Current Psychiatry

According to the U.S. Department of Health and Human Services, in 2007, 88% of 1.4 million Medicare claims for second-generation antipsychotics (SGAs) in older adult nursing home residents were associated with a dementia diagnosis. Similar trends have been observed in Canada and Europe.^1-4 In a retrospective analysis of medication data from older residents with dementia in 6 care homes in England, long-term (ie, >1 month) use of antipsychotics was the most frequent potentially inappropriate prescribing practice.³ In another study in 7 European countries and Israel, the overall prevalence of antipsychotic use among long-term care residents with dementia was 33%.¹ Similarly, a recent literature review⁵ found that 22% to 86% of antipsychotic prescriptions to older individuals were off-label; this practice was particularly common for individuals with agitation.

Because of the aging population and widespread prescription of antipsychotics to older patients, clinicians need information on the relative risks of using these medications in this population. In the United States, all antipsychotics carry a FDA “black-box” warning of the increased risk of death in older adults with dementia. In addition, the risk of death is increased when prescribing antipsychotics to older adults with other conditions, such as Parkinson’s disease,⁶ and other safety and tolerability concerns, including falls and fractures, sedation, metabolic abnormalities, and extrapyramidal effects, are highly relevant to geriatric patients.

This 3-part review summarizes findings and recommendations on prescribing antipsychotics to older individuals with schizophrenia, bipolar disorder, depression, and dementia. This third and final installment:

• briefly summarizes the major studies and analyses relevant to prescribing antipsychotics to older patients with dementia
• provides a summative opinion on safety and tolerability issues in these older patients
• highlights the gaps in the evidence base and areas that need additional research.

Summary of benefits, place in treatment armamentarium

Behavioral and psychological symptoms of dementia (BPSD) include agitation, delusional beliefs, repetitive questioning, hallucinations, aggression, wandering, and various socially inappropriate behaviors.⁷ These occur almost universally in all types and stages of dementia.⁷ BPSD are among the most complex, stressful, and costly aspects of dementia care, and lead to a myriad of poor health outcomes, including excess morbidity, mortality, hospital stays, and early nursing home placement.^8-11 Because BPSD usually occur across all types and stages of dementia,^7,12-16 the prevalence of BPSD mirrors the overall prevalence of dementia.

Although all expert organizations, including the American Psychiatric Association,¹⁷ recommend nonpharmacologic strategies as first-line treatment for BPSD, for the most part, these recommendations have not been translated into standard clinical management or routine care.¹⁸ Because of a perceived lack of other options, the current mainstay of treatment is the off-label use of psychotropics such as antipsy­chotics. Of all the agents currently used for BPSD, SGAs have the strongest evidence base, although benefits are modest at best (standardized effect size 0.13 to 0.16).^19,20 In terms of individual SGAs, only risperidone is indicated for aggression in Canada and in Europe (not in the United States); risperidone has the best evidence for efficacy, with a meta-analysis of 5 published randomized controlled trials (RCTs) reporting that risperidone is superior to other SGAs for aggression in dementia.^21,22 As a class, first-generation antipsychotics (FGAs) have no clear evidence for BPSD as defined broadly; however, there may be slight benefit for haloperidol for aggression.^23,24

Clinical Trials

Adverse effects. A meta-analysis of RCTs of SGAs found that, compared with placebo, SGAs have increased rates of several adverse effects. These include somnolence (17% drug vs 7% placebo; odds ratio [OR], 2.84; 95% confidence interval [CI], 2.25 to 3.58; P < .00001); extrapyramidal symptoms (13% drug vs 8% placebo; OR, 1.51; 95% CI, 1.20 to 1.91; P = .0005; primarily attributable to risperidone); abnormal gait (10% drug vs 2% placebo; OR, 3.42; 95% CI, 1.78 to 6.56; P = .0002; attributable to olanzapine and risperidone); edema (9% drug vs 4% placebo; OR, 1.99; 95% CI, 1.20 to 3.30; P = .008; attributable to olanzapine and risperidone); urinary tract infections/incontinence (16% drug vs 12% placebo; OR, 1.28; 95% CI, 1.02 to 1.61; P = .04); cognitive impairment measured as difference in Mini-Mental State Examination score (95% CI, 0.38 to 1.09; P < .0001)²⁵; and stroke (1.9% drug vs 0.9% placebo, OR, 2.13; 95% CI, 1.20 to 3.75; P = .009).^21,26

In the 42-site Clinical Antipsychotic Trials of Intervention Effectiveness Alzheimer’s disease RCT, 421 outpatients with Alzheimer’s disease and BPSD were randomized to an SGA (risperidone, olanzapine, or quetiapine) or placebo. Compared with placebo, SGAs had a higher rate of parkinsonism or extrapyramidal signs (olanzapine and risperidone groups); sedation; confusion/changes in mental status (olanzapine and risperidone); psychotic symptoms (olanzapine); and increase in body weight and body mass index.²⁶

In the 2005 FDA black-box warning, pneumonia and cardiac adverse effects were cited as primary causes of death for patients with dementia taking SGAs. A subsequent observational study confirmed that use of either FGAs or SGAs in geriatric patients was associated with an increased risk of pneumonia, in a dose-dependent manner.²⁷ Although there is limited data on cardiac adverse effects in older adults, especially those with dementia taking antipsychotics,²⁸ 1 observational study of nursing home residents²⁹ found that those taking FGAs had a significantly higher risk of hospitalization for ventricular arrhythmia or cardiac arrest compared with those who were not taking FGAs. In contrast, there was no increased risk with SGAs.

Mortality.
 In 2005, the FDA announced that based on a reanalysis of 17 placebo-controlled trials (many of which were unpublished) that SGAs were associated with a 1.7-fold increase in mortality compared with placebo.³⁰ As a result, the FDA issued a black-box warning for using SGAs in patients with dementia. The overall OR in a published meta-analysis of mortality with SGAs was 1.54 (1.06 to 2.23; z = 2.28; P = .02), with pooled events of 3.5% mortality vs 2.3% (drug vs placebo).²¹ This meta-analysis²¹ also included ad hoc analyses of haloperidol; using combined data from 2 contrasts of haloperidol (with risperidone and quetiapine; 243 patients receiving haloperidol and 239 receiving placebo) they also found 15 deaths (6.2%) with haloperidol and 9 (3.8%) with placebo, resulting in an OR of 1.68.

Other clinical data

Observational studies. Most observational studies have confirmed concerns regarding increased mortality in patients with BPSD who take antipsychotics, with FGAs having a higher risk than SGAs^18,31 and SGAs having a higher risk compared with most other psychotropics.³² Three studies that found no increase in mortality with antipsychotics in patients with dementia had methodological issues, including examining prevalence as opposed to new users,^33,34 not controlling for exposure,^10,33,34 power issues,^10,34 not controlling for other psychiatric medications,¹⁰ and varying lengths of follow-up.¹⁰ An FDA black-box warning for FGAs was announced in 2008³⁰ based on 2 observational studies that showed an increased risk of mortality in older adults taking FGAs vs SGAs.^35,36

In terms of specific SGAs, Kales et al³⁷ examined the mortality risk associated with individual antipsychotics using various methods to control for confounding. Among a national sample of >33,000 older veterans with dementia newly started on haloperidol, risperidone, olanzapine, quetiapine, or valproic acid and derivatives (as a nonantipsychotic comparator), the highest mortality across all analyses (intent to treat, exposure, propensity-adjusted) was associated with haloperidol, followed by risperidone and olanzapine, valproic acid, and quetiapine.

Most recently, a retrospective case-control study (90,786 patients age ≥65 with dementia) examined the number needed to harm (NNH; ie, number of patients needed to receive treatment that would result in 1 death) over 180 days following initiation of an FGA or SGA.³⁸ This study found the following NNHs: haloperidol, 26 (95% CI, 15 to 99); risperidone, 27 (95% CI, 19 to 46); olanzapine, 40 (95% CI, 21 to 312); and quetiapine, 50 (95% CI, 30 to 150).³⁸ These results are congruent with a review of observational studies that found the highest risk of mortality was associated with haloperidol and chlorpromazine, and the lowest risk with olanzapine, quetiapine, and ziprasidone.²⁸

Patterns of antipsychotic use in older dementia patients

There are high rates of antipsychotic use in patients with dementia. Before the FDA issued the black-box warning, the Aging Demographics and Memory study found that the rate of antipsychotic use in community (outpatient) older adults with dementia was approximately 19% between 2002 and 2004 in a representative sample of 307 older adults.³⁹ Another study examining trends in community antipsychotic use in the U.S. Department of Veterans Affairs (VA) found that in the 1990s, SGA use was increasing; approximately 18% of outpatients with dementia were taking these agents.⁴⁰ Use of SGAs began to decline in 2003, ahead of the 2005 black-box warning, in tandem with other advisories (eg, diabetes, metabolic syndrome,⁴¹ and stroke risk).^42,43 Olanzapine and risperidone showed declining rates between 2003 and 2005, whereas quetiapine use significantly increased during this period. All 3 SGAs declined after the black-box warning. However, by the end of 2007, the use of SGAs had leveled off to approximately 12% of VA patients with dementia. A recent U.S. Government Accountability Office (GAO) report found that in 2012, 14% of older adult Medicare Part D enrollees with dementia living in the community were prescribed an antipsychotic.⁴⁴

Use in nursing home residents. Because BPSD are one of the main reasons people with dementia are placed in nursing homes, it is not surprising that rates of antipsychotic use are higher in these settings than in the community. Prior to the black-box warning, studies found that 24% to 32% of nursing home residents were treated with antipsychotics.^45-47 A study examining VA nursing homes (n = 133 facilities, n = 3,692 veterans) found that approximately 26% of residents were prescribed antipsychotics in 2004 to 2005.⁴⁸ The Center for Medicare and Medicaid Services (CMS) National Partnership to Improve Dementia Care in Nursing Homes has appeared to lower antipsychotic medication use in nursing homes; the rate decreased from 24% in long-stay nursing home residents nationwide in 2011 to 19% by the end of 2014. Specific to dementia, a 2010 CMS report⁴⁹ indicated that approximately 40% of nursing home residents with cognitive impairment and behavioral issues, without psychosis, received antipsychotics. The GAO data indicated that approximately 33% of older Medicare Part D enrollees with dementia who spent >100 days in a nursing home were prescribed an antipsychotic in 2012.⁴⁴ A recent Canadian study using drug claims data found that overall psychotropic use in patients with dementia remains high, finding that three-fourths of all patients with dementia in long-term care are given at least 1 psychotropic, and up to one-third are prescribed SGAs.⁵⁰ European data similarly show that antipsychotics continue to be prescribed to up to one-third of long-term care residents with dementia, with 7 out of 10 receiving an SGA.¹

Conclusions

The Table provides a summary of the evidence regarding the use of antipsychotics in patients with dementia. Expert consensus is that among BPSD, aggression and psychosis are the primary indications for using antipsychotics.⁵¹ Based on multiple RCTs and meta-analyses, the evidence for using SGAs to treat these symptoms is moderate at best. However, in real-world practice settings, SGAs are widely used for symptoms, such as wandering, inappropriate behaviors, resistance to care, etc., for which there is no evidence for efficacy other than sedation. Furthermore, even when there is a potential for benefit, this must be balanced against the risk of adverse effects, including somnolence, worsened cognition, extra­pyramidal symptoms, stroke, and mortality.
 

Clinicians who care for older adults with BPSD should strive to increase the use of first-line nonpharmacologic strategies, by using structured approaches such as DICE (Describe, Investigate, Create, Evaluate) described in the Box.⁵¹ Antipsychotics should be reserved for situations in which nonpharmacologic approaches are unsuccessful, or there is concern for serious or imminent risk to the patient or others.

In the future, observational studies using biomarkers, such as neuroimaging markers, of brain health in older patients taking antipsychotics for various durations may give us a better understanding of long-term antipsychotic safety and tolerability and the monitoring required to assess long-term burden of specific antipsychotics in real-world samples.⁵² However, because of various biases, observational data may not provide answers to all questions,⁵³ and a major challenge is that the number of published RCTs specific to geriatric patients is not growing substantially. Pharmacotherapy evidence is not keeping up with demographic trends. Key developments in RCTs will be the inclusion of biomarkers via neuroimaging, drug serum or brain levels, and genetic profiling. Because of the modest findings of benefits of antipsychotics in dementia and safety concerns addressing brain health in preclinical or early stages, identification of effective non-drug interventions and identifying true disease-modifying agents will be the next challenges of dementia research.
 

According to the U.S. Department of Health and Human Services, in 2007, 88% of 1.4 million Medicare claims for second-generation antipsychotics (SGAs) in older adult nursing home residents were associated with a dementia diagnosis. Similar trends have been observed in Canada and Europe.^1-4 In a retrospective analysis of medication data from older residents with dementia in 6 care homes in England, long-term (ie, >1 month) use of antipsychotics was the most frequent potentially inappropriate prescribing practice.³ In another study in 7 European countries and Israel, the overall prevalence of antipsychotic use among long-term care residents with dementia was 33%.¹ Similarly, a recent literature review⁵ found that 22% to 86% of antipsychotic prescriptions to older individuals were off-label; this practice was particularly common for individuals with agitation.

Because of the aging population and widespread prescription of antipsychotics to older patients, clinicians need information on the relative risks of using these medications in this population. In the United States, all antipsychotics carry a FDA “black-box” warning of the increased risk of death in older adults with dementia. In addition, the risk of death is increased when prescribing antipsychotics to older adults with other conditions, such as Parkinson’s disease,⁶ and other safety and tolerability concerns, including falls and fractures, sedation, metabolic abnormalities, and extrapyramidal effects, are highly relevant to geriatric patients.

This 3-part review summarizes findings and recommendations on prescribing antipsychotics to older individuals with schizophrenia, bipolar disorder, depression, and dementia. This third and final installment:

• briefly summarizes the major studies and analyses relevant to prescribing antipsychotics to older patients with dementia
• provides a summative opinion on safety and tolerability issues in these older patients
• highlights the gaps in the evidence base and areas that need additional research.

Summary of benefits, place in treatment armamentarium

Behavioral and psychological symptoms of dementia (BPSD) include agitation, delusional beliefs, repetitive questioning, hallucinations, aggression, wandering, and various socially inappropriate behaviors.⁷ These occur almost universally in all types and stages of dementia.⁷ BPSD are among the most complex, stressful, and costly aspects of dementia care, and lead to a myriad of poor health outcomes, including excess morbidity, mortality, hospital stays, and early nursing home placement.^8-11 Because BPSD usually occur across all types and stages of dementia,^7,12-16 the prevalence of BPSD mirrors the overall prevalence of dementia.

Although all expert organizations, including the American Psychiatric Association,¹⁷ recommend nonpharmacologic strategies as first-line treatment for BPSD, for the most part, these recommendations have not been translated into standard clinical management or routine care.¹⁸ Because of a perceived lack of other options, the current mainstay of treatment is the off-label use of psychotropics such as antipsy­chotics. Of all the agents currently used for BPSD, SGAs have the strongest evidence base, although benefits are modest at best (standardized effect size 0.13 to 0.16).^19,20 In terms of individual SGAs, only risperidone is indicated for aggression in Canada and in Europe (not in the United States); risperidone has the best evidence for efficacy, with a meta-analysis of 5 published randomized controlled trials (RCTs) reporting that risperidone is superior to other SGAs for aggression in dementia.^21,22 As a class, first-generation antipsychotics (FGAs) have no clear evidence for BPSD as defined broadly; however, there may be slight benefit for haloperidol for aggression.^23,24

Clinical Trials

Adverse effects. A meta-analysis of RCTs of SGAs found that, compared with placebo, SGAs have increased rates of several adverse effects. These include somnolence (17% drug vs 7% placebo; odds ratio [OR], 2.84; 95% confidence interval [CI], 2.25 to 3.58; P < .00001); extrapyramidal symptoms (13% drug vs 8% placebo; OR, 1.51; 95% CI, 1.20 to 1.91; P = .0005; primarily attributable to risperidone); abnormal gait (10% drug vs 2% placebo; OR, 3.42; 95% CI, 1.78 to 6.56; P = .0002; attributable to olanzapine and risperidone); edema (9% drug vs 4% placebo; OR, 1.99; 95% CI, 1.20 to 3.30; P = .008; attributable to olanzapine and risperidone); urinary tract infections/incontinence (16% drug vs 12% placebo; OR, 1.28; 95% CI, 1.02 to 1.61; P = .04); cognitive impairment measured as difference in Mini-Mental State Examination score (95% CI, 0.38 to 1.09; P < .0001)²⁵; and stroke (1.9% drug vs 0.9% placebo, OR, 2.13; 95% CI, 1.20 to 3.75; P = .009).^21,26

In the 42-site Clinical Antipsychotic Trials of Intervention Effectiveness Alzheimer’s disease RCT, 421 outpatients with Alzheimer’s disease and BPSD were randomized to an SGA (risperidone, olanzapine, or quetiapine) or placebo. Compared with placebo, SGAs had a higher rate of parkinsonism or extrapyramidal signs (olanzapine and risperidone groups); sedation; confusion/changes in mental status (olanzapine and risperidone); psychotic symptoms (olanzapine); and increase in body weight and body mass index.²⁶

In the 2005 FDA black-box warning, pneumonia and cardiac adverse effects were cited as primary causes of death for patients with dementia taking SGAs. A subsequent observational study confirmed that use of either FGAs or SGAs in geriatric patients was associated with an increased risk of pneumonia, in a dose-dependent manner.²⁷ Although there is limited data on cardiac adverse effects in older adults, especially those with dementia taking antipsychotics,²⁸ 1 observational study of nursing home residents²⁹ found that those taking FGAs had a significantly higher risk of hospitalization for ventricular arrhythmia or cardiac arrest compared with those who were not taking FGAs. In contrast, there was no increased risk with SGAs.

Mortality.
 In 2005, the FDA announced that based on a reanalysis of 17 placebo-controlled trials (many of which were unpublished) that SGAs were associated with a 1.7-fold increase in mortality compared with placebo.³⁰ As a result, the FDA issued a black-box warning for using SGAs in patients with dementia. The overall OR in a published meta-analysis of mortality with SGAs was 1.54 (1.06 to 2.23; z = 2.28; P = .02), with pooled events of 3.5% mortality vs 2.3% (drug vs placebo).²¹ This meta-analysis²¹ also included ad hoc analyses of haloperidol; using combined data from 2 contrasts of haloperidol (with risperidone and quetiapine; 243 patients receiving haloperidol and 239 receiving placebo) they also found 15 deaths (6.2%) with haloperidol and 9 (3.8%) with placebo, resulting in an OR of 1.68.

Other clinical data

Observational studies. Most observational studies have confirmed concerns regarding increased mortality in patients with BPSD who take antipsychotics, with FGAs having a higher risk than SGAs^18,31 and SGAs having a higher risk compared with most other psychotropics.³² Three studies that found no increase in mortality with antipsychotics in patients with dementia had methodological issues, including examining prevalence as opposed to new users,^33,34 not controlling for exposure,^10,33,34 power issues,^10,34 not controlling for other psychiatric medications,¹⁰ and varying lengths of follow-up.¹⁰ An FDA black-box warning for FGAs was announced in 2008³⁰ based on 2 observational studies that showed an increased risk of mortality in older adults taking FGAs vs SGAs.^35,36

In terms of specific SGAs, Kales et al³⁷ examined the mortality risk associated with individual antipsychotics using various methods to control for confounding. Among a national sample of >33,000 older veterans with dementia newly started on haloperidol, risperidone, olanzapine, quetiapine, or valproic acid and derivatives (as a nonantipsychotic comparator), the highest mortality across all analyses (intent to treat, exposure, propensity-adjusted) was associated with haloperidol, followed by risperidone and olanzapine, valproic acid, and quetiapine.

Most recently, a retrospective case-control study (90,786 patients age ≥65 with dementia) examined the number needed to harm (NNH; ie, number of patients needed to receive treatment that would result in 1 death) over 180 days following initiation of an FGA or SGA.³⁸ This study found the following NNHs: haloperidol, 26 (95% CI, 15 to 99); risperidone, 27 (95% CI, 19 to 46); olanzapine, 40 (95% CI, 21 to 312); and quetiapine, 50 (95% CI, 30 to 150).³⁸ These results are congruent with a review of observational studies that found the highest risk of mortality was associated with haloperidol and chlorpromazine, and the lowest risk with olanzapine, quetiapine, and ziprasidone.²⁸

Patterns of antipsychotic use in older dementia patients

There are high rates of antipsychotic use in patients with dementia. Before the FDA issued the black-box warning, the Aging Demographics and Memory study found that the rate of antipsychotic use in community (outpatient) older adults with dementia was approximately 19% between 2002 and 2004 in a representative sample of 307 older adults.³⁹ Another study examining trends in community antipsychotic use in the U.S. Department of Veterans Affairs (VA) found that in the 1990s, SGA use was increasing; approximately 18% of outpatients with dementia were taking these agents.⁴⁰ Use of SGAs began to decline in 2003, ahead of the 2005 black-box warning, in tandem with other advisories (eg, diabetes, metabolic syndrome,⁴¹ and stroke risk).^42,43 Olanzapine and risperidone showed declining rates between 2003 and 2005, whereas quetiapine use significantly increased during this period. All 3 SGAs declined after the black-box warning. However, by the end of 2007, the use of SGAs had leveled off to approximately 12% of VA patients with dementia. A recent U.S. Government Accountability Office (GAO) report found that in 2012, 14% of older adult Medicare Part D enrollees with dementia living in the community were prescribed an antipsychotic.⁴⁴

Use in nursing home residents. Because BPSD are one of the main reasons people with dementia are placed in nursing homes, it is not surprising that rates of antipsychotic use are higher in these settings than in the community. Prior to the black-box warning, studies found that 24% to 32% of nursing home residents were treated with antipsychotics.^45-47 A study examining VA nursing homes (n = 133 facilities, n = 3,692 veterans) found that approximately 26% of residents were prescribed antipsychotics in 2004 to 2005.⁴⁸ The Center for Medicare and Medicaid Services (CMS) National Partnership to Improve Dementia Care in Nursing Homes has appeared to lower antipsychotic medication use in nursing homes; the rate decreased from 24% in long-stay nursing home residents nationwide in 2011 to 19% by the end of 2014. Specific to dementia, a 2010 CMS report⁴⁹ indicated that approximately 40% of nursing home residents with cognitive impairment and behavioral issues, without psychosis, received antipsychotics. The GAO data indicated that approximately 33% of older Medicare Part D enrollees with dementia who spent >100 days in a nursing home were prescribed an antipsychotic in 2012.⁴⁴ A recent Canadian study using drug claims data found that overall psychotropic use in patients with dementia remains high, finding that three-fourths of all patients with dementia in long-term care are given at least 1 psychotropic, and up to one-third are prescribed SGAs.⁵⁰ European data similarly show that antipsychotics continue to be prescribed to up to one-third of long-term care residents with dementia, with 7 out of 10 receiving an SGA.¹

Conclusions

The Table provides a summary of the evidence regarding the use of antipsychotics in patients with dementia. Expert consensus is that among BPSD, aggression and psychosis are the primary indications for using antipsychotics.⁵¹ Based on multiple RCTs and meta-analyses, the evidence for using SGAs to treat these symptoms is moderate at best. However, in real-world practice settings, SGAs are widely used for symptoms, such as wandering, inappropriate behaviors, resistance to care, etc., for which there is no evidence for efficacy other than sedation. Furthermore, even when there is a potential for benefit, this must be balanced against the risk of adverse effects, including somnolence, worsened cognition, extra­pyramidal symptoms, stroke, and mortality.
 

Clinicians who care for older adults with BPSD should strive to increase the use of first-line nonpharmacologic strategies, by using structured approaches such as DICE (Describe, Investigate, Create, Evaluate) described in the Box.⁵¹ Antipsychotics should be reserved for situations in which nonpharmacologic approaches are unsuccessful, or there is concern for serious or imminent risk to the patient or others.

In the future, observational studies using biomarkers, such as neuroimaging markers, of brain health in older patients taking antipsychotics for various durations may give us a better understanding of long-term antipsychotic safety and tolerability and the monitoring required to assess long-term burden of specific antipsychotics in real-world samples.⁵² However, because of various biases, observational data may not provide answers to all questions,⁵³ and a major challenge is that the number of published RCTs specific to geriatric patients is not growing substantially. Pharmacotherapy evidence is not keeping up with demographic trends. Key developments in RCTs will be the inclusion of biomarkers via neuroimaging, drug serum or brain levels, and genetic profiling. Because of the modest findings of benefits of antipsychotics in dementia and safety concerns addressing brain health in preclinical or early stages, identification of effective non-drug interventions and identifying true disease-modifying agents will be the next challenges of dementia research.
 

According to the U.S. Department of Health and Human Services, in 2007, 88% of 1.4 million Medicare claims for second-generation antipsychotics (SGAs) in older adult nursing home residents were associated with a dementia diagnosis. Similar trends have been observed in Canada and Europe.^1-4 In a retrospective analysis of medication data from older residents with dementia in 6 care homes in England, long-term (ie, >1 month) use of antipsychotics was the most frequent potentially inappropriate prescribing practice.³ In another study in 7 European countries and Israel, the overall prevalence of antipsychotic use among long-term care residents with dementia was 33%.¹ Similarly, a recent literature review⁵ found that 22% to 86% of antipsychotic prescriptions to older individuals were off-label; this practice was particularly common for individuals with agitation.

Because of the aging population and widespread prescription of antipsychotics to older patients, clinicians need information on the relative risks of using these medications in this population. In the United States, all antipsychotics carry a FDA “black-box” warning of the increased risk of death in older adults with dementia. In addition, the risk of death is increased when prescribing antipsychotics to older adults with other conditions, such as Parkinson’s disease,⁶ and other safety and tolerability concerns, including falls and fractures, sedation, metabolic abnormalities, and extrapyramidal effects, are highly relevant to geriatric patients.

This 3-part review summarizes findings and recommendations on prescribing antipsychotics to older individuals with schizophrenia, bipolar disorder, depression, and dementia. This third and final installment:

• briefly summarizes the major studies and analyses relevant to prescribing antipsychotics to older patients with dementia
• provides a summative opinion on safety and tolerability issues in these older patients
• highlights the gaps in the evidence base and areas that need additional research.

Summary of benefits, place in treatment armamentarium

Behavioral and psychological symptoms of dementia (BPSD) include agitation, delusional beliefs, repetitive questioning, hallucinations, aggression, wandering, and various socially inappropriate behaviors.⁷ These occur almost universally in all types and stages of dementia.⁷ BPSD are among the most complex, stressful, and costly aspects of dementia care, and lead to a myriad of poor health outcomes, including excess morbidity, mortality, hospital stays, and early nursing home placement.^8-11 Because BPSD usually occur across all types and stages of dementia,^7,12-16 the prevalence of BPSD mirrors the overall prevalence of dementia.

Although all expert organizations, including the American Psychiatric Association,¹⁷ recommend nonpharmacologic strategies as first-line treatment for BPSD, for the most part, these recommendations have not been translated into standard clinical management or routine care.¹⁸ Because of a perceived lack of other options, the current mainstay of treatment is the off-label use of psychotropics such as antipsy­chotics. Of all the agents currently used for BPSD, SGAs have the strongest evidence base, although benefits are modest at best (standardized effect size 0.13 to 0.16).^19,20 In terms of individual SGAs, only risperidone is indicated for aggression in Canada and in Europe (not in the United States); risperidone has the best evidence for efficacy, with a meta-analysis of 5 published randomized controlled trials (RCTs) reporting that risperidone is superior to other SGAs for aggression in dementia.^21,22 As a class, first-generation antipsychotics (FGAs) have no clear evidence for BPSD as defined broadly; however, there may be slight benefit for haloperidol for aggression.^23,24

Clinical Trials

Adverse effects. A meta-analysis of RCTs of SGAs found that, compared with placebo, SGAs have increased rates of several adverse effects. These include somnolence (17% drug vs 7% placebo; odds ratio [OR], 2.84; 95% confidence interval [CI], 2.25 to 3.58; P < .00001); extrapyramidal symptoms (13% drug vs 8% placebo; OR, 1.51; 95% CI, 1.20 to 1.91; P = .0005; primarily attributable to risperidone); abnormal gait (10% drug vs 2% placebo; OR, 3.42; 95% CI, 1.78 to 6.56; P = .0002; attributable to olanzapine and risperidone); edema (9% drug vs 4% placebo; OR, 1.99; 95% CI, 1.20 to 3.30; P = .008; attributable to olanzapine and risperidone); urinary tract infections/incontinence (16% drug vs 12% placebo; OR, 1.28; 95% CI, 1.02 to 1.61; P = .04); cognitive impairment measured as difference in Mini-Mental State Examination score (95% CI, 0.38 to 1.09; P < .0001)²⁵; and stroke (1.9% drug vs 0.9% placebo, OR, 2.13; 95% CI, 1.20 to 3.75; P = .009).^21,26

In the 42-site Clinical Antipsychotic Trials of Intervention Effectiveness Alzheimer’s disease RCT, 421 outpatients with Alzheimer’s disease and BPSD were randomized to an SGA (risperidone, olanzapine, or quetiapine) or placebo. Compared with placebo, SGAs had a higher rate of parkinsonism or extrapyramidal signs (olanzapine and risperidone groups); sedation; confusion/changes in mental status (olanzapine and risperidone); psychotic symptoms (olanzapine); and increase in body weight and body mass index.²⁶

In the 2005 FDA black-box warning, pneumonia and cardiac adverse effects were cited as primary causes of death for patients with dementia taking SGAs. A subsequent observational study confirmed that use of either FGAs or SGAs in geriatric patients was associated with an increased risk of pneumonia, in a dose-dependent manner.²⁷ Although there is limited data on cardiac adverse effects in older adults, especially those with dementia taking antipsychotics,²⁸ 1 observational study of nursing home residents²⁹ found that those taking FGAs had a significantly higher risk of hospitalization for ventricular arrhythmia or cardiac arrest compared with those who were not taking FGAs. In contrast, there was no increased risk with SGAs.

Mortality.
 In 2005, the FDA announced that based on a reanalysis of 17 placebo-controlled trials (many of which were unpublished) that SGAs were associated with a 1.7-fold increase in mortality compared with placebo.³⁰ As a result, the FDA issued a black-box warning for using SGAs in patients with dementia. The overall OR in a published meta-analysis of mortality with SGAs was 1.54 (1.06 to 2.23; z = 2.28; P = .02), with pooled events of 3.5% mortality vs 2.3% (drug vs placebo).²¹ This meta-analysis²¹ also included ad hoc analyses of haloperidol; using combined data from 2 contrasts of haloperidol (with risperidone and quetiapine; 243 patients receiving haloperidol and 239 receiving placebo) they also found 15 deaths (6.2%) with haloperidol and 9 (3.8%) with placebo, resulting in an OR of 1.68.

Other clinical data

Observational studies. Most observational studies have confirmed concerns regarding increased mortality in patients with BPSD who take antipsychotics, with FGAs having a higher risk than SGAs^18,31 and SGAs having a higher risk compared with most other psychotropics.³² Three studies that found no increase in mortality with antipsychotics in patients with dementia had methodological issues, including examining prevalence as opposed to new users,^33,34 not controlling for exposure,^10,33,34 power issues,^10,34 not controlling for other psychiatric medications,¹⁰ and varying lengths of follow-up.¹⁰ An FDA black-box warning for FGAs was announced in 2008³⁰ based on 2 observational studies that showed an increased risk of mortality in older adults taking FGAs vs SGAs.^35,36

In terms of specific SGAs, Kales et al³⁷ examined the mortality risk associated with individual antipsychotics using various methods to control for confounding. Among a national sample of >33,000 older veterans with dementia newly started on haloperidol, risperidone, olanzapine, quetiapine, or valproic acid and derivatives (as a nonantipsychotic comparator), the highest mortality across all analyses (intent to treat, exposure, propensity-adjusted) was associated with haloperidol, followed by risperidone and olanzapine, valproic acid, and quetiapine.

Most recently, a retrospective case-control study (90,786 patients age ≥65 with dementia) examined the number needed to harm (NNH; ie, number of patients needed to receive treatment that would result in 1 death) over 180 days following initiation of an FGA or SGA.³⁸ This study found the following NNHs: haloperidol, 26 (95% CI, 15 to 99); risperidone, 27 (95% CI, 19 to 46); olanzapine, 40 (95% CI, 21 to 312); and quetiapine, 50 (95% CI, 30 to 150).³⁸ These results are congruent with a review of observational studies that found the highest risk of mortality was associated with haloperidol and chlorpromazine, and the lowest risk with olanzapine, quetiapine, and ziprasidone.²⁸

Patterns of antipsychotic use in older dementia patients

There are high rates of antipsychotic use in patients with dementia. Before the FDA issued the black-box warning, the Aging Demographics and Memory study found that the rate of antipsychotic use in community (outpatient) older adults with dementia was approximately 19% between 2002 and 2004 in a representative sample of 307 older adults.³⁹ Another study examining trends in community antipsychotic use in the U.S. Department of Veterans Affairs (VA) found that in the 1990s, SGA use was increasing; approximately 18% of outpatients with dementia were taking these agents.⁴⁰ Use of SGAs began to decline in 2003, ahead of the 2005 black-box warning, in tandem with other advisories (eg, diabetes, metabolic syndrome,⁴¹ and stroke risk).^42,43 Olanzapine and risperidone showed declining rates between 2003 and 2005, whereas quetiapine use significantly increased during this period. All 3 SGAs declined after the black-box warning. However, by the end of 2007, the use of SGAs had leveled off to approximately 12% of VA patients with dementia. A recent U.S. Government Accountability Office (GAO) report found that in 2012, 14% of older adult Medicare Part D enrollees with dementia living in the community were prescribed an antipsychotic.⁴⁴

Use in nursing home residents. Because BPSD are one of the main reasons people with dementia are placed in nursing homes, it is not surprising that rates of antipsychotic use are higher in these settings than in the community. Prior to the black-box warning, studies found that 24% to 32% of nursing home residents were treated with antipsychotics.^45-47 A study examining VA nursing homes (n = 133 facilities, n = 3,692 veterans) found that approximately 26% of residents were prescribed antipsychotics in 2004 to 2005.⁴⁸ The Center for Medicare and Medicaid Services (CMS) National Partnership to Improve Dementia Care in Nursing Homes has appeared to lower antipsychotic medication use in nursing homes; the rate decreased from 24% in long-stay nursing home residents nationwide in 2011 to 19% by the end of 2014. Specific to dementia, a 2010 CMS report⁴⁹ indicated that approximately 40% of nursing home residents with cognitive impairment and behavioral issues, without psychosis, received antipsychotics. The GAO data indicated that approximately 33% of older Medicare Part D enrollees with dementia who spent >100 days in a nursing home were prescribed an antipsychotic in 2012.⁴⁴ A recent Canadian study using drug claims data found that overall psychotropic use in patients with dementia remains high, finding that three-fourths of all patients with dementia in long-term care are given at least 1 psychotropic, and up to one-third are prescribed SGAs.⁵⁰ European data similarly show that antipsychotics continue to be prescribed to up to one-third of long-term care residents with dementia, with 7 out of 10 receiving an SGA.¹

Conclusions

The Table provides a summary of the evidence regarding the use of antipsychotics in patients with dementia. Expert consensus is that among BPSD, aggression and psychosis are the primary indications for using antipsychotics.⁵¹ Based on multiple RCTs and meta-analyses, the evidence for using SGAs to treat these symptoms is moderate at best. However, in real-world practice settings, SGAs are widely used for symptoms, such as wandering, inappropriate behaviors, resistance to care, etc., for which there is no evidence for efficacy other than sedation. Furthermore, even when there is a potential for benefit, this must be balanced against the risk of adverse effects, including somnolence, worsened cognition, extra­pyramidal symptoms, stroke, and mortality.
 

Clinicians who care for older adults with BPSD should strive to increase the use of first-line nonpharmacologic strategies, by using structured approaches such as DICE (Describe, Investigate, Create, Evaluate) described in the Box.⁵¹ Antipsychotics should be reserved for situations in which nonpharmacologic approaches are unsuccessful, or there is concern for serious or imminent risk to the patient or others.

In the future, observational studies using biomarkers, such as neuroimaging markers, of brain health in older patients taking antipsychotics for various durations may give us a better understanding of long-term antipsychotic safety and tolerability and the monitoring required to assess long-term burden of specific antipsychotics in real-world samples.⁵² However, because of various biases, observational data may not provide answers to all questions,⁵³ and a major challenge is that the number of published RCTs specific to geriatric patients is not growing substantially. Pharmacotherapy evidence is not keeping up with demographic trends. Key developments in RCTs will be the inclusion of biomarkers via neuroimaging, drug serum or brain levels, and genetic profiling. Because of the modest findings of benefits of antipsychotics in dementia and safety concerns addressing brain health in preclinical or early stages, identification of effective non-drug interventions and identifying true disease-modifying agents will be the next challenges of dementia research.
 

Sexting includes sending sexually explicit (or sexually suggestive) text messages and photos, usually by cell phone. This article focuses on sexts involving photos. Cell phones are almost ubiquitous among American teens, and with technological advances, sexts are getting easier to send. Sexting may occur to initiate a relationship or sustain one. Some teenagers are coerced into sexting. Many people do not realize the potential long-term consequences of sexting—particularly because of the impulsive nature of sexting and the belief that the behavior is harmless.

Media attention has recently focused on teens who face legal charges related to sexting. Sexting photos may be considered child pornography—even though the teens made it themselves. There are also social consequences to sexting. Photos meant to be private are sometimes forwarded to others. Cyberbullying is not uncommon with teen sexting, and suicides after experiencing this behavior have been reported.

Sexting may be a form of modern flirtation, but in some cases, it may be a marker of other risk behaviors, such as substance abuse. Psychiatrists must be aware of the frequency and meaning of this potentially dangerous behavior. Clinicians should feel comfortable asking their patients about it and provide education and counseling.

CASE

Private photos get shared

K, age 14, a freshman with no psychiatric history, is referred to you by her school psychologist for evaluation of suicidal ideation. K reports depressed mood, poor sleep, inattention, loss of appetite, anhedonia, and feelings of guilt for the past month. She recently ended a relationship with her boyfriend of 1 year after she learned that he had shared with his friends naked photos of her that she had sent him. The school administration learned of the photos when a student posted them on one of the school computers.

K’s boyfriend, age 16, was suspended after the school learned that he had shared the photos without K’s consent. K, who is a good student, missed several days of school, including cheerleading practice; previously she had never missed a day of school.

On evaluation, K is tearful, stating that her life is “over.” She says that her ex-boyfriend’s friends are harassing her, calling her “slut” and making sexual comments. She also feels guilty, because she learned that the police interviewed her ex-boyfriend in connection with posting her photos on the Internet. In a text, he said he “might get charged with child pornography.” On further questioning, K confides that she had naked photos of her ex-boyfriend on her phone. She admits to sharing the pictures with her best friend, because she was “angry and wanted to get back” at her ex-boyfriend. She also reports a several-month history of sexting with her ex-boyfriend. K deleted the photos and texts after learning that her ex-boyfriend “was in trouble with the police.”

K has no prior sexual experience. She dated 1 boy her age prior to her ex-boyfriend. She had never been evaluated by a mental health clinician. She is dysphoric and reports feeling “hopeless … Unless this can be erased, I can’t go back to school.”

Sexting: What is the extent of the problem?

The true prevalence of sexting is difficult to ascertain, because different studies have used different definitions and method­ologies. However, the rates are far from negligible. Sexting rates increase with age, over the teen years.^1-3 Among American minors, 2.5% to 28% of middle school and high school students report that they have sent a sext (Table 1^1-9). Studies of American young adults (age ≥18) and university students have found 30% to 60% have sent sexts, and >40% have received a sext.^4,5

Many people receive sexts—including individuals who are not the intended recipient. In 1 study, although most teens intended to share sexts only with their boyfriend/girlfriend, 25% to 33% had received sext photos intended for other people.⁶ In another recent study, 25% of teens had forwarded a sext that they received.⁷ Moreover, 12% of teenage boys and 5% of teenage girls had sent a sexually explicit photo that they took of another teen to a third person.⁷ Forwarding sexts can add exponentially to the psychosocial risks of the photographed teenager.

Who sexts? Current research indicates that the likelihood of sexting is related to age, personality, and social situation. Teens are approaching the peak age of their sex drive, and often are curious and feel invincible. Teens are more impulsive than adults. When it takes less than a minute to send a sext, irreversible poor choices can be made quickly. Teens who send sexts often engage in more text messaging than other teens.⁷

Teens may use sexting to initiate or sustain a relationship. Sexts also may be sent because of coercion. More than one-half of girls cited pressure to sext from a boy.⁶ Temple et al³ found that more than one-half of their study sample had been asked to send a sext. Girls were more likely than boys to be asked to send a sext; most were troubled by this.

One study that assessed knowledge of potential legal consequences of sexting found that many teens who sent sexts were aware of the potential consequences.⁷ Regarding personality traits, sexting among undergraduates was predicted by neuroticism and low agreeableness.¹⁰ Conversely, sending text messages with sexually suggestive writing was predicted by extraversion and problematic cell phone use.

Comorbidities. There are mixed findings about whether sexting is simply a modern dating strategy or a marker of other risk behaviors; age may play an important discriminating role. Sexual activity appears to be correlated with sexting. According to Temple and Choi,¹¹ “Sexting fits within the context of adolescent sexual development and may be a viable indicator of adolescent sexual activity.”¹¹

Some authors have suggested that sext­ing is a contemporary risk behavior that is likely to correlate with other risk behaviors. Among young teens—seventh graders who were referred to a risk prevention trial because of behavioral/emotional difficulties—those who sexted were more likely to engage in early sexual behaviors.⁸ These younger at-risk teens also had less understanding of their emotions and greater difficulty in regulating their emotions.

Among the general population of high school students, teens who sext are more likely to be sexually active.³ High school girls who engaged in sexting were noted to engage in other risk behaviors, including having multiple partners in the past year and using alcohol or drugs before sex.³ Teens who had sent a sext were more likely to be sexually active 1 year later than teens who had not.¹¹Studies of sexting among university students also have had mixed findings. One study found that among undergraduates, sexting was associated with substance use and other risk behaviors.⁹ Another young adult study found sexting was not related to sexual risk or psychological well-being.⁴

Legal issues affect psychiatrists as well as patients

As a psychiatrist evaluating K, what are your duties as a mandated reporter? Psychiatrists are legally required to report suspected maltreatment or abuse of children.¹² The circumstances under which psychiatrists may have a mandate to report include when a psychiatrist:

• evaluates a child and suspects abuse
• suspects child abuse based on an adult patient’s report
• learns from a third party that a child may have been/is being abused.

Psychiatrists usually are not mandated to report other types of potentially criminal behavior. As such, reporting sexting might be considered a breach of confidentiality. Psychiatrists should be familiar with the specific reporting guidelines for the jurisdiction in which they practice. Psychiatrists who work with individuals who commit crimes should focus on changing the potentially dangerous behaviors rather than reporting them.

Does the transmission of naked photos of a minor in a sexual pose or act constitute child pornography or another criminal offense? The legal answer varies, but the role of the psychiatrist does not. Psychiatrists should educate their patients about potentially dangerous behaviors.

With regards to the legal consequences, some states classify underage sexting photos as child pornography. Others have less rigid definitions of child pornography and take into account the age of the participants and their intent. Such jurisdictions point out that sexting naked photos among adolescents is “age appropriate.” Some have enacted specific sexting laws to address the transmission of obscene material to a child through the Internet. In some jurisdictions, sexting laws are categorized to refer to behavior of individuals under or over age 18. The term “revenge porn” is used to refer to nonconsensual pornography with its dissemination motivated by spite.¹³ Some states have defined specific revenge porn laws to address the behavior. Currently, 20 states have sexting laws and 26 states have revenge porn laws.¹⁴ Twenty states address a minor age <18 sending the photo, while only 18 address the recipient. The law in this area can be complex and detailed, taking into account the age of the sender, the intentions of the sender, and the nature of the relationship between the sender and the recipient and the behavior of the recipient.

Laws regarding sexting vary greatly. Sexting may be a misdemeanor or a felony, depending on the state, the specific behavior, and the frequency. In the United States, 11 state laws include a diversion remedy—an option to pursue the case outside of the criminal juvenile system; 10 laws require counseling or another informal sanction; 11 states laws have the potential for misdemeanor punishment; and 4 state laws have the potential for felony punishment.¹⁴ Depending on the criminal charge, the perpetrator may have to register as a sex offender. For example, in some jurisdictions, a conviction for possession of child pornography requires sex offender registration. Thirty-eight states include juvenile sex offenders in their sex offender registries. Other states require juveniles to register if they are age ≥15 years or have been tried as an adult.¹⁵

The frequency of police involvement in sexting cases also greatly varies. A national study examining the characteristics of youth sexting cases revealed that law enforcement agencies handled approximately 3,477 cases of youth-produced sexual photos in 2008 and 2009.¹⁶ Situations that involved an adult or a minor engaged in malicious, nonconsensual, or abusive behavior comprised two-thirds of cases. Arrests occurred in 62% of the adult-involved cases and 36% of the aggravated youth-only cases. Arrests occurred in only 18% of investigated non-aggravated youth-only cases. Table 2 describes recent American sexting legal cases and their outcomes.

In K’s case, depending on the jurisdiction, K or her ex-boyfriend may be subject to arrest for child pornography, revenge pornography, or sexting.

Potential social and psychiatric consequences

What are the social and psychiatric ramifications for K? Aside from potential legal consequences of sexting, K is experiencing psychological and social consequences. She has developed depressive symptoms and suicidal ideation. Her ex-boyfriend’s dissemination of her nude photos on the school computer could be interpreted as cyberbullying. (The National Center for Missing and Exploited Children defines cyberbullying as “bullying through the use of technology or electronic devices such as telephones, cell phones, computers, and the Internet.”¹⁷ All 50 states have enacted laws against bullying; 48 states have electronic harassment in their bullying laws; and 22 states have laws specifically referencing “cyberbullying.”)

Her depressive symptoms developed in response to her feelings of guilt and shame related to sexting as well as the subsequent peer harassment. She is refusing to return to school because of her concerns about bullying. A careful inquiry into suicidality should be part of the evaluation when sexting has led to psychiatric symptoms. Several cases of sexting and cyberbullying have ended in suicide (Table 3).

How to ask patients about sexting

To screen patients for sexting, clinicians need to develop a new skill set, which at first may be uncomfortable. However, the questions to ask are not all that different from other questions about adolescent and young adult sexuality. The importance of patients seeing that we as physicians are comfortable with the topic and approachable about their sexual health cannot be overemphasized. When discussing sexting with patients, it is essential to:

• explain that you are asking questions about their sexual health because they are important to overall health
• engage patients in discussion in a nonthreatening and nonjudgmental way
• develop rapport so patients feel comfortable disclosing behavior that may be embarrassing
• listen to their stories and build a context for understanding their experiences. As you listen, ask questions when needed to help move the story along.

Sometimes when asking about topics that are uncomfortable, clinicians revert from open-ended to closed-ended questions, but when asking about a patient’s sexual life, it is especially important to be open-ended and ask questions in a nonjudgmental way. Contextualizing sexual questions by (for example) asking them while discussing the teen’s relationships will make them seem more natural.¹⁸ To best understand, inquire explicitly about specific behaviors, but do so without appearing voyeuristic.¹⁸

Sexting may precede sexual intercourse. Keep in mind that a patient may report that she (he) is not sexually active but still may be involved in sexting. Therefore, discuss sexting even if your patient reports not being sexually active. By understanding the prevalence of sexting among teens, you can ask questions in a normalizing way. Clinicians can inquire about sexting while discussing relationships and dating or online risk behaviors.

Also consider whether any of your patient’s sexual behaviors, including sext­ing, are the result of coercion: “Some of my patients tell me they feel pressured or coerced into having sex. Have you ever felt this way?”¹⁹ and “Have you ever been picked on or bullied? Is that still a problem?” are suggested safety screening questions about bullying,¹⁸ and one can also ask about specific cyberbullying behaviors.

Sexting includes sending sexually explicit (or sexually suggestive) text messages and photos, usually by cell phone. This article focuses on sexts involving photos. Cell phones are almost ubiquitous among American teens, and with technological advances, sexts are getting easier to send. Sexting may occur to initiate a relationship or sustain one. Some teenagers are coerced into sexting. Many people do not realize the potential long-term consequences of sexting—particularly because of the impulsive nature of sexting and the belief that the behavior is harmless.

Media attention has recently focused on teens who face legal charges related to sexting. Sexting photos may be considered child pornography—even though the teens made it themselves. There are also social consequences to sexting. Photos meant to be private are sometimes forwarded to others. Cyberbullying is not uncommon with teen sexting, and suicides after experiencing this behavior have been reported.

Sexting may be a form of modern flirtation, but in some cases, it may be a marker of other risk behaviors, such as substance abuse. Psychiatrists must be aware of the frequency and meaning of this potentially dangerous behavior. Clinicians should feel comfortable asking their patients about it and provide education and counseling.

CASE

Private photos get shared

K, age 14, a freshman with no psychiatric history, is referred to you by her school psychologist for evaluation of suicidal ideation. K reports depressed mood, poor sleep, inattention, loss of appetite, anhedonia, and feelings of guilt for the past month. She recently ended a relationship with her boyfriend of 1 year after she learned that he had shared with his friends naked photos of her that she had sent him. The school administration learned of the photos when a student posted them on one of the school computers.

K’s boyfriend, age 16, was suspended after the school learned that he had shared the photos without K’s consent. K, who is a good student, missed several days of school, including cheerleading practice; previously she had never missed a day of school.

On evaluation, K is tearful, stating that her life is “over.” She says that her ex-boyfriend’s friends are harassing her, calling her “slut” and making sexual comments. She also feels guilty, because she learned that the police interviewed her ex-boyfriend in connection with posting her photos on the Internet. In a text, he said he “might get charged with child pornography.” On further questioning, K confides that she had naked photos of her ex-boyfriend on her phone. She admits to sharing the pictures with her best friend, because she was “angry and wanted to get back” at her ex-boyfriend. She also reports a several-month history of sexting with her ex-boyfriend. K deleted the photos and texts after learning that her ex-boyfriend “was in trouble with the police.”

K has no prior sexual experience. She dated 1 boy her age prior to her ex-boyfriend. She had never been evaluated by a mental health clinician. She is dysphoric and reports feeling “hopeless … Unless this can be erased, I can’t go back to school.”

Sexting: What is the extent of the problem?

The true prevalence of sexting is difficult to ascertain, because different studies have used different definitions and method­ologies. However, the rates are far from negligible. Sexting rates increase with age, over the teen years.^1-3 Among American minors, 2.5% to 28% of middle school and high school students report that they have sent a sext (Table 1^1-9). Studies of American young adults (age ≥18) and university students have found 30% to 60% have sent sexts, and >40% have received a sext.^4,5

Many people receive sexts—including individuals who are not the intended recipient. In 1 study, although most teens intended to share sexts only with their boyfriend/girlfriend, 25% to 33% had received sext photos intended for other people.⁶ In another recent study, 25% of teens had forwarded a sext that they received.⁷ Moreover, 12% of teenage boys and 5% of teenage girls had sent a sexually explicit photo that they took of another teen to a third person.⁷ Forwarding sexts can add exponentially to the psychosocial risks of the photographed teenager.

Who sexts? Current research indicates that the likelihood of sexting is related to age, personality, and social situation. Teens are approaching the peak age of their sex drive, and often are curious and feel invincible. Teens are more impulsive than adults. When it takes less than a minute to send a sext, irreversible poor choices can be made quickly. Teens who send sexts often engage in more text messaging than other teens.⁷

Teens may use sexting to initiate or sustain a relationship. Sexts also may be sent because of coercion. More than one-half of girls cited pressure to sext from a boy.⁶ Temple et al³ found that more than one-half of their study sample had been asked to send a sext. Girls were more likely than boys to be asked to send a sext; most were troubled by this.

One study that assessed knowledge of potential legal consequences of sexting found that many teens who sent sexts were aware of the potential consequences.⁷ Regarding personality traits, sexting among undergraduates was predicted by neuroticism and low agreeableness.¹⁰ Conversely, sending text messages with sexually suggestive writing was predicted by extraversion and problematic cell phone use.

Comorbidities. There are mixed findings about whether sexting is simply a modern dating strategy or a marker of other risk behaviors; age may play an important discriminating role. Sexual activity appears to be correlated with sexting. According to Temple and Choi,¹¹ “Sexting fits within the context of adolescent sexual development and may be a viable indicator of adolescent sexual activity.”¹¹

Some authors have suggested that sext­ing is a contemporary risk behavior that is likely to correlate with other risk behaviors. Among young teens—seventh graders who were referred to a risk prevention trial because of behavioral/emotional difficulties—those who sexted were more likely to engage in early sexual behaviors.⁸ These younger at-risk teens also had less understanding of their emotions and greater difficulty in regulating their emotions.

Among the general population of high school students, teens who sext are more likely to be sexually active.³ High school girls who engaged in sexting were noted to engage in other risk behaviors, including having multiple partners in the past year and using alcohol or drugs before sex.³ Teens who had sent a sext were more likely to be sexually active 1 year later than teens who had not.¹¹Studies of sexting among university students also have had mixed findings. One study found that among undergraduates, sexting was associated with substance use and other risk behaviors.⁹ Another young adult study found sexting was not related to sexual risk or psychological well-being.⁴

Legal issues affect psychiatrists as well as patients

As a psychiatrist evaluating K, what are your duties as a mandated reporter? Psychiatrists are legally required to report suspected maltreatment or abuse of children.¹² The circumstances under which psychiatrists may have a mandate to report include when a psychiatrist:

• evaluates a child and suspects abuse
• suspects child abuse based on an adult patient’s report
• learns from a third party that a child may have been/is being abused.

Psychiatrists usually are not mandated to report other types of potentially criminal behavior. As such, reporting sexting might be considered a breach of confidentiality. Psychiatrists should be familiar with the specific reporting guidelines for the jurisdiction in which they practice. Psychiatrists who work with individuals who commit crimes should focus on changing the potentially dangerous behaviors rather than reporting them.

Does the transmission of naked photos of a minor in a sexual pose or act constitute child pornography or another criminal offense? The legal answer varies, but the role of the psychiatrist does not. Psychiatrists should educate their patients about potentially dangerous behaviors.

With regards to the legal consequences, some states classify underage sexting photos as child pornography. Others have less rigid definitions of child pornography and take into account the age of the participants and their intent. Such jurisdictions point out that sexting naked photos among adolescents is “age appropriate.” Some have enacted specific sexting laws to address the transmission of obscene material to a child through the Internet. In some jurisdictions, sexting laws are categorized to refer to behavior of individuals under or over age 18. The term “revenge porn” is used to refer to nonconsensual pornography with its dissemination motivated by spite.¹³ Some states have defined specific revenge porn laws to address the behavior. Currently, 20 states have sexting laws and 26 states have revenge porn laws.¹⁴ Twenty states address a minor age <18 sending the photo, while only 18 address the recipient. The law in this area can be complex and detailed, taking into account the age of the sender, the intentions of the sender, and the nature of the relationship between the sender and the recipient and the behavior of the recipient.

Laws regarding sexting vary greatly. Sexting may be a misdemeanor or a felony, depending on the state, the specific behavior, and the frequency. In the United States, 11 state laws include a diversion remedy—an option to pursue the case outside of the criminal juvenile system; 10 laws require counseling or another informal sanction; 11 states laws have the potential for misdemeanor punishment; and 4 state laws have the potential for felony punishment.¹⁴ Depending on the criminal charge, the perpetrator may have to register as a sex offender. For example, in some jurisdictions, a conviction for possession of child pornography requires sex offender registration. Thirty-eight states include juvenile sex offenders in their sex offender registries. Other states require juveniles to register if they are age ≥15 years or have been tried as an adult.¹⁵

The frequency of police involvement in sexting cases also greatly varies. A national study examining the characteristics of youth sexting cases revealed that law enforcement agencies handled approximately 3,477 cases of youth-produced sexual photos in 2008 and 2009.¹⁶ Situations that involved an adult or a minor engaged in malicious, nonconsensual, or abusive behavior comprised two-thirds of cases. Arrests occurred in 62% of the adult-involved cases and 36% of the aggravated youth-only cases. Arrests occurred in only 18% of investigated non-aggravated youth-only cases. Table 2 describes recent American sexting legal cases and their outcomes.

In K’s case, depending on the jurisdiction, K or her ex-boyfriend may be subject to arrest for child pornography, revenge pornography, or sexting.

Potential social and psychiatric consequences

What are the social and psychiatric ramifications for K? Aside from potential legal consequences of sexting, K is experiencing psychological and social consequences. She has developed depressive symptoms and suicidal ideation. Her ex-boyfriend’s dissemination of her nude photos on the school computer could be interpreted as cyberbullying. (The National Center for Missing and Exploited Children defines cyberbullying as “bullying through the use of technology or electronic devices such as telephones, cell phones, computers, and the Internet.”¹⁷ All 50 states have enacted laws against bullying; 48 states have electronic harassment in their bullying laws; and 22 states have laws specifically referencing “cyberbullying.”)

Her depressive symptoms developed in response to her feelings of guilt and shame related to sexting as well as the subsequent peer harassment. She is refusing to return to school because of her concerns about bullying. A careful inquiry into suicidality should be part of the evaluation when sexting has led to psychiatric symptoms. Several cases of sexting and cyberbullying have ended in suicide (Table 3).

How to ask patients about sexting

To screen patients for sexting, clinicians need to develop a new skill set, which at first may be uncomfortable. However, the questions to ask are not all that different from other questions about adolescent and young adult sexuality. The importance of patients seeing that we as physicians are comfortable with the topic and approachable about their sexual health cannot be overemphasized. When discussing sexting with patients, it is essential to:

• explain that you are asking questions about their sexual health because they are important to overall health
• engage patients in discussion in a nonthreatening and nonjudgmental way
• develop rapport so patients feel comfortable disclosing behavior that may be embarrassing
• listen to their stories and build a context for understanding their experiences. As you listen, ask questions when needed to help move the story along.

Sometimes when asking about topics that are uncomfortable, clinicians revert from open-ended to closed-ended questions, but when asking about a patient’s sexual life, it is especially important to be open-ended and ask questions in a nonjudgmental way. Contextualizing sexual questions by (for example) asking them while discussing the teen’s relationships will make them seem more natural.¹⁸ To best understand, inquire explicitly about specific behaviors, but do so without appearing voyeuristic.¹⁸

Sexting may precede sexual intercourse. Keep in mind that a patient may report that she (he) is not sexually active but still may be involved in sexting. Therefore, discuss sexting even if your patient reports not being sexually active. By understanding the prevalence of sexting among teens, you can ask questions in a normalizing way. Clinicians can inquire about sexting while discussing relationships and dating or online risk behaviors.

Also consider whether any of your patient’s sexual behaviors, including sext­ing, are the result of coercion: “Some of my patients tell me they feel pressured or coerced into having sex. Have you ever felt this way?”¹⁹ and “Have you ever been picked on or bullied? Is that still a problem?” are suggested safety screening questions about bullying,¹⁸ and one can also ask about specific cyberbullying behaviors.

Sexting includes sending sexually explicit (or sexually suggestive) text messages and photos, usually by cell phone. This article focuses on sexts involving photos. Cell phones are almost ubiquitous among American teens, and with technological advances, sexts are getting easier to send. Sexting may occur to initiate a relationship or sustain one. Some teenagers are coerced into sexting. Many people do not realize the potential long-term consequences of sexting—particularly because of the impulsive nature of sexting and the belief that the behavior is harmless.

Media attention has recently focused on teens who face legal charges related to sexting. Sexting photos may be considered child pornography—even though the teens made it themselves. There are also social consequences to sexting. Photos meant to be private are sometimes forwarded to others. Cyberbullying is not uncommon with teen sexting, and suicides after experiencing this behavior have been reported.

Sexting may be a form of modern flirtation, but in some cases, it may be a marker of other risk behaviors, such as substance abuse. Psychiatrists must be aware of the frequency and meaning of this potentially dangerous behavior. Clinicians should feel comfortable asking their patients about it and provide education and counseling.

CASE

Private photos get shared

K, age 14, a freshman with no psychiatric history, is referred to you by her school psychologist for evaluation of suicidal ideation. K reports depressed mood, poor sleep, inattention, loss of appetite, anhedonia, and feelings of guilt for the past month. She recently ended a relationship with her boyfriend of 1 year after she learned that he had shared with his friends naked photos of her that she had sent him. The school administration learned of the photos when a student posted them on one of the school computers.

K’s boyfriend, age 16, was suspended after the school learned that he had shared the photos without K’s consent. K, who is a good student, missed several days of school, including cheerleading practice; previously she had never missed a day of school.

On evaluation, K is tearful, stating that her life is “over.” She says that her ex-boyfriend’s friends are harassing her, calling her “slut” and making sexual comments. She also feels guilty, because she learned that the police interviewed her ex-boyfriend in connection with posting her photos on the Internet. In a text, he said he “might get charged with child pornography.” On further questioning, K confides that she had naked photos of her ex-boyfriend on her phone. She admits to sharing the pictures with her best friend, because she was “angry and wanted to get back” at her ex-boyfriend. She also reports a several-month history of sexting with her ex-boyfriend. K deleted the photos and texts after learning that her ex-boyfriend “was in trouble with the police.”

K has no prior sexual experience. She dated 1 boy her age prior to her ex-boyfriend. She had never been evaluated by a mental health clinician. She is dysphoric and reports feeling “hopeless … Unless this can be erased, I can’t go back to school.”

Sexting: What is the extent of the problem?

The true prevalence of sexting is difficult to ascertain, because different studies have used different definitions and method­ologies. However, the rates are far from negligible. Sexting rates increase with age, over the teen years.^1-3 Among American minors, 2.5% to 28% of middle school and high school students report that they have sent a sext (Table 1^1-9). Studies of American young adults (age ≥18) and university students have found 30% to 60% have sent sexts, and >40% have received a sext.^4,5

Many people receive sexts—including individuals who are not the intended recipient. In 1 study, although most teens intended to share sexts only with their boyfriend/girlfriend, 25% to 33% had received sext photos intended for other people.⁶ In another recent study, 25% of teens had forwarded a sext that they received.⁷ Moreover, 12% of teenage boys and 5% of teenage girls had sent a sexually explicit photo that they took of another teen to a third person.⁷ Forwarding sexts can add exponentially to the psychosocial risks of the photographed teenager.

Who sexts? Current research indicates that the likelihood of sexting is related to age, personality, and social situation. Teens are approaching the peak age of their sex drive, and often are curious and feel invincible. Teens are more impulsive than adults. When it takes less than a minute to send a sext, irreversible poor choices can be made quickly. Teens who send sexts often engage in more text messaging than other teens.⁷

Teens may use sexting to initiate or sustain a relationship. Sexts also may be sent because of coercion. More than one-half of girls cited pressure to sext from a boy.⁶ Temple et al³ found that more than one-half of their study sample had been asked to send a sext. Girls were more likely than boys to be asked to send a sext; most were troubled by this.

One study that assessed knowledge of potential legal consequences of sexting found that many teens who sent sexts were aware of the potential consequences.⁷ Regarding personality traits, sexting among undergraduates was predicted by neuroticism and low agreeableness.¹⁰ Conversely, sending text messages with sexually suggestive writing was predicted by extraversion and problematic cell phone use.

Comorbidities. There are mixed findings about whether sexting is simply a modern dating strategy or a marker of other risk behaviors; age may play an important discriminating role. Sexual activity appears to be correlated with sexting. According to Temple and Choi,¹¹ “Sexting fits within the context of adolescent sexual development and may be a viable indicator of adolescent sexual activity.”¹¹

Some authors have suggested that sext­ing is a contemporary risk behavior that is likely to correlate with other risk behaviors. Among young teens—seventh graders who were referred to a risk prevention trial because of behavioral/emotional difficulties—those who sexted were more likely to engage in early sexual behaviors.⁸ These younger at-risk teens also had less understanding of their emotions and greater difficulty in regulating their emotions.

Among the general population of high school students, teens who sext are more likely to be sexually active.³ High school girls who engaged in sexting were noted to engage in other risk behaviors, including having multiple partners in the past year and using alcohol or drugs before sex.³ Teens who had sent a sext were more likely to be sexually active 1 year later than teens who had not.¹¹Studies of sexting among university students also have had mixed findings. One study found that among undergraduates, sexting was associated with substance use and other risk behaviors.⁹ Another young adult study found sexting was not related to sexual risk or psychological well-being.⁴

Legal issues affect psychiatrists as well as patients

As a psychiatrist evaluating K, what are your duties as a mandated reporter? Psychiatrists are legally required to report suspected maltreatment or abuse of children.¹² The circumstances under which psychiatrists may have a mandate to report include when a psychiatrist:

• evaluates a child and suspects abuse
• suspects child abuse based on an adult patient’s report
• learns from a third party that a child may have been/is being abused.

Psychiatrists usually are not mandated to report other types of potentially criminal behavior. As such, reporting sexting might be considered a breach of confidentiality. Psychiatrists should be familiar with the specific reporting guidelines for the jurisdiction in which they practice. Psychiatrists who work with individuals who commit crimes should focus on changing the potentially dangerous behaviors rather than reporting them.

Does the transmission of naked photos of a minor in a sexual pose or act constitute child pornography or another criminal offense? The legal answer varies, but the role of the psychiatrist does not. Psychiatrists should educate their patients about potentially dangerous behaviors.

With regards to the legal consequences, some states classify underage sexting photos as child pornography. Others have less rigid definitions of child pornography and take into account the age of the participants and their intent. Such jurisdictions point out that sexting naked photos among adolescents is “age appropriate.” Some have enacted specific sexting laws to address the transmission of obscene material to a child through the Internet. In some jurisdictions, sexting laws are categorized to refer to behavior of individuals under or over age 18. The term “revenge porn” is used to refer to nonconsensual pornography with its dissemination motivated by spite.¹³ Some states have defined specific revenge porn laws to address the behavior. Currently, 20 states have sexting laws and 26 states have revenge porn laws.¹⁴ Twenty states address a minor age <18 sending the photo, while only 18 address the recipient. The law in this area can be complex and detailed, taking into account the age of the sender, the intentions of the sender, and the nature of the relationship between the sender and the recipient and the behavior of the recipient.

Laws regarding sexting vary greatly. Sexting may be a misdemeanor or a felony, depending on the state, the specific behavior, and the frequency. In the United States, 11 state laws include a diversion remedy—an option to pursue the case outside of the criminal juvenile system; 10 laws require counseling or another informal sanction; 11 states laws have the potential for misdemeanor punishment; and 4 state laws have the potential for felony punishment.¹⁴ Depending on the criminal charge, the perpetrator may have to register as a sex offender. For example, in some jurisdictions, a conviction for possession of child pornography requires sex offender registration. Thirty-eight states include juvenile sex offenders in their sex offender registries. Other states require juveniles to register if they are age ≥15 years or have been tried as an adult.¹⁵

The frequency of police involvement in sexting cases also greatly varies. A national study examining the characteristics of youth sexting cases revealed that law enforcement agencies handled approximately 3,477 cases of youth-produced sexual photos in 2008 and 2009.¹⁶ Situations that involved an adult or a minor engaged in malicious, nonconsensual, or abusive behavior comprised two-thirds of cases. Arrests occurred in 62% of the adult-involved cases and 36% of the aggravated youth-only cases. Arrests occurred in only 18% of investigated non-aggravated youth-only cases. Table 2 describes recent American sexting legal cases and their outcomes.

In K’s case, depending on the jurisdiction, K or her ex-boyfriend may be subject to arrest for child pornography, revenge pornography, or sexting.

Potential social and psychiatric consequences

What are the social and psychiatric ramifications for K? Aside from potential legal consequences of sexting, K is experiencing psychological and social consequences. She has developed depressive symptoms and suicidal ideation. Her ex-boyfriend’s dissemination of her nude photos on the school computer could be interpreted as cyberbullying. (The National Center for Missing and Exploited Children defines cyberbullying as “bullying through the use of technology or electronic devices such as telephones, cell phones, computers, and the Internet.”¹⁷ All 50 states have enacted laws against bullying; 48 states have electronic harassment in their bullying laws; and 22 states have laws specifically referencing “cyberbullying.”)

Her depressive symptoms developed in response to her feelings of guilt and shame related to sexting as well as the subsequent peer harassment. She is refusing to return to school because of her concerns about bullying. A careful inquiry into suicidality should be part of the evaluation when sexting has led to psychiatric symptoms. Several cases of sexting and cyberbullying have ended in suicide (Table 3).

How to ask patients about sexting

To screen patients for sexting, clinicians need to develop a new skill set, which at first may be uncomfortable. However, the questions to ask are not all that different from other questions about adolescent and young adult sexuality. The importance of patients seeing that we as physicians are comfortable with the topic and approachable about their sexual health cannot be overemphasized. When discussing sexting with patients, it is essential to:

• explain that you are asking questions about their sexual health because they are important to overall health
• engage patients in discussion in a nonthreatening and nonjudgmental way
• develop rapport so patients feel comfortable disclosing behavior that may be embarrassing
• listen to their stories and build a context for understanding their experiences. As you listen, ask questions when needed to help move the story along.

Sometimes when asking about topics that are uncomfortable, clinicians revert from open-ended to closed-ended questions, but when asking about a patient’s sexual life, it is especially important to be open-ended and ask questions in a nonjudgmental way. Contextualizing sexual questions by (for example) asking them while discussing the teen’s relationships will make them seem more natural.¹⁸ To best understand, inquire explicitly about specific behaviors, but do so without appearing voyeuristic.¹⁸

Sexting may precede sexual intercourse. Keep in mind that a patient may report that she (he) is not sexually active but still may be involved in sexting. Therefore, discuss sexting even if your patient reports not being sexually active. By understanding the prevalence of sexting among teens, you can ask questions in a normalizing way. Clinicians can inquire about sexting while discussing relationships and dating or online risk behaviors.

Also consider whether any of your patient’s sexual behaviors, including sext­ing, are the result of coercion: “Some of my patients tell me they feel pressured or coerced into having sex. Have you ever felt this way?”¹⁹ and “Have you ever been picked on or bullied? Is that still a problem?” are suggested safety screening questions about bullying,¹⁸ and one can also ask about specific cyberbullying behaviors.

Imagine being able to precisely select the medication with the optimal efficacy, safety, and tolerability at the outset of treatment for every psychiatric patient who needs pharma­cotherapy. Imagine how much the patient would appreciate not receiving a series of drugs and suffering multiple adverse effects and unremitting symptoms until the “right medication” is identified. Imagine how gratifying it would be for you as a psychiatrist to watch every one of your patients improve rapidly with minimal complaints or adverse effects.

Precision psychiatry is the indispensable vehicle to achieve personalized medicine for psychiatric patients. Precision psychiatry is a cherished goal, but it remains an aspirational objective. Other medical specialties, especially oncology and cardiology, have made remarkable strides in precision medicine, but the journey to precision psychiatry is still in its early stages. Yet there is every reason to believe that we are making progress toward that cherished goal.

To implement precision psychiatry, we must be able to identify the biosignature of each patient’s psychiatric brain disorder. But there is a formidable challenge to overcome: the complex, extensive heterogeneity of psychiatric disorders, which requires intense and inspired neurobiology research. So, while clinicians go on with the mundane trial-and-error approach of contemporary psychopharmacology, psychiatric neuroscientists are diligently deconstructing major psychiatric disorders into specific biotypes with unique biosignatures that will one day guide accurate and prompt clinical management.

Psychiatric practitioners may be too busy to keep tabs on the progress being made in identifying various biomarkers that are the key ingredients to decoding the biosignature of each psychiatric patient. Take schizophrenia, for example. There are myriad clinical variations that comprise this heterogeneous brain syndrome, including level of premorbid functioning; acute vs gradual onset of psychosis; the type and severity of hallucinations or delusions; the dimensional spectrum of negative symptoms and cognitive impairments; the presence and intensity of suicidal or homicidal urges; and the type of medical and psychiatric comorbidities. No wonder every patient is a unique and fascinating clinical puzzle, and yet, patients with schizophrenia are still being homogenized under a single DSM diagnostic category.

Precision psychiatry will ultimately enable practitioners to recognize various psychotic diseases that are more specific than the current DSM psychosis categories. Further, precision psychiatry will provide guidance as to which member within a class of so-called “me-too” drugs is the optimal match for each patient. This will stand in stark contrast to the chaotic hit-or-miss approach.

Precision psychiatry also will reveal the absurdity of current FDA clinical trials design for drug development. How can a molecule with a putative mechanism of action relevant to a specific biotype be administered to a hodgepodge of heterogeneous biotypes that have been lumped in 1 clinical category, and yet be expected to exert efficacy in most biotypes? It is a small miracle that some new drugs beat placebo despite the extensive variability in both placebo responses and drug responses. But it is well known that in all FDA placebo-controlled trials, the therapeutic response across the patient population varies from extremely high to extremely low, and worsening may even occur in a subset of patients receiving either the active drug or placebo. Perhaps drug response should be used as 1 methodology to classify biotypes of patients encompassed within a heterogeneous syndrome such as schizophrenia.

Precision psychiatry will represent a huge paradigm shift in the science and practice of our specialty. In his landmark book, Thomas Kuhn defined a paradigm as “an entire worldview in which a theory exists and all the implications that come from that view.”² Precision psychiatry will completely disrupt the current antiquated clinical paradigm, transforming psychiatry into the clinical neuroscience it is. Many “omics,” such as genomics, epigenomics, transcriptomics, proteomics, metabolomics, lipidomics, and metagenomics, will inevitably find their way into the jargon of psychiatrists.³

A marriage of science and technology is essential for the emergence of precision psychiatry. To achieve this transformative amalgamation, we need to reconfigure our concepts, reengineer our methods, reinvent our models, and redesign our approaches to patient care.

As Peter Drucker said, “The best way to predict the future is to create it.”⁴ Precision psychiatry is our future. Let’s create it!

Imagine being able to precisely select the medication with the optimal efficacy, safety, and tolerability at the outset of treatment for every psychiatric patient who needs pharma­cotherapy. Imagine how much the patient would appreciate not receiving a series of drugs and suffering multiple adverse effects and unremitting symptoms until the “right medication” is identified. Imagine how gratifying it would be for you as a psychiatrist to watch every one of your patients improve rapidly with minimal complaints or adverse effects.

Precision psychiatry is the indispensable vehicle to achieve personalized medicine for psychiatric patients. Precision psychiatry is a cherished goal, but it remains an aspirational objective. Other medical specialties, especially oncology and cardiology, have made remarkable strides in precision medicine, but the journey to precision psychiatry is still in its early stages. Yet there is every reason to believe that we are making progress toward that cherished goal.

To implement precision psychiatry, we must be able to identify the biosignature of each patient’s psychiatric brain disorder. But there is a formidable challenge to overcome: the complex, extensive heterogeneity of psychiatric disorders, which requires intense and inspired neurobiology research. So, while clinicians go on with the mundane trial-and-error approach of contemporary psychopharmacology, psychiatric neuroscientists are diligently deconstructing major psychiatric disorders into specific biotypes with unique biosignatures that will one day guide accurate and prompt clinical management.

Psychiatric practitioners may be too busy to keep tabs on the progress being made in identifying various biomarkers that are the key ingredients to decoding the biosignature of each psychiatric patient. Take schizophrenia, for example. There are myriad clinical variations that comprise this heterogeneous brain syndrome, including level of premorbid functioning; acute vs gradual onset of psychosis; the type and severity of hallucinations or delusions; the dimensional spectrum of negative symptoms and cognitive impairments; the presence and intensity of suicidal or homicidal urges; and the type of medical and psychiatric comorbidities. No wonder every patient is a unique and fascinating clinical puzzle, and yet, patients with schizophrenia are still being homogenized under a single DSM diagnostic category.

Precision psychiatry will ultimately enable practitioners to recognize various psychotic diseases that are more specific than the current DSM psychosis categories. Further, precision psychiatry will provide guidance as to which member within a class of so-called “me-too” drugs is the optimal match for each patient. This will stand in stark contrast to the chaotic hit-or-miss approach.

Precision psychiatry also will reveal the absurdity of current FDA clinical trials design for drug development. How can a molecule with a putative mechanism of action relevant to a specific biotype be administered to a hodgepodge of heterogeneous biotypes that have been lumped in 1 clinical category, and yet be expected to exert efficacy in most biotypes? It is a small miracle that some new drugs beat placebo despite the extensive variability in both placebo responses and drug responses. But it is well known that in all FDA placebo-controlled trials, the therapeutic response across the patient population varies from extremely high to extremely low, and worsening may even occur in a subset of patients receiving either the active drug or placebo. Perhaps drug response should be used as 1 methodology to classify biotypes of patients encompassed within a heterogeneous syndrome such as schizophrenia.

Precision psychiatry will represent a huge paradigm shift in the science and practice of our specialty. In his landmark book, Thomas Kuhn defined a paradigm as “an entire worldview in which a theory exists and all the implications that come from that view.”² Precision psychiatry will completely disrupt the current antiquated clinical paradigm, transforming psychiatry into the clinical neuroscience it is. Many “omics,” such as genomics, epigenomics, transcriptomics, proteomics, metabolomics, lipidomics, and metagenomics, will inevitably find their way into the jargon of psychiatrists.³

A marriage of science and technology is essential for the emergence of precision psychiatry. To achieve this transformative amalgamation, we need to reconfigure our concepts, reengineer our methods, reinvent our models, and redesign our approaches to patient care.

As Peter Drucker said, “The best way to predict the future is to create it.”⁴ Precision psychiatry is our future. Let’s create it!

Imagine being able to precisely select the medication with the optimal efficacy, safety, and tolerability at the outset of treatment for every psychiatric patient who needs pharma­cotherapy. Imagine how much the patient would appreciate not receiving a series of drugs and suffering multiple adverse effects and unremitting symptoms until the “right medication” is identified. Imagine how gratifying it would be for you as a psychiatrist to watch every one of your patients improve rapidly with minimal complaints or adverse effects.

Precision psychiatry is the indispensable vehicle to achieve personalized medicine for psychiatric patients. Precision psychiatry is a cherished goal, but it remains an aspirational objective. Other medical specialties, especially oncology and cardiology, have made remarkable strides in precision medicine, but the journey to precision psychiatry is still in its early stages. Yet there is every reason to believe that we are making progress toward that cherished goal.

To implement precision psychiatry, we must be able to identify the biosignature of each patient’s psychiatric brain disorder. But there is a formidable challenge to overcome: the complex, extensive heterogeneity of psychiatric disorders, which requires intense and inspired neurobiology research. So, while clinicians go on with the mundane trial-and-error approach of contemporary psychopharmacology, psychiatric neuroscientists are diligently deconstructing major psychiatric disorders into specific biotypes with unique biosignatures that will one day guide accurate and prompt clinical management.

Psychiatric practitioners may be too busy to keep tabs on the progress being made in identifying various biomarkers that are the key ingredients to decoding the biosignature of each psychiatric patient. Take schizophrenia, for example. There are myriad clinical variations that comprise this heterogeneous brain syndrome, including level of premorbid functioning; acute vs gradual onset of psychosis; the type and severity of hallucinations or delusions; the dimensional spectrum of negative symptoms and cognitive impairments; the presence and intensity of suicidal or homicidal urges; and the type of medical and psychiatric comorbidities. No wonder every patient is a unique and fascinating clinical puzzle, and yet, patients with schizophrenia are still being homogenized under a single DSM diagnostic category.

Precision psychiatry will ultimately enable practitioners to recognize various psychotic diseases that are more specific than the current DSM psychosis categories. Further, precision psychiatry will provide guidance as to which member within a class of so-called “me-too” drugs is the optimal match for each patient. This will stand in stark contrast to the chaotic hit-or-miss approach.

Precision psychiatry also will reveal the absurdity of current FDA clinical trials design for drug development. How can a molecule with a putative mechanism of action relevant to a specific biotype be administered to a hodgepodge of heterogeneous biotypes that have been lumped in 1 clinical category, and yet be expected to exert efficacy in most biotypes? It is a small miracle that some new drugs beat placebo despite the extensive variability in both placebo responses and drug responses. But it is well known that in all FDA placebo-controlled trials, the therapeutic response across the patient population varies from extremely high to extremely low, and worsening may even occur in a subset of patients receiving either the active drug or placebo. Perhaps drug response should be used as 1 methodology to classify biotypes of patients encompassed within a heterogeneous syndrome such as schizophrenia.

Precision psychiatry will represent a huge paradigm shift in the science and practice of our specialty. In his landmark book, Thomas Kuhn defined a paradigm as “an entire worldview in which a theory exists and all the implications that come from that view.”² Precision psychiatry will completely disrupt the current antiquated clinical paradigm, transforming psychiatry into the clinical neuroscience it is. Many “omics,” such as genomics, epigenomics, transcriptomics, proteomics, metabolomics, lipidomics, and metagenomics, will inevitably find their way into the jargon of psychiatrists.³

A marriage of science and technology is essential for the emergence of precision psychiatry. To achieve this transformative amalgamation, we need to reconfigure our concepts, reengineer our methods, reinvent our models, and redesign our approaches to patient care.

As Peter Drucker said, “The best way to predict the future is to create it.”⁴ Precision psychiatry is our future. Let’s create it!

Dear Dr. Mossman,
I have a possibly fatal disease. So far, my symptoms and treatment haven’t kept me from my usual activities. But if my illness worsens, I’ll have to quit practicing psychiatry. What should I be doing now to make sure I fulfill my ethical and legal obligations to my patients?
Submitted by “Dr. F”

“Remember, with great power comes great responsibility.”

- Peter Parker, Spider-Man (2002)

Peter Parker’s movie-ending statement applies to doctors as well as Spider-Man. Although we don’t swing from building to building to save cities from heinous villains, practicing medicine is a privilege that society bestows only upon physicians who retain the knowledge, skills, and ability to treat patients competently.

Doctors retire from practice for many reasons, including when deteriorating physical health or cognitive capacity prevents them from performing clinical duties properly. Dr. F’s situation is not rare. As the physician population ages,^1,2 a growing number of his colleagues will face similar circumstances,^3,4 and with them, the responsibility and emotional turmoil of arranging to end their medical practices.

In many ways, concluding a psychiatric practice is similar to retiring from practice in other specialties. But because we care for patients’ minds as well as their bodies, retirement affects psychiatrists in distinctive ways that reflect our patients’ feelings toward us and our feelings toward them. To answer Dr. F’s question, this article considers having to stop practicing from 3 vantage points:

• the emotional impact on patients
• the emotional impact on the psychiatrist
• fulfilling one’s legal obligations while attending to the emotions of patients as well as oneself.

Emotional impact on patients

A content analysis study suggests that the traits patients appreciate in family physicians include the availability to listen, caring and compassion, trusted medical judgment, conveying the patient’s importance during encounters, feelings of connectedness, knowledge and understanding of the patient’s family, and relationship longevity.⁵ The same factors likely apply to relationships between psychiatrists and their patients, particularly if treatment encounters have extended over years and have involved conversations beyond those needed merely to write prescriptions.

Psychoanalytic publications offer many descriptions of patients’ reactions to the illness or death of their mental health professional. A 1978 study of 27 analysands whose physicians died during ongoing therapy reported reactions that ranged from a minimal impact to protracted mourning accompanied by helplessness, intense crying, and recurrent dreams about the analyst.⁶ Although a few patients were relieved that death had ended a difficult treatment, many were angry at their doctor for not attending to self-care and for breaking their treatment agreement, or because they had missed out on hoped-for benefits.

A 2010 study described the pain and distress that patients may experience following the death of their analyst or psychotherapist. These accounts emphasized the emotional isolation of grieving patients, who do not have the social support that bereaved persons receive after losing a loved one.⁷ Successful psychotherapy provides a special relationship characterized by trust, intimacy, and safety. But if the therapist suddenly dies, this relationship “is transformed into a solitude like no other.”⁸

Because the sudden “rupture of an analytic process is bound to be traumatic and may cause iatrogenic injury to the patient,” Traesdal⁹ advocates that therapists in situations similar to Dr. F’s discuss their possible death “on the reality level at least once during any analysis or psychotherapy.… It is extremely helpful to a patient to have discussed … how to handle the situation” if the therapist dies. This discussion also offers the patient an opportunity to confront a cultural taboo around death and to increase capacity to tolerate pain, illness, and aging.^10,11

Most psychiatric care today is not psychoanalysis; psychiatrists provide other forms of care that create less intense doctor–patient relationships. Yet knowledge of these kinds of reactions may help Dr. F stay attuned to his patients’ concerns and to contemplate what they may experience, to greater or lesser degrees, if his health declines.

Retirement’s emotional impact on the psychiatrist

Published guidance on concluding a psychiatric practice is sparse, considering that all psychiatrists are mortal and stop practicing at some point.¹²Not thinking about or planning for retirement is a psychiatric tradition that started with Freud. He saw patients until shortly before his death and did not seem to have planned for ending his practice, despite suffering with jaw cancer for 16 years.¹³

Practicing medicine often is more than just a career; it is a core aspect of many physicians’ identity.¹⁴ Most of us spend a large fraction of our waking hours caring for patients and meeting other job requirements (eg, teaching, maintaining knowledge and skills), and many of us have scant time to pursue nonmedical interests. An intense prioritization of one’s “medical identity” makes retirement a blow to a doctor’s self-worth and sense of meaning in life.^15,16

Because their work is not physically demanding, most psychiatrists continue to practice beyond the age of 65 years.^12,17 More important, perhaps, is that being a psychiatrist is uniquely rewarding. As Benjamin Rush observed in an 1810 letter to Pennsylvania Hospital, successfully treating any medical disease is gratifying, but “what is this pleasure compared with that of restoring a fellow creature from the anguish and folly of madness and of reviving in him the knowledge of himself, his family, his friends, and his God!”¹⁸

Physicians in any specialty that involves repeated contact with the same patients form emotional bonds with their patients that retirement breaks.¹⁴ Psychiatrists’ interest in how patients think, feel, and cope with problems creates special attachments¹⁷ that can make some terminations “emotionally excruciating.”¹²

Psychiatrists with serious illness

What guidance might Dr. F find regarding whether to broach the subject of his illness with patients, and if so, how? No one has conducted controlled trials to answer these questions. Rather, published discussion of psychiatrists’ serious illness is found mainly in the psychotherapy literature. What’s available consists of individual accounts and case series that lack scientific rigor and offer little clarity about what the therapist should say, when to say it, and how to initiate the discussion.^19,20 Yet Dr. F may find some of these authors’ ideas and suggestions helpful, particularly if his psychiatric practice includes providing psychotherapy.

As a rule, psychiatrists avoid talking about themselves, but having a serious illness that could affect treatment often justifies deviating from this practice. Although Dr. F (like many psychiatrists) may be concerned that discussing his health will make patients anxious or “contaminate” what they are able or willing to say,²¹ not providing information or avoiding discussion (especially if a patient asks about your health) may quickly undermine a patient’s trust.^21,22 Even in psycho­analytic treatment, it makes little sense to encourage patients “to speak freely on the pretense that all is well, despite obvious evidence to the contrary.”¹⁹

Physicians often deny—or at least avoid thinking about—their own mortality.²³ But avoiding talking about something so important (and often so obvious) as one’s illness may risk supporting patients’ denial of crucial matters in their own lives.^19,21 Moreover, Dr. F’s inadvertent self-disclosure (eg, by displaying obvious signs of illness) may do more harm to therapy than a planned statement in which Dr. F has prepared what he’ll say to answer his patients’ questions.²⁰

That Dr. F has continued working while suffering from a potentially fatal illness seems noble. Yet by doing so, he accepts not only the burdens of his illness but also the obligation to continue to serve his patients competently. This requires maintaining emotional steadiness and not using patients for emotional support, but instead obtaining and using the support of his friends, colleagues, family, consultants, and caregivers.²⁰

Legal obligations

Retirement does not end a physician’s professional legal obligations.²⁴ The legal rules and duties for psychiatrists who leave their practices are similar to those that apply to other physicians. Mishandling these aspects of retirement can result in various legal, licensure-related, or economic consequences, depending on your circumstances and employment arrangements.

Employment contracts in hospital or group practices often require notice of impending departures. If applicable to Dr. F’s situation, failure to comply with such conditions may lead to forfeiture of buyout payments, paying for malpractice tail coverage, or lawsuits claiming violation of contractual agreements.²⁵

Retirement also creates practical and legal responsibilities to patients that are separate from the interpersonal and emotional issues previously discussed. How will those who need ongoing care and coverage be cared for? When withdrawing from a patient’s care (because of retirement or other reasons), a physician should give the patient enough advance notice to set up satisfactory treatment arrangements elsewhere and should facilitate transfer of the patient’s care, if appropriate.²⁶ Failure to meet this ethical obligation may lead to a malpractice action alleging abandonment, which is defined as “the unilateral severance of the professional relationship … without reasonable notice at a time when there is still the necessity of continuing medical attention.”²⁷

Further obligations come from medical licensing boards, which, in many states, have established time frames and specific procedures for informing patients and the public when a physician is leaving practice. Table 1^24,28-31 lists examples of these. If Dr. F works in a state where the board hasn’t promulgated such regulations, Table 1^24,28-31 may still help him think through how to discharge his ethical responsibilities to notify patients, colleagues, and business entities that he is ending his practice. References 28-30 and 32 discuss several of these matters, suggest timetables for various steps of a practice closure, and provide sample letters for notifying patients.

Physicians also must preserve their medical records for a certain period after they retire. States with rules on this matter require record preservation for 5 to 10 years or until 2 or 3 years after minor patients reach the age of majority.³³ The Health Insurance Portability and Accountability Act of 1996 requires covered entities, which include most psychiatrists, to retain records for 6 years,³⁴ and certain Medicare programs require retention for 10 years.³⁵

Depending on Dr. F’s location and type of practice, his records should be preserved for the longest period that applies. If he is leaving a group practice that owns the records, arranging for this should be easy. If leaving an independent practice, he may need to ask another practice to perform this function.²⁵

A ‘professional will’

Dr. F also might consider a measure that many psychotherapists recommend^13,19,36 and that in some states is required by mental health licensing boards or professional codes^37,38: creating a “professional will” that contains instructions for handling practice matters in case of death or disability.³⁹

Dear Dr. Mossman,
I have a possibly fatal disease. So far, my symptoms and treatment haven’t kept me from my usual activities. But if my illness worsens, I’ll have to quit practicing psychiatry. What should I be doing now to make sure I fulfill my ethical and legal obligations to my patients?
Submitted by “Dr. F”

“Remember, with great power comes great responsibility.”

- Peter Parker, Spider-Man (2002)

Peter Parker’s movie-ending statement applies to doctors as well as Spider-Man. Although we don’t swing from building to building to save cities from heinous villains, practicing medicine is a privilege that society bestows only upon physicians who retain the knowledge, skills, and ability to treat patients competently.

Doctors retire from practice for many reasons, including when deteriorating physical health or cognitive capacity prevents them from performing clinical duties properly. Dr. F’s situation is not rare. As the physician population ages,^1,2 a growing number of his colleagues will face similar circumstances,^3,4 and with them, the responsibility and emotional turmoil of arranging to end their medical practices.

In many ways, concluding a psychiatric practice is similar to retiring from practice in other specialties. But because we care for patients’ minds as well as their bodies, retirement affects psychiatrists in distinctive ways that reflect our patients’ feelings toward us and our feelings toward them. To answer Dr. F’s question, this article considers having to stop practicing from 3 vantage points:

• the emotional impact on patients
• the emotional impact on the psychiatrist
• fulfilling one’s legal obligations while attending to the emotions of patients as well as oneself.

Emotional impact on patients

A content analysis study suggests that the traits patients appreciate in family physicians include the availability to listen, caring and compassion, trusted medical judgment, conveying the patient’s importance during encounters, feelings of connectedness, knowledge and understanding of the patient’s family, and relationship longevity.⁵ The same factors likely apply to relationships between psychiatrists and their patients, particularly if treatment encounters have extended over years and have involved conversations beyond those needed merely to write prescriptions.

Psychoanalytic publications offer many descriptions of patients’ reactions to the illness or death of their mental health professional. A 1978 study of 27 analysands whose physicians died during ongoing therapy reported reactions that ranged from a minimal impact to protracted mourning accompanied by helplessness, intense crying, and recurrent dreams about the analyst.⁶ Although a few patients were relieved that death had ended a difficult treatment, many were angry at their doctor for not attending to self-care and for breaking their treatment agreement, or because they had missed out on hoped-for benefits.

A 2010 study described the pain and distress that patients may experience following the death of their analyst or psychotherapist. These accounts emphasized the emotional isolation of grieving patients, who do not have the social support that bereaved persons receive after losing a loved one.⁷ Successful psychotherapy provides a special relationship characterized by trust, intimacy, and safety. But if the therapist suddenly dies, this relationship “is transformed into a solitude like no other.”⁸

Because the sudden “rupture of an analytic process is bound to be traumatic and may cause iatrogenic injury to the patient,” Traesdal⁹ advocates that therapists in situations similar to Dr. F’s discuss their possible death “on the reality level at least once during any analysis or psychotherapy.… It is extremely helpful to a patient to have discussed … how to handle the situation” if the therapist dies. This discussion also offers the patient an opportunity to confront a cultural taboo around death and to increase capacity to tolerate pain, illness, and aging.^10,11

Most psychiatric care today is not psychoanalysis; psychiatrists provide other forms of care that create less intense doctor–patient relationships. Yet knowledge of these kinds of reactions may help Dr. F stay attuned to his patients’ concerns and to contemplate what they may experience, to greater or lesser degrees, if his health declines.

Retirement’s emotional impact on the psychiatrist

Published guidance on concluding a psychiatric practice is sparse, considering that all psychiatrists are mortal and stop practicing at some point.¹²Not thinking about or planning for retirement is a psychiatric tradition that started with Freud. He saw patients until shortly before his death and did not seem to have planned for ending his practice, despite suffering with jaw cancer for 16 years.¹³

Practicing medicine often is more than just a career; it is a core aspect of many physicians’ identity.¹⁴ Most of us spend a large fraction of our waking hours caring for patients and meeting other job requirements (eg, teaching, maintaining knowledge and skills), and many of us have scant time to pursue nonmedical interests. An intense prioritization of one’s “medical identity” makes retirement a blow to a doctor’s self-worth and sense of meaning in life.^15,16

Because their work is not physically demanding, most psychiatrists continue to practice beyond the age of 65 years.^12,17 More important, perhaps, is that being a psychiatrist is uniquely rewarding. As Benjamin Rush observed in an 1810 letter to Pennsylvania Hospital, successfully treating any medical disease is gratifying, but “what is this pleasure compared with that of restoring a fellow creature from the anguish and folly of madness and of reviving in him the knowledge of himself, his family, his friends, and his God!”¹⁸

Physicians in any specialty that involves repeated contact with the same patients form emotional bonds with their patients that retirement breaks.¹⁴ Psychiatrists’ interest in how patients think, feel, and cope with problems creates special attachments¹⁷ that can make some terminations “emotionally excruciating.”¹²

Psychiatrists with serious illness

What guidance might Dr. F find regarding whether to broach the subject of his illness with patients, and if so, how? No one has conducted controlled trials to answer these questions. Rather, published discussion of psychiatrists’ serious illness is found mainly in the psychotherapy literature. What’s available consists of individual accounts and case series that lack scientific rigor and offer little clarity about what the therapist should say, when to say it, and how to initiate the discussion.^19,20 Yet Dr. F may find some of these authors’ ideas and suggestions helpful, particularly if his psychiatric practice includes providing psychotherapy.

As a rule, psychiatrists avoid talking about themselves, but having a serious illness that could affect treatment often justifies deviating from this practice. Although Dr. F (like many psychiatrists) may be concerned that discussing his health will make patients anxious or “contaminate” what they are able or willing to say,²¹ not providing information or avoiding discussion (especially if a patient asks about your health) may quickly undermine a patient’s trust.^21,22 Even in psycho­analytic treatment, it makes little sense to encourage patients “to speak freely on the pretense that all is well, despite obvious evidence to the contrary.”¹⁹

Physicians often deny—or at least avoid thinking about—their own mortality.²³ But avoiding talking about something so important (and often so obvious) as one’s illness may risk supporting patients’ denial of crucial matters in their own lives.^19,21 Moreover, Dr. F’s inadvertent self-disclosure (eg, by displaying obvious signs of illness) may do more harm to therapy than a planned statement in which Dr. F has prepared what he’ll say to answer his patients’ questions.²⁰

That Dr. F has continued working while suffering from a potentially fatal illness seems noble. Yet by doing so, he accepts not only the burdens of his illness but also the obligation to continue to serve his patients competently. This requires maintaining emotional steadiness and not using patients for emotional support, but instead obtaining and using the support of his friends, colleagues, family, consultants, and caregivers.²⁰

Legal obligations

Retirement does not end a physician’s professional legal obligations.²⁴ The legal rules and duties for psychiatrists who leave their practices are similar to those that apply to other physicians. Mishandling these aspects of retirement can result in various legal, licensure-related, or economic consequences, depending on your circumstances and employment arrangements.

Employment contracts in hospital or group practices often require notice of impending departures. If applicable to Dr. F’s situation, failure to comply with such conditions may lead to forfeiture of buyout payments, paying for malpractice tail coverage, or lawsuits claiming violation of contractual agreements.²⁵

Retirement also creates practical and legal responsibilities to patients that are separate from the interpersonal and emotional issues previously discussed. How will those who need ongoing care and coverage be cared for? When withdrawing from a patient’s care (because of retirement or other reasons), a physician should give the patient enough advance notice to set up satisfactory treatment arrangements elsewhere and should facilitate transfer of the patient’s care, if appropriate.²⁶ Failure to meet this ethical obligation may lead to a malpractice action alleging abandonment, which is defined as “the unilateral severance of the professional relationship … without reasonable notice at a time when there is still the necessity of continuing medical attention.”²⁷

Further obligations come from medical licensing boards, which, in many states, have established time frames and specific procedures for informing patients and the public when a physician is leaving practice. Table 1^24,28-31 lists examples of these. If Dr. F works in a state where the board hasn’t promulgated such regulations, Table 1^24,28-31 may still help him think through how to discharge his ethical responsibilities to notify patients, colleagues, and business entities that he is ending his practice. References 28-30 and 32 discuss several of these matters, suggest timetables for various steps of a practice closure, and provide sample letters for notifying patients.

Physicians also must preserve their medical records for a certain period after they retire. States with rules on this matter require record preservation for 5 to 10 years or until 2 or 3 years after minor patients reach the age of majority.³³ The Health Insurance Portability and Accountability Act of 1996 requires covered entities, which include most psychiatrists, to retain records for 6 years,³⁴ and certain Medicare programs require retention for 10 years.³⁵

Depending on Dr. F’s location and type of practice, his records should be preserved for the longest period that applies. If he is leaving a group practice that owns the records, arranging for this should be easy. If leaving an independent practice, he may need to ask another practice to perform this function.²⁵

A ‘professional will’

Dr. F also might consider a measure that many psychotherapists recommend^13,19,36 and that in some states is required by mental health licensing boards or professional codes^37,38: creating a “professional will” that contains instructions for handling practice matters in case of death or disability.³⁹

Dear Dr. Mossman,
I have a possibly fatal disease. So far, my symptoms and treatment haven’t kept me from my usual activities. But if my illness worsens, I’ll have to quit practicing psychiatry. What should I be doing now to make sure I fulfill my ethical and legal obligations to my patients?
Submitted by “Dr. F”

“Remember, with great power comes great responsibility.”

- Peter Parker, Spider-Man (2002)

Peter Parker’s movie-ending statement applies to doctors as well as Spider-Man. Although we don’t swing from building to building to save cities from heinous villains, practicing medicine is a privilege that society bestows only upon physicians who retain the knowledge, skills, and ability to treat patients competently.

Doctors retire from practice for many reasons, including when deteriorating physical health or cognitive capacity prevents them from performing clinical duties properly. Dr. F’s situation is not rare. As the physician population ages,^1,2 a growing number of his colleagues will face similar circumstances,^3,4 and with them, the responsibility and emotional turmoil of arranging to end their medical practices.

In many ways, concluding a psychiatric practice is similar to retiring from practice in other specialties. But because we care for patients’ minds as well as their bodies, retirement affects psychiatrists in distinctive ways that reflect our patients’ feelings toward us and our feelings toward them. To answer Dr. F’s question, this article considers having to stop practicing from 3 vantage points:

• the emotional impact on patients
• the emotional impact on the psychiatrist
• fulfilling one’s legal obligations while attending to the emotions of patients as well as oneself.

Emotional impact on patients

A content analysis study suggests that the traits patients appreciate in family physicians include the availability to listen, caring and compassion, trusted medical judgment, conveying the patient’s importance during encounters, feelings of connectedness, knowledge and understanding of the patient’s family, and relationship longevity.⁵ The same factors likely apply to relationships between psychiatrists and their patients, particularly if treatment encounters have extended over years and have involved conversations beyond those needed merely to write prescriptions.

Psychoanalytic publications offer many descriptions of patients’ reactions to the illness or death of their mental health professional. A 1978 study of 27 analysands whose physicians died during ongoing therapy reported reactions that ranged from a minimal impact to protracted mourning accompanied by helplessness, intense crying, and recurrent dreams about the analyst.⁶ Although a few patients were relieved that death had ended a difficult treatment, many were angry at their doctor for not attending to self-care and for breaking their treatment agreement, or because they had missed out on hoped-for benefits.

A 2010 study described the pain and distress that patients may experience following the death of their analyst or psychotherapist. These accounts emphasized the emotional isolation of grieving patients, who do not have the social support that bereaved persons receive after losing a loved one.⁷ Successful psychotherapy provides a special relationship characterized by trust, intimacy, and safety. But if the therapist suddenly dies, this relationship “is transformed into a solitude like no other.”⁸

Because the sudden “rupture of an analytic process is bound to be traumatic and may cause iatrogenic injury to the patient,” Traesdal⁹ advocates that therapists in situations similar to Dr. F’s discuss their possible death “on the reality level at least once during any analysis or psychotherapy.… It is extremely helpful to a patient to have discussed … how to handle the situation” if the therapist dies. This discussion also offers the patient an opportunity to confront a cultural taboo around death and to increase capacity to tolerate pain, illness, and aging.^10,11

Most psychiatric care today is not psychoanalysis; psychiatrists provide other forms of care that create less intense doctor–patient relationships. Yet knowledge of these kinds of reactions may help Dr. F stay attuned to his patients’ concerns and to contemplate what they may experience, to greater or lesser degrees, if his health declines.

Retirement’s emotional impact on the psychiatrist

Published guidance on concluding a psychiatric practice is sparse, considering that all psychiatrists are mortal and stop practicing at some point.¹²Not thinking about or planning for retirement is a psychiatric tradition that started with Freud. He saw patients until shortly before his death and did not seem to have planned for ending his practice, despite suffering with jaw cancer for 16 years.¹³

Practicing medicine often is more than just a career; it is a core aspect of many physicians’ identity.¹⁴ Most of us spend a large fraction of our waking hours caring for patients and meeting other job requirements (eg, teaching, maintaining knowledge and skills), and many of us have scant time to pursue nonmedical interests. An intense prioritization of one’s “medical identity” makes retirement a blow to a doctor’s self-worth and sense of meaning in life.^15,16

Because their work is not physically demanding, most psychiatrists continue to practice beyond the age of 65 years.^12,17 More important, perhaps, is that being a psychiatrist is uniquely rewarding. As Benjamin Rush observed in an 1810 letter to Pennsylvania Hospital, successfully treating any medical disease is gratifying, but “what is this pleasure compared with that of restoring a fellow creature from the anguish and folly of madness and of reviving in him the knowledge of himself, his family, his friends, and his God!”¹⁸

Physicians in any specialty that involves repeated contact with the same patients form emotional bonds with their patients that retirement breaks.¹⁴ Psychiatrists’ interest in how patients think, feel, and cope with problems creates special attachments¹⁷ that can make some terminations “emotionally excruciating.”¹²

Psychiatrists with serious illness

What guidance might Dr. F find regarding whether to broach the subject of his illness with patients, and if so, how? No one has conducted controlled trials to answer these questions. Rather, published discussion of psychiatrists’ serious illness is found mainly in the psychotherapy literature. What’s available consists of individual accounts and case series that lack scientific rigor and offer little clarity about what the therapist should say, when to say it, and how to initiate the discussion.^19,20 Yet Dr. F may find some of these authors’ ideas and suggestions helpful, particularly if his psychiatric practice includes providing psychotherapy.

As a rule, psychiatrists avoid talking about themselves, but having a serious illness that could affect treatment often justifies deviating from this practice. Although Dr. F (like many psychiatrists) may be concerned that discussing his health will make patients anxious or “contaminate” what they are able or willing to say,²¹ not providing information or avoiding discussion (especially if a patient asks about your health) may quickly undermine a patient’s trust.^21,22 Even in psycho­analytic treatment, it makes little sense to encourage patients “to speak freely on the pretense that all is well, despite obvious evidence to the contrary.”¹⁹

Physicians often deny—or at least avoid thinking about—their own mortality.²³ But avoiding talking about something so important (and often so obvious) as one’s illness may risk supporting patients’ denial of crucial matters in their own lives.^19,21 Moreover, Dr. F’s inadvertent self-disclosure (eg, by displaying obvious signs of illness) may do more harm to therapy than a planned statement in which Dr. F has prepared what he’ll say to answer his patients’ questions.²⁰

That Dr. F has continued working while suffering from a potentially fatal illness seems noble. Yet by doing so, he accepts not only the burdens of his illness but also the obligation to continue to serve his patients competently. This requires maintaining emotional steadiness and not using patients for emotional support, but instead obtaining and using the support of his friends, colleagues, family, consultants, and caregivers.²⁰

Legal obligations

Retirement does not end a physician’s professional legal obligations.²⁴ The legal rules and duties for psychiatrists who leave their practices are similar to those that apply to other physicians. Mishandling these aspects of retirement can result in various legal, licensure-related, or economic consequences, depending on your circumstances and employment arrangements.

Employment contracts in hospital or group practices often require notice of impending departures. If applicable to Dr. F’s situation, failure to comply with such conditions may lead to forfeiture of buyout payments, paying for malpractice tail coverage, or lawsuits claiming violation of contractual agreements.²⁵

Retirement also creates practical and legal responsibilities to patients that are separate from the interpersonal and emotional issues previously discussed. How will those who need ongoing care and coverage be cared for? When withdrawing from a patient’s care (because of retirement or other reasons), a physician should give the patient enough advance notice to set up satisfactory treatment arrangements elsewhere and should facilitate transfer of the patient’s care, if appropriate.²⁶ Failure to meet this ethical obligation may lead to a malpractice action alleging abandonment, which is defined as “the unilateral severance of the professional relationship … without reasonable notice at a time when there is still the necessity of continuing medical attention.”²⁷

Further obligations come from medical licensing boards, which, in many states, have established time frames and specific procedures for informing patients and the public when a physician is leaving practice. Table 1^24,28-31 lists examples of these. If Dr. F works in a state where the board hasn’t promulgated such regulations, Table 1^24,28-31 may still help him think through how to discharge his ethical responsibilities to notify patients, colleagues, and business entities that he is ending his practice. References 28-30 and 32 discuss several of these matters, suggest timetables for various steps of a practice closure, and provide sample letters for notifying patients.

Physicians also must preserve their medical records for a certain period after they retire. States with rules on this matter require record preservation for 5 to 10 years or until 2 or 3 years after minor patients reach the age of majority.³³ The Health Insurance Portability and Accountability Act of 1996 requires covered entities, which include most psychiatrists, to retain records for 6 years,³⁴ and certain Medicare programs require retention for 10 years.³⁵

Depending on Dr. F’s location and type of practice, his records should be preserved for the longest period that applies. If he is leaving a group practice that owns the records, arranging for this should be easy. If leaving an independent practice, he may need to ask another practice to perform this function.²⁵

A ‘professional will’

Dr. F also might consider a measure that many psychotherapists recommend^13,19,36 and that in some states is required by mental health licensing boards or professional codes^37,38: creating a “professional will” that contains instructions for handling practice matters in case of death or disability.³⁹

CASE Bleeding, bewildered

Mr. K, age 23, a South Asian male, is discovered in the bathroom bleeding profusely. Mr. K’s parents inform emergency medical services (EMS) personnel that Mr. K is “not in his right mind” and speculate that he is depressed. EMS personnel find Mr. K sitting in a pool of blood in the bathtub, holding a cloth over his pubic area and complaining of significant pain. They estimate that Mr. K has lost approximately 1 L of blood. Cursory evaluation reveals that his penis is severed; no other injuries or lacerations are notable. Mr. K states, “I did not want it anymore.” A kitchen knife that he used to self-amputate is found nearby. He is awake, alert, and able to follow simple directives.

In the emergency room, Mr. K is in mild-to-moderate distress. He has no history of medical illness, but his parents report that he previously required psychiatric treatment. Mr. K is not able to elaborate. He reluctantly discloses an intermittent history of Cannabis use. Physical examination reveals tachycardia (heart rate: 115 to 120 beats per minute), and despite blood loss, systolic hypertension (blood pressure: 142/70 to 167/70 mm Hg). His pulse oximetry is 97% to 99%; he is afebrile. Laboratory tests are notable for anemia (hemoglobin, 7.2 g/dL [reference range, 14.0 to 17.5 g/dL]; hematocrit, 21.2% [reference range, 41% to 50%]) and serum toxicology screen is positive for benzodiazepines, which had been administered en route to allay his distress.

Mr. K continues to hold pressure on his pubic area. When pressure is released, active arterial spurting of bright red blood is notable. Genital examination reveals a cleanly amputated phallus. Emergent surgical intervention is required to stop the hemorrhage and reattach the penis. Initially, Mr. K is opposed to reattachment, but after a brief discussion with his parents, he consents to surgery. Urology and plastic surgery consultations are elicited to perform the microvascular portion of the procedure.

[polldaddy:9881368]

The authors’ observations

Self-injurious behaviors occur in approximately 1% to 4% of adults in the United States, with chronic and severe self-injury occurring among approximately 1% of the U.S. population.^1,2 Intentional GSM is a relatively rare catastrophic event that is often, but not solely, associated with severe mental illness. Because many cases go unreported, the prevalence of GSM is difficult to estimate.^3,4 Although GSM has been described in both men and women, the literature has predominantly focused on GSM among men.⁵ Genital self-injury has been described in several (ie, ethnic/racial and religious) contexts and has been legally sanctioned.^6-8

Psychiatric disorders associated with, and precipitating factors underlying, GSM have long remained elusive.⁸ GSM has been described in case reports and small case series in both psychiatric and urologic literature. These reports provide incomplete descriptions of the diagnostic conditions and psychosocial factors underlying male GSM.

A recent systematic review of 173 cases of men who engaged in GSM published in the past 115 years (since the first case of GSM was published in the psychiatric literature⁹) revealed that having some form of psychopathology elevates the probability of GSM^10,11; rarely the individual did not have a psychiatric condition.^11-17 Nearly one-half of the men had psychosis; most had a schizophrenia spectrum disorder diagnosis. Other psychiatric conditions associated with GSM include personality disorders, substance use disorder, and gender dysphoria. GSM is rarely associated with anxiety or mood disorders.

GSM is a heterogeneous form of self-injury that ranges from superficial genital lacerations, amputation, or castration to combinations of these injuries. Compared with individuals with other psychiatric disorders, a significantly greater proportion of individuals with schizophrenia spectrum disorders engage in self-amputation (auto-penectomy). By contrast, persons with gender dysphoria tend to engage in self-castration at significantly higher rates than those with other psychiatric conditions.¹¹ Despite these trends, clinicians should not infer a specific psychiatric diagnosis based on the severity or type of self-inflicted injury.

HISTORY Command hallucinations

Postoperatively, Mr. K is managed in the trauma intensive care unit. During psychiatric consultation, Mr. K demonstrates a blunted affect. His speech is low in volume but clear and coherent. His thoughts are generally linear for specific lines of inquiry (eg, about perceived level of pain) but otherwise are impoverished. Mr. K often digresses into repetitively mumbled prayers. He appears distracted, as if responding to internal stimuli. Although he acknowledges the GSM, he does not discuss the factors underlying his decision to proceed with auto-penectomy. Over successive evaluations, he reluctantly discloses that he had been experiencing disparaging auditory hallucinations that told him that his penis “was too small” and commanded him to “cut it off.”

Psychiatric history reveals that Mr. K required psychiatric hospitalization 7 months earlier due to new-onset auditory hallucinations, paranoia, and thought disorganization, in the context of daily Cannabis use. At the time, the differential diagnosis included new-onset schizophrenia and substance-induced psychosis. His symptoms improved quickly with risperidone, 2 mg/d, and he was discharged in a stable condition with referrals for outpatient care. Mr. K admits he had stopped taking risperidone several weeks before the GSM because he was convinced that he had been cured. At that time, Mr. K had told his parents he was no longer required to take medication or engage in outpatient psychiatric treatment, and they did not question this. Mr. K struggled to sustain part-time employment (in a family business), having taken a leave of absence from graduate school after his first hospitalization. He continued to use Cannabis regularly but denies being intoxicated at the time of the GSM. Throughout his surgical hospitalization, Mr. K’s thoughts remain disorganized. He denies that the GSM was a suicide attempt or having current suicidal thoughts, intent, or plans. He also denies having religious preoccupations, over-valued religious beliefs, or delusions.

Mr. K identifies as heterosexual, and denies experiencing distress related to sexual orientation or gender identity or guilt related to sexual impulses or actions. He also denies having a history of trauma or victimization and does not report any symptoms of posttraumatic stress disorder or body dysmorphic disorder.

The authors’ observations

Self-injury elicits strong, emotional responses from health care professionals, including fascination, apprehension, and hopelessness. Psychiatrists who care for such patients should monitor members of the patient’s treatment team for psychological reactions. In addition, the patient’s behavior while hospitalized may stir feelings of retaliation, anger, fear, and frustration.^11,24,37 Collaborative relationships with medical and surgical specialties can help staff manage emotional reactions and avoid the inadvertent expression of those feelings in their interactions with the patient; these reactions might otherwise undermine treatment.^24,34 Family education can help mitigate any guilt family members may harbor for not preventing the injury.³⁷

Although efforts to understand the intended goal(s) and precipitants of the self-injury are likely to be worthwhile, the overwhelming distress associated with GSM and its emergent treatment may preclude intensive exploration. Assessing precipitants of self-injury should be approached using a nonjudgmental, dispassionate, matter-of-fact manner that conveys concern for the patient³⁸ and reassures the patient that the clinician has heard and, ideally, understands the patient’s distress.³⁹ Forced exploration during the prevailing stress of treatment may overwhelm the patient, prove to be overly distressing, and compel the patient to act out in self-injurious ways. Therefore, exploration of the underpinnings of GSM may need to be postponed until surgical treatment is completed, the patient’s symptoms have been managed with psychopharmacologic intervention, and the patient has been transitioned to the safety and close monitoring of an acute psychiatric inpatient setting.

TREATMENT Restarting medication

While on the surgical unit, Mr. K is restarted on risperidone, 2 mg/d. He appears to tolerate the medication without adverse effects. However, because Mr. K continues to experience auditory hallucinations, and the treatment team remains concerned that he might again experience commands to harm himself, he is transferred to an acute psychiatric inpatient setting.

Urology follow-up reveals necrosis/mummification of the replanted penis and an open scrotal wound. After discussing options with the patient and family, the urologist transfers Mr. K back to the surgical unit for wound closure and removal of the replanted penis. A urethrostomy is performed to allow for bladder emptying.

[polldaddy:9881371]

The authors’ observations

Because most published case reports of GSM among men have focused on acute treatment, there is a dearth of literature available on the long-term course of GSM to inform treatment strategies. Because recovery is a non-static process and a patient’s reactions to his injury will likely evolve over time, a multifaceted approach invoking psychiatric and psychotherapeutic interventions is necessary to help patients after initial injury and surgical management^37,40-43 (Table 2^11,20,27,41).

OUTCOME Return to school, work

Mr. K is discharged with close follow-up at a specialized clinic for new-onset psychosis. Post-discharge treatment consists of education about the course of schizophrenia and the need for medication adherence to prevent relapse. Mr. K also is educated on the relationship between Cannabis use and psychosis, and he abstains from illicit substance use. Family involvement is encouraged to help with medication compliance and monitoring for symptom reemergence.

Therapy focuses on exploring the antecedents of the auto-penectomy, Mr. K’s body image issue concerns, and his feelings related to eventual prosthesis implantation. He insists that he cannot recall any precipitating factors for his self-injury other than the command hallucinations. He does not report sexual guilt, although he had been sexually active with his girlfriend in the months prior to his GSM, which goes against his family’s religious beliefs. He reports significant regret and shame for the self-mutilation, and blames himself for not informing family members about his hallucinations. Therapy involves addressing his attribution of blame using cognitive techniques and focuses on measures that can be taken to prevent further self-harm. Efforts are directed at exploring whether cultural and religious traditions impacted the therapeutic alliance, medication adherence, self-esteem and body image, sexuality, and future goals. Over the course of 1 year, he resumes his graduate studies and part-time work, and explores prosthetic placement for cosmetic purposes.

The authors’ observations

Research suggests that major self-mutilation among patients with psychotic illness is likely to occur during the first episode or early in the course of illness and/or with suboptimal treatment.^44,45 Mr. K was enlisted in an intensive outpatient treatment program involving biweekly psychotherapy sessions and psychiatric follow-up. Initial sessions focused on education regarding the importance of medication adherence and exploration of signs and symptoms that might suggest reemergence of a psycho­tic decompensation. The psychiatrist monitored Mr. K closely to ensure he was able to tolerate his medications to mitigate the possibility that adverse effects would undermine adherence. Mr. K’s reactions to having a psychiatric illness also were explored because of concerns that such self-appraisals might trigger shame, embarrassment, denial, and other responses that might undermine treatment adherence. His family members were apprised of treatment goals and enlisted to foster adherence with medication and follow-up appointments.

Mr. K’s Cannabis use was addressed because ongoing use likely had a negative impact on his schizophrenia (ie, a greater propensity toward relapse and rehospitalization and a poorer ther­apeutic response to antipsychotic medication).^46,47 He was strongly encouraged to avoid Cannabis and other illicit substances.

Psychiatrists can help in examining the meaning behind the injury while helping the patient to adapt to the sequelae and cultivate skills to meet functional demands.⁴¹ Once Mr. K’s psychotic symptoms were in remission, treatment began to address the antecedents of the GSM, as well as the resultant physical consequences. It was reasonable to explore how Mr. K now viewed his actions, as well as the consequences that his actions produced in terms of his physical appearance, sexual functioning, capacity for sexual intimacy, and reproductive potential. It was also important to recognize how such highly intimate and deeply personal self-schema are framed and organized against his cultural and religious background.^27,33

Body image concerns and expectations for future urologic intervention also should be explored. Although Mr. K was not averse to such exploration, he did not spontaneously address such topics in great depth. The discussion was unforced and effectively left open as an issue that could be explored in future sessions.

CASE Bleeding, bewildered

Mr. K, age 23, a South Asian male, is discovered in the bathroom bleeding profusely. Mr. K’s parents inform emergency medical services (EMS) personnel that Mr. K is “not in his right mind” and speculate that he is depressed. EMS personnel find Mr. K sitting in a pool of blood in the bathtub, holding a cloth over his pubic area and complaining of significant pain. They estimate that Mr. K has lost approximately 1 L of blood. Cursory evaluation reveals that his penis is severed; no other injuries or lacerations are notable. Mr. K states, “I did not want it anymore.” A kitchen knife that he used to self-amputate is found nearby. He is awake, alert, and able to follow simple directives.

In the emergency room, Mr. K is in mild-to-moderate distress. He has no history of medical illness, but his parents report that he previously required psychiatric treatment. Mr. K is not able to elaborate. He reluctantly discloses an intermittent history of Cannabis use. Physical examination reveals tachycardia (heart rate: 115 to 120 beats per minute), and despite blood loss, systolic hypertension (blood pressure: 142/70 to 167/70 mm Hg). His pulse oximetry is 97% to 99%; he is afebrile. Laboratory tests are notable for anemia (hemoglobin, 7.2 g/dL [reference range, 14.0 to 17.5 g/dL]; hematocrit, 21.2% [reference range, 41% to 50%]) and serum toxicology screen is positive for benzodiazepines, which had been administered en route to allay his distress.

Mr. K continues to hold pressure on his pubic area. When pressure is released, active arterial spurting of bright red blood is notable. Genital examination reveals a cleanly amputated phallus. Emergent surgical intervention is required to stop the hemorrhage and reattach the penis. Initially, Mr. K is opposed to reattachment, but after a brief discussion with his parents, he consents to surgery. Urology and plastic surgery consultations are elicited to perform the microvascular portion of the procedure.

[polldaddy:9881368]

The authors’ observations

Self-injurious behaviors occur in approximately 1% to 4% of adults in the United States, with chronic and severe self-injury occurring among approximately 1% of the U.S. population.^1,2 Intentional GSM is a relatively rare catastrophic event that is often, but not solely, associated with severe mental illness. Because many cases go unreported, the prevalence of GSM is difficult to estimate.^3,4 Although GSM has been described in both men and women, the literature has predominantly focused on GSM among men.⁵ Genital self-injury has been described in several (ie, ethnic/racial and religious) contexts and has been legally sanctioned.^6-8

Psychiatric disorders associated with, and precipitating factors underlying, GSM have long remained elusive.⁸ GSM has been described in case reports and small case series in both psychiatric and urologic literature. These reports provide incomplete descriptions of the diagnostic conditions and psychosocial factors underlying male GSM.

A recent systematic review of 173 cases of men who engaged in GSM published in the past 115 years (since the first case of GSM was published in the psychiatric literature⁹) revealed that having some form of psychopathology elevates the probability of GSM^10,11; rarely the individual did not have a psychiatric condition.^11-17 Nearly one-half of the men had psychosis; most had a schizophrenia spectrum disorder diagnosis. Other psychiatric conditions associated with GSM include personality disorders, substance use disorder, and gender dysphoria. GSM is rarely associated with anxiety or mood disorders.

GSM is a heterogeneous form of self-injury that ranges from superficial genital lacerations, amputation, or castration to combinations of these injuries. Compared with individuals with other psychiatric disorders, a significantly greater proportion of individuals with schizophrenia spectrum disorders engage in self-amputation (auto-penectomy). By contrast, persons with gender dysphoria tend to engage in self-castration at significantly higher rates than those with other psychiatric conditions.¹¹ Despite these trends, clinicians should not infer a specific psychiatric diagnosis based on the severity or type of self-inflicted injury.

HISTORY Command hallucinations

Postoperatively, Mr. K is managed in the trauma intensive care unit. During psychiatric consultation, Mr. K demonstrates a blunted affect. His speech is low in volume but clear and coherent. His thoughts are generally linear for specific lines of inquiry (eg, about perceived level of pain) but otherwise are impoverished. Mr. K often digresses into repetitively mumbled prayers. He appears distracted, as if responding to internal stimuli. Although he acknowledges the GSM, he does not discuss the factors underlying his decision to proceed with auto-penectomy. Over successive evaluations, he reluctantly discloses that he had been experiencing disparaging auditory hallucinations that told him that his penis “was too small” and commanded him to “cut it off.”

Psychiatric history reveals that Mr. K required psychiatric hospitalization 7 months earlier due to new-onset auditory hallucinations, paranoia, and thought disorganization, in the context of daily Cannabis use. At the time, the differential diagnosis included new-onset schizophrenia and substance-induced psychosis. His symptoms improved quickly with risperidone, 2 mg/d, and he was discharged in a stable condition with referrals for outpatient care. Mr. K admits he had stopped taking risperidone several weeks before the GSM because he was convinced that he had been cured. At that time, Mr. K had told his parents he was no longer required to take medication or engage in outpatient psychiatric treatment, and they did not question this. Mr. K struggled to sustain part-time employment (in a family business), having taken a leave of absence from graduate school after his first hospitalization. He continued to use Cannabis regularly but denies being intoxicated at the time of the GSM. Throughout his surgical hospitalization, Mr. K’s thoughts remain disorganized. He denies that the GSM was a suicide attempt or having current suicidal thoughts, intent, or plans. He also denies having religious preoccupations, over-valued religious beliefs, or delusions.

Mr. K identifies as heterosexual, and denies experiencing distress related to sexual orientation or gender identity or guilt related to sexual impulses or actions. He also denies having a history of trauma or victimization and does not report any symptoms of posttraumatic stress disorder or body dysmorphic disorder.

The authors’ observations

Self-injury elicits strong, emotional responses from health care professionals, including fascination, apprehension, and hopelessness. Psychiatrists who care for such patients should monitor members of the patient’s treatment team for psychological reactions. In addition, the patient’s behavior while hospitalized may stir feelings of retaliation, anger, fear, and frustration.^11,24,37 Collaborative relationships with medical and surgical specialties can help staff manage emotional reactions and avoid the inadvertent expression of those feelings in their interactions with the patient; these reactions might otherwise undermine treatment.^24,34 Family education can help mitigate any guilt family members may harbor for not preventing the injury.³⁷

Although efforts to understand the intended goal(s) and precipitants of the self-injury are likely to be worthwhile, the overwhelming distress associated with GSM and its emergent treatment may preclude intensive exploration. Assessing precipitants of self-injury should be approached using a nonjudgmental, dispassionate, matter-of-fact manner that conveys concern for the patient³⁸ and reassures the patient that the clinician has heard and, ideally, understands the patient’s distress.³⁹ Forced exploration during the prevailing stress of treatment may overwhelm the patient, prove to be overly distressing, and compel the patient to act out in self-injurious ways. Therefore, exploration of the underpinnings of GSM may need to be postponed until surgical treatment is completed, the patient’s symptoms have been managed with psychopharmacologic intervention, and the patient has been transitioned to the safety and close monitoring of an acute psychiatric inpatient setting.

TREATMENT Restarting medication

While on the surgical unit, Mr. K is restarted on risperidone, 2 mg/d. He appears to tolerate the medication without adverse effects. However, because Mr. K continues to experience auditory hallucinations, and the treatment team remains concerned that he might again experience commands to harm himself, he is transferred to an acute psychiatric inpatient setting.

Urology follow-up reveals necrosis/mummification of the replanted penis and an open scrotal wound. After discussing options with the patient and family, the urologist transfers Mr. K back to the surgical unit for wound closure and removal of the replanted penis. A urethrostomy is performed to allow for bladder emptying.

[polldaddy:9881371]

The authors’ observations

Because most published case reports of GSM among men have focused on acute treatment, there is a dearth of literature available on the long-term course of GSM to inform treatment strategies. Because recovery is a non-static process and a patient’s reactions to his injury will likely evolve over time, a multifaceted approach invoking psychiatric and psychotherapeutic interventions is necessary to help patients after initial injury and surgical management^37,40-43 (Table 2^11,20,27,41).

OUTCOME Return to school, work

Mr. K is discharged with close follow-up at a specialized clinic for new-onset psychosis. Post-discharge treatment consists of education about the course of schizophrenia and the need for medication adherence to prevent relapse. Mr. K also is educated on the relationship between Cannabis use and psychosis, and he abstains from illicit substance use. Family involvement is encouraged to help with medication compliance and monitoring for symptom reemergence.

Therapy focuses on exploring the antecedents of the auto-penectomy, Mr. K’s body image issue concerns, and his feelings related to eventual prosthesis implantation. He insists that he cannot recall any precipitating factors for his self-injury other than the command hallucinations. He does not report sexual guilt, although he had been sexually active with his girlfriend in the months prior to his GSM, which goes against his family’s religious beliefs. He reports significant regret and shame for the self-mutilation, and blames himself for not informing family members about his hallucinations. Therapy involves addressing his attribution of blame using cognitive techniques and focuses on measures that can be taken to prevent further self-harm. Efforts are directed at exploring whether cultural and religious traditions impacted the therapeutic alliance, medication adherence, self-esteem and body image, sexuality, and future goals. Over the course of 1 year, he resumes his graduate studies and part-time work, and explores prosthetic placement for cosmetic purposes.

The authors’ observations

Research suggests that major self-mutilation among patients with psychotic illness is likely to occur during the first episode or early in the course of illness and/or with suboptimal treatment.^44,45 Mr. K was enlisted in an intensive outpatient treatment program involving biweekly psychotherapy sessions and psychiatric follow-up. Initial sessions focused on education regarding the importance of medication adherence and exploration of signs and symptoms that might suggest reemergence of a psycho­tic decompensation. The psychiatrist monitored Mr. K closely to ensure he was able to tolerate his medications to mitigate the possibility that adverse effects would undermine adherence. Mr. K’s reactions to having a psychiatric illness also were explored because of concerns that such self-appraisals might trigger shame, embarrassment, denial, and other responses that might undermine treatment adherence. His family members were apprised of treatment goals and enlisted to foster adherence with medication and follow-up appointments.

Mr. K’s Cannabis use was addressed because ongoing use likely had a negative impact on his schizophrenia (ie, a greater propensity toward relapse and rehospitalization and a poorer ther­apeutic response to antipsychotic medication).^46,47 He was strongly encouraged to avoid Cannabis and other illicit substances.

Psychiatrists can help in examining the meaning behind the injury while helping the patient to adapt to the sequelae and cultivate skills to meet functional demands.⁴¹ Once Mr. K’s psychotic symptoms were in remission, treatment began to address the antecedents of the GSM, as well as the resultant physical consequences. It was reasonable to explore how Mr. K now viewed his actions, as well as the consequences that his actions produced in terms of his physical appearance, sexual functioning, capacity for sexual intimacy, and reproductive potential. It was also important to recognize how such highly intimate and deeply personal self-schema are framed and organized against his cultural and religious background.^27,33

Body image concerns and expectations for future urologic intervention also should be explored. Although Mr. K was not averse to such exploration, he did not spontaneously address such topics in great depth. The discussion was unforced and effectively left open as an issue that could be explored in future sessions.

CASE Bleeding, bewildered

Mr. K, age 23, a South Asian male, is discovered in the bathroom bleeding profusely. Mr. K’s parents inform emergency medical services (EMS) personnel that Mr. K is “not in his right mind” and speculate that he is depressed. EMS personnel find Mr. K sitting in a pool of blood in the bathtub, holding a cloth over his pubic area and complaining of significant pain. They estimate that Mr. K has lost approximately 1 L of blood. Cursory evaluation reveals that his penis is severed; no other injuries or lacerations are notable. Mr. K states, “I did not want it anymore.” A kitchen knife that he used to self-amputate is found nearby. He is awake, alert, and able to follow simple directives.

In the emergency room, Mr. K is in mild-to-moderate distress. He has no history of medical illness, but his parents report that he previously required psychiatric treatment. Mr. K is not able to elaborate. He reluctantly discloses an intermittent history of Cannabis use. Physical examination reveals tachycardia (heart rate: 115 to 120 beats per minute), and despite blood loss, systolic hypertension (blood pressure: 142/70 to 167/70 mm Hg). His pulse oximetry is 97% to 99%; he is afebrile. Laboratory tests are notable for anemia (hemoglobin, 7.2 g/dL [reference range, 14.0 to 17.5 g/dL]; hematocrit, 21.2% [reference range, 41% to 50%]) and serum toxicology screen is positive for benzodiazepines, which had been administered en route to allay his distress.

Mr. K continues to hold pressure on his pubic area. When pressure is released, active arterial spurting of bright red blood is notable. Genital examination reveals a cleanly amputated phallus. Emergent surgical intervention is required to stop the hemorrhage and reattach the penis. Initially, Mr. K is opposed to reattachment, but after a brief discussion with his parents, he consents to surgery. Urology and plastic surgery consultations are elicited to perform the microvascular portion of the procedure.

[polldaddy:9881368]

The authors’ observations

Self-injurious behaviors occur in approximately 1% to 4% of adults in the United States, with chronic and severe self-injury occurring among approximately 1% of the U.S. population.^1,2 Intentional GSM is a relatively rare catastrophic event that is often, but not solely, associated with severe mental illness. Because many cases go unreported, the prevalence of GSM is difficult to estimate.^3,4 Although GSM has been described in both men and women, the literature has predominantly focused on GSM among men.⁵ Genital self-injury has been described in several (ie, ethnic/racial and religious) contexts and has been legally sanctioned.^6-8

Psychiatric disorders associated with, and precipitating factors underlying, GSM have long remained elusive.⁸ GSM has been described in case reports and small case series in both psychiatric and urologic literature. These reports provide incomplete descriptions of the diagnostic conditions and psychosocial factors underlying male GSM.

A recent systematic review of 173 cases of men who engaged in GSM published in the past 115 years (since the first case of GSM was published in the psychiatric literature⁹) revealed that having some form of psychopathology elevates the probability of GSM^10,11; rarely the individual did not have a psychiatric condition.^11-17 Nearly one-half of the men had psychosis; most had a schizophrenia spectrum disorder diagnosis. Other psychiatric conditions associated with GSM include personality disorders, substance use disorder, and gender dysphoria. GSM is rarely associated with anxiety or mood disorders.

GSM is a heterogeneous form of self-injury that ranges from superficial genital lacerations, amputation, or castration to combinations of these injuries. Compared with individuals with other psychiatric disorders, a significantly greater proportion of individuals with schizophrenia spectrum disorders engage in self-amputation (auto-penectomy). By contrast, persons with gender dysphoria tend to engage in self-castration at significantly higher rates than those with other psychiatric conditions.¹¹ Despite these trends, clinicians should not infer a specific psychiatric diagnosis based on the severity or type of self-inflicted injury.

HISTORY Command hallucinations

Postoperatively, Mr. K is managed in the trauma intensive care unit. During psychiatric consultation, Mr. K demonstrates a blunted affect. His speech is low in volume but clear and coherent. His thoughts are generally linear for specific lines of inquiry (eg, about perceived level of pain) but otherwise are impoverished. Mr. K often digresses into repetitively mumbled prayers. He appears distracted, as if responding to internal stimuli. Although he acknowledges the GSM, he does not discuss the factors underlying his decision to proceed with auto-penectomy. Over successive evaluations, he reluctantly discloses that he had been experiencing disparaging auditory hallucinations that told him that his penis “was too small” and commanded him to “cut it off.”

Psychiatric history reveals that Mr. K required psychiatric hospitalization 7 months earlier due to new-onset auditory hallucinations, paranoia, and thought disorganization, in the context of daily Cannabis use. At the time, the differential diagnosis included new-onset schizophrenia and substance-induced psychosis. His symptoms improved quickly with risperidone, 2 mg/d, and he was discharged in a stable condition with referrals for outpatient care. Mr. K admits he had stopped taking risperidone several weeks before the GSM because he was convinced that he had been cured. At that time, Mr. K had told his parents he was no longer required to take medication or engage in outpatient psychiatric treatment, and they did not question this. Mr. K struggled to sustain part-time employment (in a family business), having taken a leave of absence from graduate school after his first hospitalization. He continued to use Cannabis regularly but denies being intoxicated at the time of the GSM. Throughout his surgical hospitalization, Mr. K’s thoughts remain disorganized. He denies that the GSM was a suicide attempt or having current suicidal thoughts, intent, or plans. He also denies having religious preoccupations, over-valued religious beliefs, or delusions.

Mr. K identifies as heterosexual, and denies experiencing distress related to sexual orientation or gender identity or guilt related to sexual impulses or actions. He also denies having a history of trauma or victimization and does not report any symptoms of posttraumatic stress disorder or body dysmorphic disorder.

The authors’ observations

Self-injury elicits strong, emotional responses from health care professionals, including fascination, apprehension, and hopelessness. Psychiatrists who care for such patients should monitor members of the patient’s treatment team for psychological reactions. In addition, the patient’s behavior while hospitalized may stir feelings of retaliation, anger, fear, and frustration.^11,24,37 Collaborative relationships with medical and surgical specialties can help staff manage emotional reactions and avoid the inadvertent expression of those feelings in their interactions with the patient; these reactions might otherwise undermine treatment.^24,34 Family education can help mitigate any guilt family members may harbor for not preventing the injury.³⁷

Although efforts to understand the intended goal(s) and precipitants of the self-injury are likely to be worthwhile, the overwhelming distress associated with GSM and its emergent treatment may preclude intensive exploration. Assessing precipitants of self-injury should be approached using a nonjudgmental, dispassionate, matter-of-fact manner that conveys concern for the patient³⁸ and reassures the patient that the clinician has heard and, ideally, understands the patient’s distress.³⁹ Forced exploration during the prevailing stress of treatment may overwhelm the patient, prove to be overly distressing, and compel the patient to act out in self-injurious ways. Therefore, exploration of the underpinnings of GSM may need to be postponed until surgical treatment is completed, the patient’s symptoms have been managed with psychopharmacologic intervention, and the patient has been transitioned to the safety and close monitoring of an acute psychiatric inpatient setting.

TREATMENT Restarting medication

While on the surgical unit, Mr. K is restarted on risperidone, 2 mg/d. He appears to tolerate the medication without adverse effects. However, because Mr. K continues to experience auditory hallucinations, and the treatment team remains concerned that he might again experience commands to harm himself, he is transferred to an acute psychiatric inpatient setting.

Urology follow-up reveals necrosis/mummification of the replanted penis and an open scrotal wound. After discussing options with the patient and family, the urologist transfers Mr. K back to the surgical unit for wound closure and removal of the replanted penis. A urethrostomy is performed to allow for bladder emptying.

[polldaddy:9881371]

The authors’ observations

Because most published case reports of GSM among men have focused on acute treatment, there is a dearth of literature available on the long-term course of GSM to inform treatment strategies. Because recovery is a non-static process and a patient’s reactions to his injury will likely evolve over time, a multifaceted approach invoking psychiatric and psychotherapeutic interventions is necessary to help patients after initial injury and surgical management^37,40-43 (Table 2^11,20,27,41).

OUTCOME Return to school, work

Mr. K is discharged with close follow-up at a specialized clinic for new-onset psychosis. Post-discharge treatment consists of education about the course of schizophrenia and the need for medication adherence to prevent relapse. Mr. K also is educated on the relationship between Cannabis use and psychosis, and he abstains from illicit substance use. Family involvement is encouraged to help with medication compliance and monitoring for symptom reemergence.

Therapy focuses on exploring the antecedents of the auto-penectomy, Mr. K’s body image issue concerns, and his feelings related to eventual prosthesis implantation. He insists that he cannot recall any precipitating factors for his self-injury other than the command hallucinations. He does not report sexual guilt, although he had been sexually active with his girlfriend in the months prior to his GSM, which goes against his family’s religious beliefs. He reports significant regret and shame for the self-mutilation, and blames himself for not informing family members about his hallucinations. Therapy involves addressing his attribution of blame using cognitive techniques and focuses on measures that can be taken to prevent further self-harm. Efforts are directed at exploring whether cultural and religious traditions impacted the therapeutic alliance, medication adherence, self-esteem and body image, sexuality, and future goals. Over the course of 1 year, he resumes his graduate studies and part-time work, and explores prosthetic placement for cosmetic purposes.

The authors’ observations

Research suggests that major self-mutilation among patients with psychotic illness is likely to occur during the first episode or early in the course of illness and/or with suboptimal treatment.^44,45 Mr. K was enlisted in an intensive outpatient treatment program involving biweekly psychotherapy sessions and psychiatric follow-up. Initial sessions focused on education regarding the importance of medication adherence and exploration of signs and symptoms that might suggest reemergence of a psycho­tic decompensation. The psychiatrist monitored Mr. K closely to ensure he was able to tolerate his medications to mitigate the possibility that adverse effects would undermine adherence. Mr. K’s reactions to having a psychiatric illness also were explored because of concerns that such self-appraisals might trigger shame, embarrassment, denial, and other responses that might undermine treatment adherence. His family members were apprised of treatment goals and enlisted to foster adherence with medication and follow-up appointments.

Mr. K’s Cannabis use was addressed because ongoing use likely had a negative impact on his schizophrenia (ie, a greater propensity toward relapse and rehospitalization and a poorer ther­apeutic response to antipsychotic medication).^46,47 He was strongly encouraged to avoid Cannabis and other illicit substances.

Psychiatrists can help in examining the meaning behind the injury while helping the patient to adapt to the sequelae and cultivate skills to meet functional demands.⁴¹ Once Mr. K’s psychotic symptoms were in remission, treatment began to address the antecedents of the GSM, as well as the resultant physical consequences. It was reasonable to explore how Mr. K now viewed his actions, as well as the consequences that his actions produced in terms of his physical appearance, sexual functioning, capacity for sexual intimacy, and reproductive potential. It was also important to recognize how such highly intimate and deeply personal self-schema are framed and organized against his cultural and religious background.^27,33

Body image concerns and expectations for future urologic intervention also should be explored. Although Mr. K was not averse to such exploration, he did not spontaneously address such topics in great depth. The discussion was unforced and effectively left open as an issue that could be explored in future sessions.

Mindfulness is actively being aware of one’s inner and outer environments in the present moment. Core mindfulness skills include observation, description, participation, a nonjudgmental approach, focusing on 1 thing at a time, and effectiveness.¹

Psychotherapeutic interventions based on each of these skills have been developed to instill a mindful state in psychiatric patients. Evidence suggests these interventions can be helpful when treating borderline personality disorder, somatization, pain, depression, and anxiety, among other conditions.²

Elements of mindfulness can be integrated into brief interventions. The following 6 simple, practical exercises can be used to help patients develop these skills.

Observation involves noticing internal and external experiences, including thoughts and sensations, without applying words or labels. Guide your patient through the following exercise:

Focus your attention on the ground beneath your feet, feeling the pressure, temperature, and texture of this sensation. Do the same with your seat, your breath, and the sounds, sights, and smells of the room. Be aware of your thoughts and watch them come and go like fish in a fishbowl.

Description entails assigning purely descriptive words to one’s observations. To help your patient develop this skill, ask him (her) to describe the sensations he (she) observed in the previous exercise.

Participation entails immersive engagement in an activity. Ask your patient to listen to a song he has never heard before, and then play it again and dance or sing along. Instruct him to engage wholly, conscious of each step or note, without being judgmental or self-conscious. If he feels embarrassed or self-critical, tell him to observe these thoughts and emotions, put them aside, and return to the activity.

A nonjudgmental approach consists of separating out the facts and recognizing emotional responses without clinging to them. To practice this skill, ask your patient to play a song that he likes and one that he dislikes. The patient should listen to each, observing and describing the way they sound without judgment. Tell the patient that if judgmental words or phrases, such as “beautiful,” “ugly,” “I love…,” or “I hate…,” appear as thoughts, he should observe them, put them aside, and then return to nonjudgmental description and observation.

Focusing on 1 thing at a time means dedicating complete attention to a single task, activity, or thought. Give your patient a short paragraph or poem to read. Instruct him to try not to focus on recent personal events or what he will eat for dinner while reading. If he would like to switch to other tasks, then he should give his whole attention to this other task, and stop reading.

Effectiveness involves focusing on what works to attain one’s goals. For this exercise, set up a task for your patient by placing several items in a location that is neither immediately obvious nor readily accessible without an intermediate step. Instruct your patient to obtain these objects. Then guide them as follows:

What do you have to do to get them? Ask permission? Borrow a key? Recruit assistance? Determine the location? Brainstorm ways to obtain the items, and then complete the task.

Mindfulness is actively being aware of one’s inner and outer environments in the present moment. Core mindfulness skills include observation, description, participation, a nonjudgmental approach, focusing on 1 thing at a time, and effectiveness.¹

Psychotherapeutic interventions based on each of these skills have been developed to instill a mindful state in psychiatric patients. Evidence suggests these interventions can be helpful when treating borderline personality disorder, somatization, pain, depression, and anxiety, among other conditions.²

Elements of mindfulness can be integrated into brief interventions. The following 6 simple, practical exercises can be used to help patients develop these skills.

Observation involves noticing internal and external experiences, including thoughts and sensations, without applying words or labels. Guide your patient through the following exercise:

Focus your attention on the ground beneath your feet, feeling the pressure, temperature, and texture of this sensation. Do the same with your seat, your breath, and the sounds, sights, and smells of the room. Be aware of your thoughts and watch them come and go like fish in a fishbowl.

Description entails assigning purely descriptive words to one’s observations. To help your patient develop this skill, ask him (her) to describe the sensations he (she) observed in the previous exercise.

Participation entails immersive engagement in an activity. Ask your patient to listen to a song he has never heard before, and then play it again and dance or sing along. Instruct him to engage wholly, conscious of each step or note, without being judgmental or self-conscious. If he feels embarrassed or self-critical, tell him to observe these thoughts and emotions, put them aside, and return to the activity.

A nonjudgmental approach consists of separating out the facts and recognizing emotional responses without clinging to them. To practice this skill, ask your patient to play a song that he likes and one that he dislikes. The patient should listen to each, observing and describing the way they sound without judgment. Tell the patient that if judgmental words or phrases, such as “beautiful,” “ugly,” “I love…,” or “I hate…,” appear as thoughts, he should observe them, put them aside, and then return to nonjudgmental description and observation.

Focusing on 1 thing at a time means dedicating complete attention to a single task, activity, or thought. Give your patient a short paragraph or poem to read. Instruct him to try not to focus on recent personal events or what he will eat for dinner while reading. If he would like to switch to other tasks, then he should give his whole attention to this other task, and stop reading.

Effectiveness involves focusing on what works to attain one’s goals. For this exercise, set up a task for your patient by placing several items in a location that is neither immediately obvious nor readily accessible without an intermediate step. Instruct your patient to obtain these objects. Then guide them as follows:

What do you have to do to get them? Ask permission? Borrow a key? Recruit assistance? Determine the location? Brainstorm ways to obtain the items, and then complete the task.

Mindfulness is actively being aware of one’s inner and outer environments in the present moment. Core mindfulness skills include observation, description, participation, a nonjudgmental approach, focusing on 1 thing at a time, and effectiveness.¹

Psychotherapeutic interventions based on each of these skills have been developed to instill a mindful state in psychiatric patients. Evidence suggests these interventions can be helpful when treating borderline personality disorder, somatization, pain, depression, and anxiety, among other conditions.²

Elements of mindfulness can be integrated into brief interventions. The following 6 simple, practical exercises can be used to help patients develop these skills.

Observation involves noticing internal and external experiences, including thoughts and sensations, without applying words or labels. Guide your patient through the following exercise:

Focus your attention on the ground beneath your feet, feeling the pressure, temperature, and texture of this sensation. Do the same with your seat, your breath, and the sounds, sights, and smells of the room. Be aware of your thoughts and watch them come and go like fish in a fishbowl.

Description entails assigning purely descriptive words to one’s observations. To help your patient develop this skill, ask him (her) to describe the sensations he (she) observed in the previous exercise.

Participation entails immersive engagement in an activity. Ask your patient to listen to a song he has never heard before, and then play it again and dance or sing along. Instruct him to engage wholly, conscious of each step or note, without being judgmental or self-conscious. If he feels embarrassed or self-critical, tell him to observe these thoughts and emotions, put them aside, and return to the activity.

A nonjudgmental approach consists of separating out the facts and recognizing emotional responses without clinging to them. To practice this skill, ask your patient to play a song that he likes and one that he dislikes. The patient should listen to each, observing and describing the way they sound without judgment. Tell the patient that if judgmental words or phrases, such as “beautiful,” “ugly,” “I love…,” or “I hate…,” appear as thoughts, he should observe them, put them aside, and then return to nonjudgmental description and observation.

Focusing on 1 thing at a time means dedicating complete attention to a single task, activity, or thought. Give your patient a short paragraph or poem to read. Instruct him to try not to focus on recent personal events or what he will eat for dinner while reading. If he would like to switch to other tasks, then he should give his whole attention to this other task, and stop reading.

Effectiveness involves focusing on what works to attain one’s goals. For this exercise, set up a task for your patient by placing several items in a location that is neither immediately obvious nor readily accessible without an intermediate step. Instruct your patient to obtain these objects. Then guide them as follows:

What do you have to do to get them? Ask permission? Borrow a key? Recruit assistance? Determine the location? Brainstorm ways to obtain the items, and then complete the task.

Patients who are Muslim—followers of the religion of Islam—struggle with a political climate that has demonized them and the continued fallout of terrorist attacks perpetrated by individuals who identify themselves as Muslim. These patients may experience low self-esteem, bullying, depression, anxiety, or posttraumatic stress disorder.¹ Some have expressed feeling judged, labeled, attacked, and subjected to discrimination. Islamophobia and a spike in hate crimes have further marginalized this already vulnerable population.² Thus, understanding your Muslim patients is the first step to treating their mental illness.

How Muslim culture might affect care

Muslims are not a monolithic group; they vary widely in their religious adherence, cultural background, and acculturation. Some are American-born, including a significant African American Muslim population. Others are children of immigrants or have recently immigrated, including many who came to the United States because of the ongoing war in Syria. Many can trace their heritage to >50 predominantly Muslim countries. Many Muslim patients want to find a balance between their religious and American identities.

As clinicians, we should not make assumptions based on outward appearances or our preconceived notions of our patients, especially when it comes to gender roles. Our job is to ask how highly personal, individualized decisions, such as a woman’s choice to wear a hijab as an expression of her faith and a symbol of modesty, factor into our patients’ day-to-day lives. Doing so can help build the therapeutic alliance and improve the accuracy of the diagnosis and the appropriateness of treatment.

Mental health clinicians are well aware of the dangers of the social stigma that their patients may experience.³ These dangers are no different when it comes to Muslim patients, who often may face “double discrimination” for their religion and for having a mental illness. They may seek support from religious leaders, family, and friends before seeing a mental health provider. Some may view their mental illness as a weakness of faith, a punishment by God, or an affliction caused by a supernatural spirit, and therefore may feel that following religious doctrine will resolve their psychological distress.⁴ They may need additional encouragement to see a therapist or take psycho­tropics, and they may prefer specific treatments that reflect their cultural values, such as supplements.

Because some Muslim patients may be more comfortable presenting their psycho­logical concerns as somatic symptoms, they may first seek care from a primary care physician. Some patients may not be open or comfortable enough to address sensitive issues, such as substance use. Providing psychoeducation, comparing mental illness with medical illness, and emphasizing doctor–patient confidentiality may help these patients overcome the stigma that can act as a barrier to care.

Provide culturally competent care

Resources are available to help us provide the best possible care to our patients from various cultures and religions, including Muslim patients. A good starting point is the DSM-5’s Cultural Formulation Interview, which is a set of 16 questions psychiatrists can use to determine the impact of culture on a patient’s clinical presentation and care.⁵ Other resources include the American Psychiatric Association’s Assessment of Cultural Factors and the American Academy of Child and Adolescent Psychiatry’s Practice Parameter for Cultural Competence.⁶

When treating Muslim patients, remember to:

• Ask about what roles their culture and religion play
• Understand their explanation of their symptoms
• Work to overcome any stigma patients may perceive related to having a psychiatric disorder
• Engage your team to identify cultural and religious factors
• Connect to community resources, such as the patient’s family and friends.

Patients who are Muslim—followers of the religion of Islam—struggle with a political climate that has demonized them and the continued fallout of terrorist attacks perpetrated by individuals who identify themselves as Muslim. These patients may experience low self-esteem, bullying, depression, anxiety, or posttraumatic stress disorder.¹ Some have expressed feeling judged, labeled, attacked, and subjected to discrimination. Islamophobia and a spike in hate crimes have further marginalized this already vulnerable population.² Thus, understanding your Muslim patients is the first step to treating their mental illness.

How Muslim culture might affect care

Muslims are not a monolithic group; they vary widely in their religious adherence, cultural background, and acculturation. Some are American-born, including a significant African American Muslim population. Others are children of immigrants or have recently immigrated, including many who came to the United States because of the ongoing war in Syria. Many can trace their heritage to >50 predominantly Muslim countries. Many Muslim patients want to find a balance between their religious and American identities.

As clinicians, we should not make assumptions based on outward appearances or our preconceived notions of our patients, especially when it comes to gender roles. Our job is to ask how highly personal, individualized decisions, such as a woman’s choice to wear a hijab as an expression of her faith and a symbol of modesty, factor into our patients’ day-to-day lives. Doing so can help build the therapeutic alliance and improve the accuracy of the diagnosis and the appropriateness of treatment.

Mental health clinicians are well aware of the dangers of the social stigma that their patients may experience.³ These dangers are no different when it comes to Muslim patients, who often may face “double discrimination” for their religion and for having a mental illness. They may seek support from religious leaders, family, and friends before seeing a mental health provider. Some may view their mental illness as a weakness of faith, a punishment by God, or an affliction caused by a supernatural spirit, and therefore may feel that following religious doctrine will resolve their psychological distress.⁴ They may need additional encouragement to see a therapist or take psycho­tropics, and they may prefer specific treatments that reflect their cultural values, such as supplements.

Because some Muslim patients may be more comfortable presenting their psycho­logical concerns as somatic symptoms, they may first seek care from a primary care physician. Some patients may not be open or comfortable enough to address sensitive issues, such as substance use. Providing psychoeducation, comparing mental illness with medical illness, and emphasizing doctor–patient confidentiality may help these patients overcome the stigma that can act as a barrier to care.

Provide culturally competent care

Resources are available to help us provide the best possible care to our patients from various cultures and religions, including Muslim patients. A good starting point is the DSM-5’s Cultural Formulation Interview, which is a set of 16 questions psychiatrists can use to determine the impact of culture on a patient’s clinical presentation and care.⁵ Other resources include the American Psychiatric Association’s Assessment of Cultural Factors and the American Academy of Child and Adolescent Psychiatry’s Practice Parameter for Cultural Competence.⁶

When treating Muslim patients, remember to:

• Ask about what roles their culture and religion play
• Understand their explanation of their symptoms
• Work to overcome any stigma patients may perceive related to having a psychiatric disorder
• Engage your team to identify cultural and religious factors
• Connect to community resources, such as the patient’s family and friends.

Patients who are Muslim—followers of the religion of Islam—struggle with a political climate that has demonized them and the continued fallout of terrorist attacks perpetrated by individuals who identify themselves as Muslim. These patients may experience low self-esteem, bullying, depression, anxiety, or posttraumatic stress disorder.¹ Some have expressed feeling judged, labeled, attacked, and subjected to discrimination. Islamophobia and a spike in hate crimes have further marginalized this already vulnerable population.² Thus, understanding your Muslim patients is the first step to treating their mental illness.

How Muslim culture might affect care

Muslims are not a monolithic group; they vary widely in their religious adherence, cultural background, and acculturation. Some are American-born, including a significant African American Muslim population. Others are children of immigrants or have recently immigrated, including many who came to the United States because of the ongoing war in Syria. Many can trace their heritage to >50 predominantly Muslim countries. Many Muslim patients want to find a balance between their religious and American identities.

As clinicians, we should not make assumptions based on outward appearances or our preconceived notions of our patients, especially when it comes to gender roles. Our job is to ask how highly personal, individualized decisions, such as a woman’s choice to wear a hijab as an expression of her faith and a symbol of modesty, factor into our patients’ day-to-day lives. Doing so can help build the therapeutic alliance and improve the accuracy of the diagnosis and the appropriateness of treatment.

Mental health clinicians are well aware of the dangers of the social stigma that their patients may experience.³ These dangers are no different when it comes to Muslim patients, who often may face “double discrimination” for their religion and for having a mental illness. They may seek support from religious leaders, family, and friends before seeing a mental health provider. Some may view their mental illness as a weakness of faith, a punishment by God, or an affliction caused by a supernatural spirit, and therefore may feel that following religious doctrine will resolve their psychological distress.⁴ They may need additional encouragement to see a therapist or take psycho­tropics, and they may prefer specific treatments that reflect their cultural values, such as supplements.

Because some Muslim patients may be more comfortable presenting their psycho­logical concerns as somatic symptoms, they may first seek care from a primary care physician. Some patients may not be open or comfortable enough to address sensitive issues, such as substance use. Providing psychoeducation, comparing mental illness with medical illness, and emphasizing doctor–patient confidentiality may help these patients overcome the stigma that can act as a barrier to care.

Provide culturally competent care

Resources are available to help us provide the best possible care to our patients from various cultures and religions, including Muslim patients. A good starting point is the DSM-5’s Cultural Formulation Interview, which is a set of 16 questions psychiatrists can use to determine the impact of culture on a patient’s clinical presentation and care.⁵ Other resources include the American Psychiatric Association’s Assessment of Cultural Factors and the American Academy of Child and Adolescent Psychiatry’s Practice Parameter for Cultural Competence.⁶

When treating Muslim patients, remember to:

• Ask about what roles their culture and religion play
• Understand their explanation of their symptoms
• Work to overcome any stigma patients may perceive related to having a psychiatric disorder
• Engage your team to identify cultural and religious factors
• Connect to community resources, such as the patient’s family and friends.

PARIS – Converging evidence suggests that attention-deficit/hyperactivity disorder and sleep difficulties share a common underlying etiology involving circadian rhythm disturbance, J.J. Sandra Kooij, MD, PhD, declared at the annual congress of the European College of Neuropsychopharmacology.

“If you review the evidence, it looks more and more like ADHD and sleeplessness are two sides of the same physiological and mental coin,” said Dr. Kooij, a psychiatrist at VU University Medical Center, Amsterdam, and chair of the European Network Adult ADHD.

Bruce Jancin/Frontline Medical News

[email protected]

PARIS – Converging evidence suggests that attention-deficit/hyperactivity disorder and sleep difficulties share a common underlying etiology involving circadian rhythm disturbance, J.J. Sandra Kooij, MD, PhD, declared at the annual congress of the European College of Neuropsychopharmacology.

“If you review the evidence, it looks more and more like ADHD and sleeplessness are two sides of the same physiological and mental coin,” said Dr. Kooij, a psychiatrist at VU University Medical Center, Amsterdam, and chair of the European Network Adult ADHD.

Bruce Jancin/Frontline Medical News

[email protected]

PARIS – Converging evidence suggests that attention-deficit/hyperactivity disorder and sleep difficulties share a common underlying etiology involving circadian rhythm disturbance, J.J. Sandra Kooij, MD, PhD, declared at the annual congress of the European College of Neuropsychopharmacology.

“If you review the evidence, it looks more and more like ADHD and sleeplessness are two sides of the same physiological and mental coin,” said Dr. Kooij, a psychiatrist at VU University Medical Center, Amsterdam, and chair of the European Network Adult ADHD.

Bruce Jancin/Frontline Medical News

[email protected]