Pearls

Partial hospitalization programs (PHPs) are a good alternative to inpatient treatment for many patients who do not pose an imminent risk of harm to themselves or others.¹ PHPs provide:

• equivalent or superior recovery-based care at a lower cost, and patients are satisfied with the treatment²
  
• clinical services such as crisis stabilization, symptom management, and structured socialization within a stable therapeutic milieu, without the increased dependence on clinicians and loss of function of hospitalization.³
  

PHPs can be used in lieu of an inpatient admission or as an intermediate step to shorten a patient’s inpatient stay. Close proximity to and coordination with an inpatient setting can facilitate transition of care and may reduce patient drop-out rates. In addition, PHPs often allow extended evaluation of psychiatric symptoms and functional ability and may help you reach difficult-to-engage patients. Keeping patients in the community might help preserve patients’ self-esteem.

PHPs focus on behavioral activation skills and encourage patients to participate in treatment planning and intervention. Using a “pressure cooker” technique, treatment encourages patients to mobilize themselves within a limited time frame.

To determine which of your patients are likely to benefit from PHPs, we use the mnemonic MOTIVATES:

Motivated. Patients who are motivated to participate in daily programs are the best candidates for this level of care.

Organized. Individuals must be able to benefit from psychoeducation and skills-building groups. Patients who are grossly psychotic or delirious are not candidates for PHPs.

Tolerate a milieu or group setting. Floridly antisocial or manic patients may be disruptive and could negatively affect the milieu.

Interested in recovery. A patient who does not want to get well or stay sober usually relapses and drops out of treatment.

Verbal. Patients who can verbalize their thoughts and feelings tend to do better, although this skill can be developed while in a PHP.

Ability. Patients must be able to participate in their vocational and social rehabilitation.

Treatment adherent. Patients who are not adherent often don’t improve in PHPs.

Experience. Look for patients who have had positive experiences with milieu treatment settings.

Safe. PHP patients must not pose an acute risk of harming themselves or others.

The Association of Ambulatory Behavioral Health encourages PHPs to embrace the concept of recovery, which encourages the patient to be an active and empowered participant in treatment. Instilling hope is one of the cornerstones of the recovery movement.

References

1. Horvitz-Lennon M, Normand SL, Gaccione P, Frank RG. Partial versus full hospitalization for adults in psychiatric distress: a systematic review of the published literature (1957-1997). Am J Psychiatry 2001;158:676-85.

2. Hoge MA, Davidson L, Hill WL, et al. The promise of partial hospitalization: a reassessment. Hosp Community Psychiatry 1992;43:345-54.

3. Dick P, Cameron L, Cohen D, et al. Day and full time psychiatric treatment: a controlled comparison. Br J Psychiatry 1985;147:250-3.

Partial hospitalization programs (PHPs) are a good alternative to inpatient treatment for many patients who do not pose an imminent risk of harm to themselves or others.¹ PHPs provide:

• equivalent or superior recovery-based care at a lower cost, and patients are satisfied with the treatment²
  
• clinical services such as crisis stabilization, symptom management, and structured socialization within a stable therapeutic milieu, without the increased dependence on clinicians and loss of function of hospitalization.³
  

PHPs can be used in lieu of an inpatient admission or as an intermediate step to shorten a patient’s inpatient stay. Close proximity to and coordination with an inpatient setting can facilitate transition of care and may reduce patient drop-out rates. In addition, PHPs often allow extended evaluation of psychiatric symptoms and functional ability and may help you reach difficult-to-engage patients. Keeping patients in the community might help preserve patients’ self-esteem.

PHPs focus on behavioral activation skills and encourage patients to participate in treatment planning and intervention. Using a “pressure cooker” technique, treatment encourages patients to mobilize themselves within a limited time frame.

To determine which of your patients are likely to benefit from PHPs, we use the mnemonic MOTIVATES:

Motivated. Patients who are motivated to participate in daily programs are the best candidates for this level of care.

Organized. Individuals must be able to benefit from psychoeducation and skills-building groups. Patients who are grossly psychotic or delirious are not candidates for PHPs.

Tolerate a milieu or group setting. Floridly antisocial or manic patients may be disruptive and could negatively affect the milieu.

Interested in recovery. A patient who does not want to get well or stay sober usually relapses and drops out of treatment.

Verbal. Patients who can verbalize their thoughts and feelings tend to do better, although this skill can be developed while in a PHP.

Ability. Patients must be able to participate in their vocational and social rehabilitation.

Treatment adherent. Patients who are not adherent often don’t improve in PHPs.

Experience. Look for patients who have had positive experiences with milieu treatment settings.

Safe. PHP patients must not pose an acute risk of harming themselves or others.

The Association of Ambulatory Behavioral Health encourages PHPs to embrace the concept of recovery, which encourages the patient to be an active and empowered participant in treatment. Instilling hope is one of the cornerstones of the recovery movement.

References

1. Horvitz-Lennon M, Normand SL, Gaccione P, Frank RG. Partial versus full hospitalization for adults in psychiatric distress: a systematic review of the published literature (1957-1997). Am J Psychiatry 2001;158:676-85.

2. Hoge MA, Davidson L, Hill WL, et al. The promise of partial hospitalization: a reassessment. Hosp Community Psychiatry 1992;43:345-54.

3. Dick P, Cameron L, Cohen D, et al. Day and full time psychiatric treatment: a controlled comparison. Br J Psychiatry 1985;147:250-3.

Partial hospitalization programs (PHPs) are a good alternative to inpatient treatment for many patients who do not pose an imminent risk of harm to themselves or others.¹ PHPs provide:

• equivalent or superior recovery-based care at a lower cost, and patients are satisfied with the treatment²
  
• clinical services such as crisis stabilization, symptom management, and structured socialization within a stable therapeutic milieu, without the increased dependence on clinicians and loss of function of hospitalization.³
  

PHPs can be used in lieu of an inpatient admission or as an intermediate step to shorten a patient’s inpatient stay. Close proximity to and coordination with an inpatient setting can facilitate transition of care and may reduce patient drop-out rates. In addition, PHPs often allow extended evaluation of psychiatric symptoms and functional ability and may help you reach difficult-to-engage patients. Keeping patients in the community might help preserve patients’ self-esteem.

PHPs focus on behavioral activation skills and encourage patients to participate in treatment planning and intervention. Using a “pressure cooker” technique, treatment encourages patients to mobilize themselves within a limited time frame.

To determine which of your patients are likely to benefit from PHPs, we use the mnemonic MOTIVATES:

Motivated. Patients who are motivated to participate in daily programs are the best candidates for this level of care.

Organized. Individuals must be able to benefit from psychoeducation and skills-building groups. Patients who are grossly psychotic or delirious are not candidates for PHPs.

Tolerate a milieu or group setting. Floridly antisocial or manic patients may be disruptive and could negatively affect the milieu.

Interested in recovery. A patient who does not want to get well or stay sober usually relapses and drops out of treatment.

Verbal. Patients who can verbalize their thoughts and feelings tend to do better, although this skill can be developed while in a PHP.

Ability. Patients must be able to participate in their vocational and social rehabilitation.

Treatment adherent. Patients who are not adherent often don’t improve in PHPs.

Experience. Look for patients who have had positive experiences with milieu treatment settings.

Safe. PHP patients must not pose an acute risk of harming themselves or others.

The Association of Ambulatory Behavioral Health encourages PHPs to embrace the concept of recovery, which encourages the patient to be an active and empowered participant in treatment. Instilling hope is one of the cornerstones of the recovery movement.

References

1. Horvitz-Lennon M, Normand SL, Gaccione P, Frank RG. Partial versus full hospitalization for adults in psychiatric distress: a systematic review of the published literature (1957-1997). Am J Psychiatry 2001;158:676-85.

2. Hoge MA, Davidson L, Hill WL, et al. The promise of partial hospitalization: a reassessment. Hosp Community Psychiatry 1992;43:345-54.

3. Dick P, Cameron L, Cohen D, et al. Day and full time psychiatric treatment: a controlled comparison. Br J Psychiatry 1985;147:250-3.

As a psychopharmacology consultant, I often encounter bits of received wisdom that do not square with results of controlled studies. Although all these “myths” contain a grain of truth, their uncritical acceptance can be a barrier to effective care.

1 Dual-acting antidepressants are more effective than serotonergic agents.

Although some serotonin/norepinephrine reuptake inhibitors may be modestly more effective than some selective serotonin reuptake inhibitors (SSRIs), no randomized studies show that one class of antidepressants is clearly superior to another. The overall difference in remission rates between venlafaxine and SSRIs—about 6% favoring venlafaxine—is not robust.¹

2 Lithium is not as effective as divalproex for treating rapid-cycling bipolar disorder.

Rapid-cycling bipolar disorder can indicate reduced drug responsiveness, but lithium should not be disregarded. The relapse rate into any mood episode among rapid cyclers is not significantly different among patients maintained on lithium vs valproate,² though concomitant antidepressant treatment complicates some studies.

3 Psychotropics with short elimination half-lives need to be administered 2 or more times a day.

This statement may be true for some patients taking short-acting benzodiazepines for panic disorder or psychostimulants for attention- deficit/hyperactivity disorder. However, no randomized, head-to-head studies show that antidepressants or antipsychotics with half-lives 3 Antipsychotic effects probably persist at dopamine-2 receptors even at trough blood levels.

4 Tardive dyskinesia (TD) is not a problem with atypical antipsychotics.

Atypical or second-generation antipsychotics (SGAs) are associated with TD rates approximately one-tenth to one-half that of first-generation antipsychotics. But TD can occur with atypicals, particularly in very old and very young patients. Some data indicate TD rates >10% in African-American children taking SGAs.⁴

5 Stimulants should never be combined with a monoamine oxidase inhibitor (MAOI) because a dangerous hypertensive reaction is likely.

No controlled studies or case reports show that carefully adding a psychostimulant—such as methylphenidate, 5 to 10 mg/d—to an MAOI leads to serious hypertensive or other life-threatening reactions.⁵ Nevertheless, a careful risk-benefit assessment and close monitoring are indicated when prescribing this combination.

6 Antidepressants are effective and necessary in maintenance treatment of bipolar disorder.

Most recent studies find little benefit from adjunctive antidepressants in maintenance treatment of bipolar disorder.⁶ Although most stabilized bipolar patients don’t need an antidepressant, some may experience depressive relapse when adjunctive antidepressants are discontinued.

7 Co-administered mood stabilizers prevent antidepressant-induced ‘switching’ into bipolar mania.

It is not clear that mood stabilizers as a class provide reliable protection against antidepressant-induced switching, though lithium may offer more protection than anticonvulsants.⁷ Even if switching is not caused by antidepressants,⁶ irritability, insomnia, and cycle acceleration may occur in susceptible patients.

As a psychopharmacology consultant, I often encounter bits of received wisdom that do not square with results of controlled studies. Although all these “myths” contain a grain of truth, their uncritical acceptance can be a barrier to effective care.

1 Dual-acting antidepressants are more effective than serotonergic agents.

Although some serotonin/norepinephrine reuptake inhibitors may be modestly more effective than some selective serotonin reuptake inhibitors (SSRIs), no randomized studies show that one class of antidepressants is clearly superior to another. The overall difference in remission rates between venlafaxine and SSRIs—about 6% favoring venlafaxine—is not robust.¹

2 Lithium is not as effective as divalproex for treating rapid-cycling bipolar disorder.

Rapid-cycling bipolar disorder can indicate reduced drug responsiveness, but lithium should not be disregarded. The relapse rate into any mood episode among rapid cyclers is not significantly different among patients maintained on lithium vs valproate,² though concomitant antidepressant treatment complicates some studies.

3 Psychotropics with short elimination half-lives need to be administered 2 or more times a day.

This statement may be true for some patients taking short-acting benzodiazepines for panic disorder or psychostimulants for attention- deficit/hyperactivity disorder. However, no randomized, head-to-head studies show that antidepressants or antipsychotics with half-lives 3 Antipsychotic effects probably persist at dopamine-2 receptors even at trough blood levels.

4 Tardive dyskinesia (TD) is not a problem with atypical antipsychotics.

Atypical or second-generation antipsychotics (SGAs) are associated with TD rates approximately one-tenth to one-half that of first-generation antipsychotics. But TD can occur with atypicals, particularly in very old and very young patients. Some data indicate TD rates >10% in African-American children taking SGAs.⁴

5 Stimulants should never be combined with a monoamine oxidase inhibitor (MAOI) because a dangerous hypertensive reaction is likely.

No controlled studies or case reports show that carefully adding a psychostimulant—such as methylphenidate, 5 to 10 mg/d—to an MAOI leads to serious hypertensive or other life-threatening reactions.⁵ Nevertheless, a careful risk-benefit assessment and close monitoring are indicated when prescribing this combination.

6 Antidepressants are effective and necessary in maintenance treatment of bipolar disorder.

Most recent studies find little benefit from adjunctive antidepressants in maintenance treatment of bipolar disorder.⁶ Although most stabilized bipolar patients don’t need an antidepressant, some may experience depressive relapse when adjunctive antidepressants are discontinued.

7 Co-administered mood stabilizers prevent antidepressant-induced ‘switching’ into bipolar mania.

It is not clear that mood stabilizers as a class provide reliable protection against antidepressant-induced switching, though lithium may offer more protection than anticonvulsants.⁷ Even if switching is not caused by antidepressants,⁶ irritability, insomnia, and cycle acceleration may occur in susceptible patients.

As a psychopharmacology consultant, I often encounter bits of received wisdom that do not square with results of controlled studies. Although all these “myths” contain a grain of truth, their uncritical acceptance can be a barrier to effective care.

1 Dual-acting antidepressants are more effective than serotonergic agents.

Although some serotonin/norepinephrine reuptake inhibitors may be modestly more effective than some selective serotonin reuptake inhibitors (SSRIs), no randomized studies show that one class of antidepressants is clearly superior to another. The overall difference in remission rates between venlafaxine and SSRIs—about 6% favoring venlafaxine—is not robust.¹

2 Lithium is not as effective as divalproex for treating rapid-cycling bipolar disorder.

Rapid-cycling bipolar disorder can indicate reduced drug responsiveness, but lithium should not be disregarded. The relapse rate into any mood episode among rapid cyclers is not significantly different among patients maintained on lithium vs valproate,² though concomitant antidepressant treatment complicates some studies.

3 Psychotropics with short elimination half-lives need to be administered 2 or more times a day.

This statement may be true for some patients taking short-acting benzodiazepines for panic disorder or psychostimulants for attention- deficit/hyperactivity disorder. However, no randomized, head-to-head studies show that antidepressants or antipsychotics with half-lives 3 Antipsychotic effects probably persist at dopamine-2 receptors even at trough blood levels.

4 Tardive dyskinesia (TD) is not a problem with atypical antipsychotics.

Atypical or second-generation antipsychotics (SGAs) are associated with TD rates approximately one-tenth to one-half that of first-generation antipsychotics. But TD can occur with atypicals, particularly in very old and very young patients. Some data indicate TD rates >10% in African-American children taking SGAs.⁴

5 Stimulants should never be combined with a monoamine oxidase inhibitor (MAOI) because a dangerous hypertensive reaction is likely.

No controlled studies or case reports show that carefully adding a psychostimulant—such as methylphenidate, 5 to 10 mg/d—to an MAOI leads to serious hypertensive or other life-threatening reactions.⁵ Nevertheless, a careful risk-benefit assessment and close monitoring are indicated when prescribing this combination.

6 Antidepressants are effective and necessary in maintenance treatment of bipolar disorder.

Most recent studies find little benefit from adjunctive antidepressants in maintenance treatment of bipolar disorder.⁶ Although most stabilized bipolar patients don’t need an antidepressant, some may experience depressive relapse when adjunctive antidepressants are discontinued.

7 Co-administered mood stabilizers prevent antidepressant-induced ‘switching’ into bipolar mania.

It is not clear that mood stabilizers as a class provide reliable protection against antidepressant-induced switching, though lithium may offer more protection than anticonvulsants.⁷ Even if switching is not caused by antidepressants,⁶ irritability, insomnia, and cycle acceleration may occur in susceptible patients.

Persons with antisocial personality disorder display a disregard for the rights of others that can put them at odds with the legal system (Table). Those charged with or convicted of domestic battery, child abuse, or sexual assault often are referred for psychiatric evaluation pretrial, post-conviction, or during incarceration. Courts also may require psychotherapy in lieu of incarceration or after release.

Antisocial personality disorder differs from psychopathy, which indicates a more severe form of sociopathy. The “psychopath” is almost entirely bereft of superego or conscience and often displays sadistic traits. Antisocial personality disorder and psychopathy often are used interchangeably, however, and the pitfalls I describe apply to both.

Table

DSM-IV-TR criteria for antisocial personality disorder

Antisocial individuals display a pervasive pattern of disregard for and violation of the rights of others as indicated by ≥3 of the following: failure to conform to social norms with respect to lawful behaviors—repeatedly performing acts that are grounds for arrest deceitfulness—repeated lying, use of aliases, or conning others for personal profit or pleasure impulsivity or failure to plan ahead irritability and aggressiveness—repeated physical fights or assaults reckless disregard for safety of self or others consistent irresponsibility—failure to sustain consistent work behavior or honor financial obligations lack of remorse—being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Source: Diagnostic and statistical manual of mental disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000

Remain skeptical

When evaluating patients with antisocial characteristics, be aware of the hazards specific to this diagnosis. Antisocial patients’ considerable “charm” and ability to appear ingenuous and sincere helps solicit sympathy, allowing them to convince victims to drop their guard, prosecutors to reduce charges, and judges to mitigate sentences. These manipulative patients are skilled at persuading clinicians that we are “working miracles”—which, unfortunately, can take very little effort—hoping to win a favorable evaluation for the judge, probation officer, or parole board.

Evaluating clinical progress in antisocial patients is difficult because improvement can be determined only by a continued lack of antisocial behavior. It might not be possible to know whether antisocial behavior is:

• continuing undetected
  
• has been temporarily checked (“laying low”)
  
• or if the patient’s personality truly has been transformed.
  

The last is least likely because personality characteristics are deeply ingrained. Such a transformation would require the patient’s honest acknowledgement of a need to change and take many years of treatment to achieve. Antisocial patients’ strong secondary gain—to mitigate the consequences of criminal behavior—demands skepticism of reported clinical progress.¹

5 treatment caveats

When treating antisocial patients, remaining vigilant to the inherent challenges of working with them, stay within strict boundaries, and keep therapy from going adrift.

• Avoid allowing the patient to engage you with fascinating stories. Such tales may be exaggerated, fabricated, or designed to manipulate, charm, or enthrall to distract you from your treatment goals. Antisocial patients might exhibit pseudologia fantastica, a form of pathological lying in which the individual—although not frankly delusional—believes his embellished claims² and is so convinced that he can easily persuade and distract the therapist.
  
• Neither accept nor reject the patient’s claim of innocence. Emphasize that you cannot determine innocence. Instead, point out that you will help the patient identify choices and actions that caused his present predicament. If your patient insists on blaming others, refocus the discussion on his actions and choices that created or facilitated the problem.
  
• Do not accept your patient’s apologies, claims of remorse, or promises to change. Point out that only victims can accept apologies. Likewise, emphasize that promises to change can only be made to oneself.
  
• Direct the patient’s attention away from you—your brilliance, talent, and empathy—and focus on the patient, his past poor choices, and how he can improve his choices going forward.
  
• Treat only the symptoms that can be treated, such as disordered mood, hallucinations, grandiose delusions, and substance abuse, without allowing them to become excuses for criminal behavior. Point out that most patients with depression, schizophrenia, alcoholism, or other mental illnesses do not commit crimes.³
  

Persons with antisocial personality disorder display a disregard for the rights of others that can put them at odds with the legal system (Table). Those charged with or convicted of domestic battery, child abuse, or sexual assault often are referred for psychiatric evaluation pretrial, post-conviction, or during incarceration. Courts also may require psychotherapy in lieu of incarceration or after release.

Antisocial personality disorder differs from psychopathy, which indicates a more severe form of sociopathy. The “psychopath” is almost entirely bereft of superego or conscience and often displays sadistic traits. Antisocial personality disorder and psychopathy often are used interchangeably, however, and the pitfalls I describe apply to both.

Table

DSM-IV-TR criteria for antisocial personality disorder

Antisocial individuals display a pervasive pattern of disregard for and violation of the rights of others as indicated by ≥3 of the following: failure to conform to social norms with respect to lawful behaviors—repeatedly performing acts that are grounds for arrest deceitfulness—repeated lying, use of aliases, or conning others for personal profit or pleasure impulsivity or failure to plan ahead irritability and aggressiveness—repeated physical fights or assaults reckless disregard for safety of self or others consistent irresponsibility—failure to sustain consistent work behavior or honor financial obligations lack of remorse—being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Source: Diagnostic and statistical manual of mental disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000

Remain skeptical

When evaluating patients with antisocial characteristics, be aware of the hazards specific to this diagnosis. Antisocial patients’ considerable “charm” and ability to appear ingenuous and sincere helps solicit sympathy, allowing them to convince victims to drop their guard, prosecutors to reduce charges, and judges to mitigate sentences. These manipulative patients are skilled at persuading clinicians that we are “working miracles”—which, unfortunately, can take very little effort—hoping to win a favorable evaluation for the judge, probation officer, or parole board.

Evaluating clinical progress in antisocial patients is difficult because improvement can be determined only by a continued lack of antisocial behavior. It might not be possible to know whether antisocial behavior is:

• continuing undetected
  
• has been temporarily checked (“laying low”)
  
• or if the patient’s personality truly has been transformed.
  

The last is least likely because personality characteristics are deeply ingrained. Such a transformation would require the patient’s honest acknowledgement of a need to change and take many years of treatment to achieve. Antisocial patients’ strong secondary gain—to mitigate the consequences of criminal behavior—demands skepticism of reported clinical progress.¹

5 treatment caveats

When treating antisocial patients, remaining vigilant to the inherent challenges of working with them, stay within strict boundaries, and keep therapy from going adrift.

• Avoid allowing the patient to engage you with fascinating stories. Such tales may be exaggerated, fabricated, or designed to manipulate, charm, or enthrall to distract you from your treatment goals. Antisocial patients might exhibit pseudologia fantastica, a form of pathological lying in which the individual—although not frankly delusional—believes his embellished claims² and is so convinced that he can easily persuade and distract the therapist.
  
• Neither accept nor reject the patient’s claim of innocence. Emphasize that you cannot determine innocence. Instead, point out that you will help the patient identify choices and actions that caused his present predicament. If your patient insists on blaming others, refocus the discussion on his actions and choices that created or facilitated the problem.
  
• Do not accept your patient’s apologies, claims of remorse, or promises to change. Point out that only victims can accept apologies. Likewise, emphasize that promises to change can only be made to oneself.
  
• Direct the patient’s attention away from you—your brilliance, talent, and empathy—and focus on the patient, his past poor choices, and how he can improve his choices going forward.
  
• Treat only the symptoms that can be treated, such as disordered mood, hallucinations, grandiose delusions, and substance abuse, without allowing them to become excuses for criminal behavior. Point out that most patients with depression, schizophrenia, alcoholism, or other mental illnesses do not commit crimes.³
  

Persons with antisocial personality disorder display a disregard for the rights of others that can put them at odds with the legal system (Table). Those charged with or convicted of domestic battery, child abuse, or sexual assault often are referred for psychiatric evaluation pretrial, post-conviction, or during incarceration. Courts also may require psychotherapy in lieu of incarceration or after release.

Antisocial personality disorder differs from psychopathy, which indicates a more severe form of sociopathy. The “psychopath” is almost entirely bereft of superego or conscience and often displays sadistic traits. Antisocial personality disorder and psychopathy often are used interchangeably, however, and the pitfalls I describe apply to both.

Table

DSM-IV-TR criteria for antisocial personality disorder

Antisocial individuals display a pervasive pattern of disregard for and violation of the rights of others as indicated by ≥3 of the following: failure to conform to social norms with respect to lawful behaviors—repeatedly performing acts that are grounds for arrest deceitfulness—repeated lying, use of aliases, or conning others for personal profit or pleasure impulsivity or failure to plan ahead irritability and aggressiveness—repeated physical fights or assaults reckless disregard for safety of self or others consistent irresponsibility—failure to sustain consistent work behavior or honor financial obligations lack of remorse—being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Source: Diagnostic and statistical manual of mental disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000

Remain skeptical

When evaluating patients with antisocial characteristics, be aware of the hazards specific to this diagnosis. Antisocial patients’ considerable “charm” and ability to appear ingenuous and sincere helps solicit sympathy, allowing them to convince victims to drop their guard, prosecutors to reduce charges, and judges to mitigate sentences. These manipulative patients are skilled at persuading clinicians that we are “working miracles”—which, unfortunately, can take very little effort—hoping to win a favorable evaluation for the judge, probation officer, or parole board.

Evaluating clinical progress in antisocial patients is difficult because improvement can be determined only by a continued lack of antisocial behavior. It might not be possible to know whether antisocial behavior is:

• continuing undetected
  
• has been temporarily checked (“laying low”)
  
• or if the patient’s personality truly has been transformed.
  

The last is least likely because personality characteristics are deeply ingrained. Such a transformation would require the patient’s honest acknowledgement of a need to change and take many years of treatment to achieve. Antisocial patients’ strong secondary gain—to mitigate the consequences of criminal behavior—demands skepticism of reported clinical progress.¹

5 treatment caveats

When treating antisocial patients, remaining vigilant to the inherent challenges of working with them, stay within strict boundaries, and keep therapy from going adrift.

• Avoid allowing the patient to engage you with fascinating stories. Such tales may be exaggerated, fabricated, or designed to manipulate, charm, or enthrall to distract you from your treatment goals. Antisocial patients might exhibit pseudologia fantastica, a form of pathological lying in which the individual—although not frankly delusional—believes his embellished claims² and is so convinced that he can easily persuade and distract the therapist.
  
• Neither accept nor reject the patient’s claim of innocence. Emphasize that you cannot determine innocence. Instead, point out that you will help the patient identify choices and actions that caused his present predicament. If your patient insists on blaming others, refocus the discussion on his actions and choices that created or facilitated the problem.
  
• Do not accept your patient’s apologies, claims of remorse, or promises to change. Point out that only victims can accept apologies. Likewise, emphasize that promises to change can only be made to oneself.
  
• Direct the patient’s attention away from you—your brilliance, talent, and empathy—and focus on the patient, his past poor choices, and how he can improve his choices going forward.
  
• Treat only the symptoms that can be treated, such as disordered mood, hallucinations, grandiose delusions, and substance abuse, without allowing them to become excuses for criminal behavior. Point out that most patients with depression, schizophrenia, alcoholism, or other mental illnesses do not commit crimes.³
  

One-third of psychiatric outpatients meet criteria for dysthymic disorder,¹ but the symptoms are easy to overlook or misdiagnose.² This problem can be exacerbated by symptoms that overlap with major depressive disorder (MDD), heterogeneity of presentation, and clinician unfamiliarity with diagnostic criteria.³

Patients might not report symptoms unless directly asked because of dysthymic disorder’s insidious onset, limited severity, and chronicity. They may believe their symptoms are part of their “nature” rather than evidence of mental illness.³

Dysthymic disorder can diminish patients’ quality of life and increase their risk of developing MDD,³ but it can be treated successfully. Proper screening and accurate diagnosis are the first steps.

The “HE’S 2 SAD” mnemonic (Table)³ describes DSM-IV-TR diagnostic criteria for dysthymic disorder. To meet these criteria, adults need only 2 of the symptoms in addition to depressed mood during the initial 2 years and cannot be without symptoms >2 months at a time.³ Also, the patient cannot have met criteria for a major depressive episode during the first 2 years or have ever met criteria for a manic, mixed, or hypo manic episode.³

In children, mood may be irritable and symptoms need last only 1 year to meet dysthymic disorder’s diagnostic criteria.3 Dysthymic disorder is 2 to 3 times more prevalent in women than men, but no gender difference is seen among children.³

Table

‘HE’S 2 SAD’: Diagnostic criteria for dysthymic disorder

Hopelessness
Energy loss or fatigue
Self-esteem is low
2 years minimum of depressed mood most of the day, for more days than not
Sleep is increased or decreased
Appetite is increased or decreased
Decision-making or concentration is impaired

Additional clues

In addition to DSM diagnostic criteria, other features might point to dysthymic disorder:³

• feelings of inadequacy
  
• generalized loss of interest or pleasure
  
• feelings of guilt or brooding about the past
  
• feelings of irritability or excessive anger
  
• decreased activity, effectiveness, or productivity.³
  

Although no American Psychiatric Association practice guidelines or FDA-approved treatments exist for dysthymic disorder, clinical improvement is possible with medication and psychotherapy. Antidepressants might have equivalent efficacy, as in MDD treatment, so base your choice on the drugs’ side effect profiles.

One-third of psychiatric outpatients meet criteria for dysthymic disorder,¹ but the symptoms are easy to overlook or misdiagnose.² This problem can be exacerbated by symptoms that overlap with major depressive disorder (MDD), heterogeneity of presentation, and clinician unfamiliarity with diagnostic criteria.³

Patients might not report symptoms unless directly asked because of dysthymic disorder’s insidious onset, limited severity, and chronicity. They may believe their symptoms are part of their “nature” rather than evidence of mental illness.³

Dysthymic disorder can diminish patients’ quality of life and increase their risk of developing MDD,³ but it can be treated successfully. Proper screening and accurate diagnosis are the first steps.

The “HE’S 2 SAD” mnemonic (Table)³ describes DSM-IV-TR diagnostic criteria for dysthymic disorder. To meet these criteria, adults need only 2 of the symptoms in addition to depressed mood during the initial 2 years and cannot be without symptoms >2 months at a time.³ Also, the patient cannot have met criteria for a major depressive episode during the first 2 years or have ever met criteria for a manic, mixed, or hypo manic episode.³

In children, mood may be irritable and symptoms need last only 1 year to meet dysthymic disorder’s diagnostic criteria.3 Dysthymic disorder is 2 to 3 times more prevalent in women than men, but no gender difference is seen among children.³

Table

‘HE’S 2 SAD’: Diagnostic criteria for dysthymic disorder

Hopelessness
Energy loss or fatigue
Self-esteem is low
2 years minimum of depressed mood most of the day, for more days than not
Sleep is increased or decreased
Appetite is increased or decreased
Decision-making or concentration is impaired

Additional clues

In addition to DSM diagnostic criteria, other features might point to dysthymic disorder:³

• feelings of inadequacy
  
• generalized loss of interest or pleasure
  
• feelings of guilt or brooding about the past
  
• feelings of irritability or excessive anger
  
• decreased activity, effectiveness, or productivity.³
  

Although no American Psychiatric Association practice guidelines or FDA-approved treatments exist for dysthymic disorder, clinical improvement is possible with medication and psychotherapy. Antidepressants might have equivalent efficacy, as in MDD treatment, so base your choice on the drugs’ side effect profiles.

One-third of psychiatric outpatients meet criteria for dysthymic disorder,¹ but the symptoms are easy to overlook or misdiagnose.² This problem can be exacerbated by symptoms that overlap with major depressive disorder (MDD), heterogeneity of presentation, and clinician unfamiliarity with diagnostic criteria.³

Patients might not report symptoms unless directly asked because of dysthymic disorder’s insidious onset, limited severity, and chronicity. They may believe their symptoms are part of their “nature” rather than evidence of mental illness.³

Dysthymic disorder can diminish patients’ quality of life and increase their risk of developing MDD,³ but it can be treated successfully. Proper screening and accurate diagnosis are the first steps.

The “HE’S 2 SAD” mnemonic (Table)³ describes DSM-IV-TR diagnostic criteria for dysthymic disorder. To meet these criteria, adults need only 2 of the symptoms in addition to depressed mood during the initial 2 years and cannot be without symptoms >2 months at a time.³ Also, the patient cannot have met criteria for a major depressive episode during the first 2 years or have ever met criteria for a manic, mixed, or hypo manic episode.³

In children, mood may be irritable and symptoms need last only 1 year to meet dysthymic disorder’s diagnostic criteria.3 Dysthymic disorder is 2 to 3 times more prevalent in women than men, but no gender difference is seen among children.³

Table

‘HE’S 2 SAD’: Diagnostic criteria for dysthymic disorder

Hopelessness
Energy loss or fatigue
Self-esteem is low
2 years minimum of depressed mood most of the day, for more days than not
Sleep is increased or decreased
Appetite is increased or decreased
Decision-making or concentration is impaired

Additional clues

In addition to DSM diagnostic criteria, other features might point to dysthymic disorder:³

• feelings of inadequacy
  
• generalized loss of interest or pleasure
  
• feelings of guilt or brooding about the past
  
• feelings of irritability or excessive anger
  
• decreased activity, effectiveness, or productivity.³
  

Although no American Psychiatric Association practice guidelines or FDA-approved treatments exist for dysthymic disorder, clinical improvement is possible with medication and psychotherapy. Antidepressants might have equivalent efficacy, as in MDD treatment, so base your choice on the drugs’ side effect profiles.

Your answering machine’s outgoing message contains a wealth of information that goes beyond “I’m not here right now.” Carefully consider these messages because they communicate to your patients important information about you and your treatment philosophy.

Three “C’s”—callbacks, contact, and crisis—can help you think about the nuances and implications of creating an appropriate outgoing answering machine message.

Callbacks. In their messages, some psychiatrists provide a timeframe within which they will return patients’ phone calls—such as within “1 business day”—whereas others intentionally omit any reference to time. What is said or omitted about call-backs speaks to your responsiveness and sets a precedent for how you will address patients’ time-related concerns.

Some patients may find comfort in knowing when they can expect a return call. This reassurance, however, also might perpetuate a patient’s unrealistic fantasies and expectations about you, such as that you always will immediately respond to the patient’s concerns.

Contact. Patients often are unsure about how to contact their doctors after office hours or during weekends. You can handle this concern by providing alternate phone numbers such as a mobile phone, answering service, or covering physician.

After-hours contact establishes your availability. Although no doctor can be available to every patient all the time, your patients’ perception of your availability is important, particularly to personality- disordered patients who have not achieved object constancy. For some clinicians, this means their answering machines contain reference to how they can be contacted after hours. Other clinicians, however, omit this information because they may believe patients need to learn how to self-soothe, and constant availability may hamper this process.

Crisis. How you will handle a crisis can bring up feelings of uncertainty and danger in patients. Statements such as “If you are having a psychiatric emergency, please call 911 or go to your nearest emergency room” might communicate to the patient that you are unable or unwilling to deal with emergencies. Subsequently, the patient might not be comfortable discussing some topics in treatment because of anxiety about whether you can handle intense therapeutic situations.

A more neutral statement that might be preferable would be: “If you are having an emergency and are unable to communicate with me in a timely manner, you may go to the nearest emergency room.” Stated in this way, you establish your willingness to deal with emergent situations and encourage rather than merely outsource or avoid contact.

Your answering machine’s outgoing message contains a wealth of information that goes beyond “I’m not here right now.” Carefully consider these messages because they communicate to your patients important information about you and your treatment philosophy.

Three “C’s”—callbacks, contact, and crisis—can help you think about the nuances and implications of creating an appropriate outgoing answering machine message.

Callbacks. In their messages, some psychiatrists provide a timeframe within which they will return patients’ phone calls—such as within “1 business day”—whereas others intentionally omit any reference to time. What is said or omitted about call-backs speaks to your responsiveness and sets a precedent for how you will address patients’ time-related concerns.

Some patients may find comfort in knowing when they can expect a return call. This reassurance, however, also might perpetuate a patient’s unrealistic fantasies and expectations about you, such as that you always will immediately respond to the patient’s concerns.

Contact. Patients often are unsure about how to contact their doctors after office hours or during weekends. You can handle this concern by providing alternate phone numbers such as a mobile phone, answering service, or covering physician.

After-hours contact establishes your availability. Although no doctor can be available to every patient all the time, your patients’ perception of your availability is important, particularly to personality- disordered patients who have not achieved object constancy. For some clinicians, this means their answering machines contain reference to how they can be contacted after hours. Other clinicians, however, omit this information because they may believe patients need to learn how to self-soothe, and constant availability may hamper this process.

Crisis. How you will handle a crisis can bring up feelings of uncertainty and danger in patients. Statements such as “If you are having a psychiatric emergency, please call 911 or go to your nearest emergency room” might communicate to the patient that you are unable or unwilling to deal with emergencies. Subsequently, the patient might not be comfortable discussing some topics in treatment because of anxiety about whether you can handle intense therapeutic situations.

A more neutral statement that might be preferable would be: “If you are having an emergency and are unable to communicate with me in a timely manner, you may go to the nearest emergency room.” Stated in this way, you establish your willingness to deal with emergent situations and encourage rather than merely outsource or avoid contact.

Your answering machine’s outgoing message contains a wealth of information that goes beyond “I’m not here right now.” Carefully consider these messages because they communicate to your patients important information about you and your treatment philosophy.

Three “C’s”—callbacks, contact, and crisis—can help you think about the nuances and implications of creating an appropriate outgoing answering machine message.

Callbacks. In their messages, some psychiatrists provide a timeframe within which they will return patients’ phone calls—such as within “1 business day”—whereas others intentionally omit any reference to time. What is said or omitted about call-backs speaks to your responsiveness and sets a precedent for how you will address patients’ time-related concerns.

Some patients may find comfort in knowing when they can expect a return call. This reassurance, however, also might perpetuate a patient’s unrealistic fantasies and expectations about you, such as that you always will immediately respond to the patient’s concerns.

Contact. Patients often are unsure about how to contact their doctors after office hours or during weekends. You can handle this concern by providing alternate phone numbers such as a mobile phone, answering service, or covering physician.

After-hours contact establishes your availability. Although no doctor can be available to every patient all the time, your patients’ perception of your availability is important, particularly to personality- disordered patients who have not achieved object constancy. For some clinicians, this means their answering machines contain reference to how they can be contacted after hours. Other clinicians, however, omit this information because they may believe patients need to learn how to self-soothe, and constant availability may hamper this process.

Crisis. How you will handle a crisis can bring up feelings of uncertainty and danger in patients. Statements such as “If you are having a psychiatric emergency, please call 911 or go to your nearest emergency room” might communicate to the patient that you are unable or unwilling to deal with emergencies. Subsequently, the patient might not be comfortable discussing some topics in treatment because of anxiety about whether you can handle intense therapeutic situations.

A more neutral statement that might be preferable would be: “If you are having an emergency and are unable to communicate with me in a timely manner, you may go to the nearest emergency room.” Stated in this way, you establish your willingness to deal with emergent situations and encourage rather than merely outsource or avoid contact.

Mania can be classified as “primary”—often associated with bipolar disorder—or “secondary”—which can have many underlying causes. Secondary mania is more common than primary mania in children and patients age ≥40.¹

Older adults in particular are at risk for developing mania associated with increased medical comorbidities and neurologic changes. In a study of 50 patients age ≥65 with mania, 14 (28%) were hospitalized for a first manic episode, and 10 of these 14 patients (71%) had comorbid neurologic disorders.²

Suspect secondary mania in patients:

• who do not have a personal or family history of bipolar disorder
  
• with an atypical clinical presentation
  
• presenting with conditions with unexplained neurologic findings.³
  

Although acute treatment of primary and secondary mania may be similar, appropriate long-term treatment of secondary mania requires identifying and addressing its many causes. The E-MANIC mnemonic^1-4 could help you identify causes of secondary mania (Table).

Table

E-MANIC: Is it secondary mania?

Endocrine
Medications
Abuse of alcohol or illicit drugs
Neurologic
Infections
Cardiovascular causes

Endocrine. Thyroid dysfunction can disrupt mood, and mood disorders can impair thyroid function. The direct physiologic effects of thyroid dysfunction can cause mania. Hyperthyroidism can cause secondary mania and trigger restlessness, hyperactivity, insomnia, and irritability. Patients with mixed states of bipolar disorder have an increased risk of hypothyroidism and other medical comorbidities that can slow recovery.⁵ Some studies suggest thyroid diseases can cause rapid-cycling bipolar disorder,⁶ although most rapid-cycling patients have normal thyroid function tests. Nevertheless, low thyroid hormone blood levels are more common among individuals with rapid cycling than among bipolar patients in general.

Increased glucocorticoid activity associated with Cushing’s disease can cause secondary mania. Contributors can include pituitary adenomas, adrenal adenomas or carcinomas, and ectopic production of corticotropin-releasing hormone or corticotropin. Cushing’s disease symptoms include:

• worsening obesity
  
• new-onset hypertension
  
• skin changes such as easy bruising, striae, poor wound healing, facial plethora, hirsutism, and acne
  
• muscle weakness and wasting
  
• peripheral edema
  
• neuropsychiatric changes such as depression or mania.
  

Medications. Corticosteroids, dopaminergic agents—especially L-dopa and bromocriptine—and antidepressants can cause secondary mania. Other culprits include bronchodilators, phenytoin, sympathomimetics, amphetamines (including methylphenidate), disulfiram, captopril, hydralazine, opiates, baclofen, bromide, procarbazine, yohimbine, cimetidine, and isoniazid. Over-the-counter agents—especially phenylpropanolamine and herbal preparations—also have been implicated in secondary mania.

Abuse of alcohol and illicit drugs—such as cocaine, amphetamines, phencyclidine (PCP), lysergic acid diethylamide (LSD), inhalants, opiates, cannabis, caffeine, anabolic steroids, and methylenedioxymeth-amphetamine (MDMA/Ecstasy)—could cause a patient’s secondary mania.

Neurologic. When diagnosing secondary mania, look for traumatic brain injury, seizures, neoplasms—especially diencephalic and third ventricle tumors—normal pressure hydrocephalus, multiple sclerosis, idiopathic basal ganglia calcification, tuberous sclerosis, Kleine-Levin syndrome (episodic periods of excessive sleep and overeating followed by amnesia of these episodes), Huntington’s disease, and headaches.

Infections. Assess for neurosyphilis, meningitis, influenza, enteric fever, Q fever, cholera, tetanus, posttyphoid immunization, herpes encephalitis, St. Louis encephalitis, HIV, and AIDS.

Cardiovascular causes, cerebrovascular accidents, and collagen vascular disease—as in cases of systemic lupus erythematosus—could cause secondary mania.

Patients presenting with secondary mania require a thorough physical evaluation. Base decisions regarding more extensive laboratory and neuroimaging studies on clinical findings of psychiatric, medical, and neurologic examinations.^4,7

Mania can be classified as “primary”—often associated with bipolar disorder—or “secondary”—which can have many underlying causes. Secondary mania is more common than primary mania in children and patients age ≥40.¹

Older adults in particular are at risk for developing mania associated with increased medical comorbidities and neurologic changes. In a study of 50 patients age ≥65 with mania, 14 (28%) were hospitalized for a first manic episode, and 10 of these 14 patients (71%) had comorbid neurologic disorders.²

Suspect secondary mania in patients:

• who do not have a personal or family history of bipolar disorder
  
• with an atypical clinical presentation
  
• presenting with conditions with unexplained neurologic findings.³
  

Although acute treatment of primary and secondary mania may be similar, appropriate long-term treatment of secondary mania requires identifying and addressing its many causes. The E-MANIC mnemonic^1-4 could help you identify causes of secondary mania (Table).

Table

E-MANIC: Is it secondary mania?

Endocrine
Medications
Abuse of alcohol or illicit drugs
Neurologic
Infections
Cardiovascular causes

Endocrine. Thyroid dysfunction can disrupt mood, and mood disorders can impair thyroid function. The direct physiologic effects of thyroid dysfunction can cause mania. Hyperthyroidism can cause secondary mania and trigger restlessness, hyperactivity, insomnia, and irritability. Patients with mixed states of bipolar disorder have an increased risk of hypothyroidism and other medical comorbidities that can slow recovery.⁵ Some studies suggest thyroid diseases can cause rapid-cycling bipolar disorder,⁶ although most rapid-cycling patients have normal thyroid function tests. Nevertheless, low thyroid hormone blood levels are more common among individuals with rapid cycling than among bipolar patients in general.

Increased glucocorticoid activity associated with Cushing’s disease can cause secondary mania. Contributors can include pituitary adenomas, adrenal adenomas or carcinomas, and ectopic production of corticotropin-releasing hormone or corticotropin. Cushing’s disease symptoms include:

• worsening obesity
  
• new-onset hypertension
  
• skin changes such as easy bruising, striae, poor wound healing, facial plethora, hirsutism, and acne
  
• muscle weakness and wasting
  
• peripheral edema
  
• neuropsychiatric changes such as depression or mania.
  

Medications. Corticosteroids, dopaminergic agents—especially L-dopa and bromocriptine—and antidepressants can cause secondary mania. Other culprits include bronchodilators, phenytoin, sympathomimetics, amphetamines (including methylphenidate), disulfiram, captopril, hydralazine, opiates, baclofen, bromide, procarbazine, yohimbine, cimetidine, and isoniazid. Over-the-counter agents—especially phenylpropanolamine and herbal preparations—also have been implicated in secondary mania.

Abuse of alcohol and illicit drugs—such as cocaine, amphetamines, phencyclidine (PCP), lysergic acid diethylamide (LSD), inhalants, opiates, cannabis, caffeine, anabolic steroids, and methylenedioxymeth-amphetamine (MDMA/Ecstasy)—could cause a patient’s secondary mania.

Neurologic. When diagnosing secondary mania, look for traumatic brain injury, seizures, neoplasms—especially diencephalic and third ventricle tumors—normal pressure hydrocephalus, multiple sclerosis, idiopathic basal ganglia calcification, tuberous sclerosis, Kleine-Levin syndrome (episodic periods of excessive sleep and overeating followed by amnesia of these episodes), Huntington’s disease, and headaches.

Infections. Assess for neurosyphilis, meningitis, influenza, enteric fever, Q fever, cholera, tetanus, posttyphoid immunization, herpes encephalitis, St. Louis encephalitis, HIV, and AIDS.

Cardiovascular causes, cerebrovascular accidents, and collagen vascular disease—as in cases of systemic lupus erythematosus—could cause secondary mania.

Patients presenting with secondary mania require a thorough physical evaluation. Base decisions regarding more extensive laboratory and neuroimaging studies on clinical findings of psychiatric, medical, and neurologic examinations.^4,7

Mania can be classified as “primary”—often associated with bipolar disorder—or “secondary”—which can have many underlying causes. Secondary mania is more common than primary mania in children and patients age ≥40.¹

Older adults in particular are at risk for developing mania associated with increased medical comorbidities and neurologic changes. In a study of 50 patients age ≥65 with mania, 14 (28%) were hospitalized for a first manic episode, and 10 of these 14 patients (71%) had comorbid neurologic disorders.²

Suspect secondary mania in patients:

• who do not have a personal or family history of bipolar disorder
  
• with an atypical clinical presentation
  
• presenting with conditions with unexplained neurologic findings.³
  

Although acute treatment of primary and secondary mania may be similar, appropriate long-term treatment of secondary mania requires identifying and addressing its many causes. The E-MANIC mnemonic^1-4 could help you identify causes of secondary mania (Table).

Table

E-MANIC: Is it secondary mania?

Endocrine
Medications
Abuse of alcohol or illicit drugs
Neurologic
Infections
Cardiovascular causes

Endocrine. Thyroid dysfunction can disrupt mood, and mood disorders can impair thyroid function. The direct physiologic effects of thyroid dysfunction can cause mania. Hyperthyroidism can cause secondary mania and trigger restlessness, hyperactivity, insomnia, and irritability. Patients with mixed states of bipolar disorder have an increased risk of hypothyroidism and other medical comorbidities that can slow recovery.⁵ Some studies suggest thyroid diseases can cause rapid-cycling bipolar disorder,⁶ although most rapid-cycling patients have normal thyroid function tests. Nevertheless, low thyroid hormone blood levels are more common among individuals with rapid cycling than among bipolar patients in general.

Increased glucocorticoid activity associated with Cushing’s disease can cause secondary mania. Contributors can include pituitary adenomas, adrenal adenomas or carcinomas, and ectopic production of corticotropin-releasing hormone or corticotropin. Cushing’s disease symptoms include:

• worsening obesity
  
• new-onset hypertension
  
• skin changes such as easy bruising, striae, poor wound healing, facial plethora, hirsutism, and acne
  
• muscle weakness and wasting
  
• peripheral edema
  
• neuropsychiatric changes such as depression or mania.
  

Medications. Corticosteroids, dopaminergic agents—especially L-dopa and bromocriptine—and antidepressants can cause secondary mania. Other culprits include bronchodilators, phenytoin, sympathomimetics, amphetamines (including methylphenidate), disulfiram, captopril, hydralazine, opiates, baclofen, bromide, procarbazine, yohimbine, cimetidine, and isoniazid. Over-the-counter agents—especially phenylpropanolamine and herbal preparations—also have been implicated in secondary mania.

Abuse of alcohol and illicit drugs—such as cocaine, amphetamines, phencyclidine (PCP), lysergic acid diethylamide (LSD), inhalants, opiates, cannabis, caffeine, anabolic steroids, and methylenedioxymeth-amphetamine (MDMA/Ecstasy)—could cause a patient’s secondary mania.

Neurologic. When diagnosing secondary mania, look for traumatic brain injury, seizures, neoplasms—especially diencephalic and third ventricle tumors—normal pressure hydrocephalus, multiple sclerosis, idiopathic basal ganglia calcification, tuberous sclerosis, Kleine-Levin syndrome (episodic periods of excessive sleep and overeating followed by amnesia of these episodes), Huntington’s disease, and headaches.

Infections. Assess for neurosyphilis, meningitis, influenza, enteric fever, Q fever, cholera, tetanus, posttyphoid immunization, herpes encephalitis, St. Louis encephalitis, HIV, and AIDS.

Cardiovascular causes, cerebrovascular accidents, and collagen vascular disease—as in cases of systemic lupus erythematosus—could cause secondary mania.

Patients presenting with secondary mania require a thorough physical evaluation. Base decisions regarding more extensive laboratory and neuroimaging studies on clinical findings of psychiatric, medical, and neurologic examinations.^4,7

Psychiatrists, like all physicians, sometimes ask patients to endure painful or unpleasant procedures in the course of diagnosis and treatment. Patients want treatment, but they also want to avoid pain—so we expect ambivalence and resistance. Distraction is one of the most effective forms of patient resistance.

Distraction can be very effective, as described in an Arabian folk tale in The Book of One Thousand and One Nights. The story tells of a cruel Persian king who marries a virgin every night, and every morning he has his new wife executed. On the night the king marries Scheherazade, she tells him a story but leaves off the ending. The king keeps Scheherazade alive for another day to find out how the tale ends, but she then starts telling another story. This practice keeps Scheherazade alive for 1,001 nights.

Like Scheherazade,patients can employ distraction to avoid an unpleasant experience. A recently retired schoolteacher consulted me because he wanted to travel but was afraid of flying, driving long distances, and spending the night alone away from home. He and I agreed on exposure and response prevention therapy, and he made good progress at first. But then treatment stalled.

My patient was a kind man from a large, turbulent family. He was always rescuing someone from divorce, bankruptcy, school failure, or criminal indictment. Discussing these crises started to dominate our treatment sessions, and there never was a good time to get down to business.

In my experience, this pattern of regular, distracting crises occurs often with:

• patients undergoing treatment for anxiety disorders
  
• drug and alcohol abusers
  
• patients referred by other physicians because the patient is avoiding a necessary procedure.
  

These strategies can help you refocus a distracting patient and manage “Scheherazade syndrome”:

Consider time-limited therapy when appropriate.

Quickly decide if a crisis that disrupts treatment is genuine or merely a distraction. A patient who has lost a loved one or suffered a life-threatening illness can be excused, but view lesser emergencies as suspect. My schoolteacher always had a good reason to avoid working on his fears, but the regularity of his excuses was a clue.

Confront the patient when you detect a pattern of avoidance. Make sure he remains interested in accomplishing the original objective.

Consider negotiating a new treatment plan. Your patient may need preliminary cognitive therapy, a gentler schedule, medication, or inpatient treatment.

Propose more structured therapy. Instruct the patient to keep a treatment diary and bring it to sessions. Sign a treatment contract, recommend a support group, or enlist the help of family members.

Reconsider the diagnosis if nothing is working. Attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, posttraumatic stress disorder, psychosis, or other cognitive problems can seem like anxiety or procrastination.

Psychiatrists, like all physicians, sometimes ask patients to endure painful or unpleasant procedures in the course of diagnosis and treatment. Patients want treatment, but they also want to avoid pain—so we expect ambivalence and resistance. Distraction is one of the most effective forms of patient resistance.

Distraction can be very effective, as described in an Arabian folk tale in The Book of One Thousand and One Nights. The story tells of a cruel Persian king who marries a virgin every night, and every morning he has his new wife executed. On the night the king marries Scheherazade, she tells him a story but leaves off the ending. The king keeps Scheherazade alive for another day to find out how the tale ends, but she then starts telling another story. This practice keeps Scheherazade alive for 1,001 nights.

Like Scheherazade,patients can employ distraction to avoid an unpleasant experience. A recently retired schoolteacher consulted me because he wanted to travel but was afraid of flying, driving long distances, and spending the night alone away from home. He and I agreed on exposure and response prevention therapy, and he made good progress at first. But then treatment stalled.

My patient was a kind man from a large, turbulent family. He was always rescuing someone from divorce, bankruptcy, school failure, or criminal indictment. Discussing these crises started to dominate our treatment sessions, and there never was a good time to get down to business.

In my experience, this pattern of regular, distracting crises occurs often with:

• patients undergoing treatment for anxiety disorders
  
• drug and alcohol abusers
  
• patients referred by other physicians because the patient is avoiding a necessary procedure.
  

These strategies can help you refocus a distracting patient and manage “Scheherazade syndrome”:

Consider time-limited therapy when appropriate.

Quickly decide if a crisis that disrupts treatment is genuine or merely a distraction. A patient who has lost a loved one or suffered a life-threatening illness can be excused, but view lesser emergencies as suspect. My schoolteacher always had a good reason to avoid working on his fears, but the regularity of his excuses was a clue.

Confront the patient when you detect a pattern of avoidance. Make sure he remains interested in accomplishing the original objective.

Consider negotiating a new treatment plan. Your patient may need preliminary cognitive therapy, a gentler schedule, medication, or inpatient treatment.

Propose more structured therapy. Instruct the patient to keep a treatment diary and bring it to sessions. Sign a treatment contract, recommend a support group, or enlist the help of family members.

Reconsider the diagnosis if nothing is working. Attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, posttraumatic stress disorder, psychosis, or other cognitive problems can seem like anxiety or procrastination.

Psychiatrists, like all physicians, sometimes ask patients to endure painful or unpleasant procedures in the course of diagnosis and treatment. Patients want treatment, but they also want to avoid pain—so we expect ambivalence and resistance. Distraction is one of the most effective forms of patient resistance.

Distraction can be very effective, as described in an Arabian folk tale in The Book of One Thousand and One Nights. The story tells of a cruel Persian king who marries a virgin every night, and every morning he has his new wife executed. On the night the king marries Scheherazade, she tells him a story but leaves off the ending. The king keeps Scheherazade alive for another day to find out how the tale ends, but she then starts telling another story. This practice keeps Scheherazade alive for 1,001 nights.

Like Scheherazade,patients can employ distraction to avoid an unpleasant experience. A recently retired schoolteacher consulted me because he wanted to travel but was afraid of flying, driving long distances, and spending the night alone away from home. He and I agreed on exposure and response prevention therapy, and he made good progress at first. But then treatment stalled.

My patient was a kind man from a large, turbulent family. He was always rescuing someone from divorce, bankruptcy, school failure, or criminal indictment. Discussing these crises started to dominate our treatment sessions, and there never was a good time to get down to business.

In my experience, this pattern of regular, distracting crises occurs often with:

• patients undergoing treatment for anxiety disorders
  
• drug and alcohol abusers
  
• patients referred by other physicians because the patient is avoiding a necessary procedure.
  

These strategies can help you refocus a distracting patient and manage “Scheherazade syndrome”:

Consider time-limited therapy when appropriate.

Quickly decide if a crisis that disrupts treatment is genuine or merely a distraction. A patient who has lost a loved one or suffered a life-threatening illness can be excused, but view lesser emergencies as suspect. My schoolteacher always had a good reason to avoid working on his fears, but the regularity of his excuses was a clue.

Confront the patient when you detect a pattern of avoidance. Make sure he remains interested in accomplishing the original objective.

Consider negotiating a new treatment plan. Your patient may need preliminary cognitive therapy, a gentler schedule, medication, or inpatient treatment.

Propose more structured therapy. Instruct the patient to keep a treatment diary and bring it to sessions. Sign a treatment contract, recommend a support group, or enlist the help of family members.

Reconsider the diagnosis if nothing is working. Attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, posttraumatic stress disorder, psychosis, or other cognitive problems can seem like anxiety or procrastination.

Marijuana-dependent patients often report that withdrawal symptoms hinder their attempts to quit and trigger relapse. Up to 95% of marijuana users report withdrawal symptoms during abstinence, and you can gauge a patient’s withdrawal risk by knowing how much cannabis he or she has used.¹

Light to heavy use

Using greater amounts of marijuana, meeting criteria for abuse or dependence, and a history of chronic use (>10 years) increase the risk of developing clinically significant withdrawal symptoms.^1,2

• Light use —smoking ≤2 joints/day on fewer than 4 days a week—is associated with low withdrawal risk.¹
  
• Moderate use—2 to 3 joints almost daily—results in significant withdrawal symptoms in 50% to 60% of marijuana users, with the higher rate associated with chronic use.^1,2
  
• Heavy use—≥4 joints daily or almost daily—usually results in significant withdrawal symptoms.¹
  

Symptoms

Marijuana withdrawal is associated with neurovegetative symptoms, such as loss of appetite that can result in transient weight loss; trouble sleeping or sleep disrupted by strange dreams; and physical malaise, such as abdominal discomfort, chills, and feeling “shaky.”¹ Patients may also report psychiatric symptoms such as anxiety, irritability, or depressed mood.²

Most studies show irritability, appetite changes, sleep disruption, and anxiety occur more frequently than craving, abdominal discomfort, and increased sex drive during marijuana abstinence.¹ One preliminary study found that women were more likely to describe abdominal discomfort and men were more likely to report marijuana craving and increased sex drive during withdrawal.³

Withdrawal symptoms usually begin 24 to 48 hours after patients’ last marijuana use, and most resolve within 2 to 4 weeks. In some cases, anxiety and irritability can persist >4 weeks.

Recommendations

Determine if your patient’s marijuana use is light, moderate, or heavy by asking about lifetime and current use. Based on these answers, the risk of withdrawal is 50%.

If irritability is prominent in a light user, consider causes other than withdrawal. In a patient with chronic anxiety symptoms and light marijuana use, consider starting medication for the anxiety. Provide psycho-education and supportive therapy to help a patient with heavy marijuana use and acute anxiety get through the withdrawal period.

Marijuana-dependent patients often report that withdrawal symptoms hinder their attempts to quit and trigger relapse. Up to 95% of marijuana users report withdrawal symptoms during abstinence, and you can gauge a patient’s withdrawal risk by knowing how much cannabis he or she has used.¹

Light to heavy use

Using greater amounts of marijuana, meeting criteria for abuse or dependence, and a history of chronic use (>10 years) increase the risk of developing clinically significant withdrawal symptoms.^1,2

• Light use —smoking ≤2 joints/day on fewer than 4 days a week—is associated with low withdrawal risk.¹
  
• Moderate use—2 to 3 joints almost daily—results in significant withdrawal symptoms in 50% to 60% of marijuana users, with the higher rate associated with chronic use.^1,2
  
• Heavy use—≥4 joints daily or almost daily—usually results in significant withdrawal symptoms.¹
  

Symptoms

Marijuana withdrawal is associated with neurovegetative symptoms, such as loss of appetite that can result in transient weight loss; trouble sleeping or sleep disrupted by strange dreams; and physical malaise, such as abdominal discomfort, chills, and feeling “shaky.”¹ Patients may also report psychiatric symptoms such as anxiety, irritability, or depressed mood.²

Most studies show irritability, appetite changes, sleep disruption, and anxiety occur more frequently than craving, abdominal discomfort, and increased sex drive during marijuana abstinence.¹ One preliminary study found that women were more likely to describe abdominal discomfort and men were more likely to report marijuana craving and increased sex drive during withdrawal.³

Withdrawal symptoms usually begin 24 to 48 hours after patients’ last marijuana use, and most resolve within 2 to 4 weeks. In some cases, anxiety and irritability can persist >4 weeks.

Recommendations

Determine if your patient’s marijuana use is light, moderate, or heavy by asking about lifetime and current use. Based on these answers, the risk of withdrawal is 50%.

If irritability is prominent in a light user, consider causes other than withdrawal. In a patient with chronic anxiety symptoms and light marijuana use, consider starting medication for the anxiety. Provide psycho-education and supportive therapy to help a patient with heavy marijuana use and acute anxiety get through the withdrawal period.

Marijuana-dependent patients often report that withdrawal symptoms hinder their attempts to quit and trigger relapse. Up to 95% of marijuana users report withdrawal symptoms during abstinence, and you can gauge a patient’s withdrawal risk by knowing how much cannabis he or she has used.¹

Light to heavy use

Using greater amounts of marijuana, meeting criteria for abuse or dependence, and a history of chronic use (>10 years) increase the risk of developing clinically significant withdrawal symptoms.^1,2

• Light use —smoking ≤2 joints/day on fewer than 4 days a week—is associated with low withdrawal risk.¹
  
• Moderate use—2 to 3 joints almost daily—results in significant withdrawal symptoms in 50% to 60% of marijuana users, with the higher rate associated with chronic use.^1,2
  
• Heavy use—≥4 joints daily or almost daily—usually results in significant withdrawal symptoms.¹
  

Symptoms

Marijuana withdrawal is associated with neurovegetative symptoms, such as loss of appetite that can result in transient weight loss; trouble sleeping or sleep disrupted by strange dreams; and physical malaise, such as abdominal discomfort, chills, and feeling “shaky.”¹ Patients may also report psychiatric symptoms such as anxiety, irritability, or depressed mood.²

Most studies show irritability, appetite changes, sleep disruption, and anxiety occur more frequently than craving, abdominal discomfort, and increased sex drive during marijuana abstinence.¹ One preliminary study found that women were more likely to describe abdominal discomfort and men were more likely to report marijuana craving and increased sex drive during withdrawal.³

Withdrawal symptoms usually begin 24 to 48 hours after patients’ last marijuana use, and most resolve within 2 to 4 weeks. In some cases, anxiety and irritability can persist >4 weeks.

Recommendations

Determine if your patient’s marijuana use is light, moderate, or heavy by asking about lifetime and current use. Based on these answers, the risk of withdrawal is 50%.

If irritability is prominent in a light user, consider causes other than withdrawal. In a patient with chronic anxiety symptoms and light marijuana use, consider starting medication for the anxiety. Provide psycho-education and supportive therapy to help a patient with heavy marijuana use and acute anxiety get through the withdrawal period.

Chronic fatigue syndrome (CFS) is characterized by prolonged, debilitating fatigue that does not improve with rest and may be worsened by physical and mental activity. This fatigue must be present for at least 6 months. This syndrome affects more than 1 million individuals in the U.S. and shares symptoms with many medical and psychiatric illnesses, particularly depression.

Keeping in mind that a patient who presents with fatigue could have depression and CFS, follow DSM-IV-TR criteria for major depressive disorder to help identify clinical factors that distinguish the 2 disorders.¹

1 Depressed mood

Individuals with major depressive disorder report being depressed most of time and often cannot provide a reason or identify a loss to explain their depressed mood. CFS patients are more likely to report feeling discouraged and depressed because a lack of energy leaves them unable to complete tasks.

2 Diminished interest in activities

Depressed patients typically report a loss or lack of interest in pleasurable activities. CFS patients say they would engage in favorite activities more if their energy level would allow it.²

3 Weight loss and decreased appetite

A depressed patient may report no interest in food or may overeat. CFS patients are interested in food but find shopping and meal preparation fatiguing. Their nutritional intake may consist of fast food or easily prepared meals.

4 Insomnia

Depressed patients will report poor sleep or excessive sleep (insomnia or hypersomnia). CFS patients experience unrefreshing sleep regardless of how long they sleep.

5 Fatigue or loss of energy

Patients with major depressive disorder will report fatigue regardless of the task. They often view all tasks as equally difficult. CFS patients present with overwhelming fatigue. They express a desire to do more but are physically unable. These patients experience postexertional malaise typically worsening 12 to 48 hours after an activity and lasting for days to weeks.² Therefore, CFS patients may avoid normal activity.³

6 Feelings of worthlessness or guilt

Guilt in major depressive disorder is often delusional and broad, extending to all areas of life. CFS patients will report guilt caused by their inability to be more active. They may feel they are letting their family or co-workers down. Some people—including some health care providers—do not regard CFS as a “real disease;” others may criticize these patients’ work and daily activity level, therefore increasing guilt.

7 Diminished ability to think or concentrate

In depressed patients, this symptom should improve with antidepressant therapy. In patients with CFS, antidepressants often do not improve concentration or memory.

8 Thoughts of death and suicide

Depressed patients often will have suicidal ideation and believe life is hopeless. CFS patients can become depressed and suicidal because of the condition’s prolonged debilitating symptoms. They may qualify suicidal thoughts with, “If I have to live like this for the rest of my life, I’d rather be dead.”

9 Medical complaints

Depressed and CFS patients often present with medical complaints and require a medical workup. Chronic symptoms— such as muscle pain, headache, multijoint pain without swelling or redness, sore throat, and tender lymph nodes—constitute some of the core symptom criteria of CFS.³ These symptoms may overlap with depressed patients’ somatic complaints.

History of symptom onset and complete medical workups are important to make an accurate diagnosis. Rule out other medical disorders such as fibromyalgia, chronic mononucleosis, hypothyroidism, and subacute infections in patients who present with prolonged fatigue.

Chronic fatigue syndrome (CFS) is characterized by prolonged, debilitating fatigue that does not improve with rest and may be worsened by physical and mental activity. This fatigue must be present for at least 6 months. This syndrome affects more than 1 million individuals in the U.S. and shares symptoms with many medical and psychiatric illnesses, particularly depression.

Keeping in mind that a patient who presents with fatigue could have depression and CFS, follow DSM-IV-TR criteria for major depressive disorder to help identify clinical factors that distinguish the 2 disorders.¹

1 Depressed mood

Individuals with major depressive disorder report being depressed most of time and often cannot provide a reason or identify a loss to explain their depressed mood. CFS patients are more likely to report feeling discouraged and depressed because a lack of energy leaves them unable to complete tasks.

2 Diminished interest in activities

Depressed patients typically report a loss or lack of interest in pleasurable activities. CFS patients say they would engage in favorite activities more if their energy level would allow it.²

3 Weight loss and decreased appetite

A depressed patient may report no interest in food or may overeat. CFS patients are interested in food but find shopping and meal preparation fatiguing. Their nutritional intake may consist of fast food or easily prepared meals.

4 Insomnia

Depressed patients will report poor sleep or excessive sleep (insomnia or hypersomnia). CFS patients experience unrefreshing sleep regardless of how long they sleep.

5 Fatigue or loss of energy

Patients with major depressive disorder will report fatigue regardless of the task. They often view all tasks as equally difficult. CFS patients present with overwhelming fatigue. They express a desire to do more but are physically unable. These patients experience postexertional malaise typically worsening 12 to 48 hours after an activity and lasting for days to weeks.² Therefore, CFS patients may avoid normal activity.³

6 Feelings of worthlessness or guilt

Guilt in major depressive disorder is often delusional and broad, extending to all areas of life. CFS patients will report guilt caused by their inability to be more active. They may feel they are letting their family or co-workers down. Some people—including some health care providers—do not regard CFS as a “real disease;” others may criticize these patients’ work and daily activity level, therefore increasing guilt.

7 Diminished ability to think or concentrate

In depressed patients, this symptom should improve with antidepressant therapy. In patients with CFS, antidepressants often do not improve concentration or memory.

8 Thoughts of death and suicide

Depressed patients often will have suicidal ideation and believe life is hopeless. CFS patients can become depressed and suicidal because of the condition’s prolonged debilitating symptoms. They may qualify suicidal thoughts with, “If I have to live like this for the rest of my life, I’d rather be dead.”

9 Medical complaints

Depressed and CFS patients often present with medical complaints and require a medical workup. Chronic symptoms— such as muscle pain, headache, multijoint pain without swelling or redness, sore throat, and tender lymph nodes—constitute some of the core symptom criteria of CFS.³ These symptoms may overlap with depressed patients’ somatic complaints.

History of symptom onset and complete medical workups are important to make an accurate diagnosis. Rule out other medical disorders such as fibromyalgia, chronic mononucleosis, hypothyroidism, and subacute infections in patients who present with prolonged fatigue.

Chronic fatigue syndrome (CFS) is characterized by prolonged, debilitating fatigue that does not improve with rest and may be worsened by physical and mental activity. This fatigue must be present for at least 6 months. This syndrome affects more than 1 million individuals in the U.S. and shares symptoms with many medical and psychiatric illnesses, particularly depression.

Keeping in mind that a patient who presents with fatigue could have depression and CFS, follow DSM-IV-TR criteria for major depressive disorder to help identify clinical factors that distinguish the 2 disorders.¹

1 Depressed mood

Individuals with major depressive disorder report being depressed most of time and often cannot provide a reason or identify a loss to explain their depressed mood. CFS patients are more likely to report feeling discouraged and depressed because a lack of energy leaves them unable to complete tasks.

2 Diminished interest in activities

Depressed patients typically report a loss or lack of interest in pleasurable activities. CFS patients say they would engage in favorite activities more if their energy level would allow it.²

3 Weight loss and decreased appetite

A depressed patient may report no interest in food or may overeat. CFS patients are interested in food but find shopping and meal preparation fatiguing. Their nutritional intake may consist of fast food or easily prepared meals.

4 Insomnia

Depressed patients will report poor sleep or excessive sleep (insomnia or hypersomnia). CFS patients experience unrefreshing sleep regardless of how long they sleep.

5 Fatigue or loss of energy

Patients with major depressive disorder will report fatigue regardless of the task. They often view all tasks as equally difficult. CFS patients present with overwhelming fatigue. They express a desire to do more but are physically unable. These patients experience postexertional malaise typically worsening 12 to 48 hours after an activity and lasting for days to weeks.² Therefore, CFS patients may avoid normal activity.³

6 Feelings of worthlessness or guilt

Guilt in major depressive disorder is often delusional and broad, extending to all areas of life. CFS patients will report guilt caused by their inability to be more active. They may feel they are letting their family or co-workers down. Some people—including some health care providers—do not regard CFS as a “real disease;” others may criticize these patients’ work and daily activity level, therefore increasing guilt.

7 Diminished ability to think or concentrate

In depressed patients, this symptom should improve with antidepressant therapy. In patients with CFS, antidepressants often do not improve concentration or memory.

8 Thoughts of death and suicide

Depressed patients often will have suicidal ideation and believe life is hopeless. CFS patients can become depressed and suicidal because of the condition’s prolonged debilitating symptoms. They may qualify suicidal thoughts with, “If I have to live like this for the rest of my life, I’d rather be dead.”

9 Medical complaints

Depressed and CFS patients often present with medical complaints and require a medical workup. Chronic symptoms— such as muscle pain, headache, multijoint pain without swelling or redness, sore throat, and tender lymph nodes—constitute some of the core symptom criteria of CFS.³ These symptoms may overlap with depressed patients’ somatic complaints.

History of symptom onset and complete medical workups are important to make an accurate diagnosis. Rule out other medical disorders such as fibromyalgia, chronic mononucleosis, hypothyroidism, and subacute infections in patients who present with prolonged fatigue.

With the rapid emergence of novel therapies, psychiatrists face the challenge of deciphering the clinical application of published clinical trials. Although double-blind, randomized, placebo-controlled trials are the gold standard, their validity should be carefully examined.¹ The FRISBEE mnemonic from Duke University’s psychiatry residency program can help you incorporate evidence-based medicine into your patient care.

Follow-up. Carefully interpret studies with inadequate follow-up or high drop-out rates. The reason for patient discontinuation might not be related to the studied intervention.

Randomization. To control for unknown confounding variables, patient assignment must be randomized.

Intent-to-treat analysis. ITT assumes that complete data are available during final analysis on every subject, but subjects often drop out. To compensate for drop-outs, researchers could:

• carry forward the last available measurement as the final result, known as last observation carried forward (LOCF).
  
• use data only from patients who complete entire study protocol (completer analysis method).
  

Both methods have statistical limitations, but LOCF generally is preferred because it accounts for every subject who enrolled in the study.²

Similar baseline. Compare known characteristics of the treatment and placebo groups at baseline. Confounding variables, such as illness severity or medical or psychiatric comorbidities, should appear equally among randomized patient groups. Not all variables will be similar because of random effects, however.

Blinding. With ineffective blinding, patients or researchers can tell which treatment was administered. If this occurs, the study’s outcome likely is biased by treatment expectations. To detect faulty blinding, some studies ask patients and/or providers if they can guess the intervention that was delivered.

Equal treatment. Even with proper randomization and blinding, other intervention-related treatments—such as blood work to monitor side effects or the duration or frequency of provider contact—might not be administered equally among patient groups. This can clue patients and researchers into which intervention was administered and create bias.

Equivalence to your patient. A typical study patient often has few medical and psychiatric comorbidities or psychosocial risk factors. Your patient might be substantially different. Carefully compare the patients in the study with the patient in your office before choosing a treatment.

With the rapid emergence of novel therapies, psychiatrists face the challenge of deciphering the clinical application of published clinical trials. Although double-blind, randomized, placebo-controlled trials are the gold standard, their validity should be carefully examined.¹ The FRISBEE mnemonic from Duke University’s psychiatry residency program can help you incorporate evidence-based medicine into your patient care.

Follow-up. Carefully interpret studies with inadequate follow-up or high drop-out rates. The reason for patient discontinuation might not be related to the studied intervention.

Randomization. To control for unknown confounding variables, patient assignment must be randomized.

Intent-to-treat analysis. ITT assumes that complete data are available during final analysis on every subject, but subjects often drop out. To compensate for drop-outs, researchers could:

• carry forward the last available measurement as the final result, known as last observation carried forward (LOCF).
  
• use data only from patients who complete entire study protocol (completer analysis method).
  

Both methods have statistical limitations, but LOCF generally is preferred because it accounts for every subject who enrolled in the study.²

Similar baseline. Compare known characteristics of the treatment and placebo groups at baseline. Confounding variables, such as illness severity or medical or psychiatric comorbidities, should appear equally among randomized patient groups. Not all variables will be similar because of random effects, however.

Blinding. With ineffective blinding, patients or researchers can tell which treatment was administered. If this occurs, the study’s outcome likely is biased by treatment expectations. To detect faulty blinding, some studies ask patients and/or providers if they can guess the intervention that was delivered.

Equal treatment. Even with proper randomization and blinding, other intervention-related treatments—such as blood work to monitor side effects or the duration or frequency of provider contact—might not be administered equally among patient groups. This can clue patients and researchers into which intervention was administered and create bias.

Equivalence to your patient. A typical study patient often has few medical and psychiatric comorbidities or psychosocial risk factors. Your patient might be substantially different. Carefully compare the patients in the study with the patient in your office before choosing a treatment.

With the rapid emergence of novel therapies, psychiatrists face the challenge of deciphering the clinical application of published clinical trials. Although double-blind, randomized, placebo-controlled trials are the gold standard, their validity should be carefully examined.¹ The FRISBEE mnemonic from Duke University’s psychiatry residency program can help you incorporate evidence-based medicine into your patient care.

Follow-up. Carefully interpret studies with inadequate follow-up or high drop-out rates. The reason for patient discontinuation might not be related to the studied intervention.

Randomization. To control for unknown confounding variables, patient assignment must be randomized.

Intent-to-treat analysis. ITT assumes that complete data are available during final analysis on every subject, but subjects often drop out. To compensate for drop-outs, researchers could:

• carry forward the last available measurement as the final result, known as last observation carried forward (LOCF).
  
• use data only from patients who complete entire study protocol (completer analysis method).
  

Both methods have statistical limitations, but LOCF generally is preferred because it accounts for every subject who enrolled in the study.²

Similar baseline. Compare known characteristics of the treatment and placebo groups at baseline. Confounding variables, such as illness severity or medical or psychiatric comorbidities, should appear equally among randomized patient groups. Not all variables will be similar because of random effects, however.

Blinding. With ineffective blinding, patients or researchers can tell which treatment was administered. If this occurs, the study’s outcome likely is biased by treatment expectations. To detect faulty blinding, some studies ask patients and/or providers if they can guess the intervention that was delivered.

Equal treatment. Even with proper randomization and blinding, other intervention-related treatments—such as blood work to monitor side effects or the duration or frequency of provider contact—might not be administered equally among patient groups. This can clue patients and researchers into which intervention was administered and create bias.

Equivalence to your patient. A typical study patient often has few medical and psychiatric comorbidities or psychosocial risk factors. Your patient might be substantially different. Carefully compare the patients in the study with the patient in your office before choosing a treatment.