Pearls

Split treatment occurs when a psychiatrist and psychotherapist share a patient’s care. These relationships create opportunities and challenges for both clinicians and patients. Some patients may experience positive transference, such as nurturing and idealization, whereas others may have negative transference, including narcissistic wounds and devaluation of 1 or both clinicians.¹ This article will help you navigate split treatment relationships.

Types of relationships

Duplicative services involve a patient receiving psychotherapy or psychopharmacology from ≥2 clinicians; the latter is more common. Duplicative psychopharmacology can occur inadvertently when drugs prescribed by a nonpsychiatrist overlap with psychotropics in their effects.

Duplicative opinions. When sought with the knowledge of all parties, second opinions can strengthen the doctor-patient relationship and improve outcomes. Duplicative opinions may be pathologic when patients do not disclose their opinion-seeking to both clinicians. This form of “doctor shopping” is common among patients with personality disorders, especially borderline personality disorder, and those who seek drugs from multiple providers to abuse, stockpile, or sell them.

Strategies for split treatment

During the first session, discuss the patient’s expectations. Establish a treatment plan, setting forth what you are and are not responsible for managing. If the patient is transferring treatment to you, ask if he or she has terminated treatment with the prior clinician.

If psychotropics are indicated, ask the patient to agree that only you will manage medications for mood, attention, cognition, energy, and sleep, except in an emergency such as an allergic reaction. Inform your patient that having multiple physicians managing these symptoms puts him or her at risk for drug-drug interactions and ineffective treatment. Ask your patient to notify you about any new medications.

A patient’s psychodynamic issues with medications can complicate pharmacotherapy. For example, a patient may experience transference reactions to medications, such as issues relating to control of the treatment process or psychogenic side effects. Ideally, the psychotherapist and psychiatrist work together to determine which clinician could better address these issues.

If a patient reports that another clinician devalued your treatment, don’t react immediately. Explore with your patient how the discussion with the other clinician came about. Patients can misinterpret what other clinicians say or lie in an attempt to create conflict between you and your colleagues. Give the other clinician the benefit of the doubt and if possible, speak to him or her before commenting about the alleged statements. Look at these situations as an opportunity to set limits with patients.

Split treatment occurs when a psychiatrist and psychotherapist share a patient’s care. These relationships create opportunities and challenges for both clinicians and patients. Some patients may experience positive transference, such as nurturing and idealization, whereas others may have negative transference, including narcissistic wounds and devaluation of 1 or both clinicians.¹ This article will help you navigate split treatment relationships.

Types of relationships

Duplicative services involve a patient receiving psychotherapy or psychopharmacology from ≥2 clinicians; the latter is more common. Duplicative psychopharmacology can occur inadvertently when drugs prescribed by a nonpsychiatrist overlap with psychotropics in their effects.

Duplicative opinions. When sought with the knowledge of all parties, second opinions can strengthen the doctor-patient relationship and improve outcomes. Duplicative opinions may be pathologic when patients do not disclose their opinion-seeking to both clinicians. This form of “doctor shopping” is common among patients with personality disorders, especially borderline personality disorder, and those who seek drugs from multiple providers to abuse, stockpile, or sell them.

Strategies for split treatment

During the first session, discuss the patient’s expectations. Establish a treatment plan, setting forth what you are and are not responsible for managing. If the patient is transferring treatment to you, ask if he or she has terminated treatment with the prior clinician.

If psychotropics are indicated, ask the patient to agree that only you will manage medications for mood, attention, cognition, energy, and sleep, except in an emergency such as an allergic reaction. Inform your patient that having multiple physicians managing these symptoms puts him or her at risk for drug-drug interactions and ineffective treatment. Ask your patient to notify you about any new medications.

A patient’s psychodynamic issues with medications can complicate pharmacotherapy. For example, a patient may experience transference reactions to medications, such as issues relating to control of the treatment process or psychogenic side effects. Ideally, the psychotherapist and psychiatrist work together to determine which clinician could better address these issues.

If a patient reports that another clinician devalued your treatment, don’t react immediately. Explore with your patient how the discussion with the other clinician came about. Patients can misinterpret what other clinicians say or lie in an attempt to create conflict between you and your colleagues. Give the other clinician the benefit of the doubt and if possible, speak to him or her before commenting about the alleged statements. Look at these situations as an opportunity to set limits with patients.

Split treatment occurs when a psychiatrist and psychotherapist share a patient’s care. These relationships create opportunities and challenges for both clinicians and patients. Some patients may experience positive transference, such as nurturing and idealization, whereas others may have negative transference, including narcissistic wounds and devaluation of 1 or both clinicians.¹ This article will help you navigate split treatment relationships.

Types of relationships

Duplicative services involve a patient receiving psychotherapy or psychopharmacology from ≥2 clinicians; the latter is more common. Duplicative psychopharmacology can occur inadvertently when drugs prescribed by a nonpsychiatrist overlap with psychotropics in their effects.

Duplicative opinions. When sought with the knowledge of all parties, second opinions can strengthen the doctor-patient relationship and improve outcomes. Duplicative opinions may be pathologic when patients do not disclose their opinion-seeking to both clinicians. This form of “doctor shopping” is common among patients with personality disorders, especially borderline personality disorder, and those who seek drugs from multiple providers to abuse, stockpile, or sell them.

Strategies for split treatment

During the first session, discuss the patient’s expectations. Establish a treatment plan, setting forth what you are and are not responsible for managing. If the patient is transferring treatment to you, ask if he or she has terminated treatment with the prior clinician.

If psychotropics are indicated, ask the patient to agree that only you will manage medications for mood, attention, cognition, energy, and sleep, except in an emergency such as an allergic reaction. Inform your patient that having multiple physicians managing these symptoms puts him or her at risk for drug-drug interactions and ineffective treatment. Ask your patient to notify you about any new medications.

A patient’s psychodynamic issues with medications can complicate pharmacotherapy. For example, a patient may experience transference reactions to medications, such as issues relating to control of the treatment process or psychogenic side effects. Ideally, the psychotherapist and psychiatrist work together to determine which clinician could better address these issues.

If a patient reports that another clinician devalued your treatment, don’t react immediately. Explore with your patient how the discussion with the other clinician came about. Patients can misinterpret what other clinicians say or lie in an attempt to create conflict between you and your colleagues. Give the other clinician the benefit of the doubt and if possible, speak to him or her before commenting about the alleged statements. Look at these situations as an opportunity to set limits with patients.

Neurodevelopmental disorders are “life span” clinical syndromes¹ that may contribute to development of axis I and axis II disorders and are associated with high rates of psychiatric comorbidity. Behaviors and symptoms of neurodevelopmental disorders are enduring and difficult to recognize—particularly in their milder and attenuated forms—because patients often “age out” of obvious manifestations. High rates of comorbidity with other DSM-IV-TR disorders also can contribute to substantial underdiagnosis and under-recognition. Failure to accurately identify a residual neurodevelopmental disorder can cause problems establishing and maintaining a working alliance and may lead to poor treatment outcomes.

Clues to help identify patients with residual neurodevelopmental symptoms include:

• repeating grade levels, requiring special education services, and/or failing to graduate high school
• academic and/or career underachievement
• developing uneven sensory, motor, cognitive, and/or academic skills
• chronically distressed “high achiever”
• long-term social ostracism and/or peculiarity.

Classification and typology

Patients within the dyslexic spectrum typically have a history of difficulty reading, spelling, and writing. These problems cannot be explained adequately by socio-cultural factors and/or general limitations in cognition.

Nonverbal learning disability patients have selective deficits in math reasoning and visuospatial processing, motor planning problems, and, at times, weak social interaction skills.

Signs of suspected residual attention-deficit/hyperactivity disorder include a history—usually dating back to elementary school—of poor concentration and weak retention abilities. These patients also have difficulty organizing, planning, and completing activities, particularly those requiring multiple steps and/or sustained mental effort.

Socially ostracized patients with social peculiarity, especially if coupled with ≥1 specific information processing and learning problems, frequently have mild residual difficulties that fall within the pervasive developmental disorder (autistic) spectrum.

Patients with histories of “across-the-board” problems acquiring academic skills and a lack of compensatory success in at least some non-academic pursuits may have generalized intellectual disability. This may be so-called “borderline” intellectual functioning or, in a much smaller number of cases, mild mental retardation/ mild intellectual disability.

Making an accurate diagnosis

To more easily identify patients with a residual developmental disorder, take a more detailed academic/educational history that includes Scholastic Aptitude Test scores, previous “coding” for ≥1 special needs psychoeducational conditions, and/or a childhood/adolescent history of psychometric testing. Also, obtain your patient’s educational/psychoeducational records.

Complete a detailed developmental history that includes exploring subtle anomalies in acquiring language pragmatics, motor coordination/planning, and social interaction skills.

Interview parents, spouses, and friends who are familiar with your patient’s longitudinal neurodevelopmental functioning.

Review recent texts on residual neurodevelopmental disorders.² Consider referring your patient for psychometric testing to firm up diagnostic impressions and assist in treatment planning.

Neurodevelopmental disorders are “life span” clinical syndromes¹ that may contribute to development of axis I and axis II disorders and are associated with high rates of psychiatric comorbidity. Behaviors and symptoms of neurodevelopmental disorders are enduring and difficult to recognize—particularly in their milder and attenuated forms—because patients often “age out” of obvious manifestations. High rates of comorbidity with other DSM-IV-TR disorders also can contribute to substantial underdiagnosis and under-recognition. Failure to accurately identify a residual neurodevelopmental disorder can cause problems establishing and maintaining a working alliance and may lead to poor treatment outcomes.

Clues to help identify patients with residual neurodevelopmental symptoms include:

• repeating grade levels, requiring special education services, and/or failing to graduate high school
• academic and/or career underachievement
• developing uneven sensory, motor, cognitive, and/or academic skills
• chronically distressed “high achiever”
• long-term social ostracism and/or peculiarity.

Classification and typology

Patients within the dyslexic spectrum typically have a history of difficulty reading, spelling, and writing. These problems cannot be explained adequately by socio-cultural factors and/or general limitations in cognition.

Nonverbal learning disability patients have selective deficits in math reasoning and visuospatial processing, motor planning problems, and, at times, weak social interaction skills.

Signs of suspected residual attention-deficit/hyperactivity disorder include a history—usually dating back to elementary school—of poor concentration and weak retention abilities. These patients also have difficulty organizing, planning, and completing activities, particularly those requiring multiple steps and/or sustained mental effort.

Socially ostracized patients with social peculiarity, especially if coupled with ≥1 specific information processing and learning problems, frequently have mild residual difficulties that fall within the pervasive developmental disorder (autistic) spectrum.

Patients with histories of “across-the-board” problems acquiring academic skills and a lack of compensatory success in at least some non-academic pursuits may have generalized intellectual disability. This may be so-called “borderline” intellectual functioning or, in a much smaller number of cases, mild mental retardation/ mild intellectual disability.

Making an accurate diagnosis

To more easily identify patients with a residual developmental disorder, take a more detailed academic/educational history that includes Scholastic Aptitude Test scores, previous “coding” for ≥1 special needs psychoeducational conditions, and/or a childhood/adolescent history of psychometric testing. Also, obtain your patient’s educational/psychoeducational records.

Complete a detailed developmental history that includes exploring subtle anomalies in acquiring language pragmatics, motor coordination/planning, and social interaction skills.

Interview parents, spouses, and friends who are familiar with your patient’s longitudinal neurodevelopmental functioning.

Review recent texts on residual neurodevelopmental disorders.² Consider referring your patient for psychometric testing to firm up diagnostic impressions and assist in treatment planning.

Neurodevelopmental disorders are “life span” clinical syndromes¹ that may contribute to development of axis I and axis II disorders and are associated with high rates of psychiatric comorbidity. Behaviors and symptoms of neurodevelopmental disorders are enduring and difficult to recognize—particularly in their milder and attenuated forms—because patients often “age out” of obvious manifestations. High rates of comorbidity with other DSM-IV-TR disorders also can contribute to substantial underdiagnosis and under-recognition. Failure to accurately identify a residual neurodevelopmental disorder can cause problems establishing and maintaining a working alliance and may lead to poor treatment outcomes.

Clues to help identify patients with residual neurodevelopmental symptoms include:

• repeating grade levels, requiring special education services, and/or failing to graduate high school
• academic and/or career underachievement
• developing uneven sensory, motor, cognitive, and/or academic skills
• chronically distressed “high achiever”
• long-term social ostracism and/or peculiarity.

Classification and typology

Patients within the dyslexic spectrum typically have a history of difficulty reading, spelling, and writing. These problems cannot be explained adequately by socio-cultural factors and/or general limitations in cognition.

Nonverbal learning disability patients have selective deficits in math reasoning and visuospatial processing, motor planning problems, and, at times, weak social interaction skills.

Signs of suspected residual attention-deficit/hyperactivity disorder include a history—usually dating back to elementary school—of poor concentration and weak retention abilities. These patients also have difficulty organizing, planning, and completing activities, particularly those requiring multiple steps and/or sustained mental effort.

Socially ostracized patients with social peculiarity, especially if coupled with ≥1 specific information processing and learning problems, frequently have mild residual difficulties that fall within the pervasive developmental disorder (autistic) spectrum.

Patients with histories of “across-the-board” problems acquiring academic skills and a lack of compensatory success in at least some non-academic pursuits may have generalized intellectual disability. This may be so-called “borderline” intellectual functioning or, in a much smaller number of cases, mild mental retardation/ mild intellectual disability.

Making an accurate diagnosis

To more easily identify patients with a residual developmental disorder, take a more detailed academic/educational history that includes Scholastic Aptitude Test scores, previous “coding” for ≥1 special needs psychoeducational conditions, and/or a childhood/adolescent history of psychometric testing. Also, obtain your patient’s educational/psychoeducational records.

Complete a detailed developmental history that includes exploring subtle anomalies in acquiring language pragmatics, motor coordination/planning, and social interaction skills.

Interview parents, spouses, and friends who are familiar with your patient’s longitudinal neurodevelopmental functioning.

Review recent texts on residual neurodevelopmental disorders.² Consider referring your patient for psychometric testing to firm up diagnostic impressions and assist in treatment planning.

Many psychiatric patients present with substance abuse problems in addition to mood, anxiety, or psychotic disorders. Addiction to cocaine or methamphetamine is widespread and difficult to treat. Also, patients who abuse these substances frequently relapse.¹

Need for treatment. There are no FDA-approved medications for treating cocaine or methamphetamine addiction. Several compounds are being studied, including therapy for addiction–cocaine addiction (TA-CD), a potential cocaine vaccine. The vaccine produces anticocaine antibodies that attach to cocaine molecules in the blood, preventing them from passing the blood-brain barrier. This mechanism blocks cocaine-induced euphoria. Although promising, it is still under investigation and pharmaceutical companies have shown little interest in producing it.²

Initial treatment. Bupropion is a norepinephrine-dopamine reuptake inhibitor with a chemical structure similar to amphetamine. It is FDA-approved for treating major depressive disorder and nicotine addiction;³ however, some clinicians have found it helpful during the initial treatment of cocaine and methamphetamine addiction. If bupropion is initiated while the patient is detoxifying, the drug significantly reduces cravings and also treats depressive symptoms, which are common during withdrawal.⁴ The patient can safely remain on bupropion after discharge if the medication is taken continuously without a lapse in treatment.

Caveat. If a patient presents with depression or another mood disorder, take a careful addiction history before prescribing bupropion. If the patient has a recent history of cocaine addiction, but has been abstinent for ≥1 month, bupropion may not be the drug of choice. Because bupropion has a chemical structure similar to amphetamine, it can be a powerful trigger for relapse. To avoid this problem, take a careful history during the initial psychiatric evaluation. Timing is crucial for effective bupropion use and for maintaining continued abstinence among dual diagnosis patients.

Many psychiatric patients present with substance abuse problems in addition to mood, anxiety, or psychotic disorders. Addiction to cocaine or methamphetamine is widespread and difficult to treat. Also, patients who abuse these substances frequently relapse.¹

Need for treatment. There are no FDA-approved medications for treating cocaine or methamphetamine addiction. Several compounds are being studied, including therapy for addiction–cocaine addiction (TA-CD), a potential cocaine vaccine. The vaccine produces anticocaine antibodies that attach to cocaine molecules in the blood, preventing them from passing the blood-brain barrier. This mechanism blocks cocaine-induced euphoria. Although promising, it is still under investigation and pharmaceutical companies have shown little interest in producing it.²

Initial treatment. Bupropion is a norepinephrine-dopamine reuptake inhibitor with a chemical structure similar to amphetamine. It is FDA-approved for treating major depressive disorder and nicotine addiction;³ however, some clinicians have found it helpful during the initial treatment of cocaine and methamphetamine addiction. If bupropion is initiated while the patient is detoxifying, the drug significantly reduces cravings and also treats depressive symptoms, which are common during withdrawal.⁴ The patient can safely remain on bupropion after discharge if the medication is taken continuously without a lapse in treatment.

Caveat. If a patient presents with depression or another mood disorder, take a careful addiction history before prescribing bupropion. If the patient has a recent history of cocaine addiction, but has been abstinent for ≥1 month, bupropion may not be the drug of choice. Because bupropion has a chemical structure similar to amphetamine, it can be a powerful trigger for relapse. To avoid this problem, take a careful history during the initial psychiatric evaluation. Timing is crucial for effective bupropion use and for maintaining continued abstinence among dual diagnosis patients.

Many psychiatric patients present with substance abuse problems in addition to mood, anxiety, or psychotic disorders. Addiction to cocaine or methamphetamine is widespread and difficult to treat. Also, patients who abuse these substances frequently relapse.¹

Need for treatment. There are no FDA-approved medications for treating cocaine or methamphetamine addiction. Several compounds are being studied, including therapy for addiction–cocaine addiction (TA-CD), a potential cocaine vaccine. The vaccine produces anticocaine antibodies that attach to cocaine molecules in the blood, preventing them from passing the blood-brain barrier. This mechanism blocks cocaine-induced euphoria. Although promising, it is still under investigation and pharmaceutical companies have shown little interest in producing it.²

Initial treatment. Bupropion is a norepinephrine-dopamine reuptake inhibitor with a chemical structure similar to amphetamine. It is FDA-approved for treating major depressive disorder and nicotine addiction;³ however, some clinicians have found it helpful during the initial treatment of cocaine and methamphetamine addiction. If bupropion is initiated while the patient is detoxifying, the drug significantly reduces cravings and also treats depressive symptoms, which are common during withdrawal.⁴ The patient can safely remain on bupropion after discharge if the medication is taken continuously without a lapse in treatment.

Caveat. If a patient presents with depression or another mood disorder, take a careful addiction history before prescribing bupropion. If the patient has a recent history of cocaine addiction, but has been abstinent for ≥1 month, bupropion may not be the drug of choice. Because bupropion has a chemical structure similar to amphetamine, it can be a powerful trigger for relapse. To avoid this problem, take a careful history during the initial psychiatric evaluation. Timing is crucial for effective bupropion use and for maintaining continued abstinence among dual diagnosis patients.

When treating deaf psychiatric patients, appropriate psychiatric care is possible when you maintain an awareness of deaf culture and language. Consider these 10 points:

1. Certified American Sign Language (ASL) interpreters are necessary. The Americans with Disabilities Act requires that all health care providers offer “auxiliary aids and services to provide effective communication.” For deaf patients, often this means an interpreter. Certified interpreters:

• have passed fluency examinations
• are culturally competent
• follow standards of practice
• have a code of ethics
• are required to pursue continuing education to keep their skills sharp and up to date.

Visit the Registry of Interpreters for the Deaf at www.rid.org to search by state for freelance qualified ASL interpreters and interpreting agencies. Be aware that clinicians must pay for the interpreting service, which is not reimbursed by insurance. Rates vary by region.

2. ASL fluency levels vary. Approximately 90% of deaf children are born to hearing parents, and exposure to ASL may be delayed or minimal. As a result, the presence of a fluent ASL interpreter does not guarantee patient comprehension. The patient may not understand the questions being asked resulting in incorrect endorsement or denial of symptoms. Dysfluent patients’ language may mimic that of a patient with a thought disorder or intellectual disability, resulting in misdiagnosis.¹

3. Meet the interpreter before the session. Discuss your goals and explain the meaning of psychiatric terms and symptoms to help him or her communicate your message and interpret the patient’s response.²

ASL is not visual English. Some concepts do not translate into ASL and need to be modified or omitted by interpreters. English idioms often used in diagnostic interviews, such as “feeling blue” or “feeling keyed up or on edge,” do not have exact ASL translations.

An interpreter has to use his or her judgment on how to translate these concepts in ASL. Some symptoms such as “panic attack” and “auditory hallucination” do not have corresponding signs in ASL.

Interpreters may convey these concepts by describing or even acting them out. Ambiguity is difficult to maintain in ASL. Interpreters often have to give examples or lists of possible choices to communicate a concept. Some open-ended questions must be transformed into multiple-choice questions, which can be leading or narrow potential responses.

4. Be aware of privacy. Certified interpreters are required to maintain confidentiality. However, a deaf patient might not have the same interpreter over the course of treatment. The deaf community is close-knit, and a patient using multiple interpreters may worry about confidentiality. Deaf people are likely to use interpreters in a variety of settings and may feel uncomfortable working with the same interpreter in a psychiatric setting and other social situations. The deaf patient always has final say over whether or not to work with a particular interpreter.

5. Avoid using families as interpreters. Even if they are fluent in ASL, family members can distort examination findings and will eliminate confidentiality. If a family member insists on serving as an interpreter, discuss his or her reasons. For example, some families use a form of idiosyncratic gestures often called “home signs” instead of ASL. In this case, you would need a family member present because an ASL interpreter would not be familiar with these. In other situations, you may have to educate family members about why a certified interpreter is more appropriate.

6. Don’t rely on written English. A typical deaf person of normal intelligence has a fourth-grade reading level. Self-report measures of symptoms often are written for an eighth-grade reading or higher level. In psychiatry, subtle nuances in communication are critical, and relying on written English could cause misunderstandings.

Do not use written notes passed back and forth with your patient to avoid the expense of an ASL interpreter. Physicians have been successfully sued for refusing to hire interpreters in the hope of “getting by” with written notes. In these cases the judgments against the physicians were not covered by malpractice insurance.

7. Don’t overpathologize. ASL is an expressive and dramatic language. In addition, deaf persons may have different personal space boundaries than hearing persons. Don’t mistake these cultural norms as evidence of a mood disorder or character pathology.

8. Be cautious when assessing a deaf person for psychosis and “hearing-based” phenomena such as auditory hallucinations. Psychotic disorders historically have been overdiagnosed in deaf patients when clinicians rely solely on subjective reports of symptoms. Instead, err on the side of caution unless you identify objective, observable evidence (such as bizarre behavior or clearly stated delusional beliefs).¹

9. Clarify. Deaf persons—just like hearing persons—do not like to appear unknowledgeable. A patient may “nod along,” leading you to inaccurate conclusions and misdiagnosis. Use open-ended questions to elicit a full description of symptoms.

10. Be patient and plan ahead. Schedule longer sessions—as much as twice as long—to allow extra time for interpretation and double-checking comprehension. Remember that each question has to be asked, interpreted, answered, and interpreted again. Follow-up questions may be necessary to ensure comprehension.

When treating deaf psychiatric patients, appropriate psychiatric care is possible when you maintain an awareness of deaf culture and language. Consider these 10 points:

1. Certified American Sign Language (ASL) interpreters are necessary. The Americans with Disabilities Act requires that all health care providers offer “auxiliary aids and services to provide effective communication.” For deaf patients, often this means an interpreter. Certified interpreters:

• have passed fluency examinations
• are culturally competent
• follow standards of practice
• have a code of ethics
• are required to pursue continuing education to keep their skills sharp and up to date.

Visit the Registry of Interpreters for the Deaf at www.rid.org to search by state for freelance qualified ASL interpreters and interpreting agencies. Be aware that clinicians must pay for the interpreting service, which is not reimbursed by insurance. Rates vary by region.

2. ASL fluency levels vary. Approximately 90% of deaf children are born to hearing parents, and exposure to ASL may be delayed or minimal. As a result, the presence of a fluent ASL interpreter does not guarantee patient comprehension. The patient may not understand the questions being asked resulting in incorrect endorsement or denial of symptoms. Dysfluent patients’ language may mimic that of a patient with a thought disorder or intellectual disability, resulting in misdiagnosis.¹

3. Meet the interpreter before the session. Discuss your goals and explain the meaning of psychiatric terms and symptoms to help him or her communicate your message and interpret the patient’s response.²

ASL is not visual English. Some concepts do not translate into ASL and need to be modified or omitted by interpreters. English idioms often used in diagnostic interviews, such as “feeling blue” or “feeling keyed up or on edge,” do not have exact ASL translations.

An interpreter has to use his or her judgment on how to translate these concepts in ASL. Some symptoms such as “panic attack” and “auditory hallucination” do not have corresponding signs in ASL.

Interpreters may convey these concepts by describing or even acting them out. Ambiguity is difficult to maintain in ASL. Interpreters often have to give examples or lists of possible choices to communicate a concept. Some open-ended questions must be transformed into multiple-choice questions, which can be leading or narrow potential responses.

4. Be aware of privacy. Certified interpreters are required to maintain confidentiality. However, a deaf patient might not have the same interpreter over the course of treatment. The deaf community is close-knit, and a patient using multiple interpreters may worry about confidentiality. Deaf people are likely to use interpreters in a variety of settings and may feel uncomfortable working with the same interpreter in a psychiatric setting and other social situations. The deaf patient always has final say over whether or not to work with a particular interpreter.

5. Avoid using families as interpreters. Even if they are fluent in ASL, family members can distort examination findings and will eliminate confidentiality. If a family member insists on serving as an interpreter, discuss his or her reasons. For example, some families use a form of idiosyncratic gestures often called “home signs” instead of ASL. In this case, you would need a family member present because an ASL interpreter would not be familiar with these. In other situations, you may have to educate family members about why a certified interpreter is more appropriate.

6. Don’t rely on written English. A typical deaf person of normal intelligence has a fourth-grade reading level. Self-report measures of symptoms often are written for an eighth-grade reading or higher level. In psychiatry, subtle nuances in communication are critical, and relying on written English could cause misunderstandings.

Do not use written notes passed back and forth with your patient to avoid the expense of an ASL interpreter. Physicians have been successfully sued for refusing to hire interpreters in the hope of “getting by” with written notes. In these cases the judgments against the physicians were not covered by malpractice insurance.

7. Don’t overpathologize. ASL is an expressive and dramatic language. In addition, deaf persons may have different personal space boundaries than hearing persons. Don’t mistake these cultural norms as evidence of a mood disorder or character pathology.

8. Be cautious when assessing a deaf person for psychosis and “hearing-based” phenomena such as auditory hallucinations. Psychotic disorders historically have been overdiagnosed in deaf patients when clinicians rely solely on subjective reports of symptoms. Instead, err on the side of caution unless you identify objective, observable evidence (such as bizarre behavior or clearly stated delusional beliefs).¹

9. Clarify. Deaf persons—just like hearing persons—do not like to appear unknowledgeable. A patient may “nod along,” leading you to inaccurate conclusions and misdiagnosis. Use open-ended questions to elicit a full description of symptoms.

10. Be patient and plan ahead. Schedule longer sessions—as much as twice as long—to allow extra time for interpretation and double-checking comprehension. Remember that each question has to be asked, interpreted, answered, and interpreted again. Follow-up questions may be necessary to ensure comprehension.

When treating deaf psychiatric patients, appropriate psychiatric care is possible when you maintain an awareness of deaf culture and language. Consider these 10 points:

1. Certified American Sign Language (ASL) interpreters are necessary. The Americans with Disabilities Act requires that all health care providers offer “auxiliary aids and services to provide effective communication.” For deaf patients, often this means an interpreter. Certified interpreters:

• have passed fluency examinations
• are culturally competent
• follow standards of practice
• have a code of ethics
• are required to pursue continuing education to keep their skills sharp and up to date.

Visit the Registry of Interpreters for the Deaf at www.rid.org to search by state for freelance qualified ASL interpreters and interpreting agencies. Be aware that clinicians must pay for the interpreting service, which is not reimbursed by insurance. Rates vary by region.

2. ASL fluency levels vary. Approximately 90% of deaf children are born to hearing parents, and exposure to ASL may be delayed or minimal. As a result, the presence of a fluent ASL interpreter does not guarantee patient comprehension. The patient may not understand the questions being asked resulting in incorrect endorsement or denial of symptoms. Dysfluent patients’ language may mimic that of a patient with a thought disorder or intellectual disability, resulting in misdiagnosis.¹

3. Meet the interpreter before the session. Discuss your goals and explain the meaning of psychiatric terms and symptoms to help him or her communicate your message and interpret the patient’s response.²

ASL is not visual English. Some concepts do not translate into ASL and need to be modified or omitted by interpreters. English idioms often used in diagnostic interviews, such as “feeling blue” or “feeling keyed up or on edge,” do not have exact ASL translations.

An interpreter has to use his or her judgment on how to translate these concepts in ASL. Some symptoms such as “panic attack” and “auditory hallucination” do not have corresponding signs in ASL.

Interpreters may convey these concepts by describing or even acting them out. Ambiguity is difficult to maintain in ASL. Interpreters often have to give examples or lists of possible choices to communicate a concept. Some open-ended questions must be transformed into multiple-choice questions, which can be leading or narrow potential responses.

4. Be aware of privacy. Certified interpreters are required to maintain confidentiality. However, a deaf patient might not have the same interpreter over the course of treatment. The deaf community is close-knit, and a patient using multiple interpreters may worry about confidentiality. Deaf people are likely to use interpreters in a variety of settings and may feel uncomfortable working with the same interpreter in a psychiatric setting and other social situations. The deaf patient always has final say over whether or not to work with a particular interpreter.

5. Avoid using families as interpreters. Even if they are fluent in ASL, family members can distort examination findings and will eliminate confidentiality. If a family member insists on serving as an interpreter, discuss his or her reasons. For example, some families use a form of idiosyncratic gestures often called “home signs” instead of ASL. In this case, you would need a family member present because an ASL interpreter would not be familiar with these. In other situations, you may have to educate family members about why a certified interpreter is more appropriate.

6. Don’t rely on written English. A typical deaf person of normal intelligence has a fourth-grade reading level. Self-report measures of symptoms often are written for an eighth-grade reading or higher level. In psychiatry, subtle nuances in communication are critical, and relying on written English could cause misunderstandings.

Do not use written notes passed back and forth with your patient to avoid the expense of an ASL interpreter. Physicians have been successfully sued for refusing to hire interpreters in the hope of “getting by” with written notes. In these cases the judgments against the physicians were not covered by malpractice insurance.

7. Don’t overpathologize. ASL is an expressive and dramatic language. In addition, deaf persons may have different personal space boundaries than hearing persons. Don’t mistake these cultural norms as evidence of a mood disorder or character pathology.

8. Be cautious when assessing a deaf person for psychosis and “hearing-based” phenomena such as auditory hallucinations. Psychotic disorders historically have been overdiagnosed in deaf patients when clinicians rely solely on subjective reports of symptoms. Instead, err on the side of caution unless you identify objective, observable evidence (such as bizarre behavior or clearly stated delusional beliefs).¹

9. Clarify. Deaf persons—just like hearing persons—do not like to appear unknowledgeable. A patient may “nod along,” leading you to inaccurate conclusions and misdiagnosis. Use open-ended questions to elicit a full description of symptoms.

10. Be patient and plan ahead. Schedule longer sessions—as much as twice as long—to allow extra time for interpretation and double-checking comprehension. Remember that each question has to be asked, interpreted, answered, and interpreted again. Follow-up questions may be necessary to ensure comprehension.

In the United States >33,000 people take their lives each year.¹ Depression is involved in 65% to 90% of all suicides;² however, some patients may not appear acutely depressed or might minimize suicidal thoughts to avoid treatment or hospitalization.

Having direct patient contact, information from collateral sources, and available medical records will guide you in developing a treatment plan, but also consider these 3 areas using the mnemonic PPD:

Past suicide attempts. One of the best predictors of future suicidal behavior is past attempts.³ Ask your patient if he or she has engaged in suicidal behaviors of increasing lethality, such as overdosing, cutting, or unintentional firearm injury. Patients who engage in “escalating attempts” are at a higher risk of harming themselves.⁴

Psychosis. Actively psychotic patients have difficulty contracting for safety. They may report hearing voices telling them to harm themselves or others. Ask patients about hallucinations and how they respond to these experiences even if the hallucinations do not involve suicidal content. For example, a patient with a delusion of having a deadly infectious disease may ingest an entire bottle of medication to eradicate the infection. This might seem like a suicide attempt, but the patient’s intent was not to die, but to “treat” himself or herself.

Drugs and alcohol. One-third of those who commit suicide test positive for alcohol and nearly 1 in 5 have evidence of opiates.⁵ Patients may abuse substances to regulate their moods; however, they are prone to suicidal behavior under the influence of drugs or alcohol. Ask your patient about substances he or she uses and how they impact suicidal thoughts.

Positive findings for ≥1 of the above criteria place a patient at higher risk for suicidal behavior.⁶ By incorporating these 3 factors into your suicide assessment, you will be better equipped to justify the level of care and treatment you recommend.

In the United States >33,000 people take their lives each year.¹ Depression is involved in 65% to 90% of all suicides;² however, some patients may not appear acutely depressed or might minimize suicidal thoughts to avoid treatment or hospitalization.

Having direct patient contact, information from collateral sources, and available medical records will guide you in developing a treatment plan, but also consider these 3 areas using the mnemonic PPD:

Past suicide attempts. One of the best predictors of future suicidal behavior is past attempts.³ Ask your patient if he or she has engaged in suicidal behaviors of increasing lethality, such as overdosing, cutting, or unintentional firearm injury. Patients who engage in “escalating attempts” are at a higher risk of harming themselves.⁴

Psychosis. Actively psychotic patients have difficulty contracting for safety. They may report hearing voices telling them to harm themselves or others. Ask patients about hallucinations and how they respond to these experiences even if the hallucinations do not involve suicidal content. For example, a patient with a delusion of having a deadly infectious disease may ingest an entire bottle of medication to eradicate the infection. This might seem like a suicide attempt, but the patient’s intent was not to die, but to “treat” himself or herself.

Drugs and alcohol. One-third of those who commit suicide test positive for alcohol and nearly 1 in 5 have evidence of opiates.⁵ Patients may abuse substances to regulate their moods; however, they are prone to suicidal behavior under the influence of drugs or alcohol. Ask your patient about substances he or she uses and how they impact suicidal thoughts.

Positive findings for ≥1 of the above criteria place a patient at higher risk for suicidal behavior.⁶ By incorporating these 3 factors into your suicide assessment, you will be better equipped to justify the level of care and treatment you recommend.

In the United States >33,000 people take their lives each year.¹ Depression is involved in 65% to 90% of all suicides;² however, some patients may not appear acutely depressed or might minimize suicidal thoughts to avoid treatment or hospitalization.

Having direct patient contact, information from collateral sources, and available medical records will guide you in developing a treatment plan, but also consider these 3 areas using the mnemonic PPD:

Past suicide attempts. One of the best predictors of future suicidal behavior is past attempts.³ Ask your patient if he or she has engaged in suicidal behaviors of increasing lethality, such as overdosing, cutting, or unintentional firearm injury. Patients who engage in “escalating attempts” are at a higher risk of harming themselves.⁴

Psychosis. Actively psychotic patients have difficulty contracting for safety. They may report hearing voices telling them to harm themselves or others. Ask patients about hallucinations and how they respond to these experiences even if the hallucinations do not involve suicidal content. For example, a patient with a delusion of having a deadly infectious disease may ingest an entire bottle of medication to eradicate the infection. This might seem like a suicide attempt, but the patient’s intent was not to die, but to “treat” himself or herself.

Drugs and alcohol. One-third of those who commit suicide test positive for alcohol and nearly 1 in 5 have evidence of opiates.⁵ Patients may abuse substances to regulate their moods; however, they are prone to suicidal behavior under the influence of drugs or alcohol. Ask your patient about substances he or she uses and how they impact suicidal thoughts.

Positive findings for ≥1 of the above criteria place a patient at higher risk for suicidal behavior.⁶ By incorporating these 3 factors into your suicide assessment, you will be better equipped to justify the level of care and treatment you recommend.

Consider the neuroendocrinology of menopause when evaluating midlife women for new or worsening mood symptoms. The risk of depression increases during perimenopause, even in women with no history of depression.¹ Fluctuating estrogen levels can cause vasomotor symptoms (VMS) and depression, presenting diagnostic and treatment challenges. In addition to conducting a comprehensive psychiatric evaluation, our collaborative rotation between the UCLA-Kern Psychiatry Residency Program and the department of obstetrics and gynecology uses the following approach for women age >40.

Obtain a menstrual history

Ask your patient when her last menstrual period was and if her periods are irregular, heavy, light, or missing. Menopausal transition begins when the length of the menstrual cycle varies and ends with the final menstrual period. Perimenopause begins early in the transition and ends 12 months after the last menses. During this time VMS and mood instability may worsen.

Ask about menopausal symptoms

Hot flashes typically begin as a sudden sensation of heat centered in the upper chest and face that rapidly generalizes. Flashes last 2 to 4 minutes and often are accompanied by profuse perspiration and occasional palpitations. VMS can occur several times during the day and night. Hot flashes—the most common symptom associated with menopausal transition—peak during the 12 months surrounding the last period and can commonly persist up to 5 years or more. Hot flashes affect a woman’s sense of well-being and often are the reason women seek medical attention during midlife.

Insomnia. Sleep disturbance during the menopausal transition is common, sometimes severe, and may be related to nocturnal hot flashes and night sweats. Hot flashes and awakenings are sometimes followed by chills, shivering, anxiety, or panic.

Mood instability. Dysregulation of monoaminergic neurotransmitter systems caused by fluctuating estrogen levels may cause both depression and VMS.² Perimenopausal women with VMS are more likely to be depressed than those who do not have VMS. VMS may signal the onset or recurrence of major depression.

Sexual changes. Estrogen deficiency may lead to vaginal dryness and urogenital atrophy, resulting in infection, painful intercourse, or decreased sexual desire.

Body aches. Many perimenopausal women complain of stiffness, joint pain, breast pain, menstrual migraines, bladder discomfort, and impaired balance.

Memory changes. Complaints of forgetfulness may reflect aging and effects of sleep disturbance.³

Diagnostic workup

Perimenopause can be diagnosed before clinical symptoms appear if the follicle stimulating hormone (FSH) level is >25 IU/L and estrogen is <40 pg/mL during the early follicular phase (day 3 of the menstrual cycle).³ In women age <45 with irregular bleeding and menopause symptoms, check serum beta human chorionic gonadotropin (to rule out pregnancy), prolactin, thyroid-stimulating hormone, and FSH.

Women of any age with estrogen deficiency—such as those undergoing chemotherapy for breast cancer, treatment with gonadotropin-releasing hormone agonists for endometriosis or in-vitro fertilization, premature ovarian failure, or who have undergone oophorectomy—might experience VMS and other perimenopausal symptoms.

Women age >45 with 12 months of amenorrhea may be diagnosed with menopause clinically without further testing.

Treatment strategies

Fewer women are choosing hormone replacement therapy (HRT) (estrogen alone or estrogen and progesterone) after the landmark Women’s Health Initiative (WHI) study in 2002.⁴ Reports that HRT may increase the risk of breast cancer and offers no cardiac protection prompted many women to forego or discontinue HRT use. Subsequent interpretation of the WHI data has reduced many of these concerns.⁵ As a result, estrogen alone currently is the most effective and only FDA-approved treatment for VMS.⁵ Because of overlap between VMS and depression, treatment for these 2 conditions could be combined. Theoretically, treating VMS could prevent a major depressive episode in vulnerable women and may improve the chance of full remission of depression.¹

Although results of studies of HRT for depression are mixed, estrogen alone may be effective for mild depression during perimenopause but not postmenopause. Estrogen also may be appropriate during perimenopause if a depressive disorder represents a first-onset episode of mild to moderate severity.⁶ Estrogen is not FDA-approved for treating perimenopausal depression. As with all medications, counsel patients on the risks and benefits and administer the medication at the lowest dose and for the shortest time period to effectively treat symptoms.

Consider antidepressants when HRT is contraindicated or declined. Selective norepinephrine reuptake inhibitors such as venlafaxine, desvenlafaxine, and duloxetine have demonstrated efficacy for VMS and depression.² Selective serotonin reuptake inhibitors (SSRIs) are effective in women age <40 but show inconsistent efficacy for VMS and depression in women age >50. SSRIs combined with estrogen therapy may be useful in postmenopausal women.²

Biopsychosocial factors

Psychosocial attitudes about aging, sexual attractiveness, and children leaving home may contribute to depression during perimenopause. However, many women welcome the freedom from menstrual periods and pregnancy worries.

Some women may not be aware of the impact of menopausal changes on mood. Educating patients with a mood disorder about what to expect and identifying and treating disabling hormonal dysregulation symptoms is an ideal opportunity to enhance the quality of life for patients during menopause and beyond.

Consider the neuroendocrinology of menopause when evaluating midlife women for new or worsening mood symptoms. The risk of depression increases during perimenopause, even in women with no history of depression.¹ Fluctuating estrogen levels can cause vasomotor symptoms (VMS) and depression, presenting diagnostic and treatment challenges. In addition to conducting a comprehensive psychiatric evaluation, our collaborative rotation between the UCLA-Kern Psychiatry Residency Program and the department of obstetrics and gynecology uses the following approach for women age >40.

Obtain a menstrual history

Ask your patient when her last menstrual period was and if her periods are irregular, heavy, light, or missing. Menopausal transition begins when the length of the menstrual cycle varies and ends with the final menstrual period. Perimenopause begins early in the transition and ends 12 months after the last menses. During this time VMS and mood instability may worsen.

Ask about menopausal symptoms

Hot flashes typically begin as a sudden sensation of heat centered in the upper chest and face that rapidly generalizes. Flashes last 2 to 4 minutes and often are accompanied by profuse perspiration and occasional palpitations. VMS can occur several times during the day and night. Hot flashes—the most common symptom associated with menopausal transition—peak during the 12 months surrounding the last period and can commonly persist up to 5 years or more. Hot flashes affect a woman’s sense of well-being and often are the reason women seek medical attention during midlife.

Insomnia. Sleep disturbance during the menopausal transition is common, sometimes severe, and may be related to nocturnal hot flashes and night sweats. Hot flashes and awakenings are sometimes followed by chills, shivering, anxiety, or panic.

Mood instability. Dysregulation of monoaminergic neurotransmitter systems caused by fluctuating estrogen levels may cause both depression and VMS.² Perimenopausal women with VMS are more likely to be depressed than those who do not have VMS. VMS may signal the onset or recurrence of major depression.

Sexual changes. Estrogen deficiency may lead to vaginal dryness and urogenital atrophy, resulting in infection, painful intercourse, or decreased sexual desire.

Body aches. Many perimenopausal women complain of stiffness, joint pain, breast pain, menstrual migraines, bladder discomfort, and impaired balance.

Memory changes. Complaints of forgetfulness may reflect aging and effects of sleep disturbance.³

Diagnostic workup

Perimenopause can be diagnosed before clinical symptoms appear if the follicle stimulating hormone (FSH) level is >25 IU/L and estrogen is <40 pg/mL during the early follicular phase (day 3 of the menstrual cycle).³ In women age <45 with irregular bleeding and menopause symptoms, check serum beta human chorionic gonadotropin (to rule out pregnancy), prolactin, thyroid-stimulating hormone, and FSH.

Women of any age with estrogen deficiency—such as those undergoing chemotherapy for breast cancer, treatment with gonadotropin-releasing hormone agonists for endometriosis or in-vitro fertilization, premature ovarian failure, or who have undergone oophorectomy—might experience VMS and other perimenopausal symptoms.

Women age >45 with 12 months of amenorrhea may be diagnosed with menopause clinically without further testing.

Treatment strategies

Fewer women are choosing hormone replacement therapy (HRT) (estrogen alone or estrogen and progesterone) after the landmark Women’s Health Initiative (WHI) study in 2002.⁴ Reports that HRT may increase the risk of breast cancer and offers no cardiac protection prompted many women to forego or discontinue HRT use. Subsequent interpretation of the WHI data has reduced many of these concerns.⁵ As a result, estrogen alone currently is the most effective and only FDA-approved treatment for VMS.⁵ Because of overlap between VMS and depression, treatment for these 2 conditions could be combined. Theoretically, treating VMS could prevent a major depressive episode in vulnerable women and may improve the chance of full remission of depression.¹

Although results of studies of HRT for depression are mixed, estrogen alone may be effective for mild depression during perimenopause but not postmenopause. Estrogen also may be appropriate during perimenopause if a depressive disorder represents a first-onset episode of mild to moderate severity.⁶ Estrogen is not FDA-approved for treating perimenopausal depression. As with all medications, counsel patients on the risks and benefits and administer the medication at the lowest dose and for the shortest time period to effectively treat symptoms.

Consider antidepressants when HRT is contraindicated or declined. Selective norepinephrine reuptake inhibitors such as venlafaxine, desvenlafaxine, and duloxetine have demonstrated efficacy for VMS and depression.² Selective serotonin reuptake inhibitors (SSRIs) are effective in women age <40 but show inconsistent efficacy for VMS and depression in women age >50. SSRIs combined with estrogen therapy may be useful in postmenopausal women.²

Biopsychosocial factors

Psychosocial attitudes about aging, sexual attractiveness, and children leaving home may contribute to depression during perimenopause. However, many women welcome the freedom from menstrual periods and pregnancy worries.

Some women may not be aware of the impact of menopausal changes on mood. Educating patients with a mood disorder about what to expect and identifying and treating disabling hormonal dysregulation symptoms is an ideal opportunity to enhance the quality of life for patients during menopause and beyond.

Consider the neuroendocrinology of menopause when evaluating midlife women for new or worsening mood symptoms. The risk of depression increases during perimenopause, even in women with no history of depression.¹ Fluctuating estrogen levels can cause vasomotor symptoms (VMS) and depression, presenting diagnostic and treatment challenges. In addition to conducting a comprehensive psychiatric evaluation, our collaborative rotation between the UCLA-Kern Psychiatry Residency Program and the department of obstetrics and gynecology uses the following approach for women age >40.

Obtain a menstrual history

Ask your patient when her last menstrual period was and if her periods are irregular, heavy, light, or missing. Menopausal transition begins when the length of the menstrual cycle varies and ends with the final menstrual period. Perimenopause begins early in the transition and ends 12 months after the last menses. During this time VMS and mood instability may worsen.

Ask about menopausal symptoms

Hot flashes typically begin as a sudden sensation of heat centered in the upper chest and face that rapidly generalizes. Flashes last 2 to 4 minutes and often are accompanied by profuse perspiration and occasional palpitations. VMS can occur several times during the day and night. Hot flashes—the most common symptom associated with menopausal transition—peak during the 12 months surrounding the last period and can commonly persist up to 5 years or more. Hot flashes affect a woman’s sense of well-being and often are the reason women seek medical attention during midlife.

Insomnia. Sleep disturbance during the menopausal transition is common, sometimes severe, and may be related to nocturnal hot flashes and night sweats. Hot flashes and awakenings are sometimes followed by chills, shivering, anxiety, or panic.

Mood instability. Dysregulation of monoaminergic neurotransmitter systems caused by fluctuating estrogen levels may cause both depression and VMS.² Perimenopausal women with VMS are more likely to be depressed than those who do not have VMS. VMS may signal the onset or recurrence of major depression.

Sexual changes. Estrogen deficiency may lead to vaginal dryness and urogenital atrophy, resulting in infection, painful intercourse, or decreased sexual desire.

Body aches. Many perimenopausal women complain of stiffness, joint pain, breast pain, menstrual migraines, bladder discomfort, and impaired balance.

Memory changes. Complaints of forgetfulness may reflect aging and effects of sleep disturbance.³

Diagnostic workup

Perimenopause can be diagnosed before clinical symptoms appear if the follicle stimulating hormone (FSH) level is >25 IU/L and estrogen is <40 pg/mL during the early follicular phase (day 3 of the menstrual cycle).³ In women age <45 with irregular bleeding and menopause symptoms, check serum beta human chorionic gonadotropin (to rule out pregnancy), prolactin, thyroid-stimulating hormone, and FSH.

Women of any age with estrogen deficiency—such as those undergoing chemotherapy for breast cancer, treatment with gonadotropin-releasing hormone agonists for endometriosis or in-vitro fertilization, premature ovarian failure, or who have undergone oophorectomy—might experience VMS and other perimenopausal symptoms.

Women age >45 with 12 months of amenorrhea may be diagnosed with menopause clinically without further testing.

Treatment strategies

Fewer women are choosing hormone replacement therapy (HRT) (estrogen alone or estrogen and progesterone) after the landmark Women’s Health Initiative (WHI) study in 2002.⁴ Reports that HRT may increase the risk of breast cancer and offers no cardiac protection prompted many women to forego or discontinue HRT use. Subsequent interpretation of the WHI data has reduced many of these concerns.⁵ As a result, estrogen alone currently is the most effective and only FDA-approved treatment for VMS.⁵ Because of overlap between VMS and depression, treatment for these 2 conditions could be combined. Theoretically, treating VMS could prevent a major depressive episode in vulnerable women and may improve the chance of full remission of depression.¹

Although results of studies of HRT for depression are mixed, estrogen alone may be effective for mild depression during perimenopause but not postmenopause. Estrogen also may be appropriate during perimenopause if a depressive disorder represents a first-onset episode of mild to moderate severity.⁶ Estrogen is not FDA-approved for treating perimenopausal depression. As with all medications, counsel patients on the risks and benefits and administer the medication at the lowest dose and for the shortest time period to effectively treat symptoms.

Consider antidepressants when HRT is contraindicated or declined. Selective norepinephrine reuptake inhibitors such as venlafaxine, desvenlafaxine, and duloxetine have demonstrated efficacy for VMS and depression.² Selective serotonin reuptake inhibitors (SSRIs) are effective in women age <40 but show inconsistent efficacy for VMS and depression in women age >50. SSRIs combined with estrogen therapy may be useful in postmenopausal women.²

Biopsychosocial factors

Psychosocial attitudes about aging, sexual attractiveness, and children leaving home may contribute to depression during perimenopause. However, many women welcome the freedom from menstrual periods and pregnancy worries.

Some women may not be aware of the impact of menopausal changes on mood. Educating patients with a mood disorder about what to expect and identifying and treating disabling hormonal dysregulation symptoms is an ideal opportunity to enhance the quality of life for patients during menopause and beyond.

Albert Einstein said, “Imagination is more important than knowledge.” Imagination is not only creative thinking, but also resourcefulness and looking ahead to consider the potential outcomes and consequences of a decision. The ability to imagine—as outlined in the mnemonic IMAGINE—in a supportive environment is critical for good clinical decision-making.¹

Issue. What is it and whose issue is it? For example, although an individual may need to be hospitalized, it also is possible that clinicians are not considering resources available to help the patient in a less restrictive setting. It could be that caregivers simply need a respite. An experienced clinician is flexible and has the ability to shift strategies based on the situation.

Move. Step outside the situation and look at it from different angles. Physicians can be prone to seek premature closure when making decisions. Be aware of cognitive errors and continue to self-assess. The busier we are, the greater the risk of maintaining the status quo. Action takes energy. When tempted to avoid a problem, face it.

Account. Consider and document the risks and benefits of your decision, and alternatives. Practice informed consent, and document as if a colleague, the patient, and the patient’s advocate were to review it.

Gut. How do you balance your “gut reaction” and your reasoning? Paying attention to intuition and assessing its plusses and minuses is more important than we might realize.²

Integration becomes crucial as more data become available.³ Often we are asked to help care for an individual we don’t know well or whose circumstances have changed dramatically. Avoid making a poor judgment by evaluating new data and considering a new context.

Network. Learn of agencies and services that could help your patients and foster those relationships. Doing so in noncrisis times can pay dividends during a crisis.

Expand the field. Feel free to ask for assistance. Because of insecurity about our limitations or overestimating our capabilities, clinicians often make decisions without reaching out.

Acknowledgment

The author wishes to thank Ronald Diamond, MD, Robert Factor, MD, PhD, and Elizabeth Faust, MD for their mentoring.

Albert Einstein said, “Imagination is more important than knowledge.” Imagination is not only creative thinking, but also resourcefulness and looking ahead to consider the potential outcomes and consequences of a decision. The ability to imagine—as outlined in the mnemonic IMAGINE—in a supportive environment is critical for good clinical decision-making.¹

Issue. What is it and whose issue is it? For example, although an individual may need to be hospitalized, it also is possible that clinicians are not considering resources available to help the patient in a less restrictive setting. It could be that caregivers simply need a respite. An experienced clinician is flexible and has the ability to shift strategies based on the situation.

Move. Step outside the situation and look at it from different angles. Physicians can be prone to seek premature closure when making decisions. Be aware of cognitive errors and continue to self-assess. The busier we are, the greater the risk of maintaining the status quo. Action takes energy. When tempted to avoid a problem, face it.

Account. Consider and document the risks and benefits of your decision, and alternatives. Practice informed consent, and document as if a colleague, the patient, and the patient’s advocate were to review it.

Gut. How do you balance your “gut reaction” and your reasoning? Paying attention to intuition and assessing its plusses and minuses is more important than we might realize.²

Integration becomes crucial as more data become available.³ Often we are asked to help care for an individual we don’t know well or whose circumstances have changed dramatically. Avoid making a poor judgment by evaluating new data and considering a new context.

Network. Learn of agencies and services that could help your patients and foster those relationships. Doing so in noncrisis times can pay dividends during a crisis.

Expand the field. Feel free to ask for assistance. Because of insecurity about our limitations or overestimating our capabilities, clinicians often make decisions without reaching out.

Acknowledgment

The author wishes to thank Ronald Diamond, MD, Robert Factor, MD, PhD, and Elizabeth Faust, MD for their mentoring.

Albert Einstein said, “Imagination is more important than knowledge.” Imagination is not only creative thinking, but also resourcefulness and looking ahead to consider the potential outcomes and consequences of a decision. The ability to imagine—as outlined in the mnemonic IMAGINE—in a supportive environment is critical for good clinical decision-making.¹

Issue. What is it and whose issue is it? For example, although an individual may need to be hospitalized, it also is possible that clinicians are not considering resources available to help the patient in a less restrictive setting. It could be that caregivers simply need a respite. An experienced clinician is flexible and has the ability to shift strategies based on the situation.

Move. Step outside the situation and look at it from different angles. Physicians can be prone to seek premature closure when making decisions. Be aware of cognitive errors and continue to self-assess. The busier we are, the greater the risk of maintaining the status quo. Action takes energy. When tempted to avoid a problem, face it.

Account. Consider and document the risks and benefits of your decision, and alternatives. Practice informed consent, and document as if a colleague, the patient, and the patient’s advocate were to review it.

Gut. How do you balance your “gut reaction” and your reasoning? Paying attention to intuition and assessing its plusses and minuses is more important than we might realize.²

Integration becomes crucial as more data become available.³ Often we are asked to help care for an individual we don’t know well or whose circumstances have changed dramatically. Avoid making a poor judgment by evaluating new data and considering a new context.

Network. Learn of agencies and services that could help your patients and foster those relationships. Doing so in noncrisis times can pay dividends during a crisis.

Expand the field. Feel free to ask for assistance. Because of insecurity about our limitations or overestimating our capabilities, clinicians often make decisions without reaching out.

Acknowledgment

The author wishes to thank Ronald Diamond, MD, Robert Factor, MD, PhD, and Elizabeth Faust, MD for their mentoring.

Psychosis can occur within a constellation of emotional dysfunctions, including schizophrenia, affective disorders, situational crisis, medical conditions, and exposure to exogenous substances. It even can present as a partial phenomenon in obsessive-compulsive disorder and posttraumatic stress disorder.

The REMINDER mnemonic (Table) can help you assess psychosis across all of these situations and evaluate the forensic implications of alleged psychotically driven behavior. The 8 components in REMINDER can guide whether you choose active listening, clarifying comments, confrontations, or interpretive commentary when working with psychotic patients. These aspects of psychosis also can be useful in differential diagnosis or in detecting feigned symptoms.

Table

REMINDER: 8 aspects of psychotic function

Reality testing. At some level, reality testing is impaired in all psychotic phenomena. Dysfunctional reality testing is evidenced by:

• auditory or visual hallucinations
• fixed false beliefs or delusions
• paranoia
• formications
• culturally bound syndromes
• psychotic constellations of Capgras or Cotard’s syndromes.

Empathic dysfunction. Individuals deteriorating into psychosis become increasingly autistic in their view of the world. Psychosis can whittle away patients’ capacity for empathy and to accurately perceive the intents and interests of others. Psychic censuring activities are paralyzed in psychotic individuals, and they cannot analyze others’ actions effectively.

Mechanisms of defense. When growth and development proceed normally, increasingly complex and sophisticated defenses evolve from immature to neurotic to mature. In psychosis, the process is arrested at or regresses to lower levels of defense. Impaired reality testing diminishes access to higher-level defenses because pathologic constraints can stunt psychological adjustments.

Impulse control. Deteriorated reality processing and empathy combined with diminished ego defense can leave patients unable to control aggressive and sometimes violent behavior. The patient often is “short-fused.” Regaining access to verbal defenses frequently requires pharmacotherapy.

Narcissistic focus. Psychotic patients shift to a narcissistic world view as their intra-psychic processing deteriorates. Sometimes they seem to have regressed to an earlier developmental stage and are described in juvenile or infantile terms. Clinicians can help patients move past this autistic affect and narcissism by forming a therapeutic alliance against the illness.

Diffuse ego boundaries. Patients often fail to perceive, maintain, and check adjustments of ego boundaries when they regress to earlier levels of functioning. Psychotic denial, psychotic introjects, projection, and pathologic enmeshments are examples of these failures. Many psychotic phenomena—especially paranoid thinking—can limit a patient’s ability to define and incorporate boundaries into ego defense mechanisms.

Explosiveness. Patients become less tolerant of frustration as psychosis worsens. The patient cannot accept or process any deviance from his or her pathologically structured world. Frequently the patient’s only defense is acting out verbally or physically. Actively psychotic patients might scream, curse, or strike out violently. Hospitalization diminishes the risk of suicide, reduces opportunity to craft violent plans, and removes access to weapons.

Rational thought impairment. Dysfunctional integration of psychotic features into patients’ emotional processing often causes their unpredictable behavior. A patient’s thought process may be influenced by any of the proceeding features to produce an illogical train of thought. Many clinicians have experienced confronting a patient’s delusional belief, only to watch the patient transform that belief into another illogical construct.

To better understand the patient and his or her needs, consider these 8 aspects of psychotic functions when evaluating a diagnosis and degree of impairment. Remember the adage “no collusion with the delusion,” but consider your timing when confronting illogical beliefs. Sometimes a neutral stance to a false belief is necessary to preserve the therapeutic alliance.

Psychosis can occur within a constellation of emotional dysfunctions, including schizophrenia, affective disorders, situational crisis, medical conditions, and exposure to exogenous substances. It even can present as a partial phenomenon in obsessive-compulsive disorder and posttraumatic stress disorder.

The REMINDER mnemonic (Table) can help you assess psychosis across all of these situations and evaluate the forensic implications of alleged psychotically driven behavior. The 8 components in REMINDER can guide whether you choose active listening, clarifying comments, confrontations, or interpretive commentary when working with psychotic patients. These aspects of psychosis also can be useful in differential diagnosis or in detecting feigned symptoms.

Table

REMINDER: 8 aspects of psychotic function

Reality testing. At some level, reality testing is impaired in all psychotic phenomena. Dysfunctional reality testing is evidenced by:

• auditory or visual hallucinations
• fixed false beliefs or delusions
• paranoia
• formications
• culturally bound syndromes
• psychotic constellations of Capgras or Cotard’s syndromes.

Empathic dysfunction. Individuals deteriorating into psychosis become increasingly autistic in their view of the world. Psychosis can whittle away patients’ capacity for empathy and to accurately perceive the intents and interests of others. Psychic censuring activities are paralyzed in psychotic individuals, and they cannot analyze others’ actions effectively.

Mechanisms of defense. When growth and development proceed normally, increasingly complex and sophisticated defenses evolve from immature to neurotic to mature. In psychosis, the process is arrested at or regresses to lower levels of defense. Impaired reality testing diminishes access to higher-level defenses because pathologic constraints can stunt psychological adjustments.

Impulse control. Deteriorated reality processing and empathy combined with diminished ego defense can leave patients unable to control aggressive and sometimes violent behavior. The patient often is “short-fused.” Regaining access to verbal defenses frequently requires pharmacotherapy.

Narcissistic focus. Psychotic patients shift to a narcissistic world view as their intra-psychic processing deteriorates. Sometimes they seem to have regressed to an earlier developmental stage and are described in juvenile or infantile terms. Clinicians can help patients move past this autistic affect and narcissism by forming a therapeutic alliance against the illness.

Diffuse ego boundaries. Patients often fail to perceive, maintain, and check adjustments of ego boundaries when they regress to earlier levels of functioning. Psychotic denial, psychotic introjects, projection, and pathologic enmeshments are examples of these failures. Many psychotic phenomena—especially paranoid thinking—can limit a patient’s ability to define and incorporate boundaries into ego defense mechanisms.

Explosiveness. Patients become less tolerant of frustration as psychosis worsens. The patient cannot accept or process any deviance from his or her pathologically structured world. Frequently the patient’s only defense is acting out verbally or physically. Actively psychotic patients might scream, curse, or strike out violently. Hospitalization diminishes the risk of suicide, reduces opportunity to craft violent plans, and removes access to weapons.

Rational thought impairment. Dysfunctional integration of psychotic features into patients’ emotional processing often causes their unpredictable behavior. A patient’s thought process may be influenced by any of the proceeding features to produce an illogical train of thought. Many clinicians have experienced confronting a patient’s delusional belief, only to watch the patient transform that belief into another illogical construct.

To better understand the patient and his or her needs, consider these 8 aspects of psychotic functions when evaluating a diagnosis and degree of impairment. Remember the adage “no collusion with the delusion,” but consider your timing when confronting illogical beliefs. Sometimes a neutral stance to a false belief is necessary to preserve the therapeutic alliance.

Psychosis can occur within a constellation of emotional dysfunctions, including schizophrenia, affective disorders, situational crisis, medical conditions, and exposure to exogenous substances. It even can present as a partial phenomenon in obsessive-compulsive disorder and posttraumatic stress disorder.

The REMINDER mnemonic (Table) can help you assess psychosis across all of these situations and evaluate the forensic implications of alleged psychotically driven behavior. The 8 components in REMINDER can guide whether you choose active listening, clarifying comments, confrontations, or interpretive commentary when working with psychotic patients. These aspects of psychosis also can be useful in differential diagnosis or in detecting feigned symptoms.

Table

REMINDER: 8 aspects of psychotic function

Reality testing. At some level, reality testing is impaired in all psychotic phenomena. Dysfunctional reality testing is evidenced by:

• auditory or visual hallucinations
• fixed false beliefs or delusions
• paranoia
• formications
• culturally bound syndromes
• psychotic constellations of Capgras or Cotard’s syndromes.

Empathic dysfunction. Individuals deteriorating into psychosis become increasingly autistic in their view of the world. Psychosis can whittle away patients’ capacity for empathy and to accurately perceive the intents and interests of others. Psychic censuring activities are paralyzed in psychotic individuals, and they cannot analyze others’ actions effectively.

Mechanisms of defense. When growth and development proceed normally, increasingly complex and sophisticated defenses evolve from immature to neurotic to mature. In psychosis, the process is arrested at or regresses to lower levels of defense. Impaired reality testing diminishes access to higher-level defenses because pathologic constraints can stunt psychological adjustments.

Impulse control. Deteriorated reality processing and empathy combined with diminished ego defense can leave patients unable to control aggressive and sometimes violent behavior. The patient often is “short-fused.” Regaining access to verbal defenses frequently requires pharmacotherapy.

Narcissistic focus. Psychotic patients shift to a narcissistic world view as their intra-psychic processing deteriorates. Sometimes they seem to have regressed to an earlier developmental stage and are described in juvenile or infantile terms. Clinicians can help patients move past this autistic affect and narcissism by forming a therapeutic alliance against the illness.

Diffuse ego boundaries. Patients often fail to perceive, maintain, and check adjustments of ego boundaries when they regress to earlier levels of functioning. Psychotic denial, psychotic introjects, projection, and pathologic enmeshments are examples of these failures. Many psychotic phenomena—especially paranoid thinking—can limit a patient’s ability to define and incorporate boundaries into ego defense mechanisms.

Explosiveness. Patients become less tolerant of frustration as psychosis worsens. The patient cannot accept or process any deviance from his or her pathologically structured world. Frequently the patient’s only defense is acting out verbally or physically. Actively psychotic patients might scream, curse, or strike out violently. Hospitalization diminishes the risk of suicide, reduces opportunity to craft violent plans, and removes access to weapons.

Rational thought impairment. Dysfunctional integration of psychotic features into patients’ emotional processing often causes their unpredictable behavior. A patient’s thought process may be influenced by any of the proceeding features to produce an illogical train of thought. Many clinicians have experienced confronting a patient’s delusional belief, only to watch the patient transform that belief into another illogical construct.

To better understand the patient and his or her needs, consider these 8 aspects of psychotic functions when evaluating a diagnosis and degree of impairment. Remember the adage “no collusion with the delusion,” but consider your timing when confronting illogical beliefs. Sometimes a neutral stance to a false belief is necessary to preserve the therapeutic alliance.

Up to one-third of psychiatric out-patients in 2006 received ≥3 medications, compared with 17% a decade earlier.¹ Polypharmacy is expensive, increases the risk of adverse effects, and may contribute to nonadherence. Although we recognize that at times long medication lists are justified, we offer 4 principles to help you limit unnecessary polypharmacy.

Do not treat patients’ symptoms indefinitely

William Osler stressed the importance of treating diseases, not symptoms.² Symptoms without a diagnosis are experiences. Whether physicians should treat experiences is an ethical question; however, even if your answer is “yes,” such treatment should be transient. Symptoms occurring within a diagnosis should be treated conservatively, but humanely, only while waiting for syndromal relief.³

Do not use syndrome-oriented drugs to treat symptoms

Mood disorders are not just unpleasant emotions, and anxiety disorders are more than simply nervousness. Medications that are effective for psychopathologic syndromes might not help isolated patient complaints. For example, antidepressants do not simply lift sadness, nor do they usually relieve the nonsyndromal “anxiety” many patients report. Some clinicians might disagree with this recommendation based on flaws in DSM-IV-TR taxonomy; however, these shortcomings do not translate into pharmacologic efficacy.

Do not accumulate medications when faced with nonresponse

If the first 3 medications you prescribed were working, you wouldn’t need to add a fourth. Consider discontinuing one medication for every new one you start. This principle can help you set limits with patients who demand more medications to try to eradicate nonsyndromal distress or clinically significant symptoms that psychopharmacology cannot address. Nonresponse to aggressive treatment should trigger a reassessment of the original diagnosis.

Do not match ‘soft’ diagnoses with ‘soft’ treatments

“Soft” diagnoses come in 2 types:

• an equivocal or mild psychopathologic picture that may be called, for example, “soft bipolar illness”
• using imprecise terms as diagnostic proxies, such as “depression and anxiety.”

Patients with soft diagnoses often receive combinations of lower-than-standard dosages or drugs with milder side effects but substandard efficacy. For these patients, we recommend postponing pharmacotherapy or “firming up” the diagnosis and then initiating the standard of care.

Up to one-third of psychiatric out-patients in 2006 received ≥3 medications, compared with 17% a decade earlier.¹ Polypharmacy is expensive, increases the risk of adverse effects, and may contribute to nonadherence. Although we recognize that at times long medication lists are justified, we offer 4 principles to help you limit unnecessary polypharmacy.

Do not treat patients’ symptoms indefinitely

William Osler stressed the importance of treating diseases, not symptoms.² Symptoms without a diagnosis are experiences. Whether physicians should treat experiences is an ethical question; however, even if your answer is “yes,” such treatment should be transient. Symptoms occurring within a diagnosis should be treated conservatively, but humanely, only while waiting for syndromal relief.³

Do not use syndrome-oriented drugs to treat symptoms

Mood disorders are not just unpleasant emotions, and anxiety disorders are more than simply nervousness. Medications that are effective for psychopathologic syndromes might not help isolated patient complaints. For example, antidepressants do not simply lift sadness, nor do they usually relieve the nonsyndromal “anxiety” many patients report. Some clinicians might disagree with this recommendation based on flaws in DSM-IV-TR taxonomy; however, these shortcomings do not translate into pharmacologic efficacy.

Do not accumulate medications when faced with nonresponse

If the first 3 medications you prescribed were working, you wouldn’t need to add a fourth. Consider discontinuing one medication for every new one you start. This principle can help you set limits with patients who demand more medications to try to eradicate nonsyndromal distress or clinically significant symptoms that psychopharmacology cannot address. Nonresponse to aggressive treatment should trigger a reassessment of the original diagnosis.

Do not match ‘soft’ diagnoses with ‘soft’ treatments

“Soft” diagnoses come in 2 types:

• an equivocal or mild psychopathologic picture that may be called, for example, “soft bipolar illness”
• using imprecise terms as diagnostic proxies, such as “depression and anxiety.”

Patients with soft diagnoses often receive combinations of lower-than-standard dosages or drugs with milder side effects but substandard efficacy. For these patients, we recommend postponing pharmacotherapy or “firming up” the diagnosis and then initiating the standard of care.

Up to one-third of psychiatric out-patients in 2006 received ≥3 medications, compared with 17% a decade earlier.¹ Polypharmacy is expensive, increases the risk of adverse effects, and may contribute to nonadherence. Although we recognize that at times long medication lists are justified, we offer 4 principles to help you limit unnecessary polypharmacy.

Do not treat patients’ symptoms indefinitely

William Osler stressed the importance of treating diseases, not symptoms.² Symptoms without a diagnosis are experiences. Whether physicians should treat experiences is an ethical question; however, even if your answer is “yes,” such treatment should be transient. Symptoms occurring within a diagnosis should be treated conservatively, but humanely, only while waiting for syndromal relief.³

Do not use syndrome-oriented drugs to treat symptoms

Mood disorders are not just unpleasant emotions, and anxiety disorders are more than simply nervousness. Medications that are effective for psychopathologic syndromes might not help isolated patient complaints. For example, antidepressants do not simply lift sadness, nor do they usually relieve the nonsyndromal “anxiety” many patients report. Some clinicians might disagree with this recommendation based on flaws in DSM-IV-TR taxonomy; however, these shortcomings do not translate into pharmacologic efficacy.

Do not accumulate medications when faced with nonresponse

If the first 3 medications you prescribed were working, you wouldn’t need to add a fourth. Consider discontinuing one medication for every new one you start. This principle can help you set limits with patients who demand more medications to try to eradicate nonsyndromal distress or clinically significant symptoms that psychopharmacology cannot address. Nonresponse to aggressive treatment should trigger a reassessment of the original diagnosis.

Do not match ‘soft’ diagnoses with ‘soft’ treatments

“Soft” diagnoses come in 2 types:

• an equivocal or mild psychopathologic picture that may be called, for example, “soft bipolar illness”
• using imprecise terms as diagnostic proxies, such as “depression and anxiety.”

Patients with soft diagnoses often receive combinations of lower-than-standard dosages or drugs with milder side effects but substandard efficacy. For these patients, we recommend postponing pharmacotherapy or “firming up” the diagnosis and then initiating the standard of care.