Evidence-Based Reviews

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Dr. G, a second-year surgical resident, becomes depressed when his girlfriend abruptly ends their relationship. His phone calls and e-mails seeking an explanation go unanswered. Having long struggled with his self-esteem, Dr. G interprets this rejection as confirmation of his self-criticism.

Because of his work schedule, Dr. G feels that there is no way to see a therapist or psychiatrist and believes that asking for time off to do so would adversely affect his evaluations. He feels too embarrassed and “weak” to disclose his breakup and depression to his colleagues and attending physicians and senses that fellow residents would resent having to “carry his load.” Dr. G has spent the past 2 years moonlighting at the local emergency room and thinks it would be humiliating to go there for psychiatric help. His work performance and attendance decline until eventually his residency director forces him to take a medical leave of absence.

Dr. G feels that his pain will never end. He writes goodbye letters to his family, makes arrangements for his possessions and funeral, and hangs himself from the balcony outside his apartment.

Although the rate of depression among physicians is comparable to that of the general population, physicians’ risk of suicide is markedly higher.¹ Depression and other mood disorders may be under-recognized and inadequately treated in physicians because physicians might:

• be reluctant to seek treatment
• attempt to diagnose and treat themselves
• seek and receive “VIP treatment” from other health care providers.

This article examines physicians’ risk for depression and suicide, licensing concerns and other barriers to effective treatment, and what can be done to overcome such obstacles.

Not immune to depression

Rates of depression are higher in medical students and residents (15% to 30%) than in the general population.^2-4 A longitudinal study of medical students at the University of California, San Francisco showed that students’ rates of depression when they enter medical school are similar to those of the general population, but students’ depression scores rise over time; approximately one-fourth of first- and second-year students were depressed.³ Fahrenkopf et al⁵ reported that 20% of 123 pediatric residents at 3 U.S. children’s hospitals were depressed. These depressed residents made 6.2 times more medication errors than did their non-depressed peers.⁵ For more information on physicians-in-training, see “Treating depression in medical residents“.

After completing residency, the risk of depression persists. The lifetime prevalence of depression among physicians is 13% in men and 20% in women⁶; these rates are comparable to those of the general population. Firth-Cozens⁷ found a range of factors that predict depression among general practitioners; relationships with senior doctors and patients were the main stressors (Table 1).⁷ Although these stressors increase depression risk, Vaillant et al⁸ showed that they did not increase suicide risk in physicians who did not have underlying psychological difficulties when they entered college. Certain personality traits common among physicians, such as self-criticism and perfectionism, may increase risk for depression and substance abuse.⁸

A depressed physician might enter a downward spiral. Feelings of hopelessness and worthlessness frequently lead to declining professional performance. Professional and personal relationships are strained as internal dysphoria manifests as irritability and anger. Spouses and partners can feel overwhelmed and bewildered by changes in the depressed person’s behavior, which may lead to separation or divorce. Patient care and the physician’s professional standing can be endangered. Signs that suggest a physician may be suffering from depression or another mental illness appear in Table 2.⁹

Table 1

Predictors of depression in physicians

Table 2

Manifestations of mental illness in physicians

Increased suicide risk

A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men and 2.5 to 5.7 for women.¹ A retrospective study of English and Welsh doctors showed elevated suicide rates in female but not male physicians compared with the general population.¹⁰ There are no recent studies of suicide rates among U.S. physicians. A 1984-1995 study showed that white male physicians have a higher risk for suicide than other white male professionals.¹¹ A survey of 4,500 women physicians found that female doctors are less likely to attempt suicide than the general female population⁶; however, their attempts more often are lethal, perhaps because they have greater knowledge of toxicology and access to lethal drugs.¹²

The relative rate of suicide among medical specialties is unknown. Studies had indicated higher rates of suicide among psychiatrists and anesthesiologists, but these trials were methodologically flawed.¹²

Silverman¹² developed a profile of the physician at high risk for suicide: a workaholic white male age ≥50 or female age ≥45 who is divorced, single, or currently experiencing marital disruption and is suffering from depression. He or she has a substance abuse problem and a history of risk-taking (high-stakes gambling, etc.). Physicians with chronic pain or illness or with a recent change in occupational or financial status also are at risk. Recent increased work demands, personal losses, diminished autonomy, and access to lethal means (medications, firearms) complete the profile.

Protective factors that lower the risk of completed suicide include effective treatment, social and family support, resilience and coping skills, religious faith, and restricted access to lethal means.^13,14

Barriers to treatment

Physicians often are hesitant to seek mental health treatment.¹⁵ They may fear social stigma and could have trouble finding a local provider who they trust but is not a colleague. Physicians might be concerned about confidentiality and fear recrimination by colleagues, facilities where they work, or licensing boards.¹⁶ Givens and Tjia³ found that only 22% of medical students who screened positive for depression sought help and only 42% of students with suicidal ideation received treatment. These students reported that time constraints, confidentiality concerns, stigma, cost, and fear that their illness will be documented on their academic record were major barriers to seeking mental health care.

Licensing concerns. Physicians may be required to disclose a mental health diagnosis or treatment history when applying for or renewing their medical license. Increasingly, medical boards are asking applicants if they have been treated for bipolar disorder, schizophrenia, paranoia, or other disorders.¹⁷ Credentialing bodies, clinics, and hospitals may make similar queries.

In an analysis of 51 medical licensing applications (50 states and the District of Columbia), Schroeder et al¹⁷ determined that 69% contained at least 1 question that was “likely impermissible” or “impermissible” in terms of compliance with the Americans with Disabilities Act (ADA). In 1993, a U.S. District Court found that the New Jersey State Board of Medical Examiners was in violation of the ADA because licensure application questions did not focus on current fitness to practice medicine but rather on information about a candidate’s status as a person with a disability (illness or diagnosis).¹⁸

In Alexander v Margolis,¹⁹ however, the court found that because patient safety is in question, medical licensing boards and credentialing bodies can solicit information about serious mental illness that could lead to impaired performance. Courts have ruled that questions regarding a history of treatment or hospitalization for bipolar disorder or schizophrenia and other psychotic disorders are permissible because they are considered “serious disorders” likely to interfere with a physician’s current ability to practice.²⁰ In a 2008 review of all U.S. -affiliated medical licensing boards (N=54), Polfliet²¹ found that 7 specifically asked applicants about a history of bipolar disorder or schizophrenia, paranoia, and other psychotic disorders. Polfliet²¹ also found that state medical boards’ compliance with ADA guidelines was not uniform and some questions were “just as broad, and potentially discriminatory, as they were before enactment of the ADA.”

Worley²² reported a successful appeal to the Arkansas State Medical Board to revise its licensure questions following a cluster of medical student and physician suicides. The Board changed the question “Have you ever, or are you presently, being treated for a mental health condition?” to “Have you ever been advised or required by any licensing or privileging body to seek treatment for a physical or mental health condition?”

Providing inaccurate information on a medical licensure application may result in denial or revocation,²³ but acknowledging a history of mental health or substance abuse treatment triggers a more in-depth inquiry by the medical board. The lack of distinction between diagnosis and impairment further stigmatizes physicians who seek care and impedes treatment.

Bipolar disorder. The trend in psychiatry toward diagnosing bipolar II disorder and “soft bipolarity” in patients previously diagnosed with and treated for major depression presents a new challenge. Despite no change in their history or functioning, a physician whose diagnosis is changed from depression to bipolar II disorder might be moved from a non-reportable to a board-reportable diagnostic category. With the evolving understanding of bipolar spectrum disorders, medical boards may need to revise their screening questions to ensure that they are seeking information about impairment, not simply the presence of a medical disorder.

Seeking special treatment

Self-treatment. Physicians may attempt to treat their mood disorder with self-prescribed medications before seeking consultation from a psychiatrist. Others use alcohol or illicit drugs to try to alleviate mood disorder symptoms. Self-diagnosis and treatment are not advisable because it is impossible to be objective. Professional boards and state medical boards discourage or prohibit self-prescribing because of the need for ongoing evaluation and monitoring for adverse reactions.

‘VIP’ treatment. When a physician comes to a colleague for help with a mental health issue, both parties might underestimate the severity of the crisis.²⁴ Weintraub²⁵ reported a case series of 12 “VIP” psychiatric inpatients, 10 of whom he described as “therapeutic failures, “including 2 who committed suicide and 3 who left the hospital against medical advice. He observed that improvement occurred only after patients lost their VIP status/treatment.

In a literature review, Groves et al²⁶ found delays in pursuing diagnostic evaluation and treatment for physician patients. He described risks of VIP treatment (Table 3),²⁶ including the physician’s ability to circumscribe the care regimen to obtain “special treatment, “which can create conflict among care providers and other patients. The ailing physician might have trouble relinquishing control. Care providers might not give physician patients necessary information about the illness or treatment because they make assumptions about the physician’s knowledge or fear causing narcissistic injury. Providers’ identification with their peers, deference to their background, and desire to preserve these patients’ autonomy may lead to interventions that are different from those they would provide to other patients.

Treating physicians might underestimate the patient’s suicide risk and tend to not hospitalize a physician patient who faces an imminent risk of self-harm. Similarly, a physician patient might know what key words to use to deny suicidal ideation or avoid hospitalization. Providers assessing physician patients should provide the same interventions they would give to nonphysician patients with the same history and suicide risk factors. To do otherwise is to risk a fatal outcome.

Physician health programs provide confidential treatment and assistance to physicians with mental illness and/or substance abuse problems. Some programs are affiliated with licensing boards, some are branches of the state medical societies, and others are independent of the licensing agencies. Directories of these programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Physician health programs aim to help impaired physicians receive treatment and rehabilitation without censure or licensure revocation, provided they comply with treatment and monitoring requirements.

Table 3

Risks of caring for ‘VIP’ patients

Related Resources

• American Foundation for Suicide Prevention. www.afsp.org. 24-hour crisis line: 1-800-273-TALK (8255).
• Center for Patient and Professional Advocacy. www.mc.vanderbilt.edu/root/vumc.php?site=CPPA.
• Depression and Bipolar Support Alliance. www.dbsalliance.org.
• Federation of State Physician Health Programs, Inc. www.fsphp.org.
• National Alliance on Mental Illness. www.nami.org.
• Vanderbilt Center for Professional Health. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

Dr. G, a second-year surgical resident, becomes depressed when his girlfriend abruptly ends their relationship. His phone calls and e-mails seeking an explanation go unanswered. Having long struggled with his self-esteem, Dr. G interprets this rejection as confirmation of his self-criticism.

Because of his work schedule, Dr. G feels that there is no way to see a therapist or psychiatrist and believes that asking for time off to do so would adversely affect his evaluations. He feels too embarrassed and “weak” to disclose his breakup and depression to his colleagues and attending physicians and senses that fellow residents would resent having to “carry his load.” Dr. G has spent the past 2 years moonlighting at the local emergency room and thinks it would be humiliating to go there for psychiatric help. His work performance and attendance decline until eventually his residency director forces him to take a medical leave of absence.

Dr. G feels that his pain will never end. He writes goodbye letters to his family, makes arrangements for his possessions and funeral, and hangs himself from the balcony outside his apartment.

Although the rate of depression among physicians is comparable to that of the general population, physicians’ risk of suicide is markedly higher.¹ Depression and other mood disorders may be under-recognized and inadequately treated in physicians because physicians might:

• be reluctant to seek treatment
• attempt to diagnose and treat themselves
• seek and receive “VIP treatment” from other health care providers.

This article examines physicians’ risk for depression and suicide, licensing concerns and other barriers to effective treatment, and what can be done to overcome such obstacles.

Not immune to depression

Rates of depression are higher in medical students and residents (15% to 30%) than in the general population.^2-4 A longitudinal study of medical students at the University of California, San Francisco showed that students’ rates of depression when they enter medical school are similar to those of the general population, but students’ depression scores rise over time; approximately one-fourth of first- and second-year students were depressed.³ Fahrenkopf et al⁵ reported that 20% of 123 pediatric residents at 3 U.S. children’s hospitals were depressed. These depressed residents made 6.2 times more medication errors than did their non-depressed peers.⁵ For more information on physicians-in-training, see “Treating depression in medical residents“.

After completing residency, the risk of depression persists. The lifetime prevalence of depression among physicians is 13% in men and 20% in women⁶; these rates are comparable to those of the general population. Firth-Cozens⁷ found a range of factors that predict depression among general practitioners; relationships with senior doctors and patients were the main stressors (Table 1).⁷ Although these stressors increase depression risk, Vaillant et al⁸ showed that they did not increase suicide risk in physicians who did not have underlying psychological difficulties when they entered college. Certain personality traits common among physicians, such as self-criticism and perfectionism, may increase risk for depression and substance abuse.⁸

A depressed physician might enter a downward spiral. Feelings of hopelessness and worthlessness frequently lead to declining professional performance. Professional and personal relationships are strained as internal dysphoria manifests as irritability and anger. Spouses and partners can feel overwhelmed and bewildered by changes in the depressed person’s behavior, which may lead to separation or divorce. Patient care and the physician’s professional standing can be endangered. Signs that suggest a physician may be suffering from depression or another mental illness appear in Table 2.⁹

Table 1

Predictors of depression in physicians

Table 2

Manifestations of mental illness in physicians

Increased suicide risk

A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men and 2.5 to 5.7 for women.¹ A retrospective study of English and Welsh doctors showed elevated suicide rates in female but not male physicians compared with the general population.¹⁰ There are no recent studies of suicide rates among U.S. physicians. A 1984-1995 study showed that white male physicians have a higher risk for suicide than other white male professionals.¹¹ A survey of 4,500 women physicians found that female doctors are less likely to attempt suicide than the general female population⁶; however, their attempts more often are lethal, perhaps because they have greater knowledge of toxicology and access to lethal drugs.¹²

The relative rate of suicide among medical specialties is unknown. Studies had indicated higher rates of suicide among psychiatrists and anesthesiologists, but these trials were methodologically flawed.¹²

Silverman¹² developed a profile of the physician at high risk for suicide: a workaholic white male age ≥50 or female age ≥45 who is divorced, single, or currently experiencing marital disruption and is suffering from depression. He or she has a substance abuse problem and a history of risk-taking (high-stakes gambling, etc.). Physicians with chronic pain or illness or with a recent change in occupational or financial status also are at risk. Recent increased work demands, personal losses, diminished autonomy, and access to lethal means (medications, firearms) complete the profile.

Protective factors that lower the risk of completed suicide include effective treatment, social and family support, resilience and coping skills, religious faith, and restricted access to lethal means.^13,14

Barriers to treatment

Physicians often are hesitant to seek mental health treatment.¹⁵ They may fear social stigma and could have trouble finding a local provider who they trust but is not a colleague. Physicians might be concerned about confidentiality and fear recrimination by colleagues, facilities where they work, or licensing boards.¹⁶ Givens and Tjia³ found that only 22% of medical students who screened positive for depression sought help and only 42% of students with suicidal ideation received treatment. These students reported that time constraints, confidentiality concerns, stigma, cost, and fear that their illness will be documented on their academic record were major barriers to seeking mental health care.

Licensing concerns. Physicians may be required to disclose a mental health diagnosis or treatment history when applying for or renewing their medical license. Increasingly, medical boards are asking applicants if they have been treated for bipolar disorder, schizophrenia, paranoia, or other disorders.¹⁷ Credentialing bodies, clinics, and hospitals may make similar queries.

In an analysis of 51 medical licensing applications (50 states and the District of Columbia), Schroeder et al¹⁷ determined that 69% contained at least 1 question that was “likely impermissible” or “impermissible” in terms of compliance with the Americans with Disabilities Act (ADA). In 1993, a U.S. District Court found that the New Jersey State Board of Medical Examiners was in violation of the ADA because licensure application questions did not focus on current fitness to practice medicine but rather on information about a candidate’s status as a person with a disability (illness or diagnosis).¹⁸

In Alexander v Margolis,¹⁹ however, the court found that because patient safety is in question, medical licensing boards and credentialing bodies can solicit information about serious mental illness that could lead to impaired performance. Courts have ruled that questions regarding a history of treatment or hospitalization for bipolar disorder or schizophrenia and other psychotic disorders are permissible because they are considered “serious disorders” likely to interfere with a physician’s current ability to practice.²⁰ In a 2008 review of all U.S. -affiliated medical licensing boards (N=54), Polfliet²¹ found that 7 specifically asked applicants about a history of bipolar disorder or schizophrenia, paranoia, and other psychotic disorders. Polfliet²¹ also found that state medical boards’ compliance with ADA guidelines was not uniform and some questions were “just as broad, and potentially discriminatory, as they were before enactment of the ADA.”

Worley²² reported a successful appeal to the Arkansas State Medical Board to revise its licensure questions following a cluster of medical student and physician suicides. The Board changed the question “Have you ever, or are you presently, being treated for a mental health condition?” to “Have you ever been advised or required by any licensing or privileging body to seek treatment for a physical or mental health condition?”

Providing inaccurate information on a medical licensure application may result in denial or revocation,²³ but acknowledging a history of mental health or substance abuse treatment triggers a more in-depth inquiry by the medical board. The lack of distinction between diagnosis and impairment further stigmatizes physicians who seek care and impedes treatment.

Bipolar disorder. The trend in psychiatry toward diagnosing bipolar II disorder and “soft bipolarity” in patients previously diagnosed with and treated for major depression presents a new challenge. Despite no change in their history or functioning, a physician whose diagnosis is changed from depression to bipolar II disorder might be moved from a non-reportable to a board-reportable diagnostic category. With the evolving understanding of bipolar spectrum disorders, medical boards may need to revise their screening questions to ensure that they are seeking information about impairment, not simply the presence of a medical disorder.

Seeking special treatment

Self-treatment. Physicians may attempt to treat their mood disorder with self-prescribed medications before seeking consultation from a psychiatrist. Others use alcohol or illicit drugs to try to alleviate mood disorder symptoms. Self-diagnosis and treatment are not advisable because it is impossible to be objective. Professional boards and state medical boards discourage or prohibit self-prescribing because of the need for ongoing evaluation and monitoring for adverse reactions.

‘VIP’ treatment. When a physician comes to a colleague for help with a mental health issue, both parties might underestimate the severity of the crisis.²⁴ Weintraub²⁵ reported a case series of 12 “VIP” psychiatric inpatients, 10 of whom he described as “therapeutic failures, “including 2 who committed suicide and 3 who left the hospital against medical advice. He observed that improvement occurred only after patients lost their VIP status/treatment.

In a literature review, Groves et al²⁶ found delays in pursuing diagnostic evaluation and treatment for physician patients. He described risks of VIP treatment (Table 3),²⁶ including the physician’s ability to circumscribe the care regimen to obtain “special treatment, “which can create conflict among care providers and other patients. The ailing physician might have trouble relinquishing control. Care providers might not give physician patients necessary information about the illness or treatment because they make assumptions about the physician’s knowledge or fear causing narcissistic injury. Providers’ identification with their peers, deference to their background, and desire to preserve these patients’ autonomy may lead to interventions that are different from those they would provide to other patients.

Treating physicians might underestimate the patient’s suicide risk and tend to not hospitalize a physician patient who faces an imminent risk of self-harm. Similarly, a physician patient might know what key words to use to deny suicidal ideation or avoid hospitalization. Providers assessing physician patients should provide the same interventions they would give to nonphysician patients with the same history and suicide risk factors. To do otherwise is to risk a fatal outcome.

Physician health programs provide confidential treatment and assistance to physicians with mental illness and/or substance abuse problems. Some programs are affiliated with licensing boards, some are branches of the state medical societies, and others are independent of the licensing agencies. Directories of these programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Physician health programs aim to help impaired physicians receive treatment and rehabilitation without censure or licensure revocation, provided they comply with treatment and monitoring requirements.

Table 3

Risks of caring for ‘VIP’ patients

Related Resources

• American Foundation for Suicide Prevention. www.afsp.org. 24-hour crisis line: 1-800-273-TALK (8255).
• Center for Patient and Professional Advocacy. www.mc.vanderbilt.edu/root/vumc.php?site=CPPA.
• Depression and Bipolar Support Alliance. www.dbsalliance.org.
• Federation of State Physician Health Programs, Inc. www.fsphp.org.
• National Alliance on Mental Illness. www.nami.org.
• Vanderbilt Center for Professional Health. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.

Disclosure

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

Discuss this article at www.facebook.com/CurrentPsychiatry

Dr. G, a second-year surgical resident, becomes depressed when his girlfriend abruptly ends their relationship. His phone calls and e-mails seeking an explanation go unanswered. Having long struggled with his self-esteem, Dr. G interprets this rejection as confirmation of his self-criticism.

Because of his work schedule, Dr. G feels that there is no way to see a therapist or psychiatrist and believes that asking for time off to do so would adversely affect his evaluations. He feels too embarrassed and “weak” to disclose his breakup and depression to his colleagues and attending physicians and senses that fellow residents would resent having to “carry his load.” Dr. G has spent the past 2 years moonlighting at the local emergency room and thinks it would be humiliating to go there for psychiatric help. His work performance and attendance decline until eventually his residency director forces him to take a medical leave of absence.

Dr. G feels that his pain will never end. He writes goodbye letters to his family, makes arrangements for his possessions and funeral, and hangs himself from the balcony outside his apartment.

Although the rate of depression among physicians is comparable to that of the general population, physicians’ risk of suicide is markedly higher.¹ Depression and other mood disorders may be under-recognized and inadequately treated in physicians because physicians might:

• be reluctant to seek treatment
• attempt to diagnose and treat themselves
• seek and receive “VIP treatment” from other health care providers.

This article examines physicians’ risk for depression and suicide, licensing concerns and other barriers to effective treatment, and what can be done to overcome such obstacles.

Not immune to depression

Rates of depression are higher in medical students and residents (15% to 30%) than in the general population.^2-4 A longitudinal study of medical students at the University of California, San Francisco showed that students’ rates of depression when they enter medical school are similar to those of the general population, but students’ depression scores rise over time; approximately one-fourth of first- and second-year students were depressed.³ Fahrenkopf et al⁵ reported that 20% of 123 pediatric residents at 3 U.S. children’s hospitals were depressed. These depressed residents made 6.2 times more medication errors than did their non-depressed peers.⁵ For more information on physicians-in-training, see “Treating depression in medical residents“.

After completing residency, the risk of depression persists. The lifetime prevalence of depression among physicians is 13% in men and 20% in women⁶; these rates are comparable to those of the general population. Firth-Cozens⁷ found a range of factors that predict depression among general practitioners; relationships with senior doctors and patients were the main stressors (Table 1).⁷ Although these stressors increase depression risk, Vaillant et al⁸ showed that they did not increase suicide risk in physicians who did not have underlying psychological difficulties when they entered college. Certain personality traits common among physicians, such as self-criticism and perfectionism, may increase risk for depression and substance abuse.⁸

A depressed physician might enter a downward spiral. Feelings of hopelessness and worthlessness frequently lead to declining professional performance. Professional and personal relationships are strained as internal dysphoria manifests as irritability and anger. Spouses and partners can feel overwhelmed and bewildered by changes in the depressed person’s behavior, which may lead to separation or divorce. Patient care and the physician’s professional standing can be endangered. Signs that suggest a physician may be suffering from depression or another mental illness appear in Table 2.⁹

Table 1

Predictors of depression in physicians

Table 2

Manifestations of mental illness in physicians

Increased suicide risk

A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men and 2.5 to 5.7 for women.¹ A retrospective study of English and Welsh doctors showed elevated suicide rates in female but not male physicians compared with the general population.¹⁰ There are no recent studies of suicide rates among U.S. physicians. A 1984-1995 study showed that white male physicians have a higher risk for suicide than other white male professionals.¹¹ A survey of 4,500 women physicians found that female doctors are less likely to attempt suicide than the general female population⁶; however, their attempts more often are lethal, perhaps because they have greater knowledge of toxicology and access to lethal drugs.¹²

The relative rate of suicide among medical specialties is unknown. Studies had indicated higher rates of suicide among psychiatrists and anesthesiologists, but these trials were methodologically flawed.¹²

Silverman¹² developed a profile of the physician at high risk for suicide: a workaholic white male age ≥50 or female age ≥45 who is divorced, single, or currently experiencing marital disruption and is suffering from depression. He or she has a substance abuse problem and a history of risk-taking (high-stakes gambling, etc.). Physicians with chronic pain or illness or with a recent change in occupational or financial status also are at risk. Recent increased work demands, personal losses, diminished autonomy, and access to lethal means (medications, firearms) complete the profile.

Protective factors that lower the risk of completed suicide include effective treatment, social and family support, resilience and coping skills, religious faith, and restricted access to lethal means.^13,14

Barriers to treatment

Physicians often are hesitant to seek mental health treatment.¹⁵ They may fear social stigma and could have trouble finding a local provider who they trust but is not a colleague. Physicians might be concerned about confidentiality and fear recrimination by colleagues, facilities where they work, or licensing boards.¹⁶ Givens and Tjia³ found that only 22% of medical students who screened positive for depression sought help and only 42% of students with suicidal ideation received treatment. These students reported that time constraints, confidentiality concerns, stigma, cost, and fear that their illness will be documented on their academic record were major barriers to seeking mental health care.

Licensing concerns. Physicians may be required to disclose a mental health diagnosis or treatment history when applying for or renewing their medical license. Increasingly, medical boards are asking applicants if they have been treated for bipolar disorder, schizophrenia, paranoia, or other disorders.¹⁷ Credentialing bodies, clinics, and hospitals may make similar queries.

In an analysis of 51 medical licensing applications (50 states and the District of Columbia), Schroeder et al¹⁷ determined that 69% contained at least 1 question that was “likely impermissible” or “impermissible” in terms of compliance with the Americans with Disabilities Act (ADA). In 1993, a U.S. District Court found that the New Jersey State Board of Medical Examiners was in violation of the ADA because licensure application questions did not focus on current fitness to practice medicine but rather on information about a candidate’s status as a person with a disability (illness or diagnosis).¹⁸

In Alexander v Margolis,¹⁹ however, the court found that because patient safety is in question, medical licensing boards and credentialing bodies can solicit information about serious mental illness that could lead to impaired performance. Courts have ruled that questions regarding a history of treatment or hospitalization for bipolar disorder or schizophrenia and other psychotic disorders are permissible because they are considered “serious disorders” likely to interfere with a physician’s current ability to practice.²⁰ In a 2008 review of all U.S. -affiliated medical licensing boards (N=54), Polfliet²¹ found that 7 specifically asked applicants about a history of bipolar disorder or schizophrenia, paranoia, and other psychotic disorders. Polfliet²¹ also found that state medical boards’ compliance with ADA guidelines was not uniform and some questions were “just as broad, and potentially discriminatory, as they were before enactment of the ADA.”

Worley²² reported a successful appeal to the Arkansas State Medical Board to revise its licensure questions following a cluster of medical student and physician suicides. The Board changed the question “Have you ever, or are you presently, being treated for a mental health condition?” to “Have you ever been advised or required by any licensing or privileging body to seek treatment for a physical or mental health condition?”

Providing inaccurate information on a medical licensure application may result in denial or revocation,²³ but acknowledging a history of mental health or substance abuse treatment triggers a more in-depth inquiry by the medical board. The lack of distinction between diagnosis and impairment further stigmatizes physicians who seek care and impedes treatment.

Bipolar disorder. The trend in psychiatry toward diagnosing bipolar II disorder and “soft bipolarity” in patients previously diagnosed with and treated for major depression presents a new challenge. Despite no change in their history or functioning, a physician whose diagnosis is changed from depression to bipolar II disorder might be moved from a non-reportable to a board-reportable diagnostic category. With the evolving understanding of bipolar spectrum disorders, medical boards may need to revise their screening questions to ensure that they are seeking information about impairment, not simply the presence of a medical disorder.

Seeking special treatment

Self-treatment. Physicians may attempt to treat their mood disorder with self-prescribed medications before seeking consultation from a psychiatrist. Others use alcohol or illicit drugs to try to alleviate mood disorder symptoms. Self-diagnosis and treatment are not advisable because it is impossible to be objective. Professional boards and state medical boards discourage or prohibit self-prescribing because of the need for ongoing evaluation and monitoring for adverse reactions.

‘VIP’ treatment. When a physician comes to a colleague for help with a mental health issue, both parties might underestimate the severity of the crisis.²⁴ Weintraub²⁵ reported a case series of 12 “VIP” psychiatric inpatients, 10 of whom he described as “therapeutic failures, “including 2 who committed suicide and 3 who left the hospital against medical advice. He observed that improvement occurred only after patients lost their VIP status/treatment.

In a literature review, Groves et al²⁶ found delays in pursuing diagnostic evaluation and treatment for physician patients. He described risks of VIP treatment (Table 3),²⁶ including the physician’s ability to circumscribe the care regimen to obtain “special treatment, “which can create conflict among care providers and other patients. The ailing physician might have trouble relinquishing control. Care providers might not give physician patients necessary information about the illness or treatment because they make assumptions about the physician’s knowledge or fear causing narcissistic injury. Providers’ identification with their peers, deference to their background, and desire to preserve these patients’ autonomy may lead to interventions that are different from those they would provide to other patients.

Treating physicians might underestimate the patient’s suicide risk and tend to not hospitalize a physician patient who faces an imminent risk of self-harm. Similarly, a physician patient might know what key words to use to deny suicidal ideation or avoid hospitalization. Providers assessing physician patients should provide the same interventions they would give to nonphysician patients with the same history and suicide risk factors. To do otherwise is to risk a fatal outcome.

Physician health programs provide confidential treatment and assistance to physicians with mental illness and/or substance abuse problems. Some programs are affiliated with licensing boards, some are branches of the state medical societies, and others are independent of the licensing agencies. Directories of these programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Physician health programs aim to help impaired physicians receive treatment and rehabilitation without censure or licensure revocation, provided they comply with treatment and monitoring requirements.

Table 3

Risks of caring for ‘VIP’ patients

Related Resources

• American Foundation for Suicide Prevention. www.afsp.org. 24-hour crisis line: 1-800-273-TALK (8255).
• Center for Patient and Professional Advocacy. www.mc.vanderbilt.edu/root/vumc.php?site=CPPA.
• Depression and Bipolar Support Alliance. www.dbsalliance.org.
• Federation of State Physician Health Programs, Inc. www.fsphp.org.
• National Alliance on Mental Illness. www.nami.org.
• Vanderbilt Center for Professional Health. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.

Disclosure

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

Discuss this article at http://currentpsychiatry.blogspot.com/2011/03/adapting-dialectical-behavior-therapy.html#comments

Treating suicidal adolescents is fraught with challenges. Antidepressants may be associated with increased suicidal ideation in adolescents,^1-3 although some data suggest that increased adolescent suicide rates are correlated with decreases in antidepressant prescribing.⁴ Adolescents hospitalized after a suicide attempt are likely to attempt suicide again after they are discharged.^5,6 Such patients might not attend outpatient psychotherapy; a study of 167 adolescents discharged after a suicide attempt found that 26% never attended follow-up appointments and 11% went once.⁷

Emerging research supports the effectiveness of dialectical behavior therapy (DBT) for suicidal adolescents. DBT is a form of cognitive-behavioral therapy that combines individual therapy, skills training, and telephone coaching and is implemented by a therapist consultation team that meets weekly. This article reviews evidence supporting the efficacy of DBT for suicidal adolescents and describes principles of outpatient DBT for these patients as developed by Miller et al.⁸

Evidence of DBT’s effectiveness

A review of DBT research found strong evidence for DBT’s effectiveness for suicidal adults.⁹ Recently, DBT has been adapted to treat adolescents with suicidal behavior and nonsuicidal self-injury (NSSI).^10-15

In a nonrandomized trial, Rathus and Miller¹⁰ compared 29 suicidal adolescent outpatients receiving DBT with 82 participants receiving treatment as usual (TAU). Patients were assigned to DBT if they had a suicide attempt in the previous 16 weeks and ≥3 borderline personality disorder (BPD) features or to TAU if they met only 1 of those conditions. Patients in the DBT group had more axis I disorders and pretreatment hospitalizations than the TAU group. Compared with those receiving TAU, patients treated with DBT had fewer hospitalizations (13% in TAU vs 0% in DBT) and a lower dropout rate (60% in TAU vs 38% in DBT). The DBT group experienced significant reductions in suicidal ideation, BPD symptoms, and general psychiatric symptoms. There was 1 suicide attempt in the DBT group vs 7 attempts in the TAU group; however, this difference was not statistically significant.

Woodberry and Popenoe¹¹ examined the use of DBT for suicidal adolescents and their families in a community outpatient clinic. Adolescents reported reductions in overall symptoms, depression, anger, dissociative symptoms, and urges for intentional self-injury. Parents reported reductions in their children’s problem behaviors and in their own depressive symptoms. In a study of DBT in 16 adolescent females with chronic intentional self-injury, patients reported significant reductions in incidents of intentional self-injury, depression, and hopelessness, and increases in overall functioning.¹²

Three studies have examined using DBT for suicidal adolescents in residential facilities. In a pilot study, Katz et al¹³ compared DBT with TAU for 62 suicidal adolescent inpatients. At 1-year follow-up, both groups experienced significant reductions in suicidal ideation, NSSI, and depression. However, compared with those who received TAU, DBT patients had fewer behavioral problems during hospitalization. Sunseri¹⁴ used DBT to treat adolescent females in residential treatment. After DBT was implemented, residents were hospitalized because of NSSI and suicidality for fewer days than before DBT. Trupin et al¹⁵ taught DBT to staff who worked with female adolescent offenders at a juvenile rehabilitation facility. After the staff implemented DBT, the rates of problem behaviors and punishment by staff decreased on 1 unit; there were no behavior or punishment changes on another unit.

Theoretical foundations

Biosocial theory. The problems DBT treats in suicidal adolescents include emotion dysregulation, interpersonal conflict, impulsivity, cognitive dysregulation, and self-dysregulation.⁸ The biosocial theory postulates that these problems are the result of the transaction, or reciprocal relationship, between biologic predispositions and an invalidating environment. The biosocial theory suggests 3 biologic characteristics often are found among suicidal adolescents:

• high emotional sensitivity
• high extremity in reactions
• a slow return to baseline after experiencing a surge in affect.⁸

Although these characteristics indicate higher emotionality, they are not sufficient to account for suicidal adolescents’ difficulties. Problems arise when individuals with these biologic characteristics are raised in an invalidating environment, where the adolescent does not learn how to regulate emotions. Common characteristics of invalidating environments and their effects on adolescents are described in Table 1 .⁸

Treatment theory. DBT for suicidal adolescents focuses on a synthesis between 2 seemingly opposite treatment strategies: change and acceptance. The change focus is derived from behavioral science, and treatment incorporates standard behavior therapy practices, including chain analysis (described below), skills training, contingency management, and exposure.

The acceptance focus draws upon principles of Zen and other Eastern spiritual traditions. Therapists teach patients to accept reality as it is in this moment, without judgment. A key extension of this acceptance is the use of validation—radical acceptance and acknowledgement that all behavior has validity and understandability. DBT therapists strive to use 6 levels of validation with their patients ( Table 2 ),¹⁶ which often is a critical strategy for adolescents who reside in an invalidating environment.

DBT attempts to synthesize the acceptance-based Zen tradition with the change-based strategies of behavioral science through a dialectical philosophy. A fundamental postulate of dialectical philosophy is that a tension occurs when an initial truth or thesis is opposed by an apparently contradictory truth or antithesis.⁸ DBT therapists work with adolescents to find a synthesis that is the “middle path, “ which includes the truth in both positions as well as what is left out of both. For an example of how this might work for an adolescent patient with NSSI, visit this article at CurrentPsychiatry.com.

Table 1

Characteristics of an invalidating environment

Table 2

6 levels of validation employed by DBT therapists

How DBT works

DBT serves 5 functions. It enhances patient capabilities, increases patient motivation, structures the environment to increase the likelihood of success, works to assure generalization from therapy to the natural environment, and enhances therapists’ capabilities and motivation to treat patients effectively.⁸ Outpatient DBT for suicidal adolescents uses 4 modes of treatment:

• weekly individual therapy
• weekly skills training
• telephone coaching
• weekly therapist consultation team meetings.⁸

Although Linehan’s original research with adults was based on a 1-year treatment model,¹⁷ treatment lasts 12 to 16 weeks in the adolescent DBT model designed and studied by Miller et al.⁸ Treatment for adolescents is shorter because research indicates that suicidal adolescents frequently fail to complete longer courses of therapy.¹⁸

Individual therapy. The rank-ordered targets of individual therapy in the first stage of DBT are to:

1. eliminate life-threatening behavior, including NSSI
2. stop therapy-interfering behaviors (eg, not showing up to sessions)
3. change behaviors that interfere with the adolescent’s quality of life (eg, substance abuse)
4. enhance the adolescent’s use of skills.⁸

The individual therapist sets treatment goals in accord with these targets, monitors progress, integrates all modes of therapy, and balances acceptance and validation of the patient with being a catalyst for change. Family members may be included in therapy sessions when family problems emerge as the highest priority.

DBT therapists use chain analysis—which is a process of assessing the series of events, link by link, that lead from a prompting event to a problem behavior (eg, suicide attempt)—to assess problematic behavior and identify methods of change.⁸ The therapist and patient use this process to develop alternative behaviors for the patient to use to reach a more effective outcome.

DBT therapists also ask adolescents to fill out a daily diary card that tracks targeted behaviors, including NSSI, suicidal urges, and important emotions. The diary card helps the therapist determine what needs to be targeted in therapy, increases mindfulness and understanding of problem behaviors, and helps change targeted behavior.

Skills training addresses skills deficits believed to be causing the suicidal adolescent’s problems. DBT systematically teaches 5 skill sets:

• emotional regulation
• mindfulness
• interpersonal effectiveness
• distress tolerance
• “walking the middle path. “⁸

These skills are designed to treat specific problems common among suicidal adolescents and their families. For example, suicidal adolescents often experience a spike in emotions that leads to urges for ineffective behavior, such as attempting suicide or attacking another person. Table 3 provides steps that teach “opposite action, “ which can reduce ineffective emotions and problematic urges associated with these emotions. Table 4 provides mindfulness practices that can help patients address problems such as mindlessness and avoiding the present moment. Although adolescent DBT skills training is similar to that in adults, Table 5 describes key differences.

Table 3

Teaching adolescents ‘opposite action’

Table 4

Mindfulness practices: Teach adolescents to live in the present moment

Table 5

Adapting DBT skills training for adolescents

Telephone consultation. The purpose of brief (5 to 15 minutes) telephone consultations between a patient and therapist is to:

• enhance the likelihood of effective behavior
• coach the use of skills
• decrease the likelihood of problematic behaviors.

DBT telephone consultation for adults differs from that for suicidal adolescents. In DBT for adults, if a patient engages in NSSI or suicidal behavior, there is no telephone contact for 24 hours. This rule aims to avoid reinforcing the behavior with additional contact. However, this rule does not apply to adolescents because restricting adolescents’ access to resources for managing the aftereffects of self-harm could increase their risk of injury or death. Nonetheless, adolescents are strongly encouraged to use telephone coaching before rather than after self-harm. A second difference is that in DBT for adolescents, telephone coaching is offered to parents to help them use skills in the home. To avoid complications with dual relationships, the parents’ telephone coach should not be the adolescent’s individual therapist.

Consultation team meetings. The consultation team meets weekly to increase therapists’ capabilities and motivation.

Therapists who treat suicidal adolescents often have a high degree of burnout, which leads to ineffective treatment and/or quitting.⁸ The team provides support, engages in problem-solving, and helps therapists adhere to the treatment model to improve effectiveness. Clinicians interested in participating a consultation team may review http://behavioraltech.org/resources/crd.cfm for a directory of existing DBT programs. Those interested in starting a consultation team may explore training programs such as those offered at www.behavioraltech.org.

Related Resources

• Lynch TR, Trost WT, Salsman N, et al. Dialectical behavior therapy for borderline personality disorder. Annu Rev Clin Psychol. 2007; 3: 181-205.
• Miller A, Rathus JH, Linehan MM. Dialectical behavior therapy with suicidal adolescents. New York, NY: The Guilford Press; 2007.
• Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav. 2002; 32(2): 146-157.

Disclosure

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

Discuss this article at http://currentpsychiatry.blogspot.com/2011/03/adapting-dialectical-behavior-therapy.html#comments

Treating suicidal adolescents is fraught with challenges. Antidepressants may be associated with increased suicidal ideation in adolescents,^1-3 although some data suggest that increased adolescent suicide rates are correlated with decreases in antidepressant prescribing.⁴ Adolescents hospitalized after a suicide attempt are likely to attempt suicide again after they are discharged.^5,6 Such patients might not attend outpatient psychotherapy; a study of 167 adolescents discharged after a suicide attempt found that 26% never attended follow-up appointments and 11% went once.⁷

Emerging research supports the effectiveness of dialectical behavior therapy (DBT) for suicidal adolescents. DBT is a form of cognitive-behavioral therapy that combines individual therapy, skills training, and telephone coaching and is implemented by a therapist consultation team that meets weekly. This article reviews evidence supporting the efficacy of DBT for suicidal adolescents and describes principles of outpatient DBT for these patients as developed by Miller et al.⁸

Evidence of DBT’s effectiveness

A review of DBT research found strong evidence for DBT’s effectiveness for suicidal adults.⁹ Recently, DBT has been adapted to treat adolescents with suicidal behavior and nonsuicidal self-injury (NSSI).^10-15

In a nonrandomized trial, Rathus and Miller¹⁰ compared 29 suicidal adolescent outpatients receiving DBT with 82 participants receiving treatment as usual (TAU). Patients were assigned to DBT if they had a suicide attempt in the previous 16 weeks and ≥3 borderline personality disorder (BPD) features or to TAU if they met only 1 of those conditions. Patients in the DBT group had more axis I disorders and pretreatment hospitalizations than the TAU group. Compared with those receiving TAU, patients treated with DBT had fewer hospitalizations (13% in TAU vs 0% in DBT) and a lower dropout rate (60% in TAU vs 38% in DBT). The DBT group experienced significant reductions in suicidal ideation, BPD symptoms, and general psychiatric symptoms. There was 1 suicide attempt in the DBT group vs 7 attempts in the TAU group; however, this difference was not statistically significant.

Woodberry and Popenoe¹¹ examined the use of DBT for suicidal adolescents and their families in a community outpatient clinic. Adolescents reported reductions in overall symptoms, depression, anger, dissociative symptoms, and urges for intentional self-injury. Parents reported reductions in their children’s problem behaviors and in their own depressive symptoms. In a study of DBT in 16 adolescent females with chronic intentional self-injury, patients reported significant reductions in incidents of intentional self-injury, depression, and hopelessness, and increases in overall functioning.¹²

Three studies have examined using DBT for suicidal adolescents in residential facilities. In a pilot study, Katz et al¹³ compared DBT with TAU for 62 suicidal adolescent inpatients. At 1-year follow-up, both groups experienced significant reductions in suicidal ideation, NSSI, and depression. However, compared with those who received TAU, DBT patients had fewer behavioral problems during hospitalization. Sunseri¹⁴ used DBT to treat adolescent females in residential treatment. After DBT was implemented, residents were hospitalized because of NSSI and suicidality for fewer days than before DBT. Trupin et al¹⁵ taught DBT to staff who worked with female adolescent offenders at a juvenile rehabilitation facility. After the staff implemented DBT, the rates of problem behaviors and punishment by staff decreased on 1 unit; there were no behavior or punishment changes on another unit.

Theoretical foundations

Biosocial theory. The problems DBT treats in suicidal adolescents include emotion dysregulation, interpersonal conflict, impulsivity, cognitive dysregulation, and self-dysregulation.⁸ The biosocial theory postulates that these problems are the result of the transaction, or reciprocal relationship, between biologic predispositions and an invalidating environment. The biosocial theory suggests 3 biologic characteristics often are found among suicidal adolescents:

• high emotional sensitivity
• high extremity in reactions
• a slow return to baseline after experiencing a surge in affect.⁸

Although these characteristics indicate higher emotionality, they are not sufficient to account for suicidal adolescents’ difficulties. Problems arise when individuals with these biologic characteristics are raised in an invalidating environment, where the adolescent does not learn how to regulate emotions. Common characteristics of invalidating environments and their effects on adolescents are described in Table 1 .⁸

Treatment theory. DBT for suicidal adolescents focuses on a synthesis between 2 seemingly opposite treatment strategies: change and acceptance. The change focus is derived from behavioral science, and treatment incorporates standard behavior therapy practices, including chain analysis (described below), skills training, contingency management, and exposure.

The acceptance focus draws upon principles of Zen and other Eastern spiritual traditions. Therapists teach patients to accept reality as it is in this moment, without judgment. A key extension of this acceptance is the use of validation—radical acceptance and acknowledgement that all behavior has validity and understandability. DBT therapists strive to use 6 levels of validation with their patients ( Table 2 ),¹⁶ which often is a critical strategy for adolescents who reside in an invalidating environment.

DBT attempts to synthesize the acceptance-based Zen tradition with the change-based strategies of behavioral science through a dialectical philosophy. A fundamental postulate of dialectical philosophy is that a tension occurs when an initial truth or thesis is opposed by an apparently contradictory truth or antithesis.⁸ DBT therapists work with adolescents to find a synthesis that is the “middle path, “ which includes the truth in both positions as well as what is left out of both. For an example of how this might work for an adolescent patient with NSSI, visit this article at CurrentPsychiatry.com.

Table 1

Characteristics of an invalidating environment

Table 2

6 levels of validation employed by DBT therapists

How DBT works

DBT serves 5 functions. It enhances patient capabilities, increases patient motivation, structures the environment to increase the likelihood of success, works to assure generalization from therapy to the natural environment, and enhances therapists’ capabilities and motivation to treat patients effectively.⁸ Outpatient DBT for suicidal adolescents uses 4 modes of treatment:

• weekly individual therapy
• weekly skills training
• telephone coaching
• weekly therapist consultation team meetings.⁸

Although Linehan’s original research with adults was based on a 1-year treatment model,¹⁷ treatment lasts 12 to 16 weeks in the adolescent DBT model designed and studied by Miller et al.⁸ Treatment for adolescents is shorter because research indicates that suicidal adolescents frequently fail to complete longer courses of therapy.¹⁸

Individual therapy. The rank-ordered targets of individual therapy in the first stage of DBT are to:

1. eliminate life-threatening behavior, including NSSI
2. stop therapy-interfering behaviors (eg, not showing up to sessions)
3. change behaviors that interfere with the adolescent’s quality of life (eg, substance abuse)
4. enhance the adolescent’s use of skills.⁸

The individual therapist sets treatment goals in accord with these targets, monitors progress, integrates all modes of therapy, and balances acceptance and validation of the patient with being a catalyst for change. Family members may be included in therapy sessions when family problems emerge as the highest priority.

DBT therapists use chain analysis—which is a process of assessing the series of events, link by link, that lead from a prompting event to a problem behavior (eg, suicide attempt)—to assess problematic behavior and identify methods of change.⁸ The therapist and patient use this process to develop alternative behaviors for the patient to use to reach a more effective outcome.

DBT therapists also ask adolescents to fill out a daily diary card that tracks targeted behaviors, including NSSI, suicidal urges, and important emotions. The diary card helps the therapist determine what needs to be targeted in therapy, increases mindfulness and understanding of problem behaviors, and helps change targeted behavior.

Skills training addresses skills deficits believed to be causing the suicidal adolescent’s problems. DBT systematically teaches 5 skill sets:

• emotional regulation
• mindfulness
• interpersonal effectiveness
• distress tolerance
• “walking the middle path. “⁸

These skills are designed to treat specific problems common among suicidal adolescents and their families. For example, suicidal adolescents often experience a spike in emotions that leads to urges for ineffective behavior, such as attempting suicide or attacking another person. Table 3 provides steps that teach “opposite action, “ which can reduce ineffective emotions and problematic urges associated with these emotions. Table 4 provides mindfulness practices that can help patients address problems such as mindlessness and avoiding the present moment. Although adolescent DBT skills training is similar to that in adults, Table 5 describes key differences.

Table 3

Teaching adolescents ‘opposite action’

Table 4

Mindfulness practices: Teach adolescents to live in the present moment

Table 5

Adapting DBT skills training for adolescents

Telephone consultation. The purpose of brief (5 to 15 minutes) telephone consultations between a patient and therapist is to:

• enhance the likelihood of effective behavior
• coach the use of skills
• decrease the likelihood of problematic behaviors.

DBT telephone consultation for adults differs from that for suicidal adolescents. In DBT for adults, if a patient engages in NSSI or suicidal behavior, there is no telephone contact for 24 hours. This rule aims to avoid reinforcing the behavior with additional contact. However, this rule does not apply to adolescents because restricting adolescents’ access to resources for managing the aftereffects of self-harm could increase their risk of injury or death. Nonetheless, adolescents are strongly encouraged to use telephone coaching before rather than after self-harm. A second difference is that in DBT for adolescents, telephone coaching is offered to parents to help them use skills in the home. To avoid complications with dual relationships, the parents’ telephone coach should not be the adolescent’s individual therapist.

Consultation team meetings. The consultation team meets weekly to increase therapists’ capabilities and motivation.

Therapists who treat suicidal adolescents often have a high degree of burnout, which leads to ineffective treatment and/or quitting.⁸ The team provides support, engages in problem-solving, and helps therapists adhere to the treatment model to improve effectiveness. Clinicians interested in participating a consultation team may review http://behavioraltech.org/resources/crd.cfm for a directory of existing DBT programs. Those interested in starting a consultation team may explore training programs such as those offered at www.behavioraltech.org.

Related Resources

• Lynch TR, Trost WT, Salsman N, et al. Dialectical behavior therapy for borderline personality disorder. Annu Rev Clin Psychol. 2007; 3: 181-205.
• Miller A, Rathus JH, Linehan MM. Dialectical behavior therapy with suicidal adolescents. New York, NY: The Guilford Press; 2007.
• Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav. 2002; 32(2): 146-157.

Disclosure

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

Discuss this article at http://currentpsychiatry.blogspot.com/2011/03/adapting-dialectical-behavior-therapy.html#comments

Treating suicidal adolescents is fraught with challenges. Antidepressants may be associated with increased suicidal ideation in adolescents,^1-3 although some data suggest that increased adolescent suicide rates are correlated with decreases in antidepressant prescribing.⁴ Adolescents hospitalized after a suicide attempt are likely to attempt suicide again after they are discharged.^5,6 Such patients might not attend outpatient psychotherapy; a study of 167 adolescents discharged after a suicide attempt found that 26% never attended follow-up appointments and 11% went once.⁷

Emerging research supports the effectiveness of dialectical behavior therapy (DBT) for suicidal adolescents. DBT is a form of cognitive-behavioral therapy that combines individual therapy, skills training, and telephone coaching and is implemented by a therapist consultation team that meets weekly. This article reviews evidence supporting the efficacy of DBT for suicidal adolescents and describes principles of outpatient DBT for these patients as developed by Miller et al.⁸

Evidence of DBT’s effectiveness

A review of DBT research found strong evidence for DBT’s effectiveness for suicidal adults.⁹ Recently, DBT has been adapted to treat adolescents with suicidal behavior and nonsuicidal self-injury (NSSI).^10-15

In a nonrandomized trial, Rathus and Miller¹⁰ compared 29 suicidal adolescent outpatients receiving DBT with 82 participants receiving treatment as usual (TAU). Patients were assigned to DBT if they had a suicide attempt in the previous 16 weeks and ≥3 borderline personality disorder (BPD) features or to TAU if they met only 1 of those conditions. Patients in the DBT group had more axis I disorders and pretreatment hospitalizations than the TAU group. Compared with those receiving TAU, patients treated with DBT had fewer hospitalizations (13% in TAU vs 0% in DBT) and a lower dropout rate (60% in TAU vs 38% in DBT). The DBT group experienced significant reductions in suicidal ideation, BPD symptoms, and general psychiatric symptoms. There was 1 suicide attempt in the DBT group vs 7 attempts in the TAU group; however, this difference was not statistically significant.

Woodberry and Popenoe¹¹ examined the use of DBT for suicidal adolescents and their families in a community outpatient clinic. Adolescents reported reductions in overall symptoms, depression, anger, dissociative symptoms, and urges for intentional self-injury. Parents reported reductions in their children’s problem behaviors and in their own depressive symptoms. In a study of DBT in 16 adolescent females with chronic intentional self-injury, patients reported significant reductions in incidents of intentional self-injury, depression, and hopelessness, and increases in overall functioning.¹²

Three studies have examined using DBT for suicidal adolescents in residential facilities. In a pilot study, Katz et al¹³ compared DBT with TAU for 62 suicidal adolescent inpatients. At 1-year follow-up, both groups experienced significant reductions in suicidal ideation, NSSI, and depression. However, compared with those who received TAU, DBT patients had fewer behavioral problems during hospitalization. Sunseri¹⁴ used DBT to treat adolescent females in residential treatment. After DBT was implemented, residents were hospitalized because of NSSI and suicidality for fewer days than before DBT. Trupin et al¹⁵ taught DBT to staff who worked with female adolescent offenders at a juvenile rehabilitation facility. After the staff implemented DBT, the rates of problem behaviors and punishment by staff decreased on 1 unit; there were no behavior or punishment changes on another unit.

Theoretical foundations

Biosocial theory. The problems DBT treats in suicidal adolescents include emotion dysregulation, interpersonal conflict, impulsivity, cognitive dysregulation, and self-dysregulation.⁸ The biosocial theory postulates that these problems are the result of the transaction, or reciprocal relationship, between biologic predispositions and an invalidating environment. The biosocial theory suggests 3 biologic characteristics often are found among suicidal adolescents:

• high emotional sensitivity
• high extremity in reactions
• a slow return to baseline after experiencing a surge in affect.⁸

Although these characteristics indicate higher emotionality, they are not sufficient to account for suicidal adolescents’ difficulties. Problems arise when individuals with these biologic characteristics are raised in an invalidating environment, where the adolescent does not learn how to regulate emotions. Common characteristics of invalidating environments and their effects on adolescents are described in Table 1 .⁸

Treatment theory. DBT for suicidal adolescents focuses on a synthesis between 2 seemingly opposite treatment strategies: change and acceptance. The change focus is derived from behavioral science, and treatment incorporates standard behavior therapy practices, including chain analysis (described below), skills training, contingency management, and exposure.

The acceptance focus draws upon principles of Zen and other Eastern spiritual traditions. Therapists teach patients to accept reality as it is in this moment, without judgment. A key extension of this acceptance is the use of validation—radical acceptance and acknowledgement that all behavior has validity and understandability. DBT therapists strive to use 6 levels of validation with their patients ( Table 2 ),¹⁶ which often is a critical strategy for adolescents who reside in an invalidating environment.

DBT attempts to synthesize the acceptance-based Zen tradition with the change-based strategies of behavioral science through a dialectical philosophy. A fundamental postulate of dialectical philosophy is that a tension occurs when an initial truth or thesis is opposed by an apparently contradictory truth or antithesis.⁸ DBT therapists work with adolescents to find a synthesis that is the “middle path, “ which includes the truth in both positions as well as what is left out of both. For an example of how this might work for an adolescent patient with NSSI, visit this article at CurrentPsychiatry.com.

Table 1

Characteristics of an invalidating environment

Table 2

6 levels of validation employed by DBT therapists

How DBT works

DBT serves 5 functions. It enhances patient capabilities, increases patient motivation, structures the environment to increase the likelihood of success, works to assure generalization from therapy to the natural environment, and enhances therapists’ capabilities and motivation to treat patients effectively.⁸ Outpatient DBT for suicidal adolescents uses 4 modes of treatment:

• weekly individual therapy
• weekly skills training
• telephone coaching
• weekly therapist consultation team meetings.⁸

Although Linehan’s original research with adults was based on a 1-year treatment model,¹⁷ treatment lasts 12 to 16 weeks in the adolescent DBT model designed and studied by Miller et al.⁸ Treatment for adolescents is shorter because research indicates that suicidal adolescents frequently fail to complete longer courses of therapy.¹⁸

Individual therapy. The rank-ordered targets of individual therapy in the first stage of DBT are to:

1. eliminate life-threatening behavior, including NSSI
2. stop therapy-interfering behaviors (eg, not showing up to sessions)
3. change behaviors that interfere with the adolescent’s quality of life (eg, substance abuse)
4. enhance the adolescent’s use of skills.⁸

The individual therapist sets treatment goals in accord with these targets, monitors progress, integrates all modes of therapy, and balances acceptance and validation of the patient with being a catalyst for change. Family members may be included in therapy sessions when family problems emerge as the highest priority.

DBT therapists use chain analysis—which is a process of assessing the series of events, link by link, that lead from a prompting event to a problem behavior (eg, suicide attempt)—to assess problematic behavior and identify methods of change.⁸ The therapist and patient use this process to develop alternative behaviors for the patient to use to reach a more effective outcome.

DBT therapists also ask adolescents to fill out a daily diary card that tracks targeted behaviors, including NSSI, suicidal urges, and important emotions. The diary card helps the therapist determine what needs to be targeted in therapy, increases mindfulness and understanding of problem behaviors, and helps change targeted behavior.

Skills training addresses skills deficits believed to be causing the suicidal adolescent’s problems. DBT systematically teaches 5 skill sets:

• emotional regulation
• mindfulness
• interpersonal effectiveness
• distress tolerance
• “walking the middle path. “⁸

These skills are designed to treat specific problems common among suicidal adolescents and their families. For example, suicidal adolescents often experience a spike in emotions that leads to urges for ineffective behavior, such as attempting suicide or attacking another person. Table 3 provides steps that teach “opposite action, “ which can reduce ineffective emotions and problematic urges associated with these emotions. Table 4 provides mindfulness practices that can help patients address problems such as mindlessness and avoiding the present moment. Although adolescent DBT skills training is similar to that in adults, Table 5 describes key differences.

Table 3

Teaching adolescents ‘opposite action’

Table 4

Mindfulness practices: Teach adolescents to live in the present moment

Table 5

Adapting DBT skills training for adolescents

Telephone consultation. The purpose of brief (5 to 15 minutes) telephone consultations between a patient and therapist is to:

• enhance the likelihood of effective behavior
• coach the use of skills
• decrease the likelihood of problematic behaviors.

DBT telephone consultation for adults differs from that for suicidal adolescents. In DBT for adults, if a patient engages in NSSI or suicidal behavior, there is no telephone contact for 24 hours. This rule aims to avoid reinforcing the behavior with additional contact. However, this rule does not apply to adolescents because restricting adolescents’ access to resources for managing the aftereffects of self-harm could increase their risk of injury or death. Nonetheless, adolescents are strongly encouraged to use telephone coaching before rather than after self-harm. A second difference is that in DBT for adolescents, telephone coaching is offered to parents to help them use skills in the home. To avoid complications with dual relationships, the parents’ telephone coach should not be the adolescent’s individual therapist.

Consultation team meetings. The consultation team meets weekly to increase therapists’ capabilities and motivation.

Therapists who treat suicidal adolescents often have a high degree of burnout, which leads to ineffective treatment and/or quitting.⁸ The team provides support, engages in problem-solving, and helps therapists adhere to the treatment model to improve effectiveness. Clinicians interested in participating a consultation team may review http://behavioraltech.org/resources/crd.cfm for a directory of existing DBT programs. Those interested in starting a consultation team may explore training programs such as those offered at www.behavioraltech.org.

Related Resources

• Lynch TR, Trost WT, Salsman N, et al. Dialectical behavior therapy for borderline personality disorder. Annu Rev Clin Psychol. 2007; 3: 181-205.
• Miller A, Rathus JH, Linehan MM. Dialectical behavior therapy with suicidal adolescents. New York, NY: The Guilford Press; 2007.
• Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav. 2002; 32(2): 146-157.

Disclosure

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

Discuss this article at http://currentpsychiatry.blogspot.com/2011/03/opioid-use-disorder-during-pregnancy.html#comments

For 3 years, your mental health clinic has been treating Ms. J, age 23, for bipolar disorder. She is single, unemployed, lives alone, and receives Social Security disability assistance and financial support from her parents. She has been successfully maintained on aripiprazole, 15 mg/d, and citalopram, 20 mg/d, for 18 months. Six months ago she began to miss therapy sessions and physician visits.

Her parents inform Ms. J’s therapist that she is “snorting oxycontin” with her new boyfriend. At her next visit Ms. J confirms she has been struggling to manage an opioid use disorder for more than 1 year, and requests help.

After you educate her about the diagnosis, pathophysiology, and treatment of opioid addiction, she chooses to include pharmacotherapy as part of her treatment. After informed consent, Ms. J agrees to take buprenorphine and naloxone, meet with her therapist weekly, and attend twice-weekly Narcotics Anonymous (NA) meetings. Over the ensuing months she is gradually inducted onto buprenorphine and naloxone, 12 mg, shows improved insight and motivation, provides negative urine drug screens, and demonstrates increased ability to manage her recovery. Two weeks later Ms. J tells you she may be pregnant but wants to continue buprenorphine and naloxone.

Opioid use disorder (OUD) during pregnancy is among the most difficult clinical scenarios to manage. The prevalence of OUD during pregnancy is largely unknown. However, stigma against pregnant patients with OUD is substantial.¹ This article briefly summarizes identification, assessment, and treatment of OUD during pregnancy. To avoid confusion with the term “physical dependence, “ we will use “opioid use disorder” instead of “opioid dependence. “ The DSM-5 Substance Use Disorders Workgroup recommends combining abuse and dependence into a single disorder of graded clinical severity; however, this has not been finalized.²

Early identification is crucial

Early identification of OUD in pregnant women can be challenging. Self-reports underestimate use³ and shame, fear of prosecution or involvement of child welfare services, and guilt can further erode self-report. Women with OUD may have irregular menses and might not be aware of their pregnancy until several months after conception.⁴ Also, women with OUD who are maintained on opioid agonist therapies may misinterpret early signs of pregnancy—such as fatigue, nausea, vomiting, headaches, and cramps—as withdrawal symptoms and may respond by increasing their opioid dosing, thus exposing their fetus to increased drug levels. Finally, many women with OUD experience amenorrhea as a result of their stressful, unhealthy lifestyle, which may preclude pregnancy despite sexual activity. When these women later enroll in an opioid maintenance program, their endocrine function may return to normal, leading to unexpected pregnancy.⁵

Screening for OUD in pregnant patients has not been well studied. An interviewer’s nonjudgmental, empathic attitude may be more important than the specific questions he or she asks. It may be best to begin with less threatening questions and proceed to more specific questions after developing a therapeutic alliance.⁶

Chasnoff et al⁷ studied >2, 000 Medicaid-eligible pregnant patients from 9 prenatal clinics to identify risk factors for substance use during pregnancy. Alcohol or tobacco use in the month before pregnancy most differentiated current drug or alcohol use from nonuse while pregnant; however, a wide variation in use rates among patients in this study limits the generalizability of these findings. Consider OUD in women with:

• physical examination findings or history that suggests substance use or withdrawal symptoms
  
• positive drug test results for illicit or nonprescribed opioids
  
• aberrant medication-taking behaviors in those receiving prescribed opioids
  
• nicotine or alcohol use in the month before they knew they were pregnant
  
• a history of addiction-related disorders
  
• evidence of diseases associated with drug use, such as human immunodeficiency virus or hepatitis C
  
• poor prenatal care attendance
  
• unexplained fetal growth abnormalities.
  

A combination of interviewing and biologic drug screening may be more effective than either approach alone.¹¹ Drug screening should include opioids typically screened for (morphine, codeine, heroin metabolite) and those for which additional tests may be required (eg, semi-synthetics such as oxycodone and synthetics such as fentanyl). Learn your state’s civil mandates regarding drug-using pregnant women, guidelines for addiction treatment, and confidentiality provisions, especially as they relate to drug testing and mandatory reporting. Ideally, patients should be informed of these issues before they undergo drug testing or other procedures. These requirements may vary according to physician specialty or role in providing care.

Diagnosis of opioid dependence is based on DSM-IV-TR criteria; however, the proposed DSM-5 criteria for OUD may better emphasize cautions about including tolerance or withdrawal when diagnosing OUD in the setting of medically supervised and appropriate opioid use.²

Table 1

The ‘4P’s Plus’ screen for substance use during pregnancy

Office management

OUD-specific treatment decreases opioid use and improves birth outcomes¹⁴ ; however, retaining these patients in treatment can be difficult. Addressing social issues— including financial burdens, unstable living conditions, intimate partner violence, transportation difficulties, and limited access to medical and child care—can facilitate treatment.⁵ The Addiction Severity Index version tailored to women and pregnancy¹⁵ examines 7 domains of functioning (drugs, alcohol, psychological, social, medical, legal, and employment), informs treatment planning, quantifies treatment progress, and has predictive validity.¹⁶ Services are more likely to be effective if started during pregnancy as opposed to after delivery. Although detoxification is possible under carefully monitored conditions, many women relapse after detoxifying, and neonatal abstinence syndrome (NAS)—a disorder in which an addicted newborn experiences drug withdrawal—is common. Therefore, the risks of detoxification often outweigh benefits.^5,17,18

Rehabilitation services for the mother can be provided at various levels of care, including outpatient, intensive outpatient, day hospital, residential, and inpatient. Although pregnancy-specific OUD treatment is ideal, it may not be available. Clinicians should attempt to locate services that can incorporate resources for pregnant women. Providing a means for child care during treatment is paramount to compliance. Develop a plan for nonconfrontational counseling, job skills training/education, and ongoing care after delivery (including child care and transportation resources) at the onset of treatment. The length of time maintained in treatment is one of the strongest predictors of abstinence.⁵

Increased education and screening for substance use as the pregnancy approaches term is necessary because patients may mistake early labor for symptoms of opioid withdrawal or worry that delivery room pain management will be inadequate and therefore relapse. Among pregnant women with addiction, preterm labor may be most common in those with OUD.¹²

Table 2

Medical complications common to pregnancy and substance abuse

Obstetric complications in women with addiction disorders

Opioid agonist therapy

Obstetric complications in women with OUD may be related to rapid, frequent fluctuations of opioid blood levels during intoxication and withdrawal. Therefore, the first goal of pharmacotherapy is to reduce physical stress associated with cycling opioid blood levels. Opioid agonist medications can be extremely effective. Opioid agonist treatment for pregnant patients is similar to that of nonpregnant patients but includes pregnancy-specific objectives ( Table 4 ).²⁰

Few anti-relapse medications have been studied in pregnant patients. Pharmacotherapies for OUD include methadone and buprenorphine. In our experience, opioid antagonists such as naltrexone typically would not be considered for pregnant patients because:

• their expected efficacy in reducing relapse in pregnant patients is lower than that of other medications
  
• their expected risk for inducing withdrawal is higher compared with methadone or buprenorphine
  
• research on the use of naltrexone during pregnancy is lacking.
  

Fluctuating blood opioid levels are minimized when methadone dosage is individually determined. Dosages should be based on a woman’s stage of pregnancy, relapse risk, pre-pregnancy methadone dose, experience with methadone, and clinical history. Some women experience lowered methadone blood levels during pregnancy because of increased fluid space, a larger tissue reservoir that can store methadone, and increased drug metabolism by both placenta and fetus. As a result, increased or split (twice daily) dosing may be indicated.^22-24

The few randomized clinical trials comparing methadone with buprenorphine during pregnancy suggest that buprenorphine is not inferior to methadone in safety and discomfort of induction from a short-acting opioid, nor in outcome measures assessing NAS and maternal and neonatal safety.^26,27 Results from the recent Maternal Opioid Treatment: Human Experimental Research project suggest that buprenorphine may have some advantages over methadone in pregnancy. Buprenorphine-maintained neonates may need less morphine, have shorter hospital stays, and require shorter treatment for NAS.²⁸ However, treatment retention may be lower for buprenorphine-maintained mothers; any resultant long-term consequences on maternal and child health are as yet unexplored. These findings require replication.

Methadone and buprenorphine are not interchangeable. Many patients maintained on methadone do not respond optimally to buprenorphine. Clinics that dispense maintenance methadone are required to provide counseling services and random drug testing; these requirements do not apply to physicians who prescribe buprenorphine. Moreover, in our experience buprenorphine at times has been prescribed without close regard to psychosocial issues, adequate random drug testing, or coordination of care with other providers.

In pregnant patients, buprenorphine is preferred over buprenorphine and naloxone to avoid fetal exposure to naloxone, which may cause intrauterine withdrawal and maternal-fetal hormonal changes. To reduce abuse or diversion, patients should undergo drug testing to ensure buprenorphine is present, smaller prescriptions may be provided, and tablets can be counted. Limited data suggests buprenorphine is not teratogenic. Some data show low placental transfer of buprenorphine, thereby limiting fetal exposure and lowering risk for intrauterine growth restriction.²⁹

Table 4

Opioid agonist treatment objectives for addicted patients who are pregnant

Delivery and postnatal care

Compared with those not in treatment, women who are engaged in a multidisciplinary treatment program at the time of delivery demonstrated higher gestational age, increased birth weights, and lower rates of neonatal ICU admissions. They also realized a cost savings of $4, 644 per mother-infant pair.³⁰

During delivery, pain medication should not be withheld solely because a pregnant woman has a history of addiction-related disorders; these women are subject to pain during delivery as much as other women. Avoid using mixed agonists/antagonists such as nalbuphine or butorphanol in women receiving opioid maintenance medication. Labor and delivery pain management for a pregnant patient maintained on opioid agonist therapies is discussed elsewhere in the literature.³¹ Every effort should be made to ensure that the mother remains in treatment through delivery and beyond.

To read about advising women with OUD on the benefits and risks of breastfeeding while receiving opioid agonist maintenance treatment, see the Box below.

CASE CONTINUED: Medication change

Ms. J’s boyfriend has left her and her parents have not readily accepted her pregnancy and need for support. She continues to attend NA meetings and weekly therapy. After educating her about the differences between buprenorphine and buprenorphine and naloxone in relation to risk, benefits, and side effects, you switch Ms. J to buprenorphine, 12 mg/d, while maintaining her on aripiprazole and citalopram. She consents to exchanging information about her medical, mental health, and addiction-related treatment with her primary care provider, who helps locate an obstetrician/gynecologist comfortable with her OUD and buprenorphine. Ms. J’s therapist helps link her with social services agencies to ensure prenatal care, assist with removing barriers to care, and plan for her needs as a parent.

After checking your state’s mandates, you determine you are not required to report Ms. J’s drug testing results. Ms. J’s ongoing drug testing shows the presence of buprenorphine and the absence of other opioids and all drugs of abuse.

Ms. J’s delivery is uncomplicated medically; however, family, financial, and parental role issues remain problematic. Encouraging her involvement in therapy and social services as part of her continued buprenorphine prescribing proves beneficial.

• Jones HE, Martin PR, Heil SH, et al. Treatment of opioid dependent pregnant women: clinical and research issues. J Subst Abuse Treat. 2008; 35(3): 245-259.
  
• Johnson RE, Jones HE, Fischer G. Use of buprenorphine in pregnancy: patient management and effects on the neonate. Drug Alcohol Depend. 2003; 70(suppl 1 ): S87-S101.
  
• Velez M, Jansson LM. The opioid dependent mother and the newborn dyad: nonpharmacologic care. J Addict Med. 2008; 2(3): 113-120.
  

• Aripiprazole • Abilify
  
• Buprenorphine and naloxone •Suboxone
  
• Buprenorphine • Subutex
  
• Butorphanol • Stadol
  
• Citalopram • Celexa
  
• Fentanyl • Duragesic, Sublimaze, others
  
• Methadone • Dolophine
  
• Naloxone • Narcan
  
• Naltrexone • ReVia
  
• Nalbuphine • Nubain
  
• Oxycodone • Oxycontin
  

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

Dr. Fernandez’ time toward this project was funded by the University Hospital/University of Cincinnati Addiction Psychiatry Fellowship Training Program operated by the Center for Treatment, Research, and Education in Addictive Disorders (CeTREAD), Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati and by the Veterans Affairs Medical Center, Cincinnati, OH.

The statements in this publication do not necessarily reflect the views or opinions of the Department of Veterans Affairs, the United States Government, or Opiate Addiction Recovery Services.

Acknowledgments

The authors wish to thank Kathleen Peak for her administrative assistance and Paul Horn, Professor, Department of Mathematical Sciences and Cincinnati VA, for statistical assistance.

Discuss this article at http://currentpsychiatry.blogspot.com/2011/03/opioid-use-disorder-during-pregnancy.html#comments

For 3 years, your mental health clinic has been treating Ms. J, age 23, for bipolar disorder. She is single, unemployed, lives alone, and receives Social Security disability assistance and financial support from her parents. She has been successfully maintained on aripiprazole, 15 mg/d, and citalopram, 20 mg/d, for 18 months. Six months ago she began to miss therapy sessions and physician visits.

Her parents inform Ms. J’s therapist that she is “snorting oxycontin” with her new boyfriend. At her next visit Ms. J confirms she has been struggling to manage an opioid use disorder for more than 1 year, and requests help.

After you educate her about the diagnosis, pathophysiology, and treatment of opioid addiction, she chooses to include pharmacotherapy as part of her treatment. After informed consent, Ms. J agrees to take buprenorphine and naloxone, meet with her therapist weekly, and attend twice-weekly Narcotics Anonymous (NA) meetings. Over the ensuing months she is gradually inducted onto buprenorphine and naloxone, 12 mg, shows improved insight and motivation, provides negative urine drug screens, and demonstrates increased ability to manage her recovery. Two weeks later Ms. J tells you she may be pregnant but wants to continue buprenorphine and naloxone.

Opioid use disorder (OUD) during pregnancy is among the most difficult clinical scenarios to manage. The prevalence of OUD during pregnancy is largely unknown. However, stigma against pregnant patients with OUD is substantial.¹ This article briefly summarizes identification, assessment, and treatment of OUD during pregnancy. To avoid confusion with the term “physical dependence, “ we will use “opioid use disorder” instead of “opioid dependence. “ The DSM-5 Substance Use Disorders Workgroup recommends combining abuse and dependence into a single disorder of graded clinical severity; however, this has not been finalized.²

Early identification is crucial

Early identification of OUD in pregnant women can be challenging. Self-reports underestimate use³ and shame, fear of prosecution or involvement of child welfare services, and guilt can further erode self-report. Women with OUD may have irregular menses and might not be aware of their pregnancy until several months after conception.⁴ Also, women with OUD who are maintained on opioid agonist therapies may misinterpret early signs of pregnancy—such as fatigue, nausea, vomiting, headaches, and cramps—as withdrawal symptoms and may respond by increasing their opioid dosing, thus exposing their fetus to increased drug levels. Finally, many women with OUD experience amenorrhea as a result of their stressful, unhealthy lifestyle, which may preclude pregnancy despite sexual activity. When these women later enroll in an opioid maintenance program, their endocrine function may return to normal, leading to unexpected pregnancy.⁵

Screening for OUD in pregnant patients has not been well studied. An interviewer’s nonjudgmental, empathic attitude may be more important than the specific questions he or she asks. It may be best to begin with less threatening questions and proceed to more specific questions after developing a therapeutic alliance.⁶

Chasnoff et al⁷ studied >2, 000 Medicaid-eligible pregnant patients from 9 prenatal clinics to identify risk factors for substance use during pregnancy. Alcohol or tobacco use in the month before pregnancy most differentiated current drug or alcohol use from nonuse while pregnant; however, a wide variation in use rates among patients in this study limits the generalizability of these findings. Consider OUD in women with:

• physical examination findings or history that suggests substance use or withdrawal symptoms
  
• positive drug test results for illicit or nonprescribed opioids
  
• aberrant medication-taking behaviors in those receiving prescribed opioids
  
• nicotine or alcohol use in the month before they knew they were pregnant
  
• a history of addiction-related disorders
  
• evidence of diseases associated with drug use, such as human immunodeficiency virus or hepatitis C
  
• poor prenatal care attendance
  
• unexplained fetal growth abnormalities.
  

A combination of interviewing and biologic drug screening may be more effective than either approach alone.¹¹ Drug screening should include opioids typically screened for (morphine, codeine, heroin metabolite) and those for which additional tests may be required (eg, semi-synthetics such as oxycodone and synthetics such as fentanyl). Learn your state’s civil mandates regarding drug-using pregnant women, guidelines for addiction treatment, and confidentiality provisions, especially as they relate to drug testing and mandatory reporting. Ideally, patients should be informed of these issues before they undergo drug testing or other procedures. These requirements may vary according to physician specialty or role in providing care.

Diagnosis of opioid dependence is based on DSM-IV-TR criteria; however, the proposed DSM-5 criteria for OUD may better emphasize cautions about including tolerance or withdrawal when diagnosing OUD in the setting of medically supervised and appropriate opioid use.²

Table 1

The ‘4P’s Plus’ screen for substance use during pregnancy

Office management

OUD-specific treatment decreases opioid use and improves birth outcomes¹⁴ ; however, retaining these patients in treatment can be difficult. Addressing social issues— including financial burdens, unstable living conditions, intimate partner violence, transportation difficulties, and limited access to medical and child care—can facilitate treatment.⁵ The Addiction Severity Index version tailored to women and pregnancy¹⁵ examines 7 domains of functioning (drugs, alcohol, psychological, social, medical, legal, and employment), informs treatment planning, quantifies treatment progress, and has predictive validity.¹⁶ Services are more likely to be effective if started during pregnancy as opposed to after delivery. Although detoxification is possible under carefully monitored conditions, many women relapse after detoxifying, and neonatal abstinence syndrome (NAS)—a disorder in which an addicted newborn experiences drug withdrawal—is common. Therefore, the risks of detoxification often outweigh benefits.^5,17,18

Rehabilitation services for the mother can be provided at various levels of care, including outpatient, intensive outpatient, day hospital, residential, and inpatient. Although pregnancy-specific OUD treatment is ideal, it may not be available. Clinicians should attempt to locate services that can incorporate resources for pregnant women. Providing a means for child care during treatment is paramount to compliance. Develop a plan for nonconfrontational counseling, job skills training/education, and ongoing care after delivery (including child care and transportation resources) at the onset of treatment. The length of time maintained in treatment is one of the strongest predictors of abstinence.⁵

Increased education and screening for substance use as the pregnancy approaches term is necessary because patients may mistake early labor for symptoms of opioid withdrawal or worry that delivery room pain management will be inadequate and therefore relapse. Among pregnant women with addiction, preterm labor may be most common in those with OUD.¹²

Table 2

Medical complications common to pregnancy and substance abuse

Obstetric complications in women with addiction disorders

Opioid agonist therapy

Obstetric complications in women with OUD may be related to rapid, frequent fluctuations of opioid blood levels during intoxication and withdrawal. Therefore, the first goal of pharmacotherapy is to reduce physical stress associated with cycling opioid blood levels. Opioid agonist medications can be extremely effective. Opioid agonist treatment for pregnant patients is similar to that of nonpregnant patients but includes pregnancy-specific objectives ( Table 4 ).²⁰

Few anti-relapse medications have been studied in pregnant patients. Pharmacotherapies for OUD include methadone and buprenorphine. In our experience, opioid antagonists such as naltrexone typically would not be considered for pregnant patients because:

• their expected efficacy in reducing relapse in pregnant patients is lower than that of other medications
  
• their expected risk for inducing withdrawal is higher compared with methadone or buprenorphine
  
• research on the use of naltrexone during pregnancy is lacking.
  

Fluctuating blood opioid levels are minimized when methadone dosage is individually determined. Dosages should be based on a woman’s stage of pregnancy, relapse risk, pre-pregnancy methadone dose, experience with methadone, and clinical history. Some women experience lowered methadone blood levels during pregnancy because of increased fluid space, a larger tissue reservoir that can store methadone, and increased drug metabolism by both placenta and fetus. As a result, increased or split (twice daily) dosing may be indicated.^22-24

The few randomized clinical trials comparing methadone with buprenorphine during pregnancy suggest that buprenorphine is not inferior to methadone in safety and discomfort of induction from a short-acting opioid, nor in outcome measures assessing NAS and maternal and neonatal safety.^26,27 Results from the recent Maternal Opioid Treatment: Human Experimental Research project suggest that buprenorphine may have some advantages over methadone in pregnancy. Buprenorphine-maintained neonates may need less morphine, have shorter hospital stays, and require shorter treatment for NAS.²⁸ However, treatment retention may be lower for buprenorphine-maintained mothers; any resultant long-term consequences on maternal and child health are as yet unexplored. These findings require replication.

Methadone and buprenorphine are not interchangeable. Many patients maintained on methadone do not respond optimally to buprenorphine. Clinics that dispense maintenance methadone are required to provide counseling services and random drug testing; these requirements do not apply to physicians who prescribe buprenorphine. Moreover, in our experience buprenorphine at times has been prescribed without close regard to psychosocial issues, adequate random drug testing, or coordination of care with other providers.

In pregnant patients, buprenorphine is preferred over buprenorphine and naloxone to avoid fetal exposure to naloxone, which may cause intrauterine withdrawal and maternal-fetal hormonal changes. To reduce abuse or diversion, patients should undergo drug testing to ensure buprenorphine is present, smaller prescriptions may be provided, and tablets can be counted. Limited data suggests buprenorphine is not teratogenic. Some data show low placental transfer of buprenorphine, thereby limiting fetal exposure and lowering risk for intrauterine growth restriction.²⁹

Table 4

Opioid agonist treatment objectives for addicted patients who are pregnant

Delivery and postnatal care

Compared with those not in treatment, women who are engaged in a multidisciplinary treatment program at the time of delivery demonstrated higher gestational age, increased birth weights, and lower rates of neonatal ICU admissions. They also realized a cost savings of $4, 644 per mother-infant pair.³⁰

During delivery, pain medication should not be withheld solely because a pregnant woman has a history of addiction-related disorders; these women are subject to pain during delivery as much as other women. Avoid using mixed agonists/antagonists such as nalbuphine or butorphanol in women receiving opioid maintenance medication. Labor and delivery pain management for a pregnant patient maintained on opioid agonist therapies is discussed elsewhere in the literature.³¹ Every effort should be made to ensure that the mother remains in treatment through delivery and beyond.

To read about advising women with OUD on the benefits and risks of breastfeeding while receiving opioid agonist maintenance treatment, see the Box below.

CASE CONTINUED: Medication change

Ms. J’s boyfriend has left her and her parents have not readily accepted her pregnancy and need for support. She continues to attend NA meetings and weekly therapy. After educating her about the differences between buprenorphine and buprenorphine and naloxone in relation to risk, benefits, and side effects, you switch Ms. J to buprenorphine, 12 mg/d, while maintaining her on aripiprazole and citalopram. She consents to exchanging information about her medical, mental health, and addiction-related treatment with her primary care provider, who helps locate an obstetrician/gynecologist comfortable with her OUD and buprenorphine. Ms. J’s therapist helps link her with social services agencies to ensure prenatal care, assist with removing barriers to care, and plan for her needs as a parent.

After checking your state’s mandates, you determine you are not required to report Ms. J’s drug testing results. Ms. J’s ongoing drug testing shows the presence of buprenorphine and the absence of other opioids and all drugs of abuse.

Ms. J’s delivery is uncomplicated medically; however, family, financial, and parental role issues remain problematic. Encouraging her involvement in therapy and social services as part of her continued buprenorphine prescribing proves beneficial.

• Jones HE, Martin PR, Heil SH, et al. Treatment of opioid dependent pregnant women: clinical and research issues. J Subst Abuse Treat. 2008; 35(3): 245-259.
  
• Johnson RE, Jones HE, Fischer G. Use of buprenorphine in pregnancy: patient management and effects on the neonate. Drug Alcohol Depend. 2003; 70(suppl 1 ): S87-S101.
  
• Velez M, Jansson LM. The opioid dependent mother and the newborn dyad: nonpharmacologic care. J Addict Med. 2008; 2(3): 113-120.
  

• Aripiprazole • Abilify
  
• Buprenorphine and naloxone •Suboxone
  
• Buprenorphine • Subutex
  
• Butorphanol • Stadol
  
• Citalopram • Celexa
  
• Fentanyl • Duragesic, Sublimaze, others
  
• Methadone • Dolophine
  
• Naloxone • Narcan
  
• Naltrexone • ReVia
  
• Nalbuphine • Nubain
  
• Oxycodone • Oxycontin
  

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

Dr. Fernandez’ time toward this project was funded by the University Hospital/University of Cincinnati Addiction Psychiatry Fellowship Training Program operated by the Center for Treatment, Research, and Education in Addictive Disorders (CeTREAD), Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati and by the Veterans Affairs Medical Center, Cincinnati, OH.

The statements in this publication do not necessarily reflect the views or opinions of the Department of Veterans Affairs, the United States Government, or Opiate Addiction Recovery Services.

Acknowledgments

The authors wish to thank Kathleen Peak for her administrative assistance and Paul Horn, Professor, Department of Mathematical Sciences and Cincinnati VA, for statistical assistance.

Discuss this article at http://currentpsychiatry.blogspot.com/2011/03/opioid-use-disorder-during-pregnancy.html#comments

For 3 years, your mental health clinic has been treating Ms. J, age 23, for bipolar disorder. She is single, unemployed, lives alone, and receives Social Security disability assistance and financial support from her parents. She has been successfully maintained on aripiprazole, 15 mg/d, and citalopram, 20 mg/d, for 18 months. Six months ago she began to miss therapy sessions and physician visits.

Her parents inform Ms. J’s therapist that she is “snorting oxycontin” with her new boyfriend. At her next visit Ms. J confirms she has been struggling to manage an opioid use disorder for more than 1 year, and requests help.

After you educate her about the diagnosis, pathophysiology, and treatment of opioid addiction, she chooses to include pharmacotherapy as part of her treatment. After informed consent, Ms. J agrees to take buprenorphine and naloxone, meet with her therapist weekly, and attend twice-weekly Narcotics Anonymous (NA) meetings. Over the ensuing months she is gradually inducted onto buprenorphine and naloxone, 12 mg, shows improved insight and motivation, provides negative urine drug screens, and demonstrates increased ability to manage her recovery. Two weeks later Ms. J tells you she may be pregnant but wants to continue buprenorphine and naloxone.

Opioid use disorder (OUD) during pregnancy is among the most difficult clinical scenarios to manage. The prevalence of OUD during pregnancy is largely unknown. However, stigma against pregnant patients with OUD is substantial.¹ This article briefly summarizes identification, assessment, and treatment of OUD during pregnancy. To avoid confusion with the term “physical dependence, “ we will use “opioid use disorder” instead of “opioid dependence. “ The DSM-5 Substance Use Disorders Workgroup recommends combining abuse and dependence into a single disorder of graded clinical severity; however, this has not been finalized.²

Early identification is crucial

Early identification of OUD in pregnant women can be challenging. Self-reports underestimate use³ and shame, fear of prosecution or involvement of child welfare services, and guilt can further erode self-report. Women with OUD may have irregular menses and might not be aware of their pregnancy until several months after conception.⁴ Also, women with OUD who are maintained on opioid agonist therapies may misinterpret early signs of pregnancy—such as fatigue, nausea, vomiting, headaches, and cramps—as withdrawal symptoms and may respond by increasing their opioid dosing, thus exposing their fetus to increased drug levels. Finally, many women with OUD experience amenorrhea as a result of their stressful, unhealthy lifestyle, which may preclude pregnancy despite sexual activity. When these women later enroll in an opioid maintenance program, their endocrine function may return to normal, leading to unexpected pregnancy.⁵

Screening for OUD in pregnant patients has not been well studied. An interviewer’s nonjudgmental, empathic attitude may be more important than the specific questions he or she asks. It may be best to begin with less threatening questions and proceed to more specific questions after developing a therapeutic alliance.⁶

Chasnoff et al⁷ studied >2, 000 Medicaid-eligible pregnant patients from 9 prenatal clinics to identify risk factors for substance use during pregnancy. Alcohol or tobacco use in the month before pregnancy most differentiated current drug or alcohol use from nonuse while pregnant; however, a wide variation in use rates among patients in this study limits the generalizability of these findings. Consider OUD in women with:

• physical examination findings or history that suggests substance use or withdrawal symptoms
  
• positive drug test results for illicit or nonprescribed opioids
  
• aberrant medication-taking behaviors in those receiving prescribed opioids
  
• nicotine or alcohol use in the month before they knew they were pregnant
  
• a history of addiction-related disorders
  
• evidence of diseases associated with drug use, such as human immunodeficiency virus or hepatitis C
  
• poor prenatal care attendance
  
• unexplained fetal growth abnormalities.
  

A combination of interviewing and biologic drug screening may be more effective than either approach alone.¹¹ Drug screening should include opioids typically screened for (morphine, codeine, heroin metabolite) and those for which additional tests may be required (eg, semi-synthetics such as oxycodone and synthetics such as fentanyl). Learn your state’s civil mandates regarding drug-using pregnant women, guidelines for addiction treatment, and confidentiality provisions, especially as they relate to drug testing and mandatory reporting. Ideally, patients should be informed of these issues before they undergo drug testing or other procedures. These requirements may vary according to physician specialty or role in providing care.

Diagnosis of opioid dependence is based on DSM-IV-TR criteria; however, the proposed DSM-5 criteria for OUD may better emphasize cautions about including tolerance or withdrawal when diagnosing OUD in the setting of medically supervised and appropriate opioid use.²

Table 1

The ‘4P’s Plus’ screen for substance use during pregnancy

Office management

OUD-specific treatment decreases opioid use and improves birth outcomes¹⁴ ; however, retaining these patients in treatment can be difficult. Addressing social issues— including financial burdens, unstable living conditions, intimate partner violence, transportation difficulties, and limited access to medical and child care—can facilitate treatment.⁵ The Addiction Severity Index version tailored to women and pregnancy¹⁵ examines 7 domains of functioning (drugs, alcohol, psychological, social, medical, legal, and employment), informs treatment planning, quantifies treatment progress, and has predictive validity.¹⁶ Services are more likely to be effective if started during pregnancy as opposed to after delivery. Although detoxification is possible under carefully monitored conditions, many women relapse after detoxifying, and neonatal abstinence syndrome (NAS)—a disorder in which an addicted newborn experiences drug withdrawal—is common. Therefore, the risks of detoxification often outweigh benefits.^5,17,18

Rehabilitation services for the mother can be provided at various levels of care, including outpatient, intensive outpatient, day hospital, residential, and inpatient. Although pregnancy-specific OUD treatment is ideal, it may not be available. Clinicians should attempt to locate services that can incorporate resources for pregnant women. Providing a means for child care during treatment is paramount to compliance. Develop a plan for nonconfrontational counseling, job skills training/education, and ongoing care after delivery (including child care and transportation resources) at the onset of treatment. The length of time maintained in treatment is one of the strongest predictors of abstinence.⁵

Increased education and screening for substance use as the pregnancy approaches term is necessary because patients may mistake early labor for symptoms of opioid withdrawal or worry that delivery room pain management will be inadequate and therefore relapse. Among pregnant women with addiction, preterm labor may be most common in those with OUD.¹²

Table 2

Medical complications common to pregnancy and substance abuse

Obstetric complications in women with addiction disorders

Opioid agonist therapy

Obstetric complications in women with OUD may be related to rapid, frequent fluctuations of opioid blood levels during intoxication and withdrawal. Therefore, the first goal of pharmacotherapy is to reduce physical stress associated with cycling opioid blood levels. Opioid agonist medications can be extremely effective. Opioid agonist treatment for pregnant patients is similar to that of nonpregnant patients but includes pregnancy-specific objectives ( Table 4 ).²⁰

Few anti-relapse medications have been studied in pregnant patients. Pharmacotherapies for OUD include methadone and buprenorphine. In our experience, opioid antagonists such as naltrexone typically would not be considered for pregnant patients because:

• their expected efficacy in reducing relapse in pregnant patients is lower than that of other medications
  
• their expected risk for inducing withdrawal is higher compared with methadone or buprenorphine
  
• research on the use of naltrexone during pregnancy is lacking.
  

Fluctuating blood opioid levels are minimized when methadone dosage is individually determined. Dosages should be based on a woman’s stage of pregnancy, relapse risk, pre-pregnancy methadone dose, experience with methadone, and clinical history. Some women experience lowered methadone blood levels during pregnancy because of increased fluid space, a larger tissue reservoir that can store methadone, and increased drug metabolism by both placenta and fetus. As a result, increased or split (twice daily) dosing may be indicated.^22-24

The few randomized clinical trials comparing methadone with buprenorphine during pregnancy suggest that buprenorphine is not inferior to methadone in safety and discomfort of induction from a short-acting opioid, nor in outcome measures assessing NAS and maternal and neonatal safety.^26,27 Results from the recent Maternal Opioid Treatment: Human Experimental Research project suggest that buprenorphine may have some advantages over methadone in pregnancy. Buprenorphine-maintained neonates may need less morphine, have shorter hospital stays, and require shorter treatment for NAS.²⁸ However, treatment retention may be lower for buprenorphine-maintained mothers; any resultant long-term consequences on maternal and child health are as yet unexplored. These findings require replication.

Methadone and buprenorphine are not interchangeable. Many patients maintained on methadone do not respond optimally to buprenorphine. Clinics that dispense maintenance methadone are required to provide counseling services and random drug testing; these requirements do not apply to physicians who prescribe buprenorphine. Moreover, in our experience buprenorphine at times has been prescribed without close regard to psychosocial issues, adequate random drug testing, or coordination of care with other providers.

In pregnant patients, buprenorphine is preferred over buprenorphine and naloxone to avoid fetal exposure to naloxone, which may cause intrauterine withdrawal and maternal-fetal hormonal changes. To reduce abuse or diversion, patients should undergo drug testing to ensure buprenorphine is present, smaller prescriptions may be provided, and tablets can be counted. Limited data suggests buprenorphine is not teratogenic. Some data show low placental transfer of buprenorphine, thereby limiting fetal exposure and lowering risk for intrauterine growth restriction.²⁹

Table 4

Opioid agonist treatment objectives for addicted patients who are pregnant

Delivery and postnatal care

Compared with those not in treatment, women who are engaged in a multidisciplinary treatment program at the time of delivery demonstrated higher gestational age, increased birth weights, and lower rates of neonatal ICU admissions. They also realized a cost savings of $4, 644 per mother-infant pair.³⁰

During delivery, pain medication should not be withheld solely because a pregnant woman has a history of addiction-related disorders; these women are subject to pain during delivery as much as other women. Avoid using mixed agonists/antagonists such as nalbuphine or butorphanol in women receiving opioid maintenance medication. Labor and delivery pain management for a pregnant patient maintained on opioid agonist therapies is discussed elsewhere in the literature.³¹ Every effort should be made to ensure that the mother remains in treatment through delivery and beyond.

To read about advising women with OUD on the benefits and risks of breastfeeding while receiving opioid agonist maintenance treatment, see the Box below.

CASE CONTINUED: Medication change

Ms. J’s boyfriend has left her and her parents have not readily accepted her pregnancy and need for support. She continues to attend NA meetings and weekly therapy. After educating her about the differences between buprenorphine and buprenorphine and naloxone in relation to risk, benefits, and side effects, you switch Ms. J to buprenorphine, 12 mg/d, while maintaining her on aripiprazole and citalopram. She consents to exchanging information about her medical, mental health, and addiction-related treatment with her primary care provider, who helps locate an obstetrician/gynecologist comfortable with her OUD and buprenorphine. Ms. J’s therapist helps link her with social services agencies to ensure prenatal care, assist with removing barriers to care, and plan for her needs as a parent.

After checking your state’s mandates, you determine you are not required to report Ms. J’s drug testing results. Ms. J’s ongoing drug testing shows the presence of buprenorphine and the absence of other opioids and all drugs of abuse.

Ms. J’s delivery is uncomplicated medically; however, family, financial, and parental role issues remain problematic. Encouraging her involvement in therapy and social services as part of her continued buprenorphine prescribing proves beneficial.

• Jones HE, Martin PR, Heil SH, et al. Treatment of opioid dependent pregnant women: clinical and research issues. J Subst Abuse Treat. 2008; 35(3): 245-259.
  
• Johnson RE, Jones HE, Fischer G. Use of buprenorphine in pregnancy: patient management and effects on the neonate. Drug Alcohol Depend. 2003; 70(suppl 1 ): S87-S101.
  
• Velez M, Jansson LM. The opioid dependent mother and the newborn dyad: nonpharmacologic care. J Addict Med. 2008; 2(3): 113-120.
  

• Aripiprazole • Abilify
  
• Buprenorphine and naloxone •Suboxone
  
• Buprenorphine • Subutex
  
• Butorphanol • Stadol
  
• Citalopram • Celexa
  
• Fentanyl • Duragesic, Sublimaze, others
  
• Methadone • Dolophine
  
• Naloxone • Narcan
  
• Naltrexone • ReVia
  
• Nalbuphine • Nubain
  
• Oxycodone • Oxycontin
  

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

Dr. Fernandez’ time toward this project was funded by the University Hospital/University of Cincinnati Addiction Psychiatry Fellowship Training Program operated by the Center for Treatment, Research, and Education in Addictive Disorders (CeTREAD), Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati and by the Veterans Affairs Medical Center, Cincinnati, OH.

The statements in this publication do not necessarily reflect the views or opinions of the Department of Veterans Affairs, the United States Government, or Opiate Addiction Recovery Services.

Acknowledgments

The authors wish to thank Kathleen Peak for her administrative assistance and Paul Horn, Professor, Department of Mathematical Sciences and Cincinnati VA, for statistical assistance.

M, age 13, is referred by her pediatrician with the chief complaint of “severe mood swings, rule out bipolar disorder (BD).” In the past she was treated for attention-deficit/hyperactivity disorder (ADHD) with stimulants with mixed results. M’s parents are concerned about her “flipping out” whenever she is asked to do something she does not want to do. Her mother has a history of depression and anxiety; her father had a “drinking problem.” There is no history of BD in her first- or second-degree relatives. Are M’s rapid mood swings a sign of BD or another disorder?

The differential diagnosis of “mood swings” is important because they are a common presenting symptom of many children and adolescents with mood and behavioral disorders. Mood swings often occur in children and adolescents with ADHD, oppositional defiant disorder (ODD), developmental disorders, depressive disorders, BD, anxiety disorders, and conduct disorders. Mood swings are analogous to a fever in pediatrics—they indicate something potentially is wrong with the patient, but are not diagnostic as an isolated symptom.

Mood swings in children are common, nonspecific symptoms that more often are a sign of anxiety or behavioral disorders than BD. This article discusses the differential diagnosis of mood swings in children and adolescents and how to best screen and diagnose these patients.

What are ‘mood swings’?

Mood swings is a popular term that is nonspecific and not part of DSM-IV-TR diagnostic criteria for BD. The complaint of “mood swings” may reflect severe mood lability of pediatric patients with BD. This mood lability is best described by the Kiddie-Mania Rating Scale (K-MRS) developed by Axelson and colleagues as “rapid mood variation with several mood states within a brief period of time which appears internally driven without regard to the circumstance.”¹ On K-MRS mood lability items, children with mania typically score:

• Moderate—many mood changes throughout the day, can vary from elevated mood to anger to sadness within a few hours; changes in mood are clearly out of proportion to circumstances and cause impairment in functioning
• Severe—rapid mood swings nearly all of the time, with mood intensity greatly out of proportion to circumstances
• Extreme—constant, explosive variability in mood, several mood changes occurring within minutes, difficult to identify a particular mood, changes in mood radically out of proportion to circumstances.

Patients with BD typically exhibit what is best described as a “mood cycle”—a pronounced shift in mood and energy from 1 extreme to another.² An example of this would be a child who wakes up with extreme silliness, high energy, and intrusive behavior that persists for several hours and then later in the day becomes sad, depressed, and suicidal with no precipitant for either mood cycle. BD patients also will exhibit other symptoms of mania during these mood cycling periods.

Rapid cycling is a DSM-IV course specifier that indicates ≥4 mood episodes per year in patients with BD with a typical course of mania or hypomania followed by depression, or vice versa.³ The episodes must be demarcated by full or partial remission that lasts ≥2 months or by a switch to a mood state of opposite polarity. In the past, children with frequent mood swings were described incorrectly as “rapid cycling,” but this term has been dropped because it engenders confusion between adult and pediatric BD phenomenology.²

A more precise method of describing mood symptoms in a child or adolescent is to use the FIND criteria, which include:⁴

• Frequency of symptoms per week
• Intensity of mood symptoms
• Number of mood cycles per day
• Duration of symptoms per day.

Visit this article at CurrentPsychiatry.com to view a table that outlines what to look for when using the FIND criteria to evaluate common pediatric psychiatric disorders that include mood swings. Table 1
describes clinical characteristics and tools and resources used to differentiate these and other disorders.⁴

Table 1

Clinical characteristics of psychiatric disorders that often feature mood swings

Mood swings: A chart review

We recently completed a retrospective chart review of 100 patients consecutively referred to our pediatric mood disorders clinic for evaluation of “mood swings, rule out BD.” These patients were self-referred, referred by a psychiatrist for a second opinion, or referred by their primary care physician. The mean age of these patients was 8±2.8 years and 68% were male.

Two experienced clinicians (RAK and EM) interviewed each patient and their caregivers and reviewed results of the Conners’ Parent Rating Scale-Revised: Long Form (CPRS-R:L)⁵ and other outside information.
Figure 1 illustrates these patients’ diagnoses. Diagnoses for each of these disorders were made using DSM-IV-TR criteria.³

The most common diagnoses among patients with the chief complaint of mood swings were ADHD (39%); ODD with ADHD (15%); an anxiety disorder, usually generalized anxiety disorder (GAD) (15%); BD (12%); and a secondary mood disorder, usually fetal alcohol spectrum disorder (10%). We were surprised at how often ADHD, ODD, and anxiety disorders were found to be responsible for these patients’ mood swings and how frequently the referring clinician did not recognize these disorders. In the following sections, we discuss each of these disorders and how they differ from BD.

Figure 1 Underlying diagnoses of 100 children/adolescents referred for ‘mood swings’

ADHD: attention-deficit/hyperactivity disorder; BD: bipolar disorder; MDD: major depressive disorder; ODD: oppositional defiant disorder; PDD: pervasive developmental disorder

ADHD and ODD

In our sample, patients with undiagnosed ADHD made up the largest group of those with frequent mood swings. ADHD inattentive type was missed frequently in adolescent girls who still had behavioral aspects of ADHD, including impulsivity and aggression.⁶

The CPRS-R:L is useful for screening and diagnosing children and adolescents with ADHD and ODD. It contains 80 items, can be used in males and females and patients age 3 to 17, and has validated norms by age and sex.⁵ It takes parents approximately 10 minutes to fill out this questionnaire and the results can be scored by hand. The CPRS-R:L includes the following scales: oppositional; cognitive problems/inattention; hyperactivity; anxious-shy; perfectionism; social problems; psychosomatic; Connors’ global index; DSM-IV symptom subscales; and an ADHD index. Patients with mood swings and ADHD combined typically score >2 standard deviations above their age/sex mean on the CPRS-R:L hyperactivity scale, Connors’ Global Index, and ADHD index.⁵

A common childhood disorder, ODD has multiple etiologies.⁷ The first DSM-IV criteria for ODD is “often loses temper”³—essentially mood swings that often are expressed behaviorally as anger and at times as aggressive outbursts.

Dodge and Cole⁸ categorized aggression as reactive (impulsivity with a high affective valence) or proactive (characterized by low arousal and premeditation, ie, predatory conduct disorder). Reactive aggression typically is an angry defensive response to frustration, threat, or provocation, whereas proactive aggression is deliberate, coercive behavior often used to obtain a goal.⁹ Reactive aggression is common among children with ADHD and ODD and typically begins as a mood swing that escalates into reactive aggressive behavior. In a study of 268 consecutively referred children and adolescents with ADHD and 100 community controls, Connor et al¹⁰ found significantly more reactive than proactive forms of aggression in ADHD patients.

It can be difficult to differentiate the moods swings and symptoms of ODD from those of pediatric BD. Mick et al¹¹ found that severe irritability may be a diagnostic indicator of BD in children with ADHD. Using the Kiddie Schedule for Affective Disorders and Schizophrenia (epidemiologic version) structured diagnostic interview,¹² they evaluated 274 children (mean age 10.8±3.2) with ADHD; 37% had no comorbid mood disorder, 36% had ADHD with depression, and 11% had ADHD with BD. Researchers characterized 3 types of irritability in these patients:

• ODD-type irritability characterized by a low frustration tolerance that is seen in ODD
• Mad/cranky irritability found in depressive disorders
• Super-angry/grouchy/cranky irritability with frequent, prolonged, and largely unprovoked anger episodes and characteristics of mania.

ODD-type irritability was common among all ADHD patients, was the least impairing type of irritability, and did not increase the risk of a mood disorder. Mad/cranky irritability was common only in children with ADHD and a mood disorder (depression or BD), was more impairing than ODD-type irritability, and was most predictive of unipolar depression. Super-angry/grouchy/cranky irritability was common only among children with ADHD and BD (77%), was the most impairing, and was predictive of both unipolar depression and BD. The type of irritability and clustering of DSM-IV manic symptoms best differentiated ADHD subjects from those with ADHD and BD. Figure 2 illustrates symptoms that differentiated patients with ADHD from those with ADHD and comorbid BD.¹¹

A review of pharmacotherapy for aggression in children found the largest effects for methylphenidate for aggression in ADHD (mean effect size=0.9, combined N=844).¹³ Our clinical experience has been that pediatric patients with ADHD or ODD with ADHD often have high levels of reactive aggression that presents as mood swings, and aggressively treating ADHD often results in improved mood and other ADHD symptoms.

Figure 2 Symptoms that differentiate BD from BD with comorbid ADHD

ADHD: attention-deficit/hyperactivity disorder; BD: bipolar disorder
Source: Reference 11

Anxiety disorders

The estimated prevalence of child and adolescent anxiety disorders is 10% to 20%¹⁴; in our sample the prevalence was 15%. These disorders include GAD, separation anxiety disorder, social phobias, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder. Often, children with GAD worry excessively and become upset during transitions when things don’t proceed as they expect, with resultant angry outbursts and mood swings. Mood swings and difficulty sleeping are common in children with anxiety disorders or BD. Anxiety disorders often will be missed unless specific triggers of the mood swings or angry outbursts—as well as differentiating symptoms such as excessive fear, worry, and psychosomatic symptoms—are assessed.

In our clinical experience, simply asking a child if he or she is anxious is not sufficient to uncover an anxiety disorder. Although the CPRS-L:R will screen for anxiety disorders, we have found that the Self-Report for Childhood Anxiety Related Disorders (SCARED) developed by Birmaher et al¹⁵ is more specific. This tool can be used in patients age ≥8. The parent and child versions of the SCARED contain 41 items that measure 5 factors:

• general anxiety
• separation anxiety
• social phobia
• school phobia
• physical symptoms of anxiety.

The SCARED takes 5 minutes to fill out and is available in parent and child versions.

Secondary mood disorders

Many patients in our sample had a mood disorder secondary to the neurologic effects of alcohol on the developing brain. For more about maternal alcohol use, fetal alcohol spectrum disorders, and mood swings, visit this article at CurrentPsychiatry.com.

What BD looks like in children

In our sample, 12% of patients referred for mood swings were diagnosed with bipolar I disorder (BDI), bipolar II disorder (BDII), or bipolar disorder, not otherwise specified (BD-NOS). In the United States, lifetime prevalence of BDI and BDII in adolescents age 13 to 17 is 2.9%.¹⁶ No large epidemiologic studies have looked at the lifetime prevalence of BD in children age <13.

How often a clinician sees BD in children and adolescents largely depends on the type of setting in which he or she practices. Although in the general population BD is relatively rare compared with other childhood psychiatric disorders, on child/adolescent inpatient units it is common to find that 30% to 40% of patients have BD.¹⁷

The best longitudinal study to date of the phenomenology, comorbidity, and outcome of BD in children and adolescents is the National Institute of Mental Health-funded Course and Outcome of Bipolar Youth study (COBY).¹⁸ In this ongoing, longitudinal study, 413 youths (age 7 to 17) with BDI (N=244), BDII (N=28), or BD-NOS (N=141) were rigorously diagnosed using state-of-the-art measures, including the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present version¹⁹ and re-evaluated every 9.4 months for 4 years. When organizing this study, investigators found that DSM-IV criteria for BD-NOS were too vague to be useful and developed their own criteria (Table 2).¹⁸

For BDI patients in the COBY study, the mean age of onset for bipolar symptoms was 9.0±4.1 years and the mean duration of illness was 4.4±3.1 years. Researchers reported that at the 4-year assessment approximately 70% of patients with BD recovered from their index episode, and 50% had at least 1 syndromal recurrence, particularly depressive episodes.²⁰ Analyses of these patients’ weekly mood symptoms showed that they had syndromal or subsyndromal symptoms with numerous changes in symptoms and shifts of mood polarity 60% of the time, and psychosis 3% of the time. During this study, 20% of BDII patients progressed to BDI, and 25% of BD-NOS patients converted to BDI or BDII.

Further analysis of the COBY data revealed that onset of mood symptoms preceded onset of clear bipolar episodes by an average of 1.0±1.7 years. Depression was the most common initial and most frequent episode for adolescents; mood lability was seen more often in childhood-onset and adolescents with early-onset BD. Depressed children had more severe irritability than depressed adolescents, and older age was associated with more severe and typical mood symptomatology.²¹

The clinical picture of a child with BD that emerges from the COBY study is:

• a fairly young child with the onset of mood symptoms between age 5 to 12
• subsyndromal and less frequently clear syndromal episodes
• primarily mixed and depressed symptoms with rapid mood cycles during these episodes.²²

It is clear that there is a spectrum of bipolar disorders in children and adolescents with varying degrees of symptom expression and children differ from adolescents and adults in their initial presentation of BD.

Table 2

COBY criteria for bipolar disorder, not otherwise specified

Related Resources

• Kowatch RA, Fristad MA, Findling RL, et al. Clinical manual for management of bipolar disorder in children and adolescents. Arlington, VA: American Psychiatric Publishing, Inc.; 2009.
• Goodwin FK, Jamison KR. Manic-depressive illness. 2nd ed. Oxford, United Kingdom: Oxford University Press; 2007.
• Miklowitz DJ, Cicchetti D, eds. Understanding bipolar disorder: a developmental perspective. New York, NY: Guilford Press; 2010.

Drug Brand Name

• Methylphenidate • Ritalin, Concerta, others

Disclosures

Dr. Kowatch receives grant/research support from the National Institute of Child Health and Human Development and the National Institute of Mental Health and is a consultant to AstraZeneca, Forest Pharmaceuticals, Merck, and the REACH Foundation.

Dr. Delgado and Ms. Monroe report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Table

FIND criteria of disorders found to cause mood swings

Box