Evidence-Based Reviews

When treating patients who abuse substances, it is important to watch for underlying clinical conditions that have been sup­pressed, relieved, or muted by alcohol or drugs. Many of these conditions can be mistaken for signs of withdrawal, drug-seeking, or new conditions arising from loss of euphoria from the drug. Prompt recogni­tion of these disorders and use of appropriate non-addictive treatments can prevent “against medical advice” discharges, relapses, and unneeded suffering in many cases.

Because the brain is the target organ, these conditions are either neuro­logic or psychiatric in nosology. Although psychiatric clinicians might not be familiar with neurologic conditions, quick recognition and treatment is necessary.

Restless legs syndrome and periodic limb movements of sleep
Restless legs syndrome (RLS) has 2 key components: paresthesia and akathisia. Although primarily involving the lower extremities, involve­ment also can include the upper extremities, torso, and head.

Paresthesia differs from typical neuropathies in that it usually is not pain­ful; rather, patients describe an odd sensation using terms such as ticklish, “creepy-crawly,” and other uncomfortable sensations.

Akathisia is a motor restlessness and need to move. The patient might feel momentary relief by moving or rubbing the extremities, only to have the paresthesia return quickly followed by the akathisia. Generally, reclining is the most prominent position that produces symptoms, but they can occur while sitting.

The cause of RLS is an abnormality of central dopamine or iron, or both, in the sub­stantia nigra; iron is a cofactor in dopamine synthesis. All RLS patients should have a serum ferritin level drawn and if <50 μg/dL, be treated with iron supplementation. Dopamine agonists, such as ropinirole, pramipexole, and carbidopa/levodopa, are effective (Table 1); other useful agents include benzodiazepines such as clonaz­epam and opioids such as hydrocodone.

When a patient withdraws from benzo­diazepines or narcotics, RLS can emerge and cause suffering until it is diagnosed and treated. Typical myalgia in opioid withdrawal can confound the diagnosis. The immediate-release (IR) and extended-release (ER) formu­lations of gabapentin often are a good choice when treating benzodiazepine or narcotic withdrawal. The side effect profile of gaba­pentin is relatively benign, with somnolence often reported by non-substance abusers, but it is unlikely that addicts, who have grown tolerant to more potent agents such as ben­zodiazepines and opioids, will complain of sleepiness. Studies have shown that gabapen­tin is useful in managing withdrawal as well as anxiety and insomnia.^1,2 A randomized trial showed that gabapentin increases abstinence rates and decreases heavy drinking.² The agent has a short half-life (5 to 7 hours); the IR form needs to be dosed at least 3 times a day to be effective. An ER formulation of gabap­entin was released in 2013 with the sole indi­cation for RLS.

Gabapentin is not significantly metabo­lized by the liver, has a 3% rate of protein bind­ing, and is excreted by the kidneys—making it safe for patients who abuse alcohol or opi­oids and have impaired hepatic function. Typical starting dosages of IR gabapentin are 100 to 300 mg, 3 times daily, if symptoms are present in the daytime. Asymmetric dosing can be helpful, with larger or single dosages given at bedtime (eg, 100 mg in morning, 100 mg in afternoon, 300 mg at bedtime). Dosing varies from patient to patient, from 300 mg to 3,600 mg/d. Increasing dosages produce lower bioavailability because of saturation in absorption or at the blood-brain barrier. At 100 mg every 8 hours, bioavail­ability is 80% but at 1,600 mg every 8 hours it drops to 27%.³

Periodic limb movements of sleep (PLMS) essentially is akathisia during sleep, and occurs in most patients with RLS. The patient feels tired in the morning because of lack of deep stage-N3 sleep. Because of the inverse relationship between serotonin and dopamine, most selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors can exacerbate RLS and PLMS.^4,5 Other culprits include antipsychot­ics, antiemetics, and antihistamines. The differential diagnosis includes withdrawal from opioids and attention-deficit/hyper­activity disorder (ADHD), which may be comorbid with RLS. There are many causes of secondary RLS including renal failure, pregnancy, varicose veins, and neuropathy.

Tremor
Benign familial, or essential, tremor is a fine intention tremor that can be suppressed by alcohol or benzodiazepines. After detoxifica­tion from either of these substances, persis­tent tremor can re-emerge; often, it is benign, although cerebellar and parkinsonian trem­ors must be ruled out. Essential tremor can be treated with gabapentin or beta blockers such as propranolol or metoprolol (Table 2).

Anxiety and panic disorder
Social anxiety often presents in addiction treatment centers in the context of group therapy, speaking in 12-step meetings, and having the patient describe his (her) autobi­ography and history of addiction. Because social anxiety disorder is the third most com­mon psychiatric disorder after simple pho­bia and major depressive disorder,⁶ it is not surprising that it emerges after withdrawal.

 

Patients with social anxiety disorder might self-medicate with alcohol or drugs, especially benzodiazepines (Box). Residential treatment presents an excellent environment for desensitization to fears of public speaking; early recognition is key. Apprehension about group therapy, present­ing a substance abuse history, or speaking at a 12-step meeting can lead to premature or “against medical advice” discharge.

Panic disorder commonly is comorbid with substance abuse. Many patients will arrive at treatment with a prescription for benzodiaz­epines. Because the risk of cross-addiction is high among recovering addicts, benzodiaze­pines should be avoided. Treating underlying anxiety is crucial for fostering sobriety. Generalized anxiety disorder is common among patients with an addiction, and can lead to relapse if not addressed. Use of non-addictive medications and cognitive therapy is useful in addressing this condition.

A quandary might arise in states where medical marijuana is legal, because Cannabis can be prescribed for anxiety disorders and posttraumatic stress disorder (PTSD). Promoting abstinence from all substances can present a challenge in patients with anxi­ety disorders who live in these states.

Medications for anxiety and panic dis­order include gabapentin, buspirone, hydroxyzine, beta blockers, and atypical antipsychotics (Table 2). Only buspirone and hydroxyzine are FDA-approved for anxiety; buspirone monotherapy generally is ineffec­tive for panic disorder.

Explaining to patients how anxiety arises, such as how classical conditioning leads to specific phobias, can be therapeu­tic. Describing Klein’s false suffocation alarm theory of panic attacks can illustrate the importance of practicing slow, deep breathing to prevent hyperventilation.⁷ Also, relabeling a panic attack with self-talk state­ments such as “I know what this is. It’s just a panic attack” can be helpful. Smartphone apps are available to help patients cope with anxiety and acute panic.⁸

Mood disorders
Many patients with bipolar disorder expe­rience substance abuse at some point; esti­mates are that up to 57% of patients have a comorbid addiction.^6,9 Persons with a mood disorder are at high risk of substance abuse because of genetic factors; patients also might self-medicate their mood symptoms.

After alcohol or drugs are withdrawn, mood disorders can emerge or resurge. Often, patients enter treatment taking antidepressants and mood stabilizers and usually haven’t been truthful with their treatment provider about their substance abuse. Care must be taken to ascertain whether mood symptoms are secondary to substance abuse. Asking “What’s the longest period of abstinence you’ve had in 2 years and how did you feel emotionally?” often will help you identify a secondary mood disorder. For example, a response of “6 months and I felt really depressed the entire time” would indicate a primary depressive disorder.

Because CNS depressants, such as alco­hol and benzodiazepines, can exacerbate a mood disorder, consider continuing or resuming a mood stabilizer or antidepres­sant during substance abuse treatment. When meeting a new patient, perform an independent evaluation, because substance use can mimic bipolar and depressive dis­orders. Careful assessment of suicidal ide­ation is necessary for all patients.

Sleep disorders
Insomnia—as a primary or secondary disorder—is common among patients with a substance use disorder. Insomnia always needs to be addressed. Not sleeping well interferes with cognition and energy and makes depression and bipolar disorder worse. Some experts recommend “waiting out” the insomnia, hoping that sobriety will resolve it—but it might not.

Initial insomnia can be treated with mela­tonin, 3 to 6 mg at bedtime or earlier in the evening.^10-12 Melatonin acts by regulating circadian rhythms, but can cause increased dreaming and nightmares; therefore, it should be avoided in patients who struggle with nightmares. Trazodone, 50 to 150 mg at bedtime, is an inexpensive sleep aid for initial insomnia and doesn’t cause weight gain, which many drugs with antihistaminic properties can. Prazosin, 1 to 2 mg initially, for nightmares in PTSD is effective.¹³

Antipsychotics might be necessary if nothing else works; quetiapine is effective for sleep and the ER form is FDA-approved as an add-on agent in major depression. Low-dose doxepin (≤10 mg) is effective for middle insomnia.¹⁴ At these low dosages, troublesome side effects of tricyclic antide­pressants can be avoided.

As many as 40% of adults with ADHD have a delayed sleep-phase disorder. Ask your patient if she is a “night owl,” how chronic the condition is, and when her best sleep occurs.15-17 Morning light and evening melatonin can help, but often are insufficient. Many patients present with undiagnosed or untreated sleep apnea, which can cause excessive daytime sleepiness. Referral to a sleep center is prudent; use of the Epworth Sleepiness Scale is a quick way to assess excessive daytime sleepiness.¹⁸

ADHD
ADHD commonly is comorbid with a sub­stance use disorder. Patients might pres­ent with an earlier diagnosis, including treatment. Several drugs of abuse can alle­viate ADHD symptoms, including amphet­amines, opioids, cocaine, and Cannabis; self-medicating is common. Because opi­oids increase dopamine release, a report of improved work and school performance while taking opioids early in addiction can be a clue to an ADHD diagnosis.

Explaining ADHD as a syndrome of “interest-based attention” helps. If a resi­dential treatment program uses reading and writing assignments, a patient with ADHD might struggle and will need extra help and time and a quiet place to do assignments.^19,20 A non-addictive medication, such as ato­moxetine, can help, but has an antidepres­sant-like delay of 3 to 5 weeks until onset of symptom relief. Using a long-acting stimu­lant can be effective and quick, with an effect size 3 to 4 times higher than atomoxetine; such agents should be avoided in patients who abuse amphetamines.

 

Studies show that treating ADHD, even with stimulants, neither helps nor hurts out­comes in substance use. Lisdexamfetamine is difficult to abuse and is an inactive prodrug (a bond of lysine and dextroamphetamine) that requires enzymatic cleavage and activa­tion by red blood cells; these characteristics creates a long-acting medication that has a lower abuse liability than other drugs for ADHD. However, abuse can occur and the drug must be used cautiously. Earley’s medi­cation guide referenced below recommends that lisdexamfetamine and other stimulants should be avoided if possible in patients in recovery. However, it adds that special­ists in treating ADHD in substance-abusing patients should weigh the potential benefits of stimulant use against the risk of relapse.¹⁷ Many patients enter treatment with a diag­nosis of bipolar disorder that might, in fact, be comorbid with ADHD.

Chronic pain
Many substance abuse patients began taking opioids for acute, then chronic, pain before their use escalated to addiction. These are challenging patients; often, they are referred for treatment without true addiction.

Keep in mind that dependence is not addiction. Pseudo-addiction is a condition in which pain is undertreated and the patient takes more medication to obtain relief, calls for early refills, and displays drug-seeking behavior but is not using drugs to achieve euphoria. A thorough history and physical and referrals to specialists such as orthopedic surgeons and pain specialists are necessary. Explaining opioid-induced hyperalgesia is important to help the patient understand that (1) pain can be made worse by increas­ing the dosage of an opioid because of supersensitivity and (2) many patients who are weaned off these drugs will experience a decrease or complete relief of pain.²¹

Gabapentin, duloxetine, or amitriptyline can be beneficial for chronic pain, as well as mindfulness techniques, physical therapy, and complementary and alternative medi­cine. Pregabalin can produce euphoria and often should be avoided.

A medication guide for recovery
Paul Earley, MD, former medical director at Talbott Recovery in Atlanta, Georgia, pub­lishes an online guide that classifies medica­tions into categories:
   • A: safe
   • B: use only under the supervision of an addiction medicine specialist or doctor
   • C: completely avoid if the patient is in recovery.¹⁷

The Talbott guide lists all stimulants in category C, (except for atomoxetine, which is category A). Hydroxyzine is listed under category B. Many programs for impaired professionals and state medical boards use the Guide, and will question the prescribing of any medication from categories B and C.¹⁷

Related Resources
• Spiegel DR, Kumari N, Petri JD. Safer use of benzodiaz­epines for alcohol detoxification. Current Psychiatry. 2012;11(10):10-15.
• Kelly TM, Daley DC, Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. Addict Behav. 2012;37(1):11-24.

Drug Brand Names
Amitriptyline • Elavil                                     Hydrocodone • Vicodin
Atenolol • Tenormin                                      Hydroxyzine • Vistaril, Atarax
Atomoxetine • Strattera                                Lisdexamfetamine • Vyvanse
Buprenorphine/ naloxone • Suboxone             Metoprolol • Lopressor, Toprol
Buspirone • BuSpar                                       Paroxetine • Paxil
Carbidopa-levodopa • Sinemet                       Pramipexole • Mirapex
Clonazepam • Klonopin                                  Prazosin • Minipress
Diazepam • Valium                                        Pregabalin • Lyrica
Doxepin • Silenor, Adapin, Sinequan               Propranolol • Inderal
Duloxetine • Cymbalta                                   Quetiapine • Seroquel
Escitalopram • Lexapro                                  Ropinirole • Requip
Gabapentin • Neurontin, Horizant                   Sertraline • Zoloft
                                                                   Trazodone • Desyrel

Disclosure
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

When treating patients who abuse substances, it is important to watch for underlying clinical conditions that have been sup­pressed, relieved, or muted by alcohol or drugs. Many of these conditions can be mistaken for signs of withdrawal, drug-seeking, or new conditions arising from loss of euphoria from the drug. Prompt recogni­tion of these disorders and use of appropriate non-addictive treatments can prevent “against medical advice” discharges, relapses, and unneeded suffering in many cases.

Because the brain is the target organ, these conditions are either neuro­logic or psychiatric in nosology. Although psychiatric clinicians might not be familiar with neurologic conditions, quick recognition and treatment is necessary.

Restless legs syndrome and periodic limb movements of sleep
Restless legs syndrome (RLS) has 2 key components: paresthesia and akathisia. Although primarily involving the lower extremities, involve­ment also can include the upper extremities, torso, and head.

Paresthesia differs from typical neuropathies in that it usually is not pain­ful; rather, patients describe an odd sensation using terms such as ticklish, “creepy-crawly,” and other uncomfortable sensations.

Akathisia is a motor restlessness and need to move. The patient might feel momentary relief by moving or rubbing the extremities, only to have the paresthesia return quickly followed by the akathisia. Generally, reclining is the most prominent position that produces symptoms, but they can occur while sitting.

The cause of RLS is an abnormality of central dopamine or iron, or both, in the sub­stantia nigra; iron is a cofactor in dopamine synthesis. All RLS patients should have a serum ferritin level drawn and if <50 μg/dL, be treated with iron supplementation. Dopamine agonists, such as ropinirole, pramipexole, and carbidopa/levodopa, are effective (Table 1); other useful agents include benzodiazepines such as clonaz­epam and opioids such as hydrocodone.

When a patient withdraws from benzo­diazepines or narcotics, RLS can emerge and cause suffering until it is diagnosed and treated. Typical myalgia in opioid withdrawal can confound the diagnosis. The immediate-release (IR) and extended-release (ER) formu­lations of gabapentin often are a good choice when treating benzodiazepine or narcotic withdrawal. The side effect profile of gaba­pentin is relatively benign, with somnolence often reported by non-substance abusers, but it is unlikely that addicts, who have grown tolerant to more potent agents such as ben­zodiazepines and opioids, will complain of sleepiness. Studies have shown that gabapen­tin is useful in managing withdrawal as well as anxiety and insomnia.^1,2 A randomized trial showed that gabapentin increases abstinence rates and decreases heavy drinking.² The agent has a short half-life (5 to 7 hours); the IR form needs to be dosed at least 3 times a day to be effective. An ER formulation of gabap­entin was released in 2013 with the sole indi­cation for RLS.

Gabapentin is not significantly metabo­lized by the liver, has a 3% rate of protein bind­ing, and is excreted by the kidneys—making it safe for patients who abuse alcohol or opi­oids and have impaired hepatic function. Typical starting dosages of IR gabapentin are 100 to 300 mg, 3 times daily, if symptoms are present in the daytime. Asymmetric dosing can be helpful, with larger or single dosages given at bedtime (eg, 100 mg in morning, 100 mg in afternoon, 300 mg at bedtime). Dosing varies from patient to patient, from 300 mg to 3,600 mg/d. Increasing dosages produce lower bioavailability because of saturation in absorption or at the blood-brain barrier. At 100 mg every 8 hours, bioavail­ability is 80% but at 1,600 mg every 8 hours it drops to 27%.³

Periodic limb movements of sleep (PLMS) essentially is akathisia during sleep, and occurs in most patients with RLS. The patient feels tired in the morning because of lack of deep stage-N3 sleep. Because of the inverse relationship between serotonin and dopamine, most selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors can exacerbate RLS and PLMS.^4,5 Other culprits include antipsychot­ics, antiemetics, and antihistamines. The differential diagnosis includes withdrawal from opioids and attention-deficit/hyper­activity disorder (ADHD), which may be comorbid with RLS. There are many causes of secondary RLS including renal failure, pregnancy, varicose veins, and neuropathy.

Tremor
Benign familial, or essential, tremor is a fine intention tremor that can be suppressed by alcohol or benzodiazepines. After detoxifica­tion from either of these substances, persis­tent tremor can re-emerge; often, it is benign, although cerebellar and parkinsonian trem­ors must be ruled out. Essential tremor can be treated with gabapentin or beta blockers such as propranolol or metoprolol (Table 2).

Anxiety and panic disorder
Social anxiety often presents in addiction treatment centers in the context of group therapy, speaking in 12-step meetings, and having the patient describe his (her) autobi­ography and history of addiction. Because social anxiety disorder is the third most com­mon psychiatric disorder after simple pho­bia and major depressive disorder,⁶ it is not surprising that it emerges after withdrawal.

 

Patients with social anxiety disorder might self-medicate with alcohol or drugs, especially benzodiazepines (Box). Residential treatment presents an excellent environment for desensitization to fears of public speaking; early recognition is key. Apprehension about group therapy, present­ing a substance abuse history, or speaking at a 12-step meeting can lead to premature or “against medical advice” discharge.

Panic disorder commonly is comorbid with substance abuse. Many patients will arrive at treatment with a prescription for benzodiaz­epines. Because the risk of cross-addiction is high among recovering addicts, benzodiaze­pines should be avoided. Treating underlying anxiety is crucial for fostering sobriety. Generalized anxiety disorder is common among patients with an addiction, and can lead to relapse if not addressed. Use of non-addictive medications and cognitive therapy is useful in addressing this condition.

A quandary might arise in states where medical marijuana is legal, because Cannabis can be prescribed for anxiety disorders and posttraumatic stress disorder (PTSD). Promoting abstinence from all substances can present a challenge in patients with anxi­ety disorders who live in these states.

Medications for anxiety and panic dis­order include gabapentin, buspirone, hydroxyzine, beta blockers, and atypical antipsychotics (Table 2). Only buspirone and hydroxyzine are FDA-approved for anxiety; buspirone monotherapy generally is ineffec­tive for panic disorder.

Explaining to patients how anxiety arises, such as how classical conditioning leads to specific phobias, can be therapeu­tic. Describing Klein’s false suffocation alarm theory of panic attacks can illustrate the importance of practicing slow, deep breathing to prevent hyperventilation.⁷ Also, relabeling a panic attack with self-talk state­ments such as “I know what this is. It’s just a panic attack” can be helpful. Smartphone apps are available to help patients cope with anxiety and acute panic.⁸

Mood disorders
Many patients with bipolar disorder expe­rience substance abuse at some point; esti­mates are that up to 57% of patients have a comorbid addiction.^6,9 Persons with a mood disorder are at high risk of substance abuse because of genetic factors; patients also might self-medicate their mood symptoms.

After alcohol or drugs are withdrawn, mood disorders can emerge or resurge. Often, patients enter treatment taking antidepressants and mood stabilizers and usually haven’t been truthful with their treatment provider about their substance abuse. Care must be taken to ascertain whether mood symptoms are secondary to substance abuse. Asking “What’s the longest period of abstinence you’ve had in 2 years and how did you feel emotionally?” often will help you identify a secondary mood disorder. For example, a response of “6 months and I felt really depressed the entire time” would indicate a primary depressive disorder.

Because CNS depressants, such as alco­hol and benzodiazepines, can exacerbate a mood disorder, consider continuing or resuming a mood stabilizer or antidepres­sant during substance abuse treatment. When meeting a new patient, perform an independent evaluation, because substance use can mimic bipolar and depressive dis­orders. Careful assessment of suicidal ide­ation is necessary for all patients.

Sleep disorders
Insomnia—as a primary or secondary disorder—is common among patients with a substance use disorder. Insomnia always needs to be addressed. Not sleeping well interferes with cognition and energy and makes depression and bipolar disorder worse. Some experts recommend “waiting out” the insomnia, hoping that sobriety will resolve it—but it might not.

Initial insomnia can be treated with mela­tonin, 3 to 6 mg at bedtime or earlier in the evening.^10-12 Melatonin acts by regulating circadian rhythms, but can cause increased dreaming and nightmares; therefore, it should be avoided in patients who struggle with nightmares. Trazodone, 50 to 150 mg at bedtime, is an inexpensive sleep aid for initial insomnia and doesn’t cause weight gain, which many drugs with antihistaminic properties can. Prazosin, 1 to 2 mg initially, for nightmares in PTSD is effective.¹³

Antipsychotics might be necessary if nothing else works; quetiapine is effective for sleep and the ER form is FDA-approved as an add-on agent in major depression. Low-dose doxepin (≤10 mg) is effective for middle insomnia.¹⁴ At these low dosages, troublesome side effects of tricyclic antide­pressants can be avoided.

As many as 40% of adults with ADHD have a delayed sleep-phase disorder. Ask your patient if she is a “night owl,” how chronic the condition is, and when her best sleep occurs.15-17 Morning light and evening melatonin can help, but often are insufficient. Many patients present with undiagnosed or untreated sleep apnea, which can cause excessive daytime sleepiness. Referral to a sleep center is prudent; use of the Epworth Sleepiness Scale is a quick way to assess excessive daytime sleepiness.¹⁸

ADHD
ADHD commonly is comorbid with a sub­stance use disorder. Patients might pres­ent with an earlier diagnosis, including treatment. Several drugs of abuse can alle­viate ADHD symptoms, including amphet­amines, opioids, cocaine, and Cannabis; self-medicating is common. Because opi­oids increase dopamine release, a report of improved work and school performance while taking opioids early in addiction can be a clue to an ADHD diagnosis.

Explaining ADHD as a syndrome of “interest-based attention” helps. If a resi­dential treatment program uses reading and writing assignments, a patient with ADHD might struggle and will need extra help and time and a quiet place to do assignments.^19,20 A non-addictive medication, such as ato­moxetine, can help, but has an antidepres­sant-like delay of 3 to 5 weeks until onset of symptom relief. Using a long-acting stimu­lant can be effective and quick, with an effect size 3 to 4 times higher than atomoxetine; such agents should be avoided in patients who abuse amphetamines.

 

Studies show that treating ADHD, even with stimulants, neither helps nor hurts out­comes in substance use. Lisdexamfetamine is difficult to abuse and is an inactive prodrug (a bond of lysine and dextroamphetamine) that requires enzymatic cleavage and activa­tion by red blood cells; these characteristics creates a long-acting medication that has a lower abuse liability than other drugs for ADHD. However, abuse can occur and the drug must be used cautiously. Earley’s medi­cation guide referenced below recommends that lisdexamfetamine and other stimulants should be avoided if possible in patients in recovery. However, it adds that special­ists in treating ADHD in substance-abusing patients should weigh the potential benefits of stimulant use against the risk of relapse.¹⁷ Many patients enter treatment with a diag­nosis of bipolar disorder that might, in fact, be comorbid with ADHD.

Chronic pain
Many substance abuse patients began taking opioids for acute, then chronic, pain before their use escalated to addiction. These are challenging patients; often, they are referred for treatment without true addiction.

Keep in mind that dependence is not addiction. Pseudo-addiction is a condition in which pain is undertreated and the patient takes more medication to obtain relief, calls for early refills, and displays drug-seeking behavior but is not using drugs to achieve euphoria. A thorough history and physical and referrals to specialists such as orthopedic surgeons and pain specialists are necessary. Explaining opioid-induced hyperalgesia is important to help the patient understand that (1) pain can be made worse by increas­ing the dosage of an opioid because of supersensitivity and (2) many patients who are weaned off these drugs will experience a decrease or complete relief of pain.²¹

Gabapentin, duloxetine, or amitriptyline can be beneficial for chronic pain, as well as mindfulness techniques, physical therapy, and complementary and alternative medi­cine. Pregabalin can produce euphoria and often should be avoided.

A medication guide for recovery
Paul Earley, MD, former medical director at Talbott Recovery in Atlanta, Georgia, pub­lishes an online guide that classifies medica­tions into categories:
   • A: safe
   • B: use only under the supervision of an addiction medicine specialist or doctor
   • C: completely avoid if the patient is in recovery.¹⁷

The Talbott guide lists all stimulants in category C, (except for atomoxetine, which is category A). Hydroxyzine is listed under category B. Many programs for impaired professionals and state medical boards use the Guide, and will question the prescribing of any medication from categories B and C.¹⁷

Related Resources
• Spiegel DR, Kumari N, Petri JD. Safer use of benzodiaz­epines for alcohol detoxification. Current Psychiatry. 2012;11(10):10-15.
• Kelly TM, Daley DC, Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. Addict Behav. 2012;37(1):11-24.

Drug Brand Names
Amitriptyline • Elavil                                     Hydrocodone • Vicodin
Atenolol • Tenormin                                      Hydroxyzine • Vistaril, Atarax
Atomoxetine • Strattera                                Lisdexamfetamine • Vyvanse
Buprenorphine/ naloxone • Suboxone             Metoprolol • Lopressor, Toprol
Buspirone • BuSpar                                       Paroxetine • Paxil
Carbidopa-levodopa • Sinemet                       Pramipexole • Mirapex
Clonazepam • Klonopin                                  Prazosin • Minipress
Diazepam • Valium                                        Pregabalin • Lyrica
Doxepin • Silenor, Adapin, Sinequan               Propranolol • Inderal
Duloxetine • Cymbalta                                   Quetiapine • Seroquel
Escitalopram • Lexapro                                  Ropinirole • Requip
Gabapentin • Neurontin, Horizant                   Sertraline • Zoloft
                                                                   Trazodone • Desyrel

Disclosure
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

When treating patients who abuse substances, it is important to watch for underlying clinical conditions that have been sup­pressed, relieved, or muted by alcohol or drugs. Many of these conditions can be mistaken for signs of withdrawal, drug-seeking, or new conditions arising from loss of euphoria from the drug. Prompt recogni­tion of these disorders and use of appropriate non-addictive treatments can prevent “against medical advice” discharges, relapses, and unneeded suffering in many cases.

Because the brain is the target organ, these conditions are either neuro­logic or psychiatric in nosology. Although psychiatric clinicians might not be familiar with neurologic conditions, quick recognition and treatment is necessary.

Restless legs syndrome and periodic limb movements of sleep
Restless legs syndrome (RLS) has 2 key components: paresthesia and akathisia. Although primarily involving the lower extremities, involve­ment also can include the upper extremities, torso, and head.

Paresthesia differs from typical neuropathies in that it usually is not pain­ful; rather, patients describe an odd sensation using terms such as ticklish, “creepy-crawly,” and other uncomfortable sensations.

Akathisia is a motor restlessness and need to move. The patient might feel momentary relief by moving or rubbing the extremities, only to have the paresthesia return quickly followed by the akathisia. Generally, reclining is the most prominent position that produces symptoms, but they can occur while sitting.

The cause of RLS is an abnormality of central dopamine or iron, or both, in the sub­stantia nigra; iron is a cofactor in dopamine synthesis. All RLS patients should have a serum ferritin level drawn and if <50 μg/dL, be treated with iron supplementation. Dopamine agonists, such as ropinirole, pramipexole, and carbidopa/levodopa, are effective (Table 1); other useful agents include benzodiazepines such as clonaz­epam and opioids such as hydrocodone.

When a patient withdraws from benzo­diazepines or narcotics, RLS can emerge and cause suffering until it is diagnosed and treated. Typical myalgia in opioid withdrawal can confound the diagnosis. The immediate-release (IR) and extended-release (ER) formu­lations of gabapentin often are a good choice when treating benzodiazepine or narcotic withdrawal. The side effect profile of gaba­pentin is relatively benign, with somnolence often reported by non-substance abusers, but it is unlikely that addicts, who have grown tolerant to more potent agents such as ben­zodiazepines and opioids, will complain of sleepiness. Studies have shown that gabapen­tin is useful in managing withdrawal as well as anxiety and insomnia.^1,2 A randomized trial showed that gabapentin increases abstinence rates and decreases heavy drinking.² The agent has a short half-life (5 to 7 hours); the IR form needs to be dosed at least 3 times a day to be effective. An ER formulation of gabap­entin was released in 2013 with the sole indi­cation for RLS.

Gabapentin is not significantly metabo­lized by the liver, has a 3% rate of protein bind­ing, and is excreted by the kidneys—making it safe for patients who abuse alcohol or opi­oids and have impaired hepatic function. Typical starting dosages of IR gabapentin are 100 to 300 mg, 3 times daily, if symptoms are present in the daytime. Asymmetric dosing can be helpful, with larger or single dosages given at bedtime (eg, 100 mg in morning, 100 mg in afternoon, 300 mg at bedtime). Dosing varies from patient to patient, from 300 mg to 3,600 mg/d. Increasing dosages produce lower bioavailability because of saturation in absorption or at the blood-brain barrier. At 100 mg every 8 hours, bioavail­ability is 80% but at 1,600 mg every 8 hours it drops to 27%.³

Periodic limb movements of sleep (PLMS) essentially is akathisia during sleep, and occurs in most patients with RLS. The patient feels tired in the morning because of lack of deep stage-N3 sleep. Because of the inverse relationship between serotonin and dopamine, most selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors can exacerbate RLS and PLMS.^4,5 Other culprits include antipsychot­ics, antiemetics, and antihistamines. The differential diagnosis includes withdrawal from opioids and attention-deficit/hyper­activity disorder (ADHD), which may be comorbid with RLS. There are many causes of secondary RLS including renal failure, pregnancy, varicose veins, and neuropathy.

Tremor
Benign familial, or essential, tremor is a fine intention tremor that can be suppressed by alcohol or benzodiazepines. After detoxifica­tion from either of these substances, persis­tent tremor can re-emerge; often, it is benign, although cerebellar and parkinsonian trem­ors must be ruled out. Essential tremor can be treated with gabapentin or beta blockers such as propranolol or metoprolol (Table 2).

Anxiety and panic disorder
Social anxiety often presents in addiction treatment centers in the context of group therapy, speaking in 12-step meetings, and having the patient describe his (her) autobi­ography and history of addiction. Because social anxiety disorder is the third most com­mon psychiatric disorder after simple pho­bia and major depressive disorder,⁶ it is not surprising that it emerges after withdrawal.

 

Patients with social anxiety disorder might self-medicate with alcohol or drugs, especially benzodiazepines (Box). Residential treatment presents an excellent environment for desensitization to fears of public speaking; early recognition is key. Apprehension about group therapy, present­ing a substance abuse history, or speaking at a 12-step meeting can lead to premature or “against medical advice” discharge.

Panic disorder commonly is comorbid with substance abuse. Many patients will arrive at treatment with a prescription for benzodiaz­epines. Because the risk of cross-addiction is high among recovering addicts, benzodiaze­pines should be avoided. Treating underlying anxiety is crucial for fostering sobriety. Generalized anxiety disorder is common among patients with an addiction, and can lead to relapse if not addressed. Use of non-addictive medications and cognitive therapy is useful in addressing this condition.

A quandary might arise in states where medical marijuana is legal, because Cannabis can be prescribed for anxiety disorders and posttraumatic stress disorder (PTSD). Promoting abstinence from all substances can present a challenge in patients with anxi­ety disorders who live in these states.

Medications for anxiety and panic dis­order include gabapentin, buspirone, hydroxyzine, beta blockers, and atypical antipsychotics (Table 2). Only buspirone and hydroxyzine are FDA-approved for anxiety; buspirone monotherapy generally is ineffec­tive for panic disorder.

Explaining to patients how anxiety arises, such as how classical conditioning leads to specific phobias, can be therapeu­tic. Describing Klein’s false suffocation alarm theory of panic attacks can illustrate the importance of practicing slow, deep breathing to prevent hyperventilation.⁷ Also, relabeling a panic attack with self-talk state­ments such as “I know what this is. It’s just a panic attack” can be helpful. Smartphone apps are available to help patients cope with anxiety and acute panic.⁸

Mood disorders
Many patients with bipolar disorder expe­rience substance abuse at some point; esti­mates are that up to 57% of patients have a comorbid addiction.^6,9 Persons with a mood disorder are at high risk of substance abuse because of genetic factors; patients also might self-medicate their mood symptoms.

After alcohol or drugs are withdrawn, mood disorders can emerge or resurge. Often, patients enter treatment taking antidepressants and mood stabilizers and usually haven’t been truthful with their treatment provider about their substance abuse. Care must be taken to ascertain whether mood symptoms are secondary to substance abuse. Asking “What’s the longest period of abstinence you’ve had in 2 years and how did you feel emotionally?” often will help you identify a secondary mood disorder. For example, a response of “6 months and I felt really depressed the entire time” would indicate a primary depressive disorder.

Because CNS depressants, such as alco­hol and benzodiazepines, can exacerbate a mood disorder, consider continuing or resuming a mood stabilizer or antidepres­sant during substance abuse treatment. When meeting a new patient, perform an independent evaluation, because substance use can mimic bipolar and depressive dis­orders. Careful assessment of suicidal ide­ation is necessary for all patients.

Sleep disorders
Insomnia—as a primary or secondary disorder—is common among patients with a substance use disorder. Insomnia always needs to be addressed. Not sleeping well interferes with cognition and energy and makes depression and bipolar disorder worse. Some experts recommend “waiting out” the insomnia, hoping that sobriety will resolve it—but it might not.

Initial insomnia can be treated with mela­tonin, 3 to 6 mg at bedtime or earlier in the evening.^10-12 Melatonin acts by regulating circadian rhythms, but can cause increased dreaming and nightmares; therefore, it should be avoided in patients who struggle with nightmares. Trazodone, 50 to 150 mg at bedtime, is an inexpensive sleep aid for initial insomnia and doesn’t cause weight gain, which many drugs with antihistaminic properties can. Prazosin, 1 to 2 mg initially, for nightmares in PTSD is effective.¹³

Antipsychotics might be necessary if nothing else works; quetiapine is effective for sleep and the ER form is FDA-approved as an add-on agent in major depression. Low-dose doxepin (≤10 mg) is effective for middle insomnia.¹⁴ At these low dosages, troublesome side effects of tricyclic antide­pressants can be avoided.

As many as 40% of adults with ADHD have a delayed sleep-phase disorder. Ask your patient if she is a “night owl,” how chronic the condition is, and when her best sleep occurs.15-17 Morning light and evening melatonin can help, but often are insufficient. Many patients present with undiagnosed or untreated sleep apnea, which can cause excessive daytime sleepiness. Referral to a sleep center is prudent; use of the Epworth Sleepiness Scale is a quick way to assess excessive daytime sleepiness.¹⁸

ADHD
ADHD commonly is comorbid with a sub­stance use disorder. Patients might pres­ent with an earlier diagnosis, including treatment. Several drugs of abuse can alle­viate ADHD symptoms, including amphet­amines, opioids, cocaine, and Cannabis; self-medicating is common. Because opi­oids increase dopamine release, a report of improved work and school performance while taking opioids early in addiction can be a clue to an ADHD diagnosis.

Explaining ADHD as a syndrome of “interest-based attention” helps. If a resi­dential treatment program uses reading and writing assignments, a patient with ADHD might struggle and will need extra help and time and a quiet place to do assignments.^19,20 A non-addictive medication, such as ato­moxetine, can help, but has an antidepres­sant-like delay of 3 to 5 weeks until onset of symptom relief. Using a long-acting stimu­lant can be effective and quick, with an effect size 3 to 4 times higher than atomoxetine; such agents should be avoided in patients who abuse amphetamines.

 

Studies show that treating ADHD, even with stimulants, neither helps nor hurts out­comes in substance use. Lisdexamfetamine is difficult to abuse and is an inactive prodrug (a bond of lysine and dextroamphetamine) that requires enzymatic cleavage and activa­tion by red blood cells; these characteristics creates a long-acting medication that has a lower abuse liability than other drugs for ADHD. However, abuse can occur and the drug must be used cautiously. Earley’s medi­cation guide referenced below recommends that lisdexamfetamine and other stimulants should be avoided if possible in patients in recovery. However, it adds that special­ists in treating ADHD in substance-abusing patients should weigh the potential benefits of stimulant use against the risk of relapse.¹⁷ Many patients enter treatment with a diag­nosis of bipolar disorder that might, in fact, be comorbid with ADHD.

Chronic pain
Many substance abuse patients began taking opioids for acute, then chronic, pain before their use escalated to addiction. These are challenging patients; often, they are referred for treatment without true addiction.

Keep in mind that dependence is not addiction. Pseudo-addiction is a condition in which pain is undertreated and the patient takes more medication to obtain relief, calls for early refills, and displays drug-seeking behavior but is not using drugs to achieve euphoria. A thorough history and physical and referrals to specialists such as orthopedic surgeons and pain specialists are necessary. Explaining opioid-induced hyperalgesia is important to help the patient understand that (1) pain can be made worse by increas­ing the dosage of an opioid because of supersensitivity and (2) many patients who are weaned off these drugs will experience a decrease or complete relief of pain.²¹

Gabapentin, duloxetine, or amitriptyline can be beneficial for chronic pain, as well as mindfulness techniques, physical therapy, and complementary and alternative medi­cine. Pregabalin can produce euphoria and often should be avoided.

A medication guide for recovery
Paul Earley, MD, former medical director at Talbott Recovery in Atlanta, Georgia, pub­lishes an online guide that classifies medica­tions into categories:
   • A: safe
   • B: use only under the supervision of an addiction medicine specialist or doctor
   • C: completely avoid if the patient is in recovery.¹⁷

The Talbott guide lists all stimulants in category C, (except for atomoxetine, which is category A). Hydroxyzine is listed under category B. Many programs for impaired professionals and state medical boards use the Guide, and will question the prescribing of any medication from categories B and C.¹⁷

Related Resources
• Spiegel DR, Kumari N, Petri JD. Safer use of benzodiaz­epines for alcohol detoxification. Current Psychiatry. 2012;11(10):10-15.
• Kelly TM, Daley DC, Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. Addict Behav. 2012;37(1):11-24.

Drug Brand Names
Amitriptyline • Elavil                                     Hydrocodone • Vicodin
Atenolol • Tenormin                                      Hydroxyzine • Vistaril, Atarax
Atomoxetine • Strattera                                Lisdexamfetamine • Vyvanse
Buprenorphine/ naloxone • Suboxone             Metoprolol • Lopressor, Toprol
Buspirone • BuSpar                                       Paroxetine • Paxil
Carbidopa-levodopa • Sinemet                       Pramipexole • Mirapex
Clonazepam • Klonopin                                  Prazosin • Minipress
Diazepam • Valium                                        Pregabalin • Lyrica
Doxepin • Silenor, Adapin, Sinequan               Propranolol • Inderal
Duloxetine • Cymbalta                                   Quetiapine • Seroquel
Escitalopram • Lexapro                                  Ropinirole • Requip
Gabapentin • Neurontin, Horizant                   Sertraline • Zoloft
                                                                   Trazodone • Desyrel

Disclosure
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

As part of a general trend among all medical spe­cialty boards, the American Board of Psychiatry and Neurology (ABPN) instituted a recertification process for all new general psychiatry certifications on October 1, 1994.¹ In 2000, the individual specialties that constitute the American Board of Medical Specialties (ABMS) subsequently agreed to develop a comprehensive maintenance of certification (MOC) pro­cess to demonstrate ongoing learning and competency beyond what could be captured by a recertification examination alone.

All ABMS member boards now use a 4-part process for recertification. For ABPN, those 4 core components are listed in the Table.^1,2

ABPN component 1 (maintaining an unrestricted medical license) and component 4 (passing the recertification examina­tion) are straightforward; however, requirements for continu­ing medical education (CME), including the specific need to accrue ABPN-approved self-assessment (SA) CME hours, and the Improvement in Medical Practice (performance in prac­tice, or PIP) module, have stoked significant commentary and confusion.

Based on feedback,^3,4 ABPN in 2014:
   • modified the SA and PIP requirements for physicians who certified or recertified between 2005 and 2011
   • changed the specific requirement for the PIP feedback component.

These modifications only added to feelings of uncertainty about the MOC process among many psychiatrists.⁵ 

Given the professional and personal importance attached to maintaining one’s general and subspecialty certifications, the 2 parts of this article—here and in the January 2015 issue—have been constructed to highlight current ABPN MOC require­ments and provide resources for understand­ing, tracking, and completing the SA and PIP portions.

In addition to this review, I urge all phy­sicians who are subject to MOC to read the 20-page revised MOC Program booklet^a (ver­sion 2.1, May 2014).⁵

^aDownload the booklet at www.abpn.com/downloads/moc/ moc_web_doc.pdf.

Who must recertify?
As of October 1, 1994, all physicians who achieve ABPN certifications in general psy­chiatry are issued a 10-year, time-limited certificate that expires on December 31 of the 10th year.³ Note that the 10-year, time-limited certificate in child and adolescent psychiatry began in 1995 and expires 10 years later on December 31.

Certificates in the subspecialties (addic­tion psychiatry, forensic psychiatry, geriat­ric psychiatry, etc.), including those issued before October 1, 1994, are 10-year, time-limited certificates that expire on December 31.³ This expiration date often is overlooked by physicians who are exempt from the MOC process for their general psychiatry, or child and adolescent psychiatry certifi­cation. There is no exemption for any sub­specialty certificate (aside from child and adolescent psychiatry before 1995), regard­less of the date of issue.

Moreover, physicians who hold a cer­tificate in a subspecialty also must maintain certification in their specialty (general psychi­atry) to apply for recertification in their sub­specialization. One exception: Diplomates in child and adolescent psychiatry do not need to maintain current certification in general psychiatry for their subspecialty certification to remain valid or to recertify in child and adolescent psychiatry.

The need to maintain multiple certifica­tions can seem onerous, but note that CME, SA, and PIP activities that have been com­pleted in one area of specialization or sub­specialization accrue and count for multiple certifications for diplomates certified in 2 or more areas.⁵

Get started!
Tracking your progress is critical to keep­ing up with MOC requirements. You can do this with a personal spreadsheet or by using online resources. Although it is not required, ABPN has established a system that allows diplomates to create and main­tain, at no cost, a physician folio on the ABPN server that facilitates documentation of CME hours, including specific SA hours, and PIP module completion.⁶ All diplomates are required to maintain records of SA activi­ties, CME activities, and PIP units; the ABPN will audit approximately 5% of examination applications.⁵

Regardless of what documentation method you choose, you should establish an active profile on the ABPN site (www.abpn. com/folios), confirm your contact infor­mation, and, if you are not active clinically, update your clinical status. ABPN requires that diplomates self-report their clinical sta­tus every 24 months—information that is available to the public. Clinical status also identifies to ABPN those PIP modules that you must complete.

ABPN recognizes 3 categories of clinical status⁵:
1. Clinically active. Provided any amount of direct or consultative care, or both, in the preceding 24 months, includ­ing supervision of residents.  
   a) Engaged in direct or consultative care, or both, sufficient to complete Improvement in Medical Practice (PIP) units.  
   b) Engaged in direct or consultative care, or both, that is insufficient to complete PIP units.

2. Clinically inactive. Did not provide direct or consultative care in the preceding 24 months.

3. Status unknown. No information is available on clinical activity.

Based on these definitions, physicians in Category 1a are required to complete all com­ponents of the MOC program, including PIP units; physicians in Category 1b or Category 2 are required to complete all components of the MOC program except PIP units.

 

A change in status from Category 1b or 2 to Category 1a (eg, moving from a purely administrative position to one with clinical duties) requires completion of ≥1 PIP unit.

The easy parts
Licenses. Maintaining your unrestricted professional license(s) is mandatory; the language of this requirement is unambigu­ous (Table).⁵ The plural form of license is intentional: Some physicians have medi­cal licenses in multiple states and, in some jurisdictions, licenses are required to super­vise physician assistants and other person­nel or to prescribe controlled substances. Any restriction on a professional license should be discussed with ABPN and resolved to prevent rejection of the exami­nation application.⁵

Examinations. For physicians who are not yet enrolled in the continuous-MOC (C-MOC) process (to be discussed in Part 2 of this article), an application to take the examination in Year 10 can be filed in Year 9 of the cycle—after the CME, SA, and PIP requirements are completed. Once a diplo­mate becomes subject to the C-MOC pro­cess by certifying or recertifying from 2012 onwards, completion of each 3-year module of CME, SA, and PIP will not coincide with the 10-year time frame of the examination.

The application deadline for all MOC examinations typically is the year before the examination; the examination should be taken in the year the certificate expires, although it can be taken earlier if desired.7 The examinations are computer-based and administered at a certified testing cen­ter. For diplomates who have more than 1 ABPN certificate and want to combine multiple examinations into 1 test session, a reduced fee structure applies.

The general psychiatry examination com­prises 220 single-answer, multiple-choice questions that must be completed within 290 minutes, with 10 extra minutes allotted to read on-screen instructions, sign in, and complete a post-examination survey.⁸ The combined examinations comprise 100 ques­tions from each ABPN specialty or subspe­cialty area.⁵

The content of the 2015 general psychiatry examination^b is available on the ABPN Web site.⁷ Note that the recertification examination in general psychiatry does not cover neurol­ogy topics.

^bDownload the outline of the examination at www.abpn.com/ downloads/content_outlines/MOC/2015-MOC-Psych-blueprint-060314-EWM-MR.pdf.

Examinations administered in 2015 and 2016 will use only diagnostic criteria that have not changed from DSM-IV-TR⁹: Neither obsolete diagnoses or subtypes from DSM-IV-TR nor new diagnoses or subtypes in DSM-5 (eg, hoarding disorder) will be tested.⁹ Diagnoses that are exactly or substantially the same will be tested; these include diagnoses:  
   • with a name change only (eg, “phono­logical disorder” in DSM-IV-TR is “speech sound disorder” in DSM-5)  
   • expanded into >1 new diagnosis (eg, hypochondriasis was expanded to 2 new diagnoses: somatic symptom disorder and ill­ness anxiety disorder)  
    • subsumed or combined into a new diag­nosis (eg, substance use and dependence are now combined into substance use disorder in DSM-5).⁹

For these diagnoses, both DSM-IV-TR and DSM-5 diagnoses will be provided on examinations.

Beginning in 2017, all examinations will use DSM-5 classifications and diagnostic criteria.⁹

Part 2 of this article in the January 2015 issue reviews other key aspects of MOC: continu­ing medical education (CME), including self-assessment requirements; performance in practice (PIP); and continuous maintenance of certification (C-MOC).

BOTTOM LINE
Maintenance of certification (MOC) is a manageable process, although it requires you to be familiar with its various elements, including the duration of certification, licensing requirements, and the examination. Start the process by (1) establishing a login on the ABPN Web site and (2) reviewing the MOC program booklet.

Related Resources
• ABPN MOC home page. www.abpn.com/moc.html
• ABPN-approved products for SA, CME, and PIP modules. www.abpn.com/moc_products.asp
• Peer and patient feedback forms– Peer feedback form v1. www.abpn.com/downloads/moc/PIP-peer-feedback-v1-051914.pdf
   – Patient feedback form v1. www.abpn.com/downloads/moc/PIP-patient-feedback-v1-051914.pdf
   – Patient feedback form v2. www.abpn.com/downloads/moc/PIP-patient-feedback-v2-051914.pdf
• ABPN physician folio page. https://application.abpn.com/webclient/folios.aspx

Disclosure
Dr. Meyer reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

As part of a general trend among all medical spe­cialty boards, the American Board of Psychiatry and Neurology (ABPN) instituted a recertification process for all new general psychiatry certifications on October 1, 1994.¹ In 2000, the individual specialties that constitute the American Board of Medical Specialties (ABMS) subsequently agreed to develop a comprehensive maintenance of certification (MOC) pro­cess to demonstrate ongoing learning and competency beyond what could be captured by a recertification examination alone.

All ABMS member boards now use a 4-part process for recertification. For ABPN, those 4 core components are listed in the Table.^1,2

ABPN component 1 (maintaining an unrestricted medical license) and component 4 (passing the recertification examina­tion) are straightforward; however, requirements for continu­ing medical education (CME), including the specific need to accrue ABPN-approved self-assessment (SA) CME hours, and the Improvement in Medical Practice (performance in prac­tice, or PIP) module, have stoked significant commentary and confusion.

Based on feedback,^3,4 ABPN in 2014:
   • modified the SA and PIP requirements for physicians who certified or recertified between 2005 and 2011
   • changed the specific requirement for the PIP feedback component.

These modifications only added to feelings of uncertainty about the MOC process among many psychiatrists.⁵ 

Given the professional and personal importance attached to maintaining one’s general and subspecialty certifications, the 2 parts of this article—here and in the January 2015 issue—have been constructed to highlight current ABPN MOC require­ments and provide resources for understand­ing, tracking, and completing the SA and PIP portions.

In addition to this review, I urge all phy­sicians who are subject to MOC to read the 20-page revised MOC Program booklet^a (ver­sion 2.1, May 2014).⁵

^aDownload the booklet at www.abpn.com/downloads/moc/ moc_web_doc.pdf.

Who must recertify?
As of October 1, 1994, all physicians who achieve ABPN certifications in general psy­chiatry are issued a 10-year, time-limited certificate that expires on December 31 of the 10th year.³ Note that the 10-year, time-limited certificate in child and adolescent psychiatry began in 1995 and expires 10 years later on December 31.

Certificates in the subspecialties (addic­tion psychiatry, forensic psychiatry, geriat­ric psychiatry, etc.), including those issued before October 1, 1994, are 10-year, time-limited certificates that expire on December 31.³ This expiration date often is overlooked by physicians who are exempt from the MOC process for their general psychiatry, or child and adolescent psychiatry certifi­cation. There is no exemption for any sub­specialty certificate (aside from child and adolescent psychiatry before 1995), regard­less of the date of issue.

Moreover, physicians who hold a cer­tificate in a subspecialty also must maintain certification in their specialty (general psychi­atry) to apply for recertification in their sub­specialization. One exception: Diplomates in child and adolescent psychiatry do not need to maintain current certification in general psychiatry for their subspecialty certification to remain valid or to recertify in child and adolescent psychiatry.

The need to maintain multiple certifica­tions can seem onerous, but note that CME, SA, and PIP activities that have been com­pleted in one area of specialization or sub­specialization accrue and count for multiple certifications for diplomates certified in 2 or more areas.⁵

Get started!
Tracking your progress is critical to keep­ing up with MOC requirements. You can do this with a personal spreadsheet or by using online resources. Although it is not required, ABPN has established a system that allows diplomates to create and main­tain, at no cost, a physician folio on the ABPN server that facilitates documentation of CME hours, including specific SA hours, and PIP module completion.⁶ All diplomates are required to maintain records of SA activi­ties, CME activities, and PIP units; the ABPN will audit approximately 5% of examination applications.⁵

Regardless of what documentation method you choose, you should establish an active profile on the ABPN site (www.abpn. com/folios), confirm your contact infor­mation, and, if you are not active clinically, update your clinical status. ABPN requires that diplomates self-report their clinical sta­tus every 24 months—information that is available to the public. Clinical status also identifies to ABPN those PIP modules that you must complete.

ABPN recognizes 3 categories of clinical status⁵:
1. Clinically active. Provided any amount of direct or consultative care, or both, in the preceding 24 months, includ­ing supervision of residents.  
   a) Engaged in direct or consultative care, or both, sufficient to complete Improvement in Medical Practice (PIP) units.  
   b) Engaged in direct or consultative care, or both, that is insufficient to complete PIP units.

2. Clinically inactive. Did not provide direct or consultative care in the preceding 24 months.

3. Status unknown. No information is available on clinical activity.

Based on these definitions, physicians in Category 1a are required to complete all com­ponents of the MOC program, including PIP units; physicians in Category 1b or Category 2 are required to complete all components of the MOC program except PIP units.

 

A change in status from Category 1b or 2 to Category 1a (eg, moving from a purely administrative position to one with clinical duties) requires completion of ≥1 PIP unit.

The easy parts
Licenses. Maintaining your unrestricted professional license(s) is mandatory; the language of this requirement is unambigu­ous (Table).⁵ The plural form of license is intentional: Some physicians have medi­cal licenses in multiple states and, in some jurisdictions, licenses are required to super­vise physician assistants and other person­nel or to prescribe controlled substances. Any restriction on a professional license should be discussed with ABPN and resolved to prevent rejection of the exami­nation application.⁵

Examinations. For physicians who are not yet enrolled in the continuous-MOC (C-MOC) process (to be discussed in Part 2 of this article), an application to take the examination in Year 10 can be filed in Year 9 of the cycle—after the CME, SA, and PIP requirements are completed. Once a diplo­mate becomes subject to the C-MOC pro­cess by certifying or recertifying from 2012 onwards, completion of each 3-year module of CME, SA, and PIP will not coincide with the 10-year time frame of the examination.

The application deadline for all MOC examinations typically is the year before the examination; the examination should be taken in the year the certificate expires, although it can be taken earlier if desired.7 The examinations are computer-based and administered at a certified testing cen­ter. For diplomates who have more than 1 ABPN certificate and want to combine multiple examinations into 1 test session, a reduced fee structure applies.

The general psychiatry examination com­prises 220 single-answer, multiple-choice questions that must be completed within 290 minutes, with 10 extra minutes allotted to read on-screen instructions, sign in, and complete a post-examination survey.⁸ The combined examinations comprise 100 ques­tions from each ABPN specialty or subspe­cialty area.⁵

The content of the 2015 general psychiatry examination^b is available on the ABPN Web site.⁷ Note that the recertification examination in general psychiatry does not cover neurol­ogy topics.

^bDownload the outline of the examination at www.abpn.com/ downloads/content_outlines/MOC/2015-MOC-Psych-blueprint-060314-EWM-MR.pdf.

Examinations administered in 2015 and 2016 will use only diagnostic criteria that have not changed from DSM-IV-TR⁹: Neither obsolete diagnoses or subtypes from DSM-IV-TR nor new diagnoses or subtypes in DSM-5 (eg, hoarding disorder) will be tested.⁹ Diagnoses that are exactly or substantially the same will be tested; these include diagnoses:  
   • with a name change only (eg, “phono­logical disorder” in DSM-IV-TR is “speech sound disorder” in DSM-5)  
   • expanded into >1 new diagnosis (eg, hypochondriasis was expanded to 2 new diagnoses: somatic symptom disorder and ill­ness anxiety disorder)  
    • subsumed or combined into a new diag­nosis (eg, substance use and dependence are now combined into substance use disorder in DSM-5).⁹

For these diagnoses, both DSM-IV-TR and DSM-5 diagnoses will be provided on examinations.

Beginning in 2017, all examinations will use DSM-5 classifications and diagnostic criteria.⁹

Part 2 of this article in the January 2015 issue reviews other key aspects of MOC: continu­ing medical education (CME), including self-assessment requirements; performance in practice (PIP); and continuous maintenance of certification (C-MOC).

BOTTOM LINE
Maintenance of certification (MOC) is a manageable process, although it requires you to be familiar with its various elements, including the duration of certification, licensing requirements, and the examination. Start the process by (1) establishing a login on the ABPN Web site and (2) reviewing the MOC program booklet.

Related Resources
• ABPN MOC home page. www.abpn.com/moc.html
• ABPN-approved products for SA, CME, and PIP modules. www.abpn.com/moc_products.asp
• Peer and patient feedback forms– Peer feedback form v1. www.abpn.com/downloads/moc/PIP-peer-feedback-v1-051914.pdf
   – Patient feedback form v1. www.abpn.com/downloads/moc/PIP-patient-feedback-v1-051914.pdf
   – Patient feedback form v2. www.abpn.com/downloads/moc/PIP-patient-feedback-v2-051914.pdf
• ABPN physician folio page. https://application.abpn.com/webclient/folios.aspx

Disclosure
Dr. Meyer reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

As part of a general trend among all medical spe­cialty boards, the American Board of Psychiatry and Neurology (ABPN) instituted a recertification process for all new general psychiatry certifications on October 1, 1994.¹ In 2000, the individual specialties that constitute the American Board of Medical Specialties (ABMS) subsequently agreed to develop a comprehensive maintenance of certification (MOC) pro­cess to demonstrate ongoing learning and competency beyond what could be captured by a recertification examination alone.

All ABMS member boards now use a 4-part process for recertification. For ABPN, those 4 core components are listed in the Table.^1,2

ABPN component 1 (maintaining an unrestricted medical license) and component 4 (passing the recertification examina­tion) are straightforward; however, requirements for continu­ing medical education (CME), including the specific need to accrue ABPN-approved self-assessment (SA) CME hours, and the Improvement in Medical Practice (performance in prac­tice, or PIP) module, have stoked significant commentary and confusion.

Based on feedback,^3,4 ABPN in 2014:
   • modified the SA and PIP requirements for physicians who certified or recertified between 2005 and 2011
   • changed the specific requirement for the PIP feedback component.

These modifications only added to feelings of uncertainty about the MOC process among many psychiatrists.⁵ 

Given the professional and personal importance attached to maintaining one’s general and subspecialty certifications, the 2 parts of this article—here and in the January 2015 issue—have been constructed to highlight current ABPN MOC require­ments and provide resources for understand­ing, tracking, and completing the SA and PIP portions.

In addition to this review, I urge all phy­sicians who are subject to MOC to read the 20-page revised MOC Program booklet^a (ver­sion 2.1, May 2014).⁵

^aDownload the booklet at www.abpn.com/downloads/moc/ moc_web_doc.pdf.

Who must recertify?
As of October 1, 1994, all physicians who achieve ABPN certifications in general psy­chiatry are issued a 10-year, time-limited certificate that expires on December 31 of the 10th year.³ Note that the 10-year, time-limited certificate in child and adolescent psychiatry began in 1995 and expires 10 years later on December 31.

Certificates in the subspecialties (addic­tion psychiatry, forensic psychiatry, geriat­ric psychiatry, etc.), including those issued before October 1, 1994, are 10-year, time-limited certificates that expire on December 31.³ This expiration date often is overlooked by physicians who are exempt from the MOC process for their general psychiatry, or child and adolescent psychiatry certifi­cation. There is no exemption for any sub­specialty certificate (aside from child and adolescent psychiatry before 1995), regard­less of the date of issue.

Moreover, physicians who hold a cer­tificate in a subspecialty also must maintain certification in their specialty (general psychi­atry) to apply for recertification in their sub­specialization. One exception: Diplomates in child and adolescent psychiatry do not need to maintain current certification in general psychiatry for their subspecialty certification to remain valid or to recertify in child and adolescent psychiatry.

The need to maintain multiple certifica­tions can seem onerous, but note that CME, SA, and PIP activities that have been com­pleted in one area of specialization or sub­specialization accrue and count for multiple certifications for diplomates certified in 2 or more areas.⁵

Get started!
Tracking your progress is critical to keep­ing up with MOC requirements. You can do this with a personal spreadsheet or by using online resources. Although it is not required, ABPN has established a system that allows diplomates to create and main­tain, at no cost, a physician folio on the ABPN server that facilitates documentation of CME hours, including specific SA hours, and PIP module completion.⁶ All diplomates are required to maintain records of SA activi­ties, CME activities, and PIP units; the ABPN will audit approximately 5% of examination applications.⁵

Regardless of what documentation method you choose, you should establish an active profile on the ABPN site (www.abpn. com/folios), confirm your contact infor­mation, and, if you are not active clinically, update your clinical status. ABPN requires that diplomates self-report their clinical sta­tus every 24 months—information that is available to the public. Clinical status also identifies to ABPN those PIP modules that you must complete.

ABPN recognizes 3 categories of clinical status⁵:
1. Clinically active. Provided any amount of direct or consultative care, or both, in the preceding 24 months, includ­ing supervision of residents.  
   a) Engaged in direct or consultative care, or both, sufficient to complete Improvement in Medical Practice (PIP) units.  
   b) Engaged in direct or consultative care, or both, that is insufficient to complete PIP units.

2. Clinically inactive. Did not provide direct or consultative care in the preceding 24 months.

3. Status unknown. No information is available on clinical activity.

Based on these definitions, physicians in Category 1a are required to complete all com­ponents of the MOC program, including PIP units; physicians in Category 1b or Category 2 are required to complete all components of the MOC program except PIP units.

 

A change in status from Category 1b or 2 to Category 1a (eg, moving from a purely administrative position to one with clinical duties) requires completion of ≥1 PIP unit.

The easy parts
Licenses. Maintaining your unrestricted professional license(s) is mandatory; the language of this requirement is unambigu­ous (Table).⁵ The plural form of license is intentional: Some physicians have medi­cal licenses in multiple states and, in some jurisdictions, licenses are required to super­vise physician assistants and other person­nel or to prescribe controlled substances. Any restriction on a professional license should be discussed with ABPN and resolved to prevent rejection of the exami­nation application.⁵

Examinations. For physicians who are not yet enrolled in the continuous-MOC (C-MOC) process (to be discussed in Part 2 of this article), an application to take the examination in Year 10 can be filed in Year 9 of the cycle—after the CME, SA, and PIP requirements are completed. Once a diplo­mate becomes subject to the C-MOC pro­cess by certifying or recertifying from 2012 onwards, completion of each 3-year module of CME, SA, and PIP will not coincide with the 10-year time frame of the examination.

The application deadline for all MOC examinations typically is the year before the examination; the examination should be taken in the year the certificate expires, although it can be taken earlier if desired.7 The examinations are computer-based and administered at a certified testing cen­ter. For diplomates who have more than 1 ABPN certificate and want to combine multiple examinations into 1 test session, a reduced fee structure applies.

The general psychiatry examination com­prises 220 single-answer, multiple-choice questions that must be completed within 290 minutes, with 10 extra minutes allotted to read on-screen instructions, sign in, and complete a post-examination survey.⁸ The combined examinations comprise 100 ques­tions from each ABPN specialty or subspe­cialty area.⁵

The content of the 2015 general psychiatry examination^b is available on the ABPN Web site.⁷ Note that the recertification examination in general psychiatry does not cover neurol­ogy topics.

^bDownload the outline of the examination at www.abpn.com/ downloads/content_outlines/MOC/2015-MOC-Psych-blueprint-060314-EWM-MR.pdf.

Examinations administered in 2015 and 2016 will use only diagnostic criteria that have not changed from DSM-IV-TR⁹: Neither obsolete diagnoses or subtypes from DSM-IV-TR nor new diagnoses or subtypes in DSM-5 (eg, hoarding disorder) will be tested.⁹ Diagnoses that are exactly or substantially the same will be tested; these include diagnoses:  
   • with a name change only (eg, “phono­logical disorder” in DSM-IV-TR is “speech sound disorder” in DSM-5)  
   • expanded into >1 new diagnosis (eg, hypochondriasis was expanded to 2 new diagnoses: somatic symptom disorder and ill­ness anxiety disorder)  
    • subsumed or combined into a new diag­nosis (eg, substance use and dependence are now combined into substance use disorder in DSM-5).⁹

For these diagnoses, both DSM-IV-TR and DSM-5 diagnoses will be provided on examinations.

Beginning in 2017, all examinations will use DSM-5 classifications and diagnostic criteria.⁹

Part 2 of this article in the January 2015 issue reviews other key aspects of MOC: continu­ing medical education (CME), including self-assessment requirements; performance in practice (PIP); and continuous maintenance of certification (C-MOC).

BOTTOM LINE
Maintenance of certification (MOC) is a manageable process, although it requires you to be familiar with its various elements, including the duration of certification, licensing requirements, and the examination. Start the process by (1) establishing a login on the ABPN Web site and (2) reviewing the MOC program booklet.

Related Resources
• ABPN MOC home page. www.abpn.com/moc.html
• ABPN-approved products for SA, CME, and PIP modules. www.abpn.com/moc_products.asp
• Peer and patient feedback forms– Peer feedback form v1. www.abpn.com/downloads/moc/PIP-peer-feedback-v1-051914.pdf
   – Patient feedback form v1. www.abpn.com/downloads/moc/PIP-patient-feedback-v1-051914.pdf
   – Patient feedback form v2. www.abpn.com/downloads/moc/PIP-patient-feedback-v2-051914.pdf
• ABPN physician folio page. https://application.abpn.com/webclient/folios.aspx

Disclosure
Dr. Meyer reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Manic episodes, by definition, are associated with significant social or occupational impairment.¹ Some manic patients are violent or engage in reckless behaviors that can harm themselves or others, such as speeding, disrupting traffic, or playing with fire. When these patients present to a psychiatrist’s outpatient practice, involuntary hospitalization might be justified.

However, some manic patients, in spite of their elevated, expansive, or irritable mood state, never behave dangerously and might not meet legal criteria for involuntary hospitalization, although these criteria differ from state to state. These patients might see a psychiatrist because manic symptoms such as irritability, talkativeness, and impulsivity are bother­some to their family members but pose no serious danger (Box). In this situation, the psychiatrist can strongly encourage the patient to seek voluntary hospitalization or attend a partial hospitalization program. If the patient declines, the psychiatrist is left with 2 choices: initiate treatment in the outpatient setting or refuse to treat the patient and refer to another provider.

Treating “non-dangerous” mania in the outpatient setting is fraught with challenges:
   • the possibility that the patient’s condition will progress to dangerousness
   • poor adherence to treatment because of the patient’s limited insight
   • the large amount of time required from the psychiatrist and care team to adequately manage the manic episode (eg, time spent with fam­ily members, frequent patient visits, and managing communications from the patient).

There are no guidelines to assist the office-based practitioner in treating mania in the outpatient setting. When considering dosing and optimal medication combina­tions for treating mania, clinical trials may be of limited value because most of these studies only included hospitalized manic patients.

Because of this dearth of knowledge, we provide recommendations based on our review of the literature and from our expe­rience working with manic patients who refuse voluntary hospitalization and could not be hospitalized against their will. These recommendations are organized into 3 sec­tions: diagnostic approach, treatment strat­egy, and family involvement.

Diagnostic approach
Making a diagnosis of mania might seem straightforward for clinicians who work in inpatient settings; however, mania might not present with classic florid symptoms among outpatients. Patients might have a chief concern of irritability, dysphoria, anxiety, or “insomnia,” which may lead clinicians to focus initially on non-bipolar conditions.²

During the interview, it is important to assess for any current DSM-5 symptoms of a manic episode, while being careful not to accept a patient’s denial of symptoms. Patients with mania often have poor insight and are unaware of changes from their base­line state when manic.³ Alternatively, manic patients may want you to believe that they are well and could minimize or deny all symptoms. Therefore, it is important to pay attention to mental status examination find­ings, such as hyperverbal speech, elated affect, psychomotor agitation, a tangential thought process, or flight of ideas.

Countertransference feelings of diagnos­tic confusion or frustration after long patient monologues or multiple interruptions by the patient should be incorporated into the diagnostic assessment. Family members or friends often can provide objective obser­vations of behavioral changes necessary to secure the diagnosis.

Treatment strategy
Decision points. When treating manic out­patients, assess the need for hospitalization at each visit. Advantages of the inpatient setting include:
   • the possibility of rapid medication adjustments
   • continuous observation to ensure the patient’s safety
   • keeping the patient temporarily removed from his community to prevent irrevers­ible social and economic harms.

However, a challenge with hospitaliza­tion is third-party payers’ influence on a patient’s length of stay, which may lead to rapid medication changes that may not be clinically ideal.

At each outpatient visit, explore with the patient and family emerging symptoms that could justify involuntary hospitaliza­tion. Document whether you recommended inpatient hospitalization, the patient’s response to the recommendation, that you are aware and have considered the risks associated with outpatient care, and that you have discussed these risks with the patient and family.

For patients well-known to the psychia­trist, a history of dangerous mania may lead him (her) to strongly recommend hos­pitalization, whereas a pre-existing thera­peutic alliance and no current or distant history of dangerous mania may lead the clinician to look for alternatives to inpatient care. Concomitant drug or alcohol use may increase the likelihood of mania becoming dangerous, making outpatient treatment ill-advised and riskier for everyone involved.

In exchange for agreeing to provide out­patient care for mania, it often is helpful to negotiate with the patient and family a threshold level of symptoms or behavior that will result in the patient agreeing to voluntary hospitalization (Table 1). Such an agreement can include stopping outpatient treatment if the patient does not improve significantly after 2 or 3 weeks or develops psychotic symptoms. The negotiation also can include partial hospitalization as an option, so long as the patient’s mania con­tinues to be non-dangerous.

 

Obtaining pretreatment blood work can help a clinician determine whether a medication is safe to prescribe and establish causality if laboratory abnormalities arise after treatment begins. Ideally, the psychia­trist should follow consensus guidelines developed by the International Society for Bipolar Disorders⁴ or the American Psychiatric Association (APA)⁵ and order appropriate laboratory tests before prescrib­ing anti-manic medications. Determine the pregnancy status of female patients of child-bearing age before prescribing a potentially teratogenic medication, especially because mania is associated with increased libido.⁶

Manic patients might be too disorga­nized to follow up with recommendations for laboratory testing, or could wait sev­eral days before completing blood work. Although not ideal, to avoid delaying treat­ment, a clinician might need to prescribe medication at the initial office visit, without pretreatment laboratory results. When the patient is more organized, complete the blood work. Keeping home pregnancy tests in the office can help rule out pregnancy before prescribing medication.

Medication. Meta-analyses have estab­lished the efficacy of mood stabilizers and antipsychotics for treating mania,^7,8 and sev­eral consensus guidelines have incorporated these findings into treatment algorithms.⁹

For a patient already taking medications recommended by the guidelines, assess treatment adherence during the initial inter­view by questioning the patient and family. When the logistics of phlebotomy permit, obtaining the blood level of psychotropics can show the presence of any detectable drug concentration, which demonstrates that the patient has taken the medication recently.

If there is no evidence of nonadherence, an initial step might be to increase the dos­age of the antipsychotic or mood stabilizer that the patient is already taking, ensuring that the dosage is optimized based on FDA indications and clinical trials data. The rec­ommended rate of dosage adjustments dif­fers among medications; however, optimal dosing should be reached quickly because a World Federation of Societies of Biological Psychiatry task force recommends that a mania treatment trial not exceed 2 weeks.¹⁰

Dosage increases can be made at weekly visits or sooner, based on treatment response and tolerability. If there is no ben­efit after optimizing the dosage, the next step would be to add a mood stabilizer to a second-generation antipsychotic (SGA), or vice versa to promote additive or syn­ergistic medication effects.¹¹ Switching one medication for the other should be avoided unless there are tolerability concerns.

For a patient who is not taking any medi­cations, select a treatment that balances rapid stabilization with long-term efficacy and tolerability. Table 2 lists FDA-approved treatments for mania. Lamotrigine provides prophylactic efficacy with few associated risks, but it has no anti-manic effects and would be a poor choice for most actively manic patients. Most studies indicate that antipsychotics work faster than lithium at the 1-week mark; however, this may be a function of the lithium titration schedule followed in the protocols, the severity of mania among enrolled patients, the inclu­sion of typically non-responsive manic patients (eg, mixed) in the analysis, and the antipsychotic’s sedative potential rela­tive to lithium. Although the anti-manic and prophylactic potential of lithium and valproate might make them an ideal first-line option, antipsychotics could stabilize a manic patient faster, especially if agitation is present.^12,13

Breaking mania quickly is important when treating patients in the outpatient set­ting. In these situations, a reasonable choice is to prescribe a SGA, because of their rapid onset of effect, low potential for switch to depression, and utility in treating classic, mixed, or psychotic mania.¹⁰ Oral loading of valproate (20 mg/kg) is another option. An inpatient study that used an oral-loading strategy demonstrated a similar time to response as olanzapine,¹⁴ in contrast to an inpatient¹⁵ and an outpatient study¹⁶ that employed a standard starting dosage for each patient and led to slower improve­ment compared with olanzapine.

SGAs should be dosed moderately and lower than if the patient were hospitalized, to avoid alienating the patient from treat­ment by causing intolerable side effects. In particular, patients and their families should be warned about immediate risks, such as orthostasis or extrapyramidal symptoms. Although treatment guidelines recommend combination therapy as a possible first-line option,⁹ in the outpatient setting, monother­apy with an optimally dosed, rapid-acting agent is preferred to promote medication adherence and avoid potentially danger­ous sedation. Manic patients experience increased distractibility and verbal memory and executive function impairments that can interfere with medication adherence.¹⁷ Therefore, patients are more likely to fol­low a simpler regimen. If SGA or valpro­ate monotherapy does not control mania, begin combination treatment with a mood stabilizer and SGA. If the patient experi­ences remission with SGA monotherapy, the risks and benefits of maintaining the SGA vs switching to a mood stabilizer can be discussed.

 

Provide medication “as needed” for agitation—additional SGA dosing or a benzodiazepine—and explain to fam­ily members when their use is warranted. Benzodiazepines can provide short-term benefits for manic patients: anxiety relief, sedation, and anti-manic efficacy as mono­therapy^18-20 and in combination with other medications.²¹ Studies showing mono­therapy efficacy employed high dosages of benzodiazepines (lorazepam mean dos­age, 14 mg/d; clonazepam mean dosage, 13 mg/d)¹⁹ and high dosages of antipsy­chotics as needed,^18,20 and often were associ­ated with excessive sedation and ataxia.^18,19 This makes benzodiazepine monotherapy a potentially dangerous approach for out­patient treatment of mania. IM lorazepam treated manic agitation less quickly than IM olanzapine, suggesting that SGAs are preferable in the outpatient setting because rapid control of agitation is crucial.²² If pre­scribed, a trusted family member should dispense benzodiazepines to the patient to minimize misuse because of impulsivity, distractibility, desperation to sleep, or plea­sure seeking.

SGAs have the benefit of sedation but occasionally additional sleep medica­tions are required. Benzodiazepine recep­tor agonists (BzRAs), such as zolpidem, eszopiclone, and zaleplon, should be used with caution. Although these medicines are effective in treating insomnia in indi­viduals with primary insomnia²³ and major depression,²⁴ they have not been studied in manic patients. The decreased need for sleep in mania is phenomenologically²⁵ and perhaps biologically different than insomnia in major depression.²⁶ Therefore, mania-associated sleep disturbance might not respond to BZRAs. BzRAs also might induce somnambulism and other parasom­nias,²⁷ especially when used in combination with psychotropics, such as valproate²⁸; it is unclear if the manic state itself increases this risk further. Sedating antihistamines with anticholinergic blockade, such as diphenhydramine and low dosages (<100 mg/d) of quetiapine, are best used only in combination with anti-manic medi­cations because of putative link between anticholinergic blockade and manic induc­tion.²⁹ Less studied but safer options include novel anticonvulsants (gabapen­tin, pregabalin), melatonin, and melatonin receptor agonists. Sedating antidepressants, such as mirtazapine and trazodone, should be avoided.²⁵

Important adjunctive treatment steps include discontinuing all pro-manic agents, including antidepressants, stimulants, and steroids, and discouraging use of caffeine, energy drinks, illicit drugs, and alcohol. The patient should return for office visits at least weekly, and possibly more frequently, depending on severity. Telephone check-in calls between scheduled visits may be nec­essary until the mania is broken.

Psychotherapy. Other than supportive therapy and psychoeducation, other forms of psychotherapy during mania are not indicated. Psychotherapy trials in bipolar disorder do not inform anti-manic efficacy because few have enrolled acutely manic patients and most report long-term benefits rather than short-term efficacy for the index manic episode.³⁰ Educate patients about the importance of maintaining regular social rhythms and taking medication as pre­scribed. Manic patients might not be aware that they are acting differently during manic episodes, therefore efforts to improve the patient’s insight are unlikely to succeed. More time should be spent emphasizing the importance of adherence to treatment and taking anti-manic medications as pre­scribed. This discussion can be enhanced by focusing on the medication’s potential to reduce the unpleasant symptoms of mania, including irritability, insomnia, anxiety, and racing thoughts. At the first visit, dis­cuss setting boundaries with the patient to reduce mania-driven, intrusive phone calls. A patient might develop insight after mania has resolved and he (she) can appre­ciate social or economic harm that occurred while manic. This discussion might foster adherence to maintenance treatment. Advise your patient to limit activities that may increase stimulation and perpetuate the mania, such as exercise, parties, concerts, or crowded shopping malls. Also, recommend that your patient stop working temporarily, to reduce stress and prevent any manic-driven interactions that could result in job loss.

If your patient has an established relationship with a psychotherapist, discuss with the therapist the plan to initiate mania treatment in the outpatient setting and work as a collaborative team, assuming that the patient has granted permission to share information. Encourage the therapist to increase the frequency of sessions with the patient to enable greater monitoring of changes in the patient’s manic symptoms. 

Family involvement
Family support is crucial when treating mania in the outpatient setting. Lacking insight and organization, manic patients require the “auxiliary” judgment of trusted family members to ensure treatment suc­cess. The family should identify a single person to act as the liaison between the family and the psychiatrist. The psychiatrist should instruct this individual to accom­pany the patient to each clinic visit and provide regular updates on the patient’s adherence to treatment, changes in symp­toms, and any new behaviors that would justify involuntary hospitalization. The treatment plan should be clearly communi­cated to this individual to ensure that it is implemented correctly. Ideally, this individ­ual would be someone who understands that bipolar disorder is a mental illness, who can tolerate the patient’s potential resentment of them for taking on this role, and who can influence the patient and the other family members to adhere to the treat­ment plan.

This family member also should watch the patient take medication to rule out nonadherence if the patient’s condition does not improve.

 

Provide extensive psychoeducation to the family (Table 3). Discuss these teaching points and their implications at length during the first visit and reinforce them at subsequent visits. Advise spouses that the acute manic period is not the time to make major decisions about their mar­riage or to engage in couple’s therapy. These options are better explored after the patient recovers from the manic episode.

Encourage the family to engage in mania harm-reduction techniques to the extent that the patient will allow (Table 4). In particu­lar, they should hold onto their loved one’s credit cards and checkbook, and discourage the patient from making any major finan­cial decisions until the mania has resolved. Additionally, patients should be relieved of childcare responsibilities during this period. If there are any child welfare safety con­cerns, the clinician will need to report this to authorities as required by local laws.

Advise family members or roommates to call emergency services and request a crisis intervention team, or to take the patient to an emergency room if he (she) makes ver­bal threats to harm themselves or others, is violent, or demonstrates behaviors that indicate that he is no longer able to care for himself. The psychiatrist should assist with completing Family and Medical Leave Act paperwork for family members who will monitor the patient at home, a work-excuse letter for the patient so he does not lose his job, and short-term disability paperwork to ensure income for the patient during the manic period.

These interventions can be challenging for the entire family system because they place family members in a paternalistic role and reduce the patient’s autonomy within the family. This is problematic when these role changes occur between spouses or between a patient-parent and his (her) children. Such changes typically need to be reversed over time and may require the help of a family or couple’s therapist. To support the psychological health of the patient’s family, refer them to the National Alliance on Mental Illness for family support groups or to individual psychotherapists.

Outpatient management can be rewarding
For “non-dangerous” manic patients who cannot be hospitalized involuntarily and refuse full or partial hospitalization, a psychiatrist must choose between beginning treatment in the clinic and referring the patient to another provider. The latter option is consistent with the APA’s ethical guidelines,³¹ but must be done appropriately to avoid legal liability.³² This decision may disappoint a family desperate to see their loved one recover quickly and may leave them feeling betrayed by the mental health system. On the other hand, choosing to treat mania in the outpatient setting can be rewarding when resolution of mania restores the family’s homeostasis.

To achieve this outcome, the outpatient psychiatrist must engage the patient’s fam­ily to ensure that the patient adheres to the treatment plan and monitor for potentially dangerous behavior. The psychiatrist also must use his knowledge of mood symp­toms, cognitive impairments, and the psy­chological experience of manic patients to create a safe and effective treatment strategy that the patient and family can implement.

Because of mania’s unpredictability and destructive potential, psychiatrists who agree to treat manic patients as outpatients should be familiar with their state’s statutes and case law that pertain to the refusal to accept a new patient, patient abandonment, involuntary hospitalization, confidentiality, and mandatory reporting. They also should seek clinical or legal consultation if they feel overwhelmed or uncertain about the safest and most legally sound approach.

Bottom Line
Treating mania in the outpatient setting is risky but can be accomplished in select patients with the help of the patient’s family and a strategy that integrates evidence-based pharmacotherapeutic and psychotherapeutic strategies. Because manic patients could display dangerous behavior, be familiar with your state’s laws regarding involuntary commitment, patient abandonment, and mandatory reporting.

Related Resources
• National Alliance on Mental Illness. www.NAMI.org.
• Depression and Bipolar Support Alliance. www.DBSAlliance.org.

Drug Brand Names
Aripiprazole • Abilify                                      Mirtazapine • Remeron
Asenapine • Saphris                                      Olanzapine • Zyprexa
Carbamazepine • Equetro, Tegretol                Pregabalin • Lyrica
Chlorpromazine • Thorazine                           Quetiapine • Seroquel
Clonazepam • Klonopin                                  Risperidone • Risperdal
Diphrenhydramine • Benadryl                         Trazodone • Desyrel
Eszopiclone • Lunesta                                    Valproate • Divalproex
Gabapentin • Neurontin                                  Zaleplon • Sonata
Lamotrigine • Lamictal                                    Ziprasidone •  Geodon
Lithium • Eskalith, Lithobid                              Zolpidem •  Ambien
Lorazepam • Ativan

 

Acknowledgement
The authors thank Peter Ash, MD, for carefully reviewing this manuscript and providing feedback.

Disclosures
Dr. Rakofsky receives research or grant support from Takeda. Dr. Dunlop receives research or grant support from Forest, GlaxoSmithKline, and Otsuka.

Manic episodes, by definition, are associated with significant social or occupational impairment.¹ Some manic patients are violent or engage in reckless behaviors that can harm themselves or others, such as speeding, disrupting traffic, or playing with fire. When these patients present to a psychiatrist’s outpatient practice, involuntary hospitalization might be justified.

However, some manic patients, in spite of their elevated, expansive, or irritable mood state, never behave dangerously and might not meet legal criteria for involuntary hospitalization, although these criteria differ from state to state. These patients might see a psychiatrist because manic symptoms such as irritability, talkativeness, and impulsivity are bother­some to their family members but pose no serious danger (Box). In this situation, the psychiatrist can strongly encourage the patient to seek voluntary hospitalization or attend a partial hospitalization program. If the patient declines, the psychiatrist is left with 2 choices: initiate treatment in the outpatient setting or refuse to treat the patient and refer to another provider.

Treating “non-dangerous” mania in the outpatient setting is fraught with challenges:
   • the possibility that the patient’s condition will progress to dangerousness
   • poor adherence to treatment because of the patient’s limited insight
   • the large amount of time required from the psychiatrist and care team to adequately manage the manic episode (eg, time spent with fam­ily members, frequent patient visits, and managing communications from the patient).

There are no guidelines to assist the office-based practitioner in treating mania in the outpatient setting. When considering dosing and optimal medication combina­tions for treating mania, clinical trials may be of limited value because most of these studies only included hospitalized manic patients.

Because of this dearth of knowledge, we provide recommendations based on our review of the literature and from our expe­rience working with manic patients who refuse voluntary hospitalization and could not be hospitalized against their will. These recommendations are organized into 3 sec­tions: diagnostic approach, treatment strat­egy, and family involvement.

Diagnostic approach
Making a diagnosis of mania might seem straightforward for clinicians who work in inpatient settings; however, mania might not present with classic florid symptoms among outpatients. Patients might have a chief concern of irritability, dysphoria, anxiety, or “insomnia,” which may lead clinicians to focus initially on non-bipolar conditions.²

During the interview, it is important to assess for any current DSM-5 symptoms of a manic episode, while being careful not to accept a patient’s denial of symptoms. Patients with mania often have poor insight and are unaware of changes from their base­line state when manic.³ Alternatively, manic patients may want you to believe that they are well and could minimize or deny all symptoms. Therefore, it is important to pay attention to mental status examination find­ings, such as hyperverbal speech, elated affect, psychomotor agitation, a tangential thought process, or flight of ideas.

Countertransference feelings of diagnos­tic confusion or frustration after long patient monologues or multiple interruptions by the patient should be incorporated into the diagnostic assessment. Family members or friends often can provide objective obser­vations of behavioral changes necessary to secure the diagnosis.

Treatment strategy
Decision points. When treating manic out­patients, assess the need for hospitalization at each visit. Advantages of the inpatient setting include:
   • the possibility of rapid medication adjustments
   • continuous observation to ensure the patient’s safety
   • keeping the patient temporarily removed from his community to prevent irrevers­ible social and economic harms.

However, a challenge with hospitaliza­tion is third-party payers’ influence on a patient’s length of stay, which may lead to rapid medication changes that may not be clinically ideal.

At each outpatient visit, explore with the patient and family emerging symptoms that could justify involuntary hospitaliza­tion. Document whether you recommended inpatient hospitalization, the patient’s response to the recommendation, that you are aware and have considered the risks associated with outpatient care, and that you have discussed these risks with the patient and family.

For patients well-known to the psychia­trist, a history of dangerous mania may lead him (her) to strongly recommend hos­pitalization, whereas a pre-existing thera­peutic alliance and no current or distant history of dangerous mania may lead the clinician to look for alternatives to inpatient care. Concomitant drug or alcohol use may increase the likelihood of mania becoming dangerous, making outpatient treatment ill-advised and riskier for everyone involved.

In exchange for agreeing to provide out­patient care for mania, it often is helpful to negotiate with the patient and family a threshold level of symptoms or behavior that will result in the patient agreeing to voluntary hospitalization (Table 1). Such an agreement can include stopping outpatient treatment if the patient does not improve significantly after 2 or 3 weeks or develops psychotic symptoms. The negotiation also can include partial hospitalization as an option, so long as the patient’s mania con­tinues to be non-dangerous.

 

Obtaining pretreatment blood work can help a clinician determine whether a medication is safe to prescribe and establish causality if laboratory abnormalities arise after treatment begins. Ideally, the psychia­trist should follow consensus guidelines developed by the International Society for Bipolar Disorders⁴ or the American Psychiatric Association (APA)⁵ and order appropriate laboratory tests before prescrib­ing anti-manic medications. Determine the pregnancy status of female patients of child-bearing age before prescribing a potentially teratogenic medication, especially because mania is associated with increased libido.⁶

Manic patients might be too disorga­nized to follow up with recommendations for laboratory testing, or could wait sev­eral days before completing blood work. Although not ideal, to avoid delaying treat­ment, a clinician might need to prescribe medication at the initial office visit, without pretreatment laboratory results. When the patient is more organized, complete the blood work. Keeping home pregnancy tests in the office can help rule out pregnancy before prescribing medication.

Medication. Meta-analyses have estab­lished the efficacy of mood stabilizers and antipsychotics for treating mania,^7,8 and sev­eral consensus guidelines have incorporated these findings into treatment algorithms.⁹

For a patient already taking medications recommended by the guidelines, assess treatment adherence during the initial inter­view by questioning the patient and family. When the logistics of phlebotomy permit, obtaining the blood level of psychotropics can show the presence of any detectable drug concentration, which demonstrates that the patient has taken the medication recently.

If there is no evidence of nonadherence, an initial step might be to increase the dos­age of the antipsychotic or mood stabilizer that the patient is already taking, ensuring that the dosage is optimized based on FDA indications and clinical trials data. The rec­ommended rate of dosage adjustments dif­fers among medications; however, optimal dosing should be reached quickly because a World Federation of Societies of Biological Psychiatry task force recommends that a mania treatment trial not exceed 2 weeks.¹⁰

Dosage increases can be made at weekly visits or sooner, based on treatment response and tolerability. If there is no ben­efit after optimizing the dosage, the next step would be to add a mood stabilizer to a second-generation antipsychotic (SGA), or vice versa to promote additive or syn­ergistic medication effects.¹¹ Switching one medication for the other should be avoided unless there are tolerability concerns.

For a patient who is not taking any medi­cations, select a treatment that balances rapid stabilization with long-term efficacy and tolerability. Table 2 lists FDA-approved treatments for mania. Lamotrigine provides prophylactic efficacy with few associated risks, but it has no anti-manic effects and would be a poor choice for most actively manic patients. Most studies indicate that antipsychotics work faster than lithium at the 1-week mark; however, this may be a function of the lithium titration schedule followed in the protocols, the severity of mania among enrolled patients, the inclu­sion of typically non-responsive manic patients (eg, mixed) in the analysis, and the antipsychotic’s sedative potential rela­tive to lithium. Although the anti-manic and prophylactic potential of lithium and valproate might make them an ideal first-line option, antipsychotics could stabilize a manic patient faster, especially if agitation is present.^12,13

Breaking mania quickly is important when treating patients in the outpatient set­ting. In these situations, a reasonable choice is to prescribe a SGA, because of their rapid onset of effect, low potential for switch to depression, and utility in treating classic, mixed, or psychotic mania.¹⁰ Oral loading of valproate (20 mg/kg) is another option. An inpatient study that used an oral-loading strategy demonstrated a similar time to response as olanzapine,¹⁴ in contrast to an inpatient¹⁵ and an outpatient study¹⁶ that employed a standard starting dosage for each patient and led to slower improve­ment compared with olanzapine.

SGAs should be dosed moderately and lower than if the patient were hospitalized, to avoid alienating the patient from treat­ment by causing intolerable side effects. In particular, patients and their families should be warned about immediate risks, such as orthostasis or extrapyramidal symptoms. Although treatment guidelines recommend combination therapy as a possible first-line option,⁹ in the outpatient setting, monother­apy with an optimally dosed, rapid-acting agent is preferred to promote medication adherence and avoid potentially danger­ous sedation. Manic patients experience increased distractibility and verbal memory and executive function impairments that can interfere with medication adherence.¹⁷ Therefore, patients are more likely to fol­low a simpler regimen. If SGA or valpro­ate monotherapy does not control mania, begin combination treatment with a mood stabilizer and SGA. If the patient experi­ences remission with SGA monotherapy, the risks and benefits of maintaining the SGA vs switching to a mood stabilizer can be discussed.

 

Provide medication “as needed” for agitation—additional SGA dosing or a benzodiazepine—and explain to fam­ily members when their use is warranted. Benzodiazepines can provide short-term benefits for manic patients: anxiety relief, sedation, and anti-manic efficacy as mono­therapy^18-20 and in combination with other medications.²¹ Studies showing mono­therapy efficacy employed high dosages of benzodiazepines (lorazepam mean dos­age, 14 mg/d; clonazepam mean dosage, 13 mg/d)¹⁹ and high dosages of antipsy­chotics as needed,^18,20 and often were associ­ated with excessive sedation and ataxia.^18,19 This makes benzodiazepine monotherapy a potentially dangerous approach for out­patient treatment of mania. IM lorazepam treated manic agitation less quickly than IM olanzapine, suggesting that SGAs are preferable in the outpatient setting because rapid control of agitation is crucial.²² If pre­scribed, a trusted family member should dispense benzodiazepines to the patient to minimize misuse because of impulsivity, distractibility, desperation to sleep, or plea­sure seeking.

SGAs have the benefit of sedation but occasionally additional sleep medica­tions are required. Benzodiazepine recep­tor agonists (BzRAs), such as zolpidem, eszopiclone, and zaleplon, should be used with caution. Although these medicines are effective in treating insomnia in indi­viduals with primary insomnia²³ and major depression,²⁴ they have not been studied in manic patients. The decreased need for sleep in mania is phenomenologically²⁵ and perhaps biologically different than insomnia in major depression.²⁶ Therefore, mania-associated sleep disturbance might not respond to BZRAs. BzRAs also might induce somnambulism and other parasom­nias,²⁷ especially when used in combination with psychotropics, such as valproate²⁸; it is unclear if the manic state itself increases this risk further. Sedating antihistamines with anticholinergic blockade, such as diphenhydramine and low dosages (<100 mg/d) of quetiapine, are best used only in combination with anti-manic medi­cations because of putative link between anticholinergic blockade and manic induc­tion.²⁹ Less studied but safer options include novel anticonvulsants (gabapen­tin, pregabalin), melatonin, and melatonin receptor agonists. Sedating antidepressants, such as mirtazapine and trazodone, should be avoided.²⁵

Important adjunctive treatment steps include discontinuing all pro-manic agents, including antidepressants, stimulants, and steroids, and discouraging use of caffeine, energy drinks, illicit drugs, and alcohol. The patient should return for office visits at least weekly, and possibly more frequently, depending on severity. Telephone check-in calls between scheduled visits may be nec­essary until the mania is broken.

Psychotherapy. Other than supportive therapy and psychoeducation, other forms of psychotherapy during mania are not indicated. Psychotherapy trials in bipolar disorder do not inform anti-manic efficacy because few have enrolled acutely manic patients and most report long-term benefits rather than short-term efficacy for the index manic episode.³⁰ Educate patients about the importance of maintaining regular social rhythms and taking medication as pre­scribed. Manic patients might not be aware that they are acting differently during manic episodes, therefore efforts to improve the patient’s insight are unlikely to succeed. More time should be spent emphasizing the importance of adherence to treatment and taking anti-manic medications as pre­scribed. This discussion can be enhanced by focusing on the medication’s potential to reduce the unpleasant symptoms of mania, including irritability, insomnia, anxiety, and racing thoughts. At the first visit, dis­cuss setting boundaries with the patient to reduce mania-driven, intrusive phone calls. A patient might develop insight after mania has resolved and he (she) can appre­ciate social or economic harm that occurred while manic. This discussion might foster adherence to maintenance treatment. Advise your patient to limit activities that may increase stimulation and perpetuate the mania, such as exercise, parties, concerts, or crowded shopping malls. Also, recommend that your patient stop working temporarily, to reduce stress and prevent any manic-driven interactions that could result in job loss.

If your patient has an established relationship with a psychotherapist, discuss with the therapist the plan to initiate mania treatment in the outpatient setting and work as a collaborative team, assuming that the patient has granted permission to share information. Encourage the therapist to increase the frequency of sessions with the patient to enable greater monitoring of changes in the patient’s manic symptoms. 

Family involvement
Family support is crucial when treating mania in the outpatient setting. Lacking insight and organization, manic patients require the “auxiliary” judgment of trusted family members to ensure treatment suc­cess. The family should identify a single person to act as the liaison between the family and the psychiatrist. The psychiatrist should instruct this individual to accom­pany the patient to each clinic visit and provide regular updates on the patient’s adherence to treatment, changes in symp­toms, and any new behaviors that would justify involuntary hospitalization. The treatment plan should be clearly communi­cated to this individual to ensure that it is implemented correctly. Ideally, this individ­ual would be someone who understands that bipolar disorder is a mental illness, who can tolerate the patient’s potential resentment of them for taking on this role, and who can influence the patient and the other family members to adhere to the treat­ment plan.

This family member also should watch the patient take medication to rule out nonadherence if the patient’s condition does not improve.

 

Provide extensive psychoeducation to the family (Table 3). Discuss these teaching points and their implications at length during the first visit and reinforce them at subsequent visits. Advise spouses that the acute manic period is not the time to make major decisions about their mar­riage or to engage in couple’s therapy. These options are better explored after the patient recovers from the manic episode.

Encourage the family to engage in mania harm-reduction techniques to the extent that the patient will allow (Table 4). In particu­lar, they should hold onto their loved one’s credit cards and checkbook, and discourage the patient from making any major finan­cial decisions until the mania has resolved. Additionally, patients should be relieved of childcare responsibilities during this period. If there are any child welfare safety con­cerns, the clinician will need to report this to authorities as required by local laws.

Advise family members or roommates to call emergency services and request a crisis intervention team, or to take the patient to an emergency room if he (she) makes ver­bal threats to harm themselves or others, is violent, or demonstrates behaviors that indicate that he is no longer able to care for himself. The psychiatrist should assist with completing Family and Medical Leave Act paperwork for family members who will monitor the patient at home, a work-excuse letter for the patient so he does not lose his job, and short-term disability paperwork to ensure income for the patient during the manic period.

These interventions can be challenging for the entire family system because they place family members in a paternalistic role and reduce the patient’s autonomy within the family. This is problematic when these role changes occur between spouses or between a patient-parent and his (her) children. Such changes typically need to be reversed over time and may require the help of a family or couple’s therapist. To support the psychological health of the patient’s family, refer them to the National Alliance on Mental Illness for family support groups or to individual psychotherapists.

Outpatient management can be rewarding
For “non-dangerous” manic patients who cannot be hospitalized involuntarily and refuse full or partial hospitalization, a psychiatrist must choose between beginning treatment in the clinic and referring the patient to another provider. The latter option is consistent with the APA’s ethical guidelines,³¹ but must be done appropriately to avoid legal liability.³² This decision may disappoint a family desperate to see their loved one recover quickly and may leave them feeling betrayed by the mental health system. On the other hand, choosing to treat mania in the outpatient setting can be rewarding when resolution of mania restores the family’s homeostasis.

To achieve this outcome, the outpatient psychiatrist must engage the patient’s fam­ily to ensure that the patient adheres to the treatment plan and monitor for potentially dangerous behavior. The psychiatrist also must use his knowledge of mood symp­toms, cognitive impairments, and the psy­chological experience of manic patients to create a safe and effective treatment strategy that the patient and family can implement.

Because of mania’s unpredictability and destructive potential, psychiatrists who agree to treat manic patients as outpatients should be familiar with their state’s statutes and case law that pertain to the refusal to accept a new patient, patient abandonment, involuntary hospitalization, confidentiality, and mandatory reporting. They also should seek clinical or legal consultation if they feel overwhelmed or uncertain about the safest and most legally sound approach.

Bottom Line
Treating mania in the outpatient setting is risky but can be accomplished in select patients with the help of the patient’s family and a strategy that integrates evidence-based pharmacotherapeutic and psychotherapeutic strategies. Because manic patients could display dangerous behavior, be familiar with your state’s laws regarding involuntary commitment, patient abandonment, and mandatory reporting.

Related Resources
• National Alliance on Mental Illness. www.NAMI.org.
• Depression and Bipolar Support Alliance. www.DBSAlliance.org.

Drug Brand Names
Aripiprazole • Abilify                                      Mirtazapine • Remeron
Asenapine • Saphris                                      Olanzapine • Zyprexa
Carbamazepine • Equetro, Tegretol                Pregabalin • Lyrica
Chlorpromazine • Thorazine                           Quetiapine • Seroquel
Clonazepam • Klonopin                                  Risperidone • Risperdal
Diphrenhydramine • Benadryl                         Trazodone • Desyrel
Eszopiclone • Lunesta                                    Valproate • Divalproex
Gabapentin • Neurontin                                  Zaleplon • Sonata
Lamotrigine • Lamictal                                    Ziprasidone •  Geodon
Lithium • Eskalith, Lithobid                              Zolpidem •  Ambien
Lorazepam • Ativan

 

Acknowledgement
The authors thank Peter Ash, MD, for carefully reviewing this manuscript and providing feedback.

Disclosures
Dr. Rakofsky receives research or grant support from Takeda. Dr. Dunlop receives research or grant support from Forest, GlaxoSmithKline, and Otsuka.

Manic episodes, by definition, are associated with significant social or occupational impairment.¹ Some manic patients are violent or engage in reckless behaviors that can harm themselves or others, such as speeding, disrupting traffic, or playing with fire. When these patients present to a psychiatrist’s outpatient practice, involuntary hospitalization might be justified.

However, some manic patients, in spite of their elevated, expansive, or irritable mood state, never behave dangerously and might not meet legal criteria for involuntary hospitalization, although these criteria differ from state to state. These patients might see a psychiatrist because manic symptoms such as irritability, talkativeness, and impulsivity are bother­some to their family members but pose no serious danger (Box). In this situation, the psychiatrist can strongly encourage the patient to seek voluntary hospitalization or attend a partial hospitalization program. If the patient declines, the psychiatrist is left with 2 choices: initiate treatment in the outpatient setting or refuse to treat the patient and refer to another provider.

Treating “non-dangerous” mania in the outpatient setting is fraught with challenges:
   • the possibility that the patient’s condition will progress to dangerousness
   • poor adherence to treatment because of the patient’s limited insight
   • the large amount of time required from the psychiatrist and care team to adequately manage the manic episode (eg, time spent with fam­ily members, frequent patient visits, and managing communications from the patient).

There are no guidelines to assist the office-based practitioner in treating mania in the outpatient setting. When considering dosing and optimal medication combina­tions for treating mania, clinical trials may be of limited value because most of these studies only included hospitalized manic patients.

Because of this dearth of knowledge, we provide recommendations based on our review of the literature and from our expe­rience working with manic patients who refuse voluntary hospitalization and could not be hospitalized against their will. These recommendations are organized into 3 sec­tions: diagnostic approach, treatment strat­egy, and family involvement.

Diagnostic approach
Making a diagnosis of mania might seem straightforward for clinicians who work in inpatient settings; however, mania might not present with classic florid symptoms among outpatients. Patients might have a chief concern of irritability, dysphoria, anxiety, or “insomnia,” which may lead clinicians to focus initially on non-bipolar conditions.²

During the interview, it is important to assess for any current DSM-5 symptoms of a manic episode, while being careful not to accept a patient’s denial of symptoms. Patients with mania often have poor insight and are unaware of changes from their base­line state when manic.³ Alternatively, manic patients may want you to believe that they are well and could minimize or deny all symptoms. Therefore, it is important to pay attention to mental status examination find­ings, such as hyperverbal speech, elated affect, psychomotor agitation, a tangential thought process, or flight of ideas.

Countertransference feelings of diagnos­tic confusion or frustration after long patient monologues or multiple interruptions by the patient should be incorporated into the diagnostic assessment. Family members or friends often can provide objective obser­vations of behavioral changes necessary to secure the diagnosis.

Treatment strategy
Decision points. When treating manic out­patients, assess the need for hospitalization at each visit. Advantages of the inpatient setting include:
   • the possibility of rapid medication adjustments
   • continuous observation to ensure the patient’s safety
   • keeping the patient temporarily removed from his community to prevent irrevers­ible social and economic harms.

However, a challenge with hospitaliza­tion is third-party payers’ influence on a patient’s length of stay, which may lead to rapid medication changes that may not be clinically ideal.

At each outpatient visit, explore with the patient and family emerging symptoms that could justify involuntary hospitaliza­tion. Document whether you recommended inpatient hospitalization, the patient’s response to the recommendation, that you are aware and have considered the risks associated with outpatient care, and that you have discussed these risks with the patient and family.

For patients well-known to the psychia­trist, a history of dangerous mania may lead him (her) to strongly recommend hos­pitalization, whereas a pre-existing thera­peutic alliance and no current or distant history of dangerous mania may lead the clinician to look for alternatives to inpatient care. Concomitant drug or alcohol use may increase the likelihood of mania becoming dangerous, making outpatient treatment ill-advised and riskier for everyone involved.

In exchange for agreeing to provide out­patient care for mania, it often is helpful to negotiate with the patient and family a threshold level of symptoms or behavior that will result in the patient agreeing to voluntary hospitalization (Table 1). Such an agreement can include stopping outpatient treatment if the patient does not improve significantly after 2 or 3 weeks or develops psychotic symptoms. The negotiation also can include partial hospitalization as an option, so long as the patient’s mania con­tinues to be non-dangerous.

 

Obtaining pretreatment blood work can help a clinician determine whether a medication is safe to prescribe and establish causality if laboratory abnormalities arise after treatment begins. Ideally, the psychia­trist should follow consensus guidelines developed by the International Society for Bipolar Disorders⁴ or the American Psychiatric Association (APA)⁵ and order appropriate laboratory tests before prescrib­ing anti-manic medications. Determine the pregnancy status of female patients of child-bearing age before prescribing a potentially teratogenic medication, especially because mania is associated with increased libido.⁶

Manic patients might be too disorga­nized to follow up with recommendations for laboratory testing, or could wait sev­eral days before completing blood work. Although not ideal, to avoid delaying treat­ment, a clinician might need to prescribe medication at the initial office visit, without pretreatment laboratory results. When the patient is more organized, complete the blood work. Keeping home pregnancy tests in the office can help rule out pregnancy before prescribing medication.

Medication. Meta-analyses have estab­lished the efficacy of mood stabilizers and antipsychotics for treating mania,^7,8 and sev­eral consensus guidelines have incorporated these findings into treatment algorithms.⁹

For a patient already taking medications recommended by the guidelines, assess treatment adherence during the initial inter­view by questioning the patient and family. When the logistics of phlebotomy permit, obtaining the blood level of psychotropics can show the presence of any detectable drug concentration, which demonstrates that the patient has taken the medication recently.

If there is no evidence of nonadherence, an initial step might be to increase the dos­age of the antipsychotic or mood stabilizer that the patient is already taking, ensuring that the dosage is optimized based on FDA indications and clinical trials data. The rec­ommended rate of dosage adjustments dif­fers among medications; however, optimal dosing should be reached quickly because a World Federation of Societies of Biological Psychiatry task force recommends that a mania treatment trial not exceed 2 weeks.¹⁰

Dosage increases can be made at weekly visits or sooner, based on treatment response and tolerability. If there is no ben­efit after optimizing the dosage, the next step would be to add a mood stabilizer to a second-generation antipsychotic (SGA), or vice versa to promote additive or syn­ergistic medication effects.¹¹ Switching one medication for the other should be avoided unless there are tolerability concerns.

For a patient who is not taking any medi­cations, select a treatment that balances rapid stabilization with long-term efficacy and tolerability. Table 2 lists FDA-approved treatments for mania. Lamotrigine provides prophylactic efficacy with few associated risks, but it has no anti-manic effects and would be a poor choice for most actively manic patients. Most studies indicate that antipsychotics work faster than lithium at the 1-week mark; however, this may be a function of the lithium titration schedule followed in the protocols, the severity of mania among enrolled patients, the inclu­sion of typically non-responsive manic patients (eg, mixed) in the analysis, and the antipsychotic’s sedative potential rela­tive to lithium. Although the anti-manic and prophylactic potential of lithium and valproate might make them an ideal first-line option, antipsychotics could stabilize a manic patient faster, especially if agitation is present.^12,13

Breaking mania quickly is important when treating patients in the outpatient set­ting. In these situations, a reasonable choice is to prescribe a SGA, because of their rapid onset of effect, low potential for switch to depression, and utility in treating classic, mixed, or psychotic mania.¹⁰ Oral loading of valproate (20 mg/kg) is another option. An inpatient study that used an oral-loading strategy demonstrated a similar time to response as olanzapine,¹⁴ in contrast to an inpatient¹⁵ and an outpatient study¹⁶ that employed a standard starting dosage for each patient and led to slower improve­ment compared with olanzapine.

SGAs should be dosed moderately and lower than if the patient were hospitalized, to avoid alienating the patient from treat­ment by causing intolerable side effects. In particular, patients and their families should be warned about immediate risks, such as orthostasis or extrapyramidal symptoms. Although treatment guidelines recommend combination therapy as a possible first-line option,⁹ in the outpatient setting, monother­apy with an optimally dosed, rapid-acting agent is preferred to promote medication adherence and avoid potentially danger­ous sedation. Manic patients experience increased distractibility and verbal memory and executive function impairments that can interfere with medication adherence.¹⁷ Therefore, patients are more likely to fol­low a simpler regimen. If SGA or valpro­ate monotherapy does not control mania, begin combination treatment with a mood stabilizer and SGA. If the patient experi­ences remission with SGA monotherapy, the risks and benefits of maintaining the SGA vs switching to a mood stabilizer can be discussed.

 

Provide medication “as needed” for agitation—additional SGA dosing or a benzodiazepine—and explain to fam­ily members when their use is warranted. Benzodiazepines can provide short-term benefits for manic patients: anxiety relief, sedation, and anti-manic efficacy as mono­therapy^18-20 and in combination with other medications.²¹ Studies showing mono­therapy efficacy employed high dosages of benzodiazepines (lorazepam mean dos­age, 14 mg/d; clonazepam mean dosage, 13 mg/d)¹⁹ and high dosages of antipsy­chotics as needed,^18,20 and often were associ­ated with excessive sedation and ataxia.^18,19 This makes benzodiazepine monotherapy a potentially dangerous approach for out­patient treatment of mania. IM lorazepam treated manic agitation less quickly than IM olanzapine, suggesting that SGAs are preferable in the outpatient setting because rapid control of agitation is crucial.²² If pre­scribed, a trusted family member should dispense benzodiazepines to the patient to minimize misuse because of impulsivity, distractibility, desperation to sleep, or plea­sure seeking.

SGAs have the benefit of sedation but occasionally additional sleep medica­tions are required. Benzodiazepine recep­tor agonists (BzRAs), such as zolpidem, eszopiclone, and zaleplon, should be used with caution. Although these medicines are effective in treating insomnia in indi­viduals with primary insomnia²³ and major depression,²⁴ they have not been studied in manic patients. The decreased need for sleep in mania is phenomenologically²⁵ and perhaps biologically different than insomnia in major depression.²⁶ Therefore, mania-associated sleep disturbance might not respond to BZRAs. BzRAs also might induce somnambulism and other parasom­nias,²⁷ especially when used in combination with psychotropics, such as valproate²⁸; it is unclear if the manic state itself increases this risk further. Sedating antihistamines with anticholinergic blockade, such as diphenhydramine and low dosages (<100 mg/d) of quetiapine, are best used only in combination with anti-manic medi­cations because of putative link between anticholinergic blockade and manic induc­tion.²⁹ Less studied but safer options include novel anticonvulsants (gabapen­tin, pregabalin), melatonin, and melatonin receptor agonists. Sedating antidepressants, such as mirtazapine and trazodone, should be avoided.²⁵

Important adjunctive treatment steps include discontinuing all pro-manic agents, including antidepressants, stimulants, and steroids, and discouraging use of caffeine, energy drinks, illicit drugs, and alcohol. The patient should return for office visits at least weekly, and possibly more frequently, depending on severity. Telephone check-in calls between scheduled visits may be nec­essary until the mania is broken.

Psychotherapy. Other than supportive therapy and psychoeducation, other forms of psychotherapy during mania are not indicated. Psychotherapy trials in bipolar disorder do not inform anti-manic efficacy because few have enrolled acutely manic patients and most report long-term benefits rather than short-term efficacy for the index manic episode.³⁰ Educate patients about the importance of maintaining regular social rhythms and taking medication as pre­scribed. Manic patients might not be aware that they are acting differently during manic episodes, therefore efforts to improve the patient’s insight are unlikely to succeed. More time should be spent emphasizing the importance of adherence to treatment and taking anti-manic medications as pre­scribed. This discussion can be enhanced by focusing on the medication’s potential to reduce the unpleasant symptoms of mania, including irritability, insomnia, anxiety, and racing thoughts. At the first visit, dis­cuss setting boundaries with the patient to reduce mania-driven, intrusive phone calls. A patient might develop insight after mania has resolved and he (she) can appre­ciate social or economic harm that occurred while manic. This discussion might foster adherence to maintenance treatment. Advise your patient to limit activities that may increase stimulation and perpetuate the mania, such as exercise, parties, concerts, or crowded shopping malls. Also, recommend that your patient stop working temporarily, to reduce stress and prevent any manic-driven interactions that could result in job loss.

If your patient has an established relationship with a psychotherapist, discuss with the therapist the plan to initiate mania treatment in the outpatient setting and work as a collaborative team, assuming that the patient has granted permission to share information. Encourage the therapist to increase the frequency of sessions with the patient to enable greater monitoring of changes in the patient’s manic symptoms. 

Family involvement
Family support is crucial when treating mania in the outpatient setting. Lacking insight and organization, manic patients require the “auxiliary” judgment of trusted family members to ensure treatment suc­cess. The family should identify a single person to act as the liaison between the family and the psychiatrist. The psychiatrist should instruct this individual to accom­pany the patient to each clinic visit and provide regular updates on the patient’s adherence to treatment, changes in symp­toms, and any new behaviors that would justify involuntary hospitalization. The treatment plan should be clearly communi­cated to this individual to ensure that it is implemented correctly. Ideally, this individ­ual would be someone who understands that bipolar disorder is a mental illness, who can tolerate the patient’s potential resentment of them for taking on this role, and who can influence the patient and the other family members to adhere to the treat­ment plan.

This family member also should watch the patient take medication to rule out nonadherence if the patient’s condition does not improve.

 

Provide extensive psychoeducation to the family (Table 3). Discuss these teaching points and their implications at length during the first visit and reinforce them at subsequent visits. Advise spouses that the acute manic period is not the time to make major decisions about their mar­riage or to engage in couple’s therapy. These options are better explored after the patient recovers from the manic episode.

Encourage the family to engage in mania harm-reduction techniques to the extent that the patient will allow (Table 4). In particu­lar, they should hold onto their loved one’s credit cards and checkbook, and discourage the patient from making any major finan­cial decisions until the mania has resolved. Additionally, patients should be relieved of childcare responsibilities during this period. If there are any child welfare safety con­cerns, the clinician will need to report this to authorities as required by local laws.

Advise family members or roommates to call emergency services and request a crisis intervention team, or to take the patient to an emergency room if he (she) makes ver­bal threats to harm themselves or others, is violent, or demonstrates behaviors that indicate that he is no longer able to care for himself. The psychiatrist should assist with completing Family and Medical Leave Act paperwork for family members who will monitor the patient at home, a work-excuse letter for the patient so he does not lose his job, and short-term disability paperwork to ensure income for the patient during the manic period.

These interventions can be challenging for the entire family system because they place family members in a paternalistic role and reduce the patient’s autonomy within the family. This is problematic when these role changes occur between spouses or between a patient-parent and his (her) children. Such changes typically need to be reversed over time and may require the help of a family or couple’s therapist. To support the psychological health of the patient’s family, refer them to the National Alliance on Mental Illness for family support groups or to individual psychotherapists.

Outpatient management can be rewarding
For “non-dangerous” manic patients who cannot be hospitalized involuntarily and refuse full or partial hospitalization, a psychiatrist must choose between beginning treatment in the clinic and referring the patient to another provider. The latter option is consistent with the APA’s ethical guidelines,³¹ but must be done appropriately to avoid legal liability.³² This decision may disappoint a family desperate to see their loved one recover quickly and may leave them feeling betrayed by the mental health system. On the other hand, choosing to treat mania in the outpatient setting can be rewarding when resolution of mania restores the family’s homeostasis.

To achieve this outcome, the outpatient psychiatrist must engage the patient’s fam­ily to ensure that the patient adheres to the treatment plan and monitor for potentially dangerous behavior. The psychiatrist also must use his knowledge of mood symp­toms, cognitive impairments, and the psy­chological experience of manic patients to create a safe and effective treatment strategy that the patient and family can implement.

Because of mania’s unpredictability and destructive potential, psychiatrists who agree to treat manic patients as outpatients should be familiar with their state’s statutes and case law that pertain to the refusal to accept a new patient, patient abandonment, involuntary hospitalization, confidentiality, and mandatory reporting. They also should seek clinical or legal consultation if they feel overwhelmed or uncertain about the safest and most legally sound approach.

Bottom Line
Treating mania in the outpatient setting is risky but can be accomplished in select patients with the help of the patient’s family and a strategy that integrates evidence-based pharmacotherapeutic and psychotherapeutic strategies. Because manic patients could display dangerous behavior, be familiar with your state’s laws regarding involuntary commitment, patient abandonment, and mandatory reporting.

Related Resources
• National Alliance on Mental Illness. www.NAMI.org.
• Depression and Bipolar Support Alliance. www.DBSAlliance.org.

Drug Brand Names
Aripiprazole • Abilify                                      Mirtazapine • Remeron
Asenapine • Saphris                                      Olanzapine • Zyprexa
Carbamazepine • Equetro, Tegretol                Pregabalin • Lyrica
Chlorpromazine • Thorazine                           Quetiapine • Seroquel
Clonazepam • Klonopin                                  Risperidone • Risperdal
Diphrenhydramine • Benadryl                         Trazodone • Desyrel
Eszopiclone • Lunesta                                    Valproate • Divalproex
Gabapentin • Neurontin                                  Zaleplon • Sonata
Lamotrigine • Lamictal                                    Ziprasidone •  Geodon
Lithium • Eskalith, Lithobid                              Zolpidem •  Ambien
Lorazepam • Ativan

 

Acknowledgement
The authors thank Peter Ash, MD, for carefully reviewing this manuscript and providing feedback.

Disclosures
Dr. Rakofsky receives research or grant support from Takeda. Dr. Dunlop receives research or grant support from Forest, GlaxoSmithKline, and Otsuka.

As explained in the first part of this article in the October 2014 issue of Current Psychiatry, assess­ing and managing suicide risk are complex, difficult tasks without clear-cut, easy solutions. The case-based, mul­tiple-choice self-test, with accompanying commentary, pre­sented here is designed to enhance one’s ability to provide care for patients at risk for suicide. Part 2 of this article poses the remaining 7 of 15 questions, which are based on clinical experience and the referenced work of others.

Question 9
Mr. N, age 62, will be discharged from the psychiatric unit tomor­row. He was admitted after an overdose suicide attempt. Mr. N was depressed after the loss of his business and was “treating” his depres­sion and anxiety with alcohol. He is successfully withdrawn from alcohol and responds to medication and supportive psychotherapy. During a family meeting with staff, Mr. N’s wife states that he keeps a gun by his bedside. Mr. N has improved and is eager to go home.

Before discharging Mr. N, the psychiatrist or staff should:
   a) instruct Mr. N to remove the gun from his bedside
   b) instruct his wife to remove the gun from the home
   c) instruct the wife to look for >1 gun
   d) instruct the wife, before Mr. N’s discharge, to call the staff once guns and
ammunition are safely removed according to the pre-arranged safety plan
   e) instruct the wife to lock up the gun in a place that is not known to the patient

The best response option is D
Guns in the home are associated with a sig­nificant increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible else­where, or if they intend to purchase a gun. Gun safety management requires a collabor­ative team approach including the clinician, patient, and person designated responsible for removing guns from the home.¹ The responsible person should be required to call the clinician to confirm that the guns have been removed and secured according to the plan. The principles of gun safety manage­ment apply to outpatients, inpatients, and emergency patients, although implementa­tion varies according to the clinical setting.

Asking the patient to remove guns from the home is too risky. Guns must be safely secured before the patient is discharged. Asking a spouse, other family member, or partner is necessary. The person asked must be willing to remove guns and ammunition according to a pre-arranged plan requiring a callback upon completion. A callback is essential because a family member in denial may do nothing to remove the guns or lock or “hide” them in the home where they will be found by a determined suicidal patient. Guns may be available outside the home, such as in the car, at the work place, or for purchase.

The essence of gun safety management is verification. Trust but verify or, better yet, verify, then trust.

Question 10
A recently admitted 56-year-old inpatient was discovered wrapping a towel around her neck. She denied suicidal intent; however, the treat­ment team viewed the incident as a suicide rehearsal. She was placed on one-to-one close observation.

Inpatient suicides frequently occur:
   a) shortly after admission
   b) during staff shift changes
   c) at meal times
   d) shortly after discharge
   e) all of the above

The best response option is E
Inpatient suicides also occur at increased frequency when psychiatric residents fin­ish their rotations and in understaffed psychiatric units.² Undue delay in the evaluation of a newly admitted acute, high-risk patient might allow the patient to commit suicide.

Most patient suicides occur shortly after hospital discharge (a few hours, days, or weeks later). Appleby et al³ found that the highest number of suicides occurred during the first week after discharge. Meehan et al⁴ found that suicide occurred most frequently during the first 2 weeks post-discharge; the highest number of suicides occurred on the first day after discharge.

Question 11
Ms. G, a 43-year-old, single woman in acute sui­cide crisis, is admitted to the psychiatric unit of a general hospital. She is diagnosed with bipolar I disorder, most recent episode depressed, and borderline personality disorder. She has had multiple psychiatric hospitalizations, all pre­cipitated by a suicide crisis. The average length of stay on the psychiatric unit is 6.3 days. After 7 days of intensive treatment, Ms. G is stabilized and suicide risk is reduced. The treatment team prepares for her discharge.

Ms. G’s suicide risk at discharge is most likely at:
   a) indeterminate risk
   b) low risk
   c) moderate risk
   d) chronic high risk
   e) acute high risk

 

The best response option is D
The length of stay in many acute care psy­chiatric facilities is <7 days. The goal of hospitalization is to stabilize the patient and discharge to appropriate community mental health resources. Discharge plan­ning begins at the time of admission.

Reducing Ms. G’s suicide risk to low or moderate is unlikely because of her diagnoses, frequent hospitalizations, and acute high risk for suicide on admission. After acute, high-risk suicidal patients are treated, many revert to chronic high risk for suicide.

Patients at chronic high risk for suicide often are treated as outpatients, except when an acute suicidal crisis requires hospi­talization.⁵ At discharge from the hospital, the goal is to return the patient to outpatient treatment.

A discharge note identifies the acute sui­cide risk factors that have abated and the chronic (long-term) suicide risk factors that remain. The discharge note also addresses a patient’s chronic vulnerability to suicide. For example, a patient can become acutely suicidal again, depending on a number of factors, including the nature and cause of the psychiatric illness, adequacy of future treat­ment, adherence to treatment recommenda­tions, and unforeseeable life vicissitudes.

Question 12
A 20-year-old college student is hospitalized after an overdose suicide attempt. Failing grades, panic attacks, and depression precipitated the suicide attempt. After 8 days of hos­pitalization, she is much improved and ready for discharge. She is assessed to be at low to moderate suicide risk. The treating psychiatrist and social worker convene a family meet­ing with both parents and an older brother. The family’s role after discharge is discussed.

All of the following options are helpful family roles except:
   a) provide constant 24-hour family supervision
   b) provide emotional support
   c) observe and report symptoms and behaviors of concern
   d) encourage adherence with treatment
   e) provide helpful feedback about the patient’s thoughts and behavior

The best response option is A
The family’s role is important, but it is not a substitute for constant safety management provided by trained mental health profes­sionals on an inpatient psychiatric unit.⁵ Early discharge of an inpatient by relying on family supervision can be precarious. Most inpatients are discharged at some level of suicide risk, given the short length of hos­pital stay. If an outpatient at risk of suicide requires constant 24-hour family supervi­sion, then psychiatric hospitalization is indicated.

Patients who are intent on killing them­selves can find ingenious ways to attempt or commit suicide. Asking family members to keep a constant watch often fails. Most family members will not follow the patient into the bathroom or be able to stay up all night to observe the patient. Moreover, fam­ily members find reasons to make exceptions to constant surveillance because of denial, fatigue, or the need to attend to other press­ing matters.


Question 13
During the initial evaluation of a patient, it is the psychiatrist’s practice to routinely inquire about current and past suicide ideation. An affirma­tive answer prompts a systematic suicide risk assessment. In the absence of current risk, if exploration of the patient’s history reveals chronic suicide risk factors, the psychiatrist con­ducts a systematic suicide risk assessment.

The chronic risk factor that has the highest association with suicide is:
   a) family history of mental illness or suicide
   b) childhood abuse
   c) history of a suicide attempt
   d) impulsivity or aggression
   e) prior psychiatric hospitalization

The best response option is C
A comprehensive suicide risk assessment may not be required at the initial outpatient evaluation in the absence of acute suicide risk factors. However, chronic suicide risk factors may be present.

The Standard Mortality Ratio (SMR) for prior suicide attempts by any method was 38.61.⁶ Suicide risk was highest in the 2 years after the first attempt. The SMR is a measure of the relative risk of suicide compared with the expected rate in the general population (SMR of 1).

Some chronic suicide risk factors are static: for example, a family history of psy­chiatric illness or earlier suicide attempt. Other chronic risk factors, usually a trait characteristic, can become acute: for exam­ple, impulsivity or aggression, or deliberate self-harm. The presence of chronic suicide risk factors should prompt a systematic sui­cide risk assessment. Evaluation of chronic suicide risk factors is an essential component of comprehensive assessment.5

Question 14
A psychiatrist is treating Dr. R, a 43-year-old physician, for anxiety and depression. The psychiatrist sees Dr. R twice a week for psy­chotherapy and medication management. A recent lawsuit filed against Dr. R has severely exacerbated her symptoms. She can sleep for only a few hours. Suicide ideation has emerged, frightening Dr. R and her family. The psychiatrist performs a systematic suicide risk assessment and determines that Dr. R is at acute high risk for suicide.

The psychiatrist recommends immediate hospitalization, but Dr. R adamantly refuses. The psychiatrist decides not to involuntarily hospitalize her because she does not meet the substantive criteria of the state involun­tary commitment statute (eg, overt suicidal behaviors). The psychiatrist chooses to con­tinue outpatient treatment.

 

Clinical interventions to reduce Dr. R’s suicide risk include:
   a) see her more often
   b) adjust medications
   c) obtain a consult
   d) refer her to an intensive outpatient program
   e) all of the above

The best response option is E
To hospitalize or not to hospitalize— that is the conundrum that psychiatrists often face with high-risk suicidal patients. The decision is more complicated when the need for hospitalization is clear but the patient refuses. The decisions that the psychiatrist makes at this point are crucial for treatment and risk management.⁵

If the patient disagrees with the psychiatrist’s recommendation to hospitalize, refusal should be addressed as a treatment issue. When the need for hospitalization is acute, a prolonged inquiry is not possible. In addition, the therapeutic alliance may become strained. This clinical situation tries a clinician’s professional mettle.

Consultation and referral are options to consider if time and the patient’s condition allows. A psychiatric clinician should never worry alone; sleepless nights benefit neither the psychiatrist nor the patient.

As Dr. R’s case shows, a psychiatrist might decide not to hospitalize a patient who is assessed to be at moderate or high risk of suicide. Protective factors may allow continuing outpatient treatment. A good therapeutic alliance may be present if the psychiatrist has worked with the patient for some time. Family support also may be available.

The clinician must determine if the patient’s suicide risk can be managed by more frequent visits and treatment adjust­ments. Also, supportive family members can help by providing observational data. Protective factors can be overwhelmed by a severe mental illness. In contrast, a patient assessed as being at moderate risk of suicide might need to be hospitalized when protec­tive factors are few or absent.

The psychiatrist may determine that a patient at high risk of suicide who refuses hospitalization does not meet criteria for involuntary hospitalization. For example, criteria might require that the patient must have made a suicide attempt within a speci­fied period of time. States have provisions in their commitment statutes granting immu­nity from liability if the clinician uses reason­able clinical judgment and acts in good faith when involuntarily hospitalizing a patient.⁷ 

Question 15
Mr. U, a 39-year-old, married engineer, is ready to be discharged from the inpatient unit. He was admitted 7 days earlier for acute alco­hol intoxication and suicidal threats. He has undergone successful detoxification. Mr. U has had 2 similar episodes within the past year.

The treatment team conducts a risk-benefit analysis for both discharge and continued hospi­talization. A consultation also is obtained.

The discharge decision will be most influenced by:
   a) presence of family support
   b) compliance with follow-up care
   c) availability of dual diagnosis programs
   d) systematic suicide risk assessment
   e) consultation


The best response option is D
All of the options in Question 15 concerning discharge planning of patients at risk for sui­cide are important. However, conducting a systematic suicide risk assessment to inform discharge planning is the most critical. Mr. U had 2 previous psychiatric admissions for alcohol abuse and suicidal ideation. He is a chronic suicide risk who becomes high risk when intoxicated.

Discharge planning begins at admission and is refined during the patient’s stay. Before a patient is discharged, a final post-discharge treatment and aftercare plan is necessary. After discharge, suicide risk increases as the intensity of treatment decreases.⁸

The patient’s willingness to cooperate with discharge and aftercare planning is critical in establishing contact with follow-up treat­ers. The treatment team should structure the follow-up plan to encourage compliance. For example, psychotic patients at risk of suicide who have a history of stopping medications after discharge can be given a long-acting IM antipsychotic that will last until they reach aftercare. Patients with comorbid drug and alcohol abuse disorders are referred to agen­cies equipped to manage dual-diagnosis patients.

Psychiatrists’ ability to ensure follow-up treatment is limited, a fact that must be acknowledged by the psychiatric and legal communities. Beyond patient stabilization, a clinician’s options to bring about posi­tive changes can be limited or nonexistent. Also, the patient’s failure to adhere to post-discharge plans and treatment often leads to rehospitalization, hopelessness, and greater suicide risk.

Psychiatric patients at moderate or moderate-to-high risk for suicide increas­ingly are treated in outpatient settings. It is the responsibility of the clinician and the treatment team to competently hand off the patient to appropriate outpatient aftercare. With the patient’s permission, the psychia­trist or social worker should call the follow-up agency or therapist before discharge to provide information about the patient’s diagnosis, treatment, and hospital course.

Last, follow-up appointments should be made as close to the time of discharge as possible. Suicide often occurs on the first day after discharge.³

 

Bottom Line
Fully commit time and effort to the ongoing assessment, treatment, and management of patients at suicide risk. Suicide risk assessment is a process, not an event. Conduct a suicide risk assessment at important clinical junctures (eg, initial evaluation, discharge, changing observation levels). Contemporaneously, document suicide risk assessments. This self-assessment helps clinicians gauge their strengths and identify skills that need further development.

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

Dr. Simon is the co-editor of The American Psychiatry Publishing textbook of Suicide Assessment and Management, 2nd edition, from which this article is adapted, by permission of the publisher, American Psychiatry Publishing, Inc. ©2012.

As explained in the first part of this article in the October 2014 issue of Current Psychiatry, assess­ing and managing suicide risk are complex, difficult tasks without clear-cut, easy solutions. The case-based, mul­tiple-choice self-test, with accompanying commentary, pre­sented here is designed to enhance one’s ability to provide care for patients at risk for suicide. Part 2 of this article poses the remaining 7 of 15 questions, which are based on clinical experience and the referenced work of others.

Question 9
Mr. N, age 62, will be discharged from the psychiatric unit tomor­row. He was admitted after an overdose suicide attempt. Mr. N was depressed after the loss of his business and was “treating” his depres­sion and anxiety with alcohol. He is successfully withdrawn from alcohol and responds to medication and supportive psychotherapy. During a family meeting with staff, Mr. N’s wife states that he keeps a gun by his bedside. Mr. N has improved and is eager to go home.

Before discharging Mr. N, the psychiatrist or staff should:
   a) instruct Mr. N to remove the gun from his bedside
   b) instruct his wife to remove the gun from the home
   c) instruct the wife to look for >1 gun
   d) instruct the wife, before Mr. N’s discharge, to call the staff once guns and
ammunition are safely removed according to the pre-arranged safety plan
   e) instruct the wife to lock up the gun in a place that is not known to the patient

The best response option is D
Guns in the home are associated with a sig­nificant increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible else­where, or if they intend to purchase a gun. Gun safety management requires a collabor­ative team approach including the clinician, patient, and person designated responsible for removing guns from the home.¹ The responsible person should be required to call the clinician to confirm that the guns have been removed and secured according to the plan. The principles of gun safety manage­ment apply to outpatients, inpatients, and emergency patients, although implementa­tion varies according to the clinical setting.

Asking the patient to remove guns from the home is too risky. Guns must be safely secured before the patient is discharged. Asking a spouse, other family member, or partner is necessary. The person asked must be willing to remove guns and ammunition according to a pre-arranged plan requiring a callback upon completion. A callback is essential because a family member in denial may do nothing to remove the guns or lock or “hide” them in the home where they will be found by a determined suicidal patient. Guns may be available outside the home, such as in the car, at the work place, or for purchase.

The essence of gun safety management is verification. Trust but verify or, better yet, verify, then trust.

Question 10
A recently admitted 56-year-old inpatient was discovered wrapping a towel around her neck. She denied suicidal intent; however, the treat­ment team viewed the incident as a suicide rehearsal. She was placed on one-to-one close observation.

Inpatient suicides frequently occur:
   a) shortly after admission
   b) during staff shift changes
   c) at meal times
   d) shortly after discharge
   e) all of the above

The best response option is E
Inpatient suicides also occur at increased frequency when psychiatric residents fin­ish their rotations and in understaffed psychiatric units.² Undue delay in the evaluation of a newly admitted acute, high-risk patient might allow the patient to commit suicide.

Most patient suicides occur shortly after hospital discharge (a few hours, days, or weeks later). Appleby et al³ found that the highest number of suicides occurred during the first week after discharge. Meehan et al⁴ found that suicide occurred most frequently during the first 2 weeks post-discharge; the highest number of suicides occurred on the first day after discharge.

Question 11
Ms. G, a 43-year-old, single woman in acute sui­cide crisis, is admitted to the psychiatric unit of a general hospital. She is diagnosed with bipolar I disorder, most recent episode depressed, and borderline personality disorder. She has had multiple psychiatric hospitalizations, all pre­cipitated by a suicide crisis. The average length of stay on the psychiatric unit is 6.3 days. After 7 days of intensive treatment, Ms. G is stabilized and suicide risk is reduced. The treatment team prepares for her discharge.

Ms. G’s suicide risk at discharge is most likely at:
   a) indeterminate risk
   b) low risk
   c) moderate risk
   d) chronic high risk
   e) acute high risk

 

The best response option is D
The length of stay in many acute care psy­chiatric facilities is <7 days. The goal of hospitalization is to stabilize the patient and discharge to appropriate community mental health resources. Discharge plan­ning begins at the time of admission.

Reducing Ms. G’s suicide risk to low or moderate is unlikely because of her diagnoses, frequent hospitalizations, and acute high risk for suicide on admission. After acute, high-risk suicidal patients are treated, many revert to chronic high risk for suicide.

Patients at chronic high risk for suicide often are treated as outpatients, except when an acute suicidal crisis requires hospi­talization.⁵ At discharge from the hospital, the goal is to return the patient to outpatient treatment.

A discharge note identifies the acute sui­cide risk factors that have abated and the chronic (long-term) suicide risk factors that remain. The discharge note also addresses a patient’s chronic vulnerability to suicide. For example, a patient can become acutely suicidal again, depending on a number of factors, including the nature and cause of the psychiatric illness, adequacy of future treat­ment, adherence to treatment recommenda­tions, and unforeseeable life vicissitudes.

Question 12
A 20-year-old college student is hospitalized after an overdose suicide attempt. Failing grades, panic attacks, and depression precipitated the suicide attempt. After 8 days of hos­pitalization, she is much improved and ready for discharge. She is assessed to be at low to moderate suicide risk. The treating psychiatrist and social worker convene a family meet­ing with both parents and an older brother. The family’s role after discharge is discussed.

All of the following options are helpful family roles except:
   a) provide constant 24-hour family supervision
   b) provide emotional support
   c) observe and report symptoms and behaviors of concern
   d) encourage adherence with treatment
   e) provide helpful feedback about the patient’s thoughts and behavior

The best response option is A
The family’s role is important, but it is not a substitute for constant safety management provided by trained mental health profes­sionals on an inpatient psychiatric unit.⁵ Early discharge of an inpatient by relying on family supervision can be precarious. Most inpatients are discharged at some level of suicide risk, given the short length of hos­pital stay. If an outpatient at risk of suicide requires constant 24-hour family supervi­sion, then psychiatric hospitalization is indicated.

Patients who are intent on killing them­selves can find ingenious ways to attempt or commit suicide. Asking family members to keep a constant watch often fails. Most family members will not follow the patient into the bathroom or be able to stay up all night to observe the patient. Moreover, fam­ily members find reasons to make exceptions to constant surveillance because of denial, fatigue, or the need to attend to other press­ing matters.


Question 13
During the initial evaluation of a patient, it is the psychiatrist’s practice to routinely inquire about current and past suicide ideation. An affirma­tive answer prompts a systematic suicide risk assessment. In the absence of current risk, if exploration of the patient’s history reveals chronic suicide risk factors, the psychiatrist con­ducts a systematic suicide risk assessment.

The chronic risk factor that has the highest association with suicide is:
   a) family history of mental illness or suicide
   b) childhood abuse
   c) history of a suicide attempt
   d) impulsivity or aggression
   e) prior psychiatric hospitalization

The best response option is C
A comprehensive suicide risk assessment may not be required at the initial outpatient evaluation in the absence of acute suicide risk factors. However, chronic suicide risk factors may be present.

The Standard Mortality Ratio (SMR) for prior suicide attempts by any method was 38.61.⁶ Suicide risk was highest in the 2 years after the first attempt. The SMR is a measure of the relative risk of suicide compared with the expected rate in the general population (SMR of 1).

Some chronic suicide risk factors are static: for example, a family history of psy­chiatric illness or earlier suicide attempt. Other chronic risk factors, usually a trait characteristic, can become acute: for exam­ple, impulsivity or aggression, or deliberate self-harm. The presence of chronic suicide risk factors should prompt a systematic sui­cide risk assessment. Evaluation of chronic suicide risk factors is an essential component of comprehensive assessment.5

Question 14
A psychiatrist is treating Dr. R, a 43-year-old physician, for anxiety and depression. The psychiatrist sees Dr. R twice a week for psy­chotherapy and medication management. A recent lawsuit filed against Dr. R has severely exacerbated her symptoms. She can sleep for only a few hours. Suicide ideation has emerged, frightening Dr. R and her family. The psychiatrist performs a systematic suicide risk assessment and determines that Dr. R is at acute high risk for suicide.

The psychiatrist recommends immediate hospitalization, but Dr. R adamantly refuses. The psychiatrist decides not to involuntarily hospitalize her because she does not meet the substantive criteria of the state involun­tary commitment statute (eg, overt suicidal behaviors). The psychiatrist chooses to con­tinue outpatient treatment.

 

Clinical interventions to reduce Dr. R’s suicide risk include:
   a) see her more often
   b) adjust medications
   c) obtain a consult
   d) refer her to an intensive outpatient program
   e) all of the above

The best response option is E
To hospitalize or not to hospitalize— that is the conundrum that psychiatrists often face with high-risk suicidal patients. The decision is more complicated when the need for hospitalization is clear but the patient refuses. The decisions that the psychiatrist makes at this point are crucial for treatment and risk management.⁵

If the patient disagrees with the psychiatrist’s recommendation to hospitalize, refusal should be addressed as a treatment issue. When the need for hospitalization is acute, a prolonged inquiry is not possible. In addition, the therapeutic alliance may become strained. This clinical situation tries a clinician’s professional mettle.

Consultation and referral are options to consider if time and the patient’s condition allows. A psychiatric clinician should never worry alone; sleepless nights benefit neither the psychiatrist nor the patient.

As Dr. R’s case shows, a psychiatrist might decide not to hospitalize a patient who is assessed to be at moderate or high risk of suicide. Protective factors may allow continuing outpatient treatment. A good therapeutic alliance may be present if the psychiatrist has worked with the patient for some time. Family support also may be available.

The clinician must determine if the patient’s suicide risk can be managed by more frequent visits and treatment adjust­ments. Also, supportive family members can help by providing observational data. Protective factors can be overwhelmed by a severe mental illness. In contrast, a patient assessed as being at moderate risk of suicide might need to be hospitalized when protec­tive factors are few or absent.

The psychiatrist may determine that a patient at high risk of suicide who refuses hospitalization does not meet criteria for involuntary hospitalization. For example, criteria might require that the patient must have made a suicide attempt within a speci­fied period of time. States have provisions in their commitment statutes granting immu­nity from liability if the clinician uses reason­able clinical judgment and acts in good faith when involuntarily hospitalizing a patient.⁷ 

Question 15
Mr. U, a 39-year-old, married engineer, is ready to be discharged from the inpatient unit. He was admitted 7 days earlier for acute alco­hol intoxication and suicidal threats. He has undergone successful detoxification. Mr. U has had 2 similar episodes within the past year.

The treatment team conducts a risk-benefit analysis for both discharge and continued hospi­talization. A consultation also is obtained.

The discharge decision will be most influenced by:
   a) presence of family support
   b) compliance with follow-up care
   c) availability of dual diagnosis programs
   d) systematic suicide risk assessment
   e) consultation


The best response option is D
All of the options in Question 15 concerning discharge planning of patients at risk for sui­cide are important. However, conducting a systematic suicide risk assessment to inform discharge planning is the most critical. Mr. U had 2 previous psychiatric admissions for alcohol abuse and suicidal ideation. He is a chronic suicide risk who becomes high risk when intoxicated.

Discharge planning begins at admission and is refined during the patient’s stay. Before a patient is discharged, a final post-discharge treatment and aftercare plan is necessary. After discharge, suicide risk increases as the intensity of treatment decreases.⁸

The patient’s willingness to cooperate with discharge and aftercare planning is critical in establishing contact with follow-up treat­ers. The treatment team should structure the follow-up plan to encourage compliance. For example, psychotic patients at risk of suicide who have a history of stopping medications after discharge can be given a long-acting IM antipsychotic that will last until they reach aftercare. Patients with comorbid drug and alcohol abuse disorders are referred to agen­cies equipped to manage dual-diagnosis patients.

Psychiatrists’ ability to ensure follow-up treatment is limited, a fact that must be acknowledged by the psychiatric and legal communities. Beyond patient stabilization, a clinician’s options to bring about posi­tive changes can be limited or nonexistent. Also, the patient’s failure to adhere to post-discharge plans and treatment often leads to rehospitalization, hopelessness, and greater suicide risk.

Psychiatric patients at moderate or moderate-to-high risk for suicide increas­ingly are treated in outpatient settings. It is the responsibility of the clinician and the treatment team to competently hand off the patient to appropriate outpatient aftercare. With the patient’s permission, the psychia­trist or social worker should call the follow-up agency or therapist before discharge to provide information about the patient’s diagnosis, treatment, and hospital course.

Last, follow-up appointments should be made as close to the time of discharge as possible. Suicide often occurs on the first day after discharge.³

 

Bottom Line
Fully commit time and effort to the ongoing assessment, treatment, and management of patients at suicide risk. Suicide risk assessment is a process, not an event. Conduct a suicide risk assessment at important clinical junctures (eg, initial evaluation, discharge, changing observation levels). Contemporaneously, document suicide risk assessments. This self-assessment helps clinicians gauge their strengths and identify skills that need further development.

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

Dr. Simon is the co-editor of The American Psychiatry Publishing textbook of Suicide Assessment and Management, 2nd edition, from which this article is adapted, by permission of the publisher, American Psychiatry Publishing, Inc. ©2012.

As explained in the first part of this article in the October 2014 issue of Current Psychiatry, assess­ing and managing suicide risk are complex, difficult tasks without clear-cut, easy solutions. The case-based, mul­tiple-choice self-test, with accompanying commentary, pre­sented here is designed to enhance one’s ability to provide care for patients at risk for suicide. Part 2 of this article poses the remaining 7 of 15 questions, which are based on clinical experience and the referenced work of others.

Question 9
Mr. N, age 62, will be discharged from the psychiatric unit tomor­row. He was admitted after an overdose suicide attempt. Mr. N was depressed after the loss of his business and was “treating” his depres­sion and anxiety with alcohol. He is successfully withdrawn from alcohol and responds to medication and supportive psychotherapy. During a family meeting with staff, Mr. N’s wife states that he keeps a gun by his bedside. Mr. N has improved and is eager to go home.

Before discharging Mr. N, the psychiatrist or staff should:
   a) instruct Mr. N to remove the gun from his bedside
   b) instruct his wife to remove the gun from the home
   c) instruct the wife to look for >1 gun
   d) instruct the wife, before Mr. N’s discharge, to call the staff once guns and
ammunition are safely removed according to the pre-arranged safety plan
   e) instruct the wife to lock up the gun in a place that is not known to the patient

The best response option is D
Guns in the home are associated with a sig­nificant increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible else­where, or if they intend to purchase a gun. Gun safety management requires a collabor­ative team approach including the clinician, patient, and person designated responsible for removing guns from the home.¹ The responsible person should be required to call the clinician to confirm that the guns have been removed and secured according to the plan. The principles of gun safety manage­ment apply to outpatients, inpatients, and emergency patients, although implementa­tion varies according to the clinical setting.

Asking the patient to remove guns from the home is too risky. Guns must be safely secured before the patient is discharged. Asking a spouse, other family member, or partner is necessary. The person asked must be willing to remove guns and ammunition according to a pre-arranged plan requiring a callback upon completion. A callback is essential because a family member in denial may do nothing to remove the guns or lock or “hide” them in the home where they will be found by a determined suicidal patient. Guns may be available outside the home, such as in the car, at the work place, or for purchase.

The essence of gun safety management is verification. Trust but verify or, better yet, verify, then trust.

Question 10
A recently admitted 56-year-old inpatient was discovered wrapping a towel around her neck. She denied suicidal intent; however, the treat­ment team viewed the incident as a suicide rehearsal. She was placed on one-to-one close observation.

Inpatient suicides frequently occur:
   a) shortly after admission
   b) during staff shift changes
   c) at meal times
   d) shortly after discharge
   e) all of the above

The best response option is E
Inpatient suicides also occur at increased frequency when psychiatric residents fin­ish their rotations and in understaffed psychiatric units.² Undue delay in the evaluation of a newly admitted acute, high-risk patient might allow the patient to commit suicide.

Most patient suicides occur shortly after hospital discharge (a few hours, days, or weeks later). Appleby et al³ found that the highest number of suicides occurred during the first week after discharge. Meehan et al⁴ found that suicide occurred most frequently during the first 2 weeks post-discharge; the highest number of suicides occurred on the first day after discharge.

Question 11
Ms. G, a 43-year-old, single woman in acute sui­cide crisis, is admitted to the psychiatric unit of a general hospital. She is diagnosed with bipolar I disorder, most recent episode depressed, and borderline personality disorder. She has had multiple psychiatric hospitalizations, all pre­cipitated by a suicide crisis. The average length of stay on the psychiatric unit is 6.3 days. After 7 days of intensive treatment, Ms. G is stabilized and suicide risk is reduced. The treatment team prepares for her discharge.

Ms. G’s suicide risk at discharge is most likely at:
   a) indeterminate risk
   b) low risk
   c) moderate risk
   d) chronic high risk
   e) acute high risk

 

The best response option is D
The length of stay in many acute care psy­chiatric facilities is <7 days. The goal of hospitalization is to stabilize the patient and discharge to appropriate community mental health resources. Discharge plan­ning begins at the time of admission.

Reducing Ms. G’s suicide risk to low or moderate is unlikely because of her diagnoses, frequent hospitalizations, and acute high risk for suicide on admission. After acute, high-risk suicidal patients are treated, many revert to chronic high risk for suicide.

Patients at chronic high risk for suicide often are treated as outpatients, except when an acute suicidal crisis requires hospi­talization.⁵ At discharge from the hospital, the goal is to return the patient to outpatient treatment.

A discharge note identifies the acute sui­cide risk factors that have abated and the chronic (long-term) suicide risk factors that remain. The discharge note also addresses a patient’s chronic vulnerability to suicide. For example, a patient can become acutely suicidal again, depending on a number of factors, including the nature and cause of the psychiatric illness, adequacy of future treat­ment, adherence to treatment recommenda­tions, and unforeseeable life vicissitudes.

Question 12
A 20-year-old college student is hospitalized after an overdose suicide attempt. Failing grades, panic attacks, and depression precipitated the suicide attempt. After 8 days of hos­pitalization, she is much improved and ready for discharge. She is assessed to be at low to moderate suicide risk. The treating psychiatrist and social worker convene a family meet­ing with both parents and an older brother. The family’s role after discharge is discussed.

All of the following options are helpful family roles except:
   a) provide constant 24-hour family supervision
   b) provide emotional support
   c) observe and report symptoms and behaviors of concern
   d) encourage adherence with treatment
   e) provide helpful feedback about the patient’s thoughts and behavior

The best response option is A
The family’s role is important, but it is not a substitute for constant safety management provided by trained mental health profes­sionals on an inpatient psychiatric unit.⁵ Early discharge of an inpatient by relying on family supervision can be precarious. Most inpatients are discharged at some level of suicide risk, given the short length of hos­pital stay. If an outpatient at risk of suicide requires constant 24-hour family supervi­sion, then psychiatric hospitalization is indicated.

Patients who are intent on killing them­selves can find ingenious ways to attempt or commit suicide. Asking family members to keep a constant watch often fails. Most family members will not follow the patient into the bathroom or be able to stay up all night to observe the patient. Moreover, fam­ily members find reasons to make exceptions to constant surveillance because of denial, fatigue, or the need to attend to other press­ing matters.


Question 13
During the initial evaluation of a patient, it is the psychiatrist’s practice to routinely inquire about current and past suicide ideation. An affirma­tive answer prompts a systematic suicide risk assessment. In the absence of current risk, if exploration of the patient’s history reveals chronic suicide risk factors, the psychiatrist con­ducts a systematic suicide risk assessment.

The chronic risk factor that has the highest association with suicide is:
   a) family history of mental illness or suicide
   b) childhood abuse
   c) history of a suicide attempt
   d) impulsivity or aggression
   e) prior psychiatric hospitalization

The best response option is C
A comprehensive suicide risk assessment may not be required at the initial outpatient evaluation in the absence of acute suicide risk factors. However, chronic suicide risk factors may be present.

The Standard Mortality Ratio (SMR) for prior suicide attempts by any method was 38.61.⁶ Suicide risk was highest in the 2 years after the first attempt. The SMR is a measure of the relative risk of suicide compared with the expected rate in the general population (SMR of 1).

Some chronic suicide risk factors are static: for example, a family history of psy­chiatric illness or earlier suicide attempt. Other chronic risk factors, usually a trait characteristic, can become acute: for exam­ple, impulsivity or aggression, or deliberate self-harm. The presence of chronic suicide risk factors should prompt a systematic sui­cide risk assessment. Evaluation of chronic suicide risk factors is an essential component of comprehensive assessment.5

Question 14
A psychiatrist is treating Dr. R, a 43-year-old physician, for anxiety and depression. The psychiatrist sees Dr. R twice a week for psy­chotherapy and medication management. A recent lawsuit filed against Dr. R has severely exacerbated her symptoms. She can sleep for only a few hours. Suicide ideation has emerged, frightening Dr. R and her family. The psychiatrist performs a systematic suicide risk assessment and determines that Dr. R is at acute high risk for suicide.

The psychiatrist recommends immediate hospitalization, but Dr. R adamantly refuses. The psychiatrist decides not to involuntarily hospitalize her because she does not meet the substantive criteria of the state involun­tary commitment statute (eg, overt suicidal behaviors). The psychiatrist chooses to con­tinue outpatient treatment.

 

Clinical interventions to reduce Dr. R’s suicide risk include:
   a) see her more often
   b) adjust medications
   c) obtain a consult
   d) refer her to an intensive outpatient program
   e) all of the above

The best response option is E
To hospitalize or not to hospitalize— that is the conundrum that psychiatrists often face with high-risk suicidal patients. The decision is more complicated when the need for hospitalization is clear but the patient refuses. The decisions that the psychiatrist makes at this point are crucial for treatment and risk management.⁵

If the patient disagrees with the psychiatrist’s recommendation to hospitalize, refusal should be addressed as a treatment issue. When the need for hospitalization is acute, a prolonged inquiry is not possible. In addition, the therapeutic alliance may become strained. This clinical situation tries a clinician’s professional mettle.

Consultation and referral are options to consider if time and the patient’s condition allows. A psychiatric clinician should never worry alone; sleepless nights benefit neither the psychiatrist nor the patient.

As Dr. R’s case shows, a psychiatrist might decide not to hospitalize a patient who is assessed to be at moderate or high risk of suicide. Protective factors may allow continuing outpatient treatment. A good therapeutic alliance may be present if the psychiatrist has worked with the patient for some time. Family support also may be available.

The clinician must determine if the patient’s suicide risk can be managed by more frequent visits and treatment adjust­ments. Also, supportive family members can help by providing observational data. Protective factors can be overwhelmed by a severe mental illness. In contrast, a patient assessed as being at moderate risk of suicide might need to be hospitalized when protec­tive factors are few or absent.

The psychiatrist may determine that a patient at high risk of suicide who refuses hospitalization does not meet criteria for involuntary hospitalization. For example, criteria might require that the patient must have made a suicide attempt within a speci­fied period of time. States have provisions in their commitment statutes granting immu­nity from liability if the clinician uses reason­able clinical judgment and acts in good faith when involuntarily hospitalizing a patient.⁷ 

Question 15
Mr. U, a 39-year-old, married engineer, is ready to be discharged from the inpatient unit. He was admitted 7 days earlier for acute alco­hol intoxication and suicidal threats. He has undergone successful detoxification. Mr. U has had 2 similar episodes within the past year.

The treatment team conducts a risk-benefit analysis for both discharge and continued hospi­talization. A consultation also is obtained.

The discharge decision will be most influenced by:
   a) presence of family support
   b) compliance with follow-up care
   c) availability of dual diagnosis programs
   d) systematic suicide risk assessment
   e) consultation


The best response option is D
All of the options in Question 15 concerning discharge planning of patients at risk for sui­cide are important. However, conducting a systematic suicide risk assessment to inform discharge planning is the most critical. Mr. U had 2 previous psychiatric admissions for alcohol abuse and suicidal ideation. He is a chronic suicide risk who becomes high risk when intoxicated.

Discharge planning begins at admission and is refined during the patient’s stay. Before a patient is discharged, a final post-discharge treatment and aftercare plan is necessary. After discharge, suicide risk increases as the intensity of treatment decreases.⁸

The patient’s willingness to cooperate with discharge and aftercare planning is critical in establishing contact with follow-up treat­ers. The treatment team should structure the follow-up plan to encourage compliance. For example, psychotic patients at risk of suicide who have a history of stopping medications after discharge can be given a long-acting IM antipsychotic that will last until they reach aftercare. Patients with comorbid drug and alcohol abuse disorders are referred to agen­cies equipped to manage dual-diagnosis patients.

Psychiatrists’ ability to ensure follow-up treatment is limited, a fact that must be acknowledged by the psychiatric and legal communities. Beyond patient stabilization, a clinician’s options to bring about posi­tive changes can be limited or nonexistent. Also, the patient’s failure to adhere to post-discharge plans and treatment often leads to rehospitalization, hopelessness, and greater suicide risk.

Psychiatric patients at moderate or moderate-to-high risk for suicide increas­ingly are treated in outpatient settings. It is the responsibility of the clinician and the treatment team to competently hand off the patient to appropriate outpatient aftercare. With the patient’s permission, the psychia­trist or social worker should call the follow-up agency or therapist before discharge to provide information about the patient’s diagnosis, treatment, and hospital course.

Last, follow-up appointments should be made as close to the time of discharge as possible. Suicide often occurs on the first day after discharge.³

 

Bottom Line
Fully commit time and effort to the ongoing assessment, treatment, and management of patients at suicide risk. Suicide risk assessment is a process, not an event. Conduct a suicide risk assessment at important clinical junctures (eg, initial evaluation, discharge, changing observation levels). Contemporaneously, document suicide risk assessments. This self-assessment helps clinicians gauge their strengths and identify skills that need further development.

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

Dr. Simon is the co-editor of The American Psychiatry Publishing textbook of Suicide Assessment and Management, 2nd edition, from which this article is adapted, by permission of the publisher, American Psychiatry Publishing, Inc. ©2012.

The assessment and management of suicide risk are com­plex and difficult tasks that raise clinical issues without clear-cut, easy answers. This case-based, multiple-choice self-assessment with accompanying commentaries is a teach­ing instrument that I designed to enhance a clinician’s ability to provide care for patients at risk for suicide. Part 1 of this article poses 8 of the 15 questions; the balance of questions will appear in Part 2, in the November 2014 issue of Current Psychiatry.

The questions and commentaries in this self-assessment orig­inate in the referenced work of others and my clinical experi­ence. Therefore, I use the preferred “best response” option—not the customary and more restrictive “correct answer” format.

How do you score?


Question 1
Mr. J, age 34, is a professional basketball player complaining of weight loss, early morning waking, and a dysphoric mood last­ing for 1 month. His performance on the basketball court has declined and his wife is seeking a separation. He describes “fleet­ing” suicidal thoughts. He has no history of suicide attempts or depression. The patient does not abuse alcohol or drugs.

The initial assessment approach is to:
   a) obtain a suicide prevention contract
   b) assess suicide risk and protective factors
   c) determine the cause of Mr. J’s depression
   d) have Mr. J complete a suicide risk self-assessment form
   e) contact his wife for additional history

The best response option is B
Suicide prevention contracts do not prevent suicide.¹ Contacting the patient’s wife may be an option at a later stage of evaluation or treat­ment, if Mr. J grants permission. Determining the cause of his depression likely will require ongoing work up. Assessing suicide risk fac­tors without also looking at protective factors is a common error. A comprehensive suicide risk assessment evaluation requires evaluat­ing both risk and protective factors.^2,3 Suicide risk assessment forms often omit questions about protective factors.⁴ Do not rely on self-assessment suicide risk forms because they are dependent on the patient’s truthfulness. Patients who are determined to commit sui­cide might regard the psychiatrist and other mental health professionals as the enemy.⁵

Question 2
Ms. P, a 56-year-old, single schoolteacher, is admitted to a psychiatric unit for severe depres­sion and suicidal ideation without a plan. She is devoutly religious, stating, “I won’t kill myself, because I don’t want to go to hell.” Ms. P attends religious services regularly. She has a history of chronic recurrent depression with suicidal ide­ation and no history of suicide attempts. You suspect a diagnosis of bipolar II disorder.


In assessing religious affiliation as a protective factor against suicide, you should consider:
   a) the nature of the patient’s religious conviction
   b) the religion’s stated position on suicide
   c) severity of the patient’s illness
   d) presence of delusional religious beliefs
   e) all of the above


The best response option is E
Dervic et al⁶ evaluated 371 depressed inpa­tients according to their religious or non-religious affiliation. Patients with no religious affiliation made significantly more suicide attempts, had more first-degree relatives who committed suicide, were younger, were less likely to be married or have children, and had fewer contacts with family members.

In general, religious affiliation is a protec­tive factor against suicide but may not be a protective factor in an individual patient. Religious affiliation, similar to other pre­summed general protective factors, requires further scrutiny. Avoid making assumptions. For example, a depressed, devoutly religious patient may curse God for abandonment. A patient with bipolar disorder may believe that God would forgive her for committing suicide. A presumed protective factor may not be protective or might even be a risk fac­tor, such as psychotic patients with religious delusions.

Abrahamic religions—ie, Judaism, Christianity, and Islam—prohibit sui­cide. Severe mental illness, however, can overcome the strongest religious prohibi­tions against suicide, including the fear of eternal damnation. For many psychiatric patients, religious affiliations and beliefs are protective factors against suicide, but only relatively. No protective factor against suicide, however strong, provides absolute protection against suicide. Moreover, other risk and protective factors also must be assessed comprehensively.


Question 3
Mr. W, age 18, is admitted to an inpatient psy­chiatric unit with severe agitation, thought disorder, disorganization, and auditory hal­lucinations. He is threatening to jump from a nearby building. He has no history of sub­stance abuse.

The psychiatrist conducts a comprehen­sive suicide risk assessment that includes the patient’s psychiatric diagnosis as a risk factor.

Which psychiatric disorder has the highest associated suicide mortality rate?
   a) schizophrenia
   b) eating disorders
   c) bipolar disorder
   d) major depressive disorder
   e) borderline personality disorder

The best response option is B
Harris and Barraclough (Table)⁷ calculated the standardized mortality ratio (SMR) for suicide among psychiat­ric disorders. SMR is calculated by divid­ing observed mortality by suicide by the expected mortality by suicide in the general population. Every psychiatric disorder in their study, except for mental retardation, was associated with a varying degree of suicide risk. Eating disorders had the high­est SMR. The patient’s psychiatric diagno­sis is a risk factor that informs the clinician’s suicide risk assessment.

Question 4
Mr. Z, a 64-year-old, recently divorced lawyer, is admitted to the psychiatric unit from the emergency room. His colleagues brought Mr. Z to the emergency room because of his sui­cide threats.

 

On the unit, Mr. Z denies suicidal ideation, plan, or intent. Agitation and suspiciousness are prominent. He refuses to authorize staff to contact his colleagues, his ex-wife, and other family members. Mr. Z demands imme­diate discharge and forbids contact with his outpatient psychotherapist. He is placed on 72-hour hold as a conditional voluntary admission.

The clinician should:
   a) contact Mr. Z’s family, as an emergency exception to confidentiality
   b) e-mail his family members with questions
   c) contact the patient’s psychotherapist as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
   d) try to develop a therapeutic alliance with Mr. Z
   e) none of the above

The best response option is C
HIPAA permits psychiatrists and other health care providers who are treating the same patient to communicate with each other about medical treatment without obtaining permission from the patient.⁸ However, mental health professionals can­not share psychotherapy notes without a patient’s consent, except when legally required, such as reporting abuse or duty to warn. This is the most expeditious and productive way of obtaining essential clin­ical information. E-mail merely changes the mode of unauthorized communication with significant others.

Mr. Z is agitated and suspicious, and developing a therapeutic alliance would require time. It is necessary to gather infor­mation about his psychiatric condition as soon as possible. An emergency exception to maintaining confidentiality is another option.⁹ The definition of emergency var­ies among jurisdictions. Consulting with a knowledgeable attorney may be neces­sary, but it usually takes time. Ethically, it is permissible to breach confidentiality to protect the suicidal patient.¹⁰

Question 5
Mr. G, a 42-year-old engineer, is re-hospitalized after a failed hanging attempt. Initially, he is profoundly depressed but improves sud­denly and requests discharge. The psychiatrist and clinical staff are perplexed. Is the sudden improvement real or feigned?

The treatment team should consider all of the following options except:
   a) obtain records of earlier hospitalizations
   b) check collateral sources of information
   c) assess Mr. G’s compliance with treatment
   d) obtain psychological testing to evaluate Mr. G’s honesty
   e) determine whether behavioral signs of depression are present

The best response option is D
Short length of hospital stay makes it diffi­cult to assess sudden patient improvement.¹¹ Real improvement in a high-risk suicidal patient is a process, even when it occurs quickly. Feigned improvement is an event. Obtaining patient information from collat­eral sources is crucial. Sudden improvement might be caused by the patient’s resolve to complete suicide. Identifying behavioral risk factors associated with psychiatric disorders informs the clinician’s systematic suicide risk assessment of a guarded or dissimula­tive patient. Psychological testing will take critical time and is not a substitute for careful clinical assessment.

Question 6
In mid-winter, Ms. M, a 42-year-old homeless woman, is seen in the emergency room of a general hospital. She complains of depres­sion and auditory hallucinations command­ing her to commit suicide. Ms. M has 5 earlier admissions to the psychiatry unit for similar complaints.

The psychiatrist conducts a compre­hensive suicide risk assessment. Acute and chronic risk factors for suicide are identified. Protective factors also are assessed. The psy­chiatrist weighs and synthesizes risk and pro­tective factors into an overall assessment of Ms. M’s suicide risk.

The main purpose of suicide risk assessment is to:  
   a) predict the likelihood of suicide  
   b) determine imminence of suicide  
   c) inform patient treatment and safety management  
   d) identify malingered suicidal ideation  
   e) provide a legal defense against a mal­practice claim

The best response option is C
Suicide cannot be predicted.¹² The term imminent suicide is a veiled attempt to pre­dict when a patient will attempt suicide.¹³ The process of a comprehensive or system­atic suicide risk assessment encompasses identification, analysis, and synthesis of risk and protective factors that inform the treatment and safety management of the patient.³ The overall suicide assessment is a clinical judgment call that determines risk along a continuum of low to high. In Ms. M’s case, comprehensive suicide risk assessment will assist the clinician in deter­mining the patient’s overall suicide risk and make an appropriate disposition. Without a systematic suicide risk assessment meth­odology, the clinician is at the mercy of the pejoratively labeled “frequent flyer” who is looking for sustenance and lodging. The frustrated clinician is left with little choice but to admit the patient.

Although not the main purpose, system­atic suicide risk assessment can help provide a sound legal defense if a suicide malpractice claim is filed against the clinician alleging negligent assessment.¹⁴

Question 7
A psychiatrist is treating Mr. S, a 36-year-old computer analyst, with once-a-week psycho­therapy and medication management for panic and depressive symptoms that emerged abruptly after the break-up of a romantic rela­tionship. Mr. S is using alcohol to sleep. He reports occasional suicidal ideation but no plan. He finds the idea of suicide to be morally repugnant. A therapeutic alliance develops.

 

The psychiatrist is concerned about Mr. S’s suicide risk and the need for hospi­talization. The psychiatrist performs a sys­tematic suicide risk assessment that includes identification of individual and evidence-based protective factors. For example, Mr. S continued to pursue his interests and to par­ticipate in civil causes. The overall suicide risk  is determined by the assessment of individ­ual and evidence-based protective factors.

All of the following options are evidence-based protective factors except:
   a) therapeutic alliance
   b) survival and coping beliefs
   c) responsibility to family
   d) fear of suicide
   e) moral objections to suicide

The best response option is A
Clinical consensus holds that the thera­peutic alliance is an important protec­tive factor against suicide. However, no evidence-based research supports or refutes this widely held belief among clinicians.

Linehan et al¹⁵ developed the Reasons for Living Inventory, a self-report instru­ment that identifies 6 subscales:
   • survival and coping beliefs
   • responsibility to family
   • child-related concerns
   • fear of suicide
   • fear of social disapproval
   • moral objections to suicide.

Survival and coping beliefs, responsi­bility to family, and child-related concerns were useful in differentiating between suicidal and non-suicidal individuals. Malone et al¹⁶ administered the Reasons for Living Inventory to 84 inpatients with major depression; 45 had attempted sui­cide. Depressed patients who had not attempted suicide demonstrated more sense of responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater survival and coping skills, and greater fear of suicide than patients who attempted suicide. The authors recommended adding the Reasons for Living Inventory to the assessment of patients at risk for suicide.

Question 8
A 38-year-old mother of a newborn child is admitted to the psychiatric unit after expressing suicidal thoughts to her husband. She has been hospitalized previously after a hypomanic episode and severe depres­sion; she has no history of suicide attempts. A psychiatrist diagnoses bipolar II disorder (recurrent major episodes with hypomanic episodes). The patient’s maternal aunt has bipolar disorder. Her paternal grandfather committed suicide.

The psychiatrist conducts a systematic suicide risk assessment and determines the patient is at high risk of suicide. He considers a suicide-risk reduction drug.

Which one of the following drugs has been shown to reduce suicide and suicide attempts in bipolar II patients?
   a) clozapine
   b) clonazepam
   c) lorazepam
   d) lithium
   e) quetiapine

The best response option is D
Prospective, randomized and controlled trials consistently have found lower rates of completed suicides and suicide attempts during lithium maintenance treatments for patients with bipolar disorder and other major affective disorders.¹⁷

Bottom Line
Suicide risk assessment and management are challenging for even experienced clinicians. Suicide risk assessment guides appropriate treatment and management for patients at risk for suicide. This self-assessment helps mental health professionals identify potential gaps in their knowledge and reinforce best practices.

Related Resources
• Simon RI. Passive suicidal ideation: Still a high-risk clinical scenario. Current Psychiatry. 2014;13(3):13-15.
• Simon RI. Suicide rehearsals: A high-risk psychiatric emer­gency. Current Psychiatry. 2012;11(7):28-32.
• Bongar B, Sullivan GR. The suicidal patient: Clinical and legal standards of care. Washington, DC: American Psychological Association; 2013.

Drug Brand Names
Clonazepam • Klonopin              Lorazepam • Ativan
Clozapine • Clozaril                    Quetiapine • Seroquel
Lithium • Eskalith, Lithobid

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

Adapted with permission from: Simon RI. Preventing patient suicide: clinical assessment and management, Arlington VA: American Psychiatric Publishing; 2011.

Editor’s note: Part 2 of this self-assessment on suicide assessment and management in the November 2014 issue of Current Psychiatry poses 7 additional questions.

The assessment and management of suicide risk are com­plex and difficult tasks that raise clinical issues without clear-cut, easy answers. This case-based, multiple-choice self-assessment with accompanying commentaries is a teach­ing instrument that I designed to enhance a clinician’s ability to provide care for patients at risk for suicide. Part 1 of this article poses 8 of the 15 questions; the balance of questions will appear in Part 2, in the November 2014 issue of Current Psychiatry.

The questions and commentaries in this self-assessment orig­inate in the referenced work of others and my clinical experi­ence. Therefore, I use the preferred “best response” option—not the customary and more restrictive “correct answer” format.

How do you score?


Question 1
Mr. J, age 34, is a professional basketball player complaining of weight loss, early morning waking, and a dysphoric mood last­ing for 1 month. His performance on the basketball court has declined and his wife is seeking a separation. He describes “fleet­ing” suicidal thoughts. He has no history of suicide attempts or depression. The patient does not abuse alcohol or drugs.

The initial assessment approach is to:
   a) obtain a suicide prevention contract
   b) assess suicide risk and protective factors
   c) determine the cause of Mr. J’s depression
   d) have Mr. J complete a suicide risk self-assessment form
   e) contact his wife for additional history

The best response option is B
Suicide prevention contracts do not prevent suicide.¹ Contacting the patient’s wife may be an option at a later stage of evaluation or treat­ment, if Mr. J grants permission. Determining the cause of his depression likely will require ongoing work up. Assessing suicide risk fac­tors without also looking at protective factors is a common error. A comprehensive suicide risk assessment evaluation requires evaluat­ing both risk and protective factors.^2,3 Suicide risk assessment forms often omit questions about protective factors.⁴ Do not rely on self-assessment suicide risk forms because they are dependent on the patient’s truthfulness. Patients who are determined to commit sui­cide might regard the psychiatrist and other mental health professionals as the enemy.⁵

Question 2
Ms. P, a 56-year-old, single schoolteacher, is admitted to a psychiatric unit for severe depres­sion and suicidal ideation without a plan. She is devoutly religious, stating, “I won’t kill myself, because I don’t want to go to hell.” Ms. P attends religious services regularly. She has a history of chronic recurrent depression with suicidal ide­ation and no history of suicide attempts. You suspect a diagnosis of bipolar II disorder.


In assessing religious affiliation as a protective factor against suicide, you should consider:
   a) the nature of the patient’s religious conviction
   b) the religion’s stated position on suicide
   c) severity of the patient’s illness
   d) presence of delusional religious beliefs
   e) all of the above


The best response option is E
Dervic et al⁶ evaluated 371 depressed inpa­tients according to their religious or non-religious affiliation. Patients with no religious affiliation made significantly more suicide attempts, had more first-degree relatives who committed suicide, were younger, were less likely to be married or have children, and had fewer contacts with family members.

In general, religious affiliation is a protec­tive factor against suicide but may not be a protective factor in an individual patient. Religious affiliation, similar to other pre­summed general protective factors, requires further scrutiny. Avoid making assumptions. For example, a depressed, devoutly religious patient may curse God for abandonment. A patient with bipolar disorder may believe that God would forgive her for committing suicide. A presumed protective factor may not be protective or might even be a risk fac­tor, such as psychotic patients with religious delusions.

Abrahamic religions—ie, Judaism, Christianity, and Islam—prohibit sui­cide. Severe mental illness, however, can overcome the strongest religious prohibi­tions against suicide, including the fear of eternal damnation. For many psychiatric patients, religious affiliations and beliefs are protective factors against suicide, but only relatively. No protective factor against suicide, however strong, provides absolute protection against suicide. Moreover, other risk and protective factors also must be assessed comprehensively.


Question 3
Mr. W, age 18, is admitted to an inpatient psy­chiatric unit with severe agitation, thought disorder, disorganization, and auditory hal­lucinations. He is threatening to jump from a nearby building. He has no history of sub­stance abuse.

The psychiatrist conducts a comprehen­sive suicide risk assessment that includes the patient’s psychiatric diagnosis as a risk factor.

Which psychiatric disorder has the highest associated suicide mortality rate?
   a) schizophrenia
   b) eating disorders
   c) bipolar disorder
   d) major depressive disorder
   e) borderline personality disorder

The best response option is B
Harris and Barraclough (Table)⁷ calculated the standardized mortality ratio (SMR) for suicide among psychiat­ric disorders. SMR is calculated by divid­ing observed mortality by suicide by the expected mortality by suicide in the general population. Every psychiatric disorder in their study, except for mental retardation, was associated with a varying degree of suicide risk. Eating disorders had the high­est SMR. The patient’s psychiatric diagno­sis is a risk factor that informs the clinician’s suicide risk assessment.

Question 4
Mr. Z, a 64-year-old, recently divorced lawyer, is admitted to the psychiatric unit from the emergency room. His colleagues brought Mr. Z to the emergency room because of his sui­cide threats.

 

On the unit, Mr. Z denies suicidal ideation, plan, or intent. Agitation and suspiciousness are prominent. He refuses to authorize staff to contact his colleagues, his ex-wife, and other family members. Mr. Z demands imme­diate discharge and forbids contact with his outpatient psychotherapist. He is placed on 72-hour hold as a conditional voluntary admission.

The clinician should:
   a) contact Mr. Z’s family, as an emergency exception to confidentiality
   b) e-mail his family members with questions
   c) contact the patient’s psychotherapist as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
   d) try to develop a therapeutic alliance with Mr. Z
   e) none of the above

The best response option is C
HIPAA permits psychiatrists and other health care providers who are treating the same patient to communicate with each other about medical treatment without obtaining permission from the patient.⁸ However, mental health professionals can­not share psychotherapy notes without a patient’s consent, except when legally required, such as reporting abuse or duty to warn. This is the most expeditious and productive way of obtaining essential clin­ical information. E-mail merely changes the mode of unauthorized communication with significant others.

Mr. Z is agitated and suspicious, and developing a therapeutic alliance would require time. It is necessary to gather infor­mation about his psychiatric condition as soon as possible. An emergency exception to maintaining confidentiality is another option.⁹ The definition of emergency var­ies among jurisdictions. Consulting with a knowledgeable attorney may be neces­sary, but it usually takes time. Ethically, it is permissible to breach confidentiality to protect the suicidal patient.¹⁰

Question 5
Mr. G, a 42-year-old engineer, is re-hospitalized after a failed hanging attempt. Initially, he is profoundly depressed but improves sud­denly and requests discharge. The psychiatrist and clinical staff are perplexed. Is the sudden improvement real or feigned?

The treatment team should consider all of the following options except:
   a) obtain records of earlier hospitalizations
   b) check collateral sources of information
   c) assess Mr. G’s compliance with treatment
   d) obtain psychological testing to evaluate Mr. G’s honesty
   e) determine whether behavioral signs of depression are present

The best response option is D
Short length of hospital stay makes it diffi­cult to assess sudden patient improvement.¹¹ Real improvement in a high-risk suicidal patient is a process, even when it occurs quickly. Feigned improvement is an event. Obtaining patient information from collat­eral sources is crucial. Sudden improvement might be caused by the patient’s resolve to complete suicide. Identifying behavioral risk factors associated with psychiatric disorders informs the clinician’s systematic suicide risk assessment of a guarded or dissimula­tive patient. Psychological testing will take critical time and is not a substitute for careful clinical assessment.

Question 6
In mid-winter, Ms. M, a 42-year-old homeless woman, is seen in the emergency room of a general hospital. She complains of depres­sion and auditory hallucinations command­ing her to commit suicide. Ms. M has 5 earlier admissions to the psychiatry unit for similar complaints.

The psychiatrist conducts a compre­hensive suicide risk assessment. Acute and chronic risk factors for suicide are identified. Protective factors also are assessed. The psy­chiatrist weighs and synthesizes risk and pro­tective factors into an overall assessment of Ms. M’s suicide risk.

The main purpose of suicide risk assessment is to:  
   a) predict the likelihood of suicide  
   b) determine imminence of suicide  
   c) inform patient treatment and safety management  
   d) identify malingered suicidal ideation  
   e) provide a legal defense against a mal­practice claim

The best response option is C
Suicide cannot be predicted.¹² The term imminent suicide is a veiled attempt to pre­dict when a patient will attempt suicide.¹³ The process of a comprehensive or system­atic suicide risk assessment encompasses identification, analysis, and synthesis of risk and protective factors that inform the treatment and safety management of the patient.³ The overall suicide assessment is a clinical judgment call that determines risk along a continuum of low to high. In Ms. M’s case, comprehensive suicide risk assessment will assist the clinician in deter­mining the patient’s overall suicide risk and make an appropriate disposition. Without a systematic suicide risk assessment meth­odology, the clinician is at the mercy of the pejoratively labeled “frequent flyer” who is looking for sustenance and lodging. The frustrated clinician is left with little choice but to admit the patient.

Although not the main purpose, system­atic suicide risk assessment can help provide a sound legal defense if a suicide malpractice claim is filed against the clinician alleging negligent assessment.¹⁴

Question 7
A psychiatrist is treating Mr. S, a 36-year-old computer analyst, with once-a-week psycho­therapy and medication management for panic and depressive symptoms that emerged abruptly after the break-up of a romantic rela­tionship. Mr. S is using alcohol to sleep. He reports occasional suicidal ideation but no plan. He finds the idea of suicide to be morally repugnant. A therapeutic alliance develops.

 

The psychiatrist is concerned about Mr. S’s suicide risk and the need for hospi­talization. The psychiatrist performs a sys­tematic suicide risk assessment that includes identification of individual and evidence-based protective factors. For example, Mr. S continued to pursue his interests and to par­ticipate in civil causes. The overall suicide risk  is determined by the assessment of individ­ual and evidence-based protective factors.

All of the following options are evidence-based protective factors except:
   a) therapeutic alliance
   b) survival and coping beliefs
   c) responsibility to family
   d) fear of suicide
   e) moral objections to suicide

The best response option is A
Clinical consensus holds that the thera­peutic alliance is an important protec­tive factor against suicide. However, no evidence-based research supports or refutes this widely held belief among clinicians.

Linehan et al¹⁵ developed the Reasons for Living Inventory, a self-report instru­ment that identifies 6 subscales:
   • survival and coping beliefs
   • responsibility to family
   • child-related concerns
   • fear of suicide
   • fear of social disapproval
   • moral objections to suicide.

Survival and coping beliefs, responsi­bility to family, and child-related concerns were useful in differentiating between suicidal and non-suicidal individuals. Malone et al¹⁶ administered the Reasons for Living Inventory to 84 inpatients with major depression; 45 had attempted sui­cide. Depressed patients who had not attempted suicide demonstrated more sense of responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater survival and coping skills, and greater fear of suicide than patients who attempted suicide. The authors recommended adding the Reasons for Living Inventory to the assessment of patients at risk for suicide.

Question 8
A 38-year-old mother of a newborn child is admitted to the psychiatric unit after expressing suicidal thoughts to her husband. She has been hospitalized previously after a hypomanic episode and severe depres­sion; she has no history of suicide attempts. A psychiatrist diagnoses bipolar II disorder (recurrent major episodes with hypomanic episodes). The patient’s maternal aunt has bipolar disorder. Her paternal grandfather committed suicide.

The psychiatrist conducts a systematic suicide risk assessment and determines the patient is at high risk of suicide. He considers a suicide-risk reduction drug.

Which one of the following drugs has been shown to reduce suicide and suicide attempts in bipolar II patients?
   a) clozapine
   b) clonazepam
   c) lorazepam
   d) lithium
   e) quetiapine

The best response option is D
Prospective, randomized and controlled trials consistently have found lower rates of completed suicides and suicide attempts during lithium maintenance treatments for patients with bipolar disorder and other major affective disorders.¹⁷

Bottom Line
Suicide risk assessment and management are challenging for even experienced clinicians. Suicide risk assessment guides appropriate treatment and management for patients at risk for suicide. This self-assessment helps mental health professionals identify potential gaps in their knowledge and reinforce best practices.

Related Resources
• Simon RI. Passive suicidal ideation: Still a high-risk clinical scenario. Current Psychiatry. 2014;13(3):13-15.
• Simon RI. Suicide rehearsals: A high-risk psychiatric emer­gency. Current Psychiatry. 2012;11(7):28-32.
• Bongar B, Sullivan GR. The suicidal patient: Clinical and legal standards of care. Washington, DC: American Psychological Association; 2013.

Drug Brand Names
Clonazepam • Klonopin              Lorazepam • Ativan
Clozapine • Clozaril                    Quetiapine • Seroquel
Lithium • Eskalith, Lithobid

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

Adapted with permission from: Simon RI. Preventing patient suicide: clinical assessment and management, Arlington VA: American Psychiatric Publishing; 2011.

Editor’s note: Part 2 of this self-assessment on suicide assessment and management in the November 2014 issue of Current Psychiatry poses 7 additional questions.

The assessment and management of suicide risk are com­plex and difficult tasks that raise clinical issues without clear-cut, easy answers. This case-based, multiple-choice self-assessment with accompanying commentaries is a teach­ing instrument that I designed to enhance a clinician’s ability to provide care for patients at risk for suicide. Part 1 of this article poses 8 of the 15 questions; the balance of questions will appear in Part 2, in the November 2014 issue of Current Psychiatry.

The questions and commentaries in this self-assessment orig­inate in the referenced work of others and my clinical experi­ence. Therefore, I use the preferred “best response” option—not the customary and more restrictive “correct answer” format.

How do you score?


Question 1
Mr. J, age 34, is a professional basketball player complaining of weight loss, early morning waking, and a dysphoric mood last­ing for 1 month. His performance on the basketball court has declined and his wife is seeking a separation. He describes “fleet­ing” suicidal thoughts. He has no history of suicide attempts or depression. The patient does not abuse alcohol or drugs.

The initial assessment approach is to:
   a) obtain a suicide prevention contract
   b) assess suicide risk and protective factors
   c) determine the cause of Mr. J’s depression
   d) have Mr. J complete a suicide risk self-assessment form
   e) contact his wife for additional history

The best response option is B
Suicide prevention contracts do not prevent suicide.¹ Contacting the patient’s wife may be an option at a later stage of evaluation or treat­ment, if Mr. J grants permission. Determining the cause of his depression likely will require ongoing work up. Assessing suicide risk fac­tors without also looking at protective factors is a common error. A comprehensive suicide risk assessment evaluation requires evaluat­ing both risk and protective factors.^2,3 Suicide risk assessment forms often omit questions about protective factors.⁴ Do not rely on self-assessment suicide risk forms because they are dependent on the patient’s truthfulness. Patients who are determined to commit sui­cide might regard the psychiatrist and other mental health professionals as the enemy.⁵

Question 2
Ms. P, a 56-year-old, single schoolteacher, is admitted to a psychiatric unit for severe depres­sion and suicidal ideation without a plan. She is devoutly religious, stating, “I won’t kill myself, because I don’t want to go to hell.” Ms. P attends religious services regularly. She has a history of chronic recurrent depression with suicidal ide­ation and no history of suicide attempts. You suspect a diagnosis of bipolar II disorder.


In assessing religious affiliation as a protective factor against suicide, you should consider:
   a) the nature of the patient’s religious conviction
   b) the religion’s stated position on suicide
   c) severity of the patient’s illness
   d) presence of delusional religious beliefs
   e) all of the above


The best response option is E
Dervic et al⁶ evaluated 371 depressed inpa­tients according to their religious or non-religious affiliation. Patients with no religious affiliation made significantly more suicide attempts, had more first-degree relatives who committed suicide, were younger, were less likely to be married or have children, and had fewer contacts with family members.

In general, religious affiliation is a protec­tive factor against suicide but may not be a protective factor in an individual patient. Religious affiliation, similar to other pre­summed general protective factors, requires further scrutiny. Avoid making assumptions. For example, a depressed, devoutly religious patient may curse God for abandonment. A patient with bipolar disorder may believe that God would forgive her for committing suicide. A presumed protective factor may not be protective or might even be a risk fac­tor, such as psychotic patients with religious delusions.

Abrahamic religions—ie, Judaism, Christianity, and Islam—prohibit sui­cide. Severe mental illness, however, can overcome the strongest religious prohibi­tions against suicide, including the fear of eternal damnation. For many psychiatric patients, religious affiliations and beliefs are protective factors against suicide, but only relatively. No protective factor against suicide, however strong, provides absolute protection against suicide. Moreover, other risk and protective factors also must be assessed comprehensively.


Question 3
Mr. W, age 18, is admitted to an inpatient psy­chiatric unit with severe agitation, thought disorder, disorganization, and auditory hal­lucinations. He is threatening to jump from a nearby building. He has no history of sub­stance abuse.

The psychiatrist conducts a comprehen­sive suicide risk assessment that includes the patient’s psychiatric diagnosis as a risk factor.

Which psychiatric disorder has the highest associated suicide mortality rate?
   a) schizophrenia
   b) eating disorders
   c) bipolar disorder
   d) major depressive disorder
   e) borderline personality disorder

The best response option is B
Harris and Barraclough (Table)⁷ calculated the standardized mortality ratio (SMR) for suicide among psychiat­ric disorders. SMR is calculated by divid­ing observed mortality by suicide by the expected mortality by suicide in the general population. Every psychiatric disorder in their study, except for mental retardation, was associated with a varying degree of suicide risk. Eating disorders had the high­est SMR. The patient’s psychiatric diagno­sis is a risk factor that informs the clinician’s suicide risk assessment.

Question 4
Mr. Z, a 64-year-old, recently divorced lawyer, is admitted to the psychiatric unit from the emergency room. His colleagues brought Mr. Z to the emergency room because of his sui­cide threats.

 

On the unit, Mr. Z denies suicidal ideation, plan, or intent. Agitation and suspiciousness are prominent. He refuses to authorize staff to contact his colleagues, his ex-wife, and other family members. Mr. Z demands imme­diate discharge and forbids contact with his outpatient psychotherapist. He is placed on 72-hour hold as a conditional voluntary admission.

The clinician should:
   a) contact Mr. Z’s family, as an emergency exception to confidentiality
   b) e-mail his family members with questions
   c) contact the patient’s psychotherapist as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
   d) try to develop a therapeutic alliance with Mr. Z
   e) none of the above

The best response option is C
HIPAA permits psychiatrists and other health care providers who are treating the same patient to communicate with each other about medical treatment without obtaining permission from the patient.⁸ However, mental health professionals can­not share psychotherapy notes without a patient’s consent, except when legally required, such as reporting abuse or duty to warn. This is the most expeditious and productive way of obtaining essential clin­ical information. E-mail merely changes the mode of unauthorized communication with significant others.

Mr. Z is agitated and suspicious, and developing a therapeutic alliance would require time. It is necessary to gather infor­mation about his psychiatric condition as soon as possible. An emergency exception to maintaining confidentiality is another option.⁹ The definition of emergency var­ies among jurisdictions. Consulting with a knowledgeable attorney may be neces­sary, but it usually takes time. Ethically, it is permissible to breach confidentiality to protect the suicidal patient.¹⁰

Question 5
Mr. G, a 42-year-old engineer, is re-hospitalized after a failed hanging attempt. Initially, he is profoundly depressed but improves sud­denly and requests discharge. The psychiatrist and clinical staff are perplexed. Is the sudden improvement real or feigned?

The treatment team should consider all of the following options except:
   a) obtain records of earlier hospitalizations
   b) check collateral sources of information
   c) assess Mr. G’s compliance with treatment
   d) obtain psychological testing to evaluate Mr. G’s honesty
   e) determine whether behavioral signs of depression are present

The best response option is D
Short length of hospital stay makes it diffi­cult to assess sudden patient improvement.¹¹ Real improvement in a high-risk suicidal patient is a process, even when it occurs quickly. Feigned improvement is an event. Obtaining patient information from collat­eral sources is crucial. Sudden improvement might be caused by the patient’s resolve to complete suicide. Identifying behavioral risk factors associated with psychiatric disorders informs the clinician’s systematic suicide risk assessment of a guarded or dissimula­tive patient. Psychological testing will take critical time and is not a substitute for careful clinical assessment.

Question 6
In mid-winter, Ms. M, a 42-year-old homeless woman, is seen in the emergency room of a general hospital. She complains of depres­sion and auditory hallucinations command­ing her to commit suicide. Ms. M has 5 earlier admissions to the psychiatry unit for similar complaints.

The psychiatrist conducts a compre­hensive suicide risk assessment. Acute and chronic risk factors for suicide are identified. Protective factors also are assessed. The psy­chiatrist weighs and synthesizes risk and pro­tective factors into an overall assessment of Ms. M’s suicide risk.

The main purpose of suicide risk assessment is to:  
   a) predict the likelihood of suicide  
   b) determine imminence of suicide  
   c) inform patient treatment and safety management  
   d) identify malingered suicidal ideation  
   e) provide a legal defense against a mal­practice claim

The best response option is C
Suicide cannot be predicted.¹² The term imminent suicide is a veiled attempt to pre­dict when a patient will attempt suicide.¹³ The process of a comprehensive or system­atic suicide risk assessment encompasses identification, analysis, and synthesis of risk and protective factors that inform the treatment and safety management of the patient.³ The overall suicide assessment is a clinical judgment call that determines risk along a continuum of low to high. In Ms. M’s case, comprehensive suicide risk assessment will assist the clinician in deter­mining the patient’s overall suicide risk and make an appropriate disposition. Without a systematic suicide risk assessment meth­odology, the clinician is at the mercy of the pejoratively labeled “frequent flyer” who is looking for sustenance and lodging. The frustrated clinician is left with little choice but to admit the patient.

Although not the main purpose, system­atic suicide risk assessment can help provide a sound legal defense if a suicide malpractice claim is filed against the clinician alleging negligent assessment.¹⁴

Question 7
A psychiatrist is treating Mr. S, a 36-year-old computer analyst, with once-a-week psycho­therapy and medication management for panic and depressive symptoms that emerged abruptly after the break-up of a romantic rela­tionship. Mr. S is using alcohol to sleep. He reports occasional suicidal ideation but no plan. He finds the idea of suicide to be morally repugnant. A therapeutic alliance develops.

 

The psychiatrist is concerned about Mr. S’s suicide risk and the need for hospi­talization. The psychiatrist performs a sys­tematic suicide risk assessment that includes identification of individual and evidence-based protective factors. For example, Mr. S continued to pursue his interests and to par­ticipate in civil causes. The overall suicide risk  is determined by the assessment of individ­ual and evidence-based protective factors.

All of the following options are evidence-based protective factors except:
   a) therapeutic alliance
   b) survival and coping beliefs
   c) responsibility to family
   d) fear of suicide
   e) moral objections to suicide

The best response option is A
Clinical consensus holds that the thera­peutic alliance is an important protec­tive factor against suicide. However, no evidence-based research supports or refutes this widely held belief among clinicians.

Linehan et al¹⁵ developed the Reasons for Living Inventory, a self-report instru­ment that identifies 6 subscales:
   • survival and coping beliefs
   • responsibility to family
   • child-related concerns
   • fear of suicide
   • fear of social disapproval
   • moral objections to suicide.

Survival and coping beliefs, responsi­bility to family, and child-related concerns were useful in differentiating between suicidal and non-suicidal individuals. Malone et al¹⁶ administered the Reasons for Living Inventory to 84 inpatients with major depression; 45 had attempted sui­cide. Depressed patients who had not attempted suicide demonstrated more sense of responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater survival and coping skills, and greater fear of suicide than patients who attempted suicide. The authors recommended adding the Reasons for Living Inventory to the assessment of patients at risk for suicide.

Question 8
A 38-year-old mother of a newborn child is admitted to the psychiatric unit after expressing suicidal thoughts to her husband. She has been hospitalized previously after a hypomanic episode and severe depres­sion; she has no history of suicide attempts. A psychiatrist diagnoses bipolar II disorder (recurrent major episodes with hypomanic episodes). The patient’s maternal aunt has bipolar disorder. Her paternal grandfather committed suicide.

The psychiatrist conducts a systematic suicide risk assessment and determines the patient is at high risk of suicide. He considers a suicide-risk reduction drug.

Which one of the following drugs has been shown to reduce suicide and suicide attempts in bipolar II patients?
   a) clozapine
   b) clonazepam
   c) lorazepam
   d) lithium
   e) quetiapine

The best response option is D
Prospective, randomized and controlled trials consistently have found lower rates of completed suicides and suicide attempts during lithium maintenance treatments for patients with bipolar disorder and other major affective disorders.¹⁷

Bottom Line
Suicide risk assessment and management are challenging for even experienced clinicians. Suicide risk assessment guides appropriate treatment and management for patients at risk for suicide. This self-assessment helps mental health professionals identify potential gaps in their knowledge and reinforce best practices.

Related Resources
• Simon RI. Passive suicidal ideation: Still a high-risk clinical scenario. Current Psychiatry. 2014;13(3):13-15.
• Simon RI. Suicide rehearsals: A high-risk psychiatric emer­gency. Current Psychiatry. 2012;11(7):28-32.
• Bongar B, Sullivan GR. The suicidal patient: Clinical and legal standards of care. Washington, DC: American Psychological Association; 2013.

Drug Brand Names
Clonazepam • Klonopin              Lorazepam • Ativan
Clozapine • Clozaril                    Quetiapine • Seroquel
Lithium • Eskalith, Lithobid

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

Adapted with permission from: Simon RI. Preventing patient suicide: clinical assessment and management, Arlington VA: American Psychiatric Publishing; 2011.

Editor’s note: Part 2 of this self-assessment on suicide assessment and management in the November 2014 issue of Current Psychiatry poses 7 additional questions.

Methamphetamine and other amphetamine-type stimulants are the world’s second most widely used group of illicit substances (after Cannabis), with prevalence of abuse varying by region and by locales within nations. As prescription use of stimulants has grown dramatically in recent years, so has abuse of these substances.

Given the widespread and growing misuse of amphetamine-type stimulants (Box,^1-3), clinicians are faced with the need to learn how to recognize and manage methamphetamine abuse. Both pre­scribed and non-prescribed uses of stimulants present complex chal­lenges; in this article, we examine effects, manifestations, and current evidence-based behavioral and medical treatments of methamphet­amine misuse and abuse, and look ahead to investigational therapies that hold promise for improving the limited existing approaches to management.

Effects and manifestations of methamphetamine use
Different routes of administration produce different consequences, in terms of medical comorbidity and propensity to induce addiction. Smoked or injected, methamphetamine enters the brain in seconds; snorted or taken by mouth, the drug produces its effects in several min­utes and a half hour, respectively.

Rapid uptake and effects of methamphetamine result from its ability to cross the blood−brain barrier. Its primary effects are caused by inhibi­tion of dopamine storage and release of intracellular dopamine.

Methamphetamine stimulates the CNS and the cardiovascular sys­tem through release of dopamine and norepinephrine, which increases blood pressure, body temperature, and heart rate, and, occasionally, induces arrhythmia that can contribute to heart attack and stroke. Users experience euphoria, hypervigilance, suppressed appetite, and increased libido.

Binge use is common to sustain eupho­ria and other reinforcing effects, which subside with rapidly developing tolerance. After days of repeated dosing, elevated methamphetamine blood levels can lead to mood disturbances, repetitive motor activities, and psychotic symptoms such as hallucinations, delusions, and paranoia. Acute psychosis can bring on violence and other injurious behaviors that involve law enforcement and emergency medical services.

When methamphetamine is used over months or years, health consequences include anorexia, tremor, so-called meth mouth (broken teeth, infections, cavities, burns), insomnia, panic attacks, confusion, depression, irritability, and impaired mem­ory and other cognitive processes.

Treating methamphetamine intoxication and withdrawal
At initial clinical contact with a person who abuses methamphetamine, practitio­ners may face several acute consequences requiring attention. Prominent among pre­senting conditions, especially during acute intoxication, are agitation, anxiety, and psy­chotic symptoms, which may improve by providing the patient with calming reassur­ance in a quiet space. In more severe cases, a benzodiazepine, antipsychotic, or both might be indicated^4,5 (Table 1).

Methamphetamine withdrawal is char­acterized by anxiety, depression, and insom­nia. These symptoms generally resolve in a matter of days after the start of withdrawal without pharmacotherapy. In some cases, depression or psychosis becomes chronic, as a result of methamphetamine use itself6 or as an emergent concomitant psychiatric condition.

A sedative-hypnotic medication or an anxiolytic can be used as necessary to ame­liorate insomnia or anxiety, respectively. Prolonged depression can be treated with an antidepressant. An antipsychotic might be indicated for long-term management of patients who have persistent psychosis.

Therapy for methamphetamine abuse
Treatment of methamphetamine abuse— with the goal of stopping drug use—is a complicated matter on 2 counts:
   • No medications are FDA-approved for treating methamphetamine addiction.
   • There are no accepted substitution medications (ie, stimulants that can be used in place of methamphetamine, as is avail­able for opioid addiction).

Pharmacotherapeutic possibilities. The rationale for considering replacement phar­macotherapy is that psychostimulants can counter the cravings, dysphoria, and fatigue produced by methamphetamine withdrawal and can alleviate methamphetamine-related cognitive impairment. Although dextro­amphetamine and other psychostimu­lants have been evaluated in small trials as replacement medication, most countries are reluctant to consider their use, because of the potential for abuse and accompanying liability.

After decades of medication research, several drugs have shown promise for reducing methamphetamine abuse, although results have not been robust (Table 2):
   • Bupropion has shown benefit in reduc­ing methamphetamine use among users with less severe addiction.^7,8
   • Methylphenidate, a psychostimulant FDA-approved for attention-deficit/hyper­activity disorder, was found to reduce methamphetamine use compared with pla­cebo in a European sample of amphetamine injectors who had attained abstinence in a residential program.⁹ Those results were not replicated in a recent study by Miles et al, however.¹⁰ A study with a more clinically realistic approach (ie, not requiring daily clinic attendance, as in the Miles trial) vs placebo for methamphetamine abuse was recently published, with promising results that require confirmation in further study.¹¹
   • Mirtazapine, an antidepressant, has demonstrated efficacy in reducing metham­phetamine use compared with placebo.¹²
   • Modafinil, another medication with stimulant properties, reduced metham­phetamine use in a subgroup analysis of heavy users, compared with placebo.¹³
   • Dextroamphetamine, 60 mg/d, showed no difference in reducing methamphet­amine compared with placebo, but did diminish cravings and withdrawal symptoms.¹⁴

A trial of the phosphodiesterase inhibitor ibudilast (not available in the United States) for methamphetamine abuse is underway. Ibudilast has anti-inflammatory activity in the peripheral immune system and the cen­tral nervous system, including modulating the activity of glial cells.¹⁵

 

Many medications have yielded negligi­ble results in studies: selegiline, baclofen, ser­traline, topiramate, gabapentin, rivastigmine, risperidone, and ondansetron.¹⁶ Recent eval­uation of disulfiram, vigabatrin, and lobeline also has yielded inconsistent findings.¹⁷

No drug has proved effective for pre­venting relapse; research continues, focus­ing on several types of compounds that target various mechanisms: the dopamine system, the opioid system (by way of the γ-aminobutyric acid inhibitory system), and cortico-limbic reward circuitry.

Once-monthly injectable naltrexone has potential for ameliorating craving and relapse by modulating the opioid receptor system. However, the drug has not been adequately explored in generalizable set­tings of methamphetamine users.

Trials of oral naltrexone in Sweden have shown encouraging results, includ­ing reduced subjective effects and amphet­amine use in open-label trials^18,19; results were replicated in a subsequent placebo-controlled trial.²⁰ In an unpublished study, however, no differences in amphetamine use were found among users randomized to depot naltrexone or placebo.²¹

Depot naltrexone with assured dos­ing might have a role in treating metham­phetamine abuse, however; a combination of depot naltrexone and oral bupropion is being examined in a National Institute on Drug Abuse Clinical Trials Networks study that commenced in 2013. Pairing medica­tions that have different mechanistic targets might work toward promoting cessation of methamphetamine abuse and reducing relapse once patients are abstinent.

In an early phase of research, but show­ing promise based on their ability to target different systems, are:  
   • N-acetylcysteine, modulator of the glutamate system  
   • D3 antagonists and partial agonists²²  
   • varenicline.²³

Potential “vaccines” against metham­phetamine are in preclinical development, including use of a protein carrier or other immune-stimulating molecule to create antibodies that bind methamphetamine in the bloodstream and block its psychoactive effects.^24,25

Sigma receptor effects are being studied in rodents as potential targets to mitigate effects of methamphetamine. The ligand AZ66, a sigma receptor antagonist, has demonstrated efficacy in reducing meth­amphetamine-induced cognitive impair­ment—suggesting that the sigma receptor has a potential role in ameliorating meth­amphetamine-related neurotoxicity.²⁶

Psychosocial and behavioral interven­tions. Among the non-drug treatments that have demonstrated efficacy for treat­ing methamphetamine abuse, cognitive-behavioral therapy (CBT) and contingency management (CM) have been most widely studied and applied in treatment settings.

CBT involves individual or group coun­seling that focuses on relapse prevention skills, including identification of relapse triggers, strategies to diminish cravings, and engagement in alternative non-drug activities^27,28 (Table 3).

CM, which is based on positive rein­forcement, offers tangible reinforcers, or rewards, for behaviors (eg, clinic atten­dance, providing a drug-free urine sam­ple) according to guidelines set by the practitioner. CM-based interventions are the most reliably documented approaches for treating methamphetamine abuse,^29,30 but their utility might prove to be most efficient in combination with medication— once suitable pharmacotherapeutic options emerge.

Although CBT and CM remain accepted standard treatments for methamphetamine abuse, outcomes are suboptimal.²⁷ Both interventions have a high rate of dropout during the first month of treatment and a >50% relapse rate 6 to 19 months after treat­ment ends.^31-33

As with treatment of other substance use disorders, patients who abuse methamphet­amine can benefit from residential treatment in a drug-free setting for ≥30 days.³⁴ In the residential approach, removing access to drugs, drug cues, and drug-using acquain­tances combined with group and individ­ual counseling reaches an inevitable end: discharge into the community. Then the patient’s battle to avoid relapse begins.

Because cognitive impairment is com­mon among patients who abuse metham­phetamine, even after they stop using,³⁵ researchers have examined the potential for increasing participation in psychosocial interventions such as CBT by using medica­tions that might have potential to increase cognitive function, such as modafinil.³⁶ Increased attention and concentration afforded by medication could enhance effi­cacy of CBT. Results of trials and new drug development have been mixed³⁷; no clear candidate for preventing relapse through any of the putative mechanisms of action has emerged.

Relapse is a problematic target for treatment
Ending methamphetamine abuse and sus­taining abstinence from stimulants require a change in the cognitive associations that have been laid down in a drug user’s memory. Relapse occurs because of recalled memories that can be cued, or triggered, by internal or external stimuli. Eliminating drug memories, perhaps assisted by medi­cations such as d-cycloserine (an antago­nist of the N-methyl-d-aspartate receptor), could be useful for suppressing the inclina­tion to relapse.

Last, alternative, non-drug forms of cog­nitive amendment have shown efficacy in preventing relapse: for example, incorpo­rating mindfulness meditation, which has shown promise in managing craving for methamphetamine and decreasing reactiv­ity to environmental cues for drug use.³⁸

Bottom Line
Practitioners who work in emergency, inpatient, and outpatient settings will be called on more and more to treat acute stimulant intoxication and withdrawal, stimulant-induced psychosis, and methamphetamine abuse. Few evidence-based treatments and no FDA-approved medications are available to treat this addiction; many drugs and a few psychotherapeutic techniques have shown promise. Ongoing research promises to deliver medical and behavioral interventions to help patients quit using methamphetamine.

 

Related Resources
• Karch SB, Drummer O. Karch’s pathology of drug abuse, fifth ed. Boca Raton, FL: CRC Press/Taylor & David; 2013.
• Roll J, Rawson RA, Ling W, eds. Methamphetamine addic­tion: from basic science to treatment. New York, NY: Guilford Press; 2009.
• Sheff D. Beautiful boy: a father’s journey through his son’s addiction. New York, NY: Houghton Mifflin Harcourt Publishing Company; 2008.
• Sheff N. Tweak: growing up on methamphetamines. New York, NY: Antheneum Books for Young Readers; 2007.
• National Institute on Drug Abuse. Drugs of abuse. www. drugabuse.gov/drugs-abuse/methamphetamine.

Drug Brand Names
Baclofen • Lioresal                                Naltrexone (depot) • Vivitrol
Bupropion • Wellbutrin                          Naltrexone (oral) • ReVia
D-cycloserine • Seromycin                     Ondansetron • Zofran
Dexreoamphetaime • Adderall                Risperidone • Risperadal
Disulfiram • Antabuse                            Rivastigimine • Exelon
Gabapentin • Neurontin                          Selegiline• EMSAM
Methylphenidate  •  Ritalin                      Sertraline • Zoloft
Mirtazapine •  Remeron                          Topiramate • Topamax
Modafinil • Provigil                                 Varenicline • Chantix
 N-acetylcysteine • Mucomyst                 Vigabatrin • Sabril

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