Pearls

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making. 

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.² 

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk. 

Impusivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be aware of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings—2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess important risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making. 

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.² 

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk. 

Impusivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be aware of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings—2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess important risk factors for violence.

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

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making. 

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.² 

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk. 

Impusivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be aware of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings—2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess important risk factors for violence.

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

For a busy clinician, learning that a prescription pad has been stolen, sub-mitted with a counterfeit signature, and used to acquire a controlled substance comes as a shock. It evokes a sense of betrayal and raises a number of medico-legal issues that can be avoided if you know how to protect yourself.

Prescription pad security
One of the simplest ways to reduce prescrip­tion pad theft is to lock the pads in a secure location when the office is closed.1 Establish and maintain an inventory of prescription pads; you should number and count pads weekly. For Schedule-II controlled substance prescription pads, document the control number on each new pad.¹ The best way to ensure that all pads are accounted for is by using sequential numbering similar to bank check numbers.

Do not allow staff to sign your prescrip­tion pad. Limit access to prescription pads to authorized personnel; be sure that they keep the prescription pad in their pocket, not on their desk or a counter, and not in examining rooms, where they could be stolen. For elec­tronic prescribing, always lock the drawer where the computer prescription paper sits.¹

Some physicians might find it helpful to invest in tamper-resistant prescription pads. As of April 2008, the Centers for Medicare and Medicaid Services mandates that for a prescription pad to be considered tamper-resistant it must include 1 or more industry-recognized features designed to prevent unauthorized copying, erasure, or modifica­tion of prescriptions.²

When you order prescription pads, do not print your Drug Enforcement Administration (DEA) number on the pads. Also, check that your printer maintains strict process controls over prescription pad production, storage, and delivery.¹

Other ways to prevent fraudulent pre­scriptions include using a gel pen to write prescriptions, because these pens contain pigments that are quickly absorbed, prevent­ing ink from being washed away with chemi­cal solvents.¹ Never leave blank space on a written prescription and do not sign blank prescription pads beforehand.³ Write instruc­tions clearly on each prescription, informing pharmacists of ways to verify the prescrip­tion’s authenticity.

Legal responsibilities
In case your prescription pads are stolen, even after taking precautionary measures, make the following actions to report and record fraudulent charges:
   • If your prescription pads for Schedule-II medications—known as “triplicates”— are missing, give the control number of the first and last prescription in the pad to your state’s pharmacy organization. Some states have an electronic alert system to aid with filing a fraud claim (eg, the Texas Pharmacy Association has a section on its Web site for reporting prescription fraud and theft).
   • Immediately inform the local police department and local DEA office of the theft.³ Keep a copy of all communications for future reference.
   • If a pharmacy alerts you that a fraudu­lent prescription has been filled using one of your pads, request a copy of each filled pre­scription. Keep these records and file a copy with the police department and DEA.

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

For a busy clinician, learning that a prescription pad has been stolen, sub-mitted with a counterfeit signature, and used to acquire a controlled substance comes as a shock. It evokes a sense of betrayal and raises a number of medico-legal issues that can be avoided if you know how to protect yourself.

Prescription pad security
One of the simplest ways to reduce prescrip­tion pad theft is to lock the pads in a secure location when the office is closed.1 Establish and maintain an inventory of prescription pads; you should number and count pads weekly. For Schedule-II controlled substance prescription pads, document the control number on each new pad.¹ The best way to ensure that all pads are accounted for is by using sequential numbering similar to bank check numbers.

Do not allow staff to sign your prescrip­tion pad. Limit access to prescription pads to authorized personnel; be sure that they keep the prescription pad in their pocket, not on their desk or a counter, and not in examining rooms, where they could be stolen. For elec­tronic prescribing, always lock the drawer where the computer prescription paper sits.¹

Some physicians might find it helpful to invest in tamper-resistant prescription pads. As of April 2008, the Centers for Medicare and Medicaid Services mandates that for a prescription pad to be considered tamper-resistant it must include 1 or more industry-recognized features designed to prevent unauthorized copying, erasure, or modifica­tion of prescriptions.²

When you order prescription pads, do not print your Drug Enforcement Administration (DEA) number on the pads. Also, check that your printer maintains strict process controls over prescription pad production, storage, and delivery.¹

Other ways to prevent fraudulent pre­scriptions include using a gel pen to write prescriptions, because these pens contain pigments that are quickly absorbed, prevent­ing ink from being washed away with chemi­cal solvents.¹ Never leave blank space on a written prescription and do not sign blank prescription pads beforehand.³ Write instruc­tions clearly on each prescription, informing pharmacists of ways to verify the prescrip­tion’s authenticity.

Legal responsibilities
In case your prescription pads are stolen, even after taking precautionary measures, make the following actions to report and record fraudulent charges:
   • If your prescription pads for Schedule-II medications—known as “triplicates”— are missing, give the control number of the first and last prescription in the pad to your state’s pharmacy organization. Some states have an electronic alert system to aid with filing a fraud claim (eg, the Texas Pharmacy Association has a section on its Web site for reporting prescription fraud and theft).
   • Immediately inform the local police department and local DEA office of the theft.³ Keep a copy of all communications for future reference.
   • If a pharmacy alerts you that a fraudu­lent prescription has been filled using one of your pads, request a copy of each filled pre­scription. Keep these records and file a copy with the police department and DEA.

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

For a busy clinician, learning that a prescription pad has been stolen, sub-mitted with a counterfeit signature, and used to acquire a controlled substance comes as a shock. It evokes a sense of betrayal and raises a number of medico-legal issues that can be avoided if you know how to protect yourself.

Prescription pad security
One of the simplest ways to reduce prescrip­tion pad theft is to lock the pads in a secure location when the office is closed.1 Establish and maintain an inventory of prescription pads; you should number and count pads weekly. For Schedule-II controlled substance prescription pads, document the control number on each new pad.¹ The best way to ensure that all pads are accounted for is by using sequential numbering similar to bank check numbers.

Do not allow staff to sign your prescrip­tion pad. Limit access to prescription pads to authorized personnel; be sure that they keep the prescription pad in their pocket, not on their desk or a counter, and not in examining rooms, where they could be stolen. For elec­tronic prescribing, always lock the drawer where the computer prescription paper sits.¹

Some physicians might find it helpful to invest in tamper-resistant prescription pads. As of April 2008, the Centers for Medicare and Medicaid Services mandates that for a prescription pad to be considered tamper-resistant it must include 1 or more industry-recognized features designed to prevent unauthorized copying, erasure, or modifica­tion of prescriptions.²

When you order prescription pads, do not print your Drug Enforcement Administration (DEA) number on the pads. Also, check that your printer maintains strict process controls over prescription pad production, storage, and delivery.¹

Other ways to prevent fraudulent pre­scriptions include using a gel pen to write prescriptions, because these pens contain pigments that are quickly absorbed, prevent­ing ink from being washed away with chemi­cal solvents.¹ Never leave blank space on a written prescription and do not sign blank prescription pads beforehand.³ Write instruc­tions clearly on each prescription, informing pharmacists of ways to verify the prescrip­tion’s authenticity.

Legal responsibilities
In case your prescription pads are stolen, even after taking precautionary measures, make the following actions to report and record fraudulent charges:
   • If your prescription pads for Schedule-II medications—known as “triplicates”— are missing, give the control number of the first and last prescription in the pad to your state’s pharmacy organization. Some states have an electronic alert system to aid with filing a fraud claim (eg, the Texas Pharmacy Association has a section on its Web site for reporting prescription fraud and theft).
   • Immediately inform the local police department and local DEA office of the theft.³ Keep a copy of all communications for future reference.
   • If a pharmacy alerts you that a fraudu­lent prescription has been filled using one of your pads, request a copy of each filled pre­scription. Keep these records and file a copy with the police department and DEA.

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

Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.¹ Poor oral hygiene is a significant problem because it results in dental pathol­ogy that has an adverse influence on the whole body.

Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.² In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.³ Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.⁴

Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.⁵ The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental ero­sions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leu­koplakia, and oral papilloma or other can­cers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.⁵

Alcohol consumption increases the risk of oral cancer. Long-term alcohol use sup­presses bone marrow function, causing leukopenia and resulting in immunosup­pression and an increased incidence of dental infections.⁶ Excessive alcohol con­sumption also can cause thrombocytope­nia and bleeding, which can complicate dental procedures.

Smoking cigarettes increases the inci­dence of periodontal disease, especially necrotizing gingivitis and candidiasis.⁷ Ninety percent of patients with schizo­phrenia smoke—compared with up to 70% of patients with other psychiatric disor­ders, and 19% of the general population.^7,8 Physiologic aspects of schizophrenia rein­force the smoking habit.⁷

Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obe­sity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.

Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that peri­odontal disease will progress.⁹ Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque for­mation.¹⁰ Depression, anxiety, and substance abuse can lead to temporomandibular disor­ders that cause pain and restrict jaw move­ment.¹¹ Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.

Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.

Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.¹¹ Misdiagnosis can result in extractions or procedures without an appropriate indica­tion and failure to alleviate the pain. 

Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candi­diasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyski­nesia, dystonia) may cause tooth damage and make managing dentures difficult.⁶

What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting sub­stances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of den­tal caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.

From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.

A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physi­cian, facilitates health care and works to offer the patient access to global medical services.

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

Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.¹ Poor oral hygiene is a significant problem because it results in dental pathol­ogy that has an adverse influence on the whole body.

Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.² In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.³ Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.⁴

Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.⁵ The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental ero­sions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leu­koplakia, and oral papilloma or other can­cers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.⁵

Alcohol consumption increases the risk of oral cancer. Long-term alcohol use sup­presses bone marrow function, causing leukopenia and resulting in immunosup­pression and an increased incidence of dental infections.⁶ Excessive alcohol con­sumption also can cause thrombocytope­nia and bleeding, which can complicate dental procedures.

Smoking cigarettes increases the inci­dence of periodontal disease, especially necrotizing gingivitis and candidiasis.⁷ Ninety percent of patients with schizo­phrenia smoke—compared with up to 70% of patients with other psychiatric disor­ders, and 19% of the general population.^7,8 Physiologic aspects of schizophrenia rein­force the smoking habit.⁷

Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obe­sity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.

Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that peri­odontal disease will progress.⁹ Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque for­mation.¹⁰ Depression, anxiety, and substance abuse can lead to temporomandibular disor­ders that cause pain and restrict jaw move­ment.¹¹ Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.

Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.

Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.¹¹ Misdiagnosis can result in extractions or procedures without an appropriate indica­tion and failure to alleviate the pain. 

Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candi­diasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyski­nesia, dystonia) may cause tooth damage and make managing dentures difficult.⁶

What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting sub­stances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of den­tal caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.

From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.

A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physi­cian, facilitates health care and works to offer the patient access to global medical services.

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

Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.¹ Poor oral hygiene is a significant problem because it results in dental pathol­ogy that has an adverse influence on the whole body.

Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.² In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.³ Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.⁴

Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.⁵ The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental ero­sions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leu­koplakia, and oral papilloma or other can­cers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.⁵

Alcohol consumption increases the risk of oral cancer. Long-term alcohol use sup­presses bone marrow function, causing leukopenia and resulting in immunosup­pression and an increased incidence of dental infections.⁶ Excessive alcohol con­sumption also can cause thrombocytope­nia and bleeding, which can complicate dental procedures.

Smoking cigarettes increases the inci­dence of periodontal disease, especially necrotizing gingivitis and candidiasis.⁷ Ninety percent of patients with schizo­phrenia smoke—compared with up to 70% of patients with other psychiatric disor­ders, and 19% of the general population.^7,8 Physiologic aspects of schizophrenia rein­force the smoking habit.⁷

Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obe­sity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.

Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that peri­odontal disease will progress.⁹ Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque for­mation.¹⁰ Depression, anxiety, and substance abuse can lead to temporomandibular disor­ders that cause pain and restrict jaw move­ment.¹¹ Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.

Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.

Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.¹¹ Misdiagnosis can result in extractions or procedures without an appropriate indica­tion and failure to alleviate the pain. 

Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candi­diasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyski­nesia, dystonia) may cause tooth damage and make managing dentures difficult.⁶

What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting sub­stances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of den­tal caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.

From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.

A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physi­cian, facilitates health care and works to offer the patient access to global medical services.

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

Clozapine is a life-saving medication for many patients with schizophre­nia, including those who have a schizophrenia spectrum disorder with sui­cidality or treatment-resistant disease, but clinicians’ discomfort with managing its risk profile has led to it being underutilized. Clinicians who are prepared to discuss the risks and benefits of clozapine—and alternatives, including no treatment—with patients may encounter less reluctance when they recommend a time-limited trial of the drug.

Risks
Clinicians need to be aware of both 1) seri­ous adverse effects that can occur when clozapine needs to be interrupted or dis­continued (Table)¹ and 2) common side effects associated with continued use that can be managed without stopping the drug.² Common side effects that patients may experience as treatment is initiated include sedation, orthostatic hypotension, constipation, drooling, tachycardia, and metabolic side effects such as weight gain, diabetes, and hyperlipidemia, which are problematic in the long term.

Reassure patients that frequent monitor­ing of metabolic metrics (including baseline HbA_1C, lipid panel, waist circumference, and body mass index, as well as weight monitor­ing at each visit and metabolic laboratory monitoring every 3 to 6 months thereafter) should be expected, along with early inter­vention (eg, adding metformin) as appropri­ate. Constipation is common and can lead to serious, large bowel ileus. Ask about drool­ing, which can be treated by reducing the dosage or adding glycopyrrolate.

Extrapyramidal symptoms (EPS) includ­ing parkinsonism, dystonia, akathisia are uncommon (clozapine was the first “atypi­cal” antipsychotic for this reason), but neuro­leptic malignant syndrome (NMS) can occur. Although tardive dyskinesia (TD) is a small risk, clozapine will improve established TD in many patients once they are switched to clozapine. Blood dyscrasias include granu­locytopenia and the rare risk of agranulo­cytosis which are monitored by means of a prescribing registry. Myocarditis and pancre­atitis are likely idiosyncratic immune-related side effects that are unique to clozapine among antipsychotics. Other dangerous side effects include a dosage-related risk of seizure, severe hyperglycemia, and dia­betic ketoacidosis.

Benefits
Clozapine is FDA-approved for treatment-resistant schizophrenia and for schizo­phrenia spectrum disorders with recurrent suicidality. Clozapine can be the best anti­psychotic for patients who are sensitive to EPS and for those with TD. Antipsychotic efficacy often can be determined in a 2 to 3 month time-limited trial, although, in prac­tice, you might need to wait 6 to 12 months to observe how well clozapine’s benefits have accrued.

Alternatives
Not using the most effective antipsychotic, or using no antipsychotic when one is indi­cated, often results in unstable psychiatric illness, which increases the risk of adverse outcomes (eg, suicide, accidents). Unstable psychiatric disease also complicates treat­ment of medical problems. An 11-year follow-up study in Finland of patients with schizophrenia showed a lower all-cause mortality with clozapine than with other antipsychotics, all of which collectively were associated with lower mortality com­pared with no antipsychotic use.³ Clozapine also is associated with the lowest discontin­uation rate of any antipsychotic, which sug­gests that patients perceive its risk-benefit ratio favorably. Last, patients who might benefit from clozapine, but do not receive it, often will receive polypharmacy, which poses its own risks.

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

Clozapine is a life-saving medication for many patients with schizophre­nia, including those who have a schizophrenia spectrum disorder with sui­cidality or treatment-resistant disease, but clinicians’ discomfort with managing its risk profile has led to it being underutilized. Clinicians who are prepared to discuss the risks and benefits of clozapine—and alternatives, including no treatment—with patients may encounter less reluctance when they recommend a time-limited trial of the drug.

Risks
Clinicians need to be aware of both 1) seri­ous adverse effects that can occur when clozapine needs to be interrupted or dis­continued (Table)¹ and 2) common side effects associated with continued use that can be managed without stopping the drug.² Common side effects that patients may experience as treatment is initiated include sedation, orthostatic hypotension, constipation, drooling, tachycardia, and metabolic side effects such as weight gain, diabetes, and hyperlipidemia, which are problematic in the long term.

Reassure patients that frequent monitor­ing of metabolic metrics (including baseline HbA_1C, lipid panel, waist circumference, and body mass index, as well as weight monitor­ing at each visit and metabolic laboratory monitoring every 3 to 6 months thereafter) should be expected, along with early inter­vention (eg, adding metformin) as appropri­ate. Constipation is common and can lead to serious, large bowel ileus. Ask about drool­ing, which can be treated by reducing the dosage or adding glycopyrrolate.

Extrapyramidal symptoms (EPS) includ­ing parkinsonism, dystonia, akathisia are uncommon (clozapine was the first “atypi­cal” antipsychotic for this reason), but neuro­leptic malignant syndrome (NMS) can occur. Although tardive dyskinesia (TD) is a small risk, clozapine will improve established TD in many patients once they are switched to clozapine. Blood dyscrasias include granu­locytopenia and the rare risk of agranulo­cytosis which are monitored by means of a prescribing registry. Myocarditis and pancre­atitis are likely idiosyncratic immune-related side effects that are unique to clozapine among antipsychotics. Other dangerous side effects include a dosage-related risk of seizure, severe hyperglycemia, and dia­betic ketoacidosis.

Benefits
Clozapine is FDA-approved for treatment-resistant schizophrenia and for schizo­phrenia spectrum disorders with recurrent suicidality. Clozapine can be the best anti­psychotic for patients who are sensitive to EPS and for those with TD. Antipsychotic efficacy often can be determined in a 2 to 3 month time-limited trial, although, in prac­tice, you might need to wait 6 to 12 months to observe how well clozapine’s benefits have accrued.

Alternatives
Not using the most effective antipsychotic, or using no antipsychotic when one is indi­cated, often results in unstable psychiatric illness, which increases the risk of adverse outcomes (eg, suicide, accidents). Unstable psychiatric disease also complicates treat­ment of medical problems. An 11-year follow-up study in Finland of patients with schizophrenia showed a lower all-cause mortality with clozapine than with other antipsychotics, all of which collectively were associated with lower mortality com­pared with no antipsychotic use.³ Clozapine also is associated with the lowest discontin­uation rate of any antipsychotic, which sug­gests that patients perceive its risk-benefit ratio favorably. Last, patients who might benefit from clozapine, but do not receive it, often will receive polypharmacy, which poses its own risks.

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

Clozapine is a life-saving medication for many patients with schizophre­nia, including those who have a schizophrenia spectrum disorder with sui­cidality or treatment-resistant disease, but clinicians’ discomfort with managing its risk profile has led to it being underutilized. Clinicians who are prepared to discuss the risks and benefits of clozapine—and alternatives, including no treatment—with patients may encounter less reluctance when they recommend a time-limited trial of the drug.

Risks
Clinicians need to be aware of both 1) seri­ous adverse effects that can occur when clozapine needs to be interrupted or dis­continued (Table)¹ and 2) common side effects associated with continued use that can be managed without stopping the drug.² Common side effects that patients may experience as treatment is initiated include sedation, orthostatic hypotension, constipation, drooling, tachycardia, and metabolic side effects such as weight gain, diabetes, and hyperlipidemia, which are problematic in the long term.

Reassure patients that frequent monitor­ing of metabolic metrics (including baseline HbA_1C, lipid panel, waist circumference, and body mass index, as well as weight monitor­ing at each visit and metabolic laboratory monitoring every 3 to 6 months thereafter) should be expected, along with early inter­vention (eg, adding metformin) as appropri­ate. Constipation is common and can lead to serious, large bowel ileus. Ask about drool­ing, which can be treated by reducing the dosage or adding glycopyrrolate.

Extrapyramidal symptoms (EPS) includ­ing parkinsonism, dystonia, akathisia are uncommon (clozapine was the first “atypi­cal” antipsychotic for this reason), but neuro­leptic malignant syndrome (NMS) can occur. Although tardive dyskinesia (TD) is a small risk, clozapine will improve established TD in many patients once they are switched to clozapine. Blood dyscrasias include granu­locytopenia and the rare risk of agranulo­cytosis which are monitored by means of a prescribing registry. Myocarditis and pancre­atitis are likely idiosyncratic immune-related side effects that are unique to clozapine among antipsychotics. Other dangerous side effects include a dosage-related risk of seizure, severe hyperglycemia, and dia­betic ketoacidosis.

Benefits
Clozapine is FDA-approved for treatment-resistant schizophrenia and for schizo­phrenia spectrum disorders with recurrent suicidality. Clozapine can be the best anti­psychotic for patients who are sensitive to EPS and for those with TD. Antipsychotic efficacy often can be determined in a 2 to 3 month time-limited trial, although, in prac­tice, you might need to wait 6 to 12 months to observe how well clozapine’s benefits have accrued.

Alternatives
Not using the most effective antipsychotic, or using no antipsychotic when one is indi­cated, often results in unstable psychiatric illness, which increases the risk of adverse outcomes (eg, suicide, accidents). Unstable psychiatric disease also complicates treat­ment of medical problems. An 11-year follow-up study in Finland of patients with schizophrenia showed a lower all-cause mortality with clozapine than with other antipsychotics, all of which collectively were associated with lower mortality com­pared with no antipsychotic use.³ Clozapine also is associated with the lowest discontin­uation rate of any antipsychotic, which sug­gests that patients perceive its risk-benefit ratio favorably. Last, patients who might benefit from clozapine, but do not receive it, often will receive polypharmacy, which poses its own risks.

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

Many patients experience difficulty swallowing pills, for various reasons:

• discomfort (particularly pediatric and geriatric patients)
• postsurgical need for an alternate route of enteral intake (nasogastric tube, gas­trostomy, jejunostomy)
• dysphagia due to a neurologic disorder (multiple sclerosis, impaired gag reflex, dementing processes)
• odynophagia (pain upon swallowing) due to gastroesophageal reflux or a structural abnormality
• a structural abnormality of the head or neck that impairs swallowing.¹

If these difficulties are not addressed, they can interfere with medication adherence. In those instances, using an alternative dosage form or manip­ulating an available formulation might be required.

Crushing guidelines
There are limited data on crushed-form prod­ucts and their impact on efficacy. Therefore, when patients have difficulty taking pills, switching to liquid solution or orally disin­tegrating forms is recommended. However, most psychotropics are available only as tablets or capsules. Patients can crush their pills immediately before administration for easier intake. The following are some general guidelines for doing so:²

• Scored tablets typically can be crushed.
• Crushing sublingual and buccal tablets can alter their effectiveness.
• Crushing sustained-release medi­cations can eliminate the sustained-release action.³
• Enteric-coated medications should not be crushed, because this can alter drug absorption.
• Capsules can generally be opened to administer powdered contents, unless the capsule has time-release properties or an enteric coating.

The accompanying Table, organized by drug class, indicates whether a drug can be crushed to a powdered form, which usu­ally is mixed with food or liquid for easier intake. The Table also lists liquid and orally disintegrating forms available, and other routes, including injectable immediate and long-acting formulations. Helping patients find a medication formulation that suits their needs strengthens adherence and the therapeutic relationship.

Many patients experience difficulty swallowing pills, for various reasons:

• discomfort (particularly pediatric and geriatric patients)
• postsurgical need for an alternate route of enteral intake (nasogastric tube, gas­trostomy, jejunostomy)
• dysphagia due to a neurologic disorder (multiple sclerosis, impaired gag reflex, dementing processes)
• odynophagia (pain upon swallowing) due to gastroesophageal reflux or a structural abnormality
• a structural abnormality of the head or neck that impairs swallowing.¹

If these difficulties are not addressed, they can interfere with medication adherence. In those instances, using an alternative dosage form or manip­ulating an available formulation might be required.

Crushing guidelines
There are limited data on crushed-form prod­ucts and their impact on efficacy. Therefore, when patients have difficulty taking pills, switching to liquid solution or orally disin­tegrating forms is recommended. However, most psychotropics are available only as tablets or capsules. Patients can crush their pills immediately before administration for easier intake. The following are some general guidelines for doing so:²

• Scored tablets typically can be crushed.
• Crushing sublingual and buccal tablets can alter their effectiveness.
• Crushing sustained-release medi­cations can eliminate the sustained-release action.³
• Enteric-coated medications should not be crushed, because this can alter drug absorption.
• Capsules can generally be opened to administer powdered contents, unless the capsule has time-release properties or an enteric coating.

The accompanying Table, organized by drug class, indicates whether a drug can be crushed to a powdered form, which usu­ally is mixed with food or liquid for easier intake. The Table also lists liquid and orally disintegrating forms available, and other routes, including injectable immediate and long-acting formulations. Helping patients find a medication formulation that suits their needs strengthens adherence and the therapeutic relationship.

Many patients experience difficulty swallowing pills, for various reasons:

• discomfort (particularly pediatric and geriatric patients)
• postsurgical need for an alternate route of enteral intake (nasogastric tube, gas­trostomy, jejunostomy)
• dysphagia due to a neurologic disorder (multiple sclerosis, impaired gag reflex, dementing processes)
• odynophagia (pain upon swallowing) due to gastroesophageal reflux or a structural abnormality
• a structural abnormality of the head or neck that impairs swallowing.¹

If these difficulties are not addressed, they can interfere with medication adherence. In those instances, using an alternative dosage form or manip­ulating an available formulation might be required.

Crushing guidelines
There are limited data on crushed-form prod­ucts and their impact on efficacy. Therefore, when patients have difficulty taking pills, switching to liquid solution or orally disin­tegrating forms is recommended. However, most psychotropics are available only as tablets or capsules. Patients can crush their pills immediately before administration for easier intake. The following are some general guidelines for doing so:²

• Scored tablets typically can be crushed.
• Crushing sublingual and buccal tablets can alter their effectiveness.
• Crushing sustained-release medi­cations can eliminate the sustained-release action.³
• Enteric-coated medications should not be crushed, because this can alter drug absorption.
• Capsules can generally be opened to administer powdered contents, unless the capsule has time-release properties or an enteric coating.

The accompanying Table, organized by drug class, indicates whether a drug can be crushed to a powdered form, which usu­ally is mixed with food or liquid for easier intake. The Table also lists liquid and orally disintegrating forms available, and other routes, including injectable immediate and long-acting formulations. Helping patients find a medication formulation that suits their needs strengthens adherence and the therapeutic relationship.