Current Psychiatry

Mr. S, age 43, has schizophrenia and been stable on clozapine for 6 years after several other antipsychotic regimens failed. Mr. S also has a history of hypertension, dyslipidemia, and gastroesophageal reflux disorder. His medication regimen includes clozapine, 400 mg/d, lisinopril, 20 mg/d, atorvastatin, 40 mg/d, omeprazole, 40 mg/d, and a multivitamin. During routine blood monitoring, Mr. S shows a significant drop in absolute neutrophil count (ANC) (750/µL) (reference range, 1,500 to 8,000 µL). Mr. S , who is African American, has no history of benign ethnic neutropenia (BEN) or ANC <1,000/µL. While reviewing his chart, clinicians note that Mr. S had an ANC of 1,350/µL3 years earlier in 2013. Because a complete workup reveals no other cause for this lab abnormality, we determine that is clozapine-induced. Mr. S’s physician asks about treatment options that would allow him to stay on clozapine.

Because of clozapine’s efficacy in treatment-resistant schizophrenia, many psychiatrists aim to

Clozapine-induced neutropenia

Clozapine was approved in 1989 for managing treatment-resistant schizophrenia after demonstrating better efficacy than chlorpromazine.¹ However, the adverse effects of neutropenia (white blood cell count [WBC] <3,000/μL) and agranulocytosis (ANC <500/μL³) leading to death were reported in later studies.^2,3 One study in the United Kingdom and Ireland reported a prevalence of 2.9% for neutropenia and 0.8% for agranulocytosis among patients taking clozapine.³ Because of this risk, the FDA mandated WBC and ANC monitoring before initiating clozapine and periodically thereafter. In October 2015, the Risk Evaluation and Mitigation Strategies program for clozapine updated recommended ANC levels and eliminated WBC monitoring. ANC monitoring frequencies are summarized in the Table.¹

The exact mechanism of clozapine-induced neutropenia is unknown, although it is possible it stems from the drug’s effect on white blood cell precursors.² Neutropenia typically appears within 3 months of clozapine initiation; however, delayed cases have been reported. Additionally, the risk is higher in certain patient populations (African heritage, Yemenite, West Indians, and Arab). Patients with a lower ANC at clozapine initiation and advanced age appear to be at higher risk.²

Filgrastim

The use of granulocyte-colony stimulating factor, such as filgrastim, often is viewed as a “rescue” treatment. Filgrastim’s mechanism of action is related to neutrophil production and proliferation. Several articles from the 1990s reported efficacy in the short-term management of low WBC or ANC. However, few articles, mainly case reports, have looked at long-term use of these agents. One article examined 3 patients, average age 45, who developed neutropenia during clozapine treatment.⁴ Filgrastim at an average dosage of 0.6 to 0.9 mg/week was used successfully. The dosage was reduced to 0.3 mg/week in 1 patient, although neutropenia returned.

Because of the lack of literature regarding long-term therapy, it is recommended to consider short-term treatment with filgrastim to normalize ANC after a severe drop in a symptomatic patient. Physicians also must consider the potential barriers to filgrastim treatment including adverse effects, such as allergic reactions, bone pain, and thrombocytopenia, and high cost.

Adjunctive lithium

Lithium could cause leukocytosis, which could balance neutropenia induced by clozapine. One of the largest studies evaluating lithium therapy with clozapine-induced neutropenia and agranulocytosis studied 25 patients taking clozapine with a previous “red result” (WBC <3,000/μL, ANC <1,500/μL, or platelets <50,000/μL).³ Lithium treatment was started before or simultaneously with the reinitiation of clozapine in most patients; the remaining patients started treatment at a later date. Only 1 of 25 patients experienced a repeat “red result.” The average lithium level was 0.54 mEq/L.

It is important to remember that initiating adjunctive lithium carries risk. Adverse effects include gastrointestinal upset, tremors, polyuria, polydipsia, and nephrotoxicity.

Additionally, there is risk that lithium simply masks the preliminary states of neutropenia leading to a more severe agranulocytosis without warning.³ Again, the mechanism of action of clozapine-induced neutropenia is thought to be related to the drug’s effect on WBC precursors. The mechanism of lithium-induced leukocytosis is unknown, therefore it’s possible that lithium will not protect a patient from clozapine-induced neutropenia or agranulocytosis, and can lead to serious adverse events.

When deciding whether to rechallenge a patient on clozapine who had a prior episode of moderate or severe neutropenia or agranulocytosis, a risk vs benefit discussion is necessary. One study found that 20 of 53 patients (38%) experienced a repeat dyscrasia when rechallenged.⁵ Of these patients, most experienced a lower ANC that presented faster and took longer to resolve.⁵ If a patient has experienced true agranulocytosis, the recommendation is to not rechallenge clozapine.

Related Resources
• Clozapine REMS Program. www.clozapinerems.com.
• Newman BM, Newman WJ. Rediscovering clozapine: adverse effects develop—what should you do now? Current Psychiatry. 2016;15(8):40-46,48,49.
• Whiskey E, Taylor D. Restarting clozapine after neutropenia: evaluating the possibilities and practicalities. CNS Drugs. 2007;21(1):25-35.

Drug Brand Names
Atorvastatin • Lipitor
Chlorpromazine • Thorazine
Clozapine • Clozaril
Fligrastim • Neupogen
Lisinopril • Prinivil
Lithium • Eskalith, Lithobid
Omeprazole • Prilosec

Mr. S, age 43, has schizophrenia and been stable on clozapine for 6 years after several other antipsychotic regimens failed. Mr. S also has a history of hypertension, dyslipidemia, and gastroesophageal reflux disorder. His medication regimen includes clozapine, 400 mg/d, lisinopril, 20 mg/d, atorvastatin, 40 mg/d, omeprazole, 40 mg/d, and a multivitamin. During routine blood monitoring, Mr. S shows a significant drop in absolute neutrophil count (ANC) (750/µL) (reference range, 1,500 to 8,000 µL). Mr. S , who is African American, has no history of benign ethnic neutropenia (BEN) or ANC <1,000/µL. While reviewing his chart, clinicians note that Mr. S had an ANC of 1,350/µL3 years earlier in 2013. Because a complete workup reveals no other cause for this lab abnormality, we determine that is clozapine-induced. Mr. S’s physician asks about treatment options that would allow him to stay on clozapine.

Because of clozapine’s efficacy in treatment-resistant schizophrenia, many psychiatrists aim to

Clozapine-induced neutropenia

Clozapine was approved in 1989 for managing treatment-resistant schizophrenia after demonstrating better efficacy than chlorpromazine.¹ However, the adverse effects of neutropenia (white blood cell count [WBC] <3,000/μL) and agranulocytosis (ANC <500/μL³) leading to death were reported in later studies.^2,3 One study in the United Kingdom and Ireland reported a prevalence of 2.9% for neutropenia and 0.8% for agranulocytosis among patients taking clozapine.³ Because of this risk, the FDA mandated WBC and ANC monitoring before initiating clozapine and periodically thereafter. In October 2015, the Risk Evaluation and Mitigation Strategies program for clozapine updated recommended ANC levels and eliminated WBC monitoring. ANC monitoring frequencies are summarized in the Table.¹

The exact mechanism of clozapine-induced neutropenia is unknown, although it is possible it stems from the drug’s effect on white blood cell precursors.² Neutropenia typically appears within 3 months of clozapine initiation; however, delayed cases have been reported. Additionally, the risk is higher in certain patient populations (African heritage, Yemenite, West Indians, and Arab). Patients with a lower ANC at clozapine initiation and advanced age appear to be at higher risk.²

Filgrastim

The use of granulocyte-colony stimulating factor, such as filgrastim, often is viewed as a “rescue” treatment. Filgrastim’s mechanism of action is related to neutrophil production and proliferation. Several articles from the 1990s reported efficacy in the short-term management of low WBC or ANC. However, few articles, mainly case reports, have looked at long-term use of these agents. One article examined 3 patients, average age 45, who developed neutropenia during clozapine treatment.⁴ Filgrastim at an average dosage of 0.6 to 0.9 mg/week was used successfully. The dosage was reduced to 0.3 mg/week in 1 patient, although neutropenia returned.

Because of the lack of literature regarding long-term therapy, it is recommended to consider short-term treatment with filgrastim to normalize ANC after a severe drop in a symptomatic patient. Physicians also must consider the potential barriers to filgrastim treatment including adverse effects, such as allergic reactions, bone pain, and thrombocytopenia, and high cost.

Adjunctive lithium

Lithium could cause leukocytosis, which could balance neutropenia induced by clozapine. One of the largest studies evaluating lithium therapy with clozapine-induced neutropenia and agranulocytosis studied 25 patients taking clozapine with a previous “red result” (WBC <3,000/μL, ANC <1,500/μL, or platelets <50,000/μL).³ Lithium treatment was started before or simultaneously with the reinitiation of clozapine in most patients; the remaining patients started treatment at a later date. Only 1 of 25 patients experienced a repeat “red result.” The average lithium level was 0.54 mEq/L.

It is important to remember that initiating adjunctive lithium carries risk. Adverse effects include gastrointestinal upset, tremors, polyuria, polydipsia, and nephrotoxicity.

Additionally, there is risk that lithium simply masks the preliminary states of neutropenia leading to a more severe agranulocytosis without warning.³ Again, the mechanism of action of clozapine-induced neutropenia is thought to be related to the drug’s effect on WBC precursors. The mechanism of lithium-induced leukocytosis is unknown, therefore it’s possible that lithium will not protect a patient from clozapine-induced neutropenia or agranulocytosis, and can lead to serious adverse events.

When deciding whether to rechallenge a patient on clozapine who had a prior episode of moderate or severe neutropenia or agranulocytosis, a risk vs benefit discussion is necessary. One study found that 20 of 53 patients (38%) experienced a repeat dyscrasia when rechallenged.⁵ Of these patients, most experienced a lower ANC that presented faster and took longer to resolve.⁵ If a patient has experienced true agranulocytosis, the recommendation is to not rechallenge clozapine.

Related Resources
• Clozapine REMS Program. www.clozapinerems.com.
• Newman BM, Newman WJ. Rediscovering clozapine: adverse effects develop—what should you do now? Current Psychiatry. 2016;15(8):40-46,48,49.
• Whiskey E, Taylor D. Restarting clozapine after neutropenia: evaluating the possibilities and practicalities. CNS Drugs. 2007;21(1):25-35.

Drug Brand Names
Atorvastatin • Lipitor
Chlorpromazine • Thorazine
Clozapine • Clozaril
Fligrastim • Neupogen
Lisinopril • Prinivil
Lithium • Eskalith, Lithobid
Omeprazole • Prilosec

Mr. S, age 43, has schizophrenia and been stable on clozapine for 6 years after several other antipsychotic regimens failed. Mr. S also has a history of hypertension, dyslipidemia, and gastroesophageal reflux disorder. His medication regimen includes clozapine, 400 mg/d, lisinopril, 20 mg/d, atorvastatin, 40 mg/d, omeprazole, 40 mg/d, and a multivitamin. During routine blood monitoring, Mr. S shows a significant drop in absolute neutrophil count (ANC) (750/µL) (reference range, 1,500 to 8,000 µL). Mr. S , who is African American, has no history of benign ethnic neutropenia (BEN) or ANC <1,000/µL. While reviewing his chart, clinicians note that Mr. S had an ANC of 1,350/µL3 years earlier in 2013. Because a complete workup reveals no other cause for this lab abnormality, we determine that is clozapine-induced. Mr. S’s physician asks about treatment options that would allow him to stay on clozapine.

Because of clozapine’s efficacy in treatment-resistant schizophrenia, many psychiatrists aim to

Clozapine-induced neutropenia

Clozapine was approved in 1989 for managing treatment-resistant schizophrenia after demonstrating better efficacy than chlorpromazine.¹ However, the adverse effects of neutropenia (white blood cell count [WBC] <3,000/μL) and agranulocytosis (ANC <500/μL³) leading to death were reported in later studies.^2,3 One study in the United Kingdom and Ireland reported a prevalence of 2.9% for neutropenia and 0.8% for agranulocytosis among patients taking clozapine.³ Because of this risk, the FDA mandated WBC and ANC monitoring before initiating clozapine and periodically thereafter. In October 2015, the Risk Evaluation and Mitigation Strategies program for clozapine updated recommended ANC levels and eliminated WBC monitoring. ANC monitoring frequencies are summarized in the Table.¹

The exact mechanism of clozapine-induced neutropenia is unknown, although it is possible it stems from the drug’s effect on white blood cell precursors.² Neutropenia typically appears within 3 months of clozapine initiation; however, delayed cases have been reported. Additionally, the risk is higher in certain patient populations (African heritage, Yemenite, West Indians, and Arab). Patients with a lower ANC at clozapine initiation and advanced age appear to be at higher risk.²

Filgrastim

The use of granulocyte-colony stimulating factor, such as filgrastim, often is viewed as a “rescue” treatment. Filgrastim’s mechanism of action is related to neutrophil production and proliferation. Several articles from the 1990s reported efficacy in the short-term management of low WBC or ANC. However, few articles, mainly case reports, have looked at long-term use of these agents. One article examined 3 patients, average age 45, who developed neutropenia during clozapine treatment.⁴ Filgrastim at an average dosage of 0.6 to 0.9 mg/week was used successfully. The dosage was reduced to 0.3 mg/week in 1 patient, although neutropenia returned.

Because of the lack of literature regarding long-term therapy, it is recommended to consider short-term treatment with filgrastim to normalize ANC after a severe drop in a symptomatic patient. Physicians also must consider the potential barriers to filgrastim treatment including adverse effects, such as allergic reactions, bone pain, and thrombocytopenia, and high cost.

Adjunctive lithium

Lithium could cause leukocytosis, which could balance neutropenia induced by clozapine. One of the largest studies evaluating lithium therapy with clozapine-induced neutropenia and agranulocytosis studied 25 patients taking clozapine with a previous “red result” (WBC <3,000/μL, ANC <1,500/μL, or platelets <50,000/μL).³ Lithium treatment was started before or simultaneously with the reinitiation of clozapine in most patients; the remaining patients started treatment at a later date. Only 1 of 25 patients experienced a repeat “red result.” The average lithium level was 0.54 mEq/L.

It is important to remember that initiating adjunctive lithium carries risk. Adverse effects include gastrointestinal upset, tremors, polyuria, polydipsia, and nephrotoxicity.

Additionally, there is risk that lithium simply masks the preliminary states of neutropenia leading to a more severe agranulocytosis without warning.³ Again, the mechanism of action of clozapine-induced neutropenia is thought to be related to the drug’s effect on WBC precursors. The mechanism of lithium-induced leukocytosis is unknown, therefore it’s possible that lithium will not protect a patient from clozapine-induced neutropenia or agranulocytosis, and can lead to serious adverse events.

When deciding whether to rechallenge a patient on clozapine who had a prior episode of moderate or severe neutropenia or agranulocytosis, a risk vs benefit discussion is necessary. One study found that 20 of 53 patients (38%) experienced a repeat dyscrasia when rechallenged.⁵ Of these patients, most experienced a lower ANC that presented faster and took longer to resolve.⁵ If a patient has experienced true agranulocytosis, the recommendation is to not rechallenge clozapine.

Related Resources
• Clozapine REMS Program. www.clozapinerems.com.
• Newman BM, Newman WJ. Rediscovering clozapine: adverse effects develop—what should you do now? Current Psychiatry. 2016;15(8):40-46,48,49.
• Whiskey E, Taylor D. Restarting clozapine after neutropenia: evaluating the possibilities and practicalities. CNS Drugs. 2007;21(1):25-35.

Drug Brand Names
Atorvastatin • Lipitor
Chlorpromazine • Thorazine
Clozapine • Clozaril
Fligrastim • Neupogen
Lisinopril • Prinivil
Lithium • Eskalith, Lithobid
Omeprazole • Prilosec

CASE Suicidal and hungry

Mr. L, age 59, attempts suicide by taking approximately 20 acetaminophen tablets of unknown dosage. He immediately comes to the emergency department where blood work reveals a 4-hour acetaminophen level of 94.8 μg/mL (therapeutic range, 10 to 30 μg/mL; toxic range, >150 μg/mL); administration of N-acetylcysteine is unnecessary. Mr. L is admitted to general medical services for monitoring and is transferred to our unit for psychiatric evaluation and management.

During our initial interview, Mr. L, who has a developmental disability, is grossly oriented and generally cooperative, reporting depressed mood with an irritable affect. He is preoccupied with having limited funds and repeatedly states he is worried that he can’t buy food, but says that the hospital could help by providing for him. Mr. L states that his depressed mood is directly related to his financial situation and, that if he had more money, he would not be suicidal. He cites worsening visual impairment that requires surgery as an additional stressor.

On several occasions, Mr. L states that the only way to help him is to give him $600 so that he can buy food and pay for medical treatment. Mr. L says he does not feel supported by his family, despite having a sister who lives nearby.

What would you include in the differential diagnosis for Mr. L?

a) major depressive disorder (MDD)
b) depression secondary to a medical condition
c) neurocognitive disorder
d) adjustment disorder with depressive features
e) factitious disorder

The authors’ observations

Our differential diagnosis included MDD, adjustment disorder, neurocognitive disorder, and factitious disorder. He did not meet criteria for MDD because he did not have excessive guilt, loss of interest, change in sleep or appetite, psychomotor dysregulation, or change in energy level. Although suicidal behavior could indicate MDD, the fact that he immediately walked to the hospital after taking an excessive amount of acetaminophen suggests that he did not want to die. Further, he attributed his suicidal thoughts to environmental stressors. Similarly, we ruled out adjustment disorder because he had no reported or observed changes in mood or anxiety. Although financial difficulties might have overwhelmed his limited coping abilities, he took too much acetaminophen to ensure that he was hospitalized. His motivation for seeking hospitalization ruled out factitious disorder. Mr. L has a developmental disability, but information obtained from collateral sources ruled out an acute change to cognitive functioning.

HISTORY Repeated admissions

Mr. L has a history of a psychiatric hospitalization 3 weeks prior to this admission. He presented to an emergency department stating that his blood glucose was low. Mr. L was noted to be confused and anxious and said he was convinced he was going to die. At that time, his thought content was hyper-religious and he claimed he could hear the devil. Mr. L was hospitalized and started on low-dosage risperidone. At discharge, he declined referral for outpatient mental health treatment because he denied having a mental illness. However, he was amenable to follow up at a wellness clinic.

Mr. L has worked at a local supermarket for 19 years and has lived independently throughout his adult life. After he returned to the community, he was repeatedly absent from work, which further exacerbated his financial strain. He attended a follow-up outpatient appointment but reported, “They didn’t help me,” although it was unclear what he meant.

Between admissions to our hospital, Mr. L had 2 visits to an emergency department, the first time saying he felt depressed and the second reporting he attempted suicide by taking 5 acetaminophen tablets. On both occasions he requested placement in a residential facility but was discharged home after an initial assessment. Emergency room records indicated that Mr. L stated, “If you cannot give me money for food, then there is no use and I would rather die.”

What is the most likely DSM-5 diagnosis for Mr. L?

a) schizophrenia
b) malingering
c) brief psychotic disorder
d) dependent personality disorder

The authors’ observations

Malingering in DSM-5 is defined as the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.”¹ These external incentives include financial compensation, avoiding military duties, evading criminal charges, and avoiding work, and are collectively considered as secondary gain. Although not considered a diagnosis in the strictest sense, clinicians must differentiate malingering from other psychiatric disorders. In the literature, case reports describe patients who feigned an array of symptoms including those of posttraumatic stress disorder, paraphilias, cognitive dysfunction, depression, anxiety, and psychosis.^2-5

In Mr. L’s case, malingering presented as suicidal behavior with an inadvertently high fatality risk. Notably, Mr. L came to an emergency room a few days before this admission after swallowing 5 acetaminophen tablets in a suicide attempt, which did not lead to a medical or psychiatric hospitalization. In an attempt to ensure admission, Mr. L then took a potentially lethal dose of 20 acetaminophen tablets. In our assessment and according to his statements, the primary motivation for the suicide attempt was to obtain reliable food and housing. Mr. L’s developmental disability might have contributed to a relative lack of understanding of the consequences of his actions. In addition, poor overall communication and coping skills led to an exaggerated response to psychosocial stressors.

Malingering and suicide attempts

Few studies have investigated malingering in regards to suicide and other psychiatric emergencies. In a study of 227 consecutive psychiatric emergencies assessed for evidence of malingering, 13% were thought to be feigned or exaggerated.⁶ Interestingly, the most commonly reported secondary gain was food and shelter, similar to Mr. L. This study did not report the types of psychiatric emergencies, therefore suicidal actions associated with malingering could not be evaluated.

In another study, 40 patients hospitalized for suicidal ideation (n = 29, 72%) or suicidal gestures (n = 11, 28%) in a large, urban tertiary care center were evaluated for malingering by anonymous report of feigned or exaggerated symptoms.⁷ Most of these patients were diagnosed with a mood disorder (28%) and/or an adjustment disorder (53%). Four (10%) admitted to malingering. Among the malingerers, reasons for feigning illness included:

• wanting to be hospitalized
• wanting to make someone angry or feel sorry
• gaining access to detoxification programs
• getting treatment for emotional problems.

Interestingly, an analysis of demographic factors associated with malingering reveals an association with suicide attempts but not persistent suicidal ideations. This could be because of selection bias; patients who reported a suicide attempt might be more likely to be hospitalized.

A follow-up study⁸ evaluated 50 additional consecutive psychiatric inpatients admitted to the same tertiary care hospital for suicide risk. Unlike the previous study, a larger proportion of these patients had made a suicide attempt (n = 21, 42%) and a greater number had made a previous suicide attempt (n = 33, 66%). Primary mood disorders comprised most of the psychiatric diagnoses (n = 28, 56%). In this study, the exact nature of the suicide gestures was not documented, leaving open the question of lethality of the attempts. These studies do not suggest that those who malinger are not at risk for suicide, only that these patients tend to exaggerate the severity of their ideations or behaviors.

OUTCOME Reluctantly discharged

We contact Mr. L’s siblings, who offer to provide temporary housing and financial support and assist him with medical needs. This abated Mr. L’s suicidal ideation; however, he wishes to remain in the hospital with the goals of obtaining eyeglasses and dentures. We explain that psychiatric hospitalization is no longer indicated and he is discharged.

Which of the following is the most effective management strategy for malingering?

a) direct confrontation of the malingering patient
b) immediate discharge once malingering is identified

c) evaluation for possible comorbid psychiatric conditions

d) neuropsychiatric consultation

The authors’ observations

The challenges of treating patients who malinger include clinician uncertainty in making the diagnosis and high variability in occurrence across settings (Table 1). Current estimates indicate that 4% to 8% of medical and psychiatric cases not involved in litigation or compensation have an element of feigned symptoms.^3,9 The rate could be higher in specific circumstances such as medicolegal disputes and criminal cases.¹⁰

The societal impact of malingering is significant. Therefore, identifying these patients is an important clinical intervention that can have a wide impact.¹¹ However, it is also important to acknowledge that genuine psychiatric illness could be comorbid with malingering. Although differentiating a patient’s true from feigned symptoms can be difficult, it is critical to carefully evaluate the patient in order to provide the best treatment.

It seems that physicians can detect malingering, but documentation often is not provided. In the Rissmiller et al study,⁷ all 4 cases of malingering were identified retrospectively by study psychiatrists; however, none of their medical records included documentation of malingering, a finding also reported in the Yates et al study.⁶ Also concerning, the clinicians suspected malingering in some patients who were not feigning symptoms, suggesting that a relatively high threshold is necessary for making the diagnosis.

How to help patients who malinger

Identifying malingering in patients with obvious secondary gain is important to prevent exposure to potential adverse effects of medication and unnecessary use of medical resources. In addition, obtaining collateral information, records from previous admissions or outpatient treatment, and psychological testing adds to the body of evidence suggesting malingering. We also recommend a comprehensive psychosocial evaluation to identify the presence of secondary gain.

Management of malingering (Table 2) includes building a strong therapeutic alliance, exploring reasons for feigning symptoms, open discussion of inciting external factors such as interpersonal conflict or difficulties at work, and/or confrontation.¹⁰ In addition, supportive psychotherapy might help strengthen coping mechanisms and problem solving strategies, thereby removing the need for secondary gain.¹² Additionally, face-saving mechanisms that allow the patient to discard their feigned symptoms, or enable the person to alter his (her) history, could be to his benefit. Lastly, and importantly, clinicians should focus efforts on ruling out or effectively treating comorbid psychiatric conditions.

From a risk management standpoint, include all available data to support the malingering diagnosis in your progress notes and discharge summaries. A clinician seeking to discharge a patient suspected of malingering who is still endorsing suicidal or homicidal intent will benefit from administrative review, including legal counsel to mitigate risk, and be more confident discharging somebody assessed to be malingering.

We recognize that certain patients could trigger countertransference reactions that impel clinicians to take on a significant caretaking role. Patients skillful at deception could manifest a desire to rescue or save them. In these instances, clinicians should examine why and how these feelings have come about, particularly if there is evidence that the individual could be attempting to use the interaction to achieve secondary gain. Awareness of these feelings could help with the diagnostic formulation. Moreover, a clinician who has such strong feelings might be tempted to abet a patient in achieving the secondary gain, or protect him (her) from the natural consequences of individual’s deception (eg, not discharging a hospitalized patient). This is counter-therapeutic and reinforces maladaptive behaviors and coping processes.¹³

CASE Suicidal and hungry

Mr. L, age 59, attempts suicide by taking approximately 20 acetaminophen tablets of unknown dosage. He immediately comes to the emergency department where blood work reveals a 4-hour acetaminophen level of 94.8 μg/mL (therapeutic range, 10 to 30 μg/mL; toxic range, >150 μg/mL); administration of N-acetylcysteine is unnecessary. Mr. L is admitted to general medical services for monitoring and is transferred to our unit for psychiatric evaluation and management.

During our initial interview, Mr. L, who has a developmental disability, is grossly oriented and generally cooperative, reporting depressed mood with an irritable affect. He is preoccupied with having limited funds and repeatedly states he is worried that he can’t buy food, but says that the hospital could help by providing for him. Mr. L states that his depressed mood is directly related to his financial situation and, that if he had more money, he would not be suicidal. He cites worsening visual impairment that requires surgery as an additional stressor.

On several occasions, Mr. L states that the only way to help him is to give him $600 so that he can buy food and pay for medical treatment. Mr. L says he does not feel supported by his family, despite having a sister who lives nearby.

What would you include in the differential diagnosis for Mr. L?

a) major depressive disorder (MDD)
b) depression secondary to a medical condition
c) neurocognitive disorder
d) adjustment disorder with depressive features
e) factitious disorder

The authors’ observations

Our differential diagnosis included MDD, adjustment disorder, neurocognitive disorder, and factitious disorder. He did not meet criteria for MDD because he did not have excessive guilt, loss of interest, change in sleep or appetite, psychomotor dysregulation, or change in energy level. Although suicidal behavior could indicate MDD, the fact that he immediately walked to the hospital after taking an excessive amount of acetaminophen suggests that he did not want to die. Further, he attributed his suicidal thoughts to environmental stressors. Similarly, we ruled out adjustment disorder because he had no reported or observed changes in mood or anxiety. Although financial difficulties might have overwhelmed his limited coping abilities, he took too much acetaminophen to ensure that he was hospitalized. His motivation for seeking hospitalization ruled out factitious disorder. Mr. L has a developmental disability, but information obtained from collateral sources ruled out an acute change to cognitive functioning.

HISTORY Repeated admissions

Mr. L has a history of a psychiatric hospitalization 3 weeks prior to this admission. He presented to an emergency department stating that his blood glucose was low. Mr. L was noted to be confused and anxious and said he was convinced he was going to die. At that time, his thought content was hyper-religious and he claimed he could hear the devil. Mr. L was hospitalized and started on low-dosage risperidone. At discharge, he declined referral for outpatient mental health treatment because he denied having a mental illness. However, he was amenable to follow up at a wellness clinic.

Mr. L has worked at a local supermarket for 19 years and has lived independently throughout his adult life. After he returned to the community, he was repeatedly absent from work, which further exacerbated his financial strain. He attended a follow-up outpatient appointment but reported, “They didn’t help me,” although it was unclear what he meant.

Between admissions to our hospital, Mr. L had 2 visits to an emergency department, the first time saying he felt depressed and the second reporting he attempted suicide by taking 5 acetaminophen tablets. On both occasions he requested placement in a residential facility but was discharged home after an initial assessment. Emergency room records indicated that Mr. L stated, “If you cannot give me money for food, then there is no use and I would rather die.”

What is the most likely DSM-5 diagnosis for Mr. L?

a) schizophrenia
b) malingering
c) brief psychotic disorder
d) dependent personality disorder

The authors’ observations

Malingering in DSM-5 is defined as the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.”¹ These external incentives include financial compensation, avoiding military duties, evading criminal charges, and avoiding work, and are collectively considered as secondary gain. Although not considered a diagnosis in the strictest sense, clinicians must differentiate malingering from other psychiatric disorders. In the literature, case reports describe patients who feigned an array of symptoms including those of posttraumatic stress disorder, paraphilias, cognitive dysfunction, depression, anxiety, and psychosis.^2-5

In Mr. L’s case, malingering presented as suicidal behavior with an inadvertently high fatality risk. Notably, Mr. L came to an emergency room a few days before this admission after swallowing 5 acetaminophen tablets in a suicide attempt, which did not lead to a medical or psychiatric hospitalization. In an attempt to ensure admission, Mr. L then took a potentially lethal dose of 20 acetaminophen tablets. In our assessment and according to his statements, the primary motivation for the suicide attempt was to obtain reliable food and housing. Mr. L’s developmental disability might have contributed to a relative lack of understanding of the consequences of his actions. In addition, poor overall communication and coping skills led to an exaggerated response to psychosocial stressors.

Malingering and suicide attempts

Few studies have investigated malingering in regards to suicide and other psychiatric emergencies. In a study of 227 consecutive psychiatric emergencies assessed for evidence of malingering, 13% were thought to be feigned or exaggerated.⁶ Interestingly, the most commonly reported secondary gain was food and shelter, similar to Mr. L. This study did not report the types of psychiatric emergencies, therefore suicidal actions associated with malingering could not be evaluated.

In another study, 40 patients hospitalized for suicidal ideation (n = 29, 72%) or suicidal gestures (n = 11, 28%) in a large, urban tertiary care center were evaluated for malingering by anonymous report of feigned or exaggerated symptoms.⁷ Most of these patients were diagnosed with a mood disorder (28%) and/or an adjustment disorder (53%). Four (10%) admitted to malingering. Among the malingerers, reasons for feigning illness included:

• wanting to be hospitalized
• wanting to make someone angry or feel sorry
• gaining access to detoxification programs
• getting treatment for emotional problems.

Interestingly, an analysis of demographic factors associated with malingering reveals an association with suicide attempts but not persistent suicidal ideations. This could be because of selection bias; patients who reported a suicide attempt might be more likely to be hospitalized.

A follow-up study⁸ evaluated 50 additional consecutive psychiatric inpatients admitted to the same tertiary care hospital for suicide risk. Unlike the previous study, a larger proportion of these patients had made a suicide attempt (n = 21, 42%) and a greater number had made a previous suicide attempt (n = 33, 66%). Primary mood disorders comprised most of the psychiatric diagnoses (n = 28, 56%). In this study, the exact nature of the suicide gestures was not documented, leaving open the question of lethality of the attempts. These studies do not suggest that those who malinger are not at risk for suicide, only that these patients tend to exaggerate the severity of their ideations or behaviors.

OUTCOME Reluctantly discharged

We contact Mr. L’s siblings, who offer to provide temporary housing and financial support and assist him with medical needs. This abated Mr. L’s suicidal ideation; however, he wishes to remain in the hospital with the goals of obtaining eyeglasses and dentures. We explain that psychiatric hospitalization is no longer indicated and he is discharged.

Which of the following is the most effective management strategy for malingering?

a) direct confrontation of the malingering patient
b) immediate discharge once malingering is identified

c) evaluation for possible comorbid psychiatric conditions

d) neuropsychiatric consultation

The authors’ observations

The challenges of treating patients who malinger include clinician uncertainty in making the diagnosis and high variability in occurrence across settings (Table 1). Current estimates indicate that 4% to 8% of medical and psychiatric cases not involved in litigation or compensation have an element of feigned symptoms.^3,9 The rate could be higher in specific circumstances such as medicolegal disputes and criminal cases.¹⁰

The societal impact of malingering is significant. Therefore, identifying these patients is an important clinical intervention that can have a wide impact.¹¹ However, it is also important to acknowledge that genuine psychiatric illness could be comorbid with malingering. Although differentiating a patient’s true from feigned symptoms can be difficult, it is critical to carefully evaluate the patient in order to provide the best treatment.

It seems that physicians can detect malingering, but documentation often is not provided. In the Rissmiller et al study,⁷ all 4 cases of malingering were identified retrospectively by study psychiatrists; however, none of their medical records included documentation of malingering, a finding also reported in the Yates et al study.⁶ Also concerning, the clinicians suspected malingering in some patients who were not feigning symptoms, suggesting that a relatively high threshold is necessary for making the diagnosis.

How to help patients who malinger

Identifying malingering in patients with obvious secondary gain is important to prevent exposure to potential adverse effects of medication and unnecessary use of medical resources. In addition, obtaining collateral information, records from previous admissions or outpatient treatment, and psychological testing adds to the body of evidence suggesting malingering. We also recommend a comprehensive psychosocial evaluation to identify the presence of secondary gain.

Management of malingering (Table 2) includes building a strong therapeutic alliance, exploring reasons for feigning symptoms, open discussion of inciting external factors such as interpersonal conflict or difficulties at work, and/or confrontation.¹⁰ In addition, supportive psychotherapy might help strengthen coping mechanisms and problem solving strategies, thereby removing the need for secondary gain.¹² Additionally, face-saving mechanisms that allow the patient to discard their feigned symptoms, or enable the person to alter his (her) history, could be to his benefit. Lastly, and importantly, clinicians should focus efforts on ruling out or effectively treating comorbid psychiatric conditions.

From a risk management standpoint, include all available data to support the malingering diagnosis in your progress notes and discharge summaries. A clinician seeking to discharge a patient suspected of malingering who is still endorsing suicidal or homicidal intent will benefit from administrative review, including legal counsel to mitigate risk, and be more confident discharging somebody assessed to be malingering.

We recognize that certain patients could trigger countertransference reactions that impel clinicians to take on a significant caretaking role. Patients skillful at deception could manifest a desire to rescue or save them. In these instances, clinicians should examine why and how these feelings have come about, particularly if there is evidence that the individual could be attempting to use the interaction to achieve secondary gain. Awareness of these feelings could help with the diagnostic formulation. Moreover, a clinician who has such strong feelings might be tempted to abet a patient in achieving the secondary gain, or protect him (her) from the natural consequences of individual’s deception (eg, not discharging a hospitalized patient). This is counter-therapeutic and reinforces maladaptive behaviors and coping processes.¹³

CASE Suicidal and hungry

Mr. L, age 59, attempts suicide by taking approximately 20 acetaminophen tablets of unknown dosage. He immediately comes to the emergency department where blood work reveals a 4-hour acetaminophen level of 94.8 μg/mL (therapeutic range, 10 to 30 μg/mL; toxic range, >150 μg/mL); administration of N-acetylcysteine is unnecessary. Mr. L is admitted to general medical services for monitoring and is transferred to our unit for psychiatric evaluation and management.

During our initial interview, Mr. L, who has a developmental disability, is grossly oriented and generally cooperative, reporting depressed mood with an irritable affect. He is preoccupied with having limited funds and repeatedly states he is worried that he can’t buy food, but says that the hospital could help by providing for him. Mr. L states that his depressed mood is directly related to his financial situation and, that if he had more money, he would not be suicidal. He cites worsening visual impairment that requires surgery as an additional stressor.

On several occasions, Mr. L states that the only way to help him is to give him $600 so that he can buy food and pay for medical treatment. Mr. L says he does not feel supported by his family, despite having a sister who lives nearby.

What would you include in the differential diagnosis for Mr. L?

a) major depressive disorder (MDD)
b) depression secondary to a medical condition
c) neurocognitive disorder
d) adjustment disorder with depressive features
e) factitious disorder

The authors’ observations

Our differential diagnosis included MDD, adjustment disorder, neurocognitive disorder, and factitious disorder. He did not meet criteria for MDD because he did not have excessive guilt, loss of interest, change in sleep or appetite, psychomotor dysregulation, or change in energy level. Although suicidal behavior could indicate MDD, the fact that he immediately walked to the hospital after taking an excessive amount of acetaminophen suggests that he did not want to die. Further, he attributed his suicidal thoughts to environmental stressors. Similarly, we ruled out adjustment disorder because he had no reported or observed changes in mood or anxiety. Although financial difficulties might have overwhelmed his limited coping abilities, he took too much acetaminophen to ensure that he was hospitalized. His motivation for seeking hospitalization ruled out factitious disorder. Mr. L has a developmental disability, but information obtained from collateral sources ruled out an acute change to cognitive functioning.

HISTORY Repeated admissions

Mr. L has a history of a psychiatric hospitalization 3 weeks prior to this admission. He presented to an emergency department stating that his blood glucose was low. Mr. L was noted to be confused and anxious and said he was convinced he was going to die. At that time, his thought content was hyper-religious and he claimed he could hear the devil. Mr. L was hospitalized and started on low-dosage risperidone. At discharge, he declined referral for outpatient mental health treatment because he denied having a mental illness. However, he was amenable to follow up at a wellness clinic.

Mr. L has worked at a local supermarket for 19 years and has lived independently throughout his adult life. After he returned to the community, he was repeatedly absent from work, which further exacerbated his financial strain. He attended a follow-up outpatient appointment but reported, “They didn’t help me,” although it was unclear what he meant.

Between admissions to our hospital, Mr. L had 2 visits to an emergency department, the first time saying he felt depressed and the second reporting he attempted suicide by taking 5 acetaminophen tablets. On both occasions he requested placement in a residential facility but was discharged home after an initial assessment. Emergency room records indicated that Mr. L stated, “If you cannot give me money for food, then there is no use and I would rather die.”

What is the most likely DSM-5 diagnosis for Mr. L?

a) schizophrenia
b) malingering
c) brief psychotic disorder
d) dependent personality disorder

The authors’ observations

Malingering in DSM-5 is defined as the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.”¹ These external incentives include financial compensation, avoiding military duties, evading criminal charges, and avoiding work, and are collectively considered as secondary gain. Although not considered a diagnosis in the strictest sense, clinicians must differentiate malingering from other psychiatric disorders. In the literature, case reports describe patients who feigned an array of symptoms including those of posttraumatic stress disorder, paraphilias, cognitive dysfunction, depression, anxiety, and psychosis.^2-5

In Mr. L’s case, malingering presented as suicidal behavior with an inadvertently high fatality risk. Notably, Mr. L came to an emergency room a few days before this admission after swallowing 5 acetaminophen tablets in a suicide attempt, which did not lead to a medical or psychiatric hospitalization. In an attempt to ensure admission, Mr. L then took a potentially lethal dose of 20 acetaminophen tablets. In our assessment and according to his statements, the primary motivation for the suicide attempt was to obtain reliable food and housing. Mr. L’s developmental disability might have contributed to a relative lack of understanding of the consequences of his actions. In addition, poor overall communication and coping skills led to an exaggerated response to psychosocial stressors.

Malingering and suicide attempts

Few studies have investigated malingering in regards to suicide and other psychiatric emergencies. In a study of 227 consecutive psychiatric emergencies assessed for evidence of malingering, 13% were thought to be feigned or exaggerated.⁶ Interestingly, the most commonly reported secondary gain was food and shelter, similar to Mr. L. This study did not report the types of psychiatric emergencies, therefore suicidal actions associated with malingering could not be evaluated.

In another study, 40 patients hospitalized for suicidal ideation (n = 29, 72%) or suicidal gestures (n = 11, 28%) in a large, urban tertiary care center were evaluated for malingering by anonymous report of feigned or exaggerated symptoms.⁷ Most of these patients were diagnosed with a mood disorder (28%) and/or an adjustment disorder (53%). Four (10%) admitted to malingering. Among the malingerers, reasons for feigning illness included:

• wanting to be hospitalized
• wanting to make someone angry or feel sorry
• gaining access to detoxification programs
• getting treatment for emotional problems.

Interestingly, an analysis of demographic factors associated with malingering reveals an association with suicide attempts but not persistent suicidal ideations. This could be because of selection bias; patients who reported a suicide attempt might be more likely to be hospitalized.

A follow-up study⁸ evaluated 50 additional consecutive psychiatric inpatients admitted to the same tertiary care hospital for suicide risk. Unlike the previous study, a larger proportion of these patients had made a suicide attempt (n = 21, 42%) and a greater number had made a previous suicide attempt (n = 33, 66%). Primary mood disorders comprised most of the psychiatric diagnoses (n = 28, 56%). In this study, the exact nature of the suicide gestures was not documented, leaving open the question of lethality of the attempts. These studies do not suggest that those who malinger are not at risk for suicide, only that these patients tend to exaggerate the severity of their ideations or behaviors.

OUTCOME Reluctantly discharged

We contact Mr. L’s siblings, who offer to provide temporary housing and financial support and assist him with medical needs. This abated Mr. L’s suicidal ideation; however, he wishes to remain in the hospital with the goals of obtaining eyeglasses and dentures. We explain that psychiatric hospitalization is no longer indicated and he is discharged.

Which of the following is the most effective management strategy for malingering?

a) direct confrontation of the malingering patient
b) immediate discharge once malingering is identified

c) evaluation for possible comorbid psychiatric conditions

d) neuropsychiatric consultation

The authors’ observations

The challenges of treating patients who malinger include clinician uncertainty in making the diagnosis and high variability in occurrence across settings (Table 1). Current estimates indicate that 4% to 8% of medical and psychiatric cases not involved in litigation or compensation have an element of feigned symptoms.^3,9 The rate could be higher in specific circumstances such as medicolegal disputes and criminal cases.¹⁰

The societal impact of malingering is significant. Therefore, identifying these patients is an important clinical intervention that can have a wide impact.¹¹ However, it is also important to acknowledge that genuine psychiatric illness could be comorbid with malingering. Although differentiating a patient’s true from feigned symptoms can be difficult, it is critical to carefully evaluate the patient in order to provide the best treatment.

It seems that physicians can detect malingering, but documentation often is not provided. In the Rissmiller et al study,⁷ all 4 cases of malingering were identified retrospectively by study psychiatrists; however, none of their medical records included documentation of malingering, a finding also reported in the Yates et al study.⁶ Also concerning, the clinicians suspected malingering in some patients who were not feigning symptoms, suggesting that a relatively high threshold is necessary for making the diagnosis.

How to help patients who malinger

Identifying malingering in patients with obvious secondary gain is important to prevent exposure to potential adverse effects of medication and unnecessary use of medical resources. In addition, obtaining collateral information, records from previous admissions or outpatient treatment, and psychological testing adds to the body of evidence suggesting malingering. We also recommend a comprehensive psychosocial evaluation to identify the presence of secondary gain.

Management of malingering (Table 2) includes building a strong therapeutic alliance, exploring reasons for feigning symptoms, open discussion of inciting external factors such as interpersonal conflict or difficulties at work, and/or confrontation.¹⁰ In addition, supportive psychotherapy might help strengthen coping mechanisms and problem solving strategies, thereby removing the need for secondary gain.¹² Additionally, face-saving mechanisms that allow the patient to discard their feigned symptoms, or enable the person to alter his (her) history, could be to his benefit. Lastly, and importantly, clinicians should focus efforts on ruling out or effectively treating comorbid psychiatric conditions.

From a risk management standpoint, include all available data to support the malingering diagnosis in your progress notes and discharge summaries. A clinician seeking to discharge a patient suspected of malingering who is still endorsing suicidal or homicidal intent will benefit from administrative review, including legal counsel to mitigate risk, and be more confident discharging somebody assessed to be malingering.

We recognize that certain patients could trigger countertransference reactions that impel clinicians to take on a significant caretaking role. Patients skillful at deception could manifest a desire to rescue or save them. In these instances, clinicians should examine why and how these feelings have come about, particularly if there is evidence that the individual could be attempting to use the interaction to achieve secondary gain. Awareness of these feelings could help with the diagnostic formulation. Moreover, a clinician who has such strong feelings might be tempted to abet a patient in achieving the secondary gain, or protect him (her) from the natural consequences of individual’s deception (eg, not discharging a hospitalized patient). This is counter-therapeutic and reinforces maladaptive behaviors and coping processes.¹³

Dear Dr. Mossman,
Each month, I see my patient, Mr. R, for a 15-minute medication management appointment. At his latest visit, Mr. R mentioned his financial difficulties. He also observed that our office needed to have some carpentry work done—not a surprise, because he’s known in our area as one of the best carpenters around. He suggested that I hire him as payment for the next 6 appointments. What risks might I encounter if I oblige him?

Submitted by “Dr. Z”

Nearly 29 million Americans are uninsured,¹ and even more have trouble accessing mental health care.² Many psychiatrists struggle to provide affordable services while remaining financially viable.^3,4 For outpatients with limited means to pay for care, spacing appointments to fit their budgets might compromise treatment.⁵ Simply not charging patients poses its own clinical and ethical challenges.^6-8

As a result, some mental health professionals make barter arrangements to help their patients enter or continue treatment. To answer Dr. Z’s question on whether exchanging services might be a way to arrange matters with some patients, we explore:

• the idea of bartering for psychiatric treatment
• related ethical and legal considerations
• when and in what situations bartering might be appropriate.

Think of what I’m saying: Bartering for treatment

“Barter” refers to exchanging commodities, products, or services of equivalent value without using money.⁹ In 2010, Nevada Republican Senate candidate Sue Lowden encouraged barter for health care and harkened back to an earlier time where “they would bring a chicken to the doctor; they would say ‘I’ll paint your house.’”¹⁰

Such payment arrangements have been encouraged as health care has become increasingly commoditized.^11-13 This happens through both direct barter between physician and patient and barter exchanges. Barter exchange systems have been set up on Web sites (as of 2013, at least 400 such online exchanges were available¹⁴), local communities,^11,15 and social programs. For example, through the “Swapping Guns for Therapy” program, psychologists in California gave free or reduced-fee care for people who traded in their guns.¹⁶

Try to see it my way: A prevailing view of barter

Several psychiatrists recommend against bartering for treatment, for a variety of reasons.^7,8,17-19 Simon¹⁸ argues that a stable fee policy is part of a proper therapeutic framework, and money is “the only acceptable medium of exchange when receiving payment from patients.” Emotional distress and the power differential inherent in treatment might prevent a patient from making an accurate assessment of the value of the bartered goods or services,^7,8,17,18,20 which could lead to future claims of undue influence from trading goods or services below market value.¹⁷ To avoid the possibility of exploitating the patient, Simon¹⁸ recommends that the psychiatrist’s professional fee be “the only material benefit received from the patient.”

The American Psychiatric Association’s code of ethics states that “it is not ethical to switch a doctor–patient relationship to an employer–employee one … and, in most cases, such an arrangement would be unethical.”²¹ In some therapeutic settings, employing a patient risks inappropriate self-disclosure and intrusion.¹⁶

More than other physicians, psychiatrists pay special attention to professional boundaries, the technical term for the “edge of appropriate behavior,” within which safe, effective care can occur.^22,23 Although some boundary crossings can be harmless and even constructive, repeated boundary crossings are the forerunners to improper behavior, including sexual relationships with patients.^24-26

Out of concern that bartering could become the first step down a slippery ethical slope toward patient exploitation, mental health clinicians have deemed the practice “ethically troubling,”¹⁹ said it did “not usually work out well,”⁷ and declared it “so fraught with risks for both parties that it seem[ed] illogical to even consider it as an option.”²⁷

While I see it your way: What barter proponents say

Reports of bartering for chickens²⁸ and purchasing fuel from a patient in remote Alaska²⁹ show that not all physicians agree and why they feel that professional codes of ethics reflect an urban bias.^28,29 In many rural areas and small towns, access to mental health services is limited, and patients often interact with their doctors outside of clinical encounters.^23,29-31

Bartering can benefit a physician’s practice by:

• reducing the need to discount services
• eliminating bureaucratic burdens of traditional insurance arrangements
• facilitating development of a patient base
• allowing patients choice and flexibility in seeking medical care.^6,16,32

Bartering could confer certain clinical benefits, such as:

• enhancing trust and empathy³²
• encouraging patients to make their needs known constructively⁶
• modeling financial self-care⁶
• helping the doctor to feel fairly compensated for providing thoughtful care⁶
• acknowledging the patient’s cultural values^15,33
• affirming that patients and doctors both produce things of value.¹⁶

I have always thought: Other ethical models

An ethical approach to bartering that requires careful thought and respect for the patient’s needs appears consistent with a primary goal of treatment: “to increase the capacity of individuals to make more rational choices in their lives and to be relatively freer from disabling conflicts.”²⁰ Some authors criticize slippery-slope arguments and strict-rule ethical approaches as being too rigid, limiting, or risk-averse.^22,26,34 In Table 1,^{6,8,16,18,27,29-31,35-37} we list several factors that might weigh for or against a decision to enter into a barter arrangement as payment for care.

In a similar manner, Martinez^33,38 proposed a graded-risk framework that encourages examination of potential harms and benefits of a decision, potential coercive or exploitative elements, the clinician’s intentions and aspiration to professional ideals, and the context of the decision. Within this framework, some bartering arrangements might be encouraged and, perhaps, even obligatory because of the potential benefits to the patient; other arrangements (eg, trading psychotherapy for menial services) might be unjustifiable. Martinez³⁸ argues that this approach fosters mutual decision-making with patients, discourages physician paternalism, and “demands that we struggle with the particulars with each case.”

Gottlieb’s decision-making model³⁵ recognizes that trying to avoid all dual relationships is unrealistic and not all dual relationships are exploitative. Instead, a clinician must assess 3 dimensions of current and proposed relationships:

• the degree of power differential
• the duration of treatment
• the clarity of termination.

The decision-making process also requires involvement of the patient, who if “unable to recognize the dilemma or is unwilling to consider the issues before deciding, should be considered at risk, and the contemplated relationship rejected.”³⁵

So I will ask you once again: Dr. Z’s decision

In the case of Dr. Z and Mr. R, a barter arrangement might work in the sense of permitting and sustaining good care. Mr. R suggested the idea and might not be able to afford care without it. Nothing in Dr. Z’s description suggests that Mr. R has personality characteristics or other conditions that would compromise his ability to give informed consent or to understand the nuances of a barter arrangement. Dr. Z is not providing a treatment (eg, psychodynamic therapy) that a barter arrangement could contaminate. That the arrangement would be circumscribed limits the effect of a power differential, as would its brief duration and defined termination endpoint. Dr. Z’s letter to the authors also shows his willingness to seek consultation.

There’s a chance that we may fall apart: Reasons for caution

Martinez’s graded-risk approach recognizes reasons for caution:

• the risk of harm to the patient or doctor–patient relationship
• the uncertain benefit to the patient
• the blurring of Dr. Z’s self-interest and Mr. R’s needs
• some ambiguity about possible exploitation.

Dr. Z and Mr. R have not discussed the value of Mr. R’s work—which might create a rift between them—and despite Mr. R’s reputation, other carpenters are available. Future med-check appointments will give them little time to explore and discuss the meanings of the barter.

Any proposed barter arrangement creates some clinical perils that can be particularly salient in mental health treatment. Patients could view themselves as “special” or entitled to enhanced access to the doctor because of exchanged services, which could take a toll on the doctor.³⁹ The physician’s objectivity might diminish, and the business aspect of their relationship could make both parties less comfortable when discussing sensitive information relevant to treatment.^31,40 Also, the suggested barter is for services to be provided at Dr. Z’s office, where confidentiality may be breeched and transference issues could arise.

A medical malpractice claim states that a doctor has breached a duty of care to a patient such that harm (or “damages”) resulted.⁴¹ Should Dr. Z and Mr. R’s barter agreement turn sour and harm follow, Mr. R could sue for recovery of damages based of a claim of duress, undue influence, or other aspects of the doctor–patient power differential.^27,42,43 Given the published views we have described, a psychiatrist who barters also may be viewed as violating state regulations that measure the standard of care against generally accepted practice.

Only time will tell if I am right or I am wrong

If you face a situation similar to Dr. Z’s and want to consider a barter arrangement, you can take several steps to mitigate potential risk to your patient and ensure competent care (Table 2^{5,6,15,16,32,35,39,40,44-47}). One of the most important steps is to seek ongoing consultation, both before and after a decision to barter. Ideally, the consulting colleague would know you and your circumstances and would have sufficient clinical grasp of the patient to make an informed assessment of risks and benefits.³⁵ This consultation, as well as your own rationale for acting on recommendations, should be thoroughly documented in the patient’s records.^26,44,45

Certain types of barter should be off limits, including:

• trading prescription drugs for goods or services
• trading for services that tie into the success of one’s business (eg, business advising or marketing)¹⁶
• offering treatment in exchange for illegal or ethically unacceptable services.⁴⁸

Beyond ethical considerations are some practical issues. The Internal Revenue Service has specific rules regarding taxation of bartered goods and services, which must be included as taxable income.⁴⁶ If possible, an independent agent should appraise the traded goods or services before the agreement.⁶ When working in a group practice, the clinician might have to figure out how to allocate the received goods or services such as shared overhead costs.²⁸ Preferably, the patient’s goods or services should be provided before care is delivered.¹⁶ If not, the duration of services rendered should be limited, and either party should have the option to disengage from the relationship if one feels dissatisfied.¹⁶

A written contract, discussed ahead of time, can be a sound way to summarize the terms of the arrangement. Both sides also should consider what would happen if an injury occurred.¹⁶ Finally, you must adhere to any relevant state laws regarding payment for services, particularly if the patient has health insurance.³²

If the bartering arrangement does not work, you should take an open and non-defensive approach. If you believe you have made a mistake, consider apologizing.⁴⁵

Dear Dr. Mossman,
Each month, I see my patient, Mr. R, for a 15-minute medication management appointment. At his latest visit, Mr. R mentioned his financial difficulties. He also observed that our office needed to have some carpentry work done—not a surprise, because he’s known in our area as one of the best carpenters around. He suggested that I hire him as payment for the next 6 appointments. What risks might I encounter if I oblige him?

Submitted by “Dr. Z”

Nearly 29 million Americans are uninsured,¹ and even more have trouble accessing mental health care.² Many psychiatrists struggle to provide affordable services while remaining financially viable.^3,4 For outpatients with limited means to pay for care, spacing appointments to fit their budgets might compromise treatment.⁵ Simply not charging patients poses its own clinical and ethical challenges.^6-8

As a result, some mental health professionals make barter arrangements to help their patients enter or continue treatment. To answer Dr. Z’s question on whether exchanging services might be a way to arrange matters with some patients, we explore:

• the idea of bartering for psychiatric treatment
• related ethical and legal considerations
• when and in what situations bartering might be appropriate.

Think of what I’m saying: Bartering for treatment

“Barter” refers to exchanging commodities, products, or services of equivalent value without using money.⁹ In 2010, Nevada Republican Senate candidate Sue Lowden encouraged barter for health care and harkened back to an earlier time where “they would bring a chicken to the doctor; they would say ‘I’ll paint your house.’”¹⁰

Such payment arrangements have been encouraged as health care has become increasingly commoditized.^11-13 This happens through both direct barter between physician and patient and barter exchanges. Barter exchange systems have been set up on Web sites (as of 2013, at least 400 such online exchanges were available¹⁴), local communities,^11,15 and social programs. For example, through the “Swapping Guns for Therapy” program, psychologists in California gave free or reduced-fee care for people who traded in their guns.¹⁶

Try to see it my way: A prevailing view of barter

Several psychiatrists recommend against bartering for treatment, for a variety of reasons.^7,8,17-19 Simon¹⁸ argues that a stable fee policy is part of a proper therapeutic framework, and money is “the only acceptable medium of exchange when receiving payment from patients.” Emotional distress and the power differential inherent in treatment might prevent a patient from making an accurate assessment of the value of the bartered goods or services,^7,8,17,18,20 which could lead to future claims of undue influence from trading goods or services below market value.¹⁷ To avoid the possibility of exploitating the patient, Simon¹⁸ recommends that the psychiatrist’s professional fee be “the only material benefit received from the patient.”

The American Psychiatric Association’s code of ethics states that “it is not ethical to switch a doctor–patient relationship to an employer–employee one … and, in most cases, such an arrangement would be unethical.”²¹ In some therapeutic settings, employing a patient risks inappropriate self-disclosure and intrusion.¹⁶

More than other physicians, psychiatrists pay special attention to professional boundaries, the technical term for the “edge of appropriate behavior,” within which safe, effective care can occur.^22,23 Although some boundary crossings can be harmless and even constructive, repeated boundary crossings are the forerunners to improper behavior, including sexual relationships with patients.^24-26

Out of concern that bartering could become the first step down a slippery ethical slope toward patient exploitation, mental health clinicians have deemed the practice “ethically troubling,”¹⁹ said it did “not usually work out well,”⁷ and declared it “so fraught with risks for both parties that it seem[ed] illogical to even consider it as an option.”²⁷

While I see it your way: What barter proponents say

Reports of bartering for chickens²⁸ and purchasing fuel from a patient in remote Alaska²⁹ show that not all physicians agree and why they feel that professional codes of ethics reflect an urban bias.^28,29 In many rural areas and small towns, access to mental health services is limited, and patients often interact with their doctors outside of clinical encounters.^23,29-31

Bartering can benefit a physician’s practice by:

• reducing the need to discount services
• eliminating bureaucratic burdens of traditional insurance arrangements
• facilitating development of a patient base
• allowing patients choice and flexibility in seeking medical care.^6,16,32

Bartering could confer certain clinical benefits, such as:

• enhancing trust and empathy³²
• encouraging patients to make their needs known constructively⁶
• modeling financial self-care⁶
• helping the doctor to feel fairly compensated for providing thoughtful care⁶
• acknowledging the patient’s cultural values^15,33
• affirming that patients and doctors both produce things of value.¹⁶

I have always thought: Other ethical models

An ethical approach to bartering that requires careful thought and respect for the patient’s needs appears consistent with a primary goal of treatment: “to increase the capacity of individuals to make more rational choices in their lives and to be relatively freer from disabling conflicts.”²⁰ Some authors criticize slippery-slope arguments and strict-rule ethical approaches as being too rigid, limiting, or risk-averse.^22,26,34 In Table 1,^{6,8,16,18,27,29-31,35-37} we list several factors that might weigh for or against a decision to enter into a barter arrangement as payment for care.

In a similar manner, Martinez^33,38 proposed a graded-risk framework that encourages examination of potential harms and benefits of a decision, potential coercive or exploitative elements, the clinician’s intentions and aspiration to professional ideals, and the context of the decision. Within this framework, some bartering arrangements might be encouraged and, perhaps, even obligatory because of the potential benefits to the patient; other arrangements (eg, trading psychotherapy for menial services) might be unjustifiable. Martinez³⁸ argues that this approach fosters mutual decision-making with patients, discourages physician paternalism, and “demands that we struggle with the particulars with each case.”

Gottlieb’s decision-making model³⁵ recognizes that trying to avoid all dual relationships is unrealistic and not all dual relationships are exploitative. Instead, a clinician must assess 3 dimensions of current and proposed relationships:

• the degree of power differential
• the duration of treatment
• the clarity of termination.

The decision-making process also requires involvement of the patient, who if “unable to recognize the dilemma or is unwilling to consider the issues before deciding, should be considered at risk, and the contemplated relationship rejected.”³⁵

So I will ask you once again: Dr. Z’s decision

In the case of Dr. Z and Mr. R, a barter arrangement might work in the sense of permitting and sustaining good care. Mr. R suggested the idea and might not be able to afford care without it. Nothing in Dr. Z’s description suggests that Mr. R has personality characteristics or other conditions that would compromise his ability to give informed consent or to understand the nuances of a barter arrangement. Dr. Z is not providing a treatment (eg, psychodynamic therapy) that a barter arrangement could contaminate. That the arrangement would be circumscribed limits the effect of a power differential, as would its brief duration and defined termination endpoint. Dr. Z’s letter to the authors also shows his willingness to seek consultation.

There’s a chance that we may fall apart: Reasons for caution

Martinez’s graded-risk approach recognizes reasons for caution:

• the risk of harm to the patient or doctor–patient relationship
• the uncertain benefit to the patient
• the blurring of Dr. Z’s self-interest and Mr. R’s needs
• some ambiguity about possible exploitation.

Dr. Z and Mr. R have not discussed the value of Mr. R’s work—which might create a rift between them—and despite Mr. R’s reputation, other carpenters are available. Future med-check appointments will give them little time to explore and discuss the meanings of the barter.

Any proposed barter arrangement creates some clinical perils that can be particularly salient in mental health treatment. Patients could view themselves as “special” or entitled to enhanced access to the doctor because of exchanged services, which could take a toll on the doctor.³⁹ The physician’s objectivity might diminish, and the business aspect of their relationship could make both parties less comfortable when discussing sensitive information relevant to treatment.^31,40 Also, the suggested barter is for services to be provided at Dr. Z’s office, where confidentiality may be breeched and transference issues could arise.

A medical malpractice claim states that a doctor has breached a duty of care to a patient such that harm (or “damages”) resulted.⁴¹ Should Dr. Z and Mr. R’s barter agreement turn sour and harm follow, Mr. R could sue for recovery of damages based of a claim of duress, undue influence, or other aspects of the doctor–patient power differential.^27,42,43 Given the published views we have described, a psychiatrist who barters also may be viewed as violating state regulations that measure the standard of care against generally accepted practice.

Only time will tell if I am right or I am wrong

If you face a situation similar to Dr. Z’s and want to consider a barter arrangement, you can take several steps to mitigate potential risk to your patient and ensure competent care (Table 2^{5,6,15,16,32,35,39,40,44-47}). One of the most important steps is to seek ongoing consultation, both before and after a decision to barter. Ideally, the consulting colleague would know you and your circumstances and would have sufficient clinical grasp of the patient to make an informed assessment of risks and benefits.³⁵ This consultation, as well as your own rationale for acting on recommendations, should be thoroughly documented in the patient’s records.^26,44,45

Certain types of barter should be off limits, including:

• trading prescription drugs for goods or services
• trading for services that tie into the success of one’s business (eg, business advising or marketing)¹⁶
• offering treatment in exchange for illegal or ethically unacceptable services.⁴⁸

Beyond ethical considerations are some practical issues. The Internal Revenue Service has specific rules regarding taxation of bartered goods and services, which must be included as taxable income.⁴⁶ If possible, an independent agent should appraise the traded goods or services before the agreement.⁶ When working in a group practice, the clinician might have to figure out how to allocate the received goods or services such as shared overhead costs.²⁸ Preferably, the patient’s goods or services should be provided before care is delivered.¹⁶ If not, the duration of services rendered should be limited, and either party should have the option to disengage from the relationship if one feels dissatisfied.¹⁶

A written contract, discussed ahead of time, can be a sound way to summarize the terms of the arrangement. Both sides also should consider what would happen if an injury occurred.¹⁶ Finally, you must adhere to any relevant state laws regarding payment for services, particularly if the patient has health insurance.³²

If the bartering arrangement does not work, you should take an open and non-defensive approach. If you believe you have made a mistake, consider apologizing.⁴⁵

Dear Dr. Mossman,
Each month, I see my patient, Mr. R, for a 15-minute medication management appointment. At his latest visit, Mr. R mentioned his financial difficulties. He also observed that our office needed to have some carpentry work done—not a surprise, because he’s known in our area as one of the best carpenters around. He suggested that I hire him as payment for the next 6 appointments. What risks might I encounter if I oblige him?

Submitted by “Dr. Z”

Nearly 29 million Americans are uninsured,¹ and even more have trouble accessing mental health care.² Many psychiatrists struggle to provide affordable services while remaining financially viable.^3,4 For outpatients with limited means to pay for care, spacing appointments to fit their budgets might compromise treatment.⁵ Simply not charging patients poses its own clinical and ethical challenges.^6-8

As a result, some mental health professionals make barter arrangements to help their patients enter or continue treatment. To answer Dr. Z’s question on whether exchanging services might be a way to arrange matters with some patients, we explore:

• the idea of bartering for psychiatric treatment
• related ethical and legal considerations
• when and in what situations bartering might be appropriate.

Think of what I’m saying: Bartering for treatment

“Barter” refers to exchanging commodities, products, or services of equivalent value without using money.⁹ In 2010, Nevada Republican Senate candidate Sue Lowden encouraged barter for health care and harkened back to an earlier time where “they would bring a chicken to the doctor; they would say ‘I’ll paint your house.’”¹⁰

Such payment arrangements have been encouraged as health care has become increasingly commoditized.^11-13 This happens through both direct barter between physician and patient and barter exchanges. Barter exchange systems have been set up on Web sites (as of 2013, at least 400 such online exchanges were available¹⁴), local communities,^11,15 and social programs. For example, through the “Swapping Guns for Therapy” program, psychologists in California gave free or reduced-fee care for people who traded in their guns.¹⁶

Try to see it my way: A prevailing view of barter

Several psychiatrists recommend against bartering for treatment, for a variety of reasons.^7,8,17-19 Simon¹⁸ argues that a stable fee policy is part of a proper therapeutic framework, and money is “the only acceptable medium of exchange when receiving payment from patients.” Emotional distress and the power differential inherent in treatment might prevent a patient from making an accurate assessment of the value of the bartered goods or services,^7,8,17,18,20 which could lead to future claims of undue influence from trading goods or services below market value.¹⁷ To avoid the possibility of exploitating the patient, Simon¹⁸ recommends that the psychiatrist’s professional fee be “the only material benefit received from the patient.”

The American Psychiatric Association’s code of ethics states that “it is not ethical to switch a doctor–patient relationship to an employer–employee one … and, in most cases, such an arrangement would be unethical.”²¹ In some therapeutic settings, employing a patient risks inappropriate self-disclosure and intrusion.¹⁶

More than other physicians, psychiatrists pay special attention to professional boundaries, the technical term for the “edge of appropriate behavior,” within which safe, effective care can occur.^22,23 Although some boundary crossings can be harmless and even constructive, repeated boundary crossings are the forerunners to improper behavior, including sexual relationships with patients.^24-26

Out of concern that bartering could become the first step down a slippery ethical slope toward patient exploitation, mental health clinicians have deemed the practice “ethically troubling,”¹⁹ said it did “not usually work out well,”⁷ and declared it “so fraught with risks for both parties that it seem[ed] illogical to even consider it as an option.”²⁷

While I see it your way: What barter proponents say

Reports of bartering for chickens²⁸ and purchasing fuel from a patient in remote Alaska²⁹ show that not all physicians agree and why they feel that professional codes of ethics reflect an urban bias.^28,29 In many rural areas and small towns, access to mental health services is limited, and patients often interact with their doctors outside of clinical encounters.^23,29-31

Bartering can benefit a physician’s practice by:

• reducing the need to discount services
• eliminating bureaucratic burdens of traditional insurance arrangements
• facilitating development of a patient base
• allowing patients choice and flexibility in seeking medical care.^6,16,32

Bartering could confer certain clinical benefits, such as:

• enhancing trust and empathy³²
• encouraging patients to make their needs known constructively⁶
• modeling financial self-care⁶
• helping the doctor to feel fairly compensated for providing thoughtful care⁶
• acknowledging the patient’s cultural values^15,33
• affirming that patients and doctors both produce things of value.¹⁶

I have always thought: Other ethical models

An ethical approach to bartering that requires careful thought and respect for the patient’s needs appears consistent with a primary goal of treatment: “to increase the capacity of individuals to make more rational choices in their lives and to be relatively freer from disabling conflicts.”²⁰ Some authors criticize slippery-slope arguments and strict-rule ethical approaches as being too rigid, limiting, or risk-averse.^22,26,34 In Table 1,^{6,8,16,18,27,29-31,35-37} we list several factors that might weigh for or against a decision to enter into a barter arrangement as payment for care.

In a similar manner, Martinez^33,38 proposed a graded-risk framework that encourages examination of potential harms and benefits of a decision, potential coercive or exploitative elements, the clinician’s intentions and aspiration to professional ideals, and the context of the decision. Within this framework, some bartering arrangements might be encouraged and, perhaps, even obligatory because of the potential benefits to the patient; other arrangements (eg, trading psychotherapy for menial services) might be unjustifiable. Martinez³⁸ argues that this approach fosters mutual decision-making with patients, discourages physician paternalism, and “demands that we struggle with the particulars with each case.”

Gottlieb’s decision-making model³⁵ recognizes that trying to avoid all dual relationships is unrealistic and not all dual relationships are exploitative. Instead, a clinician must assess 3 dimensions of current and proposed relationships:

• the degree of power differential
• the duration of treatment
• the clarity of termination.

The decision-making process also requires involvement of the patient, who if “unable to recognize the dilemma or is unwilling to consider the issues before deciding, should be considered at risk, and the contemplated relationship rejected.”³⁵

So I will ask you once again: Dr. Z’s decision

In the case of Dr. Z and Mr. R, a barter arrangement might work in the sense of permitting and sustaining good care. Mr. R suggested the idea and might not be able to afford care without it. Nothing in Dr. Z’s description suggests that Mr. R has personality characteristics or other conditions that would compromise his ability to give informed consent or to understand the nuances of a barter arrangement. Dr. Z is not providing a treatment (eg, psychodynamic therapy) that a barter arrangement could contaminate. That the arrangement would be circumscribed limits the effect of a power differential, as would its brief duration and defined termination endpoint. Dr. Z’s letter to the authors also shows his willingness to seek consultation.

There’s a chance that we may fall apart: Reasons for caution

Martinez’s graded-risk approach recognizes reasons for caution:

• the risk of harm to the patient or doctor–patient relationship
• the uncertain benefit to the patient
• the blurring of Dr. Z’s self-interest and Mr. R’s needs
• some ambiguity about possible exploitation.

Dr. Z and Mr. R have not discussed the value of Mr. R’s work—which might create a rift between them—and despite Mr. R’s reputation, other carpenters are available. Future med-check appointments will give them little time to explore and discuss the meanings of the barter.

Any proposed barter arrangement creates some clinical perils that can be particularly salient in mental health treatment. Patients could view themselves as “special” or entitled to enhanced access to the doctor because of exchanged services, which could take a toll on the doctor.³⁹ The physician’s objectivity might diminish, and the business aspect of their relationship could make both parties less comfortable when discussing sensitive information relevant to treatment.^31,40 Also, the suggested barter is for services to be provided at Dr. Z’s office, where confidentiality may be breeched and transference issues could arise.

A medical malpractice claim states that a doctor has breached a duty of care to a patient such that harm (or “damages”) resulted.⁴¹ Should Dr. Z and Mr. R’s barter agreement turn sour and harm follow, Mr. R could sue for recovery of damages based of a claim of duress, undue influence, or other aspects of the doctor–patient power differential.^27,42,43 Given the published views we have described, a psychiatrist who barters also may be viewed as violating state regulations that measure the standard of care against generally accepted practice.

Only time will tell if I am right or I am wrong

If you face a situation similar to Dr. Z’s and want to consider a barter arrangement, you can take several steps to mitigate potential risk to your patient and ensure competent care (Table 2^{5,6,15,16,32,35,39,40,44-47}). One of the most important steps is to seek ongoing consultation, both before and after a decision to barter. Ideally, the consulting colleague would know you and your circumstances and would have sufficient clinical grasp of the patient to make an informed assessment of risks and benefits.³⁵ This consultation, as well as your own rationale for acting on recommendations, should be thoroughly documented in the patient’s records.^26,44,45

Certain types of barter should be off limits, including:

• trading prescription drugs for goods or services
• trading for services that tie into the success of one’s business (eg, business advising or marketing)¹⁶
• offering treatment in exchange for illegal or ethically unacceptable services.⁴⁸

Beyond ethical considerations are some practical issues. The Internal Revenue Service has specific rules regarding taxation of bartered goods and services, which must be included as taxable income.⁴⁶ If possible, an independent agent should appraise the traded goods or services before the agreement.⁶ When working in a group practice, the clinician might have to figure out how to allocate the received goods or services such as shared overhead costs.²⁸ Preferably, the patient’s goods or services should be provided before care is delivered.¹⁶ If not, the duration of services rendered should be limited, and either party should have the option to disengage from the relationship if one feels dissatisfied.¹⁶

A written contract, discussed ahead of time, can be a sound way to summarize the terms of the arrangement. Both sides also should consider what would happen if an injury occurred.¹⁶ Finally, you must adhere to any relevant state laws regarding payment for services, particularly if the patient has health insurance.³²

If the bartering arrangement does not work, you should take an open and non-defensive approach. If you believe you have made a mistake, consider apologizing.⁴⁵

Are you ‘neuroprotecting’ your patients?

Fortunately, many studies have demonstrated that in addition to controlling clinical symptoms, antidepressants, mood stabilizers, and atypical antipsychotics all have neuroprotective effects, including stimulating neurogenesis, preventing apoptosis, and increasing neurotrophins. However, more needs to be done to protect the brain’s gray and white matter and to prevent negative neuroplasticity and disconnectivity of brain circuits that often are documented in patients with psychotic and mood disorders.

There are, in fact, many off-label supplements with strong neuroprotective effects that psychiatrists can use as an adjunct to standard evidence-based pharmacotherapy. These agents generally are safe and well tolerated and often are sold over the counter, but are not covered by insurance. However, considering the disability that often is associated with schizophrenia, treatment-resistant depression, or psychotic mania, it is reasonable to consider using these agents, many of which are supported by studies published in peer-reviewed journals. However, because they are widely available and not proprietary and large, expensive registration trials such as the ones conducted by the pharmaceutical industry are not done, none is likely to receive FDA approval. Therefore, it is up to psychiatrists and nurse practitioners to use them judiciously in patients at risk for neurotoxicity.

Here are 10 agents with neuroprotective effects supported by published data that can be considered as add-on to the standard treatments in an effort to mitigate neurotoxicity and protect the brain from the destructive processes that accompany acute episodes of psychosis, mania, and depression.

Omega-3 fatty acids have been shown in several studies to help reduce psychopathology of psychosis, mania, or depression when used as an adjunctive agent.¹ It appears to be more effective in the early stages of psychiatric disorders than in the chronic phase. It has anti-inflammatory, anti-oxidant, and anti-apoptotic effects; activates cell-signaling pathways; and prevents synaptic loss as well as neuronal and glial death.²

N-acetylcysteine (NAC) is a powerful antioxidant that increases glutathione, which is produced in the mitochondria. Schizophrenia is associated with mitochondrial dysfunction with low levels of glutathione, which puts the brain at risk for neurodegeneration caused by high levels of free radicals produced during psychosis. Adding NAC to antipsychotics during acute psychotic episodes—especially the first episode—can significantly reduce the neurotoxic effects of reactive oxygen and nitrogen species, also known as free radicals.³ In studies of traumatic brain injury in rats, NAC reduced brain edema, neuro­inflammation, blood–brain barrier permeability, and apoptosis.⁴

Minocycline. This antibiotic has been studied extensively as an adjunctive treatment in schizophrenia and has proven to have several neuroprotective effects including anti-inflammatory, anti-oxidant, and anti-apoptotic, and reduces glutamate excitotoxicity.⁵ Several studies have documented its usefulness in acute psychotic episodes.

Vitamin D. Because of its vital role in neurodevelopment (neuronal differentiation, axonal connectivity), vitamin D deficiency has been associated with several psychiatric disorders including autism, schizophrenia, depression, and Alzheimer’s disease.⁶ Measure serum levels of vitamin D in patients with psychotic and mood disorders and implement supplementation if it is low—and it often is in these patients.

Nicotine is neuroprotective against glutamate excitotoxicity and it also inhibits apoptosis.⁷ However, it should never be administered via cigarettes, which are loaded with hundreds of toxic substances! It can be administered via patches or nicotine gum, which are usually used to help in smoking cessation. Nicotine also also can have a pro-cognitive effect.

Melatonin. Many people associate melatonin with sleep. However, it has multiple neuroprotective effects by being an antioxidant, protecting mitochondrial integrity, and modulating the immune system, as well as attenuating microglial activation, which triggers neuroinflammation and oxidative stress. It also protects against cellular senescence, which is due to inflammation and reactive oxygen species. Furthermore, melatonin is useful in ameliorating the metabolic syndrome, which is associated with neurotoxic effects on brain tissue caused by the pro-inflammatory effects of peri-omental fat in obesity.⁸ Adjunctive melatonin could be helpful in patients with schizophrenia or depression who suffer from metabolic syndrome.

Erythropoietin is a hormone produced by the kidneys to promote the formation of red blood cells. It is a potent neuroprotective cytokine that promotes neuronal survival via anti-apoptotic effects. It protects against glutamate and nitrous oxide toxicity⁹ and haloperidol-induced neuronal death.¹⁰ It is clinically used (since FDA approval in 1989) in severe anemia due to chronic kidney disease or chemotherapy, as well as in inflammatory bowel disease. It does have some “black-box” warnings so its use should be limited.

The above interventions may be helpful for some patients but not others. Practitioners should consider using 1 or more of those adjunctive neuroprotective agents in patients who are at risk for neurodegenerative changes secondary to recurrences of acute and severe psychosis or mood episodes. Although clinicians cannot monitor brain structural integrity, they can assess the rate of symptomatic improvement and degree of functional restoration in their patients. Until a cure is found, these little steps—taken cautiously and judiciously—could help alleviate our patients’ suffering and the risk of neurotoxicity associated with their serious psychiatric disorder.

Are you ‘neuroprotecting’ your patients?

Fortunately, many studies have demonstrated that in addition to controlling clinical symptoms, antidepressants, mood stabilizers, and atypical antipsychotics all have neuroprotective effects, including stimulating neurogenesis, preventing apoptosis, and increasing neurotrophins. However, more needs to be done to protect the brain’s gray and white matter and to prevent negative neuroplasticity and disconnectivity of brain circuits that often are documented in patients with psychotic and mood disorders.

There are, in fact, many off-label supplements with strong neuroprotective effects that psychiatrists can use as an adjunct to standard evidence-based pharmacotherapy. These agents generally are safe and well tolerated and often are sold over the counter, but are not covered by insurance. However, considering the disability that often is associated with schizophrenia, treatment-resistant depression, or psychotic mania, it is reasonable to consider using these agents, many of which are supported by studies published in peer-reviewed journals. However, because they are widely available and not proprietary and large, expensive registration trials such as the ones conducted by the pharmaceutical industry are not done, none is likely to receive FDA approval. Therefore, it is up to psychiatrists and nurse practitioners to use them judiciously in patients at risk for neurotoxicity.

Here are 10 agents with neuroprotective effects supported by published data that can be considered as add-on to the standard treatments in an effort to mitigate neurotoxicity and protect the brain from the destructive processes that accompany acute episodes of psychosis, mania, and depression.

Omega-3 fatty acids have been shown in several studies to help reduce psychopathology of psychosis, mania, or depression when used as an adjunctive agent.¹ It appears to be more effective in the early stages of psychiatric disorders than in the chronic phase. It has anti-inflammatory, anti-oxidant, and anti-apoptotic effects; activates cell-signaling pathways; and prevents synaptic loss as well as neuronal and glial death.²

N-acetylcysteine (NAC) is a powerful antioxidant that increases glutathione, which is produced in the mitochondria. Schizophrenia is associated with mitochondrial dysfunction with low levels of glutathione, which puts the brain at risk for neurodegeneration caused by high levels of free radicals produced during psychosis. Adding NAC to antipsychotics during acute psychotic episodes—especially the first episode—can significantly reduce the neurotoxic effects of reactive oxygen and nitrogen species, also known as free radicals.³ In studies of traumatic brain injury in rats, NAC reduced brain edema, neuro­inflammation, blood–brain barrier permeability, and apoptosis.⁴

Minocycline. This antibiotic has been studied extensively as an adjunctive treatment in schizophrenia and has proven to have several neuroprotective effects including anti-inflammatory, anti-oxidant, and anti-apoptotic, and reduces glutamate excitotoxicity.⁵ Several studies have documented its usefulness in acute psychotic episodes.

Vitamin D. Because of its vital role in neurodevelopment (neuronal differentiation, axonal connectivity), vitamin D deficiency has been associated with several psychiatric disorders including autism, schizophrenia, depression, and Alzheimer’s disease.⁶ Measure serum levels of vitamin D in patients with psychotic and mood disorders and implement supplementation if it is low—and it often is in these patients.

Nicotine is neuroprotective against glutamate excitotoxicity and it also inhibits apoptosis.⁷ However, it should never be administered via cigarettes, which are loaded with hundreds of toxic substances! It can be administered via patches or nicotine gum, which are usually used to help in smoking cessation. Nicotine also also can have a pro-cognitive effect.

Melatonin. Many people associate melatonin with sleep. However, it has multiple neuroprotective effects by being an antioxidant, protecting mitochondrial integrity, and modulating the immune system, as well as attenuating microglial activation, which triggers neuroinflammation and oxidative stress. It also protects against cellular senescence, which is due to inflammation and reactive oxygen species. Furthermore, melatonin is useful in ameliorating the metabolic syndrome, which is associated with neurotoxic effects on brain tissue caused by the pro-inflammatory effects of peri-omental fat in obesity.⁸ Adjunctive melatonin could be helpful in patients with schizophrenia or depression who suffer from metabolic syndrome.

Erythropoietin is a hormone produced by the kidneys to promote the formation of red blood cells. It is a potent neuroprotective cytokine that promotes neuronal survival via anti-apoptotic effects. It protects against glutamate and nitrous oxide toxicity⁹ and haloperidol-induced neuronal death.¹⁰ It is clinically used (since FDA approval in 1989) in severe anemia due to chronic kidney disease or chemotherapy, as well as in inflammatory bowel disease. It does have some “black-box” warnings so its use should be limited.

The above interventions may be helpful for some patients but not others. Practitioners should consider using 1 or more of those adjunctive neuroprotective agents in patients who are at risk for neurodegenerative changes secondary to recurrences of acute and severe psychosis or mood episodes. Although clinicians cannot monitor brain structural integrity, they can assess the rate of symptomatic improvement and degree of functional restoration in their patients. Until a cure is found, these little steps—taken cautiously and judiciously—could help alleviate our patients’ suffering and the risk of neurotoxicity associated with their serious psychiatric disorder.

Are you ‘neuroprotecting’ your patients?

Fortunately, many studies have demonstrated that in addition to controlling clinical symptoms, antidepressants, mood stabilizers, and atypical antipsychotics all have neuroprotective effects, including stimulating neurogenesis, preventing apoptosis, and increasing neurotrophins. However, more needs to be done to protect the brain’s gray and white matter and to prevent negative neuroplasticity and disconnectivity of brain circuits that often are documented in patients with psychotic and mood disorders.

There are, in fact, many off-label supplements with strong neuroprotective effects that psychiatrists can use as an adjunct to standard evidence-based pharmacotherapy. These agents generally are safe and well tolerated and often are sold over the counter, but are not covered by insurance. However, considering the disability that often is associated with schizophrenia, treatment-resistant depression, or psychotic mania, it is reasonable to consider using these agents, many of which are supported by studies published in peer-reviewed journals. However, because they are widely available and not proprietary and large, expensive registration trials such as the ones conducted by the pharmaceutical industry are not done, none is likely to receive FDA approval. Therefore, it is up to psychiatrists and nurse practitioners to use them judiciously in patients at risk for neurotoxicity.

Here are 10 agents with neuroprotective effects supported by published data that can be considered as add-on to the standard treatments in an effort to mitigate neurotoxicity and protect the brain from the destructive processes that accompany acute episodes of psychosis, mania, and depression.

Omega-3 fatty acids have been shown in several studies to help reduce psychopathology of psychosis, mania, or depression when used as an adjunctive agent.¹ It appears to be more effective in the early stages of psychiatric disorders than in the chronic phase. It has anti-inflammatory, anti-oxidant, and anti-apoptotic effects; activates cell-signaling pathways; and prevents synaptic loss as well as neuronal and glial death.²

N-acetylcysteine (NAC) is a powerful antioxidant that increases glutathione, which is produced in the mitochondria. Schizophrenia is associated with mitochondrial dysfunction with low levels of glutathione, which puts the brain at risk for neurodegeneration caused by high levels of free radicals produced during psychosis. Adding NAC to antipsychotics during acute psychotic episodes—especially the first episode—can significantly reduce the neurotoxic effects of reactive oxygen and nitrogen species, also known as free radicals.³ In studies of traumatic brain injury in rats, NAC reduced brain edema, neuro­inflammation, blood–brain barrier permeability, and apoptosis.⁴

Minocycline. This antibiotic has been studied extensively as an adjunctive treatment in schizophrenia and has proven to have several neuroprotective effects including anti-inflammatory, anti-oxidant, and anti-apoptotic, and reduces glutamate excitotoxicity.⁵ Several studies have documented its usefulness in acute psychotic episodes.

Vitamin D. Because of its vital role in neurodevelopment (neuronal differentiation, axonal connectivity), vitamin D deficiency has been associated with several psychiatric disorders including autism, schizophrenia, depression, and Alzheimer’s disease.⁶ Measure serum levels of vitamin D in patients with psychotic and mood disorders and implement supplementation if it is low—and it often is in these patients.

Nicotine is neuroprotective against glutamate excitotoxicity and it also inhibits apoptosis.⁷ However, it should never be administered via cigarettes, which are loaded with hundreds of toxic substances! It can be administered via patches or nicotine gum, which are usually used to help in smoking cessation. Nicotine also also can have a pro-cognitive effect.

Melatonin. Many people associate melatonin with sleep. However, it has multiple neuroprotective effects by being an antioxidant, protecting mitochondrial integrity, and modulating the immune system, as well as attenuating microglial activation, which triggers neuroinflammation and oxidative stress. It also protects against cellular senescence, which is due to inflammation and reactive oxygen species. Furthermore, melatonin is useful in ameliorating the metabolic syndrome, which is associated with neurotoxic effects on brain tissue caused by the pro-inflammatory effects of peri-omental fat in obesity.⁸ Adjunctive melatonin could be helpful in patients with schizophrenia or depression who suffer from metabolic syndrome.

Erythropoietin is a hormone produced by the kidneys to promote the formation of red blood cells. It is a potent neuroprotective cytokine that promotes neuronal survival via anti-apoptotic effects. It protects against glutamate and nitrous oxide toxicity⁹ and haloperidol-induced neuronal death.¹⁰ It is clinically used (since FDA approval in 1989) in severe anemia due to chronic kidney disease or chemotherapy, as well as in inflammatory bowel disease. It does have some “black-box” warnings so its use should be limited.

The above interventions may be helpful for some patients but not others. Practitioners should consider using 1 or more of those adjunctive neuroprotective agents in patients who are at risk for neurodegenerative changes secondary to recurrences of acute and severe psychosis or mood episodes. Although clinicians cannot monitor brain structural integrity, they can assess the rate of symptomatic improvement and degree of functional restoration in their patients. Until a cure is found, these little steps—taken cautiously and judiciously—could help alleviate our patients’ suffering and the risk of neurotoxicity associated with their serious psychiatric disorder.

The merits of buprenorphine for pregnant women with opioid use disorder

Several medication-assisted treatments (MATs) for opioid use disorder were highlighted in “What clinicians need to know about treating opioid use disorder,” (Evidence-Based Reviews, Current Psychiatry. August 2016 p. 20-24,30-31,34,36,39) namely, methadone, buprenorphine/naloxone, and naltrexone. For treating pregnant women, methadone was the only MAT noted. Although methadone has been the standard treatment for pregnant patients with opioid use disorder for more than 40 years, recently, buprenorphine has become a reasonable alternative.¹ In the past, published data on the use of buprenorphine in these patients was limited; in recent years, studies have highlighted use of buprenorphine and its advantages over methadone.

The landmark study, the Maternal Opioid Treatment: Human Experimental Research, a 2010 multicenter randomized controlled trial compared buprenorphine with methadone in pregnant women with opioid use disorder. The results revealed that neonates exposed to buprenorphine needed 89% less morphine to treat neonatal abstinence syndrome (NAS), 43% shorter hospital stay, and 58% shorter duration of medical treatment for NAS compared with those receiving methadone. Other advantages of buprenorphine over methadone are lower risk of overdose, fewer drug–drug interactions, and the option of receiving treatment in an outpatient setting, rather than a licensed treatment program, such as a methadone maintenance treatment program, which is more tightly controlled.^1-3

The previous recommendation was to consider buprenorphine for patients who refused methadone or were unable to take it, or when a methadone treatment program wasn’t available. This study highlighted some clear advantages for treating this subpopulation with methadone instead of buprenorphine: only 18% of patients receiving methadone discontinued treatment, compared with 33% of those receiving buprenorphine,^1-3 and methadone had a lower risk of diversion.³ The accepted practice has been to recommend methadone treatment for patients with mental, physical, or social stressors because of the structure of opioid treatment programs (OTP) (also known as methadone maintenance treatment programs). However, buprenorphine can be dispensed through an OTP, following the same stringent rules and regulations.⁴

The single agent, buprenorphine—not buprenorphine/naloxone—is recommended to prevent prenatal exposure to naloxone. It is thought that exposure to naloxone in utero might produce hormonal changes in the fetus.^1,5 O'Connor et al⁵ noted methadone’s suitability during breast-feeding because of its low concentration in breast milk. Buprenorphine is excreted at breast milk to plasma ratio of 1:1, but because of buprenorphine’s poor oral bioavailability, infant exposure has little impact on the NAS score, therefore it’s suitable for breast-feeding mothers.⁵

Adegboyega Oyemade, MD, FAPA

Addiction Psychiatrist
Kaiser Permanente
Baltimore, Maryland

References

1. Lori W. Buprenorphine during pregnancy reduces neonate distress. https://www.drugabuse.gov/news-events/nida-notes/2012/07/buprenorphine- during-pregnancy-reduces-neonate-distress. Published July 6, 2016. Accessed September 9, 2016.
2. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010;363(24):2320-2331.
3. ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy. Obest Gynecol. 2012;119(5):1070-1076.
4. Addiction Treatment Forum. Methadone vs. buprenorphine: how do OTPs and patients make the choice? http://atforum.com/2013/11/methadone-vs-buprenorphine-how-do-otps-and-patients-make-the-choice. Published November 15, 2013. Accessed September 9, 2016.

5. O’Connor A, Alto W, Musgrave K, et al. Observational study of buprenorphine treatment of opioid-dependent pregnancy women in a family medicine residency: reports on maternal and infant outcomes. J Am Board Fam Med. 2011;24(2):194-201.

I would like to offer another pragmatic, easy, and quick solution for dealing with the shrinking psychiatrist workforce (The psychiatry workforce pool is shrinking. What are we doing about it? From the Editor. Current Psychiatry. September 2016, p. 23,24,95).

The United States is short approximately 45,000 psychiatrists.¹ Burnout—a silent epidemic among physicians—is prevalent in psychiatry. What consumes time and leads to burn out? “Scut work.”

There are thousands of unmatched residency graduates.² Most of these graduates have clinical experience in the United States. Psychiatry residency programs should give these unmatched graduates 6 months of training in psychiatry and use them as our primary workforce. These assistant physicians could be paired with 2 to 3 psychiatrists to perform the menial tasks, including, but not limited to, phone calls, prescriptions, prior authorizations, chart review, and other clinical and administrative paper work. This way, psychiatrists can focus on the interview, diagnoses, and treatment, major medical decision-making, and see more patients.

Employing assistant physicians to provide care has been suggested as a solution.³ Arkansas, Kansas, and Missouri have passed laws that allow medical school graduates who did not match with a residency program to work in underserved areas with a collaborating physician.

Because 1 out of 4 individuals have a mental illness and more of them are seeking help because of increasing awareness and the Affordable Care Act, the construct of “assistant physicians” could ease psychiatrists’ workload allowing them to deliver better care to more people.

Maju Mathew Koola, MD

Associate Professor
Department of Psychiatry and Behavioral Sciences
George Washington University
School of Medicine and Health Sciences
Washington, DC

References

1. Carlat D. 45,000 More psychiatrists, anyone? Psychiatric Times. http://www.psychiatrictimes.com/articles/45000-more-psychiatrists-anyone-0.Published August 3, 2010. Accessed November 11, 2016.
2. The Match: National Resident Matching Program. results and data: 2016 main residency match. http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf. Published April 2016. Accessed November 11, 2016.
3. Miller JG, Peterson DJ. Employing nurse practitioners and physician assistants to provide access to care as the psychiatrist shortage continues. Acad Psychiatry. 2015;39(6):685-686.

Concerns in psychiatry

The August 2016 editorial (Unresolved questions about the specialty lurk in the cortext of psychiatrists. Current Psychiatry. p. 10-11,19,19A) was absolutely, right on the mark. It is heartening to realize how consistent our concerns are through our profession. Although I try to put my shoulder to the wheel to seek answers, it can become frustrating.

Denis F. Darko, MD

CEO

NeuroSci R&D Consultancy, LLC

Maple Grove, Minnesota

The merits of buprenorphine for pregnant women with opioid use disorder

Several medication-assisted treatments (MATs) for opioid use disorder were highlighted in “What clinicians need to know about treating opioid use disorder,” (Evidence-Based Reviews, Current Psychiatry. August 2016 p. 20-24,30-31,34,36,39) namely, methadone, buprenorphine/naloxone, and naltrexone. For treating pregnant women, methadone was the only MAT noted. Although methadone has been the standard treatment for pregnant patients with opioid use disorder for more than 40 years, recently, buprenorphine has become a reasonable alternative.¹ In the past, published data on the use of buprenorphine in these patients was limited; in recent years, studies have highlighted use of buprenorphine and its advantages over methadone.

The landmark study, the Maternal Opioid Treatment: Human Experimental Research, a 2010 multicenter randomized controlled trial compared buprenorphine with methadone in pregnant women with opioid use disorder. The results revealed that neonates exposed to buprenorphine needed 89% less morphine to treat neonatal abstinence syndrome (NAS), 43% shorter hospital stay, and 58% shorter duration of medical treatment for NAS compared with those receiving methadone. Other advantages of buprenorphine over methadone are lower risk of overdose, fewer drug–drug interactions, and the option of receiving treatment in an outpatient setting, rather than a licensed treatment program, such as a methadone maintenance treatment program, which is more tightly controlled.^1-3

The previous recommendation was to consider buprenorphine for patients who refused methadone or were unable to take it, or when a methadone treatment program wasn’t available. This study highlighted some clear advantages for treating this subpopulation with methadone instead of buprenorphine: only 18% of patients receiving methadone discontinued treatment, compared with 33% of those receiving buprenorphine,^1-3 and methadone had a lower risk of diversion.³ The accepted practice has been to recommend methadone treatment for patients with mental, physical, or social stressors because of the structure of opioid treatment programs (OTP) (also known as methadone maintenance treatment programs). However, buprenorphine can be dispensed through an OTP, following the same stringent rules and regulations.⁴

The single agent, buprenorphine—not buprenorphine/naloxone—is recommended to prevent prenatal exposure to naloxone. It is thought that exposure to naloxone in utero might produce hormonal changes in the fetus.^1,5 O'Connor et al⁵ noted methadone’s suitability during breast-feeding because of its low concentration in breast milk. Buprenorphine is excreted at breast milk to plasma ratio of 1:1, but because of buprenorphine’s poor oral bioavailability, infant exposure has little impact on the NAS score, therefore it’s suitable for breast-feeding mothers.⁵

Adegboyega Oyemade, MD, FAPA

Addiction Psychiatrist
Kaiser Permanente
Baltimore, Maryland

References

1. Lori W. Buprenorphine during pregnancy reduces neonate distress. https://www.drugabuse.gov/news-events/nida-notes/2012/07/buprenorphine- during-pregnancy-reduces-neonate-distress. Published July 6, 2016. Accessed September 9, 2016.
2. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010;363(24):2320-2331.
3. ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy. Obest Gynecol. 2012;119(5):1070-1076.
4. Addiction Treatment Forum. Methadone vs. buprenorphine: how do OTPs and patients make the choice? http://atforum.com/2013/11/methadone-vs-buprenorphine-how-do-otps-and-patients-make-the-choice. Published November 15, 2013. Accessed September 9, 2016.

5. O’Connor A, Alto W, Musgrave K, et al. Observational study of buprenorphine treatment of opioid-dependent pregnancy women in a family medicine residency: reports on maternal and infant outcomes. J Am Board Fam Med. 2011;24(2):194-201.

I would like to offer another pragmatic, easy, and quick solution for dealing with the shrinking psychiatrist workforce (The psychiatry workforce pool is shrinking. What are we doing about it? From the Editor. Current Psychiatry. September 2016, p. 23,24,95).

The United States is short approximately 45,000 psychiatrists.¹ Burnout—a silent epidemic among physicians—is prevalent in psychiatry. What consumes time and leads to burn out? “Scut work.”

There are thousands of unmatched residency graduates.² Most of these graduates have clinical experience in the United States. Psychiatry residency programs should give these unmatched graduates 6 months of training in psychiatry and use them as our primary workforce. These assistant physicians could be paired with 2 to 3 psychiatrists to perform the menial tasks, including, but not limited to, phone calls, prescriptions, prior authorizations, chart review, and other clinical and administrative paper work. This way, psychiatrists can focus on the interview, diagnoses, and treatment, major medical decision-making, and see more patients.

Employing assistant physicians to provide care has been suggested as a solution.³ Arkansas, Kansas, and Missouri have passed laws that allow medical school graduates who did not match with a residency program to work in underserved areas with a collaborating physician.

Because 1 out of 4 individuals have a mental illness and more of them are seeking help because of increasing awareness and the Affordable Care Act, the construct of “assistant physicians” could ease psychiatrists’ workload allowing them to deliver better care to more people.

Maju Mathew Koola, MD

Associate Professor
Department of Psychiatry and Behavioral Sciences
George Washington University
School of Medicine and Health Sciences
Washington, DC

References

1. Carlat D. 45,000 More psychiatrists, anyone? Psychiatric Times. http://www.psychiatrictimes.com/articles/45000-more-psychiatrists-anyone-0.Published August 3, 2010. Accessed November 11, 2016.
2. The Match: National Resident Matching Program. results and data: 2016 main residency match. http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf. Published April 2016. Accessed November 11, 2016.
3. Miller JG, Peterson DJ. Employing nurse practitioners and physician assistants to provide access to care as the psychiatrist shortage continues. Acad Psychiatry. 2015;39(6):685-686.

Concerns in psychiatry

The August 2016 editorial (Unresolved questions about the specialty lurk in the cortext of psychiatrists. Current Psychiatry. p. 10-11,19,19A) was absolutely, right on the mark. It is heartening to realize how consistent our concerns are through our profession. Although I try to put my shoulder to the wheel to seek answers, it can become frustrating.

Denis F. Darko, MD

CEO

NeuroSci R&D Consultancy, LLC

Maple Grove, Minnesota

The merits of buprenorphine for pregnant women with opioid use disorder

Several medication-assisted treatments (MATs) for opioid use disorder were highlighted in “What clinicians need to know about treating opioid use disorder,” (Evidence-Based Reviews, Current Psychiatry. August 2016 p. 20-24,30-31,34,36,39) namely, methadone, buprenorphine/naloxone, and naltrexone. For treating pregnant women, methadone was the only MAT noted. Although methadone has been the standard treatment for pregnant patients with opioid use disorder for more than 40 years, recently, buprenorphine has become a reasonable alternative.¹ In the past, published data on the use of buprenorphine in these patients was limited; in recent years, studies have highlighted use of buprenorphine and its advantages over methadone.

The landmark study, the Maternal Opioid Treatment: Human Experimental Research, a 2010 multicenter randomized controlled trial compared buprenorphine with methadone in pregnant women with opioid use disorder. The results revealed that neonates exposed to buprenorphine needed 89% less morphine to treat neonatal abstinence syndrome (NAS), 43% shorter hospital stay, and 58% shorter duration of medical treatment for NAS compared with those receiving methadone. Other advantages of buprenorphine over methadone are lower risk of overdose, fewer drug–drug interactions, and the option of receiving treatment in an outpatient setting, rather than a licensed treatment program, such as a methadone maintenance treatment program, which is more tightly controlled.^1-3

The previous recommendation was to consider buprenorphine for patients who refused methadone or were unable to take it, or when a methadone treatment program wasn’t available. This study highlighted some clear advantages for treating this subpopulation with methadone instead of buprenorphine: only 18% of patients receiving methadone discontinued treatment, compared with 33% of those receiving buprenorphine,^1-3 and methadone had a lower risk of diversion.³ The accepted practice has been to recommend methadone treatment for patients with mental, physical, or social stressors because of the structure of opioid treatment programs (OTP) (also known as methadone maintenance treatment programs). However, buprenorphine can be dispensed through an OTP, following the same stringent rules and regulations.⁴

The single agent, buprenorphine—not buprenorphine/naloxone—is recommended to prevent prenatal exposure to naloxone. It is thought that exposure to naloxone in utero might produce hormonal changes in the fetus.^1,5 O'Connor et al⁵ noted methadone’s suitability during breast-feeding because of its low concentration in breast milk. Buprenorphine is excreted at breast milk to plasma ratio of 1:1, but because of buprenorphine’s poor oral bioavailability, infant exposure has little impact on the NAS score, therefore it’s suitable for breast-feeding mothers.⁵

Adegboyega Oyemade, MD, FAPA

Addiction Psychiatrist
Kaiser Permanente
Baltimore, Maryland

References

1. Lori W. Buprenorphine during pregnancy reduces neonate distress. https://www.drugabuse.gov/news-events/nida-notes/2012/07/buprenorphine- during-pregnancy-reduces-neonate-distress. Published July 6, 2016. Accessed September 9, 2016.
2. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010;363(24):2320-2331.
3. ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy. Obest Gynecol. 2012;119(5):1070-1076.
4. Addiction Treatment Forum. Methadone vs. buprenorphine: how do OTPs and patients make the choice? http://atforum.com/2013/11/methadone-vs-buprenorphine-how-do-otps-and-patients-make-the-choice. Published November 15, 2013. Accessed September 9, 2016.

5. O’Connor A, Alto W, Musgrave K, et al. Observational study of buprenorphine treatment of opioid-dependent pregnancy women in a family medicine residency: reports on maternal and infant outcomes. J Am Board Fam Med. 2011;24(2):194-201.

I would like to offer another pragmatic, easy, and quick solution for dealing with the shrinking psychiatrist workforce (The psychiatry workforce pool is shrinking. What are we doing about it? From the Editor. Current Psychiatry. September 2016, p. 23,24,95).

The United States is short approximately 45,000 psychiatrists.¹ Burnout—a silent epidemic among physicians—is prevalent in psychiatry. What consumes time and leads to burn out? “Scut work.”

There are thousands of unmatched residency graduates.² Most of these graduates have clinical experience in the United States. Psychiatry residency programs should give these unmatched graduates 6 months of training in psychiatry and use them as our primary workforce. These assistant physicians could be paired with 2 to 3 psychiatrists to perform the menial tasks, including, but not limited to, phone calls, prescriptions, prior authorizations, chart review, and other clinical and administrative paper work. This way, psychiatrists can focus on the interview, diagnoses, and treatment, major medical decision-making, and see more patients.

Employing assistant physicians to provide care has been suggested as a solution.³ Arkansas, Kansas, and Missouri have passed laws that allow medical school graduates who did not match with a residency program to work in underserved areas with a collaborating physician.

Because 1 out of 4 individuals have a mental illness and more of them are seeking help because of increasing awareness and the Affordable Care Act, the construct of “assistant physicians” could ease psychiatrists’ workload allowing them to deliver better care to more people.

Maju Mathew Koola, MD

Associate Professor
Department of Psychiatry and Behavioral Sciences
George Washington University
School of Medicine and Health Sciences
Washington, DC

References

1. Carlat D. 45,000 More psychiatrists, anyone? Psychiatric Times. http://www.psychiatrictimes.com/articles/45000-more-psychiatrists-anyone-0.Published August 3, 2010. Accessed November 11, 2016.
2. The Match: National Resident Matching Program. results and data: 2016 main residency match. http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf. Published April 2016. Accessed November 11, 2016.
3. Miller JG, Peterson DJ. Employing nurse practitioners and physician assistants to provide access to care as the psychiatrist shortage continues. Acad Psychiatry. 2015;39(6):685-686.

Concerns in psychiatry

The August 2016 editorial (Unresolved questions about the specialty lurk in the cortext of psychiatrists. Current Psychiatry. p. 10-11,19,19A) was absolutely, right on the mark. It is heartening to realize how consistent our concerns are through our profession. Although I try to put my shoulder to the wheel to seek answers, it can become frustrating.

Denis F. Darko, MD

CEO

NeuroSci R&D Consultancy, LLC

Maple Grove, Minnesota

Intrusive musical imagery (IMI) is characterized by recalling pieces of music,¹ usually repetitions of 15 to 30 seconds,² without pathology of the ear or nervous system.¹ Also known as earworm—ohrwurm in German—or involuntary musical imagery, bits of music can become a constant cause of distress.¹

IMI is prevalent in the general population; in an internet survey >85% of respondents reported experiencing IMI at least weekly.² IMI can be generated by:

• hearing music
• reading song lyrics
• being in contact with an environment or people who are linked to specific song, such as department stores that play holiday music.^2,3

IMI also is associated with stressful situations or neurological insult.¹

Any song or segment of music can be the basis of IMI. The content of IMI change over time (ie, a new song can become a source of IMI).³ The frequency of experiencing IMI is correlated to how much music a person is exposed to and the importance a person places on music.² Most episodes are intermittent; however, continuous musical episodes are known to occur.³ Episodes of IMI with obsessive-compulsive features can be classified as musical obsessions (MO).¹ MO may be part of obsessive-compulsive symptoms, including washing, checking, aggression, sexual obsessions, and religious obsessions or other obsessions.¹

Diagnosing musical obsessions

No current measures are adequate to diagnose MO. The Yale-Brown Obsessive Compulsive Scale does not distinguish MO from other intrusive auditory imagery.¹

It is important to differentiate MO from:

• Musical preoccupations or recollections in which an individual repeatedly listens or recalls a particular song or part of a song, but does not have the urge to listen or recall music in an obsessive-compulsive pattern.¹ These individuals do not display fear and avoidant behaviors that could be seen in patients with MO.¹
• Musical hallucinations lack an input stimulus and the patient believes the music comes from an outside source and interprets it as reality. Misdiagnosing MO as a psychotic symptom is common and can result in improper treatment.¹

Management

Pharmacotherapy. MO responds to the same medications used to treat obsessive-compulsive disorder, such as selective serotonin reuptake inhibitors and clomipramine.¹ Cognitive-behavioral interventions could help patients address dysfunctional beliefs, without trying to suppress them.¹

Distraction. Encourage patients to sing a different song that does not have obsessive quality¹ or engage in a task that uses working memory.³

Exposure and response prevention therapy. Some case reports have reported efficacy in treating MO.¹

Intrusive musical imagery (IMI) is characterized by recalling pieces of music,¹ usually repetitions of 15 to 30 seconds,² without pathology of the ear or nervous system.¹ Also known as earworm—ohrwurm in German—or involuntary musical imagery, bits of music can become a constant cause of distress.¹

IMI is prevalent in the general population; in an internet survey >85% of respondents reported experiencing IMI at least weekly.² IMI can be generated by:

• hearing music
• reading song lyrics
• being in contact with an environment or people who are linked to specific song, such as department stores that play holiday music.^2,3

IMI also is associated with stressful situations or neurological insult.¹

Any song or segment of music can be the basis of IMI. The content of IMI change over time (ie, a new song can become a source of IMI).³ The frequency of experiencing IMI is correlated to how much music a person is exposed to and the importance a person places on music.² Most episodes are intermittent; however, continuous musical episodes are known to occur.³ Episodes of IMI with obsessive-compulsive features can be classified as musical obsessions (MO).¹ MO may be part of obsessive-compulsive symptoms, including washing, checking, aggression, sexual obsessions, and religious obsessions or other obsessions.¹

Diagnosing musical obsessions

No current measures are adequate to diagnose MO. The Yale-Brown Obsessive Compulsive Scale does not distinguish MO from other intrusive auditory imagery.¹

It is important to differentiate MO from:

• Musical preoccupations or recollections in which an individual repeatedly listens or recalls a particular song or part of a song, but does not have the urge to listen or recall music in an obsessive-compulsive pattern.¹ These individuals do not display fear and avoidant behaviors that could be seen in patients with MO.¹
• Musical hallucinations lack an input stimulus and the patient believes the music comes from an outside source and interprets it as reality. Misdiagnosing MO as a psychotic symptom is common and can result in improper treatment.¹

Management

Pharmacotherapy. MO responds to the same medications used to treat obsessive-compulsive disorder, such as selective serotonin reuptake inhibitors and clomipramine.¹ Cognitive-behavioral interventions could help patients address dysfunctional beliefs, without trying to suppress them.¹

Distraction. Encourage patients to sing a different song that does not have obsessive quality¹ or engage in a task that uses working memory.³

Exposure and response prevention therapy. Some case reports have reported efficacy in treating MO.¹

Intrusive musical imagery (IMI) is characterized by recalling pieces of music,¹ usually repetitions of 15 to 30 seconds,² without pathology of the ear or nervous system.¹ Also known as earworm—ohrwurm in German—or involuntary musical imagery, bits of music can become a constant cause of distress.¹

IMI is prevalent in the general population; in an internet survey >85% of respondents reported experiencing IMI at least weekly.² IMI can be generated by:

• hearing music
• reading song lyrics
• being in contact with an environment or people who are linked to specific song, such as department stores that play holiday music.^2,3

IMI also is associated with stressful situations or neurological insult.¹

Any song or segment of music can be the basis of IMI. The content of IMI change over time (ie, a new song can become a source of IMI).³ The frequency of experiencing IMI is correlated to how much music a person is exposed to and the importance a person places on music.² Most episodes are intermittent; however, continuous musical episodes are known to occur.³ Episodes of IMI with obsessive-compulsive features can be classified as musical obsessions (MO).¹ MO may be part of obsessive-compulsive symptoms, including washing, checking, aggression, sexual obsessions, and religious obsessions or other obsessions.¹

Diagnosing musical obsessions

No current measures are adequate to diagnose MO. The Yale-Brown Obsessive Compulsive Scale does not distinguish MO from other intrusive auditory imagery.¹

It is important to differentiate MO from:

• Musical preoccupations or recollections in which an individual repeatedly listens or recalls a particular song or part of a song, but does not have the urge to listen or recall music in an obsessive-compulsive pattern.¹ These individuals do not display fear and avoidant behaviors that could be seen in patients with MO.¹
• Musical hallucinations lack an input stimulus and the patient believes the music comes from an outside source and interprets it as reality. Misdiagnosing MO as a psychotic symptom is common and can result in improper treatment.¹

Management

Pharmacotherapy. MO responds to the same medications used to treat obsessive-compulsive disorder, such as selective serotonin reuptake inhibitors and clomipramine.¹ Cognitive-behavioral interventions could help patients address dysfunctional beliefs, without trying to suppress them.¹

Distraction. Encourage patients to sing a different song that does not have obsessive quality¹ or engage in a task that uses working memory.³

Exposure and response prevention therapy. Some case reports have reported efficacy in treating MO.¹

A few miles from New York City’s “Million Dollar Blocks” in Brownsville—single city blocks where the state spends more than a million dollars per year to incarcerate people who once lived there—is the one of the busiest psychiatric emergency rooms in the country. Through the doors come people with “behavioral disturbances” who may be a risk to themself or others and who might have a psychiatric disorder that causes functional or cognitive impairment. Sometimes, a clear-headed individual will rattle off an impressive list of diagnoses (schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, anxiety), chronic, not in remission, on medication, which makes one wonder if a dartboard would provide better diagnostic accuracy. Without the construct validity that our colleagues in other specialties have to support our diagnoses, what is first and foremost a medical specialty has been expanded to a catch-all for what ails the human condition.

Being comfortable with uncertainty

Hyperbole aside, speculative pathologizing is risky business. Our conjectures could be influenced by personal bias and also are subject to the surrounding social climate. By watering down the field, our sins run the gamut of incorrectly diagnosing and stigmatizing a vulnerable patient to failing to protect the public from a mentally ill individual. Psychiatry, as it turns out, is not for the faint of heart.

I often am surprised at the number of medical students—it seems more than in past years—who are curious about psychiatry. I tell them one must be comfortable with some degree of uncertainty. Neurologists, for example, are far more certain of their uncertain, mysterious diseases. Likewise, internists resolutely say “idiopathic” without batting an eyelash. Psychiatrists, however, on the whole, are inclined to be an introspective and self-critical bunch. Extrapolated to the field at large, it creates a divisiveness not seen in other medical specialties. Psychiatry has its factions that are fortunately, are not mutually exclusive. Sometimes the twain can and do meet.

With flexible explanatory models come flexible roles in health care. We take on the shape of administrators, directors of clinical service, and policy advocates. Psychiatry, by assuming the mantle of phenomenology, naturally intersects with the areas of human rights, philosophy, and law. Without regard for our considerably influential positions, it is tempting to overstep our bounds as a medical provider. We are, woefully, powerful.

Refocusing community psychiatry

The well-intentioned public psychiatry movement, borne out of deinstitutionalization, endeavored to treat patients in a least restrictive, community-based setting with a focus on rehabilitation and integration. In practice, however, community psychiatry takes on a less rosy view. More often used as a Band-Aid for crime and problems associated with increasing socioeconomic divide, community psychiatry has been rebranded as mental health services for the indigent. Subverting the rights of this doubly vulnerable population is astonishingly easy when paired with a risk-averse litigious environment. “Danger to self or others” becomes our mantra; we unwittingly become ill-trained policemen.

I suggest we narrow the scope of psychiatry and we resist opining on social ills and conflating them with nebulous mental ills. Violent behavior, although troubling, is not a psychiatric symptom and unintentionally correlating it with psychiatric diagnoses does our patients a disservice. When we override an individual’s civil liberties with involuntary hospitalization or involuntary treatment, perhaps it is helpful to consider if we would do the same if the patient had more resources. It is a heavy burden to pretend that we can fix public policy with medications, therapy, and hospitalization. Not only should our actions safeguard the rights of our patients, but also the integrity of our field. In doing so, we might enjoy a less controversial place in health care.

A few miles from New York City’s “Million Dollar Blocks” in Brownsville—single city blocks where the state spends more than a million dollars per year to incarcerate people who once lived there—is the one of the busiest psychiatric emergency rooms in the country. Through the doors come people with “behavioral disturbances” who may be a risk to themself or others and who might have a psychiatric disorder that causes functional or cognitive impairment. Sometimes, a clear-headed individual will rattle off an impressive list of diagnoses (schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, anxiety), chronic, not in remission, on medication, which makes one wonder if a dartboard would provide better diagnostic accuracy. Without the construct validity that our colleagues in other specialties have to support our diagnoses, what is first and foremost a medical specialty has been expanded to a catch-all for what ails the human condition.

Being comfortable with uncertainty

Hyperbole aside, speculative pathologizing is risky business. Our conjectures could be influenced by personal bias and also are subject to the surrounding social climate. By watering down the field, our sins run the gamut of incorrectly diagnosing and stigmatizing a vulnerable patient to failing to protect the public from a mentally ill individual. Psychiatry, as it turns out, is not for the faint of heart.

I often am surprised at the number of medical students—it seems more than in past years—who are curious about psychiatry. I tell them one must be comfortable with some degree of uncertainty. Neurologists, for example, are far more certain of their uncertain, mysterious diseases. Likewise, internists resolutely say “idiopathic” without batting an eyelash. Psychiatrists, however, on the whole, are inclined to be an introspective and self-critical bunch. Extrapolated to the field at large, it creates a divisiveness not seen in other medical specialties. Psychiatry has its factions that are fortunately, are not mutually exclusive. Sometimes the twain can and do meet.

With flexible explanatory models come flexible roles in health care. We take on the shape of administrators, directors of clinical service, and policy advocates. Psychiatry, by assuming the mantle of phenomenology, naturally intersects with the areas of human rights, philosophy, and law. Without regard for our considerably influential positions, it is tempting to overstep our bounds as a medical provider. We are, woefully, powerful.

Refocusing community psychiatry

The well-intentioned public psychiatry movement, borne out of deinstitutionalization, endeavored to treat patients in a least restrictive, community-based setting with a focus on rehabilitation and integration. In practice, however, community psychiatry takes on a less rosy view. More often used as a Band-Aid for crime and problems associated with increasing socioeconomic divide, community psychiatry has been rebranded as mental health services for the indigent. Subverting the rights of this doubly vulnerable population is astonishingly easy when paired with a risk-averse litigious environment. “Danger to self or others” becomes our mantra; we unwittingly become ill-trained policemen.

I suggest we narrow the scope of psychiatry and we resist opining on social ills and conflating them with nebulous mental ills. Violent behavior, although troubling, is not a psychiatric symptom and unintentionally correlating it with psychiatric diagnoses does our patients a disservice. When we override an individual’s civil liberties with involuntary hospitalization or involuntary treatment, perhaps it is helpful to consider if we would do the same if the patient had more resources. It is a heavy burden to pretend that we can fix public policy with medications, therapy, and hospitalization. Not only should our actions safeguard the rights of our patients, but also the integrity of our field. In doing so, we might enjoy a less controversial place in health care.

A few miles from New York City’s “Million Dollar Blocks” in Brownsville—single city blocks where the state spends more than a million dollars per year to incarcerate people who once lived there—is the one of the busiest psychiatric emergency rooms in the country. Through the doors come people with “behavioral disturbances” who may be a risk to themself or others and who might have a psychiatric disorder that causes functional or cognitive impairment. Sometimes, a clear-headed individual will rattle off an impressive list of diagnoses (schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, anxiety), chronic, not in remission, on medication, which makes one wonder if a dartboard would provide better diagnostic accuracy. Without the construct validity that our colleagues in other specialties have to support our diagnoses, what is first and foremost a medical specialty has been expanded to a catch-all for what ails the human condition.

Being comfortable with uncertainty

Hyperbole aside, speculative pathologizing is risky business. Our conjectures could be influenced by personal bias and also are subject to the surrounding social climate. By watering down the field, our sins run the gamut of incorrectly diagnosing and stigmatizing a vulnerable patient to failing to protect the public from a mentally ill individual. Psychiatry, as it turns out, is not for the faint of heart.

I often am surprised at the number of medical students—it seems more than in past years—who are curious about psychiatry. I tell them one must be comfortable with some degree of uncertainty. Neurologists, for example, are far more certain of their uncertain, mysterious diseases. Likewise, internists resolutely say “idiopathic” without batting an eyelash. Psychiatrists, however, on the whole, are inclined to be an introspective and self-critical bunch. Extrapolated to the field at large, it creates a divisiveness not seen in other medical specialties. Psychiatry has its factions that are fortunately, are not mutually exclusive. Sometimes the twain can and do meet.

With flexible explanatory models come flexible roles in health care. We take on the shape of administrators, directors of clinical service, and policy advocates. Psychiatry, by assuming the mantle of phenomenology, naturally intersects with the areas of human rights, philosophy, and law. Without regard for our considerably influential positions, it is tempting to overstep our bounds as a medical provider. We are, woefully, powerful.

Refocusing community psychiatry

The well-intentioned public psychiatry movement, borne out of deinstitutionalization, endeavored to treat patients in a least restrictive, community-based setting with a focus on rehabilitation and integration. In practice, however, community psychiatry takes on a less rosy view. More often used as a Band-Aid for crime and problems associated with increasing socioeconomic divide, community psychiatry has been rebranded as mental health services for the indigent. Subverting the rights of this doubly vulnerable population is astonishingly easy when paired with a risk-averse litigious environment. “Danger to self or others” becomes our mantra; we unwittingly become ill-trained policemen.

I suggest we narrow the scope of psychiatry and we resist opining on social ills and conflating them with nebulous mental ills. Violent behavior, although troubling, is not a psychiatric symptom and unintentionally correlating it with psychiatric diagnoses does our patients a disservice. When we override an individual’s civil liberties with involuntary hospitalization or involuntary treatment, perhaps it is helpful to consider if we would do the same if the patient had more resources. It is a heavy burden to pretend that we can fix public policy with medications, therapy, and hospitalization. Not only should our actions safeguard the rights of our patients, but also the integrity of our field. In doing so, we might enjoy a less controversial place in health care.