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Shorter duration of untreated psychosis key to Navy program’s approach to schizophrenia care
WASHINGTON – Medical treatment of first-episode psychosis alone is a “cornerstone” intervention, but it’s not sufficient, according to a U.S. Navy psychiatrist who annually treats about 75 people with serious mental illness.
“We need coordinated, multimodal care for optimal treatment of psychosis,” said Michael C. Hann, MD, a Navy psychiatrist and a speaker during a panel on integrated care for schizophrenia at the American Psychiatric Association’s Institute on Psychiatric Services.
By moving away from the standard model in the past 3 years, and instead implementing a coordinated, recovery-oriented system of care as outlined in the National Institute of Mental Health’s RAISE study (Recovery After Initial Schizophrenia Episode), Dr. Hann said the Navy has seen impressive results: In six patients seen recently, the estimated duration of psychosis – the time between prodromal symptoms and first signs of a psychotic break – was as little as 6 weeks and no more than about 9 weeks.
“That is very, very short,” Dr. Hann said. “We’re very excited about that.”
The shorter the duration between first signs of psychosis and treatment, the greater chance a person has to sustain his capacity to function in his community, and enjoy higher a quality of life, according to the NIMH’s webpage about the RAISE trial.
Located at the Navy Medical Center San Diego, the Psychiatric Transition Program treats active-duty military personnel with first-episode psychosis, and also those with bipolar I disorder. Patients in the program are treated for up to 9 or 12 months, before being medically retired from service. Rates of psychosis seen in the military mirror those in the general population – about 1%. “That’s about 300 first breaks a year,” Dr. Hann, the program’s chief resident, said in an interview. “We capture about 20% of those, which is the upper limit of what we’re capable of [caring for],” he said in his presentation, noting that the program is growing as its reputation has spread across the service branches. Dr. Hann said part of the program’s success comes from the swift referrals by military commanders who are alert to signs and symptoms of psychosis.
Other strengths Dr. Hann listed are that all necessary services – including the emergency department, inpatient psychiatric services, and the outpatient clinic – are colocated. Access to inpatient psychiatric services means medication monitoring and modifications, such as being switched to a long-acting injectable antipsychotic, is easier to manage, particularly in high-risk patients. Peer support also is available through a group home model.
The program is staffed by psychiatrists, psychiatry residents, psychiatric technicians, social workers, and nurses who function as case managers. In an interview, Dr. Hann said the program typically has 30 patients in treatment at a time, with an annual average of 75 patients. Most of the patients are on the schizophrenia spectrum, although the program also accepts referrals for bipolar I.
“Currently, there is very little coordination between military and VA-based care systems,” Dr. Yoon said during the presentation. “After [these service personnel] are medically retired, they kind of go off into the wind, and it’s unclear what happens. Our preliminary data show it’s pretty bad.” This lack of coordinated transition puts affected veterans at greater risk of homelessness and suicide, Dr. Yoon said.
Because at present, there is no systematized way for medical personnel in the Department of Defense and the VA to communicate, simple measures that would help keep this patient population stable are not achieved, said Dr. Yoon. With its intended launch in January 2017, OPTICARE is intended to be the bridge between the two systems during the peritransition period, covering the 6 months prior to medical retirement to 1 year post discharge. “None of what we’re doing is rocket science, but none of it is currently being done,” he said.
Dr. Yoon, whose work focuses on how to stabilize faulty striatal dopamine signaling at the D2 receptor to minimize the duration of untreated psychosis, said using aripiprazole to maintain steady levels of D2 blocking is effective. In addition, Dr. Yoon said, he believes that emerging evidence for the stabilizing effects on D2 blocking that long-acting injectable antipsychotics provide mean they should be used more. However, this kind of evidence-based approach to care is frustrated by quirks between the two systems, such as the absence of a shared pharmacy formulary. This can lead to a person’s antipsychotic agent being switched or even noncompliance, and the possible end result can be relapse.
Dr. Yoon also emphasizes ways he expects OPTICARE can help use psychosocial support to minimize stress for patients, since stress disrupts a steady dopamine release in the brain.
“Although schizophrenia is incredibly complex and there is so much more we don’t know, enough coherent and consistent evidence is starting to emerge that I think can provide a unifying framework that should inform treatment decisions at these levels, Dr. Yoon said.
The opinions are the speakers’ own and do not represent those of the U.S. Navy.
WASHINGTON – Medical treatment of first-episode psychosis alone is a “cornerstone” intervention, but it’s not sufficient, according to a U.S. Navy psychiatrist who annually treats about 75 people with serious mental illness.
“We need coordinated, multimodal care for optimal treatment of psychosis,” said Michael C. Hann, MD, a Navy psychiatrist and a speaker during a panel on integrated care for schizophrenia at the American Psychiatric Association’s Institute on Psychiatric Services.
By moving away from the standard model in the past 3 years, and instead implementing a coordinated, recovery-oriented system of care as outlined in the National Institute of Mental Health’s RAISE study (Recovery After Initial Schizophrenia Episode), Dr. Hann said the Navy has seen impressive results: In six patients seen recently, the estimated duration of psychosis – the time between prodromal symptoms and first signs of a psychotic break – was as little as 6 weeks and no more than about 9 weeks.
“That is very, very short,” Dr. Hann said. “We’re very excited about that.”
The shorter the duration between first signs of psychosis and treatment, the greater chance a person has to sustain his capacity to function in his community, and enjoy higher a quality of life, according to the NIMH’s webpage about the RAISE trial.
Located at the Navy Medical Center San Diego, the Psychiatric Transition Program treats active-duty military personnel with first-episode psychosis, and also those with bipolar I disorder. Patients in the program are treated for up to 9 or 12 months, before being medically retired from service. Rates of psychosis seen in the military mirror those in the general population – about 1%. “That’s about 300 first breaks a year,” Dr. Hann, the program’s chief resident, said in an interview. “We capture about 20% of those, which is the upper limit of what we’re capable of [caring for],” he said in his presentation, noting that the program is growing as its reputation has spread across the service branches. Dr. Hann said part of the program’s success comes from the swift referrals by military commanders who are alert to signs and symptoms of psychosis.
Other strengths Dr. Hann listed are that all necessary services – including the emergency department, inpatient psychiatric services, and the outpatient clinic – are colocated. Access to inpatient psychiatric services means medication monitoring and modifications, such as being switched to a long-acting injectable antipsychotic, is easier to manage, particularly in high-risk patients. Peer support also is available through a group home model.
The program is staffed by psychiatrists, psychiatry residents, psychiatric technicians, social workers, and nurses who function as case managers. In an interview, Dr. Hann said the program typically has 30 patients in treatment at a time, with an annual average of 75 patients. Most of the patients are on the schizophrenia spectrum, although the program also accepts referrals for bipolar I.
“Currently, there is very little coordination between military and VA-based care systems,” Dr. Yoon said during the presentation. “After [these service personnel] are medically retired, they kind of go off into the wind, and it’s unclear what happens. Our preliminary data show it’s pretty bad.” This lack of coordinated transition puts affected veterans at greater risk of homelessness and suicide, Dr. Yoon said.
Because at present, there is no systematized way for medical personnel in the Department of Defense and the VA to communicate, simple measures that would help keep this patient population stable are not achieved, said Dr. Yoon. With its intended launch in January 2017, OPTICARE is intended to be the bridge between the two systems during the peritransition period, covering the 6 months prior to medical retirement to 1 year post discharge. “None of what we’re doing is rocket science, but none of it is currently being done,” he said.
Dr. Yoon, whose work focuses on how to stabilize faulty striatal dopamine signaling at the D2 receptor to minimize the duration of untreated psychosis, said using aripiprazole to maintain steady levels of D2 blocking is effective. In addition, Dr. Yoon said, he believes that emerging evidence for the stabilizing effects on D2 blocking that long-acting injectable antipsychotics provide mean they should be used more. However, this kind of evidence-based approach to care is frustrated by quirks between the two systems, such as the absence of a shared pharmacy formulary. This can lead to a person’s antipsychotic agent being switched or even noncompliance, and the possible end result can be relapse.
Dr. Yoon also emphasizes ways he expects OPTICARE can help use psychosocial support to minimize stress for patients, since stress disrupts a steady dopamine release in the brain.
“Although schizophrenia is incredibly complex and there is so much more we don’t know, enough coherent and consistent evidence is starting to emerge that I think can provide a unifying framework that should inform treatment decisions at these levels, Dr. Yoon said.
The opinions are the speakers’ own and do not represent those of the U.S. Navy.
WASHINGTON – Medical treatment of first-episode psychosis alone is a “cornerstone” intervention, but it’s not sufficient, according to a U.S. Navy psychiatrist who annually treats about 75 people with serious mental illness.
“We need coordinated, multimodal care for optimal treatment of psychosis,” said Michael C. Hann, MD, a Navy psychiatrist and a speaker during a panel on integrated care for schizophrenia at the American Psychiatric Association’s Institute on Psychiatric Services.
By moving away from the standard model in the past 3 years, and instead implementing a coordinated, recovery-oriented system of care as outlined in the National Institute of Mental Health’s RAISE study (Recovery After Initial Schizophrenia Episode), Dr. Hann said the Navy has seen impressive results: In six patients seen recently, the estimated duration of psychosis – the time between prodromal symptoms and first signs of a psychotic break – was as little as 6 weeks and no more than about 9 weeks.
“That is very, very short,” Dr. Hann said. “We’re very excited about that.”
The shorter the duration between first signs of psychosis and treatment, the greater chance a person has to sustain his capacity to function in his community, and enjoy higher a quality of life, according to the NIMH’s webpage about the RAISE trial.
Located at the Navy Medical Center San Diego, the Psychiatric Transition Program treats active-duty military personnel with first-episode psychosis, and also those with bipolar I disorder. Patients in the program are treated for up to 9 or 12 months, before being medically retired from service. Rates of psychosis seen in the military mirror those in the general population – about 1%. “That’s about 300 first breaks a year,” Dr. Hann, the program’s chief resident, said in an interview. “We capture about 20% of those, which is the upper limit of what we’re capable of [caring for],” he said in his presentation, noting that the program is growing as its reputation has spread across the service branches. Dr. Hann said part of the program’s success comes from the swift referrals by military commanders who are alert to signs and symptoms of psychosis.
Other strengths Dr. Hann listed are that all necessary services – including the emergency department, inpatient psychiatric services, and the outpatient clinic – are colocated. Access to inpatient psychiatric services means medication monitoring and modifications, such as being switched to a long-acting injectable antipsychotic, is easier to manage, particularly in high-risk patients. Peer support also is available through a group home model.
The program is staffed by psychiatrists, psychiatry residents, psychiatric technicians, social workers, and nurses who function as case managers. In an interview, Dr. Hann said the program typically has 30 patients in treatment at a time, with an annual average of 75 patients. Most of the patients are on the schizophrenia spectrum, although the program also accepts referrals for bipolar I.
“Currently, there is very little coordination between military and VA-based care systems,” Dr. Yoon said during the presentation. “After [these service personnel] are medically retired, they kind of go off into the wind, and it’s unclear what happens. Our preliminary data show it’s pretty bad.” This lack of coordinated transition puts affected veterans at greater risk of homelessness and suicide, Dr. Yoon said.
Because at present, there is no systematized way for medical personnel in the Department of Defense and the VA to communicate, simple measures that would help keep this patient population stable are not achieved, said Dr. Yoon. With its intended launch in January 2017, OPTICARE is intended to be the bridge between the two systems during the peritransition period, covering the 6 months prior to medical retirement to 1 year post discharge. “None of what we’re doing is rocket science, but none of it is currently being done,” he said.
Dr. Yoon, whose work focuses on how to stabilize faulty striatal dopamine signaling at the D2 receptor to minimize the duration of untreated psychosis, said using aripiprazole to maintain steady levels of D2 blocking is effective. In addition, Dr. Yoon said, he believes that emerging evidence for the stabilizing effects on D2 blocking that long-acting injectable antipsychotics provide mean they should be used more. However, this kind of evidence-based approach to care is frustrated by quirks between the two systems, such as the absence of a shared pharmacy formulary. This can lead to a person’s antipsychotic agent being switched or even noncompliance, and the possible end result can be relapse.
Dr. Yoon also emphasizes ways he expects OPTICARE can help use psychosocial support to minimize stress for patients, since stress disrupts a steady dopamine release in the brain.
“Although schizophrenia is incredibly complex and there is so much more we don’t know, enough coherent and consistent evidence is starting to emerge that I think can provide a unifying framework that should inform treatment decisions at these levels, Dr. Yoon said.
The opinions are the speakers’ own and do not represent those of the U.S. Navy.
EXPERT ANALYSIS FROM INSTITUTE ON PSYCHIATRIC SERVICES
Reframing views of patients who malinger advised
WASHINGTON – Imagine desperately wanting addiction treatment while living in a homeless shelter with many people who were using drugs. Could you remain sober for 6 weeks until treatment was available at an outpatient clinic – or would you bluff your way into treatment in an emergency department, where you would receive follow-up care within a week?
This is the kind of challenge that Margaret Balfour, MD, PhD, said she puts to her staff – and to anyone who treats patients they suspect are lying about this medical conditions. “Could [you], as a well-adjusted professional with reasonably good coping skills tolerate the things we ask our patients to do in order to help ‘appropriately’ ” asked Dr. Balfour, chief clinical officer at the Crisis Response Center in Tucson, Ariz., and a vice president for clinical innovation and quality at ConnectionsAZ in Tucson and Phoenix.
Signs of malingering
On average, 13% of the people presenting in the ED malinger, according to panelist Scott A. Simpson, MD, MPH, of the department of psychiatry at the University of Colorado at Denver, Aurora, and the medical director of psychiatric emergency services at Denver Health. So, how can a clinician differentiate whether a patient’s story is fact or fiction, and what can be done to get the real story?
Classic signs of malingering include a notable discrepancy between observed and reported symptoms, reports of atypical psychosis, and inexplicable cognitive symptoms. “Watch for things that seem odd, such as late-in-life onset of psychosis, Dr. Simpson said.
Patients who grow increasingly irritated during the patient interview, even to the point of threatening suicide if their treatment demands aren’t met, also can be patients who malinger However, some data do not necessarily support this as cause for alarm, according to Dr. Simpson, who cited a study showing that among 137 patients who endorsed suicidality, the 7-year suicide rate among those who did so conditionally was 0.0%, compared with 11% in those who did not have conditional suicidality (Psychiatr Serv. 2002 Jan;53[1]:92-4). The overall 7-year mortality in the first cohort was 4%, compared with 20% in the latter.
Rather than panic in such a situation, go deeper, said panelist John S. Rozel, MD, of the department of psychiatry at the University of Pittsburgh, where he also completed a master of studies in law program and serves as an adjunct professor of law. Dr. Rozel also is the medical director of the university’s re:solve Crisis Network.
“Maybe the person is worried they won’t be taken seriously,” said Dr. Rozel, explaining why some patients will escalate their claims and often are oblivious to their deceit. He shared an anecdote of having been called to treat a 14-year-old trauma patient with suicidality but who didn’t endorse any thoughts of self-harm during the patient interview. Instead, she told him that being suicidal is“what you say when you need more support, and the staff aren’t paying enough attention to you.”
Documenting the behavior
Even when clinicians are sure their patient is malingering, they often are reluctant to document it, according to Rachel Rodriguez, MD, an inpatient/emergency attending psychiatrist at Bellevue Hospital Center in New York.
“Malingering is lying, and lying is distasteful. It’s difficult to talk about,” Dr. Rodriguez said. “It’s also making a judgment about someone’s intentions, which is outside the bounds of what we are trained to do.”
Clinicians are reluctant to formally identify malingering for many reasons, Dr. Rodriguez said in an interview. Those reasons include:
• Future denial of necessary care.
• Fear of retaliation.
• Concerns about making a judgment about motives/intentions.
• Risk of misidentification.
• Fear of liability.
• Feeling sorry for the patient and helpless to address the patient’s actual needs.
Dr. Rodriguez said the underidentification and overidentification of malingering also include unique sets of risks.
At the session, Dr. Rozel agreed that an unwillingness to address malingering head-on does have its risks.
“Documentation is very important in medical malpractice. If we [record] our thinking in our notes, it’s kind of like high school math; you at least get partial credit if you show the work.” Thorough note taking includes recording the observations of all the personnel involved in the patient’s case, according to Dr. Rozel. As an example, he shared an anecdote of a patient endorsing suicidal symptoms in the interview with the clinician, but flirting with others in the waiting area, as witnessed by the admitting nurse.
Based on your observation and on a review of your patient’s prior history, Dr. Rozel suggested this partial list of notes and phrasing can be effective at establishing a “clear paper trail” should there need to be one:
• “Records show an established pattern of seeking inpatient services for ... and delaying discharge during admissions of [include dates].”
• “Review of prior records indicates no evidence of clinical improvement for brief or extended admissions similar to her current presentation.”
• “A second opinion obtained from ... concurs with ...”
• “This case has been reviewed in detail with ...”
• “Formulation and plan have been discussed with patient and other [relevant] providers, including ...”
Dr. Rozel offered this caveat: “I am not a lawyer. The only thing I promise that your lawyer and I will agree on is that they would rather you get your legal advice from them and not from me.”
Reframing the situation
Understanding yourself first will help you understand the patient better, according to Dr. Balfour: “What underlies all this is how you are feeling. Being aware of this is important.”
The range of emotional experiences when dealing with a patient who malingers can run from anger at being lied to, frustration with wasted time and resources, helplessness that nothing seems to make a difference, fear of making the wrong decision, and even hatred borne of constantly experiencing all the other emotions, she said.
Being honest about your own emotions helps keep them out of the way of delivering better care, as does being mindful of the language you use to describe patients. Describing a patient to other staff in words that connote negativity, such as “manipulative,” “attention seeking,” or “high maintenance,” might influence others to see the patient as problematic rather than someone to be helped, said Dr. Balfour, who is with the department of psychiatry at the University of Arizona, Tucson.
Instead of labeling patients, “I find using the techniques of dialectical behavioral training very effective in dealing with [this population],” Dr. Balfour said. A more effective approach includes reframing your view of patients not as liars, but as people who are doing the best they can with what they have in a system that is often set up in ways that prevent, more than augment, care.
In that case, a person who lives in a homeless shelter and who wants help with a drug addiction, for example, will “understandably come to the emergency department to try and get admitted to the inpatient unit where they can get into rehab,” Dr. Balfour said. “Sometimes, our system makes people do things we find annoying in order to get the help they need.”
Instead of making the prevention of unnecessary admissions the goal, find a way to create a rapport with patients to determine their actual problem and see what can be done to solve it. This might take several engagements with the patient, often with more than one staff member. Using the statement, “I don’t feel like I’m getting the whole story” in the patient interview is an effective way to engage patients without accusing them of lying, Dr. Balfour said. “It’s like a magic phrase. Its effectiveness is predicated on the idea that all people, even those who dissemble or embellish, have a wish on some level to reveal sensitive, personal material.”
Remembering not to take malingering personally and that your role is “to be a detective not a bouncer” will help de-escalate untruths, and can lead to a partnership with the patient rather than enmity, Dr. Balfour said.
Dr. Balfour disclosed that she is a consultant for Connections Health Solutions and Otsuka. Dr. Simpson, Dr. Rozel, and Dr. Rodriguez had no relevant disclosures.
WASHINGTON – Imagine desperately wanting addiction treatment while living in a homeless shelter with many people who were using drugs. Could you remain sober for 6 weeks until treatment was available at an outpatient clinic – or would you bluff your way into treatment in an emergency department, where you would receive follow-up care within a week?
This is the kind of challenge that Margaret Balfour, MD, PhD, said she puts to her staff – and to anyone who treats patients they suspect are lying about this medical conditions. “Could [you], as a well-adjusted professional with reasonably good coping skills tolerate the things we ask our patients to do in order to help ‘appropriately’ ” asked Dr. Balfour, chief clinical officer at the Crisis Response Center in Tucson, Ariz., and a vice president for clinical innovation and quality at ConnectionsAZ in Tucson and Phoenix.
Signs of malingering
On average, 13% of the people presenting in the ED malinger, according to panelist Scott A. Simpson, MD, MPH, of the department of psychiatry at the University of Colorado at Denver, Aurora, and the medical director of psychiatric emergency services at Denver Health. So, how can a clinician differentiate whether a patient’s story is fact or fiction, and what can be done to get the real story?
Classic signs of malingering include a notable discrepancy between observed and reported symptoms, reports of atypical psychosis, and inexplicable cognitive symptoms. “Watch for things that seem odd, such as late-in-life onset of psychosis, Dr. Simpson said.
Patients who grow increasingly irritated during the patient interview, even to the point of threatening suicide if their treatment demands aren’t met, also can be patients who malinger However, some data do not necessarily support this as cause for alarm, according to Dr. Simpson, who cited a study showing that among 137 patients who endorsed suicidality, the 7-year suicide rate among those who did so conditionally was 0.0%, compared with 11% in those who did not have conditional suicidality (Psychiatr Serv. 2002 Jan;53[1]:92-4). The overall 7-year mortality in the first cohort was 4%, compared with 20% in the latter.
Rather than panic in such a situation, go deeper, said panelist John S. Rozel, MD, of the department of psychiatry at the University of Pittsburgh, where he also completed a master of studies in law program and serves as an adjunct professor of law. Dr. Rozel also is the medical director of the university’s re:solve Crisis Network.
“Maybe the person is worried they won’t be taken seriously,” said Dr. Rozel, explaining why some patients will escalate their claims and often are oblivious to their deceit. He shared an anecdote of having been called to treat a 14-year-old trauma patient with suicidality but who didn’t endorse any thoughts of self-harm during the patient interview. Instead, she told him that being suicidal is“what you say when you need more support, and the staff aren’t paying enough attention to you.”
Documenting the behavior
Even when clinicians are sure their patient is malingering, they often are reluctant to document it, according to Rachel Rodriguez, MD, an inpatient/emergency attending psychiatrist at Bellevue Hospital Center in New York.
“Malingering is lying, and lying is distasteful. It’s difficult to talk about,” Dr. Rodriguez said. “It’s also making a judgment about someone’s intentions, which is outside the bounds of what we are trained to do.”
Clinicians are reluctant to formally identify malingering for many reasons, Dr. Rodriguez said in an interview. Those reasons include:
• Future denial of necessary care.
• Fear of retaliation.
• Concerns about making a judgment about motives/intentions.
• Risk of misidentification.
• Fear of liability.
• Feeling sorry for the patient and helpless to address the patient’s actual needs.
Dr. Rodriguez said the underidentification and overidentification of malingering also include unique sets of risks.
At the session, Dr. Rozel agreed that an unwillingness to address malingering head-on does have its risks.
“Documentation is very important in medical malpractice. If we [record] our thinking in our notes, it’s kind of like high school math; you at least get partial credit if you show the work.” Thorough note taking includes recording the observations of all the personnel involved in the patient’s case, according to Dr. Rozel. As an example, he shared an anecdote of a patient endorsing suicidal symptoms in the interview with the clinician, but flirting with others in the waiting area, as witnessed by the admitting nurse.
Based on your observation and on a review of your patient’s prior history, Dr. Rozel suggested this partial list of notes and phrasing can be effective at establishing a “clear paper trail” should there need to be one:
• “Records show an established pattern of seeking inpatient services for ... and delaying discharge during admissions of [include dates].”
• “Review of prior records indicates no evidence of clinical improvement for brief or extended admissions similar to her current presentation.”
• “A second opinion obtained from ... concurs with ...”
• “This case has been reviewed in detail with ...”
• “Formulation and plan have been discussed with patient and other [relevant] providers, including ...”
Dr. Rozel offered this caveat: “I am not a lawyer. The only thing I promise that your lawyer and I will agree on is that they would rather you get your legal advice from them and not from me.”
Reframing the situation
Understanding yourself first will help you understand the patient better, according to Dr. Balfour: “What underlies all this is how you are feeling. Being aware of this is important.”
The range of emotional experiences when dealing with a patient who malingers can run from anger at being lied to, frustration with wasted time and resources, helplessness that nothing seems to make a difference, fear of making the wrong decision, and even hatred borne of constantly experiencing all the other emotions, she said.
Being honest about your own emotions helps keep them out of the way of delivering better care, as does being mindful of the language you use to describe patients. Describing a patient to other staff in words that connote negativity, such as “manipulative,” “attention seeking,” or “high maintenance,” might influence others to see the patient as problematic rather than someone to be helped, said Dr. Balfour, who is with the department of psychiatry at the University of Arizona, Tucson.
Instead of labeling patients, “I find using the techniques of dialectical behavioral training very effective in dealing with [this population],” Dr. Balfour said. A more effective approach includes reframing your view of patients not as liars, but as people who are doing the best they can with what they have in a system that is often set up in ways that prevent, more than augment, care.
In that case, a person who lives in a homeless shelter and who wants help with a drug addiction, for example, will “understandably come to the emergency department to try and get admitted to the inpatient unit where they can get into rehab,” Dr. Balfour said. “Sometimes, our system makes people do things we find annoying in order to get the help they need.”
Instead of making the prevention of unnecessary admissions the goal, find a way to create a rapport with patients to determine their actual problem and see what can be done to solve it. This might take several engagements with the patient, often with more than one staff member. Using the statement, “I don’t feel like I’m getting the whole story” in the patient interview is an effective way to engage patients without accusing them of lying, Dr. Balfour said. “It’s like a magic phrase. Its effectiveness is predicated on the idea that all people, even those who dissemble or embellish, have a wish on some level to reveal sensitive, personal material.”
Remembering not to take malingering personally and that your role is “to be a detective not a bouncer” will help de-escalate untruths, and can lead to a partnership with the patient rather than enmity, Dr. Balfour said.
Dr. Balfour disclosed that she is a consultant for Connections Health Solutions and Otsuka. Dr. Simpson, Dr. Rozel, and Dr. Rodriguez had no relevant disclosures.
WASHINGTON – Imagine desperately wanting addiction treatment while living in a homeless shelter with many people who were using drugs. Could you remain sober for 6 weeks until treatment was available at an outpatient clinic – or would you bluff your way into treatment in an emergency department, where you would receive follow-up care within a week?
This is the kind of challenge that Margaret Balfour, MD, PhD, said she puts to her staff – and to anyone who treats patients they suspect are lying about this medical conditions. “Could [you], as a well-adjusted professional with reasonably good coping skills tolerate the things we ask our patients to do in order to help ‘appropriately’ ” asked Dr. Balfour, chief clinical officer at the Crisis Response Center in Tucson, Ariz., and a vice president for clinical innovation and quality at ConnectionsAZ in Tucson and Phoenix.
Signs of malingering
On average, 13% of the people presenting in the ED malinger, according to panelist Scott A. Simpson, MD, MPH, of the department of psychiatry at the University of Colorado at Denver, Aurora, and the medical director of psychiatric emergency services at Denver Health. So, how can a clinician differentiate whether a patient’s story is fact or fiction, and what can be done to get the real story?
Classic signs of malingering include a notable discrepancy between observed and reported symptoms, reports of atypical psychosis, and inexplicable cognitive symptoms. “Watch for things that seem odd, such as late-in-life onset of psychosis, Dr. Simpson said.
Patients who grow increasingly irritated during the patient interview, even to the point of threatening suicide if their treatment demands aren’t met, also can be patients who malinger However, some data do not necessarily support this as cause for alarm, according to Dr. Simpson, who cited a study showing that among 137 patients who endorsed suicidality, the 7-year suicide rate among those who did so conditionally was 0.0%, compared with 11% in those who did not have conditional suicidality (Psychiatr Serv. 2002 Jan;53[1]:92-4). The overall 7-year mortality in the first cohort was 4%, compared with 20% in the latter.
Rather than panic in such a situation, go deeper, said panelist John S. Rozel, MD, of the department of psychiatry at the University of Pittsburgh, where he also completed a master of studies in law program and serves as an adjunct professor of law. Dr. Rozel also is the medical director of the university’s re:solve Crisis Network.
“Maybe the person is worried they won’t be taken seriously,” said Dr. Rozel, explaining why some patients will escalate their claims and often are oblivious to their deceit. He shared an anecdote of having been called to treat a 14-year-old trauma patient with suicidality but who didn’t endorse any thoughts of self-harm during the patient interview. Instead, she told him that being suicidal is“what you say when you need more support, and the staff aren’t paying enough attention to you.”
Documenting the behavior
Even when clinicians are sure their patient is malingering, they often are reluctant to document it, according to Rachel Rodriguez, MD, an inpatient/emergency attending psychiatrist at Bellevue Hospital Center in New York.
“Malingering is lying, and lying is distasteful. It’s difficult to talk about,” Dr. Rodriguez said. “It’s also making a judgment about someone’s intentions, which is outside the bounds of what we are trained to do.”
Clinicians are reluctant to formally identify malingering for many reasons, Dr. Rodriguez said in an interview. Those reasons include:
• Future denial of necessary care.
• Fear of retaliation.
• Concerns about making a judgment about motives/intentions.
• Risk of misidentification.
• Fear of liability.
• Feeling sorry for the patient and helpless to address the patient’s actual needs.
Dr. Rodriguez said the underidentification and overidentification of malingering also include unique sets of risks.
At the session, Dr. Rozel agreed that an unwillingness to address malingering head-on does have its risks.
“Documentation is very important in medical malpractice. If we [record] our thinking in our notes, it’s kind of like high school math; you at least get partial credit if you show the work.” Thorough note taking includes recording the observations of all the personnel involved in the patient’s case, according to Dr. Rozel. As an example, he shared an anecdote of a patient endorsing suicidal symptoms in the interview with the clinician, but flirting with others in the waiting area, as witnessed by the admitting nurse.
Based on your observation and on a review of your patient’s prior history, Dr. Rozel suggested this partial list of notes and phrasing can be effective at establishing a “clear paper trail” should there need to be one:
• “Records show an established pattern of seeking inpatient services for ... and delaying discharge during admissions of [include dates].”
• “Review of prior records indicates no evidence of clinical improvement for brief or extended admissions similar to her current presentation.”
• “A second opinion obtained from ... concurs with ...”
• “This case has been reviewed in detail with ...”
• “Formulation and plan have been discussed with patient and other [relevant] providers, including ...”
Dr. Rozel offered this caveat: “I am not a lawyer. The only thing I promise that your lawyer and I will agree on is that they would rather you get your legal advice from them and not from me.”
Reframing the situation
Understanding yourself first will help you understand the patient better, according to Dr. Balfour: “What underlies all this is how you are feeling. Being aware of this is important.”
The range of emotional experiences when dealing with a patient who malingers can run from anger at being lied to, frustration with wasted time and resources, helplessness that nothing seems to make a difference, fear of making the wrong decision, and even hatred borne of constantly experiencing all the other emotions, she said.
Being honest about your own emotions helps keep them out of the way of delivering better care, as does being mindful of the language you use to describe patients. Describing a patient to other staff in words that connote negativity, such as “manipulative,” “attention seeking,” or “high maintenance,” might influence others to see the patient as problematic rather than someone to be helped, said Dr. Balfour, who is with the department of psychiatry at the University of Arizona, Tucson.
Instead of labeling patients, “I find using the techniques of dialectical behavioral training very effective in dealing with [this population],” Dr. Balfour said. A more effective approach includes reframing your view of patients not as liars, but as people who are doing the best they can with what they have in a system that is often set up in ways that prevent, more than augment, care.
In that case, a person who lives in a homeless shelter and who wants help with a drug addiction, for example, will “understandably come to the emergency department to try and get admitted to the inpatient unit where they can get into rehab,” Dr. Balfour said. “Sometimes, our system makes people do things we find annoying in order to get the help they need.”
Instead of making the prevention of unnecessary admissions the goal, find a way to create a rapport with patients to determine their actual problem and see what can be done to solve it. This might take several engagements with the patient, often with more than one staff member. Using the statement, “I don’t feel like I’m getting the whole story” in the patient interview is an effective way to engage patients without accusing them of lying, Dr. Balfour said. “It’s like a magic phrase. Its effectiveness is predicated on the idea that all people, even those who dissemble or embellish, have a wish on some level to reveal sensitive, personal material.”
Remembering not to take malingering personally and that your role is “to be a detective not a bouncer” will help de-escalate untruths, and can lead to a partnership with the patient rather than enmity, Dr. Balfour said.
Dr. Balfour disclosed that she is a consultant for Connections Health Solutions and Otsuka. Dr. Simpson, Dr. Rozel, and Dr. Rodriguez had no relevant disclosures.
Medication-assisted treatment in group settings may result in greater job satisfaction, more reimbursements
WASHINGTON – For practices that offer medication-assisted treatment but perhaps are struggling to balance follow-up appointments with new patient inductions, Leah K. Bauer, MD, has a suggestion: group sessions.
“It’s a lot of fun, and makes my practice more dynamic. It gets me out of the grind of ‘see a patient; write a note; repeat,’ ” Dr. Bauer said at the American Psychiatric Association’s Institute on Psychiatric Services.
Compressing 26.5 hours of individual clinical time into 12 hours of monthly group sessions held twice a week for 90 minutes each, Dr. Bauer said, resulted in an additional $41,000 of revenue annually, with inductions doubling from 8 to 16 per month.
One reason is that despite the sessions taking place in a group setting, she and her staff bill for a series of individual appointments using the CPT code 99212. “It is perfectly legal, and not very recognized,” Dr. Bauer said, noting that the sessions are in a group context, but that she does get to have one-on-one interaction with her patients with the added therapeutic value that peer support brings.
Modeling appropriate behavior is easier in the group setting, she said: “Patients don’t all have to test the same limits.” Instead, they can learn from the interaction of another patient with Dr. Bauer as the therapist. The group setting also helps her deliver more consistent care to all her patients, she said. “I am more conscious of what I am saying.”
A hospitalist and psychiatrist, Dr. Bauer leads group MAT with the help of a clinician cofacilitator who she says reinforces what is being said in the group and acts as a scribe, reducing Dr. Bauer’s administrative burden. “This improves my job satisfaction tremendously,” she said.
Patients sign a “check-in” sheet that also serves as their treatment plan that includes their goals and objectives. It includes the patients’ written self-reflections, what their week was like, and other entries about their mood and struggles with their recovery. The information also is recorded in their patient records. “The sheet is problem focused, and has a lot of counseling and coordination of care built in,” Dr. Bauer said.
If a patient comes to the session late, there is no lost time or productivity for the MAT team, because the group meets regardless of who attends. Patients can come as much or as little as they like every 1-4 weeks. “It’s very flexible,” Dr. Bauer said.
She does not have data on her patient outcomes in the group setting vs. the individual one, but Dr. Bauer said in an interview that she believes it is as effective and allows more people who need MAT to receive it, because few clinics in her state offer it.
The group structure does place more demand on the hospital’s pharmacy, she said, in that, after the sessions, patients arrive en masse to fill their buprenorphine prescriptions.
Questions about confidentiality do arise, although each session begins with a reminder to keep private what is shared during the meetings. However, Dr. Bauer said, she thinks some patients remain reluctant to speak their minds for fear of what they say not remaining confidential. “This can limit the depth of what’s discussed,” she said.
Dr. Bauer said she did not have any relevant financial disclosures.
WASHINGTON – For practices that offer medication-assisted treatment but perhaps are struggling to balance follow-up appointments with new patient inductions, Leah K. Bauer, MD, has a suggestion: group sessions.
“It’s a lot of fun, and makes my practice more dynamic. It gets me out of the grind of ‘see a patient; write a note; repeat,’ ” Dr. Bauer said at the American Psychiatric Association’s Institute on Psychiatric Services.
Compressing 26.5 hours of individual clinical time into 12 hours of monthly group sessions held twice a week for 90 minutes each, Dr. Bauer said, resulted in an additional $41,000 of revenue annually, with inductions doubling from 8 to 16 per month.
One reason is that despite the sessions taking place in a group setting, she and her staff bill for a series of individual appointments using the CPT code 99212. “It is perfectly legal, and not very recognized,” Dr. Bauer said, noting that the sessions are in a group context, but that she does get to have one-on-one interaction with her patients with the added therapeutic value that peer support brings.
Modeling appropriate behavior is easier in the group setting, she said: “Patients don’t all have to test the same limits.” Instead, they can learn from the interaction of another patient with Dr. Bauer as the therapist. The group setting also helps her deliver more consistent care to all her patients, she said. “I am more conscious of what I am saying.”
A hospitalist and psychiatrist, Dr. Bauer leads group MAT with the help of a clinician cofacilitator who she says reinforces what is being said in the group and acts as a scribe, reducing Dr. Bauer’s administrative burden. “This improves my job satisfaction tremendously,” she said.
Patients sign a “check-in” sheet that also serves as their treatment plan that includes their goals and objectives. It includes the patients’ written self-reflections, what their week was like, and other entries about their mood and struggles with their recovery. The information also is recorded in their patient records. “The sheet is problem focused, and has a lot of counseling and coordination of care built in,” Dr. Bauer said.
If a patient comes to the session late, there is no lost time or productivity for the MAT team, because the group meets regardless of who attends. Patients can come as much or as little as they like every 1-4 weeks. “It’s very flexible,” Dr. Bauer said.
She does not have data on her patient outcomes in the group setting vs. the individual one, but Dr. Bauer said in an interview that she believes it is as effective and allows more people who need MAT to receive it, because few clinics in her state offer it.
The group structure does place more demand on the hospital’s pharmacy, she said, in that, after the sessions, patients arrive en masse to fill their buprenorphine prescriptions.
Questions about confidentiality do arise, although each session begins with a reminder to keep private what is shared during the meetings. However, Dr. Bauer said, she thinks some patients remain reluctant to speak their minds for fear of what they say not remaining confidential. “This can limit the depth of what’s discussed,” she said.
Dr. Bauer said she did not have any relevant financial disclosures.
WASHINGTON – For practices that offer medication-assisted treatment but perhaps are struggling to balance follow-up appointments with new patient inductions, Leah K. Bauer, MD, has a suggestion: group sessions.
“It’s a lot of fun, and makes my practice more dynamic. It gets me out of the grind of ‘see a patient; write a note; repeat,’ ” Dr. Bauer said at the American Psychiatric Association’s Institute on Psychiatric Services.
Compressing 26.5 hours of individual clinical time into 12 hours of monthly group sessions held twice a week for 90 minutes each, Dr. Bauer said, resulted in an additional $41,000 of revenue annually, with inductions doubling from 8 to 16 per month.
One reason is that despite the sessions taking place in a group setting, she and her staff bill for a series of individual appointments using the CPT code 99212. “It is perfectly legal, and not very recognized,” Dr. Bauer said, noting that the sessions are in a group context, but that she does get to have one-on-one interaction with her patients with the added therapeutic value that peer support brings.
Modeling appropriate behavior is easier in the group setting, she said: “Patients don’t all have to test the same limits.” Instead, they can learn from the interaction of another patient with Dr. Bauer as the therapist. The group setting also helps her deliver more consistent care to all her patients, she said. “I am more conscious of what I am saying.”
A hospitalist and psychiatrist, Dr. Bauer leads group MAT with the help of a clinician cofacilitator who she says reinforces what is being said in the group and acts as a scribe, reducing Dr. Bauer’s administrative burden. “This improves my job satisfaction tremendously,” she said.
Patients sign a “check-in” sheet that also serves as their treatment plan that includes their goals and objectives. It includes the patients’ written self-reflections, what their week was like, and other entries about their mood and struggles with their recovery. The information also is recorded in their patient records. “The sheet is problem focused, and has a lot of counseling and coordination of care built in,” Dr. Bauer said.
If a patient comes to the session late, there is no lost time or productivity for the MAT team, because the group meets regardless of who attends. Patients can come as much or as little as they like every 1-4 weeks. “It’s very flexible,” Dr. Bauer said.
She does not have data on her patient outcomes in the group setting vs. the individual one, but Dr. Bauer said in an interview that she believes it is as effective and allows more people who need MAT to receive it, because few clinics in her state offer it.
The group structure does place more demand on the hospital’s pharmacy, she said, in that, after the sessions, patients arrive en masse to fill their buprenorphine prescriptions.
Questions about confidentiality do arise, although each session begins with a reminder to keep private what is shared during the meetings. However, Dr. Bauer said, she thinks some patients remain reluctant to speak their minds for fear of what they say not remaining confidential. “This can limit the depth of what’s discussed,” she said.
Dr. Bauer said she did not have any relevant financial disclosures.
Experts: Fewer opioids, more treatment laws mean nothing without better access to care
WASHINGTON – Pressure on physicians to prescribe fewer opioids could have unintended consequences in the absence of adequate access to treatment, according to experts.
“There is mixed evidence that, when medication-assisted treatment is lacking, there are higher rates of transition from prescription opioids to heroin,” Gary Tsai, MD, said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
“As we constrict our prescribing, we want to make sure that there is ready access to these interventions, so that those who are already dependent on opioids can transition to something safer,” said Dr. Tsai, medical director and science officer of Substance Abuse Prevention and Control, a division of Los Angeles County’s public health department.
Medication-assisted treatment (MAT) uses methadone, buprenorphine, or naltrexone in combination with appropriate behavioral and other other psychosocial therapies to help achieve opioid abstinence. Despite MAT’s well-established superiority to either pharmacotherapy or psychosocial interventions alone, the use of MAT has, in some cases, declined. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT was used in 35% of heroin-related treatment admissions in 2002, compared with 28% in 2010.
Reasons for MAT’s difficult path to acceptance are manifold, ranging from lack of certified facilities to administer the medications to misunderstanding about how the medications work, Dr. Tsai said.
A law passed earlier this year and the issuance of a final federal rule that increases the legal patient load that certified MAT providers can treat annually were designed to expand access to MAT. These, however, are only partial solutions, according to Margaret Chaplin, MD, a psychiatrist and program director of Community Mental Health Affiliates in New Britain, Conn.
“Can you imagine if endocrinologists were the only doctors who were certified to prescribe insulin and that each of them was only limited to prescribing to 100 patients?” Dr. Chaplin said in an interview. The final rule brought the number from 100 to 275 patients per year that a certified addiction specialist can treat. This might expand access to care, but “it sends a message that either the people with [addiction] don’t deserve treatment or that they don’t have a legitimate illness,” said Dr. Chaplin, who also was a presenter at the meeting.
Viewing people with opioid addiction through a lens of moral failing only compounds the nation’s addiction crisis, Dr. Chaplin believes. “Not to say that a person with a substance use disorder doesn’t have a responsibility to take care of their illness, [but] our [leaders] haven’t been well educated on the scientific evidence that addiction is a brain disease.”
It is true that, until the Comprehensive Addiction and Recovery Act was signed into law over the summer, nurse practitioners and physician assistants could have prescribed controlled substances such as acetaminophen/oxycontin but not the far less dangerous – and potentially life-saving – partial opioid agonist buprenorphine. Under the new law, those health care professions now have the same buprenorphine prescribing rights as physicians.
New legislation does not guarantee access to treatment, however. “Funding for MAT programs varies throughout the states, and the availability of these medications on formularies often determines how readily accessible MAT interventions are,” said Dr. Tsai, who emphasized the role of collaboration in ensuring the laws take hold.
“Addiction specialists comprise a minority of the work force. To scale MAT up, we need to engage other prescribers from other systems, including those in primary care and mental health,” Dr. Tai said. To wit, the three primary MAT facilities in Los Angeles County offer learning collaboratives with primary care clinicians who want to incorporate these services into their practice, even if they are not certified addiction specialists themselves. This helps increase referrals to the treatment facilities, he explained.
Overcoming resistance to offering MAT ultimately will depend on educating leaders about the costs of not doing so, Dr. Tsai and Dr. Chaplin said.
“Our system has been slow to adopt a disease model of addiction,” Dr. Chaplin said. “Buprenorphine and methadone are life-saving medical treatments that are regulated in ways that you don’t see for any other medical condition.”
SAMHSA currently is requesting comments through Nov. 1, 2016, on what should be required of MAT providers under the new law.
Neither Dr. Tsai nor Dr. Chaplin had any relevant disclosures.
WASHINGTON – Pressure on physicians to prescribe fewer opioids could have unintended consequences in the absence of adequate access to treatment, according to experts.
“There is mixed evidence that, when medication-assisted treatment is lacking, there are higher rates of transition from prescription opioids to heroin,” Gary Tsai, MD, said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
“As we constrict our prescribing, we want to make sure that there is ready access to these interventions, so that those who are already dependent on opioids can transition to something safer,” said Dr. Tsai, medical director and science officer of Substance Abuse Prevention and Control, a division of Los Angeles County’s public health department.
Medication-assisted treatment (MAT) uses methadone, buprenorphine, or naltrexone in combination with appropriate behavioral and other other psychosocial therapies to help achieve opioid abstinence. Despite MAT’s well-established superiority to either pharmacotherapy or psychosocial interventions alone, the use of MAT has, in some cases, declined. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT was used in 35% of heroin-related treatment admissions in 2002, compared with 28% in 2010.
Reasons for MAT’s difficult path to acceptance are manifold, ranging from lack of certified facilities to administer the medications to misunderstanding about how the medications work, Dr. Tsai said.
A law passed earlier this year and the issuance of a final federal rule that increases the legal patient load that certified MAT providers can treat annually were designed to expand access to MAT. These, however, are only partial solutions, according to Margaret Chaplin, MD, a psychiatrist and program director of Community Mental Health Affiliates in New Britain, Conn.
“Can you imagine if endocrinologists were the only doctors who were certified to prescribe insulin and that each of them was only limited to prescribing to 100 patients?” Dr. Chaplin said in an interview. The final rule brought the number from 100 to 275 patients per year that a certified addiction specialist can treat. This might expand access to care, but “it sends a message that either the people with [addiction] don’t deserve treatment or that they don’t have a legitimate illness,” said Dr. Chaplin, who also was a presenter at the meeting.
Viewing people with opioid addiction through a lens of moral failing only compounds the nation’s addiction crisis, Dr. Chaplin believes. “Not to say that a person with a substance use disorder doesn’t have a responsibility to take care of their illness, [but] our [leaders] haven’t been well educated on the scientific evidence that addiction is a brain disease.”
It is true that, until the Comprehensive Addiction and Recovery Act was signed into law over the summer, nurse practitioners and physician assistants could have prescribed controlled substances such as acetaminophen/oxycontin but not the far less dangerous – and potentially life-saving – partial opioid agonist buprenorphine. Under the new law, those health care professions now have the same buprenorphine prescribing rights as physicians.
New legislation does not guarantee access to treatment, however. “Funding for MAT programs varies throughout the states, and the availability of these medications on formularies often determines how readily accessible MAT interventions are,” said Dr. Tsai, who emphasized the role of collaboration in ensuring the laws take hold.
“Addiction specialists comprise a minority of the work force. To scale MAT up, we need to engage other prescribers from other systems, including those in primary care and mental health,” Dr. Tai said. To wit, the three primary MAT facilities in Los Angeles County offer learning collaboratives with primary care clinicians who want to incorporate these services into their practice, even if they are not certified addiction specialists themselves. This helps increase referrals to the treatment facilities, he explained.
Overcoming resistance to offering MAT ultimately will depend on educating leaders about the costs of not doing so, Dr. Tsai and Dr. Chaplin said.
“Our system has been slow to adopt a disease model of addiction,” Dr. Chaplin said. “Buprenorphine and methadone are life-saving medical treatments that are regulated in ways that you don’t see for any other medical condition.”
SAMHSA currently is requesting comments through Nov. 1, 2016, on what should be required of MAT providers under the new law.
Neither Dr. Tsai nor Dr. Chaplin had any relevant disclosures.
WASHINGTON – Pressure on physicians to prescribe fewer opioids could have unintended consequences in the absence of adequate access to treatment, according to experts.
“There is mixed evidence that, when medication-assisted treatment is lacking, there are higher rates of transition from prescription opioids to heroin,” Gary Tsai, MD, said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
“As we constrict our prescribing, we want to make sure that there is ready access to these interventions, so that those who are already dependent on opioids can transition to something safer,” said Dr. Tsai, medical director and science officer of Substance Abuse Prevention and Control, a division of Los Angeles County’s public health department.
Medication-assisted treatment (MAT) uses methadone, buprenorphine, or naltrexone in combination with appropriate behavioral and other other psychosocial therapies to help achieve opioid abstinence. Despite MAT’s well-established superiority to either pharmacotherapy or psychosocial interventions alone, the use of MAT has, in some cases, declined. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT was used in 35% of heroin-related treatment admissions in 2002, compared with 28% in 2010.
Reasons for MAT’s difficult path to acceptance are manifold, ranging from lack of certified facilities to administer the medications to misunderstanding about how the medications work, Dr. Tsai said.
A law passed earlier this year and the issuance of a final federal rule that increases the legal patient load that certified MAT providers can treat annually were designed to expand access to MAT. These, however, are only partial solutions, according to Margaret Chaplin, MD, a psychiatrist and program director of Community Mental Health Affiliates in New Britain, Conn.
“Can you imagine if endocrinologists were the only doctors who were certified to prescribe insulin and that each of them was only limited to prescribing to 100 patients?” Dr. Chaplin said in an interview. The final rule brought the number from 100 to 275 patients per year that a certified addiction specialist can treat. This might expand access to care, but “it sends a message that either the people with [addiction] don’t deserve treatment or that they don’t have a legitimate illness,” said Dr. Chaplin, who also was a presenter at the meeting.
Viewing people with opioid addiction through a lens of moral failing only compounds the nation’s addiction crisis, Dr. Chaplin believes. “Not to say that a person with a substance use disorder doesn’t have a responsibility to take care of their illness, [but] our [leaders] haven’t been well educated on the scientific evidence that addiction is a brain disease.”
It is true that, until the Comprehensive Addiction and Recovery Act was signed into law over the summer, nurse practitioners and physician assistants could have prescribed controlled substances such as acetaminophen/oxycontin but not the far less dangerous – and potentially life-saving – partial opioid agonist buprenorphine. Under the new law, those health care professions now have the same buprenorphine prescribing rights as physicians.
New legislation does not guarantee access to treatment, however. “Funding for MAT programs varies throughout the states, and the availability of these medications on formularies often determines how readily accessible MAT interventions are,” said Dr. Tsai, who emphasized the role of collaboration in ensuring the laws take hold.
“Addiction specialists comprise a minority of the work force. To scale MAT up, we need to engage other prescribers from other systems, including those in primary care and mental health,” Dr. Tai said. To wit, the three primary MAT facilities in Los Angeles County offer learning collaboratives with primary care clinicians who want to incorporate these services into their practice, even if they are not certified addiction specialists themselves. This helps increase referrals to the treatment facilities, he explained.
Overcoming resistance to offering MAT ultimately will depend on educating leaders about the costs of not doing so, Dr. Tsai and Dr. Chaplin said.
“Our system has been slow to adopt a disease model of addiction,” Dr. Chaplin said. “Buprenorphine and methadone are life-saving medical treatments that are regulated in ways that you don’t see for any other medical condition.”
SAMHSA currently is requesting comments through Nov. 1, 2016, on what should be required of MAT providers under the new law.
Neither Dr. Tsai nor Dr. Chaplin had any relevant disclosures.
EXPERT ANALYSIS FROM INSTITUTE ON PSYCHIATRIC SERVICES
Best practices discussed for using naloxone
WASHINGTON – More than 20 patients recently were admitted into New Haven, Conn., hospitals for overdoses of fentanyl on the same night – and many of them required multiple naloxone injections to stabilize, according to Margaret H. Chaplin, MD.
“We’re still going to lose people, but naloxone is obviously very important,” Dr. Chaplin, a psychiatrist who serves as program director of Community Mental Health Affiliates in New Britain, Conn., said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
The two ways it is most commonly prescribed, Dr. Chaplin said, is either to write a standing order for the drug to be shipped to the practice from the manufacturer, which is what community mental health and addiction service providers tend to do, or to write the prescription as needed when seeing patients. The former scenario means patients who are in the midst of an overdose do not need to wait for emergency personnel to arrive on the scene, Dr. Chaplin said.
There are three formulations: a nasal application, an intramuscular auto-injector version, and a syringe application; Dr. Chaplin said the nasal formulation is easier to store and to administer. The nasal version comes in a two-pack of 4 mg/0.1 mL doses, and the manufacturer also offers an app that gives video instructions for how to administer it.
“It’s incredibly easy to use. You stick it in a person’s nose and push,” Dr. Chaplin said. Do not prime the dose first, however. “If you do, you’ve lost the dose. Don’t push [the applicator] until it is in the nose.”
The auto-injectable formulation (Evzio) comes in a 0.4mg/0.4mL dose and is packaged with clear voice instructions recorded in the device.
Generic versions of naloxone are available. However, Dr. Chaplin said the branded versions are far easier to prescribe and administer because generics need additional scripts for the applicator. Until recently, the prices of generics and brand names were relatively similar. The auto-injectable version recently spiked considerably in price, Dr. Chaplin said.
Think of naloxone for people abusing opioids in the way that epinephrine for people susceptible to anaphylactic shock can save lives, Dr. Chaplin said. “Naloxone should be widely prescribed. There is no harm in administering it to a person who doesn’t need it.”
Naloxone really is effective only if it is administered at the time of the overdose, and it does not necessarily counteract the entire effect of the opioids. Therefore, people at risk of overdosing should have naloxone with them at all times, and 911 should be called at the time of naloxone’s administration.
“I always tell my patients that it will precipitate withdrawal, because I don’t want them to think of this as just a ‘morning after’ pill,” Dr. Chaplin said. Because most people with opioid addiction “fear withdrawal more than anything,” she said that usually helps prevent her patients from seeing naloxone as a tool to keep using opioids.
All people with a history of opioid overdose, anyone currently taking high doses of opioids, and anyone who has been coprescribed opioids with benzodiazepines also should be coprescribed naloxone, Dr. Chaplin said.
One dose of naloxone is not a 100% guarantee that a person will rebound from an overdose, Dr. Chaplin warned. Opioid overuse is evolving, particularly as the dangers posed by powerful street drugs, such as fentanyl and carfentanil, emerge.
Dr. Chaplin did not disclose any relevant financial information.
WASHINGTON – More than 20 patients recently were admitted into New Haven, Conn., hospitals for overdoses of fentanyl on the same night – and many of them required multiple naloxone injections to stabilize, according to Margaret H. Chaplin, MD.
“We’re still going to lose people, but naloxone is obviously very important,” Dr. Chaplin, a psychiatrist who serves as program director of Community Mental Health Affiliates in New Britain, Conn., said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
The two ways it is most commonly prescribed, Dr. Chaplin said, is either to write a standing order for the drug to be shipped to the practice from the manufacturer, which is what community mental health and addiction service providers tend to do, or to write the prescription as needed when seeing patients. The former scenario means patients who are in the midst of an overdose do not need to wait for emergency personnel to arrive on the scene, Dr. Chaplin said.
There are three formulations: a nasal application, an intramuscular auto-injector version, and a syringe application; Dr. Chaplin said the nasal formulation is easier to store and to administer. The nasal version comes in a two-pack of 4 mg/0.1 mL doses, and the manufacturer also offers an app that gives video instructions for how to administer it.
“It’s incredibly easy to use. You stick it in a person’s nose and push,” Dr. Chaplin said. Do not prime the dose first, however. “If you do, you’ve lost the dose. Don’t push [the applicator] until it is in the nose.”
The auto-injectable formulation (Evzio) comes in a 0.4mg/0.4mL dose and is packaged with clear voice instructions recorded in the device.
Generic versions of naloxone are available. However, Dr. Chaplin said the branded versions are far easier to prescribe and administer because generics need additional scripts for the applicator. Until recently, the prices of generics and brand names were relatively similar. The auto-injectable version recently spiked considerably in price, Dr. Chaplin said.
Think of naloxone for people abusing opioids in the way that epinephrine for people susceptible to anaphylactic shock can save lives, Dr. Chaplin said. “Naloxone should be widely prescribed. There is no harm in administering it to a person who doesn’t need it.”
Naloxone really is effective only if it is administered at the time of the overdose, and it does not necessarily counteract the entire effect of the opioids. Therefore, people at risk of overdosing should have naloxone with them at all times, and 911 should be called at the time of naloxone’s administration.
“I always tell my patients that it will precipitate withdrawal, because I don’t want them to think of this as just a ‘morning after’ pill,” Dr. Chaplin said. Because most people with opioid addiction “fear withdrawal more than anything,” she said that usually helps prevent her patients from seeing naloxone as a tool to keep using opioids.
All people with a history of opioid overdose, anyone currently taking high doses of opioids, and anyone who has been coprescribed opioids with benzodiazepines also should be coprescribed naloxone, Dr. Chaplin said.
One dose of naloxone is not a 100% guarantee that a person will rebound from an overdose, Dr. Chaplin warned. Opioid overuse is evolving, particularly as the dangers posed by powerful street drugs, such as fentanyl and carfentanil, emerge.
Dr. Chaplin did not disclose any relevant financial information.
WASHINGTON – More than 20 patients recently were admitted into New Haven, Conn., hospitals for overdoses of fentanyl on the same night – and many of them required multiple naloxone injections to stabilize, according to Margaret H. Chaplin, MD.
“We’re still going to lose people, but naloxone is obviously very important,” Dr. Chaplin, a psychiatrist who serves as program director of Community Mental Health Affiliates in New Britain, Conn., said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
The two ways it is most commonly prescribed, Dr. Chaplin said, is either to write a standing order for the drug to be shipped to the practice from the manufacturer, which is what community mental health and addiction service providers tend to do, or to write the prescription as needed when seeing patients. The former scenario means patients who are in the midst of an overdose do not need to wait for emergency personnel to arrive on the scene, Dr. Chaplin said.
There are three formulations: a nasal application, an intramuscular auto-injector version, and a syringe application; Dr. Chaplin said the nasal formulation is easier to store and to administer. The nasal version comes in a two-pack of 4 mg/0.1 mL doses, and the manufacturer also offers an app that gives video instructions for how to administer it.
“It’s incredibly easy to use. You stick it in a person’s nose and push,” Dr. Chaplin said. Do not prime the dose first, however. “If you do, you’ve lost the dose. Don’t push [the applicator] until it is in the nose.”
The auto-injectable formulation (Evzio) comes in a 0.4mg/0.4mL dose and is packaged with clear voice instructions recorded in the device.
Generic versions of naloxone are available. However, Dr. Chaplin said the branded versions are far easier to prescribe and administer because generics need additional scripts for the applicator. Until recently, the prices of generics and brand names were relatively similar. The auto-injectable version recently spiked considerably in price, Dr. Chaplin said.
Think of naloxone for people abusing opioids in the way that epinephrine for people susceptible to anaphylactic shock can save lives, Dr. Chaplin said. “Naloxone should be widely prescribed. There is no harm in administering it to a person who doesn’t need it.”
Naloxone really is effective only if it is administered at the time of the overdose, and it does not necessarily counteract the entire effect of the opioids. Therefore, people at risk of overdosing should have naloxone with them at all times, and 911 should be called at the time of naloxone’s administration.
“I always tell my patients that it will precipitate withdrawal, because I don’t want them to think of this as just a ‘morning after’ pill,” Dr. Chaplin said. Because most people with opioid addiction “fear withdrawal more than anything,” she said that usually helps prevent her patients from seeing naloxone as a tool to keep using opioids.
All people with a history of opioid overdose, anyone currently taking high doses of opioids, and anyone who has been coprescribed opioids with benzodiazepines also should be coprescribed naloxone, Dr. Chaplin said.
One dose of naloxone is not a 100% guarantee that a person will rebound from an overdose, Dr. Chaplin warned. Opioid overuse is evolving, particularly as the dangers posed by powerful street drugs, such as fentanyl and carfentanil, emerge.
Dr. Chaplin did not disclose any relevant financial information.
Suicide risk factors differ for women in military than in civilian population
WASHINGTON – Women service personnel face different suicide risks from their civilian counterparts, according to a Department of Defense appointee.
Data are few about suicide among women in the military – in part because not much research has been conducted over the years into service women’s health outcomes – according to Jacqueline Garrick, but insights gleaned from the reports of military women, both active duty and veterans, who survived suicide attempts, shed light on what to look for as risk factors. Ms. Garrick, special assistant, Manpower and Reserve Affairs in the Department of Defense, made her comments during a panel discussion at the American Psychiatric Association’s Institute on Psychiatric Services.*
One of the most salient of suicide risks can emerge when a service woman’s intimate relationship ends. This loss is compounded by the absence of social support that results from the military’s inherently masculine environment where “fitting in is definitely harder for women,” according to Ms. Garrick, a licensed clinical social worker, U.S. Army veteran, and policy analyst.
Deployment and combat zone traumas, whether physical, mental, or both, are other risk factors. Horrors witnessed in war can have psychological implications for men and women personnel. But for women, who also possibly face additional concerns of sexual assault and lack of social support, the traumas can become debilitating and lead to risk of suicide, Ms. Garrick said.
Women in the military overlap with civilians in their suicide risk factors where mental health history, abuse, and exposure to suicide are concerned, but where the two cohorts particularly diverge, Ms. Garrick said, is access to lethal means, particularly among women veterans. Civilian women who attempt suicide are more likely to cut themselves or overdose on drugs, whereas, “Military women have firearms, and they know how to use them,” Ms. Garrick said. “So, if you’re screening [for suicide in this population], pay close attention to whether there are weapons in the home.”
Traumatic brain injury is another area in which risks for suicide in military women could exist, but not enough is known at this point, Ms. Garrick said.
A suicide risk intervention called “safety planning” is one that Ms. Garrick said she has been developing in her work with the DOD. This includes asking these women what makes them feel “safe” at home, determining what their families know about the whereabouts and the safety features of their firearms, and learning what level of peer support exists for them and how to build it if it is lacking. Building resilience is another area, including finding military women opportunities to use their experiences in positive ways, such as through mentoring others.
For more information on suicide prevention for these women, Ms. Garrick referred clinicians to the suicide risk assessment and prevention clinical guidelines issued by the DOD and the Department of Veterans Affairs.
For patients at acute risk, Ms. Garrick said, “I recommend sitting with them as you watch them put this number into their phone: 800-273-8255. That’s the lifeline number that will connect you directly with the VA if you press 1.”
Because there has been a historic lack of interest on behalf of the military in women’s health outcomes related to their service compared with that of men, there is a need to create a database going forward to better inform DOD health and disability policies for women in the military, Ms. Garrick said. This places the onus on psychiatrists who evaluate this cohort to “tease out any potential psychological stressors that might not be obvious from their personnel file.” Some women have been exposed to the same levels of traumatic combat experiences as their male colleagues, even though it wasn’t until earlier this year that women became eligible for the same combat roles as men.
“If you look in their files, they might not have the same awards and titles as men, but they might have seen the same people being killed or the same number of dead bodies,” she said.
Ms. Garrick’s views are her own and do not represent those of the Department of Defense.
*Correction 10/14/16: An earlier version of this story misstated Ms. Garrick's position.
WASHINGTON – Women service personnel face different suicide risks from their civilian counterparts, according to a Department of Defense appointee.
Data are few about suicide among women in the military – in part because not much research has been conducted over the years into service women’s health outcomes – according to Jacqueline Garrick, but insights gleaned from the reports of military women, both active duty and veterans, who survived suicide attempts, shed light on what to look for as risk factors. Ms. Garrick, special assistant, Manpower and Reserve Affairs in the Department of Defense, made her comments during a panel discussion at the American Psychiatric Association’s Institute on Psychiatric Services.*
One of the most salient of suicide risks can emerge when a service woman’s intimate relationship ends. This loss is compounded by the absence of social support that results from the military’s inherently masculine environment where “fitting in is definitely harder for women,” according to Ms. Garrick, a licensed clinical social worker, U.S. Army veteran, and policy analyst.
Deployment and combat zone traumas, whether physical, mental, or both, are other risk factors. Horrors witnessed in war can have psychological implications for men and women personnel. But for women, who also possibly face additional concerns of sexual assault and lack of social support, the traumas can become debilitating and lead to risk of suicide, Ms. Garrick said.
Women in the military overlap with civilians in their suicide risk factors where mental health history, abuse, and exposure to suicide are concerned, but where the two cohorts particularly diverge, Ms. Garrick said, is access to lethal means, particularly among women veterans. Civilian women who attempt suicide are more likely to cut themselves or overdose on drugs, whereas, “Military women have firearms, and they know how to use them,” Ms. Garrick said. “So, if you’re screening [for suicide in this population], pay close attention to whether there are weapons in the home.”
Traumatic brain injury is another area in which risks for suicide in military women could exist, but not enough is known at this point, Ms. Garrick said.
A suicide risk intervention called “safety planning” is one that Ms. Garrick said she has been developing in her work with the DOD. This includes asking these women what makes them feel “safe” at home, determining what their families know about the whereabouts and the safety features of their firearms, and learning what level of peer support exists for them and how to build it if it is lacking. Building resilience is another area, including finding military women opportunities to use their experiences in positive ways, such as through mentoring others.
For more information on suicide prevention for these women, Ms. Garrick referred clinicians to the suicide risk assessment and prevention clinical guidelines issued by the DOD and the Department of Veterans Affairs.
For patients at acute risk, Ms. Garrick said, “I recommend sitting with them as you watch them put this number into their phone: 800-273-8255. That’s the lifeline number that will connect you directly with the VA if you press 1.”
Because there has been a historic lack of interest on behalf of the military in women’s health outcomes related to their service compared with that of men, there is a need to create a database going forward to better inform DOD health and disability policies for women in the military, Ms. Garrick said. This places the onus on psychiatrists who evaluate this cohort to “tease out any potential psychological stressors that might not be obvious from their personnel file.” Some women have been exposed to the same levels of traumatic combat experiences as their male colleagues, even though it wasn’t until earlier this year that women became eligible for the same combat roles as men.
“If you look in their files, they might not have the same awards and titles as men, but they might have seen the same people being killed or the same number of dead bodies,” she said.
Ms. Garrick’s views are her own and do not represent those of the Department of Defense.
*Correction 10/14/16: An earlier version of this story misstated Ms. Garrick's position.
WASHINGTON – Women service personnel face different suicide risks from their civilian counterparts, according to a Department of Defense appointee.
Data are few about suicide among women in the military – in part because not much research has been conducted over the years into service women’s health outcomes – according to Jacqueline Garrick, but insights gleaned from the reports of military women, both active duty and veterans, who survived suicide attempts, shed light on what to look for as risk factors. Ms. Garrick, special assistant, Manpower and Reserve Affairs in the Department of Defense, made her comments during a panel discussion at the American Psychiatric Association’s Institute on Psychiatric Services.*
One of the most salient of suicide risks can emerge when a service woman’s intimate relationship ends. This loss is compounded by the absence of social support that results from the military’s inherently masculine environment where “fitting in is definitely harder for women,” according to Ms. Garrick, a licensed clinical social worker, U.S. Army veteran, and policy analyst.
Deployment and combat zone traumas, whether physical, mental, or both, are other risk factors. Horrors witnessed in war can have psychological implications for men and women personnel. But for women, who also possibly face additional concerns of sexual assault and lack of social support, the traumas can become debilitating and lead to risk of suicide, Ms. Garrick said.
Women in the military overlap with civilians in their suicide risk factors where mental health history, abuse, and exposure to suicide are concerned, but where the two cohorts particularly diverge, Ms. Garrick said, is access to lethal means, particularly among women veterans. Civilian women who attempt suicide are more likely to cut themselves or overdose on drugs, whereas, “Military women have firearms, and they know how to use them,” Ms. Garrick said. “So, if you’re screening [for suicide in this population], pay close attention to whether there are weapons in the home.”
Traumatic brain injury is another area in which risks for suicide in military women could exist, but not enough is known at this point, Ms. Garrick said.
A suicide risk intervention called “safety planning” is one that Ms. Garrick said she has been developing in her work with the DOD. This includes asking these women what makes them feel “safe” at home, determining what their families know about the whereabouts and the safety features of their firearms, and learning what level of peer support exists for them and how to build it if it is lacking. Building resilience is another area, including finding military women opportunities to use their experiences in positive ways, such as through mentoring others.
For more information on suicide prevention for these women, Ms. Garrick referred clinicians to the suicide risk assessment and prevention clinical guidelines issued by the DOD and the Department of Veterans Affairs.
For patients at acute risk, Ms. Garrick said, “I recommend sitting with them as you watch them put this number into their phone: 800-273-8255. That’s the lifeline number that will connect you directly with the VA if you press 1.”
Because there has been a historic lack of interest on behalf of the military in women’s health outcomes related to their service compared with that of men, there is a need to create a database going forward to better inform DOD health and disability policies for women in the military, Ms. Garrick said. This places the onus on psychiatrists who evaluate this cohort to “tease out any potential psychological stressors that might not be obvious from their personnel file.” Some women have been exposed to the same levels of traumatic combat experiences as their male colleagues, even though it wasn’t until earlier this year that women became eligible for the same combat roles as men.
“If you look in their files, they might not have the same awards and titles as men, but they might have seen the same people being killed or the same number of dead bodies,” she said.
Ms. Garrick’s views are her own and do not represent those of the Department of Defense.
*Correction 10/14/16: An earlier version of this story misstated Ms. Garrick's position.
Ostracism is a growing concern as mechanism of poor health outcomes in military
WASHINGTON – The role of ostracism in overall poor health outcomes in service personnel is a growing concern, according to a panel of military experts.
“Think about the primary mechanism of suicide in kids who are bullied: It’s ostracism,” Kate McGraw, PhD, said in an interview at the American Psychiatric Association’s Institute on Psychiatric Services. Dr. McGraw is the interim director of the Deployment Health Clinical Center, a Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
Although the literature is scant at this point because the effects of being left out are “common sense,” said Dr. McGraw, “we need to take it seriously.”
While ostracism as a clinical term doesn’t actually exist and direct data on its impact are not numerous, its inherent psychological risks include suicide, depression, and trauma, according to another of the panelists, Jacqueline Garrick, acting director of the Defense Suicide Prevention Office in the Department of Defense.
Dr. McGraw defined ostracism as group behavior “designed to isolate or deprive another individual of being part of that group.”
Women in the military are particularly at risk for ostracism simply because they tend to be outnumbered by their male counterparts in a combat unit, according to Dr. McGraw. This, combined with a wariness of women after sexual assault awareness education, can exacerbate the segregation.
Add to the mix the separation from the male group that female biology can sometimes cause, whether due to menstrual cycles or toilet needs, Ms. Garrick said. This can widen the gap.
Additionally, service personnel – men or women – who report sexual assault are at risk of being isolated or can suffer retaliation, despite there being antiharassment and antibullying policies in place.
In the interview, Dr. McGraw said she recommends assessing the level of social support a serviceman or servicewoman has by asking directly: “How included do you feel in your group?” She also suggested looking for evidence of ostracism such as the patient endorsing a sense that they do not belong, or being friendless.
If a clinician suspects that a person who says “I am stressed” actually means, “My feelings are hurt,” Dr. McGraw suggested going deeper: Seek clues as to whether the person is experiencing ostracism either covertly, such as being bullied in private, or overtly such as not being given information that ends up making the person appear foolish or unprepared for a task.
“Ask some very pointed questions, such as ‘Are people behaving toward you in a certain way?’ and ‘Do you feel targeted?’ ”
The challenge, she said, is to maintain what is known as “military bearing” – essentially, cultivated stoicism, while also admitting that one’s functionality is suffering because of having been isolated. A dialogue between patient and clinician about being ostracized can lead to helping the person develop strategies for coping with its effects, such as making the commanding officer aware of what is happening.
“Most military personnel are not going to say their feelings are hurt, but they can address the behavior,” Dr. McGraw said.
Although Dr. McGraw admitted when asked that reporting the behavior to a superior could result in further ostracism, she said she has faith in the power of leadership to evoke cultural change. “In a military environment, if the leaders are aware of what is happening, and they take steps to mitigate or eliminate it as a unit, then they can create a healthier environment in the unit, improving morale and esprit de corps.”
None of the presenters had any relevant financial disclosures and said their presentations represented their own opinions, not those of the U.S. Armed Forces.
WASHINGTON – The role of ostracism in overall poor health outcomes in service personnel is a growing concern, according to a panel of military experts.
“Think about the primary mechanism of suicide in kids who are bullied: It’s ostracism,” Kate McGraw, PhD, said in an interview at the American Psychiatric Association’s Institute on Psychiatric Services. Dr. McGraw is the interim director of the Deployment Health Clinical Center, a Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
Although the literature is scant at this point because the effects of being left out are “common sense,” said Dr. McGraw, “we need to take it seriously.”
While ostracism as a clinical term doesn’t actually exist and direct data on its impact are not numerous, its inherent psychological risks include suicide, depression, and trauma, according to another of the panelists, Jacqueline Garrick, acting director of the Defense Suicide Prevention Office in the Department of Defense.
Dr. McGraw defined ostracism as group behavior “designed to isolate or deprive another individual of being part of that group.”
Women in the military are particularly at risk for ostracism simply because they tend to be outnumbered by their male counterparts in a combat unit, according to Dr. McGraw. This, combined with a wariness of women after sexual assault awareness education, can exacerbate the segregation.
Add to the mix the separation from the male group that female biology can sometimes cause, whether due to menstrual cycles or toilet needs, Ms. Garrick said. This can widen the gap.
Additionally, service personnel – men or women – who report sexual assault are at risk of being isolated or can suffer retaliation, despite there being antiharassment and antibullying policies in place.
In the interview, Dr. McGraw said she recommends assessing the level of social support a serviceman or servicewoman has by asking directly: “How included do you feel in your group?” She also suggested looking for evidence of ostracism such as the patient endorsing a sense that they do not belong, or being friendless.
If a clinician suspects that a person who says “I am stressed” actually means, “My feelings are hurt,” Dr. McGraw suggested going deeper: Seek clues as to whether the person is experiencing ostracism either covertly, such as being bullied in private, or overtly such as not being given information that ends up making the person appear foolish or unprepared for a task.
“Ask some very pointed questions, such as ‘Are people behaving toward you in a certain way?’ and ‘Do you feel targeted?’ ”
The challenge, she said, is to maintain what is known as “military bearing” – essentially, cultivated stoicism, while also admitting that one’s functionality is suffering because of having been isolated. A dialogue between patient and clinician about being ostracized can lead to helping the person develop strategies for coping with its effects, such as making the commanding officer aware of what is happening.
“Most military personnel are not going to say their feelings are hurt, but they can address the behavior,” Dr. McGraw said.
Although Dr. McGraw admitted when asked that reporting the behavior to a superior could result in further ostracism, she said she has faith in the power of leadership to evoke cultural change. “In a military environment, if the leaders are aware of what is happening, and they take steps to mitigate or eliminate it as a unit, then they can create a healthier environment in the unit, improving morale and esprit de corps.”
None of the presenters had any relevant financial disclosures and said their presentations represented their own opinions, not those of the U.S. Armed Forces.
WASHINGTON – The role of ostracism in overall poor health outcomes in service personnel is a growing concern, according to a panel of military experts.
“Think about the primary mechanism of suicide in kids who are bullied: It’s ostracism,” Kate McGraw, PhD, said in an interview at the American Psychiatric Association’s Institute on Psychiatric Services. Dr. McGraw is the interim director of the Deployment Health Clinical Center, a Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
Although the literature is scant at this point because the effects of being left out are “common sense,” said Dr. McGraw, “we need to take it seriously.”
While ostracism as a clinical term doesn’t actually exist and direct data on its impact are not numerous, its inherent psychological risks include suicide, depression, and trauma, according to another of the panelists, Jacqueline Garrick, acting director of the Defense Suicide Prevention Office in the Department of Defense.
Dr. McGraw defined ostracism as group behavior “designed to isolate or deprive another individual of being part of that group.”
Women in the military are particularly at risk for ostracism simply because they tend to be outnumbered by their male counterparts in a combat unit, according to Dr. McGraw. This, combined with a wariness of women after sexual assault awareness education, can exacerbate the segregation.
Add to the mix the separation from the male group that female biology can sometimes cause, whether due to menstrual cycles or toilet needs, Ms. Garrick said. This can widen the gap.
Additionally, service personnel – men or women – who report sexual assault are at risk of being isolated or can suffer retaliation, despite there being antiharassment and antibullying policies in place.
In the interview, Dr. McGraw said she recommends assessing the level of social support a serviceman or servicewoman has by asking directly: “How included do you feel in your group?” She also suggested looking for evidence of ostracism such as the patient endorsing a sense that they do not belong, or being friendless.
If a clinician suspects that a person who says “I am stressed” actually means, “My feelings are hurt,” Dr. McGraw suggested going deeper: Seek clues as to whether the person is experiencing ostracism either covertly, such as being bullied in private, or overtly such as not being given information that ends up making the person appear foolish or unprepared for a task.
“Ask some very pointed questions, such as ‘Are people behaving toward you in a certain way?’ and ‘Do you feel targeted?’ ”
The challenge, she said, is to maintain what is known as “military bearing” – essentially, cultivated stoicism, while also admitting that one’s functionality is suffering because of having been isolated. A dialogue between patient and clinician about being ostracized can lead to helping the person develop strategies for coping with its effects, such as making the commanding officer aware of what is happening.
“Most military personnel are not going to say their feelings are hurt, but they can address the behavior,” Dr. McGraw said.
Although Dr. McGraw admitted when asked that reporting the behavior to a superior could result in further ostracism, she said she has faith in the power of leadership to evoke cultural change. “In a military environment, if the leaders are aware of what is happening, and they take steps to mitigate or eliminate it as a unit, then they can create a healthier environment in the unit, improving morale and esprit de corps.”
None of the presenters had any relevant financial disclosures and said their presentations represented their own opinions, not those of the U.S. Armed Forces.
EXPERT ANALYSIS FROM THE INSTITUTE ON PSYCHIATRIC SERVICES