Pearls

Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

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

Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

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

Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

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

Patients often tell clinicians that they used their “left-over” medica­tions from previous refills, or that a family member shared medication with them. Other patients, who are non-adherent or have had a recent medication change, might reveal that they have some unused pills at home. As clinicians, what does this practice by our patients mean for us?

Prescription drug abuse is an emerg­ing crisis, and drug diversion is a signifi­cant contributing factor.¹ According to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health,² in 2011 and 2012, on average, more than one-half of partici­pants age ≥12 who used a pain reliever, tranquilizer, stimulant, or sedative non-medically obtained their most recently used drug “from a friend or relative for free.”

Unused, expired, and “extra” medi­cations pose a significant risk for diver­sion, abuse, and accidental overdose.³ According to the Prescription Drug Abuse Prevention Plan,¹ proper medica­tion disposal is a major problem that needs action to help reduce prescription drug abuse.

Regrettably, <20% of patients receive advice on medication disposal from their health care provider,⁴ even though clini­cians have an opportunity to educate patients and their caregivers on appro­priate use, and safe disposal of, medica­tions—in particular, controlled substances.

What should we emphasize to our patients about disposing of medications when it’s necessary?

Teach responsible use
Stress that medications prescribed for the patient are for his (her) use alone and should not be shared with friends or family. Sharing might seem kind and generous, but it can be dangerous. Medications should be used only at the prescribed dosage and frequency and for the rec­ommended duration. If the medication causes an adverse effect or other problem, instruct the patient to talk to you before making any changes to the established regimen.

Emphasize safe disposal
Follow instructions. The label on medi­cation bottles or other containers often has specific instructions on how to prop­erly store, and even dispose of, the drug. Advise your patient to follow instructions on the label carefully.

Participate in a take-back program. The U.S. Drug Enforcement Administration (DEA) sponsors several kinds of drug take-back programs, including permanent locations where unused prescriptions are collected; 1-day events; and mail-in/ship-back programs.

The National Prescription Drug Take-Back Initiative is one such program that collects unused or expired medications on “Take Back Days.” On such days, DEA-coordinated collection sites nationwide accept unneeded pills, including pre­scription painkillers and other controlled substances, for disposal only when law enforcement personnel are present. In 2014, this program collected 780,158 lb of prescribed controlled medications.⁵

Patients can get more information about these programs by contacting a local phar­macy or their household trash and recycling service division.^1,6

Discard medications properly in trash. An acceptable household strategy for disposing of prescription drugs is to mix the medication with an undesirable substance, such as used cat litter or coffee grounds, place the mixture in a sealed plastic bag or disposable container with a lid, and then place it in the trash.

Don’t flush. People sometimes flush unused medications down the toilet or drain. The current recommendation is against flush­ing unless instructions on the bottle specifi­cally say to do so. Flushing is appropriate for disposing of some medications such as opiates, thereby minimizing the risk of acci­dental overdose or misuse.⁶ It is important to remember that most municipal sewage treatment plans do not have the ability to extract pharmaceuticals from wastewater.⁷

Discard empty bottles. It is important to discard pill bottles once they are empty and to remove any identifiable personal infor­mation from the label. Educate patients not to use empty pill bottles to store or trans­port other medications; this practice might result in accidental ingestion of the wrong medication or dose.These methods of disposal are in accordance with federal, state, and local regulations, as well as human and environ­mental safety standards. Appropriate dis­posal decreases contamination of soil and bodies of water with active pharmaceutical ingredients, thereby minimizing people’s and aquatic animals’ chronic exposure to low levels of drugs.³

Encourage patients to seek drug safety information. Patients might benefit from the information and services pro­vided by:
   • National Council on Patient Information and Education (www.talkaboutrx.org)
   • Medication Use Safety Training for Seniors (www.mustforseniors.org), a nationwide initiative to promote medi­cation education and safety in the geri­atric population through an interactive program.

Remember: Although prescribing medi­cations is strictly regulated, particularly for controlled substances, those regulations do little to prevent diversion of medications after they’ve been prescribed. Educating patients and their caregivers about safe dis­posal can help protect them, their family, and others.

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

Patients often tell clinicians that they used their “left-over” medica­tions from previous refills, or that a family member shared medication with them. Other patients, who are non-adherent or have had a recent medication change, might reveal that they have some unused pills at home. As clinicians, what does this practice by our patients mean for us?

Prescription drug abuse is an emerg­ing crisis, and drug diversion is a signifi­cant contributing factor.¹ According to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health,² in 2011 and 2012, on average, more than one-half of partici­pants age ≥12 who used a pain reliever, tranquilizer, stimulant, or sedative non-medically obtained their most recently used drug “from a friend or relative for free.”

Unused, expired, and “extra” medi­cations pose a significant risk for diver­sion, abuse, and accidental overdose.³ According to the Prescription Drug Abuse Prevention Plan,¹ proper medica­tion disposal is a major problem that needs action to help reduce prescription drug abuse.

Regrettably, <20% of patients receive advice on medication disposal from their health care provider,⁴ even though clini­cians have an opportunity to educate patients and their caregivers on appro­priate use, and safe disposal of, medica­tions—in particular, controlled substances.

What should we emphasize to our patients about disposing of medications when it’s necessary?

Teach responsible use
Stress that medications prescribed for the patient are for his (her) use alone and should not be shared with friends or family. Sharing might seem kind and generous, but it can be dangerous. Medications should be used only at the prescribed dosage and frequency and for the rec­ommended duration. If the medication causes an adverse effect or other problem, instruct the patient to talk to you before making any changes to the established regimen.

Emphasize safe disposal
Follow instructions. The label on medi­cation bottles or other containers often has specific instructions on how to prop­erly store, and even dispose of, the drug. Advise your patient to follow instructions on the label carefully.

Participate in a take-back program. The U.S. Drug Enforcement Administration (DEA) sponsors several kinds of drug take-back programs, including permanent locations where unused prescriptions are collected; 1-day events; and mail-in/ship-back programs.

The National Prescription Drug Take-Back Initiative is one such program that collects unused or expired medications on “Take Back Days.” On such days, DEA-coordinated collection sites nationwide accept unneeded pills, including pre­scription painkillers and other controlled substances, for disposal only when law enforcement personnel are present. In 2014, this program collected 780,158 lb of prescribed controlled medications.⁵

Patients can get more information about these programs by contacting a local phar­macy or their household trash and recycling service division.^1,6

Discard medications properly in trash. An acceptable household strategy for disposing of prescription drugs is to mix the medication with an undesirable substance, such as used cat litter or coffee grounds, place the mixture in a sealed plastic bag or disposable container with a lid, and then place it in the trash.

Don’t flush. People sometimes flush unused medications down the toilet or drain. The current recommendation is against flush­ing unless instructions on the bottle specifi­cally say to do so. Flushing is appropriate for disposing of some medications such as opiates, thereby minimizing the risk of acci­dental overdose or misuse.⁶ It is important to remember that most municipal sewage treatment plans do not have the ability to extract pharmaceuticals from wastewater.⁷

Discard empty bottles. It is important to discard pill bottles once they are empty and to remove any identifiable personal infor­mation from the label. Educate patients not to use empty pill bottles to store or trans­port other medications; this practice might result in accidental ingestion of the wrong medication or dose.These methods of disposal are in accordance with federal, state, and local regulations, as well as human and environ­mental safety standards. Appropriate dis­posal decreases contamination of soil and bodies of water with active pharmaceutical ingredients, thereby minimizing people’s and aquatic animals’ chronic exposure to low levels of drugs.³

Encourage patients to seek drug safety information. Patients might benefit from the information and services pro­vided by:
   • National Council on Patient Information and Education (www.talkaboutrx.org)
   • Medication Use Safety Training for Seniors (www.mustforseniors.org), a nationwide initiative to promote medi­cation education and safety in the geri­atric population through an interactive program.

Remember: Although prescribing medi­cations is strictly regulated, particularly for controlled substances, those regulations do little to prevent diversion of medications after they’ve been prescribed. Educating patients and their caregivers about safe dis­posal can help protect them, their family, and others.

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

Patients often tell clinicians that they used their “left-over” medica­tions from previous refills, or that a family member shared medication with them. Other patients, who are non-adherent or have had a recent medication change, might reveal that they have some unused pills at home. As clinicians, what does this practice by our patients mean for us?

Prescription drug abuse is an emerg­ing crisis, and drug diversion is a signifi­cant contributing factor.¹ According to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health,² in 2011 and 2012, on average, more than one-half of partici­pants age ≥12 who used a pain reliever, tranquilizer, stimulant, or sedative non-medically obtained their most recently used drug “from a friend or relative for free.”

Unused, expired, and “extra” medi­cations pose a significant risk for diver­sion, abuse, and accidental overdose.³ According to the Prescription Drug Abuse Prevention Plan,¹ proper medica­tion disposal is a major problem that needs action to help reduce prescription drug abuse.

Regrettably, <20% of patients receive advice on medication disposal from their health care provider,⁴ even though clini­cians have an opportunity to educate patients and their caregivers on appro­priate use, and safe disposal of, medica­tions—in particular, controlled substances.

What should we emphasize to our patients about disposing of medications when it’s necessary?

Teach responsible use
Stress that medications prescribed for the patient are for his (her) use alone and should not be shared with friends or family. Sharing might seem kind and generous, but it can be dangerous. Medications should be used only at the prescribed dosage and frequency and for the rec­ommended duration. If the medication causes an adverse effect or other problem, instruct the patient to talk to you before making any changes to the established regimen.

Emphasize safe disposal
Follow instructions. The label on medi­cation bottles or other containers often has specific instructions on how to prop­erly store, and even dispose of, the drug. Advise your patient to follow instructions on the label carefully.

Participate in a take-back program. The U.S. Drug Enforcement Administration (DEA) sponsors several kinds of drug take-back programs, including permanent locations where unused prescriptions are collected; 1-day events; and mail-in/ship-back programs.

The National Prescription Drug Take-Back Initiative is one such program that collects unused or expired medications on “Take Back Days.” On such days, DEA-coordinated collection sites nationwide accept unneeded pills, including pre­scription painkillers and other controlled substances, for disposal only when law enforcement personnel are present. In 2014, this program collected 780,158 lb of prescribed controlled medications.⁵

Patients can get more information about these programs by contacting a local phar­macy or their household trash and recycling service division.^1,6

Discard medications properly in trash. An acceptable household strategy for disposing of prescription drugs is to mix the medication with an undesirable substance, such as used cat litter or coffee grounds, place the mixture in a sealed plastic bag or disposable container with a lid, and then place it in the trash.

Don’t flush. People sometimes flush unused medications down the toilet or drain. The current recommendation is against flush­ing unless instructions on the bottle specifi­cally say to do so. Flushing is appropriate for disposing of some medications such as opiates, thereby minimizing the risk of acci­dental overdose or misuse.⁶ It is important to remember that most municipal sewage treatment plans do not have the ability to extract pharmaceuticals from wastewater.⁷

Discard empty bottles. It is important to discard pill bottles once they are empty and to remove any identifiable personal infor­mation from the label. Educate patients not to use empty pill bottles to store or trans­port other medications; this practice might result in accidental ingestion of the wrong medication or dose.These methods of disposal are in accordance with federal, state, and local regulations, as well as human and environ­mental safety standards. Appropriate dis­posal decreases contamination of soil and bodies of water with active pharmaceutical ingredients, thereby minimizing people’s and aquatic animals’ chronic exposure to low levels of drugs.³

Encourage patients to seek drug safety information. Patients might benefit from the information and services pro­vided by:
   • National Council on Patient Information and Education (www.talkaboutrx.org)
   • Medication Use Safety Training for Seniors (www.mustforseniors.org), a nationwide initiative to promote medi­cation education and safety in the geri­atric population through an interactive program.

Remember: Although prescribing medi­cations is strictly regulated, particularly for controlled substances, those regulations do little to prevent diversion of medications after they’ve been prescribed. Educating patients and their caregivers about safe dis­posal can help protect them, their family, and others.

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

Physicians hardly need the Health Insurance Portability and Accountability Act (HIPAA) to remind them how important it is to safe­guard their patients’ records. Physicians understand that patient information is sen­sitive and it would be disastrous if their files became public or fell into the wrong hands. However, the use of health infor­mation technology to record patient infor­mation, although beneficial for medical professionals and patients, poses risks to patient privacy.¹

HIPAA requires clinicians and health care systems to protect patient information, whether it is maintained in an electronic health records system, stored on a mobile device, or transmitted via e-mail to another physician. The U.S. Department of Health and Human Services will increase HIPAA audits this year to make sure that medical practices have taken measures to protect their patients’ health information. Physicians and other clinicians can take advantage of cloud-based file-sharing services, such as Dropbox, without running afoul of HIPAA.

Mobile computing, the cloud, and patient information: A risky combination
Although mobile computing and cloud-based file-sharing sites such as Dropbox and Google Drive allow physicians to take notes on a tablet, annotate those notes on a laptop, and share them with a physician who views them on his (her) desktop, this free flow of information makes it more dif­ficult to stay compliant with HIPAA.

Dropbox and other file-sharing services encrypt documents while they’re stored in the cloud but the files are unprotected when downloaded to a device. E-mail, which isn’t as versatile or useful as these services, also is not HIPAA-compliant unless the files are encrypted.

Often, small psychiatric practices use these online services and e-mail even if they’re aware of the risks because they don’t have time to research a better solu­tion. Or they might resort to faxing or even snail-mailing documents, losing out on the increased productivity that the cloud can provide.

Secure technologies satisfy auditors
A number of tools exist to help physicians seamlessly integrate the encryption nec­essary to keep their patients’ records safe and meet HIPAA security requirements. Here’s a look at 3 options.

Sookasa (plus Dropbox). One option is to invest in a software product designed to encrypt documents shared through cloud-based services. This type of soft­ware creates a compliance “shield” around files stored on the cloud, converting files into HIPAA safe havens. The files are encrypted when synced to new devices or shared with other users, meaning they’re protected no matter where they reside.²

Sookasa is an online service that encrypts files shared and stored in Dropbox. The company plans to extend its support to other popular cloud services such as Google Drive and Microsoft OneDrive. Sookasa also audits and controls access to encrypted files, so that patient data can be blocked even if a device is lost or sto­ len. Sookasa users also can share files via e-mail with added encryption and authen­tication to make sure only the authorized receiver gets the documents.²

TigerText. Regular SMS text messages on your mobile phone aren’t compliant with HIPAA, but TigerText replicates the tex­ting experience in a secure way. Instead of being stored on your mobile phone, mes­sages sent through TigerText are stored on the company’s servers. Messages sent through the application can’t be saved, copied, or forwarded to other recipients. TigerText messages also are deleted, either after a set time period or after they’ve been read. Because the messages aren’t stored on phones, a lost or stolen phone won’t result in a data breach and a HIPAA violation.3

Secure text messaging won’t help physi­cians store and manage large amounts of patient files, but it’s a must-have if they use texting to communicate about patient care.

DataMotion SecureMail provides e-mail encryption services to health care orga­nizations and other enterprises. Using a decryption key, authorized users can open and read the encrypted e-mails, which are HIPAA-compliant.⁴ This method is supe­rior to other services that encrypt e-mails on the server. Several providers, such as Google’s e-mail encryption service Postini, ensure that e-mails are encrypted when they are stored on the server; however, the body text and attachments included in specific e-mails are not encrypted on the senders’ and receivers’ devices. If you lose a connected device, you would still be at risk of a HIPAA breach.

DataMotion’s SecureMail provides detailed tracking and logging of e-mails, which is necessary for auditing purposes. The product also works on mobile devices.

E-mail is a helpful tool for quickly shar­ing files and an e-mail encryption product such as SecureMail makes it possible to do so securely. Other e-mail encryption prod­ucts do not securely store and back up all files in a centralized way.

DisclosureDr. Cidon is CEO and Co-founder of Sookasa.

Physicians hardly need the Health Insurance Portability and Accountability Act (HIPAA) to remind them how important it is to safe­guard their patients’ records. Physicians understand that patient information is sen­sitive and it would be disastrous if their files became public or fell into the wrong hands. However, the use of health infor­mation technology to record patient infor­mation, although beneficial for medical professionals and patients, poses risks to patient privacy.¹

HIPAA requires clinicians and health care systems to protect patient information, whether it is maintained in an electronic health records system, stored on a mobile device, or transmitted via e-mail to another physician. The U.S. Department of Health and Human Services will increase HIPAA audits this year to make sure that medical practices have taken measures to protect their patients’ health information. Physicians and other clinicians can take advantage of cloud-based file-sharing services, such as Dropbox, without running afoul of HIPAA.

Mobile computing, the cloud, and patient information: A risky combination
Although mobile computing and cloud-based file-sharing sites such as Dropbox and Google Drive allow physicians to take notes on a tablet, annotate those notes on a laptop, and share them with a physician who views them on his (her) desktop, this free flow of information makes it more dif­ficult to stay compliant with HIPAA.

Dropbox and other file-sharing services encrypt documents while they’re stored in the cloud but the files are unprotected when downloaded to a device. E-mail, which isn’t as versatile or useful as these services, also is not HIPAA-compliant unless the files are encrypted.

Often, small psychiatric practices use these online services and e-mail even if they’re aware of the risks because they don’t have time to research a better solu­tion. Or they might resort to faxing or even snail-mailing documents, losing out on the increased productivity that the cloud can provide.

Secure technologies satisfy auditors
A number of tools exist to help physicians seamlessly integrate the encryption nec­essary to keep their patients’ records safe and meet HIPAA security requirements. Here’s a look at 3 options.

Sookasa (plus Dropbox). One option is to invest in a software product designed to encrypt documents shared through cloud-based services. This type of soft­ware creates a compliance “shield” around files stored on the cloud, converting files into HIPAA safe havens. The files are encrypted when synced to new devices or shared with other users, meaning they’re protected no matter where they reside.²

Sookasa is an online service that encrypts files shared and stored in Dropbox. The company plans to extend its support to other popular cloud services such as Google Drive and Microsoft OneDrive. Sookasa also audits and controls access to encrypted files, so that patient data can be blocked even if a device is lost or sto­ len. Sookasa users also can share files via e-mail with added encryption and authen­tication to make sure only the authorized receiver gets the documents.²

TigerText. Regular SMS text messages on your mobile phone aren’t compliant with HIPAA, but TigerText replicates the tex­ting experience in a secure way. Instead of being stored on your mobile phone, mes­sages sent through TigerText are stored on the company’s servers. Messages sent through the application can’t be saved, copied, or forwarded to other recipients. TigerText messages also are deleted, either after a set time period or after they’ve been read. Because the messages aren’t stored on phones, a lost or stolen phone won’t result in a data breach and a HIPAA violation.3

Secure text messaging won’t help physi­cians store and manage large amounts of patient files, but it’s a must-have if they use texting to communicate about patient care.

DataMotion SecureMail provides e-mail encryption services to health care orga­nizations and other enterprises. Using a decryption key, authorized users can open and read the encrypted e-mails, which are HIPAA-compliant.⁴ This method is supe­rior to other services that encrypt e-mails on the server. Several providers, such as Google’s e-mail encryption service Postini, ensure that e-mails are encrypted when they are stored on the server; however, the body text and attachments included in specific e-mails are not encrypted on the senders’ and receivers’ devices. If you lose a connected device, you would still be at risk of a HIPAA breach.

DataMotion’s SecureMail provides detailed tracking and logging of e-mails, which is necessary for auditing purposes. The product also works on mobile devices.

E-mail is a helpful tool for quickly shar­ing files and an e-mail encryption product such as SecureMail makes it possible to do so securely. Other e-mail encryption prod­ucts do not securely store and back up all files in a centralized way.

DisclosureDr. Cidon is CEO and Co-founder of Sookasa.

Physicians hardly need the Health Insurance Portability and Accountability Act (HIPAA) to remind them how important it is to safe­guard their patients’ records. Physicians understand that patient information is sen­sitive and it would be disastrous if their files became public or fell into the wrong hands. However, the use of health infor­mation technology to record patient infor­mation, although beneficial for medical professionals and patients, poses risks to patient privacy.¹

HIPAA requires clinicians and health care systems to protect patient information, whether it is maintained in an electronic health records system, stored on a mobile device, or transmitted via e-mail to another physician. The U.S. Department of Health and Human Services will increase HIPAA audits this year to make sure that medical practices have taken measures to protect their patients’ health information. Physicians and other clinicians can take advantage of cloud-based file-sharing services, such as Dropbox, without running afoul of HIPAA.

Mobile computing, the cloud, and patient information: A risky combination
Although mobile computing and cloud-based file-sharing sites such as Dropbox and Google Drive allow physicians to take notes on a tablet, annotate those notes on a laptop, and share them with a physician who views them on his (her) desktop, this free flow of information makes it more dif­ficult to stay compliant with HIPAA.

Dropbox and other file-sharing services encrypt documents while they’re stored in the cloud but the files are unprotected when downloaded to a device. E-mail, which isn’t as versatile or useful as these services, also is not HIPAA-compliant unless the files are encrypted.

Often, small psychiatric practices use these online services and e-mail even if they’re aware of the risks because they don’t have time to research a better solu­tion. Or they might resort to faxing or even snail-mailing documents, losing out on the increased productivity that the cloud can provide.

Secure technologies satisfy auditors
A number of tools exist to help physicians seamlessly integrate the encryption nec­essary to keep their patients’ records safe and meet HIPAA security requirements. Here’s a look at 3 options.

Sookasa (plus Dropbox). One option is to invest in a software product designed to encrypt documents shared through cloud-based services. This type of soft­ware creates a compliance “shield” around files stored on the cloud, converting files into HIPAA safe havens. The files are encrypted when synced to new devices or shared with other users, meaning they’re protected no matter where they reside.²

Sookasa is an online service that encrypts files shared and stored in Dropbox. The company plans to extend its support to other popular cloud services such as Google Drive and Microsoft OneDrive. Sookasa also audits and controls access to encrypted files, so that patient data can be blocked even if a device is lost or sto­ len. Sookasa users also can share files via e-mail with added encryption and authen­tication to make sure only the authorized receiver gets the documents.²

TigerText. Regular SMS text messages on your mobile phone aren’t compliant with HIPAA, but TigerText replicates the tex­ting experience in a secure way. Instead of being stored on your mobile phone, mes­sages sent through TigerText are stored on the company’s servers. Messages sent through the application can’t be saved, copied, or forwarded to other recipients. TigerText messages also are deleted, either after a set time period or after they’ve been read. Because the messages aren’t stored on phones, a lost or stolen phone won’t result in a data breach and a HIPAA violation.3

Secure text messaging won’t help physi­cians store and manage large amounts of patient files, but it’s a must-have if they use texting to communicate about patient care.

DataMotion SecureMail provides e-mail encryption services to health care orga­nizations and other enterprises. Using a decryption key, authorized users can open and read the encrypted e-mails, which are HIPAA-compliant.⁴ This method is supe­rior to other services that encrypt e-mails on the server. Several providers, such as Google’s e-mail encryption service Postini, ensure that e-mails are encrypted when they are stored on the server; however, the body text and attachments included in specific e-mails are not encrypted on the senders’ and receivers’ devices. If you lose a connected device, you would still be at risk of a HIPAA breach.

DataMotion’s SecureMail provides detailed tracking and logging of e-mails, which is necessary for auditing purposes. The product also works on mobile devices.

E-mail is a helpful tool for quickly shar­ing files and an e-mail encryption product such as SecureMail makes it possible to do so securely. Other e-mail encryption prod­ucts do not securely store and back up all files in a centralized way.

DisclosureDr. Cidon is CEO and Co-founder of Sookasa.

In some patients, symptoms of depres­sion, psychosis, delirium, or dementia exist concomitantly with, or as a result of, an abnormal (elevated or low) serum cal­cium concentration that has been precipi­tated by an unrecognized endocrinopathy. The apparent psychiatric presentations of such patients might reflect parathyroid pathology—not psychopathology.

Hypercalcemia and hypocalcemia often are related to a distinct spectrum of condi­tions, such as diseases of the parathyroid glands, kidneys, and various neoplasms including malignancies. Be alert to the pos­sibility of parathyroid disease in patients whose presentation suggests mental ill­ness concurrent with, or as a direct conse­quence of, an abnormal calcium level, and investigate appropriately.

The Table^1-9 illustrates how 3 clini­cal laboratory tests—serum calcium, serum parathyroid hormone (PTH), and phosphate—can narrow the differen­tial diagnosis when the clinical impres­sion is parathyroid-related illness. Seek endocrinology consultation whenever a parathyroid-associated ailment is discov­ered or suspected. Serum calcium is rou­tinely assayed in hospitalized patients; when managing a patient with treatment-refractory psychiatric illness, (1) always check the reported result of that test and (2) consider measuring PTH.

Case reports¹
Case 1: Woman with chronic depression. The patient was hospitalized while suicidal. Serial serum calcium levels were 12.5 mg/dL and 15.8 mg/dL (reference range, 8.2–10.2 mg/dL). The PTH level was elevated at 287 pg/mL (refer­ence range, 10–65 pg/mL).

After thyroid imaging, surgery revealed a parathyroid mass, which was resected. Histologic examination confirmed an adenoma.

The calcium concentration declined to 8.6 mg/dL postoperatively and stabilized at 9.2 mg/dL. Psychiatric symptoms resolved fully; she experienced a complete recovery.

Case 2: Man on long-term lithium mainte­nance. The patient was admitted in a delusional psychotic state. The serum calcium level was 14.3 mg/dL initially, decreasing to 11.5 mg/dL after lithium was discontinued. The PTH level was elevated at 97 pg/mL at admission, consis­tent with hyperparathyroidism.

A parathyroid adenoma was resected. Serum calcium level normalized at 10.7 mg/dL; psycho­sis resolved with striking, sustained improve­ment in mental status.

Full return to mental, physical health

The diagnosis of parathyroid adenoma in these 2 patients, which began with a psy­chiatric presentation, was properly made after an abnormal serum calcium level was documented. Surgical treatment of the endocrinopathy produced full remission and a return to normal mental and physi­cal health.

Although psychiatric manifestations are associated with an abnormal serum calcium concentration, the severity of those presen­tations does not correlate with the degree of abnormality of the calcium level.¹⁰

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

In some patients, symptoms of depres­sion, psychosis, delirium, or dementia exist concomitantly with, or as a result of, an abnormal (elevated or low) serum cal­cium concentration that has been precipi­tated by an unrecognized endocrinopathy. The apparent psychiatric presentations of such patients might reflect parathyroid pathology—not psychopathology.

Hypercalcemia and hypocalcemia often are related to a distinct spectrum of condi­tions, such as diseases of the parathyroid glands, kidneys, and various neoplasms including malignancies. Be alert to the pos­sibility of parathyroid disease in patients whose presentation suggests mental ill­ness concurrent with, or as a direct conse­quence of, an abnormal calcium level, and investigate appropriately.

The Table^1-9 illustrates how 3 clini­cal laboratory tests—serum calcium, serum parathyroid hormone (PTH), and phosphate—can narrow the differen­tial diagnosis when the clinical impres­sion is parathyroid-related illness. Seek endocrinology consultation whenever a parathyroid-associated ailment is discov­ered or suspected. Serum calcium is rou­tinely assayed in hospitalized patients; when managing a patient with treatment-refractory psychiatric illness, (1) always check the reported result of that test and (2) consider measuring PTH.

Case reports¹
Case 1: Woman with chronic depression. The patient was hospitalized while suicidal. Serial serum calcium levels were 12.5 mg/dL and 15.8 mg/dL (reference range, 8.2–10.2 mg/dL). The PTH level was elevated at 287 pg/mL (refer­ence range, 10–65 pg/mL).

After thyroid imaging, surgery revealed a parathyroid mass, which was resected. Histologic examination confirmed an adenoma.

The calcium concentration declined to 8.6 mg/dL postoperatively and stabilized at 9.2 mg/dL. Psychiatric symptoms resolved fully; she experienced a complete recovery.

Case 2: Man on long-term lithium mainte­nance. The patient was admitted in a delusional psychotic state. The serum calcium level was 14.3 mg/dL initially, decreasing to 11.5 mg/dL after lithium was discontinued. The PTH level was elevated at 97 pg/mL at admission, consis­tent with hyperparathyroidism.

A parathyroid adenoma was resected. Serum calcium level normalized at 10.7 mg/dL; psycho­sis resolved with striking, sustained improve­ment in mental status.

Full return to mental, physical health

The diagnosis of parathyroid adenoma in these 2 patients, which began with a psy­chiatric presentation, was properly made after an abnormal serum calcium level was documented. Surgical treatment of the endocrinopathy produced full remission and a return to normal mental and physi­cal health.

Although psychiatric manifestations are associated with an abnormal serum calcium concentration, the severity of those presen­tations does not correlate with the degree of abnormality of the calcium level.¹⁰

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

In some patients, symptoms of depres­sion, psychosis, delirium, or dementia exist concomitantly with, or as a result of, an abnormal (elevated or low) serum cal­cium concentration that has been precipi­tated by an unrecognized endocrinopathy. The apparent psychiatric presentations of such patients might reflect parathyroid pathology—not psychopathology.

Hypercalcemia and hypocalcemia often are related to a distinct spectrum of condi­tions, such as diseases of the parathyroid glands, kidneys, and various neoplasms including malignancies. Be alert to the pos­sibility of parathyroid disease in patients whose presentation suggests mental ill­ness concurrent with, or as a direct conse­quence of, an abnormal calcium level, and investigate appropriately.

The Table^1-9 illustrates how 3 clini­cal laboratory tests—serum calcium, serum parathyroid hormone (PTH), and phosphate—can narrow the differen­tial diagnosis when the clinical impres­sion is parathyroid-related illness. Seek endocrinology consultation whenever a parathyroid-associated ailment is discov­ered or suspected. Serum calcium is rou­tinely assayed in hospitalized patients; when managing a patient with treatment-refractory psychiatric illness, (1) always check the reported result of that test and (2) consider measuring PTH.

Case reports¹
Case 1: Woman with chronic depression. The patient was hospitalized while suicidal. Serial serum calcium levels were 12.5 mg/dL and 15.8 mg/dL (reference range, 8.2–10.2 mg/dL). The PTH level was elevated at 287 pg/mL (refer­ence range, 10–65 pg/mL).

After thyroid imaging, surgery revealed a parathyroid mass, which was resected. Histologic examination confirmed an adenoma.

The calcium concentration declined to 8.6 mg/dL postoperatively and stabilized at 9.2 mg/dL. Psychiatric symptoms resolved fully; she experienced a complete recovery.

Case 2: Man on long-term lithium mainte­nance. The patient was admitted in a delusional psychotic state. The serum calcium level was 14.3 mg/dL initially, decreasing to 11.5 mg/dL after lithium was discontinued. The PTH level was elevated at 97 pg/mL at admission, consis­tent with hyperparathyroidism.

A parathyroid adenoma was resected. Serum calcium level normalized at 10.7 mg/dL; psycho­sis resolved with striking, sustained improve­ment in mental status.

Full return to mental, physical health

The diagnosis of parathyroid adenoma in these 2 patients, which began with a psy­chiatric presentation, was properly made after an abnormal serum calcium level was documented. Surgical treatment of the endocrinopathy produced full remission and a return to normal mental and physi­cal health.

Although psychiatric manifestations are associated with an abnormal serum calcium concentration, the severity of those presen­tations does not correlate with the degree of abnormality of the calcium level.¹⁰

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

Suicidologists and legal experts implore clinicians to document their suicide risk assessments (SRAs) thoroughly. It’s difficult, however, to find practical guid­ance on how to write a clinically sound, legally defensible SRA.

The crux of every SRA is written justifica­tion of suicide risk. That justification should reveal your thinking and present a well-reasoned basis for your decision.

Reasoned vs right
It’s more important to provide a justifica­tion of suicide risk that’s well-reasoned rather than one that’s right. Suicide is impossible to predict. Instead of predic­tion, legally we are asked to reasonably anticipate suicide based on clinical facts. In hindsight, especially in the context of a courtroom, decisions might look ill-considered. You need to craft a logical argu­ment, be clear, and avoid jargon.

Convey thoroughness by covering each component of an SRA. Use the mnemonic device CAIPS to help the reader (and you) understand how a conclusion was reached based on the facts of the case.

Chronic and Acute factors. Address the chronic and acute factors that weigh heavi­est in your mind. Chronic factors are condi­tions, past events, and demographics that generally do not change. Acute factors are recent events or conditions that potentially are modifiable. Pay attention to combina­tions of factors that dramatically elevate risk (eg, previous attempts in the context of acute depression). Avoid repeating every factor, especially when these are documented else­where, such as on a checklist.

Imminent warning signs for suicide. Address warning signs (Table 1),¹ the nature of current suicidal thoughts (Table 2), and other aspects of mental status (eg, future ori­entation) that influenced your decision. Use words like “moreover,” “however,” and “in addition” to draw the reader’s attention to the building blocks of your argument.

Protective factors. Discuss the protective factors last; they deserve the least weight because none has been shown to immunize people against suicide. Don’t solely rely on your judgment of what is protective (eg, chil­dren in the home). Instead, elicit the patient’s reasons for living and dying. Be concerned if he (she) reports more of the latter.

Summary statement. Make an explicit statement about risk, focusing on imminent risk (ie, the next few hours and days). Avoid a “plot twist,” which is a risk level inconsis­tent with the preceding evidence, because it suggests an error in judgment. The Box gives an example of a justification that follows the CAIPS method.

Additional tips
Consider these strategies:
   • Bolster your argument by explicitly addressing hopelessness (the strongest psy­chological correlate of suicide); use quotes from the patient that support your decision; refer to consultation with family members and colleagues; and include pertinent nega­tives to show completeness2 (ie, “denied sui­cide plans”).
   • Critically resolve discrepancies between what the patient says and behavior that suggests suicidal intent (eg, a patient who minimizes suicidal intent but shopped for a gun yesterday).
   • Last, while reviewing your justification, imagine that your patient completed suicide after leaving your office and that you are in court for negligence. In our experience, this exercise reveals dangerous errors of judg­ment. A clear and reasoned justification will reduce the risk of litigation and help you make prudent treatment plans.


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

Suicidologists and legal experts implore clinicians to document their suicide risk assessments (SRAs) thoroughly. It’s difficult, however, to find practical guid­ance on how to write a clinically sound, legally defensible SRA.

The crux of every SRA is written justifica­tion of suicide risk. That justification should reveal your thinking and present a well-reasoned basis for your decision.

Reasoned vs right
It’s more important to provide a justifica­tion of suicide risk that’s well-reasoned rather than one that’s right. Suicide is impossible to predict. Instead of predic­tion, legally we are asked to reasonably anticipate suicide based on clinical facts. In hindsight, especially in the context of a courtroom, decisions might look ill-considered. You need to craft a logical argu­ment, be clear, and avoid jargon.

Convey thoroughness by covering each component of an SRA. Use the mnemonic device CAIPS to help the reader (and you) understand how a conclusion was reached based on the facts of the case.

Chronic and Acute factors. Address the chronic and acute factors that weigh heavi­est in your mind. Chronic factors are condi­tions, past events, and demographics that generally do not change. Acute factors are recent events or conditions that potentially are modifiable. Pay attention to combina­tions of factors that dramatically elevate risk (eg, previous attempts in the context of acute depression). Avoid repeating every factor, especially when these are documented else­where, such as on a checklist.

Imminent warning signs for suicide. Address warning signs (Table 1),¹ the nature of current suicidal thoughts (Table 2), and other aspects of mental status (eg, future ori­entation) that influenced your decision. Use words like “moreover,” “however,” and “in addition” to draw the reader’s attention to the building blocks of your argument.

Protective factors. Discuss the protective factors last; they deserve the least weight because none has been shown to immunize people against suicide. Don’t solely rely on your judgment of what is protective (eg, chil­dren in the home). Instead, elicit the patient’s reasons for living and dying. Be concerned if he (she) reports more of the latter.

Summary statement. Make an explicit statement about risk, focusing on imminent risk (ie, the next few hours and days). Avoid a “plot twist,” which is a risk level inconsis­tent with the preceding evidence, because it suggests an error in judgment. The Box gives an example of a justification that follows the CAIPS method.

Additional tips
Consider these strategies:
   • Bolster your argument by explicitly addressing hopelessness (the strongest psy­chological correlate of suicide); use quotes from the patient that support your decision; refer to consultation with family members and colleagues; and include pertinent nega­tives to show completeness2 (ie, “denied sui­cide plans”).
   • Critically resolve discrepancies between what the patient says and behavior that suggests suicidal intent (eg, a patient who minimizes suicidal intent but shopped for a gun yesterday).
   • Last, while reviewing your justification, imagine that your patient completed suicide after leaving your office and that you are in court for negligence. In our experience, this exercise reveals dangerous errors of judg­ment. A clear and reasoned justification will reduce the risk of litigation and help you make prudent treatment plans.


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

Suicidologists and legal experts implore clinicians to document their suicide risk assessments (SRAs) thoroughly. It’s difficult, however, to find practical guid­ance on how to write a clinically sound, legally defensible SRA.

The crux of every SRA is written justifica­tion of suicide risk. That justification should reveal your thinking and present a well-reasoned basis for your decision.

Reasoned vs right
It’s more important to provide a justifica­tion of suicide risk that’s well-reasoned rather than one that’s right. Suicide is impossible to predict. Instead of predic­tion, legally we are asked to reasonably anticipate suicide based on clinical facts. In hindsight, especially in the context of a courtroom, decisions might look ill-considered. You need to craft a logical argu­ment, be clear, and avoid jargon.

Convey thoroughness by covering each component of an SRA. Use the mnemonic device CAIPS to help the reader (and you) understand how a conclusion was reached based on the facts of the case.

Chronic and Acute factors. Address the chronic and acute factors that weigh heavi­est in your mind. Chronic factors are condi­tions, past events, and demographics that generally do not change. Acute factors are recent events or conditions that potentially are modifiable. Pay attention to combina­tions of factors that dramatically elevate risk (eg, previous attempts in the context of acute depression). Avoid repeating every factor, especially when these are documented else­where, such as on a checklist.

Imminent warning signs for suicide. Address warning signs (Table 1),¹ the nature of current suicidal thoughts (Table 2), and other aspects of mental status (eg, future ori­entation) that influenced your decision. Use words like “moreover,” “however,” and “in addition” to draw the reader’s attention to the building blocks of your argument.

Protective factors. Discuss the protective factors last; they deserve the least weight because none has been shown to immunize people against suicide. Don’t solely rely on your judgment of what is protective (eg, chil­dren in the home). Instead, elicit the patient’s reasons for living and dying. Be concerned if he (she) reports more of the latter.

Summary statement. Make an explicit statement about risk, focusing on imminent risk (ie, the next few hours and days). Avoid a “plot twist,” which is a risk level inconsis­tent with the preceding evidence, because it suggests an error in judgment. The Box gives an example of a justification that follows the CAIPS method.

Additional tips
Consider these strategies:
   • Bolster your argument by explicitly addressing hopelessness (the strongest psy­chological correlate of suicide); use quotes from the patient that support your decision; refer to consultation with family members and colleagues; and include pertinent nega­tives to show completeness2 (ie, “denied sui­cide plans”).
   • Critically resolve discrepancies between what the patient says and behavior that suggests suicidal intent (eg, a patient who minimizes suicidal intent but shopped for a gun yesterday).
   • Last, while reviewing your justification, imagine that your patient completed suicide after leaving your office and that you are in court for negligence. In our experience, this exercise reveals dangerous errors of judg­ment. A clear and reasoned justification will reduce the risk of litigation and help you make prudent treatment plans.


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

Snoring, snorting, gasping, and obstruc­tive sleep apnea are caused by col­lapse of the pharyngeal airway during sleep.¹ Pathophysiology includes a combi­nation of anatomical and physiological vari­ables.¹ Common anatomical predisposing conditions include abnormalities of pharyn­geal, lingual, and dental arches; physiologi­cal concerns are advancing age, male sex, obesity, use of sedatives, body positioning, and reduced muscle tone during rapid eye movement sleep. Coexistence of anatomic and physiological elements can produce significant narrowing of the upper airway.

Comorbidities include vascular, meta­bolic, and psychiatric conditions. As many as one-third of people with symptoms of sleep apnea report depressed mood; approx­imately 10% of these patients meet criteria for moderate or severe depression.²

In short, sleep-disordered breathing has a globally negative effect on mental health.

When should you consider obtaining a sleep apnea study?
Refer patients for a sleep study when snor­ing, snorting, gasping, or pauses in breathing occur during sleep, or in the case of daytime sleepiness, fatigue, or unrefreshing sleep that cannot be explained by another medical or psychiatric illness.² A sleep specialist can determine the most appropriate intervention for sleep-disordered breathing.

An apneic event is characterized by complete cessation of airflow; hypopnea is a partially compromised airway. In either event, at least a 3% decrease in oxygen saturation occurs for at least 10 seconds.³ A diagnosis of obstructive sleep apnea or hypopnea is required when polysomnography reveals either of:
   • ≥5 episodes of apnea or hypopnea, or both, per hour of sleep, with symptoms of a rhythmic breathing disturbance or daytime sleepiness or fatigue
   • ≥15 episodes of apnea or hypopnea, or both, per hour of sleep, regardless of accom­panying symptoms.²

What are the treatment options? 
   • Continuous positive airway pressure (CPAP) machines.
   • Surgical procedures include adeno-tonsillectomy in children and surgical maxilla-mandibular advancement or pala­tal implants for adults.
   • A novel implantable electrical stimu­lation device stimulates the hypoglossal nerve, which activates the genioglossus muscle, thus moving the tongue forward to open the airway.
   • An anterior mandibular positioning (AMP) device increases the diameter of the retroglossal space by preventing posterior movement of the mandible and tongue, thereby limiting encroachment on the air­way diameter and reducing the potential for collapse.^1-4

When should you recommend an AMP device?
Consider recommending an AMP device to treat sleep-disordered breathing when (1) lifestyle changes, such as sleep hygiene, weight loss, and stopping sedatives, do not work and (2) a CPAP machine or a surgical procedure is contraindicated or has been ineffective.¹ An AMP device can minimize snoring and relieve airway obstruction, especially in patients with supine position-related apnea.⁴ To keep the airway open in non-supine position-related cases, an AMP device might be indicated in addition to CPAP delivered nasally.¹

This plastic oral appliance is either a 1- or 2-piece design, and looks and is sized simi­larly to an athletic mouth-protection guard or an oral anti-bruxism tooth-protection appliance. It is affixed to the mandible and maxillary arches by clasps (Figure).

An AMP device is contraindicated when the device cannot be affixed to the dental arches and in some patients with an anatom­ical or pain-related temporomandibular joint disorder.⁵ The device is easy to use, nonin­vasive, readily accessible, and less expensive than alternatives.³

How can you help maintain treatment adherence?
AMP devices can induce adverse effects, including dental pain or discomfort through orthodontic alterations; patient reports and follow-up can yield detection and device adjustments can alleviate such problems. Adherence generally is good, with complaints usually limited to minor tooth discomfort, occlusive changes, and increased or decreased salivation.⁵ In our clinical experience, many patients find these devices comfortable and easy to use, but might complain of feeling awkward when wearing them.

Changes in occlusion can occur during long-term treatment with an AMP device. Proper fitting is essential to facilitate a more open airway and the ability to speak and drink fluids, and to maintain safety, even if vomiting occurs while the device is in place.

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

Snoring, snorting, gasping, and obstruc­tive sleep apnea are caused by col­lapse of the pharyngeal airway during sleep.¹ Pathophysiology includes a combi­nation of anatomical and physiological vari­ables.¹ Common anatomical predisposing conditions include abnormalities of pharyn­geal, lingual, and dental arches; physiologi­cal concerns are advancing age, male sex, obesity, use of sedatives, body positioning, and reduced muscle tone during rapid eye movement sleep. Coexistence of anatomic and physiological elements can produce significant narrowing of the upper airway.

Comorbidities include vascular, meta­bolic, and psychiatric conditions. As many as one-third of people with symptoms of sleep apnea report depressed mood; approx­imately 10% of these patients meet criteria for moderate or severe depression.²

In short, sleep-disordered breathing has a globally negative effect on mental health.

When should you consider obtaining a sleep apnea study?
Refer patients for a sleep study when snor­ing, snorting, gasping, or pauses in breathing occur during sleep, or in the case of daytime sleepiness, fatigue, or unrefreshing sleep that cannot be explained by another medical or psychiatric illness.² A sleep specialist can determine the most appropriate intervention for sleep-disordered breathing.

An apneic event is characterized by complete cessation of airflow; hypopnea is a partially compromised airway. In either event, at least a 3% decrease in oxygen saturation occurs for at least 10 seconds.³ A diagnosis of obstructive sleep apnea or hypopnea is required when polysomnography reveals either of:
   • ≥5 episodes of apnea or hypopnea, or both, per hour of sleep, with symptoms of a rhythmic breathing disturbance or daytime sleepiness or fatigue
   • ≥15 episodes of apnea or hypopnea, or both, per hour of sleep, regardless of accom­panying symptoms.²

What are the treatment options? 
   • Continuous positive airway pressure (CPAP) machines.
   • Surgical procedures include adeno-tonsillectomy in children and surgical maxilla-mandibular advancement or pala­tal implants for adults.
   • A novel implantable electrical stimu­lation device stimulates the hypoglossal nerve, which activates the genioglossus muscle, thus moving the tongue forward to open the airway.
   • An anterior mandibular positioning (AMP) device increases the diameter of the retroglossal space by preventing posterior movement of the mandible and tongue, thereby limiting encroachment on the air­way diameter and reducing the potential for collapse.^1-4

When should you recommend an AMP device?
Consider recommending an AMP device to treat sleep-disordered breathing when (1) lifestyle changes, such as sleep hygiene, weight loss, and stopping sedatives, do not work and (2) a CPAP machine or a surgical procedure is contraindicated or has been ineffective.¹ An AMP device can minimize snoring and relieve airway obstruction, especially in patients with supine position-related apnea.⁴ To keep the airway open in non-supine position-related cases, an AMP device might be indicated in addition to CPAP delivered nasally.¹

This plastic oral appliance is either a 1- or 2-piece design, and looks and is sized simi­larly to an athletic mouth-protection guard or an oral anti-bruxism tooth-protection appliance. It is affixed to the mandible and maxillary arches by clasps (Figure).

An AMP device is contraindicated when the device cannot be affixed to the dental arches and in some patients with an anatom­ical or pain-related temporomandibular joint disorder.⁵ The device is easy to use, nonin­vasive, readily accessible, and less expensive than alternatives.³

How can you help maintain treatment adherence?
AMP devices can induce adverse effects, including dental pain or discomfort through orthodontic alterations; patient reports and follow-up can yield detection and device adjustments can alleviate such problems. Adherence generally is good, with complaints usually limited to minor tooth discomfort, occlusive changes, and increased or decreased salivation.⁵ In our clinical experience, many patients find these devices comfortable and easy to use, but might complain of feeling awkward when wearing them.

Changes in occlusion can occur during long-term treatment with an AMP device. Proper fitting is essential to facilitate a more open airway and the ability to speak and drink fluids, and to maintain safety, even if vomiting occurs while the device is in place.

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

Snoring, snorting, gasping, and obstruc­tive sleep apnea are caused by col­lapse of the pharyngeal airway during sleep.¹ Pathophysiology includes a combi­nation of anatomical and physiological vari­ables.¹ Common anatomical predisposing conditions include abnormalities of pharyn­geal, lingual, and dental arches; physiologi­cal concerns are advancing age, male sex, obesity, use of sedatives, body positioning, and reduced muscle tone during rapid eye movement sleep. Coexistence of anatomic and physiological elements can produce significant narrowing of the upper airway.

Comorbidities include vascular, meta­bolic, and psychiatric conditions. As many as one-third of people with symptoms of sleep apnea report depressed mood; approx­imately 10% of these patients meet criteria for moderate or severe depression.²

In short, sleep-disordered breathing has a globally negative effect on mental health.

When should you consider obtaining a sleep apnea study?
Refer patients for a sleep study when snor­ing, snorting, gasping, or pauses in breathing occur during sleep, or in the case of daytime sleepiness, fatigue, or unrefreshing sleep that cannot be explained by another medical or psychiatric illness.² A sleep specialist can determine the most appropriate intervention for sleep-disordered breathing.

An apneic event is characterized by complete cessation of airflow; hypopnea is a partially compromised airway. In either event, at least a 3% decrease in oxygen saturation occurs for at least 10 seconds.³ A diagnosis of obstructive sleep apnea or hypopnea is required when polysomnography reveals either of:
   • ≥5 episodes of apnea or hypopnea, or both, per hour of sleep, with symptoms of a rhythmic breathing disturbance or daytime sleepiness or fatigue
   • ≥15 episodes of apnea or hypopnea, or both, per hour of sleep, regardless of accom­panying symptoms.²

What are the treatment options? 
   • Continuous positive airway pressure (CPAP) machines.
   • Surgical procedures include adeno-tonsillectomy in children and surgical maxilla-mandibular advancement or pala­tal implants for adults.
   • A novel implantable electrical stimu­lation device stimulates the hypoglossal nerve, which activates the genioglossus muscle, thus moving the tongue forward to open the airway.
   • An anterior mandibular positioning (AMP) device increases the diameter of the retroglossal space by preventing posterior movement of the mandible and tongue, thereby limiting encroachment on the air­way diameter and reducing the potential for collapse.^1-4

When should you recommend an AMP device?
Consider recommending an AMP device to treat sleep-disordered breathing when (1) lifestyle changes, such as sleep hygiene, weight loss, and stopping sedatives, do not work and (2) a CPAP machine or a surgical procedure is contraindicated or has been ineffective.¹ An AMP device can minimize snoring and relieve airway obstruction, especially in patients with supine position-related apnea.⁴ To keep the airway open in non-supine position-related cases, an AMP device might be indicated in addition to CPAP delivered nasally.¹

This plastic oral appliance is either a 1- or 2-piece design, and looks and is sized simi­larly to an athletic mouth-protection guard or an oral anti-bruxism tooth-protection appliance. It is affixed to the mandible and maxillary arches by clasps (Figure).

An AMP device is contraindicated when the device cannot be affixed to the dental arches and in some patients with an anatom­ical or pain-related temporomandibular joint disorder.⁵ The device is easy to use, nonin­vasive, readily accessible, and less expensive than alternatives.³

How can you help maintain treatment adherence?
AMP devices can induce adverse effects, including dental pain or discomfort through orthodontic alterations; patient reports and follow-up can yield detection and device adjustments can alleviate such problems. Adherence generally is good, with complaints usually limited to minor tooth discomfort, occlusive changes, and increased or decreased salivation.⁵ In our clinical experience, many patients find these devices comfortable and easy to use, but might complain of feeling awkward when wearing them.

Changes in occlusion can occur during long-term treatment with an AMP device. Proper fitting is essential to facilitate a more open airway and the ability to speak and drink fluids, and to maintain safety, even if vomiting occurs while the device is in place.

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