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Developing a personal scale for evaluating agitation on inpatient units
Agitation. As a mental health professional, you know it when you see it. While technically, it is the behavior that precedes aggression and violence, every clinical setting has its own flavor, from the voluntary psychiatric unit where I see my most acutely ill patients to the state hospital where I witnessed the type of violence that sent another patient to the emergency department.
Over the past 2 years of residency, I have developed a personal scale for measuring and responding to patient agitation. Through experiences that have provided the lower, upper (and even more upper) bounds to this scale, I have evolved from a nervous first-year intern to become a resident conscious of the need for a cool demeanor and continued engagement with the patient with escalating agitation. 
The 2003 Treatment of Behavioral Emergencies: A Summary of the Expert Consensus Guidelines1 provides an excellent visual scale to measure agitation. It begins with a patient’s refusal to cooperate and ascends stepwise toward motor restlessness, lability and loud speech, intimidation, aggression against property, and hostile verbal behavior, and it ends with directly threatening or assaultive behavior.2 Only when I witnessed signs of clinically significant agitation, hostile countenance, unpredictable anger, pacing, clenched fists, yelling, and threats, did I develop a personal understanding and approach for measuring agitation on the inpatient unit.
The upper bound for my scale initially was defined by my first incident of severe agitation and aggression while on call. I no longer remember if the patient was agitated and psychotic or just angry and agitated. Though schizophrenia and bipolar disorder often are the underlying causes of agitation, personality disorders and substance use complicate or contribute to agitation.3 The nurse called me, saying: “Can you come to the unit right now? Mr. X is agitated and has ripped the soap dispenser off the wall in his bathroom.” It was just after midnight, and already several nursing calls into this situation. Verbal de-escalation had failed with Mr. X, who moved from agitation to aggressive behavior. He already had received two doses of haloperidol and lorazepam since my evening shift began. I looked into his bedroom and saw him wrestling with the sink, which did not come off the wall as easily as the soap dispenser. The thought process of an inexperienced intern went like this: “How much haloperidol is too much haloperidol? Will this night never end?” I called my attending for help, and there was desperation in my voice as I explained: “The medications aren’t working.
These situations usually result in good clinical lessons: Medications take time to work, and in some individuals, the “standard cocktail” might not be the best option. Nonetheless, the lag time can be excruciating. As a more experienced resident, I now consider how certain medications may fail an individual, and there might be a better alternative to haloperidol and lorazepam. I’ve expanded my repertoire of pharmacological methods and opt often for second-generation antipsychotics, such as olanzapine or risperidone, without or without a benzodiazepine, when possible.2
Of course, not all agitation becomes a behavioral health emergency, and an integral part of my training as a resident has been watching an attending run an intervention smoothly. It requires coordination and experience, skills that I’m gaining. In these cases, the agitation is addressed before it escalates, nursing staff and the physicians collaborate to deliver treatment, and the patient responds to verbal redirection and, if offered, accepts oral medications. These types of patients help cement the lower bound for my agitation scale.
Nonetheless, the patients who challenge the positive archetype are the ones who cement lessons for physicians. I remember a man who with his history of serious mental illness had adverse reactions to haloperidol, aripiprazole, olanzapine, and fluphenazine. To address his agitation, the nurses prepared 2 mg of lorazepam and 50 mg of diphenhydramine. As the patient ramped up, I heard a nurse sigh, “Why can’t we add IM thorazine?” I commiserated with the nurse; the psychiatric unit is a dangerous place to work. Psychiatry and emergency department nurses, compared with their counterparts in other units, are the most likely to be assaulted at work.4,5 It is personal for me as well. Studies suggest that 30%-40% of psychiatric residents will be attacked during their 4-year training, and I am in that 70%-90% of residents who has been verbally threatened more than once.6
With time and training, my verbal de-escalation techniques have improved, as I’ve learned to avoid threatening and judgmental body language, avoiding a natural tendency to stand with my arms crossed over my chest or hands on my hips. I now more accurately and incisively inquire about a patient’s mental state. How can I address their frustration? In a nonaccusatory way, I let the patients know that they are behaving in a way that is frightening and that continued behavior may have consequences. Even when faced by the heat of agitation, I try to value the patients’ choice: This event will affect our therapeutic relationship in the longer term.
Whenever possible, I want the patients to choose their medication formulation or at least be able to ask them, “Would you be willing to take … ?” With time, I am earning that cool demeanor psychiatrists are known for. I can model calm behavior and effectively use my knowledge about mentalization to try to de-escalate the situation.
My scale of measuring of agitation and violence had its upper level increased significantly from just a soap dispenser being ripped off the wall. One patient really upped the ante by swiping a public telephone off the wall and then went tearing down the hallway to pull the fire extinguisher out of its supposed “safe” case and hurl it. So on a recent night shift, when I heard yelling through the door of the call room, it was with a sense of understanding rather than trepidation that my co-resident and I approached the patient, already being corralled to his room by nursing staff. He was an enormous man, angry, paranoid, pacing, and shouting about how the other patients wanted to attack him. Despite his size, his menacing posture, and that somewhere in his agitation he had ripped off his scrub shirt, I couldn’t help but think, “Well at least the phone and the fire extinguisher are still attached to the wall.”
References
1 J Psychiatr Pract. 2003 Jan;9(1):16-38. Treatment of behavioral emergencies: A summary of the expert consensus guidelines.
2 J Psychiatr Pract. 2005 Nov;11 Suppl 1:5-108; quiz 110-2. The expert consensus guideline series. Treatment of behavioral emergencies 2005.
3 Clin Pract Epidemiol Ment Health. 2016 Oct 27;12:75-86. State of acute agitation at psychiatric emergencies in Europe: The STAGE study.
4 J Emerg Nurs. 2014 May;40(3):218-28; quiz 295. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.
5 Work. 2010;35(2):191-200. Physical assault among nursing staff employed in acute care.
6 Psychiatr Serv. 1999 Mar;50(3):381-3. Assaults by patients on psychiatric residents: a survey and training recommendations.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
Agitation. As a mental health professional, you know it when you see it. While technically, it is the behavior that precedes aggression and violence, every clinical setting has its own flavor, from the voluntary psychiatric unit where I see my most acutely ill patients to the state hospital where I witnessed the type of violence that sent another patient to the emergency department.
Over the past 2 years of residency, I have developed a personal scale for measuring and responding to patient agitation. Through experiences that have provided the lower, upper (and even more upper) bounds to this scale, I have evolved from a nervous first-year intern to become a resident conscious of the need for a cool demeanor and continued engagement with the patient with escalating agitation.
The 2003 Treatment of Behavioral Emergencies: A Summary of the Expert Consensus Guidelines1 provides an excellent visual scale to measure agitation. It begins with a patient’s refusal to cooperate and ascends stepwise toward motor restlessness, lability and loud speech, intimidation, aggression against property, and hostile verbal behavior, and it ends with directly threatening or assaultive behavior.2 Only when I witnessed signs of clinically significant agitation, hostile countenance, unpredictable anger, pacing, clenched fists, yelling, and threats, did I develop a personal understanding and approach for measuring agitation on the inpatient unit.
The upper bound for my scale initially was defined by my first incident of severe agitation and aggression while on call. I no longer remember if the patient was agitated and psychotic or just angry and agitated. Though schizophrenia and bipolar disorder often are the underlying causes of agitation, personality disorders and substance use complicate or contribute to agitation.3 The nurse called me, saying: “Can you come to the unit right now? Mr. X is agitated and has ripped the soap dispenser off the wall in his bathroom.” It was just after midnight, and already several nursing calls into this situation. Verbal de-escalation had failed with Mr. X, who moved from agitation to aggressive behavior. He already had received two doses of haloperidol and lorazepam since my evening shift began. I looked into his bedroom and saw him wrestling with the sink, which did not come off the wall as easily as the soap dispenser. The thought process of an inexperienced intern went like this: “How much haloperidol is too much haloperidol? Will this night never end?” I called my attending for help, and there was desperation in my voice as I explained: “The medications aren’t working.
These situations usually result in good clinical lessons: Medications take time to work, and in some individuals, the “standard cocktail” might not be the best option. Nonetheless, the lag time can be excruciating. As a more experienced resident, I now consider how certain medications may fail an individual, and there might be a better alternative to haloperidol and lorazepam. I’ve expanded my repertoire of pharmacological methods and opt often for second-generation antipsychotics, such as olanzapine or risperidone, without or without a benzodiazepine, when possible.2
Of course, not all agitation becomes a behavioral health emergency, and an integral part of my training as a resident has been watching an attending run an intervention smoothly. It requires coordination and experience, skills that I’m gaining. In these cases, the agitation is addressed before it escalates, nursing staff and the physicians collaborate to deliver treatment, and the patient responds to verbal redirection and, if offered, accepts oral medications. These types of patients help cement the lower bound for my agitation scale.
Nonetheless, the patients who challenge the positive archetype are the ones who cement lessons for physicians. I remember a man who with his history of serious mental illness had adverse reactions to haloperidol, aripiprazole, olanzapine, and fluphenazine. To address his agitation, the nurses prepared 2 mg of lorazepam and 50 mg of diphenhydramine. As the patient ramped up, I heard a nurse sigh, “Why can’t we add IM thorazine?” I commiserated with the nurse; the psychiatric unit is a dangerous place to work. Psychiatry and emergency department nurses, compared with their counterparts in other units, are the most likely to be assaulted at work.4,5 It is personal for me as well. Studies suggest that 30%-40% of psychiatric residents will be attacked during their 4-year training, and I am in that 70%-90% of residents who has been verbally threatened more than once.6
With time and training, my verbal de-escalation techniques have improved, as I’ve learned to avoid threatening and judgmental body language, avoiding a natural tendency to stand with my arms crossed over my chest or hands on my hips. I now more accurately and incisively inquire about a patient’s mental state. How can I address their frustration? In a nonaccusatory way, I let the patients know that they are behaving in a way that is frightening and that continued behavior may have consequences. Even when faced by the heat of agitation, I try to value the patients’ choice: This event will affect our therapeutic relationship in the longer term.
Whenever possible, I want the patients to choose their medication formulation or at least be able to ask them, “Would you be willing to take … ?” With time, I am earning that cool demeanor psychiatrists are known for. I can model calm behavior and effectively use my knowledge about mentalization to try to de-escalate the situation.
My scale of measuring of agitation and violence had its upper level increased significantly from just a soap dispenser being ripped off the wall. One patient really upped the ante by swiping a public telephone off the wall and then went tearing down the hallway to pull the fire extinguisher out of its supposed “safe” case and hurl it. So on a recent night shift, when I heard yelling through the door of the call room, it was with a sense of understanding rather than trepidation that my co-resident and I approached the patient, already being corralled to his room by nursing staff. He was an enormous man, angry, paranoid, pacing, and shouting about how the other patients wanted to attack him. Despite his size, his menacing posture, and that somewhere in his agitation he had ripped off his scrub shirt, I couldn’t help but think, “Well at least the phone and the fire extinguisher are still attached to the wall.”
References
1 J Psychiatr Pract. 2003 Jan;9(1):16-38. Treatment of behavioral emergencies: A summary of the expert consensus guidelines.
2 J Psychiatr Pract. 2005 Nov;11 Suppl 1:5-108; quiz 110-2. The expert consensus guideline series. Treatment of behavioral emergencies 2005.
3 Clin Pract Epidemiol Ment Health. 2016 Oct 27;12:75-86. State of acute agitation at psychiatric emergencies in Europe: The STAGE study.
4 J Emerg Nurs. 2014 May;40(3):218-28; quiz 295. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.
5 Work. 2010;35(2):191-200. Physical assault among nursing staff employed in acute care.
6 Psychiatr Serv. 1999 Mar;50(3):381-3. Assaults by patients on psychiatric residents: a survey and training recommendations.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
Agitation. As a mental health professional, you know it when you see it. While technically, it is the behavior that precedes aggression and violence, every clinical setting has its own flavor, from the voluntary psychiatric unit where I see my most acutely ill patients to the state hospital where I witnessed the type of violence that sent another patient to the emergency department.
Over the past 2 years of residency, I have developed a personal scale for measuring and responding to patient agitation. Through experiences that have provided the lower, upper (and even more upper) bounds to this scale, I have evolved from a nervous first-year intern to become a resident conscious of the need for a cool demeanor and continued engagement with the patient with escalating agitation.
The 2003 Treatment of Behavioral Emergencies: A Summary of the Expert Consensus Guidelines1 provides an excellent visual scale to measure agitation. It begins with a patient’s refusal to cooperate and ascends stepwise toward motor restlessness, lability and loud speech, intimidation, aggression against property, and hostile verbal behavior, and it ends with directly threatening or assaultive behavior.2 Only when I witnessed signs of clinically significant agitation, hostile countenance, unpredictable anger, pacing, clenched fists, yelling, and threats, did I develop a personal understanding and approach for measuring agitation on the inpatient unit.
The upper bound for my scale initially was defined by my first incident of severe agitation and aggression while on call. I no longer remember if the patient was agitated and psychotic or just angry and agitated. Though schizophrenia and bipolar disorder often are the underlying causes of agitation, personality disorders and substance use complicate or contribute to agitation.3 The nurse called me, saying: “Can you come to the unit right now? Mr. X is agitated and has ripped the soap dispenser off the wall in his bathroom.” It was just after midnight, and already several nursing calls into this situation. Verbal de-escalation had failed with Mr. X, who moved from agitation to aggressive behavior. He already had received two doses of haloperidol and lorazepam since my evening shift began. I looked into his bedroom and saw him wrestling with the sink, which did not come off the wall as easily as the soap dispenser. The thought process of an inexperienced intern went like this: “How much haloperidol is too much haloperidol? Will this night never end?” I called my attending for help, and there was desperation in my voice as I explained: “The medications aren’t working.
These situations usually result in good clinical lessons: Medications take time to work, and in some individuals, the “standard cocktail” might not be the best option. Nonetheless, the lag time can be excruciating. As a more experienced resident, I now consider how certain medications may fail an individual, and there might be a better alternative to haloperidol and lorazepam. I’ve expanded my repertoire of pharmacological methods and opt often for second-generation antipsychotics, such as olanzapine or risperidone, without or without a benzodiazepine, when possible.2
Of course, not all agitation becomes a behavioral health emergency, and an integral part of my training as a resident has been watching an attending run an intervention smoothly. It requires coordination and experience, skills that I’m gaining. In these cases, the agitation is addressed before it escalates, nursing staff and the physicians collaborate to deliver treatment, and the patient responds to verbal redirection and, if offered, accepts oral medications. These types of patients help cement the lower bound for my agitation scale.
Nonetheless, the patients who challenge the positive archetype are the ones who cement lessons for physicians. I remember a man who with his history of serious mental illness had adverse reactions to haloperidol, aripiprazole, olanzapine, and fluphenazine. To address his agitation, the nurses prepared 2 mg of lorazepam and 50 mg of diphenhydramine. As the patient ramped up, I heard a nurse sigh, “Why can’t we add IM thorazine?” I commiserated with the nurse; the psychiatric unit is a dangerous place to work. Psychiatry and emergency department nurses, compared with their counterparts in other units, are the most likely to be assaulted at work.4,5 It is personal for me as well. Studies suggest that 30%-40% of psychiatric residents will be attacked during their 4-year training, and I am in that 70%-90% of residents who has been verbally threatened more than once.6
With time and training, my verbal de-escalation techniques have improved, as I’ve learned to avoid threatening and judgmental body language, avoiding a natural tendency to stand with my arms crossed over my chest or hands on my hips. I now more accurately and incisively inquire about a patient’s mental state. How can I address their frustration? In a nonaccusatory way, I let the patients know that they are behaving in a way that is frightening and that continued behavior may have consequences. Even when faced by the heat of agitation, I try to value the patients’ choice: This event will affect our therapeutic relationship in the longer term.
Whenever possible, I want the patients to choose their medication formulation or at least be able to ask them, “Would you be willing to take … ?” With time, I am earning that cool demeanor psychiatrists are known for. I can model calm behavior and effectively use my knowledge about mentalization to try to de-escalate the situation.
My scale of measuring of agitation and violence had its upper level increased significantly from just a soap dispenser being ripped off the wall. One patient really upped the ante by swiping a public telephone off the wall and then went tearing down the hallway to pull the fire extinguisher out of its supposed “safe” case and hurl it. So on a recent night shift, when I heard yelling through the door of the call room, it was with a sense of understanding rather than trepidation that my co-resident and I approached the patient, already being corralled to his room by nursing staff. He was an enormous man, angry, paranoid, pacing, and shouting about how the other patients wanted to attack him. Despite his size, his menacing posture, and that somewhere in his agitation he had ripped off his scrub shirt, I couldn’t help but think, “Well at least the phone and the fire extinguisher are still attached to the wall.”
References
1 J Psychiatr Pract. 2003 Jan;9(1):16-38. Treatment of behavioral emergencies: A summary of the expert consensus guidelines.
2 J Psychiatr Pract. 2005 Nov;11 Suppl 1:5-108; quiz 110-2. The expert consensus guideline series. Treatment of behavioral emergencies 2005.
3 Clin Pract Epidemiol Ment Health. 2016 Oct 27;12:75-86. State of acute agitation at psychiatric emergencies in Europe: The STAGE study.
4 J Emerg Nurs. 2014 May;40(3):218-28; quiz 295. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.
5 Work. 2010;35(2):191-200. Physical assault among nursing staff employed in acute care.
6 Psychiatr Serv. 1999 Mar;50(3):381-3. Assaults by patients on psychiatric residents: a survey and training recommendations.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
Antidepressant-associated purpura: A rare familial case presentation
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been a welcome addition to the armamentarium for treating depressive disorders, neuropathic pain, and anxiety disorders. Despite the more favorable side-effect profile compared with tricyclic antidepressants and monoamine oxidase inhibitors, these serotonergic agents have been associated with bleeding disorders, purpura, thrombocytopenia, and, in extreme cases, death.1-4
We describe a case of purpura associated with different classes of antidepressants, including the non-serotonergic agent bupropion, as well as a family history of similar adverse effects to antidepressants.
CASE Purpura resolves when drug is stopped
Ms. R, age 70, presents with major depressive disorder and fibromyalgia and is receiving duloxetine, 20 mg/d, which is gradually increased to 60 mg. She also has a history of chronic obstructive pulmonary disease (COPD), for which she is taking albuterol and a steroid inhaler. Ms. R responds well to treatment; however, she develops blue–purple purpura on her arms each measuring 1 to 2 inches. Laboratory test results including platelet count and prothrombin time/international normalized ratio are within normal ranges. Duloxetine is stopped, and purpura resolves in 1 to 2 weeks. To avoid serotonergic antidepressants, Ms. R receives bupropion XL, 150 mg; however, similar purpura develops, then resolves when the medication is discontinued. She is lost to follow up for approximately 6 months, but returns requesting a rechallenge with duloxetine for her depression, which has worsened. Duloxetine is restarted with similar results and is then discontinued. Because she has developed neuropathy, Ms. R is started on nortriptyline, 25 mg/d, increased to 50 mg/d, but purpura develops again, which resolves when medication is discontinued. Ms. R’s daughter reports she also developed a similar reaction with several antidepressants, which resolved with medication discontinuation.
Bleeding risk with antidepressants
The role of serotonin reuptake inhibitors (SRIs) in inducing bleeding has emerged as a safety concern,5,6 which have been documented in case reports.7-11 Mechanisms of action that have been thought to affect platelet aggregation include:
- depletion of serotonin in platelets
- increase in capillary fragility
- modification of platelet plug formation
- responsiveness of peptide-induced activation of platelets through stimulation of the thrombin receptor.7,8,12,13
The severity of bleeding varies with patient-related factors, such as a history of gastritis, peptic ulcer disease, and heavy bleeding during menses; use of gastrotoxic drugs, particularly nonsteroidal anti-inflammatory drugs (NSAIDs), also have been shown to increase this risk.14,15 For patients taking SRIs and gastrotoxic drugs (eg, NSAIDs), use of acid-suppressing agents have been shown to limit the risk of bleeding.16
Studies evaluating relative bleeding risks among classes of antidepressants have not shown increased risk with tricyclic antidepressants compared with SSRIs.17 Adenosine triphosphate (ATP), adenosine diphosphate (ADP), and adenosine monophosphate (AMP) are signaling molecules in the vascular system and are important in the thromboregulatory system. Studies in rats reported significant inhibition of ATP, ADP, and AMP hydrolysis with chronic treatment with fluoxetine and nortriptyline, and suggested that both medications changed the nucleotide catabolism, which means that homeostasis of the vascular system can be altered by antidepressant treatments.18 This is one possible pathway in the role these medications play in the etiology of dysregulation of the thromboregulatory system.
We did not anticipate that our patient would develop similar purpura with bupropion because the bleeding risk associated with antidepressants has been attributed to the effect of serotonin on platelets. Studies observing the effect of SSRIs, SNRIs, and bupropion on platelets and bleeding have not shown significant risk with bupropion.19 Bleeding associated with bupropion is atypical and needs to be further studied. Although this medication is centrally selective in its action on dopamine receptors, it might have possible peripheral effect on other neurotransmitters, including serotonin.
Ms. R had no personal or family history of purpura or a bleeding disorder. Significant improvement in her physical signs after discontinuing medications and recurrence of pupura with rechallenge indicate that this reaction was triggered by 3 different classes of antidepressants. Family history of similar reaction further suggests a genetic predisposition to platelet dysfunction to antidepressant treatment in a select group of patients.
Limitations include the possibility of senile purpura, which cannot be ruled out despite strong indications that antidepressants were the cause. The possibility of drug interactions needs be considered as well. Ms. R was taking albuterol and a steroid inhaler for her COPD at the time of the initial medication trials, which did not interact with duloxetine or bupropion. During the trials with duloxetine and then nortriptyline, she was taking acetaminophen/hydrocodone in addition to her inhalers, and no significant interactions with the antidepressants were identified. Interactions with unreported or over-the-counter medications or supplements are a possibility.
Before prescribing an antidepressant, we suggest taking a careful history including a family history of bleeding disorders and adverse effects of antidepressants, especially in patients who have risk factors (eg, concomitant use of gastrotoxic medications). Use of gastric acid-suppressing medications could be considered if antidepressants are used. Further investigations into the incidence, risk factors, mechanism of action, and treatment of this adverse effect are indicated.
Drug Brand Names
Acetaminophen/hydrocodone • Lorcet, Norco, Vicodin
Albuterol • Proventil
Bupropion • Wellbutrin
Duloxetine • Cymbalta
Nortriptyline • Pamelor, Aventyl
1. Cymbalta [package insert]. Indianapolis, IN: Eli Lilly and Company; 2014.
2. Amitriptyline. Medscape. http://reference.medscape.com/drug/levate-amitriptyline-342936. Accessed December 19, 2016.
3. Wellbutrin [package insert]. Triangle Park, NC: GlaxoSmithKline; 2004.
4. Balhara Y, Sagar R, Varghese ST. Bleeding gums: duloxetine may be the cause. J Postgrad Med. 2007;53(1):44-45.
5. Paton C, Ferrier IN. SSRIs and gastrointestinal bleeding. BMJ. 2005;331(7516):529-530.
6. Turner MS, May DB, Arthur RR, et al. Clinical impact of selective serotonin reuptake inhibitors therapy with bleeding risks. J Intern Med. 2007;261(3):205-213.
7. Humphries JE, Wheby MS, VandenBerg SR. Fluoxetine and the bleeding time. Arch Pathol Lab Med. 1990;114(7):727-728.
8. Alderman CP, Moritz CK, Ben-Tovim DI. Abnormal platelet aggregation associated with fluoxetine therapy. Ann Pharmacother. 1992;26(12):1517-1519.
9. Calhoun JW, Calhoun DD. Prolonged bleeding time in a patient treated with sertraline. Am J Psychiatry. 1996;153(3):443.
10. Ottervanger JP, Stricker BH, Huls J, et al. Bleeding attributed to the intake of paroxetine. Am J Psychiatry. 1994;151(5):781-782.
11. de Abajo FJ, Rodríguez LA, Montero D, et al. Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: population based case-control study. BMJ. 1999;319(7217):1106-1109.
12. Nelva A, Guy C, Tardy-Poncet B, et al. Hemorrhagic syndromes related to selective serotonin reuptake inhibitor (SSRI) antidepressants: seven case reports and review of the literature [in French]. Rev Med Interne. 2000;21(2):152-160.
13. de Abajo FJ, Montero D, Rodríguez LA, et al. Antidepressants and risk of upper gastrointestinal bleeding. Basic Clin Pharmacol Toxicol. 2006;98(3):304-310.
14. Tata LJ, Fortun PJ, Hubbard RB, et al. Does concurrent prescription of selective serotonin reuptake inhibitors and non-steroidal anti-inflammatory drugs substantially increase the risk of upper gastrointestinal bleeding? Aliment Pharmacol Ther. 2005;22(3):175-181.
15. Yuan Y, Tsoi K, Hunt RH. Selective serotonin reuptake inhibitors and risk of upper GI bleeding: confusion or confounding? Am J Med. 2006;119(9):719-727.
16. de Abajo FJ, García-Rodríguez LA. Risk of upper gastrointestinal tract bleeding associated with selective serotonin reuptake inhibitors and venlafaxine therapy: interaction with nonsteroidal anti-inflammatory drugs and effect of acid-suppressing agents. Arch Gen Psychiatry. 2008;65(7):795-803.
17. Barbui C, Andretta M, De Vitis G, et al. Antidepressant drug prescription and risk of abnormal bleeding: a case-control study. J Clin Pharmacol. 2009;29(1):33-38.
18. Pedrazza EL, Senger MR, Rico EP, et al. Fluoxetine and nortriptyline affect NTPDase and 5’-nucleotidase activities in rat blood serum. Life Sci. 2007;81(15):1205-1210.
19. Song HR, Jung YE, Wang HR, et al. Platelet count alterations associated with escitalopram, venlafaxine and bupropion in depressive patients. Psychiatry Clin Neurosci. 2012;66(5):457-459.
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been a welcome addition to the armamentarium for treating depressive disorders, neuropathic pain, and anxiety disorders. Despite the more favorable side-effect profile compared with tricyclic antidepressants and monoamine oxidase inhibitors, these serotonergic agents have been associated with bleeding disorders, purpura, thrombocytopenia, and, in extreme cases, death.1-4
We describe a case of purpura associated with different classes of antidepressants, including the non-serotonergic agent bupropion, as well as a family history of similar adverse effects to antidepressants.
CASE Purpura resolves when drug is stopped
Ms. R, age 70, presents with major depressive disorder and fibromyalgia and is receiving duloxetine, 20 mg/d, which is gradually increased to 60 mg. She also has a history of chronic obstructive pulmonary disease (COPD), for which she is taking albuterol and a steroid inhaler. Ms. R responds well to treatment; however, she develops blue–purple purpura on her arms each measuring 1 to 2 inches. Laboratory test results including platelet count and prothrombin time/international normalized ratio are within normal ranges. Duloxetine is stopped, and purpura resolves in 1 to 2 weeks. To avoid serotonergic antidepressants, Ms. R receives bupropion XL, 150 mg; however, similar purpura develops, then resolves when the medication is discontinued. She is lost to follow up for approximately 6 months, but returns requesting a rechallenge with duloxetine for her depression, which has worsened. Duloxetine is restarted with similar results and is then discontinued. Because she has developed neuropathy, Ms. R is started on nortriptyline, 25 mg/d, increased to 50 mg/d, but purpura develops again, which resolves when medication is discontinued. Ms. R’s daughter reports she also developed a similar reaction with several antidepressants, which resolved with medication discontinuation.
Bleeding risk with antidepressants
The role of serotonin reuptake inhibitors (SRIs) in inducing bleeding has emerged as a safety concern,5,6 which have been documented in case reports.7-11 Mechanisms of action that have been thought to affect platelet aggregation include:
- depletion of serotonin in platelets
- increase in capillary fragility
- modification of platelet plug formation
- responsiveness of peptide-induced activation of platelets through stimulation of the thrombin receptor.7,8,12,13
The severity of bleeding varies with patient-related factors, such as a history of gastritis, peptic ulcer disease, and heavy bleeding during menses; use of gastrotoxic drugs, particularly nonsteroidal anti-inflammatory drugs (NSAIDs), also have been shown to increase this risk.14,15 For patients taking SRIs and gastrotoxic drugs (eg, NSAIDs), use of acid-suppressing agents have been shown to limit the risk of bleeding.16
Studies evaluating relative bleeding risks among classes of antidepressants have not shown increased risk with tricyclic antidepressants compared with SSRIs.17 Adenosine triphosphate (ATP), adenosine diphosphate (ADP), and adenosine monophosphate (AMP) are signaling molecules in the vascular system and are important in the thromboregulatory system. Studies in rats reported significant inhibition of ATP, ADP, and AMP hydrolysis with chronic treatment with fluoxetine and nortriptyline, and suggested that both medications changed the nucleotide catabolism, which means that homeostasis of the vascular system can be altered by antidepressant treatments.18 This is one possible pathway in the role these medications play in the etiology of dysregulation of the thromboregulatory system.
We did not anticipate that our patient would develop similar purpura with bupropion because the bleeding risk associated with antidepressants has been attributed to the effect of serotonin on platelets. Studies observing the effect of SSRIs, SNRIs, and bupropion on platelets and bleeding have not shown significant risk with bupropion.19 Bleeding associated with bupropion is atypical and needs to be further studied. Although this medication is centrally selective in its action on dopamine receptors, it might have possible peripheral effect on other neurotransmitters, including serotonin.
Ms. R had no personal or family history of purpura or a bleeding disorder. Significant improvement in her physical signs after discontinuing medications and recurrence of pupura with rechallenge indicate that this reaction was triggered by 3 different classes of antidepressants. Family history of similar reaction further suggests a genetic predisposition to platelet dysfunction to antidepressant treatment in a select group of patients.
Limitations include the possibility of senile purpura, which cannot be ruled out despite strong indications that antidepressants were the cause. The possibility of drug interactions needs be considered as well. Ms. R was taking albuterol and a steroid inhaler for her COPD at the time of the initial medication trials, which did not interact with duloxetine or bupropion. During the trials with duloxetine and then nortriptyline, she was taking acetaminophen/hydrocodone in addition to her inhalers, and no significant interactions with the antidepressants were identified. Interactions with unreported or over-the-counter medications or supplements are a possibility.
Before prescribing an antidepressant, we suggest taking a careful history including a family history of bleeding disorders and adverse effects of antidepressants, especially in patients who have risk factors (eg, concomitant use of gastrotoxic medications). Use of gastric acid-suppressing medications could be considered if antidepressants are used. Further investigations into the incidence, risk factors, mechanism of action, and treatment of this adverse effect are indicated.
Drug Brand Names
Acetaminophen/hydrocodone • Lorcet, Norco, Vicodin
Albuterol • Proventil
Bupropion • Wellbutrin
Duloxetine • Cymbalta
Nortriptyline • Pamelor, Aventyl
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been a welcome addition to the armamentarium for treating depressive disorders, neuropathic pain, and anxiety disorders. Despite the more favorable side-effect profile compared with tricyclic antidepressants and monoamine oxidase inhibitors, these serotonergic agents have been associated with bleeding disorders, purpura, thrombocytopenia, and, in extreme cases, death.1-4
We describe a case of purpura associated with different classes of antidepressants, including the non-serotonergic agent bupropion, as well as a family history of similar adverse effects to antidepressants.
CASE Purpura resolves when drug is stopped
Ms. R, age 70, presents with major depressive disorder and fibromyalgia and is receiving duloxetine, 20 mg/d, which is gradually increased to 60 mg. She also has a history of chronic obstructive pulmonary disease (COPD), for which she is taking albuterol and a steroid inhaler. Ms. R responds well to treatment; however, she develops blue–purple purpura on her arms each measuring 1 to 2 inches. Laboratory test results including platelet count and prothrombin time/international normalized ratio are within normal ranges. Duloxetine is stopped, and purpura resolves in 1 to 2 weeks. To avoid serotonergic antidepressants, Ms. R receives bupropion XL, 150 mg; however, similar purpura develops, then resolves when the medication is discontinued. She is lost to follow up for approximately 6 months, but returns requesting a rechallenge with duloxetine for her depression, which has worsened. Duloxetine is restarted with similar results and is then discontinued. Because she has developed neuropathy, Ms. R is started on nortriptyline, 25 mg/d, increased to 50 mg/d, but purpura develops again, which resolves when medication is discontinued. Ms. R’s daughter reports she also developed a similar reaction with several antidepressants, which resolved with medication discontinuation.
Bleeding risk with antidepressants
The role of serotonin reuptake inhibitors (SRIs) in inducing bleeding has emerged as a safety concern,5,6 which have been documented in case reports.7-11 Mechanisms of action that have been thought to affect platelet aggregation include:
- depletion of serotonin in platelets
- increase in capillary fragility
- modification of platelet plug formation
- responsiveness of peptide-induced activation of platelets through stimulation of the thrombin receptor.7,8,12,13
The severity of bleeding varies with patient-related factors, such as a history of gastritis, peptic ulcer disease, and heavy bleeding during menses; use of gastrotoxic drugs, particularly nonsteroidal anti-inflammatory drugs (NSAIDs), also have been shown to increase this risk.14,15 For patients taking SRIs and gastrotoxic drugs (eg, NSAIDs), use of acid-suppressing agents have been shown to limit the risk of bleeding.16
Studies evaluating relative bleeding risks among classes of antidepressants have not shown increased risk with tricyclic antidepressants compared with SSRIs.17 Adenosine triphosphate (ATP), adenosine diphosphate (ADP), and adenosine monophosphate (AMP) are signaling molecules in the vascular system and are important in the thromboregulatory system. Studies in rats reported significant inhibition of ATP, ADP, and AMP hydrolysis with chronic treatment with fluoxetine and nortriptyline, and suggested that both medications changed the nucleotide catabolism, which means that homeostasis of the vascular system can be altered by antidepressant treatments.18 This is one possible pathway in the role these medications play in the etiology of dysregulation of the thromboregulatory system.
We did not anticipate that our patient would develop similar purpura with bupropion because the bleeding risk associated with antidepressants has been attributed to the effect of serotonin on platelets. Studies observing the effect of SSRIs, SNRIs, and bupropion on platelets and bleeding have not shown significant risk with bupropion.19 Bleeding associated with bupropion is atypical and needs to be further studied. Although this medication is centrally selective in its action on dopamine receptors, it might have possible peripheral effect on other neurotransmitters, including serotonin.
Ms. R had no personal or family history of purpura or a bleeding disorder. Significant improvement in her physical signs after discontinuing medications and recurrence of pupura with rechallenge indicate that this reaction was triggered by 3 different classes of antidepressants. Family history of similar reaction further suggests a genetic predisposition to platelet dysfunction to antidepressant treatment in a select group of patients.
Limitations include the possibility of senile purpura, which cannot be ruled out despite strong indications that antidepressants were the cause. The possibility of drug interactions needs be considered as well. Ms. R was taking albuterol and a steroid inhaler for her COPD at the time of the initial medication trials, which did not interact with duloxetine or bupropion. During the trials with duloxetine and then nortriptyline, she was taking acetaminophen/hydrocodone in addition to her inhalers, and no significant interactions with the antidepressants were identified. Interactions with unreported or over-the-counter medications or supplements are a possibility.
Before prescribing an antidepressant, we suggest taking a careful history including a family history of bleeding disorders and adverse effects of antidepressants, especially in patients who have risk factors (eg, concomitant use of gastrotoxic medications). Use of gastric acid-suppressing medications could be considered if antidepressants are used. Further investigations into the incidence, risk factors, mechanism of action, and treatment of this adverse effect are indicated.
Drug Brand Names
Acetaminophen/hydrocodone • Lorcet, Norco, Vicodin
Albuterol • Proventil
Bupropion • Wellbutrin
Duloxetine • Cymbalta
Nortriptyline • Pamelor, Aventyl
1. Cymbalta [package insert]. Indianapolis, IN: Eli Lilly and Company; 2014.
2. Amitriptyline. Medscape. http://reference.medscape.com/drug/levate-amitriptyline-342936. Accessed December 19, 2016.
3. Wellbutrin [package insert]. Triangle Park, NC: GlaxoSmithKline; 2004.
4. Balhara Y, Sagar R, Varghese ST. Bleeding gums: duloxetine may be the cause. J Postgrad Med. 2007;53(1):44-45.
5. Paton C, Ferrier IN. SSRIs and gastrointestinal bleeding. BMJ. 2005;331(7516):529-530.
6. Turner MS, May DB, Arthur RR, et al. Clinical impact of selective serotonin reuptake inhibitors therapy with bleeding risks. J Intern Med. 2007;261(3):205-213.
7. Humphries JE, Wheby MS, VandenBerg SR. Fluoxetine and the bleeding time. Arch Pathol Lab Med. 1990;114(7):727-728.
8. Alderman CP, Moritz CK, Ben-Tovim DI. Abnormal platelet aggregation associated with fluoxetine therapy. Ann Pharmacother. 1992;26(12):1517-1519.
9. Calhoun JW, Calhoun DD. Prolonged bleeding time in a patient treated with sertraline. Am J Psychiatry. 1996;153(3):443.
10. Ottervanger JP, Stricker BH, Huls J, et al. Bleeding attributed to the intake of paroxetine. Am J Psychiatry. 1994;151(5):781-782.
11. de Abajo FJ, Rodríguez LA, Montero D, et al. Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: population based case-control study. BMJ. 1999;319(7217):1106-1109.
12. Nelva A, Guy C, Tardy-Poncet B, et al. Hemorrhagic syndromes related to selective serotonin reuptake inhibitor (SSRI) antidepressants: seven case reports and review of the literature [in French]. Rev Med Interne. 2000;21(2):152-160.
13. de Abajo FJ, Montero D, Rodríguez LA, et al. Antidepressants and risk of upper gastrointestinal bleeding. Basic Clin Pharmacol Toxicol. 2006;98(3):304-310.
14. Tata LJ, Fortun PJ, Hubbard RB, et al. Does concurrent prescription of selective serotonin reuptake inhibitors and non-steroidal anti-inflammatory drugs substantially increase the risk of upper gastrointestinal bleeding? Aliment Pharmacol Ther. 2005;22(3):175-181.
15. Yuan Y, Tsoi K, Hunt RH. Selective serotonin reuptake inhibitors and risk of upper GI bleeding: confusion or confounding? Am J Med. 2006;119(9):719-727.
16. de Abajo FJ, García-Rodríguez LA. Risk of upper gastrointestinal tract bleeding associated with selective serotonin reuptake inhibitors and venlafaxine therapy: interaction with nonsteroidal anti-inflammatory drugs and effect of acid-suppressing agents. Arch Gen Psychiatry. 2008;65(7):795-803.
17. Barbui C, Andretta M, De Vitis G, et al. Antidepressant drug prescription and risk of abnormal bleeding: a case-control study. J Clin Pharmacol. 2009;29(1):33-38.
18. Pedrazza EL, Senger MR, Rico EP, et al. Fluoxetine and nortriptyline affect NTPDase and 5’-nucleotidase activities in rat blood serum. Life Sci. 2007;81(15):1205-1210.
19. Song HR, Jung YE, Wang HR, et al. Platelet count alterations associated with escitalopram, venlafaxine and bupropion in depressive patients. Psychiatry Clin Neurosci. 2012;66(5):457-459.
1. Cymbalta [package insert]. Indianapolis, IN: Eli Lilly and Company; 2014.
2. Amitriptyline. Medscape. http://reference.medscape.com/drug/levate-amitriptyline-342936. Accessed December 19, 2016.
3. Wellbutrin [package insert]. Triangle Park, NC: GlaxoSmithKline; 2004.
4. Balhara Y, Sagar R, Varghese ST. Bleeding gums: duloxetine may be the cause. J Postgrad Med. 2007;53(1):44-45.
5. Paton C, Ferrier IN. SSRIs and gastrointestinal bleeding. BMJ. 2005;331(7516):529-530.
6. Turner MS, May DB, Arthur RR, et al. Clinical impact of selective serotonin reuptake inhibitors therapy with bleeding risks. J Intern Med. 2007;261(3):205-213.
7. Humphries JE, Wheby MS, VandenBerg SR. Fluoxetine and the bleeding time. Arch Pathol Lab Med. 1990;114(7):727-728.
8. Alderman CP, Moritz CK, Ben-Tovim DI. Abnormal platelet aggregation associated with fluoxetine therapy. Ann Pharmacother. 1992;26(12):1517-1519.
9. Calhoun JW, Calhoun DD. Prolonged bleeding time in a patient treated with sertraline. Am J Psychiatry. 1996;153(3):443.
10. Ottervanger JP, Stricker BH, Huls J, et al. Bleeding attributed to the intake of paroxetine. Am J Psychiatry. 1994;151(5):781-782.
11. de Abajo FJ, Rodríguez LA, Montero D, et al. Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: population based case-control study. BMJ. 1999;319(7217):1106-1109.
12. Nelva A, Guy C, Tardy-Poncet B, et al. Hemorrhagic syndromes related to selective serotonin reuptake inhibitor (SSRI) antidepressants: seven case reports and review of the literature [in French]. Rev Med Interne. 2000;21(2):152-160.
13. de Abajo FJ, Montero D, Rodríguez LA, et al. Antidepressants and risk of upper gastrointestinal bleeding. Basic Clin Pharmacol Toxicol. 2006;98(3):304-310.
14. Tata LJ, Fortun PJ, Hubbard RB, et al. Does concurrent prescription of selective serotonin reuptake inhibitors and non-steroidal anti-inflammatory drugs substantially increase the risk of upper gastrointestinal bleeding? Aliment Pharmacol Ther. 2005;22(3):175-181.
15. Yuan Y, Tsoi K, Hunt RH. Selective serotonin reuptake inhibitors and risk of upper GI bleeding: confusion or confounding? Am J Med. 2006;119(9):719-727.
16. de Abajo FJ, García-Rodríguez LA. Risk of upper gastrointestinal tract bleeding associated with selective serotonin reuptake inhibitors and venlafaxine therapy: interaction with nonsteroidal anti-inflammatory drugs and effect of acid-suppressing agents. Arch Gen Psychiatry. 2008;65(7):795-803.
17. Barbui C, Andretta M, De Vitis G, et al. Antidepressant drug prescription and risk of abnormal bleeding: a case-control study. J Clin Pharmacol. 2009;29(1):33-38.
18. Pedrazza EL, Senger MR, Rico EP, et al. Fluoxetine and nortriptyline affect NTPDase and 5’-nucleotidase activities in rat blood serum. Life Sci. 2007;81(15):1205-1210.
19. Song HR, Jung YE, Wang HR, et al. Platelet count alterations associated with escitalopram, venlafaxine and bupropion in depressive patients. Psychiatry Clin Neurosci. 2012;66(5):457-459.
Is physician-assisted suicide compatible with the Hippocratic Oath?
Do we stand by our Hippocratic Oath when providing physician-assisted suicide?
Physician-assisted suicide (PAS) is a form of euthanasia in which a physician provides the patient with the pertinent information, and, in certain cases, a prescription for the necessary lethal drugs, so that the individual can willingly and successfully terminate his or her own life. The justification for PAS is the compassionate relief of intractable human suffering. Euthanasia and PAS are accepted practices in European countries such as the Netherlands, Belgium, and Luxembourg.
Such patients are mentally incapable of making the difficult decision to end their life and therefore should require a psychiatric evaluation to include counseling prior to making a decision to engage in PAS. For patients with mental illness, PAS is even more problematic than for terminally ill patients, because patients may lack the capacity to make rational and responsible decisions. Indeed, there are sizable loopholes where our medical system lacks safeguards and similarly lacks the requirements for a thorough, pre-PAS mental health examination, family notifications, and consultations, and for the minimally necessary legal pressure required to ensure patient cooperation.
Critical role of mental health workers
Although PAS has been legalized in those five U.S. states, its support and cases have stalled in recent years, indicating serious ethical concerns, mostly because of multileveled challenges of combating and delineating cultural stereotypes, quantifying mental capacity, gauging quality of life, and deciding where to situate psychiatrists in the PAS decision.
The psychiatrist’s role is being debated. In the United States, opponents take issue with current PAS-legal state’s legislation regarding psychiatric evaluations. For example, Oregon stipulates a psychiatrist referral only in cases where a physician other than a psychiatrist believes the patient’s judgment is impaired. It’s agreed that psychiatrists have the best skill set to assess a patient’s perceptions. Other PAS-legal states require a psychiatrist or psychologist assessment before making the decision. Unfortunately, though, physicians have rarely referred these patients to psychiatrists before offering PAS as an option.
PAS opponents target standards by which concepts like “quality of life” or “contributing member of society” are judged – specifically, that “unbearable suffering” and its ramifications are ill defined – people whose lives are deemed “not worth living” (including the terminally ill) would be susceptible to “sympathetic death” via PAS that might result from PAS legalization. Opponents also argue that recognizing a suicide “right” contradicts that a significant number of suicide attempters have mental illness and need help. They say that legalizing PAS would enable mentally incapacitated people to commit the irreversible act based on their distorted perceptions without providing them the expected assistance from their profession.1
The use of euthanasia or PAS gradually is trending from physically terminally ill patients toward psychiatrically complex patients. There are cases in which euthanasia or PAS was requested by psychiatric patients who had chronic psychiatric, medical, and psychosocial histories rather than purely physical ailment histories. In one study, Scott Y. H. Kim, MD, PhD, and his associates reviewed cases in the Netherlands in which either euthanasia or PAS for psychiatric disorders was deployed. The granted PAS requests appeared to involve physician judgment without psychiatric input.
The study reviewed 66 cases: 55% of patients had chronic severe conditions with extensive histories of attempted suicides and psychiatric hospitalizations, demonstrating that the granted euthanasia and PAS requests had involved extensive evaluations. However, 11% of cases had no independent psychiatric input, and 24% involved disagreement among the physicians.2 PAS proponents and opponents support the involvement and expertise of psychiatrists in all of this.
Psychiatrists have long contended that suicide attempts are often a “cry for help,” not an earnest act to end one’s life. Legalizing PAS tells suicidal individuals that society does not care whether they live or die – a truly un-Hippocratic stance. The stereotypes tossed around in the PAS debate, which could mean life or death, need to be unpacked with specific criteria attached, rather than preconceptions.
Autonomy of patients and implications of PAS
In the PAS debate, there are serious life concerns exhibited by terminally ill/psychiatrically ill patients over losing their autonomy and becoming a burden to their families and caregivers. Stereotypes must be deconstructed, yes, but such patients generally have been considered to be rendered, by the sum effect of their illnesses, mentally incapable of making the decision to end their lives. Addressing this order of patient life concerns generally has been the realm of social workers, psychologists, and, in the most desirable cases, psychiatrists. Therefore, even in keeping with established practice, some form of competent psychiatric evaluation should be required before considering PAS as a viable option.
The call for this requirement is backed up by a study, which reported that 47% of patients who had considered or committed suicide previously were diagnosed with psychiatric disorders, and 15% had undiagnosed psychiatric disorders.3 Also, inventories of thwarted suicide attempters reveal that most lack the conviction to end their lives, and this obverse phenomenon is backed by a study that revealed that 75% of 96 suicidal patients were found to be ambivalent in their intent to end their lives. Suicide attempters simply may be trying to communicate with people in their lives in order to test their love and care.4 This indicates that those who attempt suicide are predominantly psychiatrically ill and prone to distorted perceptions, impaired judgment, frustration, escapism, and manipulative guilt.
Suicide is abhorrent to most human beings’ sensibilities, because humanity has an innate will to live.5 It is wrong to offer patients life-ending options when they might rejuvenate or ease into death naturally. With the debilitated or elderly, PAS could violate their human rights. If the attitude that they are a burden to society persists, then a certain segment of society might be tempted to avoid their intergenerational obligations to elders, particularly those elders presenting with concurrent mental illnesses. PAS would additionally fuel that problem. This would represent a profound injustice and gross violation of human dignity, while also serving as a denial of basic human rights, particularly the right to life and care.6
Conclusion
The complex physical, psychological, and social challenges associated with PAS and the difficulty in enforcing its laws necessitate more adept alternatives. Instead of conditionally legalizing suicide, we should ease patient suffering with compassion and calibrated treatment.6,7
Terminally ill patients often suffer from depression, affecting their rationality. Adequate counseling, medical care, and psychological care should be the response to terminally ill patients considering suicide. If society accepts that ending a life is a reasonable response to human suffering that could otherwise be treated or reversed, then those with the most serious psychiatric conditions are destined to become more vulnerable. Therefore, physicians and psychiatrists should instead work harder to help patients recover, rather than participating in their quest for death.
Simplistic legal and regulatory oversight is insufficient, because the questions evoked by PAS are complicated by life, death, and ethics. Further research is needed to look into the mechanisms and morality of how psychiatrists and other physicians will make judgments and recommendations that are vital elements in developing regulatory oversight on PAS. Finally, future studies should look at which practices have been successful and which might be deemed unethical.
References
1. Clin Med (Lond). 2010 Aug;109(4):323-5.
2. JAMA Psychiatry. 2016;73(4):362-8.
3. “The Final Months: A Study of the Lives of 134 Persons Who Committed Suicide,” New York: Oxford University Press, 1981.
4. “Why We Shouldn’t Legalize Assisting Suicide, Part I.” Department of Medical Ethics, National Right to Life Committee.
5. “Working with Suicidal Individuals: A Guide to Providing Understanding, Assessment and Support,” Philadelphia: Jessica Kingsley Publishers, 2010.
6. “Always Care, Never Kill: How Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises the Family, and Violates Human Dignity and Equality,” Washington: The Heritage Foundation, 2015.
7. Ann Intern Med. 2012 Jan 3;156(1 Pt 2):73-104.
Dr. Ahmed is a 2nd-year resident in the psychiatry & behavioral sciences department at the Nassau University Medical Center, New York. Over the last 3 years, he has published and presented papers at national and international forums. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and undiagnosed and overdiagnosed psychiatric illnesses in children. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.
Do we stand by our Hippocratic Oath when providing physician-assisted suicide?
Physician-assisted suicide (PAS) is a form of euthanasia in which a physician provides the patient with the pertinent information, and, in certain cases, a prescription for the necessary lethal drugs, so that the individual can willingly and successfully terminate his or her own life. The justification for PAS is the compassionate relief of intractable human suffering. Euthanasia and PAS are accepted practices in European countries such as the Netherlands, Belgium, and Luxembourg.
Such patients are mentally incapable of making the difficult decision to end their life and therefore should require a psychiatric evaluation to include counseling prior to making a decision to engage in PAS. For patients with mental illness, PAS is even more problematic than for terminally ill patients, because patients may lack the capacity to make rational and responsible decisions. Indeed, there are sizable loopholes where our medical system lacks safeguards and similarly lacks the requirements for a thorough, pre-PAS mental health examination, family notifications, and consultations, and for the minimally necessary legal pressure required to ensure patient cooperation.
Critical role of mental health workers
Although PAS has been legalized in those five U.S. states, its support and cases have stalled in recent years, indicating serious ethical concerns, mostly because of multileveled challenges of combating and delineating cultural stereotypes, quantifying mental capacity, gauging quality of life, and deciding where to situate psychiatrists in the PAS decision.
The psychiatrist’s role is being debated. In the United States, opponents take issue with current PAS-legal state’s legislation regarding psychiatric evaluations. For example, Oregon stipulates a psychiatrist referral only in cases where a physician other than a psychiatrist believes the patient’s judgment is impaired. It’s agreed that psychiatrists have the best skill set to assess a patient’s perceptions. Other PAS-legal states require a psychiatrist or psychologist assessment before making the decision. Unfortunately, though, physicians have rarely referred these patients to psychiatrists before offering PAS as an option.
PAS opponents target standards by which concepts like “quality of life” or “contributing member of society” are judged – specifically, that “unbearable suffering” and its ramifications are ill defined – people whose lives are deemed “not worth living” (including the terminally ill) would be susceptible to “sympathetic death” via PAS that might result from PAS legalization. Opponents also argue that recognizing a suicide “right” contradicts that a significant number of suicide attempters have mental illness and need help. They say that legalizing PAS would enable mentally incapacitated people to commit the irreversible act based on their distorted perceptions without providing them the expected assistance from their profession.1
The use of euthanasia or PAS gradually is trending from physically terminally ill patients toward psychiatrically complex patients. There are cases in which euthanasia or PAS was requested by psychiatric patients who had chronic psychiatric, medical, and psychosocial histories rather than purely physical ailment histories. In one study, Scott Y. H. Kim, MD, PhD, and his associates reviewed cases in the Netherlands in which either euthanasia or PAS for psychiatric disorders was deployed. The granted PAS requests appeared to involve physician judgment without psychiatric input.
The study reviewed 66 cases: 55% of patients had chronic severe conditions with extensive histories of attempted suicides and psychiatric hospitalizations, demonstrating that the granted euthanasia and PAS requests had involved extensive evaluations. However, 11% of cases had no independent psychiatric input, and 24% involved disagreement among the physicians.2 PAS proponents and opponents support the involvement and expertise of psychiatrists in all of this.
Psychiatrists have long contended that suicide attempts are often a “cry for help,” not an earnest act to end one’s life. Legalizing PAS tells suicidal individuals that society does not care whether they live or die – a truly un-Hippocratic stance. The stereotypes tossed around in the PAS debate, which could mean life or death, need to be unpacked with specific criteria attached, rather than preconceptions.
Autonomy of patients and implications of PAS
In the PAS debate, there are serious life concerns exhibited by terminally ill/psychiatrically ill patients over losing their autonomy and becoming a burden to their families and caregivers. Stereotypes must be deconstructed, yes, but such patients generally have been considered to be rendered, by the sum effect of their illnesses, mentally incapable of making the decision to end their lives. Addressing this order of patient life concerns generally has been the realm of social workers, psychologists, and, in the most desirable cases, psychiatrists. Therefore, even in keeping with established practice, some form of competent psychiatric evaluation should be required before considering PAS as a viable option.
The call for this requirement is backed up by a study, which reported that 47% of patients who had considered or committed suicide previously were diagnosed with psychiatric disorders, and 15% had undiagnosed psychiatric disorders.3 Also, inventories of thwarted suicide attempters reveal that most lack the conviction to end their lives, and this obverse phenomenon is backed by a study that revealed that 75% of 96 suicidal patients were found to be ambivalent in their intent to end their lives. Suicide attempters simply may be trying to communicate with people in their lives in order to test their love and care.4 This indicates that those who attempt suicide are predominantly psychiatrically ill and prone to distorted perceptions, impaired judgment, frustration, escapism, and manipulative guilt.
Suicide is abhorrent to most human beings’ sensibilities, because humanity has an innate will to live.5 It is wrong to offer patients life-ending options when they might rejuvenate or ease into death naturally. With the debilitated or elderly, PAS could violate their human rights. If the attitude that they are a burden to society persists, then a certain segment of society might be tempted to avoid their intergenerational obligations to elders, particularly those elders presenting with concurrent mental illnesses. PAS would additionally fuel that problem. This would represent a profound injustice and gross violation of human dignity, while also serving as a denial of basic human rights, particularly the right to life and care.6
Conclusion
The complex physical, psychological, and social challenges associated with PAS and the difficulty in enforcing its laws necessitate more adept alternatives. Instead of conditionally legalizing suicide, we should ease patient suffering with compassion and calibrated treatment.6,7
Terminally ill patients often suffer from depression, affecting their rationality. Adequate counseling, medical care, and psychological care should be the response to terminally ill patients considering suicide. If society accepts that ending a life is a reasonable response to human suffering that could otherwise be treated or reversed, then those with the most serious psychiatric conditions are destined to become more vulnerable. Therefore, physicians and psychiatrists should instead work harder to help patients recover, rather than participating in their quest for death.
Simplistic legal and regulatory oversight is insufficient, because the questions evoked by PAS are complicated by life, death, and ethics. Further research is needed to look into the mechanisms and morality of how psychiatrists and other physicians will make judgments and recommendations that are vital elements in developing regulatory oversight on PAS. Finally, future studies should look at which practices have been successful and which might be deemed unethical.
References
1. Clin Med (Lond). 2010 Aug;109(4):323-5.
2. JAMA Psychiatry. 2016;73(4):362-8.
3. “The Final Months: A Study of the Lives of 134 Persons Who Committed Suicide,” New York: Oxford University Press, 1981.
4. “Why We Shouldn’t Legalize Assisting Suicide, Part I.” Department of Medical Ethics, National Right to Life Committee.
5. “Working with Suicidal Individuals: A Guide to Providing Understanding, Assessment and Support,” Philadelphia: Jessica Kingsley Publishers, 2010.
6. “Always Care, Never Kill: How Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises the Family, and Violates Human Dignity and Equality,” Washington: The Heritage Foundation, 2015.
7. Ann Intern Med. 2012 Jan 3;156(1 Pt 2):73-104.
Dr. Ahmed is a 2nd-year resident in the psychiatry & behavioral sciences department at the Nassau University Medical Center, New York. Over the last 3 years, he has published and presented papers at national and international forums. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and undiagnosed and overdiagnosed psychiatric illnesses in children. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.
Do we stand by our Hippocratic Oath when providing physician-assisted suicide?
Physician-assisted suicide (PAS) is a form of euthanasia in which a physician provides the patient with the pertinent information, and, in certain cases, a prescription for the necessary lethal drugs, so that the individual can willingly and successfully terminate his or her own life. The justification for PAS is the compassionate relief of intractable human suffering. Euthanasia and PAS are accepted practices in European countries such as the Netherlands, Belgium, and Luxembourg.
Such patients are mentally incapable of making the difficult decision to end their life and therefore should require a psychiatric evaluation to include counseling prior to making a decision to engage in PAS. For patients with mental illness, PAS is even more problematic than for terminally ill patients, because patients may lack the capacity to make rational and responsible decisions. Indeed, there are sizable loopholes where our medical system lacks safeguards and similarly lacks the requirements for a thorough, pre-PAS mental health examination, family notifications, and consultations, and for the minimally necessary legal pressure required to ensure patient cooperation.
Critical role of mental health workers
Although PAS has been legalized in those five U.S. states, its support and cases have stalled in recent years, indicating serious ethical concerns, mostly because of multileveled challenges of combating and delineating cultural stereotypes, quantifying mental capacity, gauging quality of life, and deciding where to situate psychiatrists in the PAS decision.
The psychiatrist’s role is being debated. In the United States, opponents take issue with current PAS-legal state’s legislation regarding psychiatric evaluations. For example, Oregon stipulates a psychiatrist referral only in cases where a physician other than a psychiatrist believes the patient’s judgment is impaired. It’s agreed that psychiatrists have the best skill set to assess a patient’s perceptions. Other PAS-legal states require a psychiatrist or psychologist assessment before making the decision. Unfortunately, though, physicians have rarely referred these patients to psychiatrists before offering PAS as an option.
PAS opponents target standards by which concepts like “quality of life” or “contributing member of society” are judged – specifically, that “unbearable suffering” and its ramifications are ill defined – people whose lives are deemed “not worth living” (including the terminally ill) would be susceptible to “sympathetic death” via PAS that might result from PAS legalization. Opponents also argue that recognizing a suicide “right” contradicts that a significant number of suicide attempters have mental illness and need help. They say that legalizing PAS would enable mentally incapacitated people to commit the irreversible act based on their distorted perceptions without providing them the expected assistance from their profession.1
The use of euthanasia or PAS gradually is trending from physically terminally ill patients toward psychiatrically complex patients. There are cases in which euthanasia or PAS was requested by psychiatric patients who had chronic psychiatric, medical, and psychosocial histories rather than purely physical ailment histories. In one study, Scott Y. H. Kim, MD, PhD, and his associates reviewed cases in the Netherlands in which either euthanasia or PAS for psychiatric disorders was deployed. The granted PAS requests appeared to involve physician judgment without psychiatric input.
The study reviewed 66 cases: 55% of patients had chronic severe conditions with extensive histories of attempted suicides and psychiatric hospitalizations, demonstrating that the granted euthanasia and PAS requests had involved extensive evaluations. However, 11% of cases had no independent psychiatric input, and 24% involved disagreement among the physicians.2 PAS proponents and opponents support the involvement and expertise of psychiatrists in all of this.
Psychiatrists have long contended that suicide attempts are often a “cry for help,” not an earnest act to end one’s life. Legalizing PAS tells suicidal individuals that society does not care whether they live or die – a truly un-Hippocratic stance. The stereotypes tossed around in the PAS debate, which could mean life or death, need to be unpacked with specific criteria attached, rather than preconceptions.
Autonomy of patients and implications of PAS
In the PAS debate, there are serious life concerns exhibited by terminally ill/psychiatrically ill patients over losing their autonomy and becoming a burden to their families and caregivers. Stereotypes must be deconstructed, yes, but such patients generally have been considered to be rendered, by the sum effect of their illnesses, mentally incapable of making the decision to end their lives. Addressing this order of patient life concerns generally has been the realm of social workers, psychologists, and, in the most desirable cases, psychiatrists. Therefore, even in keeping with established practice, some form of competent psychiatric evaluation should be required before considering PAS as a viable option.
The call for this requirement is backed up by a study, which reported that 47% of patients who had considered or committed suicide previously were diagnosed with psychiatric disorders, and 15% had undiagnosed psychiatric disorders.3 Also, inventories of thwarted suicide attempters reveal that most lack the conviction to end their lives, and this obverse phenomenon is backed by a study that revealed that 75% of 96 suicidal patients were found to be ambivalent in their intent to end their lives. Suicide attempters simply may be trying to communicate with people in their lives in order to test their love and care.4 This indicates that those who attempt suicide are predominantly psychiatrically ill and prone to distorted perceptions, impaired judgment, frustration, escapism, and manipulative guilt.
Suicide is abhorrent to most human beings’ sensibilities, because humanity has an innate will to live.5 It is wrong to offer patients life-ending options when they might rejuvenate or ease into death naturally. With the debilitated or elderly, PAS could violate their human rights. If the attitude that they are a burden to society persists, then a certain segment of society might be tempted to avoid their intergenerational obligations to elders, particularly those elders presenting with concurrent mental illnesses. PAS would additionally fuel that problem. This would represent a profound injustice and gross violation of human dignity, while also serving as a denial of basic human rights, particularly the right to life and care.6
Conclusion
The complex physical, psychological, and social challenges associated with PAS and the difficulty in enforcing its laws necessitate more adept alternatives. Instead of conditionally legalizing suicide, we should ease patient suffering with compassion and calibrated treatment.6,7
Terminally ill patients often suffer from depression, affecting their rationality. Adequate counseling, medical care, and psychological care should be the response to terminally ill patients considering suicide. If society accepts that ending a life is a reasonable response to human suffering that could otherwise be treated or reversed, then those with the most serious psychiatric conditions are destined to become more vulnerable. Therefore, physicians and psychiatrists should instead work harder to help patients recover, rather than participating in their quest for death.
Simplistic legal and regulatory oversight is insufficient, because the questions evoked by PAS are complicated by life, death, and ethics. Further research is needed to look into the mechanisms and morality of how psychiatrists and other physicians will make judgments and recommendations that are vital elements in developing regulatory oversight on PAS. Finally, future studies should look at which practices have been successful and which might be deemed unethical.
References
1. Clin Med (Lond). 2010 Aug;109(4):323-5.
2. JAMA Psychiatry. 2016;73(4):362-8.
3. “The Final Months: A Study of the Lives of 134 Persons Who Committed Suicide,” New York: Oxford University Press, 1981.
4. “Why We Shouldn’t Legalize Assisting Suicide, Part I.” Department of Medical Ethics, National Right to Life Committee.
5. “Working with Suicidal Individuals: A Guide to Providing Understanding, Assessment and Support,” Philadelphia: Jessica Kingsley Publishers, 2010.
6. “Always Care, Never Kill: How Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises the Family, and Violates Human Dignity and Equality,” Washington: The Heritage Foundation, 2015.
7. Ann Intern Med. 2012 Jan 3;156(1 Pt 2):73-104.
Dr. Ahmed is a 2nd-year resident in the psychiatry & behavioral sciences department at the Nassau University Medical Center, New York. Over the last 3 years, he has published and presented papers at national and international forums. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and undiagnosed and overdiagnosed psychiatric illnesses in children. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.
Expanding the portfolio of the contemporary psychiatrist: The physician as arbiter of morality, normalcy, and social justice
A few miles from New York City’s “Million Dollar Blocks” in Brownsville—single city blocks where the state spends more than a million dollars per year to incarcerate people who once lived there—is the one of the busiest psychiatric emergency rooms in the country. Through the doors come people with “behavioral disturbances” who may be a risk to themself or others and who might have a psychiatric disorder that causes functional or cognitive impairment. Sometimes, a clear-headed individual will rattle off an impressive list of diagnoses (schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, anxiety), chronic, not in remission, on medication, which makes one wonder if a dartboard would provide better diagnostic accuracy. Without the construct validity that our colleagues in other specialties have to support our diagnoses, what is first and foremost a medical specialty has been expanded to a catch-all for what ails the human condition.
Being comfortable with uncertainty
Hyperbole aside, speculative pathologizing is risky business. Our conjectures could be influenced by personal bias and also are subject to the surrounding social climate. By watering down the field, our sins run the gamut of incorrectly diagnosing and stigmatizing a vulnerable patient to failing to protect the public from a mentally ill individual. Psychiatry, as it turns out, is not for the faint of heart.
I often am surprised at the number of medical students—it seems more than in past years—who are curious about psychiatry. I tell them one must be comfortable with some degree of uncertainty. Neurologists, for example, are far more certain of their uncertain, mysterious diseases. Likewise, internists resolutely say “idiopathic” without batting an eyelash. Psychiatrists, however, on the whole, are inclined to be an introspective and self-critical bunch. Extrapolated to the field at large, it creates a divisiveness not seen in other medical specialties. Psychiatry has its factions that are fortunately, are not mutually exclusive. Sometimes the twain can and do meet.
With flexible explanatory models come flexible roles in health care. We take on the shape of administrators, directors of clinical service, and policy advocates. Psychiatry, by assuming the mantle of phenomenology, naturally intersects with the areas of human rights, philosophy, and law. Without regard for our considerably influential positions, it is tempting to overstep our bounds as a medical provider. We are, woefully, powerful.
Refocusing community psychiatry
The well-intentioned public psychiatry movement, borne out of deinstitutionalization, endeavored to treat patients in a least restrictive, community-based setting with a focus on rehabilitation and integration. In practice, however, community psychiatry takes on a less rosy view. More often used as a Band-Aid for crime and problems associated with increasing socioeconomic divide, community psychiatry has been rebranded as mental health services for the indigent. Subverting the rights of this doubly vulnerable population is astonishingly easy when paired with a risk-averse litigious environment. “Danger to self or others” becomes our mantra; we unwittingly become ill-trained policemen.
I suggest we narrow the scope of psychiatry and we resist opining on social ills and conflating them with nebulous mental ills. Violent behavior, although troubling, is not a psychiatric symptom and unintentionally correlating it with psychiatric diagnoses does our patients a disservice. When we override an individual’s civil liberties with involuntary hospitalization or involuntary treatment, perhaps it is helpful to consider if we would do the same if the patient had more resources. It is a heavy burden to pretend that we can fix public policy with medications, therapy, and hospitalization. Not only should our actions safeguard the rights of our patients, but also the integrity of our field. In doing so, we might enjoy a less controversial place in health care.
A few miles from New York City’s “Million Dollar Blocks” in Brownsville—single city blocks where the state spends more than a million dollars per year to incarcerate people who once lived there—is the one of the busiest psychiatric emergency rooms in the country. Through the doors come people with “behavioral disturbances” who may be a risk to themself or others and who might have a psychiatric disorder that causes functional or cognitive impairment. Sometimes, a clear-headed individual will rattle off an impressive list of diagnoses (schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, anxiety), chronic, not in remission, on medication, which makes one wonder if a dartboard would provide better diagnostic accuracy. Without the construct validity that our colleagues in other specialties have to support our diagnoses, what is first and foremost a medical specialty has been expanded to a catch-all for what ails the human condition.
Being comfortable with uncertainty
Hyperbole aside, speculative pathologizing is risky business. Our conjectures could be influenced by personal bias and also are subject to the surrounding social climate. By watering down the field, our sins run the gamut of incorrectly diagnosing and stigmatizing a vulnerable patient to failing to protect the public from a mentally ill individual. Psychiatry, as it turns out, is not for the faint of heart.
I often am surprised at the number of medical students—it seems more than in past years—who are curious about psychiatry. I tell them one must be comfortable with some degree of uncertainty. Neurologists, for example, are far more certain of their uncertain, mysterious diseases. Likewise, internists resolutely say “idiopathic” without batting an eyelash. Psychiatrists, however, on the whole, are inclined to be an introspective and self-critical bunch. Extrapolated to the field at large, it creates a divisiveness not seen in other medical specialties. Psychiatry has its factions that are fortunately, are not mutually exclusive. Sometimes the twain can and do meet.
With flexible explanatory models come flexible roles in health care. We take on the shape of administrators, directors of clinical service, and policy advocates. Psychiatry, by assuming the mantle of phenomenology, naturally intersects with the areas of human rights, philosophy, and law. Without regard for our considerably influential positions, it is tempting to overstep our bounds as a medical provider. We are, woefully, powerful.
Refocusing community psychiatry
The well-intentioned public psychiatry movement, borne out of deinstitutionalization, endeavored to treat patients in a least restrictive, community-based setting with a focus on rehabilitation and integration. In practice, however, community psychiatry takes on a less rosy view. More often used as a Band-Aid for crime and problems associated with increasing socioeconomic divide, community psychiatry has been rebranded as mental health services for the indigent. Subverting the rights of this doubly vulnerable population is astonishingly easy when paired with a risk-averse litigious environment. “Danger to self or others” becomes our mantra; we unwittingly become ill-trained policemen.
I suggest we narrow the scope of psychiatry and we resist opining on social ills and conflating them with nebulous mental ills. Violent behavior, although troubling, is not a psychiatric symptom and unintentionally correlating it with psychiatric diagnoses does our patients a disservice. When we override an individual’s civil liberties with involuntary hospitalization or involuntary treatment, perhaps it is helpful to consider if we would do the same if the patient had more resources. It is a heavy burden to pretend that we can fix public policy with medications, therapy, and hospitalization. Not only should our actions safeguard the rights of our patients, but also the integrity of our field. In doing so, we might enjoy a less controversial place in health care.
A few miles from New York City’s “Million Dollar Blocks” in Brownsville—single city blocks where the state spends more than a million dollars per year to incarcerate people who once lived there—is the one of the busiest psychiatric emergency rooms in the country. Through the doors come people with “behavioral disturbances” who may be a risk to themself or others and who might have a psychiatric disorder that causes functional or cognitive impairment. Sometimes, a clear-headed individual will rattle off an impressive list of diagnoses (schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, anxiety), chronic, not in remission, on medication, which makes one wonder if a dartboard would provide better diagnostic accuracy. Without the construct validity that our colleagues in other specialties have to support our diagnoses, what is first and foremost a medical specialty has been expanded to a catch-all for what ails the human condition.
Being comfortable with uncertainty
Hyperbole aside, speculative pathologizing is risky business. Our conjectures could be influenced by personal bias and also are subject to the surrounding social climate. By watering down the field, our sins run the gamut of incorrectly diagnosing and stigmatizing a vulnerable patient to failing to protect the public from a mentally ill individual. Psychiatry, as it turns out, is not for the faint of heart.
I often am surprised at the number of medical students—it seems more than in past years—who are curious about psychiatry. I tell them one must be comfortable with some degree of uncertainty. Neurologists, for example, are far more certain of their uncertain, mysterious diseases. Likewise, internists resolutely say “idiopathic” without batting an eyelash. Psychiatrists, however, on the whole, are inclined to be an introspective and self-critical bunch. Extrapolated to the field at large, it creates a divisiveness not seen in other medical specialties. Psychiatry has its factions that are fortunately, are not mutually exclusive. Sometimes the twain can and do meet.
With flexible explanatory models come flexible roles in health care. We take on the shape of administrators, directors of clinical service, and policy advocates. Psychiatry, by assuming the mantle of phenomenology, naturally intersects with the areas of human rights, philosophy, and law. Without regard for our considerably influential positions, it is tempting to overstep our bounds as a medical provider. We are, woefully, powerful.
Refocusing community psychiatry
The well-intentioned public psychiatry movement, borne out of deinstitutionalization, endeavored to treat patients in a least restrictive, community-based setting with a focus on rehabilitation and integration. In practice, however, community psychiatry takes on a less rosy view. More often used as a Band-Aid for crime and problems associated with increasing socioeconomic divide, community psychiatry has been rebranded as mental health services for the indigent. Subverting the rights of this doubly vulnerable population is astonishingly easy when paired with a risk-averse litigious environment. “Danger to self or others” becomes our mantra; we unwittingly become ill-trained policemen.
I suggest we narrow the scope of psychiatry and we resist opining on social ills and conflating them with nebulous mental ills. Violent behavior, although troubling, is not a psychiatric symptom and unintentionally correlating it with psychiatric diagnoses does our patients a disservice. When we override an individual’s civil liberties with involuntary hospitalization or involuntary treatment, perhaps it is helpful to consider if we would do the same if the patient had more resources. It is a heavy burden to pretend that we can fix public policy with medications, therapy, and hospitalization. Not only should our actions safeguard the rights of our patients, but also the integrity of our field. In doing so, we might enjoy a less controversial place in health care.
Navigating the ambiguity around whether to admit or discharge
In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.1 The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.
Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.2 Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.3 Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.4 Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.
If the situation allows in the midst of the tumult, I create an intimate space to interview my patient. I pull up a chair and lean in to listen. To maintain an empathetic stance, I must recognize and control my biases toward high utilizers, drug use, homelessness, noncompliance, and the other host of factors that may influence my judgment. Between the hours of 1 a.m. and 6 a.m., fatigue, in particular, will breed negative countertransference. Before I sit down to listen, I repeat my mantra to myself: The least I can offer is kindness. Then the assessment and the decision-making process that leads to an admission or a discharge begins.
When I’m on call, I am torn by my obligations: to the patient, their safety and well-being; to the health care system and distributive justice; to making the “right” decision to admit or discharge; to my nursing staff and their safety; to my supervisors and my fellow residents who will judge and must deal with my clinical decision to admit or discharge. Some of these obligations that I struggle to balance are outlined as core competencies by the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology, and called the Psychiatry Milestone Project.5 I am supposed to be thinking about these issues as I work up a patient, evaluating, and making purposeful trade-offs. The educational language of these core competencies does not capture the tensions of these complicated on-call experiences.
The most useful thing I have learned this year is that the decision to admit or discharge is not a binary decision. The very act of assessment through an interview and making a plan with the patient is valuable in itself as risk mitigation. Only recently as a second-year resident have I fully realized how my presence could have therapeutic effects. Even a brief interview in the emergency department can be generative. I try to bring calm to the chaos around the patient. I listen, elicit protective factors and coping skills, and try to mobilize hope and internal strength building capabilities just as we are taught in my residency program.
However, I admittedly continue to dread my overnight calls. As a second-year resident, I am still uncomfortable with the ambiguity in some decisions to admit or discharge. Nonetheless, I recognize these experiences are only helping me become a better psychiatrist with every night I spend running between the ED and the psychiatric unit. To get through this process of residency, I have formulated another mantra: Every call and every patient is a learning experience.
References
1. BMC Health Serv Res. 2006;6:150.
2. Health Policy. 2000 Oct;53(3):157-84.
3. Adm Policy Ment Health. 2012 May;39(3):200-9.
4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.
5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.1 The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.
Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.2 Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.3 Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.4 Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.
If the situation allows in the midst of the tumult, I create an intimate space to interview my patient. I pull up a chair and lean in to listen. To maintain an empathetic stance, I must recognize and control my biases toward high utilizers, drug use, homelessness, noncompliance, and the other host of factors that may influence my judgment. Between the hours of 1 a.m. and 6 a.m., fatigue, in particular, will breed negative countertransference. Before I sit down to listen, I repeat my mantra to myself: The least I can offer is kindness. Then the assessment and the decision-making process that leads to an admission or a discharge begins.
When I’m on call, I am torn by my obligations: to the patient, their safety and well-being; to the health care system and distributive justice; to making the “right” decision to admit or discharge; to my nursing staff and their safety; to my supervisors and my fellow residents who will judge and must deal with my clinical decision to admit or discharge. Some of these obligations that I struggle to balance are outlined as core competencies by the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology, and called the Psychiatry Milestone Project.5 I am supposed to be thinking about these issues as I work up a patient, evaluating, and making purposeful trade-offs. The educational language of these core competencies does not capture the tensions of these complicated on-call experiences.
The most useful thing I have learned this year is that the decision to admit or discharge is not a binary decision. The very act of assessment through an interview and making a plan with the patient is valuable in itself as risk mitigation. Only recently as a second-year resident have I fully realized how my presence could have therapeutic effects. Even a brief interview in the emergency department can be generative. I try to bring calm to the chaos around the patient. I listen, elicit protective factors and coping skills, and try to mobilize hope and internal strength building capabilities just as we are taught in my residency program.
However, I admittedly continue to dread my overnight calls. As a second-year resident, I am still uncomfortable with the ambiguity in some decisions to admit or discharge. Nonetheless, I recognize these experiences are only helping me become a better psychiatrist with every night I spend running between the ED and the psychiatric unit. To get through this process of residency, I have formulated another mantra: Every call and every patient is a learning experience.
References
1. BMC Health Serv Res. 2006;6:150.
2. Health Policy. 2000 Oct;53(3):157-84.
3. Adm Policy Ment Health. 2012 May;39(3):200-9.
4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.
5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.1 The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.
Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.2 Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.3 Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.4 Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.
If the situation allows in the midst of the tumult, I create an intimate space to interview my patient. I pull up a chair and lean in to listen. To maintain an empathetic stance, I must recognize and control my biases toward high utilizers, drug use, homelessness, noncompliance, and the other host of factors that may influence my judgment. Between the hours of 1 a.m. and 6 a.m., fatigue, in particular, will breed negative countertransference. Before I sit down to listen, I repeat my mantra to myself: The least I can offer is kindness. Then the assessment and the decision-making process that leads to an admission or a discharge begins.
When I’m on call, I am torn by my obligations: to the patient, their safety and well-being; to the health care system and distributive justice; to making the “right” decision to admit or discharge; to my nursing staff and their safety; to my supervisors and my fellow residents who will judge and must deal with my clinical decision to admit or discharge. Some of these obligations that I struggle to balance are outlined as core competencies by the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology, and called the Psychiatry Milestone Project.5 I am supposed to be thinking about these issues as I work up a patient, evaluating, and making purposeful trade-offs. The educational language of these core competencies does not capture the tensions of these complicated on-call experiences.
The most useful thing I have learned this year is that the decision to admit or discharge is not a binary decision. The very act of assessment through an interview and making a plan with the patient is valuable in itself as risk mitigation. Only recently as a second-year resident have I fully realized how my presence could have therapeutic effects. Even a brief interview in the emergency department can be generative. I try to bring calm to the chaos around the patient. I listen, elicit protective factors and coping skills, and try to mobilize hope and internal strength building capabilities just as we are taught in my residency program.
However, I admittedly continue to dread my overnight calls. As a second-year resident, I am still uncomfortable with the ambiguity in some decisions to admit or discharge. Nonetheless, I recognize these experiences are only helping me become a better psychiatrist with every night I spend running between the ED and the psychiatric unit. To get through this process of residency, I have formulated another mantra: Every call and every patient is a learning experience.
References
1. BMC Health Serv Res. 2006;6:150.
2. Health Policy. 2000 Oct;53(3):157-84.
3. Adm Policy Ment Health. 2012 May;39(3):200-9.
4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.
5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
Don’t balk at using medical therapy to manage alcohol use disorder
There is ample evidence in the medical literature, as well as clinical experience, that patients seeking help for chemical dependency benefit from pharmacotherapy. It is common, however, for physicians, patients, and family to balk at the idea. Even within the psychiatry community, where there should be better understanding of substance use disorders, many practitioners hesitate to employ medications, especially for alcohol use disorder (AUD).
Efficacy for such FDA-approved medications has been demonstrated in well-designed, randomized controlled trials, but many trainees, and even experienced professionals, have never seen these medications used effectively and appropriately. Medication-assisted treatment (MAT) is not an alternative to biopsychosocial approaches but is an augmentation that can (1) help stabilize the patient until he (she) can be educated in relapse prevention skills and (2) allow the brain to rewire and heal until he regains impulse control.
Diverse presentations
Do you remember that patient who often arrived for appointments intoxicated, promising that he plans to cut down? How about the man you saw in the emergency department with an elevated blood alcohol level, who was constantly endorsing suicidal thoughts that subsided when he reached clinical sobriety? What about the college student who often was treated for alcohol poisoning after binge drinking on weekends, but who never considered this behavior problematic? And, how about the elderly woman who was evaluated for anxiety, but had been drinking 4 beers nightly for the past 30 years?
Despite the diverse presentations, these patients all have a chronic disease and we fail them when we do not apply evidence-based medicine to their treatment.
As psychiatrists, we encounter many patients with AUD as a primary or comorbid diagnosis. This is a global problem associated with significant human and financial cost. With 80% of American adolescents having reported using alcohol in the past year, the problem will continue to grow.1 Furthermore, a greater prevalence of AUD is noted in clinical populations undergoing psychiatric treatment.2 Ongoing alcohol abuse complicates the course of medical and psychiatric conditions and incites significant societal exclusion.
Pharmacotherapy is underutilized
Despite an increase in the use of psychotropic medications for treating psychiatric illness, pharmacotherapy for AUD is underutilized: only 3% of patients have received an FDA-approved treatment.2,3 Nearly one-third of adults are affected by AUD during their lifetime, yet only 20% seek help.3 Management today remains limited to episodic, brief inpatient detoxification and psychosocial therapy.
Recovery rates are highest when addiction treatment that monitors abstinence is continuous; yet, for most part, alcohol addiction is treated in discrete episodes upon relapse. Although MAT is recommended by experts for “moderate” and “severe” substance use disorders, practitioners, in general, have demonstrated considerable resistance to using this modality as part of routine practice.4,5 This is regrettable: Regardless of terminology used to describe their condition, these people suffer a potentially fatal disease characterized by high post-treatment recidivism.
Neuroscience supports the brain disease model of addiction, with neuroplasticity changes being made during phases of drug use. Medications are shown to assist in preventing relapse while the brain is healing and normal emotional and decision-making capacities are being restored.6
Why hesitate to use pharmacotherapeutics?
There are diverse pharmacotherapeutic options that can be pursued for treating AUD with minimal disruption to home and work life. Alarmingly, many trainees have never prescribed or even considered such medications. Despite modest effect sizes in randomized controlled trials, efficacy has been demonstrated in reducing relapse rates and overall severity of drinking days.4,5 So, from where does the ambivalence of patients and providers about using these treatments to achieve lasting recovery stem?
Starting MAT certainly requires both parties to be in agreement. A patient might decline medication because of a fear of dependence or because he overestimates his ability to achieve remission on his own. There also may be financial barriers in a current alcohol treatment system that is traditionally non-medically oriented. Prescribers also fail to offer medications because of:
- lack of familiarity with available agents
- absence of guidelines for use
- disbelief that the condition is treatable.
Given that treatment often is based on a 12-step approach, such as Alcoholics Anonymous (AA), providers might hesitate to prescribe medication for an illness that is thought to be managed through psychosocial interventions, such as group and motivational therapy.
Therapeutic options
Choice of medication depends on the prescriber’s comfort level, reputation of the medication, potential side-effect profile, medical contraindications, and affordability; the most important consideration, however, should be the overall goals and expectations of the patient.
There are 4 FDA-approved medications for AUD (Table); many others are off-label. It is advisable to start with an FDA-approved medication such as disulfiram for the motivated patient who has a collaborator and desires complete abstinence; naltrexone for a patient who wants to cut down on intake (a long-acting formulation can be used for poorly adherent patients); and acamprosate for a patient with at least some established sobriety who needs help with post-withdrawal sleep disturbances.
With regard to off-label medications, topiramate has the highest evidence for efficacy. Gabapentin can augment naltrexone and also helps with sleep, anxiety, withdrawal, and cravings.4,5
Psychosocial interventions
Medications are just 1 tool in recovery; patients should be engaged in a program of counseling. Encourage attendance at AA meetings. An up-and-coming concept is the use of smartphone applications to prevent relapse (or even induce remission); apps that provide an accurate blood alcohol tracking systems and integrated psychosocial therapies are in the pipeline. The novel Reddit online forum r/StopDrinking is a 24-hour peer-support community that relies on
fellowship, accountability, monitoring, and anonymity; the forum can compete with
motivational interviewing for efficacy in increasing abstinence and preventing relapse.
1. Johnson L, O’Malley P, Miech RA, et al. Monitoring the Future national survey results on drug use, 1975-2015: overview, key findings on adolescent drug use. http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2015.pdf. Published February 2016. Accessed January 20, 2016.
2. Substance Abuse and Mental Health Services Administration. Results from the 2013 national survey on drug use and health: mental health findings, NSDUH Series H-49, HHS Publication No. (SMA) 14-4887. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
3. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiological Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757-766.
4. Robinson S, Meeks TW, Geniza C. Medication for alcohol use disorder: which agents work best. Current Psychiatry. 2014;13(1):22-29.
5. Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for the treatment of alcohol use disorder: a brief guide. HHS Publication No. (SMA) 15-4907. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015.
6. Volkow ND, Koob GF, McLellan AT. Neurobiological advances from the brain disease model of addiction. N Engl J Med. 2016;374(4):363-371.
Acknowledgment
The authors would like to thank Thomas M. Penders, MS, MD, Medical Director for Consultation-Liaison Psychiatry at Cape Cod Healthcare, Hyannis, Massachusetts, and Affiliate Professor at East Carolina University, Greenville, North Carolina, for all his guidance, support, and mentorship.
Cornel N. Stanciu, MD
Samantha A. Gnanasegaram, MD
Drs. Stanciu and Gnanasegaram are PGY-4 Residents, Department of Psychiatric Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Cornel N. Stanciu, MD
Samantha A. Gnanasegaram, MD
Drs. Stanciu and Gnanasegaram are PGY-4 Residents, Department of Psychiatric Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Cornel N. Stanciu, MD
Samantha A. Gnanasegaram, MD
Drs. Stanciu and Gnanasegaram are PGY-4 Residents, Department of Psychiatric Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
There is ample evidence in the medical literature, as well as clinical experience, that patients seeking help for chemical dependency benefit from pharmacotherapy. It is common, however, for physicians, patients, and family to balk at the idea. Even within the psychiatry community, where there should be better understanding of substance use disorders, many practitioners hesitate to employ medications, especially for alcohol use disorder (AUD).
Efficacy for such FDA-approved medications has been demonstrated in well-designed, randomized controlled trials, but many trainees, and even experienced professionals, have never seen these medications used effectively and appropriately. Medication-assisted treatment (MAT) is not an alternative to biopsychosocial approaches but is an augmentation that can (1) help stabilize the patient until he (she) can be educated in relapse prevention skills and (2) allow the brain to rewire and heal until he regains impulse control.
Diverse presentations
Do you remember that patient who often arrived for appointments intoxicated, promising that he plans to cut down? How about the man you saw in the emergency department with an elevated blood alcohol level, who was constantly endorsing suicidal thoughts that subsided when he reached clinical sobriety? What about the college student who often was treated for alcohol poisoning after binge drinking on weekends, but who never considered this behavior problematic? And, how about the elderly woman who was evaluated for anxiety, but had been drinking 4 beers nightly for the past 30 years?
Despite the diverse presentations, these patients all have a chronic disease and we fail them when we do not apply evidence-based medicine to their treatment.
As psychiatrists, we encounter many patients with AUD as a primary or comorbid diagnosis. This is a global problem associated with significant human and financial cost. With 80% of American adolescents having reported using alcohol in the past year, the problem will continue to grow.1 Furthermore, a greater prevalence of AUD is noted in clinical populations undergoing psychiatric treatment.2 Ongoing alcohol abuse complicates the course of medical and psychiatric conditions and incites significant societal exclusion.
Pharmacotherapy is underutilized
Despite an increase in the use of psychotropic medications for treating psychiatric illness, pharmacotherapy for AUD is underutilized: only 3% of patients have received an FDA-approved treatment.2,3 Nearly one-third of adults are affected by AUD during their lifetime, yet only 20% seek help.3 Management today remains limited to episodic, brief inpatient detoxification and psychosocial therapy.
Recovery rates are highest when addiction treatment that monitors abstinence is continuous; yet, for most part, alcohol addiction is treated in discrete episodes upon relapse. Although MAT is recommended by experts for “moderate” and “severe” substance use disorders, practitioners, in general, have demonstrated considerable resistance to using this modality as part of routine practice.4,5 This is regrettable: Regardless of terminology used to describe their condition, these people suffer a potentially fatal disease characterized by high post-treatment recidivism.
Neuroscience supports the brain disease model of addiction, with neuroplasticity changes being made during phases of drug use. Medications are shown to assist in preventing relapse while the brain is healing and normal emotional and decision-making capacities are being restored.6
Why hesitate to use pharmacotherapeutics?
There are diverse pharmacotherapeutic options that can be pursued for treating AUD with minimal disruption to home and work life. Alarmingly, many trainees have never prescribed or even considered such medications. Despite modest effect sizes in randomized controlled trials, efficacy has been demonstrated in reducing relapse rates and overall severity of drinking days.4,5 So, from where does the ambivalence of patients and providers about using these treatments to achieve lasting recovery stem?
Starting MAT certainly requires both parties to be in agreement. A patient might decline medication because of a fear of dependence or because he overestimates his ability to achieve remission on his own. There also may be financial barriers in a current alcohol treatment system that is traditionally non-medically oriented. Prescribers also fail to offer medications because of:
- lack of familiarity with available agents
- absence of guidelines for use
- disbelief that the condition is treatable.
Given that treatment often is based on a 12-step approach, such as Alcoholics Anonymous (AA), providers might hesitate to prescribe medication for an illness that is thought to be managed through psychosocial interventions, such as group and motivational therapy.
Therapeutic options
Choice of medication depends on the prescriber’s comfort level, reputation of the medication, potential side-effect profile, medical contraindications, and affordability; the most important consideration, however, should be the overall goals and expectations of the patient.
There are 4 FDA-approved medications for AUD (Table); many others are off-label. It is advisable to start with an FDA-approved medication such as disulfiram for the motivated patient who has a collaborator and desires complete abstinence; naltrexone for a patient who wants to cut down on intake (a long-acting formulation can be used for poorly adherent patients); and acamprosate for a patient with at least some established sobriety who needs help with post-withdrawal sleep disturbances.
With regard to off-label medications, topiramate has the highest evidence for efficacy. Gabapentin can augment naltrexone and also helps with sleep, anxiety, withdrawal, and cravings.4,5
Psychosocial interventions
Medications are just 1 tool in recovery; patients should be engaged in a program of counseling. Encourage attendance at AA meetings. An up-and-coming concept is the use of smartphone applications to prevent relapse (or even induce remission); apps that provide an accurate blood alcohol tracking systems and integrated psychosocial therapies are in the pipeline. The novel Reddit online forum r/StopDrinking is a 24-hour peer-support community that relies on
fellowship, accountability, monitoring, and anonymity; the forum can compete with
motivational interviewing for efficacy in increasing abstinence and preventing relapse.
There is ample evidence in the medical literature, as well as clinical experience, that patients seeking help for chemical dependency benefit from pharmacotherapy. It is common, however, for physicians, patients, and family to balk at the idea. Even within the psychiatry community, where there should be better understanding of substance use disorders, many practitioners hesitate to employ medications, especially for alcohol use disorder (AUD).
Efficacy for such FDA-approved medications has been demonstrated in well-designed, randomized controlled trials, but many trainees, and even experienced professionals, have never seen these medications used effectively and appropriately. Medication-assisted treatment (MAT) is not an alternative to biopsychosocial approaches but is an augmentation that can (1) help stabilize the patient until he (she) can be educated in relapse prevention skills and (2) allow the brain to rewire and heal until he regains impulse control.
Diverse presentations
Do you remember that patient who often arrived for appointments intoxicated, promising that he plans to cut down? How about the man you saw in the emergency department with an elevated blood alcohol level, who was constantly endorsing suicidal thoughts that subsided when he reached clinical sobriety? What about the college student who often was treated for alcohol poisoning after binge drinking on weekends, but who never considered this behavior problematic? And, how about the elderly woman who was evaluated for anxiety, but had been drinking 4 beers nightly for the past 30 years?
Despite the diverse presentations, these patients all have a chronic disease and we fail them when we do not apply evidence-based medicine to their treatment.
As psychiatrists, we encounter many patients with AUD as a primary or comorbid diagnosis. This is a global problem associated with significant human and financial cost. With 80% of American adolescents having reported using alcohol in the past year, the problem will continue to grow.1 Furthermore, a greater prevalence of AUD is noted in clinical populations undergoing psychiatric treatment.2 Ongoing alcohol abuse complicates the course of medical and psychiatric conditions and incites significant societal exclusion.
Pharmacotherapy is underutilized
Despite an increase in the use of psychotropic medications for treating psychiatric illness, pharmacotherapy for AUD is underutilized: only 3% of patients have received an FDA-approved treatment.2,3 Nearly one-third of adults are affected by AUD during their lifetime, yet only 20% seek help.3 Management today remains limited to episodic, brief inpatient detoxification and psychosocial therapy.
Recovery rates are highest when addiction treatment that monitors abstinence is continuous; yet, for most part, alcohol addiction is treated in discrete episodes upon relapse. Although MAT is recommended by experts for “moderate” and “severe” substance use disorders, practitioners, in general, have demonstrated considerable resistance to using this modality as part of routine practice.4,5 This is regrettable: Regardless of terminology used to describe their condition, these people suffer a potentially fatal disease characterized by high post-treatment recidivism.
Neuroscience supports the brain disease model of addiction, with neuroplasticity changes being made during phases of drug use. Medications are shown to assist in preventing relapse while the brain is healing and normal emotional and decision-making capacities are being restored.6
Why hesitate to use pharmacotherapeutics?
There are diverse pharmacotherapeutic options that can be pursued for treating AUD with minimal disruption to home and work life. Alarmingly, many trainees have never prescribed or even considered such medications. Despite modest effect sizes in randomized controlled trials, efficacy has been demonstrated in reducing relapse rates and overall severity of drinking days.4,5 So, from where does the ambivalence of patients and providers about using these treatments to achieve lasting recovery stem?
Starting MAT certainly requires both parties to be in agreement. A patient might decline medication because of a fear of dependence or because he overestimates his ability to achieve remission on his own. There also may be financial barriers in a current alcohol treatment system that is traditionally non-medically oriented. Prescribers also fail to offer medications because of:
- lack of familiarity with available agents
- absence of guidelines for use
- disbelief that the condition is treatable.
Given that treatment often is based on a 12-step approach, such as Alcoholics Anonymous (AA), providers might hesitate to prescribe medication for an illness that is thought to be managed through psychosocial interventions, such as group and motivational therapy.
Therapeutic options
Choice of medication depends on the prescriber’s comfort level, reputation of the medication, potential side-effect profile, medical contraindications, and affordability; the most important consideration, however, should be the overall goals and expectations of the patient.
There are 4 FDA-approved medications for AUD (Table); many others are off-label. It is advisable to start with an FDA-approved medication such as disulfiram for the motivated patient who has a collaborator and desires complete abstinence; naltrexone for a patient who wants to cut down on intake (a long-acting formulation can be used for poorly adherent patients); and acamprosate for a patient with at least some established sobriety who needs help with post-withdrawal sleep disturbances.
With regard to off-label medications, topiramate has the highest evidence for efficacy. Gabapentin can augment naltrexone and also helps with sleep, anxiety, withdrawal, and cravings.4,5
Psychosocial interventions
Medications are just 1 tool in recovery; patients should be engaged in a program of counseling. Encourage attendance at AA meetings. An up-and-coming concept is the use of smartphone applications to prevent relapse (or even induce remission); apps that provide an accurate blood alcohol tracking systems and integrated psychosocial therapies are in the pipeline. The novel Reddit online forum r/StopDrinking is a 24-hour peer-support community that relies on
fellowship, accountability, monitoring, and anonymity; the forum can compete with
motivational interviewing for efficacy in increasing abstinence and preventing relapse.
1. Johnson L, O’Malley P, Miech RA, et al. Monitoring the Future national survey results on drug use, 1975-2015: overview, key findings on adolescent drug use. http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2015.pdf. Published February 2016. Accessed January 20, 2016.
2. Substance Abuse and Mental Health Services Administration. Results from the 2013 national survey on drug use and health: mental health findings, NSDUH Series H-49, HHS Publication No. (SMA) 14-4887. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
3. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiological Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757-766.
4. Robinson S, Meeks TW, Geniza C. Medication for alcohol use disorder: which agents work best. Current Psychiatry. 2014;13(1):22-29.
5. Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for the treatment of alcohol use disorder: a brief guide. HHS Publication No. (SMA) 15-4907. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015.
6. Volkow ND, Koob GF, McLellan AT. Neurobiological advances from the brain disease model of addiction. N Engl J Med. 2016;374(4):363-371.
Acknowledgment
The authors would like to thank Thomas M. Penders, MS, MD, Medical Director for Consultation-Liaison Psychiatry at Cape Cod Healthcare, Hyannis, Massachusetts, and Affiliate Professor at East Carolina University, Greenville, North Carolina, for all his guidance, support, and mentorship.
1. Johnson L, O’Malley P, Miech RA, et al. Monitoring the Future national survey results on drug use, 1975-2015: overview, key findings on adolescent drug use. http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2015.pdf. Published February 2016. Accessed January 20, 2016.
2. Substance Abuse and Mental Health Services Administration. Results from the 2013 national survey on drug use and health: mental health findings, NSDUH Series H-49, HHS Publication No. (SMA) 14-4887. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
3. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiological Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757-766.
4. Robinson S, Meeks TW, Geniza C. Medication for alcohol use disorder: which agents work best. Current Psychiatry. 2014;13(1):22-29.
5. Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for the treatment of alcohol use disorder: a brief guide. HHS Publication No. (SMA) 15-4907. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015.
6. Volkow ND, Koob GF, McLellan AT. Neurobiological advances from the brain disease model of addiction. N Engl J Med. 2016;374(4):363-371.
Acknowledgment
The authors would like to thank Thomas M. Penders, MS, MD, Medical Director for Consultation-Liaison Psychiatry at Cape Cod Healthcare, Hyannis, Massachusetts, and Affiliate Professor at East Carolina University, Greenville, North Carolina, for all his guidance, support, and mentorship.
Unspoken ethical challenges of many psychiatric consultation services
A psychiatric consultation service in an academic medical center usually is a robust and busy setting. In addition to expert faculty, the service is staffed by trainees (psychosomatic medicine fellows and psychiatry residents), nurse practitioners, and medical students. I have been drawn to this growing field, which is evolving hand in hand with advances in medical therapy (eg, new antineoplastic, antiretroviral, and anticonvulsant regimens) and surgical intervention (eg, heart, lung, and gut transplantation).
As a consultant, I have learned that we have an obligation to a dual clientele:
- the patient, through an established doctor–patient relationship
- the primary team, which requires our assistance or raises questions about management.
While working as a trainee in providing psychiatric consultative services, I have noted a number of ethical challenges that consultants face. Below are noteworthy examples.
Justice: Is less, more?
We live in an era of growing advocacy of the recognition, acceptance, and treatment of mental illness.1 However, there does not appear to be enough psychiatric providers for the American population.2 Regrettably, a timely psychiatric assessment is, for many, a unaffordable luxury; in some regions of the United States, the wait for an outpatient psychiatric appointment is longer than 6 months.3
When a patient is admitted to the hospital, admitting physicians often consider ordering a psychiatric consult if they suspect an underlying psychiatric disorder or if they would like an expert’s opinion on some matter—such as (1) medications already prescribed for the patient as an outpatient and (2) a patient’s decision-making capacity in complex situations—without reflecting on how much of a commodity this expert opinion is. (After all, in an ideal world, concerns about cost shouldn’t factor in to what we offer our patients.)
Different practitioners have different thresholds for requesting a psychiatric consultation; no clear guidelines or recommendations exist as to how to “calibrate” one’s self to be a good consultee. As psychiatrists, we rarely call for a cardiology consult just because a patient is hypertensive and takes a diuretic at home, or call in an orthopedic surgeon because a patient with a history of arthroplasty has knee pain today. Sometimes, however, it seems to me that our non-psychiatry colleagues don’t think twice to ask for our services if their patients have a history of mental illness, even if it’s well controlled.
There is no winning formula for calculating how many psychiatric providers and resources (represented by the clinical currencies of, respectively, full-time equivalents and relative value units) a consultation service should have, but efforts have been made to solve this mystery.4 Some institutions track, with different methods and variable accuracy, the number of consults they provide annually; others wing it. Lack of accuracy and standardization means that the system is prone to sacrificing quality for quantity in the provision of services, and to provide services in an inconsistent manner (think: better quality on slower days).
Nonmaleficence: Good intentions…
Within the U.S. health care system, a consulting psychiatrist must diagnose a billable condition to be reimbursed for a consult. But what if a so-called soft consult is requested and, after the evaluation, a major mental disorder that warranted our time and expertise can’t be identified?
That situation places the provider in an awkward position. Up-diagnosing might seem like a necessity to ensure reimbursement but, in a society that still stigmatizes mental illness, the health risks of charting a major mental disorder (and prescribing a vaguely warranted psychotropic) might outweigh the benefits for some patients, in the long run.
Coding systems can impact and complicate this scenario even more. We are required to comply with coding systems by providing as many predetermined historical and clinical details of any specific major mental disorder as we can document. As we become more detail-oriented, I wonder if we are losing touch with the reality of our patients’ suffering and deviating from the human emotional experience, as we focus on complying with the health care system and maximizing hospital reimbursement.
Beneficence: The care you would want for your loved ones
For me, an attractive aspect of becoming a psychiatric consultant in the medical setting was to function as a mental health ambassador, so to speak. We often evaluate patients who have never seen a psychiatrist before (eg, when there are symptoms of acute stress disorder in a trauma patient or postoperative delirium in a patient who does not have a psychiatric history). On those occasions, we have the opportunity to make an effective, long-lasting intervention with our clinical encounter, accurate diagnosis, medication recommendations, and outpatient referrals.
Sometimes, the best follow-up plans and intentions are undone by uneven discharge coordination efforts and limited community resources. Some medical institutions have become better at tracking reasons for re-hospitalization and at making post-discharge telephone calls to support good transition to outpatient services. Often, it is necessary to call on nonprofit organizations and public institutions to provide referral and crisis services, but we can always do a better job at offering our patients a comprehensive mental health treatment plan, even from the consultation arena.
Autonomy: Who is in control?
Psychiatry provides varying levels of intervention for acutely mentally ill patients. Laws and criteria for involuntary commitment and the use of psychotropic medication under such circumstances vary from state to state.5
In the consultation-liaison setting, we often co-manage patients with a neuropsychiatric disorder that precludes them from participating fully in medical decisions. Other times, patients come to our attention involuntarily (eg, by way of medical admission) having a high level of premorbid autonomy: They make their own life decisions, choose not to engage in psychiatric treatment, administer their funds (when they have them), and so on.
Complex ethical situations can arise when (1) there is disagreement between physician and patient and (2) payment for care or insurance coverage plays a role in disposition plans or long-term placement. Public institutions might have a modus operandi that allows for extra room to deliberate and keep the treatment conversation going—more so than for-profit health centers, where financial forces can sway providers’ judgment toward autonomy, regardless of what is best for the patient.
Summing up: Let’s be Hippocratic psychiatrists
As many forces continue to influence the way we practice the art and science of medicine and psychiatry, it’s important to pay close attention to ongoing challenges and utilize organized medicine to advocate for better ways of running an effective consultation service in an ethical manner. As a trainee and future psychosomatic medicine psychiatrist, I am committed to starting these conversations wherever I go.
We need novel ways to look at, question, understand, study, and review our clinical practice to effectively tackle these challenges as we continue advancing as a field.
1. Remarks by the President at National Conference on Mental Health. Office of the Press Secretary. June 3, 2013. https://www.whitehouse.gov/the-press-office/2013/06/03/remarks-president-national-conference-mental-health. Accessed July 28, 2016.
2. Crary D. There’s a serious shortage of psychiatrists in the U.S. The Huffington Post. http://www.huffingtonpost.com/entry/theres-a-serious-shortage-of-psychiatrists-in-the-us_us_55eef13ce4b093be51bc128f. Published September 8, 2015. Accessed January 22, 2016.
3. Frantz J. Mental health care: average wait to see a psychiatrist in Dauphin County is 8 months. Penn Live. http://www.pennlive.com/midstate/index.ssf/2013/01/mental_illness_help_for_famili_1.html. Published January 24, 2013. Accessed January 22, 2016.
4. Kunkel E, Del Busto E, Kathol R, et al. Physician staffing for the practice of psychosomatic medicine in general hospitals: a pilot study. Psychosomatics. 2010;51(6):520-527.
5. Stettin B, Geller J, Ragosta K, et al. Mental health commitment laws: a survey of the states. http://tacreports.org/storage/documents/2014-state-survey-abridged.pdf. Published February 2014. Accessed February 25, 2016.
Dr. Jovel is a Public Psychiatry Fellow, Columbia University Medical Center/New York State Psychiatric Institute, New York, New York. He was a Psychosomatic Medicine Fellow, Jackson Health System/University of Miami, Miami, Florida, when he wrote this article.
Dr. Jovel is a Public Psychiatry Fellow, Columbia University Medical Center/New York State Psychiatric Institute, New York, New York. He was a Psychosomatic Medicine Fellow, Jackson Health System/University of Miami, Miami, Florida, when he wrote this article.
Dr. Jovel is a Public Psychiatry Fellow, Columbia University Medical Center/New York State Psychiatric Institute, New York, New York. He was a Psychosomatic Medicine Fellow, Jackson Health System/University of Miami, Miami, Florida, when he wrote this article.
A psychiatric consultation service in an academic medical center usually is a robust and busy setting. In addition to expert faculty, the service is staffed by trainees (psychosomatic medicine fellows and psychiatry residents), nurse practitioners, and medical students. I have been drawn to this growing field, which is evolving hand in hand with advances in medical therapy (eg, new antineoplastic, antiretroviral, and anticonvulsant regimens) and surgical intervention (eg, heart, lung, and gut transplantation).
As a consultant, I have learned that we have an obligation to a dual clientele:
- the patient, through an established doctor–patient relationship
- the primary team, which requires our assistance or raises questions about management.
While working as a trainee in providing psychiatric consultative services, I have noted a number of ethical challenges that consultants face. Below are noteworthy examples.
Justice: Is less, more?
We live in an era of growing advocacy of the recognition, acceptance, and treatment of mental illness.1 However, there does not appear to be enough psychiatric providers for the American population.2 Regrettably, a timely psychiatric assessment is, for many, a unaffordable luxury; in some regions of the United States, the wait for an outpatient psychiatric appointment is longer than 6 months.3
When a patient is admitted to the hospital, admitting physicians often consider ordering a psychiatric consult if they suspect an underlying psychiatric disorder or if they would like an expert’s opinion on some matter—such as (1) medications already prescribed for the patient as an outpatient and (2) a patient’s decision-making capacity in complex situations—without reflecting on how much of a commodity this expert opinion is. (After all, in an ideal world, concerns about cost shouldn’t factor in to what we offer our patients.)
Different practitioners have different thresholds for requesting a psychiatric consultation; no clear guidelines or recommendations exist as to how to “calibrate” one’s self to be a good consultee. As psychiatrists, we rarely call for a cardiology consult just because a patient is hypertensive and takes a diuretic at home, or call in an orthopedic surgeon because a patient with a history of arthroplasty has knee pain today. Sometimes, however, it seems to me that our non-psychiatry colleagues don’t think twice to ask for our services if their patients have a history of mental illness, even if it’s well controlled.
There is no winning formula for calculating how many psychiatric providers and resources (represented by the clinical currencies of, respectively, full-time equivalents and relative value units) a consultation service should have, but efforts have been made to solve this mystery.4 Some institutions track, with different methods and variable accuracy, the number of consults they provide annually; others wing it. Lack of accuracy and standardization means that the system is prone to sacrificing quality for quantity in the provision of services, and to provide services in an inconsistent manner (think: better quality on slower days).
Nonmaleficence: Good intentions…
Within the U.S. health care system, a consulting psychiatrist must diagnose a billable condition to be reimbursed for a consult. But what if a so-called soft consult is requested and, after the evaluation, a major mental disorder that warranted our time and expertise can’t be identified?
That situation places the provider in an awkward position. Up-diagnosing might seem like a necessity to ensure reimbursement but, in a society that still stigmatizes mental illness, the health risks of charting a major mental disorder (and prescribing a vaguely warranted psychotropic) might outweigh the benefits for some patients, in the long run.
Coding systems can impact and complicate this scenario even more. We are required to comply with coding systems by providing as many predetermined historical and clinical details of any specific major mental disorder as we can document. As we become more detail-oriented, I wonder if we are losing touch with the reality of our patients’ suffering and deviating from the human emotional experience, as we focus on complying with the health care system and maximizing hospital reimbursement.
Beneficence: The care you would want for your loved ones
For me, an attractive aspect of becoming a psychiatric consultant in the medical setting was to function as a mental health ambassador, so to speak. We often evaluate patients who have never seen a psychiatrist before (eg, when there are symptoms of acute stress disorder in a trauma patient or postoperative delirium in a patient who does not have a psychiatric history). On those occasions, we have the opportunity to make an effective, long-lasting intervention with our clinical encounter, accurate diagnosis, medication recommendations, and outpatient referrals.
Sometimes, the best follow-up plans and intentions are undone by uneven discharge coordination efforts and limited community resources. Some medical institutions have become better at tracking reasons for re-hospitalization and at making post-discharge telephone calls to support good transition to outpatient services. Often, it is necessary to call on nonprofit organizations and public institutions to provide referral and crisis services, but we can always do a better job at offering our patients a comprehensive mental health treatment plan, even from the consultation arena.
Autonomy: Who is in control?
Psychiatry provides varying levels of intervention for acutely mentally ill patients. Laws and criteria for involuntary commitment and the use of psychotropic medication under such circumstances vary from state to state.5
In the consultation-liaison setting, we often co-manage patients with a neuropsychiatric disorder that precludes them from participating fully in medical decisions. Other times, patients come to our attention involuntarily (eg, by way of medical admission) having a high level of premorbid autonomy: They make their own life decisions, choose not to engage in psychiatric treatment, administer their funds (when they have them), and so on.
Complex ethical situations can arise when (1) there is disagreement between physician and patient and (2) payment for care or insurance coverage plays a role in disposition plans or long-term placement. Public institutions might have a modus operandi that allows for extra room to deliberate and keep the treatment conversation going—more so than for-profit health centers, where financial forces can sway providers’ judgment toward autonomy, regardless of what is best for the patient.
Summing up: Let’s be Hippocratic psychiatrists
As many forces continue to influence the way we practice the art and science of medicine and psychiatry, it’s important to pay close attention to ongoing challenges and utilize organized medicine to advocate for better ways of running an effective consultation service in an ethical manner. As a trainee and future psychosomatic medicine psychiatrist, I am committed to starting these conversations wherever I go.
We need novel ways to look at, question, understand, study, and review our clinical practice to effectively tackle these challenges as we continue advancing as a field.
A psychiatric consultation service in an academic medical center usually is a robust and busy setting. In addition to expert faculty, the service is staffed by trainees (psychosomatic medicine fellows and psychiatry residents), nurse practitioners, and medical students. I have been drawn to this growing field, which is evolving hand in hand with advances in medical therapy (eg, new antineoplastic, antiretroviral, and anticonvulsant regimens) and surgical intervention (eg, heart, lung, and gut transplantation).
As a consultant, I have learned that we have an obligation to a dual clientele:
- the patient, through an established doctor–patient relationship
- the primary team, which requires our assistance or raises questions about management.
While working as a trainee in providing psychiatric consultative services, I have noted a number of ethical challenges that consultants face. Below are noteworthy examples.
Justice: Is less, more?
We live in an era of growing advocacy of the recognition, acceptance, and treatment of mental illness.1 However, there does not appear to be enough psychiatric providers for the American population.2 Regrettably, a timely psychiatric assessment is, for many, a unaffordable luxury; in some regions of the United States, the wait for an outpatient psychiatric appointment is longer than 6 months.3
When a patient is admitted to the hospital, admitting physicians often consider ordering a psychiatric consult if they suspect an underlying psychiatric disorder or if they would like an expert’s opinion on some matter—such as (1) medications already prescribed for the patient as an outpatient and (2) a patient’s decision-making capacity in complex situations—without reflecting on how much of a commodity this expert opinion is. (After all, in an ideal world, concerns about cost shouldn’t factor in to what we offer our patients.)
Different practitioners have different thresholds for requesting a psychiatric consultation; no clear guidelines or recommendations exist as to how to “calibrate” one’s self to be a good consultee. As psychiatrists, we rarely call for a cardiology consult just because a patient is hypertensive and takes a diuretic at home, or call in an orthopedic surgeon because a patient with a history of arthroplasty has knee pain today. Sometimes, however, it seems to me that our non-psychiatry colleagues don’t think twice to ask for our services if their patients have a history of mental illness, even if it’s well controlled.
There is no winning formula for calculating how many psychiatric providers and resources (represented by the clinical currencies of, respectively, full-time equivalents and relative value units) a consultation service should have, but efforts have been made to solve this mystery.4 Some institutions track, with different methods and variable accuracy, the number of consults they provide annually; others wing it. Lack of accuracy and standardization means that the system is prone to sacrificing quality for quantity in the provision of services, and to provide services in an inconsistent manner (think: better quality on slower days).
Nonmaleficence: Good intentions…
Within the U.S. health care system, a consulting psychiatrist must diagnose a billable condition to be reimbursed for a consult. But what if a so-called soft consult is requested and, after the evaluation, a major mental disorder that warranted our time and expertise can’t be identified?
That situation places the provider in an awkward position. Up-diagnosing might seem like a necessity to ensure reimbursement but, in a society that still stigmatizes mental illness, the health risks of charting a major mental disorder (and prescribing a vaguely warranted psychotropic) might outweigh the benefits for some patients, in the long run.
Coding systems can impact and complicate this scenario even more. We are required to comply with coding systems by providing as many predetermined historical and clinical details of any specific major mental disorder as we can document. As we become more detail-oriented, I wonder if we are losing touch with the reality of our patients’ suffering and deviating from the human emotional experience, as we focus on complying with the health care system and maximizing hospital reimbursement.
Beneficence: The care you would want for your loved ones
For me, an attractive aspect of becoming a psychiatric consultant in the medical setting was to function as a mental health ambassador, so to speak. We often evaluate patients who have never seen a psychiatrist before (eg, when there are symptoms of acute stress disorder in a trauma patient or postoperative delirium in a patient who does not have a psychiatric history). On those occasions, we have the opportunity to make an effective, long-lasting intervention with our clinical encounter, accurate diagnosis, medication recommendations, and outpatient referrals.
Sometimes, the best follow-up plans and intentions are undone by uneven discharge coordination efforts and limited community resources. Some medical institutions have become better at tracking reasons for re-hospitalization and at making post-discharge telephone calls to support good transition to outpatient services. Often, it is necessary to call on nonprofit organizations and public institutions to provide referral and crisis services, but we can always do a better job at offering our patients a comprehensive mental health treatment plan, even from the consultation arena.
Autonomy: Who is in control?
Psychiatry provides varying levels of intervention for acutely mentally ill patients. Laws and criteria for involuntary commitment and the use of psychotropic medication under such circumstances vary from state to state.5
In the consultation-liaison setting, we often co-manage patients with a neuropsychiatric disorder that precludes them from participating fully in medical decisions. Other times, patients come to our attention involuntarily (eg, by way of medical admission) having a high level of premorbid autonomy: They make their own life decisions, choose not to engage in psychiatric treatment, administer their funds (when they have them), and so on.
Complex ethical situations can arise when (1) there is disagreement between physician and patient and (2) payment for care or insurance coverage plays a role in disposition plans or long-term placement. Public institutions might have a modus operandi that allows for extra room to deliberate and keep the treatment conversation going—more so than for-profit health centers, where financial forces can sway providers’ judgment toward autonomy, regardless of what is best for the patient.
Summing up: Let’s be Hippocratic psychiatrists
As many forces continue to influence the way we practice the art and science of medicine and psychiatry, it’s important to pay close attention to ongoing challenges and utilize organized medicine to advocate for better ways of running an effective consultation service in an ethical manner. As a trainee and future psychosomatic medicine psychiatrist, I am committed to starting these conversations wherever I go.
We need novel ways to look at, question, understand, study, and review our clinical practice to effectively tackle these challenges as we continue advancing as a field.
1. Remarks by the President at National Conference on Mental Health. Office of the Press Secretary. June 3, 2013. https://www.whitehouse.gov/the-press-office/2013/06/03/remarks-president-national-conference-mental-health. Accessed July 28, 2016.
2. Crary D. There’s a serious shortage of psychiatrists in the U.S. The Huffington Post. http://www.huffingtonpost.com/entry/theres-a-serious-shortage-of-psychiatrists-in-the-us_us_55eef13ce4b093be51bc128f. Published September 8, 2015. Accessed January 22, 2016.
3. Frantz J. Mental health care: average wait to see a psychiatrist in Dauphin County is 8 months. Penn Live. http://www.pennlive.com/midstate/index.ssf/2013/01/mental_illness_help_for_famili_1.html. Published January 24, 2013. Accessed January 22, 2016.
4. Kunkel E, Del Busto E, Kathol R, et al. Physician staffing for the practice of psychosomatic medicine in general hospitals: a pilot study. Psychosomatics. 2010;51(6):520-527.
5. Stettin B, Geller J, Ragosta K, et al. Mental health commitment laws: a survey of the states. http://tacreports.org/storage/documents/2014-state-survey-abridged.pdf. Published February 2014. Accessed February 25, 2016.
1. Remarks by the President at National Conference on Mental Health. Office of the Press Secretary. June 3, 2013. https://www.whitehouse.gov/the-press-office/2013/06/03/remarks-president-national-conference-mental-health. Accessed July 28, 2016.
2. Crary D. There’s a serious shortage of psychiatrists in the U.S. The Huffington Post. http://www.huffingtonpost.com/entry/theres-a-serious-shortage-of-psychiatrists-in-the-us_us_55eef13ce4b093be51bc128f. Published September 8, 2015. Accessed January 22, 2016.
3. Frantz J. Mental health care: average wait to see a psychiatrist in Dauphin County is 8 months. Penn Live. http://www.pennlive.com/midstate/index.ssf/2013/01/mental_illness_help_for_famili_1.html. Published January 24, 2013. Accessed January 22, 2016.
4. Kunkel E, Del Busto E, Kathol R, et al. Physician staffing for the practice of psychosomatic medicine in general hospitals: a pilot study. Psychosomatics. 2010;51(6):520-527.
5. Stettin B, Geller J, Ragosta K, et al. Mental health commitment laws: a survey of the states. http://tacreports.org/storage/documents/2014-state-survey-abridged.pdf. Published February 2014. Accessed February 25, 2016.
After-hours texting and professional boundaries
Recently, I was out on a Friday night with a friend who is a resident in another program. I hadn’t seen her in a very long time because of our hectic schedules. Around 10 p.m., she received a text from her attending asking her if she had left the scripts ready for the patient who was leaving on Monday.
Much has been written about professional boundaries and bosses texting their employees. For most jobs, a boss texting after hours over nonurgent matters is completely out of line. But in the medical field, there are no limits. People say, “Oh well, it’s the physician life.” Well maybe if we had more professional boundaries, our quality of life would be better. Maybe there wouldn’t be such a huge rate of burnout.
I encourage physicians to remember to contact your resident and coworkers during business hours. If the matter is not placing patients in danger, it can wait till the next morning. Nobody wants to pick up his phone in the middle of dinner to deal with patient care–related expectations that can be addressed the next business day.
Receiving a text brings all the stress of work back in the middle of our time off in which we are trying to take care of ourselves and the rest of our lives. It adds unnecessary stress to the overall high stress level and undermines our attempt to have a social life and meet a friend. A quick Internet search shows many blogs, journals, and different websites discussing this issue, but the voices of doctors and other health care providers are strangely silent on this topic.
I consider emails a more professional way of communicating than a text. I check my email often during a 24-hour period, and when I do, I’m ready for any potential information I might receive. I do not get notifications on my phone from my work email. But like my friend, I can’t avoid texts. We should have the opportunity to use our right to disconnect.
Some may argue, “Put your phone on silent if you don’t want to deal with it.” But not only do I use my phone for my life outside of work (as a resident, I make an effort to have one), but I want to be available for my peers and juniors when they are in the hospital. I want to be a resident my coworkers can text when they have a question and appreciate my advice. That is a decision I have made about the type of resident I want to be, and I am comfortable with it. Now if they text me asking a question that can wait till business hours the following day, they are crossing boundaries.
It might seem like a gray line. Somebody – maybe residency programs or our professional organizations – should address this so we have clear guidelines to protect our off-work time. Doesn’t our culture need to change the “physician life” so that we don’t bring our work responsibilities out for dinner on a Friday night? If the issue doesn’t need to be resolved quickly, it should be a given that texting is inappropriate.
Dr. Serrano is a PGY3 psychiatry resident at the Einstein Medical Center in Philadelphia.
Recently, I was out on a Friday night with a friend who is a resident in another program. I hadn’t seen her in a very long time because of our hectic schedules. Around 10 p.m., she received a text from her attending asking her if she had left the scripts ready for the patient who was leaving on Monday.
Much has been written about professional boundaries and bosses texting their employees. For most jobs, a boss texting after hours over nonurgent matters is completely out of line. But in the medical field, there are no limits. People say, “Oh well, it’s the physician life.” Well maybe if we had more professional boundaries, our quality of life would be better. Maybe there wouldn’t be such a huge rate of burnout.
I encourage physicians to remember to contact your resident and coworkers during business hours. If the matter is not placing patients in danger, it can wait till the next morning. Nobody wants to pick up his phone in the middle of dinner to deal with patient care–related expectations that can be addressed the next business day.
Receiving a text brings all the stress of work back in the middle of our time off in which we are trying to take care of ourselves and the rest of our lives. It adds unnecessary stress to the overall high stress level and undermines our attempt to have a social life and meet a friend. A quick Internet search shows many blogs, journals, and different websites discussing this issue, but the voices of doctors and other health care providers are strangely silent on this topic.
I consider emails a more professional way of communicating than a text. I check my email often during a 24-hour period, and when I do, I’m ready for any potential information I might receive. I do not get notifications on my phone from my work email. But like my friend, I can’t avoid texts. We should have the opportunity to use our right to disconnect.
Some may argue, “Put your phone on silent if you don’t want to deal with it.” But not only do I use my phone for my life outside of work (as a resident, I make an effort to have one), but I want to be available for my peers and juniors when they are in the hospital. I want to be a resident my coworkers can text when they have a question and appreciate my advice. That is a decision I have made about the type of resident I want to be, and I am comfortable with it. Now if they text me asking a question that can wait till business hours the following day, they are crossing boundaries.
It might seem like a gray line. Somebody – maybe residency programs or our professional organizations – should address this so we have clear guidelines to protect our off-work time. Doesn’t our culture need to change the “physician life” so that we don’t bring our work responsibilities out for dinner on a Friday night? If the issue doesn’t need to be resolved quickly, it should be a given that texting is inappropriate.
Dr. Serrano is a PGY3 psychiatry resident at the Einstein Medical Center in Philadelphia.
Recently, I was out on a Friday night with a friend who is a resident in another program. I hadn’t seen her in a very long time because of our hectic schedules. Around 10 p.m., she received a text from her attending asking her if she had left the scripts ready for the patient who was leaving on Monday.
Much has been written about professional boundaries and bosses texting their employees. For most jobs, a boss texting after hours over nonurgent matters is completely out of line. But in the medical field, there are no limits. People say, “Oh well, it’s the physician life.” Well maybe if we had more professional boundaries, our quality of life would be better. Maybe there wouldn’t be such a huge rate of burnout.
I encourage physicians to remember to contact your resident and coworkers during business hours. If the matter is not placing patients in danger, it can wait till the next morning. Nobody wants to pick up his phone in the middle of dinner to deal with patient care–related expectations that can be addressed the next business day.
Receiving a text brings all the stress of work back in the middle of our time off in which we are trying to take care of ourselves and the rest of our lives. It adds unnecessary stress to the overall high stress level and undermines our attempt to have a social life and meet a friend. A quick Internet search shows many blogs, journals, and different websites discussing this issue, but the voices of doctors and other health care providers are strangely silent on this topic.
I consider emails a more professional way of communicating than a text. I check my email often during a 24-hour period, and when I do, I’m ready for any potential information I might receive. I do not get notifications on my phone from my work email. But like my friend, I can’t avoid texts. We should have the opportunity to use our right to disconnect.
Some may argue, “Put your phone on silent if you don’t want to deal with it.” But not only do I use my phone for my life outside of work (as a resident, I make an effort to have one), but I want to be available for my peers and juniors when they are in the hospital. I want to be a resident my coworkers can text when they have a question and appreciate my advice. That is a decision I have made about the type of resident I want to be, and I am comfortable with it. Now if they text me asking a question that can wait till business hours the following day, they are crossing boundaries.
It might seem like a gray line. Somebody – maybe residency programs or our professional organizations – should address this so we have clear guidelines to protect our off-work time. Doesn’t our culture need to change the “physician life” so that we don’t bring our work responsibilities out for dinner on a Friday night? If the issue doesn’t need to be resolved quickly, it should be a given that texting is inappropriate.
Dr. Serrano is a PGY3 psychiatry resident at the Einstein Medical Center in Philadelphia.
The importance of ‘delivery factors’ and ‘patient factors’ in the therapeutic alliance
The therapeutic alliance (interchangeably, the therapeutic relationship) is a subjective measure of the relationship between a clinician and a patient. It is an indicator of clinical trustworthiness: what a patient is referring to when she (he) expresses trust in her provider. The therapeutic alliance also is known as the working alliance, the therapeutic bond, and the helping alliance,1 and it is an important factor in patient satisfaction ratings—the gauging parameter through which clinicians and institutions measure the quality of care they provide.2
A therapeutic alliance is essential to the delivery of psychiatric care. Itself, it can be a healing factor3 and has been linked to patients’ adherence to treatment and continuation of care.4 For example, psychiatric patients who perceive the therapeutic alliance more positively have:
- a better long-term health outcome after discharge
- a significantly better psychological quality of life5
- a better follow-up record of outpatient care after inpatient discharge4,6
- better adherence to prescribed treatment7
- a reduced likelihood of relapse and readmission.6
Patient satisfaction is an indirect measure of the therapeutic alliance; many variables of the therapeutic relationship can affect that satisfaction. In this article, we call those variables patient factors and delivery factors; our aim, using the example of 2 hypothetical cases, is to highlight their importance in patients’ perception of the therapeutic alliance they have with providers.
CASE Paranoid delusions lead to termination of care
Mr. D, age 21, unmarried, unemployed, and with no medical or psychiatric history, is transferred from the medical floor to the inpatient psychiatric unit after coming to the hospital’s emergency room (ER) with a report of chest pain. Workup on the medical floor was negative for a serious cardiac event.
On questioning, Mr. D tells the team that his chest pain is caused by National Security Agency (NSA) satellites “locking” onto his heart and causing veins in his heart to “pop.”
Mr. D agrees to be transferred to the psychiatric unit. Once there, however, he refuses to take the psychotropic medications that have been prescribed or to comply with the balance of the treatment protocol. He is adamant about the influence of NSA satellites, and requests daily imaging to locate evidence of the path of the satellite tracking device that he claims is inside his body.
The treatment team repeatedly refuses to comply with Mr. D’s demand for imaging. He becomes angry and says that he does not think he is getting proper care because the nature of his problem is medical, not psychiatric.
Mr. D repeatedly asserts that he will not take any of the psychotropic medications that have been prescribed for him and will not attend follow-up appointments with the psychiatry team because he does not need treatment. He accuses the treatment team of conspiring with the NSA and causing his chest pain.
Mr. D asks to be discharged.
Patient factors: Unmodifiable and static
As Mr. D’s case exemplifies, patient factors are a set of elements, intrinsic to a given patient, that affect that patient’s perceptions independent of the quality of the care delivered. Included among patient factors are personal sociodemographic and psychopathological characteristics. These patient factors influence the therapeutic relationship in many ways.
Sociodemographics. It has been reported that patients of minority heritage and those who are male, young, and unmarried tend to be less satisfied with medical treatment in general and with psychiatric inpatient treatment in particular.8,9 Females and older patients, on the other hand, are more likely to be satisfied with the perceived delivery of care and the therapeutic alliance.8-10
Psychopathology affects patients’ perception of the delivery of care and the therapeutic alliance. Patients who are highly distressed psychologically and those who suffer chronic psychiatric illness, for example, tend to perceive themselves as having benefitted less from treatment than healthier counterparts.9,11 Such patients also tend to see their therapeutic outcome in a much less favorable light.11,12 Patients with borderline personality disorder and antisocial personality disorder12-14 and those hospitalized involuntarily8 tend to (1) be less satisfied with their therapeutic outcome and (2) see the therapeutic alliance less favorably compared with those who do not have these psychopathologies.
CASE Denied a blanket, she feels like a 'burden'
Ms. X, age 34, married and a homemaker, has a history of bipolar I disorder. She brings herself to the ER complaining of depression and suicidal ideation.
After Ms. X is seen by the psychiatry consult service in the ER, she reports that she feels frustrated and angry and thinks that the hospital’s physicians do not really want to help her. She states that she felt that the ER staff “dismissed” her, in part because she spent 4 hours in the ER waiting room before she was given a bed.
Ms. X says that, once she was placed in a room, she felt that the nursing staff and medical assistants ignored her because they did not give her the extra blanket she requested. She said she was cold as a result, while she waited to see the psychiatrist and the ER physician.
Ms. X states that she came to the ER seeking help because she felt depressed and thought that no one cared about her. Coming to the hospital made her feel worse, after all, she said, because there she has been treated like she is a burden, much like she is treated at home.
Delivery factors: Amenable to change
These mutable elements of the therapeutic alliance are dependent on the quality of the care, as they were in Ms. X’s case; they can be changed. Included among delivery factors is the quality of the relationship between provider and patient—that is, how the psychiatrist and the nursing staff relate to the patient.
Perceptions are key. Delivery factors rank as one of the most important elements that influence the patient’s perception of the therapeutic alliance.15,16 Given the objectives of psychiatric treatment—to relieve psychiatric symptoms, improve patient functioning, and alleviate psychological distress—it is no wonder that delivery factors play an important role in the perception of the therapeutic alliance: The quality of the provider−patient relationship is the axis around which treatment takes place. This relationship constantly ranks high on surveys of what is important to patients15—especially in an inpatient psychiatric setting.
Attitudes are modifiable. From the treating psychiatrist to nursing and ancillary staffs, all team members need to express attitudes and behaviors that reflect positively on the patient.17 Behaviors such as involving the patient fully in therapeutic decision-making; exuding an attitude of caring, equanimity, empathy, sincerity, and respect; and listening to the patient’s concerns can go a long way to improving the therapeutic relationship. Displaying such attitudes and behaviors also help improve the larger vision of psychiatric intervention: to bring about positive therapeutic changes.
Summing up
Ratings of the therapeutic alliance are the currency of patient satisfaction. The value of this therapeutic currency is affected by delivery factors, which are adjustable, and patient factors, which are not. Taken together, however, both types of factors are the foundation of patient satisfaction and the therapeutic alliance.
1. Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J Consult Clin Psychol. 2000;68(3):438-450.
2. Chue P. The relationship between patient satisfaction and treatment outcomes in schizophrenia. J Psychopharmacol. 2006;20(suppl 6):38-56.
3. Priebe S, McCabe R. The therapeutic relationship in psychiatric settings. Acta Psychiatrica Scandinavica Suppl. 2006;113(429):69-72.
4. Bowersox NW, Bohnert AS, Ganoczy D, et al. Inpatient psychiatric care experience and its relationship to posthospitalization treatment participation. Psychiatr Serv. 2013;64(6):554-562.
5. Zendjidjian XY, Baumstarck K, Auquier P, et al. Satisfaction of hospitalized psychiatry patients: why should clinicians care? Patient Preference Adherence. 2014;8:575-583.
6. Druss BG, Rosenheck RA, Stolar M. Patient satisfaction and administrative measures as indicators of the quality of mental health care. Psychiatr Serv. 1999;50(8):1053-1058.
7. Sapra M, Weiden PJ, Schooler NR, et al. Reasons for adherence and nonadherence: a pilot study comparing first- and multi-episode schizophrenia patients. Clin Schizophr Relat Psychoses. 2014;7(4):199-206.
8. Rosenheck R, Wilson NJ, Meterko M. Influence of patient and hospital factors on consumer satisfaction with inpatient mental health treatment. Psychiatr Serv. 1997;48(12):1553-1561.
9. Hoff RA, Rosenheck RA, Meterko M, et al. Mental illness as a predictor of satisfaction with inpatient care at Veterans Affairs hospitals. Psychiatr Serv. 1999;50(5):680-685.
10. Bjørngaard JH, Ruud T, Friis S. The impact of mental illness on patient satisfaction with the therapeutic relationship: a multilevel analysis. Soc Psychiatry Psychiatr Epidemiol. 2007;42(10):803-809.
11. Greenley JR, Young TB, Schoenherr RA. Psychological distress and patient satisfaction. Med Care. 1982;20(4):373-385.
12. Svensson B, Hansson L. Patient satisfaction with inpatient psychiatric care. The influence of personality traits, diagnosis and perceived coercion. Acta Psychiatr Scand. 1994;90(5):379-384.
13. Köhler S, Unger T, Hoffmann S, et al. Patient satisfaction with inpatient psychiatric treatment and its relation to treatment outcome in unipolar depression and schizophrenia. Int J Psychiatry Clin Pract. 2015;19(2):119-123.
14. Holcomb WR, Parker JC, Leong GB, et al. Customer satisfaction and self-reported treatment outcomes among psychiatric inpatients. Psychiatr Serv. 1998;49(7):929-934.
15. Hansson L, Björkman T, Berglund I. What is important in psychiatric inpatient care? Quality of care from the patient’s perspective. Qual Assur Health Care. 1993;5(1):41-48.
16. Remnik Y, Melamed Y, Swartz M, et al. Patients’ satisfaction with psychiatric inpatient care. Isr J Psychiatry Relat Sci. 2003;41(3):208-212.
17. Norcross JC, ed. Psychotherapy relationships that work: therapist contributions and responsiveness to patients. New York, NY: Oxford University Press; 2002.
The therapeutic alliance (interchangeably, the therapeutic relationship) is a subjective measure of the relationship between a clinician and a patient. It is an indicator of clinical trustworthiness: what a patient is referring to when she (he) expresses trust in her provider. The therapeutic alliance also is known as the working alliance, the therapeutic bond, and the helping alliance,1 and it is an important factor in patient satisfaction ratings—the gauging parameter through which clinicians and institutions measure the quality of care they provide.2
A therapeutic alliance is essential to the delivery of psychiatric care. Itself, it can be a healing factor3 and has been linked to patients’ adherence to treatment and continuation of care.4 For example, psychiatric patients who perceive the therapeutic alliance more positively have:
- a better long-term health outcome after discharge
- a significantly better psychological quality of life5
- a better follow-up record of outpatient care after inpatient discharge4,6
- better adherence to prescribed treatment7
- a reduced likelihood of relapse and readmission.6
Patient satisfaction is an indirect measure of the therapeutic alliance; many variables of the therapeutic relationship can affect that satisfaction. In this article, we call those variables patient factors and delivery factors; our aim, using the example of 2 hypothetical cases, is to highlight their importance in patients’ perception of the therapeutic alliance they have with providers.
CASE Paranoid delusions lead to termination of care
Mr. D, age 21, unmarried, unemployed, and with no medical or psychiatric history, is transferred from the medical floor to the inpatient psychiatric unit after coming to the hospital’s emergency room (ER) with a report of chest pain. Workup on the medical floor was negative for a serious cardiac event.
On questioning, Mr. D tells the team that his chest pain is caused by National Security Agency (NSA) satellites “locking” onto his heart and causing veins in his heart to “pop.”
Mr. D agrees to be transferred to the psychiatric unit. Once there, however, he refuses to take the psychotropic medications that have been prescribed or to comply with the balance of the treatment protocol. He is adamant about the influence of NSA satellites, and requests daily imaging to locate evidence of the path of the satellite tracking device that he claims is inside his body.
The treatment team repeatedly refuses to comply with Mr. D’s demand for imaging. He becomes angry and says that he does not think he is getting proper care because the nature of his problem is medical, not psychiatric.
Mr. D repeatedly asserts that he will not take any of the psychotropic medications that have been prescribed for him and will not attend follow-up appointments with the psychiatry team because he does not need treatment. He accuses the treatment team of conspiring with the NSA and causing his chest pain.
Mr. D asks to be discharged.
Patient factors: Unmodifiable and static
As Mr. D’s case exemplifies, patient factors are a set of elements, intrinsic to a given patient, that affect that patient’s perceptions independent of the quality of the care delivered. Included among patient factors are personal sociodemographic and psychopathological characteristics. These patient factors influence the therapeutic relationship in many ways.
Sociodemographics. It has been reported that patients of minority heritage and those who are male, young, and unmarried tend to be less satisfied with medical treatment in general and with psychiatric inpatient treatment in particular.8,9 Females and older patients, on the other hand, are more likely to be satisfied with the perceived delivery of care and the therapeutic alliance.8-10
Psychopathology affects patients’ perception of the delivery of care and the therapeutic alliance. Patients who are highly distressed psychologically and those who suffer chronic psychiatric illness, for example, tend to perceive themselves as having benefitted less from treatment than healthier counterparts.9,11 Such patients also tend to see their therapeutic outcome in a much less favorable light.11,12 Patients with borderline personality disorder and antisocial personality disorder12-14 and those hospitalized involuntarily8 tend to (1) be less satisfied with their therapeutic outcome and (2) see the therapeutic alliance less favorably compared with those who do not have these psychopathologies.
CASE Denied a blanket, she feels like a 'burden'
Ms. X, age 34, married and a homemaker, has a history of bipolar I disorder. She brings herself to the ER complaining of depression and suicidal ideation.
After Ms. X is seen by the psychiatry consult service in the ER, she reports that she feels frustrated and angry and thinks that the hospital’s physicians do not really want to help her. She states that she felt that the ER staff “dismissed” her, in part because she spent 4 hours in the ER waiting room before she was given a bed.
Ms. X says that, once she was placed in a room, she felt that the nursing staff and medical assistants ignored her because they did not give her the extra blanket she requested. She said she was cold as a result, while she waited to see the psychiatrist and the ER physician.
Ms. X states that she came to the ER seeking help because she felt depressed and thought that no one cared about her. Coming to the hospital made her feel worse, after all, she said, because there she has been treated like she is a burden, much like she is treated at home.
Delivery factors: Amenable to change
These mutable elements of the therapeutic alliance are dependent on the quality of the care, as they were in Ms. X’s case; they can be changed. Included among delivery factors is the quality of the relationship between provider and patient—that is, how the psychiatrist and the nursing staff relate to the patient.
Perceptions are key. Delivery factors rank as one of the most important elements that influence the patient’s perception of the therapeutic alliance.15,16 Given the objectives of psychiatric treatment—to relieve psychiatric symptoms, improve patient functioning, and alleviate psychological distress—it is no wonder that delivery factors play an important role in the perception of the therapeutic alliance: The quality of the provider−patient relationship is the axis around which treatment takes place. This relationship constantly ranks high on surveys of what is important to patients15—especially in an inpatient psychiatric setting.
Attitudes are modifiable. From the treating psychiatrist to nursing and ancillary staffs, all team members need to express attitudes and behaviors that reflect positively on the patient.17 Behaviors such as involving the patient fully in therapeutic decision-making; exuding an attitude of caring, equanimity, empathy, sincerity, and respect; and listening to the patient’s concerns can go a long way to improving the therapeutic relationship. Displaying such attitudes and behaviors also help improve the larger vision of psychiatric intervention: to bring about positive therapeutic changes.
Summing up
Ratings of the therapeutic alliance are the currency of patient satisfaction. The value of this therapeutic currency is affected by delivery factors, which are adjustable, and patient factors, which are not. Taken together, however, both types of factors are the foundation of patient satisfaction and the therapeutic alliance.
The therapeutic alliance (interchangeably, the therapeutic relationship) is a subjective measure of the relationship between a clinician and a patient. It is an indicator of clinical trustworthiness: what a patient is referring to when she (he) expresses trust in her provider. The therapeutic alliance also is known as the working alliance, the therapeutic bond, and the helping alliance,1 and it is an important factor in patient satisfaction ratings—the gauging parameter through which clinicians and institutions measure the quality of care they provide.2
A therapeutic alliance is essential to the delivery of psychiatric care. Itself, it can be a healing factor3 and has been linked to patients’ adherence to treatment and continuation of care.4 For example, psychiatric patients who perceive the therapeutic alliance more positively have:
- a better long-term health outcome after discharge
- a significantly better psychological quality of life5
- a better follow-up record of outpatient care after inpatient discharge4,6
- better adherence to prescribed treatment7
- a reduced likelihood of relapse and readmission.6
Patient satisfaction is an indirect measure of the therapeutic alliance; many variables of the therapeutic relationship can affect that satisfaction. In this article, we call those variables patient factors and delivery factors; our aim, using the example of 2 hypothetical cases, is to highlight their importance in patients’ perception of the therapeutic alliance they have with providers.
CASE Paranoid delusions lead to termination of care
Mr. D, age 21, unmarried, unemployed, and with no medical or psychiatric history, is transferred from the medical floor to the inpatient psychiatric unit after coming to the hospital’s emergency room (ER) with a report of chest pain. Workup on the medical floor was negative for a serious cardiac event.
On questioning, Mr. D tells the team that his chest pain is caused by National Security Agency (NSA) satellites “locking” onto his heart and causing veins in his heart to “pop.”
Mr. D agrees to be transferred to the psychiatric unit. Once there, however, he refuses to take the psychotropic medications that have been prescribed or to comply with the balance of the treatment protocol. He is adamant about the influence of NSA satellites, and requests daily imaging to locate evidence of the path of the satellite tracking device that he claims is inside his body.
The treatment team repeatedly refuses to comply with Mr. D’s demand for imaging. He becomes angry and says that he does not think he is getting proper care because the nature of his problem is medical, not psychiatric.
Mr. D repeatedly asserts that he will not take any of the psychotropic medications that have been prescribed for him and will not attend follow-up appointments with the psychiatry team because he does not need treatment. He accuses the treatment team of conspiring with the NSA and causing his chest pain.
Mr. D asks to be discharged.
Patient factors: Unmodifiable and static
As Mr. D’s case exemplifies, patient factors are a set of elements, intrinsic to a given patient, that affect that patient’s perceptions independent of the quality of the care delivered. Included among patient factors are personal sociodemographic and psychopathological characteristics. These patient factors influence the therapeutic relationship in many ways.
Sociodemographics. It has been reported that patients of minority heritage and those who are male, young, and unmarried tend to be less satisfied with medical treatment in general and with psychiatric inpatient treatment in particular.8,9 Females and older patients, on the other hand, are more likely to be satisfied with the perceived delivery of care and the therapeutic alliance.8-10
Psychopathology affects patients’ perception of the delivery of care and the therapeutic alliance. Patients who are highly distressed psychologically and those who suffer chronic psychiatric illness, for example, tend to perceive themselves as having benefitted less from treatment than healthier counterparts.9,11 Such patients also tend to see their therapeutic outcome in a much less favorable light.11,12 Patients with borderline personality disorder and antisocial personality disorder12-14 and those hospitalized involuntarily8 tend to (1) be less satisfied with their therapeutic outcome and (2) see the therapeutic alliance less favorably compared with those who do not have these psychopathologies.
CASE Denied a blanket, she feels like a 'burden'
Ms. X, age 34, married and a homemaker, has a history of bipolar I disorder. She brings herself to the ER complaining of depression and suicidal ideation.
After Ms. X is seen by the psychiatry consult service in the ER, she reports that she feels frustrated and angry and thinks that the hospital’s physicians do not really want to help her. She states that she felt that the ER staff “dismissed” her, in part because she spent 4 hours in the ER waiting room before she was given a bed.
Ms. X says that, once she was placed in a room, she felt that the nursing staff and medical assistants ignored her because they did not give her the extra blanket she requested. She said she was cold as a result, while she waited to see the psychiatrist and the ER physician.
Ms. X states that she came to the ER seeking help because she felt depressed and thought that no one cared about her. Coming to the hospital made her feel worse, after all, she said, because there she has been treated like she is a burden, much like she is treated at home.
Delivery factors: Amenable to change
These mutable elements of the therapeutic alliance are dependent on the quality of the care, as they were in Ms. X’s case; they can be changed. Included among delivery factors is the quality of the relationship between provider and patient—that is, how the psychiatrist and the nursing staff relate to the patient.
Perceptions are key. Delivery factors rank as one of the most important elements that influence the patient’s perception of the therapeutic alliance.15,16 Given the objectives of psychiatric treatment—to relieve psychiatric symptoms, improve patient functioning, and alleviate psychological distress—it is no wonder that delivery factors play an important role in the perception of the therapeutic alliance: The quality of the provider−patient relationship is the axis around which treatment takes place. This relationship constantly ranks high on surveys of what is important to patients15—especially in an inpatient psychiatric setting.
Attitudes are modifiable. From the treating psychiatrist to nursing and ancillary staffs, all team members need to express attitudes and behaviors that reflect positively on the patient.17 Behaviors such as involving the patient fully in therapeutic decision-making; exuding an attitude of caring, equanimity, empathy, sincerity, and respect; and listening to the patient’s concerns can go a long way to improving the therapeutic relationship. Displaying such attitudes and behaviors also help improve the larger vision of psychiatric intervention: to bring about positive therapeutic changes.
Summing up
Ratings of the therapeutic alliance are the currency of patient satisfaction. The value of this therapeutic currency is affected by delivery factors, which are adjustable, and patient factors, which are not. Taken together, however, both types of factors are the foundation of patient satisfaction and the therapeutic alliance.
1. Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J Consult Clin Psychol. 2000;68(3):438-450.
2. Chue P. The relationship between patient satisfaction and treatment outcomes in schizophrenia. J Psychopharmacol. 2006;20(suppl 6):38-56.
3. Priebe S, McCabe R. The therapeutic relationship in psychiatric settings. Acta Psychiatrica Scandinavica Suppl. 2006;113(429):69-72.
4. Bowersox NW, Bohnert AS, Ganoczy D, et al. Inpatient psychiatric care experience and its relationship to posthospitalization treatment participation. Psychiatr Serv. 2013;64(6):554-562.
5. Zendjidjian XY, Baumstarck K, Auquier P, et al. Satisfaction of hospitalized psychiatry patients: why should clinicians care? Patient Preference Adherence. 2014;8:575-583.
6. Druss BG, Rosenheck RA, Stolar M. Patient satisfaction and administrative measures as indicators of the quality of mental health care. Psychiatr Serv. 1999;50(8):1053-1058.
7. Sapra M, Weiden PJ, Schooler NR, et al. Reasons for adherence and nonadherence: a pilot study comparing first- and multi-episode schizophrenia patients. Clin Schizophr Relat Psychoses. 2014;7(4):199-206.
8. Rosenheck R, Wilson NJ, Meterko M. Influence of patient and hospital factors on consumer satisfaction with inpatient mental health treatment. Psychiatr Serv. 1997;48(12):1553-1561.
9. Hoff RA, Rosenheck RA, Meterko M, et al. Mental illness as a predictor of satisfaction with inpatient care at Veterans Affairs hospitals. Psychiatr Serv. 1999;50(5):680-685.
10. Bjørngaard JH, Ruud T, Friis S. The impact of mental illness on patient satisfaction with the therapeutic relationship: a multilevel analysis. Soc Psychiatry Psychiatr Epidemiol. 2007;42(10):803-809.
11. Greenley JR, Young TB, Schoenherr RA. Psychological distress and patient satisfaction. Med Care. 1982;20(4):373-385.
12. Svensson B, Hansson L. Patient satisfaction with inpatient psychiatric care. The influence of personality traits, diagnosis and perceived coercion. Acta Psychiatr Scand. 1994;90(5):379-384.
13. Köhler S, Unger T, Hoffmann S, et al. Patient satisfaction with inpatient psychiatric treatment and its relation to treatment outcome in unipolar depression and schizophrenia. Int J Psychiatry Clin Pract. 2015;19(2):119-123.
14. Holcomb WR, Parker JC, Leong GB, et al. Customer satisfaction and self-reported treatment outcomes among psychiatric inpatients. Psychiatr Serv. 1998;49(7):929-934.
15. Hansson L, Björkman T, Berglund I. What is important in psychiatric inpatient care? Quality of care from the patient’s perspective. Qual Assur Health Care. 1993;5(1):41-48.
16. Remnik Y, Melamed Y, Swartz M, et al. Patients’ satisfaction with psychiatric inpatient care. Isr J Psychiatry Relat Sci. 2003;41(3):208-212.
17. Norcross JC, ed. Psychotherapy relationships that work: therapist contributions and responsiveness to patients. New York, NY: Oxford University Press; 2002.
1. Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J Consult Clin Psychol. 2000;68(3):438-450.
2. Chue P. The relationship between patient satisfaction and treatment outcomes in schizophrenia. J Psychopharmacol. 2006;20(suppl 6):38-56.
3. Priebe S, McCabe R. The therapeutic relationship in psychiatric settings. Acta Psychiatrica Scandinavica Suppl. 2006;113(429):69-72.
4. Bowersox NW, Bohnert AS, Ganoczy D, et al. Inpatient psychiatric care experience and its relationship to posthospitalization treatment participation. Psychiatr Serv. 2013;64(6):554-562.
5. Zendjidjian XY, Baumstarck K, Auquier P, et al. Satisfaction of hospitalized psychiatry patients: why should clinicians care? Patient Preference Adherence. 2014;8:575-583.
6. Druss BG, Rosenheck RA, Stolar M. Patient satisfaction and administrative measures as indicators of the quality of mental health care. Psychiatr Serv. 1999;50(8):1053-1058.
7. Sapra M, Weiden PJ, Schooler NR, et al. Reasons for adherence and nonadherence: a pilot study comparing first- and multi-episode schizophrenia patients. Clin Schizophr Relat Psychoses. 2014;7(4):199-206.
8. Rosenheck R, Wilson NJ, Meterko M. Influence of patient and hospital factors on consumer satisfaction with inpatient mental health treatment. Psychiatr Serv. 1997;48(12):1553-1561.
9. Hoff RA, Rosenheck RA, Meterko M, et al. Mental illness as a predictor of satisfaction with inpatient care at Veterans Affairs hospitals. Psychiatr Serv. 1999;50(5):680-685.
10. Bjørngaard JH, Ruud T, Friis S. The impact of mental illness on patient satisfaction with the therapeutic relationship: a multilevel analysis. Soc Psychiatry Psychiatr Epidemiol. 2007;42(10):803-809.
11. Greenley JR, Young TB, Schoenherr RA. Psychological distress and patient satisfaction. Med Care. 1982;20(4):373-385.
12. Svensson B, Hansson L. Patient satisfaction with inpatient psychiatric care. The influence of personality traits, diagnosis and perceived coercion. Acta Psychiatr Scand. 1994;90(5):379-384.
13. Köhler S, Unger T, Hoffmann S, et al. Patient satisfaction with inpatient psychiatric treatment and its relation to treatment outcome in unipolar depression and schizophrenia. Int J Psychiatry Clin Pract. 2015;19(2):119-123.
14. Holcomb WR, Parker JC, Leong GB, et al. Customer satisfaction and self-reported treatment outcomes among psychiatric inpatients. Psychiatr Serv. 1998;49(7):929-934.
15. Hansson L, Björkman T, Berglund I. What is important in psychiatric inpatient care? Quality of care from the patient’s perspective. Qual Assur Health Care. 1993;5(1):41-48.
16. Remnik Y, Melamed Y, Swartz M, et al. Patients’ satisfaction with psychiatric inpatient care. Isr J Psychiatry Relat Sci. 2003;41(3):208-212.
17. Norcross JC, ed. Psychotherapy relationships that work: therapist contributions and responsiveness to patients. New York, NY: Oxford University Press; 2002.
Lessons learned working in the clinical trial industry
As a resident in psychiatry, I am being trained in the art of diagnosis, treatment, and prevention of mental illness and emotional problems. As part of my training, research and scholarly activities are encouraged—reminding us that clinical medicine is always evolving and that it is every physician’s duty to be at the forefront of advancements in medical science.
Last year, I worked in the clinical trial industry under a seasoned principal investigator. I learned several lessons from my time with him and in the industry. Here, I present these lessons as a starting point for residents who are looking to gain experience or contemplating a career as an expert trialist or principal investigator.
Lesson 1: Know the lingo
To make the transition from physician to principal investigator go more smoothly, I recommend taking the time to learn the language of the industry. The good news? Clinical trials involve patients who have a medical history and take medications, which you are well acquainted with. In addition to medical jargon, the industry has developed its own distinctive terminology and abbreviations: adverse drug reaction (ADR), good clinical practice (GCP), contract research organization (CRO), and more.
Don’t stop there, however. I recommend that you read FDA research guidelines and guidelines of the International Conference on Harmonisation of Good Clinical Practice (ICH-GCP) to be familiar with the ethics and standard regulations of the industry.
Lesson 2: When in doubt, refer to the Protocol
Every clinical trial has a manual, so to speak, known as the Study Protocol, which outlines approved methods of performing diagnostic tests and procedures; provides information on the study timeline; and specifies patient inclusion and exclusion criteria. This document ensures conformity across all study sites, helps prevent errors, limits bias, and answers questions that might come up during the study. It’s worth noting that, in my experience, many of the questions about exclusionary medications arise when psychiatric drugs are involved.
Lesson 3: Document. Document. And document.
The golden rule in clinical practice and research is: “If it isn’t documented, it didn’t happen.” (Recall what I said about reading FDA and ICH-GCP guidelines to learn about regulations.) Documentation of all study-related activities must be meticulous. At any time, your documents might be subject to external or internal audit, conducted to preserve conformity to the protocol and maintain patient safety. Improper documentation can delay, even invalidate, your research.
Lesson 4: Remember that advertising is an art
The real work begins when your site is ready to accept patients. To fill the study, patients need to be aware that you are recruiting participants. A good starting point is to inform likely candidates from your existing patient population about any studies from which they might benefit.
Most times, however, recruiting among your patients is not enough to meet necessary enrollment numbers. You will have to advertise the study to the general public. Advertisements must target the specific patient population, informing them of the study but, at the same time, not be coercive or make false promises. The advertisements must be approved by the study’s institutional review board, which is responsible for protecting the rights and welfare of study participants.
Advertising can be tricky. If an advertisement is too vague, you will get a huge response, causing time and resources to be spent screening patients—most of whom might not be suitable for the study. If an advertisement is too specific, on the other hand, the response might be poor or none at all.
Advertising is its own industry. It might be best to hire an advertising expert who can help you decide on the selection of media (radio, television, print, digital) and can design a campaign that best suits your needs. If you decide to hire a professional, I recommend close collaboration with him (her), to help him understand the medical nature of the study.
Related Resources
• ClinicalTrials.gov. About clinical studies. https://clinicaltrials.gov/ct2/about-studies.
• U.S. Food and Drug Administration. Clinical trials and human subject protection. http://www.fda.gov/ScienceResearch/SpecialTopics/RunningClinicalTrials/default.htm.
• ICH GCP. International Conference on Harmonisation of technical requirements for registration of pharmaceuticals for human use. http://ichgcp.net/.
As a resident in psychiatry, I am being trained in the art of diagnosis, treatment, and prevention of mental illness and emotional problems. As part of my training, research and scholarly activities are encouraged—reminding us that clinical medicine is always evolving and that it is every physician’s duty to be at the forefront of advancements in medical science.
Last year, I worked in the clinical trial industry under a seasoned principal investigator. I learned several lessons from my time with him and in the industry. Here, I present these lessons as a starting point for residents who are looking to gain experience or contemplating a career as an expert trialist or principal investigator.
Lesson 1: Know the lingo
To make the transition from physician to principal investigator go more smoothly, I recommend taking the time to learn the language of the industry. The good news? Clinical trials involve patients who have a medical history and take medications, which you are well acquainted with. In addition to medical jargon, the industry has developed its own distinctive terminology and abbreviations: adverse drug reaction (ADR), good clinical practice (GCP), contract research organization (CRO), and more.
Don’t stop there, however. I recommend that you read FDA research guidelines and guidelines of the International Conference on Harmonisation of Good Clinical Practice (ICH-GCP) to be familiar with the ethics and standard regulations of the industry.
Lesson 2: When in doubt, refer to the Protocol
Every clinical trial has a manual, so to speak, known as the Study Protocol, which outlines approved methods of performing diagnostic tests and procedures; provides information on the study timeline; and specifies patient inclusion and exclusion criteria. This document ensures conformity across all study sites, helps prevent errors, limits bias, and answers questions that might come up during the study. It’s worth noting that, in my experience, many of the questions about exclusionary medications arise when psychiatric drugs are involved.
Lesson 3: Document. Document. And document.
The golden rule in clinical practice and research is: “If it isn’t documented, it didn’t happen.” (Recall what I said about reading FDA and ICH-GCP guidelines to learn about regulations.) Documentation of all study-related activities must be meticulous. At any time, your documents might be subject to external or internal audit, conducted to preserve conformity to the protocol and maintain patient safety. Improper documentation can delay, even invalidate, your research.
Lesson 4: Remember that advertising is an art
The real work begins when your site is ready to accept patients. To fill the study, patients need to be aware that you are recruiting participants. A good starting point is to inform likely candidates from your existing patient population about any studies from which they might benefit.
Most times, however, recruiting among your patients is not enough to meet necessary enrollment numbers. You will have to advertise the study to the general public. Advertisements must target the specific patient population, informing them of the study but, at the same time, not be coercive or make false promises. The advertisements must be approved by the study’s institutional review board, which is responsible for protecting the rights and welfare of study participants.
Advertising can be tricky. If an advertisement is too vague, you will get a huge response, causing time and resources to be spent screening patients—most of whom might not be suitable for the study. If an advertisement is too specific, on the other hand, the response might be poor or none at all.
Advertising is its own industry. It might be best to hire an advertising expert who can help you decide on the selection of media (radio, television, print, digital) and can design a campaign that best suits your needs. If you decide to hire a professional, I recommend close collaboration with him (her), to help him understand the medical nature of the study.
Related Resources
• ClinicalTrials.gov. About clinical studies. https://clinicaltrials.gov/ct2/about-studies.
• U.S. Food and Drug Administration. Clinical trials and human subject protection. http://www.fda.gov/ScienceResearch/SpecialTopics/RunningClinicalTrials/default.htm.
• ICH GCP. International Conference on Harmonisation of technical requirements for registration of pharmaceuticals for human use. http://ichgcp.net/.
As a resident in psychiatry, I am being trained in the art of diagnosis, treatment, and prevention of mental illness and emotional problems. As part of my training, research and scholarly activities are encouraged—reminding us that clinical medicine is always evolving and that it is every physician’s duty to be at the forefront of advancements in medical science.
Last year, I worked in the clinical trial industry under a seasoned principal investigator. I learned several lessons from my time with him and in the industry. Here, I present these lessons as a starting point for residents who are looking to gain experience or contemplating a career as an expert trialist or principal investigator.
Lesson 1: Know the lingo
To make the transition from physician to principal investigator go more smoothly, I recommend taking the time to learn the language of the industry. The good news? Clinical trials involve patients who have a medical history and take medications, which you are well acquainted with. In addition to medical jargon, the industry has developed its own distinctive terminology and abbreviations: adverse drug reaction (ADR), good clinical practice (GCP), contract research organization (CRO), and more.
Don’t stop there, however. I recommend that you read FDA research guidelines and guidelines of the International Conference on Harmonisation of Good Clinical Practice (ICH-GCP) to be familiar with the ethics and standard regulations of the industry.
Lesson 2: When in doubt, refer to the Protocol
Every clinical trial has a manual, so to speak, known as the Study Protocol, which outlines approved methods of performing diagnostic tests and procedures; provides information on the study timeline; and specifies patient inclusion and exclusion criteria. This document ensures conformity across all study sites, helps prevent errors, limits bias, and answers questions that might come up during the study. It’s worth noting that, in my experience, many of the questions about exclusionary medications arise when psychiatric drugs are involved.
Lesson 3: Document. Document. And document.
The golden rule in clinical practice and research is: “If it isn’t documented, it didn’t happen.” (Recall what I said about reading FDA and ICH-GCP guidelines to learn about regulations.) Documentation of all study-related activities must be meticulous. At any time, your documents might be subject to external or internal audit, conducted to preserve conformity to the protocol and maintain patient safety. Improper documentation can delay, even invalidate, your research.
Lesson 4: Remember that advertising is an art
The real work begins when your site is ready to accept patients. To fill the study, patients need to be aware that you are recruiting participants. A good starting point is to inform likely candidates from your existing patient population about any studies from which they might benefit.
Most times, however, recruiting among your patients is not enough to meet necessary enrollment numbers. You will have to advertise the study to the general public. Advertisements must target the specific patient population, informing them of the study but, at the same time, not be coercive or make false promises. The advertisements must be approved by the study’s institutional review board, which is responsible for protecting the rights and welfare of study participants.
Advertising can be tricky. If an advertisement is too vague, you will get a huge response, causing time and resources to be spent screening patients—most of whom might not be suitable for the study. If an advertisement is too specific, on the other hand, the response might be poor or none at all.
Advertising is its own industry. It might be best to hire an advertising expert who can help you decide on the selection of media (radio, television, print, digital) and can design a campaign that best suits your needs. If you decide to hire a professional, I recommend close collaboration with him (her), to help him understand the medical nature of the study.
Related Resources
• ClinicalTrials.gov. About clinical studies. https://clinicaltrials.gov/ct2/about-studies.
• U.S. Food and Drug Administration. Clinical trials and human subject protection. http://www.fda.gov/ScienceResearch/SpecialTopics/RunningClinicalTrials/default.htm.
• ICH GCP. International Conference on Harmonisation of technical requirements for registration of pharmaceuticals for human use. http://ichgcp.net/.
