Current Psychiatry

Which psychotropics reduce the risk of suicide in patients with psychiatric disorders? Although no drugs eliminate the risk, new evidence is clarifying that some therapeutic choices can make a difference:

• Long-term lithium treatment apparently reduces suicide risk in patients with affective disorders; mood-altering anticonvulsants are less well studied but show less benefit than lithium.
• Effects of antidepressants remain inconclusive without adequate long-term studies.
• At least one atypical antipsychotic—clozapine—probably lowers suicide risk, although direct comparisons of antipsychotic agents are rare.
• Surprisingly little evidence is available on nondrug interventions, including rapid hospitalization, psychotherapy, and electroconvulsive therapy.¹

Suicide is the leading cause of malpractice liability in psychiatry and of the heightened risk of death in persons with major affective and psychotic disorders (Box).^1-4 Here are the latest findings to help you choose medications for at-risk patients with bipolar disorder, major depression, or chronic psychoses.

Box

BIPOLAR DISORDER AND MOOD STABILIZERS

Bipolar disorder is associated with the highest suicide rate among all major psychiatric illnesses, with an international incidence averaging 0.31% of patients per year.⁴ This rate may slightly exceed the suicide rate of patients with major depression, which averages 0.29%/year.

Risk of suicidal behavior is similar among patients with bipolar type II (depression with hypomania) and type I disorder (depression with mania), supporting the view that type II is not a milder form of bipolar illness.^4-6 Indeed, one study of suicide attempts found a higher risk among bipolar II patients (24%) than in bipolar I patients (17%) as well as a higher risk in both bipolar types than in persons diagnosed with unipolar major depression (12%).⁴

Suicidal behavior in bipolar disorder is associated almost entirely with ongoing depression or dysphoria and is especially likely to follow severe and highly recurrent depressive episodes.^5,6 Combinations of depressive-dysphoric and irritable, agitated, anxious features in “mixed states” may be particularly dangerous and can be hard to diagnose with confidence. Moreover, DSM-IV criteria for mixed states are far too narrow in requiring symptoms to simultaneously fulfill criteria for both mania and major depression. More broadly defined mixed states are very common. Underdiagnosis risks underestimation of suicidal potential, and misdiagnosis as “agitated depression” encourages potentially dangerous overuse of antidepressants.^5,7

Depression or dysphoria is the most prevalent morbidity in patients with bipolar disorder. Major and minor depressive states and mixed-dysphoric phases account for nearly one-third of time in follow-up care, exceeding time in mania or hypomania by more than 4-fold.⁸ Ironically, however, bipolar depression is one of the least-studied forms of major depression. Suicidal bipolar patients are typically excluded from antidepressant studies because of the risks of inducing greater instability, agitation, or mania while treating them with an antidepressant but without a mood stabilizer.⁷

LITHIUM’S PROTECTIVE EFFECT

Decades of research and clinical use demonstrate substantially lower risks of suicide and serious suicide attempts when patients with bipolar disorder are treated long-term with lithium salts in standard clinical doses (serum concentrations typically 0.6 to 0.8 mEq/L). Lithium is highly effective in treating all phases of bipolar disorder. A recent meta-analysis of 26 long-term trials of lithium reported between 1967 and 2001 found an average 3.2-fold sparing of morbidity or relapse risk.⁹

Benefits in types I and II. A large European sample¹⁰ compared percent-time-ill in bipolar patients before and after they received lithium as maintenance treatment. Unexpectedly, lithium therapy reduced percent-time-ill to a greater extent among patients with type II than type I bipolar disorder. Time in mania and time in depression were reduced 2.5-fold and 2.0-fold, respectively, in type I patients, compared with nearly 5-fold for time in hypomania and 2.5-fold for time in depression among type II patients.

Because depression is associated with the highest rates of suicidal behavior in all phases of bipolar disorders, lithium’s effects in preventing depressive recurrence are especially important for reducing suicide risk.⁶

In a review of 22 studies¹¹ —some including patients with bipolar or recurrent unipolar major depression—risk of death by suicide was reduced at least 5-fold, based on an informal comparison of pooled rates in treated versus untreated samples. Based on quantitative meta-analysis, the pooled risk of death by suicide was reduced nearly 9-fold (or by 89%) in patients who received lithium maintenance treatment compared with those who did not. The risk for suicide attempts fell nearly 10-fold in a compilation of 33 studies (Table 2).¹² Available studies do not permit separate analysis of lithium’s effects on suicidal behavior among patients with bipolar disorder and recurrent unipolar depression, leaving the relative benefit by diagnosis uncertain.

Table 1

Suicide risks in selected psychiatric disorders*

Dangers of stopping lithium. In our study⁵ of more than 200 patients with DSM-IV bipolar I or II disorder, prophylactic lithium treatment for an average of 4 years reduced the risk of completed and attempted suicide by 6.5-fold. A subgroup of more than 100 patients discontinued lithium, usually after prolonged stability, and we excluded from analysis any cases of suspected emerging illness associated with discontinuation. Within 6 to 12 months after stopping treatment, this subgroup’s rates of suicidal behavior increased markedly—by 20-fold above treated rates.⁵ Thereafter, their rates returned to prelithium treatment levels.

Of particular clinical importance:

• discontinuing lithium gradually—over at least 2 weeks—was associated with a 2-fold lower suicide risk than more-abrupt discontinuation
• suicidal behavior after lithium discontinuation was almost always associated with emerging depression, which can provide an early warning of impending suicidal risk.

Table 2

Effect of lithium treatment on risk of completed and attempted suicide in patients with bipolar and recurrent depressive disorders*

This is not the first time we have found evidence of a dramatic—but time-limited—increase in risk of recurrent bipolar illness when lithium treatment was discontinued.¹³ Bipolar disorder patients who discontinue long-term lithium treatment abruptly are at high risk of recurrent depression and mania.¹³

Incomplete protection. Lithium’s protection against suicidal risk is incomplete, as one can see by comparing lithium-treated versus untreated bipolar patients’ suicide rates with those of the general population (Table 2).⁶

With lithium:

• suicides plus attempts declined 8.6-fold to levels 2.6 times greater than those of the general population
• suicide attempts fell 10-fold to levels that are about twice that of the general population
• risk of completed suicides declined 5.5-fold with lithium treatment but remained 11 times higher than that of the general population.

Without lithium:

• risk of suicide in bipolar patients is approximately 22 times greater than that of the general population
• ratio of attempts to suicides among bipolar disorder patients averages 4.6, suggesting that suicide attempts by patients with bipolar disorder are relatively lethal.⁶

Effect of delayed lithium therapy. Many patients with bipolar disorder do not receive sustained prophylactic treatment early in the illness.

Studies typically show an average 5- to 10-year gap between illness onset and the start of sustained lithium maintenance treatment. This delay averages more than 3 years longer among women with bipolar II disorder than men with bipolar I disorder, evidently reflecting major clinical dissimilarities between these groups.^6,14 In contrast, we found that nearly one-quarter of long-term risk of suicidal behavior emerges within the first year of bipolar illness.⁵ Clearly, patients with recurrent major affective illness require earlier intervention and more consistent clinical care.

We have also found that delayed maintenance treatment or the number of prior episodes of bipolar illness do not seem to limit therapeutic response to lithium.^14,15 These findings support the conclusion that prophylactic lithium treatment can be worthwhile, even after years of illness and many recurrences. Moreover, our recent meta-analysis of treatment options for rapid-cycling bipolar illness indicates that—even though all treatments have yielded inferior results compared with nonrapidly-cycling patients—no alternative has outperformed lithium.¹⁶

Anticonvulsants. Evidence regarding the effects of other mood stabilizers on suicide risk in bipolar disorder remains limited:

• In a European collaborative study, several hundred patients with bipolar or schizoaffective disorder were randomly assigned to receive lithium or carbamazepine for nearly 2 years. Rates of suicidal acts were 2.5%/year with the anticonvulsant, but there were no suicides or attempts in patients receiving lithium.¹⁷ Direct comparisons are rare, but this difference was both striking and statistically significant.
• Computerized records of approximately 20,000 patients diagnosed with bipolar disorder at two large American HMOs were analyzed to compare suicidal behaviors associated with specific treatments. Lithium yielded 2.7-fold greater protection against suicidal behavior (mainly attempts because suicides were rare) compared with anticonvulsants (mainly divalproex).¹⁸

Treatment recommendation. These observations support lithium’s value in long-term maintenance of patients with bipolar disorder. Lithium’s apparent reduction of suicide risk is striking and may be superior to that of other mood-stabilizers. Alternate treatments and lithium’s potential value for reducing suicide risk in patients with unipolar depression require further study.

It is important to emphasize that lithium can be toxic or even fatal in acute overdose. This risk is integral to the equation when you assess risks and benefits for individual patients.

MAJOR DEPRESSION AND ANTIDEPRESSANTS

Major depression and depressive components of other disorders are major risk factors for suicide.^1,2,6 Depression continues to be surprisingly underrecognized and undertreated, even though relatively safe and tolerable antidepressants are readily available.^1,6,19,20 Patients with recurrent unipolar major depression often remain inconsistently or inadequately treated, even after they attempt suicide.¹⁹

Recent reviews of suicide risk during research on antidepressant treatment in major depression suggest that:

• antidepressants of various kinds may tend to reduce the risk of suicidal behavior, but any such effect is small and statistically nonsignificant (Baldessarini et al, 2003, unpublished)
• tricyclic antidepressants may yield lower rates of suicidal behavior than selective serotonin reuptake inhibitors (SSRIs). Similarly, however, such trends reflect highly variable research methods and inconsistent findings and do not hold up to quantitative analysis (Baldessarini et al, 2003, unpublished).

The suicidal events encountered during research mainly involve attempts because suicides are rare, particularly in relatively brief treatment trials that exclude acutely suicidal subjects. Analyses are further complicated by trends toward paradoxically lower suicidal risks among depressed patients randomized to a placebo in controlled antidepressant trials. This paradox is paralleled by often earlier removal of patients treated with a placebo than with an active antidepressant, perhaps in association with emerging suicidality.²¹

Table 3

Preventing suicide: How effective are specific treatments?

These trends toward lower suicide risk among patients receiving a placebo are somewhat reassuring, given concern that placebo randomization for scientific purposes may endanger study subjects. However, these artifacts confound interpretation of results and make it difficult to measure the effects of antidepressant treatment.

Treatment recommendation. Clinical prudence requires us to treat potentially lethal major depressive illness aggressively, even though one cannot state with confidence that any antidepressant class lowers suicide risk or that one class is significantly more effective than others (Table 3).

SCHIZOPHRENIA AND ANTIPSYCHOTICS

For schizophrenia and other primary psychotic disorders, little research exists to indicate that atypical antipsychotics reduce suicide risk. Evidence is emerging, however, that clozapine may offer this benefit,²² in addition to its well-substantiated clinical superiority in treatment-resistant psychotic illness.²³

Pooled evidence from controlled trials comparing clozapine with other antipsychotics indicates a 2-fold lower risk of mortality from all causes.²³ This finding was highly suggestive but not statistically significant, and the specific contribution of suicide to this risk is unknown.²³ Our recent meta-analysis of the few available studies found that clozapine was associated with a statistically significant, 3.3-fold lower overall suicidal risk compared with other antipsychotic treatments.²²

A well-designed, 2-year study randomly assigned 980 patients with schizophrenia or schizoaffective disorder who were at high risk for suicide to clozapine (mean 274 mg/d) or olanzapine (mean 16.6 mg/d). Clozapine showed moderately greater benefit in reducing suicide attempts and need for urgent intervention for perceived emerging suicide risk, although it did not lower suicide risk per se.²⁴ Another study associated olanzapine with a 2.3-fold lower risk of suicidal behavior, compared with haloperidol.²⁵

Comparing two potentially effective agents may have limited the observed difference between clozapine and olanzapine.²⁴ Nevertheless, previous (largely uncontrolled) comparisons with other treatment options indicate substantially lower risks of both suicides and attempts with clozapine.²² In December 2002, the FDA approved a unique indication for clozapine: to reduce the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder.

Treatment recommendation. Risks of suicide and other causes of premature death are high in patients with chronic psychotic disorders, underlining the importance of appropriate longterm care. Clozapine has shown benefit in reducing risk of suicidal behaviors. When clozapine is otherwise a plausible option, this additional potential benefit can be considered when selecting therapy for individual patients.

Related resources

• American Psychiatric Association. Suicide-prevention practice guidelines. Washington, DC: American Psychiatric Press, 2003 (in press).
• American Foundation for Suicide Prevention. http://www.afsp.org
• American Association of Suicidology. www.suicidology.org
• National Institute of Mental Health (NIMH)/Suicide.

Drug brand names

• Clozapine • Clozaril
• Carbamazepine • Tegretol
• Divalproex • Depakote
• Haloperidol • Haldol
• Lithium carbonate • Eskalith, Lithobid, others
• Olanzapine • Zyprexa

Disclosure

Dr. Baldessarini has received research grants from Molecular Insight Pharmaceuticals, Eli Lilly and Co., Janssen Pharmaceutica, Protarga Inc., and Solvay Pharmaceuticals, and is a consultant to Auritec Laboratories, Molecular Insight Pharmaceuticals, Eli Lilly and Co., GlaxoSmithKline, Janssen Pharmaceutica, and Protarga Inc.

Which psychotropics reduce the risk of suicide in patients with psychiatric disorders? Although no drugs eliminate the risk, new evidence is clarifying that some therapeutic choices can make a difference:

• Long-term lithium treatment apparently reduces suicide risk in patients with affective disorders; mood-altering anticonvulsants are less well studied but show less benefit than lithium.
• Effects of antidepressants remain inconclusive without adequate long-term studies.
• At least one atypical antipsychotic—clozapine—probably lowers suicide risk, although direct comparisons of antipsychotic agents are rare.
• Surprisingly little evidence is available on nondrug interventions, including rapid hospitalization, psychotherapy, and electroconvulsive therapy.¹

Suicide is the leading cause of malpractice liability in psychiatry and of the heightened risk of death in persons with major affective and psychotic disorders (Box).^1-4 Here are the latest findings to help you choose medications for at-risk patients with bipolar disorder, major depression, or chronic psychoses.

Box

BIPOLAR DISORDER AND MOOD STABILIZERS

Bipolar disorder is associated with the highest suicide rate among all major psychiatric illnesses, with an international incidence averaging 0.31% of patients per year.⁴ This rate may slightly exceed the suicide rate of patients with major depression, which averages 0.29%/year.

Risk of suicidal behavior is similar among patients with bipolar type II (depression with hypomania) and type I disorder (depression with mania), supporting the view that type II is not a milder form of bipolar illness.^4-6 Indeed, one study of suicide attempts found a higher risk among bipolar II patients (24%) than in bipolar I patients (17%) as well as a higher risk in both bipolar types than in persons diagnosed with unipolar major depression (12%).⁴

Suicidal behavior in bipolar disorder is associated almost entirely with ongoing depression or dysphoria and is especially likely to follow severe and highly recurrent depressive episodes.^5,6 Combinations of depressive-dysphoric and irritable, agitated, anxious features in “mixed states” may be particularly dangerous and can be hard to diagnose with confidence. Moreover, DSM-IV criteria for mixed states are far too narrow in requiring symptoms to simultaneously fulfill criteria for both mania and major depression. More broadly defined mixed states are very common. Underdiagnosis risks underestimation of suicidal potential, and misdiagnosis as “agitated depression” encourages potentially dangerous overuse of antidepressants.^5,7

Depression or dysphoria is the most prevalent morbidity in patients with bipolar disorder. Major and minor depressive states and mixed-dysphoric phases account for nearly one-third of time in follow-up care, exceeding time in mania or hypomania by more than 4-fold.⁸ Ironically, however, bipolar depression is one of the least-studied forms of major depression. Suicidal bipolar patients are typically excluded from antidepressant studies because of the risks of inducing greater instability, agitation, or mania while treating them with an antidepressant but without a mood stabilizer.⁷

LITHIUM’S PROTECTIVE EFFECT

Decades of research and clinical use demonstrate substantially lower risks of suicide and serious suicide attempts when patients with bipolar disorder are treated long-term with lithium salts in standard clinical doses (serum concentrations typically 0.6 to 0.8 mEq/L). Lithium is highly effective in treating all phases of bipolar disorder. A recent meta-analysis of 26 long-term trials of lithium reported between 1967 and 2001 found an average 3.2-fold sparing of morbidity or relapse risk.⁹

Benefits in types I and II. A large European sample¹⁰ compared percent-time-ill in bipolar patients before and after they received lithium as maintenance treatment. Unexpectedly, lithium therapy reduced percent-time-ill to a greater extent among patients with type II than type I bipolar disorder. Time in mania and time in depression were reduced 2.5-fold and 2.0-fold, respectively, in type I patients, compared with nearly 5-fold for time in hypomania and 2.5-fold for time in depression among type II patients.

Because depression is associated with the highest rates of suicidal behavior in all phases of bipolar disorders, lithium’s effects in preventing depressive recurrence are especially important for reducing suicide risk.⁶

In a review of 22 studies¹¹ —some including patients with bipolar or recurrent unipolar major depression—risk of death by suicide was reduced at least 5-fold, based on an informal comparison of pooled rates in treated versus untreated samples. Based on quantitative meta-analysis, the pooled risk of death by suicide was reduced nearly 9-fold (or by 89%) in patients who received lithium maintenance treatment compared with those who did not. The risk for suicide attempts fell nearly 10-fold in a compilation of 33 studies (Table 2).¹² Available studies do not permit separate analysis of lithium’s effects on suicidal behavior among patients with bipolar disorder and recurrent unipolar depression, leaving the relative benefit by diagnosis uncertain.

Table 1

Suicide risks in selected psychiatric disorders*

Dangers of stopping lithium. In our study⁵ of more than 200 patients with DSM-IV bipolar I or II disorder, prophylactic lithium treatment for an average of 4 years reduced the risk of completed and attempted suicide by 6.5-fold. A subgroup of more than 100 patients discontinued lithium, usually after prolonged stability, and we excluded from analysis any cases of suspected emerging illness associated with discontinuation. Within 6 to 12 months after stopping treatment, this subgroup’s rates of suicidal behavior increased markedly—by 20-fold above treated rates.⁵ Thereafter, their rates returned to prelithium treatment levels.

Of particular clinical importance:

• discontinuing lithium gradually—over at least 2 weeks—was associated with a 2-fold lower suicide risk than more-abrupt discontinuation
• suicidal behavior after lithium discontinuation was almost always associated with emerging depression, which can provide an early warning of impending suicidal risk.

Table 2

Effect of lithium treatment on risk of completed and attempted suicide in patients with bipolar and recurrent depressive disorders*

This is not the first time we have found evidence of a dramatic—but time-limited—increase in risk of recurrent bipolar illness when lithium treatment was discontinued.¹³ Bipolar disorder patients who discontinue long-term lithium treatment abruptly are at high risk of recurrent depression and mania.¹³

Incomplete protection. Lithium’s protection against suicidal risk is incomplete, as one can see by comparing lithium-treated versus untreated bipolar patients’ suicide rates with those of the general population (Table 2).⁶

With lithium:

• suicides plus attempts declined 8.6-fold to levels 2.6 times greater than those of the general population
• suicide attempts fell 10-fold to levels that are about twice that of the general population
• risk of completed suicides declined 5.5-fold with lithium treatment but remained 11 times higher than that of the general population.

Without lithium:

• risk of suicide in bipolar patients is approximately 22 times greater than that of the general population
• ratio of attempts to suicides among bipolar disorder patients averages 4.6, suggesting that suicide attempts by patients with bipolar disorder are relatively lethal.⁶

Effect of delayed lithium therapy. Many patients with bipolar disorder do not receive sustained prophylactic treatment early in the illness.

Studies typically show an average 5- to 10-year gap between illness onset and the start of sustained lithium maintenance treatment. This delay averages more than 3 years longer among women with bipolar II disorder than men with bipolar I disorder, evidently reflecting major clinical dissimilarities between these groups.^6,14 In contrast, we found that nearly one-quarter of long-term risk of suicidal behavior emerges within the first year of bipolar illness.⁵ Clearly, patients with recurrent major affective illness require earlier intervention and more consistent clinical care.

We have also found that delayed maintenance treatment or the number of prior episodes of bipolar illness do not seem to limit therapeutic response to lithium.^14,15 These findings support the conclusion that prophylactic lithium treatment can be worthwhile, even after years of illness and many recurrences. Moreover, our recent meta-analysis of treatment options for rapid-cycling bipolar illness indicates that—even though all treatments have yielded inferior results compared with nonrapidly-cycling patients—no alternative has outperformed lithium.¹⁶

Anticonvulsants. Evidence regarding the effects of other mood stabilizers on suicide risk in bipolar disorder remains limited:

• In a European collaborative study, several hundred patients with bipolar or schizoaffective disorder were randomly assigned to receive lithium or carbamazepine for nearly 2 years. Rates of suicidal acts were 2.5%/year with the anticonvulsant, but there were no suicides or attempts in patients receiving lithium.¹⁷ Direct comparisons are rare, but this difference was both striking and statistically significant.
• Computerized records of approximately 20,000 patients diagnosed with bipolar disorder at two large American HMOs were analyzed to compare suicidal behaviors associated with specific treatments. Lithium yielded 2.7-fold greater protection against suicidal behavior (mainly attempts because suicides were rare) compared with anticonvulsants (mainly divalproex).¹⁸

Treatment recommendation. These observations support lithium’s value in long-term maintenance of patients with bipolar disorder. Lithium’s apparent reduction of suicide risk is striking and may be superior to that of other mood-stabilizers. Alternate treatments and lithium’s potential value for reducing suicide risk in patients with unipolar depression require further study.

It is important to emphasize that lithium can be toxic or even fatal in acute overdose. This risk is integral to the equation when you assess risks and benefits for individual patients.

MAJOR DEPRESSION AND ANTIDEPRESSANTS

Major depression and depressive components of other disorders are major risk factors for suicide.^1,2,6 Depression continues to be surprisingly underrecognized and undertreated, even though relatively safe and tolerable antidepressants are readily available.^1,6,19,20 Patients with recurrent unipolar major depression often remain inconsistently or inadequately treated, even after they attempt suicide.¹⁹

Recent reviews of suicide risk during research on antidepressant treatment in major depression suggest that:

• antidepressants of various kinds may tend to reduce the risk of suicidal behavior, but any such effect is small and statistically nonsignificant (Baldessarini et al, 2003, unpublished)
• tricyclic antidepressants may yield lower rates of suicidal behavior than selective serotonin reuptake inhibitors (SSRIs). Similarly, however, such trends reflect highly variable research methods and inconsistent findings and do not hold up to quantitative analysis (Baldessarini et al, 2003, unpublished).

The suicidal events encountered during research mainly involve attempts because suicides are rare, particularly in relatively brief treatment trials that exclude acutely suicidal subjects. Analyses are further complicated by trends toward paradoxically lower suicidal risks among depressed patients randomized to a placebo in controlled antidepressant trials. This paradox is paralleled by often earlier removal of patients treated with a placebo than with an active antidepressant, perhaps in association with emerging suicidality.²¹

Table 3

Preventing suicide: How effective are specific treatments?

These trends toward lower suicide risk among patients receiving a placebo are somewhat reassuring, given concern that placebo randomization for scientific purposes may endanger study subjects. However, these artifacts confound interpretation of results and make it difficult to measure the effects of antidepressant treatment.

Treatment recommendation. Clinical prudence requires us to treat potentially lethal major depressive illness aggressively, even though one cannot state with confidence that any antidepressant class lowers suicide risk or that one class is significantly more effective than others (Table 3).

SCHIZOPHRENIA AND ANTIPSYCHOTICS

For schizophrenia and other primary psychotic disorders, little research exists to indicate that atypical antipsychotics reduce suicide risk. Evidence is emerging, however, that clozapine may offer this benefit,²² in addition to its well-substantiated clinical superiority in treatment-resistant psychotic illness.²³

Pooled evidence from controlled trials comparing clozapine with other antipsychotics indicates a 2-fold lower risk of mortality from all causes.²³ This finding was highly suggestive but not statistically significant, and the specific contribution of suicide to this risk is unknown.²³ Our recent meta-analysis of the few available studies found that clozapine was associated with a statistically significant, 3.3-fold lower overall suicidal risk compared with other antipsychotic treatments.²²

A well-designed, 2-year study randomly assigned 980 patients with schizophrenia or schizoaffective disorder who were at high risk for suicide to clozapine (mean 274 mg/d) or olanzapine (mean 16.6 mg/d). Clozapine showed moderately greater benefit in reducing suicide attempts and need for urgent intervention for perceived emerging suicide risk, although it did not lower suicide risk per se.²⁴ Another study associated olanzapine with a 2.3-fold lower risk of suicidal behavior, compared with haloperidol.²⁵

Comparing two potentially effective agents may have limited the observed difference between clozapine and olanzapine.²⁴ Nevertheless, previous (largely uncontrolled) comparisons with other treatment options indicate substantially lower risks of both suicides and attempts with clozapine.²² In December 2002, the FDA approved a unique indication for clozapine: to reduce the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder.

Treatment recommendation. Risks of suicide and other causes of premature death are high in patients with chronic psychotic disorders, underlining the importance of appropriate longterm care. Clozapine has shown benefit in reducing risk of suicidal behaviors. When clozapine is otherwise a plausible option, this additional potential benefit can be considered when selecting therapy for individual patients.

Related resources

• American Psychiatric Association. Suicide-prevention practice guidelines. Washington, DC: American Psychiatric Press, 2003 (in press).
• American Foundation for Suicide Prevention. http://www.afsp.org
• American Association of Suicidology. www.suicidology.org
• National Institute of Mental Health (NIMH)/Suicide.

Drug brand names

• Clozapine • Clozaril
• Carbamazepine • Tegretol
• Divalproex • Depakote
• Haloperidol • Haldol
• Lithium carbonate • Eskalith, Lithobid, others
• Olanzapine • Zyprexa

Disclosure

Dr. Baldessarini has received research grants from Molecular Insight Pharmaceuticals, Eli Lilly and Co., Janssen Pharmaceutica, Protarga Inc., and Solvay Pharmaceuticals, and is a consultant to Auritec Laboratories, Molecular Insight Pharmaceuticals, Eli Lilly and Co., GlaxoSmithKline, Janssen Pharmaceutica, and Protarga Inc.

Which psychotropics reduce the risk of suicide in patients with psychiatric disorders? Although no drugs eliminate the risk, new evidence is clarifying that some therapeutic choices can make a difference:

• Long-term lithium treatment apparently reduces suicide risk in patients with affective disorders; mood-altering anticonvulsants are less well studied but show less benefit than lithium.
• Effects of antidepressants remain inconclusive without adequate long-term studies.
• At least one atypical antipsychotic—clozapine—probably lowers suicide risk, although direct comparisons of antipsychotic agents are rare.
• Surprisingly little evidence is available on nondrug interventions, including rapid hospitalization, psychotherapy, and electroconvulsive therapy.¹

Suicide is the leading cause of malpractice liability in psychiatry and of the heightened risk of death in persons with major affective and psychotic disorders (Box).^1-4 Here are the latest findings to help you choose medications for at-risk patients with bipolar disorder, major depression, or chronic psychoses.

Box

BIPOLAR DISORDER AND MOOD STABILIZERS

Bipolar disorder is associated with the highest suicide rate among all major psychiatric illnesses, with an international incidence averaging 0.31% of patients per year.⁴ This rate may slightly exceed the suicide rate of patients with major depression, which averages 0.29%/year.

Risk of suicidal behavior is similar among patients with bipolar type II (depression with hypomania) and type I disorder (depression with mania), supporting the view that type II is not a milder form of bipolar illness.^4-6 Indeed, one study of suicide attempts found a higher risk among bipolar II patients (24%) than in bipolar I patients (17%) as well as a higher risk in both bipolar types than in persons diagnosed with unipolar major depression (12%).⁴

Suicidal behavior in bipolar disorder is associated almost entirely with ongoing depression or dysphoria and is especially likely to follow severe and highly recurrent depressive episodes.^5,6 Combinations of depressive-dysphoric and irritable, agitated, anxious features in “mixed states” may be particularly dangerous and can be hard to diagnose with confidence. Moreover, DSM-IV criteria for mixed states are far too narrow in requiring symptoms to simultaneously fulfill criteria for both mania and major depression. More broadly defined mixed states are very common. Underdiagnosis risks underestimation of suicidal potential, and misdiagnosis as “agitated depression” encourages potentially dangerous overuse of antidepressants.^5,7

Depression or dysphoria is the most prevalent morbidity in patients with bipolar disorder. Major and minor depressive states and mixed-dysphoric phases account for nearly one-third of time in follow-up care, exceeding time in mania or hypomania by more than 4-fold.⁸ Ironically, however, bipolar depression is one of the least-studied forms of major depression. Suicidal bipolar patients are typically excluded from antidepressant studies because of the risks of inducing greater instability, agitation, or mania while treating them with an antidepressant but without a mood stabilizer.⁷

LITHIUM’S PROTECTIVE EFFECT

Decades of research and clinical use demonstrate substantially lower risks of suicide and serious suicide attempts when patients with bipolar disorder are treated long-term with lithium salts in standard clinical doses (serum concentrations typically 0.6 to 0.8 mEq/L). Lithium is highly effective in treating all phases of bipolar disorder. A recent meta-analysis of 26 long-term trials of lithium reported between 1967 and 2001 found an average 3.2-fold sparing of morbidity or relapse risk.⁹

Benefits in types I and II. A large European sample¹⁰ compared percent-time-ill in bipolar patients before and after they received lithium as maintenance treatment. Unexpectedly, lithium therapy reduced percent-time-ill to a greater extent among patients with type II than type I bipolar disorder. Time in mania and time in depression were reduced 2.5-fold and 2.0-fold, respectively, in type I patients, compared with nearly 5-fold for time in hypomania and 2.5-fold for time in depression among type II patients.

Because depression is associated with the highest rates of suicidal behavior in all phases of bipolar disorders, lithium’s effects in preventing depressive recurrence are especially important for reducing suicide risk.⁶

In a review of 22 studies¹¹ —some including patients with bipolar or recurrent unipolar major depression—risk of death by suicide was reduced at least 5-fold, based on an informal comparison of pooled rates in treated versus untreated samples. Based on quantitative meta-analysis, the pooled risk of death by suicide was reduced nearly 9-fold (or by 89%) in patients who received lithium maintenance treatment compared with those who did not. The risk for suicide attempts fell nearly 10-fold in a compilation of 33 studies (Table 2).¹² Available studies do not permit separate analysis of lithium’s effects on suicidal behavior among patients with bipolar disorder and recurrent unipolar depression, leaving the relative benefit by diagnosis uncertain.

Table 1

Suicide risks in selected psychiatric disorders*

Dangers of stopping lithium. In our study⁵ of more than 200 patients with DSM-IV bipolar I or II disorder, prophylactic lithium treatment for an average of 4 years reduced the risk of completed and attempted suicide by 6.5-fold. A subgroup of more than 100 patients discontinued lithium, usually after prolonged stability, and we excluded from analysis any cases of suspected emerging illness associated with discontinuation. Within 6 to 12 months after stopping treatment, this subgroup’s rates of suicidal behavior increased markedly—by 20-fold above treated rates.⁵ Thereafter, their rates returned to prelithium treatment levels.

Of particular clinical importance:

• discontinuing lithium gradually—over at least 2 weeks—was associated with a 2-fold lower suicide risk than more-abrupt discontinuation
• suicidal behavior after lithium discontinuation was almost always associated with emerging depression, which can provide an early warning of impending suicidal risk.

Table 2

Effect of lithium treatment on risk of completed and attempted suicide in patients with bipolar and recurrent depressive disorders*

This is not the first time we have found evidence of a dramatic—but time-limited—increase in risk of recurrent bipolar illness when lithium treatment was discontinued.¹³ Bipolar disorder patients who discontinue long-term lithium treatment abruptly are at high risk of recurrent depression and mania.¹³

Incomplete protection. Lithium’s protection against suicidal risk is incomplete, as one can see by comparing lithium-treated versus untreated bipolar patients’ suicide rates with those of the general population (Table 2).⁶

With lithium:

• suicides plus attempts declined 8.6-fold to levels 2.6 times greater than those of the general population
• suicide attempts fell 10-fold to levels that are about twice that of the general population
• risk of completed suicides declined 5.5-fold with lithium treatment but remained 11 times higher than that of the general population.

Without lithium:

• risk of suicide in bipolar patients is approximately 22 times greater than that of the general population
• ratio of attempts to suicides among bipolar disorder patients averages 4.6, suggesting that suicide attempts by patients with bipolar disorder are relatively lethal.⁶

Effect of delayed lithium therapy. Many patients with bipolar disorder do not receive sustained prophylactic treatment early in the illness.

Studies typically show an average 5- to 10-year gap between illness onset and the start of sustained lithium maintenance treatment. This delay averages more than 3 years longer among women with bipolar II disorder than men with bipolar I disorder, evidently reflecting major clinical dissimilarities between these groups.^6,14 In contrast, we found that nearly one-quarter of long-term risk of suicidal behavior emerges within the first year of bipolar illness.⁵ Clearly, patients with recurrent major affective illness require earlier intervention and more consistent clinical care.

We have also found that delayed maintenance treatment or the number of prior episodes of bipolar illness do not seem to limit therapeutic response to lithium.^14,15 These findings support the conclusion that prophylactic lithium treatment can be worthwhile, even after years of illness and many recurrences. Moreover, our recent meta-analysis of treatment options for rapid-cycling bipolar illness indicates that—even though all treatments have yielded inferior results compared with nonrapidly-cycling patients—no alternative has outperformed lithium.¹⁶

Anticonvulsants. Evidence regarding the effects of other mood stabilizers on suicide risk in bipolar disorder remains limited:

• In a European collaborative study, several hundred patients with bipolar or schizoaffective disorder were randomly assigned to receive lithium or carbamazepine for nearly 2 years. Rates of suicidal acts were 2.5%/year with the anticonvulsant, but there were no suicides or attempts in patients receiving lithium.¹⁷ Direct comparisons are rare, but this difference was both striking and statistically significant.
• Computerized records of approximately 20,000 patients diagnosed with bipolar disorder at two large American HMOs were analyzed to compare suicidal behaviors associated with specific treatments. Lithium yielded 2.7-fold greater protection against suicidal behavior (mainly attempts because suicides were rare) compared with anticonvulsants (mainly divalproex).¹⁸

Treatment recommendation. These observations support lithium’s value in long-term maintenance of patients with bipolar disorder. Lithium’s apparent reduction of suicide risk is striking and may be superior to that of other mood-stabilizers. Alternate treatments and lithium’s potential value for reducing suicide risk in patients with unipolar depression require further study.

It is important to emphasize that lithium can be toxic or even fatal in acute overdose. This risk is integral to the equation when you assess risks and benefits for individual patients.

MAJOR DEPRESSION AND ANTIDEPRESSANTS

Major depression and depressive components of other disorders are major risk factors for suicide.^1,2,6 Depression continues to be surprisingly underrecognized and undertreated, even though relatively safe and tolerable antidepressants are readily available.^1,6,19,20 Patients with recurrent unipolar major depression often remain inconsistently or inadequately treated, even after they attempt suicide.¹⁹

Recent reviews of suicide risk during research on antidepressant treatment in major depression suggest that:

• antidepressants of various kinds may tend to reduce the risk of suicidal behavior, but any such effect is small and statistically nonsignificant (Baldessarini et al, 2003, unpublished)
• tricyclic antidepressants may yield lower rates of suicidal behavior than selective serotonin reuptake inhibitors (SSRIs). Similarly, however, such trends reflect highly variable research methods and inconsistent findings and do not hold up to quantitative analysis (Baldessarini et al, 2003, unpublished).

The suicidal events encountered during research mainly involve attempts because suicides are rare, particularly in relatively brief treatment trials that exclude acutely suicidal subjects. Analyses are further complicated by trends toward paradoxically lower suicidal risks among depressed patients randomized to a placebo in controlled antidepressant trials. This paradox is paralleled by often earlier removal of patients treated with a placebo than with an active antidepressant, perhaps in association with emerging suicidality.²¹

Table 3

Preventing suicide: How effective are specific treatments?

These trends toward lower suicide risk among patients receiving a placebo are somewhat reassuring, given concern that placebo randomization for scientific purposes may endanger study subjects. However, these artifacts confound interpretation of results and make it difficult to measure the effects of antidepressant treatment.

Treatment recommendation. Clinical prudence requires us to treat potentially lethal major depressive illness aggressively, even though one cannot state with confidence that any antidepressant class lowers suicide risk or that one class is significantly more effective than others (Table 3).

SCHIZOPHRENIA AND ANTIPSYCHOTICS

For schizophrenia and other primary psychotic disorders, little research exists to indicate that atypical antipsychotics reduce suicide risk. Evidence is emerging, however, that clozapine may offer this benefit,²² in addition to its well-substantiated clinical superiority in treatment-resistant psychotic illness.²³

Pooled evidence from controlled trials comparing clozapine with other antipsychotics indicates a 2-fold lower risk of mortality from all causes.²³ This finding was highly suggestive but not statistically significant, and the specific contribution of suicide to this risk is unknown.²³ Our recent meta-analysis of the few available studies found that clozapine was associated with a statistically significant, 3.3-fold lower overall suicidal risk compared with other antipsychotic treatments.²²

A well-designed, 2-year study randomly assigned 980 patients with schizophrenia or schizoaffective disorder who were at high risk for suicide to clozapine (mean 274 mg/d) or olanzapine (mean 16.6 mg/d). Clozapine showed moderately greater benefit in reducing suicide attempts and need for urgent intervention for perceived emerging suicide risk, although it did not lower suicide risk per se.²⁴ Another study associated olanzapine with a 2.3-fold lower risk of suicidal behavior, compared with haloperidol.²⁵

Comparing two potentially effective agents may have limited the observed difference between clozapine and olanzapine.²⁴ Nevertheless, previous (largely uncontrolled) comparisons with other treatment options indicate substantially lower risks of both suicides and attempts with clozapine.²² In December 2002, the FDA approved a unique indication for clozapine: to reduce the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder.

Treatment recommendation. Risks of suicide and other causes of premature death are high in patients with chronic psychotic disorders, underlining the importance of appropriate longterm care. Clozapine has shown benefit in reducing risk of suicidal behaviors. When clozapine is otherwise a plausible option, this additional potential benefit can be considered when selecting therapy for individual patients.

Related resources

• American Psychiatric Association. Suicide-prevention practice guidelines. Washington, DC: American Psychiatric Press, 2003 (in press).
• American Foundation for Suicide Prevention. http://www.afsp.org
• American Association of Suicidology. www.suicidology.org
• National Institute of Mental Health (NIMH)/Suicide.

Drug brand names

• Clozapine • Clozaril
• Carbamazepine • Tegretol
• Divalproex • Depakote
• Haloperidol • Haldol
• Lithium carbonate • Eskalith, Lithobid, others
• Olanzapine • Zyprexa

Disclosure

Dr. Baldessarini has received research grants from Molecular Insight Pharmaceuticals, Eli Lilly and Co., Janssen Pharmaceutica, Protarga Inc., and Solvay Pharmaceuticals, and is a consultant to Auritec Laboratories, Molecular Insight Pharmaceuticals, Eli Lilly and Co., GlaxoSmithKline, Janssen Pharmaceutica, and Protarga Inc.

Psychiatrists frequently encounter dual-diagnosis patients (Box) and may often wonder which to treat first—the substance abuse or the psychiatric comorbidity. Five principles can help you counsel dual-diagnosis patients more effectively. Briefly, they are to:

• appreciate this population’s heterogeneity
• adopt a longitudinal treatment approach, reassessing patients’ progress and adjusting interventions as needed over time
• be empathic rather than confrontational
• realize that treatment often proceeds in stages—not on a smooth, linear path
• recognize the importance of medication compliance.

ASSESSMENT

Different patients, different problems. All counseling of dual-diagnosis patients begins with a thorough assessment aimed at making an accurate diagnosis and understanding the relationship between the co-existing disorders. Although some people refer to “dual-diagnosis patients” as a single entity, these patients differ according to:

Box

• diagnosis, with a myriad of potential combinations of substance use and psychiatric disorders
• severity of disorder, with some having a predominant psychiatric or substance use problem and others experiencing severe courses of both problems
• causes of their substance abuse and psychiatric disorders, based in part on which problem is primary and which is secondary
• level of motivation for treatment and their treatment goals.

Primary versus secondary disorders. How to distinguish “primary” from “secondary” disorders in dually diagnosed patients has prompted much research and debate.

A psychiatric disorder is typically called primary when it can be viewed as independent from the substance use disorder. The term “secondary psychiatric disorder” connotes that the substance use disorder is causing the psychiatric symptoms. For example, alcohol-dependent patients in detoxification programs often have depressive symptoms, some of which abate with abstinence. They are frequently diagnosed as having “secondary depression,” or—in DSM-IV diagnostic terms—substance-induced mood disorder.

Unfortunately, distinguishing primary from secondary disorders is sometimes difficult because of patients’ poor memory, recall bias, and inadequate periods of sobriety (“I’ve been drinking for a long time and have been depressed for a long time, so I don’t remember what I was like when I was sober”). Thus, the diagnostic assessment is generally accomplished over time, rather than in a single interview.

Our research³ and clinical experience have taught us that patients’ recall about the relationship between their substance use and psychiatric symptoms often changes over time. Determining the “primary” disorder may also have limited validity in predicting treatment response.⁴

Stages of Change model. The Stages of Change model^5,6 is useful for assessing a dually diagnosed patient’s motivation to change, although its use in addictive disorders has been challenged.^7,8 According to the transtheoretical model developed by Prochaska et al (Table 1),⁵ people generally make behavioral changes in stages defined by their level of willingness to make these changes.

When counseling the dually diagnosed patient, it is useful to assess readiness to change and to suggest behavioral steps the patient is able and willing to make. Thus, it would not be appropriate to discuss drug refusal methods with a patient who does not see his substance use as a problem. Rather, addressing this patient’s ambivalence would be more useful.

Table 1

5 stages of change: The transtheoretical model of behavior change

It is important to note that many patients move back and forth between stages of readiness to change. For example, a patient in the action stage (entering treatment and pursuing a goal of abstinence) may revert to contemplation and again question whether he or she has a serious substance abuse problem. We recommend that clinicians reassess patients regularly and continue to match interventions with the current level of motivation.

WHICH DISORDER IS TREATED FIRST?

Three approaches are used for treating the coexisting problems of dual-diagnosis patients—sequential, parallel, and integrated.

Sequential treatment addresses the more acute disorder first; the other disorder receives greater attention later. This model is commonly used with hospital treatment, in which comparatively little attention would be paid to substance use in a patient who is acutely psychotic.

Parallel treatment addresses each disorder contemporaneously but in different settings (such as at a substance abuse program on Monday and a mental health center on Thursday).

One limitation of the sequential and parallel models is that psychiatric and substance abuse programs typically have different orientations. A lack of comprehensive assessment may leave the substance abuse or psychiatric disorder underdiagnosed, depending on the setting. Staff members may also project negative attitudes toward patients with psychiatric or substance use disorders if they know comparatively little about the diagnosis and treatment of the other type of disorder. Treatment in two settings also can lead to communication problems and differences of opinion among the treating clinicians.

Integrated treatment, in which both disorders are treated simultaneously in the same setting, has shown favorable outcomes in several initial studies.^{9 11} Different integrated treatment models have been described, which vary according to the psychiatric disorders’ nature and the treatment’s theoretical orientation. Integrated treatment strategies include:

• focusing on psychiatric and substance abuse issues simultaneously or in alternating sessions
• providing intense case management
• stressing the importance of medication compliance.¹²

COUNSELING PRINCIPLES

As mentioned, a careful history and thorough assessment are the keys to effectively treating the dually diagnosed patient.

Assess how the patient perceives the relationship between his substance use disorder and psychiatric symptoms. For example, ask, “What do you see as the relationship between your drinking and your depression, if any?”

As part of this process, explore both the immediate and long-term relationships between the two phenomena. For example, some patients will say that drinking offers them immediate relief from their depressive symptoms but exacerbates their depression the following day. Encouraging patients to look beyond the immediate—often positive—effects of their substance use may help them understand the negative consequences of continued use.

Review previous periods of recovery and relapse. For patients who have had substantial periods of recovery, it is important to acknowledge these successes and to ask in an upbeat and admiring way, “How did you do it?” This approach may remind patients of past successes and counterbalance their frequent feelings of discouragement and hopelessness.

Table 2

4 phases in treating the dually diagnosed patient

To help clarify the relationship between coexisting disorders, ask patients about psychiatric symptoms they have experienced during periods of substance use and recovery. Taking a relapse history can help you and the patient identify decisions and behaviors he or she must avoid (such as stopping medication, failing to attend treatment, or engaging in high-risk activities as in going to bars).

PHASES OF TREATMENT

Four phases of dual-diagnosis treatment—engagement, persuasion, active treatment, and relapse prevention—have been described, along with their therapeutic goals (Table 2).¹³ Consider these phases when treating this population, even though most patients do not proceed through them in an orderly, linear fashion.

Engagement. At the onset, the therapist tries to build an alliance and begins to establish trust and credibility.

Persuasion involves helping the patient comprehend the need to seriously address his or her substance use. It is important during engagement and persuasion stages to be empathic, using reflective listening and validating techniques.

Helping the patient see the discrepancy between his or her long-term goals and current behavior can create the impetus for change. Linking the substance use and psychiatric symptoms and exploring their impact on each other may help the patient understand the problem.

Ambivalence and resistance are normal reactions to this process of change, so avoid arguing with the patient. Confrontation—long a common strategy in substance abuse treatment—is losing favor and is being supplanted in many cases by a more supportive, empathic approach.¹⁴ Indeed, patients with co-occurring psychiatric illness generally respond particularly poorly to confrontation.

Active treatment focuses on techniques to achieve abstinence, including alcohol and drug refusal skills, methods to deal with craving, and ways to recognize and avoid situations that present a high risk for relapse.

Relapse prevention reinforces gains made in previous stages. Here, the patient learns how to identify and deal with risky situations and how to handle a “slip” if it occurs.

ADJUNCTIVE TREATMENTS

Self-help groups. Ask whether the patient has attended self-help groups for addiction or psychiatric illness. If so, then ask, “What did you think of the meetings? What did you like and dislike?”

Self-help groups such as Alcoholics Anonymous (AA) or the Manic-Depressive and Depressive Association (MDDA) can help enormously in the recovery process. These groups are free, readily available, and can offer patients a support network. Although many dual-diagnosis patients are reluctant to attend self-help groups, they may benefit from the support, role modeling, practical advice, and structure that these meetings offer.

Drug therapy for the dual-diagnosis patient focuses on the psychiatric disorder and is usually combined with psychosocial approaches. There is little evidence that one medication is more effective than others for these patients.

Because medication compliance is key to their effective treatment, be sure to ask patients at each visit, “Have you been taking your medication as prescribed?” Because dual-diagnosis patients have been shown to take more or less medication than prescribed,¹⁵ asking how much medication they are taking can be revealing.

Related resources

• American Academy of Addiction Psychiatry www.aaap.org
• National Institute on Drug Abuse www.nida.nih.gov
• National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov

Disclosure

Dr. Manwani receives research support from Abbott Laboratories.

Dr. Weiss is a speaker for Abbott Laboratories and Eli Lilly and Co.

Acknowledgment

Supported by grants K0200326, DA09400, and DA15968 from the National Institute on Drug Abuse and a grant from the Dr. Ralph and Marian C. Falk Medical Research Trust.

Psychiatrists frequently encounter dual-diagnosis patients (Box) and may often wonder which to treat first—the substance abuse or the psychiatric comorbidity. Five principles can help you counsel dual-diagnosis patients more effectively. Briefly, they are to:

• appreciate this population’s heterogeneity
• adopt a longitudinal treatment approach, reassessing patients’ progress and adjusting interventions as needed over time
• be empathic rather than confrontational
• realize that treatment often proceeds in stages—not on a smooth, linear path
• recognize the importance of medication compliance.

ASSESSMENT

Different patients, different problems. All counseling of dual-diagnosis patients begins with a thorough assessment aimed at making an accurate diagnosis and understanding the relationship between the co-existing disorders. Although some people refer to “dual-diagnosis patients” as a single entity, these patients differ according to:

Box

• diagnosis, with a myriad of potential combinations of substance use and psychiatric disorders
• severity of disorder, with some having a predominant psychiatric or substance use problem and others experiencing severe courses of both problems
• causes of their substance abuse and psychiatric disorders, based in part on which problem is primary and which is secondary
• level of motivation for treatment and their treatment goals.

Primary versus secondary disorders. How to distinguish “primary” from “secondary” disorders in dually diagnosed patients has prompted much research and debate.

A psychiatric disorder is typically called primary when it can be viewed as independent from the substance use disorder. The term “secondary psychiatric disorder” connotes that the substance use disorder is causing the psychiatric symptoms. For example, alcohol-dependent patients in detoxification programs often have depressive symptoms, some of which abate with abstinence. They are frequently diagnosed as having “secondary depression,” or—in DSM-IV diagnostic terms—substance-induced mood disorder.

Unfortunately, distinguishing primary from secondary disorders is sometimes difficult because of patients’ poor memory, recall bias, and inadequate periods of sobriety (“I’ve been drinking for a long time and have been depressed for a long time, so I don’t remember what I was like when I was sober”). Thus, the diagnostic assessment is generally accomplished over time, rather than in a single interview.

Our research³ and clinical experience have taught us that patients’ recall about the relationship between their substance use and psychiatric symptoms often changes over time. Determining the “primary” disorder may also have limited validity in predicting treatment response.⁴

Stages of Change model. The Stages of Change model^5,6 is useful for assessing a dually diagnosed patient’s motivation to change, although its use in addictive disorders has been challenged.^7,8 According to the transtheoretical model developed by Prochaska et al (Table 1),⁵ people generally make behavioral changes in stages defined by their level of willingness to make these changes.

When counseling the dually diagnosed patient, it is useful to assess readiness to change and to suggest behavioral steps the patient is able and willing to make. Thus, it would not be appropriate to discuss drug refusal methods with a patient who does not see his substance use as a problem. Rather, addressing this patient’s ambivalence would be more useful.

Table 1

5 stages of change: The transtheoretical model of behavior change

It is important to note that many patients move back and forth between stages of readiness to change. For example, a patient in the action stage (entering treatment and pursuing a goal of abstinence) may revert to contemplation and again question whether he or she has a serious substance abuse problem. We recommend that clinicians reassess patients regularly and continue to match interventions with the current level of motivation.

WHICH DISORDER IS TREATED FIRST?

Three approaches are used for treating the coexisting problems of dual-diagnosis patients—sequential, parallel, and integrated.

Sequential treatment addresses the more acute disorder first; the other disorder receives greater attention later. This model is commonly used with hospital treatment, in which comparatively little attention would be paid to substance use in a patient who is acutely psychotic.

Parallel treatment addresses each disorder contemporaneously but in different settings (such as at a substance abuse program on Monday and a mental health center on Thursday).

One limitation of the sequential and parallel models is that psychiatric and substance abuse programs typically have different orientations. A lack of comprehensive assessment may leave the substance abuse or psychiatric disorder underdiagnosed, depending on the setting. Staff members may also project negative attitudes toward patients with psychiatric or substance use disorders if they know comparatively little about the diagnosis and treatment of the other type of disorder. Treatment in two settings also can lead to communication problems and differences of opinion among the treating clinicians.

Integrated treatment, in which both disorders are treated simultaneously in the same setting, has shown favorable outcomes in several initial studies.^{9 11} Different integrated treatment models have been described, which vary according to the psychiatric disorders’ nature and the treatment’s theoretical orientation. Integrated treatment strategies include:

• focusing on psychiatric and substance abuse issues simultaneously or in alternating sessions
• providing intense case management
• stressing the importance of medication compliance.¹²

COUNSELING PRINCIPLES

As mentioned, a careful history and thorough assessment are the keys to effectively treating the dually diagnosed patient.

Assess how the patient perceives the relationship between his substance use disorder and psychiatric symptoms. For example, ask, “What do you see as the relationship between your drinking and your depression, if any?”

As part of this process, explore both the immediate and long-term relationships between the two phenomena. For example, some patients will say that drinking offers them immediate relief from their depressive symptoms but exacerbates their depression the following day. Encouraging patients to look beyond the immediate—often positive—effects of their substance use may help them understand the negative consequences of continued use.

Review previous periods of recovery and relapse. For patients who have had substantial periods of recovery, it is important to acknowledge these successes and to ask in an upbeat and admiring way, “How did you do it?” This approach may remind patients of past successes and counterbalance their frequent feelings of discouragement and hopelessness.

Table 2

4 phases in treating the dually diagnosed patient

To help clarify the relationship between coexisting disorders, ask patients about psychiatric symptoms they have experienced during periods of substance use and recovery. Taking a relapse history can help you and the patient identify decisions and behaviors he or she must avoid (such as stopping medication, failing to attend treatment, or engaging in high-risk activities as in going to bars).

PHASES OF TREATMENT

Four phases of dual-diagnosis treatment—engagement, persuasion, active treatment, and relapse prevention—have been described, along with their therapeutic goals (Table 2).¹³ Consider these phases when treating this population, even though most patients do not proceed through them in an orderly, linear fashion.

Engagement. At the onset, the therapist tries to build an alliance and begins to establish trust and credibility.

Persuasion involves helping the patient comprehend the need to seriously address his or her substance use. It is important during engagement and persuasion stages to be empathic, using reflective listening and validating techniques.

Helping the patient see the discrepancy between his or her long-term goals and current behavior can create the impetus for change. Linking the substance use and psychiatric symptoms and exploring their impact on each other may help the patient understand the problem.

Ambivalence and resistance are normal reactions to this process of change, so avoid arguing with the patient. Confrontation—long a common strategy in substance abuse treatment—is losing favor and is being supplanted in many cases by a more supportive, empathic approach.¹⁴ Indeed, patients with co-occurring psychiatric illness generally respond particularly poorly to confrontation.

Active treatment focuses on techniques to achieve abstinence, including alcohol and drug refusal skills, methods to deal with craving, and ways to recognize and avoid situations that present a high risk for relapse.

Relapse prevention reinforces gains made in previous stages. Here, the patient learns how to identify and deal with risky situations and how to handle a “slip” if it occurs.

ADJUNCTIVE TREATMENTS

Self-help groups. Ask whether the patient has attended self-help groups for addiction or psychiatric illness. If so, then ask, “What did you think of the meetings? What did you like and dislike?”

Self-help groups such as Alcoholics Anonymous (AA) or the Manic-Depressive and Depressive Association (MDDA) can help enormously in the recovery process. These groups are free, readily available, and can offer patients a support network. Although many dual-diagnosis patients are reluctant to attend self-help groups, they may benefit from the support, role modeling, practical advice, and structure that these meetings offer.

Drug therapy for the dual-diagnosis patient focuses on the psychiatric disorder and is usually combined with psychosocial approaches. There is little evidence that one medication is more effective than others for these patients.

Because medication compliance is key to their effective treatment, be sure to ask patients at each visit, “Have you been taking your medication as prescribed?” Because dual-diagnosis patients have been shown to take more or less medication than prescribed,¹⁵ asking how much medication they are taking can be revealing.

Related resources

• American Academy of Addiction Psychiatry www.aaap.org
• National Institute on Drug Abuse www.nida.nih.gov
• National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov

Disclosure

Dr. Manwani receives research support from Abbott Laboratories.

Dr. Weiss is a speaker for Abbott Laboratories and Eli Lilly and Co.

Acknowledgment

Supported by grants K0200326, DA09400, and DA15968 from the National Institute on Drug Abuse and a grant from the Dr. Ralph and Marian C. Falk Medical Research Trust.

Psychiatrists frequently encounter dual-diagnosis patients (Box) and may often wonder which to treat first—the substance abuse or the psychiatric comorbidity. Five principles can help you counsel dual-diagnosis patients more effectively. Briefly, they are to:

• appreciate this population’s heterogeneity
• adopt a longitudinal treatment approach, reassessing patients’ progress and adjusting interventions as needed over time
• be empathic rather than confrontational
• realize that treatment often proceeds in stages—not on a smooth, linear path
• recognize the importance of medication compliance.

ASSESSMENT

Different patients, different problems. All counseling of dual-diagnosis patients begins with a thorough assessment aimed at making an accurate diagnosis and understanding the relationship between the co-existing disorders. Although some people refer to “dual-diagnosis patients” as a single entity, these patients differ according to:

Box

• diagnosis, with a myriad of potential combinations of substance use and psychiatric disorders
• severity of disorder, with some having a predominant psychiatric or substance use problem and others experiencing severe courses of both problems
• causes of their substance abuse and psychiatric disorders, based in part on which problem is primary and which is secondary
• level of motivation for treatment and their treatment goals.

Primary versus secondary disorders. How to distinguish “primary” from “secondary” disorders in dually diagnosed patients has prompted much research and debate.

A psychiatric disorder is typically called primary when it can be viewed as independent from the substance use disorder. The term “secondary psychiatric disorder” connotes that the substance use disorder is causing the psychiatric symptoms. For example, alcohol-dependent patients in detoxification programs often have depressive symptoms, some of which abate with abstinence. They are frequently diagnosed as having “secondary depression,” or—in DSM-IV diagnostic terms—substance-induced mood disorder.

Unfortunately, distinguishing primary from secondary disorders is sometimes difficult because of patients’ poor memory, recall bias, and inadequate periods of sobriety (“I’ve been drinking for a long time and have been depressed for a long time, so I don’t remember what I was like when I was sober”). Thus, the diagnostic assessment is generally accomplished over time, rather than in a single interview.

Our research³ and clinical experience have taught us that patients’ recall about the relationship between their substance use and psychiatric symptoms often changes over time. Determining the “primary” disorder may also have limited validity in predicting treatment response.⁴

Stages of Change model. The Stages of Change model^5,6 is useful for assessing a dually diagnosed patient’s motivation to change, although its use in addictive disorders has been challenged.^7,8 According to the transtheoretical model developed by Prochaska et al (Table 1),⁵ people generally make behavioral changes in stages defined by their level of willingness to make these changes.

When counseling the dually diagnosed patient, it is useful to assess readiness to change and to suggest behavioral steps the patient is able and willing to make. Thus, it would not be appropriate to discuss drug refusal methods with a patient who does not see his substance use as a problem. Rather, addressing this patient’s ambivalence would be more useful.

Table 1

5 stages of change: The transtheoretical model of behavior change

It is important to note that many patients move back and forth between stages of readiness to change. For example, a patient in the action stage (entering treatment and pursuing a goal of abstinence) may revert to contemplation and again question whether he or she has a serious substance abuse problem. We recommend that clinicians reassess patients regularly and continue to match interventions with the current level of motivation.

WHICH DISORDER IS TREATED FIRST?

Three approaches are used for treating the coexisting problems of dual-diagnosis patients—sequential, parallel, and integrated.

Sequential treatment addresses the more acute disorder first; the other disorder receives greater attention later. This model is commonly used with hospital treatment, in which comparatively little attention would be paid to substance use in a patient who is acutely psychotic.

Parallel treatment addresses each disorder contemporaneously but in different settings (such as at a substance abuse program on Monday and a mental health center on Thursday).

One limitation of the sequential and parallel models is that psychiatric and substance abuse programs typically have different orientations. A lack of comprehensive assessment may leave the substance abuse or psychiatric disorder underdiagnosed, depending on the setting. Staff members may also project negative attitudes toward patients with psychiatric or substance use disorders if they know comparatively little about the diagnosis and treatment of the other type of disorder. Treatment in two settings also can lead to communication problems and differences of opinion among the treating clinicians.

Integrated treatment, in which both disorders are treated simultaneously in the same setting, has shown favorable outcomes in several initial studies.^{9 11} Different integrated treatment models have been described, which vary according to the psychiatric disorders’ nature and the treatment’s theoretical orientation. Integrated treatment strategies include:

• focusing on psychiatric and substance abuse issues simultaneously or in alternating sessions
• providing intense case management
• stressing the importance of medication compliance.¹²

COUNSELING PRINCIPLES

As mentioned, a careful history and thorough assessment are the keys to effectively treating the dually diagnosed patient.

Assess how the patient perceives the relationship between his substance use disorder and psychiatric symptoms. For example, ask, “What do you see as the relationship between your drinking and your depression, if any?”

As part of this process, explore both the immediate and long-term relationships between the two phenomena. For example, some patients will say that drinking offers them immediate relief from their depressive symptoms but exacerbates their depression the following day. Encouraging patients to look beyond the immediate—often positive—effects of their substance use may help them understand the negative consequences of continued use.

Review previous periods of recovery and relapse. For patients who have had substantial periods of recovery, it is important to acknowledge these successes and to ask in an upbeat and admiring way, “How did you do it?” This approach may remind patients of past successes and counterbalance their frequent feelings of discouragement and hopelessness.

Table 2

4 phases in treating the dually diagnosed patient

To help clarify the relationship between coexisting disorders, ask patients about psychiatric symptoms they have experienced during periods of substance use and recovery. Taking a relapse history can help you and the patient identify decisions and behaviors he or she must avoid (such as stopping medication, failing to attend treatment, or engaging in high-risk activities as in going to bars).

PHASES OF TREATMENT

Four phases of dual-diagnosis treatment—engagement, persuasion, active treatment, and relapse prevention—have been described, along with their therapeutic goals (Table 2).¹³ Consider these phases when treating this population, even though most patients do not proceed through them in an orderly, linear fashion.

Engagement. At the onset, the therapist tries to build an alliance and begins to establish trust and credibility.

Persuasion involves helping the patient comprehend the need to seriously address his or her substance use. It is important during engagement and persuasion stages to be empathic, using reflective listening and validating techniques.

Helping the patient see the discrepancy between his or her long-term goals and current behavior can create the impetus for change. Linking the substance use and psychiatric symptoms and exploring their impact on each other may help the patient understand the problem.

Ambivalence and resistance are normal reactions to this process of change, so avoid arguing with the patient. Confrontation—long a common strategy in substance abuse treatment—is losing favor and is being supplanted in many cases by a more supportive, empathic approach.¹⁴ Indeed, patients with co-occurring psychiatric illness generally respond particularly poorly to confrontation.

Active treatment focuses on techniques to achieve abstinence, including alcohol and drug refusal skills, methods to deal with craving, and ways to recognize and avoid situations that present a high risk for relapse.

Relapse prevention reinforces gains made in previous stages. Here, the patient learns how to identify and deal with risky situations and how to handle a “slip” if it occurs.

ADJUNCTIVE TREATMENTS

Self-help groups. Ask whether the patient has attended self-help groups for addiction or psychiatric illness. If so, then ask, “What did you think of the meetings? What did you like and dislike?”

Self-help groups such as Alcoholics Anonymous (AA) or the Manic-Depressive and Depressive Association (MDDA) can help enormously in the recovery process. These groups are free, readily available, and can offer patients a support network. Although many dual-diagnosis patients are reluctant to attend self-help groups, they may benefit from the support, role modeling, practical advice, and structure that these meetings offer.

Drug therapy for the dual-diagnosis patient focuses on the psychiatric disorder and is usually combined with psychosocial approaches. There is little evidence that one medication is more effective than others for these patients.

Because medication compliance is key to their effective treatment, be sure to ask patients at each visit, “Have you been taking your medication as prescribed?” Because dual-diagnosis patients have been shown to take more or less medication than prescribed,¹⁵ asking how much medication they are taking can be revealing.

Related resources

• American Academy of Addiction Psychiatry www.aaap.org
• National Institute on Drug Abuse www.nida.nih.gov
• National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov

Disclosure

Dr. Manwani receives research support from Abbott Laboratories.

Dr. Weiss is a speaker for Abbott Laboratories and Eli Lilly and Co.

Acknowledgment

Supported by grants K0200326, DA09400, and DA15968 from the National Institute on Drug Abuse and a grant from the Dr. Ralph and Marian C. Falk Medical Research Trust.

You’re anxiously awaiting an important e-mail from a patient or colleague. You click into your in box, only to find a string of solicitations urging you to refinance your mortgage, buy cheap Viagra, or get rich quick.

Meanwhile, that important message may have been bounced back to the sender and lost.

This is just one way electronic junk mail, or spam, wreaks havoc on millions of e-mail users. If you’re tired of ‘spammers’ feeding you unwanted messages, read on.

Why spam is a problem

Mailing printed advertisements to 20 million people can cost tens of thousands of dollars in postage, mailing lists, and printing. By contrast, a spammer can reach that same audience for a fraction of the cost. Anyone with an Internet service provider (ISP) and a mass-mailing program can flood cyberspace with junk messages.

As a result, users waste precious time and money deleting junk messages by the score. Spam is especially costly to users who pay by the hour for dial-up Internet access.

What’s more, ISPs need to purchase additional processing servers to handle the increase in e-mail volume caused by excessive junk messages. This often leads to rate increases for subscribers with DSL, cable-modem, or other broadband connections.

Fighting back

Federal lawmakers have begun taking aim at unwanted e-mails. The Can Spam Act of 2003, which awaits a Senate vote, would outlaw misleading advertising and mandate a range of requirements on e-solicitors, from inclusion of unsubscribe options on messages to use of functional return e-mail addresses. Violators would face fines of as much as $1 million and/or 1 year in prison.¹ Several states, such as Minnesota, also have been considering fines for junk e-mail.²

In the meantime, users can take measures—common-sense and technological—against spam.

Follow these 4 steps

To keep your e-mail address out of spammers’ hands, do not:

1. Open spam messages. Just as traditional junk mail is immediately discarded, spam should be deleted without opening. By clicking anywhere in the body of the junk e-mail, the sender receives a return message that e-mail access is valid, subjecting you to more spam.
2. Click on the ‘unsubscribe’ link. “Spammers” will not honor this request but will instead store your e-mail address for future reference. For similar reasons, do not reply to the e-mail.
3. Post your e-mail address on a Web page. Many spammers use programs that “harvest” e-mail addresses. These programs are particularly attracted to Web pages with hyperlinked e-mail addresses.
4. Use an obvious address. Some spammers use “dictionary spamming” by combining common last names and initials to find new e-mail targets. Try to include unusual numeral and character combinations in your address.

Also, use “jsluo|at|email.com” instead of [email protected]. Replacing @ with |at| prevents mass-mailing programs from automatically harvesting and using that address. However, some novice users may not realize they need to type |at| instead of @ to contact you.

Finally, use an alternate e-mail address for contests and newsletters if you suspect these will open the floodgates for spam.

Fighting spam with technology

Many free Web-based e-mail accounts such as Hotmail or Yahoo allow users to receive and delete e-mail in bulk by checking one box. Most providers also employ proprietary anti-spam software to protect their subscribers and servers.

E-mail clients such as Microsoft Outlook or Outlook Express allow you to set up rules to organize mail. Mail from certain users or with particular subjects can be automatically moved from the in box to designated folders. Messages containing terms such as ‘mortgage’ or ‘improve your sex life’ can be automatically deleted. Certain senders can be sent directly to the trash. Consult the “Help” section of these clients for directions.

Check your “deleted items” box to ensure that your rules are not sending important mail to the trash. Once you know that the rules work, you can automatically delete the files.

An anti-spam program can be added to your mail client (Table). These programs work via a combination of methods:

• The program checks a message’s subject content and source to see if the address matches with a list of known spammers. Most spam has a characteristic style, format and phrasing that programs can spot.
• Users can “teach” the program which e-mails to block by verifying wanted and unwanted messages. Some programs send an e-mail to the sender requesting verification. Once the sender replies, mail will go through automatically.

But be careful. If you set your filter to get rid of any subject with ‘urgent,’ the filter may block a patient’s urgent message.

Blowing the whistle

You can also report a spammer to his or her ISP, which in turn may rescind the spammer’s account or assess “cleanup fees.”

Programs such as SpamCop and the Network Abuse Clearinghouse offer reporting/filtering programs that electronically forward spam complaints to ISPs and, in some cases, get a spammer’s address blacklisted, meaning that the user can be denied Internet access through that ISP.

Senders who advertise fraudulent products can also be reported to the Federal Trade Commission. Those who advertise unapproved medical products can be reported to the Food and Drug Administration at (800) 532-4440.

Selected anti-spam programs

Related Resources

Spam safety tips. http://www.spamfilterreview.com/spam-saftey-tips.html

Spam Tips and Help. http://spam.abuse.net/userhelp/

Mark R. Senate panel overwhelmingly passes anti-spam bill. dc.internet.com June 19, 2003. Available at: http://dc.internet.com/news/article.php/2224681. Accessed Sept. 5, 2003

Sturdevant C. Can-Spam Act can’t. eWeek June 9, 2003. Available at: http://www.eweek.com/print_article/0,3668,a=43121,00.asp. Accessed Sept. 5, 2003

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to [email protected].

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.

You’re anxiously awaiting an important e-mail from a patient or colleague. You click into your in box, only to find a string of solicitations urging you to refinance your mortgage, buy cheap Viagra, or get rich quick.

Meanwhile, that important message may have been bounced back to the sender and lost.

This is just one way electronic junk mail, or spam, wreaks havoc on millions of e-mail users. If you’re tired of ‘spammers’ feeding you unwanted messages, read on.

Why spam is a problem

Mailing printed advertisements to 20 million people can cost tens of thousands of dollars in postage, mailing lists, and printing. By contrast, a spammer can reach that same audience for a fraction of the cost. Anyone with an Internet service provider (ISP) and a mass-mailing program can flood cyberspace with junk messages.

As a result, users waste precious time and money deleting junk messages by the score. Spam is especially costly to users who pay by the hour for dial-up Internet access.

What’s more, ISPs need to purchase additional processing servers to handle the increase in e-mail volume caused by excessive junk messages. This often leads to rate increases for subscribers with DSL, cable-modem, or other broadband connections.

Fighting back

Federal lawmakers have begun taking aim at unwanted e-mails. The Can Spam Act of 2003, which awaits a Senate vote, would outlaw misleading advertising and mandate a range of requirements on e-solicitors, from inclusion of unsubscribe options on messages to use of functional return e-mail addresses. Violators would face fines of as much as $1 million and/or 1 year in prison.¹ Several states, such as Minnesota, also have been considering fines for junk e-mail.²

In the meantime, users can take measures—common-sense and technological—against spam.

Follow these 4 steps

To keep your e-mail address out of spammers’ hands, do not:

1. Open spam messages. Just as traditional junk mail is immediately discarded, spam should be deleted without opening. By clicking anywhere in the body of the junk e-mail, the sender receives a return message that e-mail access is valid, subjecting you to more spam.
2. Click on the ‘unsubscribe’ link. “Spammers” will not honor this request but will instead store your e-mail address for future reference. For similar reasons, do not reply to the e-mail.
3. Post your e-mail address on a Web page. Many spammers use programs that “harvest” e-mail addresses. These programs are particularly attracted to Web pages with hyperlinked e-mail addresses.
4. Use an obvious address. Some spammers use “dictionary spamming” by combining common last names and initials to find new e-mail targets. Try to include unusual numeral and character combinations in your address.

Also, use “jsluo|at|email.com” instead of [email protected]. Replacing @ with |at| prevents mass-mailing programs from automatically harvesting and using that address. However, some novice users may not realize they need to type |at| instead of @ to contact you.

Finally, use an alternate e-mail address for contests and newsletters if you suspect these will open the floodgates for spam.

Fighting spam with technology

Many free Web-based e-mail accounts such as Hotmail or Yahoo allow users to receive and delete e-mail in bulk by checking one box. Most providers also employ proprietary anti-spam software to protect their subscribers and servers.

E-mail clients such as Microsoft Outlook or Outlook Express allow you to set up rules to organize mail. Mail from certain users or with particular subjects can be automatically moved from the in box to designated folders. Messages containing terms such as ‘mortgage’ or ‘improve your sex life’ can be automatically deleted. Certain senders can be sent directly to the trash. Consult the “Help” section of these clients for directions.

Check your “deleted items” box to ensure that your rules are not sending important mail to the trash. Once you know that the rules work, you can automatically delete the files.

An anti-spam program can be added to your mail client (Table). These programs work via a combination of methods:

• The program checks a message’s subject content and source to see if the address matches with a list of known spammers. Most spam has a characteristic style, format and phrasing that programs can spot.
• Users can “teach” the program which e-mails to block by verifying wanted and unwanted messages. Some programs send an e-mail to the sender requesting verification. Once the sender replies, mail will go through automatically.

But be careful. If you set your filter to get rid of any subject with ‘urgent,’ the filter may block a patient’s urgent message.

Blowing the whistle

You can also report a spammer to his or her ISP, which in turn may rescind the spammer’s account or assess “cleanup fees.”

Programs such as SpamCop and the Network Abuse Clearinghouse offer reporting/filtering programs that electronically forward spam complaints to ISPs and, in some cases, get a spammer’s address blacklisted, meaning that the user can be denied Internet access through that ISP.

Senders who advertise fraudulent products can also be reported to the Federal Trade Commission. Those who advertise unapproved medical products can be reported to the Food and Drug Administration at (800) 532-4440.

Selected anti-spam programs

Related Resources

Spam safety tips. http://www.spamfilterreview.com/spam-saftey-tips.html

Spam Tips and Help. http://spam.abuse.net/userhelp/

Mark R. Senate panel overwhelmingly passes anti-spam bill. dc.internet.com June 19, 2003. Available at: http://dc.internet.com/news/article.php/2224681. Accessed Sept. 5, 2003

Sturdevant C. Can-Spam Act can’t. eWeek June 9, 2003. Available at: http://www.eweek.com/print_article/0,3668,a=43121,00.asp. Accessed Sept. 5, 2003

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to [email protected].

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.

You’re anxiously awaiting an important e-mail from a patient or colleague. You click into your in box, only to find a string of solicitations urging you to refinance your mortgage, buy cheap Viagra, or get rich quick.

Meanwhile, that important message may have been bounced back to the sender and lost.

This is just one way electronic junk mail, or spam, wreaks havoc on millions of e-mail users. If you’re tired of ‘spammers’ feeding you unwanted messages, read on.

Why spam is a problem

Mailing printed advertisements to 20 million people can cost tens of thousands of dollars in postage, mailing lists, and printing. By contrast, a spammer can reach that same audience for a fraction of the cost. Anyone with an Internet service provider (ISP) and a mass-mailing program can flood cyberspace with junk messages.

As a result, users waste precious time and money deleting junk messages by the score. Spam is especially costly to users who pay by the hour for dial-up Internet access.

What’s more, ISPs need to purchase additional processing servers to handle the increase in e-mail volume caused by excessive junk messages. This often leads to rate increases for subscribers with DSL, cable-modem, or other broadband connections.

Fighting back

Federal lawmakers have begun taking aim at unwanted e-mails. The Can Spam Act of 2003, which awaits a Senate vote, would outlaw misleading advertising and mandate a range of requirements on e-solicitors, from inclusion of unsubscribe options on messages to use of functional return e-mail addresses. Violators would face fines of as much as $1 million and/or 1 year in prison.¹ Several states, such as Minnesota, also have been considering fines for junk e-mail.²

In the meantime, users can take measures—common-sense and technological—against spam.

Follow these 4 steps

To keep your e-mail address out of spammers’ hands, do not:

1. Open spam messages. Just as traditional junk mail is immediately discarded, spam should be deleted without opening. By clicking anywhere in the body of the junk e-mail, the sender receives a return message that e-mail access is valid, subjecting you to more spam.
2. Click on the ‘unsubscribe’ link. “Spammers” will not honor this request but will instead store your e-mail address for future reference. For similar reasons, do not reply to the e-mail.
3. Post your e-mail address on a Web page. Many spammers use programs that “harvest” e-mail addresses. These programs are particularly attracted to Web pages with hyperlinked e-mail addresses.
4. Use an obvious address. Some spammers use “dictionary spamming” by combining common last names and initials to find new e-mail targets. Try to include unusual numeral and character combinations in your address.

Also, use “jsluo|at|email.com” instead of [email protected]. Replacing @ with |at| prevents mass-mailing programs from automatically harvesting and using that address. However, some novice users may not realize they need to type |at| instead of @ to contact you.

Finally, use an alternate e-mail address for contests and newsletters if you suspect these will open the floodgates for spam.

Fighting spam with technology

Many free Web-based e-mail accounts such as Hotmail or Yahoo allow users to receive and delete e-mail in bulk by checking one box. Most providers also employ proprietary anti-spam software to protect their subscribers and servers.

E-mail clients such as Microsoft Outlook or Outlook Express allow you to set up rules to organize mail. Mail from certain users or with particular subjects can be automatically moved from the in box to designated folders. Messages containing terms such as ‘mortgage’ or ‘improve your sex life’ can be automatically deleted. Certain senders can be sent directly to the trash. Consult the “Help” section of these clients for directions.

Check your “deleted items” box to ensure that your rules are not sending important mail to the trash. Once you know that the rules work, you can automatically delete the files.

An anti-spam program can be added to your mail client (Table). These programs work via a combination of methods:

• The program checks a message’s subject content and source to see if the address matches with a list of known spammers. Most spam has a characteristic style, format and phrasing that programs can spot.
• Users can “teach” the program which e-mails to block by verifying wanted and unwanted messages. Some programs send an e-mail to the sender requesting verification. Once the sender replies, mail will go through automatically.

But be careful. If you set your filter to get rid of any subject with ‘urgent,’ the filter may block a patient’s urgent message.

Blowing the whistle

You can also report a spammer to his or her ISP, which in turn may rescind the spammer’s account or assess “cleanup fees.”

Programs such as SpamCop and the Network Abuse Clearinghouse offer reporting/filtering programs that electronically forward spam complaints to ISPs and, in some cases, get a spammer’s address blacklisted, meaning that the user can be denied Internet access through that ISP.

Senders who advertise fraudulent products can also be reported to the Federal Trade Commission. Those who advertise unapproved medical products can be reported to the Food and Drug Administration at (800) 532-4440.

Selected anti-spam programs

Related Resources

Spam safety tips. http://www.spamfilterreview.com/spam-saftey-tips.html

Spam Tips and Help. http://spam.abuse.net/userhelp/

Mark R. Senate panel overwhelmingly passes anti-spam bill. dc.internet.com June 19, 2003. Available at: http://dc.internet.com/news/article.php/2224681. Accessed Sept. 5, 2003

Sturdevant C. Can-Spam Act can’t. eWeek June 9, 2003. Available at: http://www.eweek.com/print_article/0,3668,a=43121,00.asp. Accessed Sept. 5, 2003

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to [email protected].

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.

Despite numerous drug treatment innovations, just about all patients with bipolar disorder that I have treated reported improvement after starting a lithium regimen.

In the 1970s, the clinical literature began highlighting numerous drug therapies for different bipolar symptoms. Before then, I had been taught to treat all “manic-depressive” patients with lithium—regardless of whether mood swings, bouts of anger, depression, or mania were the dominant symptoms.

So I experimented. I prescribed lithium to any potential bipolar patient who did not meet DSM criteria for another mental illness. I discovered the following:

1. A family history of any mental illness, especially alcohol abuse and depression, is a strong indicator of bipolar disorder and of potential positive response to lithium.
2. The existence of mood swings, especially without cause, confirms the diagnosis of bipolar disorder when paired with family history.
3. Lithium, 900 mg/d, works fine as acute or maintenance therapy. I would decrease the dosage for smaller people (eg, 600 mg/d for a patient weighing approximately 125 lbs). I would only increase the dosage—to 1,200 mg/d—for patients with severe mania.
4. Gauging lithium blood levels is a waste of time, assuming you have checked for kidney disease. Across 3 decades in practice, the only patient I have ever seen with an abnormally high lithium blood count also suffered renal failure.
5. Side effects I have seen most commonly with lithium are:
   • weight gain in women, in which case another medication should be prescribed
   • tremor, which should warrant a check of the patient’s caffeine intake.

Other side effects (such as diarrhea and GI upset) are usually mild and easy to control by adding other medications.

Despite numerous drug treatment innovations, just about all patients with bipolar disorder that I have treated reported improvement after starting a lithium regimen.

In the 1970s, the clinical literature began highlighting numerous drug therapies for different bipolar symptoms. Before then, I had been taught to treat all “manic-depressive” patients with lithium—regardless of whether mood swings, bouts of anger, depression, or mania were the dominant symptoms.

So I experimented. I prescribed lithium to any potential bipolar patient who did not meet DSM criteria for another mental illness. I discovered the following:

1. A family history of any mental illness, especially alcohol abuse and depression, is a strong indicator of bipolar disorder and of potential positive response to lithium.
2. The existence of mood swings, especially without cause, confirms the diagnosis of bipolar disorder when paired with family history.
3. Lithium, 900 mg/d, works fine as acute or maintenance therapy. I would decrease the dosage for smaller people (eg, 600 mg/d for a patient weighing approximately 125 lbs). I would only increase the dosage—to 1,200 mg/d—for patients with severe mania.
4. Gauging lithium blood levels is a waste of time, assuming you have checked for kidney disease. Across 3 decades in practice, the only patient I have ever seen with an abnormally high lithium blood count also suffered renal failure.
5. Side effects I have seen most commonly with lithium are:
   • weight gain in women, in which case another medication should be prescribed
   • tremor, which should warrant a check of the patient’s caffeine intake.

Other side effects (such as diarrhea and GI upset) are usually mild and easy to control by adding other medications.

Despite numerous drug treatment innovations, just about all patients with bipolar disorder that I have treated reported improvement after starting a lithium regimen.

In the 1970s, the clinical literature began highlighting numerous drug therapies for different bipolar symptoms. Before then, I had been taught to treat all “manic-depressive” patients with lithium—regardless of whether mood swings, bouts of anger, depression, or mania were the dominant symptoms.

So I experimented. I prescribed lithium to any potential bipolar patient who did not meet DSM criteria for another mental illness. I discovered the following:

1. A family history of any mental illness, especially alcohol abuse and depression, is a strong indicator of bipolar disorder and of potential positive response to lithium.
2. The existence of mood swings, especially without cause, confirms the diagnosis of bipolar disorder when paired with family history.
3. Lithium, 900 mg/d, works fine as acute or maintenance therapy. I would decrease the dosage for smaller people (eg, 600 mg/d for a patient weighing approximately 125 lbs). I would only increase the dosage—to 1,200 mg/d—for patients with severe mania.
4. Gauging lithium blood levels is a waste of time, assuming you have checked for kidney disease. Across 3 decades in practice, the only patient I have ever seen with an abnormally high lithium blood count also suffered renal failure.
5. Side effects I have seen most commonly with lithium are:
   • weight gain in women, in which case another medication should be prescribed
   • tremor, which should warrant a check of the patient’s caffeine intake.

Other side effects (such as diarrhea and GI upset) are usually mild and easy to control by adding other medications.

Psychotic disorders are difficult to detect in children and adolescents. Such disorders often masquerade as a general medical condition or as a substance abuse, anxiety, mood, or pervasive developmental disorder. On the other hand, some youths whose presentations meet no psychiatric syndrome criteria may complain of psychotic symptoms.¹

Consider these six issues when a youth presents with symptoms that may indicate psychosis.

1. Mood disorders. Psychotic symptoms in the young:
   • often point to major depression with psychotic features¹
   • are common in youths with bipolar disorder and may initially be misidentified as onset of schizophrenia.² Conversely, negative symptoms of schizophrenia may be mistaken for major depression.
2. Cluster of symptoms. Psychosis is characterized by positive and negative symptoms and by symptoms of disorganization such as thought disorder. Youths with schizophrenia present with a cluster of psychotic symptoms.^3,4
3. Age. Childhood-onset schizophrenia is rare; adolescent-onset schizophrenia is not.⁵ The younger the patient, the less likely he or she is psychotic.
4. Course. A careful retrospective assessment may confirm schizophrenia by uncovering premorbid difficulties with function and a prodrome that preceded more-extensive symptom expression.⁴
5. Family history. Genetics are an important risk factor for schizophrenia.⁶ A thorough family history may help assess for schizophrenia and schizophrenia-spectrum disorders (including cluster A personality disorders).
6. Multidimensionally impaired syndrome (MIS). Patients with MIS do not have schizophrenia per se. Their symptoms include mild hallucinations, mood instability, social skills deficits, neuropsychological impairments, or excessive preoccupations with fantasy or magical thinking that are developmentally inappropriate but not clearly delusional.⁷

Psychotic disorders are difficult to detect in children and adolescents. Such disorders often masquerade as a general medical condition or as a substance abuse, anxiety, mood, or pervasive developmental disorder. On the other hand, some youths whose presentations meet no psychiatric syndrome criteria may complain of psychotic symptoms.¹

Consider these six issues when a youth presents with symptoms that may indicate psychosis.

1. Mood disorders. Psychotic symptoms in the young:
   • often point to major depression with psychotic features¹
   • are common in youths with bipolar disorder and may initially be misidentified as onset of schizophrenia.² Conversely, negative symptoms of schizophrenia may be mistaken for major depression.
2. Cluster of symptoms. Psychosis is characterized by positive and negative symptoms and by symptoms of disorganization such as thought disorder. Youths with schizophrenia present with a cluster of psychotic symptoms.^3,4
3. Age. Childhood-onset schizophrenia is rare; adolescent-onset schizophrenia is not.⁵ The younger the patient, the less likely he or she is psychotic.
4. Course. A careful retrospective assessment may confirm schizophrenia by uncovering premorbid difficulties with function and a prodrome that preceded more-extensive symptom expression.⁴
5. Family history. Genetics are an important risk factor for schizophrenia.⁶ A thorough family history may help assess for schizophrenia and schizophrenia-spectrum disorders (including cluster A personality disorders).
6. Multidimensionally impaired syndrome (MIS). Patients with MIS do not have schizophrenia per se. Their symptoms include mild hallucinations, mood instability, social skills deficits, neuropsychological impairments, or excessive preoccupations with fantasy or magical thinking that are developmentally inappropriate but not clearly delusional.⁷

Psychotic disorders are difficult to detect in children and adolescents. Such disorders often masquerade as a general medical condition or as a substance abuse, anxiety, mood, or pervasive developmental disorder. On the other hand, some youths whose presentations meet no psychiatric syndrome criteria may complain of psychotic symptoms.¹

Consider these six issues when a youth presents with symptoms that may indicate psychosis.

1. Mood disorders. Psychotic symptoms in the young:
   • often point to major depression with psychotic features¹
   • are common in youths with bipolar disorder and may initially be misidentified as onset of schizophrenia.² Conversely, negative symptoms of schizophrenia may be mistaken for major depression.
2. Cluster of symptoms. Psychosis is characterized by positive and negative symptoms and by symptoms of disorganization such as thought disorder. Youths with schizophrenia present with a cluster of psychotic symptoms.^3,4
3. Age. Childhood-onset schizophrenia is rare; adolescent-onset schizophrenia is not.⁵ The younger the patient, the less likely he or she is psychotic.
4. Course. A careful retrospective assessment may confirm schizophrenia by uncovering premorbid difficulties with function and a prodrome that preceded more-extensive symptom expression.⁴
5. Family history. Genetics are an important risk factor for schizophrenia.⁶ A thorough family history may help assess for schizophrenia and schizophrenia-spectrum disorders (including cluster A personality disorders).
6. Multidimensionally impaired syndrome (MIS). Patients with MIS do not have schizophrenia per se. Their symptoms include mild hallucinations, mood instability, social skills deficits, neuropsychological impairments, or excessive preoccupations with fantasy or magical thinking that are developmentally inappropriate but not clearly delusional.⁷

Victims of domestic abuse/violence often present with medical and psychiatric disorders (Box 1, Table 1). Identifying abuse—and encouraging the frightened or ashamed patient to seek help—is critical to evaluating presenting complaints, improving out-come,⁷ and possibly saving the patient’s life.

This article will discuss ways to:

• detect signs of abuse
• determine whether a victim is in danger
• share information about crisis resources
• help those who are considering leaving an abusive partner to make a safety plan.

Box 1

Medical complaints in victims of domestic violence/abuse

Domestic violence/abuse affects 1 of 4 women in the United States. Men also are victims, but the prevalence (1 of 14) and degree of injury is much lower.¹ Domestic violence/abuse occurs among all socioeconomic and ethnic groups.^1,2

Domestic violence/abuse impairs victims’ physical and mental health.² Injuries and ailments more prevalent among domestic abuse victims than among the general population include:^2,3

• digestive problems (diarrhea, nausea, appetite loss, spastic colon, constipation, eating disorders,
• urinary problems and infections
• vaginal infections, sexually transmitted diseases, pelvic pain, menstrual problems
• sexual dysfunction
• hypertension
• fainting
• chronic pain (headaches, pelvic, abdominal, back and neck)
• pregnancy problems (preterm labor, poor weight gain)

CASE REPORT: TWO YEARS OF HURT

Ms. W, age 26, is referred to a psychiatrist for treatment-resistant depression. Courses of fluoxetine, 20 mg/d titrated to 80 mg/d, and venlafaxine, 150 mg bid, failed to improve her symptoms. Her Beck Depression Inventory score at baseline is 18, suggesting borderline clinical depression.

Table 1

Psychiatric disorders in victims of domestic abuse/violence

She has two children—ages 2 and 4—with her husband, a habitual crack cocaine user. She does not use drugs or alcohol.

When asked about her life at home, Ms. W laments that her husband is not helpful. When asked if her husband hurts her, she replies tearfully that he constantly yells at her and insults her, calling her “ugly” and “a lousy mom.” Upon further questioning, she reveals that her husband, when high on crack, sometimes hits her.

Ms. W does not work outside the home and did not finish high school. She is afraid to leave her husband because his mother helps care for the children and provides money, housing, and food. She constantly feels tearful and trapped.

The psychiatrist increases the venlafaxine to 375 mg/d and suggests that Ms. W call a domestic violence crisis center. She does not call the center, but agrees to see the psychiatrist monthly. Across 3 months her Beck score improves to 14.

SCREENING FOR ABUSE

The American Medical Association, American College of Physicians, and other physician and nursing organizations recommend routinely screening women for domestic abuse/violence.^8-10 Some patients will not disclose abuse to their physicians when asked, but most patients say they want doctors to ask them about domestic violence/abuse and to offer crisis phone numbers, pamphlets, and other resources.¹¹

Anyone who presents with complaints of fatigue, depression, anxiety, insomnia, hypervigilance, a treatment-resistant psychiatric disorder, or a visible physical injury (such as a black eye or bruises) should be screened for domestic abuse.

Prevention and treatment guidelines for physicians^9,12,13 recommend interviewing the patient—without the partner or children—in a nonjudgmental and empathic fashion.¹¹

Written questionnaires—such as the Woman Abuse Screening Tool (WAST), WAST-short, and HITS—are another screening option.

WAST-Short has demonstrated 92% sensitivity in identifying emotional or physical abuse (Table 2).¹⁴

WAST. The longer version of WAST has demonstrated 96% sensitivity in detecting physical or emotional abuse.¹⁴ It includes the two WAST-short questions, plus five questions about whether:

• arguments with an intimate partner ever diminish the patient’s self-esteem
• such arguments ever result in kicking or hitting
• the patient ever feels frightened by the partner’s words or actions
• the patient has ever been physically or emotionally abused by his or her partner.

Because the additional questions are not scored, the longer WAST is not well suited to clinical practice. However, a patient who scores a 1 on the WAST-Short exam can provide more in-depth information on her troubled relationship by answering the extra questions.

HITS can be self-administered and its title is easy to remember, but the scoring system is cumbersome. The patient is asked: “How often does your partner:

• Hurt you physically?
• Insult you or talk down to you?
• Threaten you with harm?
• Scream or curse at you?”

Each answer is scored on a 1-to-5 scale—never, rarely, sometimes, fairly often, or frequently. A score ≥ 10.5 has demonstrated 96% sensitivity in identifying physical and verbal abuse.¹⁵

Encouraging disclosure. Ask patients about domestic abuse when inquiring about smoking, alcohol use, or household makeup as part of the patient history. Your line of questioning might proceed as follows:

• “Do you live alone?”
• “Do you have a significant other?”
• “How is your relationship going?”
• “Is your partner supportive?”
• “What happens when you and your partner disagree?”

Table 2

Woman Abuse Screening Tool-Short version

Be empathic. Explain the association between domestic abuse/violence and mental and physical disorders. Tell the patient that domestic abuse is common and help is readily available. Share information about crisis services even if the patient does not immediately disclose suspected abuse. Victims generally feel tremendous shame from living with the abuse, so disclosure takes time and trust.

Most states do not require physicians to report domestic abuse to the police unless injuries are caused by a weapon (knife or gun). However, physicians in California, Colorado, Kentucky, and New York must report any injuries resulting from domestic abuse—even if not caused by a weapon.¹⁶ In these states, clinicians should disclose their reporting obligation at the start of the patient interview.

Box 2

Box 3

WHEN A PATIENT CONFIRMS ABUSE

Affirm the difficulty of sharing this information and reassure the patient that she is not alone. Tell her, for example, “I know this is difficult to talk about. No one deserves to be treated this way.”

Reaffirm confidentiality. Victims fear harm to themselves or their children if their abusers find out they have discussed the abuse.

Assess the danger to the patient (Box 2).¹⁷

Refer the patient to a local domestic violence crisis agency or to a therapist knowledgeable about domestic abuse. A patient who reports being threatened at gunpoint or who fears for her safety should be urged to call police.

Do not refer the victim and partner to couples counseling. Such therapy is contraindicated because of the relationship’s power imbalance and the risk that the abuser will retaliate when alone with the victim.

DEVELOPING A SAFETY PLAN

Patients who have decided to leave an abusive partner need help forming a safety plan. Assistance from a domestic violence crisis agency is invaluable, but some patients prefer to work with their physicians. Safety planning involves helping the victim identify options and needs upon leaving the relationship.

Start by asking the patient:

• “If you leave home, where will you go?
• Is there an alternative if you cannot stay where you planned?
• Do you have an emergency bag?” (Box 3) ¹⁷

Remind the patient to keep her emergency bag, purse, and keys handy in case she needs to leave quickly.

Instruct the patient to:

• Tell a neighbor about the violence and ask him or her to call police if he or she hears suspicious noises from the victim’s residence.
• Teach children to dial 911 or 0 or to make a collect call to a relative, friend, minister, or other trusted person in an emergency. Also teach children addresses of close relatives and friends.
• Learn the local domestic violence hotline number.¹⁷

IF A PATIENT DENIES ABUSE

If a suspected victim denies she is being abused, schedule regular visits and let her know you are concerned. Ask how the relationship is progressing at the next monthly visit. If you fear the patient is in danger, schedule weekly or biweekly visits.

Above all, do not tell the victim what to do. Some patients are not ready to act, while others may call the local agency from your office.

Related resources

• National Domestic Violence Hotline (24-hour). 1-800-799-SAFE (7233). Translation services available.
• National Resource Center on Domestic Violence. (800) 537-2238 or www.ndvh.org
• American Medical Association Domestic Violence Resources. www.ama-assn.org/ama/pub/article/3216-6827.html
• American Medical Women’s Association online CME course educates physicians about domestic violence. Physicians can earn two CME credits at no charge. www.dvcme.org

Drug brand names

• Fluoxetine • Prozac
• Venlafaxine • Effexor

Disclosure

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

Victims of domestic abuse/violence often present with medical and psychiatric disorders (Box 1, Table 1). Identifying abuse—and encouraging the frightened or ashamed patient to seek help—is critical to evaluating presenting complaints, improving out-come,⁷ and possibly saving the patient’s life.

This article will discuss ways to:

• detect signs of abuse
• determine whether a victim is in danger
• share information about crisis resources
• help those who are considering leaving an abusive partner to make a safety plan.

Box 1

Medical complaints in victims of domestic violence/abuse

Domestic violence/abuse affects 1 of 4 women in the United States. Men also are victims, but the prevalence (1 of 14) and degree of injury is much lower.¹ Domestic violence/abuse occurs among all socioeconomic and ethnic groups.^1,2

Domestic violence/abuse impairs victims’ physical and mental health.² Injuries and ailments more prevalent among domestic abuse victims than among the general population include:^2,3

• digestive problems (diarrhea, nausea, appetite loss, spastic colon, constipation, eating disorders,
• urinary problems and infections
• vaginal infections, sexually transmitted diseases, pelvic pain, menstrual problems
• sexual dysfunction
• hypertension
• fainting
• chronic pain (headaches, pelvic, abdominal, back and neck)
• pregnancy problems (preterm labor, poor weight gain)

CASE REPORT: TWO YEARS OF HURT

Ms. W, age 26, is referred to a psychiatrist for treatment-resistant depression. Courses of fluoxetine, 20 mg/d titrated to 80 mg/d, and venlafaxine, 150 mg bid, failed to improve her symptoms. Her Beck Depression Inventory score at baseline is 18, suggesting borderline clinical depression.

Table 1

Psychiatric disorders in victims of domestic abuse/violence

She has two children—ages 2 and 4—with her husband, a habitual crack cocaine user. She does not use drugs or alcohol.

When asked about her life at home, Ms. W laments that her husband is not helpful. When asked if her husband hurts her, she replies tearfully that he constantly yells at her and insults her, calling her “ugly” and “a lousy mom.” Upon further questioning, she reveals that her husband, when high on crack, sometimes hits her.

Ms. W does not work outside the home and did not finish high school. She is afraid to leave her husband because his mother helps care for the children and provides money, housing, and food. She constantly feels tearful and trapped.

The psychiatrist increases the venlafaxine to 375 mg/d and suggests that Ms. W call a domestic violence crisis center. She does not call the center, but agrees to see the psychiatrist monthly. Across 3 months her Beck score improves to 14.

SCREENING FOR ABUSE

The American Medical Association, American College of Physicians, and other physician and nursing organizations recommend routinely screening women for domestic abuse/violence.^8-10 Some patients will not disclose abuse to their physicians when asked, but most patients say they want doctors to ask them about domestic violence/abuse and to offer crisis phone numbers, pamphlets, and other resources.¹¹

Anyone who presents with complaints of fatigue, depression, anxiety, insomnia, hypervigilance, a treatment-resistant psychiatric disorder, or a visible physical injury (such as a black eye or bruises) should be screened for domestic abuse.

Prevention and treatment guidelines for physicians^9,12,13 recommend interviewing the patient—without the partner or children—in a nonjudgmental and empathic fashion.¹¹

Written questionnaires—such as the Woman Abuse Screening Tool (WAST), WAST-short, and HITS—are another screening option.

WAST-Short has demonstrated 92% sensitivity in identifying emotional or physical abuse (Table 2).¹⁴

WAST. The longer version of WAST has demonstrated 96% sensitivity in detecting physical or emotional abuse.¹⁴ It includes the two WAST-short questions, plus five questions about whether:

• arguments with an intimate partner ever diminish the patient’s self-esteem
• such arguments ever result in kicking or hitting
• the patient ever feels frightened by the partner’s words or actions
• the patient has ever been physically or emotionally abused by his or her partner.

Because the additional questions are not scored, the longer WAST is not well suited to clinical practice. However, a patient who scores a 1 on the WAST-Short exam can provide more in-depth information on her troubled relationship by answering the extra questions.

HITS can be self-administered and its title is easy to remember, but the scoring system is cumbersome. The patient is asked: “How often does your partner:

• Hurt you physically?
• Insult you or talk down to you?
• Threaten you with harm?
• Scream or curse at you?”

Each answer is scored on a 1-to-5 scale—never, rarely, sometimes, fairly often, or frequently. A score ≥ 10.5 has demonstrated 96% sensitivity in identifying physical and verbal abuse.¹⁵

Encouraging disclosure. Ask patients about domestic abuse when inquiring about smoking, alcohol use, or household makeup as part of the patient history. Your line of questioning might proceed as follows:

• “Do you live alone?”
• “Do you have a significant other?”
• “How is your relationship going?”
• “Is your partner supportive?”
• “What happens when you and your partner disagree?”

Table 2

Woman Abuse Screening Tool-Short version

Be empathic. Explain the association between domestic abuse/violence and mental and physical disorders. Tell the patient that domestic abuse is common and help is readily available. Share information about crisis services even if the patient does not immediately disclose suspected abuse. Victims generally feel tremendous shame from living with the abuse, so disclosure takes time and trust.

Most states do not require physicians to report domestic abuse to the police unless injuries are caused by a weapon (knife or gun). However, physicians in California, Colorado, Kentucky, and New York must report any injuries resulting from domestic abuse—even if not caused by a weapon.¹⁶ In these states, clinicians should disclose their reporting obligation at the start of the patient interview.

Box 2

Box 3

WHEN A PATIENT CONFIRMS ABUSE

Affirm the difficulty of sharing this information and reassure the patient that she is not alone. Tell her, for example, “I know this is difficult to talk about. No one deserves to be treated this way.”

Reaffirm confidentiality. Victims fear harm to themselves or their children if their abusers find out they have discussed the abuse.

Assess the danger to the patient (Box 2).¹⁷

Refer the patient to a local domestic violence crisis agency or to a therapist knowledgeable about domestic abuse. A patient who reports being threatened at gunpoint or who fears for her safety should be urged to call police.

Do not refer the victim and partner to couples counseling. Such therapy is contraindicated because of the relationship’s power imbalance and the risk that the abuser will retaliate when alone with the victim.

DEVELOPING A SAFETY PLAN

Patients who have decided to leave an abusive partner need help forming a safety plan. Assistance from a domestic violence crisis agency is invaluable, but some patients prefer to work with their physicians. Safety planning involves helping the victim identify options and needs upon leaving the relationship.

Start by asking the patient:

• “If you leave home, where will you go?
• Is there an alternative if you cannot stay where you planned?
• Do you have an emergency bag?” (Box 3) ¹⁷

Remind the patient to keep her emergency bag, purse, and keys handy in case she needs to leave quickly.

Instruct the patient to:

• Tell a neighbor about the violence and ask him or her to call police if he or she hears suspicious noises from the victim’s residence.
• Teach children to dial 911 or 0 or to make a collect call to a relative, friend, minister, or other trusted person in an emergency. Also teach children addresses of close relatives and friends.
• Learn the local domestic violence hotline number.¹⁷

IF A PATIENT DENIES ABUSE

If a suspected victim denies she is being abused, schedule regular visits and let her know you are concerned. Ask how the relationship is progressing at the next monthly visit. If you fear the patient is in danger, schedule weekly or biweekly visits.

Above all, do not tell the victim what to do. Some patients are not ready to act, while others may call the local agency from your office.

Related resources

• National Domestic Violence Hotline (24-hour). 1-800-799-SAFE (7233). Translation services available.
• National Resource Center on Domestic Violence. (800) 537-2238 or www.ndvh.org
• American Medical Association Domestic Violence Resources. www.ama-assn.org/ama/pub/article/3216-6827.html
• American Medical Women’s Association online CME course educates physicians about domestic violence. Physicians can earn two CME credits at no charge. www.dvcme.org

Drug brand names

• Fluoxetine • Prozac
• Venlafaxine • Effexor

Disclosure

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

Victims of domestic abuse/violence often present with medical and psychiatric disorders (Box 1, Table 1). Identifying abuse—and encouraging the frightened or ashamed patient to seek help—is critical to evaluating presenting complaints, improving out-come,⁷ and possibly saving the patient’s life.

This article will discuss ways to:

• detect signs of abuse
• determine whether a victim is in danger
• share information about crisis resources
• help those who are considering leaving an abusive partner to make a safety plan.

Box 1

Medical complaints in victims of domestic violence/abuse

Domestic violence/abuse affects 1 of 4 women in the United States. Men also are victims, but the prevalence (1 of 14) and degree of injury is much lower.¹ Domestic violence/abuse occurs among all socioeconomic and ethnic groups.^1,2

Domestic violence/abuse impairs victims’ physical and mental health.² Injuries and ailments more prevalent among domestic abuse victims than among the general population include:^2,3

• digestive problems (diarrhea, nausea, appetite loss, spastic colon, constipation, eating disorders,
• urinary problems and infections
• vaginal infections, sexually transmitted diseases, pelvic pain, menstrual problems
• sexual dysfunction
• hypertension
• fainting
• chronic pain (headaches, pelvic, abdominal, back and neck)
• pregnancy problems (preterm labor, poor weight gain)

CASE REPORT: TWO YEARS OF HURT

Ms. W, age 26, is referred to a psychiatrist for treatment-resistant depression. Courses of fluoxetine, 20 mg/d titrated to 80 mg/d, and venlafaxine, 150 mg bid, failed to improve her symptoms. Her Beck Depression Inventory score at baseline is 18, suggesting borderline clinical depression.

Table 1

Psychiatric disorders in victims of domestic abuse/violence

She has two children—ages 2 and 4—with her husband, a habitual crack cocaine user. She does not use drugs or alcohol.

When asked about her life at home, Ms. W laments that her husband is not helpful. When asked if her husband hurts her, she replies tearfully that he constantly yells at her and insults her, calling her “ugly” and “a lousy mom.” Upon further questioning, she reveals that her husband, when high on crack, sometimes hits her.

Ms. W does not work outside the home and did not finish high school. She is afraid to leave her husband because his mother helps care for the children and provides money, housing, and food. She constantly feels tearful and trapped.

The psychiatrist increases the venlafaxine to 375 mg/d and suggests that Ms. W call a domestic violence crisis center. She does not call the center, but agrees to see the psychiatrist monthly. Across 3 months her Beck score improves to 14.

SCREENING FOR ABUSE

The American Medical Association, American College of Physicians, and other physician and nursing organizations recommend routinely screening women for domestic abuse/violence.^8-10 Some patients will not disclose abuse to their physicians when asked, but most patients say they want doctors to ask them about domestic violence/abuse and to offer crisis phone numbers, pamphlets, and other resources.¹¹

Anyone who presents with complaints of fatigue, depression, anxiety, insomnia, hypervigilance, a treatment-resistant psychiatric disorder, or a visible physical injury (such as a black eye or bruises) should be screened for domestic abuse.

Prevention and treatment guidelines for physicians^9,12,13 recommend interviewing the patient—without the partner or children—in a nonjudgmental and empathic fashion.¹¹

Written questionnaires—such as the Woman Abuse Screening Tool (WAST), WAST-short, and HITS—are another screening option.

WAST-Short has demonstrated 92% sensitivity in identifying emotional or physical abuse (Table 2).¹⁴

WAST. The longer version of WAST has demonstrated 96% sensitivity in detecting physical or emotional abuse.¹⁴ It includes the two WAST-short questions, plus five questions about whether:

• arguments with an intimate partner ever diminish the patient’s self-esteem
• such arguments ever result in kicking or hitting
• the patient ever feels frightened by the partner’s words or actions
• the patient has ever been physically or emotionally abused by his or her partner.

Because the additional questions are not scored, the longer WAST is not well suited to clinical practice. However, a patient who scores a 1 on the WAST-Short exam can provide more in-depth information on her troubled relationship by answering the extra questions.

HITS can be self-administered and its title is easy to remember, but the scoring system is cumbersome. The patient is asked: “How often does your partner:

• Hurt you physically?
• Insult you or talk down to you?
• Threaten you with harm?
• Scream or curse at you?”

Each answer is scored on a 1-to-5 scale—never, rarely, sometimes, fairly often, or frequently. A score ≥ 10.5 has demonstrated 96% sensitivity in identifying physical and verbal abuse.¹⁵

Encouraging disclosure. Ask patients about domestic abuse when inquiring about smoking, alcohol use, or household makeup as part of the patient history. Your line of questioning might proceed as follows:

• “Do you live alone?”
• “Do you have a significant other?”
• “How is your relationship going?”
• “Is your partner supportive?”
• “What happens when you and your partner disagree?”

Table 2

Woman Abuse Screening Tool-Short version

Be empathic. Explain the association between domestic abuse/violence and mental and physical disorders. Tell the patient that domestic abuse is common and help is readily available. Share information about crisis services even if the patient does not immediately disclose suspected abuse. Victims generally feel tremendous shame from living with the abuse, so disclosure takes time and trust.

Most states do not require physicians to report domestic abuse to the police unless injuries are caused by a weapon (knife or gun). However, physicians in California, Colorado, Kentucky, and New York must report any injuries resulting from domestic abuse—even if not caused by a weapon.¹⁶ In these states, clinicians should disclose their reporting obligation at the start of the patient interview.

Box 2

Box 3

WHEN A PATIENT CONFIRMS ABUSE

Affirm the difficulty of sharing this information and reassure the patient that she is not alone. Tell her, for example, “I know this is difficult to talk about. No one deserves to be treated this way.”

Reaffirm confidentiality. Victims fear harm to themselves or their children if their abusers find out they have discussed the abuse.

Assess the danger to the patient (Box 2).¹⁷

Refer the patient to a local domestic violence crisis agency or to a therapist knowledgeable about domestic abuse. A patient who reports being threatened at gunpoint or who fears for her safety should be urged to call police.

Do not refer the victim and partner to couples counseling. Such therapy is contraindicated because of the relationship’s power imbalance and the risk that the abuser will retaliate when alone with the victim.

DEVELOPING A SAFETY PLAN

Patients who have decided to leave an abusive partner need help forming a safety plan. Assistance from a domestic violence crisis agency is invaluable, but some patients prefer to work with their physicians. Safety planning involves helping the victim identify options and needs upon leaving the relationship.

Start by asking the patient:

• “If you leave home, where will you go?
• Is there an alternative if you cannot stay where you planned?
• Do you have an emergency bag?” (Box 3) ¹⁷

Remind the patient to keep her emergency bag, purse, and keys handy in case she needs to leave quickly.

Instruct the patient to:

• Tell a neighbor about the violence and ask him or her to call police if he or she hears suspicious noises from the victim’s residence.
• Teach children to dial 911 or 0 or to make a collect call to a relative, friend, minister, or other trusted person in an emergency. Also teach children addresses of close relatives and friends.
• Learn the local domestic violence hotline number.¹⁷

IF A PATIENT DENIES ABUSE

If a suspected victim denies she is being abused, schedule regular visits and let her know you are concerned. Ask how the relationship is progressing at the next monthly visit. If you fear the patient is in danger, schedule weekly or biweekly visits.

Above all, do not tell the victim what to do. Some patients are not ready to act, while others may call the local agency from your office.

Related resources

• National Domestic Violence Hotline (24-hour). 1-800-799-SAFE (7233). Translation services available.
• National Resource Center on Domestic Violence. (800) 537-2238 or www.ndvh.org
• American Medical Association Domestic Violence Resources. www.ama-assn.org/ama/pub/article/3216-6827.html
• American Medical Women’s Association online CME course educates physicians about domestic violence. Physicians can earn two CME credits at no charge. www.dvcme.org

Drug brand names

• Fluoxetine • Prozac
• Venlafaxine • Effexor

Disclosure

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

Culture-related anxiety and paranoia can be difficult to treat because they are reinforced by socially normative practices and beliefs.¹ As in the two cases described below, psychiatric patients with deep underlying mistrust may view a therapist from another culture—even though well-meaning—as a racist oppressor.

The clinician’s approach to therapy can help prevent cultural misunderstandings and—most important—misdiagnosis (Box).

MR. A’S CASE: ‘She’s out to get me’

Mr. A, age 38 and African-American, was admitted to the inpatient psychiatry service with neurovegetative depressive symptoms and apparent delusional thinking.

His wife of 20 years, also African-American, was concerned that he was becoming increasingly irrational. She said he accused her of conspiring with his predominantly white supervisors to “bring about my destruction.”

Mr. A consented to admission, acknowledging to the psychiatrist that he had felt depressed and at times considered suicide. He complained that he had recently experienced several unusual “happenings:”

• Pointing to recent weight loss, Mr. A feared someone was poisoning his food or that he had swallowed a “tracking” device.
• Mr. A feared that workers who were repairing flood damage in his home were sent to kill him. He remained home during the project, but the fear drove him to a panic attack.
• After more than 18 years working for the same employer with no notable interpersonal difficulties, Mr. A suddenly could not get along with his coworkers. He accused one colleague of following him to a restaurant.

Mr. A had no previous psychiatric disorder, but some distant relatives had schizophrenia. He was diagnosed as having major depressive disorder, severe with psychotic features; delusional disorder was ruled out. He was prescribed olanzapine, 10 mg at bedtime, and fluoxetine, 20 mg/d.

In the hospital, Mr. A spoke normally with no agitation, increased activity, or evidence of racing thoughts. In group therapy, he explained that he felt “confused.” He also disclosed that a recent extramarital affair left him feeling extremely guilty.

Box

A few days later, Mr. A’s suicidal and paranoid ideations disappeared. He expressed anger only while discussing his diagnosis with the attending psychiatrist, who is white. The patient feared that being diagnosed with a psychotic illness would hurt his career. He admitted he felt depressed, but insisted that he now realized his paranoid thoughts were irrational.

Mr. A was discharged after 6 days. He remained on fluoxetine, 20 mg/d; olanzapine was discontinued due to excessive sedation.

The patient also entered insight-oriented psychotherapy to address his depression. Mr. A and the therapist, who is white, spent most of the initial sessions discussing their racial differences. At one point, Mr. A complained to the therapist that white physicians were trying to “railroad” him because of his race.

After nine sessions, Mr. A revealed that he felt isolated at an early age, thinking that others “will use what they know about me against me.” He described growing up in a predominantly black community where most of his neighbors felt oppressed by white people. As therapy progressed, Mr. A realized that this experience influenced his attitudes about race, and that his extramarital affair destroyed his sense of self-trust, which may have fueled his mistrust of others.

After 20 sessions, his marriage and work relationships were stable and his overall mood was much improved. His Outcome Questionnaire 45.2 score decreased across 12 months from 88 (moderate to severe distress) to 55 (level of distress similar to that of non-patients). Delusional behavior has not re-emerged, although his comments continue to reflect mistrust of his supervisors and of white people in general.

What would your diagnosis be? What clues would you gather from Mr. A’s pretreatment behavior and from his progress in therapy?

Dr. Benzick’s observations

Mr. A’s diagnosis upon admission reflected the psychiatrist’s belief that he suffered fixed delusions. By definition, however, a delusion is a false belief that is not “ordinarily accepted by other members of the person’s culture or subculture.”²

Growing up, Mr. A shared his neighbors’ suspicion of white people. Further, his overvalued conspiracy theory involving his wife might have projected his own guilt over his infidelity onto a pre-existing paranoid personality.

Based on his psychosocial history, rapid progress in psychotherapy, and marked improvement in Outcome Questionnaire 45.2 scores, Mr. A does not have a personality disorder. What’s more, paranoid ideation is not uncommon in African-Americans with depressive symptoms, as demonstrated by Bazargan et al. ³

Mr. A’s diagnosis was changed to major depressive disorder, moderate, in partial remission. He is still seen approximately every 6 weeks for medication maintenance; he continues taking fluoxetine, 20 mg/d.

MR. B’S CASE: ‘Singled’ out

Mr. B, age 42 and African-American, was referred from an alcohol rehabilitation program to the psychiatry unit after exhibiting depressive and paranoid symptoms.

After 17 years with his employer, he started clashing with his supervisors and coworkers—most of whom are white. He claimed his colleagues were talking behind his back, jealous that he is single and spends his evenings at nightclubs. He alleged that his bosses were singling him out after he was transferred to another department and reprimanded for arriving late to work. Resultant worry about job security brought on panic symptoms (shortness of breath, lightheadedness, dissociative feelings, and palpitations).

Upon further questioning, Mr. B said he felt depressed and isolated. He had been prescribed nortriptyline 2 years ago but discontinued it after a few weeks because of side effects.

Mr. B said that not having a steady companion contributed to his depression and alcohol use. He had been drinking heavily for about 3 years, consuming at least a six-pack daily. He acknowledged that his suspicion of his white coworkers long preceded his alcoholism. Still, he did not see this mistrust as a problem.

Mr. B was diagnosed with major depressive disorder, severe with psychotic features. Treatment consisted of:

• paroxetine, 20 mg/d
• attendance at Alcoholics Anonymous meetings (at least three meetings per week were recommended)
• and 12 sessions of interpersonal psychotherapy. During these sessions, the therapist began to uncover the roots of Mr. B’s symptoms.

School days. Mr. B described how, as a little boy, he once watched his mother being beaten by his drunken father. He told the therapist that the beatings occurred frequently.

When he was age 5, Mr. B’s parents divorced and he and his mother moved to a mostly white Midwest neighborhood so that he could attend a high school with an advanced music program (he was honored for exceptional talent on several instruments).

In his youth, Mr. B’s mother repeatedly told him that teachers and students would treat him “differently” because of his color, though she never explained what she meant. While in high school, he began to worry about his social functioning, appearance, work performance, and future accomplishments.

After four psychotherapy sessions, Mr. B revealed that while in grade school, he was sexually assaulted by an older white boy. For more than 30 years, he had told no one. He denied hyperautonomic and re-experiencing symptoms but realized that this incident may have kept him from starting a romantic relationship.

After psychotherapy, Mr. B reported reduced depression and increased social interaction. His Beck Depression Inventory score dropped from 23 (moderate depression) to 4 (normal mood), and his Beck Anxiety Inventory score improved from 33 (moderate anxiety) to 3 (very low anxiety). He has been sober for 6 months and handles stress more effectively, although his mistrust toward coworkers is still apparent.

How would you diagnose Mr. B? Do his symptoms characterize “psychotic features” or an anxiety or alcohol-related disorder?

Dr. Benzick’s observations

Mr. B’s case illustrates how deep-seated cultural perceptions and past trauma together can cause severe anxiety—and how that anxiety can be misperceived as psychosis.⁴ Anxiety also can manifest as paranoia in “psychotically vulnerable” individuals.^5-7

Chronic anxiety seemed to cause Mr. B’s depressed mood and social withdrawal. Several anxiety disorder diagnoses were considered, including:

• panic disorder
• posttraumatic stress disorder
• social phobia
• alcohol-induced anxiety disorder
• and generalized anxiety disorder.

Mr. B, however, exhibited no evidence of repeated episodic anxiety, nor did he describe reexperiencing phenomena. His anxiety extended beyond social situations and preceded his heavy alcohol consumption. Paranoid personality disorder was also considered, but Mr. B sought relationships and lacked the angry, unforgiving qualities associated with this pathology. Finally, a battery of psychological tests did not reveal frank psychosis but suggested an avoidant personality style.

Mr. B’s diagnosis was changed to generalized anxiety disorder. He requested a trial off medications during the latter stages of therapy, but his severe anxiety returned. He was then prescribed venlafaxine, 37.5 mg/d titrated to 225 mg/d across 3 weeks. His anxiety symptoms again abated.

How could Mr A’s and Mr. B’s doctors have avoided their initial misdiagnoses?

Dr. Benzick’s observations

“Cultural paranoia” describes adaptive or healthy responses by African-Americans living in a society they perceive as racially prejudiced.⁸ Several researchers have studied this concept of protecting self-esteem by blaming an external source for negative events. Women who plausibly attribute unflattering feedback to prejudice exhibit higher self-esteem.⁹ A person who believes he or she is a target of discrimination identifies more strongly with his or her racial or ethnic group, leading to reduced depression, higher self-esteem, and improved psychological adjustment.⁹

Perceived discrimination, however, can also elicit feelings of hopelessness and resignation when it leads to widespread bias against the alleged oppressing racial or ethnic group. The resulting sense of social exclusion has been linked to lower self-esteem and higher rates of anxiety and depression.⁹ Thus, the individual’s environment and ability to develop relationships will determine whether “cultural paranoia” is “adaptive.”

Paranoia or prejudice? Distinguishing culturally sanctioned “paranoia” from “prejudice” can be difficult. “Prejudice” is defined as the negative evaluation of a group or individual based on group membership.¹⁰ “Paranoia” (using the DSM-IV definition of “paranoid ideation”) is a belief of less than delusional intensity “involving suspiciousness or the belief that one is being harassed, persecuted, or unfairly treated.”²

So while an individual may be prejudiced toward a group, cultural paranoia would exist only if other family members or acquaintances believe the other group is conspiring against them. Additionally, while prejudice tends to be ego-syntonic,¹¹ paranoia is more distressing because it produces heightened vigilance and possibly fear.

Both cases describe how a lack of cultural understanding between African-American patients and physicians of other ethnicities or races can lead to misdiagnosis of psychosis.¹² They also illustrate that while prejudice may be tightly focused (eg, hatred of anyone from a specific racial or ethnic group), paranoid ideation can be generalized. For example, Mr. A believed that his wife, an African-American, conspired with his white supervisors against him.

Mr. A’s and Mr. B’s depressive and anxiety symptoms unmasked longstanding, deeply rooted beliefs. Both patients’ neurovegetative symptoms responded to medication and brief psychotherapy, and both returned to prior levels of functioning. The underlying mistrust remained, however.

Related resources

• Lu FG. Annotated bibliography on cultural psychiatry and related topics-June 2003. Available at: http://www.admsep.org/culture.html. Accessed July 18, 2003.
• Forsell Y, Henderson S. Epidemiology of paranoid disorders in an elderly population. Br J Psychiatry 1998; 172:429-32.

Drug brand names

• Fluoxetine • Prozac
• Olanzapine • Zyprexa
• Nortriptyline • Aventyl, Pamelor
• Paroxetine • Paxil
• Venlafaxine • Effexor

Disclosure

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

Culture-related anxiety and paranoia can be difficult to treat because they are reinforced by socially normative practices and beliefs.¹ As in the two cases described below, psychiatric patients with deep underlying mistrust may view a therapist from another culture—even though well-meaning—as a racist oppressor.

The clinician’s approach to therapy can help prevent cultural misunderstandings and—most important—misdiagnosis (Box).

MR. A’S CASE: ‘She’s out to get me’

Mr. A, age 38 and African-American, was admitted to the inpatient psychiatry service with neurovegetative depressive symptoms and apparent delusional thinking.

His wife of 20 years, also African-American, was concerned that he was becoming increasingly irrational. She said he accused her of conspiring with his predominantly white supervisors to “bring about my destruction.”

Mr. A consented to admission, acknowledging to the psychiatrist that he had felt depressed and at times considered suicide. He complained that he had recently experienced several unusual “happenings:”

• Pointing to recent weight loss, Mr. A feared someone was poisoning his food or that he had swallowed a “tracking” device.
• Mr. A feared that workers who were repairing flood damage in his home were sent to kill him. He remained home during the project, but the fear drove him to a panic attack.
• After more than 18 years working for the same employer with no notable interpersonal difficulties, Mr. A suddenly could not get along with his coworkers. He accused one colleague of following him to a restaurant.

Mr. A had no previous psychiatric disorder, but some distant relatives had schizophrenia. He was diagnosed as having major depressive disorder, severe with psychotic features; delusional disorder was ruled out. He was prescribed olanzapine, 10 mg at bedtime, and fluoxetine, 20 mg/d.

In the hospital, Mr. A spoke normally with no agitation, increased activity, or evidence of racing thoughts. In group therapy, he explained that he felt “confused.” He also disclosed that a recent extramarital affair left him feeling extremely guilty.

Box

A few days later, Mr. A’s suicidal and paranoid ideations disappeared. He expressed anger only while discussing his diagnosis with the attending psychiatrist, who is white. The patient feared that being diagnosed with a psychotic illness would hurt his career. He admitted he felt depressed, but insisted that he now realized his paranoid thoughts were irrational.

Mr. A was discharged after 6 days. He remained on fluoxetine, 20 mg/d; olanzapine was discontinued due to excessive sedation.

The patient also entered insight-oriented psychotherapy to address his depression. Mr. A and the therapist, who is white, spent most of the initial sessions discussing their racial differences. At one point, Mr. A complained to the therapist that white physicians were trying to “railroad” him because of his race.

After nine sessions, Mr. A revealed that he felt isolated at an early age, thinking that others “will use what they know about me against me.” He described growing up in a predominantly black community where most of his neighbors felt oppressed by white people. As therapy progressed, Mr. A realized that this experience influenced his attitudes about race, and that his extramarital affair destroyed his sense of self-trust, which may have fueled his mistrust of others.

After 20 sessions, his marriage and work relationships were stable and his overall mood was much improved. His Outcome Questionnaire 45.2 score decreased across 12 months from 88 (moderate to severe distress) to 55 (level of distress similar to that of non-patients). Delusional behavior has not re-emerged, although his comments continue to reflect mistrust of his supervisors and of white people in general.

What would your diagnosis be? What clues would you gather from Mr. A’s pretreatment behavior and from his progress in therapy?

Dr. Benzick’s observations

Mr. A’s diagnosis upon admission reflected the psychiatrist’s belief that he suffered fixed delusions. By definition, however, a delusion is a false belief that is not “ordinarily accepted by other members of the person’s culture or subculture.”²

Growing up, Mr. A shared his neighbors’ suspicion of white people. Further, his overvalued conspiracy theory involving his wife might have projected his own guilt over his infidelity onto a pre-existing paranoid personality.

Based on his psychosocial history, rapid progress in psychotherapy, and marked improvement in Outcome Questionnaire 45.2 scores, Mr. A does not have a personality disorder. What’s more, paranoid ideation is not uncommon in African-Americans with depressive symptoms, as demonstrated by Bazargan et al. ³

Mr. A’s diagnosis was changed to major depressive disorder, moderate, in partial remission. He is still seen approximately every 6 weeks for medication maintenance; he continues taking fluoxetine, 20 mg/d.

MR. B’S CASE: ‘Singled’ out

Mr. B, age 42 and African-American, was referred from an alcohol rehabilitation program to the psychiatry unit after exhibiting depressive and paranoid symptoms.

After 17 years with his employer, he started clashing with his supervisors and coworkers—most of whom are white. He claimed his colleagues were talking behind his back, jealous that he is single and spends his evenings at nightclubs. He alleged that his bosses were singling him out after he was transferred to another department and reprimanded for arriving late to work. Resultant worry about job security brought on panic symptoms (shortness of breath, lightheadedness, dissociative feelings, and palpitations).

Upon further questioning, Mr. B said he felt depressed and isolated. He had been prescribed nortriptyline 2 years ago but discontinued it after a few weeks because of side effects.

Mr. B said that not having a steady companion contributed to his depression and alcohol use. He had been drinking heavily for about 3 years, consuming at least a six-pack daily. He acknowledged that his suspicion of his white coworkers long preceded his alcoholism. Still, he did not see this mistrust as a problem.

Mr. B was diagnosed with major depressive disorder, severe with psychotic features. Treatment consisted of:

• paroxetine, 20 mg/d
• attendance at Alcoholics Anonymous meetings (at least three meetings per week were recommended)
• and 12 sessions of interpersonal psychotherapy. During these sessions, the therapist began to uncover the roots of Mr. B’s symptoms.

School days. Mr. B described how, as a little boy, he once watched his mother being beaten by his drunken father. He told the therapist that the beatings occurred frequently.

When he was age 5, Mr. B’s parents divorced and he and his mother moved to a mostly white Midwest neighborhood so that he could attend a high school with an advanced music program (he was honored for exceptional talent on several instruments).

In his youth, Mr. B’s mother repeatedly told him that teachers and students would treat him “differently” because of his color, though she never explained what she meant. While in high school, he began to worry about his social functioning, appearance, work performance, and future accomplishments.

After four psychotherapy sessions, Mr. B revealed that while in grade school, he was sexually assaulted by an older white boy. For more than 30 years, he had told no one. He denied hyperautonomic and re-experiencing symptoms but realized that this incident may have kept him from starting a romantic relationship.

After psychotherapy, Mr. B reported reduced depression and increased social interaction. His Beck Depression Inventory score dropped from 23 (moderate depression) to 4 (normal mood), and his Beck Anxiety Inventory score improved from 33 (moderate anxiety) to 3 (very low anxiety). He has been sober for 6 months and handles stress more effectively, although his mistrust toward coworkers is still apparent.

How would you diagnose Mr. B? Do his symptoms characterize “psychotic features” or an anxiety or alcohol-related disorder?

Dr. Benzick’s observations

Mr. B’s case illustrates how deep-seated cultural perceptions and past trauma together can cause severe anxiety—and how that anxiety can be misperceived as psychosis.⁴ Anxiety also can manifest as paranoia in “psychotically vulnerable” individuals.^5-7

Chronic anxiety seemed to cause Mr. B’s depressed mood and social withdrawal. Several anxiety disorder diagnoses were considered, including:

• panic disorder
• posttraumatic stress disorder
• social phobia
• alcohol-induced anxiety disorder
• and generalized anxiety disorder.

Mr. B, however, exhibited no evidence of repeated episodic anxiety, nor did he describe reexperiencing phenomena. His anxiety extended beyond social situations and preceded his heavy alcohol consumption. Paranoid personality disorder was also considered, but Mr. B sought relationships and lacked the angry, unforgiving qualities associated with this pathology. Finally, a battery of psychological tests did not reveal frank psychosis but suggested an avoidant personality style.

Mr. B’s diagnosis was changed to generalized anxiety disorder. He requested a trial off medications during the latter stages of therapy, but his severe anxiety returned. He was then prescribed venlafaxine, 37.5 mg/d titrated to 225 mg/d across 3 weeks. His anxiety symptoms again abated.

How could Mr A’s and Mr. B’s doctors have avoided their initial misdiagnoses?

Dr. Benzick’s observations

“Cultural paranoia” describes adaptive or healthy responses by African-Americans living in a society they perceive as racially prejudiced.⁸ Several researchers have studied this concept of protecting self-esteem by blaming an external source for negative events. Women who plausibly attribute unflattering feedback to prejudice exhibit higher self-esteem.⁹ A person who believes he or she is a target of discrimination identifies more strongly with his or her racial or ethnic group, leading to reduced depression, higher self-esteem, and improved psychological adjustment.⁹

Perceived discrimination, however, can also elicit feelings of hopelessness and resignation when it leads to widespread bias against the alleged oppressing racial or ethnic group. The resulting sense of social exclusion has been linked to lower self-esteem and higher rates of anxiety and depression.⁹ Thus, the individual’s environment and ability to develop relationships will determine whether “cultural paranoia” is “adaptive.”

Paranoia or prejudice? Distinguishing culturally sanctioned “paranoia” from “prejudice” can be difficult. “Prejudice” is defined as the negative evaluation of a group or individual based on group membership.¹⁰ “Paranoia” (using the DSM-IV definition of “paranoid ideation”) is a belief of less than delusional intensity “involving suspiciousness or the belief that one is being harassed, persecuted, or unfairly treated.”²

So while an individual may be prejudiced toward a group, cultural paranoia would exist only if other family members or acquaintances believe the other group is conspiring against them. Additionally, while prejudice tends to be ego-syntonic,¹¹ paranoia is more distressing because it produces heightened vigilance and possibly fear.

Both cases describe how a lack of cultural understanding between African-American patients and physicians of other ethnicities or races can lead to misdiagnosis of psychosis.¹² They also illustrate that while prejudice may be tightly focused (eg, hatred of anyone from a specific racial or ethnic group), paranoid ideation can be generalized. For example, Mr. A believed that his wife, an African-American, conspired with his white supervisors against him.

Mr. A’s and Mr. B’s depressive and anxiety symptoms unmasked longstanding, deeply rooted beliefs. Both patients’ neurovegetative symptoms responded to medication and brief psychotherapy, and both returned to prior levels of functioning. The underlying mistrust remained, however.

Related resources

• Lu FG. Annotated bibliography on cultural psychiatry and related topics-June 2003. Available at: http://www.admsep.org/culture.html. Accessed July 18, 2003.
• Forsell Y, Henderson S. Epidemiology of paranoid disorders in an elderly population. Br J Psychiatry 1998; 172:429-32.

Drug brand names

• Fluoxetine • Prozac
• Olanzapine • Zyprexa
• Nortriptyline • Aventyl, Pamelor
• Paroxetine • Paxil
• Venlafaxine • Effexor

Disclosure

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

Culture-related anxiety and paranoia can be difficult to treat because they are reinforced by socially normative practices and beliefs.¹ As in the two cases described below, psychiatric patients with deep underlying mistrust may view a therapist from another culture—even though well-meaning—as a racist oppressor.

The clinician’s approach to therapy can help prevent cultural misunderstandings and—most important—misdiagnosis (Box).

MR. A’S CASE: ‘She’s out to get me’

Mr. A, age 38 and African-American, was admitted to the inpatient psychiatry service with neurovegetative depressive symptoms and apparent delusional thinking.

His wife of 20 years, also African-American, was concerned that he was becoming increasingly irrational. She said he accused her of conspiring with his predominantly white supervisors to “bring about my destruction.”

Mr. A consented to admission, acknowledging to the psychiatrist that he had felt depressed and at times considered suicide. He complained that he had recently experienced several unusual “happenings:”

• Pointing to recent weight loss, Mr. A feared someone was poisoning his food or that he had swallowed a “tracking” device.
• Mr. A feared that workers who were repairing flood damage in his home were sent to kill him. He remained home during the project, but the fear drove him to a panic attack.
• After more than 18 years working for the same employer with no notable interpersonal difficulties, Mr. A suddenly could not get along with his coworkers. He accused one colleague of following him to a restaurant.

Mr. A had no previous psychiatric disorder, but some distant relatives had schizophrenia. He was diagnosed as having major depressive disorder, severe with psychotic features; delusional disorder was ruled out. He was prescribed olanzapine, 10 mg at bedtime, and fluoxetine, 20 mg/d.

In the hospital, Mr. A spoke normally with no agitation, increased activity, or evidence of racing thoughts. In group therapy, he explained that he felt “confused.” He also disclosed that a recent extramarital affair left him feeling extremely guilty.

Box

A few days later, Mr. A’s suicidal and paranoid ideations disappeared. He expressed anger only while discussing his diagnosis with the attending psychiatrist, who is white. The patient feared that being diagnosed with a psychotic illness would hurt his career. He admitted he felt depressed, but insisted that he now realized his paranoid thoughts were irrational.

Mr. A was discharged after 6 days. He remained on fluoxetine, 20 mg/d; olanzapine was discontinued due to excessive sedation.

The patient also entered insight-oriented psychotherapy to address his depression. Mr. A and the therapist, who is white, spent most of the initial sessions discussing their racial differences. At one point, Mr. A complained to the therapist that white physicians were trying to “railroad” him because of his race.

After nine sessions, Mr. A revealed that he felt isolated at an early age, thinking that others “will use what they know about me against me.” He described growing up in a predominantly black community where most of his neighbors felt oppressed by white people. As therapy progressed, Mr. A realized that this experience influenced his attitudes about race, and that his extramarital affair destroyed his sense of self-trust, which may have fueled his mistrust of others.

After 20 sessions, his marriage and work relationships were stable and his overall mood was much improved. His Outcome Questionnaire 45.2 score decreased across 12 months from 88 (moderate to severe distress) to 55 (level of distress similar to that of non-patients). Delusional behavior has not re-emerged, although his comments continue to reflect mistrust of his supervisors and of white people in general.

What would your diagnosis be? What clues would you gather from Mr. A’s pretreatment behavior and from his progress in therapy?

Dr. Benzick’s observations

Mr. A’s diagnosis upon admission reflected the psychiatrist’s belief that he suffered fixed delusions. By definition, however, a delusion is a false belief that is not “ordinarily accepted by other members of the person’s culture or subculture.”²

Growing up, Mr. A shared his neighbors’ suspicion of white people. Further, his overvalued conspiracy theory involving his wife might have projected his own guilt over his infidelity onto a pre-existing paranoid personality.

Based on his psychosocial history, rapid progress in psychotherapy, and marked improvement in Outcome Questionnaire 45.2 scores, Mr. A does not have a personality disorder. What’s more, paranoid ideation is not uncommon in African-Americans with depressive symptoms, as demonstrated by Bazargan et al. ³

Mr. A’s diagnosis was changed to major depressive disorder, moderate, in partial remission. He is still seen approximately every 6 weeks for medication maintenance; he continues taking fluoxetine, 20 mg/d.

MR. B’S CASE: ‘Singled’ out

Mr. B, age 42 and African-American, was referred from an alcohol rehabilitation program to the psychiatry unit after exhibiting depressive and paranoid symptoms.

After 17 years with his employer, he started clashing with his supervisors and coworkers—most of whom are white. He claimed his colleagues were talking behind his back, jealous that he is single and spends his evenings at nightclubs. He alleged that his bosses were singling him out after he was transferred to another department and reprimanded for arriving late to work. Resultant worry about job security brought on panic symptoms (shortness of breath, lightheadedness, dissociative feelings, and palpitations).

Upon further questioning, Mr. B said he felt depressed and isolated. He had been prescribed nortriptyline 2 years ago but discontinued it after a few weeks because of side effects.

Mr. B said that not having a steady companion contributed to his depression and alcohol use. He had been drinking heavily for about 3 years, consuming at least a six-pack daily. He acknowledged that his suspicion of his white coworkers long preceded his alcoholism. Still, he did not see this mistrust as a problem.

Mr. B was diagnosed with major depressive disorder, severe with psychotic features. Treatment consisted of:

• paroxetine, 20 mg/d
• attendance at Alcoholics Anonymous meetings (at least three meetings per week were recommended)
• and 12 sessions of interpersonal psychotherapy. During these sessions, the therapist began to uncover the roots of Mr. B’s symptoms.

School days. Mr. B described how, as a little boy, he once watched his mother being beaten by his drunken father. He told the therapist that the beatings occurred frequently.

When he was age 5, Mr. B’s parents divorced and he and his mother moved to a mostly white Midwest neighborhood so that he could attend a high school with an advanced music program (he was honored for exceptional talent on several instruments).

In his youth, Mr. B’s mother repeatedly told him that teachers and students would treat him “differently” because of his color, though she never explained what she meant. While in high school, he began to worry about his social functioning, appearance, work performance, and future accomplishments.

After four psychotherapy sessions, Mr. B revealed that while in grade school, he was sexually assaulted by an older white boy. For more than 30 years, he had told no one. He denied hyperautonomic and re-experiencing symptoms but realized that this incident may have kept him from starting a romantic relationship.

After psychotherapy, Mr. B reported reduced depression and increased social interaction. His Beck Depression Inventory score dropped from 23 (moderate depression) to 4 (normal mood), and his Beck Anxiety Inventory score improved from 33 (moderate anxiety) to 3 (very low anxiety). He has been sober for 6 months and handles stress more effectively, although his mistrust toward coworkers is still apparent.

How would you diagnose Mr. B? Do his symptoms characterize “psychotic features” or an anxiety or alcohol-related disorder?

Dr. Benzick’s observations

Mr. B’s case illustrates how deep-seated cultural perceptions and past trauma together can cause severe anxiety—and how that anxiety can be misperceived as psychosis.⁴ Anxiety also can manifest as paranoia in “psychotically vulnerable” individuals.^5-7

Chronic anxiety seemed to cause Mr. B’s depressed mood and social withdrawal. Several anxiety disorder diagnoses were considered, including:

• panic disorder
• posttraumatic stress disorder
• social phobia
• alcohol-induced anxiety disorder
• and generalized anxiety disorder.

Mr. B, however, exhibited no evidence of repeated episodic anxiety, nor did he describe reexperiencing phenomena. His anxiety extended beyond social situations and preceded his heavy alcohol consumption. Paranoid personality disorder was also considered, but Mr. B sought relationships and lacked the angry, unforgiving qualities associated with this pathology. Finally, a battery of psychological tests did not reveal frank psychosis but suggested an avoidant personality style.

Mr. B’s diagnosis was changed to generalized anxiety disorder. He requested a trial off medications during the latter stages of therapy, but his severe anxiety returned. He was then prescribed venlafaxine, 37.5 mg/d titrated to 225 mg/d across 3 weeks. His anxiety symptoms again abated.

How could Mr A’s and Mr. B’s doctors have avoided their initial misdiagnoses?

Dr. Benzick’s observations

“Cultural paranoia” describes adaptive or healthy responses by African-Americans living in a society they perceive as racially prejudiced.⁸ Several researchers have studied this concept of protecting self-esteem by blaming an external source for negative events. Women who plausibly attribute unflattering feedback to prejudice exhibit higher self-esteem.⁹ A person who believes he or she is a target of discrimination identifies more strongly with his or her racial or ethnic group, leading to reduced depression, higher self-esteem, and improved psychological adjustment.⁹

Perceived discrimination, however, can also elicit feelings of hopelessness and resignation when it leads to widespread bias against the alleged oppressing racial or ethnic group. The resulting sense of social exclusion has been linked to lower self-esteem and higher rates of anxiety and depression.⁹ Thus, the individual’s environment and ability to develop relationships will determine whether “cultural paranoia” is “adaptive.”

Paranoia or prejudice? Distinguishing culturally sanctioned “paranoia” from “prejudice” can be difficult. “Prejudice” is defined as the negative evaluation of a group or individual based on group membership.¹⁰ “Paranoia” (using the DSM-IV definition of “paranoid ideation”) is a belief of less than delusional intensity “involving suspiciousness or the belief that one is being harassed, persecuted, or unfairly treated.”²

So while an individual may be prejudiced toward a group, cultural paranoia would exist only if other family members or acquaintances believe the other group is conspiring against them. Additionally, while prejudice tends to be ego-syntonic,¹¹ paranoia is more distressing because it produces heightened vigilance and possibly fear.

Both cases describe how a lack of cultural understanding between African-American patients and physicians of other ethnicities or races can lead to misdiagnosis of psychosis.¹² They also illustrate that while prejudice may be tightly focused (eg, hatred of anyone from a specific racial or ethnic group), paranoid ideation can be generalized. For example, Mr. A believed that his wife, an African-American, conspired with his white supervisors against him.

Mr. A’s and Mr. B’s depressive and anxiety symptoms unmasked longstanding, deeply rooted beliefs. Both patients’ neurovegetative symptoms responded to medication and brief psychotherapy, and both returned to prior levels of functioning. The underlying mistrust remained, however.

Related resources

• Lu FG. Annotated bibliography on cultural psychiatry and related topics-June 2003. Available at: http://www.admsep.org/culture.html. Accessed July 18, 2003.
• Forsell Y, Henderson S. Epidemiology of paranoid disorders in an elderly population. Br J Psychiatry 1998; 172:429-32.

Drug brand names

• Fluoxetine • Prozac
• Olanzapine • Zyprexa
• Nortriptyline • Aventyl, Pamelor
• Paroxetine • Paxil
• Venlafaxine • Effexor

Disclosure

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