Pearls

Methadone maintenance therapy is widely used for helping patients recover from an opioid use disor­der. When these patients develop an acute medical problem that requires hospital­ization, there often is confusion among providers regarding methadone pharma­cology, regulations, and general safety issues. We have observed that the lack of awareness of these practices can lead to poor medical and surgical outcomes, increased length of stay, and diminished patient satisfaction.

Consider the following common pit­falls—all of which we have encountered on our psychiatry consult service—and ways to avoid them when treating methadone-maintained patients.

Don’t give a full methadone maintenance dosage without verifying the dosage and the date when it was last administered. Methadone typically has a long, but vari­able, half-life, with ranges of 4 to 130 hours being reported.¹ Do not rush to give the full dose without verification from the patient’s methadone maintenance treatment pro­gram (MMTP). Small doses—not to exceed 40 mg in 24 hours—can be administered until you verify the dosage. Multiple days of missed dosing result in decreased toler­ance and will require a dosage reduction.

Consult with the MMTP when restarting methadone in a patient who has missed any days of outpatient dosing. Because metha­done can take days to reach a serum steady state, it can cause oversedation or obtunda­tion after it’s restarted in a person who has lost tolerance due to multiple consecutive days of missed doses.

Don’t automatically give the full, veri­fied dose if the patient appears sedated. A variety of other substances (benzodiaz­epines, heroin, tricyclic antidepressants) can increase the effects of methadone. Even the verified methadone maintenance dos­age may need to be reduced or held until these other substances are cleared from the patient’s system.

Don’t be afraid to adjust the metha­done dosage if medically indicated. Medically hospitalized patients might be placed on medications that can alter metha­done metabolism. The primary enzyme responsible for methadone metabolism is cytochrome P450 3A4, which can cre­ate significant drug-drug interactions with rifampin, carbamazepine, phenytoin, and barbiturates, among others.²

Don’t taper methadone just because the patient does not want to be on it any longer. A patient’s methadone dosage should be adjusted in the hospital only if there is an acute medical indication to do so. Otherwise, all dosage changes must be made on an outpatient basis at the MMTP.

Don’t be afraid to give opioids to treat acute pain. Methadone maintenance does not treat acute pain. In fact, compared with the general population, these patients likely will need a higher-than-expected opioid dosage to treat acute pain.³

Don’t initiate methadone maintenance in the hospital. Methadone maintenance can be initiated only at an MMTP that has been certified by appropriate federal and state agencies.⁴ Small doses of methadone can be given to treat or prevent opioid withdrawal in patients admitted to the hospital for conditions other than an opi­oid use disorder. An exception: A pregnant woman with an opioid use disorder who seeks methadone initiation in the hospital.

Don’t forget to monitor the QTc interval. Methadone can prolong the QTc interval. Although the overall rate of cardiac toxicity is low, it is reasonable to obtain an electro­cardiogram in patients with heart disease, those predisposed to prolonged QTc, or those taking another QT-prolonging agent.5

Don’t let negative countertransference prevent you from giving quality care. Patients with a drug addiction can be challenging. They can elicit anger among members of their treatment team because of their character pathology or a provid­er’s discomfort and unfamiliarity. One might be tempted to spend less time with so-called “difficult” patients, but keep in mind that methadone-maintained patients often carry chaotic medical and social issues that require a thoughtful and thor­ough approach to treatment.

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

Methadone maintenance therapy is widely used for helping patients recover from an opioid use disor­der. When these patients develop an acute medical problem that requires hospital­ization, there often is confusion among providers regarding methadone pharma­cology, regulations, and general safety issues. We have observed that the lack of awareness of these practices can lead to poor medical and surgical outcomes, increased length of stay, and diminished patient satisfaction.

Consider the following common pit­falls—all of which we have encountered on our psychiatry consult service—and ways to avoid them when treating methadone-maintained patients.

Don’t give a full methadone maintenance dosage without verifying the dosage and the date when it was last administered. Methadone typically has a long, but vari­able, half-life, with ranges of 4 to 130 hours being reported.¹ Do not rush to give the full dose without verification from the patient’s methadone maintenance treatment pro­gram (MMTP). Small doses—not to exceed 40 mg in 24 hours—can be administered until you verify the dosage. Multiple days of missed dosing result in decreased toler­ance and will require a dosage reduction.

Consult with the MMTP when restarting methadone in a patient who has missed any days of outpatient dosing. Because metha­done can take days to reach a serum steady state, it can cause oversedation or obtunda­tion after it’s restarted in a person who has lost tolerance due to multiple consecutive days of missed doses.

Don’t automatically give the full, veri­fied dose if the patient appears sedated. A variety of other substances (benzodiaz­epines, heroin, tricyclic antidepressants) can increase the effects of methadone. Even the verified methadone maintenance dos­age may need to be reduced or held until these other substances are cleared from the patient’s system.

Don’t be afraid to adjust the metha­done dosage if medically indicated. Medically hospitalized patients might be placed on medications that can alter metha­done metabolism. The primary enzyme responsible for methadone metabolism is cytochrome P450 3A4, which can cre­ate significant drug-drug interactions with rifampin, carbamazepine, phenytoin, and barbiturates, among others.²

Don’t taper methadone just because the patient does not want to be on it any longer. A patient’s methadone dosage should be adjusted in the hospital only if there is an acute medical indication to do so. Otherwise, all dosage changes must be made on an outpatient basis at the MMTP.

Don’t be afraid to give opioids to treat acute pain. Methadone maintenance does not treat acute pain. In fact, compared with the general population, these patients likely will need a higher-than-expected opioid dosage to treat acute pain.³

Don’t initiate methadone maintenance in the hospital. Methadone maintenance can be initiated only at an MMTP that has been certified by appropriate federal and state agencies.⁴ Small doses of methadone can be given to treat or prevent opioid withdrawal in patients admitted to the hospital for conditions other than an opi­oid use disorder. An exception: A pregnant woman with an opioid use disorder who seeks methadone initiation in the hospital.

Don’t forget to monitor the QTc interval. Methadone can prolong the QTc interval. Although the overall rate of cardiac toxicity is low, it is reasonable to obtain an electro­cardiogram in patients with heart disease, those predisposed to prolonged QTc, or those taking another QT-prolonging agent.5

Don’t let negative countertransference prevent you from giving quality care. Patients with a drug addiction can be challenging. They can elicit anger among members of their treatment team because of their character pathology or a provid­er’s discomfort and unfamiliarity. One might be tempted to spend less time with so-called “difficult” patients, but keep in mind that methadone-maintained patients often carry chaotic medical and social issues that require a thoughtful and thor­ough approach to treatment.

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

Methadone maintenance therapy is widely used for helping patients recover from an opioid use disor­der. When these patients develop an acute medical problem that requires hospital­ization, there often is confusion among providers regarding methadone pharma­cology, regulations, and general safety issues. We have observed that the lack of awareness of these practices can lead to poor medical and surgical outcomes, increased length of stay, and diminished patient satisfaction.

Consider the following common pit­falls—all of which we have encountered on our psychiatry consult service—and ways to avoid them when treating methadone-maintained patients.

Don’t give a full methadone maintenance dosage without verifying the dosage and the date when it was last administered. Methadone typically has a long, but vari­able, half-life, with ranges of 4 to 130 hours being reported.¹ Do not rush to give the full dose without verification from the patient’s methadone maintenance treatment pro­gram (MMTP). Small doses—not to exceed 40 mg in 24 hours—can be administered until you verify the dosage. Multiple days of missed dosing result in decreased toler­ance and will require a dosage reduction.

Consult with the MMTP when restarting methadone in a patient who has missed any days of outpatient dosing. Because metha­done can take days to reach a serum steady state, it can cause oversedation or obtunda­tion after it’s restarted in a person who has lost tolerance due to multiple consecutive days of missed doses.

Don’t automatically give the full, veri­fied dose if the patient appears sedated. A variety of other substances (benzodiaz­epines, heroin, tricyclic antidepressants) can increase the effects of methadone. Even the verified methadone maintenance dos­age may need to be reduced or held until these other substances are cleared from the patient’s system.

Don’t be afraid to adjust the metha­done dosage if medically indicated. Medically hospitalized patients might be placed on medications that can alter metha­done metabolism. The primary enzyme responsible for methadone metabolism is cytochrome P450 3A4, which can cre­ate significant drug-drug interactions with rifampin, carbamazepine, phenytoin, and barbiturates, among others.²

Don’t taper methadone just because the patient does not want to be on it any longer. A patient’s methadone dosage should be adjusted in the hospital only if there is an acute medical indication to do so. Otherwise, all dosage changes must be made on an outpatient basis at the MMTP.

Don’t be afraid to give opioids to treat acute pain. Methadone maintenance does not treat acute pain. In fact, compared with the general population, these patients likely will need a higher-than-expected opioid dosage to treat acute pain.³

Don’t initiate methadone maintenance in the hospital. Methadone maintenance can be initiated only at an MMTP that has been certified by appropriate federal and state agencies.⁴ Small doses of methadone can be given to treat or prevent opioid withdrawal in patients admitted to the hospital for conditions other than an opi­oid use disorder. An exception: A pregnant woman with an opioid use disorder who seeks methadone initiation in the hospital.

Don’t forget to monitor the QTc interval. Methadone can prolong the QTc interval. Although the overall rate of cardiac toxicity is low, it is reasonable to obtain an electro­cardiogram in patients with heart disease, those predisposed to prolonged QTc, or those taking another QT-prolonging agent.5

Don’t let negative countertransference prevent you from giving quality care. Patients with a drug addiction can be challenging. They can elicit anger among members of their treatment team because of their character pathology or a provid­er’s discomfort and unfamiliarity. One might be tempted to spend less time with so-called “difficult” patients, but keep in mind that methadone-maintained patients often carry chaotic medical and social issues that require a thoughtful and thor­ough approach to treatment.

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

Mindfulness has become an impor­tant supportive psychotherapeutic intervention for a variety of psychi­atric conditions,^1-3 regardless of what other modalities the psychiatrist employs (eg, phar­macotherapy, other psychotherapeutic inter­ventions). In general, mindfulness involves engaging in meditation exercises, analogous to working out in the gym, to strengthen “mindfulness muscles.” These exercises increase the patient’s ability to remain in the moment, “as is,” and without judgment.

I think of mindfulness exercises as an “ego gym” for the patient as he (she) gets to exercise the ego functions of agency, atten­tion, awareness, acceptance, and empathy. Advising and helping patients to be present and exist with their thoughts is a psycho-educational approach and form of advice consistent with principles of supportive therapy. In this article, I provide a practical framework for doing and teaching mind­fulness using the mnemonic BREATHE.

Flow is more important than sequence
The 7 elements of mindfulness exercises contained in BREATHE do not need to be done in order. Rather, mindfulness gener­ally involves each of the following elements flowing, or tumbling, into each other, not standing as a distinct entity.

Being in the now, “as is,” without judg­ment (eg, being present/being vs doing; Buddhist origins; diaphragmatic breath­ing/body scans; “breathing-space” medi­tation exercises). In general, mindfulness meditation exercises focus on some sen­sory experience (eg, the physical sensa­tion of breathing or of a difficult emotion, or sounds and smells in the environment). Some mindfulness meditations are called “body scans.”

A patient can shift his (her) focus during mindfulness meditation to a sound or some other stimulus intruding on his original meditative focus, such as an intense emo­tion or pain, that might arise and become the new focus of mindfulness meditation. Ideally, mindfulness exercises are done without the intention of achieving anything (ie, there is no “striving” for anything when being mindful). Striving, after all, is doing; mindfulness is being.

R(AIN). Mindfulness, as operationalized by Kabat-Zinn,⁴ starts with a focus on breath­ing similar to many meditation practices in Buddhism. When the patient wanders into intense emotions, such as suffering, that become the focus of mindfulness, use the mnemonic-within-a-mnemonic RAIN as a guide; typically, this involves first anchoring with a few deep breaths, and then becoming mindful by:
   • Recognizing (and labeling, nam­ing, “tagging”) the emotion (eg, sad, hurt, angry, embarrassed); this engages frontal lobe processes that diminishes amygdaloid limbic system overactivity¹
   • Allowing (ie, accepting suffering)
   • Investigating, with an open and curious attitude, using one’s senses to experience, feel, and explore thoughts and emotions
   • Non-identifying with one’s thoughts, feelings, emotions, or suffering (expressed in the important mindfulness refrain: “You are not your thoughts or emotions. You are the entity that simply is aware of them.”).

Experiencing. The patient stops at the perceived experience or sensation and does not automatically react with thoughts, emo­tions, distress, or judgments. Mindfulness is a psychotherapeutic intervention that is “more experiential than cognitive.” Encourage the patient to stop at the “door of experience” and not enter the doors of thinking, emotion, and feeling.

Accepting without judgment—also called “awarenessing” or “avoid avoiding.” This involves being aware of the experi­ence regardless of what it entails, whether suffering, thoughts, emotions, or pain, and not trying to escape or avoid the difficult experience. Psychodynamic principles help us understand how psychological defenses designed to avoid the experience of the “unbearable affect” often lead to more problems for patients. In mindfulness, only avoiding is to be avoided.

Thoughts. People tend to over-identify with their thoughts and emotions. In mindfulness, you emphasize to the patient that (1) he is not his thoughts or emotions and (2) these cognitive processes do not represent facts.

Heartfulness—or, healthy, happy, free from harm. Mindfulness from the Buddhist tradition also includes “heartfulness” and “loving-kindness” and the development of compassion and kindness for one’s self and others. Mindfulness meditation there­fore also involves development of loving-kindness/compassion toward oneself and others—even one’s enemies (eg, “May I be healthy, happy, and free from harm.”). I have found this aspect of mindfulness useful for patients who feel angry or entitled, with characterological problems.

Empathy for others. As an extension of, or further emphasis on, loving-kindness, medi­tation focuses on understanding the suffer­ing of others. In certain monastic practices, this mindfulness meditation involves “tak­ing on” the suffering of another.

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

Mindfulness has become an impor­tant supportive psychotherapeutic intervention for a variety of psychi­atric conditions,^1-3 regardless of what other modalities the psychiatrist employs (eg, phar­macotherapy, other psychotherapeutic inter­ventions). In general, mindfulness involves engaging in meditation exercises, analogous to working out in the gym, to strengthen “mindfulness muscles.” These exercises increase the patient’s ability to remain in the moment, “as is,” and without judgment.

I think of mindfulness exercises as an “ego gym” for the patient as he (she) gets to exercise the ego functions of agency, atten­tion, awareness, acceptance, and empathy. Advising and helping patients to be present and exist with their thoughts is a psycho-educational approach and form of advice consistent with principles of supportive therapy. In this article, I provide a practical framework for doing and teaching mind­fulness using the mnemonic BREATHE.

Flow is more important than sequence
The 7 elements of mindfulness exercises contained in BREATHE do not need to be done in order. Rather, mindfulness gener­ally involves each of the following elements flowing, or tumbling, into each other, not standing as a distinct entity.

Being in the now, “as is,” without judg­ment (eg, being present/being vs doing; Buddhist origins; diaphragmatic breath­ing/body scans; “breathing-space” medi­tation exercises). In general, mindfulness meditation exercises focus on some sen­sory experience (eg, the physical sensa­tion of breathing or of a difficult emotion, or sounds and smells in the environment). Some mindfulness meditations are called “body scans.”

A patient can shift his (her) focus during mindfulness meditation to a sound or some other stimulus intruding on his original meditative focus, such as an intense emo­tion or pain, that might arise and become the new focus of mindfulness meditation. Ideally, mindfulness exercises are done without the intention of achieving anything (ie, there is no “striving” for anything when being mindful). Striving, after all, is doing; mindfulness is being.

R(AIN). Mindfulness, as operationalized by Kabat-Zinn,⁴ starts with a focus on breath­ing similar to many meditation practices in Buddhism. When the patient wanders into intense emotions, such as suffering, that become the focus of mindfulness, use the mnemonic-within-a-mnemonic RAIN as a guide; typically, this involves first anchoring with a few deep breaths, and then becoming mindful by:
   • Recognizing (and labeling, nam­ing, “tagging”) the emotion (eg, sad, hurt, angry, embarrassed); this engages frontal lobe processes that diminishes amygdaloid limbic system overactivity¹
   • Allowing (ie, accepting suffering)
   • Investigating, with an open and curious attitude, using one’s senses to experience, feel, and explore thoughts and emotions
   • Non-identifying with one’s thoughts, feelings, emotions, or suffering (expressed in the important mindfulness refrain: “You are not your thoughts or emotions. You are the entity that simply is aware of them.”).

Experiencing. The patient stops at the perceived experience or sensation and does not automatically react with thoughts, emo­tions, distress, or judgments. Mindfulness is a psychotherapeutic intervention that is “more experiential than cognitive.” Encourage the patient to stop at the “door of experience” and not enter the doors of thinking, emotion, and feeling.

Accepting without judgment—also called “awarenessing” or “avoid avoiding.” This involves being aware of the experi­ence regardless of what it entails, whether suffering, thoughts, emotions, or pain, and not trying to escape or avoid the difficult experience. Psychodynamic principles help us understand how psychological defenses designed to avoid the experience of the “unbearable affect” often lead to more problems for patients. In mindfulness, only avoiding is to be avoided.

Thoughts. People tend to over-identify with their thoughts and emotions. In mindfulness, you emphasize to the patient that (1) he is not his thoughts or emotions and (2) these cognitive processes do not represent facts.

Heartfulness—or, healthy, happy, free from harm. Mindfulness from the Buddhist tradition also includes “heartfulness” and “loving-kindness” and the development of compassion and kindness for one’s self and others. Mindfulness meditation there­fore also involves development of loving-kindness/compassion toward oneself and others—even one’s enemies (eg, “May I be healthy, happy, and free from harm.”). I have found this aspect of mindfulness useful for patients who feel angry or entitled, with characterological problems.

Empathy for others. As an extension of, or further emphasis on, loving-kindness, medi­tation focuses on understanding the suffer­ing of others. In certain monastic practices, this mindfulness meditation involves “tak­ing on” the suffering of another.

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

Mindfulness has become an impor­tant supportive psychotherapeutic intervention for a variety of psychi­atric conditions,^1-3 regardless of what other modalities the psychiatrist employs (eg, phar­macotherapy, other psychotherapeutic inter­ventions). In general, mindfulness involves engaging in meditation exercises, analogous to working out in the gym, to strengthen “mindfulness muscles.” These exercises increase the patient’s ability to remain in the moment, “as is,” and without judgment.

I think of mindfulness exercises as an “ego gym” for the patient as he (she) gets to exercise the ego functions of agency, atten­tion, awareness, acceptance, and empathy. Advising and helping patients to be present and exist with their thoughts is a psycho-educational approach and form of advice consistent with principles of supportive therapy. In this article, I provide a practical framework for doing and teaching mind­fulness using the mnemonic BREATHE.

Flow is more important than sequence
The 7 elements of mindfulness exercises contained in BREATHE do not need to be done in order. Rather, mindfulness gener­ally involves each of the following elements flowing, or tumbling, into each other, not standing as a distinct entity.

Being in the now, “as is,” without judg­ment (eg, being present/being vs doing; Buddhist origins; diaphragmatic breath­ing/body scans; “breathing-space” medi­tation exercises). In general, mindfulness meditation exercises focus on some sen­sory experience (eg, the physical sensa­tion of breathing or of a difficult emotion, or sounds and smells in the environment). Some mindfulness meditations are called “body scans.”

A patient can shift his (her) focus during mindfulness meditation to a sound or some other stimulus intruding on his original meditative focus, such as an intense emo­tion or pain, that might arise and become the new focus of mindfulness meditation. Ideally, mindfulness exercises are done without the intention of achieving anything (ie, there is no “striving” for anything when being mindful). Striving, after all, is doing; mindfulness is being.

R(AIN). Mindfulness, as operationalized by Kabat-Zinn,⁴ starts with a focus on breath­ing similar to many meditation practices in Buddhism. When the patient wanders into intense emotions, such as suffering, that become the focus of mindfulness, use the mnemonic-within-a-mnemonic RAIN as a guide; typically, this involves first anchoring with a few deep breaths, and then becoming mindful by:
   • Recognizing (and labeling, nam­ing, “tagging”) the emotion (eg, sad, hurt, angry, embarrassed); this engages frontal lobe processes that diminishes amygdaloid limbic system overactivity¹
   • Allowing (ie, accepting suffering)
   • Investigating, with an open and curious attitude, using one’s senses to experience, feel, and explore thoughts and emotions
   • Non-identifying with one’s thoughts, feelings, emotions, or suffering (expressed in the important mindfulness refrain: “You are not your thoughts or emotions. You are the entity that simply is aware of them.”).

Experiencing. The patient stops at the perceived experience or sensation and does not automatically react with thoughts, emo­tions, distress, or judgments. Mindfulness is a psychotherapeutic intervention that is “more experiential than cognitive.” Encourage the patient to stop at the “door of experience” and not enter the doors of thinking, emotion, and feeling.

Accepting without judgment—also called “awarenessing” or “avoid avoiding.” This involves being aware of the experi­ence regardless of what it entails, whether suffering, thoughts, emotions, or pain, and not trying to escape or avoid the difficult experience. Psychodynamic principles help us understand how psychological defenses designed to avoid the experience of the “unbearable affect” often lead to more problems for patients. In mindfulness, only avoiding is to be avoided.

Thoughts. People tend to over-identify with their thoughts and emotions. In mindfulness, you emphasize to the patient that (1) he is not his thoughts or emotions and (2) these cognitive processes do not represent facts.

Heartfulness—or, healthy, happy, free from harm. Mindfulness from the Buddhist tradition also includes “heartfulness” and “loving-kindness” and the development of compassion and kindness for one’s self and others. Mindfulness meditation there­fore also involves development of loving-kindness/compassion toward oneself and others—even one’s enemies (eg, “May I be healthy, happy, and free from harm.”). I have found this aspect of mindfulness useful for patients who feel angry or entitled, with characterological problems.

Empathy for others. As an extension of, or further emphasis on, loving-kindness, medi­tation focuses on understanding the suffer­ing of others. In certain monastic practices, this mindfulness meditation involves “tak­ing on” the suffering of another.

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

Pulling up charts. Phone tag. Prior authorizations. Rinse, repeat.

Reminiscent of the movie Groundhog Day, the daily grind in running a practice rarely gives way. Some days there are more faxes to process or paperwork to push than other days but, on the whole, there’s no escaping the tedium and time sink that these gloomy chores engender. In some practices, an assistant is hired to absorb the barrage; if not, it is left to the clinician to handle at the expense of time for patient care or life out­side practice.

Compounding matters, creating new systems to assuage these tasks can feel like a sisyphean endeavor, because the energy required to start likely will be more than what is already being expended. For example, switching from paper-based to electronic systems is tantalizing but incurs its own learning curve and has a financial cost. Likewise, hiring administrative help demands a significant investment in train­ing and, if patient contact is part of the job description, even more preparation is nec­essary because she (he) becomes the public face of the practice. Fortunately, both of these options pay dividends in the long run.

Yet, even with some basic strategies, what seems like the inevitability of inertia can be reshaped into a more efficient, less quotid­ian experience. Consider the following ways to streamline processes and eliminate time wasted and not spent on providing care.

Patient-specific tasks
Prior authorizations. The typical process is to have to call the insurance company to have the paperwork faxed, burning 5 to 15 minutes by being placed on hold or being transferred between departments. Instead, ask the patient to call the insurance com­pany (she [he] should get the phone num­ber from the pharmacist and have your fax number handy) and request the paper­work, with her (his) demographic informa­tion pre-filled in, be faxed to your office. If she is told by the insurance company that the doctor has to call, instruct the patient to explain it is merely a request to have forms faxed and to call again and speak with a different agent if necessary. If the patient pushes back, explaining that this helps keeps your rates lower or from having to bill for this specific time usually smooths things over.

Voicemails. Listening (and re-listening) to a long voicemail takes time. Although using a professional transcription service might be costly, it may be less expensive than your time if you get lots of long voicemails. Or, consider using a service that provides com­puter-generated transcriptions. Although less accurate, it often allows you to skim and is more affordable.

Scheduling. Booking follow-up appoint­ments during a session uses valuable clini­cal care time, but booking them outside of session can be laborious. As an alter­native, offer online scheduling through your electronic medical record (EMR) or a stand-alone service that allows you to retain control over what times you are available and how soon and far out patients can book. Be sure that only your current patients and, perhaps, colleagues (for scheduling phone calls) have access to your calendar, and make your cancellation policy explicitly clear.

Refill requests. Patients routinely opt-in for automatic prescription refill requests at their pharmacy, believing it is a no-brainer for convenience’s sake. However, for psychiatrists who prescribe only enough refills to last until the patient’s next appointment, these requests can become a burden because they can’t be ignored, but shouldn’t necessarily be acted upon either. Often, time is spent clarifying with the patient if a refill is really needed, and some­times—consciously or unconsciously— patients use automatic requests to bypass having to come in for an appointment. As an alternative, ask your patients to opt-out of auto-refill programs and to contact you directly if they are about to run out of medication.

Prescreening. An inordinate amount of time can be spent ensuring that a pro­spective patient is a good fit from a clini­cal, scheduling, and payment perspective. Save time by having a simple prescreen­ing process that conveys that you care, yet want to make sure certain criteria are met before you accept a patient into the prac­tice. This is where having a trained assis­tant or an electronic prescreening option can be useful.

Practice at large
Electronic charts. Common complaints about EMRs among users are they are clunky, convoluted, and slow, and the EMR “flow” does not match the provider’s. Although each extra click might only take a few sec­onds, the loss of rhythm is draining and leads to a dissatisfying, tired feeling. Be sure when selecting an EMR that the user experience is considered as important as functionality.

Billing statements. Write or print, fold, place in an envelope, put a stamp on the envelope, address the envelope, take it to the mailbox. Need more be said about how inefficient this is? Use your EMR, a biller, or billing software to send statements automatically.

Of course, make sure that any method that employs technology or outsourc­ing to a service has appropriate Health Insurance Portability and Accountability Act safeguards.

Nothing to lose but your chains
Although running a practice gives you some freedom in your schedule, with that comes the shackles of processing adminis­trative tasks that accompany clinical care. Finding ways to handle them more effi­ciently leads to improved job satisfaction and more time for patient care. You and your patients will both benefit.

Disclosure
Dr. Braslow is the founder of Luminello.com.

Pulling up charts. Phone tag. Prior authorizations. Rinse, repeat.

Reminiscent of the movie Groundhog Day, the daily grind in running a practice rarely gives way. Some days there are more faxes to process or paperwork to push than other days but, on the whole, there’s no escaping the tedium and time sink that these gloomy chores engender. In some practices, an assistant is hired to absorb the barrage; if not, it is left to the clinician to handle at the expense of time for patient care or life out­side practice.

Compounding matters, creating new systems to assuage these tasks can feel like a sisyphean endeavor, because the energy required to start likely will be more than what is already being expended. For example, switching from paper-based to electronic systems is tantalizing but incurs its own learning curve and has a financial cost. Likewise, hiring administrative help demands a significant investment in train­ing and, if patient contact is part of the job description, even more preparation is nec­essary because she (he) becomes the public face of the practice. Fortunately, both of these options pay dividends in the long run.

Yet, even with some basic strategies, what seems like the inevitability of inertia can be reshaped into a more efficient, less quotid­ian experience. Consider the following ways to streamline processes and eliminate time wasted and not spent on providing care.

Patient-specific tasks
Prior authorizations. The typical process is to have to call the insurance company to have the paperwork faxed, burning 5 to 15 minutes by being placed on hold or being transferred between departments. Instead, ask the patient to call the insurance com­pany (she [he] should get the phone num­ber from the pharmacist and have your fax number handy) and request the paper­work, with her (his) demographic informa­tion pre-filled in, be faxed to your office. If she is told by the insurance company that the doctor has to call, instruct the patient to explain it is merely a request to have forms faxed and to call again and speak with a different agent if necessary. If the patient pushes back, explaining that this helps keeps your rates lower or from having to bill for this specific time usually smooths things over.

Voicemails. Listening (and re-listening) to a long voicemail takes time. Although using a professional transcription service might be costly, it may be less expensive than your time if you get lots of long voicemails. Or, consider using a service that provides com­puter-generated transcriptions. Although less accurate, it often allows you to skim and is more affordable.

Scheduling. Booking follow-up appoint­ments during a session uses valuable clini­cal care time, but booking them outside of session can be laborious. As an alter­native, offer online scheduling through your electronic medical record (EMR) or a stand-alone service that allows you to retain control over what times you are available and how soon and far out patients can book. Be sure that only your current patients and, perhaps, colleagues (for scheduling phone calls) have access to your calendar, and make your cancellation policy explicitly clear.

Refill requests. Patients routinely opt-in for automatic prescription refill requests at their pharmacy, believing it is a no-brainer for convenience’s sake. However, for psychiatrists who prescribe only enough refills to last until the patient’s next appointment, these requests can become a burden because they can’t be ignored, but shouldn’t necessarily be acted upon either. Often, time is spent clarifying with the patient if a refill is really needed, and some­times—consciously or unconsciously— patients use automatic requests to bypass having to come in for an appointment. As an alternative, ask your patients to opt-out of auto-refill programs and to contact you directly if they are about to run out of medication.

Prescreening. An inordinate amount of time can be spent ensuring that a pro­spective patient is a good fit from a clini­cal, scheduling, and payment perspective. Save time by having a simple prescreen­ing process that conveys that you care, yet want to make sure certain criteria are met before you accept a patient into the prac­tice. This is where having a trained assis­tant or an electronic prescreening option can be useful.

Practice at large
Electronic charts. Common complaints about EMRs among users are they are clunky, convoluted, and slow, and the EMR “flow” does not match the provider’s. Although each extra click might only take a few sec­onds, the loss of rhythm is draining and leads to a dissatisfying, tired feeling. Be sure when selecting an EMR that the user experience is considered as important as functionality.

Billing statements. Write or print, fold, place in an envelope, put a stamp on the envelope, address the envelope, take it to the mailbox. Need more be said about how inefficient this is? Use your EMR, a biller, or billing software to send statements automatically.

Of course, make sure that any method that employs technology or outsourc­ing to a service has appropriate Health Insurance Portability and Accountability Act safeguards.

Nothing to lose but your chains
Although running a practice gives you some freedom in your schedule, with that comes the shackles of processing adminis­trative tasks that accompany clinical care. Finding ways to handle them more effi­ciently leads to improved job satisfaction and more time for patient care. You and your patients will both benefit.

Disclosure
Dr. Braslow is the founder of Luminello.com.

Pulling up charts. Phone tag. Prior authorizations. Rinse, repeat.

Reminiscent of the movie Groundhog Day, the daily grind in running a practice rarely gives way. Some days there are more faxes to process or paperwork to push than other days but, on the whole, there’s no escaping the tedium and time sink that these gloomy chores engender. In some practices, an assistant is hired to absorb the barrage; if not, it is left to the clinician to handle at the expense of time for patient care or life out­side practice.

Compounding matters, creating new systems to assuage these tasks can feel like a sisyphean endeavor, because the energy required to start likely will be more than what is already being expended. For example, switching from paper-based to electronic systems is tantalizing but incurs its own learning curve and has a financial cost. Likewise, hiring administrative help demands a significant investment in train­ing and, if patient contact is part of the job description, even more preparation is nec­essary because she (he) becomes the public face of the practice. Fortunately, both of these options pay dividends in the long run.

Yet, even with some basic strategies, what seems like the inevitability of inertia can be reshaped into a more efficient, less quotid­ian experience. Consider the following ways to streamline processes and eliminate time wasted and not spent on providing care.

Patient-specific tasks
Prior authorizations. The typical process is to have to call the insurance company to have the paperwork faxed, burning 5 to 15 minutes by being placed on hold or being transferred between departments. Instead, ask the patient to call the insurance com­pany (she [he] should get the phone num­ber from the pharmacist and have your fax number handy) and request the paper­work, with her (his) demographic informa­tion pre-filled in, be faxed to your office. If she is told by the insurance company that the doctor has to call, instruct the patient to explain it is merely a request to have forms faxed and to call again and speak with a different agent if necessary. If the patient pushes back, explaining that this helps keeps your rates lower or from having to bill for this specific time usually smooths things over.

Voicemails. Listening (and re-listening) to a long voicemail takes time. Although using a professional transcription service might be costly, it may be less expensive than your time if you get lots of long voicemails. Or, consider using a service that provides com­puter-generated transcriptions. Although less accurate, it often allows you to skim and is more affordable.

Scheduling. Booking follow-up appoint­ments during a session uses valuable clini­cal care time, but booking them outside of session can be laborious. As an alter­native, offer online scheduling through your electronic medical record (EMR) or a stand-alone service that allows you to retain control over what times you are available and how soon and far out patients can book. Be sure that only your current patients and, perhaps, colleagues (for scheduling phone calls) have access to your calendar, and make your cancellation policy explicitly clear.

Refill requests. Patients routinely opt-in for automatic prescription refill requests at their pharmacy, believing it is a no-brainer for convenience’s sake. However, for psychiatrists who prescribe only enough refills to last until the patient’s next appointment, these requests can become a burden because they can’t be ignored, but shouldn’t necessarily be acted upon either. Often, time is spent clarifying with the patient if a refill is really needed, and some­times—consciously or unconsciously— patients use automatic requests to bypass having to come in for an appointment. As an alternative, ask your patients to opt-out of auto-refill programs and to contact you directly if they are about to run out of medication.

Prescreening. An inordinate amount of time can be spent ensuring that a pro­spective patient is a good fit from a clini­cal, scheduling, and payment perspective. Save time by having a simple prescreen­ing process that conveys that you care, yet want to make sure certain criteria are met before you accept a patient into the prac­tice. This is where having a trained assis­tant or an electronic prescreening option can be useful.

Practice at large
Electronic charts. Common complaints about EMRs among users are they are clunky, convoluted, and slow, and the EMR “flow” does not match the provider’s. Although each extra click might only take a few sec­onds, the loss of rhythm is draining and leads to a dissatisfying, tired feeling. Be sure when selecting an EMR that the user experience is considered as important as functionality.

Billing statements. Write or print, fold, place in an envelope, put a stamp on the envelope, address the envelope, take it to the mailbox. Need more be said about how inefficient this is? Use your EMR, a biller, or billing software to send statements automatically.

Of course, make sure that any method that employs technology or outsourc­ing to a service has appropriate Health Insurance Portability and Accountability Act safeguards.

Nothing to lose but your chains
Although running a practice gives you some freedom in your schedule, with that comes the shackles of processing adminis­trative tasks that accompany clinical care. Finding ways to handle them more effi­ciently leads to improved job satisfaction and more time for patient care. You and your patients will both benefit.

Disclosure
Dr. Braslow is the founder of Luminello.com.

Brief cognitive screening is essential for assessing neurocognitive disor­ders. Such screening can give clini­cians a snapshot of patients’ cognitive abilities across a range of disorders and help tailor interventions to yield better outcomes. Appropriate administration of a brief cognitive screening using telehealth technology can improve access to care and treatment planning.

Neurocognitive decline can be a barrier to treatment
Persons with neurocognitive impairment, regardless of the cause, often face barriers when they seek treatment. Memory and attention difficulties often interfere with attending appointments; driving restric­tions, smaller social networks, caregiver burden, and medical conditions limit access to care. For such patients, tele­health assessment is a tool that physicians can use to help patients overcome these barriers.

Cognitive screening tools
Brief cognitive assessments need to dem­onstrate (1) consistent and accurate scores over time (reliability) and (2) that they are measuring the intended cognitive domain (validity). The Mini-Mental State Examination is used often; the Montreal Cognitive Assessment and the Short Blessed Test are additional cognitive screeners that have support in the literature for use with telehealth technology.¹

Telehealth assessment modalities
Modalities for telehealth assessment² include:
   • Audio-based systems. Pro: Telephone-based telehealth screening usually does not require extra equipment or advanced planning. Con: Visual information is absent and there is overreliance on verbal tasks.
   • Video-based systems. Pro: Using video­phones or video conferencing systems allow physicians to observe patients’ behaviors and their ability to complete tasks on paper. Con: A video system often requires more planning and effort to set up than other types of systems.
   • Web-based systems. Pro: Web sites on which patient and provider can interact in real time—through a combination of audio, video, and programmed applications—offer immediate access to a patient’s responses and test results, thus providing a wealth of clinical information such as exact timing and calculation of patients’ responses, abil­ity to record and review patients’ approach to construction tasks, and the capability to adapt test batteries in real-time based on patients’ ongoing performance. Con: Such systems require specialized software and infrastructure.

Support for telehealth screening
Our patients report feeling comfortable with telehealth screening; they overwhelmingly report that they prefer telehealth services to in-person services that require travel. Studies on the reliability and validity of using cog­nitive screeners have shown that telehealth screening is a feasible and acceptable prac­tice.³ Although the telehealth approaches mentioned here can all be used effectively, we have found that video-based cognitive screening might offer the best balance of flexibility, accessibility, and ease of use at this time.

Our recommendations
Consider your resources, patient popula­tion, and the scope of available telehealth services to guide your approach. Use vali­dated measures that fit the limitations of the modality you have chosen:
   • Telephone-based screenings should use verbally based measures (eg, the Short Blessed Test and the Telephone Interview for Cognitive Status).
   • Video-based screenings can include visual elements, but you need to decide how to best administer, record, and score the patient’s written responses. You might need to mail portions of tests along with a writing utensil and paper to their home. Patients can hold up their responses to the camera or send back the completed tests for scoring.
   • Adapt testing to the constraints of a particular situation, but modifications to tests should be limited as much as possible to minimize decreases in reliability and validity.
   • Have a clear policy for dealing with unexpected events, such as technological malfunctions, patient privacy concerns, and mental health emergencies.

Acknowledgement
This article was supported by the facilities and resources of the Salem VA Medical Center. The views expressed in this article are those of the authors and not necessarily those of the Department of Veterans Affairs.

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

Brief cognitive screening is essential for assessing neurocognitive disor­ders. Such screening can give clini­cians a snapshot of patients’ cognitive abilities across a range of disorders and help tailor interventions to yield better outcomes. Appropriate administration of a brief cognitive screening using telehealth technology can improve access to care and treatment planning.

Neurocognitive decline can be a barrier to treatment
Persons with neurocognitive impairment, regardless of the cause, often face barriers when they seek treatment. Memory and attention difficulties often interfere with attending appointments; driving restric­tions, smaller social networks, caregiver burden, and medical conditions limit access to care. For such patients, tele­health assessment is a tool that physicians can use to help patients overcome these barriers.

Cognitive screening tools
Brief cognitive assessments need to dem­onstrate (1) consistent and accurate scores over time (reliability) and (2) that they are measuring the intended cognitive domain (validity). The Mini-Mental State Examination is used often; the Montreal Cognitive Assessment and the Short Blessed Test are additional cognitive screeners that have support in the literature for use with telehealth technology.¹

Telehealth assessment modalities
Modalities for telehealth assessment² include:
   • Audio-based systems. Pro: Telephone-based telehealth screening usually does not require extra equipment or advanced planning. Con: Visual information is absent and there is overreliance on verbal tasks.
   • Video-based systems. Pro: Using video­phones or video conferencing systems allow physicians to observe patients’ behaviors and their ability to complete tasks on paper. Con: A video system often requires more planning and effort to set up than other types of systems.
   • Web-based systems. Pro: Web sites on which patient and provider can interact in real time—through a combination of audio, video, and programmed applications—offer immediate access to a patient’s responses and test results, thus providing a wealth of clinical information such as exact timing and calculation of patients’ responses, abil­ity to record and review patients’ approach to construction tasks, and the capability to adapt test batteries in real-time based on patients’ ongoing performance. Con: Such systems require specialized software and infrastructure.

Support for telehealth screening
Our patients report feeling comfortable with telehealth screening; they overwhelmingly report that they prefer telehealth services to in-person services that require travel. Studies on the reliability and validity of using cog­nitive screeners have shown that telehealth screening is a feasible and acceptable prac­tice.³ Although the telehealth approaches mentioned here can all be used effectively, we have found that video-based cognitive screening might offer the best balance of flexibility, accessibility, and ease of use at this time.

Our recommendations
Consider your resources, patient popula­tion, and the scope of available telehealth services to guide your approach. Use vali­dated measures that fit the limitations of the modality you have chosen:
   • Telephone-based screenings should use verbally based measures (eg, the Short Blessed Test and the Telephone Interview for Cognitive Status).
   • Video-based screenings can include visual elements, but you need to decide how to best administer, record, and score the patient’s written responses. You might need to mail portions of tests along with a writing utensil and paper to their home. Patients can hold up their responses to the camera or send back the completed tests for scoring.
   • Adapt testing to the constraints of a particular situation, but modifications to tests should be limited as much as possible to minimize decreases in reliability and validity.
   • Have a clear policy for dealing with unexpected events, such as technological malfunctions, patient privacy concerns, and mental health emergencies.

Acknowledgement
This article was supported by the facilities and resources of the Salem VA Medical Center. The views expressed in this article are those of the authors and not necessarily those of the Department of Veterans Affairs.

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

Brief cognitive screening is essential for assessing neurocognitive disor­ders. Such screening can give clini­cians a snapshot of patients’ cognitive abilities across a range of disorders and help tailor interventions to yield better outcomes. Appropriate administration of a brief cognitive screening using telehealth technology can improve access to care and treatment planning.

Neurocognitive decline can be a barrier to treatment
Persons with neurocognitive impairment, regardless of the cause, often face barriers when they seek treatment. Memory and attention difficulties often interfere with attending appointments; driving restric­tions, smaller social networks, caregiver burden, and medical conditions limit access to care. For such patients, tele­health assessment is a tool that physicians can use to help patients overcome these barriers.

Cognitive screening tools
Brief cognitive assessments need to dem­onstrate (1) consistent and accurate scores over time (reliability) and (2) that they are measuring the intended cognitive domain (validity). The Mini-Mental State Examination is used often; the Montreal Cognitive Assessment and the Short Blessed Test are additional cognitive screeners that have support in the literature for use with telehealth technology.¹

Telehealth assessment modalities
Modalities for telehealth assessment² include:
   • Audio-based systems. Pro: Telephone-based telehealth screening usually does not require extra equipment or advanced planning. Con: Visual information is absent and there is overreliance on verbal tasks.
   • Video-based systems. Pro: Using video­phones or video conferencing systems allow physicians to observe patients’ behaviors and their ability to complete tasks on paper. Con: A video system often requires more planning and effort to set up than other types of systems.
   • Web-based systems. Pro: Web sites on which patient and provider can interact in real time—through a combination of audio, video, and programmed applications—offer immediate access to a patient’s responses and test results, thus providing a wealth of clinical information such as exact timing and calculation of patients’ responses, abil­ity to record and review patients’ approach to construction tasks, and the capability to adapt test batteries in real-time based on patients’ ongoing performance. Con: Such systems require specialized software and infrastructure.

Support for telehealth screening
Our patients report feeling comfortable with telehealth screening; they overwhelmingly report that they prefer telehealth services to in-person services that require travel. Studies on the reliability and validity of using cog­nitive screeners have shown that telehealth screening is a feasible and acceptable prac­tice.³ Although the telehealth approaches mentioned here can all be used effectively, we have found that video-based cognitive screening might offer the best balance of flexibility, accessibility, and ease of use at this time.

Our recommendations
Consider your resources, patient popula­tion, and the scope of available telehealth services to guide your approach. Use vali­dated measures that fit the limitations of the modality you have chosen:
   • Telephone-based screenings should use verbally based measures (eg, the Short Blessed Test and the Telephone Interview for Cognitive Status).
   • Video-based screenings can include visual elements, but you need to decide how to best administer, record, and score the patient’s written responses. You might need to mail portions of tests along with a writing utensil and paper to their home. Patients can hold up their responses to the camera or send back the completed tests for scoring.
   • Adapt testing to the constraints of a particular situation, but modifications to tests should be limited as much as possible to minimize decreases in reliability and validity.
   • Have a clear policy for dealing with unexpected events, such as technological malfunctions, patient privacy concerns, and mental health emergencies.

Acknowledgement
This article was supported by the facilities and resources of the Salem VA Medical Center. The views expressed in this article are those of the authors and not necessarily those of the Department of Veterans Affairs.

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

Psychiatric providers often encounter older adult patients who report dif­ficulty with memory and express the fear they are “developing dementia.” Often, after a thorough evaluation of the reported deficits and history, we find that a serious or progressive neurocognitive disorder is unlikely. However, such occasions are an opportunity to discuss lifestyle changes that may help prevent, or at least slow, development of later-life cognitive decline.

Although I inform my patients that the body of evidence supporting many of these preventive measures still is evolving, I suggest the following approach that may provide a DEFENSE against future cogni­tive disability.

Diet options that are “heart healthy” seem to be “brain healthy” as well. This may be due, in part, to the antioxidant and anti-inflammatory effects of particular foods.¹ Therefore, I suggest patients try to implement a Mediterranean-type diet that emphasizes fish (especially those rich in omega-3 fats, such as salmon and tuna), poultry, fresh fruit, and vegetables, as well as legumes.

ETOH has been shown, in a moderate amount (eg, 1 drink a day for women and 1 to 2 drinks for men), to be brain protec­tive because of the antioxidants found in the alcohol or the direct relaxation effects that are produced—or both. Although red wine often is recommended, recent stud­ies have shown that those who enjoyed an active life into their 70s and 80s had consumed a moderate amount of alcohol over their lifetime regardless of the type of spirit (eg, 12 oz of beer, 4 oz of wine, 1 oz of hard liquor).²

Friends contribute to an active, stimulating, and emotionally supported life. Having a strong social network, an antidote to lone­liness and depression, has been shown to reduce the risk of “turning on” specific genes that stimulate an inflammatory process that can lead to brain cell death and neural damage.³

Exercise might be the most important ingre­dient for a longer, healthier, and more cogni­tively intact life. Moderate exercise, several times a week, increases blood flow to the brain and, subsequently, stimulates neuronal synapses and the hippocampus.⁴ The forms of exercise include walking, biking, swimming, resistance training, and even gardening.

No tobacco! It is known that smoking leads to accelerated aging for the heart and brain, so it is our responsibility to remain vigilant in promoting smoking cessation strategies.

Sleep has received increased attention, with recent studies providing evidence that the brain uses that time to “flush out” neurotoxic by-products of cognitive activity that have accumulated throughout the day.⁵ As evi­dence continues to be examined on this pro­cess, it is reasonable to recommend adequate sleep and a consistent sleep pattern as pos­sible defenses against brain cell insult.

Engagement in tasks that are cognitively stimulating has been promoted as potential “brain exercises” to stave off future memory loss. For example, computer games that are mentally challenging; lively and frequent conversations; and learning a language all appear to increase neural activation and communication throughout the brain.⁶

As brain research continues to expand, providers will become more knowledgeable and aware of the steps our patients can take when they discuss concerns about their risk of progressive cognitive disability and mem­ory loss. For now, however, it is important to describe what we do know based on cur­rent research and help our patients develop the best defense they can against age-related cognitive decline.

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

Psychiatric providers often encounter older adult patients who report dif­ficulty with memory and express the fear they are “developing dementia.” Often, after a thorough evaluation of the reported deficits and history, we find that a serious or progressive neurocognitive disorder is unlikely. However, such occasions are an opportunity to discuss lifestyle changes that may help prevent, or at least slow, development of later-life cognitive decline.

Although I inform my patients that the body of evidence supporting many of these preventive measures still is evolving, I suggest the following approach that may provide a DEFENSE against future cogni­tive disability.

Diet options that are “heart healthy” seem to be “brain healthy” as well. This may be due, in part, to the antioxidant and anti-inflammatory effects of particular foods.¹ Therefore, I suggest patients try to implement a Mediterranean-type diet that emphasizes fish (especially those rich in omega-3 fats, such as salmon and tuna), poultry, fresh fruit, and vegetables, as well as legumes.

ETOH has been shown, in a moderate amount (eg, 1 drink a day for women and 1 to 2 drinks for men), to be brain protec­tive because of the antioxidants found in the alcohol or the direct relaxation effects that are produced—or both. Although red wine often is recommended, recent stud­ies have shown that those who enjoyed an active life into their 70s and 80s had consumed a moderate amount of alcohol over their lifetime regardless of the type of spirit (eg, 12 oz of beer, 4 oz of wine, 1 oz of hard liquor).²

Friends contribute to an active, stimulating, and emotionally supported life. Having a strong social network, an antidote to lone­liness and depression, has been shown to reduce the risk of “turning on” specific genes that stimulate an inflammatory process that can lead to brain cell death and neural damage.³

Exercise might be the most important ingre­dient for a longer, healthier, and more cogni­tively intact life. Moderate exercise, several times a week, increases blood flow to the brain and, subsequently, stimulates neuronal synapses and the hippocampus.⁴ The forms of exercise include walking, biking, swimming, resistance training, and even gardening.

No tobacco! It is known that smoking leads to accelerated aging for the heart and brain, so it is our responsibility to remain vigilant in promoting smoking cessation strategies.

Sleep has received increased attention, with recent studies providing evidence that the brain uses that time to “flush out” neurotoxic by-products of cognitive activity that have accumulated throughout the day.⁵ As evi­dence continues to be examined on this pro­cess, it is reasonable to recommend adequate sleep and a consistent sleep pattern as pos­sible defenses against brain cell insult.

Engagement in tasks that are cognitively stimulating has been promoted as potential “brain exercises” to stave off future memory loss. For example, computer games that are mentally challenging; lively and frequent conversations; and learning a language all appear to increase neural activation and communication throughout the brain.⁶

As brain research continues to expand, providers will become more knowledgeable and aware of the steps our patients can take when they discuss concerns about their risk of progressive cognitive disability and mem­ory loss. For now, however, it is important to describe what we do know based on cur­rent research and help our patients develop the best defense they can against age-related cognitive decline.

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

Psychiatric providers often encounter older adult patients who report dif­ficulty with memory and express the fear they are “developing dementia.” Often, after a thorough evaluation of the reported deficits and history, we find that a serious or progressive neurocognitive disorder is unlikely. However, such occasions are an opportunity to discuss lifestyle changes that may help prevent, or at least slow, development of later-life cognitive decline.

Although I inform my patients that the body of evidence supporting many of these preventive measures still is evolving, I suggest the following approach that may provide a DEFENSE against future cogni­tive disability.

Diet options that are “heart healthy” seem to be “brain healthy” as well. This may be due, in part, to the antioxidant and anti-inflammatory effects of particular foods.¹ Therefore, I suggest patients try to implement a Mediterranean-type diet that emphasizes fish (especially those rich in omega-3 fats, such as salmon and tuna), poultry, fresh fruit, and vegetables, as well as legumes.

ETOH has been shown, in a moderate amount (eg, 1 drink a day for women and 1 to 2 drinks for men), to be brain protec­tive because of the antioxidants found in the alcohol or the direct relaxation effects that are produced—or both. Although red wine often is recommended, recent stud­ies have shown that those who enjoyed an active life into their 70s and 80s had consumed a moderate amount of alcohol over their lifetime regardless of the type of spirit (eg, 12 oz of beer, 4 oz of wine, 1 oz of hard liquor).²

Friends contribute to an active, stimulating, and emotionally supported life. Having a strong social network, an antidote to lone­liness and depression, has been shown to reduce the risk of “turning on” specific genes that stimulate an inflammatory process that can lead to brain cell death and neural damage.³

Exercise might be the most important ingre­dient for a longer, healthier, and more cogni­tively intact life. Moderate exercise, several times a week, increases blood flow to the brain and, subsequently, stimulates neuronal synapses and the hippocampus.⁴ The forms of exercise include walking, biking, swimming, resistance training, and even gardening.

No tobacco! It is known that smoking leads to accelerated aging for the heart and brain, so it is our responsibility to remain vigilant in promoting smoking cessation strategies.

Sleep has received increased attention, with recent studies providing evidence that the brain uses that time to “flush out” neurotoxic by-products of cognitive activity that have accumulated throughout the day.⁵ As evi­dence continues to be examined on this pro­cess, it is reasonable to recommend adequate sleep and a consistent sleep pattern as pos­sible defenses against brain cell insult.

Engagement in tasks that are cognitively stimulating has been promoted as potential “brain exercises” to stave off future memory loss. For example, computer games that are mentally challenging; lively and frequent conversations; and learning a language all appear to increase neural activation and communication throughout the brain.⁶

As brain research continues to expand, providers will become more knowledgeable and aware of the steps our patients can take when they discuss concerns about their risk of progressive cognitive disability and mem­ory loss. For now, however, it is important to describe what we do know based on cur­rent research and help our patients develop the best defense they can against age-related cognitive decline.

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

Anorexia nervosa can affect a number of systems of the body, including the otolaryngologic presentation of autophonia^1,2—a rare hyperperception of an abnormally intense hearing of one’s own voice and respiratory sounds.² The most common cause of autophonia in patients with anorexia is a patulous (patent) eusta­chian tube, which can be caused by extreme weight loss.^2,3

Significant reduction in the quantity of fat tissue at the location of the eustachian tube can cause patency.³ This creates an abnor­mal connection between the nasopharynx and tympanic membrane, in which sounds are transmitted directly from the oral cavity to the middle ear, causing autophonia, tin­nitus, or sound distortion.⁴
What are the symptoms?Patients often report hearing their own voice more loudly in the affected ear. This can be distressing, and they might become preoccupied with the sound of their voice—thus affecting quality of life.^2,4

The intensity of symptoms varies: from a mild sensation of a clogged ear to extremely bothersome discomfort much like a middle-ear infection.^2,4 Autophonia, however, cannot be relieved by conven­tional therapies for those conditions.^2,3

A patulous eustachian tube is difficult to detect and can be misdiagnosed as another condition. Pregnancy, stress, fatigue, radia­tion therapy, hormonal therapy, and dra­matic weight loss also can cause a patulous eustachian tube.²
How is the diagnosis made?The diagnosis of autophonia is clinical and begins with a detailed history. Symptoms often appear within the time frame of rapid weight loss and without evidence of infection or other illness.^2,3 The clinical examination is otherwise unremarkable.^2,4
Is there treatment?To improve the patient’s comfort and qual­ity of life, intervention is required, best provided by an integrated team of medi­cal specialists. Weight gain, of course, is the treatment goal in anorexia, but this is a complex process often marked by relapse; a detailed discussion of treatment strate­gies is beyond the scope of this “Pearl.” Symptoms usually diminish as fatty tissue is restored upon successful treatment of anorexia, which closes the abnormal eusta­chian tube opening.^2,3
 

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

Anorexia nervosa can affect a number of systems of the body, including the otolaryngologic presentation of autophonia^1,2—a rare hyperperception of an abnormally intense hearing of one’s own voice and respiratory sounds.² The most common cause of autophonia in patients with anorexia is a patulous (patent) eusta­chian tube, which can be caused by extreme weight loss.^2,3

Significant reduction in the quantity of fat tissue at the location of the eustachian tube can cause patency.³ This creates an abnor­mal connection between the nasopharynx and tympanic membrane, in which sounds are transmitted directly from the oral cavity to the middle ear, causing autophonia, tin­nitus, or sound distortion.⁴
What are the symptoms?Patients often report hearing their own voice more loudly in the affected ear. This can be distressing, and they might become preoccupied with the sound of their voice—thus affecting quality of life.^2,4

The intensity of symptoms varies: from a mild sensation of a clogged ear to extremely bothersome discomfort much like a middle-ear infection.^2,4 Autophonia, however, cannot be relieved by conven­tional therapies for those conditions.^2,3

A patulous eustachian tube is difficult to detect and can be misdiagnosed as another condition. Pregnancy, stress, fatigue, radia­tion therapy, hormonal therapy, and dra­matic weight loss also can cause a patulous eustachian tube.²
How is the diagnosis made?The diagnosis of autophonia is clinical and begins with a detailed history. Symptoms often appear within the time frame of rapid weight loss and without evidence of infection or other illness.^2,3 The clinical examination is otherwise unremarkable.^2,4
Is there treatment?To improve the patient’s comfort and qual­ity of life, intervention is required, best provided by an integrated team of medi­cal specialists. Weight gain, of course, is the treatment goal in anorexia, but this is a complex process often marked by relapse; a detailed discussion of treatment strate­gies is beyond the scope of this “Pearl.” Symptoms usually diminish as fatty tissue is restored upon successful treatment of anorexia, which closes the abnormal eusta­chian tube opening.^2,3
 

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

Anorexia nervosa can affect a number of systems of the body, including the otolaryngologic presentation of autophonia^1,2—a rare hyperperception of an abnormally intense hearing of one’s own voice and respiratory sounds.² The most common cause of autophonia in patients with anorexia is a patulous (patent) eusta­chian tube, which can be caused by extreme weight loss.^2,3

Significant reduction in the quantity of fat tissue at the location of the eustachian tube can cause patency.³ This creates an abnor­mal connection between the nasopharynx and tympanic membrane, in which sounds are transmitted directly from the oral cavity to the middle ear, causing autophonia, tin­nitus, or sound distortion.⁴
What are the symptoms?Patients often report hearing their own voice more loudly in the affected ear. This can be distressing, and they might become preoccupied with the sound of their voice—thus affecting quality of life.^2,4

The intensity of symptoms varies: from a mild sensation of a clogged ear to extremely bothersome discomfort much like a middle-ear infection.^2,4 Autophonia, however, cannot be relieved by conven­tional therapies for those conditions.^2,3

A patulous eustachian tube is difficult to detect and can be misdiagnosed as another condition. Pregnancy, stress, fatigue, radia­tion therapy, hormonal therapy, and dra­matic weight loss also can cause a patulous eustachian tube.²
How is the diagnosis made?The diagnosis of autophonia is clinical and begins with a detailed history. Symptoms often appear within the time frame of rapid weight loss and without evidence of infection or other illness.^2,3 The clinical examination is otherwise unremarkable.^2,4
Is there treatment?To improve the patient’s comfort and qual­ity of life, intervention is required, best provided by an integrated team of medi­cal specialists. Weight gain, of course, is the treatment goal in anorexia, but this is a complex process often marked by relapse; a detailed discussion of treatment strate­gies is beyond the scope of this “Pearl.” Symptoms usually diminish as fatty tissue is restored upon successful treatment of anorexia, which closes the abnormal eusta­chian tube opening.^2,3
 

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

Psychiatrists often serve as risk-management consultants for our medical colleagues. As part of this role, psychiatrists working with trainees— including resident physicians, medical students, and physician assistant students— have an opportunity to emphasize the impor­tance of professional boundaries.¹ Discussing appropriate professional boundaries and describing what might represent a violation of these boundaries is meaningful because a good understanding of these concepts pro­motes high-quality treatment and minimizes professional liability.²

Physical boundaries
Psychiatric patients might be agitated or display potentially dangerous behaviors; discussing the importance of body language and contact between physicians and their patients is, therefore, first and foremost, a matter of safety. Students who can recognize the signs and symptoms of agitation and maintain a safe distance between themselves and their patients are less likely to be injured.

Addressing romantic and sexual rela­tionships between patients and their health care providers also is necessary. One study reported that 21% of medical students sur­veyed might not regard sexual contact with a patient as inappropriate.³ An adequate discus­sion of this topic is necessary to protect train­ees and patients from a catastrophic misstep.

Emotional boundaries
Maintaining appropriate emotional bound­aries is necessary in psychiatry. Given the prevalence of mental illness and substance abuse, many trainees have personal experi­ence with psychiatric illness outside of their training. Discussing issues of transference and countertransference with students will prepare them for intense emotional reac­tions they will experience while working in psychiatry. Students who feel comfortable recognizing their own countertransference feelings and discussing them in supervision with their attending psychiatrist will be more successful in addressing the complex inter­personal challenges that their patients face.

Personal and informational boundaries
Discussing personal and informational boundaries can protect trainees from uncom­fortable experiences in their non-clinical lives. Although, in previous decades, we needed to discourage students only from sharing their home address and telephone number with patients, the Internet and social media have made it easier for patients to discover personal information about their treatment team. Addressing issues related to social networks and instructing students on how to appropriately address and decline requests for personal information can pre­vent unwanted boundary crossings.

Psychiatrists are well suited to discuss these issues with trainees. In doing so, we can help them become knowledgeable health care providers—no matter which medical discipline they specialize in.

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

Psychiatrists often serve as risk-management consultants for our medical colleagues. As part of this role, psychiatrists working with trainees— including resident physicians, medical students, and physician assistant students— have an opportunity to emphasize the impor­tance of professional boundaries.¹ Discussing appropriate professional boundaries and describing what might represent a violation of these boundaries is meaningful because a good understanding of these concepts pro­motes high-quality treatment and minimizes professional liability.²

Physical boundaries
Psychiatric patients might be agitated or display potentially dangerous behaviors; discussing the importance of body language and contact between physicians and their patients is, therefore, first and foremost, a matter of safety. Students who can recognize the signs and symptoms of agitation and maintain a safe distance between themselves and their patients are less likely to be injured.

Addressing romantic and sexual rela­tionships between patients and their health care providers also is necessary. One study reported that 21% of medical students sur­veyed might not regard sexual contact with a patient as inappropriate.³ An adequate discus­sion of this topic is necessary to protect train­ees and patients from a catastrophic misstep.

Emotional boundaries
Maintaining appropriate emotional bound­aries is necessary in psychiatry. Given the prevalence of mental illness and substance abuse, many trainees have personal experi­ence with psychiatric illness outside of their training. Discussing issues of transference and countertransference with students will prepare them for intense emotional reac­tions they will experience while working in psychiatry. Students who feel comfortable recognizing their own countertransference feelings and discussing them in supervision with their attending psychiatrist will be more successful in addressing the complex inter­personal challenges that their patients face.

Personal and informational boundaries
Discussing personal and informational boundaries can protect trainees from uncom­fortable experiences in their non-clinical lives. Although, in previous decades, we needed to discourage students only from sharing their home address and telephone number with patients, the Internet and social media have made it easier for patients to discover personal information about their treatment team. Addressing issues related to social networks and instructing students on how to appropriately address and decline requests for personal information can pre­vent unwanted boundary crossings.

Psychiatrists are well suited to discuss these issues with trainees. In doing so, we can help them become knowledgeable health care providers—no matter which medical discipline they specialize in.

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

Psychiatrists often serve as risk-management consultants for our medical colleagues. As part of this role, psychiatrists working with trainees— including resident physicians, medical students, and physician assistant students— have an opportunity to emphasize the impor­tance of professional boundaries.¹ Discussing appropriate professional boundaries and describing what might represent a violation of these boundaries is meaningful because a good understanding of these concepts pro­motes high-quality treatment and minimizes professional liability.²

Physical boundaries
Psychiatric patients might be agitated or display potentially dangerous behaviors; discussing the importance of body language and contact between physicians and their patients is, therefore, first and foremost, a matter of safety. Students who can recognize the signs and symptoms of agitation and maintain a safe distance between themselves and their patients are less likely to be injured.

Addressing romantic and sexual rela­tionships between patients and their health care providers also is necessary. One study reported that 21% of medical students sur­veyed might not regard sexual contact with a patient as inappropriate.³ An adequate discus­sion of this topic is necessary to protect train­ees and patients from a catastrophic misstep.

Emotional boundaries
Maintaining appropriate emotional bound­aries is necessary in psychiatry. Given the prevalence of mental illness and substance abuse, many trainees have personal experi­ence with psychiatric illness outside of their training. Discussing issues of transference and countertransference with students will prepare them for intense emotional reac­tions they will experience while working in psychiatry. Students who feel comfortable recognizing their own countertransference feelings and discussing them in supervision with their attending psychiatrist will be more successful in addressing the complex inter­personal challenges that their patients face.

Personal and informational boundaries
Discussing personal and informational boundaries can protect trainees from uncom­fortable experiences in their non-clinical lives. Although, in previous decades, we needed to discourage students only from sharing their home address and telephone number with patients, the Internet and social media have made it easier for patients to discover personal information about their treatment team. Addressing issues related to social networks and instructing students on how to appropriately address and decline requests for personal information can pre­vent unwanted boundary crossings.

Psychiatrists are well suited to discuss these issues with trainees. In doing so, we can help them become knowledgeable health care providers—no matter which medical discipline they specialize in.

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

Only recently has paternal postpartum depression (PPD) received much attention. Research has shown that maternal PPD is associated with negative outcomes in the child’s cognitive develop­ment and social and marital problems for the parents. Likewise, depressed fathers are less likely to play outside with their child and more likely to put the child to bed awake.¹

Recent studies reported that 10.4% of men experienced depression within 12 month of delivery.¹ Edmondson et al² estimate the prevalence of paternal PPD to be 8% between birth and 3 months, 26% from 3 to 6 months, and 9% from 6 to 12 months.

Risk factors
Risk factors for paternal PPD have not been studied extensively. Some studies have shown that immaturity, lack of social sup­port, first or unplanned pregnancies, marital relationship problems, and unemployment were the most common risk factors for depression in men postnatally.³ A history of depression and other psychiatric disorders also increases risk.⁴ Psychosocial factors, such as quality of the spousal relationship, parenting distress, and perceived parenting efficacy, contribute to paternal depression.

Similarly, depressed postpartum fathers experience higher levels of parenting dis­tress and a lower sense of parenting effi­cacy.⁵ Interestingly, negative life events were associated with increased risk for depression in mothers, but not fathers.³

Clinical presentation
Paternal PPD symptoms appear within 12 months after the birth of the child and last for at least 2 weeks. Signs and symptoms of depression in men might not resemble those seen in postpartum women. Men tend to show aggression, increased or easy irritabil­ity, and agitation, and might not seek help for emotional issues as readily as women do. Typical symptoms of depression often are present, such as sleep disturbance or changes in sleep patterns, difficulty concen­trating, memory problems, and feelings of worthlessness, hopelessness, inadequacy, and excess guilt with suicidal ideation.⁶

Making the diagnosis
Maternal PPD commonly is evaluated using the Edinburgh Postnatal Depression Scale- Partner (EDPS-P) or Postpartum Depression Screening Scale. However, studies are lack­ing to determine which diagnostic modal­ity is most accurate for diagnosing paternal PPD.

A paternal PPD screening tool could include the EDPS-P administered to moth­ers. Edmonson et al² determined an EDPS-P score of >10 was the optimal cut-off point for screening for paternal depression, with a sensitivity of 89.5% and a specificity of 78.2%, compared with a structured clini­cal interview. Fisher et al⁴ determined that the EDPS-P report was a reliable method for detecting paternal PPD compared with validated depression scales completed by fathers. Madsen et al⁵ determined the Gotland Male Depression Scale, which detects typical male depressive symptoms, also was effective in recognizing paternal PPD at 6 weeks postpartum.⁷

Treatment of paternal PPD
Specific treatment for paternal PPD has not been studied extensively. Psychotherapy targeted at interpersonal family relation­ships and parenting is indicated for mild depression, whereas a combination of psy­chotherapy and pharmacotherapy is recom­mended for moderate or severe depression.

Depending on specific patient factors, pharmacotherapy options include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibi­tors, tricyclic antidepressants, and atypical antipsychotics.⁸ SSRIs often are used because of their efficacy and relative lack of serious side effects, as demonstrated in numerous trials.² Recovery is more likely with combi­nation therapy than monotherapy.⁹ Fathers with psychosis or suicidal ideation should be referred for inpatient treatment.


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

Only recently has paternal postpartum depression (PPD) received much attention. Research has shown that maternal PPD is associated with negative outcomes in the child’s cognitive develop­ment and social and marital problems for the parents. Likewise, depressed fathers are less likely to play outside with their child and more likely to put the child to bed awake.¹

Recent studies reported that 10.4% of men experienced depression within 12 month of delivery.¹ Edmondson et al² estimate the prevalence of paternal PPD to be 8% between birth and 3 months, 26% from 3 to 6 months, and 9% from 6 to 12 months.

Risk factors
Risk factors for paternal PPD have not been studied extensively. Some studies have shown that immaturity, lack of social sup­port, first or unplanned pregnancies, marital relationship problems, and unemployment were the most common risk factors for depression in men postnatally.³ A history of depression and other psychiatric disorders also increases risk.⁴ Psychosocial factors, such as quality of the spousal relationship, parenting distress, and perceived parenting efficacy, contribute to paternal depression.

Similarly, depressed postpartum fathers experience higher levels of parenting dis­tress and a lower sense of parenting effi­cacy.⁵ Interestingly, negative life events were associated with increased risk for depression in mothers, but not fathers.³

Clinical presentation
Paternal PPD symptoms appear within 12 months after the birth of the child and last for at least 2 weeks. Signs and symptoms of depression in men might not resemble those seen in postpartum women. Men tend to show aggression, increased or easy irritabil­ity, and agitation, and might not seek help for emotional issues as readily as women do. Typical symptoms of depression often are present, such as sleep disturbance or changes in sleep patterns, difficulty concen­trating, memory problems, and feelings of worthlessness, hopelessness, inadequacy, and excess guilt with suicidal ideation.⁶

Making the diagnosis
Maternal PPD commonly is evaluated using the Edinburgh Postnatal Depression Scale- Partner (EDPS-P) or Postpartum Depression Screening Scale. However, studies are lack­ing to determine which diagnostic modal­ity is most accurate for diagnosing paternal PPD.

A paternal PPD screening tool could include the EDPS-P administered to moth­ers. Edmonson et al² determined an EDPS-P score of >10 was the optimal cut-off point for screening for paternal depression, with a sensitivity of 89.5% and a specificity of 78.2%, compared with a structured clini­cal interview. Fisher et al⁴ determined that the EDPS-P report was a reliable method for detecting paternal PPD compared with validated depression scales completed by fathers. Madsen et al⁵ determined the Gotland Male Depression Scale, which detects typical male depressive symptoms, also was effective in recognizing paternal PPD at 6 weeks postpartum.⁷

Treatment of paternal PPD
Specific treatment for paternal PPD has not been studied extensively. Psychotherapy targeted at interpersonal family relation­ships and parenting is indicated for mild depression, whereas a combination of psy­chotherapy and pharmacotherapy is recom­mended for moderate or severe depression.

Depending on specific patient factors, pharmacotherapy options include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibi­tors, tricyclic antidepressants, and atypical antipsychotics.⁸ SSRIs often are used because of their efficacy and relative lack of serious side effects, as demonstrated in numerous trials.² Recovery is more likely with combi­nation therapy than monotherapy.⁹ Fathers with psychosis or suicidal ideation should be referred for inpatient treatment.


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

Only recently has paternal postpartum depression (PPD) received much attention. Research has shown that maternal PPD is associated with negative outcomes in the child’s cognitive develop­ment and social and marital problems for the parents. Likewise, depressed fathers are less likely to play outside with their child and more likely to put the child to bed awake.¹

Recent studies reported that 10.4% of men experienced depression within 12 month of delivery.¹ Edmondson et al² estimate the prevalence of paternal PPD to be 8% between birth and 3 months, 26% from 3 to 6 months, and 9% from 6 to 12 months.

Risk factors
Risk factors for paternal PPD have not been studied extensively. Some studies have shown that immaturity, lack of social sup­port, first or unplanned pregnancies, marital relationship problems, and unemployment were the most common risk factors for depression in men postnatally.³ A history of depression and other psychiatric disorders also increases risk.⁴ Psychosocial factors, such as quality of the spousal relationship, parenting distress, and perceived parenting efficacy, contribute to paternal depression.

Similarly, depressed postpartum fathers experience higher levels of parenting dis­tress and a lower sense of parenting effi­cacy.⁵ Interestingly, negative life events were associated with increased risk for depression in mothers, but not fathers.³

Clinical presentation
Paternal PPD symptoms appear within 12 months after the birth of the child and last for at least 2 weeks. Signs and symptoms of depression in men might not resemble those seen in postpartum women. Men tend to show aggression, increased or easy irritabil­ity, and agitation, and might not seek help for emotional issues as readily as women do. Typical symptoms of depression often are present, such as sleep disturbance or changes in sleep patterns, difficulty concen­trating, memory problems, and feelings of worthlessness, hopelessness, inadequacy, and excess guilt with suicidal ideation.⁶

Making the diagnosis
Maternal PPD commonly is evaluated using the Edinburgh Postnatal Depression Scale- Partner (EDPS-P) or Postpartum Depression Screening Scale. However, studies are lack­ing to determine which diagnostic modal­ity is most accurate for diagnosing paternal PPD.

A paternal PPD screening tool could include the EDPS-P administered to moth­ers. Edmonson et al² determined an EDPS-P score of >10 was the optimal cut-off point for screening for paternal depression, with a sensitivity of 89.5% and a specificity of 78.2%, compared with a structured clini­cal interview. Fisher et al⁴ determined that the EDPS-P report was a reliable method for detecting paternal PPD compared with validated depression scales completed by fathers. Madsen et al⁵ determined the Gotland Male Depression Scale, which detects typical male depressive symptoms, also was effective in recognizing paternal PPD at 6 weeks postpartum.⁷

Treatment of paternal PPD
Specific treatment for paternal PPD has not been studied extensively. Psychotherapy targeted at interpersonal family relation­ships and parenting is indicated for mild depression, whereas a combination of psy­chotherapy and pharmacotherapy is recom­mended for moderate or severe depression.

Depending on specific patient factors, pharmacotherapy options include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibi­tors, tricyclic antidepressants, and atypical antipsychotics.⁸ SSRIs often are used because of their efficacy and relative lack of serious side effects, as demonstrated in numerous trials.² Recovery is more likely with combi­nation therapy than monotherapy.⁹ Fathers with psychosis or suicidal ideation should be referred for inpatient treatment.


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

Ah! the dream of opening private practice! Whether you’re a resident making less than minimum wage or a clinic employee seeing ever more patients, the allure is powerful. But, just because you’re whip-smart in matters of the mind, doesn’t mean you know how to run a business. To prevent your dream from succumbing to the siren’s allure, you’ll need to create a blueprint that gets you moving today, as well as prepare sys­tems that will endure over the years.

Establish a business model
Before signing a lease or scheduling patients, think through these fundamental questions, not just from a clinical perspec­tive but a business one as well:
   • What kind of care would you like to provide? If you want to practice psycho­therapy and medication, you’ll have fewer time slots to have to fill, but it may be more challenging to find patients who want and can afford psychotherapy from you as well.
   • Where do you want to practice? Time spent commuting rarely produces income, so how close do you want your office to be to where you live? Being able to walk to work is wonderful, but is where you live the best location for your patients?
For example, downtown areas in big cit­ies are good for providing a critical mass of patients, especially if you only want to manage patients’ medications. But if you want to see children and families, you should consider a location that is friendlier for them—usually more residential areas. Having a coffee shop nearby for waiting parents doesn’t hurt. If you work in a rural area, how easily can patients get to your office?
   • Which hours do you want to work? Many patients will want to see you at “prime time”—before or after their work day or during the weekend. This might, not coincidentally, be when you don’t want to work. Consider whether there is room for compromise: Can you work 1 or 2 early or late days? Can you do 1 weekend day once in a while? If you want to see children, can you regularly be available after school?
   • Will you accept insurance? Pros: The insurance companies will do the marketing for you; your practice will fill quickly; their checks don’t bounce; and, 98% of the time, the claims and payment process works just fine.
Cons: You will make less money per patient, in return for the higher volume of patients that are sent your way; the insur­ance companies won’t want to pay you more than they pay non-psychiatrists for psychotherapy; and the small amount of time that there are administrative problems can consume a disproportionate share of your sanity.

Run the numbers carefully
Next, think about the financial aspect. How much do you need to make, after you’ve paid business expenses and taxes, to be content? You might be tempted to work as many hours as possible, think­ing that every hour off is an hour that you could have billed. Shifting your viewpoint from “hours lost” to “hours free” is a nec­essary approach to reduce burnout.

Once you have figured out your finan­cial goal, do the math: multiply hours/ week × hourly rate × how many weeks/ year you’ll work to determine your annual income. Play around with the numbers to test your priorities, such as optimiz­ing daily hours vs vacation time vs charg­ing more or less.

Build your brand
This is your professional identity—the pic­ture of your practice that your colleagues and future patients will see and that will start to get those hours filled. How will you convey your strengths and personal­ity? The answer: Get out of the office.
   • Take clinicians who will refer patients to you out to lunch (and pick up the tab).
   • Give free talks to psychotherapists or primary care providers. Grand rounds, group practice meetings, or local clinical associations are potential venues. Give the organizer a menu of topic options that con­nect your clinical interests and theirs, and then create a dynamic presentation based on their feedback. Tip: Do not PowerPoint them to tears.
   • Start blogging. If you enjoy writing, use a blog to showcase your talent and expertise. It is free advertising and makes you seem like a trusted authority. However, don’t start a blog unless you can commit to posting regularly.

Proceed thoughtfully; seek advice
As you think through the matrix of issues presented above, each set of answers may lead to a deeper set of questions. Consultation with a colleague or mentor can save you valuable time. Although you don’t have to have all the answers before you open your practice, spending time thinking through these and other issues beforehand will optimize the chance that your dream becomes a reality.

Disclosure
Dr. Braslow is the founder of Luminello.com.

Ah! the dream of opening private practice! Whether you’re a resident making less than minimum wage or a clinic employee seeing ever more patients, the allure is powerful. But, just because you’re whip-smart in matters of the mind, doesn’t mean you know how to run a business. To prevent your dream from succumbing to the siren’s allure, you’ll need to create a blueprint that gets you moving today, as well as prepare sys­tems that will endure over the years.

Establish a business model
Before signing a lease or scheduling patients, think through these fundamental questions, not just from a clinical perspec­tive but a business one as well:
   • What kind of care would you like to provide? If you want to practice psycho­therapy and medication, you’ll have fewer time slots to have to fill, but it may be more challenging to find patients who want and can afford psychotherapy from you as well.
   • Where do you want to practice? Time spent commuting rarely produces income, so how close do you want your office to be to where you live? Being able to walk to work is wonderful, but is where you live the best location for your patients?
For example, downtown areas in big cit­ies are good for providing a critical mass of patients, especially if you only want to manage patients’ medications. But if you want to see children and families, you should consider a location that is friendlier for them—usually more residential areas. Having a coffee shop nearby for waiting parents doesn’t hurt. If you work in a rural area, how easily can patients get to your office?
   • Which hours do you want to work? Many patients will want to see you at “prime time”—before or after their work day or during the weekend. This might, not coincidentally, be when you don’t want to work. Consider whether there is room for compromise: Can you work 1 or 2 early or late days? Can you do 1 weekend day once in a while? If you want to see children, can you regularly be available after school?
   • Will you accept insurance? Pros: The insurance companies will do the marketing for you; your practice will fill quickly; their checks don’t bounce; and, 98% of the time, the claims and payment process works just fine.
Cons: You will make less money per patient, in return for the higher volume of patients that are sent your way; the insur­ance companies won’t want to pay you more than they pay non-psychiatrists for psychotherapy; and the small amount of time that there are administrative problems can consume a disproportionate share of your sanity.

Run the numbers carefully
Next, think about the financial aspect. How much do you need to make, after you’ve paid business expenses and taxes, to be content? You might be tempted to work as many hours as possible, think­ing that every hour off is an hour that you could have billed. Shifting your viewpoint from “hours lost” to “hours free” is a nec­essary approach to reduce burnout.

Once you have figured out your finan­cial goal, do the math: multiply hours/ week × hourly rate × how many weeks/ year you’ll work to determine your annual income. Play around with the numbers to test your priorities, such as optimiz­ing daily hours vs vacation time vs charg­ing more or less.

Build your brand
This is your professional identity—the pic­ture of your practice that your colleagues and future patients will see and that will start to get those hours filled. How will you convey your strengths and personal­ity? The answer: Get out of the office.
   • Take clinicians who will refer patients to you out to lunch (and pick up the tab).
   • Give free talks to psychotherapists or primary care providers. Grand rounds, group practice meetings, or local clinical associations are potential venues. Give the organizer a menu of topic options that con­nect your clinical interests and theirs, and then create a dynamic presentation based on their feedback. Tip: Do not PowerPoint them to tears.
   • Start blogging. If you enjoy writing, use a blog to showcase your talent and expertise. It is free advertising and makes you seem like a trusted authority. However, don’t start a blog unless you can commit to posting regularly.

Proceed thoughtfully; seek advice
As you think through the matrix of issues presented above, each set of answers may lead to a deeper set of questions. Consultation with a colleague or mentor can save you valuable time. Although you don’t have to have all the answers before you open your practice, spending time thinking through these and other issues beforehand will optimize the chance that your dream becomes a reality.

Disclosure
Dr. Braslow is the founder of Luminello.com.

Ah! the dream of opening private practice! Whether you’re a resident making less than minimum wage or a clinic employee seeing ever more patients, the allure is powerful. But, just because you’re whip-smart in matters of the mind, doesn’t mean you know how to run a business. To prevent your dream from succumbing to the siren’s allure, you’ll need to create a blueprint that gets you moving today, as well as prepare sys­tems that will endure over the years.

Establish a business model
Before signing a lease or scheduling patients, think through these fundamental questions, not just from a clinical perspec­tive but a business one as well:
   • What kind of care would you like to provide? If you want to practice psycho­therapy and medication, you’ll have fewer time slots to have to fill, but it may be more challenging to find patients who want and can afford psychotherapy from you as well.
   • Where do you want to practice? Time spent commuting rarely produces income, so how close do you want your office to be to where you live? Being able to walk to work is wonderful, but is where you live the best location for your patients?
For example, downtown areas in big cit­ies are good for providing a critical mass of patients, especially if you only want to manage patients’ medications. But if you want to see children and families, you should consider a location that is friendlier for them—usually more residential areas. Having a coffee shop nearby for waiting parents doesn’t hurt. If you work in a rural area, how easily can patients get to your office?
   • Which hours do you want to work? Many patients will want to see you at “prime time”—before or after their work day or during the weekend. This might, not coincidentally, be when you don’t want to work. Consider whether there is room for compromise: Can you work 1 or 2 early or late days? Can you do 1 weekend day once in a while? If you want to see children, can you regularly be available after school?
   • Will you accept insurance? Pros: The insurance companies will do the marketing for you; your practice will fill quickly; their checks don’t bounce; and, 98% of the time, the claims and payment process works just fine.
Cons: You will make less money per patient, in return for the higher volume of patients that are sent your way; the insur­ance companies won’t want to pay you more than they pay non-psychiatrists for psychotherapy; and the small amount of time that there are administrative problems can consume a disproportionate share of your sanity.

Run the numbers carefully
Next, think about the financial aspect. How much do you need to make, after you’ve paid business expenses and taxes, to be content? You might be tempted to work as many hours as possible, think­ing that every hour off is an hour that you could have billed. Shifting your viewpoint from “hours lost” to “hours free” is a nec­essary approach to reduce burnout.

Once you have figured out your finan­cial goal, do the math: multiply hours/ week × hourly rate × how many weeks/ year you’ll work to determine your annual income. Play around with the numbers to test your priorities, such as optimiz­ing daily hours vs vacation time vs charg­ing more or less.

Build your brand
This is your professional identity—the pic­ture of your practice that your colleagues and future patients will see and that will start to get those hours filled. How will you convey your strengths and personal­ity? The answer: Get out of the office.
   • Take clinicians who will refer patients to you out to lunch (and pick up the tab).
   • Give free talks to psychotherapists or primary care providers. Grand rounds, group practice meetings, or local clinical associations are potential venues. Give the organizer a menu of topic options that con­nect your clinical interests and theirs, and then create a dynamic presentation based on their feedback. Tip: Do not PowerPoint them to tears.
   • Start blogging. If you enjoy writing, use a blog to showcase your talent and expertise. It is free advertising and makes you seem like a trusted authority. However, don’t start a blog unless you can commit to posting regularly.

Proceed thoughtfully; seek advice
As you think through the matrix of issues presented above, each set of answers may lead to a deeper set of questions. Consultation with a colleague or mentor can save you valuable time. Although you don’t have to have all the answers before you open your practice, spending time thinking through these and other issues beforehand will optimize the chance that your dream becomes a reality.

Disclosure
Dr. Braslow is the founder of Luminello.com.

More and more time is being allocated to training psychiatric residents in cognitive-behavioral therapy and crafting a cognitive-behavioral formulation. However, the psychodynamic formulation, once considered the backbone of psychiatry, should not be forgotten. The psychodynamic formulation is a cohesive portrait of an individual’s inner world based on the biopsychosocial approach.¹ The purpose in crafting a psychodynamic formulation is to create a succinct and focused case conceptualization that can guide treatment and anticipate possible outcomes.^2,3 To teach this in a simple, prac­tical, and relatable way, we propose an approach that can be summarized with the acronym PRESS.

Psychologically minded
Can the patient be introspective and contemplate his (her) thoughts and feel­ings before acting? Without the capacity to look within—distinct from intelli­gence—a patient could struggle with the psychodynamic approach and could benefit from a more supportive form of psychotherapy.⁴

Relationships
Examine the patient’s relationships with others:
   • Who are the prominent people in his (her) life?
   • What are his interpersonal relations like?
   • How does he (she) recall important relationships from the past?
   • Do these relationships appear to be recurring?⁴

Just as themes and patterns recur, so do relationships. Predict how the patient’s relationship pattern could be recreated in the therapeutic dynamic and how this could influence treatment. Then, by examining this transference and coun­tertransference data, you can illustrate a pattern from past relationships that is being recreated in the doctor-patient relationship.^3,5

Ego strength
Determining how the patient expresses or inhibits wishes and exhibits impulse con­trol can shed light onto how he operates on a daily basis:  
   • Does he have the ability to regulate his impulses?   
   • Is he capable of anticipating the conse­quences of inappropriate action?  
   • Does he show a lack of insight and judgment by exhibiting too many repetitive maladaptive behaviors?

Additionally, how does the patient keep unwanted fantasies, wishes, and memo­ries out of conscious awareness?

Identifying which constellation of defense mechanisms the patient is using can help categorize his level of functioning and personality type, and identify anxiety-provoking thoughts and events.^1,6 Often, one of these situations has consciously or subconsciously triggered the need for psychotherapy.

Stimulus
The hallmark of any psychodynamic formulation starts with a concise sum­marizing statement that describes the fun­damental details about the patient and his motivation for treatment.² Determining the patient’s impetus for treatment is 2-fold: Why does the patient want to receive treat­ment? Why now?

Superego
Review the patient’s ego ideal—what one should not do—and the moral conscience— what one should do.¹ Do there seem to be any deficits (recurrent shoplifting, crimi­nality, etc.)? Who contributed to his sense of right and wrong, and how harsh or lax is it? Is the patient self-defeating or self-punishing? Contrarily, does the patient seem to have little conscience?

Acknowledgment
Franklin Maleson, MD, provided advice and input to the authors.

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

More and more time is being allocated to training psychiatric residents in cognitive-behavioral therapy and crafting a cognitive-behavioral formulation. However, the psychodynamic formulation, once considered the backbone of psychiatry, should not be forgotten. The psychodynamic formulation is a cohesive portrait of an individual’s inner world based on the biopsychosocial approach.¹ The purpose in crafting a psychodynamic formulation is to create a succinct and focused case conceptualization that can guide treatment and anticipate possible outcomes.^2,3 To teach this in a simple, prac­tical, and relatable way, we propose an approach that can be summarized with the acronym PRESS.

Psychologically minded
Can the patient be introspective and contemplate his (her) thoughts and feel­ings before acting? Without the capacity to look within—distinct from intelli­gence—a patient could struggle with the psychodynamic approach and could benefit from a more supportive form of psychotherapy.⁴

Relationships
Examine the patient’s relationships with others:
   • Who are the prominent people in his (her) life?
   • What are his interpersonal relations like?
   • How does he (she) recall important relationships from the past?
   • Do these relationships appear to be recurring?⁴

Just as themes and patterns recur, so do relationships. Predict how the patient’s relationship pattern could be recreated in the therapeutic dynamic and how this could influence treatment. Then, by examining this transference and coun­tertransference data, you can illustrate a pattern from past relationships that is being recreated in the doctor-patient relationship.^3,5

Ego strength
Determining how the patient expresses or inhibits wishes and exhibits impulse con­trol can shed light onto how he operates on a daily basis:  
   • Does he have the ability to regulate his impulses?   
   • Is he capable of anticipating the conse­quences of inappropriate action?  
   • Does he show a lack of insight and judgment by exhibiting too many repetitive maladaptive behaviors?

Additionally, how does the patient keep unwanted fantasies, wishes, and memo­ries out of conscious awareness?

Identifying which constellation of defense mechanisms the patient is using can help categorize his level of functioning and personality type, and identify anxiety-provoking thoughts and events.^1,6 Often, one of these situations has consciously or subconsciously triggered the need for psychotherapy.

Stimulus
The hallmark of any psychodynamic formulation starts with a concise sum­marizing statement that describes the fun­damental details about the patient and his motivation for treatment.² Determining the patient’s impetus for treatment is 2-fold: Why does the patient want to receive treat­ment? Why now?

Superego
Review the patient’s ego ideal—what one should not do—and the moral conscience— what one should do.¹ Do there seem to be any deficits (recurrent shoplifting, crimi­nality, etc.)? Who contributed to his sense of right and wrong, and how harsh or lax is it? Is the patient self-defeating or self-punishing? Contrarily, does the patient seem to have little conscience?

Acknowledgment
Franklin Maleson, MD, provided advice and input to the authors.

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

More and more time is being allocated to training psychiatric residents in cognitive-behavioral therapy and crafting a cognitive-behavioral formulation. However, the psychodynamic formulation, once considered the backbone of psychiatry, should not be forgotten. The psychodynamic formulation is a cohesive portrait of an individual’s inner world based on the biopsychosocial approach.¹ The purpose in crafting a psychodynamic formulation is to create a succinct and focused case conceptualization that can guide treatment and anticipate possible outcomes.^2,3 To teach this in a simple, prac­tical, and relatable way, we propose an approach that can be summarized with the acronym PRESS.

Psychologically minded
Can the patient be introspective and contemplate his (her) thoughts and feel­ings before acting? Without the capacity to look within—distinct from intelli­gence—a patient could struggle with the psychodynamic approach and could benefit from a more supportive form of psychotherapy.⁴

Relationships
Examine the patient’s relationships with others:
   • Who are the prominent people in his (her) life?
   • What are his interpersonal relations like?
   • How does he (she) recall important relationships from the past?
   • Do these relationships appear to be recurring?⁴

Just as themes and patterns recur, so do relationships. Predict how the patient’s relationship pattern could be recreated in the therapeutic dynamic and how this could influence treatment. Then, by examining this transference and coun­tertransference data, you can illustrate a pattern from past relationships that is being recreated in the doctor-patient relationship.^3,5

Ego strength
Determining how the patient expresses or inhibits wishes and exhibits impulse con­trol can shed light onto how he operates on a daily basis:  
   • Does he have the ability to regulate his impulses?   
   • Is he capable of anticipating the conse­quences of inappropriate action?  
   • Does he show a lack of insight and judgment by exhibiting too many repetitive maladaptive behaviors?

Additionally, how does the patient keep unwanted fantasies, wishes, and memo­ries out of conscious awareness?

Identifying which constellation of defense mechanisms the patient is using can help categorize his level of functioning and personality type, and identify anxiety-provoking thoughts and events.^1,6 Often, one of these situations has consciously or subconsciously triggered the need for psychotherapy.

Stimulus
The hallmark of any psychodynamic formulation starts with a concise sum­marizing statement that describes the fun­damental details about the patient and his motivation for treatment.² Determining the patient’s impetus for treatment is 2-fold: Why does the patient want to receive treat­ment? Why now?

Superego
Review the patient’s ego ideal—what one should not do—and the moral conscience— what one should do.¹ Do there seem to be any deficits (recurrent shoplifting, crimi­nality, etc.)? Who contributed to his sense of right and wrong, and how harsh or lax is it? Is the patient self-defeating or self-punishing? Contrarily, does the patient seem to have little conscience?

Acknowledgment
Franklin Maleson, MD, provided advice and input to the authors.

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