Pearls

Patients voluntarily admitted to locked psychiatric intensive care units sometimes ask to leave against medical advice. They may minimize the severity of their acute illness or deny psychiatric symptoms to obtain a discharge.

Patient characteristics and provider procedures contribute to patients’ decisions to request a discharge against medical advice (DAMA) (Table).¹

Table

Risk factors for discharge against medical advice

Not for everyone. Acutely psychotic, delusional, delirious, or demented patients or those with suicidal and homicidal ideation are not candidates for DAMA. For others, approach the patient calmly, explain with empathy what DAMA entails, and support the reasons for admission. Emphasize that following the treatment plan will alleviate psychiatric symptoms sooner and may shorten their stay.

Know the involuntary commitment procedures for your jurisdiction, and be prepared to discuss them with the patient. Assess the patient’s decision-making capacity, including awareness of the severity of his or her psychiatric illness and potential consequences of leaving against medical advice.

Arrange follow-up care for DAMA patients:

• Provide the patient with a brief summary of diagnosis, medications, and follow-up plans.
  
• Arrange the next available office or telephone appointment.
  
• Obtain contact information of those responsible for the patient’s safety.
  
• Provide the patient with emergency room and other phone numbers for crisis intervention.
  

DAMA does not absolve the physician of responsibility for poor outcomes. Carefully document the DAMA process because these patients are at increased risk of harm.² Make sure the patient signs, dates, and notes the time on the DAMA request.

Patients voluntarily admitted to locked psychiatric intensive care units sometimes ask to leave against medical advice. They may minimize the severity of their acute illness or deny psychiatric symptoms to obtain a discharge.

Patient characteristics and provider procedures contribute to patients’ decisions to request a discharge against medical advice (DAMA) (Table).¹

Table

Risk factors for discharge against medical advice

Not for everyone. Acutely psychotic, delusional, delirious, or demented patients or those with suicidal and homicidal ideation are not candidates for DAMA. For others, approach the patient calmly, explain with empathy what DAMA entails, and support the reasons for admission. Emphasize that following the treatment plan will alleviate psychiatric symptoms sooner and may shorten their stay.

Know the involuntary commitment procedures for your jurisdiction, and be prepared to discuss them with the patient. Assess the patient’s decision-making capacity, including awareness of the severity of his or her psychiatric illness and potential consequences of leaving against medical advice.

Arrange follow-up care for DAMA patients:

• Provide the patient with a brief summary of diagnosis, medications, and follow-up plans.
  
• Arrange the next available office or telephone appointment.
  
• Obtain contact information of those responsible for the patient’s safety.
  
• Provide the patient with emergency room and other phone numbers for crisis intervention.
  

DAMA does not absolve the physician of responsibility for poor outcomes. Carefully document the DAMA process because these patients are at increased risk of harm.² Make sure the patient signs, dates, and notes the time on the DAMA request.

Patients voluntarily admitted to locked psychiatric intensive care units sometimes ask to leave against medical advice. They may minimize the severity of their acute illness or deny psychiatric symptoms to obtain a discharge.

Patient characteristics and provider procedures contribute to patients’ decisions to request a discharge against medical advice (DAMA) (Table).¹

Table

Risk factors for discharge against medical advice

Not for everyone. Acutely psychotic, delusional, delirious, or demented patients or those with suicidal and homicidal ideation are not candidates for DAMA. For others, approach the patient calmly, explain with empathy what DAMA entails, and support the reasons for admission. Emphasize that following the treatment plan will alleviate psychiatric symptoms sooner and may shorten their stay.

Know the involuntary commitment procedures for your jurisdiction, and be prepared to discuss them with the patient. Assess the patient’s decision-making capacity, including awareness of the severity of his or her psychiatric illness and potential consequences of leaving against medical advice.

Arrange follow-up care for DAMA patients:

• Provide the patient with a brief summary of diagnosis, medications, and follow-up plans.
  
• Arrange the next available office or telephone appointment.
  
• Obtain contact information of those responsible for the patient’s safety.
  
• Provide the patient with emergency room and other phone numbers for crisis intervention.
  

DAMA does not absolve the physician of responsibility for poor outcomes. Carefully document the DAMA process because these patients are at increased risk of harm.² Make sure the patient signs, dates, and notes the time on the DAMA request.

Most mental health patients are appropriate candidates for telemedicine services—using telecommunication technologies to provide healthcare from a distance—if they agree to this treatment modality.

Psychiatry has an advantage over other specialties because we need only an image—not complex monitoring equipment—to evaluate and treat our patients. We can manage medications and perform consultation, psychological testing, and individual, family, or group psychotherapy using telehealth technologies.

Consider 3 factors before implementing a telemental health program:

What does your patient need? The nature of needed mental health services and point of service suggest which technology to choose. Determine if the barrier to an office visit is geographic or if the patient’s mobility is limited by a comorbidity.

Use videoconferencing or videophones? Videoconferencing equipment used for telemental health applications—a video screen, camera, speakers, and software—provides a clear image, but usually requires dedicated space, integrated services digital network (ISDN) lines, and technical support. These factors can limit clinical applications to “hub and spoke”¹ programs that require patients to travel to a central location where videoconferencing technology is available.

Videophones are portable, affordable, durable, and work over conventional telephone lines. These devices resemble a desk telephone with a small screen and built-in camera. Videophones are ideal for:

• community case management²
  
• settings where space and budgets are limited.
  

Small image size and narrow bandwidth limit some clinical assessments such as evaluating negative symptoms of schizophrenia or medication-induced movement disorders. Videophones require a power source and a conventional telephone line. Cellular phones do not support videophone technology, which can be a problem for many patients who lack access to conventional telephone services.

Patient selection. Acutely agitated patients and those who pose a danger to themselves or others require face-to-face evaluation. Patients with hearing or vision deficits, delusions, ideas of reference, or hallucinations are not candidates for telehealth treatment.

Telehealth equipment does not allow you to evaluate subtle psychiatric signs such as affect, speech cadence, and certain movement disorders.

Nonverbal information can be crucial, such as in a multicultural environment. You might need periodic face-to-face evaluations to ensure that you do not miss nuances or “back channel” communication³ such as pauses, speech cadence, or gestures.

Most mental health patients are appropriate candidates for telemedicine services—using telecommunication technologies to provide healthcare from a distance—if they agree to this treatment modality.

Psychiatry has an advantage over other specialties because we need only an image—not complex monitoring equipment—to evaluate and treat our patients. We can manage medications and perform consultation, psychological testing, and individual, family, or group psychotherapy using telehealth technologies.

Consider 3 factors before implementing a telemental health program:

What does your patient need? The nature of needed mental health services and point of service suggest which technology to choose. Determine if the barrier to an office visit is geographic or if the patient’s mobility is limited by a comorbidity.

Use videoconferencing or videophones? Videoconferencing equipment used for telemental health applications—a video screen, camera, speakers, and software—provides a clear image, but usually requires dedicated space, integrated services digital network (ISDN) lines, and technical support. These factors can limit clinical applications to “hub and spoke”¹ programs that require patients to travel to a central location where videoconferencing technology is available.

Videophones are portable, affordable, durable, and work over conventional telephone lines. These devices resemble a desk telephone with a small screen and built-in camera. Videophones are ideal for:

• community case management²
  
• settings where space and budgets are limited.
  

Small image size and narrow bandwidth limit some clinical assessments such as evaluating negative symptoms of schizophrenia or medication-induced movement disorders. Videophones require a power source and a conventional telephone line. Cellular phones do not support videophone technology, which can be a problem for many patients who lack access to conventional telephone services.

Patient selection. Acutely agitated patients and those who pose a danger to themselves or others require face-to-face evaluation. Patients with hearing or vision deficits, delusions, ideas of reference, or hallucinations are not candidates for telehealth treatment.

Telehealth equipment does not allow you to evaluate subtle psychiatric signs such as affect, speech cadence, and certain movement disorders.

Nonverbal information can be crucial, such as in a multicultural environment. You might need periodic face-to-face evaluations to ensure that you do not miss nuances or “back channel” communication³ such as pauses, speech cadence, or gestures.

Most mental health patients are appropriate candidates for telemedicine services—using telecommunication technologies to provide healthcare from a distance—if they agree to this treatment modality.

Psychiatry has an advantage over other specialties because we need only an image—not complex monitoring equipment—to evaluate and treat our patients. We can manage medications and perform consultation, psychological testing, and individual, family, or group psychotherapy using telehealth technologies.

Consider 3 factors before implementing a telemental health program:

What does your patient need? The nature of needed mental health services and point of service suggest which technology to choose. Determine if the barrier to an office visit is geographic or if the patient’s mobility is limited by a comorbidity.

Use videoconferencing or videophones? Videoconferencing equipment used for telemental health applications—a video screen, camera, speakers, and software—provides a clear image, but usually requires dedicated space, integrated services digital network (ISDN) lines, and technical support. These factors can limit clinical applications to “hub and spoke”¹ programs that require patients to travel to a central location where videoconferencing technology is available.

Videophones are portable, affordable, durable, and work over conventional telephone lines. These devices resemble a desk telephone with a small screen and built-in camera. Videophones are ideal for:

• community case management²
  
• settings where space and budgets are limited.
  

Small image size and narrow bandwidth limit some clinical assessments such as evaluating negative symptoms of schizophrenia or medication-induced movement disorders. Videophones require a power source and a conventional telephone line. Cellular phones do not support videophone technology, which can be a problem for many patients who lack access to conventional telephone services.

Patient selection. Acutely agitated patients and those who pose a danger to themselves or others require face-to-face evaluation. Patients with hearing or vision deficits, delusions, ideas of reference, or hallucinations are not candidates for telehealth treatment.

Telehealth equipment does not allow you to evaluate subtle psychiatric signs such as affect, speech cadence, and certain movement disorders.

Nonverbal information can be crucial, such as in a multicultural environment. You might need periodic face-to-face evaluations to ensure that you do not miss nuances or “back channel” communication³ such as pauses, speech cadence, or gestures.

In our experience, psychiatry residents often are encouraged to present rich psychodynamic or biopsychosocial formulations,¹ while diagnostic assessments are relegated to robotic statements about whether patients meet DSM-IV-TR criteria. This practice can lead to “checklist psychiatry.”²

However, thoughtfully invoking DSM criteria can enhance clinical acumen if the following conclusions are chosen and justified during patient assessments.

“This person meets diagnostic criteria, and I believe this is the correct diagnosis.”

Ask the resident to back up his or her conclusion that symptoms are “not due to another condition” and cause “significant distress or impairment” as required by DSM. Emphasize differential diagnosis and understanding illness impact and illness behaviors. Also ask the resident to explain why the patient is considered a reliable reporter of his or her experience.

“This person seems to meet criteria, but I do not believe the diagnosis is correct.”

Seeming to meet criteria is not the same as “having” a psychiatric diagnosis. Ask the resident to discuss alternate diagnoses and confounding factors in the patient’s presentation. Some patients overreport psychological distress to pursue secondary gain or because of idiosyncratic ways of experiencing distress. Likewise, some clinicians interpret too narrowly patients’ endorsements of symptoms and assume that patients share their definitions of terms such as depression and panic.³

“This person does not meet criteria, but I believe the disorder is present.”

This scenario often leads to a rapid “not otherwise specified” (NOS) diagnosis. However, if a patient has an incomplete yet longitudinally consistent and sufficiently severe version of a known syndrome, an NOS diagnosis is not clinically useful (research settings are a different story). Encourage the trainee to justify the diagnosis that he or she plans to treat.

“This person does not meet criteria, and I believe no disorder is present.”

Some people are not mentally ill; in fact, most are not. Yet most residents we supervise cannot recall the last time they diagnosed “no mental illness” or saw a supervisor do so. Adopt this practice, and give trainees overt permission to make this assessment.

In our experience, psychiatry residents often are encouraged to present rich psychodynamic or biopsychosocial formulations,¹ while diagnostic assessments are relegated to robotic statements about whether patients meet DSM-IV-TR criteria. This practice can lead to “checklist psychiatry.”²

However, thoughtfully invoking DSM criteria can enhance clinical acumen if the following conclusions are chosen and justified during patient assessments.

“This person meets diagnostic criteria, and I believe this is the correct diagnosis.”

Ask the resident to back up his or her conclusion that symptoms are “not due to another condition” and cause “significant distress or impairment” as required by DSM. Emphasize differential diagnosis and understanding illness impact and illness behaviors. Also ask the resident to explain why the patient is considered a reliable reporter of his or her experience.

“This person seems to meet criteria, but I do not believe the diagnosis is correct.”

Seeming to meet criteria is not the same as “having” a psychiatric diagnosis. Ask the resident to discuss alternate diagnoses and confounding factors in the patient’s presentation. Some patients overreport psychological distress to pursue secondary gain or because of idiosyncratic ways of experiencing distress. Likewise, some clinicians interpret too narrowly patients’ endorsements of symptoms and assume that patients share their definitions of terms such as depression and panic.³

“This person does not meet criteria, but I believe the disorder is present.”

This scenario often leads to a rapid “not otherwise specified” (NOS) diagnosis. However, if a patient has an incomplete yet longitudinally consistent and sufficiently severe version of a known syndrome, an NOS diagnosis is not clinically useful (research settings are a different story). Encourage the trainee to justify the diagnosis that he or she plans to treat.

“This person does not meet criteria, and I believe no disorder is present.”

Some people are not mentally ill; in fact, most are not. Yet most residents we supervise cannot recall the last time they diagnosed “no mental illness” or saw a supervisor do so. Adopt this practice, and give trainees overt permission to make this assessment.

In our experience, psychiatry residents often are encouraged to present rich psychodynamic or biopsychosocial formulations,¹ while diagnostic assessments are relegated to robotic statements about whether patients meet DSM-IV-TR criteria. This practice can lead to “checklist psychiatry.”²

However, thoughtfully invoking DSM criteria can enhance clinical acumen if the following conclusions are chosen and justified during patient assessments.

“This person meets diagnostic criteria, and I believe this is the correct diagnosis.”

Ask the resident to back up his or her conclusion that symptoms are “not due to another condition” and cause “significant distress or impairment” as required by DSM. Emphasize differential diagnosis and understanding illness impact and illness behaviors. Also ask the resident to explain why the patient is considered a reliable reporter of his or her experience.

“This person seems to meet criteria, but I do not believe the diagnosis is correct.”

Seeming to meet criteria is not the same as “having” a psychiatric diagnosis. Ask the resident to discuss alternate diagnoses and confounding factors in the patient’s presentation. Some patients overreport psychological distress to pursue secondary gain or because of idiosyncratic ways of experiencing distress. Likewise, some clinicians interpret too narrowly patients’ endorsements of symptoms and assume that patients share their definitions of terms such as depression and panic.³

“This person does not meet criteria, but I believe the disorder is present.”

This scenario often leads to a rapid “not otherwise specified” (NOS) diagnosis. However, if a patient has an incomplete yet longitudinally consistent and sufficiently severe version of a known syndrome, an NOS diagnosis is not clinically useful (research settings are a different story). Encourage the trainee to justify the diagnosis that he or she plans to treat.

“This person does not meet criteria, and I believe no disorder is present.”

Some people are not mentally ill; in fact, most are not. Yet most residents we supervise cannot recall the last time they diagnosed “no mental illness” or saw a supervisor do so. Adopt this practice, and give trainees overt permission to make this assessment.

Despite much education and research, bipolar disorder is still under-recognized and inappropriately treated in many clinical settings.¹ Bipolar and unipolar depression display similar symptoms, making correct diagnosis difficult. The differential diagnosis is especially problematic in patients suffering a first major depressive episode, when there is no clear history of mania or hypomania.

Nevertheless, bipolar depression does have telltale signs—remembered with the mnemonic WHIPLASHED—to guide diagnosis.^2-8

Worse or “wired” when taking antidepressants. The patient complains of feeling “antsy” or being agitated or unable to sleep when taking traditional anti-depressants.

Look for numerous failed antidepressant trials, apparent tolerance to antidepressants that does not resolve with increased dose, and antidepressant-induced mania or mood cycle acceleration.

Hypomania, hyperthymic temperament, or mood swings in a patient’s history. Patients with hyperthymic temperament show persistent traits such as intense optimism, increased energy, reduced need for sleep, extroversion, and overconfidence.

Ask about periods of elevated mood or energy that might not fit formal DSM-IV-TR criteria for hypomania—such as episodes that last only a day or two. Mood lability in younger patients can be especially dramatic and poorly demarcated.

Irritable, hostile, or mixed features. Some patients show one or more hypomanic features, such as racing thoughts when depressed.

Psychomotor retardation appears more common in bipolar I depression than in unipolar major depression. Psychomotor agitation, however, is more likely in bipolar II than in unipolar major depression.

Loaded family history of mood swings, frank bipolar disorder, or affective illness. A family history of comorbid mood disorder and alcoholism may also point to bipolarity.

Abrupt onset and/or termination of depressive bouts or relatively brief episodes (

Seasonal or postpartum depression. “Winter-type” seasonal affective disorder—feeling depressed in the fall and winter, hypomanic in the spring—and postpartum psychosis have clinical and epidemiologic links with bipolar disorder.

Hyperphagia and hypersomnia—sometimes termed atypical features—are common in bipolar depression. Paradoxically, hypersomnia may co-exist with psychomotor agitation in bipolar II patients, resulting in so-called “sleepy speeders.”

Early age of onset. Major depression that appears before age 25—especially with psychotic features—may herald subsequent bipolarity.

Delusions, hallucinations, or other psychotic features are more common in bipolar than in unipolar depression.

Acknowledgment

The author thanks Nassir Ghaemi, MD, and Jim Phelps, MD, for suggesting modifications to the mnemonic.

Despite much education and research, bipolar disorder is still under-recognized and inappropriately treated in many clinical settings.¹ Bipolar and unipolar depression display similar symptoms, making correct diagnosis difficult. The differential diagnosis is especially problematic in patients suffering a first major depressive episode, when there is no clear history of mania or hypomania.

Nevertheless, bipolar depression does have telltale signs—remembered with the mnemonic WHIPLASHED—to guide diagnosis.^2-8

Worse or “wired” when taking antidepressants. The patient complains of feeling “antsy” or being agitated or unable to sleep when taking traditional anti-depressants.

Look for numerous failed antidepressant trials, apparent tolerance to antidepressants that does not resolve with increased dose, and antidepressant-induced mania or mood cycle acceleration.

Hypomania, hyperthymic temperament, or mood swings in a patient’s history. Patients with hyperthymic temperament show persistent traits such as intense optimism, increased energy, reduced need for sleep, extroversion, and overconfidence.

Ask about periods of elevated mood or energy that might not fit formal DSM-IV-TR criteria for hypomania—such as episodes that last only a day or two. Mood lability in younger patients can be especially dramatic and poorly demarcated.

Irritable, hostile, or mixed features. Some patients show one or more hypomanic features, such as racing thoughts when depressed.

Psychomotor retardation appears more common in bipolar I depression than in unipolar major depression. Psychomotor agitation, however, is more likely in bipolar II than in unipolar major depression.

Loaded family history of mood swings, frank bipolar disorder, or affective illness. A family history of comorbid mood disorder and alcoholism may also point to bipolarity.

Abrupt onset and/or termination of depressive bouts or relatively brief episodes (

Seasonal or postpartum depression. “Winter-type” seasonal affective disorder—feeling depressed in the fall and winter, hypomanic in the spring—and postpartum psychosis have clinical and epidemiologic links with bipolar disorder.

Hyperphagia and hypersomnia—sometimes termed atypical features—are common in bipolar depression. Paradoxically, hypersomnia may co-exist with psychomotor agitation in bipolar II patients, resulting in so-called “sleepy speeders.”

Early age of onset. Major depression that appears before age 25—especially with psychotic features—may herald subsequent bipolarity.

Delusions, hallucinations, or other psychotic features are more common in bipolar than in unipolar depression.

Acknowledgment

The author thanks Nassir Ghaemi, MD, and Jim Phelps, MD, for suggesting modifications to the mnemonic.

Despite much education and research, bipolar disorder is still under-recognized and inappropriately treated in many clinical settings.¹ Bipolar and unipolar depression display similar symptoms, making correct diagnosis difficult. The differential diagnosis is especially problematic in patients suffering a first major depressive episode, when there is no clear history of mania or hypomania.

Nevertheless, bipolar depression does have telltale signs—remembered with the mnemonic WHIPLASHED—to guide diagnosis.^2-8

Worse or “wired” when taking antidepressants. The patient complains of feeling “antsy” or being agitated or unable to sleep when taking traditional anti-depressants.

Look for numerous failed antidepressant trials, apparent tolerance to antidepressants that does not resolve with increased dose, and antidepressant-induced mania or mood cycle acceleration.

Hypomania, hyperthymic temperament, or mood swings in a patient’s history. Patients with hyperthymic temperament show persistent traits such as intense optimism, increased energy, reduced need for sleep, extroversion, and overconfidence.

Ask about periods of elevated mood or energy that might not fit formal DSM-IV-TR criteria for hypomania—such as episodes that last only a day or two. Mood lability in younger patients can be especially dramatic and poorly demarcated.

Irritable, hostile, or mixed features. Some patients show one or more hypomanic features, such as racing thoughts when depressed.

Psychomotor retardation appears more common in bipolar I depression than in unipolar major depression. Psychomotor agitation, however, is more likely in bipolar II than in unipolar major depression.

Loaded family history of mood swings, frank bipolar disorder, or affective illness. A family history of comorbid mood disorder and alcoholism may also point to bipolarity.

Abrupt onset and/or termination of depressive bouts or relatively brief episodes (

Seasonal or postpartum depression. “Winter-type” seasonal affective disorder—feeling depressed in the fall and winter, hypomanic in the spring—and postpartum psychosis have clinical and epidemiologic links with bipolar disorder.

Hyperphagia and hypersomnia—sometimes termed atypical features—are common in bipolar depression. Paradoxically, hypersomnia may co-exist with psychomotor agitation in bipolar II patients, resulting in so-called “sleepy speeders.”

Early age of onset. Major depression that appears before age 25—especially with psychotic features—may herald subsequent bipolarity.

Delusions, hallucinations, or other psychotic features are more common in bipolar than in unipolar depression.

Acknowledgment

The author thanks Nassir Ghaemi, MD, and Jim Phelps, MD, for suggesting modifications to the mnemonic.

Most clinicians can easily identify the biological and psychological aspects of mental illness, but the social components often are overlooked.¹ These include a negative life event, familial or interpersonal stressor, environmental difficulty or deficiency, or inadequate social support.²

We have found that these significant psychosocial factors listed in DSM-IV-TR² can be easily assessed using the mnemonic, “Family and friends with a WISE HALO.”

Family and friends. Stressful events include family disruption by divorce or separation; illness or death of family members; neglect; emotional, physical or sexual abuse; remarriage of a parent; or birth or adoption of a new sibling.

Work. Stressors associated with work include actual or perceived job loss, difficult working conditions, irregular schedules, difficulty getting along with superiors or coworkers, and job dissatisfaction.

Income. Poverty and inadequate finances can influence the patient’s mental health.

Social environment. Problems with living alone, poor support, difficulty with acculturation, and discrimination are some possible difficulties.

Education. Learning problems, conflicts with teachers and classmates, bullying, and illiteracy could harm your patient’s mental health.

Housing. Stressors include homelessness, unsafe neighborhoods, and problems with a landlord.

Access to health care services. Inadequate access to health care, lack of medical insurance, and absence of transportation can influence your patient’s care.

Legal. Arrest, incarceration, ongoing lawsuits, and being the perpetrator or victim of a crime are included here.

Others. This catchall category includes exposure to disasters or wars and unavailability of social services.

After identifying the psychosocial issues affecting your patient, assimilate this information into a biopsychosocial formulation and treatment plan. Interventions could include referrals for individual and family therapy, bereavement and support groups, recreational therapy, or to subsidized housing programs or job training.

Most clinicians can easily identify the biological and psychological aspects of mental illness, but the social components often are overlooked.¹ These include a negative life event, familial or interpersonal stressor, environmental difficulty or deficiency, or inadequate social support.²

We have found that these significant psychosocial factors listed in DSM-IV-TR² can be easily assessed using the mnemonic, “Family and friends with a WISE HALO.”

Family and friends. Stressful events include family disruption by divorce or separation; illness or death of family members; neglect; emotional, physical or sexual abuse; remarriage of a parent; or birth or adoption of a new sibling.

Work. Stressors associated with work include actual or perceived job loss, difficult working conditions, irregular schedules, difficulty getting along with superiors or coworkers, and job dissatisfaction.

Income. Poverty and inadequate finances can influence the patient’s mental health.

Social environment. Problems with living alone, poor support, difficulty with acculturation, and discrimination are some possible difficulties.

Education. Learning problems, conflicts with teachers and classmates, bullying, and illiteracy could harm your patient’s mental health.

Housing. Stressors include homelessness, unsafe neighborhoods, and problems with a landlord.

Access to health care services. Inadequate access to health care, lack of medical insurance, and absence of transportation can influence your patient’s care.

Legal. Arrest, incarceration, ongoing lawsuits, and being the perpetrator or victim of a crime are included here.

Others. This catchall category includes exposure to disasters or wars and unavailability of social services.

After identifying the psychosocial issues affecting your patient, assimilate this information into a biopsychosocial formulation and treatment plan. Interventions could include referrals for individual and family therapy, bereavement and support groups, recreational therapy, or to subsidized housing programs or job training.

Most clinicians can easily identify the biological and psychological aspects of mental illness, but the social components often are overlooked.¹ These include a negative life event, familial or interpersonal stressor, environmental difficulty or deficiency, or inadequate social support.²

We have found that these significant psychosocial factors listed in DSM-IV-TR² can be easily assessed using the mnemonic, “Family and friends with a WISE HALO.”

Family and friends. Stressful events include family disruption by divorce or separation; illness or death of family members; neglect; emotional, physical or sexual abuse; remarriage of a parent; or birth or adoption of a new sibling.

Work. Stressors associated with work include actual or perceived job loss, difficult working conditions, irregular schedules, difficulty getting along with superiors or coworkers, and job dissatisfaction.

Income. Poverty and inadequate finances can influence the patient’s mental health.

Social environment. Problems with living alone, poor support, difficulty with acculturation, and discrimination are some possible difficulties.

Education. Learning problems, conflicts with teachers and classmates, bullying, and illiteracy could harm your patient’s mental health.

Housing. Stressors include homelessness, unsafe neighborhoods, and problems with a landlord.

Access to health care services. Inadequate access to health care, lack of medical insurance, and absence of transportation can influence your patient’s care.

Legal. Arrest, incarceration, ongoing lawsuits, and being the perpetrator or victim of a crime are included here.

Others. This catchall category includes exposure to disasters or wars and unavailability of social services.

After identifying the psychosocial issues affecting your patient, assimilate this information into a biopsychosocial formulation and treatment plan. Interventions could include referrals for individual and family therapy, bereavement and support groups, recreational therapy, or to subsidized housing programs or job training.

Assessing suicide risk is a fundamental skill for all psychiatrists. Early in training we are taught to look for prior attempts, family history of suicide, related psychiatric diagnoses (such as depression, psychosis, or substance abuse), symptomatology, and medical comorbidities, as well as demographic risk factors such as age, race, marital status, and religion.

This tendency to focus on data, document risks factors, and differentiate between ideation, intent, and plan may cause us to overlook why a patient wants to commit suicide, however. And rapid-fire questioning—particularly about suicide—can compromise rapport and leave the patient feeling alienated.

Positive inquiry

I always end the suicide risk assessment component of the interview by asking, “What keeps you from killing yourself?” Patients’ responses to this question often reveal compelling reasons why they do not want to harm themselves, including meaningful relationships or religious beliefs.

Examining these so-called protective factors—or the lack thereof—in conjunction with the overall clinical picture often can help clarify the patient’s risk of suicide. When patients identify factors that prevent them from committing suicide, such as a relationship with a loving spouse or a religious conviction, I am inclined to use a more liberal treatment plan, such as immediate outpatient follow-up, rather than a more conservative approach, such as inpatient hospitalization.

Asking a supportive question helps to end difficult discussions on a positive note. After talking about ways a patient has thought about ending his or her life, for example, I can use a protective factor as the endpoint to the suicide risk evaluation before segueing into other questions.

Supportive interviewing embodies a framework of inquiry in which mental health clinicians can gather valuable information and at the same time build up the patient’s psychological defenses. This line of questioning does not guarantee a successful suicide-risk assessment. However, focusing on protective factors ensures that these difficult conversations—often undertaken when patients are under extreme stress—accomplish more than simply gathering data.

Assessing suicide risk is a fundamental skill for all psychiatrists. Early in training we are taught to look for prior attempts, family history of suicide, related psychiatric diagnoses (such as depression, psychosis, or substance abuse), symptomatology, and medical comorbidities, as well as demographic risk factors such as age, race, marital status, and religion.

This tendency to focus on data, document risks factors, and differentiate between ideation, intent, and plan may cause us to overlook why a patient wants to commit suicide, however. And rapid-fire questioning—particularly about suicide—can compromise rapport and leave the patient feeling alienated.

Positive inquiry

I always end the suicide risk assessment component of the interview by asking, “What keeps you from killing yourself?” Patients’ responses to this question often reveal compelling reasons why they do not want to harm themselves, including meaningful relationships or religious beliefs.

Examining these so-called protective factors—or the lack thereof—in conjunction with the overall clinical picture often can help clarify the patient’s risk of suicide. When patients identify factors that prevent them from committing suicide, such as a relationship with a loving spouse or a religious conviction, I am inclined to use a more liberal treatment plan, such as immediate outpatient follow-up, rather than a more conservative approach, such as inpatient hospitalization.

Asking a supportive question helps to end difficult discussions on a positive note. After talking about ways a patient has thought about ending his or her life, for example, I can use a protective factor as the endpoint to the suicide risk evaluation before segueing into other questions.

Supportive interviewing embodies a framework of inquiry in which mental health clinicians can gather valuable information and at the same time build up the patient’s psychological defenses. This line of questioning does not guarantee a successful suicide-risk assessment. However, focusing on protective factors ensures that these difficult conversations—often undertaken when patients are under extreme stress—accomplish more than simply gathering data.

Assessing suicide risk is a fundamental skill for all psychiatrists. Early in training we are taught to look for prior attempts, family history of suicide, related psychiatric diagnoses (such as depression, psychosis, or substance abuse), symptomatology, and medical comorbidities, as well as demographic risk factors such as age, race, marital status, and religion.

This tendency to focus on data, document risks factors, and differentiate between ideation, intent, and plan may cause us to overlook why a patient wants to commit suicide, however. And rapid-fire questioning—particularly about suicide—can compromise rapport and leave the patient feeling alienated.

Positive inquiry

I always end the suicide risk assessment component of the interview by asking, “What keeps you from killing yourself?” Patients’ responses to this question often reveal compelling reasons why they do not want to harm themselves, including meaningful relationships or religious beliefs.

Examining these so-called protective factors—or the lack thereof—in conjunction with the overall clinical picture often can help clarify the patient’s risk of suicide. When patients identify factors that prevent them from committing suicide, such as a relationship with a loving spouse or a religious conviction, I am inclined to use a more liberal treatment plan, such as immediate outpatient follow-up, rather than a more conservative approach, such as inpatient hospitalization.

Asking a supportive question helps to end difficult discussions on a positive note. After talking about ways a patient has thought about ending his or her life, for example, I can use a protective factor as the endpoint to the suicide risk evaluation before segueing into other questions.

Supportive interviewing embodies a framework of inquiry in which mental health clinicians can gather valuable information and at the same time build up the patient’s psychological defenses. This line of questioning does not guarantee a successful suicide-risk assessment. However, focusing on protective factors ensures that these difficult conversations—often undertaken when patients are under extreme stress—accomplish more than simply gathering data.

Web sites that offer questionable information about psychiatric illnesses and treatments can sway patients toward unproven, often worthless “remedies.” These sites may present themselves as patient resources but instead are promoting political or antipsychiatry agendas or selling unregulated, untested therapies.

Don’t let unscrupulous sites fool your patients. This article offers tools to help patients find evidence-based mental health information from objective, reputable sites.

Why counsel patients on web use?

Bad information can be harmful. I have lost many patients to follow-up because they discovered an unsubstantiated treatment complication or off-the-wall “remedy” on an antipsychiatry or antimedication site.

Years ago, I treated another mental health clinician. After she viewed an antimedication site, she was convinced that her bipolar disorder had “run its course” and stopped treatment, even though she had suffered a severe manic episode 1 year earlier. Another doctor treated her as if her bipolar disorder had been “cured.”

I resolved never to let patients troll the Internet for medical information without rudimentary guidance.

Most patients do not know how to analyze medical information. In medical school we learned—by implementing dictums of evidence-based medicine—where to find clinical information and how to assess its quality and objectivity. Most patients have not received such training.

Patients need our support. Most patients seeing a psychiatrist for the first time are anxious and fearful of what they might find out about themselves or their lives. Exploring their inner worlds is routine to us, but unsettling and disorienting to them. Unfiltered, uncensored Web sites prey upon new patients by offering a ready source of comfort.

Guiding new patients during this vulnerable time can cement the doctor-patient relationship and prevent faulty information from jeopardizing recovery. Patients who do not receive emotional support could turn to a Church of Scientology site—such as http://psychiatrysucks.com—or one of many other antipsychiatry sites to fill the void.

Encourage patients to describe their anxieties and trepidations toward their illnesses and medications. Help them explore questions about trust and hope, and anticipate and solicit questions resulting from their Internet exploration.

Setting web search guidelines

When new patients ask where to find information on their disorder or treatment, suggest the National Institutes of Health’s Web site, which offers a wealth of current information written in plain English, and links to databases, such as Medline and ongoing clinical trials.

Then give patients basic guidelines for broader Internet exploration. Warn them against sites that post personal attacks, exude a zealous tone, or present extreme positions or statements. Sites infused with fervor—positive or negative—should always warrant suspicion.

For more subtle concerns about quality of information, encourage patients to ask the following six questions—easily recalled with the acronym NO BASH (Table)—when visiting a mental health site:

Table

NO BASH: 6 questions to ask when perusing a health site

• IS THE SITE NETWORKED?
• IS THE INFORMATION OBJECTIVE?
• IS THE CONTENT BALANCED?
• DOES THE SITE’S AUTHOR MAKE ACCUSATIONS?
• IS THE SITE SELLING SOMETHING?
• IS THE SITE ‘HYPERHOLY’?

Other considerations

Also consider the site’s domain designation:

• sites with the .edu domain—operated by educational institutions—are most reliable
• .com designates a commercial site that is generally geared to selling goods or services and might or might not support psychiatric treatment
• .net and .org sites tend to be noncommercial, although some might be antipsychiatry.

Also steer patients to health care sites that display the HON Code seal of the Health On the Net Foundation (HON). HON, a nonprofit international organization that promotes development of useful, reliable online medical and health information, certifies health sites that meet its rigorous ethical standards (see Related resources).

Related resources

• Health Care on the Net Foundation code of conduct (HON code) for medical and health Web sites. www.hon.ch/HONcode/Conduct.html.

Disclosure

Dr. Montgomery reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Web sites that offer questionable information about psychiatric illnesses and treatments can sway patients toward unproven, often worthless “remedies.” These sites may present themselves as patient resources but instead are promoting political or antipsychiatry agendas or selling unregulated, untested therapies.

Don’t let unscrupulous sites fool your patients. This article offers tools to help patients find evidence-based mental health information from objective, reputable sites.

Why counsel patients on web use?

Bad information can be harmful. I have lost many patients to follow-up because they discovered an unsubstantiated treatment complication or off-the-wall “remedy” on an antipsychiatry or antimedication site.

Years ago, I treated another mental health clinician. After she viewed an antimedication site, she was convinced that her bipolar disorder had “run its course” and stopped treatment, even though she had suffered a severe manic episode 1 year earlier. Another doctor treated her as if her bipolar disorder had been “cured.”

I resolved never to let patients troll the Internet for medical information without rudimentary guidance.

Most patients do not know how to analyze medical information. In medical school we learned—by implementing dictums of evidence-based medicine—where to find clinical information and how to assess its quality and objectivity. Most patients have not received such training.

Patients need our support. Most patients seeing a psychiatrist for the first time are anxious and fearful of what they might find out about themselves or their lives. Exploring their inner worlds is routine to us, but unsettling and disorienting to them. Unfiltered, uncensored Web sites prey upon new patients by offering a ready source of comfort.

Guiding new patients during this vulnerable time can cement the doctor-patient relationship and prevent faulty information from jeopardizing recovery. Patients who do not receive emotional support could turn to a Church of Scientology site—such as http://psychiatrysucks.com—or one of many other antipsychiatry sites to fill the void.

Encourage patients to describe their anxieties and trepidations toward their illnesses and medications. Help them explore questions about trust and hope, and anticipate and solicit questions resulting from their Internet exploration.

Setting web search guidelines

When new patients ask where to find information on their disorder or treatment, suggest the National Institutes of Health’s Web site, which offers a wealth of current information written in plain English, and links to databases, such as Medline and ongoing clinical trials.

Then give patients basic guidelines for broader Internet exploration. Warn them against sites that post personal attacks, exude a zealous tone, or present extreme positions or statements. Sites infused with fervor—positive or negative—should always warrant suspicion.

For more subtle concerns about quality of information, encourage patients to ask the following six questions—easily recalled with the acronym NO BASH (Table)—when visiting a mental health site:

Table

NO BASH: 6 questions to ask when perusing a health site

• IS THE SITE NETWORKED?
• IS THE INFORMATION OBJECTIVE?
• IS THE CONTENT BALANCED?
• DOES THE SITE’S AUTHOR MAKE ACCUSATIONS?
• IS THE SITE SELLING SOMETHING?
• IS THE SITE ‘HYPERHOLY’?

Other considerations

Also consider the site’s domain designation:

• sites with the .edu domain—operated by educational institutions—are most reliable
• .com designates a commercial site that is generally geared to selling goods or services and might or might not support psychiatric treatment
• .net and .org sites tend to be noncommercial, although some might be antipsychiatry.

Also steer patients to health care sites that display the HON Code seal of the Health On the Net Foundation (HON). HON, a nonprofit international organization that promotes development of useful, reliable online medical and health information, certifies health sites that meet its rigorous ethical standards (see Related resources).

Related resources

• Health Care on the Net Foundation code of conduct (HON code) for medical and health Web sites. www.hon.ch/HONcode/Conduct.html.

Disclosure

Dr. Montgomery reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Web sites that offer questionable information about psychiatric illnesses and treatments can sway patients toward unproven, often worthless “remedies.” These sites may present themselves as patient resources but instead are promoting political or antipsychiatry agendas or selling unregulated, untested therapies.

Don’t let unscrupulous sites fool your patients. This article offers tools to help patients find evidence-based mental health information from objective, reputable sites.

Why counsel patients on web use?

Bad information can be harmful. I have lost many patients to follow-up because they discovered an unsubstantiated treatment complication or off-the-wall “remedy” on an antipsychiatry or antimedication site.

Years ago, I treated another mental health clinician. After she viewed an antimedication site, she was convinced that her bipolar disorder had “run its course” and stopped treatment, even though she had suffered a severe manic episode 1 year earlier. Another doctor treated her as if her bipolar disorder had been “cured.”

I resolved never to let patients troll the Internet for medical information without rudimentary guidance.

Most patients do not know how to analyze medical information. In medical school we learned—by implementing dictums of evidence-based medicine—where to find clinical information and how to assess its quality and objectivity. Most patients have not received such training.

Patients need our support. Most patients seeing a psychiatrist for the first time are anxious and fearful of what they might find out about themselves or their lives. Exploring their inner worlds is routine to us, but unsettling and disorienting to them. Unfiltered, uncensored Web sites prey upon new patients by offering a ready source of comfort.

Guiding new patients during this vulnerable time can cement the doctor-patient relationship and prevent faulty information from jeopardizing recovery. Patients who do not receive emotional support could turn to a Church of Scientology site—such as http://psychiatrysucks.com—or one of many other antipsychiatry sites to fill the void.

Encourage patients to describe their anxieties and trepidations toward their illnesses and medications. Help them explore questions about trust and hope, and anticipate and solicit questions resulting from their Internet exploration.

Setting web search guidelines

When new patients ask where to find information on their disorder or treatment, suggest the National Institutes of Health’s Web site, which offers a wealth of current information written in plain English, and links to databases, such as Medline and ongoing clinical trials.

Then give patients basic guidelines for broader Internet exploration. Warn them against sites that post personal attacks, exude a zealous tone, or present extreme positions or statements. Sites infused with fervor—positive or negative—should always warrant suspicion.

For more subtle concerns about quality of information, encourage patients to ask the following six questions—easily recalled with the acronym NO BASH (Table)—when visiting a mental health site:

Table

NO BASH: 6 questions to ask when perusing a health site

• IS THE SITE NETWORKED?
• IS THE INFORMATION OBJECTIVE?
• IS THE CONTENT BALANCED?
• DOES THE SITE’S AUTHOR MAKE ACCUSATIONS?
• IS THE SITE SELLING SOMETHING?
• IS THE SITE ‘HYPERHOLY’?

Other considerations

Also consider the site’s domain designation:

• sites with the .edu domain—operated by educational institutions—are most reliable
• .com designates a commercial site that is generally geared to selling goods or services and might or might not support psychiatric treatment
• .net and .org sites tend to be noncommercial, although some might be antipsychiatry.

Also steer patients to health care sites that display the HON Code seal of the Health On the Net Foundation (HON). HON, a nonprofit international organization that promotes development of useful, reliable online medical and health information, certifies health sites that meet its rigorous ethical standards (see Related resources).

Related resources

• Health Care on the Net Foundation code of conduct (HON code) for medical and health Web sites. www.hon.ch/HONcode/Conduct.html.

Disclosure

Dr. Montgomery reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Teaching medical students and psychiatry residents the principles of safe, effective clinical psychopharmacology can be challenging. Psychotropic agents from the same category often possess different mechanisms of action, cause various side effects, and have distinct safety profiles. Moreover, similar agents can be differentiated by the amount of evidence supporting their efficacy in treating particular disorders.

To help, I encourage prescribers to add a “STEP”—Safety, Tolerability, Efficacy, and Practicality—to their clinical decision-making. This is an invaluable “pearl” I learned nearly a decade ago and present here in a slightly modified form.¹

Safety. Know the psychotropic’s safety profile, especially regarding comorbid medical illness and potential drug-drug interactions. Bupropion, for instance, may be an excellent choice for a depressed patient who recently had a myocardial infarction, but research shows the drug is risky for a person with a comorbid seizure disorder.

Tolerability. Evaluate the short- and long-term effects of each medication. Haloperidol, for example, is a reasonable choice for acute treatment of psychotic agitation in the emergency department, but a young woman struggling to manage her schizophrenia may not tolerate the drug as a maintenance therapy.

Efficacy. Familiarize yourself with the clinical evidence supporting a drug’s use for a particular disorder. Evidence strongly supports lithium carbonate for treating bipolar affective disorder, but current evidence-based clinical guidelines do not endorse gabapentin as a first choice for mood stabilization.

Practicality. Consider cost, adherence, and monitoring issues. A medication will certainly fail if the patient never fills the prescription because of cost or cannot adhere to a multiple daily dosing regimen or routine serum chemistries. This aspect may be the most essential to dispensing psychotropics because the student or resident must have a thoughtful grasp of the patient’s life circumstances, deficits, strengths, and motivation. Such understanding can be achieved only through careful, empathic listening and active involvement in the patient’s care and well-being.

Teaching medical students and psychiatry residents the principles of safe, effective clinical psychopharmacology can be challenging. Psychotropic agents from the same category often possess different mechanisms of action, cause various side effects, and have distinct safety profiles. Moreover, similar agents can be differentiated by the amount of evidence supporting their efficacy in treating particular disorders.

To help, I encourage prescribers to add a “STEP”—Safety, Tolerability, Efficacy, and Practicality—to their clinical decision-making. This is an invaluable “pearl” I learned nearly a decade ago and present here in a slightly modified form.¹

Safety. Know the psychotropic’s safety profile, especially regarding comorbid medical illness and potential drug-drug interactions. Bupropion, for instance, may be an excellent choice for a depressed patient who recently had a myocardial infarction, but research shows the drug is risky for a person with a comorbid seizure disorder.

Tolerability. Evaluate the short- and long-term effects of each medication. Haloperidol, for example, is a reasonable choice for acute treatment of psychotic agitation in the emergency department, but a young woman struggling to manage her schizophrenia may not tolerate the drug as a maintenance therapy.

Efficacy. Familiarize yourself with the clinical evidence supporting a drug’s use for a particular disorder. Evidence strongly supports lithium carbonate for treating bipolar affective disorder, but current evidence-based clinical guidelines do not endorse gabapentin as a first choice for mood stabilization.

Practicality. Consider cost, adherence, and monitoring issues. A medication will certainly fail if the patient never fills the prescription because of cost or cannot adhere to a multiple daily dosing regimen or routine serum chemistries. This aspect may be the most essential to dispensing psychotropics because the student or resident must have a thoughtful grasp of the patient’s life circumstances, deficits, strengths, and motivation. Such understanding can be achieved only through careful, empathic listening and active involvement in the patient’s care and well-being.

Teaching medical students and psychiatry residents the principles of safe, effective clinical psychopharmacology can be challenging. Psychotropic agents from the same category often possess different mechanisms of action, cause various side effects, and have distinct safety profiles. Moreover, similar agents can be differentiated by the amount of evidence supporting their efficacy in treating particular disorders.

To help, I encourage prescribers to add a “STEP”—Safety, Tolerability, Efficacy, and Practicality—to their clinical decision-making. This is an invaluable “pearl” I learned nearly a decade ago and present here in a slightly modified form.¹

Safety. Know the psychotropic’s safety profile, especially regarding comorbid medical illness and potential drug-drug interactions. Bupropion, for instance, may be an excellent choice for a depressed patient who recently had a myocardial infarction, but research shows the drug is risky for a person with a comorbid seizure disorder.

Tolerability. Evaluate the short- and long-term effects of each medication. Haloperidol, for example, is a reasonable choice for acute treatment of psychotic agitation in the emergency department, but a young woman struggling to manage her schizophrenia may not tolerate the drug as a maintenance therapy.

Efficacy. Familiarize yourself with the clinical evidence supporting a drug’s use for a particular disorder. Evidence strongly supports lithium carbonate for treating bipolar affective disorder, but current evidence-based clinical guidelines do not endorse gabapentin as a first choice for mood stabilization.

Practicality. Consider cost, adherence, and monitoring issues. A medication will certainly fail if the patient never fills the prescription because of cost or cannot adhere to a multiple daily dosing regimen or routine serum chemistries. This aspect may be the most essential to dispensing psychotropics because the student or resident must have a thoughtful grasp of the patient’s life circumstances, deficits, strengths, and motivation. Such understanding can be achieved only through careful, empathic listening and active involvement in the patient’s care and well-being.

Clinicians and patients look to pill splitting to reduce psychotropics’ costs and fine-tune pharmacotherapy, but pill splitting has not been rigorously studied for safety or efficacy. It is important to understand the risks and benefits of pill splitting before you recommend the practice to patients.

Pros of pill splitting

Lower costs for patients. Many psychotropics come in multiple strengths, and one larger pill often costs less than 2 smaller pills of equivalent dosage.¹ Writing a prescription for a higher dose and instructing the patient to cut the pill in half can lower costs.

Fine-tune titration. Pill splitting allows you to prescribe a lower strength to gradually titrate dosages up or taper them down. This practice can prevent side effects and improve adherence because a lower dose may have a more favorable pharmacokinetic profile.

Improve tolerability. Patients might better tolerate half a pill taken twice daily rather than an entire pill once daily. A smaller dose may prevent a spike in serum level, which could aid tolerability.

Cons of pill splitting

Unequal dosing. In most instances, pill splitting leads to slightly unequal dosing.² This could be a problem if:

• the medication such as lithium has a narrow therapeutic index
  
• the patient’s condition is unstable
  
• the patient’s condition is stable but minor dose variations might cause problems, such as a patient who relapses with small dosing changes.
  

Table

Appropriate and inappropriate medications for pill splitting

Scoring. Cutting unscored tablets can be difficult, especially if the pills are not round or oval. Because patients can get injured using a knife, recommend pill cutters, which are available at most pharmacies.

Capsule splitting. Some psychotropics are sold only in capsules. Some capsules can be opened and sprinkled on food, but splitting the contents into approximately equal dosages can be difficult.

Clinicians and patients look to pill splitting to reduce psychotropics’ costs and fine-tune pharmacotherapy, but pill splitting has not been rigorously studied for safety or efficacy. It is important to understand the risks and benefits of pill splitting before you recommend the practice to patients.

Pros of pill splitting

Lower costs for patients. Many psychotropics come in multiple strengths, and one larger pill often costs less than 2 smaller pills of equivalent dosage.¹ Writing a prescription for a higher dose and instructing the patient to cut the pill in half can lower costs.

Fine-tune titration. Pill splitting allows you to prescribe a lower strength to gradually titrate dosages up or taper them down. This practice can prevent side effects and improve adherence because a lower dose may have a more favorable pharmacokinetic profile.

Improve tolerability. Patients might better tolerate half a pill taken twice daily rather than an entire pill once daily. A smaller dose may prevent a spike in serum level, which could aid tolerability.

Cons of pill splitting

Unequal dosing. In most instances, pill splitting leads to slightly unequal dosing.² This could be a problem if:

• the medication such as lithium has a narrow therapeutic index
  
• the patient’s condition is unstable
  
• the patient’s condition is stable but minor dose variations might cause problems, such as a patient who relapses with small dosing changes.
  

Table

Appropriate and inappropriate medications for pill splitting

Scoring. Cutting unscored tablets can be difficult, especially if the pills are not round or oval. Because patients can get injured using a knife, recommend pill cutters, which are available at most pharmacies.

Capsule splitting. Some psychotropics are sold only in capsules. Some capsules can be opened and sprinkled on food, but splitting the contents into approximately equal dosages can be difficult.

Clinicians and patients look to pill splitting to reduce psychotropics’ costs and fine-tune pharmacotherapy, but pill splitting has not been rigorously studied for safety or efficacy. It is important to understand the risks and benefits of pill splitting before you recommend the practice to patients.

Pros of pill splitting

Lower costs for patients. Many psychotropics come in multiple strengths, and one larger pill often costs less than 2 smaller pills of equivalent dosage.¹ Writing a prescription for a higher dose and instructing the patient to cut the pill in half can lower costs.

Fine-tune titration. Pill splitting allows you to prescribe a lower strength to gradually titrate dosages up or taper them down. This practice can prevent side effects and improve adherence because a lower dose may have a more favorable pharmacokinetic profile.

Improve tolerability. Patients might better tolerate half a pill taken twice daily rather than an entire pill once daily. A smaller dose may prevent a spike in serum level, which could aid tolerability.

Cons of pill splitting

Unequal dosing. In most instances, pill splitting leads to slightly unequal dosing.² This could be a problem if:

• the medication such as lithium has a narrow therapeutic index
  
• the patient’s condition is unstable
  
• the patient’s condition is stable but minor dose variations might cause problems, such as a patient who relapses with small dosing changes.
  

Table

Appropriate and inappropriate medications for pill splitting

Scoring. Cutting unscored tablets can be difficult, especially if the pills are not round or oval. Because patients can get injured using a knife, recommend pill cutters, which are available at most pharmacies.

Capsule splitting. Some psychotropics are sold only in capsules. Some capsules can be opened and sprinkled on food, but splitting the contents into approximately equal dosages can be difficult.