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Preventing prescription drug abuse: Make it LAST
Medications that psychiatrists routinely prescribe—such as benzodiazepines for anxiety and psychostimulants for attention-deficit/hyperactivity disorder—often are diverted and abused. In 2011, 6.1 million Americans age ≥12 abused prescription drugs.1
The mnemonic LAST can bring to mind 4 clinical “red flags” that can assist you in determining whether prescription abuse or diversion is occurring. Incorporating these 4 warning signs in your clinical assessment and medication reviews will make it easier for you to detect when medications are not being taken as prescribed.
Lost or stolen prescriptions. Patients who want to obtain a new or replacement prescription may claim that their medication was lost or stolen. Although this can occur, the prescriber should be suspicious if this becomes a recurrent situation. Some clinicians require patients to produce a filed police report for stolen medications before they will consider writing a new prescription.
Alternating medications/providers. Patients may obtain similar medications from multiple providers. Prescription Drug Monitoring Programs (PDMPs), which are databases that allow physicians to track where patients are getting their prescriptions, may help prevent this. According to the Alliance of States with Prescription Monitoring Programs, as of January 2010, 48 states had instituted PDMPs or passed legislation to implement them.2
Specific medication. Patients may have an allergy or respond better to a particular drug; however, be cautious when a patient refuses to consider an alternate medication or claims he or she has taken a specific medication without a prescription and it was the only thing that worked for them.
Time between prescriptions. Patients may get a prescription for a medication, then shortly after their visit claim the medication doesn’t work and request a second prescription for a similar medication. One way to address this is to require the patient to return the unused portion of the first medication before writing a new prescription. A patient also may complain that they have to come to your office too frequently and ask for multiple refills of medication, which would decrease your ability to monitor his or her response to treatment.
A patient who meets ≥1 of the above criteria could be a higher risk for prescription drug abuse or diversion. Documenting these findings and talking with the patient could help justify the need to switch to a medication with a lower abuse potential or possibly referral to a drug treatment program.
In a 2009 survey, 56% of teens stated that prescription medications were easier to obtain than illicit drugs.3 Medications such as benzodiazepines and stimulants can be beneficial to patients, but because of their abuse potential, they may be underprescribed. Be vigilant when prescribing these medications, and monitor patients carefully to ensure that they are taking all medications as directed.
Disclosure
Dr. Wiley reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
References
1. Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: Summary of findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm. Accessed May 2, 2013.
2. Alliance of States with Prescription Monitoring Programs. http://www.pmpalliance.org/content/about-alliance. Accessed May 1, 2013.
3. Partnership for a Drug-Free America. 2009 parents and teens attitude tracking study report. New York, NY: Partnership for a Drug-Free America; 2010. http://www.drugfree.org/wp-content/uploads/2011/04/FULL-REPORT-PATS-2009-3-2-10.pdf. Accessed May 2, 2013.
Medications that psychiatrists routinely prescribe—such as benzodiazepines for anxiety and psychostimulants for attention-deficit/hyperactivity disorder—often are diverted and abused. In 2011, 6.1 million Americans age ≥12 abused prescription drugs.1
The mnemonic LAST can bring to mind 4 clinical “red flags” that can assist you in determining whether prescription abuse or diversion is occurring. Incorporating these 4 warning signs in your clinical assessment and medication reviews will make it easier for you to detect when medications are not being taken as prescribed.
Lost or stolen prescriptions. Patients who want to obtain a new or replacement prescription may claim that their medication was lost or stolen. Although this can occur, the prescriber should be suspicious if this becomes a recurrent situation. Some clinicians require patients to produce a filed police report for stolen medications before they will consider writing a new prescription.
Alternating medications/providers. Patients may obtain similar medications from multiple providers. Prescription Drug Monitoring Programs (PDMPs), which are databases that allow physicians to track where patients are getting their prescriptions, may help prevent this. According to the Alliance of States with Prescription Monitoring Programs, as of January 2010, 48 states had instituted PDMPs or passed legislation to implement them.2
Specific medication. Patients may have an allergy or respond better to a particular drug; however, be cautious when a patient refuses to consider an alternate medication or claims he or she has taken a specific medication without a prescription and it was the only thing that worked for them.
Time between prescriptions. Patients may get a prescription for a medication, then shortly after their visit claim the medication doesn’t work and request a second prescription for a similar medication. One way to address this is to require the patient to return the unused portion of the first medication before writing a new prescription. A patient also may complain that they have to come to your office too frequently and ask for multiple refills of medication, which would decrease your ability to monitor his or her response to treatment.
A patient who meets ≥1 of the above criteria could be a higher risk for prescription drug abuse or diversion. Documenting these findings and talking with the patient could help justify the need to switch to a medication with a lower abuse potential or possibly referral to a drug treatment program.
In a 2009 survey, 56% of teens stated that prescription medications were easier to obtain than illicit drugs.3 Medications such as benzodiazepines and stimulants can be beneficial to patients, but because of their abuse potential, they may be underprescribed. Be vigilant when prescribing these medications, and monitor patients carefully to ensure that they are taking all medications as directed.
Disclosure
Dr. Wiley reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
References
1. Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: Summary of findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm. Accessed May 2, 2013.
2. Alliance of States with Prescription Monitoring Programs. http://www.pmpalliance.org/content/about-alliance. Accessed May 1, 2013.
3. Partnership for a Drug-Free America. 2009 parents and teens attitude tracking study report. New York, NY: Partnership for a Drug-Free America; 2010. http://www.drugfree.org/wp-content/uploads/2011/04/FULL-REPORT-PATS-2009-3-2-10.pdf. Accessed May 2, 2013.
Medications that psychiatrists routinely prescribe—such as benzodiazepines for anxiety and psychostimulants for attention-deficit/hyperactivity disorder—often are diverted and abused. In 2011, 6.1 million Americans age ≥12 abused prescription drugs.1
The mnemonic LAST can bring to mind 4 clinical “red flags” that can assist you in determining whether prescription abuse or diversion is occurring. Incorporating these 4 warning signs in your clinical assessment and medication reviews will make it easier for you to detect when medications are not being taken as prescribed.
Lost or stolen prescriptions. Patients who want to obtain a new or replacement prescription may claim that their medication was lost or stolen. Although this can occur, the prescriber should be suspicious if this becomes a recurrent situation. Some clinicians require patients to produce a filed police report for stolen medications before they will consider writing a new prescription.
Alternating medications/providers. Patients may obtain similar medications from multiple providers. Prescription Drug Monitoring Programs (PDMPs), which are databases that allow physicians to track where patients are getting their prescriptions, may help prevent this. According to the Alliance of States with Prescription Monitoring Programs, as of January 2010, 48 states had instituted PDMPs or passed legislation to implement them.2
Specific medication. Patients may have an allergy or respond better to a particular drug; however, be cautious when a patient refuses to consider an alternate medication or claims he or she has taken a specific medication without a prescription and it was the only thing that worked for them.
Time between prescriptions. Patients may get a prescription for a medication, then shortly after their visit claim the medication doesn’t work and request a second prescription for a similar medication. One way to address this is to require the patient to return the unused portion of the first medication before writing a new prescription. A patient also may complain that they have to come to your office too frequently and ask for multiple refills of medication, which would decrease your ability to monitor his or her response to treatment.
A patient who meets ≥1 of the above criteria could be a higher risk for prescription drug abuse or diversion. Documenting these findings and talking with the patient could help justify the need to switch to a medication with a lower abuse potential or possibly referral to a drug treatment program.
In a 2009 survey, 56% of teens stated that prescription medications were easier to obtain than illicit drugs.3 Medications such as benzodiazepines and stimulants can be beneficial to patients, but because of their abuse potential, they may be underprescribed. Be vigilant when prescribing these medications, and monitor patients carefully to ensure that they are taking all medications as directed.
Disclosure
Dr. Wiley reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
References
1. Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: Summary of findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm. Accessed May 2, 2013.
2. Alliance of States with Prescription Monitoring Programs. http://www.pmpalliance.org/content/about-alliance. Accessed May 1, 2013.
3. Partnership for a Drug-Free America. 2009 parents and teens attitude tracking study report. New York, NY: Partnership for a Drug-Free America; 2010. http://www.drugfree.org/wp-content/uploads/2011/04/FULL-REPORT-PATS-2009-3-2-10.pdf. Accessed May 2, 2013.
Ending a physician/patient relationship: 8 tips for writing a termination letter
For many valid reasons, a physician-patient relationship may need to end before treatment is completed. When terminating a clinical relationship, send a letter to the patient, even if the patient initiated the termination. Here are 8 tips for writing and sending a termination letter:
1. Don’t send a form letter. Start with a standard letter but personalize it for each patient. Address the patient by name and, if possible, allude to specifics of the patient’s situation.
2. Wish the patient well, but avoid hyperbole, such as “It truly has been an honor and a privilege to participate in your treatment.” Also, be unambiguous in stating that the treatment relationship is terminated.
3. Don’t mention confidential information. Because someone other than the patient may open the letter, do not include confidential information.
4. Provide appropriate notice. Specify a date after which you can no longer provide care. A reasonable period is 30 days from the date of the letter, but if you expect the patient will need more time to find an appropriate clinician, a longer period may be necessary.1,2 Occasionally, a patient’s care may need to be terminated immediately because of a serious problem such as actual or threatened violence. Even in these cases, communicate and document how the patient can obtain emergency psychiatric care.
5. State the reason for termination. Although you are not required legally to do so, briefly state the reason for terminating the relationship, although you should never use emotional or harshly critical language. Use nonjudgmental language and avoid referring to your “policy,” which can imply unthinking application of rigid rules.
6. Recommend continued treatment. Make a clear recommendation that the patient continue treatment elsewhere. Provide a list of mental health professionals with whom the patient could continue treatment or offer to provide referrals. Offer to send a copy of your records to the patient’s new clinician. Consider enclosing a blank copy of the release form you use so that the patient can mail it to you to request his or her records.
7. Sign the letter yourself. Don’t have a staff member sign the letter or use a stamp.
8. Send the letter by certified mail. Request a return receipt and put a copy of the letter, along with the certified mail form, in the patient’s chart. When the return receipt is received, put it in the chart. If a certified letter is returned to you, put the undelivered letter and envelope in the chart, then send a copy of the letter through regular mail and document that you did so.
If the patient requests an appointment after the notice period is over, including saying that he or she did not receive the letter, you are not legally obligated to resume his or her care.2
1. The Psychiatrist’s Program. Termination of the psychiatrist-patient relationship dos and donts. http://www.psychprogram.com/risk-management/tip-termination.html. Accessed February 1, 2013.
2. Willis DR, Zerr A. Terminating a patient: is it time to part ways? Fam Pract Manag. 2005;12(8):34-38.
For many valid reasons, a physician-patient relationship may need to end before treatment is completed. When terminating a clinical relationship, send a letter to the patient, even if the patient initiated the termination. Here are 8 tips for writing and sending a termination letter:
1. Don’t send a form letter. Start with a standard letter but personalize it for each patient. Address the patient by name and, if possible, allude to specifics of the patient’s situation.
2. Wish the patient well, but avoid hyperbole, such as “It truly has been an honor and a privilege to participate in your treatment.” Also, be unambiguous in stating that the treatment relationship is terminated.
3. Don’t mention confidential information. Because someone other than the patient may open the letter, do not include confidential information.
4. Provide appropriate notice. Specify a date after which you can no longer provide care. A reasonable period is 30 days from the date of the letter, but if you expect the patient will need more time to find an appropriate clinician, a longer period may be necessary.1,2 Occasionally, a patient’s care may need to be terminated immediately because of a serious problem such as actual or threatened violence. Even in these cases, communicate and document how the patient can obtain emergency psychiatric care.
5. State the reason for termination. Although you are not required legally to do so, briefly state the reason for terminating the relationship, although you should never use emotional or harshly critical language. Use nonjudgmental language and avoid referring to your “policy,” which can imply unthinking application of rigid rules.
6. Recommend continued treatment. Make a clear recommendation that the patient continue treatment elsewhere. Provide a list of mental health professionals with whom the patient could continue treatment or offer to provide referrals. Offer to send a copy of your records to the patient’s new clinician. Consider enclosing a blank copy of the release form you use so that the patient can mail it to you to request his or her records.
7. Sign the letter yourself. Don’t have a staff member sign the letter or use a stamp.
8. Send the letter by certified mail. Request a return receipt and put a copy of the letter, along with the certified mail form, in the patient’s chart. When the return receipt is received, put it in the chart. If a certified letter is returned to you, put the undelivered letter and envelope in the chart, then send a copy of the letter through regular mail and document that you did so.
If the patient requests an appointment after the notice period is over, including saying that he or she did not receive the letter, you are not legally obligated to resume his or her care.2
For many valid reasons, a physician-patient relationship may need to end before treatment is completed. When terminating a clinical relationship, send a letter to the patient, even if the patient initiated the termination. Here are 8 tips for writing and sending a termination letter:
1. Don’t send a form letter. Start with a standard letter but personalize it for each patient. Address the patient by name and, if possible, allude to specifics of the patient’s situation.
2. Wish the patient well, but avoid hyperbole, such as “It truly has been an honor and a privilege to participate in your treatment.” Also, be unambiguous in stating that the treatment relationship is terminated.
3. Don’t mention confidential information. Because someone other than the patient may open the letter, do not include confidential information.
4. Provide appropriate notice. Specify a date after which you can no longer provide care. A reasonable period is 30 days from the date of the letter, but if you expect the patient will need more time to find an appropriate clinician, a longer period may be necessary.1,2 Occasionally, a patient’s care may need to be terminated immediately because of a serious problem such as actual or threatened violence. Even in these cases, communicate and document how the patient can obtain emergency psychiatric care.
5. State the reason for termination. Although you are not required legally to do so, briefly state the reason for terminating the relationship, although you should never use emotional or harshly critical language. Use nonjudgmental language and avoid referring to your “policy,” which can imply unthinking application of rigid rules.
6. Recommend continued treatment. Make a clear recommendation that the patient continue treatment elsewhere. Provide a list of mental health professionals with whom the patient could continue treatment or offer to provide referrals. Offer to send a copy of your records to the patient’s new clinician. Consider enclosing a blank copy of the release form you use so that the patient can mail it to you to request his or her records.
7. Sign the letter yourself. Don’t have a staff member sign the letter or use a stamp.
8. Send the letter by certified mail. Request a return receipt and put a copy of the letter, along with the certified mail form, in the patient’s chart. When the return receipt is received, put it in the chart. If a certified letter is returned to you, put the undelivered letter and envelope in the chart, then send a copy of the letter through regular mail and document that you did so.
If the patient requests an appointment after the notice period is over, including saying that he or she did not receive the letter, you are not legally obligated to resume his or her care.2
1. The Psychiatrist’s Program. Termination of the psychiatrist-patient relationship dos and donts. http://www.psychprogram.com/risk-management/tip-termination.html. Accessed February 1, 2013.
2. Willis DR, Zerr A. Terminating a patient: is it time to part ways? Fam Pract Manag. 2005;12(8):34-38.
1. The Psychiatrist’s Program. Termination of the psychiatrist-patient relationship dos and donts. http://www.psychprogram.com/risk-management/tip-termination.html. Accessed February 1, 2013.
2. Willis DR, Zerr A. Terminating a patient: is it time to part ways? Fam Pract Manag. 2005;12(8):34-38.
Treating a patient who has ‘everything’
Patients who endorse multiple psychiatric symptoms and meet criteria for several DSM diagnoses pose diagnostic and therapeutic challenges. In community samples, approximately 40% of patients with a DSM diagnosis have >1 illness, and comorbidity is more frequent in clinical trials.1 We highlight things to consider when managing a patient who has “everything.”
Endorsing ‘everything’ means something in itself. Patients with borderline personality disorder often present with myriad, disparate diagnoses and urgent requests for care.2 Also consider primary or secondary gain, particularly if the patient’s descriptions of symptoms are unusual. Saying “yes” to every question or endorsing highly unusual symptoms described by the interviewer may represent suggestibility related to catatonia or confabulation.
Focus on the most impairing symptom. This may help put other symptoms in context and focus treatment.
Find a common goal. If you can’t pick a simple symptom, move on to helping the patient identify his or her goals by asking questions such as, “Four weeks from now, what would you like to be doing?” Picking an achievable, measurable goal may be therapeutic.
Are the symptoms valid? Examine individual symptoms for validity using the SAFER criteria (Table).3
Table
SAFER criteria for symptom validity
| State vs trait: has the symptom lasted <12 weeks? |
| Assessable: can the symptom be measured? |
| Face validity: does the symptom clearly affect the patient’s behavior and functioning? |
| Ecological validity: is the symptom valid with our knowledge of its occurrence? |
| Rule of the 3Ps: is the symptom Persistent; Pathologically disruptive and different than usual; and Pervasive across normal domains? |
| Source: Reference 3 |
Multiple diagnoses may be in play, but start by treating one. Many patients meet criteria for multiple diagnoses. There is little evidence about which diagnosis should be treated first. Use your judgment in picking “the best first step” and treat accordingly.
Resist polypharmacy. Target specific symptoms or goals until a clear diagnostic picture emerges.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
2. Gunderson JG. Borderline personality disorder: ontogeny of a diagnosis. Am J Psychiatry. 2009;166(5):530-539.
3. Targum SD, Pollack MH, Fava M. Redefining affective disorders: relevance for drug development. CNS Neurosci Ther. 2008;14(1):2-9.
Patients who endorse multiple psychiatric symptoms and meet criteria for several DSM diagnoses pose diagnostic and therapeutic challenges. In community samples, approximately 40% of patients with a DSM diagnosis have >1 illness, and comorbidity is more frequent in clinical trials.1 We highlight things to consider when managing a patient who has “everything.”
Endorsing ‘everything’ means something in itself. Patients with borderline personality disorder often present with myriad, disparate diagnoses and urgent requests for care.2 Also consider primary or secondary gain, particularly if the patient’s descriptions of symptoms are unusual. Saying “yes” to every question or endorsing highly unusual symptoms described by the interviewer may represent suggestibility related to catatonia or confabulation.
Focus on the most impairing symptom. This may help put other symptoms in context and focus treatment.
Find a common goal. If you can’t pick a simple symptom, move on to helping the patient identify his or her goals by asking questions such as, “Four weeks from now, what would you like to be doing?” Picking an achievable, measurable goal may be therapeutic.
Are the symptoms valid? Examine individual symptoms for validity using the SAFER criteria (Table).3
Table
SAFER criteria for symptom validity
| State vs trait: has the symptom lasted <12 weeks? |
| Assessable: can the symptom be measured? |
| Face validity: does the symptom clearly affect the patient’s behavior and functioning? |
| Ecological validity: is the symptom valid with our knowledge of its occurrence? |
| Rule of the 3Ps: is the symptom Persistent; Pathologically disruptive and different than usual; and Pervasive across normal domains? |
| Source: Reference 3 |
Multiple diagnoses may be in play, but start by treating one. Many patients meet criteria for multiple diagnoses. There is little evidence about which diagnosis should be treated first. Use your judgment in picking “the best first step” and treat accordingly.
Resist polypharmacy. Target specific symptoms or goals until a clear diagnostic picture emerges.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Patients who endorse multiple psychiatric symptoms and meet criteria for several DSM diagnoses pose diagnostic and therapeutic challenges. In community samples, approximately 40% of patients with a DSM diagnosis have >1 illness, and comorbidity is more frequent in clinical trials.1 We highlight things to consider when managing a patient who has “everything.”
Endorsing ‘everything’ means something in itself. Patients with borderline personality disorder often present with myriad, disparate diagnoses and urgent requests for care.2 Also consider primary or secondary gain, particularly if the patient’s descriptions of symptoms are unusual. Saying “yes” to every question or endorsing highly unusual symptoms described by the interviewer may represent suggestibility related to catatonia or confabulation.
Focus on the most impairing symptom. This may help put other symptoms in context and focus treatment.
Find a common goal. If you can’t pick a simple symptom, move on to helping the patient identify his or her goals by asking questions such as, “Four weeks from now, what would you like to be doing?” Picking an achievable, measurable goal may be therapeutic.
Are the symptoms valid? Examine individual symptoms for validity using the SAFER criteria (Table).3
Table
SAFER criteria for symptom validity
| State vs trait: has the symptom lasted <12 weeks? |
| Assessable: can the symptom be measured? |
| Face validity: does the symptom clearly affect the patient’s behavior and functioning? |
| Ecological validity: is the symptom valid with our knowledge of its occurrence? |
| Rule of the 3Ps: is the symptom Persistent; Pathologically disruptive and different than usual; and Pervasive across normal domains? |
| Source: Reference 3 |
Multiple diagnoses may be in play, but start by treating one. Many patients meet criteria for multiple diagnoses. There is little evidence about which diagnosis should be treated first. Use your judgment in picking “the best first step” and treat accordingly.
Resist polypharmacy. Target specific symptoms or goals until a clear diagnostic picture emerges.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
2. Gunderson JG. Borderline personality disorder: ontogeny of a diagnosis. Am J Psychiatry. 2009;166(5):530-539.
3. Targum SD, Pollack MH, Fava M. Redefining affective disorders: relevance for drug development. CNS Neurosci Ther. 2008;14(1):2-9.
1. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
2. Gunderson JG. Borderline personality disorder: ontogeny of a diagnosis. Am J Psychiatry. 2009;166(5):530-539.
3. Targum SD, Pollack MH, Fava M. Redefining affective disorders: relevance for drug development. CNS Neurosci Ther. 2008;14(1):2-9.
Depressive recurrence on antidepressant treatment (DRAT): 4 next-step options
“Poop-out” and “tachyphylaxis” are terms used to describe loss of antidepressant response after initial benefit, but both descriptors are problematic. Poop-out carries a mildly offensive aura that conveys a lack of seriousness about the patient’s suffering. Tachyphylaxis is a pharmacologic term describing rapid or acute reduction in response to a drug after administration; it is not appropriate for antidepressant loss of response, which typically occurs months to years after treatment initiation.1
Depressive recurrence on antidepressant treatment (DRAT) is a better term to describe recurrence of a major depressive episode despite sustained treatment with an antidepressant that had induced remission. Maintenance studies of antidepressant treatment indicate DRAT occurs in approximately 10% of patients at 6 months and 20% at 2 years.2
Despite this high prevalence, there is little clinical trial data on which to base treatment decisions for patients who experience DRAT. There are 4 options:
1. Raise the dose. In small studies, doubling the dose of fluoxetine or duloxetine led to regaining response in approximately 60% of patients.3 However, these studies lacked a placebo comparison arm, so the specific benefit derived from the dose increase is unknown. Improvement with a dose increase is somewhat at odds with the known mechanism of action of selective serotonin reuptake inhibitors (SSRIs), which are thought to have a flat dose-response curve. That is, once an SSRI blocks approximately 80% of the serotonin transporters, further dose increases produce minimal further blockade and, presumably, little clinical benefit via this mechanism.4
2. Switch medication. No studies have examined switching antidepressants after DRAT. Switching to a medication with a different mechanism may be justified based on the results of treatment-resistant depression (TRD) trials, in which patients who failed to respond to an initial medication—typically an SSRI—improved after switching to an antidepressant from a different class. However, the biology of DRAT may differ from that of SSRI nonresponse. Unlike many patients with TRD, patients who experience DRAT while taking an SSRI have demonstrated previous response to serotonergic modulation.
3. Augmentation. Similar to switching, this approach has not been studied specifically for DRAT. This approach is derived from trials in which patients who did not attain response after treatment with a single antidepressant had a second medication added. Again, the biology of these patients may differ from those with DRAT, who at one point did remit with antidepressant treatment.
4. Psychotherapy. This addition is a low-risk option for patients who previously have not received evidence-based psychotherapy for depression.
Clinicians have scant evidence on which to base their decisions for this common and important problem. Dose increase after DRAT represents the best supported, simplest, and perhaps least costly next step in treatment.
Disclosure
Dr. Dunlop receives grant or research support from Bristol-Myers Squibb, Forest Pharmaceuticals, and GlaxoSmithKline, and is a consultant to MedAvante and Roche.
1. Rothschild AJ, Dunlop BW, Dunner DL, et al. Assessing rates and predictors of tachyphylaxis during the prevention of recurrent episodes of depression with venlafaxine ER for two years (PREVENT) study. Psychopharmacol Bull. 2009;42(3):5-20.
2. Hansen R, Gaynes B, Thieda P, et al. Meta-analysis of major depressive disorder relapse and recurrence with second-generation antidepressants. Psychiatr Serv. 2008;59(10):1121-1130.
3. Schmidt ME, Fava M, Zhang S, et al. Treatment approaches to major depressive disorder relapse. Part 1: dose increase. Psychother Psychosom. 2002;71(4):190-194.
4. Meyer JH, Wilson AA, Sagrati S, et al. Serotonin transporter occupancy of five selective serotonin reuptake inhibitors at different doses: an [11C]DASB positron emission tomography study. Am J Psychiatry. 2004;161(5):826-835.
“Poop-out” and “tachyphylaxis” are terms used to describe loss of antidepressant response after initial benefit, but both descriptors are problematic. Poop-out carries a mildly offensive aura that conveys a lack of seriousness about the patient’s suffering. Tachyphylaxis is a pharmacologic term describing rapid or acute reduction in response to a drug after administration; it is not appropriate for antidepressant loss of response, which typically occurs months to years after treatment initiation.1
Depressive recurrence on antidepressant treatment (DRAT) is a better term to describe recurrence of a major depressive episode despite sustained treatment with an antidepressant that had induced remission. Maintenance studies of antidepressant treatment indicate DRAT occurs in approximately 10% of patients at 6 months and 20% at 2 years.2
Despite this high prevalence, there is little clinical trial data on which to base treatment decisions for patients who experience DRAT. There are 4 options:
1. Raise the dose. In small studies, doubling the dose of fluoxetine or duloxetine led to regaining response in approximately 60% of patients.3 However, these studies lacked a placebo comparison arm, so the specific benefit derived from the dose increase is unknown. Improvement with a dose increase is somewhat at odds with the known mechanism of action of selective serotonin reuptake inhibitors (SSRIs), which are thought to have a flat dose-response curve. That is, once an SSRI blocks approximately 80% of the serotonin transporters, further dose increases produce minimal further blockade and, presumably, little clinical benefit via this mechanism.4
2. Switch medication. No studies have examined switching antidepressants after DRAT. Switching to a medication with a different mechanism may be justified based on the results of treatment-resistant depression (TRD) trials, in which patients who failed to respond to an initial medication—typically an SSRI—improved after switching to an antidepressant from a different class. However, the biology of DRAT may differ from that of SSRI nonresponse. Unlike many patients with TRD, patients who experience DRAT while taking an SSRI have demonstrated previous response to serotonergic modulation.
3. Augmentation. Similar to switching, this approach has not been studied specifically for DRAT. This approach is derived from trials in which patients who did not attain response after treatment with a single antidepressant had a second medication added. Again, the biology of these patients may differ from those with DRAT, who at one point did remit with antidepressant treatment.
4. Psychotherapy. This addition is a low-risk option for patients who previously have not received evidence-based psychotherapy for depression.
Clinicians have scant evidence on which to base their decisions for this common and important problem. Dose increase after DRAT represents the best supported, simplest, and perhaps least costly next step in treatment.
Disclosure
Dr. Dunlop receives grant or research support from Bristol-Myers Squibb, Forest Pharmaceuticals, and GlaxoSmithKline, and is a consultant to MedAvante and Roche.
“Poop-out” and “tachyphylaxis” are terms used to describe loss of antidepressant response after initial benefit, but both descriptors are problematic. Poop-out carries a mildly offensive aura that conveys a lack of seriousness about the patient’s suffering. Tachyphylaxis is a pharmacologic term describing rapid or acute reduction in response to a drug after administration; it is not appropriate for antidepressant loss of response, which typically occurs months to years after treatment initiation.1
Depressive recurrence on antidepressant treatment (DRAT) is a better term to describe recurrence of a major depressive episode despite sustained treatment with an antidepressant that had induced remission. Maintenance studies of antidepressant treatment indicate DRAT occurs in approximately 10% of patients at 6 months and 20% at 2 years.2
Despite this high prevalence, there is little clinical trial data on which to base treatment decisions for patients who experience DRAT. There are 4 options:
1. Raise the dose. In small studies, doubling the dose of fluoxetine or duloxetine led to regaining response in approximately 60% of patients.3 However, these studies lacked a placebo comparison arm, so the specific benefit derived from the dose increase is unknown. Improvement with a dose increase is somewhat at odds with the known mechanism of action of selective serotonin reuptake inhibitors (SSRIs), which are thought to have a flat dose-response curve. That is, once an SSRI blocks approximately 80% of the serotonin transporters, further dose increases produce minimal further blockade and, presumably, little clinical benefit via this mechanism.4
2. Switch medication. No studies have examined switching antidepressants after DRAT. Switching to a medication with a different mechanism may be justified based on the results of treatment-resistant depression (TRD) trials, in which patients who failed to respond to an initial medication—typically an SSRI—improved after switching to an antidepressant from a different class. However, the biology of DRAT may differ from that of SSRI nonresponse. Unlike many patients with TRD, patients who experience DRAT while taking an SSRI have demonstrated previous response to serotonergic modulation.
3. Augmentation. Similar to switching, this approach has not been studied specifically for DRAT. This approach is derived from trials in which patients who did not attain response after treatment with a single antidepressant had a second medication added. Again, the biology of these patients may differ from those with DRAT, who at one point did remit with antidepressant treatment.
4. Psychotherapy. This addition is a low-risk option for patients who previously have not received evidence-based psychotherapy for depression.
Clinicians have scant evidence on which to base their decisions for this common and important problem. Dose increase after DRAT represents the best supported, simplest, and perhaps least costly next step in treatment.
Disclosure
Dr. Dunlop receives grant or research support from Bristol-Myers Squibb, Forest Pharmaceuticals, and GlaxoSmithKline, and is a consultant to MedAvante and Roche.
1. Rothschild AJ, Dunlop BW, Dunner DL, et al. Assessing rates and predictors of tachyphylaxis during the prevention of recurrent episodes of depression with venlafaxine ER for two years (PREVENT) study. Psychopharmacol Bull. 2009;42(3):5-20.
2. Hansen R, Gaynes B, Thieda P, et al. Meta-analysis of major depressive disorder relapse and recurrence with second-generation antidepressants. Psychiatr Serv. 2008;59(10):1121-1130.
3. Schmidt ME, Fava M, Zhang S, et al. Treatment approaches to major depressive disorder relapse. Part 1: dose increase. Psychother Psychosom. 2002;71(4):190-194.
4. Meyer JH, Wilson AA, Sagrati S, et al. Serotonin transporter occupancy of five selective serotonin reuptake inhibitors at different doses: an [11C]DASB positron emission tomography study. Am J Psychiatry. 2004;161(5):826-835.
1. Rothschild AJ, Dunlop BW, Dunner DL, et al. Assessing rates and predictors of tachyphylaxis during the prevention of recurrent episodes of depression with venlafaxine ER for two years (PREVENT) study. Psychopharmacol Bull. 2009;42(3):5-20.
2. Hansen R, Gaynes B, Thieda P, et al. Meta-analysis of major depressive disorder relapse and recurrence with second-generation antidepressants. Psychiatr Serv. 2008;59(10):1121-1130.
3. Schmidt ME, Fava M, Zhang S, et al. Treatment approaches to major depressive disorder relapse. Part 1: dose increase. Psychother Psychosom. 2002;71(4):190-194.
4. Meyer JH, Wilson AA, Sagrati S, et al. Serotonin transporter occupancy of five selective serotonin reuptake inhibitors at different doses: an [11C]DASB positron emission tomography study. Am J Psychiatry. 2004;161(5):826-835.
New ‘legal’ highs: Kratom and methoxetamine
The demand for “legal highs”— intoxicating natural or synthetic substances that are not prohibited by law—continues to increase. Young adults may use these substances, which are widely available on the internet, at “head shops,” and at gas stations. Such substances frequently cause adverse medical and psychiatric effects, exemplified by recent reports concerning the dangers of using synthetic cannabinoids (eg, “Spice,” “K2”) and synthetic cathinones (“bath salts”). Although these 2 substances now are illegal in many jurisdictions, other novel substances of misuse remain legal and widely available, including Kratom and methoxetamine.
Because these substances usually are not detectable on standard urine toxicology screens, clinicians need to be aware of them to be able to take an accurate substance use history, consider possible dangerous interactions with prescribed psychotropics, and address medical and psychiatric complications.
Kratom is an herbal product derived from Mitragyna speciosa, a plant native to Southeast Asia. Traditionally used as a medicinal herb, it increasingly is being used for recreational purposes and remains legal and widely available in the United States. Kratom’s leaves contain multiple alkaloids, including mitragynine and 7-hydroxymitragynine, which are believed to act as agonists at the μ-opioid receptor. Mitragynine also may have agonist activity at post-synaptic α2-adrenergic receptors, as well as antagonist activity at 5-HT2A receptors.1 Mitragynine is 13 times more potent than morphine, and 7-hydroxymitragynine is 4 times more potent than mitragynine.2
Kratom is available as leaves, powdered leaves, or gum. It can be smoked, brewed into tea, or mixed with liquid and ingested. Effects are dose-dependent; lower doses tend to produce a stimulant effect and higher doses produce an opioid effect. A typical dose is 1 to 8 g.3 Users may take Kratom to experience euphoria or analgesia, or to self-treat opioid withdrawal symptoms.3 Kratom withdrawal syndrome shares many features of classic opioid withdrawal—diarrhea, rhinorrhea, cravings, anxiety, tremor, myalgia, sweating, and irritability—but has been reported to be less severe and shorter-lasting.1 Kratom withdrawal, like opioid withdrawal, may respond to supportive care in combination with opioid-replacement therapy. Airway management and naloxone treatment may be needed on an emergent basis if a user develops respiratory depression.2 There have been case reports of seizures occurring following Kratom use.2
Methoxetamine is a ketamine analog originally developed as an alternative to ketamine. It isn’t classified as a controlled substance in the United States and is available on the internet.2 Methoxetamine is a white powder typically snorted or taken sublingually, although it can be injected intramuscularly. Because methoxetamine’s structure is similar to ketamine, its mechanism of action is assumed to involve glutamate N-methyl-D-aspartate receptor antagonism and dopamine reuptake inhibition. Doses range from 20 to 100 mg orally and 10 to 50 mg when injected. Effects may not be apparent for 30 to 90 minutes after the drug is snorted, which may cause users to take another dose or ingest a different substance, possibly leading to synergistic adverse effects. Effects may emerge within 5 minutes when injected. The duration of effect generally is 5 to 7 hours—notably longer than ketamine—but as little as 1 hour when injected.
No clinical human or animal studies have been conducted on methoxetamine, which makes it difficult to ascertain the drug’s true clinical and toxic effects; instead, these effects must be surmised from user reports and case studies. Desired effects described by users are similar to those of ketamine: dissociation, short-term mood elevation, visual hallucinations, and alteration of sensory experiences. Reported adverse effects include catatonia, confusion, agitation, and depression.4 In addition, methoxetamine may induce sympathomimetic toxicity as evidenced by tachycardia and hypertension. Researchers have suggested that patients who experience methoxetamine toxicity and require emergency treatment be managed with supportive care and benzodiazepines.5
Staying current is key
A paucity of clinical research on these substances means their effects are poorly understood, which creates a dangerous situation for users and physicians. In addition, many users assume these substances are safer than illegal substances. New and potentially dangerous substances are being produced so quickly distributors are able to stay ahead of regulatory efforts. When one substance is declared illegal, another related substance quickly is available to take its place. To provide the best care for our patients, it is essential for psychiatrists to stay up-to-date about these novel substances.
Disclosure
Dr. Troy reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. McWhirter L, Morris S. A case report of inpatient detoxification after kratom (Mitragyna speciosa) dependence. Eur Addict Res. 2010;16(4):229-231.
2. Rosenbaum CD, Carreiro SP, Babu KM. Here today gone tomorrow…and back again? A review of herbal marijuana alternatives (K2, Spice), synthetic cathinones (bath salts), Kratom, Salvia divinorum, methoxetamine, and piperazines. J Med Toxicol. 2012;8(1):15-32.
3. Boyer EW, Babu KM, Macalino GE. Self-treatment of opioid withdrawal with a dietary supplement Kratom. Am J Addict. 2007;16(5):352-356.
4. Corazza O, Schifano F, Simonato P, et al. Phenomenon of new drugs on the Internet: the case of ketamine derivative methoxetamine. Hum Psychopharmacol. 2012;27(2):145-149.
5. Wood DM, Davies S, Puchnarewicz M, et al. Acute toxicity associated with the recreational use of the ketamine derivative methoxetamine. Eur J Clin Pharmacol. 2012;68(5):853-856.
The demand for “legal highs”— intoxicating natural or synthetic substances that are not prohibited by law—continues to increase. Young adults may use these substances, which are widely available on the internet, at “head shops,” and at gas stations. Such substances frequently cause adverse medical and psychiatric effects, exemplified by recent reports concerning the dangers of using synthetic cannabinoids (eg, “Spice,” “K2”) and synthetic cathinones (“bath salts”). Although these 2 substances now are illegal in many jurisdictions, other novel substances of misuse remain legal and widely available, including Kratom and methoxetamine.
Because these substances usually are not detectable on standard urine toxicology screens, clinicians need to be aware of them to be able to take an accurate substance use history, consider possible dangerous interactions with prescribed psychotropics, and address medical and psychiatric complications.
Kratom is an herbal product derived from Mitragyna speciosa, a plant native to Southeast Asia. Traditionally used as a medicinal herb, it increasingly is being used for recreational purposes and remains legal and widely available in the United States. Kratom’s leaves contain multiple alkaloids, including mitragynine and 7-hydroxymitragynine, which are believed to act as agonists at the μ-opioid receptor. Mitragynine also may have agonist activity at post-synaptic α2-adrenergic receptors, as well as antagonist activity at 5-HT2A receptors.1 Mitragynine is 13 times more potent than morphine, and 7-hydroxymitragynine is 4 times more potent than mitragynine.2
Kratom is available as leaves, powdered leaves, or gum. It can be smoked, brewed into tea, or mixed with liquid and ingested. Effects are dose-dependent; lower doses tend to produce a stimulant effect and higher doses produce an opioid effect. A typical dose is 1 to 8 g.3 Users may take Kratom to experience euphoria or analgesia, or to self-treat opioid withdrawal symptoms.3 Kratom withdrawal syndrome shares many features of classic opioid withdrawal—diarrhea, rhinorrhea, cravings, anxiety, tremor, myalgia, sweating, and irritability—but has been reported to be less severe and shorter-lasting.1 Kratom withdrawal, like opioid withdrawal, may respond to supportive care in combination with opioid-replacement therapy. Airway management and naloxone treatment may be needed on an emergent basis if a user develops respiratory depression.2 There have been case reports of seizures occurring following Kratom use.2
Methoxetamine is a ketamine analog originally developed as an alternative to ketamine. It isn’t classified as a controlled substance in the United States and is available on the internet.2 Methoxetamine is a white powder typically snorted or taken sublingually, although it can be injected intramuscularly. Because methoxetamine’s structure is similar to ketamine, its mechanism of action is assumed to involve glutamate N-methyl-D-aspartate receptor antagonism and dopamine reuptake inhibition. Doses range from 20 to 100 mg orally and 10 to 50 mg when injected. Effects may not be apparent for 30 to 90 minutes after the drug is snorted, which may cause users to take another dose or ingest a different substance, possibly leading to synergistic adverse effects. Effects may emerge within 5 minutes when injected. The duration of effect generally is 5 to 7 hours—notably longer than ketamine—but as little as 1 hour when injected.
No clinical human or animal studies have been conducted on methoxetamine, which makes it difficult to ascertain the drug’s true clinical and toxic effects; instead, these effects must be surmised from user reports and case studies. Desired effects described by users are similar to those of ketamine: dissociation, short-term mood elevation, visual hallucinations, and alteration of sensory experiences. Reported adverse effects include catatonia, confusion, agitation, and depression.4 In addition, methoxetamine may induce sympathomimetic toxicity as evidenced by tachycardia and hypertension. Researchers have suggested that patients who experience methoxetamine toxicity and require emergency treatment be managed with supportive care and benzodiazepines.5
Staying current is key
A paucity of clinical research on these substances means their effects are poorly understood, which creates a dangerous situation for users and physicians. In addition, many users assume these substances are safer than illegal substances. New and potentially dangerous substances are being produced so quickly distributors are able to stay ahead of regulatory efforts. When one substance is declared illegal, another related substance quickly is available to take its place. To provide the best care for our patients, it is essential for psychiatrists to stay up-to-date about these novel substances.
Disclosure
Dr. Troy reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
The demand for “legal highs”— intoxicating natural or synthetic substances that are not prohibited by law—continues to increase. Young adults may use these substances, which are widely available on the internet, at “head shops,” and at gas stations. Such substances frequently cause adverse medical and psychiatric effects, exemplified by recent reports concerning the dangers of using synthetic cannabinoids (eg, “Spice,” “K2”) and synthetic cathinones (“bath salts”). Although these 2 substances now are illegal in many jurisdictions, other novel substances of misuse remain legal and widely available, including Kratom and methoxetamine.
Because these substances usually are not detectable on standard urine toxicology screens, clinicians need to be aware of them to be able to take an accurate substance use history, consider possible dangerous interactions with prescribed psychotropics, and address medical and psychiatric complications.
Kratom is an herbal product derived from Mitragyna speciosa, a plant native to Southeast Asia. Traditionally used as a medicinal herb, it increasingly is being used for recreational purposes and remains legal and widely available in the United States. Kratom’s leaves contain multiple alkaloids, including mitragynine and 7-hydroxymitragynine, which are believed to act as agonists at the μ-opioid receptor. Mitragynine also may have agonist activity at post-synaptic α2-adrenergic receptors, as well as antagonist activity at 5-HT2A receptors.1 Mitragynine is 13 times more potent than morphine, and 7-hydroxymitragynine is 4 times more potent than mitragynine.2
Kratom is available as leaves, powdered leaves, or gum. It can be smoked, brewed into tea, or mixed with liquid and ingested. Effects are dose-dependent; lower doses tend to produce a stimulant effect and higher doses produce an opioid effect. A typical dose is 1 to 8 g.3 Users may take Kratom to experience euphoria or analgesia, or to self-treat opioid withdrawal symptoms.3 Kratom withdrawal syndrome shares many features of classic opioid withdrawal—diarrhea, rhinorrhea, cravings, anxiety, tremor, myalgia, sweating, and irritability—but has been reported to be less severe and shorter-lasting.1 Kratom withdrawal, like opioid withdrawal, may respond to supportive care in combination with opioid-replacement therapy. Airway management and naloxone treatment may be needed on an emergent basis if a user develops respiratory depression.2 There have been case reports of seizures occurring following Kratom use.2
Methoxetamine is a ketamine analog originally developed as an alternative to ketamine. It isn’t classified as a controlled substance in the United States and is available on the internet.2 Methoxetamine is a white powder typically snorted or taken sublingually, although it can be injected intramuscularly. Because methoxetamine’s structure is similar to ketamine, its mechanism of action is assumed to involve glutamate N-methyl-D-aspartate receptor antagonism and dopamine reuptake inhibition. Doses range from 20 to 100 mg orally and 10 to 50 mg when injected. Effects may not be apparent for 30 to 90 minutes after the drug is snorted, which may cause users to take another dose or ingest a different substance, possibly leading to synergistic adverse effects. Effects may emerge within 5 minutes when injected. The duration of effect generally is 5 to 7 hours—notably longer than ketamine—but as little as 1 hour when injected.
No clinical human or animal studies have been conducted on methoxetamine, which makes it difficult to ascertain the drug’s true clinical and toxic effects; instead, these effects must be surmised from user reports and case studies. Desired effects described by users are similar to those of ketamine: dissociation, short-term mood elevation, visual hallucinations, and alteration of sensory experiences. Reported adverse effects include catatonia, confusion, agitation, and depression.4 In addition, methoxetamine may induce sympathomimetic toxicity as evidenced by tachycardia and hypertension. Researchers have suggested that patients who experience methoxetamine toxicity and require emergency treatment be managed with supportive care and benzodiazepines.5
Staying current is key
A paucity of clinical research on these substances means their effects are poorly understood, which creates a dangerous situation for users and physicians. In addition, many users assume these substances are safer than illegal substances. New and potentially dangerous substances are being produced so quickly distributors are able to stay ahead of regulatory efforts. When one substance is declared illegal, another related substance quickly is available to take its place. To provide the best care for our patients, it is essential for psychiatrists to stay up-to-date about these novel substances.
Disclosure
Dr. Troy reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. McWhirter L, Morris S. A case report of inpatient detoxification after kratom (Mitragyna speciosa) dependence. Eur Addict Res. 2010;16(4):229-231.
2. Rosenbaum CD, Carreiro SP, Babu KM. Here today gone tomorrow…and back again? A review of herbal marijuana alternatives (K2, Spice), synthetic cathinones (bath salts), Kratom, Salvia divinorum, methoxetamine, and piperazines. J Med Toxicol. 2012;8(1):15-32.
3. Boyer EW, Babu KM, Macalino GE. Self-treatment of opioid withdrawal with a dietary supplement Kratom. Am J Addict. 2007;16(5):352-356.
4. Corazza O, Schifano F, Simonato P, et al. Phenomenon of new drugs on the Internet: the case of ketamine derivative methoxetamine. Hum Psychopharmacol. 2012;27(2):145-149.
5. Wood DM, Davies S, Puchnarewicz M, et al. Acute toxicity associated with the recreational use of the ketamine derivative methoxetamine. Eur J Clin Pharmacol. 2012;68(5):853-856.
1. McWhirter L, Morris S. A case report of inpatient detoxification after kratom (Mitragyna speciosa) dependence. Eur Addict Res. 2010;16(4):229-231.
2. Rosenbaum CD, Carreiro SP, Babu KM. Here today gone tomorrow…and back again? A review of herbal marijuana alternatives (K2, Spice), synthetic cathinones (bath salts), Kratom, Salvia divinorum, methoxetamine, and piperazines. J Med Toxicol. 2012;8(1):15-32.
3. Boyer EW, Babu KM, Macalino GE. Self-treatment of opioid withdrawal with a dietary supplement Kratom. Am J Addict. 2007;16(5):352-356.
4. Corazza O, Schifano F, Simonato P, et al. Phenomenon of new drugs on the Internet: the case of ketamine derivative methoxetamine. Hum Psychopharmacol. 2012;27(2):145-149.
5. Wood DM, Davies S, Puchnarewicz M, et al. Acute toxicity associated with the recreational use of the ketamine derivative methoxetamine. Eur J Clin Pharmacol. 2012;68(5):853-856.
MEAN: How to manage a child who bullies
A survey from the National Institute of Child Health and Human Development estimated that 20% of 6th through 10th graders admitted to bullying their classmates.1 In addition to an increased risk for personal injury, bullied children are more likely to report low self-esteem and emotional problems2 and often experience loneliness.1 In contrast, children who bully suffer in their school performance1 and are more likely to engage in drug use3 and violence4 later in life. Child psychiatrists often see both bullies and their victims.
Evidence-based recommendations are available to help educators improve the school climate5 and identify children who are at an increased risk for bullying,6 but research supporting specific clinical strategies for managing a child who bullies is limited. Establishing rapport and engaging a bully often is challenging; these difficulties further complicate assessment and successful management of such children.
We present the mnemonic MEAN to help clinicians assess and understand children who bully.
Model. Discuss, demonstrate, and practice models of alternative social skills and behaviors, including active listening, being open to others’ views, accepting failure, controlling impulses, developing problem-solving techniques, and treating others with respect.
Empathize. Encourage children who bully to explore their feelings about themselves—which may uncover poor self-esteem, anger, or guilt—and acknowledge the hurt they cause others by bullying. Focusing on the pain they inflict on others in the context of personal experiences of pain that likely is driving their aggression may enable bullies to empathize with their victims.
Assess. Help the bully assess the costs and benefits of his or her behavior. Point out what the bully stands to gain from ending his or her aggressive behavior, which likely already has resulted in lost recesses, after school detentions, missed sports practices, and the loss of privileges at home. Most importantly, assess and treat any underlying psychopathology, including mood and anxiety disorders.
Nurture. Aid the bully in identifying his or her prosocial strengths to build self-esteem and thereby reduce the need to commit aggressive acts as a means of gaining a sense of control or personal security. Disarm the child with your genuine concern for his or her well-being.
Using these psychotherapeutic techniques may enhance establishing rapport with a child who bullies and may improve outcomes.
Disclosures
Dr. Kepple reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Madaan receives grant or research support from Eli Lilly and Company, Forest Pharmaceuticals, Merck, Otsuka, Pfizer Inc., and Shire.
1. Nansel TR, Overpeck M, Pilla RS, et al. Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA. 2001;285(16):2094-2100.
2. Guerra NG, Williams KR, Sadek S. Understanding bullying and victimization during childhood and adolescence: a mixed methods study. Child Dev. 2011;82(1):295-310.
3. Tharp-Taylor S, Haviland A, D’Amico EJ. Victimization from mental and physical bullying and substance use in early adolescence. Addict Behav. 2009;34(6-7):561-567.
4. Duke NN, Pettingell SL, McMorris BJ, et al. Adolescent violence perpetration: associations with multiple types of adverse childhood experiences. Pediatrics. 2010;125(4):e778-e786.
5. Olweus D, Limber SP. Bullying in school: evaluation and dissemination of the Olweus Bullying Prevention Program. Am J Orthopsychiatry. 2010;80(1):124-134.
6. Jansen DE, Veenstra R, Ormel J, et al. Early risk factors for being a bully, victim, or bully/victim in late elementary and early secondary education. The longitudinal TRAILS study. BMC Public Health. 2011;11:440.-
A survey from the National Institute of Child Health and Human Development estimated that 20% of 6th through 10th graders admitted to bullying their classmates.1 In addition to an increased risk for personal injury, bullied children are more likely to report low self-esteem and emotional problems2 and often experience loneliness.1 In contrast, children who bully suffer in their school performance1 and are more likely to engage in drug use3 and violence4 later in life. Child psychiatrists often see both bullies and their victims.
Evidence-based recommendations are available to help educators improve the school climate5 and identify children who are at an increased risk for bullying,6 but research supporting specific clinical strategies for managing a child who bullies is limited. Establishing rapport and engaging a bully often is challenging; these difficulties further complicate assessment and successful management of such children.
We present the mnemonic MEAN to help clinicians assess and understand children who bully.
Model. Discuss, demonstrate, and practice models of alternative social skills and behaviors, including active listening, being open to others’ views, accepting failure, controlling impulses, developing problem-solving techniques, and treating others with respect.
Empathize. Encourage children who bully to explore their feelings about themselves—which may uncover poor self-esteem, anger, or guilt—and acknowledge the hurt they cause others by bullying. Focusing on the pain they inflict on others in the context of personal experiences of pain that likely is driving their aggression may enable bullies to empathize with their victims.
Assess. Help the bully assess the costs and benefits of his or her behavior. Point out what the bully stands to gain from ending his or her aggressive behavior, which likely already has resulted in lost recesses, after school detentions, missed sports practices, and the loss of privileges at home. Most importantly, assess and treat any underlying psychopathology, including mood and anxiety disorders.
Nurture. Aid the bully in identifying his or her prosocial strengths to build self-esteem and thereby reduce the need to commit aggressive acts as a means of gaining a sense of control or personal security. Disarm the child with your genuine concern for his or her well-being.
Using these psychotherapeutic techniques may enhance establishing rapport with a child who bullies and may improve outcomes.
Disclosures
Dr. Kepple reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Madaan receives grant or research support from Eli Lilly and Company, Forest Pharmaceuticals, Merck, Otsuka, Pfizer Inc., and Shire.
A survey from the National Institute of Child Health and Human Development estimated that 20% of 6th through 10th graders admitted to bullying their classmates.1 In addition to an increased risk for personal injury, bullied children are more likely to report low self-esteem and emotional problems2 and often experience loneliness.1 In contrast, children who bully suffer in their school performance1 and are more likely to engage in drug use3 and violence4 later in life. Child psychiatrists often see both bullies and their victims.
Evidence-based recommendations are available to help educators improve the school climate5 and identify children who are at an increased risk for bullying,6 but research supporting specific clinical strategies for managing a child who bullies is limited. Establishing rapport and engaging a bully often is challenging; these difficulties further complicate assessment and successful management of such children.
We present the mnemonic MEAN to help clinicians assess and understand children who bully.
Model. Discuss, demonstrate, and practice models of alternative social skills and behaviors, including active listening, being open to others’ views, accepting failure, controlling impulses, developing problem-solving techniques, and treating others with respect.
Empathize. Encourage children who bully to explore their feelings about themselves—which may uncover poor self-esteem, anger, or guilt—and acknowledge the hurt they cause others by bullying. Focusing on the pain they inflict on others in the context of personal experiences of pain that likely is driving their aggression may enable bullies to empathize with their victims.
Assess. Help the bully assess the costs and benefits of his or her behavior. Point out what the bully stands to gain from ending his or her aggressive behavior, which likely already has resulted in lost recesses, after school detentions, missed sports practices, and the loss of privileges at home. Most importantly, assess and treat any underlying psychopathology, including mood and anxiety disorders.
Nurture. Aid the bully in identifying his or her prosocial strengths to build self-esteem and thereby reduce the need to commit aggressive acts as a means of gaining a sense of control or personal security. Disarm the child with your genuine concern for his or her well-being.
Using these psychotherapeutic techniques may enhance establishing rapport with a child who bullies and may improve outcomes.
Disclosures
Dr. Kepple reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Madaan receives grant or research support from Eli Lilly and Company, Forest Pharmaceuticals, Merck, Otsuka, Pfizer Inc., and Shire.
1. Nansel TR, Overpeck M, Pilla RS, et al. Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA. 2001;285(16):2094-2100.
2. Guerra NG, Williams KR, Sadek S. Understanding bullying and victimization during childhood and adolescence: a mixed methods study. Child Dev. 2011;82(1):295-310.
3. Tharp-Taylor S, Haviland A, D’Amico EJ. Victimization from mental and physical bullying and substance use in early adolescence. Addict Behav. 2009;34(6-7):561-567.
4. Duke NN, Pettingell SL, McMorris BJ, et al. Adolescent violence perpetration: associations with multiple types of adverse childhood experiences. Pediatrics. 2010;125(4):e778-e786.
5. Olweus D, Limber SP. Bullying in school: evaluation and dissemination of the Olweus Bullying Prevention Program. Am J Orthopsychiatry. 2010;80(1):124-134.
6. Jansen DE, Veenstra R, Ormel J, et al. Early risk factors for being a bully, victim, or bully/victim in late elementary and early secondary education. The longitudinal TRAILS study. BMC Public Health. 2011;11:440.-
1. Nansel TR, Overpeck M, Pilla RS, et al. Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA. 2001;285(16):2094-2100.
2. Guerra NG, Williams KR, Sadek S. Understanding bullying and victimization during childhood and adolescence: a mixed methods study. Child Dev. 2011;82(1):295-310.
3. Tharp-Taylor S, Haviland A, D’Amico EJ. Victimization from mental and physical bullying and substance use in early adolescence. Addict Behav. 2009;34(6-7):561-567.
4. Duke NN, Pettingell SL, McMorris BJ, et al. Adolescent violence perpetration: associations with multiple types of adverse childhood experiences. Pediatrics. 2010;125(4):e778-e786.
5. Olweus D, Limber SP. Bullying in school: evaluation and dissemination of the Olweus Bullying Prevention Program. Am J Orthopsychiatry. 2010;80(1):124-134.
6. Jansen DE, Veenstra R, Ormel J, et al. Early risk factors for being a bully, victim, or bully/victim in late elementary and early secondary education. The longitudinal TRAILS study. BMC Public Health. 2011;11:440.-
8 tips for talking to parents and children about school shootings
In the aftermath of a school shooting, parents and teachers may seek a psychiatrist’s advice on how to best discuss these incidents with children. We offer guidelines on what to tell concerned parents, educators, and other adults who may interact with children affected by a school shooting.
6 tips for interacting with children
1. Talk about the event. Instruct adults to ask children to share their feelings about the incident and to show genuine interest in listening to the child’s thoughts and point of view. Adults shouldn’t pretend the event hasn’t occurred or isn’t serious. Children may be more worried if they think adults are too afraid to tell them what is happening. It is important to gently correct any misinformation older students may have received via social media.1
2. Reinforce that home is a safe haven. Overwhelming emotions and uncertainty can bring about a sense of insecurity in children. Children may come home seeking a safe environment. Advise parents to plan a night where family members participate in a favorite family activity.1 Tell parents to remind their children that trust-worthy adults—parents, emergency workers, police, firefighters, doctors, and the military—are helping provide safety, comfort, and support.2
3. Limit television time. If children are exposed to the news, parents should watch it with them briefly, but avoid letting children rewatch the same event repetitively. Constant exposure to the event may heighten a child’s anxiety and fears.
4. Maintain a normal routine. Tell parents they should maintain, as best they can, their normal routine for dinner, homework, chores, and bedtime, but to remain flexible.2 Children may have a hard time concentrating on schoolwork or falling asleep. Advise parents to spend extra time reading or playing quiet games with their children, particularly at bedtime. These activities are calming, foster a sense of closeness and security, and reinforce a feeling of normalcy.
5. Encourage emotions. Instruct parents to explain to their children that all feelings are okay and normal, and to let children talk about their feelings and help put them into perspective.1 Children may need help in expressing these feelings, so be patient. If an incident happened at the child’s school, teachers and administrators may conduct group sessions to help children express their concerns about being back in school.
6. Seek creativity or spirituality. Encourage parents and other adults to provide a creative outlet for children, such as making get well cards or sending letters to the survivors and their families. Writing thank you letters to doctors, nurses, fire-fighters, and police officers also may be comforting.1,2 Suggest that parents encourage their children to pray or think hopeful thoughts for the victims and their families.
2 tips for interacting with adults
7. Recommend they take care of themselves. Explain to adult caregivers that because children learn by observing, they shouldn’t ignore their own feelings of anxiety, grief, and anger. By expressing their emotions in a productive manner, adults will be better able to support their children. Encourage adults to talk to friends, family, religious leaders, or mental health counselors.
8. Advise adults to be alert for children who may need professional help. Tell them to be vigilant when monitoring a child’s emotional state. Children who may benefit from mental health counseling after a tragedy may exhibit warning signs, such as changes in behavior, appetite, and sleep patterns, which may indicate the child is experiencing grief, anxiety, or discomfort.
Remind adults to be aware of children who are at greater risk for mental health issues, including those who are already struggling with other recent traumatic experiences—past traumatic experiences, personal loss, depression, or other mental illness.1 Be particularly observant for children who may be at risk of suicide.1,2 Professional counseling may be needed for a child who is experiencing an emotional reaction that lasts >1 month and is impacting his or her daily functioning.1
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. American Psychological Association. Helping your children manage distress in the aftermath of a shooting. http://www.apa.org/helpcenter/aftermath.aspx. Updated April 2011. Accessed February 15, 2013.
2. National Association of School Psychologists resources. A national tragedy: helping children cope. http://www.nasponline.org/resources/crisis_safety/terror_general.aspx. Published September 2001. Accessed February 15, 2013.
In the aftermath of a school shooting, parents and teachers may seek a psychiatrist’s advice on how to best discuss these incidents with children. We offer guidelines on what to tell concerned parents, educators, and other adults who may interact with children affected by a school shooting.
6 tips for interacting with children
1. Talk about the event. Instruct adults to ask children to share their feelings about the incident and to show genuine interest in listening to the child’s thoughts and point of view. Adults shouldn’t pretend the event hasn’t occurred or isn’t serious. Children may be more worried if they think adults are too afraid to tell them what is happening. It is important to gently correct any misinformation older students may have received via social media.1
2. Reinforce that home is a safe haven. Overwhelming emotions and uncertainty can bring about a sense of insecurity in children. Children may come home seeking a safe environment. Advise parents to plan a night where family members participate in a favorite family activity.1 Tell parents to remind their children that trust-worthy adults—parents, emergency workers, police, firefighters, doctors, and the military—are helping provide safety, comfort, and support.2
3. Limit television time. If children are exposed to the news, parents should watch it with them briefly, but avoid letting children rewatch the same event repetitively. Constant exposure to the event may heighten a child’s anxiety and fears.
4. Maintain a normal routine. Tell parents they should maintain, as best they can, their normal routine for dinner, homework, chores, and bedtime, but to remain flexible.2 Children may have a hard time concentrating on schoolwork or falling asleep. Advise parents to spend extra time reading or playing quiet games with their children, particularly at bedtime. These activities are calming, foster a sense of closeness and security, and reinforce a feeling of normalcy.
5. Encourage emotions. Instruct parents to explain to their children that all feelings are okay and normal, and to let children talk about their feelings and help put them into perspective.1 Children may need help in expressing these feelings, so be patient. If an incident happened at the child’s school, teachers and administrators may conduct group sessions to help children express their concerns about being back in school.
6. Seek creativity or spirituality. Encourage parents and other adults to provide a creative outlet for children, such as making get well cards or sending letters to the survivors and their families. Writing thank you letters to doctors, nurses, fire-fighters, and police officers also may be comforting.1,2 Suggest that parents encourage their children to pray or think hopeful thoughts for the victims and their families.
2 tips for interacting with adults
7. Recommend they take care of themselves. Explain to adult caregivers that because children learn by observing, they shouldn’t ignore their own feelings of anxiety, grief, and anger. By expressing their emotions in a productive manner, adults will be better able to support their children. Encourage adults to talk to friends, family, religious leaders, or mental health counselors.
8. Advise adults to be alert for children who may need professional help. Tell them to be vigilant when monitoring a child’s emotional state. Children who may benefit from mental health counseling after a tragedy may exhibit warning signs, such as changes in behavior, appetite, and sleep patterns, which may indicate the child is experiencing grief, anxiety, or discomfort.
Remind adults to be aware of children who are at greater risk for mental health issues, including those who are already struggling with other recent traumatic experiences—past traumatic experiences, personal loss, depression, or other mental illness.1 Be particularly observant for children who may be at risk of suicide.1,2 Professional counseling may be needed for a child who is experiencing an emotional reaction that lasts >1 month and is impacting his or her daily functioning.1
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
In the aftermath of a school shooting, parents and teachers may seek a psychiatrist’s advice on how to best discuss these incidents with children. We offer guidelines on what to tell concerned parents, educators, and other adults who may interact with children affected by a school shooting.
6 tips for interacting with children
1. Talk about the event. Instruct adults to ask children to share their feelings about the incident and to show genuine interest in listening to the child’s thoughts and point of view. Adults shouldn’t pretend the event hasn’t occurred or isn’t serious. Children may be more worried if they think adults are too afraid to tell them what is happening. It is important to gently correct any misinformation older students may have received via social media.1
2. Reinforce that home is a safe haven. Overwhelming emotions and uncertainty can bring about a sense of insecurity in children. Children may come home seeking a safe environment. Advise parents to plan a night where family members participate in a favorite family activity.1 Tell parents to remind their children that trust-worthy adults—parents, emergency workers, police, firefighters, doctors, and the military—are helping provide safety, comfort, and support.2
3. Limit television time. If children are exposed to the news, parents should watch it with them briefly, but avoid letting children rewatch the same event repetitively. Constant exposure to the event may heighten a child’s anxiety and fears.
4. Maintain a normal routine. Tell parents they should maintain, as best they can, their normal routine for dinner, homework, chores, and bedtime, but to remain flexible.2 Children may have a hard time concentrating on schoolwork or falling asleep. Advise parents to spend extra time reading or playing quiet games with their children, particularly at bedtime. These activities are calming, foster a sense of closeness and security, and reinforce a feeling of normalcy.
5. Encourage emotions. Instruct parents to explain to their children that all feelings are okay and normal, and to let children talk about their feelings and help put them into perspective.1 Children may need help in expressing these feelings, so be patient. If an incident happened at the child’s school, teachers and administrators may conduct group sessions to help children express their concerns about being back in school.
6. Seek creativity or spirituality. Encourage parents and other adults to provide a creative outlet for children, such as making get well cards or sending letters to the survivors and their families. Writing thank you letters to doctors, nurses, fire-fighters, and police officers also may be comforting.1,2 Suggest that parents encourage their children to pray or think hopeful thoughts for the victims and their families.
2 tips for interacting with adults
7. Recommend they take care of themselves. Explain to adult caregivers that because children learn by observing, they shouldn’t ignore their own feelings of anxiety, grief, and anger. By expressing their emotions in a productive manner, adults will be better able to support their children. Encourage adults to talk to friends, family, religious leaders, or mental health counselors.
8. Advise adults to be alert for children who may need professional help. Tell them to be vigilant when monitoring a child’s emotional state. Children who may benefit from mental health counseling after a tragedy may exhibit warning signs, such as changes in behavior, appetite, and sleep patterns, which may indicate the child is experiencing grief, anxiety, or discomfort.
Remind adults to be aware of children who are at greater risk for mental health issues, including those who are already struggling with other recent traumatic experiences—past traumatic experiences, personal loss, depression, or other mental illness.1 Be particularly observant for children who may be at risk of suicide.1,2 Professional counseling may be needed for a child who is experiencing an emotional reaction that lasts >1 month and is impacting his or her daily functioning.1
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. American Psychological Association. Helping your children manage distress in the aftermath of a shooting. http://www.apa.org/helpcenter/aftermath.aspx. Updated April 2011. Accessed February 15, 2013.
2. National Association of School Psychologists resources. A national tragedy: helping children cope. http://www.nasponline.org/resources/crisis_safety/terror_general.aspx. Published September 2001. Accessed February 15, 2013.
1. American Psychological Association. Helping your children manage distress in the aftermath of a shooting. http://www.apa.org/helpcenter/aftermath.aspx. Updated April 2011. Accessed February 15, 2013.
2. National Association of School Psychologists resources. A national tragedy: helping children cope. http://www.nasponline.org/resources/crisis_safety/terror_general.aspx. Published September 2001. Accessed February 15, 2013.
Emergency brain imaging: CT or MRI?
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Together with a clinical assessment, neuroimaging increases diagnostic accuracy of detecting neuropathology. Direct patient benefit from scanning is best documented in those with overt, new clinical signs and symptoms of neurologic or psychiatric disease.1,2
Computerized tomography (CT) and magnetic resonance imaging (MRI) are the most common head scanning techniques used in emergency medicine.3 CT is quicker and cheaper, has less movement artifact, and is excellent at delineating acute hemorrhage, calcification, and bony anatomy.3,4 Unfortunately, CT exposes patients to radiation and poorly visualizes white matter or posterior fossa pathology.4
MRI is outstanding for well-defined tissue contrast in multiplanar views and excellent for identifying demyelination or metastatic processes,5 but may be contraindicated for patients with implanted metallic objects such as pacemakers, certain vascular clips or stents, and certain orthopedic devices.3-5 Some patients cannot tolerate the narrow space surrounding them during an MRI.4,5
Safety concerns with CT during pregnancy are well established, but are less clear with MRI. The opposite is true of contrast enhancement; gadolinium with MRI is better tolerated than CT procedures, for which contrast risks include allergy and renal dysfunction. When scanning for a hemorrhage, select a CT scan for patients in whom you suspect bleeding developed within the past 3 days; MRI may be better at screening for older bleeds.
For a list of indications for which a patient should undergo a CT or MRI, see the Table.1-5
Table
Indications for CT or MRI
| New or first-onset psychiatric illness |
| Recent head trauma |
| Recent or advancing cognitive dysfunction |
| New or worsening instances of syncope, vertigo, loss of consciousness, etc. |
| New, worsening, or altered pattern headaches |
| New signs of brain pathology, eg, seizure, paresis, or brain-related visual alteration |
| New neurologic examination abnormalities |
| Concerns about intracranial infection, inflammation, metastases, or increased pressure |
| Change in mental status in persons age >50 |
| Prescreening patients who are candidates for electroconvulsive therapy |
| Source: References 1-5 |
Disclosure
Dr. Lippmann reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Pary R, Lippmann S. Clinical review of head CT scans in psychiatric patients. VA Practitioner. 1986;3:48-53.
2. Capote HA. Neuroimaging in psychiatry. Neurol Clin. 2009;27(1):237-249.
3. Malhi GS, Lagopoulos J. Making sense of neuroimaging in psychiatry. Acta Psychiatr Scand. 2008;117(2):100-117.
4. Small GW, Bookheimer SY, Thompson PM, et al. Current and future uses of neuroimaging for cognitively impaired patients. Lancet Neurol. 2008;7(2):161-172.
5. Broderick DF. Neuroimaging in neuropsychiatry. Psychiatr Clin North Am. 2005;28(3):549-566,64.
Discuss this article at www.facebook.com/CurrentPsychiatry
Together with a clinical assessment, neuroimaging increases diagnostic accuracy of detecting neuropathology. Direct patient benefit from scanning is best documented in those with overt, new clinical signs and symptoms of neurologic or psychiatric disease.1,2
Computerized tomography (CT) and magnetic resonance imaging (MRI) are the most common head scanning techniques used in emergency medicine.3 CT is quicker and cheaper, has less movement artifact, and is excellent at delineating acute hemorrhage, calcification, and bony anatomy.3,4 Unfortunately, CT exposes patients to radiation and poorly visualizes white matter or posterior fossa pathology.4
MRI is outstanding for well-defined tissue contrast in multiplanar views and excellent for identifying demyelination or metastatic processes,5 but may be contraindicated for patients with implanted metallic objects such as pacemakers, certain vascular clips or stents, and certain orthopedic devices.3-5 Some patients cannot tolerate the narrow space surrounding them during an MRI.4,5
Safety concerns with CT during pregnancy are well established, but are less clear with MRI. The opposite is true of contrast enhancement; gadolinium with MRI is better tolerated than CT procedures, for which contrast risks include allergy and renal dysfunction. When scanning for a hemorrhage, select a CT scan for patients in whom you suspect bleeding developed within the past 3 days; MRI may be better at screening for older bleeds.
For a list of indications for which a patient should undergo a CT or MRI, see the Table.1-5
Table
Indications for CT or MRI
| New or first-onset psychiatric illness |
| Recent head trauma |
| Recent or advancing cognitive dysfunction |
| New or worsening instances of syncope, vertigo, loss of consciousness, etc. |
| New, worsening, or altered pattern headaches |
| New signs of brain pathology, eg, seizure, paresis, or brain-related visual alteration |
| New neurologic examination abnormalities |
| Concerns about intracranial infection, inflammation, metastases, or increased pressure |
| Change in mental status in persons age >50 |
| Prescreening patients who are candidates for electroconvulsive therapy |
| Source: References 1-5 |
Disclosure
Dr. Lippmann reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Discuss this article at www.facebook.com/CurrentPsychiatry
Together with a clinical assessment, neuroimaging increases diagnostic accuracy of detecting neuropathology. Direct patient benefit from scanning is best documented in those with overt, new clinical signs and symptoms of neurologic or psychiatric disease.1,2
Computerized tomography (CT) and magnetic resonance imaging (MRI) are the most common head scanning techniques used in emergency medicine.3 CT is quicker and cheaper, has less movement artifact, and is excellent at delineating acute hemorrhage, calcification, and bony anatomy.3,4 Unfortunately, CT exposes patients to radiation and poorly visualizes white matter or posterior fossa pathology.4
MRI is outstanding for well-defined tissue contrast in multiplanar views and excellent for identifying demyelination or metastatic processes,5 but may be contraindicated for patients with implanted metallic objects such as pacemakers, certain vascular clips or stents, and certain orthopedic devices.3-5 Some patients cannot tolerate the narrow space surrounding them during an MRI.4,5
Safety concerns with CT during pregnancy are well established, but are less clear with MRI. The opposite is true of contrast enhancement; gadolinium with MRI is better tolerated than CT procedures, for which contrast risks include allergy and renal dysfunction. When scanning for a hemorrhage, select a CT scan for patients in whom you suspect bleeding developed within the past 3 days; MRI may be better at screening for older bleeds.
For a list of indications for which a patient should undergo a CT or MRI, see the Table.1-5
Table
Indications for CT or MRI
| New or first-onset psychiatric illness |
| Recent head trauma |
| Recent or advancing cognitive dysfunction |
| New or worsening instances of syncope, vertigo, loss of consciousness, etc. |
| New, worsening, or altered pattern headaches |
| New signs of brain pathology, eg, seizure, paresis, or brain-related visual alteration |
| New neurologic examination abnormalities |
| Concerns about intracranial infection, inflammation, metastases, or increased pressure |
| Change in mental status in persons age >50 |
| Prescreening patients who are candidates for electroconvulsive therapy |
| Source: References 1-5 |
Disclosure
Dr. Lippmann reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Pary R, Lippmann S. Clinical review of head CT scans in psychiatric patients. VA Practitioner. 1986;3:48-53.
2. Capote HA. Neuroimaging in psychiatry. Neurol Clin. 2009;27(1):237-249.
3. Malhi GS, Lagopoulos J. Making sense of neuroimaging in psychiatry. Acta Psychiatr Scand. 2008;117(2):100-117.
4. Small GW, Bookheimer SY, Thompson PM, et al. Current and future uses of neuroimaging for cognitively impaired patients. Lancet Neurol. 2008;7(2):161-172.
5. Broderick DF. Neuroimaging in neuropsychiatry. Psychiatr Clin North Am. 2005;28(3):549-566,64.
1. Pary R, Lippmann S. Clinical review of head CT scans in psychiatric patients. VA Practitioner. 1986;3:48-53.
2. Capote HA. Neuroimaging in psychiatry. Neurol Clin. 2009;27(1):237-249.
3. Malhi GS, Lagopoulos J. Making sense of neuroimaging in psychiatry. Acta Psychiatr Scand. 2008;117(2):100-117.
4. Small GW, Bookheimer SY, Thompson PM, et al. Current and future uses of neuroimaging for cognitively impaired patients. Lancet Neurol. 2008;7(2):161-172.
5. Broderick DF. Neuroimaging in neuropsychiatry. Psychiatr Clin North Am. 2005;28(3):549-566,64.
Better psychiatric documentation: From SOAP to PROMISE
Discuss this article at www.facebook.com/CurrentPsychiatry
Because documentation is an important part of medical practice,1 numerous tools have been developed to help physicians across all specialties, including the best-known acronym SOAP, which stands for Subjective, Objective, Assessment, and Plan. The SOAP note has been used in mental health settings,2 although this format may fall short for psychiatrists because objective tests are not diagnostic. Also, there’s no clear guidance to document specific information, such as behavioral risk assessment.
The acronym PROMISE—Problems, Resolved, Outcomes, Medications, Instructions, Safety, and Education—may be better suited for psychiatric documentation. The PROMISE note provides an easy-to-remember method to document specific information that might be overlooked in a less detailed format, such as normal findings, adherence and tolerability to medications, outcome ratings, and risk assessment.
Problems are described as ongoing symptoms, signs, and stressors. Resolved indicates improvement and normal findings. Outcome measures include patient or clinician rating scales. Medications documents the effectiveness and tolerability of current and past medications. Instructions are directives given; the rationale—cost-benefit analysis—can be documented in this section as well. Safety describes a behavioral risk assessment, including demographic, historical, clinical, and environmental risk and protective factors regarding suicidal or homicidal behavior. Education describes the verbal or written material shared with the patient.
Psychotherapists can use the same template. For them the M would stand for Methods of psychotherapy practiced in the session.
For an example of the PROMISE note used in practice, see the Table.
Table
Example of a patient’s PROMISE note
| Problems | Ongoing depressive symptoms: low mood, negative thinking, low interest level; patient has no insurance, pays out of pocket |
| Resolved | Mild improvement in motivation noted; sleeping and concentration both OK; continues to work full-time; spends time with parents |
| Outcomes | Clinical Global Impression-Severity Scale score: 4; PHQ-9 depression rating scale score: 12/27, indicating moderate depression (score 1 month ago was 15/27; 20% reduction) |
| Medications | Current treatment: citalopram, 20 mg/d, nortriptyline, 50 mg/d Prior medications: bupropion, citalopram, clomipramine, fluoxetine, MAOIs, sertraline, and venlafaxine. Patient’s adherence to medication is good Tolerability issues: sweating, constipation, dry mouth |
| Instructions | Increase both medications (20% improvement noted; recommend increase in nortriptyline; patient requests increase in citalopram). Ongoing moderate depression; initial side effects may subside |
| Safety | Identified risk or protective factors for suicidal, aggressive, or homicidal behavior: chronic depression without remission No current SI, HI, SIB, hopelessness, anxiety, agitation, insomnia, substance use, psychosis, or interpersonal aggression. No access to weapons. No history of suicide attempts. Good supports. Risk assessment: low |
| Education |
|
| HI: homicidal ideation; MAOIs: monoamine oxidase inhibitors; PHQ-9: 9-Question Patient Health Questionnaire; SI: suicidal ideation; SIB: self-injurious behavior | |
Disclosure
Dr. Bastiaens reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Discuss this article at www.facebook.com/CurrentPsychiatry
Because documentation is an important part of medical practice,1 numerous tools have been developed to help physicians across all specialties, including the best-known acronym SOAP, which stands for Subjective, Objective, Assessment, and Plan. The SOAP note has been used in mental health settings,2 although this format may fall short for psychiatrists because objective tests are not diagnostic. Also, there’s no clear guidance to document specific information, such as behavioral risk assessment.
The acronym PROMISE—Problems, Resolved, Outcomes, Medications, Instructions, Safety, and Education—may be better suited for psychiatric documentation. The PROMISE note provides an easy-to-remember method to document specific information that might be overlooked in a less detailed format, such as normal findings, adherence and tolerability to medications, outcome ratings, and risk assessment.
Problems are described as ongoing symptoms, signs, and stressors. Resolved indicates improvement and normal findings. Outcome measures include patient or clinician rating scales. Medications documents the effectiveness and tolerability of current and past medications. Instructions are directives given; the rationale—cost-benefit analysis—can be documented in this section as well. Safety describes a behavioral risk assessment, including demographic, historical, clinical, and environmental risk and protective factors regarding suicidal or homicidal behavior. Education describes the verbal or written material shared with the patient.
Psychotherapists can use the same template. For them the M would stand for Methods of psychotherapy practiced in the session.
For an example of the PROMISE note used in practice, see the Table.
Table
Example of a patient’s PROMISE note
| Problems | Ongoing depressive symptoms: low mood, negative thinking, low interest level; patient has no insurance, pays out of pocket |
| Resolved | Mild improvement in motivation noted; sleeping and concentration both OK; continues to work full-time; spends time with parents |
| Outcomes | Clinical Global Impression-Severity Scale score: 4; PHQ-9 depression rating scale score: 12/27, indicating moderate depression (score 1 month ago was 15/27; 20% reduction) |
| Medications | Current treatment: citalopram, 20 mg/d, nortriptyline, 50 mg/d Prior medications: bupropion, citalopram, clomipramine, fluoxetine, MAOIs, sertraline, and venlafaxine. Patient’s adherence to medication is good Tolerability issues: sweating, constipation, dry mouth |
| Instructions | Increase both medications (20% improvement noted; recommend increase in nortriptyline; patient requests increase in citalopram). Ongoing moderate depression; initial side effects may subside |
| Safety | Identified risk or protective factors for suicidal, aggressive, or homicidal behavior: chronic depression without remission No current SI, HI, SIB, hopelessness, anxiety, agitation, insomnia, substance use, psychosis, or interpersonal aggression. No access to weapons. No history of suicide attempts. Good supports. Risk assessment: low |
| Education |
|
| HI: homicidal ideation; MAOIs: monoamine oxidase inhibitors; PHQ-9: 9-Question Patient Health Questionnaire; SI: suicidal ideation; SIB: self-injurious behavior | |
Disclosure
Dr. Bastiaens reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Discuss this article at www.facebook.com/CurrentPsychiatry
Because documentation is an important part of medical practice,1 numerous tools have been developed to help physicians across all specialties, including the best-known acronym SOAP, which stands for Subjective, Objective, Assessment, and Plan. The SOAP note has been used in mental health settings,2 although this format may fall short for psychiatrists because objective tests are not diagnostic. Also, there’s no clear guidance to document specific information, such as behavioral risk assessment.
The acronym PROMISE—Problems, Resolved, Outcomes, Medications, Instructions, Safety, and Education—may be better suited for psychiatric documentation. The PROMISE note provides an easy-to-remember method to document specific information that might be overlooked in a less detailed format, such as normal findings, adherence and tolerability to medications, outcome ratings, and risk assessment.
Problems are described as ongoing symptoms, signs, and stressors. Resolved indicates improvement and normal findings. Outcome measures include patient or clinician rating scales. Medications documents the effectiveness and tolerability of current and past medications. Instructions are directives given; the rationale—cost-benefit analysis—can be documented in this section as well. Safety describes a behavioral risk assessment, including demographic, historical, clinical, and environmental risk and protective factors regarding suicidal or homicidal behavior. Education describes the verbal or written material shared with the patient.
Psychotherapists can use the same template. For them the M would stand for Methods of psychotherapy practiced in the session.
For an example of the PROMISE note used in practice, see the Table.
Table
Example of a patient’s PROMISE note
| Problems | Ongoing depressive symptoms: low mood, negative thinking, low interest level; patient has no insurance, pays out of pocket |
| Resolved | Mild improvement in motivation noted; sleeping and concentration both OK; continues to work full-time; spends time with parents |
| Outcomes | Clinical Global Impression-Severity Scale score: 4; PHQ-9 depression rating scale score: 12/27, indicating moderate depression (score 1 month ago was 15/27; 20% reduction) |
| Medications | Current treatment: citalopram, 20 mg/d, nortriptyline, 50 mg/d Prior medications: bupropion, citalopram, clomipramine, fluoxetine, MAOIs, sertraline, and venlafaxine. Patient’s adherence to medication is good Tolerability issues: sweating, constipation, dry mouth |
| Instructions | Increase both medications (20% improvement noted; recommend increase in nortriptyline; patient requests increase in citalopram). Ongoing moderate depression; initial side effects may subside |
| Safety | Identified risk or protective factors for suicidal, aggressive, or homicidal behavior: chronic depression without remission No current SI, HI, SIB, hopelessness, anxiety, agitation, insomnia, substance use, psychosis, or interpersonal aggression. No access to weapons. No history of suicide attempts. Good supports. Risk assessment: low |
| Education |
|
| HI: homicidal ideation; MAOIs: monoamine oxidase inhibitors; PHQ-9: 9-Question Patient Health Questionnaire; SI: suicidal ideation; SIB: self-injurious behavior | |
Disclosure
Dr. Bastiaens reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
The ABCDEs of obstructive sleep apnea
Symptoms of sleep-disordered breathing range from primary snoring and upper airway resistance to obstructive sleep apnea (OSA). Psychiatric disorders and OSA frequently are comorbid. In a study of veterans with OSA, 22% had depression, 17% had anxiety, 12% had posttraumatic stress disorder, and 5% had psychosis.1 Treatments for OSA include dental devices, positive airway pressure ventilation, and surgery. Treating OSA often improves comorbid psychiatric disorders.2 However, medication-induced weight gain (eg, from antipsychotics) and hypnotics can worsen OSA. The mnemonic ABCDE can help you remember precipitating factors of OSA, associated sleep patterns, and complications of untreated OSA.
Precipitating factors
Age, gender, and race. OSA has a higher prevalence among middle-age men and the incidence of OSA gradually increases in postmenopausal women. African American patients also are at increased risk.
Bulkiness. Obesity is a significant risk factor for OSA, especially among middle-age men. Secondary fat deposition around the neck and decreased muscle tone and lung volume may lead to OSA.
Circumference of the neck. A neck circumference of >16 inches in women and >17 inches in men indicates a greater risk of developing OSA.3
Disrupted air flow. Airway narrowing can be present in patients with a small oropharynx, large tongue or uvula, backward tongue displacement, nasal obstruction, or craniofacial abnormalities.4 Certain medications (eg, muscle relaxants), alcohol, or hypothyroidism can reduce muscle tone and lead to OSA.5 Gastroesophageal reflux, asthma, pregnancy, stroke, and neuromuscular disease increase susceptibility to OSA. Patients with cardiac failure often have associated central sleep apnea.4
Extended family members. Patients with first-degree relatives who have OSA are at an increased risk of developing it themselves.5
Associated sleep patterns
Arousals. Intermittent nighttime sleep, non-restorative sleep, restless sleep, and insomnia are common among patients with OSA.5
Blocked airway and snoring. Snoring is common in OSA and signifies partial airway obstruction.
Choking, coughing, and gasping for air. As a result of decreased oxygenation, OSA patients usually wake up gasping for air. Associated gastroesophageal reflux also can cause cough.
Dry and/or open mouth. Most OSA patients breathe through their mouth because of obstruction in the upper airway.6 Patients often complain of dry mouth and morning thirst.
Excessive daytime sleepiness. Because of lack of nighttime sleep, it is common for individuals with OSA to feel tired during the day or want to nap.
Complications of untreated OSA
Anxiety and depression. There is a strong relationship between untreated OSA and psychiatric disorders, especially anxiety and depression in adults.1
Body mass index elevation or obesity. Frequent apneas are linked to an increase in leptin and ghrelin levels, which leads to increased appetite.4,5
Cardiovascular complications. Increased incidences of pulmonary or systemic hypertension, cardiac arrhythmias, myocardial infarctions, and strokes have been associated with untreated OSA.5
Daytime tiredness and sleepiness. Attention problems, tardiness, and accidents are common among patients with OSA.
Endocrine abnormalities. Individuals with moderate to severe OSA have a higher risk of developing diabetes mellitus and hypercholesterolemia.4
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Sharafkhaneh A, Giray N, Richardson P, et al. Association of psychiatric disorders and sleep apnea in a large cohort. Sleep. 2005;28(11):1405-1411.
2. Schröder CM, O’Hara R. Depression and obstructive sleep apnea (OSA). Ann Gen Psychiatry. 2005;4:13.-
3. Victor LD. Obstructive sleep apnea. Am Fam Physician. 1999;60(8):2279-2286.
4. Kryger MH, Roth T, Dement WC. Principles and practice of sleep medicine. 5th ed. Philadelphia PA: Elsevier Saunders; 2010.
5. Al Lawati NM, Patel SR, Ayas NT. Epidemiology risk factors, and consequences of obstructive sleep apnea and short sleep duration. Prog Cardiovasc Dis. 2009;51(4):285-293.
6. Oksenberg A, Froom P, Melamed S. Dry mouth upon awakening in obstructive sleep apnea. J Sleep Res. 2006;15(3):317-320.
Symptoms of sleep-disordered breathing range from primary snoring and upper airway resistance to obstructive sleep apnea (OSA). Psychiatric disorders and OSA frequently are comorbid. In a study of veterans with OSA, 22% had depression, 17% had anxiety, 12% had posttraumatic stress disorder, and 5% had psychosis.1 Treatments for OSA include dental devices, positive airway pressure ventilation, and surgery. Treating OSA often improves comorbid psychiatric disorders.2 However, medication-induced weight gain (eg, from antipsychotics) and hypnotics can worsen OSA. The mnemonic ABCDE can help you remember precipitating factors of OSA, associated sleep patterns, and complications of untreated OSA.
Precipitating factors
Age, gender, and race. OSA has a higher prevalence among middle-age men and the incidence of OSA gradually increases in postmenopausal women. African American patients also are at increased risk.
Bulkiness. Obesity is a significant risk factor for OSA, especially among middle-age men. Secondary fat deposition around the neck and decreased muscle tone and lung volume may lead to OSA.
Circumference of the neck. A neck circumference of >16 inches in women and >17 inches in men indicates a greater risk of developing OSA.3
Disrupted air flow. Airway narrowing can be present in patients with a small oropharynx, large tongue or uvula, backward tongue displacement, nasal obstruction, or craniofacial abnormalities.4 Certain medications (eg, muscle relaxants), alcohol, or hypothyroidism can reduce muscle tone and lead to OSA.5 Gastroesophageal reflux, asthma, pregnancy, stroke, and neuromuscular disease increase susceptibility to OSA. Patients with cardiac failure often have associated central sleep apnea.4
Extended family members. Patients with first-degree relatives who have OSA are at an increased risk of developing it themselves.5
Associated sleep patterns
Arousals. Intermittent nighttime sleep, non-restorative sleep, restless sleep, and insomnia are common among patients with OSA.5
Blocked airway and snoring. Snoring is common in OSA and signifies partial airway obstruction.
Choking, coughing, and gasping for air. As a result of decreased oxygenation, OSA patients usually wake up gasping for air. Associated gastroesophageal reflux also can cause cough.
Dry and/or open mouth. Most OSA patients breathe through their mouth because of obstruction in the upper airway.6 Patients often complain of dry mouth and morning thirst.
Excessive daytime sleepiness. Because of lack of nighttime sleep, it is common for individuals with OSA to feel tired during the day or want to nap.
Complications of untreated OSA
Anxiety and depression. There is a strong relationship between untreated OSA and psychiatric disorders, especially anxiety and depression in adults.1
Body mass index elevation or obesity. Frequent apneas are linked to an increase in leptin and ghrelin levels, which leads to increased appetite.4,5
Cardiovascular complications. Increased incidences of pulmonary or systemic hypertension, cardiac arrhythmias, myocardial infarctions, and strokes have been associated with untreated OSA.5
Daytime tiredness and sleepiness. Attention problems, tardiness, and accidents are common among patients with OSA.
Endocrine abnormalities. Individuals with moderate to severe OSA have a higher risk of developing diabetes mellitus and hypercholesterolemia.4
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Symptoms of sleep-disordered breathing range from primary snoring and upper airway resistance to obstructive sleep apnea (OSA). Psychiatric disorders and OSA frequently are comorbid. In a study of veterans with OSA, 22% had depression, 17% had anxiety, 12% had posttraumatic stress disorder, and 5% had psychosis.1 Treatments for OSA include dental devices, positive airway pressure ventilation, and surgery. Treating OSA often improves comorbid psychiatric disorders.2 However, medication-induced weight gain (eg, from antipsychotics) and hypnotics can worsen OSA. The mnemonic ABCDE can help you remember precipitating factors of OSA, associated sleep patterns, and complications of untreated OSA.
Precipitating factors
Age, gender, and race. OSA has a higher prevalence among middle-age men and the incidence of OSA gradually increases in postmenopausal women. African American patients also are at increased risk.
Bulkiness. Obesity is a significant risk factor for OSA, especially among middle-age men. Secondary fat deposition around the neck and decreased muscle tone and lung volume may lead to OSA.
Circumference of the neck. A neck circumference of >16 inches in women and >17 inches in men indicates a greater risk of developing OSA.3
Disrupted air flow. Airway narrowing can be present in patients with a small oropharynx, large tongue or uvula, backward tongue displacement, nasal obstruction, or craniofacial abnormalities.4 Certain medications (eg, muscle relaxants), alcohol, or hypothyroidism can reduce muscle tone and lead to OSA.5 Gastroesophageal reflux, asthma, pregnancy, stroke, and neuromuscular disease increase susceptibility to OSA. Patients with cardiac failure often have associated central sleep apnea.4
Extended family members. Patients with first-degree relatives who have OSA are at an increased risk of developing it themselves.5
Associated sleep patterns
Arousals. Intermittent nighttime sleep, non-restorative sleep, restless sleep, and insomnia are common among patients with OSA.5
Blocked airway and snoring. Snoring is common in OSA and signifies partial airway obstruction.
Choking, coughing, and gasping for air. As a result of decreased oxygenation, OSA patients usually wake up gasping for air. Associated gastroesophageal reflux also can cause cough.
Dry and/or open mouth. Most OSA patients breathe through their mouth because of obstruction in the upper airway.6 Patients often complain of dry mouth and morning thirst.
Excessive daytime sleepiness. Because of lack of nighttime sleep, it is common for individuals with OSA to feel tired during the day or want to nap.
Complications of untreated OSA
Anxiety and depression. There is a strong relationship between untreated OSA and psychiatric disorders, especially anxiety and depression in adults.1
Body mass index elevation or obesity. Frequent apneas are linked to an increase in leptin and ghrelin levels, which leads to increased appetite.4,5
Cardiovascular complications. Increased incidences of pulmonary or systemic hypertension, cardiac arrhythmias, myocardial infarctions, and strokes have been associated with untreated OSA.5
Daytime tiredness and sleepiness. Attention problems, tardiness, and accidents are common among patients with OSA.
Endocrine abnormalities. Individuals with moderate to severe OSA have a higher risk of developing diabetes mellitus and hypercholesterolemia.4
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Sharafkhaneh A, Giray N, Richardson P, et al. Association of psychiatric disorders and sleep apnea in a large cohort. Sleep. 2005;28(11):1405-1411.
2. Schröder CM, O’Hara R. Depression and obstructive sleep apnea (OSA). Ann Gen Psychiatry. 2005;4:13.-
3. Victor LD. Obstructive sleep apnea. Am Fam Physician. 1999;60(8):2279-2286.
4. Kryger MH, Roth T, Dement WC. Principles and practice of sleep medicine. 5th ed. Philadelphia PA: Elsevier Saunders; 2010.
5. Al Lawati NM, Patel SR, Ayas NT. Epidemiology risk factors, and consequences of obstructive sleep apnea and short sleep duration. Prog Cardiovasc Dis. 2009;51(4):285-293.
6. Oksenberg A, Froom P, Melamed S. Dry mouth upon awakening in obstructive sleep apnea. J Sleep Res. 2006;15(3):317-320.
1. Sharafkhaneh A, Giray N, Richardson P, et al. Association of psychiatric disorders and sleep apnea in a large cohort. Sleep. 2005;28(11):1405-1411.
2. Schröder CM, O’Hara R. Depression and obstructive sleep apnea (OSA). Ann Gen Psychiatry. 2005;4:13.-
3. Victor LD. Obstructive sleep apnea. Am Fam Physician. 1999;60(8):2279-2286.
4. Kryger MH, Roth T, Dement WC. Principles and practice of sleep medicine. 5th ed. Philadelphia PA: Elsevier Saunders; 2010.
5. Al Lawati NM, Patel SR, Ayas NT. Epidemiology risk factors, and consequences of obstructive sleep apnea and short sleep duration. Prog Cardiovasc Dis. 2009;51(4):285-293.
6. Oksenberg A, Froom P, Melamed S. Dry mouth upon awakening in obstructive sleep apnea. J Sleep Res. 2006;15(3):317-320.