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Help your patients keep appointments
Patients’ failure to keep appointments is a common problem. On average, patients miss approximately 15% of follow-up psychiatric appointments,1 but the percentage is much higher in some patient populations, such as patients with significant socioeconomic difficulties. Those who miss appointments often have worse outcomes and even a higher likelihood of psychiatric readmission.2
We present strategies to help patients keep appointments and to handle occasional and repeated absences. Although the problem of missed appointments will never go away, following these suggestions could help minimize it.
Prevent the problem
Explain to the patient why regular appointments are important. The most important point is that clinician and patient must agree that—to best help the patient—treatment requires that all appointments be kept, barring emergencies.
Communicate clearly. Avoid emphasizing rules, such as that patients must keep 80% of appointments, give 48-hours’ notice for cancellations, or pay a no-show fee. These suggest that patients may miss appointments as long as they follow the rules.
Fix structural problems in your practice that may be barriers to making, rescheduling, or cancelling appointments. Be clear with patients about:
- the phone number they should call for appointments
- if they or you must cancel, that person is to reschedule at the earliest opportunity.
If the patient is missing appointments because the frequency is too burdensome, in many cases less frequent but more regular visits may be better.
During your early sessions with patients, be sure they understand that you reserve specific times for them. Make sure, however, that patients don’t interpret this to mean that attending every appointment is for your benefit, rather than important for their treatment.
Emphasize responsibility. At the end of each session, set a goal with patients for the next appointment. With a patient who has missed appointments, ask for a commitment that he or she will come to the next session. We have found that stating that you are concerned the patient might not come to the next session can paradoxically be helpful.
Having your receptionist call and remind patients the day before their visits might not be a good idea in many cases. Patients might think these calls relieve them of the responsibility for remembering to keep appointments.
With patients you think might miss appointments—especially those on a medication that requires careful monitoring—consider writing prescriptions to last no longer than the next appointment.
Occasional missed appointments
Don’t just let it go when patients occasionally miss appointments without adequate reason. Ignoring the problem lets it progress.
Resist the temptation to be courteous and say, “That’s all right” when patients apologize or give a reason for missing the session. Doing so gives a subtle message that missing appointments is acceptable.
Discussing the patients’ reasons for missing appointments might solve the problem at times. For example, patients might not mention transportation or child care problems.
Note in the chart when a patient does not come to an appointment so you can calculate how many have been missed. This notation also will remind you to address these missed appointments during the next visit. Because discussing missed appointments at the start of the session might seem confrontational or punitive, inquire about the reasons for missing the previous appointment in a gentle manner and later in the session.
Remind patients that therapy is the tool to solve their emotional problems and thus has a special place in their lives. If patients want to solve other problems, they must start by regularly attending therapy.
Repeatedly missed appointments
When a patient misses appointments repeatedly, take 1 or more sessions to discuss it. This has to be done before therapy can proceed effectively (of course you might need to postpone this discussion if the patient has experienced major stressful events or has other pressing clinical issues).
When doing this, resist the temptation to become sidetracked by other issues the patient brings up. You can let the patient vent for a few minutes, but don’t let most of the session go by before addressing the missed appointments.
1. Mitchell AJ, Selmes T. A comparative survey of missed initial and follow-up appointments to psychiatric specialties in the United Kingdom. Psychiatr Serv 2007;58(6):868-71.
2. Killaspy H, Banerjee S, King M, Lloyd M. Prospective controlled study of psychiatric out-patient non-attendance. Characteristics and outcome. Br J Psychiatry 2000;176:160-5.
Dr. Mago is assistant professor of psychiatry and director of the mood disorders program; Dr. Mahajan is a research volunteer; and Dr. McFadden is an instructor and associate director of adult outpatient services, Thomas Jefferson University, Philadelphia.
Patients’ failure to keep appointments is a common problem. On average, patients miss approximately 15% of follow-up psychiatric appointments,1 but the percentage is much higher in some patient populations, such as patients with significant socioeconomic difficulties. Those who miss appointments often have worse outcomes and even a higher likelihood of psychiatric readmission.2
We present strategies to help patients keep appointments and to handle occasional and repeated absences. Although the problem of missed appointments will never go away, following these suggestions could help minimize it.
Prevent the problem
Explain to the patient why regular appointments are important. The most important point is that clinician and patient must agree that—to best help the patient—treatment requires that all appointments be kept, barring emergencies.
Communicate clearly. Avoid emphasizing rules, such as that patients must keep 80% of appointments, give 48-hours’ notice for cancellations, or pay a no-show fee. These suggest that patients may miss appointments as long as they follow the rules.
Fix structural problems in your practice that may be barriers to making, rescheduling, or cancelling appointments. Be clear with patients about:
- the phone number they should call for appointments
- if they or you must cancel, that person is to reschedule at the earliest opportunity.
If the patient is missing appointments because the frequency is too burdensome, in many cases less frequent but more regular visits may be better.
During your early sessions with patients, be sure they understand that you reserve specific times for them. Make sure, however, that patients don’t interpret this to mean that attending every appointment is for your benefit, rather than important for their treatment.
Emphasize responsibility. At the end of each session, set a goal with patients for the next appointment. With a patient who has missed appointments, ask for a commitment that he or she will come to the next session. We have found that stating that you are concerned the patient might not come to the next session can paradoxically be helpful.
Having your receptionist call and remind patients the day before their visits might not be a good idea in many cases. Patients might think these calls relieve them of the responsibility for remembering to keep appointments.
With patients you think might miss appointments—especially those on a medication that requires careful monitoring—consider writing prescriptions to last no longer than the next appointment.
Occasional missed appointments
Don’t just let it go when patients occasionally miss appointments without adequate reason. Ignoring the problem lets it progress.
Resist the temptation to be courteous and say, “That’s all right” when patients apologize or give a reason for missing the session. Doing so gives a subtle message that missing appointments is acceptable.
Discussing the patients’ reasons for missing appointments might solve the problem at times. For example, patients might not mention transportation or child care problems.
Note in the chart when a patient does not come to an appointment so you can calculate how many have been missed. This notation also will remind you to address these missed appointments during the next visit. Because discussing missed appointments at the start of the session might seem confrontational or punitive, inquire about the reasons for missing the previous appointment in a gentle manner and later in the session.
Remind patients that therapy is the tool to solve their emotional problems and thus has a special place in their lives. If patients want to solve other problems, they must start by regularly attending therapy.
Repeatedly missed appointments
When a patient misses appointments repeatedly, take 1 or more sessions to discuss it. This has to be done before therapy can proceed effectively (of course you might need to postpone this discussion if the patient has experienced major stressful events or has other pressing clinical issues).
When doing this, resist the temptation to become sidetracked by other issues the patient brings up. You can let the patient vent for a few minutes, but don’t let most of the session go by before addressing the missed appointments.
Patients’ failure to keep appointments is a common problem. On average, patients miss approximately 15% of follow-up psychiatric appointments,1 but the percentage is much higher in some patient populations, such as patients with significant socioeconomic difficulties. Those who miss appointments often have worse outcomes and even a higher likelihood of psychiatric readmission.2
We present strategies to help patients keep appointments and to handle occasional and repeated absences. Although the problem of missed appointments will never go away, following these suggestions could help minimize it.
Prevent the problem
Explain to the patient why regular appointments are important. The most important point is that clinician and patient must agree that—to best help the patient—treatment requires that all appointments be kept, barring emergencies.
Communicate clearly. Avoid emphasizing rules, such as that patients must keep 80% of appointments, give 48-hours’ notice for cancellations, or pay a no-show fee. These suggest that patients may miss appointments as long as they follow the rules.
Fix structural problems in your practice that may be barriers to making, rescheduling, or cancelling appointments. Be clear with patients about:
- the phone number they should call for appointments
- if they or you must cancel, that person is to reschedule at the earliest opportunity.
If the patient is missing appointments because the frequency is too burdensome, in many cases less frequent but more regular visits may be better.
During your early sessions with patients, be sure they understand that you reserve specific times for them. Make sure, however, that patients don’t interpret this to mean that attending every appointment is for your benefit, rather than important for their treatment.
Emphasize responsibility. At the end of each session, set a goal with patients for the next appointment. With a patient who has missed appointments, ask for a commitment that he or she will come to the next session. We have found that stating that you are concerned the patient might not come to the next session can paradoxically be helpful.
Having your receptionist call and remind patients the day before their visits might not be a good idea in many cases. Patients might think these calls relieve them of the responsibility for remembering to keep appointments.
With patients you think might miss appointments—especially those on a medication that requires careful monitoring—consider writing prescriptions to last no longer than the next appointment.
Occasional missed appointments
Don’t just let it go when patients occasionally miss appointments without adequate reason. Ignoring the problem lets it progress.
Resist the temptation to be courteous and say, “That’s all right” when patients apologize or give a reason for missing the session. Doing so gives a subtle message that missing appointments is acceptable.
Discussing the patients’ reasons for missing appointments might solve the problem at times. For example, patients might not mention transportation or child care problems.
Note in the chart when a patient does not come to an appointment so you can calculate how many have been missed. This notation also will remind you to address these missed appointments during the next visit. Because discussing missed appointments at the start of the session might seem confrontational or punitive, inquire about the reasons for missing the previous appointment in a gentle manner and later in the session.
Remind patients that therapy is the tool to solve their emotional problems and thus has a special place in their lives. If patients want to solve other problems, they must start by regularly attending therapy.
Repeatedly missed appointments
When a patient misses appointments repeatedly, take 1 or more sessions to discuss it. This has to be done before therapy can proceed effectively (of course you might need to postpone this discussion if the patient has experienced major stressful events or has other pressing clinical issues).
When doing this, resist the temptation to become sidetracked by other issues the patient brings up. You can let the patient vent for a few minutes, but don’t let most of the session go by before addressing the missed appointments.
1. Mitchell AJ, Selmes T. A comparative survey of missed initial and follow-up appointments to psychiatric specialties in the United Kingdom. Psychiatr Serv 2007;58(6):868-71.
2. Killaspy H, Banerjee S, King M, Lloyd M. Prospective controlled study of psychiatric out-patient non-attendance. Characteristics and outcome. Br J Psychiatry 2000;176:160-5.
Dr. Mago is assistant professor of psychiatry and director of the mood disorders program; Dr. Mahajan is a research volunteer; and Dr. McFadden is an instructor and associate director of adult outpatient services, Thomas Jefferson University, Philadelphia.
1. Mitchell AJ, Selmes T. A comparative survey of missed initial and follow-up appointments to psychiatric specialties in the United Kingdom. Psychiatr Serv 2007;58(6):868-71.
2. Killaspy H, Banerjee S, King M, Lloyd M. Prospective controlled study of psychiatric out-patient non-attendance. Characteristics and outcome. Br J Psychiatry 2000;176:160-5.
Dr. Mago is assistant professor of psychiatry and director of the mood disorders program; Dr. Mahajan is a research volunteer; and Dr. McFadden is an instructor and associate director of adult outpatient services, Thomas Jefferson University, Philadelphia.
Lost in translation: Be leery of lay language
Patients may use diagnostic labels of psychiatric disorders when describing their mental distress to clinicians. Sometimes they use these words appropriately, but often they don’t understand the meaning of psychiatric terms they have read or heard (Table). For example, a study of U.S. newspapers found that 28% of articles incorrectly used “schizophrenic” to refer to a “split” or inconsistent personality.1
Terminology confusion could lead to 2 clinical problems:
- The patient may be confident in his or her self-diagnosis, which can strain the therapeutic relationship.
- The clinician may passively accept that the patient’s use of terms is accurate, resulting in a distorted diagnosis.
Table
Psychiatric terms patients misuse to describe symptoms
| Psychiatric term | Possible implied symptoms |
|---|---|
| ‘ADHD’ or ‘ADD’ | Poor concentration or forgetfulness, excessive energy or restlessness |
| ‘Antisocial’ | Social withdrawal, unpleasant interpersonal relationships |
| ‘Bipolar’ | Mood lability, unpredictability, anxiety attacks |
| ‘Depression’ | Grief, remorse, loneliness, disappointment |
| ‘Obsessing’ | Ruminating, worrying |
| ‘OCD’ | Meticulousness, excessive worrying |
| ‘Panic attack’ | Intense anxiety, even without physical symptoms |
| ‘Paranoid’ | Worry, dread, pessimism |
| ‘Psychotic’ | Enraged, unpredictable |
| ‘PTSD’ | Emotional change following a significant, though not necessarily traumatic, event |
| ‘Schizophrenic’ | Indecisive, ‘split personality’ |
| ADHD: attention-deficit/hyperactivity disorder; OCD: obsessive-compulsive disorder; PTSD: posttraumatic stress disorder | |
Searching for meaning
When a patient uses a psychiatric term to describe symptoms, clarify what he or she means by asking; “Can you tell me more about your experience of (the term) without using that word to describe it?” Alternately, you could say, “Let’s not worry about applying a label right now, just describe what you are going through.”
Another approach is to offer phrases that are synonyms of the term’s standard use. For example, ask your patient, “By ‘schizophrenic’ do you mean ‘being in 2 minds’ or ‘having really unusual experiences?’” Using popular culture references also may be helpful. For example, “When I use the term ‘schizophrenia,’ I think of someone like Russell Crowe’s character in the movie A Beautiful Mind.” Similarly, for obsessive-compulsive disorder, reference Jack Nicholson’s character in As Good as it Gets.
Clarifying terminology also can help you gather a complete family history. A patient may say “Oh, that sounds like my mother” when you accurately describe a psychiatric symptom or disorder.
1. Duckworth K, Halpern JH, Schutt K, et al. Use of schizophrenia as a metaphor in U.S. newspapers. Psychiatr Serv 2003;54:1402-4.
Dr. Dunlop is assistant professor, department of psychiatry and behavioral sciences, Emory University, Atlanta, GA.
Patients may use diagnostic labels of psychiatric disorders when describing their mental distress to clinicians. Sometimes they use these words appropriately, but often they don’t understand the meaning of psychiatric terms they have read or heard (Table). For example, a study of U.S. newspapers found that 28% of articles incorrectly used “schizophrenic” to refer to a “split” or inconsistent personality.1
Terminology confusion could lead to 2 clinical problems:
- The patient may be confident in his or her self-diagnosis, which can strain the therapeutic relationship.
- The clinician may passively accept that the patient’s use of terms is accurate, resulting in a distorted diagnosis.
Table
Psychiatric terms patients misuse to describe symptoms
| Psychiatric term | Possible implied symptoms |
|---|---|
| ‘ADHD’ or ‘ADD’ | Poor concentration or forgetfulness, excessive energy or restlessness |
| ‘Antisocial’ | Social withdrawal, unpleasant interpersonal relationships |
| ‘Bipolar’ | Mood lability, unpredictability, anxiety attacks |
| ‘Depression’ | Grief, remorse, loneliness, disappointment |
| ‘Obsessing’ | Ruminating, worrying |
| ‘OCD’ | Meticulousness, excessive worrying |
| ‘Panic attack’ | Intense anxiety, even without physical symptoms |
| ‘Paranoid’ | Worry, dread, pessimism |
| ‘Psychotic’ | Enraged, unpredictable |
| ‘PTSD’ | Emotional change following a significant, though not necessarily traumatic, event |
| ‘Schizophrenic’ | Indecisive, ‘split personality’ |
| ADHD: attention-deficit/hyperactivity disorder; OCD: obsessive-compulsive disorder; PTSD: posttraumatic stress disorder | |
Searching for meaning
When a patient uses a psychiatric term to describe symptoms, clarify what he or she means by asking; “Can you tell me more about your experience of (the term) without using that word to describe it?” Alternately, you could say, “Let’s not worry about applying a label right now, just describe what you are going through.”
Another approach is to offer phrases that are synonyms of the term’s standard use. For example, ask your patient, “By ‘schizophrenic’ do you mean ‘being in 2 minds’ or ‘having really unusual experiences?’” Using popular culture references also may be helpful. For example, “When I use the term ‘schizophrenia,’ I think of someone like Russell Crowe’s character in the movie A Beautiful Mind.” Similarly, for obsessive-compulsive disorder, reference Jack Nicholson’s character in As Good as it Gets.
Clarifying terminology also can help you gather a complete family history. A patient may say “Oh, that sounds like my mother” when you accurately describe a psychiatric symptom or disorder.
Patients may use diagnostic labels of psychiatric disorders when describing their mental distress to clinicians. Sometimes they use these words appropriately, but often they don’t understand the meaning of psychiatric terms they have read or heard (Table). For example, a study of U.S. newspapers found that 28% of articles incorrectly used “schizophrenic” to refer to a “split” or inconsistent personality.1
Terminology confusion could lead to 2 clinical problems:
- The patient may be confident in his or her self-diagnosis, which can strain the therapeutic relationship.
- The clinician may passively accept that the patient’s use of terms is accurate, resulting in a distorted diagnosis.
Table
Psychiatric terms patients misuse to describe symptoms
| Psychiatric term | Possible implied symptoms |
|---|---|
| ‘ADHD’ or ‘ADD’ | Poor concentration or forgetfulness, excessive energy or restlessness |
| ‘Antisocial’ | Social withdrawal, unpleasant interpersonal relationships |
| ‘Bipolar’ | Mood lability, unpredictability, anxiety attacks |
| ‘Depression’ | Grief, remorse, loneliness, disappointment |
| ‘Obsessing’ | Ruminating, worrying |
| ‘OCD’ | Meticulousness, excessive worrying |
| ‘Panic attack’ | Intense anxiety, even without physical symptoms |
| ‘Paranoid’ | Worry, dread, pessimism |
| ‘Psychotic’ | Enraged, unpredictable |
| ‘PTSD’ | Emotional change following a significant, though not necessarily traumatic, event |
| ‘Schizophrenic’ | Indecisive, ‘split personality’ |
| ADHD: attention-deficit/hyperactivity disorder; OCD: obsessive-compulsive disorder; PTSD: posttraumatic stress disorder | |
Searching for meaning
When a patient uses a psychiatric term to describe symptoms, clarify what he or she means by asking; “Can you tell me more about your experience of (the term) without using that word to describe it?” Alternately, you could say, “Let’s not worry about applying a label right now, just describe what you are going through.”
Another approach is to offer phrases that are synonyms of the term’s standard use. For example, ask your patient, “By ‘schizophrenic’ do you mean ‘being in 2 minds’ or ‘having really unusual experiences?’” Using popular culture references also may be helpful. For example, “When I use the term ‘schizophrenia,’ I think of someone like Russell Crowe’s character in the movie A Beautiful Mind.” Similarly, for obsessive-compulsive disorder, reference Jack Nicholson’s character in As Good as it Gets.
Clarifying terminology also can help you gather a complete family history. A patient may say “Oh, that sounds like my mother” when you accurately describe a psychiatric symptom or disorder.
1. Duckworth K, Halpern JH, Schutt K, et al. Use of schizophrenia as a metaphor in U.S. newspapers. Psychiatr Serv 2003;54:1402-4.
Dr. Dunlop is assistant professor, department of psychiatry and behavioral sciences, Emory University, Atlanta, GA.
1. Duckworth K, Halpern JH, Schutt K, et al. Use of schizophrenia as a metaphor in U.S. newspapers. Psychiatr Serv 2003;54:1402-4.
Dr. Dunlop is assistant professor, department of psychiatry and behavioral sciences, Emory University, Atlanta, GA.
Tips for telling your patients good-bye
Transferring to another psychiatrist can distress mental health patients and disrupt treatment, whether you part ways with them because of an insurance change or relocation. A smooth transfer helps maintain patients’ clinical progress and reduces the risk of losing them to follow-up. We suggest a timeline for saying good-bye (Table) and some strategies to ease the transition.
Table
Timeline for transferring your patient’s care
| Issues to discuss/explore | |
|---|---|
| 6 months before departure | Determine which issues patient would like to address before transfer Current or past medications |
| 1 month before departure | Focus on closure Avoid addressing new issues Avoid changing medications or session time, day, or frequency Go over transfer summary |
| Final session | Give 1 to 2 prescription refills Encourage patient to follow up with new doctor End session on positive note |
Starting the conversation
Inform the patient of your approximate departure date as soon as possible. Most residents, for example, should have this conversation in January, allowing approximately 6 months to address issues your departure may bring up. Don’t be surprised if your patient does not recall this conversation, however, because he or she might unconsciously repress this information. You might have to discuss your departure several times before it becomes “real” for your patient.
Identify specific issues to address before transferring the patient’s care. For example, explore whether any medications need to be changed.
Tell your patient you would like to write the transfer summary together, and encourage him or her to think about what information to include. If another physician transferred the patient to you, inquire about that process. Did the earlier physician do or say something that was helpful?
Initiating transfer of care
Encourage your patient to talk about feelings related to the transfer by asking how he or she thinks the process will go. Don’t assume your patient is anxious or upset about the change, however. Some patients “bond” to the clinic rather than to a particular doctor.
Be alert for unconscious communication about your impending departure. For example, your patient might talk about others who have left in the past. Consider these statements as opportunities to discuss your departure against the backdrop of other losses and changes.
Patients might unconsciously act out in response to your upcoming departure. For example, a patient who has faithfully attended appointments might “accidentally” miss a visit or discontinue 1 or more medications.
Examine your feelings about the impending transfer of care. Guard against attributing your feelings about the process to your patient. If you find that these feelings lead to difficulty helping your patient find closure, consider consulting with a colleague or mentor.
1 month before the transfer
Your patient might initiate more intense work than in the past. Your impending departure might make it seem safer to share previously undiscussed information because there is little time to explore it.
Although you may be tempted to take advantage of your patient’s impulse, carefully assess this strategy. This is the time to work toward closure, rather than delving into new areas. Keep treatment structured; avoid increasing or decreasing the frequency of visits as you approach the last session.
Also avoid changing the patient’s medication regimen, if possible. If your patient is anxious about your departure, new medication side effects might exacerbate this anxiety.
If possible, personally introduce your patient to the new physician and discuss the transfer summary. Don’t say that the new doctor is “really good.” The qualities you like about this clinician might not appeal to the patient. Encourage the patient to “interview” the new physician.
Don’t discuss what you will be doing after you leave. If the patient asks, talk about your plans in general terms. Detailed or persistent questioning might have psychological meaning and could be discussed in psychotherapy.
The last session
Write 1 or 2 prescription refills. Many patients are concerned about a possible delay in starting treatment with the new physician, and adequate refills may allay fears about obtaining medication. Having refills also may act as a temporary “transitional object” until the patient feels comfortable with the new physician.
Tell your patient that many individuals don’t follow up with a new physician, but it is important to do so. Discussing this phenomenon may increase the probability that your patient will follow up because you can talk about his or her concerns about seeing a new physician or ending treatment with you.
Don’t agree to correspond with the patient after you transfer care. Further communication might interfere with the new therapeutic relationship. The patient might communicate clinical concerns to you, not to the new physician.
Don’t initiate a hug at the end of the session. If your patient initiates a hug or a handshake, you may accept it if you are comfortable with physical contact. End the session on a positive note, and express your best wishes for the patient’s continued growth and well-being.
Still having problems?
If the transition of your patient’s care is unusually difficult, do not hesitate to ask a supervisor or colleague for assistance.
Dr. Kay is instructor in psychiatry and Dr. Mago is assistant professor of psychiatry, Thomas Jefferson University, Philadelphia, PA.
Transferring to another psychiatrist can distress mental health patients and disrupt treatment, whether you part ways with them because of an insurance change or relocation. A smooth transfer helps maintain patients’ clinical progress and reduces the risk of losing them to follow-up. We suggest a timeline for saying good-bye (Table) and some strategies to ease the transition.
Table
Timeline for transferring your patient’s care
| Issues to discuss/explore | |
|---|---|
| 6 months before departure | Determine which issues patient would like to address before transfer Current or past medications |
| 1 month before departure | Focus on closure Avoid addressing new issues Avoid changing medications or session time, day, or frequency Go over transfer summary |
| Final session | Give 1 to 2 prescription refills Encourage patient to follow up with new doctor End session on positive note |
Starting the conversation
Inform the patient of your approximate departure date as soon as possible. Most residents, for example, should have this conversation in January, allowing approximately 6 months to address issues your departure may bring up. Don’t be surprised if your patient does not recall this conversation, however, because he or she might unconsciously repress this information. You might have to discuss your departure several times before it becomes “real” for your patient.
Identify specific issues to address before transferring the patient’s care. For example, explore whether any medications need to be changed.
Tell your patient you would like to write the transfer summary together, and encourage him or her to think about what information to include. If another physician transferred the patient to you, inquire about that process. Did the earlier physician do or say something that was helpful?
Initiating transfer of care
Encourage your patient to talk about feelings related to the transfer by asking how he or she thinks the process will go. Don’t assume your patient is anxious or upset about the change, however. Some patients “bond” to the clinic rather than to a particular doctor.
Be alert for unconscious communication about your impending departure. For example, your patient might talk about others who have left in the past. Consider these statements as opportunities to discuss your departure against the backdrop of other losses and changes.
Patients might unconsciously act out in response to your upcoming departure. For example, a patient who has faithfully attended appointments might “accidentally” miss a visit or discontinue 1 or more medications.
Examine your feelings about the impending transfer of care. Guard against attributing your feelings about the process to your patient. If you find that these feelings lead to difficulty helping your patient find closure, consider consulting with a colleague or mentor.
1 month before the transfer
Your patient might initiate more intense work than in the past. Your impending departure might make it seem safer to share previously undiscussed information because there is little time to explore it.
Although you may be tempted to take advantage of your patient’s impulse, carefully assess this strategy. This is the time to work toward closure, rather than delving into new areas. Keep treatment structured; avoid increasing or decreasing the frequency of visits as you approach the last session.
Also avoid changing the patient’s medication regimen, if possible. If your patient is anxious about your departure, new medication side effects might exacerbate this anxiety.
If possible, personally introduce your patient to the new physician and discuss the transfer summary. Don’t say that the new doctor is “really good.” The qualities you like about this clinician might not appeal to the patient. Encourage the patient to “interview” the new physician.
Don’t discuss what you will be doing after you leave. If the patient asks, talk about your plans in general terms. Detailed or persistent questioning might have psychological meaning and could be discussed in psychotherapy.
The last session
Write 1 or 2 prescription refills. Many patients are concerned about a possible delay in starting treatment with the new physician, and adequate refills may allay fears about obtaining medication. Having refills also may act as a temporary “transitional object” until the patient feels comfortable with the new physician.
Tell your patient that many individuals don’t follow up with a new physician, but it is important to do so. Discussing this phenomenon may increase the probability that your patient will follow up because you can talk about his or her concerns about seeing a new physician or ending treatment with you.
Don’t agree to correspond with the patient after you transfer care. Further communication might interfere with the new therapeutic relationship. The patient might communicate clinical concerns to you, not to the new physician.
Don’t initiate a hug at the end of the session. If your patient initiates a hug or a handshake, you may accept it if you are comfortable with physical contact. End the session on a positive note, and express your best wishes for the patient’s continued growth and well-being.
Still having problems?
If the transition of your patient’s care is unusually difficult, do not hesitate to ask a supervisor or colleague for assistance.
Transferring to another psychiatrist can distress mental health patients and disrupt treatment, whether you part ways with them because of an insurance change or relocation. A smooth transfer helps maintain patients’ clinical progress and reduces the risk of losing them to follow-up. We suggest a timeline for saying good-bye (Table) and some strategies to ease the transition.
Table
Timeline for transferring your patient’s care
| Issues to discuss/explore | |
|---|---|
| 6 months before departure | Determine which issues patient would like to address before transfer Current or past medications |
| 1 month before departure | Focus on closure Avoid addressing new issues Avoid changing medications or session time, day, or frequency Go over transfer summary |
| Final session | Give 1 to 2 prescription refills Encourage patient to follow up with new doctor End session on positive note |
Starting the conversation
Inform the patient of your approximate departure date as soon as possible. Most residents, for example, should have this conversation in January, allowing approximately 6 months to address issues your departure may bring up. Don’t be surprised if your patient does not recall this conversation, however, because he or she might unconsciously repress this information. You might have to discuss your departure several times before it becomes “real” for your patient.
Identify specific issues to address before transferring the patient’s care. For example, explore whether any medications need to be changed.
Tell your patient you would like to write the transfer summary together, and encourage him or her to think about what information to include. If another physician transferred the patient to you, inquire about that process. Did the earlier physician do or say something that was helpful?
Initiating transfer of care
Encourage your patient to talk about feelings related to the transfer by asking how he or she thinks the process will go. Don’t assume your patient is anxious or upset about the change, however. Some patients “bond” to the clinic rather than to a particular doctor.
Be alert for unconscious communication about your impending departure. For example, your patient might talk about others who have left in the past. Consider these statements as opportunities to discuss your departure against the backdrop of other losses and changes.
Patients might unconsciously act out in response to your upcoming departure. For example, a patient who has faithfully attended appointments might “accidentally” miss a visit or discontinue 1 or more medications.
Examine your feelings about the impending transfer of care. Guard against attributing your feelings about the process to your patient. If you find that these feelings lead to difficulty helping your patient find closure, consider consulting with a colleague or mentor.
1 month before the transfer
Your patient might initiate more intense work than in the past. Your impending departure might make it seem safer to share previously undiscussed information because there is little time to explore it.
Although you may be tempted to take advantage of your patient’s impulse, carefully assess this strategy. This is the time to work toward closure, rather than delving into new areas. Keep treatment structured; avoid increasing or decreasing the frequency of visits as you approach the last session.
Also avoid changing the patient’s medication regimen, if possible. If your patient is anxious about your departure, new medication side effects might exacerbate this anxiety.
If possible, personally introduce your patient to the new physician and discuss the transfer summary. Don’t say that the new doctor is “really good.” The qualities you like about this clinician might not appeal to the patient. Encourage the patient to “interview” the new physician.
Don’t discuss what you will be doing after you leave. If the patient asks, talk about your plans in general terms. Detailed or persistent questioning might have psychological meaning and could be discussed in psychotherapy.
The last session
Write 1 or 2 prescription refills. Many patients are concerned about a possible delay in starting treatment with the new physician, and adequate refills may allay fears about obtaining medication. Having refills also may act as a temporary “transitional object” until the patient feels comfortable with the new physician.
Tell your patient that many individuals don’t follow up with a new physician, but it is important to do so. Discussing this phenomenon may increase the probability that your patient will follow up because you can talk about his or her concerns about seeing a new physician or ending treatment with you.
Don’t agree to correspond with the patient after you transfer care. Further communication might interfere with the new therapeutic relationship. The patient might communicate clinical concerns to you, not to the new physician.
Don’t initiate a hug at the end of the session. If your patient initiates a hug or a handshake, you may accept it if you are comfortable with physical contact. End the session on a positive note, and express your best wishes for the patient’s continued growth and well-being.
Still having problems?
If the transition of your patient’s care is unusually difficult, do not hesitate to ask a supervisor or colleague for assistance.
Dr. Kay is instructor in psychiatry and Dr. Mago is assistant professor of psychiatry, Thomas Jefferson University, Philadelphia, PA.
Dr. Kay is instructor in psychiatry and Dr. Mago is assistant professor of psychiatry, Thomas Jefferson University, Philadelphia, PA.
The #1 question to ask inpatients
When consulting on a medical or surgical ward, consider asking the patient, “How are they treating you here in the hospital?” The response to this straightforward question often clarifies the reason for the consultation and helps establish the patient’s psychiatric diagnosis.
Asking about the patient’s experience in the hospital can reveal the dynamics of his or her interpersonal relationships. In a well-functioning ward, healthy answers are, “Everybody is really nice,” or “The staff is great, but I can’t wait to go home.” Any other answer should be investigated.
Questioning reveals disorders
Patients with borderline personality disorder (BPD) will describe a hospital staff split into idealized and rejected components and try to enlist you in their fight. However, most BPD patients won’t need encouragement to discuss their conflicts with the staff.
Unhappy narcissistic patients will com-plain about assaults on their dignity—often housekeeping issues such as poor-quality food and linens, indifferent cleanliness, or delayed response when they use the call button. Happier narcissistic patients will celebrate their doctors’ outstanding credentials and clinical brilliance.
Patients with substance abuse disorders will respond by discussing the timing and adequacy of their opioid and benzodiazepine prescriptions.
Depressed patients may guiltily apologize for wasting everybody’s time.
When patients hint that they are enjoying the hospital experience or would like to prolong their stay, inquire into their situations outside the hospital. They may be homeless, abused, or destitute. Malingerers and patients with factitious disorder typically will insist on their desire to be cured and discharged.
Proper phrasing is essential
As phrased, the question is a “counterprojective” maneuver.1 It distances you from patients’ suspicions, resentments, and presuppositions. By referring to hospital personnel as “they,” you signal that you are distinct and neutral if the patient is feuding with the staff. By comparison, asking “How are my friends on the medical staff treating you?” would invalidate this counterprojective effect, align you with the hospital staff, and subtly encourage the patient to keep his problems to himself.
If the question elicits a complaint, try to stay neutral as long as possible. Guard against perceived defensiveness and the patient’s projections by saying, “I’m sorry to hear things aren’t going well. Tell me more.” Offer to help if there is a concrete and reasonable solution.
Patients might not tell you about problems with their care in the hospital unless you ask. Some patients are too polite to say anything. Others are afraid to complain because they recognize that their comfort and perhaps even survival are in the hands of hospital staff.
Reference
1. Havens L. Making contact: uses of language in psychotherapy Cambridge MA: Harvard University Press; 1988;29:126-9.
Dr. Lakritz is a psychiatrist at the Lahey Clinic Medical Center in Burlington, MA.
When consulting on a medical or surgical ward, consider asking the patient, “How are they treating you here in the hospital?” The response to this straightforward question often clarifies the reason for the consultation and helps establish the patient’s psychiatric diagnosis.
Asking about the patient’s experience in the hospital can reveal the dynamics of his or her interpersonal relationships. In a well-functioning ward, healthy answers are, “Everybody is really nice,” or “The staff is great, but I can’t wait to go home.” Any other answer should be investigated.
Questioning reveals disorders
Patients with borderline personality disorder (BPD) will describe a hospital staff split into idealized and rejected components and try to enlist you in their fight. However, most BPD patients won’t need encouragement to discuss their conflicts with the staff.
Unhappy narcissistic patients will com-plain about assaults on their dignity—often housekeeping issues such as poor-quality food and linens, indifferent cleanliness, or delayed response when they use the call button. Happier narcissistic patients will celebrate their doctors’ outstanding credentials and clinical brilliance.
Patients with substance abuse disorders will respond by discussing the timing and adequacy of their opioid and benzodiazepine prescriptions.
Depressed patients may guiltily apologize for wasting everybody’s time.
When patients hint that they are enjoying the hospital experience or would like to prolong their stay, inquire into their situations outside the hospital. They may be homeless, abused, or destitute. Malingerers and patients with factitious disorder typically will insist on their desire to be cured and discharged.
Proper phrasing is essential
As phrased, the question is a “counterprojective” maneuver.1 It distances you from patients’ suspicions, resentments, and presuppositions. By referring to hospital personnel as “they,” you signal that you are distinct and neutral if the patient is feuding with the staff. By comparison, asking “How are my friends on the medical staff treating you?” would invalidate this counterprojective effect, align you with the hospital staff, and subtly encourage the patient to keep his problems to himself.
If the question elicits a complaint, try to stay neutral as long as possible. Guard against perceived defensiveness and the patient’s projections by saying, “I’m sorry to hear things aren’t going well. Tell me more.” Offer to help if there is a concrete and reasonable solution.
Patients might not tell you about problems with their care in the hospital unless you ask. Some patients are too polite to say anything. Others are afraid to complain because they recognize that their comfort and perhaps even survival are in the hands of hospital staff.
When consulting on a medical or surgical ward, consider asking the patient, “How are they treating you here in the hospital?” The response to this straightforward question often clarifies the reason for the consultation and helps establish the patient’s psychiatric diagnosis.
Asking about the patient’s experience in the hospital can reveal the dynamics of his or her interpersonal relationships. In a well-functioning ward, healthy answers are, “Everybody is really nice,” or “The staff is great, but I can’t wait to go home.” Any other answer should be investigated.
Questioning reveals disorders
Patients with borderline personality disorder (BPD) will describe a hospital staff split into idealized and rejected components and try to enlist you in their fight. However, most BPD patients won’t need encouragement to discuss their conflicts with the staff.
Unhappy narcissistic patients will com-plain about assaults on their dignity—often housekeeping issues such as poor-quality food and linens, indifferent cleanliness, or delayed response when they use the call button. Happier narcissistic patients will celebrate their doctors’ outstanding credentials and clinical brilliance.
Patients with substance abuse disorders will respond by discussing the timing and adequacy of their opioid and benzodiazepine prescriptions.
Depressed patients may guiltily apologize for wasting everybody’s time.
When patients hint that they are enjoying the hospital experience or would like to prolong their stay, inquire into their situations outside the hospital. They may be homeless, abused, or destitute. Malingerers and patients with factitious disorder typically will insist on their desire to be cured and discharged.
Proper phrasing is essential
As phrased, the question is a “counterprojective” maneuver.1 It distances you from patients’ suspicions, resentments, and presuppositions. By referring to hospital personnel as “they,” you signal that you are distinct and neutral if the patient is feuding with the staff. By comparison, asking “How are my friends on the medical staff treating you?” would invalidate this counterprojective effect, align you with the hospital staff, and subtly encourage the patient to keep his problems to himself.
If the question elicits a complaint, try to stay neutral as long as possible. Guard against perceived defensiveness and the patient’s projections by saying, “I’m sorry to hear things aren’t going well. Tell me more.” Offer to help if there is a concrete and reasonable solution.
Patients might not tell you about problems with their care in the hospital unless you ask. Some patients are too polite to say anything. Others are afraid to complain because they recognize that their comfort and perhaps even survival are in the hands of hospital staff.
Reference
1. Havens L. Making contact: uses of language in psychotherapy Cambridge MA: Harvard University Press; 1988;29:126-9.
Dr. Lakritz is a psychiatrist at the Lahey Clinic Medical Center in Burlington, MA.
Reference
1. Havens L. Making contact: uses of language in psychotherapy Cambridge MA: Harvard University Press; 1988;29:126-9.
Dr. Lakritz is a psychiatrist at the Lahey Clinic Medical Center in Burlington, MA.
Sleep hygiene helps patients catch some ZZZs
Proper sleep hygiene can help your patients fall and stay asleep consistently. Patients with insomnia are at a higher risk of developing or experiencing a recurrence of a mood disorder, and poor sleep can worsen psychiatric symptoms such as depression or mania.1 Data about combining behavioral approaches and hypnotic medications to treat insomnia are inconclusive;2 however, using the 2 together may help patients who do not respond to a single approach.
First rule out other causes of insomnia, such as sleep apnea, other medical conditions, or medications. Patients may improve after these factors are addressed.
Teaching sleep hygiene principles (Box) does not mean patients will adopt these habits, but employing the following suggestions could improve adherence:
Obtain a detailed sleep history to identify specific behaviors to be changed. For example, a patient might only have to stop watching television in bed to get a good night’s sleep, although some may find a brief exposure to television or radio facilitates relaxation.
Explain the rationale for changing a behavior. For example, when telling patients to limit caffeine or alcohol at night, list these substances’ negative effects on sleep. Similarly, when instructing patients to avoid watching television in bed, tell them that using the bedroom only for sleep or sex will help condition them for sleep at bedtime.
- Establish a regular sleep-wake schedule
- Limit caffeine and alcohol consumption
- Avoid naps
- Eliminate noise and light from the sleep environment
- Use the bed only for sleep or sex
- Avoid looking at a clock when trying to sleep
Discuss sleep regularly. A patient might not disclose poor sleeping habits during the first session.
Give your patient handouts on sleep hygiene principles and highlight the most pertinent information. Ask the patient to place the handout where he or she will see it regularly.
Involve the family to help identify a patient’s poor sleep habits and find ways to implement sleep hygiene principles.
Encourage patients to keep a sleep diary. Ask the patient to note how many hours and at what time he or she slept for at least 2 weeks, then bring this information to the next appointment. This record allows you to examine patients’ sleep patterns and recommend appropriate changes.
Ask patients for creative ideas to improve their sleep. This dialogue will facilitate the therapeutic alliance and encourage positive changes in patients’ lives.
1. Peterson MJ, Benca RM. Sleep in mood disorders. Psychiatr Clin North Am 2006;29:1009-32.
2. Mendelson WB. Combining pharmacological and non-pharmacological therapies for insomnia. J Clin Psychiatry 2007;68(suppl 5):19-23.
Dr. Khawaja is staff psychiatrist, VA Medical Center, Minneapolis, MN; Dr. Hurwitz is a psychiatrist and sleep medicine physician, VA Medical Center, Minneapolis, MN; Dr. Ebrahim is an endocrinologist, Minnesota Center for Obesity, Metabolism, and Endocrinology, Eagan, MN.
Proper sleep hygiene can help your patients fall and stay asleep consistently. Patients with insomnia are at a higher risk of developing or experiencing a recurrence of a mood disorder, and poor sleep can worsen psychiatric symptoms such as depression or mania.1 Data about combining behavioral approaches and hypnotic medications to treat insomnia are inconclusive;2 however, using the 2 together may help patients who do not respond to a single approach.
First rule out other causes of insomnia, such as sleep apnea, other medical conditions, or medications. Patients may improve after these factors are addressed.
Teaching sleep hygiene principles (Box) does not mean patients will adopt these habits, but employing the following suggestions could improve adherence:
Obtain a detailed sleep history to identify specific behaviors to be changed. For example, a patient might only have to stop watching television in bed to get a good night’s sleep, although some may find a brief exposure to television or radio facilitates relaxation.
Explain the rationale for changing a behavior. For example, when telling patients to limit caffeine or alcohol at night, list these substances’ negative effects on sleep. Similarly, when instructing patients to avoid watching television in bed, tell them that using the bedroom only for sleep or sex will help condition them for sleep at bedtime.
- Establish a regular sleep-wake schedule
- Limit caffeine and alcohol consumption
- Avoid naps
- Eliminate noise and light from the sleep environment
- Use the bed only for sleep or sex
- Avoid looking at a clock when trying to sleep
Discuss sleep regularly. A patient might not disclose poor sleeping habits during the first session.
Give your patient handouts on sleep hygiene principles and highlight the most pertinent information. Ask the patient to place the handout where he or she will see it regularly.
Involve the family to help identify a patient’s poor sleep habits and find ways to implement sleep hygiene principles.
Encourage patients to keep a sleep diary. Ask the patient to note how many hours and at what time he or she slept for at least 2 weeks, then bring this information to the next appointment. This record allows you to examine patients’ sleep patterns and recommend appropriate changes.
Ask patients for creative ideas to improve their sleep. This dialogue will facilitate the therapeutic alliance and encourage positive changes in patients’ lives.
Proper sleep hygiene can help your patients fall and stay asleep consistently. Patients with insomnia are at a higher risk of developing or experiencing a recurrence of a mood disorder, and poor sleep can worsen psychiatric symptoms such as depression or mania.1 Data about combining behavioral approaches and hypnotic medications to treat insomnia are inconclusive;2 however, using the 2 together may help patients who do not respond to a single approach.
First rule out other causes of insomnia, such as sleep apnea, other medical conditions, or medications. Patients may improve after these factors are addressed.
Teaching sleep hygiene principles (Box) does not mean patients will adopt these habits, but employing the following suggestions could improve adherence:
Obtain a detailed sleep history to identify specific behaviors to be changed. For example, a patient might only have to stop watching television in bed to get a good night’s sleep, although some may find a brief exposure to television or radio facilitates relaxation.
Explain the rationale for changing a behavior. For example, when telling patients to limit caffeine or alcohol at night, list these substances’ negative effects on sleep. Similarly, when instructing patients to avoid watching television in bed, tell them that using the bedroom only for sleep or sex will help condition them for sleep at bedtime.
- Establish a regular sleep-wake schedule
- Limit caffeine and alcohol consumption
- Avoid naps
- Eliminate noise and light from the sleep environment
- Use the bed only for sleep or sex
- Avoid looking at a clock when trying to sleep
Discuss sleep regularly. A patient might not disclose poor sleeping habits during the first session.
Give your patient handouts on sleep hygiene principles and highlight the most pertinent information. Ask the patient to place the handout where he or she will see it regularly.
Involve the family to help identify a patient’s poor sleep habits and find ways to implement sleep hygiene principles.
Encourage patients to keep a sleep diary. Ask the patient to note how many hours and at what time he or she slept for at least 2 weeks, then bring this information to the next appointment. This record allows you to examine patients’ sleep patterns and recommend appropriate changes.
Ask patients for creative ideas to improve their sleep. This dialogue will facilitate the therapeutic alliance and encourage positive changes in patients’ lives.
1. Peterson MJ, Benca RM. Sleep in mood disorders. Psychiatr Clin North Am 2006;29:1009-32.
2. Mendelson WB. Combining pharmacological and non-pharmacological therapies for insomnia. J Clin Psychiatry 2007;68(suppl 5):19-23.
Dr. Khawaja is staff psychiatrist, VA Medical Center, Minneapolis, MN; Dr. Hurwitz is a psychiatrist and sleep medicine physician, VA Medical Center, Minneapolis, MN; Dr. Ebrahim is an endocrinologist, Minnesota Center for Obesity, Metabolism, and Endocrinology, Eagan, MN.
1. Peterson MJ, Benca RM. Sleep in mood disorders. Psychiatr Clin North Am 2006;29:1009-32.
2. Mendelson WB. Combining pharmacological and non-pharmacological therapies for insomnia. J Clin Psychiatry 2007;68(suppl 5):19-23.
Dr. Khawaja is staff psychiatrist, VA Medical Center, Minneapolis, MN; Dr. Hurwitz is a psychiatrist and sleep medicine physician, VA Medical Center, Minneapolis, MN; Dr. Ebrahim is an endocrinologist, Minnesota Center for Obesity, Metabolism, and Endocrinology, Eagan, MN.
‘DARE’ to spot borderline personality disorder
Patients with borderline personality disorder (BPD) exhibit a pattern of instability in interpersonal relation-ships, self-image, and affects, and marked impulsivity beginning in early adulthood.1 These patients may experience other symptoms, such as mood swings or transient psychotic episodes, that are exacerbated by stress.
A BPD patient likely has additional diagnoses from previous clinicians—such as bipolar disorder, dysthymic disorder, panic disorder, major recurrent depression, substance abuse, posttraumatic stress disorder, intermittent explosive disorder, or any variety of adjustment, anxiety, eating, impulse control, mood, somatoform, or personality disorders.2 However, a BPD diagnosis best describes many of these patients, and the mnemonic “DARE” enumerates the most commonly encountered clinical picture.
Depression, Destruction, Denial. Chronic low-grade depression is the baseline mood for BPD. The patients might not report suicidal ideation or might deny a desire to die. But the predilection and potential for risky behavior that could result in accidental injury or death tends to confirm the presence of an underlying self-destructive wish.
Anger, Abandonment, Abuse. Typically, BPD patients are angry at the world. Anger simmers just below the threshold of self-control. When it boils over, BPD patients are apt to take their anger out on themselves by committing suicide or a self-mutilative act, or on others with passive aggression or the kind of physical or emotional abuse they themselves suffered.
BPD patients’ histories often include physical or emotional abandonment or abuse.
Relationships, Regrets, Repetition. Repeated patterns of unstable relationships are characteristic. Often BPD patients have multiple romantic partners, frequent job turnover, interrupted education, and few long-term, mature friendships. These patients’ friends and partners frequently suffer from similar problematic personality characteristics. BPD patients seem unable to break free of their unsuccessful patterns and repeatedly fail to maintain healthy, productive relationships.
Extremes, Emergencies, Ennui. Overuse of prescription drugs, alcohol, or other substances result in frequent emergency room visits. Bulimia, sexual promiscuity, and multiple body piercings or tattoos are emblematic of BPD. Ennui—a feeling of weariness or discontent—is fought off by engaging in extreme behaviors, such as reckless driving.
Many BPD patients improve and show greater stability in jobs and relationships with therapeutic intervention, although they often have a lifelong tendency toward impulsivity and intense relationships and emotions.
Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.
Patients with borderline personality disorder (BPD) exhibit a pattern of instability in interpersonal relation-ships, self-image, and affects, and marked impulsivity beginning in early adulthood.1 These patients may experience other symptoms, such as mood swings or transient psychotic episodes, that are exacerbated by stress.
A BPD patient likely has additional diagnoses from previous clinicians—such as bipolar disorder, dysthymic disorder, panic disorder, major recurrent depression, substance abuse, posttraumatic stress disorder, intermittent explosive disorder, or any variety of adjustment, anxiety, eating, impulse control, mood, somatoform, or personality disorders.2 However, a BPD diagnosis best describes many of these patients, and the mnemonic “DARE” enumerates the most commonly encountered clinical picture.
Depression, Destruction, Denial. Chronic low-grade depression is the baseline mood for BPD. The patients might not report suicidal ideation or might deny a desire to die. But the predilection and potential for risky behavior that could result in accidental injury or death tends to confirm the presence of an underlying self-destructive wish.
Anger, Abandonment, Abuse. Typically, BPD patients are angry at the world. Anger simmers just below the threshold of self-control. When it boils over, BPD patients are apt to take their anger out on themselves by committing suicide or a self-mutilative act, or on others with passive aggression or the kind of physical or emotional abuse they themselves suffered.
BPD patients’ histories often include physical or emotional abandonment or abuse.
Relationships, Regrets, Repetition. Repeated patterns of unstable relationships are characteristic. Often BPD patients have multiple romantic partners, frequent job turnover, interrupted education, and few long-term, mature friendships. These patients’ friends and partners frequently suffer from similar problematic personality characteristics. BPD patients seem unable to break free of their unsuccessful patterns and repeatedly fail to maintain healthy, productive relationships.
Extremes, Emergencies, Ennui. Overuse of prescription drugs, alcohol, or other substances result in frequent emergency room visits. Bulimia, sexual promiscuity, and multiple body piercings or tattoos are emblematic of BPD. Ennui—a feeling of weariness or discontent—is fought off by engaging in extreme behaviors, such as reckless driving.
Many BPD patients improve and show greater stability in jobs and relationships with therapeutic intervention, although they often have a lifelong tendency toward impulsivity and intense relationships and emotions.
Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.
Patients with borderline personality disorder (BPD) exhibit a pattern of instability in interpersonal relation-ships, self-image, and affects, and marked impulsivity beginning in early adulthood.1 These patients may experience other symptoms, such as mood swings or transient psychotic episodes, that are exacerbated by stress.
A BPD patient likely has additional diagnoses from previous clinicians—such as bipolar disorder, dysthymic disorder, panic disorder, major recurrent depression, substance abuse, posttraumatic stress disorder, intermittent explosive disorder, or any variety of adjustment, anxiety, eating, impulse control, mood, somatoform, or personality disorders.2 However, a BPD diagnosis best describes many of these patients, and the mnemonic “DARE” enumerates the most commonly encountered clinical picture.
Depression, Destruction, Denial. Chronic low-grade depression is the baseline mood for BPD. The patients might not report suicidal ideation or might deny a desire to die. But the predilection and potential for risky behavior that could result in accidental injury or death tends to confirm the presence of an underlying self-destructive wish.
Anger, Abandonment, Abuse. Typically, BPD patients are angry at the world. Anger simmers just below the threshold of self-control. When it boils over, BPD patients are apt to take their anger out on themselves by committing suicide or a self-mutilative act, or on others with passive aggression or the kind of physical or emotional abuse they themselves suffered.
BPD patients’ histories often include physical or emotional abandonment or abuse.
Relationships, Regrets, Repetition. Repeated patterns of unstable relationships are characteristic. Often BPD patients have multiple romantic partners, frequent job turnover, interrupted education, and few long-term, mature friendships. These patients’ friends and partners frequently suffer from similar problematic personality characteristics. BPD patients seem unable to break free of their unsuccessful patterns and repeatedly fail to maintain healthy, productive relationships.
Extremes, Emergencies, Ennui. Overuse of prescription drugs, alcohol, or other substances result in frequent emergency room visits. Bulimia, sexual promiscuity, and multiple body piercings or tattoos are emblematic of BPD. Ennui—a feeling of weariness or discontent—is fought off by engaging in extreme behaviors, such as reckless driving.
Many BPD patients improve and show greater stability in jobs and relationships with therapeutic intervention, although they often have a lifelong tendency toward impulsivity and intense relationships and emotions.
Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.
Dangerous duo: Antiepileptics plus herbals
Antiepileptic drugs (AEDs)—one of the most frequently prescribed medication classes—are used to manage seizures, epilepsy, pain syndromes, migraines, and psychiatric disorders such as bipolar disorder, anxiety, schizophrenia, and depression. When prescribing AEDs and monitoring patient response, consider possible adverse interactions with complementary and alternative medicines (CAM).
Approximately 40% of Americans use herbals or botanicals,1 whose pharmacokinetics, efficacy, or safety have not been rigorously studied. When used concurrently, these alternative remedies may reduce AEDs’ efficacy, increase the risk of seizures, or cause other neurologic adverse effects.
Common agents. In the United States, the most commonly used herbals and botanicals are garlic, ginkgo biloba, soy, melatonin, kava kava, St. John’s Wort, saw palmetto, and ginseng.2 Many first- and second-generation AEDs are known to interact with herbals and botanicals. All first-generation AEDs (such as carbamazepine, valproic acid, phenytoin, phenobarbital, and primidone) are cytochrome P-450 inducers or inhibitors, which means they have the potential to interact with other drugs that undergo hepatic metabolism. Because these interactions are unpredictable, it is important to carefully question your patient about the clinical effect of a prescribed AED.
Moreover, some botanicals—such as black cohosh, water hemlock, ephedra, kava kava, yohimbine, guarana, and ginkgo seeds—are known to induce seizures, which could negate an AED’s efficacy.
Communication. When managing psychiatric patients taking AEDs, maintain open communication regarding CAM. If a patient does not show clinical response to an AED or reports an adverse effect, gently inquire about his or her use of herbal remedies. Maintain a nonjudgmental tone when a patient reports using alternative remedies. Several studies have shown that patients often are reluctant to share this information with their physicians2-4 because they fear the physician may have a negative opinion about CAM.
The key to any patient inquiry regarding herbals is to identify why the patient initially chose the CAM. Doing so might reveal that the patient is not happy with the prescribed therapy, in which case you might be able to lower the risk of an adverse drug interaction by switching to another AED or persuading the patient to discontinue the herbal remedy.
Referneces
1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280(18):1569-75.
2. Sirven JI, Drazkowski JF, Zimmerman RS, et al. Complementary/alternative medicine for epilepsy in Arizona. Neurology 2003;61(4):576-7.
3. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998;279(19):1548-53.
4. National Center for Complementary and Alternative Medicine. What is CAM? Available at: http://nccam.nih.gov/health/whatiscam. Accessed June 7, 2007.
Dr. Sirven is associate professor of neurology, Mayo Clinic College of Medicine, Phoenix, AZ.
Antiepileptic drugs (AEDs)—one of the most frequently prescribed medication classes—are used to manage seizures, epilepsy, pain syndromes, migraines, and psychiatric disorders such as bipolar disorder, anxiety, schizophrenia, and depression. When prescribing AEDs and monitoring patient response, consider possible adverse interactions with complementary and alternative medicines (CAM).
Approximately 40% of Americans use herbals or botanicals,1 whose pharmacokinetics, efficacy, or safety have not been rigorously studied. When used concurrently, these alternative remedies may reduce AEDs’ efficacy, increase the risk of seizures, or cause other neurologic adverse effects.
Common agents. In the United States, the most commonly used herbals and botanicals are garlic, ginkgo biloba, soy, melatonin, kava kava, St. John’s Wort, saw palmetto, and ginseng.2 Many first- and second-generation AEDs are known to interact with herbals and botanicals. All first-generation AEDs (such as carbamazepine, valproic acid, phenytoin, phenobarbital, and primidone) are cytochrome P-450 inducers or inhibitors, which means they have the potential to interact with other drugs that undergo hepatic metabolism. Because these interactions are unpredictable, it is important to carefully question your patient about the clinical effect of a prescribed AED.
Moreover, some botanicals—such as black cohosh, water hemlock, ephedra, kava kava, yohimbine, guarana, and ginkgo seeds—are known to induce seizures, which could negate an AED’s efficacy.
Communication. When managing psychiatric patients taking AEDs, maintain open communication regarding CAM. If a patient does not show clinical response to an AED or reports an adverse effect, gently inquire about his or her use of herbal remedies. Maintain a nonjudgmental tone when a patient reports using alternative remedies. Several studies have shown that patients often are reluctant to share this information with their physicians2-4 because they fear the physician may have a negative opinion about CAM.
The key to any patient inquiry regarding herbals is to identify why the patient initially chose the CAM. Doing so might reveal that the patient is not happy with the prescribed therapy, in which case you might be able to lower the risk of an adverse drug interaction by switching to another AED or persuading the patient to discontinue the herbal remedy.
Antiepileptic drugs (AEDs)—one of the most frequently prescribed medication classes—are used to manage seizures, epilepsy, pain syndromes, migraines, and psychiatric disorders such as bipolar disorder, anxiety, schizophrenia, and depression. When prescribing AEDs and monitoring patient response, consider possible adverse interactions with complementary and alternative medicines (CAM).
Approximately 40% of Americans use herbals or botanicals,1 whose pharmacokinetics, efficacy, or safety have not been rigorously studied. When used concurrently, these alternative remedies may reduce AEDs’ efficacy, increase the risk of seizures, or cause other neurologic adverse effects.
Common agents. In the United States, the most commonly used herbals and botanicals are garlic, ginkgo biloba, soy, melatonin, kava kava, St. John’s Wort, saw palmetto, and ginseng.2 Many first- and second-generation AEDs are known to interact with herbals and botanicals. All first-generation AEDs (such as carbamazepine, valproic acid, phenytoin, phenobarbital, and primidone) are cytochrome P-450 inducers or inhibitors, which means they have the potential to interact with other drugs that undergo hepatic metabolism. Because these interactions are unpredictable, it is important to carefully question your patient about the clinical effect of a prescribed AED.
Moreover, some botanicals—such as black cohosh, water hemlock, ephedra, kava kava, yohimbine, guarana, and ginkgo seeds—are known to induce seizures, which could negate an AED’s efficacy.
Communication. When managing psychiatric patients taking AEDs, maintain open communication regarding CAM. If a patient does not show clinical response to an AED or reports an adverse effect, gently inquire about his or her use of herbal remedies. Maintain a nonjudgmental tone when a patient reports using alternative remedies. Several studies have shown that patients often are reluctant to share this information with their physicians2-4 because they fear the physician may have a negative opinion about CAM.
The key to any patient inquiry regarding herbals is to identify why the patient initially chose the CAM. Doing so might reveal that the patient is not happy with the prescribed therapy, in which case you might be able to lower the risk of an adverse drug interaction by switching to another AED or persuading the patient to discontinue the herbal remedy.
Referneces
1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280(18):1569-75.
2. Sirven JI, Drazkowski JF, Zimmerman RS, et al. Complementary/alternative medicine for epilepsy in Arizona. Neurology 2003;61(4):576-7.
3. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998;279(19):1548-53.
4. National Center for Complementary and Alternative Medicine. What is CAM? Available at: http://nccam.nih.gov/health/whatiscam. Accessed June 7, 2007.
Dr. Sirven is associate professor of neurology, Mayo Clinic College of Medicine, Phoenix, AZ.
Referneces
1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280(18):1569-75.
2. Sirven JI, Drazkowski JF, Zimmerman RS, et al. Complementary/alternative medicine for epilepsy in Arizona. Neurology 2003;61(4):576-7.
3. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998;279(19):1548-53.
4. National Center for Complementary and Alternative Medicine. What is CAM? Available at: http://nccam.nih.gov/health/whatiscam. Accessed June 7, 2007.
Dr. Sirven is associate professor of neurology, Mayo Clinic College of Medicine, Phoenix, AZ.
FLIGHTY patients a clue to hypomania
Dramatic, provocative, and confusing often describes the presentation of individuals with hypomania. But their lack of insight, rationalization, and minimization of maladaptive behavior can complicate diagnosis. Hypomanic patients often go for as long as a decade without receiving a correct diagnosis.
Full-blown mania usually is easy to recognize, but hypomania and other bipolar spectrum disorders that do not meet DSM-IV-TR criteria for bipolar I disorder are less obvious.1 The dictionary defines “flighty” as frivolous, irresponsible, capricious, mercurial, and volatile, words that also could describe hypomanic individuals. To help diagnose hypomania, I came up with a mnemonic called FLIGHTY based on the 7 DSM-IV-TR criteria for hypomania:
Flight of ideas, racing thoughts. Ask patients if they talk before they think or if their thinking is too fast.
Lacking attention and concentration, distractible. Ask patients if they have trouble reading or watching television or if they become preoccupied with unimportant details.
Insomnia or decreased need for sleep. Patients report feeling energetic despite remarkably few hours of sleep.
Grandiosity, inflated self-esteem. Inquire if patients feel more creative and powerful than others.
Hyperactive, psychomotor agitation. Determine of patients have an increase in repetitive activities or if they start many tasks but complete few.
Talkative, pressured speech. A reliable third party often can best assess talkativeness, though some patients are aware of their pressured speech and recount being “tongue-tied.”
Yearnings that lead to excessive involvement in pleasurable activities and risky behaviors. Ask whether patients have given in to their yearnings or engaged in behaviors with high potential for harm or legal consequences.
Many hypomania symptoms overlap with those of other illnesses such as attention-deficit/hyperactivity disorder, personality disorders, and anxiety disorders. Accurate diagnosis of hypomania can be critical. Chemical dependence, sexual indiscretions, delusional thinking, spending sprees, unexplained travel, suicide, and more symptoms can contribute to morbidity. Remember that DSM-IV-TR criteria for hypomania require a 4-day period of elevated or irritable mood with:
- 3 of the above symptoms if there is expansive mood
- 4 if there is only irritable mood.
Clinical judgment and examination of the overall picture—not 1 or 2 isolated symptoms—are key to the correct diagnosis.
Reference
1. Young RC, Klerman GL. Mania in late life: focus on age at onset. Am J Psychiatry 1992;149:867-76.
Dr. Wagner is assistant clinical professor, Indiana University, Bloomington, and staff psychiatrist, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis.
Dramatic, provocative, and confusing often describes the presentation of individuals with hypomania. But their lack of insight, rationalization, and minimization of maladaptive behavior can complicate diagnosis. Hypomanic patients often go for as long as a decade without receiving a correct diagnosis.
Full-blown mania usually is easy to recognize, but hypomania and other bipolar spectrum disorders that do not meet DSM-IV-TR criteria for bipolar I disorder are less obvious.1 The dictionary defines “flighty” as frivolous, irresponsible, capricious, mercurial, and volatile, words that also could describe hypomanic individuals. To help diagnose hypomania, I came up with a mnemonic called FLIGHTY based on the 7 DSM-IV-TR criteria for hypomania:
Flight of ideas, racing thoughts. Ask patients if they talk before they think or if their thinking is too fast.
Lacking attention and concentration, distractible. Ask patients if they have trouble reading or watching television or if they become preoccupied with unimportant details.
Insomnia or decreased need for sleep. Patients report feeling energetic despite remarkably few hours of sleep.
Grandiosity, inflated self-esteem. Inquire if patients feel more creative and powerful than others.
Hyperactive, psychomotor agitation. Determine of patients have an increase in repetitive activities or if they start many tasks but complete few.
Talkative, pressured speech. A reliable third party often can best assess talkativeness, though some patients are aware of their pressured speech and recount being “tongue-tied.”
Yearnings that lead to excessive involvement in pleasurable activities and risky behaviors. Ask whether patients have given in to their yearnings or engaged in behaviors with high potential for harm or legal consequences.
Many hypomania symptoms overlap with those of other illnesses such as attention-deficit/hyperactivity disorder, personality disorders, and anxiety disorders. Accurate diagnosis of hypomania can be critical. Chemical dependence, sexual indiscretions, delusional thinking, spending sprees, unexplained travel, suicide, and more symptoms can contribute to morbidity. Remember that DSM-IV-TR criteria for hypomania require a 4-day period of elevated or irritable mood with:
- 3 of the above symptoms if there is expansive mood
- 4 if there is only irritable mood.
Clinical judgment and examination of the overall picture—not 1 or 2 isolated symptoms—are key to the correct diagnosis.
Dramatic, provocative, and confusing often describes the presentation of individuals with hypomania. But their lack of insight, rationalization, and minimization of maladaptive behavior can complicate diagnosis. Hypomanic patients often go for as long as a decade without receiving a correct diagnosis.
Full-blown mania usually is easy to recognize, but hypomania and other bipolar spectrum disorders that do not meet DSM-IV-TR criteria for bipolar I disorder are less obvious.1 The dictionary defines “flighty” as frivolous, irresponsible, capricious, mercurial, and volatile, words that also could describe hypomanic individuals. To help diagnose hypomania, I came up with a mnemonic called FLIGHTY based on the 7 DSM-IV-TR criteria for hypomania:
Flight of ideas, racing thoughts. Ask patients if they talk before they think or if their thinking is too fast.
Lacking attention and concentration, distractible. Ask patients if they have trouble reading or watching television or if they become preoccupied with unimportant details.
Insomnia or decreased need for sleep. Patients report feeling energetic despite remarkably few hours of sleep.
Grandiosity, inflated self-esteem. Inquire if patients feel more creative and powerful than others.
Hyperactive, psychomotor agitation. Determine of patients have an increase in repetitive activities or if they start many tasks but complete few.
Talkative, pressured speech. A reliable third party often can best assess talkativeness, though some patients are aware of their pressured speech and recount being “tongue-tied.”
Yearnings that lead to excessive involvement in pleasurable activities and risky behaviors. Ask whether patients have given in to their yearnings or engaged in behaviors with high potential for harm or legal consequences.
Many hypomania symptoms overlap with those of other illnesses such as attention-deficit/hyperactivity disorder, personality disorders, and anxiety disorders. Accurate diagnosis of hypomania can be critical. Chemical dependence, sexual indiscretions, delusional thinking, spending sprees, unexplained travel, suicide, and more symptoms can contribute to morbidity. Remember that DSM-IV-TR criteria for hypomania require a 4-day period of elevated or irritable mood with:
- 3 of the above symptoms if there is expansive mood
- 4 if there is only irritable mood.
Clinical judgment and examination of the overall picture—not 1 or 2 isolated symptoms—are key to the correct diagnosis.
Reference
1. Young RC, Klerman GL. Mania in late life: focus on age at onset. Am J Psychiatry 1992;149:867-76.
Dr. Wagner is assistant clinical professor, Indiana University, Bloomington, and staff psychiatrist, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis.
Reference
1. Young RC, Klerman GL. Mania in late life: focus on age at onset. Am J Psychiatry 1992;149:867-76.
Dr. Wagner is assistant clinical professor, Indiana University, Bloomington, and staff psychiatrist, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis.
Does this patient have prodromal psychosis?
Schizophrenia prodrome is an early or prepsychotic state that is a deviation from an individual’s usual behavior and experience.1 Prepsychotic patients can differentiate reality from fantasy but gradually lose this ability as their illness progresses.2 Therefore, early identification and treatment of prepsychotic adolescents and those with early psychosis can reduce social withdrawal, isolation, and psychosocial morbidity and mortality.
Detective work
Probing for possible paranoia and psychotic symptoms in adolescents who do not present with these complaints can be challenging. Maintain rapport as you probe for unusual thought content and delusional ideas by inquiring about your patient’s “experiences” rather than the more pejorative term “problems.” Some prodromal patients may be at imminent risk of conversion to psychosis and continued deterioration. The following questions that are based on prodrome assessment scales1,3 can help detect emerging psychosis.
Thinking can be evaluated by asking:
- Do you feel that you or people around you have changed in a way you can’t explain?
- Do people seem alien or evil?
- Have you been confused about whether something is real or imaginary?
- Do you daydream a lot?
- Are you preoccupied with stories or ideas?
- How are others treating you?
- Do you feel that people think about you in a negative way?
- Do you feel singled out?
- Do you feel that you must be vigilant around others to be safe?
- How do you spend your free time?
- How often do you talk with friends and family?
- What groups do you participate in?
- How friendly are others at school or work?
Ask your patient about computer use, especially favorite Web sites and electronic games. Some alienated and schizoid adolescents may be heavily involved in role-playing fantasy electronic games.4 Loners may fill their free time in cyberspace.
Perceptual abnormalities and hallucinations can be determined by asking:
- Do you ever feel your mind plays tricks on you?
- Do you hear unusual sounds?
- Do you ever hear your name being called when no one is there?
- Do you feel a presence around you?
- Do you ever see people or things but realize they may not be real?
- Do you feel numb?
- Do you feel disconnected from yourself or your life, as if you are a spectator?
- Do you lack rapport with others?
- Are you bored?
Estimate deteriorating role functioning by inquiring about problems completing assignments and impaired tolerance of normal stress.
- Do you avoid or feel overwhelmed by situations that previously you could deal with?
- Is it harder to get through the day?
- Are you easily thrown off by unexpected events?
1. Yung AR, McGorry PD. The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophr Bull 1996;22:353-70.
2. Tully E, McGlashan TH. The prodrome. In: Lieberman JA, Stroup TS, Perkins DO, eds. The American Psychiatric Publishing textbook of schizophrenia. Washington, DC: American Psychiatric Publishing, Inc.; 2006:341-52.
3. McGlashan TH, Miller TJ, Woods SW, et al. Instrument for the assessment of prodromal symptoms and states. In: Miller T, Mednick SA, McGlashan TH, et al, eds. Early intervention in psychotic disorders. Amsterdam: Kluwer Academic; 2001:135-49.
4. Allison SE, von Wahlde L, Shockley T, Gabbard GO. The development of the self in the era of the internet and role-playing fantasy games. Am J Psychiatry 2006;163(3):381-5.
5. Grube M. Towards an empirically based validation of intuitive diagnostic: Rumke’s “praecox feeling” across the schizophrenia spectrum: preliminary results. Psychopathology 2006;39(5):209-17.
Dr. Tully is assistant professor of psychiatry, University of New Mexico, Albuquerque.
Schizophrenia prodrome is an early or prepsychotic state that is a deviation from an individual’s usual behavior and experience.1 Prepsychotic patients can differentiate reality from fantasy but gradually lose this ability as their illness progresses.2 Therefore, early identification and treatment of prepsychotic adolescents and those with early psychosis can reduce social withdrawal, isolation, and psychosocial morbidity and mortality.
Detective work
Probing for possible paranoia and psychotic symptoms in adolescents who do not present with these complaints can be challenging. Maintain rapport as you probe for unusual thought content and delusional ideas by inquiring about your patient’s “experiences” rather than the more pejorative term “problems.” Some prodromal patients may be at imminent risk of conversion to psychosis and continued deterioration. The following questions that are based on prodrome assessment scales1,3 can help detect emerging psychosis.
Thinking can be evaluated by asking:
- Do you feel that you or people around you have changed in a way you can’t explain?
- Do people seem alien or evil?
- Have you been confused about whether something is real or imaginary?
- Do you daydream a lot?
- Are you preoccupied with stories or ideas?
- How are others treating you?
- Do you feel that people think about you in a negative way?
- Do you feel singled out?
- Do you feel that you must be vigilant around others to be safe?
- How do you spend your free time?
- How often do you talk with friends and family?
- What groups do you participate in?
- How friendly are others at school or work?
Ask your patient about computer use, especially favorite Web sites and electronic games. Some alienated and schizoid adolescents may be heavily involved in role-playing fantasy electronic games.4 Loners may fill their free time in cyberspace.
Perceptual abnormalities and hallucinations can be determined by asking:
- Do you ever feel your mind plays tricks on you?
- Do you hear unusual sounds?
- Do you ever hear your name being called when no one is there?
- Do you feel a presence around you?
- Do you ever see people or things but realize they may not be real?
- Do you feel numb?
- Do you feel disconnected from yourself or your life, as if you are a spectator?
- Do you lack rapport with others?
- Are you bored?
Estimate deteriorating role functioning by inquiring about problems completing assignments and impaired tolerance of normal stress.
- Do you avoid or feel overwhelmed by situations that previously you could deal with?
- Is it harder to get through the day?
- Are you easily thrown off by unexpected events?
Schizophrenia prodrome is an early or prepsychotic state that is a deviation from an individual’s usual behavior and experience.1 Prepsychotic patients can differentiate reality from fantasy but gradually lose this ability as their illness progresses.2 Therefore, early identification and treatment of prepsychotic adolescents and those with early psychosis can reduce social withdrawal, isolation, and psychosocial morbidity and mortality.
Detective work
Probing for possible paranoia and psychotic symptoms in adolescents who do not present with these complaints can be challenging. Maintain rapport as you probe for unusual thought content and delusional ideas by inquiring about your patient’s “experiences” rather than the more pejorative term “problems.” Some prodromal patients may be at imminent risk of conversion to psychosis and continued deterioration. The following questions that are based on prodrome assessment scales1,3 can help detect emerging psychosis.
Thinking can be evaluated by asking:
- Do you feel that you or people around you have changed in a way you can’t explain?
- Do people seem alien or evil?
- Have you been confused about whether something is real or imaginary?
- Do you daydream a lot?
- Are you preoccupied with stories or ideas?
- How are others treating you?
- Do you feel that people think about you in a negative way?
- Do you feel singled out?
- Do you feel that you must be vigilant around others to be safe?
- How do you spend your free time?
- How often do you talk with friends and family?
- What groups do you participate in?
- How friendly are others at school or work?
Ask your patient about computer use, especially favorite Web sites and electronic games. Some alienated and schizoid adolescents may be heavily involved in role-playing fantasy electronic games.4 Loners may fill their free time in cyberspace.
Perceptual abnormalities and hallucinations can be determined by asking:
- Do you ever feel your mind plays tricks on you?
- Do you hear unusual sounds?
- Do you ever hear your name being called when no one is there?
- Do you feel a presence around you?
- Do you ever see people or things but realize they may not be real?
- Do you feel numb?
- Do you feel disconnected from yourself or your life, as if you are a spectator?
- Do you lack rapport with others?
- Are you bored?
Estimate deteriorating role functioning by inquiring about problems completing assignments and impaired tolerance of normal stress.
- Do you avoid or feel overwhelmed by situations that previously you could deal with?
- Is it harder to get through the day?
- Are you easily thrown off by unexpected events?
1. Yung AR, McGorry PD. The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophr Bull 1996;22:353-70.
2. Tully E, McGlashan TH. The prodrome. In: Lieberman JA, Stroup TS, Perkins DO, eds. The American Psychiatric Publishing textbook of schizophrenia. Washington, DC: American Psychiatric Publishing, Inc.; 2006:341-52.
3. McGlashan TH, Miller TJ, Woods SW, et al. Instrument for the assessment of prodromal symptoms and states. In: Miller T, Mednick SA, McGlashan TH, et al, eds. Early intervention in psychotic disorders. Amsterdam: Kluwer Academic; 2001:135-49.
4. Allison SE, von Wahlde L, Shockley T, Gabbard GO. The development of the self in the era of the internet and role-playing fantasy games. Am J Psychiatry 2006;163(3):381-5.
5. Grube M. Towards an empirically based validation of intuitive diagnostic: Rumke’s “praecox feeling” across the schizophrenia spectrum: preliminary results. Psychopathology 2006;39(5):209-17.
Dr. Tully is assistant professor of psychiatry, University of New Mexico, Albuquerque.
1. Yung AR, McGorry PD. The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophr Bull 1996;22:353-70.
2. Tully E, McGlashan TH. The prodrome. In: Lieberman JA, Stroup TS, Perkins DO, eds. The American Psychiatric Publishing textbook of schizophrenia. Washington, DC: American Psychiatric Publishing, Inc.; 2006:341-52.
3. McGlashan TH, Miller TJ, Woods SW, et al. Instrument for the assessment of prodromal symptoms and states. In: Miller T, Mednick SA, McGlashan TH, et al, eds. Early intervention in psychotic disorders. Amsterdam: Kluwer Academic; 2001:135-49.
4. Allison SE, von Wahlde L, Shockley T, Gabbard GO. The development of the self in the era of the internet and role-playing fantasy games. Am J Psychiatry 2006;163(3):381-5.
5. Grube M. Towards an empirically based validation of intuitive diagnostic: Rumke’s “praecox feeling” across the schizophrenia spectrum: preliminary results. Psychopathology 2006;39(5):209-17.
Dr. Tully is assistant professor of psychiatry, University of New Mexico, Albuquerque.
How long to wait for an antidepressant to ‘work’
Prevailing wisdom says it takes 3 to 4 weeks for an antidepressant to show clinical effect. Historically, patients who improve in the first 2 weeks have been labeled “placebo responders.”1 Several recent studies, however, demonstrate a real, drug-based response in many patients as early as the first week of treatment, depending on the medication (Table).2-5 In practical terms, these studies raise the question of how long you should wait for an antidepressant to “work.”
Table
Variables in antidepressant response
It is not surprising that onset of antidepressant response in some patients varies. The new data—derived mainly from meta-analyses of studies using the Hamilton Depression Rating Scale (HAM-D)—do not tease out sources of variability in the studies, including:
|
Early indications. Here are some tips for gauging antidepressant response, depending on what you see in the first 2 to 4 weeks:
- Obtain a pretreatment score on the Beck Depression Inventory or other depression rating scale, and repeat the assessment at least once between days 7 and 10 of treatment. If there is little or no improvement, consider a modest dosage increase.
- Don’t assume that a patient who responds to an antidepressant during the first 2 weeks is experiencing a placebo effect. It may be a drug-mediated response. Some patients will retain and build on this early response, whereas others’ response may wane over subsequent weeks.
- No response to an antidepressant during weeks 1 through 4 does not bode well for most patients,5,6 although the data do not support giving up on an antidepressant after 1 to 2 weeks of nonresponse. Responses will “accumulate” during weeks 3 to 5 of treatment.7
- Patients who show little response during the first 2 weeks of treatment but experience some improvement during weeks 3 and 4 may be late responders. However, if the patient shows no improvement by week 3 or 4, consider switching to a different antidepressant, perhaps one from a different chemical class.8
- Different neurovegetative signs and symptoms of depression may improve at different rates, with some requiring >8 weeks of treatment. Insight, for example, may not improve until the second month of treatment.9
- Individualize treatment. Many treatment-refractory depressed patients—who failed to respond to 1 or more adequate drug trials—may require longer and more intensive treatment (>3 months) beffore showing a robust response.10
- “Onset of response” does not equal “clinical recovery,” nor is an improved Hamilton Depression Scale score a proxy for “high quality of life.” Patients may need ≥2 months for clinically significant improvement in interpersonal, social, and vocational function.11
Acknowledgement
The author expresses his appreciation to Michael Posternak, MD, Andrew Nierenberg, MD, and Alex J. Mitchell, MD, for their helpful comments on an early draft of this article.
1. Quitkin FM, McGrath PJ, Rabkin JG, et al. Different types of placebo response in patients receiving antidepressants. Am J Psychiatry 1991;148:197-203.
2. Posternak MA, Zimmerman M. Is there a delay in the antidepressant effect? A meta-analysis. J Clin Psychiatry 2005;66:148-58.
3. Taylor MJ, Freemantle N, Geddes JR, et al. Early onset of selective serotonin reuptake inhibitor antidepressant action. Arch Gen Psychiatry 2006;63:1217-23.
4. Mitchell AJ. Two week delay in onset of action of antidepressants: new evidence. Br J Psychiatry 2006;188:105-6.
5. Katz MM, Bowden CL, Berman N, et al. Resolving the onset of antidepressants’ clinical actions. J Clin Psychopharmacol 2006;26:549-53.
6. Nierenberg AA, Farabaugh AH, Alpert JE, et al. Timing of onset of antidepressant response with fluoxetine. Am J Psychiatry 2000;157:1423-8.
7. Stassen HH, Angst J, Delini-Stula A. Delayed onset of action of antidepressant drugs: fact or fiction? CNS Drugs 1998;3:177-84.
8. Trivedi MH, Morris DW, Grannemann BD, et al. Symptom clusters as predictors of late response to antidepressant treatment. J Clin Psychiatry 2005;66:1064-70.
9. Hirschfeld RM, Mallinckrodt C, Lee TC, et al. Time course of depression-symptom improvement during treatment with duloxetine. Depress Anxiety 2005;21(4):170-7.
10. Tew JD, Jr, Mulsant BH, Houck PR, et al. Impact of prior treatment exposure on response to antidepressant treatment in late life. Am J Geriatr Psychiatry 2006 Nov;14(11):957-65.
11. Dubini A, Bosc M, Polin V. Noradrenaline-selective versus serotonin-selective antidepressant therapy: differential effects on social functioning. J Psychopharmacol 1997;11(suppl 4):S17-S23.
Dr. Pies is clinical professor of psychiatry, Tufts University School of Medicine, Boston, MA.
Prevailing wisdom says it takes 3 to 4 weeks for an antidepressant to show clinical effect. Historically, patients who improve in the first 2 weeks have been labeled “placebo responders.”1 Several recent studies, however, demonstrate a real, drug-based response in many patients as early as the first week of treatment, depending on the medication (Table).2-5 In practical terms, these studies raise the question of how long you should wait for an antidepressant to “work.”
Table
Variables in antidepressant response
It is not surprising that onset of antidepressant response in some patients varies. The new data—derived mainly from meta-analyses of studies using the Hamilton Depression Rating Scale (HAM-D)—do not tease out sources of variability in the studies, including:
|
Early indications. Here are some tips for gauging antidepressant response, depending on what you see in the first 2 to 4 weeks:
- Obtain a pretreatment score on the Beck Depression Inventory or other depression rating scale, and repeat the assessment at least once between days 7 and 10 of treatment. If there is little or no improvement, consider a modest dosage increase.
- Don’t assume that a patient who responds to an antidepressant during the first 2 weeks is experiencing a placebo effect. It may be a drug-mediated response. Some patients will retain and build on this early response, whereas others’ response may wane over subsequent weeks.
- No response to an antidepressant during weeks 1 through 4 does not bode well for most patients,5,6 although the data do not support giving up on an antidepressant after 1 to 2 weeks of nonresponse. Responses will “accumulate” during weeks 3 to 5 of treatment.7
- Patients who show little response during the first 2 weeks of treatment but experience some improvement during weeks 3 and 4 may be late responders. However, if the patient shows no improvement by week 3 or 4, consider switching to a different antidepressant, perhaps one from a different chemical class.8
- Different neurovegetative signs and symptoms of depression may improve at different rates, with some requiring >8 weeks of treatment. Insight, for example, may not improve until the second month of treatment.9
- Individualize treatment. Many treatment-refractory depressed patients—who failed to respond to 1 or more adequate drug trials—may require longer and more intensive treatment (>3 months) beffore showing a robust response.10
- “Onset of response” does not equal “clinical recovery,” nor is an improved Hamilton Depression Scale score a proxy for “high quality of life.” Patients may need ≥2 months for clinically significant improvement in interpersonal, social, and vocational function.11
Acknowledgement
The author expresses his appreciation to Michael Posternak, MD, Andrew Nierenberg, MD, and Alex J. Mitchell, MD, for their helpful comments on an early draft of this article.
Prevailing wisdom says it takes 3 to 4 weeks for an antidepressant to show clinical effect. Historically, patients who improve in the first 2 weeks have been labeled “placebo responders.”1 Several recent studies, however, demonstrate a real, drug-based response in many patients as early as the first week of treatment, depending on the medication (Table).2-5 In practical terms, these studies raise the question of how long you should wait for an antidepressant to “work.”
Table
Variables in antidepressant response
It is not surprising that onset of antidepressant response in some patients varies. The new data—derived mainly from meta-analyses of studies using the Hamilton Depression Rating Scale (HAM-D)—do not tease out sources of variability in the studies, including:
|
Early indications. Here are some tips for gauging antidepressant response, depending on what you see in the first 2 to 4 weeks:
- Obtain a pretreatment score on the Beck Depression Inventory or other depression rating scale, and repeat the assessment at least once between days 7 and 10 of treatment. If there is little or no improvement, consider a modest dosage increase.
- Don’t assume that a patient who responds to an antidepressant during the first 2 weeks is experiencing a placebo effect. It may be a drug-mediated response. Some patients will retain and build on this early response, whereas others’ response may wane over subsequent weeks.
- No response to an antidepressant during weeks 1 through 4 does not bode well for most patients,5,6 although the data do not support giving up on an antidepressant after 1 to 2 weeks of nonresponse. Responses will “accumulate” during weeks 3 to 5 of treatment.7
- Patients who show little response during the first 2 weeks of treatment but experience some improvement during weeks 3 and 4 may be late responders. However, if the patient shows no improvement by week 3 or 4, consider switching to a different antidepressant, perhaps one from a different chemical class.8
- Different neurovegetative signs and symptoms of depression may improve at different rates, with some requiring >8 weeks of treatment. Insight, for example, may not improve until the second month of treatment.9
- Individualize treatment. Many treatment-refractory depressed patients—who failed to respond to 1 or more adequate drug trials—may require longer and more intensive treatment (>3 months) beffore showing a robust response.10
- “Onset of response” does not equal “clinical recovery,” nor is an improved Hamilton Depression Scale score a proxy for “high quality of life.” Patients may need ≥2 months for clinically significant improvement in interpersonal, social, and vocational function.11
Acknowledgement
The author expresses his appreciation to Michael Posternak, MD, Andrew Nierenberg, MD, and Alex J. Mitchell, MD, for their helpful comments on an early draft of this article.
1. Quitkin FM, McGrath PJ, Rabkin JG, et al. Different types of placebo response in patients receiving antidepressants. Am J Psychiatry 1991;148:197-203.
2. Posternak MA, Zimmerman M. Is there a delay in the antidepressant effect? A meta-analysis. J Clin Psychiatry 2005;66:148-58.
3. Taylor MJ, Freemantle N, Geddes JR, et al. Early onset of selective serotonin reuptake inhibitor antidepressant action. Arch Gen Psychiatry 2006;63:1217-23.
4. Mitchell AJ. Two week delay in onset of action of antidepressants: new evidence. Br J Psychiatry 2006;188:105-6.
5. Katz MM, Bowden CL, Berman N, et al. Resolving the onset of antidepressants’ clinical actions. J Clin Psychopharmacol 2006;26:549-53.
6. Nierenberg AA, Farabaugh AH, Alpert JE, et al. Timing of onset of antidepressant response with fluoxetine. Am J Psychiatry 2000;157:1423-8.
7. Stassen HH, Angst J, Delini-Stula A. Delayed onset of action of antidepressant drugs: fact or fiction? CNS Drugs 1998;3:177-84.
8. Trivedi MH, Morris DW, Grannemann BD, et al. Symptom clusters as predictors of late response to antidepressant treatment. J Clin Psychiatry 2005;66:1064-70.
9. Hirschfeld RM, Mallinckrodt C, Lee TC, et al. Time course of depression-symptom improvement during treatment with duloxetine. Depress Anxiety 2005;21(4):170-7.
10. Tew JD, Jr, Mulsant BH, Houck PR, et al. Impact of prior treatment exposure on response to antidepressant treatment in late life. Am J Geriatr Psychiatry 2006 Nov;14(11):957-65.
11. Dubini A, Bosc M, Polin V. Noradrenaline-selective versus serotonin-selective antidepressant therapy: differential effects on social functioning. J Psychopharmacol 1997;11(suppl 4):S17-S23.
Dr. Pies is clinical professor of psychiatry, Tufts University School of Medicine, Boston, MA.
1. Quitkin FM, McGrath PJ, Rabkin JG, et al. Different types of placebo response in patients receiving antidepressants. Am J Psychiatry 1991;148:197-203.
2. Posternak MA, Zimmerman M. Is there a delay in the antidepressant effect? A meta-analysis. J Clin Psychiatry 2005;66:148-58.
3. Taylor MJ, Freemantle N, Geddes JR, et al. Early onset of selective serotonin reuptake inhibitor antidepressant action. Arch Gen Psychiatry 2006;63:1217-23.
4. Mitchell AJ. Two week delay in onset of action of antidepressants: new evidence. Br J Psychiatry 2006;188:105-6.
5. Katz MM, Bowden CL, Berman N, et al. Resolving the onset of antidepressants’ clinical actions. J Clin Psychopharmacol 2006;26:549-53.
6. Nierenberg AA, Farabaugh AH, Alpert JE, et al. Timing of onset of antidepressant response with fluoxetine. Am J Psychiatry 2000;157:1423-8.
7. Stassen HH, Angst J, Delini-Stula A. Delayed onset of action of antidepressant drugs: fact or fiction? CNS Drugs 1998;3:177-84.
8. Trivedi MH, Morris DW, Grannemann BD, et al. Symptom clusters as predictors of late response to antidepressant treatment. J Clin Psychiatry 2005;66:1064-70.
9. Hirschfeld RM, Mallinckrodt C, Lee TC, et al. Time course of depression-symptom improvement during treatment with duloxetine. Depress Anxiety 2005;21(4):170-7.
10. Tew JD, Jr, Mulsant BH, Houck PR, et al. Impact of prior treatment exposure on response to antidepressant treatment in late life. Am J Geriatr Psychiatry 2006 Nov;14(11):957-65.
11. Dubini A, Bosc M, Polin V. Noradrenaline-selective versus serotonin-selective antidepressant therapy: differential effects on social functioning. J Psychopharmacol 1997;11(suppl 4):S17-S23.
Dr. Pies is clinical professor of psychiatry, Tufts University School of Medicine, Boston, MA.