be associated with alcohol use, organic disease, or toxic psychosis (such as anticholinergic toxicity) but are rarely seen by persons with schizophrenia.

Psychotic visual hallucinations do not typically change if the eyes are closed or open, whereas drug-induced hallucinations are more readily seen with eyes closed or in the dark. Unformed hallucinations—such as flashes of light, shadows, or moving objects—are typically associated with neurologic disease and substance use.¹⁹

Suspect malingering if the patient reports dramatic or atypical visual hallucinations. For example, one defendant charged with bank robbery calmly reported seeing “a 30-foot tall, red giant smashing down the walls” of the interview room. When he was asked detailed questions, he frequently replied, “I don’t know.” He eventually admitted to malingering.

Delusions. Genuine delusions vary in content, theme, degree of systemization, and relevance to the person’s life. The complexity and sophistication of delusional systems usually reflect the individual’s intelligence. Persecutory delusions are more likely to be acted upon than are other types of delusions.²⁰

Malingerers may claim that a delusion began or disappeared suddenly. In reality, systematized delusions usually take weeks to develop and much longer to disappear. Typically, the delusion will become somewhat less relevant, and the individual will gradually relinquish its importance over time after adequate treatment. In general, the more bizarre the delusion’s content, the more disorganized the individual’s thinking is likely to be (Table 3).

With genuine delusions, the individual’s behavior usually conforms to the delusions’ content. For example, Russell Weston—who suffered from schizophrenia—made a deadly assault on the U.S. Capitol in 1998 because he held a delusional belief that cannibalism was destroying Washington, DC. Before he shot and killed two U.S. Capitol security officers, he had gone to the Central Intelligence Agency several years before and voiced the same delusional concerns.

Suspect malingering if a patient alleges persecutory delusions without engaging in corresponding paranoid behaviors. One exception is the person with long-standing schizophrenia who has grown accustomed to the delusion and whose behavior is no longer consistent with it.

Table 3

Uncommon psychosis presentations that suggest malingering

Where Malingerers Trip Up

Malingerers may have inadequate or incomplete knowledge of the mental illness they are faking. Indeed, malingerers are like actors who can portray a role only as well as they understand it. They often overact their part or mistakenly believe the more bizarre their behavior, the more convincing they will be. Conversely, “successful” malingerers are more likely to endorse fewer symptoms and avoid endorsing overly bizarre or unusual symptoms.²¹

Continue to: Numerous clinical factors suggest malingering...

Numerous clinical factors suggest malingering (Table 4). Malingerers are more likely to eagerly “thrust forward” their illness, whereas patients with genuine schizophrenia are often reluctant to discuss their symptoms.²²

Malingerers may attempt to take control of the interview and behave in an intimidating or hostile manner. They may accuse the psychiatrist of inferring that they are faking. Such behavior is rare in genuinely psychotic individuals. Although DSM-IV-TR states that antisocial personality disorder should arouse suspicions of malingering, some studies have failed to show a relationship. One study has associated psychopathic traits with malingering.²³

Malingerers often believe that faking intellectual deficits, in addition to psychotic symptoms, will make them more believable. For example, a man who had completed several years of college alleged that he did not know the colors of the American flag.

Malingerers are more likely to give vague or hedging answers to straightforward questions. For example, when asked whether an alleged voice was male or female, one malingerer replied, “It was probably a man’s voice.” Malingerers may also answer, “I don’t know” to detailed questions about psychotic symptoms. Whereas a person with genuine psychotic symptoms could easily give an answer, the malingerer may have never experienced the symptoms and consequently “doesn’t know” the correct answer.

Psychotic symptoms such as derailment, neologisms, loose associations, and word salad are rarely simulated. This is because it is much more difficult for a malingerer to successfully imitate psychotic thought processes than psychotic thought content. Similarly, it is unusual for a malingerer to fake schizophrenia’s subtle signs, such as negative symptoms.

Table 4

Clinical factors that suggest malingering

Psychological Testing

Although many psychometric tests are available for detecting malingered psychosis, few have been validated. Among the more reliable are:

• Structured Interview of Reported Symptoms (SIRS)
• Minnesota Multiphasic Personality Inventory, Revised (MMPI-2)
• Miller Forensic Assessment of Symptoms Test (M-FAST).¹¹

SIRS includes questions about rare symptoms, uncommon symptom pairing, atypical symptoms, and other indices involving excessive symptom reporting. It takes 30 to 60 minutes to administer. Tested in inpatient, forensic, and correctional populations, the SIRS has shown consistently high accuracy in detecting malingered psychiatric illness.²⁴

Two MMPI-2 scales—F-scale and F-K Index—are the most frequently used test for evaluating suspected malingering. When using the MMPI-2 in this manner, consult the literature for appropriate cutoff scores (see Related resources). Although the MMPI-2 is the most validated psychometric method to detect malingering, a malingerer with high intelligence and previous knowledge of the test could evade detection.²⁵

M-FAST was developed to provide a brief, reliable screen for malingered mental illness. This test takes 10 to 15 minutes to administer and measures rare symptom combinations, excessive reporting, and atypical symptoms.¹¹ It has shown good validity and high correlation with the SIRS and MMPI-2.^26,27

Confronting the Malingerer

If a thorough investigation indicates that a patient is malingering psychosis, you may decide to confront the evaluee. Avoid direct accusations of lying,¹⁰ and give the suspected malingerer every opportunity to save face. For example, it is preferable to say, “You haven’t told me the whole truth.”

A thoughtful approach that asks the evaluee to clarify inconsistencies is more likely to be productive and safer for the examiner. When confronting individuals with a history of violence and aggression, have adequate security personnel with you.

Related resources

• Structured Interview of Reported Symptoms (SIRS). Available for purchase from Psychological Assessment Resources at www3.parinc.com (enter “SIRS” in search field).
• Graham JR. MMPI-2: Assessing personality and psychopathology. New York: Oxford Press; 2000. (Source of cutoff scores to use MMPI-2 scales [F-scale and F-K Index] to evaluate suspected malingering).
• Psychological Assessment Resources, Inc. Miller Forensic Assessment of Symptoms Test (M-FAST). Available at: www3.parinc.com (enter “M-FAST” in search field).

Voice-over Internet protocol (VoIP), once a cutting-edge telecommunications innovation, has quickly reached the information age mainstream (See Fast facts). Homes and businesses are increasingly using broadband Internet connections to make inexpensive long-distance telephone calls.

Can VoIP help you communicate efficiently and cost-effectively with patients, staff, and colleagues? Read on.

How VoIP works

VoIP lets you make telephone calls using your Internet connection or other computer network. Calls from one PC to another are free, while calls from a PC to a landline or mobile phone are not.

In the most basic VoIP, a user at a computer with a microphone headset calls a similarly equipped user by entering an e-mail address or user name on a network, such as Skype’s “SkypeOut” program. Software transmits the audio signal over the Internet. The technology is similar to that of a mobile phone, which requires cellular towers to send packets of your audio signal.

For as little as 17 cents per minute, you can call from your computer to a regular telephone number anywhere in the world. Skype, SunRocket, and Vonage are among the more popular and inexpensive VoIP providers (Table). In addition to “SkypeOut,” Google, Yahoo, and MSN also offer free PC-to-PC calling with voice conferencing.

Another Skype service, “SkypeIn,” offers portable local numbers that allow callers—using a computer or a regular phone—to reach you wherever you go. You can be traveling in Paris and receive a phone call at a local Internet café with your notebook computer, yet the caller pays only the regular rate to call your number.

Only Skype offers software that allows telecommunication via Pocket PC. Blackberry is not supported for VoIP communication and SunRocket and Vonage do not offer PDA support.

Table

VoIP Providers

VoIP advantages

The ability to make free or low-cost calls to any location worldwide is an obvious advantage. For clinical use, VoIP can help psychiatrists reach patients who travel frequently and have Internet access.

For the psychiatrist who shuttles between offices, a portable number offers flexibility. Psychiatrists attending national meetings or CME courses can use VoIP to contact colleagues or communicate with patients or staff back home.

Online phone communication is also secure, because VoIP data packets are encrypted as they are sent over the Internet.

VoIP users may be able to eliminate their local telephone service and pay only for broadband Internet access. For emergencies when the Internet is not working, a mobile phone may be sufficient backup.

If you prefer a traditional phone to a microphone headset, you can use a phone equipped with a universal serial bus (USB) connector to make online calls. Skype offers phones with built-in USB connectors, while Vonage and SunRocket offer adapters that connect to regular phones and specialized phone adapters that connect to a phone, computer, or fax machine.

Skype, SunRocket, and Vonage offer call waiting and voice mail functions. Many VoIP software clients also offer text messaging and conference calling, allowing you to use your computer to type notes or send files while making a VoIP call. Some VoIP providers, such as Yahoo! Messenger, offer a video signal as well.

Skype offers a Pocket PC software client that lets you make telephone calls while connected to the Internet with a Pocket PC personal digital assistant (PDA). Having a Pocket PC with unlimited monthly wireless Internet data service and using SkypeOut to make mobile telephone calls for 2.4 cents per minute within the continental United States can help control combined PDA/phone charges. Skype will release a Palm OS version of this software sometime this month.¹

Drawbacks

When your Internet access is down, you cannot make or receive VoIP calls. Also, as with mobile phones, the connection at times may be dropped or sound somewhat muffled. Overall, VoIP sound quality is on par with mobile phones, but not as good as conventional landline phones.

If traffic over your Internet connection is heavy—with downloads and other applications competing for bandwidth—connection quality can suffer. One solution is to use a router that gives priority to the VoIP application and its data. A router, similar to a “traffic cop” on a shared Internet connection, knows which data to send to and from the different computers/devices and the Internet connection.² The D-Link Broadband Phone Service VoIP Router, for example, enables VoIP calls and Internet sharing.

VoIP inboxes theoretically are vulnerable to spam attacks because of e-mail addresses associated with accounts. Qovia is seeking a patent for technology designed to guard against VoIP spam, but VoIP spam attacks have not yet been reported because VoIP has only recently become popular.²

As mentioned, VoIP could eliminate the need for a regular telephone line, but if you use a digital subscriber line (DSL) for Internet access, you will need to keep at least a local telephone service.

Telecommunication: the future

The development of faster Internet access with Internet2 could lead to consolidation in the communications industry, allowing voice, data, video and other media to be managed via one connection. Internet2 is a consortium of universities working with industry and government to develop and deploy advanced network applications and technologies for the creation of tomorrow’s Internet.

Related resources

• 1. Federal Communications Commission. Voice-over Internet protocol: frequently asked questions. http://www.fcc.gov/voip/
• 2. Internet2. http://www.internet2.edu/

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

Voice-over Internet protocol (VoIP), once a cutting-edge telecommunications innovation, has quickly reached the information age mainstream (See Fast facts). Homes and businesses are increasingly using broadband Internet connections to make inexpensive long-distance telephone calls.

Can VoIP help you communicate efficiently and cost-effectively with patients, staff, and colleagues? Read on.

How VoIP works

VoIP lets you make telephone calls using your Internet connection or other computer network. Calls from one PC to another are free, while calls from a PC to a landline or mobile phone are not.

In the most basic VoIP, a user at a computer with a microphone headset calls a similarly equipped user by entering an e-mail address or user name on a network, such as Skype’s “SkypeOut” program. Software transmits the audio signal over the Internet. The technology is similar to that of a mobile phone, which requires cellular towers to send packets of your audio signal.

For as little as 17 cents per minute, you can call from your computer to a regular telephone number anywhere in the world. Skype, SunRocket, and Vonage are among the more popular and inexpensive VoIP providers (Table). In addition to “SkypeOut,” Google, Yahoo, and MSN also offer free PC-to-PC calling with voice conferencing.

Another Skype service, “SkypeIn,” offers portable local numbers that allow callers—using a computer or a regular phone—to reach you wherever you go. You can be traveling in Paris and receive a phone call at a local Internet café with your notebook computer, yet the caller pays only the regular rate to call your number.

Only Skype offers software that allows telecommunication via Pocket PC. Blackberry is not supported for VoIP communication and SunRocket and Vonage do not offer PDA support.

Table

VoIP Providers

VoIP advantages

The ability to make free or low-cost calls to any location worldwide is an obvious advantage. For clinical use, VoIP can help psychiatrists reach patients who travel frequently and have Internet access.

For the psychiatrist who shuttles between offices, a portable number offers flexibility. Psychiatrists attending national meetings or CME courses can use VoIP to contact colleagues or communicate with patients or staff back home.

Online phone communication is also secure, because VoIP data packets are encrypted as they are sent over the Internet.

VoIP users may be able to eliminate their local telephone service and pay only for broadband Internet access. For emergencies when the Internet is not working, a mobile phone may be sufficient backup.

If you prefer a traditional phone to a microphone headset, you can use a phone equipped with a universal serial bus (USB) connector to make online calls. Skype offers phones with built-in USB connectors, while Vonage and SunRocket offer adapters that connect to regular phones and specialized phone adapters that connect to a phone, computer, or fax machine.

Skype, SunRocket, and Vonage offer call waiting and voice mail functions. Many VoIP software clients also offer text messaging and conference calling, allowing you to use your computer to type notes or send files while making a VoIP call. Some VoIP providers, such as Yahoo! Messenger, offer a video signal as well.

Skype offers a Pocket PC software client that lets you make telephone calls while connected to the Internet with a Pocket PC personal digital assistant (PDA). Having a Pocket PC with unlimited monthly wireless Internet data service and using SkypeOut to make mobile telephone calls for 2.4 cents per minute within the continental United States can help control combined PDA/phone charges. Skype will release a Palm OS version of this software sometime this month.¹

Drawbacks

When your Internet access is down, you cannot make or receive VoIP calls. Also, as with mobile phones, the connection at times may be dropped or sound somewhat muffled. Overall, VoIP sound quality is on par with mobile phones, but not as good as conventional landline phones.

If traffic over your Internet connection is heavy—with downloads and other applications competing for bandwidth—connection quality can suffer. One solution is to use a router that gives priority to the VoIP application and its data. A router, similar to a “traffic cop” on a shared Internet connection, knows which data to send to and from the different computers/devices and the Internet connection.² The D-Link Broadband Phone Service VoIP Router, for example, enables VoIP calls and Internet sharing.

VoIP inboxes theoretically are vulnerable to spam attacks because of e-mail addresses associated with accounts. Qovia is seeking a patent for technology designed to guard against VoIP spam, but VoIP spam attacks have not yet been reported because VoIP has only recently become popular.²

As mentioned, VoIP could eliminate the need for a regular telephone line, but if you use a digital subscriber line (DSL) for Internet access, you will need to keep at least a local telephone service.

Telecommunication: the future

The development of faster Internet access with Internet2 could lead to consolidation in the communications industry, allowing voice, data, video and other media to be managed via one connection. Internet2 is a consortium of universities working with industry and government to develop and deploy advanced network applications and technologies for the creation of tomorrow’s Internet.

Related resources

• 1. Federal Communications Commission. Voice-over Internet protocol: frequently asked questions. http://www.fcc.gov/voip/
• 2. Internet2. http://www.internet2.edu/

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

Voice-over Internet protocol (VoIP), once a cutting-edge telecommunications innovation, has quickly reached the information age mainstream (See Fast facts). Homes and businesses are increasingly using broadband Internet connections to make inexpensive long-distance telephone calls.

Can VoIP help you communicate efficiently and cost-effectively with patients, staff, and colleagues? Read on.

How VoIP works

VoIP lets you make telephone calls using your Internet connection or other computer network. Calls from one PC to another are free, while calls from a PC to a landline or mobile phone are not.

In the most basic VoIP, a user at a computer with a microphone headset calls a similarly equipped user by entering an e-mail address or user name on a network, such as Skype’s “SkypeOut” program. Software transmits the audio signal over the Internet. The technology is similar to that of a mobile phone, which requires cellular towers to send packets of your audio signal.

For as little as 17 cents per minute, you can call from your computer to a regular telephone number anywhere in the world. Skype, SunRocket, and Vonage are among the more popular and inexpensive VoIP providers (Table). In addition to “SkypeOut,” Google, Yahoo, and MSN also offer free PC-to-PC calling with voice conferencing.

Another Skype service, “SkypeIn,” offers portable local numbers that allow callers—using a computer or a regular phone—to reach you wherever you go. You can be traveling in Paris and receive a phone call at a local Internet café with your notebook computer, yet the caller pays only the regular rate to call your number.

Only Skype offers software that allows telecommunication via Pocket PC. Blackberry is not supported for VoIP communication and SunRocket and Vonage do not offer PDA support.

Table

VoIP Providers

VoIP advantages

The ability to make free or low-cost calls to any location worldwide is an obvious advantage. For clinical use, VoIP can help psychiatrists reach patients who travel frequently and have Internet access.

For the psychiatrist who shuttles between offices, a portable number offers flexibility. Psychiatrists attending national meetings or CME courses can use VoIP to contact colleagues or communicate with patients or staff back home.

Online phone communication is also secure, because VoIP data packets are encrypted as they are sent over the Internet.

VoIP users may be able to eliminate their local telephone service and pay only for broadband Internet access. For emergencies when the Internet is not working, a mobile phone may be sufficient backup.

If you prefer a traditional phone to a microphone headset, you can use a phone equipped with a universal serial bus (USB) connector to make online calls. Skype offers phones with built-in USB connectors, while Vonage and SunRocket offer adapters that connect to regular phones and specialized phone adapters that connect to a phone, computer, or fax machine.

Skype, SunRocket, and Vonage offer call waiting and voice mail functions. Many VoIP software clients also offer text messaging and conference calling, allowing you to use your computer to type notes or send files while making a VoIP call. Some VoIP providers, such as Yahoo! Messenger, offer a video signal as well.

Skype offers a Pocket PC software client that lets you make telephone calls while connected to the Internet with a Pocket PC personal digital assistant (PDA). Having a Pocket PC with unlimited monthly wireless Internet data service and using SkypeOut to make mobile telephone calls for 2.4 cents per minute within the continental United States can help control combined PDA/phone charges. Skype will release a Palm OS version of this software sometime this month.¹

Drawbacks

When your Internet access is down, you cannot make or receive VoIP calls. Also, as with mobile phones, the connection at times may be dropped or sound somewhat muffled. Overall, VoIP sound quality is on par with mobile phones, but not as good as conventional landline phones.

If traffic over your Internet connection is heavy—with downloads and other applications competing for bandwidth—connection quality can suffer. One solution is to use a router that gives priority to the VoIP application and its data. A router, similar to a “traffic cop” on a shared Internet connection, knows which data to send to and from the different computers/devices and the Internet connection.² The D-Link Broadband Phone Service VoIP Router, for example, enables VoIP calls and Internet sharing.

VoIP inboxes theoretically are vulnerable to spam attacks because of e-mail addresses associated with accounts. Qovia is seeking a patent for technology designed to guard against VoIP spam, but VoIP spam attacks have not yet been reported because VoIP has only recently become popular.²

As mentioned, VoIP could eliminate the need for a regular telephone line, but if you use a digital subscriber line (DSL) for Internet access, you will need to keep at least a local telephone service.

Telecommunication: the future

The development of faster Internet access with Internet2 could lead to consolidation in the communications industry, allowing voice, data, video and other media to be managed via one connection. Internet2 is a consortium of universities working with industry and government to develop and deploy advanced network applications and technologies for the creation of tomorrow’s Internet.

Related resources

• 1. Federal Communications Commission. Voice-over Internet protocol: frequently asked questions. http://www.fcc.gov/voip/
• 2. Internet2. http://www.internet2.edu/

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

A new, FDA-approved in-office lithium test (Table) can eliminate the inconvenience and fallibility of testing venous blood samples that often discourage lithium use. The test, which measures lithium in capillary blood drawn from a finger stick, has shown reliability when compared in clinical trials with established testing methods.

Why finger-stick testing?

Periodically monitoring serum or plasma lithium minimizes side effects and toxicity, maintains therapeutic dosing, and ensures treatment adherence. Laboratories generally use flame photometry, atomic absorption (AA) spectrophotometry, or ion-selective electrode analysis to measure lithium in blood drawn via venipuncture. A colorimetric assay is also available.¹

Table

Lithium fingerstick test: Fast facts

For years, researchers have investigated alternatives to venipuncture lithium testing. Aside from being inconvenient, venipuncture draws can increase risk of excessive bleeding, hematoma, infection, vasovagal syncope, and multiple punctures to locate a vein. In some cases:

• psychiatrists wait 2 or more days for a laboratory to return results
• patients forget to have blood drawn before the office visit
• samples are incorrectly timed in relation to the last dose
• results are filed away unnoticed
• or the psychiatrist needs to call the patient 3 days or so after the visit to discuss an abnormal reading.

With the new in-office test, clinicians can ensure they will obtain a valid blood sample in minutes, 12 hours after dosing. Psychiatrists then can immediately discuss the result with patients, perform a repeat test 5 minutes later to check an abnormal reading, and counsel patients on raising low lithium levels. This instant feedback can powerfully reinforce a physician’s advice and promote treatment adherence.²

How it works

A 50-μl blood sample is drawn via finger stick and converted to plasma in a lectin-coated membrane separator. The clinician then adds 0.2 μl of the plasma to a micro-cuvette containing a colorimetric reagent that is photometrically analyzed for lithium. The test takes 5 minutes or less (Figure).

The assay has been shown to be sensitive to 0.1 mEq/L of lithium and linear between 0.1 and 2.5 mEq/L.³

Figure How finger-stick lithium test works

Clinician obtains blood sample (a) and empties it into a separator (b), which processes blood to plasma. Clinician then adds plasma to a reagent vial (c), which is inserted into a reader (d) to obtain a lithium level.

Reliability

In clinical trials during which patients were tested and retested, the colorimetric assay showed reliability when compared with:

• routine lithium spectrophotometry. Researchers compared venipuncture blood samples split for colorimetric and spectrophotometric testing
• atomic absorption spectrophotometry of venipuncture blood from psychiatric patients
• standard spectrophotometry of venipuncture samples to which a known amount of lithium was added.⁴

Colorimetric finger-stick testing also was compared with AA spectrophotometry testing of 88 matched venipuncture samples from 56 bipolar patients.⁵ Results were not identical, but most fingerstick results varied no more than±0.2 mEq/L from the AA results. Differences were positive and negative, indicating random variation between the two methods rather than systematic bias.

Clinical applicability

In-office finger-stick blood testing for lithium levels could improve quality of care for patients taking lithium.

The manufacturer, ReliaLAB, says the test costs $399, plus $264 for a refill kit containing 24 patient test packs. A certain volume of patients taking lithium would seem to be necessary to justify purchasing the instrument.

The test may be reimbursable under certain circumstances. ReliaLAB offers information on coding and reimbursement for in-office lithium monitoring (Table).

Also, because instant in-office creatinine and thyroid-stimulating hormone tests are not available, lithium therapy monitoring will still require laboratory visits when these tests are needed. Nonetheless, point-of-care plasma lithium level determination should improve convenience, compliance, and overall comprehensiveness of care.

Related resources

• Online information on in-office lithium test. www.relialab.com/Lith.html.
• Johnson FN. The origins of lithium therapy. Rev Contemp Pharmacother 1999;10:193-265.

Drug brand names

• Lithium • Eskalith, others

Disclosure

Dr. Jefferson reports no financial relationship with or proprietary interest in ReliaLAB.

A new, FDA-approved in-office lithium test (Table) can eliminate the inconvenience and fallibility of testing venous blood samples that often discourage lithium use. The test, which measures lithium in capillary blood drawn from a finger stick, has shown reliability when compared in clinical trials with established testing methods.

Why finger-stick testing?

Periodically monitoring serum or plasma lithium minimizes side effects and toxicity, maintains therapeutic dosing, and ensures treatment adherence. Laboratories generally use flame photometry, atomic absorption (AA) spectrophotometry, or ion-selective electrode analysis to measure lithium in blood drawn via venipuncture. A colorimetric assay is also available.¹

Table

Lithium fingerstick test: Fast facts

For years, researchers have investigated alternatives to venipuncture lithium testing. Aside from being inconvenient, venipuncture draws can increase risk of excessive bleeding, hematoma, infection, vasovagal syncope, and multiple punctures to locate a vein. In some cases:

• psychiatrists wait 2 or more days for a laboratory to return results
• patients forget to have blood drawn before the office visit
• samples are incorrectly timed in relation to the last dose
• results are filed away unnoticed
• or the psychiatrist needs to call the patient 3 days or so after the visit to discuss an abnormal reading.

With the new in-office test, clinicians can ensure they will obtain a valid blood sample in minutes, 12 hours after dosing. Psychiatrists then can immediately discuss the result with patients, perform a repeat test 5 minutes later to check an abnormal reading, and counsel patients on raising low lithium levels. This instant feedback can powerfully reinforce a physician’s advice and promote treatment adherence.²

How it works

A 50-μl blood sample is drawn via finger stick and converted to plasma in a lectin-coated membrane separator. The clinician then adds 0.2 μl of the plasma to a micro-cuvette containing a colorimetric reagent that is photometrically analyzed for lithium. The test takes 5 minutes or less (Figure).

The assay has been shown to be sensitive to 0.1 mEq/L of lithium and linear between 0.1 and 2.5 mEq/L.³

Figure How finger-stick lithium test works

Clinician obtains blood sample (a) and empties it into a separator (b), which processes blood to plasma. Clinician then adds plasma to a reagent vial (c), which is inserted into a reader (d) to obtain a lithium level.

Reliability

In clinical trials during which patients were tested and retested, the colorimetric assay showed reliability when compared with:

• routine lithium spectrophotometry. Researchers compared venipuncture blood samples split for colorimetric and spectrophotometric testing
• atomic absorption spectrophotometry of venipuncture blood from psychiatric patients
• standard spectrophotometry of venipuncture samples to which a known amount of lithium was added.⁴

Colorimetric finger-stick testing also was compared with AA spectrophotometry testing of 88 matched venipuncture samples from 56 bipolar patients.⁵ Results were not identical, but most fingerstick results varied no more than±0.2 mEq/L from the AA results. Differences were positive and negative, indicating random variation between the two methods rather than systematic bias.

Clinical applicability

In-office finger-stick blood testing for lithium levels could improve quality of care for patients taking lithium.

The manufacturer, ReliaLAB, says the test costs $399, plus $264 for a refill kit containing 24 patient test packs. A certain volume of patients taking lithium would seem to be necessary to justify purchasing the instrument.

The test may be reimbursable under certain circumstances. ReliaLAB offers information on coding and reimbursement for in-office lithium monitoring (Table).

Also, because instant in-office creatinine and thyroid-stimulating hormone tests are not available, lithium therapy monitoring will still require laboratory visits when these tests are needed. Nonetheless, point-of-care plasma lithium level determination should improve convenience, compliance, and overall comprehensiveness of care.

Related resources

• Online information on in-office lithium test. www.relialab.com/Lith.html.
• Johnson FN. The origins of lithium therapy. Rev Contemp Pharmacother 1999;10:193-265.

Drug brand names

• Lithium • Eskalith, others

Disclosure

Dr. Jefferson reports no financial relationship with or proprietary interest in ReliaLAB.

A new, FDA-approved in-office lithium test (Table) can eliminate the inconvenience and fallibility of testing venous blood samples that often discourage lithium use. The test, which measures lithium in capillary blood drawn from a finger stick, has shown reliability when compared in clinical trials with established testing methods.

Why finger-stick testing?

Periodically monitoring serum or plasma lithium minimizes side effects and toxicity, maintains therapeutic dosing, and ensures treatment adherence. Laboratories generally use flame photometry, atomic absorption (AA) spectrophotometry, or ion-selective electrode analysis to measure lithium in blood drawn via venipuncture. A colorimetric assay is also available.¹

Table

Lithium fingerstick test: Fast facts

For years, researchers have investigated alternatives to venipuncture lithium testing. Aside from being inconvenient, venipuncture draws can increase risk of excessive bleeding, hematoma, infection, vasovagal syncope, and multiple punctures to locate a vein. In some cases:

• psychiatrists wait 2 or more days for a laboratory to return results
• patients forget to have blood drawn before the office visit
• samples are incorrectly timed in relation to the last dose
• results are filed away unnoticed
• or the psychiatrist needs to call the patient 3 days or so after the visit to discuss an abnormal reading.

With the new in-office test, clinicians can ensure they will obtain a valid blood sample in minutes, 12 hours after dosing. Psychiatrists then can immediately discuss the result with patients, perform a repeat test 5 minutes later to check an abnormal reading, and counsel patients on raising low lithium levels. This instant feedback can powerfully reinforce a physician’s advice and promote treatment adherence.²

How it works

A 50-μl blood sample is drawn via finger stick and converted to plasma in a lectin-coated membrane separator. The clinician then adds 0.2 μl of the plasma to a micro-cuvette containing a colorimetric reagent that is photometrically analyzed for lithium. The test takes 5 minutes or less (Figure).

The assay has been shown to be sensitive to 0.1 mEq/L of lithium and linear between 0.1 and 2.5 mEq/L.³

Figure How finger-stick lithium test works

Clinician obtains blood sample (a) and empties it into a separator (b), which processes blood to plasma. Clinician then adds plasma to a reagent vial (c), which is inserted into a reader (d) to obtain a lithium level.

Reliability

In clinical trials during which patients were tested and retested, the colorimetric assay showed reliability when compared with:

• routine lithium spectrophotometry. Researchers compared venipuncture blood samples split for colorimetric and spectrophotometric testing
• atomic absorption spectrophotometry of venipuncture blood from psychiatric patients
• standard spectrophotometry of venipuncture samples to which a known amount of lithium was added.⁴

Colorimetric finger-stick testing also was compared with AA spectrophotometry testing of 88 matched venipuncture samples from 56 bipolar patients.⁵ Results were not identical, but most fingerstick results varied no more than±0.2 mEq/L from the AA results. Differences were positive and negative, indicating random variation between the two methods rather than systematic bias.

Clinical applicability

In-office finger-stick blood testing for lithium levels could improve quality of care for patients taking lithium.

The manufacturer, ReliaLAB, says the test costs $399, plus $264 for a refill kit containing 24 patient test packs. A certain volume of patients taking lithium would seem to be necessary to justify purchasing the instrument.

The test may be reimbursable under certain circumstances. ReliaLAB offers information on coding and reimbursement for in-office lithium monitoring (Table).

Also, because instant in-office creatinine and thyroid-stimulating hormone tests are not available, lithium therapy monitoring will still require laboratory visits when these tests are needed. Nonetheless, point-of-care plasma lithium level determination should improve convenience, compliance, and overall comprehensiveness of care.

Related resources

• Online information on in-office lithium test. www.relialab.com/Lith.html.
• Johnson FN. The origins of lithium therapy. Rev Contemp Pharmacother 1999;10:193-265.

Drug brand names

• Lithium • Eskalith, others

Disclosure

Dr. Jefferson reports no financial relationship with or proprietary interest in ReliaLAB.

A patient with early-stage dementia may wish to write a will before diminishing memory and cognition void future legal transactions.¹You can help patients protect their heirs from posthumous legal struggles by:

• advising them to consult an attorney about drafting a will
  
• and explaining the basics of testamentary capacity.
  

Testamentary capacity is a person’s ability to understand his property ownership, rights to claiming that property, and the practical effects of executing his will. Determining whether a person has testamentary capacity rests with a judge or jury, but courts often ask psychiatrists—especially those who diagnose dementia—to help describe the deceased’s state of mind when he or she wrote a contested will.

When a will is in probate, a usual heir or some other person may challenge its validity. Lawsuits questioning whether an elderly person had the mental capacity to authorize a legal transaction often hinge on two possible claims:

• undue influence (the will writer was not capable of resisting pressure or manipulation by a person who wanted to influence property distribution)²
  
• insane delusion (the will writer had mistaken beliefs that were not based in reason and could only be explained by mental illness).
  

The mere presence of mental illnesses, even severe schizophrenia or dementia, does not automatically render a person incapable of creating a valid will.² In fact, the court requires a higher level of decision-making capacity for other legal transactions such as contracts. Will writing is an individual matter, whereas a valid contract involves an agreement between two or more persons and necessitates a higher level of functioning to understand.¹

When counselling patients and their families, explain the basics of testamentary capacity so they can get help navigating end-of-life legal decisions. Legal transactions are more likely to be upheld in court if they are made in the early stages of a dementing disorder, rather than after it progresses.

A patient with early-stage dementia may wish to write a will before diminishing memory and cognition void future legal transactions.¹You can help patients protect their heirs from posthumous legal struggles by:

• advising them to consult an attorney about drafting a will
  
• and explaining the basics of testamentary capacity.
  

Testamentary capacity is a person’s ability to understand his property ownership, rights to claiming that property, and the practical effects of executing his will. Determining whether a person has testamentary capacity rests with a judge or jury, but courts often ask psychiatrists—especially those who diagnose dementia—to help describe the deceased’s state of mind when he or she wrote a contested will.

When a will is in probate, a usual heir or some other person may challenge its validity. Lawsuits questioning whether an elderly person had the mental capacity to authorize a legal transaction often hinge on two possible claims:

• undue influence (the will writer was not capable of resisting pressure or manipulation by a person who wanted to influence property distribution)²
  
• insane delusion (the will writer had mistaken beliefs that were not based in reason and could only be explained by mental illness).
  

The mere presence of mental illnesses, even severe schizophrenia or dementia, does not automatically render a person incapable of creating a valid will.² In fact, the court requires a higher level of decision-making capacity for other legal transactions such as contracts. Will writing is an individual matter, whereas a valid contract involves an agreement between two or more persons and necessitates a higher level of functioning to understand.¹

When counselling patients and their families, explain the basics of testamentary capacity so they can get help navigating end-of-life legal decisions. Legal transactions are more likely to be upheld in court if they are made in the early stages of a dementing disorder, rather than after it progresses.

A patient with early-stage dementia may wish to write a will before diminishing memory and cognition void future legal transactions.¹You can help patients protect their heirs from posthumous legal struggles by:

• advising them to consult an attorney about drafting a will
  
• and explaining the basics of testamentary capacity.
  

Testamentary capacity is a person’s ability to understand his property ownership, rights to claiming that property, and the practical effects of executing his will. Determining whether a person has testamentary capacity rests with a judge or jury, but courts often ask psychiatrists—especially those who diagnose dementia—to help describe the deceased’s state of mind when he or she wrote a contested will.

When a will is in probate, a usual heir or some other person may challenge its validity. Lawsuits questioning whether an elderly person had the mental capacity to authorize a legal transaction often hinge on two possible claims:

• undue influence (the will writer was not capable of resisting pressure or manipulation by a person who wanted to influence property distribution)²
  
• insane delusion (the will writer had mistaken beliefs that were not based in reason and could only be explained by mental illness).
  

The mere presence of mental illnesses, even severe schizophrenia or dementia, does not automatically render a person incapable of creating a valid will.² In fact, the court requires a higher level of decision-making capacity for other legal transactions such as contracts. Will writing is an individual matter, whereas a valid contract involves an agreement between two or more persons and necessitates a higher level of functioning to understand.¹

When counselling patients and their families, explain the basics of testamentary capacity so they can get help navigating end-of-life legal decisions. Legal transactions are more likely to be upheld in court if they are made in the early stages of a dementing disorder, rather than after it progresses.

Collaborative (or split) treatment—when therapists provide primarily psychotherapy while psychiatrists manage medication¹—carries benefits and risks (Table).² Six simple steps can improve treatment quality for both patients and the treatment teams.

Obtain the therapist’s diagnostic evaluation before the patient’s first visit with you to learn why he or she sought help from a mental health professional.

Reduce liability risk by asking the collaborative therapist to share significant developments in the patient’s life such as suicide attempts, traumatic events, medication side effects, etc. Document that you had this discussion.

Read the therapist’s recent progress notes every time you see the patient to greatly reduce chances of “splitting,” a type of interference in which a patient sides with one person or faction that causes infighting within the team. If the collaborative therapist practices at a facility other than your own, ask the therapist to send you a summary of his or her notes periodically.

Encourage the therapist to discuss medication early. Even if the therapist does not expect medication to become necessary, suggest a discussion about the possibility of a medication trial with the patient early in treatment. This can avoid confusion about the psychiatrist’s and therapist’s roles later in therapy.

Discuss medications’ limitations to minimize therapists’ and patients’ impulse to change medication whenever the patient endures an emotional challenge or mild side effect.

Maximize communication with e-mail and phone calls. Schedule time for communicating with collaborative therapists. Above all, maintain mutual respect for different disciplines.

Table

Benefits and risks of collaborative treatment

Collaborative (or split) treatment—when therapists provide primarily psychotherapy while psychiatrists manage medication¹—carries benefits and risks (Table).² Six simple steps can improve treatment quality for both patients and the treatment teams.

Obtain the therapist’s diagnostic evaluation before the patient’s first visit with you to learn why he or she sought help from a mental health professional.

Reduce liability risk by asking the collaborative therapist to share significant developments in the patient’s life such as suicide attempts, traumatic events, medication side effects, etc. Document that you had this discussion.

Read the therapist’s recent progress notes every time you see the patient to greatly reduce chances of “splitting,” a type of interference in which a patient sides with one person or faction that causes infighting within the team. If the collaborative therapist practices at a facility other than your own, ask the therapist to send you a summary of his or her notes periodically.

Encourage the therapist to discuss medication early. Even if the therapist does not expect medication to become necessary, suggest a discussion about the possibility of a medication trial with the patient early in treatment. This can avoid confusion about the psychiatrist’s and therapist’s roles later in therapy.

Discuss medications’ limitations to minimize therapists’ and patients’ impulse to change medication whenever the patient endures an emotional challenge or mild side effect.

Maximize communication with e-mail and phone calls. Schedule time for communicating with collaborative therapists. Above all, maintain mutual respect for different disciplines.

Table

Benefits and risks of collaborative treatment

Collaborative (or split) treatment—when therapists provide primarily psychotherapy while psychiatrists manage medication¹—carries benefits and risks (Table).² Six simple steps can improve treatment quality for both patients and the treatment teams.

Obtain the therapist’s diagnostic evaluation before the patient’s first visit with you to learn why he or she sought help from a mental health professional.

Reduce liability risk by asking the collaborative therapist to share significant developments in the patient’s life such as suicide attempts, traumatic events, medication side effects, etc. Document that you had this discussion.

Read the therapist’s recent progress notes every time you see the patient to greatly reduce chances of “splitting,” a type of interference in which a patient sides with one person or faction that causes infighting within the team. If the collaborative therapist practices at a facility other than your own, ask the therapist to send you a summary of his or her notes periodically.

Encourage the therapist to discuss medication early. Even if the therapist does not expect medication to become necessary, suggest a discussion about the possibility of a medication trial with the patient early in treatment. This can avoid confusion about the psychiatrist’s and therapist’s roles later in therapy.

Discuss medications’ limitations to minimize therapists’ and patients’ impulse to change medication whenever the patient endures an emotional challenge or mild side effect.

Maximize communication with e-mail and phone calls. Schedule time for communicating with collaborative therapists. Above all, maintain mutual respect for different disciplines.

Table

Benefits and risks of collaborative treatment

As I read your article on adolescent violence (Current Psychiatry, June 2005), I wondered whether two adolescent profiles contribute to school-related violence.

The first group may be as described in the article: adolescents who are alienated, victims of bullying, overwhelmingly male, and prone to outbursts of homicidal violence in response to vengeful feelings.

The second group may seem more connected to others and viewed as popular by peers. The basis for their violence—which takes the form of degrading and humiliating behavior—is less evident. These individuals populate the bully group and often victimize the first group, sometimes contributing to violent responses from the victims.

I appreciate this practical paper being published in a psychiatric journal. I look forward to possible further exploration of this important topic for psychiatrists.

Marshall L. Garrick, MD
Clinical instructor of psychiatry
University of Illinois at Urbana-Champaign, Urbana

As I read your article on adolescent violence (Current Psychiatry, June 2005), I wondered whether two adolescent profiles contribute to school-related violence.

The first group may be as described in the article: adolescents who are alienated, victims of bullying, overwhelmingly male, and prone to outbursts of homicidal violence in response to vengeful feelings.

The second group may seem more connected to others and viewed as popular by peers. The basis for their violence—which takes the form of degrading and humiliating behavior—is less evident. These individuals populate the bully group and often victimize the first group, sometimes contributing to violent responses from the victims.

I appreciate this practical paper being published in a psychiatric journal. I look forward to possible further exploration of this important topic for psychiatrists.

Marshall L. Garrick, MD
Clinical instructor of psychiatry
University of Illinois at Urbana-Champaign, Urbana

As I read your article on adolescent violence (Current Psychiatry, June 2005), I wondered whether two adolescent profiles contribute to school-related violence.

The first group may be as described in the article: adolescents who are alienated, victims of bullying, overwhelmingly male, and prone to outbursts of homicidal violence in response to vengeful feelings.

The second group may seem more connected to others and viewed as popular by peers. The basis for their violence—which takes the form of degrading and humiliating behavior—is less evident. These individuals populate the bully group and often victimize the first group, sometimes contributing to violent responses from the victims.

I appreciate this practical paper being published in a psychiatric journal. I look forward to possible further exploration of this important topic for psychiatrists.

Marshall L. Garrick, MD
Clinical instructor of psychiatry
University of Illinois at Urbana-Champaign, Urbana

In “Nothing More than Feelings?” (Current Psychiatry, July 2005), a psychiatrist is asked to decide whether a convicted child molester should receive testosterone treatment so that he can have sex with his girlfriend.

The article demonstrates a physician’s failure to do one of his or her most important functions: obtain as much information as possible before deciding on any course of treatment.

First, talk in person with the girlfriend with whom the patient says he wishes to have sexual intercourse. Does she really exist, or did the patient make up this story to obtain testosterone? What does she have to say about the patient and his sexual potency? Is she a reliable informant?

Second, talk to the patient’s parole agent. He or she is legally responsible for making sure that the patient stays out of trouble. The parole agent should have much information about the patient and be able to tell the psychiatrist whom else to contact. Also, talk to anyone else—such as a family member or roommate—who might have information about the patient.

Finally, the physicians should have tried one of the newer erectile dysfunction medications, such as sildenafil, before considering testosterone therapy.

Yehuda Sherman, MD
Lafayette, CA

The authors respond

We agree with Dr. Sherman’s comments and thank him for his feedback. We are happy that this important article is grabbing readers’ interest.

David Krassner, MD
San Luis Obispo County Mental Health Services
San Luis Obispo, CA
Robert Hierholzer, MD
Matthew Battista, PhD
University of California, San Francisco

In “Nothing More than Feelings?” (Current Psychiatry, July 2005), a psychiatrist is asked to decide whether a convicted child molester should receive testosterone treatment so that he can have sex with his girlfriend.

The article demonstrates a physician’s failure to do one of his or her most important functions: obtain as much information as possible before deciding on any course of treatment.

First, talk in person with the girlfriend with whom the patient says he wishes to have sexual intercourse. Does she really exist, or did the patient make up this story to obtain testosterone? What does she have to say about the patient and his sexual potency? Is she a reliable informant?

Second, talk to the patient’s parole agent. He or she is legally responsible for making sure that the patient stays out of trouble. The parole agent should have much information about the patient and be able to tell the psychiatrist whom else to contact. Also, talk to anyone else—such as a family member or roommate—who might have information about the patient.

Finally, the physicians should have tried one of the newer erectile dysfunction medications, such as sildenafil, before considering testosterone therapy.

Yehuda Sherman, MD
Lafayette, CA

The authors respond

We agree with Dr. Sherman’s comments and thank him for his feedback. We are happy that this important article is grabbing readers’ interest.

David Krassner, MD
San Luis Obispo County Mental Health Services
San Luis Obispo, CA
Robert Hierholzer, MD
Matthew Battista, PhD
University of California, San Francisco

In “Nothing More than Feelings?” (Current Psychiatry, July 2005), a psychiatrist is asked to decide whether a convicted child molester should receive testosterone treatment so that he can have sex with his girlfriend.

The article demonstrates a physician’s failure to do one of his or her most important functions: obtain as much information as possible before deciding on any course of treatment.

First, talk in person with the girlfriend with whom the patient says he wishes to have sexual intercourse. Does she really exist, or did the patient make up this story to obtain testosterone? What does she have to say about the patient and his sexual potency? Is she a reliable informant?

Second, talk to the patient’s parole agent. He or she is legally responsible for making sure that the patient stays out of trouble. The parole agent should have much information about the patient and be able to tell the psychiatrist whom else to contact. Also, talk to anyone else—such as a family member or roommate—who might have information about the patient.

Finally, the physicians should have tried one of the newer erectile dysfunction medications, such as sildenafil, before considering testosterone therapy.

Yehuda Sherman, MD
Lafayette, CA

The authors respond

We agree with Dr. Sherman’s comments and thank him for his feedback. We are happy that this important article is grabbing readers’ interest.

David Krassner, MD
San Luis Obispo County Mental Health Services
San Luis Obispo, CA
Robert Hierholzer, MD
Matthew Battista, PhD
University of California, San Francisco

“Managing dementia: Risks of using vs. not using atypical antipsychotics” (Current Psychiatry, August 2005) presents an informative debate on atypicals’ risk-benefit ratio. It is good practice to monitor all elderly patients with risk factors for cerebrovascular and cardiovascular events, regardless of which psychotropic is prescribed.

The FDA, however, has reported increased mortality with atypical antipsychotics in elderly patients with dementia-related psychosis, but not among older persons with psychosis secondary to other causes, such as schizophrenia or mood disorders. Upon reading the “Bottom Line” of this well-written article, one might erroneously generalize the FDA warning to all elderly patients.

Harpriya A. Bhagar, MBBS
Assistant professor, department of psychiatry
Indiana University School of Medicine
Indianapolis

It was amazing that in “Managing dementia: Risks of using vs. not using atypical antipsychotics,” gabapentin was never mentioned among the anticonvulsants being used to stabilize mood.

Gabapentin is by far the most benign anticonvulsant with respect to drug-drug interactions, metabolism, and protein binding (so benign that it is not effective for mania because it lacks affinity for glutamate and other receptors). Montoring gabapentin blood levels is not necessary—a plus considering that added venipuncture is not desirable in easily agitated, often combative patients with dementia. Gabapentin may also provide pain relief.

Gamma-aminobutyric acid (GABA) is, after all, the universal inhibitor. Gabapentin is structurally related to the neuroregulator, but to my knowledge its mechanism of action has not been explained.

I have had good results when giving gabapentin, 100 mg/d to approximately 1,000 mg/d in divided doses, to agitated, nonpsychotic patients with dementia. Oversedation is the main—and certainly not unexpected—adverse effect. I recommend an atypical antipsychotic only if staff or I have heard frank delusions; quetiapine appears to be the most sedating and is associated with intermediate cardiovascular and metabolic risk.

Mary N. Smith, MD
Lexington, KY

“Managing dementia: Risks of using vs. not using atypical antipsychotics” (Current Psychiatry, August 2005) presents an informative debate on atypicals’ risk-benefit ratio. It is good practice to monitor all elderly patients with risk factors for cerebrovascular and cardiovascular events, regardless of which psychotropic is prescribed.

The FDA, however, has reported increased mortality with atypical antipsychotics in elderly patients with dementia-related psychosis, but not among older persons with psychosis secondary to other causes, such as schizophrenia or mood disorders. Upon reading the “Bottom Line” of this well-written article, one might erroneously generalize the FDA warning to all elderly patients.

Harpriya A. Bhagar, MBBS
Assistant professor, department of psychiatry
Indiana University School of Medicine
Indianapolis

It was amazing that in “Managing dementia: Risks of using vs. not using atypical antipsychotics,” gabapentin was never mentioned among the anticonvulsants being used to stabilize mood.

Gabapentin is by far the most benign anticonvulsant with respect to drug-drug interactions, metabolism, and protein binding (so benign that it is not effective for mania because it lacks affinity for glutamate and other receptors). Montoring gabapentin blood levels is not necessary—a plus considering that added venipuncture is not desirable in easily agitated, often combative patients with dementia. Gabapentin may also provide pain relief.

Gamma-aminobutyric acid (GABA) is, after all, the universal inhibitor. Gabapentin is structurally related to the neuroregulator, but to my knowledge its mechanism of action has not been explained.

I have had good results when giving gabapentin, 100 mg/d to approximately 1,000 mg/d in divided doses, to agitated, nonpsychotic patients with dementia. Oversedation is the main—and certainly not unexpected—adverse effect. I recommend an atypical antipsychotic only if staff or I have heard frank delusions; quetiapine appears to be the most sedating and is associated with intermediate cardiovascular and metabolic risk.

Mary N. Smith, MD
Lexington, KY

“Managing dementia: Risks of using vs. not using atypical antipsychotics” (Current Psychiatry, August 2005) presents an informative debate on atypicals’ risk-benefit ratio. It is good practice to monitor all elderly patients with risk factors for cerebrovascular and cardiovascular events, regardless of which psychotropic is prescribed.

The FDA, however, has reported increased mortality with atypical antipsychotics in elderly patients with dementia-related psychosis, but not among older persons with psychosis secondary to other causes, such as schizophrenia or mood disorders. Upon reading the “Bottom Line” of this well-written article, one might erroneously generalize the FDA warning to all elderly patients.

Harpriya A. Bhagar, MBBS
Assistant professor, department of psychiatry
Indiana University School of Medicine
Indianapolis

It was amazing that in “Managing dementia: Risks of using vs. not using atypical antipsychotics,” gabapentin was never mentioned among the anticonvulsants being used to stabilize mood.

Gabapentin is by far the most benign anticonvulsant with respect to drug-drug interactions, metabolism, and protein binding (so benign that it is not effective for mania because it lacks affinity for glutamate and other receptors). Montoring gabapentin blood levels is not necessary—a plus considering that added venipuncture is not desirable in easily agitated, often combative patients with dementia. Gabapentin may also provide pain relief.

Gamma-aminobutyric acid (GABA) is, after all, the universal inhibitor. Gabapentin is structurally related to the neuroregulator, but to my knowledge its mechanism of action has not been explained.

I have had good results when giving gabapentin, 100 mg/d to approximately 1,000 mg/d in divided doses, to agitated, nonpsychotic patients with dementia. Oversedation is the main—and certainly not unexpected—adverse effect. I recommend an atypical antipsychotic only if staff or I have heard frank delusions; quetiapine appears to be the most sedating and is associated with intermediate cardiovascular and metabolic risk.

Mary N. Smith, MD
Lexington, KY

We all watched with horror the news reports of Hurricane Katrina submerging New Orleans and devastating the Gulf Coast. As individuals and as a profession, we want to help—but what can we do?

Many of us have worked with victims of mass disasters at some point in our careers, and we all have worked with victims of individual disasters, such as fires, auto accidents, and domestic violence. If you are like me, you have sometimes felt helpless in the face of disaster and wondered whether what we do makes a difference.

Fortunately, our training equips us for disasters, whether mass or individual. Two articles in this month’s issue address psychiatric responses to trauma:

• Drs. Patricia Gerbarg and Richard Brown examine data on why yoga breathing practices may rapidly reduce posttraumatic stress, anxiety, and depression in survivors of natural and man-made disasters, including Hurricane Katrina, the 9/11 World Trade Center terrorist attacks, and many others.
• Drs. Charles Gillespie and Charles Nemeroff document the association between early life stress (particularly child abuse or neglect) and what appears to be a neurobiologically unique form of depression in adults.

Together, these articles suggest strategies to help disaster victims in the short run and patients with chronic depressive symptoms in the long run.

Of course, we need more research to refine our approaches to patients battered by storms or cruelty, but at least we have some guidance. Under the circumstances, we do the best we can.

We all watched with horror the news reports of Hurricane Katrina submerging New Orleans and devastating the Gulf Coast. As individuals and as a profession, we want to help—but what can we do?

Many of us have worked with victims of mass disasters at some point in our careers, and we all have worked with victims of individual disasters, such as fires, auto accidents, and domestic violence. If you are like me, you have sometimes felt helpless in the face of disaster and wondered whether what we do makes a difference.

Fortunately, our training equips us for disasters, whether mass or individual. Two articles in this month’s issue address psychiatric responses to trauma:

• Drs. Patricia Gerbarg and Richard Brown examine data on why yoga breathing practices may rapidly reduce posttraumatic stress, anxiety, and depression in survivors of natural and man-made disasters, including Hurricane Katrina, the 9/11 World Trade Center terrorist attacks, and many others.
• Drs. Charles Gillespie and Charles Nemeroff document the association between early life stress (particularly child abuse or neglect) and what appears to be a neurobiologically unique form of depression in adults.

Together, these articles suggest strategies to help disaster victims in the short run and patients with chronic depressive symptoms in the long run.

Of course, we need more research to refine our approaches to patients battered by storms or cruelty, but at least we have some guidance. Under the circumstances, we do the best we can.

We all watched with horror the news reports of Hurricane Katrina submerging New Orleans and devastating the Gulf Coast. As individuals and as a profession, we want to help—but what can we do?

Many of us have worked with victims of mass disasters at some point in our careers, and we all have worked with victims of individual disasters, such as fires, auto accidents, and domestic violence. If you are like me, you have sometimes felt helpless in the face of disaster and wondered whether what we do makes a difference.

Fortunately, our training equips us for disasters, whether mass or individual. Two articles in this month’s issue address psychiatric responses to trauma:

• Drs. Patricia Gerbarg and Richard Brown examine data on why yoga breathing practices may rapidly reduce posttraumatic stress, anxiety, and depression in survivors of natural and man-made disasters, including Hurricane Katrina, the 9/11 World Trade Center terrorist attacks, and many others.
• Drs. Charles Gillespie and Charles Nemeroff document the association between early life stress (particularly child abuse or neglect) and what appears to be a neurobiologically unique form of depression in adults.

Together, these articles suggest strategies to help disaster victims in the short run and patients with chronic depressive symptoms in the long run.

Of course, we need more research to refine our approaches to patients battered by storms or cruelty, but at least we have some guidance. Under the circumstances, we do the best we can.