Pearls

Difficulty with time management and organization is one of the most common complaints of patients with attention-deficit/hyperactivity disorder (ADHD). Being unproductive and inefficient also is anxiety-producing and depressing, leaving patients with additional comorbidity.

Although medication can help improve a person’s focus, if the patient is focusing on a set of poorly designed systems, he (she) will see little improvement. A comprehensive approach to improving day-to-day task management, similar to the one I describe here and use with my patients, is therefore as important as medication.

Needed: An ‘organizing principle’

Imagine that supermarkets displayed food in the order it arrives from the food distributors and producers. You’d walk in to the store and see a display of food that lacks hierarchy—1 random item placed next to another. The experience would be jarring, and shopping would be a much slower chore. Furthermore, what if you had to go to 5 stores to cover all your needs?

Yet, that is how most “to-do” lists are executed: A thought comes in, a thought goes down on paper. Or on a sticky note. Or in an app. Or in a calendar. Or all of the above! Often, there is neither an organizing principle (other than perhaps chronological order) or a central repository. No wonder it’s hard to feel present and clear-minded. Add to this disorganization the volume of information coming in from the environment—e-mails, voice mails, texts, notifications, dings, beeps, buzzes, and maybe even snail mail—and the feeling of being overwhelmed grows.

Unconscious motives for maintaining poor systems also might play a role. People with a “need to please” personality type or who are more passive-aggressive in their communication are more likely to overcommit, and then forget or be late completing their tasks, rather than saying “No” from the outset or delegating the work. 

Survival basics for time management

Assuming there is simply a skills deficit, you can teach basic time and project management skills to patients with ADHD (and to any patient with suboptimal executive functioning). Here are basic principles to adopt:

• If you can forget it, you will, so all tasks should go onto the to-do list.
• You should keep only 1 list. Adding on “stickies” is not allowed.
• Your list is like an extra lobe of your brain: It should be present at all times, whether you keep it in “the Cloud,” on your desktop, or on paper.
• Review your list and clean it up at least daily. This takes time, but it also saves time—in spades—when you can call upon the right task, at the right time, with energy and drive.
• The first action you should take in the daily review is to weed out or delegate tasks.
• Next, categorize remaining tasks. (Note: The free smartphone app Evernote allows you to do this with “tags.”) Categorizing allows you to process sets of tasks in buckets that can be tackled as a bundle and, therefore, more efficiently. For example, having all of your errands, items to research, and telephone calls that need to be returned in separate buckets allows for speedier processing—as opposed to veering back and forth between line items.
• Then, move remaining high-priority items to the top of the list. However, remember that, if everything is urgent, nothing is. Items that are low-hanging fruit that you can cross off the list in a matter of minutes can be prioritized even if they are not as urgent. By doing that, your list becomes more manageable and your brain can dive deeper into more complex tasks.
• Block out calendar time for each of your buckets with this formula: (1) Estimate how much time you’ll need to complete the tasks in each bucket, then add 50% for each bucket. (2) Add in commuting, set-up, or wind-down time, if you need it, to the grand total for all buckets, and then add 50% more than you’ve estimated

Set the brain free!

This process will seem like a burden at the beginning, when the synapses underneath it still need to get stronger (much like how the body responds to exercise). However, as long as these principles are put into action daily, they will become a trusted, second-nature system that frees the brain from distraction and anxiety—and, ultimately, for being more creative and mindful.

Difficulty with time management and organization is one of the most common complaints of patients with attention-deficit/hyperactivity disorder (ADHD). Being unproductive and inefficient also is anxiety-producing and depressing, leaving patients with additional comorbidity.

Although medication can help improve a person’s focus, if the patient is focusing on a set of poorly designed systems, he (she) will see little improvement. A comprehensive approach to improving day-to-day task management, similar to the one I describe here and use with my patients, is therefore as important as medication.

Needed: An ‘organizing principle’

Imagine that supermarkets displayed food in the order it arrives from the food distributors and producers. You’d walk in to the store and see a display of food that lacks hierarchy—1 random item placed next to another. The experience would be jarring, and shopping would be a much slower chore. Furthermore, what if you had to go to 5 stores to cover all your needs?

Yet, that is how most “to-do” lists are executed: A thought comes in, a thought goes down on paper. Or on a sticky note. Or in an app. Or in a calendar. Or all of the above! Often, there is neither an organizing principle (other than perhaps chronological order) or a central repository. No wonder it’s hard to feel present and clear-minded. Add to this disorganization the volume of information coming in from the environment—e-mails, voice mails, texts, notifications, dings, beeps, buzzes, and maybe even snail mail—and the feeling of being overwhelmed grows.

Unconscious motives for maintaining poor systems also might play a role. People with a “need to please” personality type or who are more passive-aggressive in their communication are more likely to overcommit, and then forget or be late completing their tasks, rather than saying “No” from the outset or delegating the work. 

Survival basics for time management

Assuming there is simply a skills deficit, you can teach basic time and project management skills to patients with ADHD (and to any patient with suboptimal executive functioning). Here are basic principles to adopt:

• If you can forget it, you will, so all tasks should go onto the to-do list.
• You should keep only 1 list. Adding on “stickies” is not allowed.
• Your list is like an extra lobe of your brain: It should be present at all times, whether you keep it in “the Cloud,” on your desktop, or on paper.
• Review your list and clean it up at least daily. This takes time, but it also saves time—in spades—when you can call upon the right task, at the right time, with energy and drive.
• The first action you should take in the daily review is to weed out or delegate tasks.
• Next, categorize remaining tasks. (Note: The free smartphone app Evernote allows you to do this with “tags.”) Categorizing allows you to process sets of tasks in buckets that can be tackled as a bundle and, therefore, more efficiently. For example, having all of your errands, items to research, and telephone calls that need to be returned in separate buckets allows for speedier processing—as opposed to veering back and forth between line items.
• Then, move remaining high-priority items to the top of the list. However, remember that, if everything is urgent, nothing is. Items that are low-hanging fruit that you can cross off the list in a matter of minutes can be prioritized even if they are not as urgent. By doing that, your list becomes more manageable and your brain can dive deeper into more complex tasks.
• Block out calendar time for each of your buckets with this formula: (1) Estimate how much time you’ll need to complete the tasks in each bucket, then add 50% for each bucket. (2) Add in commuting, set-up, or wind-down time, if you need it, to the grand total for all buckets, and then add 50% more than you’ve estimated

Set the brain free!

This process will seem like a burden at the beginning, when the synapses underneath it still need to get stronger (much like how the body responds to exercise). However, as long as these principles are put into action daily, they will become a trusted, second-nature system that frees the brain from distraction and anxiety—and, ultimately, for being more creative and mindful.

Difficulty with time management and organization is one of the most common complaints of patients with attention-deficit/hyperactivity disorder (ADHD). Being unproductive and inefficient also is anxiety-producing and depressing, leaving patients with additional comorbidity.

Although medication can help improve a person’s focus, if the patient is focusing on a set of poorly designed systems, he (she) will see little improvement. A comprehensive approach to improving day-to-day task management, similar to the one I describe here and use with my patients, is therefore as important as medication.

Needed: An ‘organizing principle’

Imagine that supermarkets displayed food in the order it arrives from the food distributors and producers. You’d walk in to the store and see a display of food that lacks hierarchy—1 random item placed next to another. The experience would be jarring, and shopping would be a much slower chore. Furthermore, what if you had to go to 5 stores to cover all your needs?

Yet, that is how most “to-do” lists are executed: A thought comes in, a thought goes down on paper. Or on a sticky note. Or in an app. Or in a calendar. Or all of the above! Often, there is neither an organizing principle (other than perhaps chronological order) or a central repository. No wonder it’s hard to feel present and clear-minded. Add to this disorganization the volume of information coming in from the environment—e-mails, voice mails, texts, notifications, dings, beeps, buzzes, and maybe even snail mail—and the feeling of being overwhelmed grows.

Unconscious motives for maintaining poor systems also might play a role. People with a “need to please” personality type or who are more passive-aggressive in their communication are more likely to overcommit, and then forget or be late completing their tasks, rather than saying “No” from the outset or delegating the work. 

Survival basics for time management

Assuming there is simply a skills deficit, you can teach basic time and project management skills to patients with ADHD (and to any patient with suboptimal executive functioning). Here are basic principles to adopt:

• If you can forget it, you will, so all tasks should go onto the to-do list.
• You should keep only 1 list. Adding on “stickies” is not allowed.
• Your list is like an extra lobe of your brain: It should be present at all times, whether you keep it in “the Cloud,” on your desktop, or on paper.
• Review your list and clean it up at least daily. This takes time, but it also saves time—in spades—when you can call upon the right task, at the right time, with energy and drive.
• The first action you should take in the daily review is to weed out or delegate tasks.
• Next, categorize remaining tasks. (Note: The free smartphone app Evernote allows you to do this with “tags.”) Categorizing allows you to process sets of tasks in buckets that can be tackled as a bundle and, therefore, more efficiently. For example, having all of your errands, items to research, and telephone calls that need to be returned in separate buckets allows for speedier processing—as opposed to veering back and forth between line items.
• Then, move remaining high-priority items to the top of the list. However, remember that, if everything is urgent, nothing is. Items that are low-hanging fruit that you can cross off the list in a matter of minutes can be prioritized even if they are not as urgent. By doing that, your list becomes more manageable and your brain can dive deeper into more complex tasks.
• Block out calendar time for each of your buckets with this formula: (1) Estimate how much time you’ll need to complete the tasks in each bucket, then add 50% for each bucket. (2) Add in commuting, set-up, or wind-down time, if you need it, to the grand total for all buckets, and then add 50% more than you’ve estimated

Set the brain free!

This process will seem like a burden at the beginning, when the synapses underneath it still need to get stronger (much like how the body responds to exercise). However, as long as these principles are put into action daily, they will become a trusted, second-nature system that frees the brain from distraction and anxiety—and, ultimately, for being more creative and mindful.

Pharmacogenomics—the study of how genetic variability influences drug response—is increasingly being used to personalize pharmacotherapy. Used in the context of other clinical variables, genetic-based drug selection and dosing could help clinicians choose the right therapy for a patient, thus minimizing the incidence of treatment failure and intolerable side effects. Pharmacogenomics could be particularly useful in psychiatric pharmacotherapy, where response rates are low and the risk of adverse effects and nonadherence is high.

Despite the potential benefits of pharmacogenetic testing, many barriers prevent its routine use in practice, including a lack of knowledge about how to (1) order gene tests, (2) interpret results for an individual patient, and (3) apply those results to care. To help bridge this knowledge gap, we list practical, freely available pharmacogenomics resources that a psychiatric practitioner can use.

CPIC guidelines

The Clinical Pharmacogenetics Implement­ation Consortium (CPIC) is an international collaboration of pharmacogenomics experts that publishes clinical practice guidelines on using pharmacogenetic test results to optimize drug therapy.¹ Note: These guidelines do not address when tests should be ordered, but rather how results should be used to guide prescribing.

• how to convert genotype to phenotype
• how to modify drug selection or dosing based on these results
• the level of evidence for each recommendation.

CPIC guidelines and supplementary information are available on the CPIC Web site (https://www.cpicpgx.org) and are updated regularly. Table 1 provides current CPIC guidelines for neuropsychiatric drugs.

PharmGKB

Providing searchable annotations of pharmacogenetic variants, PharmGKB summarizes the clinical implications of important pharmacogenes, and includes FDA drug labels containing pharmacogenomics information (https://www.pharmgkb.org).² The Web site also provides users with evidence-based figures illustrating the pharmacokinetic and pharmacodynamic pathways of drugs that have pharmacogenetic implications.

PharmGKB is an excellent resource to consult for a summary of available evidence when a CPIC guideline does not exist for a given gene or drug.

Other resources

Table 2^3-8 lists other online resources for practitioners to aid in advancing pharmacogenomics knowledge as it relates to practice.

Putting guidance to best use

Familiarity with resources such as CPIC guidelines and PharmGKB can help ensure that patients with pharmacogenetic test results receive genetically tailored therapy that is more likely to be effective and less likely to cause adverse effects.^9,10

Pharmacogenomics—the study of how genetic variability influences drug response—is increasingly being used to personalize pharmacotherapy. Used in the context of other clinical variables, genetic-based drug selection and dosing could help clinicians choose the right therapy for a patient, thus minimizing the incidence of treatment failure and intolerable side effects. Pharmacogenomics could be particularly useful in psychiatric pharmacotherapy, where response rates are low and the risk of adverse effects and nonadherence is high.

Despite the potential benefits of pharmacogenetic testing, many barriers prevent its routine use in practice, including a lack of knowledge about how to (1) order gene tests, (2) interpret results for an individual patient, and (3) apply those results to care. To help bridge this knowledge gap, we list practical, freely available pharmacogenomics resources that a psychiatric practitioner can use.

CPIC guidelines

The Clinical Pharmacogenetics Implement­ation Consortium (CPIC) is an international collaboration of pharmacogenomics experts that publishes clinical practice guidelines on using pharmacogenetic test results to optimize drug therapy.¹ Note: These guidelines do not address when tests should be ordered, but rather how results should be used to guide prescribing.

• how to convert genotype to phenotype
• how to modify drug selection or dosing based on these results
• the level of evidence for each recommendation.

CPIC guidelines and supplementary information are available on the CPIC Web site (https://www.cpicpgx.org) and are updated regularly. Table 1 provides current CPIC guidelines for neuropsychiatric drugs.

PharmGKB

Providing searchable annotations of pharmacogenetic variants, PharmGKB summarizes the clinical implications of important pharmacogenes, and includes FDA drug labels containing pharmacogenomics information (https://www.pharmgkb.org).² The Web site also provides users with evidence-based figures illustrating the pharmacokinetic and pharmacodynamic pathways of drugs that have pharmacogenetic implications.

PharmGKB is an excellent resource to consult for a summary of available evidence when a CPIC guideline does not exist for a given gene or drug.

Other resources

Table 2^3-8 lists other online resources for practitioners to aid in advancing pharmacogenomics knowledge as it relates to practice.

Putting guidance to best use

Familiarity with resources such as CPIC guidelines and PharmGKB can help ensure that patients with pharmacogenetic test results receive genetically tailored therapy that is more likely to be effective and less likely to cause adverse effects.^9,10

Pharmacogenomics—the study of how genetic variability influences drug response—is increasingly being used to personalize pharmacotherapy. Used in the context of other clinical variables, genetic-based drug selection and dosing could help clinicians choose the right therapy for a patient, thus minimizing the incidence of treatment failure and intolerable side effects. Pharmacogenomics could be particularly useful in psychiatric pharmacotherapy, where response rates are low and the risk of adverse effects and nonadherence is high.

Despite the potential benefits of pharmacogenetic testing, many barriers prevent its routine use in practice, including a lack of knowledge about how to (1) order gene tests, (2) interpret results for an individual patient, and (3) apply those results to care. To help bridge this knowledge gap, we list practical, freely available pharmacogenomics resources that a psychiatric practitioner can use.

CPIC guidelines

The Clinical Pharmacogenetics Implement­ation Consortium (CPIC) is an international collaboration of pharmacogenomics experts that publishes clinical practice guidelines on using pharmacogenetic test results to optimize drug therapy.¹ Note: These guidelines do not address when tests should be ordered, but rather how results should be used to guide prescribing.

• how to convert genotype to phenotype
• how to modify drug selection or dosing based on these results
• the level of evidence for each recommendation.

CPIC guidelines and supplementary information are available on the CPIC Web site (https://www.cpicpgx.org) and are updated regularly. Table 1 provides current CPIC guidelines for neuropsychiatric drugs.

PharmGKB

Providing searchable annotations of pharmacogenetic variants, PharmGKB summarizes the clinical implications of important pharmacogenes, and includes FDA drug labels containing pharmacogenomics information (https://www.pharmgkb.org).² The Web site also provides users with evidence-based figures illustrating the pharmacokinetic and pharmacodynamic pathways of drugs that have pharmacogenetic implications.

PharmGKB is an excellent resource to consult for a summary of available evidence when a CPIC guideline does not exist for a given gene or drug.

Other resources

Table 2^3-8 lists other online resources for practitioners to aid in advancing pharmacogenomics knowledge as it relates to practice.

Putting guidance to best use

Familiarity with resources such as CPIC guidelines and PharmGKB can help ensure that patients with pharmacogenetic test results receive genetically tailored therapy that is more likely to be effective and less likely to cause adverse effects.^9,10

Ketamine, a high-affinity, noncompetitive N-methyl-D-aspartate (NMDA)-glutamate receptor antagonist, is used in human and veterinary medicine for its anesthetic and analgesic properties.¹ NMDA receptors could trigger cellular and behavioral responses, and ketamine blocks neuronal communication pathways.

How ketamine works

Water- and lipid-soluble, ketamine is available in oral, topical, IM, and IV forms. Plasma concentrations reach maximum levels minutes after IV infusion; 5 to 15 minutes after IM administration; and 30 minutes after oral ingestion.¹ The duration of action is as long as 2 hours after IM injection, and 4 to 6 hours orally. Metabolites are eliminated in urine.

Ketamine, co-prescribed with stimulants and some antidepressant drugs, can induce unwanted effects, such as increased blood pressure. Auditory and visual hallucinations are reported occasionally, especially in patients receiving a high dosage or in those with alcohol dependence.¹ Hypertension, tachycardia, cardiac arrhythmia, and pain at injection site are the most common adverse effects.

Some advantages over ECT in treating depression

The efficacy of electroconvulsive therapy (ECT) in alleviating depression depends on seizure duration. Compared with methohexital, an anesthetic used for ECT, ketamine offers some advantages:

• increased ictal time
• augmented mid-ictal slow-wave amplitude
• shortened post-treatment re-orientation time
• less cognitive dysfunction.²

Uses for ketamine

Treatment-resistant depression. The glutamatergic system is implicated in depression.^2,3 Ketamine works in patients with treatment-resistant depression by blocking glutamate NMDA receptors and increasing the activity of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors, resulting in a rapid, sustained antidepressant effect. Response to ketamine occurs within 2 hours and lasts approximately 1 week.

Abuse potential

There is documented risk of ketamine abuse. It may create psychedelic effects that some people find pleasurable, such as sedation, disinhibition, and altered perceptions.⁶ There also may be a component of physiological dependence.⁶

Conclusion

Ketamine’s rapid antidepressant effect results could be beneficial when used in severely depressed and suicidal patients. Given the potential risks of ketamine, safety considerations will determine whether this drug is successful as a therapy for people with a mood disorder.

Further research about ketamine usage including pain management and affective disorders is anticipated.⁷ Investigations substantiating relative safety and clinical trials are still on-going.⁸

Related Resources
• Nichols SD, Bishop J. Is the evidence compelling for using ketamine to treat resistant depression? Current Psychiatry. 2015;15(5):48-51.
• National Institute of Mental Health. Highlight: ketamine: a new (and faster) path to treating depression. www.nimh.nih.gov/about/strategic-planning-reports/highlights/highlight-ketamine-a-new-and-faster-path-to-treatingdepression.shtml.

Ketamine, a high-affinity, noncompetitive N-methyl-D-aspartate (NMDA)-glutamate receptor antagonist, is used in human and veterinary medicine for its anesthetic and analgesic properties.¹ NMDA receptors could trigger cellular and behavioral responses, and ketamine blocks neuronal communication pathways.

How ketamine works

Water- and lipid-soluble, ketamine is available in oral, topical, IM, and IV forms. Plasma concentrations reach maximum levels minutes after IV infusion; 5 to 15 minutes after IM administration; and 30 minutes after oral ingestion.¹ The duration of action is as long as 2 hours after IM injection, and 4 to 6 hours orally. Metabolites are eliminated in urine.

Ketamine, co-prescribed with stimulants and some antidepressant drugs, can induce unwanted effects, such as increased blood pressure. Auditory and visual hallucinations are reported occasionally, especially in patients receiving a high dosage or in those with alcohol dependence.¹ Hypertension, tachycardia, cardiac arrhythmia, and pain at injection site are the most common adverse effects.

Some advantages over ECT in treating depression

The efficacy of electroconvulsive therapy (ECT) in alleviating depression depends on seizure duration. Compared with methohexital, an anesthetic used for ECT, ketamine offers some advantages:

• increased ictal time
• augmented mid-ictal slow-wave amplitude
• shortened post-treatment re-orientation time
• less cognitive dysfunction.²

Uses for ketamine

Treatment-resistant depression. The glutamatergic system is implicated in depression.^2,3 Ketamine works in patients with treatment-resistant depression by blocking glutamate NMDA receptors and increasing the activity of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors, resulting in a rapid, sustained antidepressant effect. Response to ketamine occurs within 2 hours and lasts approximately 1 week.

Abuse potential

There is documented risk of ketamine abuse. It may create psychedelic effects that some people find pleasurable, such as sedation, disinhibition, and altered perceptions.⁶ There also may be a component of physiological dependence.⁶

Conclusion

Ketamine’s rapid antidepressant effect results could be beneficial when used in severely depressed and suicidal patients. Given the potential risks of ketamine, safety considerations will determine whether this drug is successful as a therapy for people with a mood disorder.

Further research about ketamine usage including pain management and affective disorders is anticipated.⁷ Investigations substantiating relative safety and clinical trials are still on-going.⁸

Related Resources
• Nichols SD, Bishop J. Is the evidence compelling for using ketamine to treat resistant depression? Current Psychiatry. 2015;15(5):48-51.
• National Institute of Mental Health. Highlight: ketamine: a new (and faster) path to treating depression. www.nimh.nih.gov/about/strategic-planning-reports/highlights/highlight-ketamine-a-new-and-faster-path-to-treatingdepression.shtml.

Ketamine, a high-affinity, noncompetitive N-methyl-D-aspartate (NMDA)-glutamate receptor antagonist, is used in human and veterinary medicine for its anesthetic and analgesic properties.¹ NMDA receptors could trigger cellular and behavioral responses, and ketamine blocks neuronal communication pathways.

How ketamine works

Water- and lipid-soluble, ketamine is available in oral, topical, IM, and IV forms. Plasma concentrations reach maximum levels minutes after IV infusion; 5 to 15 minutes after IM administration; and 30 minutes after oral ingestion.¹ The duration of action is as long as 2 hours after IM injection, and 4 to 6 hours orally. Metabolites are eliminated in urine.

Ketamine, co-prescribed with stimulants and some antidepressant drugs, can induce unwanted effects, such as increased blood pressure. Auditory and visual hallucinations are reported occasionally, especially in patients receiving a high dosage or in those with alcohol dependence.¹ Hypertension, tachycardia, cardiac arrhythmia, and pain at injection site are the most common adverse effects.

Some advantages over ECT in treating depression

The efficacy of electroconvulsive therapy (ECT) in alleviating depression depends on seizure duration. Compared with methohexital, an anesthetic used for ECT, ketamine offers some advantages:

• increased ictal time
• augmented mid-ictal slow-wave amplitude
• shortened post-treatment re-orientation time
• less cognitive dysfunction.²

Uses for ketamine

Treatment-resistant depression. The glutamatergic system is implicated in depression.^2,3 Ketamine works in patients with treatment-resistant depression by blocking glutamate NMDA receptors and increasing the activity of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors, resulting in a rapid, sustained antidepressant effect. Response to ketamine occurs within 2 hours and lasts approximately 1 week.

Abuse potential

There is documented risk of ketamine abuse. It may create psychedelic effects that some people find pleasurable, such as sedation, disinhibition, and altered perceptions.⁶ There also may be a component of physiological dependence.⁶

Conclusion

Ketamine’s rapid antidepressant effect results could be beneficial when used in severely depressed and suicidal patients. Given the potential risks of ketamine, safety considerations will determine whether this drug is successful as a therapy for people with a mood disorder.

Further research about ketamine usage including pain management and affective disorders is anticipated.⁷ Investigations substantiating relative safety and clinical trials are still on-going.⁸

Related Resources
• Nichols SD, Bishop J. Is the evidence compelling for using ketamine to treat resistant depression? Current Psychiatry. 2015;15(5):48-51.
• National Institute of Mental Health. Highlight: ketamine: a new (and faster) path to treating depression. www.nimh.nih.gov/about/strategic-planning-reports/highlights/highlight-ketamine-a-new-and-faster-path-to-treatingdepression.shtml.

CASE REPORTMr. C, age 72, reports a lack of desire to swallow food. He denies feeling a lump in his throat. Over the past 6 months, he lost >30 lb.

The patient had a similar episode 2 years ago, which resolved without intervention. The death of his wife recently has led to isolation and lack of desire to swallow food.

Testing with standard food samples to elicit eating behaviors is normal. Electromyography and video fluoroscopy test results show no abnormalities.

What is phagophobia?The case of Mr. C brings to light the condition known as phagophobia—a sensation of not being able to swallow. Phagophobia mimics oral apraxia; pharyngoesophageal and neurologic functions as well as the ability to speak remain intact, however.¹

It is estimated that about 6% of the adult general population reports dysphagia.² About 47% of patients with dysphagic complaints do not show motor-manometric or radiological abnormalities of the upper digestive tract. A number of psychiatric conditions, including panic disorder, obsessive-compulsive disorder, social phobia, anorexia nervosa, globus hystericus, hypersensitive gag reflex, and posttraumatic stress disorder can simulate this condition.³

When Barofsky and Fontaine⁴ compared phagophobia patients with other subjects—healthy controls, anorexia nervosa restrictors, dysphagic patients with esophageal obstruction, dysphagic patients with motility disturbance, and patients with non-motility non-obstructive dysphagia—they found that patients with psychogenic dysphagia did not appear to have an eating disorder. However, they did have a clinically significant level of psychological distress, particularly anxiety.

Diagnostic tools and management stepsThere are a number of approaches to assess your patient’s fear of swallowing (Table,^5-7 page 68). Non-invasive assessment tools along with educational modalities usually are tried alone or together with psychopharmacological intervention. It is, however, imperative that you have an empathetic and understanding approach to such patients. When patients have confidence in the clinician they tend to respond more effectively with such approaches.

Investigations⁴ include questionnaires (swallow disorder history, Eating Disorder Inventory-2, and Symptom Checklist–90-R); weight assessment; testing with standardized food samples to elicit eating behaviors; self-reports; electromyography; and videofluoroscopy.

Education and reassurance includes individual demonstration of swallowing, combined with group therapy, exercises, and reassurance. Patients benefit from advice on how to maximize sensation within the oropharynx to increase taste, perception of temperature, and texture stimulation.⁸

Behavioral intervention involves practicing slow breathing and muscle relaxation techniques to gradually increase bite size and reduce the amount of time spent chewing each bite.

Introspection therapycomprises psychoeducation, cognitive restructuring, and in vivo and introspective exposure; helps patients replace anxiety-producing thoughts with probability estimation and decatastrophizing. Introspective exposure targets the fear of choking by having the patient create sensations of throat tightening by holding a swallow in mid-action and by rapid swallowing. In vivo exposure targets the fear of swallowing by having the patient practice feeding foods (such as semi-solid easy-to-swallow choices), in and outside of the session.⁶

Aversion therapy requires that you pinch the patient’s hand while he (she) chews, and release the hand when he swallows.

Psychopharmacotherapeutic intervention. A number of medications can be used to help, such as imipramine up to 150 mg; desipramine, up to 150 mg; or lorazepam, 0.25 mg, twice daily, to address anxiety or panic symptoms.
 

Acknowledgment
Duy Li, BS, and Yu Hsuan Liao, BS, contributed to the development of the manuscript of this article.

CASE REPORTMr. C, age 72, reports a lack of desire to swallow food. He denies feeling a lump in his throat. Over the past 6 months, he lost >30 lb.

The patient had a similar episode 2 years ago, which resolved without intervention. The death of his wife recently has led to isolation and lack of desire to swallow food.

Testing with standard food samples to elicit eating behaviors is normal. Electromyography and video fluoroscopy test results show no abnormalities.

What is phagophobia?The case of Mr. C brings to light the condition known as phagophobia—a sensation of not being able to swallow. Phagophobia mimics oral apraxia; pharyngoesophageal and neurologic functions as well as the ability to speak remain intact, however.¹

It is estimated that about 6% of the adult general population reports dysphagia.² About 47% of patients with dysphagic complaints do not show motor-manometric or radiological abnormalities of the upper digestive tract. A number of psychiatric conditions, including panic disorder, obsessive-compulsive disorder, social phobia, anorexia nervosa, globus hystericus, hypersensitive gag reflex, and posttraumatic stress disorder can simulate this condition.³

When Barofsky and Fontaine⁴ compared phagophobia patients with other subjects—healthy controls, anorexia nervosa restrictors, dysphagic patients with esophageal obstruction, dysphagic patients with motility disturbance, and patients with non-motility non-obstructive dysphagia—they found that patients with psychogenic dysphagia did not appear to have an eating disorder. However, they did have a clinically significant level of psychological distress, particularly anxiety.

Diagnostic tools and management stepsThere are a number of approaches to assess your patient’s fear of swallowing (Table,^5-7 page 68). Non-invasive assessment tools along with educational modalities usually are tried alone or together with psychopharmacological intervention. It is, however, imperative that you have an empathetic and understanding approach to such patients. When patients have confidence in the clinician they tend to respond more effectively with such approaches.

Investigations⁴ include questionnaires (swallow disorder history, Eating Disorder Inventory-2, and Symptom Checklist–90-R); weight assessment; testing with standardized food samples to elicit eating behaviors; self-reports; electromyography; and videofluoroscopy.

Education and reassurance includes individual demonstration of swallowing, combined with group therapy, exercises, and reassurance. Patients benefit from advice on how to maximize sensation within the oropharynx to increase taste, perception of temperature, and texture stimulation.⁸

Behavioral intervention involves practicing slow breathing and muscle relaxation techniques to gradually increase bite size and reduce the amount of time spent chewing each bite.

Introspection therapycomprises psychoeducation, cognitive restructuring, and in vivo and introspective exposure; helps patients replace anxiety-producing thoughts with probability estimation and decatastrophizing. Introspective exposure targets the fear of choking by having the patient create sensations of throat tightening by holding a swallow in mid-action and by rapid swallowing. In vivo exposure targets the fear of swallowing by having the patient practice feeding foods (such as semi-solid easy-to-swallow choices), in and outside of the session.⁶

Aversion therapy requires that you pinch the patient’s hand while he (she) chews, and release the hand when he swallows.

Psychopharmacotherapeutic intervention. A number of medications can be used to help, such as imipramine up to 150 mg; desipramine, up to 150 mg; or lorazepam, 0.25 mg, twice daily, to address anxiety or panic symptoms.
 

Acknowledgment
Duy Li, BS, and Yu Hsuan Liao, BS, contributed to the development of the manuscript of this article.

CASE REPORTMr. C, age 72, reports a lack of desire to swallow food. He denies feeling a lump in his throat. Over the past 6 months, he lost >30 lb.

The patient had a similar episode 2 years ago, which resolved without intervention. The death of his wife recently has led to isolation and lack of desire to swallow food.

Testing with standard food samples to elicit eating behaviors is normal. Electromyography and video fluoroscopy test results show no abnormalities.

What is phagophobia?The case of Mr. C brings to light the condition known as phagophobia—a sensation of not being able to swallow. Phagophobia mimics oral apraxia; pharyngoesophageal and neurologic functions as well as the ability to speak remain intact, however.¹

It is estimated that about 6% of the adult general population reports dysphagia.² About 47% of patients with dysphagic complaints do not show motor-manometric or radiological abnormalities of the upper digestive tract. A number of psychiatric conditions, including panic disorder, obsessive-compulsive disorder, social phobia, anorexia nervosa, globus hystericus, hypersensitive gag reflex, and posttraumatic stress disorder can simulate this condition.³

When Barofsky and Fontaine⁴ compared phagophobia patients with other subjects—healthy controls, anorexia nervosa restrictors, dysphagic patients with esophageal obstruction, dysphagic patients with motility disturbance, and patients with non-motility non-obstructive dysphagia—they found that patients with psychogenic dysphagia did not appear to have an eating disorder. However, they did have a clinically significant level of psychological distress, particularly anxiety.

Diagnostic tools and management stepsThere are a number of approaches to assess your patient’s fear of swallowing (Table,^5-7 page 68). Non-invasive assessment tools along with educational modalities usually are tried alone or together with psychopharmacological intervention. It is, however, imperative that you have an empathetic and understanding approach to such patients. When patients have confidence in the clinician they tend to respond more effectively with such approaches.

Investigations⁴ include questionnaires (swallow disorder history, Eating Disorder Inventory-2, and Symptom Checklist–90-R); weight assessment; testing with standardized food samples to elicit eating behaviors; self-reports; electromyography; and videofluoroscopy.

Education and reassurance includes individual demonstration of swallowing, combined with group therapy, exercises, and reassurance. Patients benefit from advice on how to maximize sensation within the oropharynx to increase taste, perception of temperature, and texture stimulation.⁸

Behavioral intervention involves practicing slow breathing and muscle relaxation techniques to gradually increase bite size and reduce the amount of time spent chewing each bite.

Introspection therapycomprises psychoeducation, cognitive restructuring, and in vivo and introspective exposure; helps patients replace anxiety-producing thoughts with probability estimation and decatastrophizing. Introspective exposure targets the fear of choking by having the patient create sensations of throat tightening by holding a swallow in mid-action and by rapid swallowing. In vivo exposure targets the fear of swallowing by having the patient practice feeding foods (such as semi-solid easy-to-swallow choices), in and outside of the session.⁶

Aversion therapy requires that you pinch the patient’s hand while he (she) chews, and release the hand when he swallows.

Psychopharmacotherapeutic intervention. A number of medications can be used to help, such as imipramine up to 150 mg; desipramine, up to 150 mg; or lorazepam, 0.25 mg, twice daily, to address anxiety or panic symptoms.
 

Acknowledgment
Duy Li, BS, and Yu Hsuan Liao, BS, contributed to the development of the manuscript of this article.

It seems like common sense: Sleeping poorly results in not feeling good. The truth is that many of our patients are sleep deprived but are either unaware of, or unwilling to acknowledge, their problem. The busy life that many patients have does not allow adequate time for sleep. In fact, I have encountered patients who think of sleep as an inconvenience that takes away time from other pursuits.

Sleep deprivation in psychiatric disorders
Sleep deprivation occurs when the duration or quality of sleep is inadequate. Inadequate sleep duration can be caused by insomnia or simply not allowing enough time for sleep (1 aspect of poor sleep hygiene). Poor sleep quality often is caused by sleep-disordered breathing.

Sleep deprivation can result in either sleepiness or fatigue. Sleepiness is a propensity to fall asleep; fatigue is a lack of energy that is not alleviated by additional sleep. Fatigue is more likely to be associated with a psychiatric disorder; sleepiness is more predominant in sleep disorders (although there is significant overlap). For example, patients with a major depressive disorder can experience fatigue as much as patients with sleep deprivation, but the latter also is more likely to result in sleepiness. Trouble concentrating is seen in anxiety, depression, attention-deficit/hyperactivity disorder (ADHD), and sleep deprivation.¹

Insomnia or poor sleep hygiene can be diagnosed with a thorough sleep history. I take special care to consider sleep problems by presenting 5 groups of questions to the patient (Box).

Sleep-disordered breathing
A sleep study is required to accurately diagnose sleep-disordered breathing. Unless this diagnosis is specifically looked for, it remains hidden from both physicians and patients. Clues to the presence of sleep-disordered breathing include snorting, snoring, and gasping for air during sleep; witnessed apnea during sleep; nighttime awakening; daytime fatigue; nocturia; mouth breathing or dry mouth; acid reflux; irritability; morning headache; nighttime sweating; and low libido. Risk factors for sleep-disordered breathing include obesity; smoking; menopause; family history; increasing age; and anatomical factors (eg, deviation of the nasal septum; retrognathia; long face syndrome; high-arched narrow hard palate; large tonsils, uvula, or tongue).²

Measuring sleep quality
Some patients are unaware of the extent to which they are sleepy. The most widely used scale to measure sleepiness is the Epworth Sleepiness Scale.³ Sleep specialists view a score of ≥10 on the Epworth scale as indicative of daytime sleepiness. In addition, a patient’s daily consumption of caffeinated beverages can be a clue to excessive sleepiness or, at least, fatigue. If the degree of sleepiness cannot be determined subjectively, objective measures, such as the Multiple Sleep Latency Test (MSLT), can quantify it. In a randomly selected sample from the general population, 13.4% had excessive daytime sleepiness as measured by the MSLT.⁴

Adult ADHD and sleep deprivation
In my practice, sleep problems confound both the diagnosis and treatment of psychiatric disorders, especially ADHD. Often, patients who report ADHD symptoms have no clear history of ADHD during childhood. In these cases, I always consider the possibility that their ADHD symptoms are due to sleep deprivation. Sleep deprivation can mimic the poor executive function and difficulty concentrating that is often seen in ADHD, because such deprivation is associated with decreased activity in the prefrontal cortex during wakefulness.⁵

In patients who provide a clear history of ADHD symptoms during childhood, it is possible that inadequate sleep exacerbates ADHD symptoms as adults. Unless sleep deprivation is diagnosed and treated in these patients, they can end up taking a higher-than-necessary dosage of a stimulant. Also, patients who have ADHD might have a difficult time managing their sleep schedule because of poor executive functioning. This, in turn, can result in additional sleep deprivation, thus worsening their ADHD symptoms, creating a vicious circle.

Psychotropics and sedation
Many psychiatric medications list sedation as a side effect. Patients with untreated sleep problems might be more likely to notice this side effect because sleep problems contribute to their fatigue. I have had patients who were unable to tolerate sedative medications until their sleep apnea was treated.

In conclusion
It is important to consider sleep deprivation in your differential diagnosis of psychiatric patients. This will allow for more accurate diagnosis and treatment and, in some cases, can avoid treatment resistance.

It seems like common sense: Sleeping poorly results in not feeling good. The truth is that many of our patients are sleep deprived but are either unaware of, or unwilling to acknowledge, their problem. The busy life that many patients have does not allow adequate time for sleep. In fact, I have encountered patients who think of sleep as an inconvenience that takes away time from other pursuits.

Sleep deprivation in psychiatric disorders
Sleep deprivation occurs when the duration or quality of sleep is inadequate. Inadequate sleep duration can be caused by insomnia or simply not allowing enough time for sleep (1 aspect of poor sleep hygiene). Poor sleep quality often is caused by sleep-disordered breathing.

Sleep deprivation can result in either sleepiness or fatigue. Sleepiness is a propensity to fall asleep; fatigue is a lack of energy that is not alleviated by additional sleep. Fatigue is more likely to be associated with a psychiatric disorder; sleepiness is more predominant in sleep disorders (although there is significant overlap). For example, patients with a major depressive disorder can experience fatigue as much as patients with sleep deprivation, but the latter also is more likely to result in sleepiness. Trouble concentrating is seen in anxiety, depression, attention-deficit/hyperactivity disorder (ADHD), and sleep deprivation.¹

Insomnia or poor sleep hygiene can be diagnosed with a thorough sleep history. I take special care to consider sleep problems by presenting 5 groups of questions to the patient (Box).

Sleep-disordered breathing
A sleep study is required to accurately diagnose sleep-disordered breathing. Unless this diagnosis is specifically looked for, it remains hidden from both physicians and patients. Clues to the presence of sleep-disordered breathing include snorting, snoring, and gasping for air during sleep; witnessed apnea during sleep; nighttime awakening; daytime fatigue; nocturia; mouth breathing or dry mouth; acid reflux; irritability; morning headache; nighttime sweating; and low libido. Risk factors for sleep-disordered breathing include obesity; smoking; menopause; family history; increasing age; and anatomical factors (eg, deviation of the nasal septum; retrognathia; long face syndrome; high-arched narrow hard palate; large tonsils, uvula, or tongue).²

Measuring sleep quality
Some patients are unaware of the extent to which they are sleepy. The most widely used scale to measure sleepiness is the Epworth Sleepiness Scale.³ Sleep specialists view a score of ≥10 on the Epworth scale as indicative of daytime sleepiness. In addition, a patient’s daily consumption of caffeinated beverages can be a clue to excessive sleepiness or, at least, fatigue. If the degree of sleepiness cannot be determined subjectively, objective measures, such as the Multiple Sleep Latency Test (MSLT), can quantify it. In a randomly selected sample from the general population, 13.4% had excessive daytime sleepiness as measured by the MSLT.⁴

Adult ADHD and sleep deprivation
In my practice, sleep problems confound both the diagnosis and treatment of psychiatric disorders, especially ADHD. Often, patients who report ADHD symptoms have no clear history of ADHD during childhood. In these cases, I always consider the possibility that their ADHD symptoms are due to sleep deprivation. Sleep deprivation can mimic the poor executive function and difficulty concentrating that is often seen in ADHD, because such deprivation is associated with decreased activity in the prefrontal cortex during wakefulness.⁵

In patients who provide a clear history of ADHD symptoms during childhood, it is possible that inadequate sleep exacerbates ADHD symptoms as adults. Unless sleep deprivation is diagnosed and treated in these patients, they can end up taking a higher-than-necessary dosage of a stimulant. Also, patients who have ADHD might have a difficult time managing their sleep schedule because of poor executive functioning. This, in turn, can result in additional sleep deprivation, thus worsening their ADHD symptoms, creating a vicious circle.

Psychotropics and sedation
Many psychiatric medications list sedation as a side effect. Patients with untreated sleep problems might be more likely to notice this side effect because sleep problems contribute to their fatigue. I have had patients who were unable to tolerate sedative medications until their sleep apnea was treated.

In conclusion
It is important to consider sleep deprivation in your differential diagnosis of psychiatric patients. This will allow for more accurate diagnosis and treatment and, in some cases, can avoid treatment resistance.

It seems like common sense: Sleeping poorly results in not feeling good. The truth is that many of our patients are sleep deprived but are either unaware of, or unwilling to acknowledge, their problem. The busy life that many patients have does not allow adequate time for sleep. In fact, I have encountered patients who think of sleep as an inconvenience that takes away time from other pursuits.

Sleep deprivation in psychiatric disorders
Sleep deprivation occurs when the duration or quality of sleep is inadequate. Inadequate sleep duration can be caused by insomnia or simply not allowing enough time for sleep (1 aspect of poor sleep hygiene). Poor sleep quality often is caused by sleep-disordered breathing.

Sleep deprivation can result in either sleepiness or fatigue. Sleepiness is a propensity to fall asleep; fatigue is a lack of energy that is not alleviated by additional sleep. Fatigue is more likely to be associated with a psychiatric disorder; sleepiness is more predominant in sleep disorders (although there is significant overlap). For example, patients with a major depressive disorder can experience fatigue as much as patients with sleep deprivation, but the latter also is more likely to result in sleepiness. Trouble concentrating is seen in anxiety, depression, attention-deficit/hyperactivity disorder (ADHD), and sleep deprivation.¹

Insomnia or poor sleep hygiene can be diagnosed with a thorough sleep history. I take special care to consider sleep problems by presenting 5 groups of questions to the patient (Box).

Sleep-disordered breathing
A sleep study is required to accurately diagnose sleep-disordered breathing. Unless this diagnosis is specifically looked for, it remains hidden from both physicians and patients. Clues to the presence of sleep-disordered breathing include snorting, snoring, and gasping for air during sleep; witnessed apnea during sleep; nighttime awakening; daytime fatigue; nocturia; mouth breathing or dry mouth; acid reflux; irritability; morning headache; nighttime sweating; and low libido. Risk factors for sleep-disordered breathing include obesity; smoking; menopause; family history; increasing age; and anatomical factors (eg, deviation of the nasal septum; retrognathia; long face syndrome; high-arched narrow hard palate; large tonsils, uvula, or tongue).²

Measuring sleep quality
Some patients are unaware of the extent to which they are sleepy. The most widely used scale to measure sleepiness is the Epworth Sleepiness Scale.³ Sleep specialists view a score of ≥10 on the Epworth scale as indicative of daytime sleepiness. In addition, a patient’s daily consumption of caffeinated beverages can be a clue to excessive sleepiness or, at least, fatigue. If the degree of sleepiness cannot be determined subjectively, objective measures, such as the Multiple Sleep Latency Test (MSLT), can quantify it. In a randomly selected sample from the general population, 13.4% had excessive daytime sleepiness as measured by the MSLT.⁴

Adult ADHD and sleep deprivation
In my practice, sleep problems confound both the diagnosis and treatment of psychiatric disorders, especially ADHD. Often, patients who report ADHD symptoms have no clear history of ADHD during childhood. In these cases, I always consider the possibility that their ADHD symptoms are due to sleep deprivation. Sleep deprivation can mimic the poor executive function and difficulty concentrating that is often seen in ADHD, because such deprivation is associated with decreased activity in the prefrontal cortex during wakefulness.⁵

In patients who provide a clear history of ADHD symptoms during childhood, it is possible that inadequate sleep exacerbates ADHD symptoms as adults. Unless sleep deprivation is diagnosed and treated in these patients, they can end up taking a higher-than-necessary dosage of a stimulant. Also, patients who have ADHD might have a difficult time managing their sleep schedule because of poor executive functioning. This, in turn, can result in additional sleep deprivation, thus worsening their ADHD symptoms, creating a vicious circle.

Psychotropics and sedation
Many psychiatric medications list sedation as a side effect. Patients with untreated sleep problems might be more likely to notice this side effect because sleep problems contribute to their fatigue. I have had patients who were unable to tolerate sedative medications until their sleep apnea was treated.

In conclusion
It is important to consider sleep deprivation in your differential diagnosis of psychiatric patients. This will allow for more accurate diagnosis and treatment and, in some cases, can avoid treatment resistance.

Brain stimulation often is used for treatment-resistant depression when medications and psychotherapy are not enough to elicit a meaningful response. It is both old and new again: electroconvulsive therapy (ECT) has been used for decades, while emerging technologies, such as transcranial magnetic stimulation (TMS), are gaining acceptance.

Patients and families often arrive at the office with fears and assumptions about these types of treatments, which should be discussed openly. There are also differences between these treatment approaches that can be discussed (Table).

Electroconvulsive therapy
Although ECT has been shown to be the most efficacious treatment for treatment-resistant depression,¹ the most common response from patients and families that I hear when discussing ECT use is, “Do you really still do that?” Many patients and family members associate this treatment with mass media portrayals over the past several decades, such as the motion picture One Flew Over the Cuckoo’s Nest, which paired inhumane and unnecessary use of ECT with a frontal lobotomy, thereby associating this treatment with something inherently unethical.

My approach to discussing ECT with patients and families is to convey these main points:

• Consensual. In most cases, ECT is performed with the explicit informed consent of the patient, and is not done against the patient’s will.
• Effective. ECT has a remission rate of 75% after the first 2 weeks of use in patients suffering from acute depressive illnesses.²
• Safe. ECT protocols have evolved to maximize efficacy while minimizing adverse effects. Advances in anesthesia use with paralytic agents and anti-inflammatory medications reduce convulsions and subsequent musculoskeletal discomfort.

In addition, I note that:

• Ultra-brief stimulation parameters often are used to minimize cognitive side effects.
• ECT is associated with some psychosocial limitations, including being unable to drive during acute treatment and requiring supervision for several hours after sessions.

Transcranial magnetic stimulation
The field of non-invasive brain stimulation—in particular, TMS—faces a different set of complex issues to navigate. Because TMS is relatively new (approved by the FDA in 2008 for treatment-resistant depression),³ patients and families might believe that TMS may be more effective than ECT, which has not been demonstrated.⁴ It is important to communicate that:

• Although TMS is a FDA-approved treatment that has helped many patients with treatment-resistant depression, ECT remains the clinical treatment of choice for severe depression.
• Among antidepressant non-responders who had stopped all other antidepressant treatment, 44% of those who received deep TMS responded to treatment after 16 weeks, compared with 26% who received sham treatment.⁵
• Most patients usually require TMS for 4 to 6 weeks, 5 days a week, before beginning a taper phase.
• TMS has few side effects (headache being the most common); serious adverse effects (seizures, mania) have been reported but are rare.³
• Patients usually are able to continue their daily life and other outpatient treatments without the restrictions often placed on patients receiving ECT.
• If the patient responded to ECT in the past but could not tolerate adverse cognitive effects, TMS might be a better choice than other treatments.

Brain stimulation often is used for treatment-resistant depression when medications and psychotherapy are not enough to elicit a meaningful response. It is both old and new again: electroconvulsive therapy (ECT) has been used for decades, while emerging technologies, such as transcranial magnetic stimulation (TMS), are gaining acceptance.

Patients and families often arrive at the office with fears and assumptions about these types of treatments, which should be discussed openly. There are also differences between these treatment approaches that can be discussed (Table).

Electroconvulsive therapy
Although ECT has been shown to be the most efficacious treatment for treatment-resistant depression,¹ the most common response from patients and families that I hear when discussing ECT use is, “Do you really still do that?” Many patients and family members associate this treatment with mass media portrayals over the past several decades, such as the motion picture One Flew Over the Cuckoo’s Nest, which paired inhumane and unnecessary use of ECT with a frontal lobotomy, thereby associating this treatment with something inherently unethical.

My approach to discussing ECT with patients and families is to convey these main points:

• Consensual. In most cases, ECT is performed with the explicit informed consent of the patient, and is not done against the patient’s will.
• Effective. ECT has a remission rate of 75% after the first 2 weeks of use in patients suffering from acute depressive illnesses.²
• Safe. ECT protocols have evolved to maximize efficacy while minimizing adverse effects. Advances in anesthesia use with paralytic agents and anti-inflammatory medications reduce convulsions and subsequent musculoskeletal discomfort.

In addition, I note that:

• Ultra-brief stimulation parameters often are used to minimize cognitive side effects.
• ECT is associated with some psychosocial limitations, including being unable to drive during acute treatment and requiring supervision for several hours after sessions.

Transcranial magnetic stimulation
The field of non-invasive brain stimulation—in particular, TMS—faces a different set of complex issues to navigate. Because TMS is relatively new (approved by the FDA in 2008 for treatment-resistant depression),³ patients and families might believe that TMS may be more effective than ECT, which has not been demonstrated.⁴ It is important to communicate that:

• Although TMS is a FDA-approved treatment that has helped many patients with treatment-resistant depression, ECT remains the clinical treatment of choice for severe depression.
• Among antidepressant non-responders who had stopped all other antidepressant treatment, 44% of those who received deep TMS responded to treatment after 16 weeks, compared with 26% who received sham treatment.⁵
• Most patients usually require TMS for 4 to 6 weeks, 5 days a week, before beginning a taper phase.
• TMS has few side effects (headache being the most common); serious adverse effects (seizures, mania) have been reported but are rare.³
• Patients usually are able to continue their daily life and other outpatient treatments without the restrictions often placed on patients receiving ECT.
• If the patient responded to ECT in the past but could not tolerate adverse cognitive effects, TMS might be a better choice than other treatments.

Brain stimulation often is used for treatment-resistant depression when medications and psychotherapy are not enough to elicit a meaningful response. It is both old and new again: electroconvulsive therapy (ECT) has been used for decades, while emerging technologies, such as transcranial magnetic stimulation (TMS), are gaining acceptance.

Patients and families often arrive at the office with fears and assumptions about these types of treatments, which should be discussed openly. There are also differences between these treatment approaches that can be discussed (Table).

Electroconvulsive therapy
Although ECT has been shown to be the most efficacious treatment for treatment-resistant depression,¹ the most common response from patients and families that I hear when discussing ECT use is, “Do you really still do that?” Many patients and family members associate this treatment with mass media portrayals over the past several decades, such as the motion picture One Flew Over the Cuckoo’s Nest, which paired inhumane and unnecessary use of ECT with a frontal lobotomy, thereby associating this treatment with something inherently unethical.

My approach to discussing ECT with patients and families is to convey these main points:

• Consensual. In most cases, ECT is performed with the explicit informed consent of the patient, and is not done against the patient’s will.
• Effective. ECT has a remission rate of 75% after the first 2 weeks of use in patients suffering from acute depressive illnesses.²
• Safe. ECT protocols have evolved to maximize efficacy while minimizing adverse effects. Advances in anesthesia use with paralytic agents and anti-inflammatory medications reduce convulsions and subsequent musculoskeletal discomfort.

In addition, I note that:

• Ultra-brief stimulation parameters often are used to minimize cognitive side effects.
• ECT is associated with some psychosocial limitations, including being unable to drive during acute treatment and requiring supervision for several hours after sessions.

Transcranial magnetic stimulation
The field of non-invasive brain stimulation—in particular, TMS—faces a different set of complex issues to navigate. Because TMS is relatively new (approved by the FDA in 2008 for treatment-resistant depression),³ patients and families might believe that TMS may be more effective than ECT, which has not been demonstrated.⁴ It is important to communicate that:

• Although TMS is a FDA-approved treatment that has helped many patients with treatment-resistant depression, ECT remains the clinical treatment of choice for severe depression.
• Among antidepressant non-responders who had stopped all other antidepressant treatment, 44% of those who received deep TMS responded to treatment after 16 weeks, compared with 26% who received sham treatment.⁵
• Most patients usually require TMS for 4 to 6 weeks, 5 days a week, before beginning a taper phase.
• TMS has few side effects (headache being the most common); serious adverse effects (seizures, mania) have been reported but are rare.³
• Patients usually are able to continue their daily life and other outpatient treatments without the restrictions often placed on patients receiving ECT.
• If the patient responded to ECT in the past but could not tolerate adverse cognitive effects, TMS might be a better choice than other treatments.

Baby Boomers represent a rapidly growing segment of digital device users.¹ As these people age, their continued, even increasing, use of the Internet can be expected.¹ At the same time, many older adults (age ≥65) are engaged in intimate relationships and regard sexuality as an important part of life.²

At this intersection, the Internet is likely to play a role in geriatric sexuality and “digital intimacy”—in that older adults can adopt patterns of using online dating sites similar to what their younger counterparts engage in. There is a need among clinicians to avoid stereotypical perceptions of “ageism” and the myth of “geriatric asexuality” as a result of older patients’ continued sexual interest and their adoption of social media technologies to facilitate the development of new intimate relationships. Acknowledgement of these realities by clinicians may assist in understanding and communication regarding these important areas of patients’ lives.

Why online dating?
Contemporary social and demographic changes (eg, higher divorce rates, increased longevity, aging of Baby Boomers) have influenced patterns of dating behaviors.³ Consistent with evolutionary theory, studies on courtship behaviors show that women remain the “choosers” of partners in relationships at all ages³; in contemporary society, however, there is an increasing ratio of women to men in later life, and the degree to which this demographic change might influence older men and women who are pursuing sexual relationships is unclear.³ Older adults might be aware of these demographic realities, and may use the Internet to increase their chances of finding a relationship.

For older homosexual men and women, demographic trends also are important because fewer available partners of similar sexual orientation might be available in their immediate communities, similarly incentivizing the use of online dating sites.

Hand in hand: Risk and vulnerability
Clinicians can discuss with geriatric patients who present with questions or concerns about sexuality and risks of online dating. Although risks associated with digital dating can involve anyone, those who are recently divorced, widowed, disabled, or elderly can be targeted by predators or fraudulent schemes, and thus become victims. Recognizing those risks and the vulnerability in the geriatric patient is crucial.

Chronic illness. Age-related physiological changes do not necessarily make one vulnerable; however, chronic diseases of aging, including major neurocognitive disorders, can impair daily function and increase disability and vulnerability. The majority of online dating sites do not discriminate among users, including those with disabilities such as incapacitating neuropsychiatric disorders. The clinician may need to assess cognitive status of patients specific to their capacity to fully understand the risks of use of social media. Inability to accomplish basic mastery of computer skills or inability to maintain appropriate boundaries and safeguards in relationships initiated and maintained using the Internet may assist in this determination. Patients with other problematic Internet use (eg, excessive devotion to online shopping or online gambling) may be prone to misusing social media and dating sites as well. Patients with clear impairment of memory or poor social judgment based on a neurocognitive disorder also might not maintain proper boundaries with social media use.

Feeling alone. Older persons might feel socially isolated, and therefore may be more willing to participate in online dating to increase their chances of establishing an intimate relationship or companionship. Research has shown that increased social ties, participation in groups, contact with friends and family, and perceived social support are associated with longer survival; on the other hand, social disengagement, low participation in leisure activities, and limited social networks are associated with higher risk of major neurocognitive disorders and increased disability.⁴

Little is known about social vulnerability in institutional settings, but institutional living could decrease social vulnerability in important ways (eg, access to social support, networks and activities, not living alone).⁴ Although the literature on older adults and “digital” or “virtual” dating is limited, there are essentially no such data from within institutional settings. It is important to separately address the issue of cognitively impaired patients’ capacity to consent to sexual activity both within institutional settings and elsewhere, as it raises numerous ethical dilemmas for clinicians.

Being sexually active. Early research into online dating focused particularly on the risks of sexually transmitted infections (STIs),⁵ which could be acquired through failure to use condoms with a new partner.⁶ Older women particularly are less likely to use condoms with new sexual partners.⁶ Screening at-risk adults should occur regardless of age. Effective interventions are needed to increase condom use in this age group. Research in the general population has started to investigate how the use of technology can minimize the risks associated with online dating.⁵ The Table^5,6 lists strategies that can be used to minimize some of the risks of online dating among geriatric patients, including STIs and victimization.

Clinicians working with sexually active geriatric patients need to perform sexual risk assessments, complete capacity assessments, and provide preventive measures.

Legal issues
Criminal and civil liability issues have arisen with online dating involving cases of murder, rape, fraud, identity theft, loans, theft, domestic violence, stalking, and burglary. Online dating also raises concerns around the right to fair use of the Internet in different contexts. Flirting in cyberspace can occur with e-mail, text, Twitter, Skype, and Instant Messenger. Practices likely will vary depending on whether older adults are institutionalized or living in the community, as well as their mental status (eg, having a major neurocognitive disorder).

Some questions with legal implications worth considering include:

• To what extent is there a duty to accommodate healthy sexual relationships in institutionalized settings?
• At what point does monitoring and supervision become overly intrusive?
• Are older adults fully aware of the potential ramifications of sharing sensitive information in cyberspace?
• What is the threshold for capacity to consent among older adults to understand the sexual nature of the act and consent to the act?

Nursing homes and health care providers may become concerned about potential liability if their organization provides digital devices or electronic platforms that are not closely monitored. Clinicians have a duty to protect patients under their care from risks associated with predators who target vulnerable and lonely people, whether financially, emotionally, or physically. Some patients in nursing home settings may benefit from discussing with their family members or attorney the possibility of completing a “sexual power of attorney”⁷ that could be completed in conjunction with an advance health care directive that addresses or authorizes an agent to make decisions about their sexual activities if cognitively impaired in the future.

One might also consider to what extent local regulatory oversight will protect your patient. Not all jurisdictions regulate online dating services similarly; many existing regulations focus on unfair contracts and pay less heed to safety concerns.

As a result, some dissatisfied clients have been known to sue an online dating service for breach of contract or misrepresentation. One of the most significant issues, however, is making sure there are appropriate background checks. Online dating services may need to change their policies to screen and verify for criminal background checks.⁸ Older adults interested in online dating should be made aware of these emerging issues.

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

Baby Boomers represent a rapidly growing segment of digital device users.¹ As these people age, their continued, even increasing, use of the Internet can be expected.¹ At the same time, many older adults (age ≥65) are engaged in intimate relationships and regard sexuality as an important part of life.²

At this intersection, the Internet is likely to play a role in geriatric sexuality and “digital intimacy”—in that older adults can adopt patterns of using online dating sites similar to what their younger counterparts engage in. There is a need among clinicians to avoid stereotypical perceptions of “ageism” and the myth of “geriatric asexuality” as a result of older patients’ continued sexual interest and their adoption of social media technologies to facilitate the development of new intimate relationships. Acknowledgement of these realities by clinicians may assist in understanding and communication regarding these important areas of patients’ lives.

Why online dating?
Contemporary social and demographic changes (eg, higher divorce rates, increased longevity, aging of Baby Boomers) have influenced patterns of dating behaviors.³ Consistent with evolutionary theory, studies on courtship behaviors show that women remain the “choosers” of partners in relationships at all ages³; in contemporary society, however, there is an increasing ratio of women to men in later life, and the degree to which this demographic change might influence older men and women who are pursuing sexual relationships is unclear.³ Older adults might be aware of these demographic realities, and may use the Internet to increase their chances of finding a relationship.

For older homosexual men and women, demographic trends also are important because fewer available partners of similar sexual orientation might be available in their immediate communities, similarly incentivizing the use of online dating sites.

Hand in hand: Risk and vulnerability
Clinicians can discuss with geriatric patients who present with questions or concerns about sexuality and risks of online dating. Although risks associated with digital dating can involve anyone, those who are recently divorced, widowed, disabled, or elderly can be targeted by predators or fraudulent schemes, and thus become victims. Recognizing those risks and the vulnerability in the geriatric patient is crucial.

Chronic illness. Age-related physiological changes do not necessarily make one vulnerable; however, chronic diseases of aging, including major neurocognitive disorders, can impair daily function and increase disability and vulnerability. The majority of online dating sites do not discriminate among users, including those with disabilities such as incapacitating neuropsychiatric disorders. The clinician may need to assess cognitive status of patients specific to their capacity to fully understand the risks of use of social media. Inability to accomplish basic mastery of computer skills or inability to maintain appropriate boundaries and safeguards in relationships initiated and maintained using the Internet may assist in this determination. Patients with other problematic Internet use (eg, excessive devotion to online shopping or online gambling) may be prone to misusing social media and dating sites as well. Patients with clear impairment of memory or poor social judgment based on a neurocognitive disorder also might not maintain proper boundaries with social media use.

Feeling alone. Older persons might feel socially isolated, and therefore may be more willing to participate in online dating to increase their chances of establishing an intimate relationship or companionship. Research has shown that increased social ties, participation in groups, contact with friends and family, and perceived social support are associated with longer survival; on the other hand, social disengagement, low participation in leisure activities, and limited social networks are associated with higher risk of major neurocognitive disorders and increased disability.⁴

Little is known about social vulnerability in institutional settings, but institutional living could decrease social vulnerability in important ways (eg, access to social support, networks and activities, not living alone).⁴ Although the literature on older adults and “digital” or “virtual” dating is limited, there are essentially no such data from within institutional settings. It is important to separately address the issue of cognitively impaired patients’ capacity to consent to sexual activity both within institutional settings and elsewhere, as it raises numerous ethical dilemmas for clinicians.

Being sexually active. Early research into online dating focused particularly on the risks of sexually transmitted infections (STIs),⁵ which could be acquired through failure to use condoms with a new partner.⁶ Older women particularly are less likely to use condoms with new sexual partners.⁶ Screening at-risk adults should occur regardless of age. Effective interventions are needed to increase condom use in this age group. Research in the general population has started to investigate how the use of technology can minimize the risks associated with online dating.⁵ The Table^5,6 lists strategies that can be used to minimize some of the risks of online dating among geriatric patients, including STIs and victimization.

Clinicians working with sexually active geriatric patients need to perform sexual risk assessments, complete capacity assessments, and provide preventive measures.

Legal issues
Criminal and civil liability issues have arisen with online dating involving cases of murder, rape, fraud, identity theft, loans, theft, domestic violence, stalking, and burglary. Online dating also raises concerns around the right to fair use of the Internet in different contexts. Flirting in cyberspace can occur with e-mail, text, Twitter, Skype, and Instant Messenger. Practices likely will vary depending on whether older adults are institutionalized or living in the community, as well as their mental status (eg, having a major neurocognitive disorder).

Some questions with legal implications worth considering include:

• To what extent is there a duty to accommodate healthy sexual relationships in institutionalized settings?
• At what point does monitoring and supervision become overly intrusive?
• Are older adults fully aware of the potential ramifications of sharing sensitive information in cyberspace?
• What is the threshold for capacity to consent among older adults to understand the sexual nature of the act and consent to the act?

Nursing homes and health care providers may become concerned about potential liability if their organization provides digital devices or electronic platforms that are not closely monitored. Clinicians have a duty to protect patients under their care from risks associated with predators who target vulnerable and lonely people, whether financially, emotionally, or physically. Some patients in nursing home settings may benefit from discussing with their family members or attorney the possibility of completing a “sexual power of attorney”⁷ that could be completed in conjunction with an advance health care directive that addresses or authorizes an agent to make decisions about their sexual activities if cognitively impaired in the future.

One might also consider to what extent local regulatory oversight will protect your patient. Not all jurisdictions regulate online dating services similarly; many existing regulations focus on unfair contracts and pay less heed to safety concerns.

As a result, some dissatisfied clients have been known to sue an online dating service for breach of contract or misrepresentation. One of the most significant issues, however, is making sure there are appropriate background checks. Online dating services may need to change their policies to screen and verify for criminal background checks.⁸ Older adults interested in online dating should be made aware of these emerging issues.

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

Baby Boomers represent a rapidly growing segment of digital device users.¹ As these people age, their continued, even increasing, use of the Internet can be expected.¹ At the same time, many older adults (age ≥65) are engaged in intimate relationships and regard sexuality as an important part of life.²

At this intersection, the Internet is likely to play a role in geriatric sexuality and “digital intimacy”—in that older adults can adopt patterns of using online dating sites similar to what their younger counterparts engage in. There is a need among clinicians to avoid stereotypical perceptions of “ageism” and the myth of “geriatric asexuality” as a result of older patients’ continued sexual interest and their adoption of social media technologies to facilitate the development of new intimate relationships. Acknowledgement of these realities by clinicians may assist in understanding and communication regarding these important areas of patients’ lives.

Why online dating?
Contemporary social and demographic changes (eg, higher divorce rates, increased longevity, aging of Baby Boomers) have influenced patterns of dating behaviors.³ Consistent with evolutionary theory, studies on courtship behaviors show that women remain the “choosers” of partners in relationships at all ages³; in contemporary society, however, there is an increasing ratio of women to men in later life, and the degree to which this demographic change might influence older men and women who are pursuing sexual relationships is unclear.³ Older adults might be aware of these demographic realities, and may use the Internet to increase their chances of finding a relationship.

For older homosexual men and women, demographic trends also are important because fewer available partners of similar sexual orientation might be available in their immediate communities, similarly incentivizing the use of online dating sites.

Hand in hand: Risk and vulnerability
Clinicians can discuss with geriatric patients who present with questions or concerns about sexuality and risks of online dating. Although risks associated with digital dating can involve anyone, those who are recently divorced, widowed, disabled, or elderly can be targeted by predators or fraudulent schemes, and thus become victims. Recognizing those risks and the vulnerability in the geriatric patient is crucial.

Chronic illness. Age-related physiological changes do not necessarily make one vulnerable; however, chronic diseases of aging, including major neurocognitive disorders, can impair daily function and increase disability and vulnerability. The majority of online dating sites do not discriminate among users, including those with disabilities such as incapacitating neuropsychiatric disorders. The clinician may need to assess cognitive status of patients specific to their capacity to fully understand the risks of use of social media. Inability to accomplish basic mastery of computer skills or inability to maintain appropriate boundaries and safeguards in relationships initiated and maintained using the Internet may assist in this determination. Patients with other problematic Internet use (eg, excessive devotion to online shopping or online gambling) may be prone to misusing social media and dating sites as well. Patients with clear impairment of memory or poor social judgment based on a neurocognitive disorder also might not maintain proper boundaries with social media use.

Feeling alone. Older persons might feel socially isolated, and therefore may be more willing to participate in online dating to increase their chances of establishing an intimate relationship or companionship. Research has shown that increased social ties, participation in groups, contact with friends and family, and perceived social support are associated with longer survival; on the other hand, social disengagement, low participation in leisure activities, and limited social networks are associated with higher risk of major neurocognitive disorders and increased disability.⁴

Little is known about social vulnerability in institutional settings, but institutional living could decrease social vulnerability in important ways (eg, access to social support, networks and activities, not living alone).⁴ Although the literature on older adults and “digital” or “virtual” dating is limited, there are essentially no such data from within institutional settings. It is important to separately address the issue of cognitively impaired patients’ capacity to consent to sexual activity both within institutional settings and elsewhere, as it raises numerous ethical dilemmas for clinicians.

Being sexually active. Early research into online dating focused particularly on the risks of sexually transmitted infections (STIs),⁵ which could be acquired through failure to use condoms with a new partner.⁶ Older women particularly are less likely to use condoms with new sexual partners.⁶ Screening at-risk adults should occur regardless of age. Effective interventions are needed to increase condom use in this age group. Research in the general population has started to investigate how the use of technology can minimize the risks associated with online dating.⁵ The Table^5,6 lists strategies that can be used to minimize some of the risks of online dating among geriatric patients, including STIs and victimization.

Clinicians working with sexually active geriatric patients need to perform sexual risk assessments, complete capacity assessments, and provide preventive measures.

Legal issues
Criminal and civil liability issues have arisen with online dating involving cases of murder, rape, fraud, identity theft, loans, theft, domestic violence, stalking, and burglary. Online dating also raises concerns around the right to fair use of the Internet in different contexts. Flirting in cyberspace can occur with e-mail, text, Twitter, Skype, and Instant Messenger. Practices likely will vary depending on whether older adults are institutionalized or living in the community, as well as their mental status (eg, having a major neurocognitive disorder).

Some questions with legal implications worth considering include:

• To what extent is there a duty to accommodate healthy sexual relationships in institutionalized settings?
• At what point does monitoring and supervision become overly intrusive?
• Are older adults fully aware of the potential ramifications of sharing sensitive information in cyberspace?
• What is the threshold for capacity to consent among older adults to understand the sexual nature of the act and consent to the act?

Nursing homes and health care providers may become concerned about potential liability if their organization provides digital devices or electronic platforms that are not closely monitored. Clinicians have a duty to protect patients under their care from risks associated with predators who target vulnerable and lonely people, whether financially, emotionally, or physically. Some patients in nursing home settings may benefit from discussing with their family members or attorney the possibility of completing a “sexual power of attorney”⁷ that could be completed in conjunction with an advance health care directive that addresses or authorizes an agent to make decisions about their sexual activities if cognitively impaired in the future.

One might also consider to what extent local regulatory oversight will protect your patient. Not all jurisdictions regulate online dating services similarly; many existing regulations focus on unfair contracts and pay less heed to safety concerns.

As a result, some dissatisfied clients have been known to sue an online dating service for breach of contract or misrepresentation. One of the most significant issues, however, is making sure there are appropriate background checks. Online dating services may need to change their policies to screen and verify for criminal background checks.⁸ Older adults interested in online dating should be made aware of these emerging issues.

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

Here are 5 commonly held beliefs about stopping tobacco use, and about your role in helping these patients, that go up in smoke on close inspection.

Treating nicotine use disorder isn’t really a psychiatrist’s job. False! Smoking is the leading preventable cause of death, causing 1 in every 5 deaths in the United States and as many as 1 of every 2 deaths among patients with depression, bipolar disorder, or schizophrenia.^1,2 As psychiatrists, our experience with treating addiction positions us to address nicotine use disorder more effectively than deferring exclusively to primary care.

I can’t treat my patients’ nicotine dependence until they are ready to quit. Not so! Treatment with varenicline, bupropion, or nicotine replacement therapy is likely to decrease smoking even if the patient has not made a commitment to quit. A smoker treated with pharmacotherapy is more likely to try to quit than one who is not receiving medication.^3,4

Motivational interviewing is an excellent intervention to facilitate readiness to quit smoking. Many smokers want to quit—but if they don’t believe that effective treatments exist or that psychiatrists provide such care, they won’t initiate that conversation with you.

Smokeless tobacco isn’t so bad. Poppycock! Chewing and dipping tobacco contains many undesirable chemicals, including abrasives, salts, sweeteners, and carcinogens. Smokeless tobacco is a risk factor for cancer of the mouth and pancreas, as well as tooth decay, periodontal disease, hypertension, hyperlipidemia, myocardial infarction, and fatal stroke.⁵

Nicotine replacement products are as bad as smoking. Claptrap! You can reassure patients that nicotine is not a carcinogen. If your patients use the same amount of nicotine but replace tobacco in whole or in part with a patch, gum, or an inhaler, they will have better health even if they use nicotine replacement for the rest of their life. Nicotine replacement products are less addictive than cigarettes because they release nicotine more slowly. (Cigarettes bring peak levels of nicotine to the brain even faster than IV administration does.) Nicotine replacement is recommended for at least 3 months after quitting tobacco or for as long the patient needs it.³

Nicotine replacement products are dangerous for current smokers. Balderdash! Many patients are afraid of using nicotine from >1 source. A common myth is that using a nicotine patch while smoking increases the risk of heart attack, which discourages patients from trying a nicotine replacement product before they are sure they will stop smoking. Nicotine replacement is likely to reduce the frequency of their smoking and reduce harm, not add to it.³

Here are 5 commonly held beliefs about stopping tobacco use, and about your role in helping these patients, that go up in smoke on close inspection.

Treating nicotine use disorder isn’t really a psychiatrist’s job. False! Smoking is the leading preventable cause of death, causing 1 in every 5 deaths in the United States and as many as 1 of every 2 deaths among patients with depression, bipolar disorder, or schizophrenia.^1,2 As psychiatrists, our experience with treating addiction positions us to address nicotine use disorder more effectively than deferring exclusively to primary care.

I can’t treat my patients’ nicotine dependence until they are ready to quit. Not so! Treatment with varenicline, bupropion, or nicotine replacement therapy is likely to decrease smoking even if the patient has not made a commitment to quit. A smoker treated with pharmacotherapy is more likely to try to quit than one who is not receiving medication.^3,4

Motivational interviewing is an excellent intervention to facilitate readiness to quit smoking. Many smokers want to quit—but if they don’t believe that effective treatments exist or that psychiatrists provide such care, they won’t initiate that conversation with you.

Smokeless tobacco isn’t so bad. Poppycock! Chewing and dipping tobacco contains many undesirable chemicals, including abrasives, salts, sweeteners, and carcinogens. Smokeless tobacco is a risk factor for cancer of the mouth and pancreas, as well as tooth decay, periodontal disease, hypertension, hyperlipidemia, myocardial infarction, and fatal stroke.⁵

Nicotine replacement products are as bad as smoking. Claptrap! You can reassure patients that nicotine is not a carcinogen. If your patients use the same amount of nicotine but replace tobacco in whole or in part with a patch, gum, or an inhaler, they will have better health even if they use nicotine replacement for the rest of their life. Nicotine replacement products are less addictive than cigarettes because they release nicotine more slowly. (Cigarettes bring peak levels of nicotine to the brain even faster than IV administration does.) Nicotine replacement is recommended for at least 3 months after quitting tobacco or for as long the patient needs it.³

Nicotine replacement products are dangerous for current smokers. Balderdash! Many patients are afraid of using nicotine from >1 source. A common myth is that using a nicotine patch while smoking increases the risk of heart attack, which discourages patients from trying a nicotine replacement product before they are sure they will stop smoking. Nicotine replacement is likely to reduce the frequency of their smoking and reduce harm, not add to it.³

Here are 5 commonly held beliefs about stopping tobacco use, and about your role in helping these patients, that go up in smoke on close inspection.

Treating nicotine use disorder isn’t really a psychiatrist’s job. False! Smoking is the leading preventable cause of death, causing 1 in every 5 deaths in the United States and as many as 1 of every 2 deaths among patients with depression, bipolar disorder, or schizophrenia.^1,2 As psychiatrists, our experience with treating addiction positions us to address nicotine use disorder more effectively than deferring exclusively to primary care.

I can’t treat my patients’ nicotine dependence until they are ready to quit. Not so! Treatment with varenicline, bupropion, or nicotine replacement therapy is likely to decrease smoking even if the patient has not made a commitment to quit. A smoker treated with pharmacotherapy is more likely to try to quit than one who is not receiving medication.^3,4

Motivational interviewing is an excellent intervention to facilitate readiness to quit smoking. Many smokers want to quit—but if they don’t believe that effective treatments exist or that psychiatrists provide such care, they won’t initiate that conversation with you.

Smokeless tobacco isn’t so bad. Poppycock! Chewing and dipping tobacco contains many undesirable chemicals, including abrasives, salts, sweeteners, and carcinogens. Smokeless tobacco is a risk factor for cancer of the mouth and pancreas, as well as tooth decay, periodontal disease, hypertension, hyperlipidemia, myocardial infarction, and fatal stroke.⁵

Nicotine replacement products are as bad as smoking. Claptrap! You can reassure patients that nicotine is not a carcinogen. If your patients use the same amount of nicotine but replace tobacco in whole or in part with a patch, gum, or an inhaler, they will have better health even if they use nicotine replacement for the rest of their life. Nicotine replacement products are less addictive than cigarettes because they release nicotine more slowly. (Cigarettes bring peak levels of nicotine to the brain even faster than IV administration does.) Nicotine replacement is recommended for at least 3 months after quitting tobacco or for as long the patient needs it.³

Nicotine replacement products are dangerous for current smokers. Balderdash! Many patients are afraid of using nicotine from >1 source. A common myth is that using a nicotine patch while smoking increases the risk of heart attack, which discourages patients from trying a nicotine replacement product before they are sure they will stop smoking. Nicotine replacement is likely to reduce the frequency of their smoking and reduce harm, not add to it.³

Developing your practice policies and sharing them with your patients is essential to building long-term, trusting relationships. Having a clear starting point helps avert disagreement down the road and allows patients to feel comfortable knowing what they are getting in to, which will provide a foundation on which you and the patient can focus on clinical matters.

What’s in a policy?
Policies should cover administrative aspects of care, such as mandated disclosures; relevant Health Insurance Portability and Accountability Act and Health Information Technology for Economic and Clinical Health Act information; hospital privilege status; and fees and payment policies. Your policies also will touch on areas where business overlaps with patient care, such as confidentiality and its limits, communication methods outside of session, and the risks and benefits of treatment (Table).
 

Address communication and billing policies for complex scenarios. Although these scenarios might not come up often, if you wait until you are confronted with the situation, the patient might (rightly) feel that she (he) wasn’t properly informed before giving consent. For example:

• For college students. Do you try to build college students’ autonomy by sending them all billing statements directly? If not, how will you handle the diagnosis code that appears on the statement, which their parents could see? What if the student doesn’t act on the statements—will you start mailing them to the parents? Should you mandate that you be able to talk with their parents?
• For adolescents. Consider whether you will allow them to communicate with you directly. Will they be able to e-mail you? How will you communicate with her (his) parents if your relationship is primarily with the teenager? How will you handle medication changes when the teenager prefers you keep everything private, but the parents have the right to informed consent?
• Will you charge for the time it takes you to talk with other providers (CPT 90887); review reports (CPT 90885); for e-mails or phone calls that are only a minute, or 10 minutes (e-mail, CPT 99444; brief phone calls, CPT 99441); or out-of-session refills? What if an insurance company does, or doesn’t, cover these codes? Is it different for patients you see occasionally for medication checks and for those whom you see weekly for therapy?

Psychodynamics of policies
Nowhere does being both a business and a service intersect more than when discussing how much you charge, and for what services. Patients may have little understanding of all the time you spend on their care, and why you choose to bill or not to bill for certain services. They could naturally develop transference reactions based on your policies, or might not even read them and just sign off, which also can give you useful clinical data.

Patients should review and accept your policies before the first appointment is booked. However, it is still meaningful to extend the opportunity to discuss them with a patient at the first session—but if they do not want to ask questions or discuss administrative matters, then follow their lead. By at least offering, this conveys to the patient that you wish to develop a trusting relationship, and that you are open to addressing conflicts or confusion at the beginning.

A valuable investment in time
Spending a bit of time now to create or review your current policies will save a lot of time—and perhaps money or legal action—later. If you can’t think of every scenario or issue today, don’t fret. Your experience in practice will inevitably lead you to recalibrate and update your policies. What’s most important is that your patients know where you stand and that they can trust you over the long-term.

Developing your practice policies and sharing them with your patients is essential to building long-term, trusting relationships. Having a clear starting point helps avert disagreement down the road and allows patients to feel comfortable knowing what they are getting in to, which will provide a foundation on which you and the patient can focus on clinical matters.

What’s in a policy?
Policies should cover administrative aspects of care, such as mandated disclosures; relevant Health Insurance Portability and Accountability Act and Health Information Technology for Economic and Clinical Health Act information; hospital privilege status; and fees and payment policies. Your policies also will touch on areas where business overlaps with patient care, such as confidentiality and its limits, communication methods outside of session, and the risks and benefits of treatment (Table).
 

Address communication and billing policies for complex scenarios. Although these scenarios might not come up often, if you wait until you are confronted with the situation, the patient might (rightly) feel that she (he) wasn’t properly informed before giving consent. For example:

• For college students. Do you try to build college students’ autonomy by sending them all billing statements directly? If not, how will you handle the diagnosis code that appears on the statement, which their parents could see? What if the student doesn’t act on the statements—will you start mailing them to the parents? Should you mandate that you be able to talk with their parents?
• For adolescents. Consider whether you will allow them to communicate with you directly. Will they be able to e-mail you? How will you communicate with her (his) parents if your relationship is primarily with the teenager? How will you handle medication changes when the teenager prefers you keep everything private, but the parents have the right to informed consent?
• Will you charge for the time it takes you to talk with other providers (CPT 90887); review reports (CPT 90885); for e-mails or phone calls that are only a minute, or 10 minutes (e-mail, CPT 99444; brief phone calls, CPT 99441); or out-of-session refills? What if an insurance company does, or doesn’t, cover these codes? Is it different for patients you see occasionally for medication checks and for those whom you see weekly for therapy?

Psychodynamics of policies
Nowhere does being both a business and a service intersect more than when discussing how much you charge, and for what services. Patients may have little understanding of all the time you spend on their care, and why you choose to bill or not to bill for certain services. They could naturally develop transference reactions based on your policies, or might not even read them and just sign off, which also can give you useful clinical data.

Patients should review and accept your policies before the first appointment is booked. However, it is still meaningful to extend the opportunity to discuss them with a patient at the first session—but if they do not want to ask questions or discuss administrative matters, then follow their lead. By at least offering, this conveys to the patient that you wish to develop a trusting relationship, and that you are open to addressing conflicts or confusion at the beginning.

A valuable investment in time
Spending a bit of time now to create or review your current policies will save a lot of time—and perhaps money or legal action—later. If you can’t think of every scenario or issue today, don’t fret. Your experience in practice will inevitably lead you to recalibrate and update your policies. What’s most important is that your patients know where you stand and that they can trust you over the long-term.

Developing your practice policies and sharing them with your patients is essential to building long-term, trusting relationships. Having a clear starting point helps avert disagreement down the road and allows patients to feel comfortable knowing what they are getting in to, which will provide a foundation on which you and the patient can focus on clinical matters.

What’s in a policy?
Policies should cover administrative aspects of care, such as mandated disclosures; relevant Health Insurance Portability and Accountability Act and Health Information Technology for Economic and Clinical Health Act information; hospital privilege status; and fees and payment policies. Your policies also will touch on areas where business overlaps with patient care, such as confidentiality and its limits, communication methods outside of session, and the risks and benefits of treatment (Table).
 

Address communication and billing policies for complex scenarios. Although these scenarios might not come up often, if you wait until you are confronted with the situation, the patient might (rightly) feel that she (he) wasn’t properly informed before giving consent. For example:

• For college students. Do you try to build college students’ autonomy by sending them all billing statements directly? If not, how will you handle the diagnosis code that appears on the statement, which their parents could see? What if the student doesn’t act on the statements—will you start mailing them to the parents? Should you mandate that you be able to talk with their parents?
• For adolescents. Consider whether you will allow them to communicate with you directly. Will they be able to e-mail you? How will you communicate with her (his) parents if your relationship is primarily with the teenager? How will you handle medication changes when the teenager prefers you keep everything private, but the parents have the right to informed consent?
• Will you charge for the time it takes you to talk with other providers (CPT 90887); review reports (CPT 90885); for e-mails or phone calls that are only a minute, or 10 minutes (e-mail, CPT 99444; brief phone calls, CPT 99441); or out-of-session refills? What if an insurance company does, or doesn’t, cover these codes? Is it different for patients you see occasionally for medication checks and for those whom you see weekly for therapy?

Psychodynamics of policies
Nowhere does being both a business and a service intersect more than when discussing how much you charge, and for what services. Patients may have little understanding of all the time you spend on their care, and why you choose to bill or not to bill for certain services. They could naturally develop transference reactions based on your policies, or might not even read them and just sign off, which also can give you useful clinical data.

Patients should review and accept your policies before the first appointment is booked. However, it is still meaningful to extend the opportunity to discuss them with a patient at the first session—but if they do not want to ask questions or discuss administrative matters, then follow their lead. By at least offering, this conveys to the patient that you wish to develop a trusting relationship, and that you are open to addressing conflicts or confusion at the beginning.

A valuable investment in time
Spending a bit of time now to create or review your current policies will save a lot of time—and perhaps money or legal action—later. If you can’t think of every scenario or issue today, don’t fret. Your experience in practice will inevitably lead you to recalibrate and update your policies. What’s most important is that your patients know where you stand and that they can trust you over the long-term.

Many of my patients ask, “Why do you have fortune cookies on your desk?” Then, I offer them one. I considered having other treats, but decided on fortune cookies because of:

Comfort. The cookie is a small treat for those who want one.

Diet. You don’t have to eat the cookie to enjoy it; you can still read the fortune. For patients who have an eating disorder, the cookie allows us to naturally transition the conversation to issues they are experiencing.

Cultural competency. I treat patients of many backgrounds. Some have never seen a fortune cookie (remember to warn them there is a fortune inside!). Others know the fortune cookie is not a Chinese invention,¹ as it is popularly thought to be.

Impulsivity. Do patients grab a cookie immediately, wait for one to be offered, or ask for one?

At this point, I ask patients to tell me their fortune. This allows me to assess:

Fine motor skills. Do they have a hand tremor or weakness, or a problem with involuntary movement? How well do they open the individually wrapped cookie?

Problem solving. On the slip of paper in the cookie, fortunes are printed on one side; on the other side are lucky numbers and a Chinese phrase. Some patients fail to turn the slip of paper over; they look it and say, “There are only numbers on this piece of paper.”

Eyesight. Can they see without glasses? Did they bring their glasses? (By extension, I can gauge whether they need, and use, glasses when reaching for a pill bottle in the medicine cabinet.)

Literacy. Can they read their fortune aloud?

Last, I ask what the fortune means and how it might apply to them. This helps me understand their:

Thought process. I am looking for how they think: Abstractly? Concretely? How well do they articulate and explain the meaning of the fortune?

Insight. Having them explain how the fortune applies to them can be helpful to understanding their thinking.

Many of my patients ask, “Why do you have fortune cookies on your desk?” Then, I offer them one. I considered having other treats, but decided on fortune cookies because of:

Comfort. The cookie is a small treat for those who want one.

Diet. You don’t have to eat the cookie to enjoy it; you can still read the fortune. For patients who have an eating disorder, the cookie allows us to naturally transition the conversation to issues they are experiencing.

Cultural competency. I treat patients of many backgrounds. Some have never seen a fortune cookie (remember to warn them there is a fortune inside!). Others know the fortune cookie is not a Chinese invention,¹ as it is popularly thought to be.

Impulsivity. Do patients grab a cookie immediately, wait for one to be offered, or ask for one?

At this point, I ask patients to tell me their fortune. This allows me to assess:

Fine motor skills. Do they have a hand tremor or weakness, or a problem with involuntary movement? How well do they open the individually wrapped cookie?

Problem solving. On the slip of paper in the cookie, fortunes are printed on one side; on the other side are lucky numbers and a Chinese phrase. Some patients fail to turn the slip of paper over; they look it and say, “There are only numbers on this piece of paper.”

Eyesight. Can they see without glasses? Did they bring their glasses? (By extension, I can gauge whether they need, and use, glasses when reaching for a pill bottle in the medicine cabinet.)

Literacy. Can they read their fortune aloud?

Last, I ask what the fortune means and how it might apply to them. This helps me understand their:

Thought process. I am looking for how they think: Abstractly? Concretely? How well do they articulate and explain the meaning of the fortune?

Insight. Having them explain how the fortune applies to them can be helpful to understanding their thinking.

Many of my patients ask, “Why do you have fortune cookies on your desk?” Then, I offer them one. I considered having other treats, but decided on fortune cookies because of:

Comfort. The cookie is a small treat for those who want one.

Diet. You don’t have to eat the cookie to enjoy it; you can still read the fortune. For patients who have an eating disorder, the cookie allows us to naturally transition the conversation to issues they are experiencing.

Cultural competency. I treat patients of many backgrounds. Some have never seen a fortune cookie (remember to warn them there is a fortune inside!). Others know the fortune cookie is not a Chinese invention,¹ as it is popularly thought to be.

Impulsivity. Do patients grab a cookie immediately, wait for one to be offered, or ask for one?

At this point, I ask patients to tell me their fortune. This allows me to assess:

Fine motor skills. Do they have a hand tremor or weakness, or a problem with involuntary movement? How well do they open the individually wrapped cookie?

Problem solving. On the slip of paper in the cookie, fortunes are printed on one side; on the other side are lucky numbers and a Chinese phrase. Some patients fail to turn the slip of paper over; they look it and say, “There are only numbers on this piece of paper.”

Eyesight. Can they see without glasses? Did they bring their glasses? (By extension, I can gauge whether they need, and use, glasses when reaching for a pill bottle in the medicine cabinet.)

Literacy. Can they read their fortune aloud?

Last, I ask what the fortune means and how it might apply to them. This helps me understand their:

Thought process. I am looking for how they think: Abstractly? Concretely? How well do they articulate and explain the meaning of the fortune?

Insight. Having them explain how the fortune applies to them can be helpful to understanding their thinking.