APA 2011

HONOLULU – The use of Internet-based cognitive-behavioral therapy could cure half of patients with internalizing mental disorders, including depression, social phobia, panic disorder, and generalized anxiety disorder, a review of data suggests.

Internalizing disorders account for half of mental disorders, Dr. Gavin P. Andrews said at the annual meeting of the American Psychiatric Association.

"A quarter of the burden of mental disorders is potentially removable by Internet-based cognitive-behavioral therapy" (CBT), said Dr. Andrews, professor of psychiatry at the University of New South Wales, Sydney, Australia. "If our profession could get a handle on effective treatment for internalizing disorders, we’d make a fundamental move forward."

Internet-based CBT is a self-help program mediated through the Internet. The patient is in contact through e-mail with the person directing the therapy, which consists of psychoeducation and various exercises are completed online.

Dr. Andrews and his associates conducted a review of the literature and metaanalysis of data from 22 studies of Internet-based CBT involving 1,746 patients. The effect-size superiority over comparison groups was larger than the effect-size superiority traditionally seen for treatment of anxiety disorders using face-to-face CBT or selective serotonin reuptake inhibitors (SSRIs), compared with control groups, he said.

For each of the disorders (depression, social phobia, panic disorder, and generalized anxiety disorder), the number needed to treat with Internet-based CBT in order to show an effect was two (PLoS One 2010;5:e13196).

"Treat two people and one gets better. This is powerful treatment in psychiatry. It’s powerful treatment in medicine," said Dr. Andrews, who is a member of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group for the DSM-5.

The effects of Internet-based CBT appear to last, he added. Although the median follow-up time in the studies was approximately 6 months, some Swedish studies had 18-month follow-up data.

"There was no hint of relapse reported in any study, which is just foreign to my experience," he said. "Depression is supposed to be a relapsing and recurring disorder. What on earth is it doing just disappearing after someone does CBT over the Web? This is not what any of us were trained for."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

Dr. Andrews said the study was commissioned by the Journal of the American Medical Association, which declined to publish the results. He and his associates have now published 15 randomized, controlled trials, including approximately 1,500 people showing the effectiveness of Internet-based CBT, he said.

In a recent randomized, controlled study, Dr. Andrews and his associates tested the third iteration of transdiagnostic Internet-based CBT that they developed for patients with depression, social phobia, panic disorder, or generalized anxiety disorder. The study, recently published online in advance of print, compared 75 patients who underwent the clinician-guided Internet-based CBT or were on a waiting list for treatment. (Behav. Res. and Therapy 2011 [doi: 10.1016/j.brat.2011.03.007]). The effect-size superiority of the Internet-based CBT was 0.6 a measured on the Depression Anxiety Stress Scales, he said, roughly equivalent to effect sizes seen previously with face-to-face CBT or SSRI treatment. Measures of adherence showed that 76% of patients finished all eight of the Internet-based CBT lessons. Therapist guidance amounted to 70 minutes per patient by e-mail or phone over a 10-week period, on average. About 90% of patients said they would recommend the treatment to a friend.

In general, adherence to Internet-based CBT in Dr. Andrews’s studies averages around 75% of patients, "which is definitely better than what we see in our face-to-face clinics," he said. Data from approximately 1,300 Australian primary care physicians who are using Internet-based CBT with their patients suggest that the adherence rate is 54%. "Even 54% is extraordinarily good," Dr. Andrews said.

A separate analysis by Dr. Andrews and his associates suggests that the patients using Internet-based CBT are similar to patients seen in face-to-face CBT clinics. Among patients with depression, most are treatment experienced, with a history of multiple episodes of depression that began before age 20 years. "Those would not be easy cases," he said.

The simplicity, accessibility, and effectiveness of Internet-based CBT make it a powerful tool for treating internalizing mental disorders, but one that could downgrade the central role of the clinician in treating patients with these problems, he suggested. "You and I were trained that we were the key variable, and it offends me" to be usurped, he said facetiously.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

Dr. Andrews said he has no relevant conflicts of interest.

HONOLULU – The use of Internet-based cognitive-behavioral therapy could cure half of patients with internalizing mental disorders, including depression, social phobia, panic disorder, and generalized anxiety disorder, a review of data suggests.

Internalizing disorders account for half of mental disorders, Dr. Gavin P. Andrews said at the annual meeting of the American Psychiatric Association.

"A quarter of the burden of mental disorders is potentially removable by Internet-based cognitive-behavioral therapy" (CBT), said Dr. Andrews, professor of psychiatry at the University of New South Wales, Sydney, Australia. "If our profession could get a handle on effective treatment for internalizing disorders, we’d make a fundamental move forward."

Internet-based CBT is a self-help program mediated through the Internet. The patient is in contact through e-mail with the person directing the therapy, which consists of psychoeducation and various exercises are completed online.

Dr. Andrews and his associates conducted a review of the literature and metaanalysis of data from 22 studies of Internet-based CBT involving 1,746 patients. The effect-size superiority over comparison groups was larger than the effect-size superiority traditionally seen for treatment of anxiety disorders using face-to-face CBT or selective serotonin reuptake inhibitors (SSRIs), compared with control groups, he said.

For each of the disorders (depression, social phobia, panic disorder, and generalized anxiety disorder), the number needed to treat with Internet-based CBT in order to show an effect was two (PLoS One 2010;5:e13196).

"Treat two people and one gets better. This is powerful treatment in psychiatry. It’s powerful treatment in medicine," said Dr. Andrews, who is a member of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group for the DSM-5.

The effects of Internet-based CBT appear to last, he added. Although the median follow-up time in the studies was approximately 6 months, some Swedish studies had 18-month follow-up data.

"There was no hint of relapse reported in any study, which is just foreign to my experience," he said. "Depression is supposed to be a relapsing and recurring disorder. What on earth is it doing just disappearing after someone does CBT over the Web? This is not what any of us were trained for."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

Dr. Andrews said the study was commissioned by the Journal of the American Medical Association, which declined to publish the results. He and his associates have now published 15 randomized, controlled trials, including approximately 1,500 people showing the effectiveness of Internet-based CBT, he said.

In a recent randomized, controlled study, Dr. Andrews and his associates tested the third iteration of transdiagnostic Internet-based CBT that they developed for patients with depression, social phobia, panic disorder, or generalized anxiety disorder. The study, recently published online in advance of print, compared 75 patients who underwent the clinician-guided Internet-based CBT or were on a waiting list for treatment. (Behav. Res. and Therapy 2011 [doi: 10.1016/j.brat.2011.03.007]). The effect-size superiority of the Internet-based CBT was 0.6 a measured on the Depression Anxiety Stress Scales, he said, roughly equivalent to effect sizes seen previously with face-to-face CBT or SSRI treatment. Measures of adherence showed that 76% of patients finished all eight of the Internet-based CBT lessons. Therapist guidance amounted to 70 minutes per patient by e-mail or phone over a 10-week period, on average. About 90% of patients said they would recommend the treatment to a friend.

In general, adherence to Internet-based CBT in Dr. Andrews’s studies averages around 75% of patients, "which is definitely better than what we see in our face-to-face clinics," he said. Data from approximately 1,300 Australian primary care physicians who are using Internet-based CBT with their patients suggest that the adherence rate is 54%. "Even 54% is extraordinarily good," Dr. Andrews said.

A separate analysis by Dr. Andrews and his associates suggests that the patients using Internet-based CBT are similar to patients seen in face-to-face CBT clinics. Among patients with depression, most are treatment experienced, with a history of multiple episodes of depression that began before age 20 years. "Those would not be easy cases," he said.

The simplicity, accessibility, and effectiveness of Internet-based CBT make it a powerful tool for treating internalizing mental disorders, but one that could downgrade the central role of the clinician in treating patients with these problems, he suggested. "You and I were trained that we were the key variable, and it offends me" to be usurped, he said facetiously.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

Dr. Andrews said he has no relevant conflicts of interest.

HONOLULU – The use of Internet-based cognitive-behavioral therapy could cure half of patients with internalizing mental disorders, including depression, social phobia, panic disorder, and generalized anxiety disorder, a review of data suggests.

Internalizing disorders account for half of mental disorders, Dr. Gavin P. Andrews said at the annual meeting of the American Psychiatric Association.

"A quarter of the burden of mental disorders is potentially removable by Internet-based cognitive-behavioral therapy" (CBT), said Dr. Andrews, professor of psychiatry at the University of New South Wales, Sydney, Australia. "If our profession could get a handle on effective treatment for internalizing disorders, we’d make a fundamental move forward."

Internet-based CBT is a self-help program mediated through the Internet. The patient is in contact through e-mail with the person directing the therapy, which consists of psychoeducation and various exercises are completed online.

Dr. Andrews and his associates conducted a review of the literature and metaanalysis of data from 22 studies of Internet-based CBT involving 1,746 patients. The effect-size superiority over comparison groups was larger than the effect-size superiority traditionally seen for treatment of anxiety disorders using face-to-face CBT or selective serotonin reuptake inhibitors (SSRIs), compared with control groups, he said.

For each of the disorders (depression, social phobia, panic disorder, and generalized anxiety disorder), the number needed to treat with Internet-based CBT in order to show an effect was two (PLoS One 2010;5:e13196).

"Treat two people and one gets better. This is powerful treatment in psychiatry. It’s powerful treatment in medicine," said Dr. Andrews, who is a member of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group for the DSM-5.

The effects of Internet-based CBT appear to last, he added. Although the median follow-up time in the studies was approximately 6 months, some Swedish studies had 18-month follow-up data.

"There was no hint of relapse reported in any study, which is just foreign to my experience," he said. "Depression is supposed to be a relapsing and recurring disorder. What on earth is it doing just disappearing after someone does CBT over the Web? This is not what any of us were trained for."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

Dr. Andrews said the study was commissioned by the Journal of the American Medical Association, which declined to publish the results. He and his associates have now published 15 randomized, controlled trials, including approximately 1,500 people showing the effectiveness of Internet-based CBT, he said.

In a recent randomized, controlled study, Dr. Andrews and his associates tested the third iteration of transdiagnostic Internet-based CBT that they developed for patients with depression, social phobia, panic disorder, or generalized anxiety disorder. The study, recently published online in advance of print, compared 75 patients who underwent the clinician-guided Internet-based CBT or were on a waiting list for treatment. (Behav. Res. and Therapy 2011 [doi: 10.1016/j.brat.2011.03.007]). The effect-size superiority of the Internet-based CBT was 0.6 a measured on the Depression Anxiety Stress Scales, he said, roughly equivalent to effect sizes seen previously with face-to-face CBT or SSRI treatment. Measures of adherence showed that 76% of patients finished all eight of the Internet-based CBT lessons. Therapist guidance amounted to 70 minutes per patient by e-mail or phone over a 10-week period, on average. About 90% of patients said they would recommend the treatment to a friend.

In general, adherence to Internet-based CBT in Dr. Andrews’s studies averages around 75% of patients, "which is definitely better than what we see in our face-to-face clinics," he said. Data from approximately 1,300 Australian primary care physicians who are using Internet-based CBT with their patients suggest that the adherence rate is 54%. "Even 54% is extraordinarily good," Dr. Andrews said.

A separate analysis by Dr. Andrews and his associates suggests that the patients using Internet-based CBT are similar to patients seen in face-to-face CBT clinics. Among patients with depression, most are treatment experienced, with a history of multiple episodes of depression that began before age 20 years. "Those would not be easy cases," he said.

The simplicity, accessibility, and effectiveness of Internet-based CBT make it a powerful tool for treating internalizing mental disorders, but one that could downgrade the central role of the clinician in treating patients with these problems, he suggested. "You and I were trained that we were the key variable, and it offends me" to be usurped, he said facetiously.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

Dr. Andrews said he has no relevant conflicts of interest.

HONOLULU – Twenty minutes per day of either meditation or relaxation improved depression scores in family caregivers of people with dementia, but meditation seemed to provide additional benefits in a randomized, controlled pilot study in 39 caregivers.

Mental functioning and cognition scores improved significantly in the meditation group, compared with the relaxation group, Dr. Helen Lavretsky and Dr. Michael Irwin reported in a poster presentation at the annual meeting of the American Psychiatric Association. Both are professors of psychiatry and biobehavioral sciences at the University of California, Los Angeles.

The 23 caregivers in the meditation group averaged 61 years of age and the 16 caregivers in the relaxation group averaged 61 years of age. They had been caring for a family member with dementia for 5 years and 4 years, respectively. Participants in the relaxation group spent significantly more time per week in caregiving, averaging 63 hours vs. 48 in the meditation group. Hamilton Rating Scale–Depression (HAM-D) scores at baseline were 11.8 in the meditation group and 11.4 in the relaxation group.

Participants in the meditation group were trained in a yoga practice of meditation called Kirtan Kriya that involves chanting, breath work, and finger poses. Participants in the control group were asked to rest quietly while listening to relaxation recordings. Each group devoted 20 minutes per day to the activity for 8 weeks.

In both groups, devoting time each day to self-care was new to participants, all but two of whom were women, Dr. Lavretsky said in an interview.

HAM-D scores improved by 7 points in the meditation group and by 5 points in the relaxation group, a difference that was not statistically significant. The perceived burden of care improved in both groups, too.

In the meditation group, however, 52% showed at least a 50% improvement on the 36-item short form health survey (SF-36) global mental health score, compared with 19% in the relaxation group, which was a significant difference between groups.

Measures of cognition also improved significantly in the meditation group, compared with the control group. Mini-Mental Status Examination scores increased by 0.2 points in the meditation group and decreased by 0.9 points in the relaxation group. Times to complete the Trail Making Test (Part B), a measure of executive function, decreased by 11.2 seconds in the meditation group but increased by 9.9 seconds in the relaxation group.

Preliminary data from several other measures in the study suggest biological differences in outcomes, Dr. Lavretsky said. Intranuclear staining and flow cytometry showed that a significantly lower proportion of lymphocytes was positive for nuclear transcription factor–kappa beta (a protein complex that has been linked to chronic stress and inflammatory responses) in the meditation practitioners, compared with the control group. The meditation group also showed increased telomerase activity, compared with the relaxation group. Telomere length and telomerase activity are markers of biological age linking stress and disease, she said.

PET scan results suggested that improvements in cognition were associated with changes in regional brain metabolism in areas relevant for executive dysfunction and global cognition.

This and other studies suggest that meditation, tai chi, or other mind-body techniques seem to be helpful stress-reducing therapies for family caregivers of people with dementia, Dr. Lavretsky said.

A larger study is planned that also will compare the Kirtan Kriya form of meditation with aerobic exercise in stressed family caregivers of people with dementia, she said.

The Alzheimer’s Research and Prevention Foundation funded the study. Dr. Lavretsky is a certified yoga instructor who has practices the Kirtan Kriya form of meditation.

HONOLULU – Twenty minutes per day of either meditation or relaxation improved depression scores in family caregivers of people with dementia, but meditation seemed to provide additional benefits in a randomized, controlled pilot study in 39 caregivers.

Mental functioning and cognition scores improved significantly in the meditation group, compared with the relaxation group, Dr. Helen Lavretsky and Dr. Michael Irwin reported in a poster presentation at the annual meeting of the American Psychiatric Association. Both are professors of psychiatry and biobehavioral sciences at the University of California, Los Angeles.

The 23 caregivers in the meditation group averaged 61 years of age and the 16 caregivers in the relaxation group averaged 61 years of age. They had been caring for a family member with dementia for 5 years and 4 years, respectively. Participants in the relaxation group spent significantly more time per week in caregiving, averaging 63 hours vs. 48 in the meditation group. Hamilton Rating Scale–Depression (HAM-D) scores at baseline were 11.8 in the meditation group and 11.4 in the relaxation group.

Participants in the meditation group were trained in a yoga practice of meditation called Kirtan Kriya that involves chanting, breath work, and finger poses. Participants in the control group were asked to rest quietly while listening to relaxation recordings. Each group devoted 20 minutes per day to the activity for 8 weeks.

In both groups, devoting time each day to self-care was new to participants, all but two of whom were women, Dr. Lavretsky said in an interview.

HAM-D scores improved by 7 points in the meditation group and by 5 points in the relaxation group, a difference that was not statistically significant. The perceived burden of care improved in both groups, too.

In the meditation group, however, 52% showed at least a 50% improvement on the 36-item short form health survey (SF-36) global mental health score, compared with 19% in the relaxation group, which was a significant difference between groups.

Measures of cognition also improved significantly in the meditation group, compared with the control group. Mini-Mental Status Examination scores increased by 0.2 points in the meditation group and decreased by 0.9 points in the relaxation group. Times to complete the Trail Making Test (Part B), a measure of executive function, decreased by 11.2 seconds in the meditation group but increased by 9.9 seconds in the relaxation group.

Preliminary data from several other measures in the study suggest biological differences in outcomes, Dr. Lavretsky said. Intranuclear staining and flow cytometry showed that a significantly lower proportion of lymphocytes was positive for nuclear transcription factor–kappa beta (a protein complex that has been linked to chronic stress and inflammatory responses) in the meditation practitioners, compared with the control group. The meditation group also showed increased telomerase activity, compared with the relaxation group. Telomere length and telomerase activity are markers of biological age linking stress and disease, she said.

PET scan results suggested that improvements in cognition were associated with changes in regional brain metabolism in areas relevant for executive dysfunction and global cognition.

This and other studies suggest that meditation, tai chi, or other mind-body techniques seem to be helpful stress-reducing therapies for family caregivers of people with dementia, Dr. Lavretsky said.

A larger study is planned that also will compare the Kirtan Kriya form of meditation with aerobic exercise in stressed family caregivers of people with dementia, she said.

The Alzheimer’s Research and Prevention Foundation funded the study. Dr. Lavretsky is a certified yoga instructor who has practices the Kirtan Kriya form of meditation.

HONOLULU – Twenty minutes per day of either meditation or relaxation improved depression scores in family caregivers of people with dementia, but meditation seemed to provide additional benefits in a randomized, controlled pilot study in 39 caregivers.

Mental functioning and cognition scores improved significantly in the meditation group, compared with the relaxation group, Dr. Helen Lavretsky and Dr. Michael Irwin reported in a poster presentation at the annual meeting of the American Psychiatric Association. Both are professors of psychiatry and biobehavioral sciences at the University of California, Los Angeles.

The 23 caregivers in the meditation group averaged 61 years of age and the 16 caregivers in the relaxation group averaged 61 years of age. They had been caring for a family member with dementia for 5 years and 4 years, respectively. Participants in the relaxation group spent significantly more time per week in caregiving, averaging 63 hours vs. 48 in the meditation group. Hamilton Rating Scale–Depression (HAM-D) scores at baseline were 11.8 in the meditation group and 11.4 in the relaxation group.

Participants in the meditation group were trained in a yoga practice of meditation called Kirtan Kriya that involves chanting, breath work, and finger poses. Participants in the control group were asked to rest quietly while listening to relaxation recordings. Each group devoted 20 minutes per day to the activity for 8 weeks.

In both groups, devoting time each day to self-care was new to participants, all but two of whom were women, Dr. Lavretsky said in an interview.

HAM-D scores improved by 7 points in the meditation group and by 5 points in the relaxation group, a difference that was not statistically significant. The perceived burden of care improved in both groups, too.

In the meditation group, however, 52% showed at least a 50% improvement on the 36-item short form health survey (SF-36) global mental health score, compared with 19% in the relaxation group, which was a significant difference between groups.

Measures of cognition also improved significantly in the meditation group, compared with the control group. Mini-Mental Status Examination scores increased by 0.2 points in the meditation group and decreased by 0.9 points in the relaxation group. Times to complete the Trail Making Test (Part B), a measure of executive function, decreased by 11.2 seconds in the meditation group but increased by 9.9 seconds in the relaxation group.

Preliminary data from several other measures in the study suggest biological differences in outcomes, Dr. Lavretsky said. Intranuclear staining and flow cytometry showed that a significantly lower proportion of lymphocytes was positive for nuclear transcription factor–kappa beta (a protein complex that has been linked to chronic stress and inflammatory responses) in the meditation practitioners, compared with the control group. The meditation group also showed increased telomerase activity, compared with the relaxation group. Telomere length and telomerase activity are markers of biological age linking stress and disease, she said.

PET scan results suggested that improvements in cognition were associated with changes in regional brain metabolism in areas relevant for executive dysfunction and global cognition.

This and other studies suggest that meditation, tai chi, or other mind-body techniques seem to be helpful stress-reducing therapies for family caregivers of people with dementia, Dr. Lavretsky said.

A larger study is planned that also will compare the Kirtan Kriya form of meditation with aerobic exercise in stressed family caregivers of people with dementia, she said.

The Alzheimer’s Research and Prevention Foundation funded the study. Dr. Lavretsky is a certified yoga instructor who has practices the Kirtan Kriya form of meditation.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – When it comes to working with patients at risk for suicide in psychotherapy, universal themes apply, according to Barbara Stanley, Ph.D.

Be sure to ask patients explicitly about suicide ideation and collaborate with them on a safety plan and other survival strategies. It also is important to consult with other clinicians, said Dr. Stanley, a clinical psychologist who serves as director of the suicide intervention center at New York State Psychiatric Institute.

At her institute, staff members document this information from patients every time. "If there is any suicidal ideation, they have to document a collaborative plan for managing the suicidality," Dr. Stanley said at the annual meeting of the American Psychiatric Association.

"That is important, no matter what kind of therapy you do."

Patients at greatest risk, in order, are those with bipolar disorder, borderline personality disorder, major depression, schizophrenia, and posttraumatic stress disorder.

Cognitive-behavioral therapy and dialectical behavior therapy have the most support in the literature. However, other therapeutic basics should be used when working with suicidal patients.

Monitor patients for suicidal ideation on an ongoing basis and do not make any assumptions, said Dr. Stanley, also a lecturer in psychiatry at Columbia University, New York. Even if your patient appears well, do not assume that she is not suicidal, particularly if an attempt was made previously. Actively inquire about suicidal ideation and suicidal behavior, because patients might not volunteer the information for various reasons. Some patients say they believe their physician "doesn’t want to hear about it"; others fear they will end up admitted to a facility.

A key goal is to work toward "a collaborative relationship that encourages disclosure."

Keeping an approach that is flexible is important, Dr. Stanley said. "A fixed-treatment model is not such a good idea for people who are suicidal." For example, make some provision for increased contact during periods of suicidal crisis and decreased frequency later – as appropriate. Consider between-session communication either by telephone or e-mail. "This can include the patient checking in without the therapist contacting the patient," she said. "I have someone doing that while I’m here at this meeting."

Group therapy sessions, day programs, and other services can provide therapeutic support between consultations. Also use diary cards (or some variant) to track feedback from the patient.

Communicate with other clinicians, especially experienced, trusted colleagues. "When in doubt, consult. Seek support if you feel you are not on the right track or you are not sure."

Balance your concern without being overly anxious; if you cannot tolerate a frank discussion about suicidality, the patients can become more frightened, Dr. Stanley said. "We use a matter-of-fact tone – with no bold letters or parentheses around this – when we talk to patients about suicidality. It’s like asking about anxiety."

In addition, you have to have some sense when you ask about suicidality that a patient is telling the truth. "I tell patients directly that I need to be able to sleep at night. The deal when you are working with me is, ‘We are going to talk about it.’ My deal in return is I will not automatically throw them in the hospital."

Devise a collaborative strategy with your patient to discuss suicidality in advance. Instead of stating, "When you are suicidal, this is what you do," it is better to say, "Let’s figure out together what will work if you become suicidal again," she said. "Many adolescents will tell me that was a ‘one-time thing.’ I say, ‘Humor me, just in case.’"

No patient should leave a first appointment without a safety plan, Dr. Stanley said. This plan is different from a no-suicide contract, which is popular but not very useful, she said, and is built from a perspective that patients are not simply at the mercy of their suicidal feelings. Also, it acknowledges that suicidal feelings tend to ebb and flow. At her facility, patients are taught how to recognize warning signs and how to employ internal coping strategies, for example.

"When someone has suicidal urges, we [typically] tell them to call 911 or a hotline," Dr. Stanley said. "Do we tell patients with anxiety to call a hotline? No, we teach them how to cope."

A greater structuring of treatment can help suicidal patients as well. Prioritize the therapeutic goals and establish ways to review suicidality with the patient. This will help you to stay on a path of change, she said, versus focusing on crisis after crisis. Set an agenda, conduct a behavioral analysis, and balance validation with problem solving, she added.

"Working with suicidal patients is inevitable," Dr. Stanley said. "Many clinicians are likely to experience a suicide of at least one of their patients." A suicide can take a considerable toll on all survivors, including the therapist. More than one-third of therapists reported extreme distress after a patient suicide in a survey (Suicide Life Threat. Behavior 2010;40:328-36).

Shock, guilt, shame, grief, and fear of blame are among the typical reactions that clinicians feel in the wake of a patient suicide, Dr. Stanley said. "We want to try to avoid this for our own sake as well as for the sake of our patient."

"When young therapists ask me, ‘How can I work with this population?’ I say, ‘I try my best to attend to their suicidality in each and every moment I’m with them,’ " Dr. Stanley said. "And then if something happens, I did my best."

About 90 people per day, or more than 33,000 people each year, die by suicide in the United States. "This is the third-leading cause of death in young people," Dr. Stanley said. "More people die by suicide in the U.S. than by homicide."

These figures are probably an underestimate, Dr. Stanley said. Determination of cause of death, suicide versus accident, can be difficult. Coroners sometimes leave cause of death as "questionable" to protect surviving family members.

In addition, an estimated 3-10 suicide attempts take place for every completed suicide. Many attempts never come to the attention of mental health professionals or physicians, although attempts are a strong predictor of another attempt and of committing suicide.

Researchers found 62% of adults received medical attention after an attempt, "which means almost 40% did not," Dr. Stanley said. The 2009 National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration, also showed that young adults, aged 18 to 25 years, are at highest risk for suicidal ideation, making a plan, and attempting suicide, compared with older adults.

Dr. Stanley said she had no relevant disclosures.

HONOLULU – When it comes to working with patients at risk for suicide in psychotherapy, universal themes apply, according to Barbara Stanley, Ph.D.

Be sure to ask patients explicitly about suicide ideation and collaborate with them on a safety plan and other survival strategies. It also is important to consult with other clinicians, said Dr. Stanley, a clinical psychologist who serves as director of the suicide intervention center at New York State Psychiatric Institute.

At her institute, staff members document this information from patients every time. "If there is any suicidal ideation, they have to document a collaborative plan for managing the suicidality," Dr. Stanley said at the annual meeting of the American Psychiatric Association.

"That is important, no matter what kind of therapy you do."

Patients at greatest risk, in order, are those with bipolar disorder, borderline personality disorder, major depression, schizophrenia, and posttraumatic stress disorder.

Cognitive-behavioral therapy and dialectical behavior therapy have the most support in the literature. However, other therapeutic basics should be used when working with suicidal patients.

Monitor patients for suicidal ideation on an ongoing basis and do not make any assumptions, said Dr. Stanley, also a lecturer in psychiatry at Columbia University, New York. Even if your patient appears well, do not assume that she is not suicidal, particularly if an attempt was made previously. Actively inquire about suicidal ideation and suicidal behavior, because patients might not volunteer the information for various reasons. Some patients say they believe their physician "doesn’t want to hear about it"; others fear they will end up admitted to a facility.

A key goal is to work toward "a collaborative relationship that encourages disclosure."

Keeping an approach that is flexible is important, Dr. Stanley said. "A fixed-treatment model is not such a good idea for people who are suicidal." For example, make some provision for increased contact during periods of suicidal crisis and decreased frequency later – as appropriate. Consider between-session communication either by telephone or e-mail. "This can include the patient checking in without the therapist contacting the patient," she said. "I have someone doing that while I’m here at this meeting."

Group therapy sessions, day programs, and other services can provide therapeutic support between consultations. Also use diary cards (or some variant) to track feedback from the patient.

Communicate with other clinicians, especially experienced, trusted colleagues. "When in doubt, consult. Seek support if you feel you are not on the right track or you are not sure."

Balance your concern without being overly anxious; if you cannot tolerate a frank discussion about suicidality, the patients can become more frightened, Dr. Stanley said. "We use a matter-of-fact tone – with no bold letters or parentheses around this – when we talk to patients about suicidality. It’s like asking about anxiety."

In addition, you have to have some sense when you ask about suicidality that a patient is telling the truth. "I tell patients directly that I need to be able to sleep at night. The deal when you are working with me is, ‘We are going to talk about it.’ My deal in return is I will not automatically throw them in the hospital."

Devise a collaborative strategy with your patient to discuss suicidality in advance. Instead of stating, "When you are suicidal, this is what you do," it is better to say, "Let’s figure out together what will work if you become suicidal again," she said. "Many adolescents will tell me that was a ‘one-time thing.’ I say, ‘Humor me, just in case.’"

No patient should leave a first appointment without a safety plan, Dr. Stanley said. This plan is different from a no-suicide contract, which is popular but not very useful, she said, and is built from a perspective that patients are not simply at the mercy of their suicidal feelings. Also, it acknowledges that suicidal feelings tend to ebb and flow. At her facility, patients are taught how to recognize warning signs and how to employ internal coping strategies, for example.

"When someone has suicidal urges, we [typically] tell them to call 911 or a hotline," Dr. Stanley said. "Do we tell patients with anxiety to call a hotline? No, we teach them how to cope."

A greater structuring of treatment can help suicidal patients as well. Prioritize the therapeutic goals and establish ways to review suicidality with the patient. This will help you to stay on a path of change, she said, versus focusing on crisis after crisis. Set an agenda, conduct a behavioral analysis, and balance validation with problem solving, she added.

"Working with suicidal patients is inevitable," Dr. Stanley said. "Many clinicians are likely to experience a suicide of at least one of their patients." A suicide can take a considerable toll on all survivors, including the therapist. More than one-third of therapists reported extreme distress after a patient suicide in a survey (Suicide Life Threat. Behavior 2010;40:328-36).

Shock, guilt, shame, grief, and fear of blame are among the typical reactions that clinicians feel in the wake of a patient suicide, Dr. Stanley said. "We want to try to avoid this for our own sake as well as for the sake of our patient."

"When young therapists ask me, ‘How can I work with this population?’ I say, ‘I try my best to attend to their suicidality in each and every moment I’m with them,’ " Dr. Stanley said. "And then if something happens, I did my best."

About 90 people per day, or more than 33,000 people each year, die by suicide in the United States. "This is the third-leading cause of death in young people," Dr. Stanley said. "More people die by suicide in the U.S. than by homicide."

These figures are probably an underestimate, Dr. Stanley said. Determination of cause of death, suicide versus accident, can be difficult. Coroners sometimes leave cause of death as "questionable" to protect surviving family members.

In addition, an estimated 3-10 suicide attempts take place for every completed suicide. Many attempts never come to the attention of mental health professionals or physicians, although attempts are a strong predictor of another attempt and of committing suicide.

Researchers found 62% of adults received medical attention after an attempt, "which means almost 40% did not," Dr. Stanley said. The 2009 National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration, also showed that young adults, aged 18 to 25 years, are at highest risk for suicidal ideation, making a plan, and attempting suicide, compared with older adults.

Dr. Stanley said she had no relevant disclosures.

HONOLULU – When it comes to working with patients at risk for suicide in psychotherapy, universal themes apply, according to Barbara Stanley, Ph.D.

Be sure to ask patients explicitly about suicide ideation and collaborate with them on a safety plan and other survival strategies. It also is important to consult with other clinicians, said Dr. Stanley, a clinical psychologist who serves as director of the suicide intervention center at New York State Psychiatric Institute.

At her institute, staff members document this information from patients every time. "If there is any suicidal ideation, they have to document a collaborative plan for managing the suicidality," Dr. Stanley said at the annual meeting of the American Psychiatric Association.

"That is important, no matter what kind of therapy you do."

Patients at greatest risk, in order, are those with bipolar disorder, borderline personality disorder, major depression, schizophrenia, and posttraumatic stress disorder.

Cognitive-behavioral therapy and dialectical behavior therapy have the most support in the literature. However, other therapeutic basics should be used when working with suicidal patients.

Monitor patients for suicidal ideation on an ongoing basis and do not make any assumptions, said Dr. Stanley, also a lecturer in psychiatry at Columbia University, New York. Even if your patient appears well, do not assume that she is not suicidal, particularly if an attempt was made previously. Actively inquire about suicidal ideation and suicidal behavior, because patients might not volunteer the information for various reasons. Some patients say they believe their physician "doesn’t want to hear about it"; others fear they will end up admitted to a facility.

A key goal is to work toward "a collaborative relationship that encourages disclosure."

Keeping an approach that is flexible is important, Dr. Stanley said. "A fixed-treatment model is not such a good idea for people who are suicidal." For example, make some provision for increased contact during periods of suicidal crisis and decreased frequency later – as appropriate. Consider between-session communication either by telephone or e-mail. "This can include the patient checking in without the therapist contacting the patient," she said. "I have someone doing that while I’m here at this meeting."

Group therapy sessions, day programs, and other services can provide therapeutic support between consultations. Also use diary cards (or some variant) to track feedback from the patient.

Communicate with other clinicians, especially experienced, trusted colleagues. "When in doubt, consult. Seek support if you feel you are not on the right track or you are not sure."

Balance your concern without being overly anxious; if you cannot tolerate a frank discussion about suicidality, the patients can become more frightened, Dr. Stanley said. "We use a matter-of-fact tone – with no bold letters or parentheses around this – when we talk to patients about suicidality. It’s like asking about anxiety."

In addition, you have to have some sense when you ask about suicidality that a patient is telling the truth. "I tell patients directly that I need to be able to sleep at night. The deal when you are working with me is, ‘We are going to talk about it.’ My deal in return is I will not automatically throw them in the hospital."

Devise a collaborative strategy with your patient to discuss suicidality in advance. Instead of stating, "When you are suicidal, this is what you do," it is better to say, "Let’s figure out together what will work if you become suicidal again," she said. "Many adolescents will tell me that was a ‘one-time thing.’ I say, ‘Humor me, just in case.’"

No patient should leave a first appointment without a safety plan, Dr. Stanley said. This plan is different from a no-suicide contract, which is popular but not very useful, she said, and is built from a perspective that patients are not simply at the mercy of their suicidal feelings. Also, it acknowledges that suicidal feelings tend to ebb and flow. At her facility, patients are taught how to recognize warning signs and how to employ internal coping strategies, for example.

"When someone has suicidal urges, we [typically] tell them to call 911 or a hotline," Dr. Stanley said. "Do we tell patients with anxiety to call a hotline? No, we teach them how to cope."

A greater structuring of treatment can help suicidal patients as well. Prioritize the therapeutic goals and establish ways to review suicidality with the patient. This will help you to stay on a path of change, she said, versus focusing on crisis after crisis. Set an agenda, conduct a behavioral analysis, and balance validation with problem solving, she added.

"Working with suicidal patients is inevitable," Dr. Stanley said. "Many clinicians are likely to experience a suicide of at least one of their patients." A suicide can take a considerable toll on all survivors, including the therapist. More than one-third of therapists reported extreme distress after a patient suicide in a survey (Suicide Life Threat. Behavior 2010;40:328-36).

Shock, guilt, shame, grief, and fear of blame are among the typical reactions that clinicians feel in the wake of a patient suicide, Dr. Stanley said. "We want to try to avoid this for our own sake as well as for the sake of our patient."

"When young therapists ask me, ‘How can I work with this population?’ I say, ‘I try my best to attend to their suicidality in each and every moment I’m with them,’ " Dr. Stanley said. "And then if something happens, I did my best."

About 90 people per day, or more than 33,000 people each year, die by suicide in the United States. "This is the third-leading cause of death in young people," Dr. Stanley said. "More people die by suicide in the U.S. than by homicide."

These figures are probably an underestimate, Dr. Stanley said. Determination of cause of death, suicide versus accident, can be difficult. Coroners sometimes leave cause of death as "questionable" to protect surviving family members.

In addition, an estimated 3-10 suicide attempts take place for every completed suicide. Many attempts never come to the attention of mental health professionals or physicians, although attempts are a strong predictor of another attempt and of committing suicide.

Researchers found 62% of adults received medical attention after an attempt, "which means almost 40% did not," Dr. Stanley said. The 2009 National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration, also showed that young adults, aged 18 to 25 years, are at highest risk for suicidal ideation, making a plan, and attempting suicide, compared with older adults.

Dr. Stanley said she had no relevant disclosures.

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.