"Ramadan will be depressing this year,” a patient told me as I entered the room for an evaluation. This is one of many similar reactions my patients expressed in March, when mosques began to close and social distancing parameters were put in place to limit the spread of coronavirus disease 2019 (COVID-19). Muslims began to adjust to new social norms, such as replacing warm hugs with waving hands from 6 feet away. They were suddenly advised to avoid century-long cultural practices, such as spending time with extended family, visiting the sick and the elderly, and meeting for Jummah (Friday) prayer at mosque. With increasing anxiety and uncertainty in the air, I began thinking about how the pandemic would psychologically affect Islamic spirituality, especially during Ramadan (the Islamic month of fasting) this year.

As a Muslim psychiatry resident working on an inpatient psychiatric unit and in a psychiatry consultation service during the COVID-19 pandemic, I often explore spirituality and faith with my patients as a way of providing supportive therapy for anxiety. Many of my Christian patients endorsed anxiety about how Easter would be “terrible” this year because they could not attend church. Upon hearing this, I realized that I could not picture a Ramadan during which I was not permitted to go to mosque. How was I supposed to provide supportive therapy for my patients when I also felt so uncertain? These concerns led me to take a step back and remind myself of what I frequently tell my patients when they feel hopeless: “With every difficulty, there comes an opportunity to gain a new perspective.”

A time for spirituality

When Ramadan began in April, many people who are Muslim and were working from home told me that it felt strange to have so much time during the day to pray, reflect, and read the Quran. Others mentioned that they enjoyed the peace of Iftar (breaking fast) at home, because they could avoid the hustle and bustle of this at mosque. Halfway through Ramadan, a Muslim patient I was treating reported that her “coronavirus anxiety” had improved as she began focusing her energy on Allah, rather than spending hours watching the news and obsessing over death tolls.

Due to the pandemic, many more opportunities for donating to those in need arose, which led my religious community to perform Zakat (providing charity) and send supplies to food banks in our area. Because of social distancing, Muslim families were able to spend more time preparing meals, learning together, and supporting each other. Although mosques were closed due to the pandemic, it seemed as though each home became its own gathering place for spirituality, gratitude, and self-reflection. By the end of Ramadan, the values of self-discipline, empathy, and patience became self-evident.

Increased attention to mental health among Muslims

Psychologically, I believe resilience has grown stronger among Muslims worldwide during this pandemic. Along with adopting a positive mindset, Muslims have committed to creating their own routines to combat anxiety during this stressful time. The Salat (praying 5 times a day) and Taharat (cleanliness) that Islam emphasizes have been helpful in creating structure to offset the uncertainty and fear that is associated with COVID-19.

The discussion of mental illness, which previously has been regarded as a culturally stigmatized topic, has been gaining significant recognition within Islamic communities. Depression, anxiety, and self-care are now emphasized during virtual sermons, and contact information for mental health hotlines and professionals are being rapidly disseminated. There is now a greater sense of encouragement for people of Islamic faith to seek psychiatric help when needed.

Although COVID-19 has limited some social and physical religious practices, this pandemic has helped to strengthen faith and spirituality not only among Muslims, but also people of other faiths. During periods of stress, change, and uncertainty, it is important to remember that “With every difficulty, there comes an opportunity to gain a new perspective.” Although mosques and churches continue to stay closed and anxiety persists, I can now confidently reassure my patients that through this experience we are becoming resilient and learning to value patience, gratitude, and empathy more than ever.

"Ramadan will be depressing this year,” a patient told me as I entered the room for an evaluation. This is one of many similar reactions my patients expressed in March, when mosques began to close and social distancing parameters were put in place to limit the spread of coronavirus disease 2019 (COVID-19). Muslims began to adjust to new social norms, such as replacing warm hugs with waving hands from 6 feet away. They were suddenly advised to avoid century-long cultural practices, such as spending time with extended family, visiting the sick and the elderly, and meeting for Jummah (Friday) prayer at mosque. With increasing anxiety and uncertainty in the air, I began thinking about how the pandemic would psychologically affect Islamic spirituality, especially during Ramadan (the Islamic month of fasting) this year.

As a Muslim psychiatry resident working on an inpatient psychiatric unit and in a psychiatry consultation service during the COVID-19 pandemic, I often explore spirituality and faith with my patients as a way of providing supportive therapy for anxiety. Many of my Christian patients endorsed anxiety about how Easter would be “terrible” this year because they could not attend church. Upon hearing this, I realized that I could not picture a Ramadan during which I was not permitted to go to mosque. How was I supposed to provide supportive therapy for my patients when I also felt so uncertain? These concerns led me to take a step back and remind myself of what I frequently tell my patients when they feel hopeless: “With every difficulty, there comes an opportunity to gain a new perspective.”

A time for spirituality

When Ramadan began in April, many people who are Muslim and were working from home told me that it felt strange to have so much time during the day to pray, reflect, and read the Quran. Others mentioned that they enjoyed the peace of Iftar (breaking fast) at home, because they could avoid the hustle and bustle of this at mosque. Halfway through Ramadan, a Muslim patient I was treating reported that her “coronavirus anxiety” had improved as she began focusing her energy on Allah, rather than spending hours watching the news and obsessing over death tolls.

Due to the pandemic, many more opportunities for donating to those in need arose, which led my religious community to perform Zakat (providing charity) and send supplies to food banks in our area. Because of social distancing, Muslim families were able to spend more time preparing meals, learning together, and supporting each other. Although mosques were closed due to the pandemic, it seemed as though each home became its own gathering place for spirituality, gratitude, and self-reflection. By the end of Ramadan, the values of self-discipline, empathy, and patience became self-evident.

Increased attention to mental health among Muslims

Psychologically, I believe resilience has grown stronger among Muslims worldwide during this pandemic. Along with adopting a positive mindset, Muslims have committed to creating their own routines to combat anxiety during this stressful time. The Salat (praying 5 times a day) and Taharat (cleanliness) that Islam emphasizes have been helpful in creating structure to offset the uncertainty and fear that is associated with COVID-19.

The discussion of mental illness, which previously has been regarded as a culturally stigmatized topic, has been gaining significant recognition within Islamic communities. Depression, anxiety, and self-care are now emphasized during virtual sermons, and contact information for mental health hotlines and professionals are being rapidly disseminated. There is now a greater sense of encouragement for people of Islamic faith to seek psychiatric help when needed.

Although COVID-19 has limited some social and physical religious practices, this pandemic has helped to strengthen faith and spirituality not only among Muslims, but also people of other faiths. During periods of stress, change, and uncertainty, it is important to remember that “With every difficulty, there comes an opportunity to gain a new perspective.” Although mosques and churches continue to stay closed and anxiety persists, I can now confidently reassure my patients that through this experience we are becoming resilient and learning to value patience, gratitude, and empathy more than ever.

"Ramadan will be depressing this year,” a patient told me as I entered the room for an evaluation. This is one of many similar reactions my patients expressed in March, when mosques began to close and social distancing parameters were put in place to limit the spread of coronavirus disease 2019 (COVID-19). Muslims began to adjust to new social norms, such as replacing warm hugs with waving hands from 6 feet away. They were suddenly advised to avoid century-long cultural practices, such as spending time with extended family, visiting the sick and the elderly, and meeting for Jummah (Friday) prayer at mosque. With increasing anxiety and uncertainty in the air, I began thinking about how the pandemic would psychologically affect Islamic spirituality, especially during Ramadan (the Islamic month of fasting) this year.

As a Muslim psychiatry resident working on an inpatient psychiatric unit and in a psychiatry consultation service during the COVID-19 pandemic, I often explore spirituality and faith with my patients as a way of providing supportive therapy for anxiety. Many of my Christian patients endorsed anxiety about how Easter would be “terrible” this year because they could not attend church. Upon hearing this, I realized that I could not picture a Ramadan during which I was not permitted to go to mosque. How was I supposed to provide supportive therapy for my patients when I also felt so uncertain? These concerns led me to take a step back and remind myself of what I frequently tell my patients when they feel hopeless: “With every difficulty, there comes an opportunity to gain a new perspective.”

A time for spirituality

When Ramadan began in April, many people who are Muslim and were working from home told me that it felt strange to have so much time during the day to pray, reflect, and read the Quran. Others mentioned that they enjoyed the peace of Iftar (breaking fast) at home, because they could avoid the hustle and bustle of this at mosque. Halfway through Ramadan, a Muslim patient I was treating reported that her “coronavirus anxiety” had improved as she began focusing her energy on Allah, rather than spending hours watching the news and obsessing over death tolls.

Due to the pandemic, many more opportunities for donating to those in need arose, which led my religious community to perform Zakat (providing charity) and send supplies to food banks in our area. Because of social distancing, Muslim families were able to spend more time preparing meals, learning together, and supporting each other. Although mosques were closed due to the pandemic, it seemed as though each home became its own gathering place for spirituality, gratitude, and self-reflection. By the end of Ramadan, the values of self-discipline, empathy, and patience became self-evident.

Increased attention to mental health among Muslims

Psychologically, I believe resilience has grown stronger among Muslims worldwide during this pandemic. Along with adopting a positive mindset, Muslims have committed to creating their own routines to combat anxiety during this stressful time. The Salat (praying 5 times a day) and Taharat (cleanliness) that Islam emphasizes have been helpful in creating structure to offset the uncertainty and fear that is associated with COVID-19.

The discussion of mental illness, which previously has been regarded as a culturally stigmatized topic, has been gaining significant recognition within Islamic communities. Depression, anxiety, and self-care are now emphasized during virtual sermons, and contact information for mental health hotlines and professionals are being rapidly disseminated. There is now a greater sense of encouragement for people of Islamic faith to seek psychiatric help when needed.

Although COVID-19 has limited some social and physical religious practices, this pandemic has helped to strengthen faith and spirituality not only among Muslims, but also people of other faiths. During periods of stress, change, and uncertainty, it is important to remember that “With every difficulty, there comes an opportunity to gain a new perspective.” Although mosques and churches continue to stay closed and anxiety persists, I can now confidently reassure my patients that through this experience we are becoming resilient and learning to value patience, gratitude, and empathy more than ever.

After graduating from medical school in India, where I was born and raised, I came to the United States in 2009 to expand my medical knowledge. At that time, I completed my clinical skills exam and soon after began a volunteer rotation at New York-Presbyterian Queens Hospital. In those early days, as I made my rounds through the emergency department (ED) of the hospital, I would introduce myself as Dr. Siva, which is my first name; this is how the doctors back home in India would introduce themselves to patients. Little did I know that the same name convention was not necessarily used here in the United States. Nonetheless, in those formative days, I learned a great deal from listening to the unique stories of how my patients had ended up in the ED, and I quickly felt right at home getting to know them.

When I first came to the United States, I had limited knowledge of psychiatry because I had only had a few months of psychiatry rotations during medical school. But in 2012, while I served as a volunteer in a research and observership program at Beth Israel Medical Center, one of my colleagues who was a psychiatry resident piqued my interest in the specialty and motivated me to explore and learn more about the various treatment modalities, strategies, and nuances this new modern world of psychiatry had to offer.

So I began by attending training sessions and evening seminars at the New York Psychoanalytic Society & Institute, where I became interested in Sigmund Freud’s work on the development of psychoanalysis. From there, my appetite for knowledge only continued to grow, and I took every opportunity to participate in various learning exercises, present at poster sessions, and give lectures at national conferences. I read and absorbed significant theories and texts and interacted with and learned from colleagues and mentors as I strived to sculpt my mind, with the aim of becoming a well-rounded psychiatrist.

Overcoming challenges

As I worked to further my understanding of psychiatry and understand the different treatment modalities—my goals becoming more clear with each step of my journey—I faced a significant setback. I was unable to secure a residency position to officially enter the specialty. I was devastated in my pursuit to realize the American Dream. At that point, I had been in the United States for 4 years with the financial and emotional support of my parents back home in India. I continued to struggle; another 2 years passed, and I was still coming up empty in my search for a residency position.

In the meantime, I kept moving forward, with my sights firmly on learning more about psychiatry. This time, I sought out several projects, including one where I served as a research assistant (volunteer) for nonpharmacologic clinical trials in patients with bipolar disorder, and another where I served as a research assistant (volunteer) at a substance use disorder clinic at Columbia University. I was also accepted into the “Prelude to Training” program at the Psychoanalytic Association of New York, which is affiliated with the NYU Grossman School of Medicine. Through that program, I was introduced to psychodynamic thinking and practice, which gave me the valuable foundation of thinking beyond oneself.

Grit and determination

To further my education, I studied clinical and translational sciences at Creighton University in Omaha. I was given opportunities to discuss topics related to the historical aspects of and recent advances in psychoanalysis through my involvement with the Professional Reading Alliance on Psychoanalysis at The Circle for the Lacanian Orientation of Omaha. Then came the moment when all my dreams came to fruition—I was accepted into the psychiatry residency program at Creighton University.

Those 4 years of residency passed by in a flash! Recently, I began a neuromodulation fellowship at the University of Florida in Gainesville. Here, my journey continues, as I search for tools to help the disenfranchised and those in need of mental health support. After the neuromodulation fellowship, I plan to pursue a pain medicine fellowship.

Continue to: Through the years...

Through the years, I have grown both professionally and personally. I have also overcome the instinctual urge to introduce myself to patients by my first name and have adapted to the American style of using my last name, and now introduce myself as Dr. Koppolu.

My educational journey in a place far from home has impacted me in ways I never knew possible, and I believe my strength to continue the pursuit is rooted in my passion and ambition to become a psychiatrist. I never gave up working toward that dream—a dream that is slowly becoming a reality.

After graduating from medical school in India, where I was born and raised, I came to the United States in 2009 to expand my medical knowledge. At that time, I completed my clinical skills exam and soon after began a volunteer rotation at New York-Presbyterian Queens Hospital. In those early days, as I made my rounds through the emergency department (ED) of the hospital, I would introduce myself as Dr. Siva, which is my first name; this is how the doctors back home in India would introduce themselves to patients. Little did I know that the same name convention was not necessarily used here in the United States. Nonetheless, in those formative days, I learned a great deal from listening to the unique stories of how my patients had ended up in the ED, and I quickly felt right at home getting to know them.

When I first came to the United States, I had limited knowledge of psychiatry because I had only had a few months of psychiatry rotations during medical school. But in 2012, while I served as a volunteer in a research and observership program at Beth Israel Medical Center, one of my colleagues who was a psychiatry resident piqued my interest in the specialty and motivated me to explore and learn more about the various treatment modalities, strategies, and nuances this new modern world of psychiatry had to offer.

So I began by attending training sessions and evening seminars at the New York Psychoanalytic Society & Institute, where I became interested in Sigmund Freud’s work on the development of psychoanalysis. From there, my appetite for knowledge only continued to grow, and I took every opportunity to participate in various learning exercises, present at poster sessions, and give lectures at national conferences. I read and absorbed significant theories and texts and interacted with and learned from colleagues and mentors as I strived to sculpt my mind, with the aim of becoming a well-rounded psychiatrist.

Overcoming challenges

As I worked to further my understanding of psychiatry and understand the different treatment modalities—my goals becoming more clear with each step of my journey—I faced a significant setback. I was unable to secure a residency position to officially enter the specialty. I was devastated in my pursuit to realize the American Dream. At that point, I had been in the United States for 4 years with the financial and emotional support of my parents back home in India. I continued to struggle; another 2 years passed, and I was still coming up empty in my search for a residency position.

In the meantime, I kept moving forward, with my sights firmly on learning more about psychiatry. This time, I sought out several projects, including one where I served as a research assistant (volunteer) for nonpharmacologic clinical trials in patients with bipolar disorder, and another where I served as a research assistant (volunteer) at a substance use disorder clinic at Columbia University. I was also accepted into the “Prelude to Training” program at the Psychoanalytic Association of New York, which is affiliated with the NYU Grossman School of Medicine. Through that program, I was introduced to psychodynamic thinking and practice, which gave me the valuable foundation of thinking beyond oneself.

Grit and determination

To further my education, I studied clinical and translational sciences at Creighton University in Omaha. I was given opportunities to discuss topics related to the historical aspects of and recent advances in psychoanalysis through my involvement with the Professional Reading Alliance on Psychoanalysis at The Circle for the Lacanian Orientation of Omaha. Then came the moment when all my dreams came to fruition—I was accepted into the psychiatry residency program at Creighton University.

Those 4 years of residency passed by in a flash! Recently, I began a neuromodulation fellowship at the University of Florida in Gainesville. Here, my journey continues, as I search for tools to help the disenfranchised and those in need of mental health support. After the neuromodulation fellowship, I plan to pursue a pain medicine fellowship.

Continue to: Through the years...

Through the years, I have grown both professionally and personally. I have also overcome the instinctual urge to introduce myself to patients by my first name and have adapted to the American style of using my last name, and now introduce myself as Dr. Koppolu.

My educational journey in a place far from home has impacted me in ways I never knew possible, and I believe my strength to continue the pursuit is rooted in my passion and ambition to become a psychiatrist. I never gave up working toward that dream—a dream that is slowly becoming a reality.

After graduating from medical school in India, where I was born and raised, I came to the United States in 2009 to expand my medical knowledge. At that time, I completed my clinical skills exam and soon after began a volunteer rotation at New York-Presbyterian Queens Hospital. In those early days, as I made my rounds through the emergency department (ED) of the hospital, I would introduce myself as Dr. Siva, which is my first name; this is how the doctors back home in India would introduce themselves to patients. Little did I know that the same name convention was not necessarily used here in the United States. Nonetheless, in those formative days, I learned a great deal from listening to the unique stories of how my patients had ended up in the ED, and I quickly felt right at home getting to know them.

When I first came to the United States, I had limited knowledge of psychiatry because I had only had a few months of psychiatry rotations during medical school. But in 2012, while I served as a volunteer in a research and observership program at Beth Israel Medical Center, one of my colleagues who was a psychiatry resident piqued my interest in the specialty and motivated me to explore and learn more about the various treatment modalities, strategies, and nuances this new modern world of psychiatry had to offer.

So I began by attending training sessions and evening seminars at the New York Psychoanalytic Society & Institute, where I became interested in Sigmund Freud’s work on the development of psychoanalysis. From there, my appetite for knowledge only continued to grow, and I took every opportunity to participate in various learning exercises, present at poster sessions, and give lectures at national conferences. I read and absorbed significant theories and texts and interacted with and learned from colleagues and mentors as I strived to sculpt my mind, with the aim of becoming a well-rounded psychiatrist.

Overcoming challenges

As I worked to further my understanding of psychiatry and understand the different treatment modalities—my goals becoming more clear with each step of my journey—I faced a significant setback. I was unable to secure a residency position to officially enter the specialty. I was devastated in my pursuit to realize the American Dream. At that point, I had been in the United States for 4 years with the financial and emotional support of my parents back home in India. I continued to struggle; another 2 years passed, and I was still coming up empty in my search for a residency position.

In the meantime, I kept moving forward, with my sights firmly on learning more about psychiatry. This time, I sought out several projects, including one where I served as a research assistant (volunteer) for nonpharmacologic clinical trials in patients with bipolar disorder, and another where I served as a research assistant (volunteer) at a substance use disorder clinic at Columbia University. I was also accepted into the “Prelude to Training” program at the Psychoanalytic Association of New York, which is affiliated with the NYU Grossman School of Medicine. Through that program, I was introduced to psychodynamic thinking and practice, which gave me the valuable foundation of thinking beyond oneself.

Grit and determination

To further my education, I studied clinical and translational sciences at Creighton University in Omaha. I was given opportunities to discuss topics related to the historical aspects of and recent advances in psychoanalysis through my involvement with the Professional Reading Alliance on Psychoanalysis at The Circle for the Lacanian Orientation of Omaha. Then came the moment when all my dreams came to fruition—I was accepted into the psychiatry residency program at Creighton University.

Those 4 years of residency passed by in a flash! Recently, I began a neuromodulation fellowship at the University of Florida in Gainesville. Here, my journey continues, as I search for tools to help the disenfranchised and those in need of mental health support. After the neuromodulation fellowship, I plan to pursue a pain medicine fellowship.

Continue to: Through the years...

Through the years, I have grown both professionally and personally. I have also overcome the instinctual urge to introduce myself to patients by my first name and have adapted to the American style of using my last name, and now introduce myself as Dr. Koppolu.

My educational journey in a place far from home has impacted me in ways I never knew possible, and I believe my strength to continue the pursuit is rooted in my passion and ambition to become a psychiatrist. I never gave up working toward that dream—a dream that is slowly becoming a reality.

The use of electronic cigarettes (e-cigarettes) in teenagers has been increasing rapidly in the United States, leading Surgeon General Jerome Adams, MD, MPH, to label it a public health concern.¹ Easy accessibility and extensive marketing for e-cigarettes counteract public education campaigns and policies aimed at decreasing e-cigarette use in teenagers.

E-cigarettes are marketed to teenagers as small, easy-to-use pens or USB flash drive–like devices that can be hidden easily. Some devices can be used to smoke nicotine, delta-9-tetrahydrocannabinol (THC), cannabidiol, and butane hash oil. Some are sold with different nicotine flavors to increase their appeal. E-cigarette ads appear in retail stores, movies, magazines, newspapers, and on the internet. 

According to the CDC, the number of middle and high school students using e-cigarettes increased from 3.6 million in 2018 to 5.4 million in 2019.² Nicotine dependence from e-cigarette use can increase the risk of starting to smoke cigarettes. A 2015-2016 National Institute on Drug Abuse survey found a higher prevalence of e-cigarette use among 9th-, 10th-, and 12th-grade students compared with cigarette smoking (9.5%, 14%, 16.2% vs 3.6%, 6.2%, 11.4%, respectively).³ Due to the growing popularity of vaping among adolescents in the United States, Congress recently raised the legal age to purchase tobacco and vaping products to 21 years.

Evidence of adverse health effects associated with e-cigarette use continues to grow. In 2020, the Department of Health and Services in Wisconsin and the Department of Public Health in Illinois looked at e-cigarette use and pulmonary disease.⁴ Of 98 participants who reported e-cigarette use, 97% presented with respiratory symptoms, 77% had gastrointestinal symptoms, and 100% had constitutional symptoms. Chest imaging showed bilateral infiltrates in all patients. In addition, 95% were hospitalized, 26% underwent intubation and mechanical ventilation, and 1 patient died. Most participants (89%) reported using THC in their e-cigarette devices.⁴ Blount et al⁵ recently found a link between e-cigarette- or vaping-associated lung injury and vitamin E acetate, a toxicant found in bronchoalveolar lavage fluid of some patients who reported using e-cigarettes. Also, nicotine dependency from e-cigarettes may adversely affect brain development in children and adolescents.²

The first step in fighting this crisis is to educate children, parents, teachers, and health care professionals about e-cigarette use, including its prevalence, use compared with cigarette smoking, trends among teenagers, marketing techniques, and adverse effects. Fortunately, the US government and medical professionals and organizations have made ongoing efforts to discourage e-cigarette use. For example, the American Academy of Child and Adolescent Psychiatry supports the FDA’s regulation of e-cigarette use; encourages using evidence-based treatments for tobacco cessation; advocates for vigorous education regarding adolescent e-cigarette use; and endorses restrictions on e-cigarette advertisement.⁶ We strongly urge clinicians to be vigilant about e-cigarette use in their adolescent patients and to intervene in this public health crisis.

Immad A. Kiani, MD
PGY-3 Psychiatry Resident
Christiana Care Health Services
Department of Psychiatry
Wilmington, Delaware

Narpinder K. Malhi, MD
Child and Adolescent Psychiatrist
Christiana Care Health Services
Wilmington, Delaware

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

The use of electronic cigarettes (e-cigarettes) in teenagers has been increasing rapidly in the United States, leading Surgeon General Jerome Adams, MD, MPH, to label it a public health concern.¹ Easy accessibility and extensive marketing for e-cigarettes counteract public education campaigns and policies aimed at decreasing e-cigarette use in teenagers.

E-cigarettes are marketed to teenagers as small, easy-to-use pens or USB flash drive–like devices that can be hidden easily. Some devices can be used to smoke nicotine, delta-9-tetrahydrocannabinol (THC), cannabidiol, and butane hash oil. Some are sold with different nicotine flavors to increase their appeal. E-cigarette ads appear in retail stores, movies, magazines, newspapers, and on the internet. 

According to the CDC, the number of middle and high school students using e-cigarettes increased from 3.6 million in 2018 to 5.4 million in 2019.² Nicotine dependence from e-cigarette use can increase the risk of starting to smoke cigarettes. A 2015-2016 National Institute on Drug Abuse survey found a higher prevalence of e-cigarette use among 9th-, 10th-, and 12th-grade students compared with cigarette smoking (9.5%, 14%, 16.2% vs 3.6%, 6.2%, 11.4%, respectively).³ Due to the growing popularity of vaping among adolescents in the United States, Congress recently raised the legal age to purchase tobacco and vaping products to 21 years.

Evidence of adverse health effects associated with e-cigarette use continues to grow. In 2020, the Department of Health and Services in Wisconsin and the Department of Public Health in Illinois looked at e-cigarette use and pulmonary disease.⁴ Of 98 participants who reported e-cigarette use, 97% presented with respiratory symptoms, 77% had gastrointestinal symptoms, and 100% had constitutional symptoms. Chest imaging showed bilateral infiltrates in all patients. In addition, 95% were hospitalized, 26% underwent intubation and mechanical ventilation, and 1 patient died. Most participants (89%) reported using THC in their e-cigarette devices.⁴ Blount et al⁵ recently found a link between e-cigarette- or vaping-associated lung injury and vitamin E acetate, a toxicant found in bronchoalveolar lavage fluid of some patients who reported using e-cigarettes. Also, nicotine dependency from e-cigarettes may adversely affect brain development in children and adolescents.²

The first step in fighting this crisis is to educate children, parents, teachers, and health care professionals about e-cigarette use, including its prevalence, use compared with cigarette smoking, trends among teenagers, marketing techniques, and adverse effects. Fortunately, the US government and medical professionals and organizations have made ongoing efforts to discourage e-cigarette use. For example, the American Academy of Child and Adolescent Psychiatry supports the FDA’s regulation of e-cigarette use; encourages using evidence-based treatments for tobacco cessation; advocates for vigorous education regarding adolescent e-cigarette use; and endorses restrictions on e-cigarette advertisement.⁶ We strongly urge clinicians to be vigilant about e-cigarette use in their adolescent patients and to intervene in this public health crisis.

Immad A. Kiani, MD
PGY-3 Psychiatry Resident
Christiana Care Health Services
Department of Psychiatry
Wilmington, Delaware

Narpinder K. Malhi, MD
Child and Adolescent Psychiatrist
Christiana Care Health Services
Wilmington, Delaware

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

The use of electronic cigarettes (e-cigarettes) in teenagers has been increasing rapidly in the United States, leading Surgeon General Jerome Adams, MD, MPH, to label it a public health concern.¹ Easy accessibility and extensive marketing for e-cigarettes counteract public education campaigns and policies aimed at decreasing e-cigarette use in teenagers.

E-cigarettes are marketed to teenagers as small, easy-to-use pens or USB flash drive–like devices that can be hidden easily. Some devices can be used to smoke nicotine, delta-9-tetrahydrocannabinol (THC), cannabidiol, and butane hash oil. Some are sold with different nicotine flavors to increase their appeal. E-cigarette ads appear in retail stores, movies, magazines, newspapers, and on the internet. 

According to the CDC, the number of middle and high school students using e-cigarettes increased from 3.6 million in 2018 to 5.4 million in 2019.² Nicotine dependence from e-cigarette use can increase the risk of starting to smoke cigarettes. A 2015-2016 National Institute on Drug Abuse survey found a higher prevalence of e-cigarette use among 9th-, 10th-, and 12th-grade students compared with cigarette smoking (9.5%, 14%, 16.2% vs 3.6%, 6.2%, 11.4%, respectively).³ Due to the growing popularity of vaping among adolescents in the United States, Congress recently raised the legal age to purchase tobacco and vaping products to 21 years.

Evidence of adverse health effects associated with e-cigarette use continues to grow. In 2020, the Department of Health and Services in Wisconsin and the Department of Public Health in Illinois looked at e-cigarette use and pulmonary disease.⁴ Of 98 participants who reported e-cigarette use, 97% presented with respiratory symptoms, 77% had gastrointestinal symptoms, and 100% had constitutional symptoms. Chest imaging showed bilateral infiltrates in all patients. In addition, 95% were hospitalized, 26% underwent intubation and mechanical ventilation, and 1 patient died. Most participants (89%) reported using THC in their e-cigarette devices.⁴ Blount et al⁵ recently found a link between e-cigarette- or vaping-associated lung injury and vitamin E acetate, a toxicant found in bronchoalveolar lavage fluid of some patients who reported using e-cigarettes. Also, nicotine dependency from e-cigarettes may adversely affect brain development in children and adolescents.²

The first step in fighting this crisis is to educate children, parents, teachers, and health care professionals about e-cigarette use, including its prevalence, use compared with cigarette smoking, trends among teenagers, marketing techniques, and adverse effects. Fortunately, the US government and medical professionals and organizations have made ongoing efforts to discourage e-cigarette use. For example, the American Academy of Child and Adolescent Psychiatry supports the FDA’s regulation of e-cigarette use; encourages using evidence-based treatments for tobacco cessation; advocates for vigorous education regarding adolescent e-cigarette use; and endorses restrictions on e-cigarette advertisement.⁶ We strongly urge clinicians to be vigilant about e-cigarette use in their adolescent patients and to intervene in this public health crisis.

Immad A. Kiani, MD
PGY-3 Psychiatry Resident
Christiana Care Health Services
Department of Psychiatry
Wilmington, Delaware

Narpinder K. Malhi, MD
Child and Adolescent Psychiatrist
Christiana Care Health Services
Wilmington, Delaware

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

There are few things that psychiatrists have come to despise more than the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) program. It has become a professional boondoggle for psychiatric practitioners.

The program needs an overhaul and simplification. There are better, more efficient, cost-effective ways to ensure psychiatric physicians’ ongoing clinical competence after they complete their residency training. Technological advances can also facilitate a more valid assessment of competence without having to jump through more and more hoops between recertifications every 10 years.

I passed the boards long before the MOC was created. For 20 years, I also served as a senior examiner for the oral boards, where clinical competency was rigorously assessed by direct observations of psychiatrists examining and establishing rapport with patients and formulating the data into a differential diagnosis, treatment plan, and prognosis. It is noteworthy that psychiatrists who sat for the oral boards had already passed a written exam that tested their cognitive knowledge. Yet approximately one-third of the candidates failed the live oral exam, which clearly implies that passing a written exam is necessary but not sufficient to establish clinical competence, which is the primary purpose of board certification. It was an unfortunate decision to discontinue the face-to-face oral board exam, which is so vital for psychiatry, and to replace it with a written exam and a barrage of time-consuming activities to document lifelong learning and self-assessment, but not genuine clinical competence. The MOC has been MOCkingly referred to as a major pain in the neck for practically all psychiatrists who were not grandfathered with lifetime certification, as was the case in the first 60 years of the ABPN.

Benefits of the patient-based oral exam

Let’s face it: Passing a patient-based oral exam was the ideal mechanism to establish that a psychiatric physician deserved to be a diplomate of the ABPN. During the oral exam, the candidate’s skills were observed from the minute he/she met the patient. The candidate was then observed as he/she systematically explored a wide range of past and current psychiatric symptoms; reviewed the patient’s developmental, medical, family, and social histories; and conducted a competent mental status exam while demonstrating an empathic stance, responding to the patient’s often subtle verbal and nonverbal cues, establishing rapport, and providing psychoeducation before concluding the interview. All these essential components of a psychiatric exam were observed in a compact 30-minute tour de force of clinical skills, communication, and cognitive acumen. This was followed by another 30 minutes of organizing and presenting the clinical data to 2 or 3 colleagues/examiners, in a coherent fashion, connecting all the dots, formulating the case, presenting a meaningful differential diagnosis, and suggesting a rational array of potential treatment options across the biopsychosocial continuum. To top it off, the candidate had to respond effectively, in an evidence-based manner, to a series of questions related to the disease state, its treatment, adverse effects, and prognosis.

It was a joy to watch many colleagues navigate this clinical examination with skill and competence, without crumbling under the pressure of the examiners’ scrutiny. There were some who passed with flying colors, and others who passed despite having a forgivable minor gap here and there because of their overall strong performance. Finally, there were those who stumbled in several components across data collection, doctor–patient interactions, synthesis of the clinical findings, or treatment recommendations. These candidates inevitably received a failing grade by a consensus of 3 examiners. That they failed to demonstrate clinical competence despite having passed the required written exams a year earlier proved that the true competency of a psychiatrist cannot be judged solely by passing a written test but requires a clinical examination of a live patient.

The oral exams represented an unimpeachable evaluation of clinical competence. The examiners often spoke of how they would feel confident and comfortable with referring a family member to those who successfully passed this rigorous, authentic exam on real patients. It was justifiable to give lifetime certification to those who passed the oral exam. Those permanently certified psychiatrists maintained their lifelong learning by having an unrestricted state medical license, which is contingent on acquiring 50 category 1 continuing medical education (CME) credits annually. Why not restore lifelong certification for those who pass both a written and oral exam, as long as they maintain a valid medical license?

According to the ABPN 2019 Annual Report,¹ 31,514 psychiatrists have received lifetime certification, of whom an estimated 9,547 were still clinically active in 2019. This is the “grandfathered” cohort of psychiatrists to which I belong. I was tested on neurologic patients, not just psychiatric patients, a tribute to the strong bridge that existed between these sister brain specialties. As of 2019, of the 33,277 psychiatrists who received a time-limited certification, 29,343 were still clinically active, an attrition rate of 12% over the past 25 years. This includes psychiatrists who found the MOC too onerous to complete, or are in private practice where MOC is not a vital requirement. However, these days most psychiatrists are obligated to be recertified because so many entities require it. This includes hiring institutions, government agencies (Medicare/Medicaid), health insurance companies, hospital medical staff for privileging and credentialing, and various regulatory boards, such as The Joint Commission, the Accreditation Council for Graduate Medical Education, and academic medical centers. Because most psychiatrists are involved with at least one of these entities, 29,343 have no choice but to perform all the requirements of the MOC, with its countless hours, numerous documentations, and many fees, to remain certified by the ABPN. Notably absent is an alternative mechanism for a certification process that is widely accepted by all agencies and institutions. Psychiatrists are actively seeking alternatives.

Continue to: The ABPN...

The ABPN, long regarded as an esteemed nonprofit organization, has been accused of being a monopoly. Some angry psychiatrists have filed a class action lawsuit to demand other board certification methods. Some have gone to the media to complain about the American Board of Medical Specialties (of which the ABPN is a member board), accusing both of unfair regulations or of raking in substantial profits to support excessively compensated executives. Perception often trumps reality, so no matter how vigorously the ABPN defends itself, its procedures, or its MOC requirements, its customers—psychiatric physicians—feel oppressed or exploited.

How the MOC can be improved

So what can be done to improve the MOC? The need for recertification is arguably necessary to document clinical competency over an approximately 40-year psychiatric career following residency. I conducted a brief survey of Current Psychiatry readers. Of the 319 respondents, 86.5% recommended abolishing the MOC, while 13.5% said it should remain or were unsure. In a follow-up question, 60% agreed that the American Psychiatric Association (APA) should establish a Council on Board Certification, and 33% agreed that the MOC should only be a clinical vignette-based written exam every 10 years, along with an unrestricted or active state medical license.

Significant advances in remote communication technology should be harnessed by the ABPN (or the APA, if it decides to conduct its own board certification) to restore the old model at a fraction of the cost. The oral exams have been replaced by a written exam that is not an accurate reflection or documentation of clinical competence. The traditional oral exam (after passing a written exam) was a magnificent but costly feat of massive logistical complexity, with >1,000 candidates and examiners traveling to a city where the ABPN arranged for several hospitals to shut down their clinics for 2 full days to use their clinical offices for the oral exams. Multiple teams examined the candidates twice on the same day: once with a live patient, and again with a video of a real patient. The examiners filled out scoring cards after observing the candidates conduct the live interview or discussing the video. A consensus grade of pass or fail was documented. At the end of the 2 days, examiners and candidates boarded buses to the airport. It was a highly expensive process (exam fees + airfare + hotel + food). Twice a year, the examiners generously donated their time to the ABPN without compensation, as a token of love for and service to the profession.

That initial certification of a written exam, followed by an oral exam, validated the competence of a psychiatrist both cognitively and clinically. The lifetime certification was truly earned. The same model can now be replicated virtually via videoconferencing at a far lower cost to the ABPN, the candidates, and the examiners. The MOC 10-year recertification can be reduced to a written exam with clinical vignettes and an unrestricted license to practice medicine in any state, which implies that the psychiatrist has received the 50 CME annual credits to renew the license. The rest of the bells and whistles can be strongly recommended but not required. The cost in time and money to both the ABPN and the candidates can be significantly reduced, but more importantly, the clinical competence will be validated at baseline with virtual oral boards after passing the written exam (formerly labeled as part I, preceding the part II oral boards).

The traditional board certification model of the past should be resurrected via videoconferencing and offered as an option to the candidates who prefer it to the current MOC. The MOC can then be simplified to lifetime certification or to only a written exam with clinical vignettes every 10 years to ensure that psychiatrists continue to incorporate relevant clinical and treatment advances in their practice. The KISS principle (keep it simple, stupid) worked very well for many generations of psychiatrists in the past, and will work again going forward if offered as an option. Psychiatrists can then focus on treating patients instead of being burdened by the many time-consuming requirements and hoops of the current MOC.

There are few things that psychiatrists have come to despise more than the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) program. It has become a professional boondoggle for psychiatric practitioners.

The program needs an overhaul and simplification. There are better, more efficient, cost-effective ways to ensure psychiatric physicians’ ongoing clinical competence after they complete their residency training. Technological advances can also facilitate a more valid assessment of competence without having to jump through more and more hoops between recertifications every 10 years.

I passed the boards long before the MOC was created. For 20 years, I also served as a senior examiner for the oral boards, where clinical competency was rigorously assessed by direct observations of psychiatrists examining and establishing rapport with patients and formulating the data into a differential diagnosis, treatment plan, and prognosis. It is noteworthy that psychiatrists who sat for the oral boards had already passed a written exam that tested their cognitive knowledge. Yet approximately one-third of the candidates failed the live oral exam, which clearly implies that passing a written exam is necessary but not sufficient to establish clinical competence, which is the primary purpose of board certification. It was an unfortunate decision to discontinue the face-to-face oral board exam, which is so vital for psychiatry, and to replace it with a written exam and a barrage of time-consuming activities to document lifelong learning and self-assessment, but not genuine clinical competence. The MOC has been MOCkingly referred to as a major pain in the neck for practically all psychiatrists who were not grandfathered with lifetime certification, as was the case in the first 60 years of the ABPN.

Benefits of the patient-based oral exam

Let’s face it: Passing a patient-based oral exam was the ideal mechanism to establish that a psychiatric physician deserved to be a diplomate of the ABPN. During the oral exam, the candidate’s skills were observed from the minute he/she met the patient. The candidate was then observed as he/she systematically explored a wide range of past and current psychiatric symptoms; reviewed the patient’s developmental, medical, family, and social histories; and conducted a competent mental status exam while demonstrating an empathic stance, responding to the patient’s often subtle verbal and nonverbal cues, establishing rapport, and providing psychoeducation before concluding the interview. All these essential components of a psychiatric exam were observed in a compact 30-minute tour de force of clinical skills, communication, and cognitive acumen. This was followed by another 30 minutes of organizing and presenting the clinical data to 2 or 3 colleagues/examiners, in a coherent fashion, connecting all the dots, formulating the case, presenting a meaningful differential diagnosis, and suggesting a rational array of potential treatment options across the biopsychosocial continuum. To top it off, the candidate had to respond effectively, in an evidence-based manner, to a series of questions related to the disease state, its treatment, adverse effects, and prognosis.

It was a joy to watch many colleagues navigate this clinical examination with skill and competence, without crumbling under the pressure of the examiners’ scrutiny. There were some who passed with flying colors, and others who passed despite having a forgivable minor gap here and there because of their overall strong performance. Finally, there were those who stumbled in several components across data collection, doctor–patient interactions, synthesis of the clinical findings, or treatment recommendations. These candidates inevitably received a failing grade by a consensus of 3 examiners. That they failed to demonstrate clinical competence despite having passed the required written exams a year earlier proved that the true competency of a psychiatrist cannot be judged solely by passing a written test but requires a clinical examination of a live patient.

The oral exams represented an unimpeachable evaluation of clinical competence. The examiners often spoke of how they would feel confident and comfortable with referring a family member to those who successfully passed this rigorous, authentic exam on real patients. It was justifiable to give lifetime certification to those who passed the oral exam. Those permanently certified psychiatrists maintained their lifelong learning by having an unrestricted state medical license, which is contingent on acquiring 50 category 1 continuing medical education (CME) credits annually. Why not restore lifelong certification for those who pass both a written and oral exam, as long as they maintain a valid medical license?

According to the ABPN 2019 Annual Report,¹ 31,514 psychiatrists have received lifetime certification, of whom an estimated 9,547 were still clinically active in 2019. This is the “grandfathered” cohort of psychiatrists to which I belong. I was tested on neurologic patients, not just psychiatric patients, a tribute to the strong bridge that existed between these sister brain specialties. As of 2019, of the 33,277 psychiatrists who received a time-limited certification, 29,343 were still clinically active, an attrition rate of 12% over the past 25 years. This includes psychiatrists who found the MOC too onerous to complete, or are in private practice where MOC is not a vital requirement. However, these days most psychiatrists are obligated to be recertified because so many entities require it. This includes hiring institutions, government agencies (Medicare/Medicaid), health insurance companies, hospital medical staff for privileging and credentialing, and various regulatory boards, such as The Joint Commission, the Accreditation Council for Graduate Medical Education, and academic medical centers. Because most psychiatrists are involved with at least one of these entities, 29,343 have no choice but to perform all the requirements of the MOC, with its countless hours, numerous documentations, and many fees, to remain certified by the ABPN. Notably absent is an alternative mechanism for a certification process that is widely accepted by all agencies and institutions. Psychiatrists are actively seeking alternatives.

Continue to: The ABPN...

The ABPN, long regarded as an esteemed nonprofit organization, has been accused of being a monopoly. Some angry psychiatrists have filed a class action lawsuit to demand other board certification methods. Some have gone to the media to complain about the American Board of Medical Specialties (of which the ABPN is a member board), accusing both of unfair regulations or of raking in substantial profits to support excessively compensated executives. Perception often trumps reality, so no matter how vigorously the ABPN defends itself, its procedures, or its MOC requirements, its customers—psychiatric physicians—feel oppressed or exploited.

How the MOC can be improved

So what can be done to improve the MOC? The need for recertification is arguably necessary to document clinical competency over an approximately 40-year psychiatric career following residency. I conducted a brief survey of Current Psychiatry readers. Of the 319 respondents, 86.5% recommended abolishing the MOC, while 13.5% said it should remain or were unsure. In a follow-up question, 60% agreed that the American Psychiatric Association (APA) should establish a Council on Board Certification, and 33% agreed that the MOC should only be a clinical vignette-based written exam every 10 years, along with an unrestricted or active state medical license.

Significant advances in remote communication technology should be harnessed by the ABPN (or the APA, if it decides to conduct its own board certification) to restore the old model at a fraction of the cost. The oral exams have been replaced by a written exam that is not an accurate reflection or documentation of clinical competence. The traditional oral exam (after passing a written exam) was a magnificent but costly feat of massive logistical complexity, with >1,000 candidates and examiners traveling to a city where the ABPN arranged for several hospitals to shut down their clinics for 2 full days to use their clinical offices for the oral exams. Multiple teams examined the candidates twice on the same day: once with a live patient, and again with a video of a real patient. The examiners filled out scoring cards after observing the candidates conduct the live interview or discussing the video. A consensus grade of pass or fail was documented. At the end of the 2 days, examiners and candidates boarded buses to the airport. It was a highly expensive process (exam fees + airfare + hotel + food). Twice a year, the examiners generously donated their time to the ABPN without compensation, as a token of love for and service to the profession.

That initial certification of a written exam, followed by an oral exam, validated the competence of a psychiatrist both cognitively and clinically. The lifetime certification was truly earned. The same model can now be replicated virtually via videoconferencing at a far lower cost to the ABPN, the candidates, and the examiners. The MOC 10-year recertification can be reduced to a written exam with clinical vignettes and an unrestricted license to practice medicine in any state, which implies that the psychiatrist has received the 50 CME annual credits to renew the license. The rest of the bells and whistles can be strongly recommended but not required. The cost in time and money to both the ABPN and the candidates can be significantly reduced, but more importantly, the clinical competence will be validated at baseline with virtual oral boards after passing the written exam (formerly labeled as part I, preceding the part II oral boards).

The traditional board certification model of the past should be resurrected via videoconferencing and offered as an option to the candidates who prefer it to the current MOC. The MOC can then be simplified to lifetime certification or to only a written exam with clinical vignettes every 10 years to ensure that psychiatrists continue to incorporate relevant clinical and treatment advances in their practice. The KISS principle (keep it simple, stupid) worked very well for many generations of psychiatrists in the past, and will work again going forward if offered as an option. Psychiatrists can then focus on treating patients instead of being burdened by the many time-consuming requirements and hoops of the current MOC.

There are few things that psychiatrists have come to despise more than the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) program. It has become a professional boondoggle for psychiatric practitioners.

The program needs an overhaul and simplification. There are better, more efficient, cost-effective ways to ensure psychiatric physicians’ ongoing clinical competence after they complete their residency training. Technological advances can also facilitate a more valid assessment of competence without having to jump through more and more hoops between recertifications every 10 years.

I passed the boards long before the MOC was created. For 20 years, I also served as a senior examiner for the oral boards, where clinical competency was rigorously assessed by direct observations of psychiatrists examining and establishing rapport with patients and formulating the data into a differential diagnosis, treatment plan, and prognosis. It is noteworthy that psychiatrists who sat for the oral boards had already passed a written exam that tested their cognitive knowledge. Yet approximately one-third of the candidates failed the live oral exam, which clearly implies that passing a written exam is necessary but not sufficient to establish clinical competence, which is the primary purpose of board certification. It was an unfortunate decision to discontinue the face-to-face oral board exam, which is so vital for psychiatry, and to replace it with a written exam and a barrage of time-consuming activities to document lifelong learning and self-assessment, but not genuine clinical competence. The MOC has been MOCkingly referred to as a major pain in the neck for practically all psychiatrists who were not grandfathered with lifetime certification, as was the case in the first 60 years of the ABPN.

Benefits of the patient-based oral exam

Let’s face it: Passing a patient-based oral exam was the ideal mechanism to establish that a psychiatric physician deserved to be a diplomate of the ABPN. During the oral exam, the candidate’s skills were observed from the minute he/she met the patient. The candidate was then observed as he/she systematically explored a wide range of past and current psychiatric symptoms; reviewed the patient’s developmental, medical, family, and social histories; and conducted a competent mental status exam while demonstrating an empathic stance, responding to the patient’s often subtle verbal and nonverbal cues, establishing rapport, and providing psychoeducation before concluding the interview. All these essential components of a psychiatric exam were observed in a compact 30-minute tour de force of clinical skills, communication, and cognitive acumen. This was followed by another 30 minutes of organizing and presenting the clinical data to 2 or 3 colleagues/examiners, in a coherent fashion, connecting all the dots, formulating the case, presenting a meaningful differential diagnosis, and suggesting a rational array of potential treatment options across the biopsychosocial continuum. To top it off, the candidate had to respond effectively, in an evidence-based manner, to a series of questions related to the disease state, its treatment, adverse effects, and prognosis.

It was a joy to watch many colleagues navigate this clinical examination with skill and competence, without crumbling under the pressure of the examiners’ scrutiny. There were some who passed with flying colors, and others who passed despite having a forgivable minor gap here and there because of their overall strong performance. Finally, there were those who stumbled in several components across data collection, doctor–patient interactions, synthesis of the clinical findings, or treatment recommendations. These candidates inevitably received a failing grade by a consensus of 3 examiners. That they failed to demonstrate clinical competence despite having passed the required written exams a year earlier proved that the true competency of a psychiatrist cannot be judged solely by passing a written test but requires a clinical examination of a live patient.

The oral exams represented an unimpeachable evaluation of clinical competence. The examiners often spoke of how they would feel confident and comfortable with referring a family member to those who successfully passed this rigorous, authentic exam on real patients. It was justifiable to give lifetime certification to those who passed the oral exam. Those permanently certified psychiatrists maintained their lifelong learning by having an unrestricted state medical license, which is contingent on acquiring 50 category 1 continuing medical education (CME) credits annually. Why not restore lifelong certification for those who pass both a written and oral exam, as long as they maintain a valid medical license?

According to the ABPN 2019 Annual Report,¹ 31,514 psychiatrists have received lifetime certification, of whom an estimated 9,547 were still clinically active in 2019. This is the “grandfathered” cohort of psychiatrists to which I belong. I was tested on neurologic patients, not just psychiatric patients, a tribute to the strong bridge that existed between these sister brain specialties. As of 2019, of the 33,277 psychiatrists who received a time-limited certification, 29,343 were still clinically active, an attrition rate of 12% over the past 25 years. This includes psychiatrists who found the MOC too onerous to complete, or are in private practice where MOC is not a vital requirement. However, these days most psychiatrists are obligated to be recertified because so many entities require it. This includes hiring institutions, government agencies (Medicare/Medicaid), health insurance companies, hospital medical staff for privileging and credentialing, and various regulatory boards, such as The Joint Commission, the Accreditation Council for Graduate Medical Education, and academic medical centers. Because most psychiatrists are involved with at least one of these entities, 29,343 have no choice but to perform all the requirements of the MOC, with its countless hours, numerous documentations, and many fees, to remain certified by the ABPN. Notably absent is an alternative mechanism for a certification process that is widely accepted by all agencies and institutions. Psychiatrists are actively seeking alternatives.

Continue to: The ABPN...

The ABPN, long regarded as an esteemed nonprofit organization, has been accused of being a monopoly. Some angry psychiatrists have filed a class action lawsuit to demand other board certification methods. Some have gone to the media to complain about the American Board of Medical Specialties (of which the ABPN is a member board), accusing both of unfair regulations or of raking in substantial profits to support excessively compensated executives. Perception often trumps reality, so no matter how vigorously the ABPN defends itself, its procedures, or its MOC requirements, its customers—psychiatric physicians—feel oppressed or exploited.

How the MOC can be improved

So what can be done to improve the MOC? The need for recertification is arguably necessary to document clinical competency over an approximately 40-year psychiatric career following residency. I conducted a brief survey of Current Psychiatry readers. Of the 319 respondents, 86.5% recommended abolishing the MOC, while 13.5% said it should remain or were unsure. In a follow-up question, 60% agreed that the American Psychiatric Association (APA) should establish a Council on Board Certification, and 33% agreed that the MOC should only be a clinical vignette-based written exam every 10 years, along with an unrestricted or active state medical license.

Significant advances in remote communication technology should be harnessed by the ABPN (or the APA, if it decides to conduct its own board certification) to restore the old model at a fraction of the cost. The oral exams have been replaced by a written exam that is not an accurate reflection or documentation of clinical competence. The traditional oral exam (after passing a written exam) was a magnificent but costly feat of massive logistical complexity, with >1,000 candidates and examiners traveling to a city where the ABPN arranged for several hospitals to shut down their clinics for 2 full days to use their clinical offices for the oral exams. Multiple teams examined the candidates twice on the same day: once with a live patient, and again with a video of a real patient. The examiners filled out scoring cards after observing the candidates conduct the live interview or discussing the video. A consensus grade of pass or fail was documented. At the end of the 2 days, examiners and candidates boarded buses to the airport. It was a highly expensive process (exam fees + airfare + hotel + food). Twice a year, the examiners generously donated their time to the ABPN without compensation, as a token of love for and service to the profession.

That initial certification of a written exam, followed by an oral exam, validated the competence of a psychiatrist both cognitively and clinically. The lifetime certification was truly earned. The same model can now be replicated virtually via videoconferencing at a far lower cost to the ABPN, the candidates, and the examiners. The MOC 10-year recertification can be reduced to a written exam with clinical vignettes and an unrestricted license to practice medicine in any state, which implies that the psychiatrist has received the 50 CME annual credits to renew the license. The rest of the bells and whistles can be strongly recommended but not required. The cost in time and money to both the ABPN and the candidates can be significantly reduced, but more importantly, the clinical competence will be validated at baseline with virtual oral boards after passing the written exam (formerly labeled as part I, preceding the part II oral boards).

The traditional board certification model of the past should be resurrected via videoconferencing and offered as an option to the candidates who prefer it to the current MOC. The MOC can then be simplified to lifetime certification or to only a written exam with clinical vignettes every 10 years to ensure that psychiatrists continue to incorporate relevant clinical and treatment advances in their practice. The KISS principle (keep it simple, stupid) worked very well for many generations of psychiatrists in the past, and will work again going forward if offered as an option. Psychiatrists can then focus on treating patients instead of being burdened by the many time-consuming requirements and hoops of the current MOC.

The prevalence of insomnia in the general population is approximately 6% to 10%.¹ In addition, an estimated 30% of the general population may have symptoms of insomnia without meeting the diagnostic criteria.² As a disorder, insomnia is characterized by a persistent difficulty initiating or maintaining sleep, or early morning awakening with inability to return to sleep, that has been present for at least 3 months. Additionally, the sleep difficulties must occur at least 3 nights a week, result in impaired daytime functioning, and cause significant distress.¹

Cognitive-behavioral therapy for insomnia (CBT-I) is an effective treatment, supported by several systematic reviews and meta-analyses.^3-5 In the short term, CBT-I is as effective as pharmacotherapy.⁶ However, CBT-I is the preferred treatment for chronic insomnia, according to recommendations in European and American guidelines.^7,8

Here we review 8 recent studies that examined CBT-I. These studies are summarized in the Table.^9-16

1. Cheng P, Kalmbach DA, Tallent G, et al. Depression prevention via digital cognitive behavioral therapy for insomnia: a randomized controlled trial. Sleep. 2019;42(10):zsz150. doi: 10.1093/sleep/zsz150.

Although CBT-I is a first-line treatment for chronic insomnia, it is underutilized in clinical practice primarily due to limited availability. Because few clinicians are certified in CBT-I, it has become necessary to develop alternative modes of delivery for CBT-I, such as fully automated, internet-delivered approaches to reach more patients with insomnia. Digital CBT-I (dCBT-I) is comparable to in-person CBT-I in improving insomnia symptoms and reducing concurrent depressive symptoms with insomnia. It is unclear if unguided, internet-delivered CBT-I is effective for achieving remission from depression or preventing depression in the long term. Chen et al⁹ examined the efficacy of dCBT-I in reducing and preventing depression over a 1-year follow-up.

Study design

• Participants from various centers in Southeastern Michigan were recruited between 2016 and 2017. Data was obtained from the Sleep to Prevent Evolving Affective Disorders (SPREAD) trial.
• Participants who met DSM-5 criteria for chronic insomnia disorder were randomized to dCBT-I (n = 358) using the Sleepio digital CBT program via the internet or to online sleep education (n = 300).
• The primary outcome was depression, measured using the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR-16) at 1-year follow-up. Depression incidence was also tested against insomnia treatment response.

Outcomes

• The severity of depression was significantly lower at 1-year follow-up in the dCBT-I group compared with the control group.
• The dCBT-I group showed a 51% higher remission rate than the control group at 1-year follow-up.
• The incidence of moderate to severe depression in individuals with minimal to no depression at baseline was halved at 1 year after receiving dCBT-I treatment compared with the control group.

Continue to: Conclusion

• dCBT-I can improve depression and insomnia and has a sustained antidepressant effect.
• dCBT-I is effective for preventing depression. In other words, the risk of developing depression is decreased when dCBT-I is used to treat insomnia in individuals with minimal to no depression at baseline.

2. Vedaa Ø, Hagatun S, Kallestad H, et al. Long-term effects of an unguided online cognitive behavioral therapy for chronic insomnia. J Clin Sleep Med. 2019;15(1):101-110.

dCBT-I is effective for treating insomnia in the short term; however, little is known about the long-term effectiveness of dCBT-I on sleep and daytime symptoms. Vedaa et al¹⁰ evaluated the efficacy of dCBT-I at 18 months after the intervention.

Study design

• In this randomized controlled trial (RCT), the efficacy of unguided, internet-delivered CBT-I (n = 95) was compared with web-based patient education (n = 86) for patients with chronic insomnia.
• Participants were assessed at baseline, after a 9-week intervention period, and at 6-month follow-up. Participants in the internet CBT-I group were reassessed at 18 months after the intervention using online questionnaires, including the Insomnia Severity Index (ISI), Bergen Insomnia Scale (BIS), Brief Dysfunctional Beliefs and Attitudes Scale, Hospital Anxiety and Depression Scale, Chalder Fatigue Questionnaire, and sleep diaries.

Outcomes

• At 18 months, significant improvements were noted from baseline ISI and BIS scores and in levels of daytime fatigue, as well as psychological distress and beliefs about sleep.
• Sleep diary variables—including sleep onset latency, time awake during the night (wake time after sleep onset), early morning awakening, total sleep time, and sleep efficiency—showed significant improvement from baseline to 18-month follow-up (at least moderate effect size).
• Improvements were maintained from the completion of the 9-week intervention to follow-up at 18 months.

Continue to: Conclusion

• Fully-automated, internet-based CBT-I is efficacious in maintaining positive effects on sleep and daytime functioning up to 18 months after completing treatment.

3. Sweetman A, Lack L, Catcheside PG, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial. Sleep. 2019;42(12):zsz178. doi: 10.1093/sleep/zsz178.

Comorbid insomnia and sleep apnea (COMISA) can affect a patient’s ability to accept and comply with continuous positive airway pressure (CPAP) therapy. Providing adequate treatment for these patients can be challenging.

Sweetman et al¹¹ evaluated the acceptance and use of CPAP in patients with obstructive sleep apnea and chronic insomnia following initial treatment with CBT-I compared with treatment as usual (TAU).

Study design

• In this RCT, 145 participants with COMISA were randomized to 4 sessions of CBT-I or TAU before starting CPAP therapy until 6 months after randomization.
• Primary outcomes were objective CPAP adherence and objective sleep efficiency at the end of 6 months.
• Secondary outcomes were CPAP acceptance/rejection, changes in sleep parameters, global insomnia severity, and daytime impairments at 6 months.

Continue to: Outcomes

• The CBT-I group had higher initial CPAP acceptance and greater average nightly adherence to CPAP (61 minutes more) than the TAU group.
• Significant improvements were noted in global insomnia severity, nighttime insomnia complaints, and dysfunctional sleep-related cognitions at 6 months in the CBT-I group compared with TAU.
• No differences between the 2 groups were noted in sleep diary parameters or daytime impairments at 6 months.

Conclusions

• Patients with COMISA can benefit from receiving CBT-I before starting CPAP therapy because CBT-I can improve immediate acceptance of CPAP and may help to maintain adherence to CPAP over time.
• Patients with sleep apnea should be evaluated for comorbid insomnia, and CBT-I should be considered before starting CPAP treatment.

4. Asarnow LD, Bei B, Krystal A, et al. Circadian preference as a moderator of depression outcome following cognitive behavioral therapy for insomnia plus antidepressant medications: a report from the TRIAD study. J Clin Sleep Med. 2019;15(4):573-580.

The Treatment of Insomnia and Depression (TRIAD) study reported the effects of combining antidepressants with CBT-I in patients with major depressive disorder (MDD) and insomnia. Asarnow et al¹² examined the moderation of circadian preference in the reduction of depression and insomnia symptoms severity during the same trial.

Study design

• In this RCT, 139 participants with MDD and insomnia were treated with an antidepressant (escitalopram, sertraline, or desvenlafaxine) and randomized to 8 weeks of CBT-I or control therapy (sleep education).
• Measurements used were Composite Scale of Morningness for circadian preference (morningness vs eveningness), depression severity with the Hamilton Rating Scale for Depression, and insomnia severity using the ISI.

Continue to: Outcomes

• CBT-I was effective for insomnia regardless of circadian preference.
• A smaller reduction in depression scores was noted in participants with greater evening preference.
• Depression outcomes were better among participants with evening preference if they were assigned to CBT-I vs control therapy.
• The control therapy (sleep education) was particularly ineffective in reducing depression symptoms in participants with evening preference.

Conclusion

• Individuals with MDD and insomnia and an evening preference are at an increased risk for poor response to antidepressants alone.
• Outcomes for both depression and insomnia improve if CBT-I is combined with antidepressants.
• Offering sleep education alone is not sufficient.

5. Drake CL, Kalmbach DA, Arnedt JT, et al. Treating chronic insomnia in postmenopausal women: a randomized clinical trial comparing cognitive-behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. Sleep. 2019;42(2):zsy217. doi: 10.1093/sleep/zsy217.

Postmenopausal women with sleep disturbances experience higher medical and psychiatric comorbidities, and have higher alcohol consumption and stress levels than postmenopausal women with good sleep. Nonpharmacologic insomnia treatments with durable effects are imperative for postmenopausal women because they are safer than pharmacologic approaches. Although CBT-I is the recommended first-line treatment for chronic insomnia, its application in menopause-related insomnia is limited. Drake et al¹³ evaluated the efficacy of CBT-I in menopause-related insomnia compared with sleep restriction therapy (SRT) and sleep hygiene education (SHE).

Study design

• This RCT was conducted at a health system with 6 hospitals in Michigan.
• Postmenopausal women who met DSM-5 criteria for chronic insomnia disorder (n = 150) were randomized into 1 of 3 groups: SHE, SRT, or CBT-I.
• Primary outcome measures were ISI scores and sleep diaries that documented multiple sleep parameters, including sleep onset latency, wake time after sleep onset, number of awakenings in the middle of the night, time in bed, total sleep time, and sleep efficiency. These were measured at baseline, after completion of treatment, and 6 months after treatment.

Continue to: Outcomes

Outcomes

• Both CBT-I and SRT outperformed SHE on the ISI and for most of the sleep parameters on sleep diaries immediately after treatment completion and at 6 months after treatment.
• Total sleep time was 40 to 43 minutes longer in the CBT-I group than in the SRT and SHE groups at 6-month follow-up.
• Remission rates (sleep onset latency ≤30 minutes, wake time after sleep onset ≤30 minutes, sleep efficiency ≥85%) were significantly higher in CBT-I group (CBT-I > SRT > SHE).

Conclusion

• Sleep hygiene education as a standalone treatment is not useful for treating chronic insomnia.
• Both CBT-I and SRT are efficacious for menopause-related insomnia.
• CBT-I may be a better option than SRT because it produces higher remission rates and better long-term outcomes.

6. Kalmbach DA, Cheng P, Arnedt JT, et al. Improving daytime functioning, work performance, and quality of life in postmenopausal women with insomnia: comparing cognitive behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. J Clin Sleep Med. 2019;15(7):999-1010.

CBT-I has shown efficacy in the treatment of insomnia in postmenopausal women. In this study, Kalmbach et al¹⁴ compared 3 nonpharmacologic modalities—CBT-I, SRT, and SHE—for the treatment of menopause-related insomnia and daytime impairment.

Study design

• In this RCT, 150 participants with new peri- and post-menopausal onset or exacerbation of insomnia were randomized to 1 of 3 groups: SHE, SRT, or CBT-I.
• Participants were assessed at baseline, after treatment completion, and at 6-month follow-up using the ISI, sleep diaries, Fatigue Severity Scale, Epworth Sleepiness Scale, Work Productivity and Activity Impairment Questionnaire, and 36-item Medical Outcomes Study Short Form Health Survey.

Continue to: Outcomes

• In both the CBT-I and SRT groups, significant improvements were noted in fatigue, energy, daytime sleepiness, and work function after treatment completion and at 6-month follow-up.
• Improvements were noted in emotional well-being and resiliency to physical and emotional problems in the CBT-I group at 6 months.
• Improvements in overall general health and social functioning, less pain, and fewer hot flashes were reported by postmenopausal women who remitted from insomnia; however, these benefits were not directly related to any specific treatment modality.

Conclusion

• CBT-I and SRT are superior to SHE for improving daytime functioning, and some aspects of life quality and work productivity, in postmenopausal women with insomnia.
• CBT-I may be superior to SRT in producing larger improvements in fatigue, energy level, and daytime sleep propensity.
• CBT-I can improve emotional well-being and resilience to emotional problems in postmenopausal women with insomnia.

7. Peoples AR, Garland SN, Pigeon WR, et al. Cognitive behavioral therapy for insomnia reduces depression in cancer survivors. J Clin Sleep Med. 2019;15(1):129-137.

Depression is common in patients with cancer and is usually associated with comorbid insomnia. Depression has significant effect on treatment compliance, coping with illness, and quality of life. Peoples et al¹⁵ examined the effects of CBT-I on depression in cancer survivors.

Study design

• This was a secondary analysis of a multi­center, randomized, placebo-controlled trial that evaluated interventions for cancer survivors with chronic insomnia in which the primary outcome measure was insomnia severity.
• Cancer survivors (n = 67) were randomized to CBT-I plus armodafinil or placebo or to SHE plus armodafinil or placebo.
• The Patient Health Questionnaire-9 (PHQ-9) and ISI were used to measure depression and insomnia at baseline, after 7-weeks of intervention, and at 3 months postintervention.

Continue to: Outcomes

• Immediately after completing the intervention, cancer survivors treated with CBT-I had significantly less depression (38% greater improvement in depression) compared with those who received SHE (control group).
• In the CBT-I group, 23% of cancer survivors achieved a clinically important reduction (5-point reduction on PHQ-9 total score) in depression at postintervention compared with 6% of those in the control group.
• At 3 months after the intervention, only 14% of cancer survivors in CBT-I group reported depression (PHQ-9 score >4), whereas 47% of those in the control group (SHE) reported depression.

Conclusion

• CBT-I improves both depression and insomnia in cancer survivors, and the improvements are sustained at 3 months after completing treatment.
• Improvement in insomnia severity appears to mediate the positive effects of CBT-I on depression.

8. Harb GC, Cook JM, Phelps AJ, et al. Randomized controlled trial of imagery rehearsal for posttraumatic nightmares in combat veterans. J Clin Sleep Med. 2019;15(5):757-767.

The American Academy of Sleep Medicine recommends imagery rehearsal (IR) therapy, which incorporates some components of CBT-I, for the treatment of recurrent posttraumatic stress disorder (PTSD)–related nightmares. In this study, Harb et al¹⁶ compared CBT-I plus IR to CBT-I alone for the treatment of nightmares in veterans with combat-related PTSD.

Study design

• This RCT included male and female US veterans (n = 108) deployed to Iraq and Afghanistan with current PTSD and recurrent nightmares related to deployment.
• Participants were randomized to 6 sessions of CBT-I plus IR or CBT-I alone.
• Primary outcome measures included frequency of nightmares and distress associated with nightmares.

Continue to: Outcomes

• A significant improvement in nightmares was noted in both groups (29% of participants showed a clinically-significant reduction in nightmare frequency and 22% of participants achieved remission).
• CBT-I plus IR was not superior to CBT-I only at postintervention and at 6-month follow-up.

Conclusion

• Both IR and CBT-I demonstrated efficacy for decreasing nightmare frequency and distress.
• Combining IR and CBT-I may not provide a synergistic advantage over CBT-I alone for treating PTSD-related nightmares in veterans.

The prevalence of insomnia in the general population is approximately 6% to 10%.¹ In addition, an estimated 30% of the general population may have symptoms of insomnia without meeting the diagnostic criteria.² As a disorder, insomnia is characterized by a persistent difficulty initiating or maintaining sleep, or early morning awakening with inability to return to sleep, that has been present for at least 3 months. Additionally, the sleep difficulties must occur at least 3 nights a week, result in impaired daytime functioning, and cause significant distress.¹

Cognitive-behavioral therapy for insomnia (CBT-I) is an effective treatment, supported by several systematic reviews and meta-analyses.^3-5 In the short term, CBT-I is as effective as pharmacotherapy.⁶ However, CBT-I is the preferred treatment for chronic insomnia, according to recommendations in European and American guidelines.^7,8

Here we review 8 recent studies that examined CBT-I. These studies are summarized in the Table.^9-16

1. Cheng P, Kalmbach DA, Tallent G, et al. Depression prevention via digital cognitive behavioral therapy for insomnia: a randomized controlled trial. Sleep. 2019;42(10):zsz150. doi: 10.1093/sleep/zsz150.

Although CBT-I is a first-line treatment for chronic insomnia, it is underutilized in clinical practice primarily due to limited availability. Because few clinicians are certified in CBT-I, it has become necessary to develop alternative modes of delivery for CBT-I, such as fully automated, internet-delivered approaches to reach more patients with insomnia. Digital CBT-I (dCBT-I) is comparable to in-person CBT-I in improving insomnia symptoms and reducing concurrent depressive symptoms with insomnia. It is unclear if unguided, internet-delivered CBT-I is effective for achieving remission from depression or preventing depression in the long term. Chen et al⁹ examined the efficacy of dCBT-I in reducing and preventing depression over a 1-year follow-up.

Study design

• Participants from various centers in Southeastern Michigan were recruited between 2016 and 2017. Data was obtained from the Sleep to Prevent Evolving Affective Disorders (SPREAD) trial.
• Participants who met DSM-5 criteria for chronic insomnia disorder were randomized to dCBT-I (n = 358) using the Sleepio digital CBT program via the internet or to online sleep education (n = 300).
• The primary outcome was depression, measured using the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR-16) at 1-year follow-up. Depression incidence was also tested against insomnia treatment response.

Outcomes

• The severity of depression was significantly lower at 1-year follow-up in the dCBT-I group compared with the control group.
• The dCBT-I group showed a 51% higher remission rate than the control group at 1-year follow-up.
• The incidence of moderate to severe depression in individuals with minimal to no depression at baseline was halved at 1 year after receiving dCBT-I treatment compared with the control group.

Continue to: Conclusion

• dCBT-I can improve depression and insomnia and has a sustained antidepressant effect.
• dCBT-I is effective for preventing depression. In other words, the risk of developing depression is decreased when dCBT-I is used to treat insomnia in individuals with minimal to no depression at baseline.

2. Vedaa Ø, Hagatun S, Kallestad H, et al. Long-term effects of an unguided online cognitive behavioral therapy for chronic insomnia. J Clin Sleep Med. 2019;15(1):101-110.

dCBT-I is effective for treating insomnia in the short term; however, little is known about the long-term effectiveness of dCBT-I on sleep and daytime symptoms. Vedaa et al¹⁰ evaluated the efficacy of dCBT-I at 18 months after the intervention.

Study design

• In this randomized controlled trial (RCT), the efficacy of unguided, internet-delivered CBT-I (n = 95) was compared with web-based patient education (n = 86) for patients with chronic insomnia.
• Participants were assessed at baseline, after a 9-week intervention period, and at 6-month follow-up. Participants in the internet CBT-I group were reassessed at 18 months after the intervention using online questionnaires, including the Insomnia Severity Index (ISI), Bergen Insomnia Scale (BIS), Brief Dysfunctional Beliefs and Attitudes Scale, Hospital Anxiety and Depression Scale, Chalder Fatigue Questionnaire, and sleep diaries.

Outcomes

• At 18 months, significant improvements were noted from baseline ISI and BIS scores and in levels of daytime fatigue, as well as psychological distress and beliefs about sleep.
• Sleep diary variables—including sleep onset latency, time awake during the night (wake time after sleep onset), early morning awakening, total sleep time, and sleep efficiency—showed significant improvement from baseline to 18-month follow-up (at least moderate effect size).
• Improvements were maintained from the completion of the 9-week intervention to follow-up at 18 months.

Continue to: Conclusion

• Fully-automated, internet-based CBT-I is efficacious in maintaining positive effects on sleep and daytime functioning up to 18 months after completing treatment.

3. Sweetman A, Lack L, Catcheside PG, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial. Sleep. 2019;42(12):zsz178. doi: 10.1093/sleep/zsz178.

Comorbid insomnia and sleep apnea (COMISA) can affect a patient’s ability to accept and comply with continuous positive airway pressure (CPAP) therapy. Providing adequate treatment for these patients can be challenging.

Sweetman et al¹¹ evaluated the acceptance and use of CPAP in patients with obstructive sleep apnea and chronic insomnia following initial treatment with CBT-I compared with treatment as usual (TAU).

Study design

• In this RCT, 145 participants with COMISA were randomized to 4 sessions of CBT-I or TAU before starting CPAP therapy until 6 months after randomization.
• Primary outcomes were objective CPAP adherence and objective sleep efficiency at the end of 6 months.
• Secondary outcomes were CPAP acceptance/rejection, changes in sleep parameters, global insomnia severity, and daytime impairments at 6 months.

Continue to: Outcomes

• The CBT-I group had higher initial CPAP acceptance and greater average nightly adherence to CPAP (61 minutes more) than the TAU group.
• Significant improvements were noted in global insomnia severity, nighttime insomnia complaints, and dysfunctional sleep-related cognitions at 6 months in the CBT-I group compared with TAU.
• No differences between the 2 groups were noted in sleep diary parameters or daytime impairments at 6 months.

Conclusions

• Patients with COMISA can benefit from receiving CBT-I before starting CPAP therapy because CBT-I can improve immediate acceptance of CPAP and may help to maintain adherence to CPAP over time.
• Patients with sleep apnea should be evaluated for comorbid insomnia, and CBT-I should be considered before starting CPAP treatment.

4. Asarnow LD, Bei B, Krystal A, et al. Circadian preference as a moderator of depression outcome following cognitive behavioral therapy for insomnia plus antidepressant medications: a report from the TRIAD study. J Clin Sleep Med. 2019;15(4):573-580.

The Treatment of Insomnia and Depression (TRIAD) study reported the effects of combining antidepressants with CBT-I in patients with major depressive disorder (MDD) and insomnia. Asarnow et al¹² examined the moderation of circadian preference in the reduction of depression and insomnia symptoms severity during the same trial.

Study design

• In this RCT, 139 participants with MDD and insomnia were treated with an antidepressant (escitalopram, sertraline, or desvenlafaxine) and randomized to 8 weeks of CBT-I or control therapy (sleep education).
• Measurements used were Composite Scale of Morningness for circadian preference (morningness vs eveningness), depression severity with the Hamilton Rating Scale for Depression, and insomnia severity using the ISI.

Continue to: Outcomes

• CBT-I was effective for insomnia regardless of circadian preference.
• A smaller reduction in depression scores was noted in participants with greater evening preference.
• Depression outcomes were better among participants with evening preference if they were assigned to CBT-I vs control therapy.
• The control therapy (sleep education) was particularly ineffective in reducing depression symptoms in participants with evening preference.

Conclusion

• Individuals with MDD and insomnia and an evening preference are at an increased risk for poor response to antidepressants alone.
• Outcomes for both depression and insomnia improve if CBT-I is combined with antidepressants.
• Offering sleep education alone is not sufficient.

5. Drake CL, Kalmbach DA, Arnedt JT, et al. Treating chronic insomnia in postmenopausal women: a randomized clinical trial comparing cognitive-behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. Sleep. 2019;42(2):zsy217. doi: 10.1093/sleep/zsy217.

Postmenopausal women with sleep disturbances experience higher medical and psychiatric comorbidities, and have higher alcohol consumption and stress levels than postmenopausal women with good sleep. Nonpharmacologic insomnia treatments with durable effects are imperative for postmenopausal women because they are safer than pharmacologic approaches. Although CBT-I is the recommended first-line treatment for chronic insomnia, its application in menopause-related insomnia is limited. Drake et al¹³ evaluated the efficacy of CBT-I in menopause-related insomnia compared with sleep restriction therapy (SRT) and sleep hygiene education (SHE).

Study design

• This RCT was conducted at a health system with 6 hospitals in Michigan.
• Postmenopausal women who met DSM-5 criteria for chronic insomnia disorder (n = 150) were randomized into 1 of 3 groups: SHE, SRT, or CBT-I.
• Primary outcome measures were ISI scores and sleep diaries that documented multiple sleep parameters, including sleep onset latency, wake time after sleep onset, number of awakenings in the middle of the night, time in bed, total sleep time, and sleep efficiency. These were measured at baseline, after completion of treatment, and 6 months after treatment.

Continue to: Outcomes

Outcomes

• Both CBT-I and SRT outperformed SHE on the ISI and for most of the sleep parameters on sleep diaries immediately after treatment completion and at 6 months after treatment.
• Total sleep time was 40 to 43 minutes longer in the CBT-I group than in the SRT and SHE groups at 6-month follow-up.
• Remission rates (sleep onset latency ≤30 minutes, wake time after sleep onset ≤30 minutes, sleep efficiency ≥85%) were significantly higher in CBT-I group (CBT-I > SRT > SHE).

Conclusion

• Sleep hygiene education as a standalone treatment is not useful for treating chronic insomnia.
• Both CBT-I and SRT are efficacious for menopause-related insomnia.
• CBT-I may be a better option than SRT because it produces higher remission rates and better long-term outcomes.

6. Kalmbach DA, Cheng P, Arnedt JT, et al. Improving daytime functioning, work performance, and quality of life in postmenopausal women with insomnia: comparing cognitive behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. J Clin Sleep Med. 2019;15(7):999-1010.

CBT-I has shown efficacy in the treatment of insomnia in postmenopausal women. In this study, Kalmbach et al¹⁴ compared 3 nonpharmacologic modalities—CBT-I, SRT, and SHE—for the treatment of menopause-related insomnia and daytime impairment.

Study design

• In this RCT, 150 participants with new peri- and post-menopausal onset or exacerbation of insomnia were randomized to 1 of 3 groups: SHE, SRT, or CBT-I.
• Participants were assessed at baseline, after treatment completion, and at 6-month follow-up using the ISI, sleep diaries, Fatigue Severity Scale, Epworth Sleepiness Scale, Work Productivity and Activity Impairment Questionnaire, and 36-item Medical Outcomes Study Short Form Health Survey.

Continue to: Outcomes

• In both the CBT-I and SRT groups, significant improvements were noted in fatigue, energy, daytime sleepiness, and work function after treatment completion and at 6-month follow-up.
• Improvements were noted in emotional well-being and resiliency to physical and emotional problems in the CBT-I group at 6 months.
• Improvements in overall general health and social functioning, less pain, and fewer hot flashes were reported by postmenopausal women who remitted from insomnia; however, these benefits were not directly related to any specific treatment modality.

Conclusion

• CBT-I and SRT are superior to SHE for improving daytime functioning, and some aspects of life quality and work productivity, in postmenopausal women with insomnia.
• CBT-I may be superior to SRT in producing larger improvements in fatigue, energy level, and daytime sleep propensity.
• CBT-I can improve emotional well-being and resilience to emotional problems in postmenopausal women with insomnia.

7. Peoples AR, Garland SN, Pigeon WR, et al. Cognitive behavioral therapy for insomnia reduces depression in cancer survivors. J Clin Sleep Med. 2019;15(1):129-137.

Depression is common in patients with cancer and is usually associated with comorbid insomnia. Depression has significant effect on treatment compliance, coping with illness, and quality of life. Peoples et al¹⁵ examined the effects of CBT-I on depression in cancer survivors.

Study design

• This was a secondary analysis of a multi­center, randomized, placebo-controlled trial that evaluated interventions for cancer survivors with chronic insomnia in which the primary outcome measure was insomnia severity.
• Cancer survivors (n = 67) were randomized to CBT-I plus armodafinil or placebo or to SHE plus armodafinil or placebo.
• The Patient Health Questionnaire-9 (PHQ-9) and ISI were used to measure depression and insomnia at baseline, after 7-weeks of intervention, and at 3 months postintervention.

Continue to: Outcomes

• Immediately after completing the intervention, cancer survivors treated with CBT-I had significantly less depression (38% greater improvement in depression) compared with those who received SHE (control group).
• In the CBT-I group, 23% of cancer survivors achieved a clinically important reduction (5-point reduction on PHQ-9 total score) in depression at postintervention compared with 6% of those in the control group.
• At 3 months after the intervention, only 14% of cancer survivors in CBT-I group reported depression (PHQ-9 score >4), whereas 47% of those in the control group (SHE) reported depression.

Conclusion

• CBT-I improves both depression and insomnia in cancer survivors, and the improvements are sustained at 3 months after completing treatment.
• Improvement in insomnia severity appears to mediate the positive effects of CBT-I on depression.

8. Harb GC, Cook JM, Phelps AJ, et al. Randomized controlled trial of imagery rehearsal for posttraumatic nightmares in combat veterans. J Clin Sleep Med. 2019;15(5):757-767.

The American Academy of Sleep Medicine recommends imagery rehearsal (IR) therapy, which incorporates some components of CBT-I, for the treatment of recurrent posttraumatic stress disorder (PTSD)–related nightmares. In this study, Harb et al¹⁶ compared CBT-I plus IR to CBT-I alone for the treatment of nightmares in veterans with combat-related PTSD.

Study design

• This RCT included male and female US veterans (n = 108) deployed to Iraq and Afghanistan with current PTSD and recurrent nightmares related to deployment.
• Participants were randomized to 6 sessions of CBT-I plus IR or CBT-I alone.
• Primary outcome measures included frequency of nightmares and distress associated with nightmares.

Continue to: Outcomes

• A significant improvement in nightmares was noted in both groups (29% of participants showed a clinically-significant reduction in nightmare frequency and 22% of participants achieved remission).
• CBT-I plus IR was not superior to CBT-I only at postintervention and at 6-month follow-up.

Conclusion

• Both IR and CBT-I demonstrated efficacy for decreasing nightmare frequency and distress.
• Combining IR and CBT-I may not provide a synergistic advantage over CBT-I alone for treating PTSD-related nightmares in veterans.

The prevalence of insomnia in the general population is approximately 6% to 10%.¹ In addition, an estimated 30% of the general population may have symptoms of insomnia without meeting the diagnostic criteria.² As a disorder, insomnia is characterized by a persistent difficulty initiating or maintaining sleep, or early morning awakening with inability to return to sleep, that has been present for at least 3 months. Additionally, the sleep difficulties must occur at least 3 nights a week, result in impaired daytime functioning, and cause significant distress.¹

Cognitive-behavioral therapy for insomnia (CBT-I) is an effective treatment, supported by several systematic reviews and meta-analyses.^3-5 In the short term, CBT-I is as effective as pharmacotherapy.⁶ However, CBT-I is the preferred treatment for chronic insomnia, according to recommendations in European and American guidelines.^7,8

Here we review 8 recent studies that examined CBT-I. These studies are summarized in the Table.^9-16

1. Cheng P, Kalmbach DA, Tallent G, et al. Depression prevention via digital cognitive behavioral therapy for insomnia: a randomized controlled trial. Sleep. 2019;42(10):zsz150. doi: 10.1093/sleep/zsz150.

Although CBT-I is a first-line treatment for chronic insomnia, it is underutilized in clinical practice primarily due to limited availability. Because few clinicians are certified in CBT-I, it has become necessary to develop alternative modes of delivery for CBT-I, such as fully automated, internet-delivered approaches to reach more patients with insomnia. Digital CBT-I (dCBT-I) is comparable to in-person CBT-I in improving insomnia symptoms and reducing concurrent depressive symptoms with insomnia. It is unclear if unguided, internet-delivered CBT-I is effective for achieving remission from depression or preventing depression in the long term. Chen et al⁹ examined the efficacy of dCBT-I in reducing and preventing depression over a 1-year follow-up.

Study design

• Participants from various centers in Southeastern Michigan were recruited between 2016 and 2017. Data was obtained from the Sleep to Prevent Evolving Affective Disorders (SPREAD) trial.
• Participants who met DSM-5 criteria for chronic insomnia disorder were randomized to dCBT-I (n = 358) using the Sleepio digital CBT program via the internet or to online sleep education (n = 300).
• The primary outcome was depression, measured using the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR-16) at 1-year follow-up. Depression incidence was also tested against insomnia treatment response.

Outcomes

• The severity of depression was significantly lower at 1-year follow-up in the dCBT-I group compared with the control group.
• The dCBT-I group showed a 51% higher remission rate than the control group at 1-year follow-up.
• The incidence of moderate to severe depression in individuals with minimal to no depression at baseline was halved at 1 year after receiving dCBT-I treatment compared with the control group.

Continue to: Conclusion

• dCBT-I can improve depression and insomnia and has a sustained antidepressant effect.
• dCBT-I is effective for preventing depression. In other words, the risk of developing depression is decreased when dCBT-I is used to treat insomnia in individuals with minimal to no depression at baseline.

2. Vedaa Ø, Hagatun S, Kallestad H, et al. Long-term effects of an unguided online cognitive behavioral therapy for chronic insomnia. J Clin Sleep Med. 2019;15(1):101-110.

dCBT-I is effective for treating insomnia in the short term; however, little is known about the long-term effectiveness of dCBT-I on sleep and daytime symptoms. Vedaa et al¹⁰ evaluated the efficacy of dCBT-I at 18 months after the intervention.

Study design

• In this randomized controlled trial (RCT), the efficacy of unguided, internet-delivered CBT-I (n = 95) was compared with web-based patient education (n = 86) for patients with chronic insomnia.
• Participants were assessed at baseline, after a 9-week intervention period, and at 6-month follow-up. Participants in the internet CBT-I group were reassessed at 18 months after the intervention using online questionnaires, including the Insomnia Severity Index (ISI), Bergen Insomnia Scale (BIS), Brief Dysfunctional Beliefs and Attitudes Scale, Hospital Anxiety and Depression Scale, Chalder Fatigue Questionnaire, and sleep diaries.

Outcomes

• At 18 months, significant improvements were noted from baseline ISI and BIS scores and in levels of daytime fatigue, as well as psychological distress and beliefs about sleep.
• Sleep diary variables—including sleep onset latency, time awake during the night (wake time after sleep onset), early morning awakening, total sleep time, and sleep efficiency—showed significant improvement from baseline to 18-month follow-up (at least moderate effect size).
• Improvements were maintained from the completion of the 9-week intervention to follow-up at 18 months.

Continue to: Conclusion

• Fully-automated, internet-based CBT-I is efficacious in maintaining positive effects on sleep and daytime functioning up to 18 months after completing treatment.

3. Sweetman A, Lack L, Catcheside PG, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial. Sleep. 2019;42(12):zsz178. doi: 10.1093/sleep/zsz178.

Comorbid insomnia and sleep apnea (COMISA) can affect a patient’s ability to accept and comply with continuous positive airway pressure (CPAP) therapy. Providing adequate treatment for these patients can be challenging.

Sweetman et al¹¹ evaluated the acceptance and use of CPAP in patients with obstructive sleep apnea and chronic insomnia following initial treatment with CBT-I compared with treatment as usual (TAU).

Study design

• In this RCT, 145 participants with COMISA were randomized to 4 sessions of CBT-I or TAU before starting CPAP therapy until 6 months after randomization.
• Primary outcomes were objective CPAP adherence and objective sleep efficiency at the end of 6 months.
• Secondary outcomes were CPAP acceptance/rejection, changes in sleep parameters, global insomnia severity, and daytime impairments at 6 months.

Continue to: Outcomes

• The CBT-I group had higher initial CPAP acceptance and greater average nightly adherence to CPAP (61 minutes more) than the TAU group.
• Significant improvements were noted in global insomnia severity, nighttime insomnia complaints, and dysfunctional sleep-related cognitions at 6 months in the CBT-I group compared with TAU.
• No differences between the 2 groups were noted in sleep diary parameters or daytime impairments at 6 months.

Conclusions

• Patients with COMISA can benefit from receiving CBT-I before starting CPAP therapy because CBT-I can improve immediate acceptance of CPAP and may help to maintain adherence to CPAP over time.
• Patients with sleep apnea should be evaluated for comorbid insomnia, and CBT-I should be considered before starting CPAP treatment.

4. Asarnow LD, Bei B, Krystal A, et al. Circadian preference as a moderator of depression outcome following cognitive behavioral therapy for insomnia plus antidepressant medications: a report from the TRIAD study. J Clin Sleep Med. 2019;15(4):573-580.

The Treatment of Insomnia and Depression (TRIAD) study reported the effects of combining antidepressants with CBT-I in patients with major depressive disorder (MDD) and insomnia. Asarnow et al¹² examined the moderation of circadian preference in the reduction of depression and insomnia symptoms severity during the same trial.

Study design

• In this RCT, 139 participants with MDD and insomnia were treated with an antidepressant (escitalopram, sertraline, or desvenlafaxine) and randomized to 8 weeks of CBT-I or control therapy (sleep education).
• Measurements used were Composite Scale of Morningness for circadian preference (morningness vs eveningness), depression severity with the Hamilton Rating Scale for Depression, and insomnia severity using the ISI.

Continue to: Outcomes

• CBT-I was effective for insomnia regardless of circadian preference.
• A smaller reduction in depression scores was noted in participants with greater evening preference.
• Depression outcomes were better among participants with evening preference if they were assigned to CBT-I vs control therapy.
• The control therapy (sleep education) was particularly ineffective in reducing depression symptoms in participants with evening preference.

Conclusion

• Individuals with MDD and insomnia and an evening preference are at an increased risk for poor response to antidepressants alone.
• Outcomes for both depression and insomnia improve if CBT-I is combined with antidepressants.
• Offering sleep education alone is not sufficient.

5. Drake CL, Kalmbach DA, Arnedt JT, et al. Treating chronic insomnia in postmenopausal women: a randomized clinical trial comparing cognitive-behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. Sleep. 2019;42(2):zsy217. doi: 10.1093/sleep/zsy217.

Postmenopausal women with sleep disturbances experience higher medical and psychiatric comorbidities, and have higher alcohol consumption and stress levels than postmenopausal women with good sleep. Nonpharmacologic insomnia treatments with durable effects are imperative for postmenopausal women because they are safer than pharmacologic approaches. Although CBT-I is the recommended first-line treatment for chronic insomnia, its application in menopause-related insomnia is limited. Drake et al¹³ evaluated the efficacy of CBT-I in menopause-related insomnia compared with sleep restriction therapy (SRT) and sleep hygiene education (SHE).

Study design

• This RCT was conducted at a health system with 6 hospitals in Michigan.
• Postmenopausal women who met DSM-5 criteria for chronic insomnia disorder (n = 150) were randomized into 1 of 3 groups: SHE, SRT, or CBT-I.
• Primary outcome measures were ISI scores and sleep diaries that documented multiple sleep parameters, including sleep onset latency, wake time after sleep onset, number of awakenings in the middle of the night, time in bed, total sleep time, and sleep efficiency. These were measured at baseline, after completion of treatment, and 6 months after treatment.

Continue to: Outcomes

Outcomes

• Both CBT-I and SRT outperformed SHE on the ISI and for most of the sleep parameters on sleep diaries immediately after treatment completion and at 6 months after treatment.
• Total sleep time was 40 to 43 minutes longer in the CBT-I group than in the SRT and SHE groups at 6-month follow-up.
• Remission rates (sleep onset latency ≤30 minutes, wake time after sleep onset ≤30 minutes, sleep efficiency ≥85%) were significantly higher in CBT-I group (CBT-I > SRT > SHE).

Conclusion

• Sleep hygiene education as a standalone treatment is not useful for treating chronic insomnia.
• Both CBT-I and SRT are efficacious for menopause-related insomnia.
• CBT-I may be a better option than SRT because it produces higher remission rates and better long-term outcomes.

6. Kalmbach DA, Cheng P, Arnedt JT, et al. Improving daytime functioning, work performance, and quality of life in postmenopausal women with insomnia: comparing cognitive behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. J Clin Sleep Med. 2019;15(7):999-1010.

CBT-I has shown efficacy in the treatment of insomnia in postmenopausal women. In this study, Kalmbach et al¹⁴ compared 3 nonpharmacologic modalities—CBT-I, SRT, and SHE—for the treatment of menopause-related insomnia and daytime impairment.

Study design

• In this RCT, 150 participants with new peri- and post-menopausal onset or exacerbation of insomnia were randomized to 1 of 3 groups: SHE, SRT, or CBT-I.
• Participants were assessed at baseline, after treatment completion, and at 6-month follow-up using the ISI, sleep diaries, Fatigue Severity Scale, Epworth Sleepiness Scale, Work Productivity and Activity Impairment Questionnaire, and 36-item Medical Outcomes Study Short Form Health Survey.

Continue to: Outcomes

• In both the CBT-I and SRT groups, significant improvements were noted in fatigue, energy, daytime sleepiness, and work function after treatment completion and at 6-month follow-up.
• Improvements were noted in emotional well-being and resiliency to physical and emotional problems in the CBT-I group at 6 months.
• Improvements in overall general health and social functioning, less pain, and fewer hot flashes were reported by postmenopausal women who remitted from insomnia; however, these benefits were not directly related to any specific treatment modality.

Conclusion

• CBT-I and SRT are superior to SHE for improving daytime functioning, and some aspects of life quality and work productivity, in postmenopausal women with insomnia.
• CBT-I may be superior to SRT in producing larger improvements in fatigue, energy level, and daytime sleep propensity.
• CBT-I can improve emotional well-being and resilience to emotional problems in postmenopausal women with insomnia.

7. Peoples AR, Garland SN, Pigeon WR, et al. Cognitive behavioral therapy for insomnia reduces depression in cancer survivors. J Clin Sleep Med. 2019;15(1):129-137.

Depression is common in patients with cancer and is usually associated with comorbid insomnia. Depression has significant effect on treatment compliance, coping with illness, and quality of life. Peoples et al¹⁵ examined the effects of CBT-I on depression in cancer survivors.

Study design

• This was a secondary analysis of a multi­center, randomized, placebo-controlled trial that evaluated interventions for cancer survivors with chronic insomnia in which the primary outcome measure was insomnia severity.
• Cancer survivors (n = 67) were randomized to CBT-I plus armodafinil or placebo or to SHE plus armodafinil or placebo.
• The Patient Health Questionnaire-9 (PHQ-9) and ISI were used to measure depression and insomnia at baseline, after 7-weeks of intervention, and at 3 months postintervention.

Continue to: Outcomes

• Immediately after completing the intervention, cancer survivors treated with CBT-I had significantly less depression (38% greater improvement in depression) compared with those who received SHE (control group).
• In the CBT-I group, 23% of cancer survivors achieved a clinically important reduction (5-point reduction on PHQ-9 total score) in depression at postintervention compared with 6% of those in the control group.
• At 3 months after the intervention, only 14% of cancer survivors in CBT-I group reported depression (PHQ-9 score >4), whereas 47% of those in the control group (SHE) reported depression.

Conclusion

• CBT-I improves both depression and insomnia in cancer survivors, and the improvements are sustained at 3 months after completing treatment.
• Improvement in insomnia severity appears to mediate the positive effects of CBT-I on depression.

8. Harb GC, Cook JM, Phelps AJ, et al. Randomized controlled trial of imagery rehearsal for posttraumatic nightmares in combat veterans. J Clin Sleep Med. 2019;15(5):757-767.

The American Academy of Sleep Medicine recommends imagery rehearsal (IR) therapy, which incorporates some components of CBT-I, for the treatment of recurrent posttraumatic stress disorder (PTSD)–related nightmares. In this study, Harb et al¹⁶ compared CBT-I plus IR to CBT-I alone for the treatment of nightmares in veterans with combat-related PTSD.

Study design

• This RCT included male and female US veterans (n = 108) deployed to Iraq and Afghanistan with current PTSD and recurrent nightmares related to deployment.
• Participants were randomized to 6 sessions of CBT-I plus IR or CBT-I alone.
• Primary outcome measures included frequency of nightmares and distress associated with nightmares.

Continue to: Outcomes

• A significant improvement in nightmares was noted in both groups (29% of participants showed a clinically-significant reduction in nightmare frequency and 22% of participants achieved remission).
• CBT-I plus IR was not superior to CBT-I only at postintervention and at 6-month follow-up.

Conclusion

• Both IR and CBT-I demonstrated efficacy for decreasing nightmare frequency and distress.
• Combining IR and CBT-I may not provide a synergistic advantage over CBT-I alone for treating PTSD-related nightmares in veterans.

CASE Perseverating on nonexistent sexual assaults

Mr. R, age 17, who has been diagnosed with obsessive-compulsive disorder (OCD), presents to the emergency department (ED) because he thinks that he is being sexually assaulted and is concerned that he is sexually assaulting other people. His family reports that Mr. R has perseverated over these thoughts for months, although there is no evidence to suggest these events have occurred. In order to ameliorate his distress, he performs rituals of looking upwards and repeatedly saying, “It didn’t happen.”

Mr. R is admitted to the inpatient psychiatry unit for further evaluation.

HISTORY Decompensation while attending a PHP

Mr. R had been diagnosed with bipolar disorder and attention-deficit/hyperactivity disorder when he was 13. During that time, he was treated with divalproex sodium and dextroamphetamine. At age 15, Mr. R’s diagnosis was changed to OCD. Seven months before coming to the ED, his symptoms had been getting worse. On one occasion, Mr. R was talking in a nonsensical fashion at school, and the police were called. Mr. R became physically aggressive with the police and was subsequently hospitalized, after which he attended a partial hospitalization program (PHP). At the PHP, Mr. R received exposure and response prevention therapy for OCD, but did not improve, and his symptoms deteriorated until he was unable to brush his teeth or shower regularly. While attending the PHP, Mr. R also developed disorganized speech. The PHP clinicians became concerned that Mr. R’s symptoms may have been prodromal symptoms of schizophrenia because he did not respond to the OCD treatment and his symptoms had worsened over the 3 months he attended the PHP.

EVALUATION Normal laboratory results

Upon admission to the inpatient psychiatric unit, Mr. R is restarted on his home medications, which include fluvoxamine, 150 mg in the morning and 200 mg at bedtime; methylfolate, 2,000 mcg/d; risperidone, 3 mg nightly; and hydroxyzine, 25 mg as needed for anxiety.

His laboratory workup, including a complete blood count, comprehensive metabolic panel, urine drug screen, and blood ethanol, are all within normal limits. Previous laboratory results, including a thyroid function panel, vitamin D level, and various autoimmune panels, were also within normal limits.

His family reports that Mr. R’s symptoms seem to worsen when he is under increased stress from school and prepping for standardized college admission examinations. The family also says that while he is playing tennis, Mr. R will posture himself in a crouched down position and at times will remain in this position for 30 minutes.

Mr. R says he eventually wants to go to college and have a professional career.

[polldaddy:10600530]

Continue to: The authors' observations

When considering Mr. R’s diagnosis, our treatment team considered the possibility of OCD with absent insight/delusional beliefs, OCD with comorbid schizophrenia, bipolar disorder, and psychotic disorder due to another medical condition.

Overlap between OCD and schizophrenia

There appears to be both an epidemiologic and biologic overlap between OCD and schizophrenia. The Table¹ summarizes the DSM-5 criteria for OCD and for schizophrenia. Schirmbeck et al² reported that the estimated prevalence of OCD in patients with schizophrenia is 12%, which is higher than in the general population. Obsessive-compulsive symptoms (OCS) in patients with schizophrenia have been reported to be even more prevalent (30.7%).² In a prospective cohort study, de Haan et al³ assessed 172 patients with first-episode schizophrenia, schizophreniform disorder, or schizoaffective disorder for the development of OCS over a 5-year follow-up period. Symptoms were tracked over time and included OCS on first assessment, persistent OCS, subsequent emergence of OCS, and intermittent OCS. A striking 51.1% of the patient sample screened positive.³ Obsessions and delusions are similar because they are both irrational thoughts, the former with insight and the latter without insight. The fact that OCS were present in up to 14% of drug-naïve patients with schizophrenia in this study suggests that this was not merely an adverse effect of antipsychotic medication.

Much of the literature about OCD examines its functional impairment in adults, with findings extrapolated to pediatric patients. Children differ from adults in a variety of meaningful ways. Baytunca et al⁴ examined adolescents with early-onset schizophrenia, with and without comorbid OCD. Patients with comorbid OCD required higher doses of antipsychotic medication to treat acute psychotic symptoms and maintain a reduction in symptoms. The study controlled for the severity of schizophrenia, and its findings suggest that schizophrenia with comorbid OCD is more treatment-resistant than schizophrenia alone.⁴

Some researchers have theorized that in adolescents, OCD and psychosis are integrally related such that one disorder could represent a prodrome or a cause of the other disorder. Niendam et al⁵ studied OCS in the psychosis prodrome. They found that OCS can present as a part of the prodromal picture in youth at high risk for psychosis. However, because none of the patients experiencing OCS converted to full-blown psychosis, these results suggest that OCS may not represent a prodrome to psychosis per se. Instead, these individuals may represent a subset of false positives over the follow-up period.⁵ Another possible explanation for the increased emergence of pre-psychotic symptoms in adolescents with OCD could be a difference in their threshold of perception. OCS compels adolescents with OCD to self-analyze more critically and frequently. As a result, these patients may more often report depressive symptoms, distress, and exacerbations of pre-psychotic symptoms. These findings highlight that comorbid OCD can amplify the psychosocial distress among higher-risk youth. It is therefore essential for physicians to perform a thorough interview in this population because subtle psychotic symptoms may be present.

[polldaddy:10600532]

Continue to: TREATMENT Improvement after switching to haloperidol

The treatment team decides to change Mr. R’s medications by cross-titrating risperidone to lurasidone and increasing hydroxyzine from 25 to 50 mg every 6 hours as needed for anxiety. Over the next several days, Mr. R reports some improvement in symptoms. However, according to staff on the unit, he continues to display disorganized behavior, respond to internal stimuli, and posture in his room. It is unclear if these symptoms are due to a psychotic illness or part of his OCD rituals. Due to worsening of symptoms, the team decides to taper lurasidone and switch to haloperidol. Mr. R starts haloperidol, 1 mg twice a day, and this is titrated to 7.5 mg three times a day. Soon after, his thoughts become more organized, he has fewer delusional thoughts, his concentration is improved, and he no longer appears to respond to internal stimuli.

The treatment team obtains a consultation on whether electroconvulsive therapy would be appropriate, but this treatment is not recommended. Instead, the team considers switching Mr. R to clozapine if the current treatment fails. Because Mr. R’s psychotic symptoms continue to improve while he is receiving haloperidol, clozapine is not added. To address Mr. R’s persistent, severe OCD symptoms, fluvoxamine is cross-tapered to sertraline, started at 50 mg/d and titrated to 100 mg/d. Mr. R shows significant improvement in the days that follow.

Throughout admission, Mr. R focuses on his lack of improvement and how this episode is negatively impacting his grades and his dream of going to college and having a professional career.

OUTCOME Relief at last

Mr. R improves with the addition of sertraline and tolerates rapid titration well. He continues haloperidol without adverse effects, and is discharged home with close follow-up in a PHP and outpatient psychiatry.

However, after discharge, Mr. R’s symptoms get worse, and he is admitted to a different inpatient facility. At this facility, he continues sertraline, but haloperidol is cross-titrated to olanzapine.

Continue to: Currently...

Currently, Mr. R has greatly improved and is able to function in school. He takes sertraline, 100 mg twice a day, and olanzapine, 7.5 mg twice a day. Mr. R reports his rituals have reduced in frequency to less than 15 minutes each day. His thought processes are organized, and he is confident he will be able to achieve his goals.

The authors’ observations

Given Mr. R’s rapid improvement once an effective pharmacologic regimen was established, we concluded that he had a severe case of OCD with absent insight/delusional beliefs, and that he did not have schizophrenia. Mr. R’s case highlights how a psychiatric diagnosis can produce anxiety as a result of the psychosocial stressors and limitations associated with that diagnosis.

Bottom Line

There is both an epidemiologic and biologic overlap between obsessive-compulsive disorder and schizophrenia. In adolescents, either disorder could represent a prodrome or a cause of the other. It is essential to perform a thorough assessment of individuals with obsessive-compulsive disorder because these patients may exhibit subtle psychotic symptoms.

Related Resources

• Cunill R, Castells X, Simeon D. Relationships between obsessivecompulsive symptomatology and severity of psychosis in schizophrenia: a systematic review and meta-analysis. J Clin Psychiatry. 2009;70(1):70-82.
• Harris E, Delgado SV. Treatment-resistant OCD: there’s more we can do. Current Psychiatry. 2018;17(11):10-12,14-18,51.

Drug Brand Names

Clozapine • Clozaril
Dextroamphetamine • Dexedrine
Divalproex sodium • Depakote
Fluvoxamine • Luvox
Haloperidol • Haldol
Hydroxyzine • Atarax, Vistaril
Lurasidone • Latuda
Olanzapine • Zyprexa
Risperidone • Risperdal
Sertraline • Zoloft

CASE Perseverating on nonexistent sexual assaults

Mr. R, age 17, who has been diagnosed with obsessive-compulsive disorder (OCD), presents to the emergency department (ED) because he thinks that he is being sexually assaulted and is concerned that he is sexually assaulting other people. His family reports that Mr. R has perseverated over these thoughts for months, although there is no evidence to suggest these events have occurred. In order to ameliorate his distress, he performs rituals of looking upwards and repeatedly saying, “It didn’t happen.”

Mr. R is admitted to the inpatient psychiatry unit for further evaluation.

HISTORY Decompensation while attending a PHP

Mr. R had been diagnosed with bipolar disorder and attention-deficit/hyperactivity disorder when he was 13. During that time, he was treated with divalproex sodium and dextroamphetamine. At age 15, Mr. R’s diagnosis was changed to OCD. Seven months before coming to the ED, his symptoms had been getting worse. On one occasion, Mr. R was talking in a nonsensical fashion at school, and the police were called. Mr. R became physically aggressive with the police and was subsequently hospitalized, after which he attended a partial hospitalization program (PHP). At the PHP, Mr. R received exposure and response prevention therapy for OCD, but did not improve, and his symptoms deteriorated until he was unable to brush his teeth or shower regularly. While attending the PHP, Mr. R also developed disorganized speech. The PHP clinicians became concerned that Mr. R’s symptoms may have been prodromal symptoms of schizophrenia because he did not respond to the OCD treatment and his symptoms had worsened over the 3 months he attended the PHP.

EVALUATION Normal laboratory results

Upon admission to the inpatient psychiatric unit, Mr. R is restarted on his home medications, which include fluvoxamine, 150 mg in the morning and 200 mg at bedtime; methylfolate, 2,000 mcg/d; risperidone, 3 mg nightly; and hydroxyzine, 25 mg as needed for anxiety.

His laboratory workup, including a complete blood count, comprehensive metabolic panel, urine drug screen, and blood ethanol, are all within normal limits. Previous laboratory results, including a thyroid function panel, vitamin D level, and various autoimmune panels, were also within normal limits.

His family reports that Mr. R’s symptoms seem to worsen when he is under increased stress from school and prepping for standardized college admission examinations. The family also says that while he is playing tennis, Mr. R will posture himself in a crouched down position and at times will remain in this position for 30 minutes.

Mr. R says he eventually wants to go to college and have a professional career.

[polldaddy:10600530]

Continue to: The authors' observations

When considering Mr. R’s diagnosis, our treatment team considered the possibility of OCD with absent insight/delusional beliefs, OCD with comorbid schizophrenia, bipolar disorder, and psychotic disorder due to another medical condition.

Overlap between OCD and schizophrenia

There appears to be both an epidemiologic and biologic overlap between OCD and schizophrenia. The Table¹ summarizes the DSM-5 criteria for OCD and for schizophrenia. Schirmbeck et al² reported that the estimated prevalence of OCD in patients with schizophrenia is 12%, which is higher than in the general population. Obsessive-compulsive symptoms (OCS) in patients with schizophrenia have been reported to be even more prevalent (30.7%).² In a prospective cohort study, de Haan et al³ assessed 172 patients with first-episode schizophrenia, schizophreniform disorder, or schizoaffective disorder for the development of OCS over a 5-year follow-up period. Symptoms were tracked over time and included OCS on first assessment, persistent OCS, subsequent emergence of OCS, and intermittent OCS. A striking 51.1% of the patient sample screened positive.³ Obsessions and delusions are similar because they are both irrational thoughts, the former with insight and the latter without insight. The fact that OCS were present in up to 14% of drug-naïve patients with schizophrenia in this study suggests that this was not merely an adverse effect of antipsychotic medication.

Much of the literature about OCD examines its functional impairment in adults, with findings extrapolated to pediatric patients. Children differ from adults in a variety of meaningful ways. Baytunca et al⁴ examined adolescents with early-onset schizophrenia, with and without comorbid OCD. Patients with comorbid OCD required higher doses of antipsychotic medication to treat acute psychotic symptoms and maintain a reduction in symptoms. The study controlled for the severity of schizophrenia, and its findings suggest that schizophrenia with comorbid OCD is more treatment-resistant than schizophrenia alone.⁴

Some researchers have theorized that in adolescents, OCD and psychosis are integrally related such that one disorder could represent a prodrome or a cause of the other disorder. Niendam et al⁵ studied OCS in the psychosis prodrome. They found that OCS can present as a part of the prodromal picture in youth at high risk for psychosis. However, because none of the patients experiencing OCS converted to full-blown psychosis, these results suggest that OCS may not represent a prodrome to psychosis per se. Instead, these individuals may represent a subset of false positives over the follow-up period.⁵ Another possible explanation for the increased emergence of pre-psychotic symptoms in adolescents with OCD could be a difference in their threshold of perception. OCS compels adolescents with OCD to self-analyze more critically and frequently. As a result, these patients may more often report depressive symptoms, distress, and exacerbations of pre-psychotic symptoms. These findings highlight that comorbid OCD can amplify the psychosocial distress among higher-risk youth. It is therefore essential for physicians to perform a thorough interview in this population because subtle psychotic symptoms may be present.

[polldaddy:10600532]

Continue to: TREATMENT Improvement after switching to haloperidol

The treatment team decides to change Mr. R’s medications by cross-titrating risperidone to lurasidone and increasing hydroxyzine from 25 to 50 mg every 6 hours as needed for anxiety. Over the next several days, Mr. R reports some improvement in symptoms. However, according to staff on the unit, he continues to display disorganized behavior, respond to internal stimuli, and posture in his room. It is unclear if these symptoms are due to a psychotic illness or part of his OCD rituals. Due to worsening of symptoms, the team decides to taper lurasidone and switch to haloperidol. Mr. R starts haloperidol, 1 mg twice a day, and this is titrated to 7.5 mg three times a day. Soon after, his thoughts become more organized, he has fewer delusional thoughts, his concentration is improved, and he no longer appears to respond to internal stimuli.

The treatment team obtains a consultation on whether electroconvulsive therapy would be appropriate, but this treatment is not recommended. Instead, the team considers switching Mr. R to clozapine if the current treatment fails. Because Mr. R’s psychotic symptoms continue to improve while he is receiving haloperidol, clozapine is not added. To address Mr. R’s persistent, severe OCD symptoms, fluvoxamine is cross-tapered to sertraline, started at 50 mg/d and titrated to 100 mg/d. Mr. R shows significant improvement in the days that follow.

Throughout admission, Mr. R focuses on his lack of improvement and how this episode is negatively impacting his grades and his dream of going to college and having a professional career.

OUTCOME Relief at last

Mr. R improves with the addition of sertraline and tolerates rapid titration well. He continues haloperidol without adverse effects, and is discharged home with close follow-up in a PHP and outpatient psychiatry.

However, after discharge, Mr. R’s symptoms get worse, and he is admitted to a different inpatient facility. At this facility, he continues sertraline, but haloperidol is cross-titrated to olanzapine.

Continue to: Currently...

Currently, Mr. R has greatly improved and is able to function in school. He takes sertraline, 100 mg twice a day, and olanzapine, 7.5 mg twice a day. Mr. R reports his rituals have reduced in frequency to less than 15 minutes each day. His thought processes are organized, and he is confident he will be able to achieve his goals.

The authors’ observations

Given Mr. R’s rapid improvement once an effective pharmacologic regimen was established, we concluded that he had a severe case of OCD with absent insight/delusional beliefs, and that he did not have schizophrenia. Mr. R’s case highlights how a psychiatric diagnosis can produce anxiety as a result of the psychosocial stressors and limitations associated with that diagnosis.

Bottom Line

There is both an epidemiologic and biologic overlap between obsessive-compulsive disorder and schizophrenia. In adolescents, either disorder could represent a prodrome or a cause of the other. It is essential to perform a thorough assessment of individuals with obsessive-compulsive disorder because these patients may exhibit subtle psychotic symptoms.

Related Resources

• Cunill R, Castells X, Simeon D. Relationships between obsessivecompulsive symptomatology and severity of psychosis in schizophrenia: a systematic review and meta-analysis. J Clin Psychiatry. 2009;70(1):70-82.
• Harris E, Delgado SV. Treatment-resistant OCD: there’s more we can do. Current Psychiatry. 2018;17(11):10-12,14-18,51.

Drug Brand Names

Clozapine • Clozaril
Dextroamphetamine • Dexedrine
Divalproex sodium • Depakote
Fluvoxamine • Luvox
Haloperidol • Haldol
Hydroxyzine • Atarax, Vistaril
Lurasidone • Latuda
Olanzapine • Zyprexa
Risperidone • Risperdal
Sertraline • Zoloft

CASE Perseverating on nonexistent sexual assaults

Mr. R, age 17, who has been diagnosed with obsessive-compulsive disorder (OCD), presents to the emergency department (ED) because he thinks that he is being sexually assaulted and is concerned that he is sexually assaulting other people. His family reports that Mr. R has perseverated over these thoughts for months, although there is no evidence to suggest these events have occurred. In order to ameliorate his distress, he performs rituals of looking upwards and repeatedly saying, “It didn’t happen.”

Mr. R is admitted to the inpatient psychiatry unit for further evaluation.

HISTORY Decompensation while attending a PHP

Mr. R had been diagnosed with bipolar disorder and attention-deficit/hyperactivity disorder when he was 13. During that time, he was treated with divalproex sodium and dextroamphetamine. At age 15, Mr. R’s diagnosis was changed to OCD. Seven months before coming to the ED, his symptoms had been getting worse. On one occasion, Mr. R was talking in a nonsensical fashion at school, and the police were called. Mr. R became physically aggressive with the police and was subsequently hospitalized, after which he attended a partial hospitalization program (PHP). At the PHP, Mr. R received exposure and response prevention therapy for OCD, but did not improve, and his symptoms deteriorated until he was unable to brush his teeth or shower regularly. While attending the PHP, Mr. R also developed disorganized speech. The PHP clinicians became concerned that Mr. R’s symptoms may have been prodromal symptoms of schizophrenia because he did not respond to the OCD treatment and his symptoms had worsened over the 3 months he attended the PHP.

EVALUATION Normal laboratory results

Upon admission to the inpatient psychiatric unit, Mr. R is restarted on his home medications, which include fluvoxamine, 150 mg in the morning and 200 mg at bedtime; methylfolate, 2,000 mcg/d; risperidone, 3 mg nightly; and hydroxyzine, 25 mg as needed for anxiety.

His laboratory workup, including a complete blood count, comprehensive metabolic panel, urine drug screen, and blood ethanol, are all within normal limits. Previous laboratory results, including a thyroid function panel, vitamin D level, and various autoimmune panels, were also within normal limits.

His family reports that Mr. R’s symptoms seem to worsen when he is under increased stress from school and prepping for standardized college admission examinations. The family also says that while he is playing tennis, Mr. R will posture himself in a crouched down position and at times will remain in this position for 30 minutes.

Mr. R says he eventually wants to go to college and have a professional career.

[polldaddy:10600530]

Continue to: The authors' observations

When considering Mr. R’s diagnosis, our treatment team considered the possibility of OCD with absent insight/delusional beliefs, OCD with comorbid schizophrenia, bipolar disorder, and psychotic disorder due to another medical condition.

Overlap between OCD and schizophrenia

There appears to be both an epidemiologic and biologic overlap between OCD and schizophrenia. The Table¹ summarizes the DSM-5 criteria for OCD and for schizophrenia. Schirmbeck et al² reported that the estimated prevalence of OCD in patients with schizophrenia is 12%, which is higher than in the general population. Obsessive-compulsive symptoms (OCS) in patients with schizophrenia have been reported to be even more prevalent (30.7%).² In a prospective cohort study, de Haan et al³ assessed 172 patients with first-episode schizophrenia, schizophreniform disorder, or schizoaffective disorder for the development of OCS over a 5-year follow-up period. Symptoms were tracked over time and included OCS on first assessment, persistent OCS, subsequent emergence of OCS, and intermittent OCS. A striking 51.1% of the patient sample screened positive.³ Obsessions and delusions are similar because they are both irrational thoughts, the former with insight and the latter without insight. The fact that OCS were present in up to 14% of drug-naïve patients with schizophrenia in this study suggests that this was not merely an adverse effect of antipsychotic medication.

Much of the literature about OCD examines its functional impairment in adults, with findings extrapolated to pediatric patients. Children differ from adults in a variety of meaningful ways. Baytunca et al⁴ examined adolescents with early-onset schizophrenia, with and without comorbid OCD. Patients with comorbid OCD required higher doses of antipsychotic medication to treat acute psychotic symptoms and maintain a reduction in symptoms. The study controlled for the severity of schizophrenia, and its findings suggest that schizophrenia with comorbid OCD is more treatment-resistant than schizophrenia alone.⁴

Some researchers have theorized that in adolescents, OCD and psychosis are integrally related such that one disorder could represent a prodrome or a cause of the other disorder. Niendam et al⁵ studied OCS in the psychosis prodrome. They found that OCS can present as a part of the prodromal picture in youth at high risk for psychosis. However, because none of the patients experiencing OCS converted to full-blown psychosis, these results suggest that OCS may not represent a prodrome to psychosis per se. Instead, these individuals may represent a subset of false positives over the follow-up period.⁵ Another possible explanation for the increased emergence of pre-psychotic symptoms in adolescents with OCD could be a difference in their threshold of perception. OCS compels adolescents with OCD to self-analyze more critically and frequently. As a result, these patients may more often report depressive symptoms, distress, and exacerbations of pre-psychotic symptoms. These findings highlight that comorbid OCD can amplify the psychosocial distress among higher-risk youth. It is therefore essential for physicians to perform a thorough interview in this population because subtle psychotic symptoms may be present.

[polldaddy:10600532]

Continue to: TREATMENT Improvement after switching to haloperidol

The treatment team decides to change Mr. R’s medications by cross-titrating risperidone to lurasidone and increasing hydroxyzine from 25 to 50 mg every 6 hours as needed for anxiety. Over the next several days, Mr. R reports some improvement in symptoms. However, according to staff on the unit, he continues to display disorganized behavior, respond to internal stimuli, and posture in his room. It is unclear if these symptoms are due to a psychotic illness or part of his OCD rituals. Due to worsening of symptoms, the team decides to taper lurasidone and switch to haloperidol. Mr. R starts haloperidol, 1 mg twice a day, and this is titrated to 7.5 mg three times a day. Soon after, his thoughts become more organized, he has fewer delusional thoughts, his concentration is improved, and he no longer appears to respond to internal stimuli.

The treatment team obtains a consultation on whether electroconvulsive therapy would be appropriate, but this treatment is not recommended. Instead, the team considers switching Mr. R to clozapine if the current treatment fails. Because Mr. R’s psychotic symptoms continue to improve while he is receiving haloperidol, clozapine is not added. To address Mr. R’s persistent, severe OCD symptoms, fluvoxamine is cross-tapered to sertraline, started at 50 mg/d and titrated to 100 mg/d. Mr. R shows significant improvement in the days that follow.

Throughout admission, Mr. R focuses on his lack of improvement and how this episode is negatively impacting his grades and his dream of going to college and having a professional career.

OUTCOME Relief at last

Mr. R improves with the addition of sertraline and tolerates rapid titration well. He continues haloperidol without adverse effects, and is discharged home with close follow-up in a PHP and outpatient psychiatry.

However, after discharge, Mr. R’s symptoms get worse, and he is admitted to a different inpatient facility. At this facility, he continues sertraline, but haloperidol is cross-titrated to olanzapine.

Continue to: Currently...

Currently, Mr. R has greatly improved and is able to function in school. He takes sertraline, 100 mg twice a day, and olanzapine, 7.5 mg twice a day. Mr. R reports his rituals have reduced in frequency to less than 15 minutes each day. His thought processes are organized, and he is confident he will be able to achieve his goals.

The authors’ observations

Given Mr. R’s rapid improvement once an effective pharmacologic regimen was established, we concluded that he had a severe case of OCD with absent insight/delusional beliefs, and that he did not have schizophrenia. Mr. R’s case highlights how a psychiatric diagnosis can produce anxiety as a result of the psychosocial stressors and limitations associated with that diagnosis.

Bottom Line

There is both an epidemiologic and biologic overlap between obsessive-compulsive disorder and schizophrenia. In adolescents, either disorder could represent a prodrome or a cause of the other. It is essential to perform a thorough assessment of individuals with obsessive-compulsive disorder because these patients may exhibit subtle psychotic symptoms.

Related Resources

• Cunill R, Castells X, Simeon D. Relationships between obsessivecompulsive symptomatology and severity of psychosis in schizophrenia: a systematic review and meta-analysis. J Clin Psychiatry. 2009;70(1):70-82.
• Harris E, Delgado SV. Treatment-resistant OCD: there’s more we can do. Current Psychiatry. 2018;17(11):10-12,14-18,51.

Drug Brand Names

Clozapine • Clozaril
Dextroamphetamine • Dexedrine
Divalproex sodium • Depakote
Fluvoxamine • Luvox
Haloperidol • Haldol
Hydroxyzine • Atarax, Vistaril
Lurasidone • Latuda
Olanzapine • Zyprexa
Risperidone • Risperdal
Sertraline • Zoloft

The FDA defines “off-label” prescribing as prescribing an FDA-approved medication for an unapproved use, such as for an unapproved clinical indication, for a higher-than-approved dose, or for a patient who is not part of the FDA-approved population (eg, children or geriatric patients).¹ Off-label prescribing is common in psychiatry; approximately 13% of psychiatry patients are prescribed off-label psychotropic medications.² The American Psychiatric Association strongly supports “the autonomous clinical decision-making authority of a physician” and “a physician’s lawful use of an FDA-approved drug product or medical device for an off-label indication when such use is based upon sound scientific evidence in conjunction with sound medical judgment.”³ Because many psychiatric diagnoses have no FDA-approved medications, off-label prescribing often may be a psychiatrist’s only pharmacologic option.

Unfortunately, off-label prescribing can increase a psychiatrist’s risk for liability when treatment falls short of patients’ expectations, or when patients allege that they were injured by the use of an off-label medication. Off-label prescribing does not automatically lead to losing a malpractice suit because the FDA states that physicians can prescribe approved medications for any scientifically supported use, including off-label.¹ Medical malpractice lawsuits alleging negligence in prescribing practices, such as off-label prescribing, typically include allegations against the psychiatrist for failure to⁴:

• adequately assess the patient
• consult the patient’s medical records
• obtain informed consent from the patient
• appropriately prescribe a medication for the clinical indication, dosage, patient’s age, etc.
• monitor for adverse effects and therapeutic effectiveness.

Steps to minimize your risk

When prescribing a medication off-label, the following approaches can help reduce your liability risk:

Conduct a comprehensive clinical assess­ment. This should include requesting and reviewing your patient’s medical records.

Explain your motivation. Explain to your patient how prescribing an off-label medication can directly benefit him/her. Make it clear that you are not conducting experimental research by prescribing off-label because some patients might perceive this as a covert form of research.

Know the medications you prescribe. Although this sounds obvious, psychiatrists should thoroughly understand how each medication they prescribe is likely to clinically affect their patient. This information is available from many sources, including the FDA’s medication information sheets and the manufacturer’s medication package inserts. If possible, make sure that your off-label prescribing is supported by reputable, peer-reviewed literature.

Obtain informed consent. Tell your patient that the medication you are recommending is being prescribed off-label. Discuss the medication’s risks, benefits, adverse effects, associated “black-box” warnings, off-label uses, and alternatives to the off-label medication.⁴ Allow time for the patient to ask questions about these treatments.

Continue to: Document all steps

Document all steps. There is an adage in medicine that “If it’s not written, it wasn’t done.” To help reduce your liability risk when prescribing off-label, be sure to document the following⁴:

• your clinical assessment
• information you gleaned from the patient’s medical records
• your review of information regarding both therapeutic and adverse effects of the medication you want to prescribe
• your discussion of informed consent, including documentation that the patient is aware that the medication is being prescribed off-label
• your clinical rationale for why the off-label medication is in the patient’s best interest.

Also, document the steps you take to monitor for adverse events and therapeutic effectiveness.⁴ Overall, the goal of documentation should be to support the adequate continuing care of our patients.

The FDA defines “off-label” prescribing as prescribing an FDA-approved medication for an unapproved use, such as for an unapproved clinical indication, for a higher-than-approved dose, or for a patient who is not part of the FDA-approved population (eg, children or geriatric patients).¹ Off-label prescribing is common in psychiatry; approximately 13% of psychiatry patients are prescribed off-label psychotropic medications.² The American Psychiatric Association strongly supports “the autonomous clinical decision-making authority of a physician” and “a physician’s lawful use of an FDA-approved drug product or medical device for an off-label indication when such use is based upon sound scientific evidence in conjunction with sound medical judgment.”³ Because many psychiatric diagnoses have no FDA-approved medications, off-label prescribing often may be a psychiatrist’s only pharmacologic option.

Unfortunately, off-label prescribing can increase a psychiatrist’s risk for liability when treatment falls short of patients’ expectations, or when patients allege that they were injured by the use of an off-label medication. Off-label prescribing does not automatically lead to losing a malpractice suit because the FDA states that physicians can prescribe approved medications for any scientifically supported use, including off-label.¹ Medical malpractice lawsuits alleging negligence in prescribing practices, such as off-label prescribing, typically include allegations against the psychiatrist for failure to⁴:

• adequately assess the patient
• consult the patient’s medical records
• obtain informed consent from the patient
• appropriately prescribe a medication for the clinical indication, dosage, patient’s age, etc.
• monitor for adverse effects and therapeutic effectiveness.

Steps to minimize your risk

When prescribing a medication off-label, the following approaches can help reduce your liability risk:

Conduct a comprehensive clinical assess­ment. This should include requesting and reviewing your patient’s medical records.

Explain your motivation. Explain to your patient how prescribing an off-label medication can directly benefit him/her. Make it clear that you are not conducting experimental research by prescribing off-label because some patients might perceive this as a covert form of research.

Know the medications you prescribe. Although this sounds obvious, psychiatrists should thoroughly understand how each medication they prescribe is likely to clinically affect their patient. This information is available from many sources, including the FDA’s medication information sheets and the manufacturer’s medication package inserts. If possible, make sure that your off-label prescribing is supported by reputable, peer-reviewed literature.

Obtain informed consent. Tell your patient that the medication you are recommending is being prescribed off-label. Discuss the medication’s risks, benefits, adverse effects, associated “black-box” warnings, off-label uses, and alternatives to the off-label medication.⁴ Allow time for the patient to ask questions about these treatments.

Continue to: Document all steps

Document all steps. There is an adage in medicine that “If it’s not written, it wasn’t done.” To help reduce your liability risk when prescribing off-label, be sure to document the following⁴:

• your clinical assessment
• information you gleaned from the patient’s medical records
• your review of information regarding both therapeutic and adverse effects of the medication you want to prescribe
• your discussion of informed consent, including documentation that the patient is aware that the medication is being prescribed off-label
• your clinical rationale for why the off-label medication is in the patient’s best interest.

Also, document the steps you take to monitor for adverse events and therapeutic effectiveness.⁴ Overall, the goal of documentation should be to support the adequate continuing care of our patients.

The FDA defines “off-label” prescribing as prescribing an FDA-approved medication for an unapproved use, such as for an unapproved clinical indication, for a higher-than-approved dose, or for a patient who is not part of the FDA-approved population (eg, children or geriatric patients).¹ Off-label prescribing is common in psychiatry; approximately 13% of psychiatry patients are prescribed off-label psychotropic medications.² The American Psychiatric Association strongly supports “the autonomous clinical decision-making authority of a physician” and “a physician’s lawful use of an FDA-approved drug product or medical device for an off-label indication when such use is based upon sound scientific evidence in conjunction with sound medical judgment.”³ Because many psychiatric diagnoses have no FDA-approved medications, off-label prescribing often may be a psychiatrist’s only pharmacologic option.

Unfortunately, off-label prescribing can increase a psychiatrist’s risk for liability when treatment falls short of patients’ expectations, or when patients allege that they were injured by the use of an off-label medication. Off-label prescribing does not automatically lead to losing a malpractice suit because the FDA states that physicians can prescribe approved medications for any scientifically supported use, including off-label.¹ Medical malpractice lawsuits alleging negligence in prescribing practices, such as off-label prescribing, typically include allegations against the psychiatrist for failure to⁴:

• adequately assess the patient
• consult the patient’s medical records
• obtain informed consent from the patient
• appropriately prescribe a medication for the clinical indication, dosage, patient’s age, etc.
• monitor for adverse effects and therapeutic effectiveness.

Steps to minimize your risk

When prescribing a medication off-label, the following approaches can help reduce your liability risk:

Conduct a comprehensive clinical assess­ment. This should include requesting and reviewing your patient’s medical records.

Explain your motivation. Explain to your patient how prescribing an off-label medication can directly benefit him/her. Make it clear that you are not conducting experimental research by prescribing off-label because some patients might perceive this as a covert form of research.

Know the medications you prescribe. Although this sounds obvious, psychiatrists should thoroughly understand how each medication they prescribe is likely to clinically affect their patient. This information is available from many sources, including the FDA’s medication information sheets and the manufacturer’s medication package inserts. If possible, make sure that your off-label prescribing is supported by reputable, peer-reviewed literature.

Obtain informed consent. Tell your patient that the medication you are recommending is being prescribed off-label. Discuss the medication’s risks, benefits, adverse effects, associated “black-box” warnings, off-label uses, and alternatives to the off-label medication.⁴ Allow time for the patient to ask questions about these treatments.

Continue to: Document all steps

Document all steps. There is an adage in medicine that “If it’s not written, it wasn’t done.” To help reduce your liability risk when prescribing off-label, be sure to document the following⁴:

• your clinical assessment
• information you gleaned from the patient’s medical records
• your review of information regarding both therapeutic and adverse effects of the medication you want to prescribe
• your discussion of informed consent, including documentation that the patient is aware that the medication is being prescribed off-label
• your clinical rationale for why the off-label medication is in the patient’s best interest.

Also, document the steps you take to monitor for adverse events and therapeutic effectiveness.⁴ Overall, the goal of documentation should be to support the adequate continuing care of our patients.

Psychiatric emergencies—such as a patient who is agitated, self-destructive, or suicidal—may arise in a variety of settings, including emergency departments and inpatient units.¹ Before emergently prescribing psychotropic medications to address acute psychiatric symptoms, there are numerous factors a clinician needs to consider.^1-3 Asking the following questions may help you quickly obtain important clinical information to determine which medication to use during a psychiatric emergency:

Age. Is the patient a child, adolescent, adult, or older adult?

Allergies. Does the patient have any medication allergies or sensitivities?

Behaviors. What are the imminent dangerous behaviors that warrant emergent medication use

Collateral information. If the patient was brought by police or family, how was he/she behaving in the community or at home? If brought from a correctional facility or other institution, how did he/she behave in that setting?

Concurrent diagnoses/interventions. Does the patient have a psychiatric or medical diagnosis? Is the patient receiving any pharmacologic or nonpharmacologic treatments?

First visit. Is this the patient’s first visit to your facility? Or has the patient been to the facility previously and/or repeatedly? Has the patient ever been prescribed psychotropic medications? If the patient has received emergent medications before, which medications were used, and were they helpful?

Continue to: Legal status

Legal status. Is the patient voluntary for treatment or involuntary for treatment? If voluntary, is involuntary treatment needed?

Street. Was this patient evaluated in a medical setting before presenting to your facility? Or did this patient arrive directly from the community/street?

Substance use. Has the patient been using any licit and/or illicit substances?

In my experience with psychiatric emergencies, asking these questions has helped guide my decision-making during these situations. They have helped me to determine the appropriate medication, route of administration, dose, and monitoring requirements. Although other factors can impact clinicians’ decision-making in these situations, I have found these questions to be a good starting point.

Psychiatric emergencies—such as a patient who is agitated, self-destructive, or suicidal—may arise in a variety of settings, including emergency departments and inpatient units.¹ Before emergently prescribing psychotropic medications to address acute psychiatric symptoms, there are numerous factors a clinician needs to consider.^1-3 Asking the following questions may help you quickly obtain important clinical information to determine which medication to use during a psychiatric emergency:

Age. Is the patient a child, adolescent, adult, or older adult?

Allergies. Does the patient have any medication allergies or sensitivities?

Behaviors. What are the imminent dangerous behaviors that warrant emergent medication use

Collateral information. If the patient was brought by police or family, how was he/she behaving in the community or at home? If brought from a correctional facility or other institution, how did he/she behave in that setting?

Concurrent diagnoses/interventions. Does the patient have a psychiatric or medical diagnosis? Is the patient receiving any pharmacologic or nonpharmacologic treatments?

First visit. Is this the patient’s first visit to your facility? Or has the patient been to the facility previously and/or repeatedly? Has the patient ever been prescribed psychotropic medications? If the patient has received emergent medications before, which medications were used, and were they helpful?

Continue to: Legal status

Legal status. Is the patient voluntary for treatment or involuntary for treatment? If voluntary, is involuntary treatment needed?

Street. Was this patient evaluated in a medical setting before presenting to your facility? Or did this patient arrive directly from the community/street?

Substance use. Has the patient been using any licit and/or illicit substances?

In my experience with psychiatric emergencies, asking these questions has helped guide my decision-making during these situations. They have helped me to determine the appropriate medication, route of administration, dose, and monitoring requirements. Although other factors can impact clinicians’ decision-making in these situations, I have found these questions to be a good starting point.

Psychiatric emergencies—such as a patient who is agitated, self-destructive, or suicidal—may arise in a variety of settings, including emergency departments and inpatient units.¹ Before emergently prescribing psychotropic medications to address acute psychiatric symptoms, there are numerous factors a clinician needs to consider.^1-3 Asking the following questions may help you quickly obtain important clinical information to determine which medication to use during a psychiatric emergency:

Age. Is the patient a child, adolescent, adult, or older adult?

Allergies. Does the patient have any medication allergies or sensitivities?

Behaviors. What are the imminent dangerous behaviors that warrant emergent medication use

Collateral information. If the patient was brought by police or family, how was he/she behaving in the community or at home? If brought from a correctional facility or other institution, how did he/she behave in that setting?

Concurrent diagnoses/interventions. Does the patient have a psychiatric or medical diagnosis? Is the patient receiving any pharmacologic or nonpharmacologic treatments?

First visit. Is this the patient’s first visit to your facility? Or has the patient been to the facility previously and/or repeatedly? Has the patient ever been prescribed psychotropic medications? If the patient has received emergent medications before, which medications were used, and were they helpful?

Continue to: Legal status

Legal status. Is the patient voluntary for treatment or involuntary for treatment? If voluntary, is involuntary treatment needed?

Street. Was this patient evaluated in a medical setting before presenting to your facility? Or did this patient arrive directly from the community/street?

Substance use. Has the patient been using any licit and/or illicit substances?

In my experience with psychiatric emergencies, asking these questions has helped guide my decision-making during these situations. They have helped me to determine the appropriate medication, route of administration, dose, and monitoring requirements. Although other factors can impact clinicians’ decision-making in these situations, I have found these questions to be a good starting point.

References

1. CDC. Coronavirus Disease 2019 (COVID-19): Cases in the US. www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed August 18, 2020.
2. US Department of Health and Human Services. Fact Sheet: explaining Operation Warp Speed. www.hhs.gov/coronavirus/explaining-operation-warp-speed/index.html. Accessed August 18, 2020.
3. O’Callahan KP, Blatz AM, Offit PA. Developing a SARS-CoV-2 vaccine at warp speed. JAMA. 2020;324:437-438.
4. Pardi N, Hogan MJ, Porter FW, et al. mRNA vaccines—a new era in vaccinology. Nat Rev Drug Discov. 2018;17:261-279.
5. Lurie N, Sharfstein JM, Goodman JL. The development of COVID-19 vaccines: safeguards needed [commentary]. JAMA. 2020;324:439-440.
6. Salman DA, Akhtar A, Mergler MJ, et al; H1N1 Working Group of Federal Immunization Safety Task Force. Immunization safety monitoring systems for the 2009 H1N1 monovalent influenza vaccination program. Pediatrics. 2011;127(suppl 1):S78-S86.

References

1. CDC. Coronavirus Disease 2019 (COVID-19): Cases in the US. www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed August 18, 2020.
2. US Department of Health and Human Services. Fact Sheet: explaining Operation Warp Speed. www.hhs.gov/coronavirus/explaining-operation-warp-speed/index.html. Accessed August 18, 2020.
3. O’Callahan KP, Blatz AM, Offit PA. Developing a SARS-CoV-2 vaccine at warp speed. JAMA. 2020;324:437-438.
4. Pardi N, Hogan MJ, Porter FW, et al. mRNA vaccines—a new era in vaccinology. Nat Rev Drug Discov. 2018;17:261-279.
5. Lurie N, Sharfstein JM, Goodman JL. The development of COVID-19 vaccines: safeguards needed [commentary]. JAMA. 2020;324:439-440.
6. Salman DA, Akhtar A, Mergler MJ, et al; H1N1 Working Group of Federal Immunization Safety Task Force. Immunization safety monitoring systems for the 2009 H1N1 monovalent influenza vaccination program. Pediatrics. 2011;127(suppl 1):S78-S86.

References

1. CDC. Coronavirus Disease 2019 (COVID-19): Cases in the US. www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed August 18, 2020.
2. US Department of Health and Human Services. Fact Sheet: explaining Operation Warp Speed. www.hhs.gov/coronavirus/explaining-operation-warp-speed/index.html. Accessed August 18, 2020.
3. O’Callahan KP, Blatz AM, Offit PA. Developing a SARS-CoV-2 vaccine at warp speed. JAMA. 2020;324:437-438.
4. Pardi N, Hogan MJ, Porter FW, et al. mRNA vaccines—a new era in vaccinology. Nat Rev Drug Discov. 2018;17:261-279.
5. Lurie N, Sharfstein JM, Goodman JL. The development of COVID-19 vaccines: safeguards needed [commentary]. JAMA. 2020;324:439-440.
6. Salman DA, Akhtar A, Mergler MJ, et al; H1N1 Working Group of Federal Immunization Safety Task Force. Immunization safety monitoring systems for the 2009 H1N1 monovalent influenza vaccination program. Pediatrics. 2011;127(suppl 1):S78-S86.

It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.

In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.

In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.

This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.

John I. Allen, MD, MBA, AGAF
Editor in Chief

It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.

In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.

In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.

This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.

John I. Allen, MD, MBA, AGAF
Editor in Chief

It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.

In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.

In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.

This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.

John I. Allen, MD, MBA, AGAF
Editor in Chief