Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE ‘I’ve had enough’
The psychiatry consultation team is asked to evaluate Mr. M, age 76, for a passive death wish and depression 2 months after he was admit­ted to the hospital after a traumatic fall.

Mr. M has several chronic medical condi­tions, including hypertension, type 2 diabetes mellitus, and coronary artery disease. Within 2 weeks of his admission, he developed Proteus mirabilis pneumonia and persistent respiratory failure requiring tracheostomy. Records indi­cate that Mr. M has told family and his treat­ment team, “I’m tired, just let me go.” He then developed antibiotic-induced Clostridium diffi­cile colitis and acute renal failure requiring tem­porary renal replacement therapy (RRT).

Mr. M’s clinical status improves, allowing his transfer to a transitional unit, where he contin­ues to state, “I have had enough. I’m done.” He asks for the tracheostomy tube to be removed and RRT discontinued. He is treated again for persistent C. difficile colitis and, within 2 weeks, develops hypotension, hypoxia, emesis, and abdominal distension, requiring transfer to the ICU for management of ileus.

He is stabilized with vasopressors and arti­ficial nutritional support by nasogastric tube. Renal function improves, RRT is discontinued, and he is transferred to the general medical floor.

After a few days on the general medical floor, Mr. M develops a urinary tract infection and develops antibiotic-induced acute renal failure requiring re-initiation of RRT. A percu­taneous endoscopic gastrostomy (PEG) tube is placed for nutrition when he shows little improvement with swallowing exercises. Two days after placing the PEG tube, he develops respiratory failure secondary to a left-sided pneumothorax and is transferred to the ICU for the third time, where he undergoes repeated bronchoscopies and requires pressure sup­port ventilation.

One week later, Mr. M is weaned off the ventilator and transferred to the general medical floor with aggressive respiratory therapy, tube feeding, and RRT. Mr. M’s chart indicates that he expresses an ongoing desire to withdraw RRT, the tracheostomy, and feeding tube.

Which of the following would you consider when assessing Mr. M’s decision-making capacity (DMC)?
   a) his ability to understand information relevant to treatment decision-making
   b) his ability to appreciate the significance of his diagnoses and treatment options and consequences in the context of his own life circumstances
   c) his ability to communicate a preference
   d) his ability to reason through the relevant information to weigh the potential costs and benefits of treatment options
   e) all of the above

HISTORY Guilt and regret
Mr. M reports a 30-year history of depression that has responded poorly to a variety of med­ications, outpatient psychotherapy, and elec­troconvulsive therapy. Before admission, he says, he was adherent to citalopram, 20 mg/d, and buspirone, 30 mg/d. Citalopram is contin­ued throughout his hospitalization, although buspirone was discontinued for unknown rea­sons during admission.

Mr. M is undergoing hemodialysis during his initial encounter with the psychiatry team. He struggles to communicate clearly because of the tracheostomy but is alert, oriented to person and location, answers questions appropriately, maintains good eye contact, and does not demonstrate any psychomotor abnormalities. He describes his disposition as “tired,” and is on the verge of tears during the interview.

Mr. M denies physical discomfort and states, “I have just had enough. I do not want all of this done.” He clarifies that he is not sui­cidal and denies a history of suicidal or self-injurious behaviors.

Mr. M describes having low mood, anhedo­nia, and insomnia to varying degrees through­out his adult life. He also reports feeling guilt and regret about earlier experiences, but does not elaborate. He denies symptoms of panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, mania, or hypo­mania. He reports an episode of visual halluci­nations during an earlier hospitalization, likely a symptom of delirium, but denies any recent visual disturbances.

Mr. M’s thought process is linear and logical, with intact abstract reasoning and no evidence of delusions. Attention and concentration are intact for most of the interview but diminish as he becomes fatigued. Mr. M can describe past treatments in detail and recounts the events leading to this hospitalization.

The authors’ observations
Literature on assessment of DMC recently has centered on the 4-ability model, pro­posed by Grisso and Appelbaum.¹ With this approach, impairment to any of the 4 processes of understanding, appre­ciation, ability to express a choice, and ability to use reasoning to weigh treat­ment options could interfere with capac­ity to make decisions. Few studies have clarified the mechanism and degree to which depression may impair these 4 ele­ments, making capacity assessments in a depressed patient challenging.

Preliminary evidence suggests that depression severity, not the presence of depression, determines the degree to which DMC is impaired, if at all. In several studies, depressed patients did not dem­onstrate more impaired DMC compared with non-depressed patients based on standardized assessments.^2-4 In depressed patients who lack DMC, case reports^5-7 and cross-sectional studies⁸ indicate that appreciation—one’s ability to comprehend the personal relevance of illness and poten­tial consequences of treatments in the con­text of one’s life—is most often impaired. Other studies suggest that the ability to reason through decision-specific informa­tion and weigh the risks and benefits of treatment options is commonly impaired in depressed patients.^9,10

Even when a depressed patient demon­strates the 4 elements of DMC, providers might be concerned that the patient’s pref­erences are skewed by the negative emo­tions associated with depression.^11-13 In such a case, the patient’s expressed wishes might not be consistent with views and priorities that were expressed during an earlier, euthymic period.

Rather than focusing on whether cog­nitive elements of DMC are impaired, some experts advocate for assessing how depression might lead to “unbalanced” decision-making that is impaired by a patient’s tendency to undervalue positive outcomes and overvalue negative ones.¹⁴ Some depressed patients will decide to forego additional medical interventions because they do not see the potential ben­efits of treatment, view events through a negative lens, and lack hope for the future; however, studies indicate this is not typi­cally the case.^15-17

In a study of >2,500 patients age >65 with chronic medical conditions, Garrett et al¹⁵ found that those who were depressed communicated a desire for more treatment compared with non-depressed patients. Another study of patients’ wishes for life-sustaining treatment among those who had mild or moderate depression found that most patients did not express a greater desire for life-sustaining medi­cal interventions after their depressive episode remitted. An increased desire for life-sustaining medical interventions occurred only among the most severely depressed patients.¹⁶ Similarly, Lee and Ganzini¹⁷ found that treatment preferences among patients with mild or moderate depression and serious physical illness were unchanged after the mood disorder was treated.

These findings demonstrate that a cli­nician charged with assessing DMC must evaluate the severity of a patient’s depres­sion and carefully consider how mood is influencing his (her) perspective and cog­nitive abilities. It is important to observe how the depressed patient perceives feel­ings of sadness or hopelessness in the con­text of decision-making, and how he (she) integrates these feelings when assigning relative value to potential outcomes and alternative treatment options. Because the intensity of depression could vary over time, assessment of the depressed patient’s decision-making abilities must be viewed as a dynamic process.

Clinical application
Recent studies indicate that, although the in-hospital mortality rate for critically ill patients who develop acute renal failure is high, it is variable, ranging from 28% to 90%.¹⁸ In one study, patients who required more interventions over the course of a hospital stay (eg, mechanical ventilation, vasopressors) had an in-hospital mortality rate closer to 60% after initiating RRT.¹⁹ In a similar trial,^20,21 mean survival for critically ill patients with acute renal failure was 32 days from initiation of dialysis; only 27% of these patients were alive 6 months later.²¹

Given his complicated hospital course, the medical team estimates that Mr. M has a reasonable chance of surviving to dis­charge, although his longer-term progno­sis is poor.

EVALUATION Conflicting preferences
Mr. M expresses reasonable understanding of the medical indications for temporary RRT, respiratory therapy, and enteral tube feed­ings, and the consequences of withdrawing these interventions. He understands that the primary team recommended ongoing but temporary use of life-sustaining interven­tions, anticipating that he would recover from his acute medical conditions. Mr. M clearly articulates that he wants to terminate RRT knowing that this would cause a buildup of urea and other toxins, to resume eating by mouth despite the risk of aspiration, and to be allowed to die “naturally.”

Mr. M declines to speak with a clergy mem­ber, explaining that he preferred direct con­tact with God and had reconciled himself to the “consequences” of his actions. He reports having “nothing left to live for” and “nothing left to do.” He says that he is “tired of being a burden” to his wife and son, regrets the way he treated them in the past, and believes they would be better off without him.

Although Mr. M’s abilities to understand, reason, and express a preference are intact, the psychiatry team is concerned that depres­sion could be influencing his perspective, thereby compromising his appreciation for the personal relevance of his request to withdraw life-sustaining treatments. The psychiatrist shares this concern with Mr. M, who voices an understanding that undertreated depression could lead him to make irreversible decisions about his medical treatment that he might not make if he were not depressed; nevertheless, he continues to state that he is “ready” to die. With his permission, the team seeks additional information from Mr. M’s family.

Mr. M’s wife recalls a conversation with her husband 5 years ago in which he said that, were he to become seriously ill, “he would want everything done.” However, she also reports that Mr. M has been expressing a pas­sive death wish “for years,” as he was strug­gling with chronic medical conditions that led to recurrent hospital admissions.

“He has always been a negative person,” she adds, and confirms that he has been depressed for most of their marriage.

The conflict between Mr. M’s earlier expressed preference for full care and his cur­rent wish to withdraw life-sustaining thera­pies and experience a “natural death” raises significant concern that depression could explain this change in perspective. When asked about this discrepancy, Mr. M admits that he “wanted everything done” in the past, when he was younger and healthier, but his preferences changed as his chronic medical problems progressed.

OUTCOME Better mood, discharge
We encourage Mr. M to continue discussing his treatment preferences with his family, while meeting with the palliative care team to address medical conditions that could be exac­erbating depression and to clarify his goals of care. The medical team and Mr. M report feel­ing relieved when a palliative care consult is suggested, although his wife and son ask that it be delayed until Mr. M is more medically stable. The treatment team acknowledges the competing risks of proceeding too hastily with Mr. M’s request to withdraw life-sustain­ing treatments because of depression, and of delaying his decision, which could prolong suffering and violate his right to refuse medi­cal treatment.

Mr. M agrees to increase citalopram to 40 mg/d to target depressive symptoms. We monitor Mr. M for treatment response and side effects, to provide ongoing support, to facili­tate communication with the medical team, and to evaluate the influence of depression on treatment preferences and decision-making.

As Mr. M is stabilized over the next 3 weeks, he begins to reply, “I’m alive,” when asked about passive death wish. His renal func­tion improves and RRT is discontinued. Mr. M reports a slight improvement in his mood and is discharged to a skilled nursing facility, with plans for closing his tracheostomy.

The authors’ observations
Capacity assessments can be challenging in depressed patients, often because of the uncertain role of features such as hopeless­ness, anhedonia, and passive death wish in the decision-making process. Depressed patients do not automatically lack DMC, and existing studies suggest that decisions regarding life-saving interventions typi­cally are stable across time. The 4-ability model for capacity assessment is a useful starting point, but additional consider­ations are warranted in depressed patients with chronic illness (Figure). There is no evidence to date to guide these assess­ments in chronically depressed or dys­thymic patients; therefore additional safeguards may be needed (Table).

When positive outcomes are not achieved or ethical dilemmas arise, health care providers could experience high moral distress.²¹ In Mr. M’s case, the con­sultation team felt moral distress because of the delayed involvement of pallia­tive care, especially because this decision was driven by the family rather than the patient.

Related Resources
• Sessums LL, Zembrzuska H, Jackson JL. Does this pa­tient have medical decision-making capacity? JAMA. 2011;306(4):420-427.
• American Academy of Hospice and Palliative Medicine. www. aahpm.org.

Drug Brand Names
Buspirone • Buspar       Citalopram • Celexa

Disclosures

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

CASE ‘I’ve had enough’
The psychiatry consultation team is asked to evaluate Mr. M, age 76, for a passive death wish and depression 2 months after he was admit­ted to the hospital after a traumatic fall.

Mr. M has several chronic medical condi­tions, including hypertension, type 2 diabetes mellitus, and coronary artery disease. Within 2 weeks of his admission, he developed Proteus mirabilis pneumonia and persistent respiratory failure requiring tracheostomy. Records indi­cate that Mr. M has told family and his treat­ment team, “I’m tired, just let me go.” He then developed antibiotic-induced Clostridium diffi­cile colitis and acute renal failure requiring tem­porary renal replacement therapy (RRT).

Mr. M’s clinical status improves, allowing his transfer to a transitional unit, where he contin­ues to state, “I have had enough. I’m done.” He asks for the tracheostomy tube to be removed and RRT discontinued. He is treated again for persistent C. difficile colitis and, within 2 weeks, develops hypotension, hypoxia, emesis, and abdominal distension, requiring transfer to the ICU for management of ileus.

He is stabilized with vasopressors and arti­ficial nutritional support by nasogastric tube. Renal function improves, RRT is discontinued, and he is transferred to the general medical floor.

After a few days on the general medical floor, Mr. M develops a urinary tract infection and develops antibiotic-induced acute renal failure requiring re-initiation of RRT. A percu­taneous endoscopic gastrostomy (PEG) tube is placed for nutrition when he shows little improvement with swallowing exercises. Two days after placing the PEG tube, he develops respiratory failure secondary to a left-sided pneumothorax and is transferred to the ICU for the third time, where he undergoes repeated bronchoscopies and requires pressure sup­port ventilation.

One week later, Mr. M is weaned off the ventilator and transferred to the general medical floor with aggressive respiratory therapy, tube feeding, and RRT. Mr. M’s chart indicates that he expresses an ongoing desire to withdraw RRT, the tracheostomy, and feeding tube.

Which of the following would you consider when assessing Mr. M’s decision-making capacity (DMC)?
   a) his ability to understand information relevant to treatment decision-making
   b) his ability to appreciate the significance of his diagnoses and treatment options and consequences in the context of his own life circumstances
   c) his ability to communicate a preference
   d) his ability to reason through the relevant information to weigh the potential costs and benefits of treatment options
   e) all of the above

HISTORY Guilt and regret
Mr. M reports a 30-year history of depression that has responded poorly to a variety of med­ications, outpatient psychotherapy, and elec­troconvulsive therapy. Before admission, he says, he was adherent to citalopram, 20 mg/d, and buspirone, 30 mg/d. Citalopram is contin­ued throughout his hospitalization, although buspirone was discontinued for unknown rea­sons during admission.

Mr. M is undergoing hemodialysis during his initial encounter with the psychiatry team. He struggles to communicate clearly because of the tracheostomy but is alert, oriented to person and location, answers questions appropriately, maintains good eye contact, and does not demonstrate any psychomotor abnormalities. He describes his disposition as “tired,” and is on the verge of tears during the interview.

Mr. M denies physical discomfort and states, “I have just had enough. I do not want all of this done.” He clarifies that he is not sui­cidal and denies a history of suicidal or self-injurious behaviors.

Mr. M describes having low mood, anhedo­nia, and insomnia to varying degrees through­out his adult life. He also reports feeling guilt and regret about earlier experiences, but does not elaborate. He denies symptoms of panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, mania, or hypo­mania. He reports an episode of visual halluci­nations during an earlier hospitalization, likely a symptom of delirium, but denies any recent visual disturbances.

Mr. M’s thought process is linear and logical, with intact abstract reasoning and no evidence of delusions. Attention and concentration are intact for most of the interview but diminish as he becomes fatigued. Mr. M can describe past treatments in detail and recounts the events leading to this hospitalization.

The authors’ observations
Literature on assessment of DMC recently has centered on the 4-ability model, pro­posed by Grisso and Appelbaum.¹ With this approach, impairment to any of the 4 processes of understanding, appre­ciation, ability to express a choice, and ability to use reasoning to weigh treat­ment options could interfere with capac­ity to make decisions. Few studies have clarified the mechanism and degree to which depression may impair these 4 ele­ments, making capacity assessments in a depressed patient challenging.

Preliminary evidence suggests that depression severity, not the presence of depression, determines the degree to which DMC is impaired, if at all. In several studies, depressed patients did not dem­onstrate more impaired DMC compared with non-depressed patients based on standardized assessments.^2-4 In depressed patients who lack DMC, case reports^5-7 and cross-sectional studies⁸ indicate that appreciation—one’s ability to comprehend the personal relevance of illness and poten­tial consequences of treatments in the con­text of one’s life—is most often impaired. Other studies suggest that the ability to reason through decision-specific informa­tion and weigh the risks and benefits of treatment options is commonly impaired in depressed patients.^9,10

Even when a depressed patient demon­strates the 4 elements of DMC, providers might be concerned that the patient’s pref­erences are skewed by the negative emo­tions associated with depression.^11-13 In such a case, the patient’s expressed wishes might not be consistent with views and priorities that were expressed during an earlier, euthymic period.

Rather than focusing on whether cog­nitive elements of DMC are impaired, some experts advocate for assessing how depression might lead to “unbalanced” decision-making that is impaired by a patient’s tendency to undervalue positive outcomes and overvalue negative ones.¹⁴ Some depressed patients will decide to forego additional medical interventions because they do not see the potential ben­efits of treatment, view events through a negative lens, and lack hope for the future; however, studies indicate this is not typi­cally the case.^15-17

In a study of >2,500 patients age >65 with chronic medical conditions, Garrett et al¹⁵ found that those who were depressed communicated a desire for more treatment compared with non-depressed patients. Another study of patients’ wishes for life-sustaining treatment among those who had mild or moderate depression found that most patients did not express a greater desire for life-sustaining medi­cal interventions after their depressive episode remitted. An increased desire for life-sustaining medical interventions occurred only among the most severely depressed patients.¹⁶ Similarly, Lee and Ganzini¹⁷ found that treatment preferences among patients with mild or moderate depression and serious physical illness were unchanged after the mood disorder was treated.

These findings demonstrate that a cli­nician charged with assessing DMC must evaluate the severity of a patient’s depres­sion and carefully consider how mood is influencing his (her) perspective and cog­nitive abilities. It is important to observe how the depressed patient perceives feel­ings of sadness or hopelessness in the con­text of decision-making, and how he (she) integrates these feelings when assigning relative value to potential outcomes and alternative treatment options. Because the intensity of depression could vary over time, assessment of the depressed patient’s decision-making abilities must be viewed as a dynamic process.

Clinical application
Recent studies indicate that, although the in-hospital mortality rate for critically ill patients who develop acute renal failure is high, it is variable, ranging from 28% to 90%.¹⁸ In one study, patients who required more interventions over the course of a hospital stay (eg, mechanical ventilation, vasopressors) had an in-hospital mortality rate closer to 60% after initiating RRT.¹⁹ In a similar trial,^20,21 mean survival for critically ill patients with acute renal failure was 32 days from initiation of dialysis; only 27% of these patients were alive 6 months later.²¹

Given his complicated hospital course, the medical team estimates that Mr. M has a reasonable chance of surviving to dis­charge, although his longer-term progno­sis is poor.

EVALUATION Conflicting preferences
Mr. M expresses reasonable understanding of the medical indications for temporary RRT, respiratory therapy, and enteral tube feed­ings, and the consequences of withdrawing these interventions. He understands that the primary team recommended ongoing but temporary use of life-sustaining interven­tions, anticipating that he would recover from his acute medical conditions. Mr. M clearly articulates that he wants to terminate RRT knowing that this would cause a buildup of urea and other toxins, to resume eating by mouth despite the risk of aspiration, and to be allowed to die “naturally.”

Mr. M declines to speak with a clergy mem­ber, explaining that he preferred direct con­tact with God and had reconciled himself to the “consequences” of his actions. He reports having “nothing left to live for” and “nothing left to do.” He says that he is “tired of being a burden” to his wife and son, regrets the way he treated them in the past, and believes they would be better off without him.

Although Mr. M’s abilities to understand, reason, and express a preference are intact, the psychiatry team is concerned that depres­sion could be influencing his perspective, thereby compromising his appreciation for the personal relevance of his request to withdraw life-sustaining treatments. The psychiatrist shares this concern with Mr. M, who voices an understanding that undertreated depression could lead him to make irreversible decisions about his medical treatment that he might not make if he were not depressed; nevertheless, he continues to state that he is “ready” to die. With his permission, the team seeks additional information from Mr. M’s family.

Mr. M’s wife recalls a conversation with her husband 5 years ago in which he said that, were he to become seriously ill, “he would want everything done.” However, she also reports that Mr. M has been expressing a pas­sive death wish “for years,” as he was strug­gling with chronic medical conditions that led to recurrent hospital admissions.

“He has always been a negative person,” she adds, and confirms that he has been depressed for most of their marriage.

The conflict between Mr. M’s earlier expressed preference for full care and his cur­rent wish to withdraw life-sustaining thera­pies and experience a “natural death” raises significant concern that depression could explain this change in perspective. When asked about this discrepancy, Mr. M admits that he “wanted everything done” in the past, when he was younger and healthier, but his preferences changed as his chronic medical problems progressed.

OUTCOME Better mood, discharge
We encourage Mr. M to continue discussing his treatment preferences with his family, while meeting with the palliative care team to address medical conditions that could be exac­erbating depression and to clarify his goals of care. The medical team and Mr. M report feel­ing relieved when a palliative care consult is suggested, although his wife and son ask that it be delayed until Mr. M is more medically stable. The treatment team acknowledges the competing risks of proceeding too hastily with Mr. M’s request to withdraw life-sustain­ing treatments because of depression, and of delaying his decision, which could prolong suffering and violate his right to refuse medi­cal treatment.

Mr. M agrees to increase citalopram to 40 mg/d to target depressive symptoms. We monitor Mr. M for treatment response and side effects, to provide ongoing support, to facili­tate communication with the medical team, and to evaluate the influence of depression on treatment preferences and decision-making.

As Mr. M is stabilized over the next 3 weeks, he begins to reply, “I’m alive,” when asked about passive death wish. His renal func­tion improves and RRT is discontinued. Mr. M reports a slight improvement in his mood and is discharged to a skilled nursing facility, with plans for closing his tracheostomy.

The authors’ observations
Capacity assessments can be challenging in depressed patients, often because of the uncertain role of features such as hopeless­ness, anhedonia, and passive death wish in the decision-making process. Depressed patients do not automatically lack DMC, and existing studies suggest that decisions regarding life-saving interventions typi­cally are stable across time. The 4-ability model for capacity assessment is a useful starting point, but additional consider­ations are warranted in depressed patients with chronic illness (Figure). There is no evidence to date to guide these assess­ments in chronically depressed or dys­thymic patients; therefore additional safeguards may be needed (Table).

When positive outcomes are not achieved or ethical dilemmas arise, health care providers could experience high moral distress.²¹ In Mr. M’s case, the con­sultation team felt moral distress because of the delayed involvement of pallia­tive care, especially because this decision was driven by the family rather than the patient.

Related Resources
• Sessums LL, Zembrzuska H, Jackson JL. Does this pa­tient have medical decision-making capacity? JAMA. 2011;306(4):420-427.
• American Academy of Hospice and Palliative Medicine. www. aahpm.org.

Drug Brand Names
Buspirone • Buspar       Citalopram • Celexa

Disclosures

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

CASE ‘I’ve had enough’
The psychiatry consultation team is asked to evaluate Mr. M, age 76, for a passive death wish and depression 2 months after he was admit­ted to the hospital after a traumatic fall.

Mr. M has several chronic medical condi­tions, including hypertension, type 2 diabetes mellitus, and coronary artery disease. Within 2 weeks of his admission, he developed Proteus mirabilis pneumonia and persistent respiratory failure requiring tracheostomy. Records indi­cate that Mr. M has told family and his treat­ment team, “I’m tired, just let me go.” He then developed antibiotic-induced Clostridium diffi­cile colitis and acute renal failure requiring tem­porary renal replacement therapy (RRT).

Mr. M’s clinical status improves, allowing his transfer to a transitional unit, where he contin­ues to state, “I have had enough. I’m done.” He asks for the tracheostomy tube to be removed and RRT discontinued. He is treated again for persistent C. difficile colitis and, within 2 weeks, develops hypotension, hypoxia, emesis, and abdominal distension, requiring transfer to the ICU for management of ileus.

He is stabilized with vasopressors and arti­ficial nutritional support by nasogastric tube. Renal function improves, RRT is discontinued, and he is transferred to the general medical floor.

After a few days on the general medical floor, Mr. M develops a urinary tract infection and develops antibiotic-induced acute renal failure requiring re-initiation of RRT. A percu­taneous endoscopic gastrostomy (PEG) tube is placed for nutrition when he shows little improvement with swallowing exercises. Two days after placing the PEG tube, he develops respiratory failure secondary to a left-sided pneumothorax and is transferred to the ICU for the third time, where he undergoes repeated bronchoscopies and requires pressure sup­port ventilation.

One week later, Mr. M is weaned off the ventilator and transferred to the general medical floor with aggressive respiratory therapy, tube feeding, and RRT. Mr. M’s chart indicates that he expresses an ongoing desire to withdraw RRT, the tracheostomy, and feeding tube.

Which of the following would you consider when assessing Mr. M’s decision-making capacity (DMC)?
   a) his ability to understand information relevant to treatment decision-making
   b) his ability to appreciate the significance of his diagnoses and treatment options and consequences in the context of his own life circumstances
   c) his ability to communicate a preference
   d) his ability to reason through the relevant information to weigh the potential costs and benefits of treatment options
   e) all of the above

HISTORY Guilt and regret
Mr. M reports a 30-year history of depression that has responded poorly to a variety of med­ications, outpatient psychotherapy, and elec­troconvulsive therapy. Before admission, he says, he was adherent to citalopram, 20 mg/d, and buspirone, 30 mg/d. Citalopram is contin­ued throughout his hospitalization, although buspirone was discontinued for unknown rea­sons during admission.

Mr. M is undergoing hemodialysis during his initial encounter with the psychiatry team. He struggles to communicate clearly because of the tracheostomy but is alert, oriented to person and location, answers questions appropriately, maintains good eye contact, and does not demonstrate any psychomotor abnormalities. He describes his disposition as “tired,” and is on the verge of tears during the interview.

Mr. M denies physical discomfort and states, “I have just had enough. I do not want all of this done.” He clarifies that he is not sui­cidal and denies a history of suicidal or self-injurious behaviors.

Mr. M describes having low mood, anhedo­nia, and insomnia to varying degrees through­out his adult life. He also reports feeling guilt and regret about earlier experiences, but does not elaborate. He denies symptoms of panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, mania, or hypo­mania. He reports an episode of visual halluci­nations during an earlier hospitalization, likely a symptom of delirium, but denies any recent visual disturbances.

Mr. M’s thought process is linear and logical, with intact abstract reasoning and no evidence of delusions. Attention and concentration are intact for most of the interview but diminish as he becomes fatigued. Mr. M can describe past treatments in detail and recounts the events leading to this hospitalization.

The authors’ observations
Literature on assessment of DMC recently has centered on the 4-ability model, pro­posed by Grisso and Appelbaum.¹ With this approach, impairment to any of the 4 processes of understanding, appre­ciation, ability to express a choice, and ability to use reasoning to weigh treat­ment options could interfere with capac­ity to make decisions. Few studies have clarified the mechanism and degree to which depression may impair these 4 ele­ments, making capacity assessments in a depressed patient challenging.

Preliminary evidence suggests that depression severity, not the presence of depression, determines the degree to which DMC is impaired, if at all. In several studies, depressed patients did not dem­onstrate more impaired DMC compared with non-depressed patients based on standardized assessments.^2-4 In depressed patients who lack DMC, case reports^5-7 and cross-sectional studies⁸ indicate that appreciation—one’s ability to comprehend the personal relevance of illness and poten­tial consequences of treatments in the con­text of one’s life—is most often impaired. Other studies suggest that the ability to reason through decision-specific informa­tion and weigh the risks and benefits of treatment options is commonly impaired in depressed patients.^9,10

Even when a depressed patient demon­strates the 4 elements of DMC, providers might be concerned that the patient’s pref­erences are skewed by the negative emo­tions associated with depression.^11-13 In such a case, the patient’s expressed wishes might not be consistent with views and priorities that were expressed during an earlier, euthymic period.

Rather than focusing on whether cog­nitive elements of DMC are impaired, some experts advocate for assessing how depression might lead to “unbalanced” decision-making that is impaired by a patient’s tendency to undervalue positive outcomes and overvalue negative ones.¹⁴ Some depressed patients will decide to forego additional medical interventions because they do not see the potential ben­efits of treatment, view events through a negative lens, and lack hope for the future; however, studies indicate this is not typi­cally the case.^15-17

In a study of >2,500 patients age >65 with chronic medical conditions, Garrett et al¹⁵ found that those who were depressed communicated a desire for more treatment compared with non-depressed patients. Another study of patients’ wishes for life-sustaining treatment among those who had mild or moderate depression found that most patients did not express a greater desire for life-sustaining medi­cal interventions after their depressive episode remitted. An increased desire for life-sustaining medical interventions occurred only among the most severely depressed patients.¹⁶ Similarly, Lee and Ganzini¹⁷ found that treatment preferences among patients with mild or moderate depression and serious physical illness were unchanged after the mood disorder was treated.

These findings demonstrate that a cli­nician charged with assessing DMC must evaluate the severity of a patient’s depres­sion and carefully consider how mood is influencing his (her) perspective and cog­nitive abilities. It is important to observe how the depressed patient perceives feel­ings of sadness or hopelessness in the con­text of decision-making, and how he (she) integrates these feelings when assigning relative value to potential outcomes and alternative treatment options. Because the intensity of depression could vary over time, assessment of the depressed patient’s decision-making abilities must be viewed as a dynamic process.

Clinical application
Recent studies indicate that, although the in-hospital mortality rate for critically ill patients who develop acute renal failure is high, it is variable, ranging from 28% to 90%.¹⁸ In one study, patients who required more interventions over the course of a hospital stay (eg, mechanical ventilation, vasopressors) had an in-hospital mortality rate closer to 60% after initiating RRT.¹⁹ In a similar trial,^20,21 mean survival for critically ill patients with acute renal failure was 32 days from initiation of dialysis; only 27% of these patients were alive 6 months later.²¹

Given his complicated hospital course, the medical team estimates that Mr. M has a reasonable chance of surviving to dis­charge, although his longer-term progno­sis is poor.

EVALUATION Conflicting preferences
Mr. M expresses reasonable understanding of the medical indications for temporary RRT, respiratory therapy, and enteral tube feed­ings, and the consequences of withdrawing these interventions. He understands that the primary team recommended ongoing but temporary use of life-sustaining interven­tions, anticipating that he would recover from his acute medical conditions. Mr. M clearly articulates that he wants to terminate RRT knowing that this would cause a buildup of urea and other toxins, to resume eating by mouth despite the risk of aspiration, and to be allowed to die “naturally.”

Mr. M declines to speak with a clergy mem­ber, explaining that he preferred direct con­tact with God and had reconciled himself to the “consequences” of his actions. He reports having “nothing left to live for” and “nothing left to do.” He says that he is “tired of being a burden” to his wife and son, regrets the way he treated them in the past, and believes they would be better off without him.

Although Mr. M’s abilities to understand, reason, and express a preference are intact, the psychiatry team is concerned that depres­sion could be influencing his perspective, thereby compromising his appreciation for the personal relevance of his request to withdraw life-sustaining treatments. The psychiatrist shares this concern with Mr. M, who voices an understanding that undertreated depression could lead him to make irreversible decisions about his medical treatment that he might not make if he were not depressed; nevertheless, he continues to state that he is “ready” to die. With his permission, the team seeks additional information from Mr. M’s family.

Mr. M’s wife recalls a conversation with her husband 5 years ago in which he said that, were he to become seriously ill, “he would want everything done.” However, she also reports that Mr. M has been expressing a pas­sive death wish “for years,” as he was strug­gling with chronic medical conditions that led to recurrent hospital admissions.

“He has always been a negative person,” she adds, and confirms that he has been depressed for most of their marriage.

The conflict between Mr. M’s earlier expressed preference for full care and his cur­rent wish to withdraw life-sustaining thera­pies and experience a “natural death” raises significant concern that depression could explain this change in perspective. When asked about this discrepancy, Mr. M admits that he “wanted everything done” in the past, when he was younger and healthier, but his preferences changed as his chronic medical problems progressed.

OUTCOME Better mood, discharge
We encourage Mr. M to continue discussing his treatment preferences with his family, while meeting with the palliative care team to address medical conditions that could be exac­erbating depression and to clarify his goals of care. The medical team and Mr. M report feel­ing relieved when a palliative care consult is suggested, although his wife and son ask that it be delayed until Mr. M is more medically stable. The treatment team acknowledges the competing risks of proceeding too hastily with Mr. M’s request to withdraw life-sustain­ing treatments because of depression, and of delaying his decision, which could prolong suffering and violate his right to refuse medi­cal treatment.

Mr. M agrees to increase citalopram to 40 mg/d to target depressive symptoms. We monitor Mr. M for treatment response and side effects, to provide ongoing support, to facili­tate communication with the medical team, and to evaluate the influence of depression on treatment preferences and decision-making.

As Mr. M is stabilized over the next 3 weeks, he begins to reply, “I’m alive,” when asked about passive death wish. His renal func­tion improves and RRT is discontinued. Mr. M reports a slight improvement in his mood and is discharged to a skilled nursing facility, with plans for closing his tracheostomy.

The authors’ observations
Capacity assessments can be challenging in depressed patients, often because of the uncertain role of features such as hopeless­ness, anhedonia, and passive death wish in the decision-making process. Depressed patients do not automatically lack DMC, and existing studies suggest that decisions regarding life-saving interventions typi­cally are stable across time. The 4-ability model for capacity assessment is a useful starting point, but additional consider­ations are warranted in depressed patients with chronic illness (Figure). There is no evidence to date to guide these assess­ments in chronically depressed or dys­thymic patients; therefore additional safeguards may be needed (Table).

When positive outcomes are not achieved or ethical dilemmas arise, health care providers could experience high moral distress.²¹ In Mr. M’s case, the con­sultation team felt moral distress because of the delayed involvement of pallia­tive care, especially because this decision was driven by the family rather than the patient.

Related Resources
• Sessums LL, Zembrzuska H, Jackson JL. Does this pa­tient have medical decision-making capacity? JAMA. 2011;306(4):420-427.
• American Academy of Hospice and Palliative Medicine. www. aahpm.org.

Drug Brand Names
Buspirone • Buspar       Citalopram • Celexa

Disclosures

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

Patients often tell clinicians that they used their “left-over” medica­tions from previous refills, or that a family member shared medication with them. Other patients, who are non-adherent or have had a recent medication change, might reveal that they have some unused pills at home. As clinicians, what does this practice by our patients mean for us?

Prescription drug abuse is an emerg­ing crisis, and drug diversion is a signifi­cant contributing factor.¹ According to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health,² in 2011 and 2012, on average, more than one-half of partici­pants age ≥12 who used a pain reliever, tranquilizer, stimulant, or sedative non-medically obtained their most recently used drug “from a friend or relative for free.”

Unused, expired, and “extra” medi­cations pose a significant risk for diver­sion, abuse, and accidental overdose.³ According to the Prescription Drug Abuse Prevention Plan,¹ proper medica­tion disposal is a major problem that needs action to help reduce prescription drug abuse.

Regrettably, <20% of patients receive advice on medication disposal from their health care provider,⁴ even though clini­cians have an opportunity to educate patients and their caregivers on appro­priate use, and safe disposal of, medica­tions—in particular, controlled substances.

What should we emphasize to our patients about disposing of medications when it’s necessary?

Teach responsible use
Stress that medications prescribed for the patient are for his (her) use alone and should not be shared with friends or family. Sharing might seem kind and generous, but it can be dangerous. Medications should be used only at the prescribed dosage and frequency and for the rec­ommended duration. If the medication causes an adverse effect or other problem, instruct the patient to talk to you before making any changes to the established regimen.

Emphasize safe disposal
Follow instructions. The label on medi­cation bottles or other containers often has specific instructions on how to prop­erly store, and even dispose of, the drug. Advise your patient to follow instructions on the label carefully.

Participate in a take-back program. The U.S. Drug Enforcement Administration (DEA) sponsors several kinds of drug take-back programs, including permanent locations where unused prescriptions are collected; 1-day events; and mail-in/ship-back programs.

The National Prescription Drug Take-Back Initiative is one such program that collects unused or expired medications on “Take Back Days.” On such days, DEA-coordinated collection sites nationwide accept unneeded pills, including pre­scription painkillers and other controlled substances, for disposal only when law enforcement personnel are present. In 2014, this program collected 780,158 lb of prescribed controlled medications.⁵

Patients can get more information about these programs by contacting a local phar­macy or their household trash and recycling service division.^1,6

Discard medications properly in trash. An acceptable household strategy for disposing of prescription drugs is to mix the medication with an undesirable substance, such as used cat litter or coffee grounds, place the mixture in a sealed plastic bag or disposable container with a lid, and then place it in the trash.

Don’t flush. People sometimes flush unused medications down the toilet or drain. The current recommendation is against flush­ing unless instructions on the bottle specifi­cally say to do so. Flushing is appropriate for disposing of some medications such as opiates, thereby minimizing the risk of acci­dental overdose or misuse.⁶ It is important to remember that most municipal sewage treatment plans do not have the ability to extract pharmaceuticals from wastewater.⁷

Discard empty bottles. It is important to discard pill bottles once they are empty and to remove any identifiable personal infor­mation from the label. Educate patients not to use empty pill bottles to store or trans­port other medications; this practice might result in accidental ingestion of the wrong medication or dose.These methods of disposal are in accordance with federal, state, and local regulations, as well as human and environ­mental safety standards. Appropriate dis­posal decreases contamination of soil and bodies of water with active pharmaceutical ingredients, thereby minimizing people’s and aquatic animals’ chronic exposure to low levels of drugs.³

Encourage patients to seek drug safety information. Patients might benefit from the information and services pro­vided by:
   • National Council on Patient Information and Education (www.talkaboutrx.org)
   • Medication Use Safety Training for Seniors (www.mustforseniors.org), a nationwide initiative to promote medi­cation education and safety in the geri­atric population through an interactive program.

Remember: Although prescribing medi­cations is strictly regulated, particularly for controlled substances, those regulations do little to prevent diversion of medications after they’ve been prescribed. Educating patients and their caregivers about safe dis­posal can help protect them, their family, and others.

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

Patients often tell clinicians that they used their “left-over” medica­tions from previous refills, or that a family member shared medication with them. Other patients, who are non-adherent or have had a recent medication change, might reveal that they have some unused pills at home. As clinicians, what does this practice by our patients mean for us?

Prescription drug abuse is an emerg­ing crisis, and drug diversion is a signifi­cant contributing factor.¹ According to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health,² in 2011 and 2012, on average, more than one-half of partici­pants age ≥12 who used a pain reliever, tranquilizer, stimulant, or sedative non-medically obtained their most recently used drug “from a friend or relative for free.”

Unused, expired, and “extra” medi­cations pose a significant risk for diver­sion, abuse, and accidental overdose.³ According to the Prescription Drug Abuse Prevention Plan,¹ proper medica­tion disposal is a major problem that needs action to help reduce prescription drug abuse.

Regrettably, <20% of patients receive advice on medication disposal from their health care provider,⁴ even though clini­cians have an opportunity to educate patients and their caregivers on appro­priate use, and safe disposal of, medica­tions—in particular, controlled substances.

What should we emphasize to our patients about disposing of medications when it’s necessary?

Teach responsible use
Stress that medications prescribed for the patient are for his (her) use alone and should not be shared with friends or family. Sharing might seem kind and generous, but it can be dangerous. Medications should be used only at the prescribed dosage and frequency and for the rec­ommended duration. If the medication causes an adverse effect or other problem, instruct the patient to talk to you before making any changes to the established regimen.

Emphasize safe disposal
Follow instructions. The label on medi­cation bottles or other containers often has specific instructions on how to prop­erly store, and even dispose of, the drug. Advise your patient to follow instructions on the label carefully.

Participate in a take-back program. The U.S. Drug Enforcement Administration (DEA) sponsors several kinds of drug take-back programs, including permanent locations where unused prescriptions are collected; 1-day events; and mail-in/ship-back programs.

The National Prescription Drug Take-Back Initiative is one such program that collects unused or expired medications on “Take Back Days.” On such days, DEA-coordinated collection sites nationwide accept unneeded pills, including pre­scription painkillers and other controlled substances, for disposal only when law enforcement personnel are present. In 2014, this program collected 780,158 lb of prescribed controlled medications.⁵

Patients can get more information about these programs by contacting a local phar­macy or their household trash and recycling service division.^1,6

Discard medications properly in trash. An acceptable household strategy for disposing of prescription drugs is to mix the medication with an undesirable substance, such as used cat litter or coffee grounds, place the mixture in a sealed plastic bag or disposable container with a lid, and then place it in the trash.

Don’t flush. People sometimes flush unused medications down the toilet or drain. The current recommendation is against flush­ing unless instructions on the bottle specifi­cally say to do so. Flushing is appropriate for disposing of some medications such as opiates, thereby minimizing the risk of acci­dental overdose or misuse.⁶ It is important to remember that most municipal sewage treatment plans do not have the ability to extract pharmaceuticals from wastewater.⁷

Discard empty bottles. It is important to discard pill bottles once they are empty and to remove any identifiable personal infor­mation from the label. Educate patients not to use empty pill bottles to store or trans­port other medications; this practice might result in accidental ingestion of the wrong medication or dose.These methods of disposal are in accordance with federal, state, and local regulations, as well as human and environ­mental safety standards. Appropriate dis­posal decreases contamination of soil and bodies of water with active pharmaceutical ingredients, thereby minimizing people’s and aquatic animals’ chronic exposure to low levels of drugs.³

Encourage patients to seek drug safety information. Patients might benefit from the information and services pro­vided by:
   • National Council on Patient Information and Education (www.talkaboutrx.org)
   • Medication Use Safety Training for Seniors (www.mustforseniors.org), a nationwide initiative to promote medi­cation education and safety in the geri­atric population through an interactive program.

Remember: Although prescribing medi­cations is strictly regulated, particularly for controlled substances, those regulations do little to prevent diversion of medications after they’ve been prescribed. Educating patients and their caregivers about safe dis­posal can help protect them, their family, and others.

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

Patients often tell clinicians that they used their “left-over” medica­tions from previous refills, or that a family member shared medication with them. Other patients, who are non-adherent or have had a recent medication change, might reveal that they have some unused pills at home. As clinicians, what does this practice by our patients mean for us?

Prescription drug abuse is an emerg­ing crisis, and drug diversion is a signifi­cant contributing factor.¹ According to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health,² in 2011 and 2012, on average, more than one-half of partici­pants age ≥12 who used a pain reliever, tranquilizer, stimulant, or sedative non-medically obtained their most recently used drug “from a friend or relative for free.”

Unused, expired, and “extra” medi­cations pose a significant risk for diver­sion, abuse, and accidental overdose.³ According to the Prescription Drug Abuse Prevention Plan,¹ proper medica­tion disposal is a major problem that needs action to help reduce prescription drug abuse.

Regrettably, <20% of patients receive advice on medication disposal from their health care provider,⁴ even though clini­cians have an opportunity to educate patients and their caregivers on appro­priate use, and safe disposal of, medica­tions—in particular, controlled substances.

What should we emphasize to our patients about disposing of medications when it’s necessary?

Teach responsible use
Stress that medications prescribed for the patient are for his (her) use alone and should not be shared with friends or family. Sharing might seem kind and generous, but it can be dangerous. Medications should be used only at the prescribed dosage and frequency and for the rec­ommended duration. If the medication causes an adverse effect or other problem, instruct the patient to talk to you before making any changes to the established regimen.

Emphasize safe disposal
Follow instructions. The label on medi­cation bottles or other containers often has specific instructions on how to prop­erly store, and even dispose of, the drug. Advise your patient to follow instructions on the label carefully.

Participate in a take-back program. The U.S. Drug Enforcement Administration (DEA) sponsors several kinds of drug take-back programs, including permanent locations where unused prescriptions are collected; 1-day events; and mail-in/ship-back programs.

The National Prescription Drug Take-Back Initiative is one such program that collects unused or expired medications on “Take Back Days.” On such days, DEA-coordinated collection sites nationwide accept unneeded pills, including pre­scription painkillers and other controlled substances, for disposal only when law enforcement personnel are present. In 2014, this program collected 780,158 lb of prescribed controlled medications.⁵

Patients can get more information about these programs by contacting a local phar­macy or their household trash and recycling service division.^1,6

Discard medications properly in trash. An acceptable household strategy for disposing of prescription drugs is to mix the medication with an undesirable substance, such as used cat litter or coffee grounds, place the mixture in a sealed plastic bag or disposable container with a lid, and then place it in the trash.

Don’t flush. People sometimes flush unused medications down the toilet or drain. The current recommendation is against flush­ing unless instructions on the bottle specifi­cally say to do so. Flushing is appropriate for disposing of some medications such as opiates, thereby minimizing the risk of acci­dental overdose or misuse.⁶ It is important to remember that most municipal sewage treatment plans do not have the ability to extract pharmaceuticals from wastewater.⁷

Discard empty bottles. It is important to discard pill bottles once they are empty and to remove any identifiable personal infor­mation from the label. Educate patients not to use empty pill bottles to store or trans­port other medications; this practice might result in accidental ingestion of the wrong medication or dose.These methods of disposal are in accordance with federal, state, and local regulations, as well as human and environ­mental safety standards. Appropriate dis­posal decreases contamination of soil and bodies of water with active pharmaceutical ingredients, thereby minimizing people’s and aquatic animals’ chronic exposure to low levels of drugs.³

Encourage patients to seek drug safety information. Patients might benefit from the information and services pro­vided by:
   • National Council on Patient Information and Education (www.talkaboutrx.org)
   • Medication Use Safety Training for Seniors (www.mustforseniors.org), a nationwide initiative to promote medi­cation education and safety in the geri­atric population through an interactive program.

Remember: Although prescribing medi­cations is strictly regulated, particularly for controlled substances, those regulations do little to prevent diversion of medications after they’ve been prescribed. Educating patients and their caregivers about safe dis­posal can help protect them, their family, and others.

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

Hospitalized lung cancer patients who had venous thromboembolisms had significantly worse outcomes than did other patients, according to a study published in Lung Cancer.

Of the more than 570,000 included lung cancer patient hospitalizations, just over 3.6% also presented with venous thromboembolisms (VTE). Patients with VTE had a longer length of stay (7.15 days vs. 6.05 days), higher inpatient mortality (10.03% vs. 8.69%), greater hospital costs ($43,800 vs. $37,800), and were more likely to have moderate to severe disability after being discharged (55% vs. 49%) than patients who did not have VTE. Blacks were also at a higher risk, comprising 13.07% of the VTE group but only 10.66% of the non-VTE group, reported Dr. Conor Steuer and his associates at Emory University, Atlanta.

The study results “highlight the need for prospective studies to clarify the impact of VTE complications in lung cancer patients and identify effective interventions to improve the poorer outcome observed in this population,” Dr. Steuer and his associates concluded.

Find the full study in Lung Cancer (doi: 10.1016/j.lungcan.2015.01.022).

Hospitalized lung cancer patients who had venous thromboembolisms had significantly worse outcomes than did other patients, according to a study published in Lung Cancer.

Of the more than 570,000 included lung cancer patient hospitalizations, just over 3.6% also presented with venous thromboembolisms (VTE). Patients with VTE had a longer length of stay (7.15 days vs. 6.05 days), higher inpatient mortality (10.03% vs. 8.69%), greater hospital costs ($43,800 vs. $37,800), and were more likely to have moderate to severe disability after being discharged (55% vs. 49%) than patients who did not have VTE. Blacks were also at a higher risk, comprising 13.07% of the VTE group but only 10.66% of the non-VTE group, reported Dr. Conor Steuer and his associates at Emory University, Atlanta.

The study results “highlight the need for prospective studies to clarify the impact of VTE complications in lung cancer patients and identify effective interventions to improve the poorer outcome observed in this population,” Dr. Steuer and his associates concluded.

Find the full study in Lung Cancer (doi: 10.1016/j.lungcan.2015.01.022).

Hospitalized lung cancer patients who had venous thromboembolisms had significantly worse outcomes than did other patients, according to a study published in Lung Cancer.

Of the more than 570,000 included lung cancer patient hospitalizations, just over 3.6% also presented with venous thromboembolisms (VTE). Patients with VTE had a longer length of stay (7.15 days vs. 6.05 days), higher inpatient mortality (10.03% vs. 8.69%), greater hospital costs ($43,800 vs. $37,800), and were more likely to have moderate to severe disability after being discharged (55% vs. 49%) than patients who did not have VTE. Blacks were also at a higher risk, comprising 13.07% of the VTE group but only 10.66% of the non-VTE group, reported Dr. Conor Steuer and his associates at Emory University, Atlanta.

The study results “highlight the need for prospective studies to clarify the impact of VTE complications in lung cancer patients and identify effective interventions to improve the poorer outcome observed in this population,” Dr. Steuer and his associates concluded.

Find the full study in Lung Cancer (doi: 10.1016/j.lungcan.2015.01.022).

Lack of insight or “unawareness of illness” occurs within a set of self-assessment problems commonly seen in schizophrenia.¹ In the clinical domain, people who do not realize they are ill typically are unwilling to accept treatment, including medication, with potential for worsened illness. They also may have difficulty self-assess­ing everyday function and functional potential, cognition, social cognition, and attitude, often to a variable degree across these domains (Table 1).^1-3

Self-assessment of performance can be clinically help­ful whether performance is objectively good or bad. Those with poor performance could be helped to attempt to match their aspirations to accomplishments and improve over time. Good performers could have their functioning bolstered by recognizing their competence. Thus, even a population whose performance often is poor could ben­efit from accurate self-assessment or experience additional challenges from inaccurate self-evaluation.

This article discusses patient characteristics associated with impairments in self-assessment and the most accu­rate sources of information for clinicians about patient functioning. Our research shows that an experienced psy­chiatrist is well positioned to make accurate judgments of functional potential and cognitive abilities for people with schizophrenia.

Patterns in patients with impaired self-assessment
Healthy individuals routinely overestimate their abilities and their attractiveness to others.⁴ Feedback that deflates these exag­gerated estimates increases the accuracy of their self-assessments. Mildly depressed individuals typically are the most accurate judges of their true functioning; those with more severe levels of depression tend to underestimate their competence. Thus, sim­ply being an inaccurate self-assessor is not “abnormal.” These response biases are con­sistent and predictable in healthy people.

People with severe mental illness pose a different challenge. As in the following cases, their reports manifest minimal cor­relation with other sources of information, including objective information about performance.

CASE 1
JR, age 28, is referred for occupational therapy because he has never worked since graduat­ing from high school. He tells the therapist his cognitive abilities are average and intact, although his scores on a comprehensive cog­nitive assessment suggest performance at the first percentile of normal distribution or less. His self-reported Beck Depression Inventory (BDI) score is 4. He says he would like to work as a certified public accountant, because he believes he has an aptitude for math. He admits he has no idea what the job entails, but he is quite motivated to set up an interview as soon as possible.

CASE 2
LM, age 48, says his “best job” was managing an auto parts store for 18 months after he earned an associate’s degree and until his second psychotic episode. His most recent work was approximately 12 years ago at an oil-change facility. He agrees to discuss employment but feels his vocational skills are too deteriorated for him to succeed and requests an assessment for Alzheimer’s disease. His cognitive perfor­mance averages in the 10th percentile of the overall population, and his BDI score is 18. Tests of his ability to perform vocational skills sug­gest he is qualified for multiple jobs, including his previous technician position.

Individuals with schizophrenia who report no depression and no work history routinely overestimate their functional potential, whereas those with a history of unsuccessful vocational attempts often underestimate their functional potential. Inaccurate self-assessment can contrib­ute to reduced functioning—in JR’s case because of unrealistic assessment of the match between skills and vocational poten­tial, and in LM’s case because of overly  pessimistic self-evaluation. For people with schizophrenia, inability to self-evaluate can have a bidirectional adverse impact on func­tioning: overestimation may lead to trying tasks that are too challenging, and under­estimation may lead to reduced effort and motivation to take on functional tasks.

Metacognition and introspective accuracy
“Metacognition” refers to self-assessment of the quality and accuracy of performance on cognitive tests.^5-7 Problem-solving tests— such as the Wisconsin Card Sorting test (WCST), in which the person being assessed needs to solve the test through performance feedback—are metacognition tests. When errors are made, the strategy in use needs to be discarded; when responses are correct, the strategy is retained. People with schizo­phrenia have disproportionate difficulties with the WCST, and deficits are especially salient when the test is modified to measure self-assessment of performance and ability to use feedback to change strategies.

“Introspective accuracy” is used to describe the wide-ranging self-assessment impairments in severe mental illness. Theories of metacognition implicate a broad spectrum, of which self-assessment is 1 component, whereas introspective accuracy more specifically indicates judg­ments of accuracy. Because self-assessment is focused on the self, and hence is intro­spective, this conceptualization can be applied to self-evaluations of:
   • achievement in everyday functioning (“Did I complete that task well?”)
   • potential for achievement in everyday functioning (“I could do that job”)
   • cognitive performance (“Yes, I remembered all of those words”)
   • social cognition (“He really is angry”).

Domains of impaired introspective accuracy
Everyday functioning. The 3 global domains of everyday functioning are social outcomes, productive/vocational out­comes, and everyday activities, including residential independence/support for peo­ple with severe mental illness. Two areas of inquiry are used in self-assessing everyday functioning: (1) what are you doing now and (2) what could you do in the future? For people with schizophrenia, a related question is how perceived impairments in everyday functioning are associated with subjective illness burden.

People with schizophrenia report illness burden consistent with their self-reported disability, suggesting their reports in these domains are not random.⁸ Studies have consistently found, however, that these patients report:
   • less impairment on average in their everyday functioning than observed by clinicians
   • less subjective illness burden com­pared with individuals with much less severe illnesses.

Their reports also fail to correlate with cli­nicians’ observations.9 Patients with schizo­phrenia who have never been employed may report greater vocational potential than those employed full-time. Interestingly, patients who were previously—but not currently—employed reported the least vocational potential.¹⁰ These data suggest that experience may be a factor: individuals who have never worked have no context for their self-assessments, whereas people who are persistently unemployed may have a perspective on the challenges associated with employment.

In our research,⁹ high-contact clinicians (ie, case manager, psychiatrist, therapist, or residential facility manager) were bet­ter able than family or friends to generate ratings from an assessment questionnaire that correlated with performance-based measures of patients’ ability to perform everyday functional skills. The ratings were generated across multiple functional status scales, suggesting that the rater was more important than the specific scale. We concluded that high-contact clinicians can generate ratings of everyday functioning that are convergent with patients’ abilities, even when they have no information about actual performance scores.

Cognitive performance. When self-reported cognitive abilities are correlated with the results of performance on neuro­psychological assessments, the results are quite consistent. Patients provide reports that do not correlate with their objective performance.¹¹ Interestingly, when clini­cians were asked to use the same strategies as patients to generate ratings of cognitive impairment, clinician ratings had consider­ably greater evidence of validity. In several studies, patients’ ratings of their cognitive performance did not correlate with their neuropsychological test performance, even though they had just been tested on the assessment battery. Ratings by clinicians or other high-contact informants (who were unaware of patients’ test performance) were much more strongly related to patients’ objective test performance, compared with patient self-reports.¹²

The convergence of clinician ratings of cognitive performance with objective test data has been impressive. Correlation coef­ficients of at least r = 0.5, reflecting a moder­ate to large relationships between clinician ratings and objective performance, have been detected. Individual cognitive test domains, such as working memory and processing speed, often do not correlate with each other or with aspects of everyday functioning to that extent.¹³ These data sug­gest that a clinician assessment of cognitive performance, when focused on the correct aspects of cognitive functioning, can be a highly useful proxy for extensive neuropsy­chological testing.

Social cognitive performance. Introspective accuracy for social cognitive judg­ments can be assessed similarly to the strategies used to assess the domains of everyday functioning and cognitive perfor­mance. Patients are asked to complete a typi­cal social cognitive task, such as determining emotions from facial stimuli or examin­ing the eye region of the face, to determine the mental state of the depicted person. Immediately after responding to each stimu­lus, participants rate their confidence in the correctness of that response.

Consistent with the pattern of introspec­tive accuracy for everyday functioning, patients with schizophrenia tend to make more high-confidence errors than healthy individuals on social cognitive tasks. That is, the patients are less likely to realize when they are wrong in their judgments of social stimuli. A similar pattern has been found for mental state attribution,¹⁴ rec­ognition of facial emotion from the self,¹⁵ and recognition of facial emotion from others.¹⁶ These high-confidence errors also are more likely to occur for more difficult stimuli, such as faces that display only mildly emotional expressions. These dif­ficulties appear to be specific to judgments in an immediate evaluation situation. When asked to determine if the behavior of another individual is socially appropri­ate, individuals with schizophrenia are as able as healthy individuals to recognize social mistakes.¹⁷ This work suggests that, at least within the domain of social cogni­tion, introspective accuracy impairment is not caused by generalized poor judgment, just as self-assessments of disability and illness burden are generated at random.

Choosing a reliable informant
If a clinician has not had adequate time or exposure to a patient to make a cogni­tive or functional judgment, what should the strategy be? If asking the patient is uninformative, who should be asked? Our group has gathered information that may help clinicians identify informants who can provide ratings of cognitive perfor­mance and everyday functioning that are convergent with objective evidence.

In a systematic study of validity of reports of various informants, we com­pared correlations between reports of competence of everyday functioning with objective measures of cognitive test per­formance and ability to perform everyday functional skills. Our findings:
   • Patient reports of everyday function­ing were not correlated with performance-based measures for any of 6 rating scales.⁹
   • Clinician reports of everyday func­tioning were correlated with objective per­formance across 4 of 6 rating scales.
   • Correlations between ratings gener­ated by friend or relative informants and other information were almost shocking in their lack of validity (Table 2).⁹

We concluded that ratings generated by a generic informant—someone who simply knows the patient and is willing to provide ratings—are highly likely to be uninformative. If a friend or relative provides information of limited useful­ness, the report could easily lead to clinical decisions with high potential for bad out­comes. For example, attempts could fail to transition someone with impaired every­day living skills to independent living, or a patient whose potential is underesti­mated might not be offered opportunities to achieve attainable functional goals.

We found that the closer the rater was to a full caregiver role, the better and more accurate the information obtained. Caregivers who had regular contact with patients had much more valid rat­ings when performance on functionally relevant objective measures was consid­ered. Patients with caregivers had greater impairments in everyday outcomes, how­ever, suggesting that this subset was more impaired than the overall sample. For patients without caregivers, other sources of information—including careful obser­vation by high-contact clinicians—seem to be required to generate a valid assessment of functioning.

Direct functional implications of impaired introspective accuracy
Clinical effects of reduced awareness of ill­ness include reduced adherence to medi­cation, followed by relapse, disturbed behavior, leading to emergency room treat­ments or acute admissions, and—more rarely—disturbed behavior associated with violence or self-harm. Relapses such as these can adversely affect brain structure and function, with declines in cognitive functioning early in the illness.

Our recent study¹⁸ quantifies the direct impact of impairments in introspective accuracy on everyday functioning. We asked 214 individuals with schizophrenia to self-evaluate their cognitive ability with a systematic rating scale and to self-report their everyday functioning in social, voca­tional, and everyday activities domains. We used performance-based measures to assess their cognitive abilities and everyday functional skills. Concurrently, high-contact clinicians rated these same abilities with the same rating scales. We then predicted everyday functioning, as rated by the cli­nicians, with the discrepancies between self-assessed and clinician-assessed func­tioning, and patients’ scores on the perfor­mance-based measures.

Impaired introspective accuracy, as indexed by difference scores between cli­nician ratings and self-reports, was a more potent predictor of everyday functional deficits in social, vocational, and every­day activities domains than scores on performance-based measures of cognitive abilities and functional skills. Even when we analyzed only deficits in introspective accuracy for cognition as the predictor of everyday outcomes in these 3 real-world functional domains, the results were the same. Impaired introspective accuracy was the single best predictor of everyday func­tioning in all 3 domains, with actual abili­ties considerably less important.

Patient characteristics that predict introspective accuracy
Patient characteristics associated with impairments in introspective accuracy (Table 3)^19,20 are easy to identify and assess. Subjective reports of depression have a bell-shaped relationship with introspec­tive accuracy. A self-reported score of 0 by a disabled schizophrenia patient suggests some unawareness of an unfortunate life situation; mild to moderate scores are asso­ciated with more accurate self-assessment; and more severe scores, as seen in other conditions, often predict overestimation of disability.¹⁹

Tips to manage impairments in introspective accuracy
Ensure that assessment information is valid. If a patient has limited ability to self-assess, seek other sources of data. If a patient has psychotic symptoms, denies being depressed, or has limited life experi­ence, the clinician should adjust her (his) interpretation of the self-report accord­ingly, because these factors are known to adversely affect the accuracy of self-assessment. Consider informants’ level and quality of contact with the patient, as well as any motivation or bias that might influence the accuracy of their reports. Other professionals, such as occupational therapists, can provide useful information as reference points for treatment planning.

Consider treatments aimed at increasing introspective accuracy, such as structured training and exposure to self-assessment situations,⁶ and interventions aimed at increasing organization and skills perfor­mance. Cognitive remediation therapies, although not widely available, have poten­tial to improve functioning, with excellent persistence over time.²¹

Related Resources
• Harvey PD, ed. Cognitive impairment in schizophrenia: characteristics, assessment and treatment. Cambridge, United Kingdom: Cambridge University Press; 2013.
• Gould F, McGuire LS, Durand D, et al. Self-assessment in schizophrenia: accuracy of assessment of cognition and everyday functioning [published online February 2, 2015]. Neuropsychology.
• Dunning D. Self-insight: detours and roadblocks on the path to knowing thyself. New York, NY: Psychology Press; 2012.

Acknowledgment
This paper was supported by Grants MH078775 to Dr. Harvey and MH093432 to Drs. Harvey and Pinkham from the National Institute of Mental Health.

Disclosures
Dr. Harvey has received consulting fees from AbbVie, Boehringer Ingelheim, Forum Pharmaceuticals, Genentech, Otsuka America Pharmaceuticals, Roche, Sanofi, Sunovion Pharmaceuticals, and Takeda Pharmaceuticals. Dr. Pinkham has served as a consultant for Otsuka America Pharmaceuticals.

Lack of insight or “unawareness of illness” occurs within a set of self-assessment problems commonly seen in schizophrenia.¹ In the clinical domain, people who do not realize they are ill typically are unwilling to accept treatment, including medication, with potential for worsened illness. They also may have difficulty self-assess­ing everyday function and functional potential, cognition, social cognition, and attitude, often to a variable degree across these domains (Table 1).^1-3

Self-assessment of performance can be clinically help­ful whether performance is objectively good or bad. Those with poor performance could be helped to attempt to match their aspirations to accomplishments and improve over time. Good performers could have their functioning bolstered by recognizing their competence. Thus, even a population whose performance often is poor could ben­efit from accurate self-assessment or experience additional challenges from inaccurate self-evaluation.

This article discusses patient characteristics associated with impairments in self-assessment and the most accu­rate sources of information for clinicians about patient functioning. Our research shows that an experienced psy­chiatrist is well positioned to make accurate judgments of functional potential and cognitive abilities for people with schizophrenia.

Patterns in patients with impaired self-assessment
Healthy individuals routinely overestimate their abilities and their attractiveness to others.⁴ Feedback that deflates these exag­gerated estimates increases the accuracy of their self-assessments. Mildly depressed individuals typically are the most accurate judges of their true functioning; those with more severe levels of depression tend to underestimate their competence. Thus, sim­ply being an inaccurate self-assessor is not “abnormal.” These response biases are con­sistent and predictable in healthy people.

People with severe mental illness pose a different challenge. As in the following cases, their reports manifest minimal cor­relation with other sources of information, including objective information about performance.

CASE 1
JR, age 28, is referred for occupational therapy because he has never worked since graduat­ing from high school. He tells the therapist his cognitive abilities are average and intact, although his scores on a comprehensive cog­nitive assessment suggest performance at the first percentile of normal distribution or less. His self-reported Beck Depression Inventory (BDI) score is 4. He says he would like to work as a certified public accountant, because he believes he has an aptitude for math. He admits he has no idea what the job entails, but he is quite motivated to set up an interview as soon as possible.

CASE 2
LM, age 48, says his “best job” was managing an auto parts store for 18 months after he earned an associate’s degree and until his second psychotic episode. His most recent work was approximately 12 years ago at an oil-change facility. He agrees to discuss employment but feels his vocational skills are too deteriorated for him to succeed and requests an assessment for Alzheimer’s disease. His cognitive perfor­mance averages in the 10th percentile of the overall population, and his BDI score is 18. Tests of his ability to perform vocational skills sug­gest he is qualified for multiple jobs, including his previous technician position.

Individuals with schizophrenia who report no depression and no work history routinely overestimate their functional potential, whereas those with a history of unsuccessful vocational attempts often underestimate their functional potential. Inaccurate self-assessment can contrib­ute to reduced functioning—in JR’s case because of unrealistic assessment of the match between skills and vocational poten­tial, and in LM’s case because of overly  pessimistic self-evaluation. For people with schizophrenia, inability to self-evaluate can have a bidirectional adverse impact on func­tioning: overestimation may lead to trying tasks that are too challenging, and under­estimation may lead to reduced effort and motivation to take on functional tasks.

Metacognition and introspective accuracy
“Metacognition” refers to self-assessment of the quality and accuracy of performance on cognitive tests.^5-7 Problem-solving tests— such as the Wisconsin Card Sorting test (WCST), in which the person being assessed needs to solve the test through performance feedback—are metacognition tests. When errors are made, the strategy in use needs to be discarded; when responses are correct, the strategy is retained. People with schizo­phrenia have disproportionate difficulties with the WCST, and deficits are especially salient when the test is modified to measure self-assessment of performance and ability to use feedback to change strategies.

“Introspective accuracy” is used to describe the wide-ranging self-assessment impairments in severe mental illness. Theories of metacognition implicate a broad spectrum, of which self-assessment is 1 component, whereas introspective accuracy more specifically indicates judg­ments of accuracy. Because self-assessment is focused on the self, and hence is intro­spective, this conceptualization can be applied to self-evaluations of:
   • achievement in everyday functioning (“Did I complete that task well?”)
   • potential for achievement in everyday functioning (“I could do that job”)
   • cognitive performance (“Yes, I remembered all of those words”)
   • social cognition (“He really is angry”).

Domains of impaired introspective accuracy
Everyday functioning. The 3 global domains of everyday functioning are social outcomes, productive/vocational out­comes, and everyday activities, including residential independence/support for peo­ple with severe mental illness. Two areas of inquiry are used in self-assessing everyday functioning: (1) what are you doing now and (2) what could you do in the future? For people with schizophrenia, a related question is how perceived impairments in everyday functioning are associated with subjective illness burden.

People with schizophrenia report illness burden consistent with their self-reported disability, suggesting their reports in these domains are not random.⁸ Studies have consistently found, however, that these patients report:
   • less impairment on average in their everyday functioning than observed by clinicians
   • less subjective illness burden com­pared with individuals with much less severe illnesses.

Their reports also fail to correlate with cli­nicians’ observations.9 Patients with schizo­phrenia who have never been employed may report greater vocational potential than those employed full-time. Interestingly, patients who were previously—but not currently—employed reported the least vocational potential.¹⁰ These data suggest that experience may be a factor: individuals who have never worked have no context for their self-assessments, whereas people who are persistently unemployed may have a perspective on the challenges associated with employment.

In our research,⁹ high-contact clinicians (ie, case manager, psychiatrist, therapist, or residential facility manager) were bet­ter able than family or friends to generate ratings from an assessment questionnaire that correlated with performance-based measures of patients’ ability to perform everyday functional skills. The ratings were generated across multiple functional status scales, suggesting that the rater was more important than the specific scale. We concluded that high-contact clinicians can generate ratings of everyday functioning that are convergent with patients’ abilities, even when they have no information about actual performance scores.

Cognitive performance. When self-reported cognitive abilities are correlated with the results of performance on neuro­psychological assessments, the results are quite consistent. Patients provide reports that do not correlate with their objective performance.¹¹ Interestingly, when clini­cians were asked to use the same strategies as patients to generate ratings of cognitive impairment, clinician ratings had consider­ably greater evidence of validity. In several studies, patients’ ratings of their cognitive performance did not correlate with their neuropsychological test performance, even though they had just been tested on the assessment battery. Ratings by clinicians or other high-contact informants (who were unaware of patients’ test performance) were much more strongly related to patients’ objective test performance, compared with patient self-reports.¹²

The convergence of clinician ratings of cognitive performance with objective test data has been impressive. Correlation coef­ficients of at least r = 0.5, reflecting a moder­ate to large relationships between clinician ratings and objective performance, have been detected. Individual cognitive test domains, such as working memory and processing speed, often do not correlate with each other or with aspects of everyday functioning to that extent.¹³ These data sug­gest that a clinician assessment of cognitive performance, when focused on the correct aspects of cognitive functioning, can be a highly useful proxy for extensive neuropsy­chological testing.

Social cognitive performance. Introspective accuracy for social cognitive judg­ments can be assessed similarly to the strategies used to assess the domains of everyday functioning and cognitive perfor­mance. Patients are asked to complete a typi­cal social cognitive task, such as determining emotions from facial stimuli or examin­ing the eye region of the face, to determine the mental state of the depicted person. Immediately after responding to each stimu­lus, participants rate their confidence in the correctness of that response.

Consistent with the pattern of introspec­tive accuracy for everyday functioning, patients with schizophrenia tend to make more high-confidence errors than healthy individuals on social cognitive tasks. That is, the patients are less likely to realize when they are wrong in their judgments of social stimuli. A similar pattern has been found for mental state attribution,¹⁴ rec­ognition of facial emotion from the self,¹⁵ and recognition of facial emotion from others.¹⁶ These high-confidence errors also are more likely to occur for more difficult stimuli, such as faces that display only mildly emotional expressions. These dif­ficulties appear to be specific to judgments in an immediate evaluation situation. When asked to determine if the behavior of another individual is socially appropri­ate, individuals with schizophrenia are as able as healthy individuals to recognize social mistakes.¹⁷ This work suggests that, at least within the domain of social cogni­tion, introspective accuracy impairment is not caused by generalized poor judgment, just as self-assessments of disability and illness burden are generated at random.

Choosing a reliable informant
If a clinician has not had adequate time or exposure to a patient to make a cogni­tive or functional judgment, what should the strategy be? If asking the patient is uninformative, who should be asked? Our group has gathered information that may help clinicians identify informants who can provide ratings of cognitive perfor­mance and everyday functioning that are convergent with objective evidence.

In a systematic study of validity of reports of various informants, we com­pared correlations between reports of competence of everyday functioning with objective measures of cognitive test per­formance and ability to perform everyday functional skills. Our findings:
   • Patient reports of everyday function­ing were not correlated with performance-based measures for any of 6 rating scales.⁹
   • Clinician reports of everyday func­tioning were correlated with objective per­formance across 4 of 6 rating scales.
   • Correlations between ratings gener­ated by friend or relative informants and other information were almost shocking in their lack of validity (Table 2).⁹

We concluded that ratings generated by a generic informant—someone who simply knows the patient and is willing to provide ratings—are highly likely to be uninformative. If a friend or relative provides information of limited useful­ness, the report could easily lead to clinical decisions with high potential for bad out­comes. For example, attempts could fail to transition someone with impaired every­day living skills to independent living, or a patient whose potential is underesti­mated might not be offered opportunities to achieve attainable functional goals.

We found that the closer the rater was to a full caregiver role, the better and more accurate the information obtained. Caregivers who had regular contact with patients had much more valid rat­ings when performance on functionally relevant objective measures was consid­ered. Patients with caregivers had greater impairments in everyday outcomes, how­ever, suggesting that this subset was more impaired than the overall sample. For patients without caregivers, other sources of information—including careful obser­vation by high-contact clinicians—seem to be required to generate a valid assessment of functioning.

Direct functional implications of impaired introspective accuracy
Clinical effects of reduced awareness of ill­ness include reduced adherence to medi­cation, followed by relapse, disturbed behavior, leading to emergency room treat­ments or acute admissions, and—more rarely—disturbed behavior associated with violence or self-harm. Relapses such as these can adversely affect brain structure and function, with declines in cognitive functioning early in the illness.

Our recent study¹⁸ quantifies the direct impact of impairments in introspective accuracy on everyday functioning. We asked 214 individuals with schizophrenia to self-evaluate their cognitive ability with a systematic rating scale and to self-report their everyday functioning in social, voca­tional, and everyday activities domains. We used performance-based measures to assess their cognitive abilities and everyday functional skills. Concurrently, high-contact clinicians rated these same abilities with the same rating scales. We then predicted everyday functioning, as rated by the cli­nicians, with the discrepancies between self-assessed and clinician-assessed func­tioning, and patients’ scores on the perfor­mance-based measures.

Impaired introspective accuracy, as indexed by difference scores between cli­nician ratings and self-reports, was a more potent predictor of everyday functional deficits in social, vocational, and every­day activities domains than scores on performance-based measures of cognitive abilities and functional skills. Even when we analyzed only deficits in introspective accuracy for cognition as the predictor of everyday outcomes in these 3 real-world functional domains, the results were the same. Impaired introspective accuracy was the single best predictor of everyday func­tioning in all 3 domains, with actual abili­ties considerably less important.

Patient characteristics that predict introspective accuracy
Patient characteristics associated with impairments in introspective accuracy (Table 3)^19,20 are easy to identify and assess. Subjective reports of depression have a bell-shaped relationship with introspec­tive accuracy. A self-reported score of 0 by a disabled schizophrenia patient suggests some unawareness of an unfortunate life situation; mild to moderate scores are asso­ciated with more accurate self-assessment; and more severe scores, as seen in other conditions, often predict overestimation of disability.¹⁹

Tips to manage impairments in introspective accuracy
Ensure that assessment information is valid. If a patient has limited ability to self-assess, seek other sources of data. If a patient has psychotic symptoms, denies being depressed, or has limited life experi­ence, the clinician should adjust her (his) interpretation of the self-report accord­ingly, because these factors are known to adversely affect the accuracy of self-assessment. Consider informants’ level and quality of contact with the patient, as well as any motivation or bias that might influence the accuracy of their reports. Other professionals, such as occupational therapists, can provide useful information as reference points for treatment planning.

Consider treatments aimed at increasing introspective accuracy, such as structured training and exposure to self-assessment situations,⁶ and interventions aimed at increasing organization and skills perfor­mance. Cognitive remediation therapies, although not widely available, have poten­tial to improve functioning, with excellent persistence over time.²¹

Related Resources
• Harvey PD, ed. Cognitive impairment in schizophrenia: characteristics, assessment and treatment. Cambridge, United Kingdom: Cambridge University Press; 2013.
• Gould F, McGuire LS, Durand D, et al. Self-assessment in schizophrenia: accuracy of assessment of cognition and everyday functioning [published online February 2, 2015]. Neuropsychology.
• Dunning D. Self-insight: detours and roadblocks on the path to knowing thyself. New York, NY: Psychology Press; 2012.

Acknowledgment
This paper was supported by Grants MH078775 to Dr. Harvey and MH093432 to Drs. Harvey and Pinkham from the National Institute of Mental Health.

Disclosures
Dr. Harvey has received consulting fees from AbbVie, Boehringer Ingelheim, Forum Pharmaceuticals, Genentech, Otsuka America Pharmaceuticals, Roche, Sanofi, Sunovion Pharmaceuticals, and Takeda Pharmaceuticals. Dr. Pinkham has served as a consultant for Otsuka America Pharmaceuticals.

Lack of insight or “unawareness of illness” occurs within a set of self-assessment problems commonly seen in schizophrenia.¹ In the clinical domain, people who do not realize they are ill typically are unwilling to accept treatment, including medication, with potential for worsened illness. They also may have difficulty self-assess­ing everyday function and functional potential, cognition, social cognition, and attitude, often to a variable degree across these domains (Table 1).^1-3

Self-assessment of performance can be clinically help­ful whether performance is objectively good or bad. Those with poor performance could be helped to attempt to match their aspirations to accomplishments and improve over time. Good performers could have their functioning bolstered by recognizing their competence. Thus, even a population whose performance often is poor could ben­efit from accurate self-assessment or experience additional challenges from inaccurate self-evaluation.

This article discusses patient characteristics associated with impairments in self-assessment and the most accu­rate sources of information for clinicians about patient functioning. Our research shows that an experienced psy­chiatrist is well positioned to make accurate judgments of functional potential and cognitive abilities for people with schizophrenia.

Patterns in patients with impaired self-assessment
Healthy individuals routinely overestimate their abilities and their attractiveness to others.⁴ Feedback that deflates these exag­gerated estimates increases the accuracy of their self-assessments. Mildly depressed individuals typically are the most accurate judges of their true functioning; those with more severe levels of depression tend to underestimate their competence. Thus, sim­ply being an inaccurate self-assessor is not “abnormal.” These response biases are con­sistent and predictable in healthy people.

People with severe mental illness pose a different challenge. As in the following cases, their reports manifest minimal cor­relation with other sources of information, including objective information about performance.

CASE 1
JR, age 28, is referred for occupational therapy because he has never worked since graduat­ing from high school. He tells the therapist his cognitive abilities are average and intact, although his scores on a comprehensive cog­nitive assessment suggest performance at the first percentile of normal distribution or less. His self-reported Beck Depression Inventory (BDI) score is 4. He says he would like to work as a certified public accountant, because he believes he has an aptitude for math. He admits he has no idea what the job entails, but he is quite motivated to set up an interview as soon as possible.

CASE 2
LM, age 48, says his “best job” was managing an auto parts store for 18 months after he earned an associate’s degree and until his second psychotic episode. His most recent work was approximately 12 years ago at an oil-change facility. He agrees to discuss employment but feels his vocational skills are too deteriorated for him to succeed and requests an assessment for Alzheimer’s disease. His cognitive perfor­mance averages in the 10th percentile of the overall population, and his BDI score is 18. Tests of his ability to perform vocational skills sug­gest he is qualified for multiple jobs, including his previous technician position.

Individuals with schizophrenia who report no depression and no work history routinely overestimate their functional potential, whereas those with a history of unsuccessful vocational attempts often underestimate their functional potential. Inaccurate self-assessment can contrib­ute to reduced functioning—in JR’s case because of unrealistic assessment of the match between skills and vocational poten­tial, and in LM’s case because of overly  pessimistic self-evaluation. For people with schizophrenia, inability to self-evaluate can have a bidirectional adverse impact on func­tioning: overestimation may lead to trying tasks that are too challenging, and under­estimation may lead to reduced effort and motivation to take on functional tasks.

Metacognition and introspective accuracy
“Metacognition” refers to self-assessment of the quality and accuracy of performance on cognitive tests.^5-7 Problem-solving tests— such as the Wisconsin Card Sorting test (WCST), in which the person being assessed needs to solve the test through performance feedback—are metacognition tests. When errors are made, the strategy in use needs to be discarded; when responses are correct, the strategy is retained. People with schizo­phrenia have disproportionate difficulties with the WCST, and deficits are especially salient when the test is modified to measure self-assessment of performance and ability to use feedback to change strategies.

“Introspective accuracy” is used to describe the wide-ranging self-assessment impairments in severe mental illness. Theories of metacognition implicate a broad spectrum, of which self-assessment is 1 component, whereas introspective accuracy more specifically indicates judg­ments of accuracy. Because self-assessment is focused on the self, and hence is intro­spective, this conceptualization can be applied to self-evaluations of:
   • achievement in everyday functioning (“Did I complete that task well?”)
   • potential for achievement in everyday functioning (“I could do that job”)
   • cognitive performance (“Yes, I remembered all of those words”)
   • social cognition (“He really is angry”).

Domains of impaired introspective accuracy
Everyday functioning. The 3 global domains of everyday functioning are social outcomes, productive/vocational out­comes, and everyday activities, including residential independence/support for peo­ple with severe mental illness. Two areas of inquiry are used in self-assessing everyday functioning: (1) what are you doing now and (2) what could you do in the future? For people with schizophrenia, a related question is how perceived impairments in everyday functioning are associated with subjective illness burden.

People with schizophrenia report illness burden consistent with their self-reported disability, suggesting their reports in these domains are not random.⁸ Studies have consistently found, however, that these patients report:
   • less impairment on average in their everyday functioning than observed by clinicians
   • less subjective illness burden com­pared with individuals with much less severe illnesses.

Their reports also fail to correlate with cli­nicians’ observations.9 Patients with schizo­phrenia who have never been employed may report greater vocational potential than those employed full-time. Interestingly, patients who were previously—but not currently—employed reported the least vocational potential.¹⁰ These data suggest that experience may be a factor: individuals who have never worked have no context for their self-assessments, whereas people who are persistently unemployed may have a perspective on the challenges associated with employment.

In our research,⁹ high-contact clinicians (ie, case manager, psychiatrist, therapist, or residential facility manager) were bet­ter able than family or friends to generate ratings from an assessment questionnaire that correlated with performance-based measures of patients’ ability to perform everyday functional skills. The ratings were generated across multiple functional status scales, suggesting that the rater was more important than the specific scale. We concluded that high-contact clinicians can generate ratings of everyday functioning that are convergent with patients’ abilities, even when they have no information about actual performance scores.

Cognitive performance. When self-reported cognitive abilities are correlated with the results of performance on neuro­psychological assessments, the results are quite consistent. Patients provide reports that do not correlate with their objective performance.¹¹ Interestingly, when clini­cians were asked to use the same strategies as patients to generate ratings of cognitive impairment, clinician ratings had consider­ably greater evidence of validity. In several studies, patients’ ratings of their cognitive performance did not correlate with their neuropsychological test performance, even though they had just been tested on the assessment battery. Ratings by clinicians or other high-contact informants (who were unaware of patients’ test performance) were much more strongly related to patients’ objective test performance, compared with patient self-reports.¹²

The convergence of clinician ratings of cognitive performance with objective test data has been impressive. Correlation coef­ficients of at least r = 0.5, reflecting a moder­ate to large relationships between clinician ratings and objective performance, have been detected. Individual cognitive test domains, such as working memory and processing speed, often do not correlate with each other or with aspects of everyday functioning to that extent.¹³ These data sug­gest that a clinician assessment of cognitive performance, when focused on the correct aspects of cognitive functioning, can be a highly useful proxy for extensive neuropsy­chological testing.

Social cognitive performance. Introspective accuracy for social cognitive judg­ments can be assessed similarly to the strategies used to assess the domains of everyday functioning and cognitive perfor­mance. Patients are asked to complete a typi­cal social cognitive task, such as determining emotions from facial stimuli or examin­ing the eye region of the face, to determine the mental state of the depicted person. Immediately after responding to each stimu­lus, participants rate their confidence in the correctness of that response.

Consistent with the pattern of introspec­tive accuracy for everyday functioning, patients with schizophrenia tend to make more high-confidence errors than healthy individuals on social cognitive tasks. That is, the patients are less likely to realize when they are wrong in their judgments of social stimuli. A similar pattern has been found for mental state attribution,¹⁴ rec­ognition of facial emotion from the self,¹⁵ and recognition of facial emotion from others.¹⁶ These high-confidence errors also are more likely to occur for more difficult stimuli, such as faces that display only mildly emotional expressions. These dif­ficulties appear to be specific to judgments in an immediate evaluation situation. When asked to determine if the behavior of another individual is socially appropri­ate, individuals with schizophrenia are as able as healthy individuals to recognize social mistakes.¹⁷ This work suggests that, at least within the domain of social cogni­tion, introspective accuracy impairment is not caused by generalized poor judgment, just as self-assessments of disability and illness burden are generated at random.

Choosing a reliable informant
If a clinician has not had adequate time or exposure to a patient to make a cogni­tive or functional judgment, what should the strategy be? If asking the patient is uninformative, who should be asked? Our group has gathered information that may help clinicians identify informants who can provide ratings of cognitive perfor­mance and everyday functioning that are convergent with objective evidence.

In a systematic study of validity of reports of various informants, we com­pared correlations between reports of competence of everyday functioning with objective measures of cognitive test per­formance and ability to perform everyday functional skills. Our findings:
   • Patient reports of everyday function­ing were not correlated with performance-based measures for any of 6 rating scales.⁹
   • Clinician reports of everyday func­tioning were correlated with objective per­formance across 4 of 6 rating scales.
   • Correlations between ratings gener­ated by friend or relative informants and other information were almost shocking in their lack of validity (Table 2).⁹

We concluded that ratings generated by a generic informant—someone who simply knows the patient and is willing to provide ratings—are highly likely to be uninformative. If a friend or relative provides information of limited useful­ness, the report could easily lead to clinical decisions with high potential for bad out­comes. For example, attempts could fail to transition someone with impaired every­day living skills to independent living, or a patient whose potential is underesti­mated might not be offered opportunities to achieve attainable functional goals.

We found that the closer the rater was to a full caregiver role, the better and more accurate the information obtained. Caregivers who had regular contact with patients had much more valid rat­ings when performance on functionally relevant objective measures was consid­ered. Patients with caregivers had greater impairments in everyday outcomes, how­ever, suggesting that this subset was more impaired than the overall sample. For patients without caregivers, other sources of information—including careful obser­vation by high-contact clinicians—seem to be required to generate a valid assessment of functioning.

Direct functional implications of impaired introspective accuracy
Clinical effects of reduced awareness of ill­ness include reduced adherence to medi­cation, followed by relapse, disturbed behavior, leading to emergency room treat­ments or acute admissions, and—more rarely—disturbed behavior associated with violence or self-harm. Relapses such as these can adversely affect brain structure and function, with declines in cognitive functioning early in the illness.

Our recent study¹⁸ quantifies the direct impact of impairments in introspective accuracy on everyday functioning. We asked 214 individuals with schizophrenia to self-evaluate their cognitive ability with a systematic rating scale and to self-report their everyday functioning in social, voca­tional, and everyday activities domains. We used performance-based measures to assess their cognitive abilities and everyday functional skills. Concurrently, high-contact clinicians rated these same abilities with the same rating scales. We then predicted everyday functioning, as rated by the cli­nicians, with the discrepancies between self-assessed and clinician-assessed func­tioning, and patients’ scores on the perfor­mance-based measures.

Impaired introspective accuracy, as indexed by difference scores between cli­nician ratings and self-reports, was a more potent predictor of everyday functional deficits in social, vocational, and every­day activities domains than scores on performance-based measures of cognitive abilities and functional skills. Even when we analyzed only deficits in introspective accuracy for cognition as the predictor of everyday outcomes in these 3 real-world functional domains, the results were the same. Impaired introspective accuracy was the single best predictor of everyday func­tioning in all 3 domains, with actual abili­ties considerably less important.

Patient characteristics that predict introspective accuracy
Patient characteristics associated with impairments in introspective accuracy (Table 3)^19,20 are easy to identify and assess. Subjective reports of depression have a bell-shaped relationship with introspec­tive accuracy. A self-reported score of 0 by a disabled schizophrenia patient suggests some unawareness of an unfortunate life situation; mild to moderate scores are asso­ciated with more accurate self-assessment; and more severe scores, as seen in other conditions, often predict overestimation of disability.¹⁹

Tips to manage impairments in introspective accuracy
Ensure that assessment information is valid. If a patient has limited ability to self-assess, seek other sources of data. If a patient has psychotic symptoms, denies being depressed, or has limited life experi­ence, the clinician should adjust her (his) interpretation of the self-report accord­ingly, because these factors are known to adversely affect the accuracy of self-assessment. Consider informants’ level and quality of contact with the patient, as well as any motivation or bias that might influence the accuracy of their reports. Other professionals, such as occupational therapists, can provide useful information as reference points for treatment planning.

Consider treatments aimed at increasing introspective accuracy, such as structured training and exposure to self-assessment situations,⁶ and interventions aimed at increasing organization and skills perfor­mance. Cognitive remediation therapies, although not widely available, have poten­tial to improve functioning, with excellent persistence over time.²¹

Related Resources
• Harvey PD, ed. Cognitive impairment in schizophrenia: characteristics, assessment and treatment. Cambridge, United Kingdom: Cambridge University Press; 2013.
• Gould F, McGuire LS, Durand D, et al. Self-assessment in schizophrenia: accuracy of assessment of cognition and everyday functioning [published online February 2, 2015]. Neuropsychology.
• Dunning D. Self-insight: detours and roadblocks on the path to knowing thyself. New York, NY: Psychology Press; 2012.

Acknowledgment
This paper was supported by Grants MH078775 to Dr. Harvey and MH093432 to Drs. Harvey and Pinkham from the National Institute of Mental Health.

Disclosures
Dr. Harvey has received consulting fees from AbbVie, Boehringer Ingelheim, Forum Pharmaceuticals, Genentech, Otsuka America Pharmaceuticals, Roche, Sanofi, Sunovion Pharmaceuticals, and Takeda Pharmaceuticals. Dr. Pinkham has served as a consultant for Otsuka America Pharmaceuticals.

Substances use during adolescence is common in the United States. Data from the 2014 Monitoring the Future Survey estimated that among 12th graders, 60.2% used alcohol, 35.1% used mari­juana, and 13.9% used a prescription drug for nonmedical use within the previous year.¹ An estimated 11.4% of adolescents meet DSM-IV threshold criteria for a substance use disorder (SUD).² Substance use in adolescents often co-occurs with psychological distress and psychi­atric illness. Adolescents with a psychiatric disorder are at increased risk for developing a SUD; conversely, high rates of psychiatric illness are seen in adolescents with a SUD.^3,4 In one study, 82% of adolescents hospitalized for SUD treatment were found to have a co-occurring axis I disorder.⁵ Furthermore, co-occurring psychiatric illness and SUD complicates treatment course and prognosis. Adolescents with co-occurring psychiatric illness and SUD often benefit from an inte­grated, multimodal treatment approach that includes psychotherapy, pharmacologic interventions, family involvement, and collaboration with community supports.

In this article, we focus on pharmacologic management of non-nicotinic SUDs in adolescents, with an emphasis on those with comor­bid psychiatric illness.

Screening and assessment of substance use
It is important to counsel children with a psychiatric illness and their parents about the increased risk for SUD before a patient transitions to adolescence. Discussions about substance abuse should begin during the 5th grade because data suggests that adolescent sub­stance use often starts in middle school (6th to 9th grade). Clinicians should routinely screen adolescent patients for substance use. Nonproprietary screening tools available through the National Institute on Alcohol and Alcoholism and the National Institute on Drug Abuse are listed in Table 1.^6-8 The Screening to Brief Intervention (S2BI) is a newer tool that has been shown to be highly effective in identifying adolescents at risk for substance abuse and differentiating severity of illness.⁸ The S2BI includes screening ques­tions that assess for use of 8 substances in the past year.

Adolescents with psychiatric illness who are identified to be at risk for problems asso­ciated with substance use should be evalu­ated further for the presence or absence of a SUD. The number of criteria a patient endorses over the past year (Table 2⁹) is used to assess SUD severity—mild, moderate, or severe. Additional considerations include substance use patterns such as type, site, quantity, frequency, context, and combina­tions of substances.

It is important to be curious and non­judgmental when evaluating substance use patterns with adolescents to obtain a com­prehensive assessment. Teenagers often are creative and inventive in their efforts to maximize intoxication, which can put them at risk for complications associated with acute intoxication. Rapidly evolving meth­ods of ingesting highly concentrated forms of tetrahydrocannabinol (“wax,” “dabs”) are an example of use patterns that are ahead of what is reported in the literature.

Any substance use in an adolescent with a psychiatric illness is of concern and should be monitored closely because of the potential impact of substance use on the co-occurring psychiatric illness and pos­sible interactions between the abused sub­stance and prescribed medication.

Treatment interventions
Although this review will focus on phar­macotherapy, individual, group, and fam­ily psychotherapies are a critical part of a treatment plan for adolescents with comor­bid psychiatric illness and SUD (Table 3). Collaboration with community supports, including school and legal offi­cials, can help reinforce contingencies and assist with connecting a teen with posi­tive prosocial activities. Involvement with mutual help organizations, such as Alcoholics Anonymous, can facilitate adolescent engagement with a positive sober network.¹⁰

Medication to decrease substance use and promote abstinence. One strategy is to target cravings and urges to use sub­stances with medication. Naltrexone is an opiate antagonist FDA-approved for treating alcohol and opioid use disorders in adults and is available as a daily oral medication and a monthly injectable depot preparation (extended-release naltrexone). Two small open-label studies showed decreased alcohol use with naltrexone treatment in adolescents with alcohol use disorder.^11,12 In a randomized double-blind placebo controlled (RCT) crossover study of 22 adolescent problem drinkers, nal­trexone, 50 mg/d, reduced the likelihood of drinking and heavy drinking (P ≤ .03).¹³ Acamprosate, another anti-craving medi­cation FDA-approved for treating alcohol use disorder in adults, has no data on the safety or efficacy for adolescent alcohol use disorder.

There is limited research on agents that decrease use and promote abstinence from non-nicotinic substances other than alco­hol. There is one pilot RCT that evaluated N-acetylcysteine (NAC)—an over-the-counter supplement that modulates the glutamate system—for treating adoles­cent Cannabis dependence. Treatment with NAC, 2,400 mg/d, was well tolerated and had twice the odds of increasing negative urine cannabinoid tests during treatment than placebo.¹⁴ Although NAC treatment was associated with decreased Cannabis use, it did not significantly decrease crav­ings compared with placebo.¹⁵

Medication to alleviate withdrawal symptoms. Some patients may find the physical discomfort and psychological dis­tress associated with substance withdrawal so intolerable that to avoid it they continue to use drugs or alcohol. Medication to treat withdrawal symptoms and agonist treat­ments can be used to alleviate discomfort and distress associated with withdrawal. Agonist treatments, such as methadone and buprenorphine, bind to the same receptors as the target substance, which allows the patient to shift to controlled use of a prescribed substitute. Agonist treatments are used for short detoxifi­cation and over longer periods of time for maintenance treatment. Methadone, which decreases craving and withdrawal symptoms from opiates by binding to the μ-opiate receptor and blocking other sub­stances from binding, is frequently used for detoxification and maintenance treat­ment in adults. There is limited data on methadone substitution therapy for adolescents in the United States.¹⁶ Methadone maintenance for adolescents in the United States is restricted to severe cases of opioid use disorder. Federal guidelines specify that adolescents age <18 can only receive methadone if they have had 2 unsuccess­ful detoxification attempts or outpatient psychosocial treatments and have met DSM criteria for an opioid use disorder for 1 year.¹⁷

Buprenorphine is a partial μ-opiate receptor agonist that is FDA-approved for use in adolescents age ≥16 with opioid dependence. Although a waiver from the U.S. Drug Enforcement Administration is required to prescribe buprenorphine, it generally can be administered in outpa­tient settings with relative ease compared with methadone.

Marsch et al¹⁸ examined the efficacy of buprenorphine compared with clonidine for detoxification over 1 month in 36 ado­lescents with opioid dependence. Clonidine is an α-2 adrenergic agonist that often is used during detoxification from opioids.¹⁹ Although both buprenorphine and cloni­dine relieved withdrawal symptoms, a significantly higher percentage of patients receiving buprenorphine completed treat­ment (72%) compared with those taking clonidine (39%) (P < .05).¹⁸ Detoxification with buprenorphine also was associated with a higher percentage of negative urine drug screens (64% vs 32%, P = .01), and those receiving buprenorphine were more likely to continue on naltrexone mainte­nance for continued medication-assisted treatment after detoxification compared with those randomized to clonidine.

Woody et al²⁰ compared use of buprenor­phine/naloxone for opioid detoxification vs short-term maintenance. Patients age 16 to 21 were randomized to detoxification over 2 weeks vs stabilization and maintenance for 9 weeks and taper over 3 weeks. Maintenance treatment with buprenorphine/naloxone was associated with less opioid use, less injection drug use, and less need for addic­tion treatment outside of that received through the study compared with detoxifica­tion treatment. When buprenorphine/nalox­one was discontinued both the detoxification and maintenance groups had high rates of positive urine toxicology screens at 1-year follow up (mean 48% to 72%). These data suggests maintenance with buprenorphine/ naloxone for adolescents and young adults is more effective than short-term detoxifi­cation for stabilizing opioid use disorders, although optimal treatment duration is unclear. Clinically, it is important to continue buprenorphine/naloxone maintenance until the patient has stabilized in recovery and has acquired coping skills to manage urges, crav­ings, and psychological distress (eg, anger, stress) that often arise during a slow taper of agonist treatment.

Antagonist treatment to block the effect of substance use
As an opioid receptor antagonist, naltrex­one is effective for treating opioid use dis­order because it blocks the action of opioids. Fishman et al²¹ published a descriptive series of 16 adolescents and young adults followed over 4 months who received the injectable depot preparation (extended-release) nal­trexone while in residential treatment, and then discharged to outpatient care. Most patients who received extended-release nal­trexone remained in outpatient treatment (63%) and reduced their opioid use or were abstinent at 4 months (56%). One barrier to naltrexone treatment is the need to be absti­nent from opioids for 7 to 10 days to prevent precipitated opioid withdrawal. Therefore, naltrexone is a good option for adolescents who present for treatment early and are not physiologically dependent on opioids or are receiving treatment in a structured environ­ment after detoxification, such as residential treatment or sober living.

Aversive agents to diminish substance use. Aversive agents produce an unpleas­ant reaction when a target substance is consumed. Disulfiram is prototypic aver­sive agent that prevents the breakdown of acetaldehyde, a toxic metabolite of alcohol. Patients who drink alcohol while taking disulfiram may experience adverse effects, including tachycardia, shortness of breath, nausea, dizziness, and confusion. There have been 2 studies examining the efficacy of disulfiram in adolescents with alcohol use disorder. Niederhofer et al²² found that disulfiram treatment significantly increased cumulative abstinence in a small RCT (P = .012). In another small randomized, open-label, 3-month study of adolescents who received disulfiram or naltrexone in addition to weekly psychotherapy, disul­firam was superior to naltrexone in mean days abstinent from alcohol, 84 days vs 51 days, respectively (P = .0001).²³ Often adolescents are not willing to adhere to disulfiram because they are concerned about the aversive reaction when combined with alcohol use. Consider prescribing disulfiram for adolescents who are about to go “on pass” from a therapeutic school or residen­tial SUD treatment center and will be return­ing to an environment where they may be tempted to use alcohol.

Pharmacotherapy to treat co-occurring psychiatric illness
Continued treatment of a psychiatric illness that co-occurs with SUD is important. As we recommended, consider psychosocial treatments for both the SUD and comorbid psychopathology. Several single-site RCTs have evaluated the efficacy of the selective serotonin reuptake inhibitors (SSRIs) fluox­etine and sertraline for depressive disorders in adolescents with a co-occurring SUD.^24-28 Most studies have shown improvement in depressive symptoms and substance use in medication and placebo groups.^24,25,27,28 However, treatment with fluoxetine, 20 mg/d, or sertraline, 100 mg/d, when compared with placebo was associated with improved depressive symptoms in 1 of 3 studies and had no significant differ­ence in SUD outcome. The authors of these studies believe that the general improve­ment in depression and the SUD was related to use of cognitive-behavioral ther­apy (CBT) and/or motivational enhance­ment therapy.^24,25,27,28

Research on the use of mood stabilizers for adolescents with mood dysregulation and a SUD is limited but has suggested benefit associated with pharmacotherapy (Table 4).^29-32 Two RCTs and 1 open-label study demonstrated reductions in sub­stance use with mood stabilizer treatment in adolescents with co-occurring SUD and mood dysregulation.^29-32 The effect of phar­macotherapy on mood dysregulation rat­ings are less clear because there was no change in severity of affective symptoms observed in a small RCT of lithium (average blood level 0.9 mEq/L)²⁹; and improvement in affective symptoms was noted in topira­mate (300 mg/d) and placebo groups when both groups were treated with concurrent quetiapine.³² Because of the high risk of SUD and severe morbidity in juvenile bipo­lar disorder and severe mood dysregula­tion,³³ larger RCTs are warranted.

Although conduct disorder and anxiety disorders commonly co-occur with SUD, there has been less research evaluating the impact of pharmacotherapy on treating these disorders. Riggs et al^25,34,35,41 evaluated the impact of pharmacotherapy targeted to co-occurring ADHD and major depressive disorder in the context of conduct disorder and SUD. When evaluated in an outpatient setting, the presence of a treatment inter­vention to address the co-occurring SUD was an important component that led to a reduction in conduct symptoms.^25,35 There have been no comprehensive studies on the impact of pharmacotherapy for treat­ing anxiety and SUD in adolescents.

Recommendations for clinical management
Although more research is needed to evaluate the role of pharmacotherapy for adolescents with co-occurring psychiatric illness and a SUD, recommended practice is to continue pharmacotherapy and closely monitor response to treatment when at-risk substance use begins in patients with co-occurring psychiatric illness. In ado­lescents with a threshold SUD, continue pharmacotherapy for unstable mood dis­orders with first-line choices of SSRIs for unipolar depression and second-generation antipsychotics for bipolar spectrum illness. Suggested conservative pharmacological interventions for anxiety disorders include SSRIs and buspirone, which have been shown to be effective for treating anxiety in children and adolescents.^42,43 For patients with comorbid ADHD and SUD, if pos­sible, it is recommended to first stabilize substance use (low-level use or abstinence) and consider treating ADHD immediately thereafter with a nonstimulant such as ato­moxetine, which has data on efficacy and safety in context to substance use; and/or an α-agonist or an extended-release stimu­lant. Because of the potential for misuse and toxicity associated with concurrent substance use, benzodiazepines should be considered a last treatment of choice for adolescents with anxiety disorders and a SUD. Similarly, the use of immediate-release stimulants should be avoided in patients with ADHD and a SUD. When pre­scribing medications that could be misused or toxic when combined with a substance, it is important to evaluate the risk and benefit of continued use of a particular medication and consider prescribing lower quantities to decrease risk for misuse (1- to 2-week supply). Adolescents often are reluctant to engage in SUD treatment and one strat­egy to consider is to make continued pre­scription of any medication contingent on engaging in SUD treatment. Enlist parents in helping to monitor, store, and administer their child’s medication to improve adher­ence and decrease the potential for misuse, diversion, and complications associated with substance intoxication.

Bottom Line
It is important to screen for substance use in adolescents with co-occurring
psychiatric illness and vice versa. When at-risk or hazardous substance use is
detected there are effective psychosocial and pharmacologic interventions that
can be used to treat adolescent substance use disorders alone and in combination
with certain psychiatric disorders.

Related Resources
• National Institute on Drug Abuse. www.drugabuse.gov.
• National Institute on Alcohol Abuse and Alcoholism. www.niaaa.nih.gov.
• Substance Abuse and Mental Health Services Administration. www.samhsa.gov.

Drug Brand Names
Acamprosate • Campral
Atomoxetine • Strattera
Buprenorphine• Subutex
Buprenorphine/naloxone • Suboxone
Buspirone • Buspar
Clonidine • Catapres
Disulfiram • Antabuse
Fluoxetine • Prozac
Lithium • Lithobid, Eskalith
Methadone • Dolophine
Naltrexone • ReVia, Vivitrol
Osmotic (extended) release methylphenidate • Concerta
Sertraline • Zoloft
Topiramate • Topamax
Quetiapine • Seroquel
Valproic acid • Depakote

Disclosures
Dr. Yule received grant support from the 2012 American Academy of Child and Adolescent Psychiatry Pilot Research Award for Junior Faculty supported by Lilly USA, LLC, and receives grant support from the 2014 Louis V. Gerstner III Research Scholar Award. Dr. Wilens has received grant support from the National Institute on Drug Abuse (NIDA); has been a consultant for Euthymics/Neurovance, NIDA, Ironshore Pharmaceuticals and Development, Theravance Biopharma, Tris Pharma, the U.S. National Football League (ERM Associates), U.S. Minor/Major League Baseball, and Bay Cove Human Services (Clinical Services).

Substances use during adolescence is common in the United States. Data from the 2014 Monitoring the Future Survey estimated that among 12th graders, 60.2% used alcohol, 35.1% used mari­juana, and 13.9% used a prescription drug for nonmedical use within the previous year.¹ An estimated 11.4% of adolescents meet DSM-IV threshold criteria for a substance use disorder (SUD).² Substance use in adolescents often co-occurs with psychological distress and psychi­atric illness. Adolescents with a psychiatric disorder are at increased risk for developing a SUD; conversely, high rates of psychiatric illness are seen in adolescents with a SUD.^3,4 In one study, 82% of adolescents hospitalized for SUD treatment were found to have a co-occurring axis I disorder.⁵ Furthermore, co-occurring psychiatric illness and SUD complicates treatment course and prognosis. Adolescents with co-occurring psychiatric illness and SUD often benefit from an inte­grated, multimodal treatment approach that includes psychotherapy, pharmacologic interventions, family involvement, and collaboration with community supports.

In this article, we focus on pharmacologic management of non-nicotinic SUDs in adolescents, with an emphasis on those with comor­bid psychiatric illness.

Screening and assessment of substance use
It is important to counsel children with a psychiatric illness and their parents about the increased risk for SUD before a patient transitions to adolescence. Discussions about substance abuse should begin during the 5th grade because data suggests that adolescent sub­stance use often starts in middle school (6th to 9th grade). Clinicians should routinely screen adolescent patients for substance use. Nonproprietary screening tools available through the National Institute on Alcohol and Alcoholism and the National Institute on Drug Abuse are listed in Table 1.^6-8 The Screening to Brief Intervention (S2BI) is a newer tool that has been shown to be highly effective in identifying adolescents at risk for substance abuse and differentiating severity of illness.⁸ The S2BI includes screening ques­tions that assess for use of 8 substances in the past year.

Adolescents with psychiatric illness who are identified to be at risk for problems asso­ciated with substance use should be evalu­ated further for the presence or absence of a SUD. The number of criteria a patient endorses over the past year (Table 2⁹) is used to assess SUD severity—mild, moderate, or severe. Additional considerations include substance use patterns such as type, site, quantity, frequency, context, and combina­tions of substances.

It is important to be curious and non­judgmental when evaluating substance use patterns with adolescents to obtain a com­prehensive assessment. Teenagers often are creative and inventive in their efforts to maximize intoxication, which can put them at risk for complications associated with acute intoxication. Rapidly evolving meth­ods of ingesting highly concentrated forms of tetrahydrocannabinol (“wax,” “dabs”) are an example of use patterns that are ahead of what is reported in the literature.

Any substance use in an adolescent with a psychiatric illness is of concern and should be monitored closely because of the potential impact of substance use on the co-occurring psychiatric illness and pos­sible interactions between the abused sub­stance and prescribed medication.

Treatment interventions
Although this review will focus on phar­macotherapy, individual, group, and fam­ily psychotherapies are a critical part of a treatment plan for adolescents with comor­bid psychiatric illness and SUD (Table 3). Collaboration with community supports, including school and legal offi­cials, can help reinforce contingencies and assist with connecting a teen with posi­tive prosocial activities. Involvement with mutual help organizations, such as Alcoholics Anonymous, can facilitate adolescent engagement with a positive sober network.¹⁰

Medication to decrease substance use and promote abstinence. One strategy is to target cravings and urges to use sub­stances with medication. Naltrexone is an opiate antagonist FDA-approved for treating alcohol and opioid use disorders in adults and is available as a daily oral medication and a monthly injectable depot preparation (extended-release naltrexone). Two small open-label studies showed decreased alcohol use with naltrexone treatment in adolescents with alcohol use disorder.^11,12 In a randomized double-blind placebo controlled (RCT) crossover study of 22 adolescent problem drinkers, nal­trexone, 50 mg/d, reduced the likelihood of drinking and heavy drinking (P ≤ .03).¹³ Acamprosate, another anti-craving medi­cation FDA-approved for treating alcohol use disorder in adults, has no data on the safety or efficacy for adolescent alcohol use disorder.

There is limited research on agents that decrease use and promote abstinence from non-nicotinic substances other than alco­hol. There is one pilot RCT that evaluated N-acetylcysteine (NAC)—an over-the-counter supplement that modulates the glutamate system—for treating adoles­cent Cannabis dependence. Treatment with NAC, 2,400 mg/d, was well tolerated and had twice the odds of increasing negative urine cannabinoid tests during treatment than placebo.¹⁴ Although NAC treatment was associated with decreased Cannabis use, it did not significantly decrease crav­ings compared with placebo.¹⁵

Medication to alleviate withdrawal symptoms. Some patients may find the physical discomfort and psychological dis­tress associated with substance withdrawal so intolerable that to avoid it they continue to use drugs or alcohol. Medication to treat withdrawal symptoms and agonist treat­ments can be used to alleviate discomfort and distress associated with withdrawal. Agonist treatments, such as methadone and buprenorphine, bind to the same receptors as the target substance, which allows the patient to shift to controlled use of a prescribed substitute. Agonist treatments are used for short detoxifi­cation and over longer periods of time for maintenance treatment. Methadone, which decreases craving and withdrawal symptoms from opiates by binding to the μ-opiate receptor and blocking other sub­stances from binding, is frequently used for detoxification and maintenance treat­ment in adults. There is limited data on methadone substitution therapy for adolescents in the United States.¹⁶ Methadone maintenance for adolescents in the United States is restricted to severe cases of opioid use disorder. Federal guidelines specify that adolescents age <18 can only receive methadone if they have had 2 unsuccess­ful detoxification attempts or outpatient psychosocial treatments and have met DSM criteria for an opioid use disorder for 1 year.¹⁷

Buprenorphine is a partial μ-opiate receptor agonist that is FDA-approved for use in adolescents age ≥16 with opioid dependence. Although a waiver from the U.S. Drug Enforcement Administration is required to prescribe buprenorphine, it generally can be administered in outpa­tient settings with relative ease compared with methadone.

Marsch et al¹⁸ examined the efficacy of buprenorphine compared with clonidine for detoxification over 1 month in 36 ado­lescents with opioid dependence. Clonidine is an α-2 adrenergic agonist that often is used during detoxification from opioids.¹⁹ Although both buprenorphine and cloni­dine relieved withdrawal symptoms, a significantly higher percentage of patients receiving buprenorphine completed treat­ment (72%) compared with those taking clonidine (39%) (P < .05).¹⁸ Detoxification with buprenorphine also was associated with a higher percentage of negative urine drug screens (64% vs 32%, P = .01), and those receiving buprenorphine were more likely to continue on naltrexone mainte­nance for continued medication-assisted treatment after detoxification compared with those randomized to clonidine.

Woody et al²⁰ compared use of buprenor­phine/naloxone for opioid detoxification vs short-term maintenance. Patients age 16 to 21 were randomized to detoxification over 2 weeks vs stabilization and maintenance for 9 weeks and taper over 3 weeks. Maintenance treatment with buprenorphine/naloxone was associated with less opioid use, less injection drug use, and less need for addic­tion treatment outside of that received through the study compared with detoxifica­tion treatment. When buprenorphine/nalox­one was discontinued both the detoxification and maintenance groups had high rates of positive urine toxicology screens at 1-year follow up (mean 48% to 72%). These data suggests maintenance with buprenorphine/ naloxone for adolescents and young adults is more effective than short-term detoxifi­cation for stabilizing opioid use disorders, although optimal treatment duration is unclear. Clinically, it is important to continue buprenorphine/naloxone maintenance until the patient has stabilized in recovery and has acquired coping skills to manage urges, crav­ings, and psychological distress (eg, anger, stress) that often arise during a slow taper of agonist treatment.

Antagonist treatment to block the effect of substance use
As an opioid receptor antagonist, naltrex­one is effective for treating opioid use dis­order because it blocks the action of opioids. Fishman et al²¹ published a descriptive series of 16 adolescents and young adults followed over 4 months who received the injectable depot preparation (extended-release) nal­trexone while in residential treatment, and then discharged to outpatient care. Most patients who received extended-release nal­trexone remained in outpatient treatment (63%) and reduced their opioid use or were abstinent at 4 months (56%). One barrier to naltrexone treatment is the need to be absti­nent from opioids for 7 to 10 days to prevent precipitated opioid withdrawal. Therefore, naltrexone is a good option for adolescents who present for treatment early and are not physiologically dependent on opioids or are receiving treatment in a structured environ­ment after detoxification, such as residential treatment or sober living.

Aversive agents to diminish substance use. Aversive agents produce an unpleas­ant reaction when a target substance is consumed. Disulfiram is prototypic aver­sive agent that prevents the breakdown of acetaldehyde, a toxic metabolite of alcohol. Patients who drink alcohol while taking disulfiram may experience adverse effects, including tachycardia, shortness of breath, nausea, dizziness, and confusion. There have been 2 studies examining the efficacy of disulfiram in adolescents with alcohol use disorder. Niederhofer et al²² found that disulfiram treatment significantly increased cumulative abstinence in a small RCT (P = .012). In another small randomized, open-label, 3-month study of adolescents who received disulfiram or naltrexone in addition to weekly psychotherapy, disul­firam was superior to naltrexone in mean days abstinent from alcohol, 84 days vs 51 days, respectively (P = .0001).²³ Often adolescents are not willing to adhere to disulfiram because they are concerned about the aversive reaction when combined with alcohol use. Consider prescribing disulfiram for adolescents who are about to go “on pass” from a therapeutic school or residen­tial SUD treatment center and will be return­ing to an environment where they may be tempted to use alcohol.

Pharmacotherapy to treat co-occurring psychiatric illness
Continued treatment of a psychiatric illness that co-occurs with SUD is important. As we recommended, consider psychosocial treatments for both the SUD and comorbid psychopathology. Several single-site RCTs have evaluated the efficacy of the selective serotonin reuptake inhibitors (SSRIs) fluox­etine and sertraline for depressive disorders in adolescents with a co-occurring SUD.^24-28 Most studies have shown improvement in depressive symptoms and substance use in medication and placebo groups.^24,25,27,28 However, treatment with fluoxetine, 20 mg/d, or sertraline, 100 mg/d, when compared with placebo was associated with improved depressive symptoms in 1 of 3 studies and had no significant differ­ence in SUD outcome. The authors of these studies believe that the general improve­ment in depression and the SUD was related to use of cognitive-behavioral ther­apy (CBT) and/or motivational enhance­ment therapy.^24,25,27,28

Research on the use of mood stabilizers for adolescents with mood dysregulation and a SUD is limited but has suggested benefit associated with pharmacotherapy (Table 4).^29-32 Two RCTs and 1 open-label study demonstrated reductions in sub­stance use with mood stabilizer treatment in adolescents with co-occurring SUD and mood dysregulation.^29-32 The effect of phar­macotherapy on mood dysregulation rat­ings are less clear because there was no change in severity of affective symptoms observed in a small RCT of lithium (average blood level 0.9 mEq/L)²⁹; and improvement in affective symptoms was noted in topira­mate (300 mg/d) and placebo groups when both groups were treated with concurrent quetiapine.³² Because of the high risk of SUD and severe morbidity in juvenile bipo­lar disorder and severe mood dysregula­tion,³³ larger RCTs are warranted.

Although conduct disorder and anxiety disorders commonly co-occur with SUD, there has been less research evaluating the impact of pharmacotherapy on treating these disorders. Riggs et al^25,34,35,41 evaluated the impact of pharmacotherapy targeted to co-occurring ADHD and major depressive disorder in the context of conduct disorder and SUD. When evaluated in an outpatient setting, the presence of a treatment inter­vention to address the co-occurring SUD was an important component that led to a reduction in conduct symptoms.^25,35 There have been no comprehensive studies on the impact of pharmacotherapy for treat­ing anxiety and SUD in adolescents.

Recommendations for clinical management
Although more research is needed to evaluate the role of pharmacotherapy for adolescents with co-occurring psychiatric illness and a SUD, recommended practice is to continue pharmacotherapy and closely monitor response to treatment when at-risk substance use begins in patients with co-occurring psychiatric illness. In ado­lescents with a threshold SUD, continue pharmacotherapy for unstable mood dis­orders with first-line choices of SSRIs for unipolar depression and second-generation antipsychotics for bipolar spectrum illness. Suggested conservative pharmacological interventions for anxiety disorders include SSRIs and buspirone, which have been shown to be effective for treating anxiety in children and adolescents.^42,43 For patients with comorbid ADHD and SUD, if pos­sible, it is recommended to first stabilize substance use (low-level use or abstinence) and consider treating ADHD immediately thereafter with a nonstimulant such as ato­moxetine, which has data on efficacy and safety in context to substance use; and/or an α-agonist or an extended-release stimu­lant. Because of the potential for misuse and toxicity associated with concurrent substance use, benzodiazepines should be considered a last treatment of choice for adolescents with anxiety disorders and a SUD. Similarly, the use of immediate-release stimulants should be avoided in patients with ADHD and a SUD. When pre­scribing medications that could be misused or toxic when combined with a substance, it is important to evaluate the risk and benefit of continued use of a particular medication and consider prescribing lower quantities to decrease risk for misuse (1- to 2-week supply). Adolescents often are reluctant to engage in SUD treatment and one strat­egy to consider is to make continued pre­scription of any medication contingent on engaging in SUD treatment. Enlist parents in helping to monitor, store, and administer their child’s medication to improve adher­ence and decrease the potential for misuse, diversion, and complications associated with substance intoxication.

Bottom Line
It is important to screen for substance use in adolescents with co-occurring
psychiatric illness and vice versa. When at-risk or hazardous substance use is
detected there are effective psychosocial and pharmacologic interventions that
can be used to treat adolescent substance use disorders alone and in combination
with certain psychiatric disorders.

Related Resources
• National Institute on Drug Abuse. www.drugabuse.gov.
• National Institute on Alcohol Abuse and Alcoholism. www.niaaa.nih.gov.
• Substance Abuse and Mental Health Services Administration. www.samhsa.gov.

Drug Brand Names
Acamprosate • Campral
Atomoxetine • Strattera
Buprenorphine• Subutex
Buprenorphine/naloxone • Suboxone
Buspirone • Buspar
Clonidine • Catapres
Disulfiram • Antabuse
Fluoxetine • Prozac
Lithium • Lithobid, Eskalith
Methadone • Dolophine
Naltrexone • ReVia, Vivitrol
Osmotic (extended) release methylphenidate • Concerta
Sertraline • Zoloft
Topiramate • Topamax
Quetiapine • Seroquel
Valproic acid • Depakote

Disclosures
Dr. Yule received grant support from the 2012 American Academy of Child and Adolescent Psychiatry Pilot Research Award for Junior Faculty supported by Lilly USA, LLC, and receives grant support from the 2014 Louis V. Gerstner III Research Scholar Award. Dr. Wilens has received grant support from the National Institute on Drug Abuse (NIDA); has been a consultant for Euthymics/Neurovance, NIDA, Ironshore Pharmaceuticals and Development, Theravance Biopharma, Tris Pharma, the U.S. National Football League (ERM Associates), U.S. Minor/Major League Baseball, and Bay Cove Human Services (Clinical Services).

Substances use during adolescence is common in the United States. Data from the 2014 Monitoring the Future Survey estimated that among 12th graders, 60.2% used alcohol, 35.1% used mari­juana, and 13.9% used a prescription drug for nonmedical use within the previous year.¹ An estimated 11.4% of adolescents meet DSM-IV threshold criteria for a substance use disorder (SUD).² Substance use in adolescents often co-occurs with psychological distress and psychi­atric illness. Adolescents with a psychiatric disorder are at increased risk for developing a SUD; conversely, high rates of psychiatric illness are seen in adolescents with a SUD.^3,4 In one study, 82% of adolescents hospitalized for SUD treatment were found to have a co-occurring axis I disorder.⁵ Furthermore, co-occurring psychiatric illness and SUD complicates treatment course and prognosis. Adolescents with co-occurring psychiatric illness and SUD often benefit from an inte­grated, multimodal treatment approach that includes psychotherapy, pharmacologic interventions, family involvement, and collaboration with community supports.

In this article, we focus on pharmacologic management of non-nicotinic SUDs in adolescents, with an emphasis on those with comor­bid psychiatric illness.

Screening and assessment of substance use
It is important to counsel children with a psychiatric illness and their parents about the increased risk for SUD before a patient transitions to adolescence. Discussions about substance abuse should begin during the 5th grade because data suggests that adolescent sub­stance use often starts in middle school (6th to 9th grade). Clinicians should routinely screen adolescent patients for substance use. Nonproprietary screening tools available through the National Institute on Alcohol and Alcoholism and the National Institute on Drug Abuse are listed in Table 1.^6-8 The Screening to Brief Intervention (S2BI) is a newer tool that has been shown to be highly effective in identifying adolescents at risk for substance abuse and differentiating severity of illness.⁸ The S2BI includes screening ques­tions that assess for use of 8 substances in the past year.

Adolescents with psychiatric illness who are identified to be at risk for problems asso­ciated with substance use should be evalu­ated further for the presence or absence of a SUD. The number of criteria a patient endorses over the past year (Table 2⁹) is used to assess SUD severity—mild, moderate, or severe. Additional considerations include substance use patterns such as type, site, quantity, frequency, context, and combina­tions of substances.

It is important to be curious and non­judgmental when evaluating substance use patterns with adolescents to obtain a com­prehensive assessment. Teenagers often are creative and inventive in their efforts to maximize intoxication, which can put them at risk for complications associated with acute intoxication. Rapidly evolving meth­ods of ingesting highly concentrated forms of tetrahydrocannabinol (“wax,” “dabs”) are an example of use patterns that are ahead of what is reported in the literature.

Any substance use in an adolescent with a psychiatric illness is of concern and should be monitored closely because of the potential impact of substance use on the co-occurring psychiatric illness and pos­sible interactions between the abused sub­stance and prescribed medication.

Treatment interventions
Although this review will focus on phar­macotherapy, individual, group, and fam­ily psychotherapies are a critical part of a treatment plan for adolescents with comor­bid psychiatric illness and SUD (Table 3). Collaboration with community supports, including school and legal offi­cials, can help reinforce contingencies and assist with connecting a teen with posi­tive prosocial activities. Involvement with mutual help organizations, such as Alcoholics Anonymous, can facilitate adolescent engagement with a positive sober network.¹⁰

Medication to decrease substance use and promote abstinence. One strategy is to target cravings and urges to use sub­stances with medication. Naltrexone is an opiate antagonist FDA-approved for treating alcohol and opioid use disorders in adults and is available as a daily oral medication and a monthly injectable depot preparation (extended-release naltrexone). Two small open-label studies showed decreased alcohol use with naltrexone treatment in adolescents with alcohol use disorder.^11,12 In a randomized double-blind placebo controlled (RCT) crossover study of 22 adolescent problem drinkers, nal­trexone, 50 mg/d, reduced the likelihood of drinking and heavy drinking (P ≤ .03).¹³ Acamprosate, another anti-craving medi­cation FDA-approved for treating alcohol use disorder in adults, has no data on the safety or efficacy for adolescent alcohol use disorder.

There is limited research on agents that decrease use and promote abstinence from non-nicotinic substances other than alco­hol. There is one pilot RCT that evaluated N-acetylcysteine (NAC)—an over-the-counter supplement that modulates the glutamate system—for treating adoles­cent Cannabis dependence. Treatment with NAC, 2,400 mg/d, was well tolerated and had twice the odds of increasing negative urine cannabinoid tests during treatment than placebo.¹⁴ Although NAC treatment was associated with decreased Cannabis use, it did not significantly decrease crav­ings compared with placebo.¹⁵

Medication to alleviate withdrawal symptoms. Some patients may find the physical discomfort and psychological dis­tress associated with substance withdrawal so intolerable that to avoid it they continue to use drugs or alcohol. Medication to treat withdrawal symptoms and agonist treat­ments can be used to alleviate discomfort and distress associated with withdrawal. Agonist treatments, such as methadone and buprenorphine, bind to the same receptors as the target substance, which allows the patient to shift to controlled use of a prescribed substitute. Agonist treatments are used for short detoxifi­cation and over longer periods of time for maintenance treatment. Methadone, which decreases craving and withdrawal symptoms from opiates by binding to the μ-opiate receptor and blocking other sub­stances from binding, is frequently used for detoxification and maintenance treat­ment in adults. There is limited data on methadone substitution therapy for adolescents in the United States.¹⁶ Methadone maintenance for adolescents in the United States is restricted to severe cases of opioid use disorder. Federal guidelines specify that adolescents age <18 can only receive methadone if they have had 2 unsuccess­ful detoxification attempts or outpatient psychosocial treatments and have met DSM criteria for an opioid use disorder for 1 year.¹⁷

Buprenorphine is a partial μ-opiate receptor agonist that is FDA-approved for use in adolescents age ≥16 with opioid dependence. Although a waiver from the U.S. Drug Enforcement Administration is required to prescribe buprenorphine, it generally can be administered in outpa­tient settings with relative ease compared with methadone.

Marsch et al¹⁸ examined the efficacy of buprenorphine compared with clonidine for detoxification over 1 month in 36 ado­lescents with opioid dependence. Clonidine is an α-2 adrenergic agonist that often is used during detoxification from opioids.¹⁹ Although both buprenorphine and cloni­dine relieved withdrawal symptoms, a significantly higher percentage of patients receiving buprenorphine completed treat­ment (72%) compared with those taking clonidine (39%) (P < .05).¹⁸ Detoxification with buprenorphine also was associated with a higher percentage of negative urine drug screens (64% vs 32%, P = .01), and those receiving buprenorphine were more likely to continue on naltrexone mainte­nance for continued medication-assisted treatment after detoxification compared with those randomized to clonidine.

Woody et al²⁰ compared use of buprenor­phine/naloxone for opioid detoxification vs short-term maintenance. Patients age 16 to 21 were randomized to detoxification over 2 weeks vs stabilization and maintenance for 9 weeks and taper over 3 weeks. Maintenance treatment with buprenorphine/naloxone was associated with less opioid use, less injection drug use, and less need for addic­tion treatment outside of that received through the study compared with detoxifica­tion treatment. When buprenorphine/nalox­one was discontinued both the detoxification and maintenance groups had high rates of positive urine toxicology screens at 1-year follow up (mean 48% to 72%). These data suggests maintenance with buprenorphine/ naloxone for adolescents and young adults is more effective than short-term detoxifi­cation for stabilizing opioid use disorders, although optimal treatment duration is unclear. Clinically, it is important to continue buprenorphine/naloxone maintenance until the patient has stabilized in recovery and has acquired coping skills to manage urges, crav­ings, and psychological distress (eg, anger, stress) that often arise during a slow taper of agonist treatment.

Antagonist treatment to block the effect of substance use
As an opioid receptor antagonist, naltrex­one is effective for treating opioid use dis­order because it blocks the action of opioids. Fishman et al²¹ published a descriptive series of 16 adolescents and young adults followed over 4 months who received the injectable depot preparation (extended-release) nal­trexone while in residential treatment, and then discharged to outpatient care. Most patients who received extended-release nal­trexone remained in outpatient treatment (63%) and reduced their opioid use or were abstinent at 4 months (56%). One barrier to naltrexone treatment is the need to be absti­nent from opioids for 7 to 10 days to prevent precipitated opioid withdrawal. Therefore, naltrexone is a good option for adolescents who present for treatment early and are not physiologically dependent on opioids or are receiving treatment in a structured environ­ment after detoxification, such as residential treatment or sober living.

Aversive agents to diminish substance use. Aversive agents produce an unpleas­ant reaction when a target substance is consumed. Disulfiram is prototypic aver­sive agent that prevents the breakdown of acetaldehyde, a toxic metabolite of alcohol. Patients who drink alcohol while taking disulfiram may experience adverse effects, including tachycardia, shortness of breath, nausea, dizziness, and confusion. There have been 2 studies examining the efficacy of disulfiram in adolescents with alcohol use disorder. Niederhofer et al²² found that disulfiram treatment significantly increased cumulative abstinence in a small RCT (P = .012). In another small randomized, open-label, 3-month study of adolescents who received disulfiram or naltrexone in addition to weekly psychotherapy, disul­firam was superior to naltrexone in mean days abstinent from alcohol, 84 days vs 51 days, respectively (P = .0001).²³ Often adolescents are not willing to adhere to disulfiram because they are concerned about the aversive reaction when combined with alcohol use. Consider prescribing disulfiram for adolescents who are about to go “on pass” from a therapeutic school or residen­tial SUD treatment center and will be return­ing to an environment where they may be tempted to use alcohol.

Pharmacotherapy to treat co-occurring psychiatric illness
Continued treatment of a psychiatric illness that co-occurs with SUD is important. As we recommended, consider psychosocial treatments for both the SUD and comorbid psychopathology. Several single-site RCTs have evaluated the efficacy of the selective serotonin reuptake inhibitors (SSRIs) fluox­etine and sertraline for depressive disorders in adolescents with a co-occurring SUD.^24-28 Most studies have shown improvement in depressive symptoms and substance use in medication and placebo groups.^24,25,27,28 However, treatment with fluoxetine, 20 mg/d, or sertraline, 100 mg/d, when compared with placebo was associated with improved depressive symptoms in 1 of 3 studies and had no significant differ­ence in SUD outcome. The authors of these studies believe that the general improve­ment in depression and the SUD was related to use of cognitive-behavioral ther­apy (CBT) and/or motivational enhance­ment therapy.^24,25,27,28

Research on the use of mood stabilizers for adolescents with mood dysregulation and a SUD is limited but has suggested benefit associated with pharmacotherapy (Table 4).^29-32 Two RCTs and 1 open-label study demonstrated reductions in sub­stance use with mood stabilizer treatment in adolescents with co-occurring SUD and mood dysregulation.^29-32 The effect of phar­macotherapy on mood dysregulation rat­ings are less clear because there was no change in severity of affective symptoms observed in a small RCT of lithium (average blood level 0.9 mEq/L)²⁹; and improvement in affective symptoms was noted in topira­mate (300 mg/d) and placebo groups when both groups were treated with concurrent quetiapine.³² Because of the high risk of SUD and severe morbidity in juvenile bipo­lar disorder and severe mood dysregula­tion,³³ larger RCTs are warranted.

Although conduct disorder and anxiety disorders commonly co-occur with SUD, there has been less research evaluating the impact of pharmacotherapy on treating these disorders. Riggs et al^25,34,35,41 evaluated the impact of pharmacotherapy targeted to co-occurring ADHD and major depressive disorder in the context of conduct disorder and SUD. When evaluated in an outpatient setting, the presence of a treatment inter­vention to address the co-occurring SUD was an important component that led to a reduction in conduct symptoms.^25,35 There have been no comprehensive studies on the impact of pharmacotherapy for treat­ing anxiety and SUD in adolescents.

Recommendations for clinical management
Although more research is needed to evaluate the role of pharmacotherapy for adolescents with co-occurring psychiatric illness and a SUD, recommended practice is to continue pharmacotherapy and closely monitor response to treatment when at-risk substance use begins in patients with co-occurring psychiatric illness. In ado­lescents with a threshold SUD, continue pharmacotherapy for unstable mood dis­orders with first-line choices of SSRIs for unipolar depression and second-generation antipsychotics for bipolar spectrum illness. Suggested conservative pharmacological interventions for anxiety disorders include SSRIs and buspirone, which have been shown to be effective for treating anxiety in children and adolescents.^42,43 For patients with comorbid ADHD and SUD, if pos­sible, it is recommended to first stabilize substance use (low-level use or abstinence) and consider treating ADHD immediately thereafter with a nonstimulant such as ato­moxetine, which has data on efficacy and safety in context to substance use; and/or an α-agonist or an extended-release stimu­lant. Because of the potential for misuse and toxicity associated with concurrent substance use, benzodiazepines should be considered a last treatment of choice for adolescents with anxiety disorders and a SUD. Similarly, the use of immediate-release stimulants should be avoided in patients with ADHD and a SUD. When pre­scribing medications that could be misused or toxic when combined with a substance, it is important to evaluate the risk and benefit of continued use of a particular medication and consider prescribing lower quantities to decrease risk for misuse (1- to 2-week supply). Adolescents often are reluctant to engage in SUD treatment and one strat­egy to consider is to make continued pre­scription of any medication contingent on engaging in SUD treatment. Enlist parents in helping to monitor, store, and administer their child’s medication to improve adher­ence and decrease the potential for misuse, diversion, and complications associated with substance intoxication.

Bottom Line
It is important to screen for substance use in adolescents with co-occurring
psychiatric illness and vice versa. When at-risk or hazardous substance use is
detected there are effective psychosocial and pharmacologic interventions that
can be used to treat adolescent substance use disorders alone and in combination
with certain psychiatric disorders.

Related Resources
• National Institute on Drug Abuse. www.drugabuse.gov.
• National Institute on Alcohol Abuse and Alcoholism. www.niaaa.nih.gov.
• Substance Abuse and Mental Health Services Administration. www.samhsa.gov.

Drug Brand Names
Acamprosate • Campral
Atomoxetine • Strattera
Buprenorphine• Subutex
Buprenorphine/naloxone • Suboxone
Buspirone • Buspar
Clonidine • Catapres
Disulfiram • Antabuse
Fluoxetine • Prozac
Lithium • Lithobid, Eskalith
Methadone • Dolophine
Naltrexone • ReVia, Vivitrol
Osmotic (extended) release methylphenidate • Concerta
Sertraline • Zoloft
Topiramate • Topamax
Quetiapine • Seroquel
Valproic acid • Depakote

Disclosures
Dr. Yule received grant support from the 2012 American Academy of Child and Adolescent Psychiatry Pilot Research Award for Junior Faculty supported by Lilly USA, LLC, and receives grant support from the 2014 Louis V. Gerstner III Research Scholar Award. Dr. Wilens has received grant support from the National Institute on Drug Abuse (NIDA); has been a consultant for Euthymics/Neurovance, NIDA, Ironshore Pharmaceuticals and Development, Theravance Biopharma, Tris Pharma, the U.S. National Football League (ERM Associates), U.S. Minor/Major League Baseball, and Bay Cove Human Services (Clinical Services).

Ms. K, age 35, soon will deliver her sec­ond child. She has a 12-year history of bipolar disorder, which was well controlled with lithium, 1,200 mg/d. During her first pregnancy 3 years ago, Ms. K stopped tak­ing lithium because she was concerned about the risk of Ebstein’s anomaly. She experienced a bipolar relapse after her healthy baby was born, and developed postpartum psychosis that was treated by restarting lithium, 1,200 mg/d, and adding olanzapine, 10 mg/d.

Ms. K has continued these medications throughout her current pregnancy. She wants to breast-feed her infant and is concerned about the effects that psychotropics might have on her newborn.

Breast-feeding and medications

The benefits of breast-feeding for mother and infant are well-known. Despite this, some women with bipolar disorder are advised not to breast-feed or, worse, to discontinue their medications in order to breast-feed. Decisions about breast-feeding while taking medications should be based on evidence of benefits and risks to the infant, along with a discussion of the risks of untreated illness, which is high postpartum. The prescribing information for many of the medications used to treat bipolar disorder advise against breast-feeding, although there is little evidence of harm.

Drug dosages and levels in breast milk can be reported a few different ways:
   • percentage of maternal dosage mea­sured in the breast milk
   • percentage weight-adjusted maternal dosage
   • percentage of maternal plasma level, and milk-to-plasma ratio (M:P).

Daily infant dosage can be calculated by multiplying the average concentration of the drug in breast milk (mg/mL) by the average volume of milk the baby ingests in 24 hours (usually 150 mL).¹ The rela­tive infant dosage can be calculated as the percentage maternal dosage, which is the daily infant dosage (mg/kg/d) ÷ maternal dosage (mg/kg/d) × 100.¹

According to the American Academy of Pediatrics, ≤10% of the maternal dos­age is compatible with breast-feeding.¹ Most psychotropics studied fall below this threshold. Keep in mind that all published research is for breast-feeding a full-term infant; exercise caution with premature or low birth weight infants. Infants born to mothers taking a psychotropic should be monitored for withdrawal symptoms, which might be associated with antide­pressants and benzodiazepines, but other­wise are rare.

Lithium
Breast-feeding during lithium treatment has been considered contraindicated based on early reports that lithium was highly excreted in breast milk.² A 2003 study² of 11 women found that lithium was excreted in breast milk in amounts between zero and 30% of maternal dosage (mean, 12.2% ± 8.5%; median, 11.2%; 95% CI, 6.3% to 18.0%). Researchers measured serum con­centrations in 2 infants and found that 1 received 17% to 20% of the maternal dos­age, and the other showed 50%. None of the infants experienced adverse events. In a study of 10 mother-infant pairs, breast milk lithium concentration averaged 0.35 mEq/L (standard deviation [SD] = 0.10, range 0.19 to 0.48 mEq/L), with paired infant serum concentrations of 0.16 mEq/L (SD = 0.06, range 0.09 to 0.25 mEq/L).³ Some transient abnormali­ties were found in infant serum concen­trations of thyroid-stimulating hormone (TSH), blood urea nitrogen, and creatinine; there were no adverse effects on develop­ment. The authors recommend monitoring for TSH abnormalities in infants.

Olanzapine
Olanzapine prescribing information cites a study reporting that 1.8% of the maternal dosage is transferred to breast milk.⁴ Yet the olanzapine prescribing information states, “It is recommended that women receiv­ing olanzapine should not breast-feed.” Olanzapine use during breast-feeding has been studied more than many medications, in part because of a database maintained by the manufacturer. In a study using the man­ufacturer’s database (N = 102) adverse reac­tions were reported in 15.6% of the infants, with the most common being somnolence (3.9%), irritability (2%), tremor (2%), and insomnia (2%).⁵

Other second-generation antipsychotics
Aripiprazole. The only case report of aripip­razole excretion in human breast milk found a concentration of approximately 20% of the maternal plasma level and an M:P ratio of 0.18:0.2.⁶

Asenapine. According to asenapine pre­scribing information⁷ and a literature search, it is not known whether asenapine is excreted in breast milk of humans, although it is found in the milk of lactating rats.

Lurasidone. According to the lurasidone prescribing information⁸ and a literature search, it is not known whether lurasidone is excreted in human breast milk, although it is found in the milk of lactating rats.

Quetiapine. An initial study reported that 0.09% to 0.43% of the maternal dosage of quetiapine was excreted in breast milk.⁹ Further studies found excretion to be 0.09% of maternal dosage, with infant plasma levels reaching 6% of the maternal dos­age.¹⁰ A case series found that one-third of babies exposed to quetiapine during breast-feeding showed some neurodevelopmental delay, although these mothers also were taking other psychotropics.¹¹

Risperidone. A 2000 study¹² of risperidone in lactation reported that 0.84% weight-adjusted maternal risperidone dosage and 3.46% of its metabolite 9-hydroxyrisperi­done is transferred to the infant. A later study showed 2.3% to 4.7% of the mater­nal dosage is transferred, with no adverse events reported in infants.¹³ A case study reported no adverse events and normal neu­rodevelopment in a the child of a mother taking risperidone.¹⁴

Ziprasidone. According to the ziprasidone prescribing information¹⁵ and a literature search, is not known whether ziprasidone is excreted in human breast milk.

See the Table^{4,6-10,12,13,15} for a summary of the evidence levels of second-generation antipsychotics that are excreted in breast milk.

Valproic acid. Because of its high plasma protein binding, valproic acid does not pass readily into the breast milk. Newborns receive approximately 1.4% to 1.7% of the maternal dosage.¹⁶ Caution is advised, however, because of some reported adverse events. One case reported thrombocytopenic purpura and anemia in an infant.¹⁹ Valproic acid is considered to be compatible with breast-feeding with proper monitoring.

Benzodiazepines
Benzodiazepines can be helpful adjunctive medications to aid sleep, which is essen­tial for the mother’s and infant’s health. In a prospectively recruited, retrospec­tively assessed cohort study that evaluated 124 women taking benzodiazepines while breast-feeding, adverse effects, specifically sedation, were noted in 1.6% of infants.²⁰

Future developments in prescribing information
Under a 2008 FDA recommendation, the “Nursing Mothers” section of prescribing information would be replaced with a sec­tion entitled “Lactation.” This new head­ing would include the sub-headings Risk Summary, Clinical Considerations, and Data.¹ It is expected that this new format will be more practical and will help clini­cians and patients make informed deci­sions. The prescribing changes will be in effect on June 30, 2015.²¹

Related Resources
• Massachusetts General Hospital Center for Women’s Mental Health. www.womensmentalhealth.org.
• LactMed. http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm.
• MOTHERISK. www.motherisk.org/women/ breastfeeding.jsp.

Drug Brand Names
Aripiprazole • Abilify                    Olanzapine • Zyprexa
Asenapine • Saphris                    Quetiapine • Seroquel
Carbamazepine • Tegretol           Risperidone • Risperdal
Lamotrigine • Lamictal                 Valproic acid • Depakene
Lithium • Eskalith, Lithobid           Ziprasidone • Geodon
Lurasidone • Latuda

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Ms. K, age 35, soon will deliver her sec­ond child. She has a 12-year history of bipolar disorder, which was well controlled with lithium, 1,200 mg/d. During her first pregnancy 3 years ago, Ms. K stopped tak­ing lithium because she was concerned about the risk of Ebstein’s anomaly. She experienced a bipolar relapse after her healthy baby was born, and developed postpartum psychosis that was treated by restarting lithium, 1,200 mg/d, and adding olanzapine, 10 mg/d.

Ms. K has continued these medications throughout her current pregnancy. She wants to breast-feed her infant and is concerned about the effects that psychotropics might have on her newborn.

Breast-feeding and medications

The benefits of breast-feeding for mother and infant are well-known. Despite this, some women with bipolar disorder are advised not to breast-feed or, worse, to discontinue their medications in order to breast-feed. Decisions about breast-feeding while taking medications should be based on evidence of benefits and risks to the infant, along with a discussion of the risks of untreated illness, which is high postpartum. The prescribing information for many of the medications used to treat bipolar disorder advise against breast-feeding, although there is little evidence of harm.

Drug dosages and levels in breast milk can be reported a few different ways:
   • percentage of maternal dosage mea­sured in the breast milk
   • percentage weight-adjusted maternal dosage
   • percentage of maternal plasma level, and milk-to-plasma ratio (M:P).

Daily infant dosage can be calculated by multiplying the average concentration of the drug in breast milk (mg/mL) by the average volume of milk the baby ingests in 24 hours (usually 150 mL).¹ The rela­tive infant dosage can be calculated as the percentage maternal dosage, which is the daily infant dosage (mg/kg/d) ÷ maternal dosage (mg/kg/d) × 100.¹

According to the American Academy of Pediatrics, ≤10% of the maternal dos­age is compatible with breast-feeding.¹ Most psychotropics studied fall below this threshold. Keep in mind that all published research is for breast-feeding a full-term infant; exercise caution with premature or low birth weight infants. Infants born to mothers taking a psychotropic should be monitored for withdrawal symptoms, which might be associated with antide­pressants and benzodiazepines, but other­wise are rare.

Lithium
Breast-feeding during lithium treatment has been considered contraindicated based on early reports that lithium was highly excreted in breast milk.² A 2003 study² of 11 women found that lithium was excreted in breast milk in amounts between zero and 30% of maternal dosage (mean, 12.2% ± 8.5%; median, 11.2%; 95% CI, 6.3% to 18.0%). Researchers measured serum con­centrations in 2 infants and found that 1 received 17% to 20% of the maternal dos­age, and the other showed 50%. None of the infants experienced adverse events. In a study of 10 mother-infant pairs, breast milk lithium concentration averaged 0.35 mEq/L (standard deviation [SD] = 0.10, range 0.19 to 0.48 mEq/L), with paired infant serum concentrations of 0.16 mEq/L (SD = 0.06, range 0.09 to 0.25 mEq/L).³ Some transient abnormali­ties were found in infant serum concen­trations of thyroid-stimulating hormone (TSH), blood urea nitrogen, and creatinine; there were no adverse effects on develop­ment. The authors recommend monitoring for TSH abnormalities in infants.

Olanzapine
Olanzapine prescribing information cites a study reporting that 1.8% of the maternal dosage is transferred to breast milk.⁴ Yet the olanzapine prescribing information states, “It is recommended that women receiv­ing olanzapine should not breast-feed.” Olanzapine use during breast-feeding has been studied more than many medications, in part because of a database maintained by the manufacturer. In a study using the man­ufacturer’s database (N = 102) adverse reac­tions were reported in 15.6% of the infants, with the most common being somnolence (3.9%), irritability (2%), tremor (2%), and insomnia (2%).⁵

Other second-generation antipsychotics
Aripiprazole. The only case report of aripip­razole excretion in human breast milk found a concentration of approximately 20% of the maternal plasma level and an M:P ratio of 0.18:0.2.⁶

Asenapine. According to asenapine pre­scribing information⁷ and a literature search, it is not known whether asenapine is excreted in breast milk of humans, although it is found in the milk of lactating rats.

Lurasidone. According to the lurasidone prescribing information⁸ and a literature search, it is not known whether lurasidone is excreted in human breast milk, although it is found in the milk of lactating rats.

Quetiapine. An initial study reported that 0.09% to 0.43% of the maternal dosage of quetiapine was excreted in breast milk.⁹ Further studies found excretion to be 0.09% of maternal dosage, with infant plasma levels reaching 6% of the maternal dos­age.¹⁰ A case series found that one-third of babies exposed to quetiapine during breast-feeding showed some neurodevelopmental delay, although these mothers also were taking other psychotropics.¹¹

Risperidone. A 2000 study¹² of risperidone in lactation reported that 0.84% weight-adjusted maternal risperidone dosage and 3.46% of its metabolite 9-hydroxyrisperi­done is transferred to the infant. A later study showed 2.3% to 4.7% of the mater­nal dosage is transferred, with no adverse events reported in infants.¹³ A case study reported no adverse events and normal neu­rodevelopment in a the child of a mother taking risperidone.¹⁴

Ziprasidone. According to the ziprasidone prescribing information¹⁵ and a literature search, is not known whether ziprasidone is excreted in human breast milk.

See the Table^{4,6-10,12,13,15} for a summary of the evidence levels of second-generation antipsychotics that are excreted in breast milk.

Valproic acid. Because of its high plasma protein binding, valproic acid does not pass readily into the breast milk. Newborns receive approximately 1.4% to 1.7% of the maternal dosage.¹⁶ Caution is advised, however, because of some reported adverse events. One case reported thrombocytopenic purpura and anemia in an infant.¹⁹ Valproic acid is considered to be compatible with breast-feeding with proper monitoring.

Benzodiazepines
Benzodiazepines can be helpful adjunctive medications to aid sleep, which is essen­tial for the mother’s and infant’s health. In a prospectively recruited, retrospec­tively assessed cohort study that evaluated 124 women taking benzodiazepines while breast-feeding, adverse effects, specifically sedation, were noted in 1.6% of infants.²⁰

Future developments in prescribing information
Under a 2008 FDA recommendation, the “Nursing Mothers” section of prescribing information would be replaced with a sec­tion entitled “Lactation.” This new head­ing would include the sub-headings Risk Summary, Clinical Considerations, and Data.¹ It is expected that this new format will be more practical and will help clini­cians and patients make informed deci­sions. The prescribing changes will be in effect on June 30, 2015.²¹

Related Resources
• Massachusetts General Hospital Center for Women’s Mental Health. www.womensmentalhealth.org.
• LactMed. http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm.
• MOTHERISK. www.motherisk.org/women/ breastfeeding.jsp.

Drug Brand Names
Aripiprazole • Abilify                    Olanzapine • Zyprexa
Asenapine • Saphris                    Quetiapine • Seroquel
Carbamazepine • Tegretol           Risperidone • Risperdal
Lamotrigine • Lamictal                 Valproic acid • Depakene
Lithium • Eskalith, Lithobid           Ziprasidone • Geodon
Lurasidone • Latuda

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Ms. K, age 35, soon will deliver her sec­ond child. She has a 12-year history of bipolar disorder, which was well controlled with lithium, 1,200 mg/d. During her first pregnancy 3 years ago, Ms. K stopped tak­ing lithium because she was concerned about the risk of Ebstein’s anomaly. She experienced a bipolar relapse after her healthy baby was born, and developed postpartum psychosis that was treated by restarting lithium, 1,200 mg/d, and adding olanzapine, 10 mg/d.

Ms. K has continued these medications throughout her current pregnancy. She wants to breast-feed her infant and is concerned about the effects that psychotropics might have on her newborn.

Breast-feeding and medications

The benefits of breast-feeding for mother and infant are well-known. Despite this, some women with bipolar disorder are advised not to breast-feed or, worse, to discontinue their medications in order to breast-feed. Decisions about breast-feeding while taking medications should be based on evidence of benefits and risks to the infant, along with a discussion of the risks of untreated illness, which is high postpartum. The prescribing information for many of the medications used to treat bipolar disorder advise against breast-feeding, although there is little evidence of harm.

Drug dosages and levels in breast milk can be reported a few different ways:
   • percentage of maternal dosage mea­sured in the breast milk
   • percentage weight-adjusted maternal dosage
   • percentage of maternal plasma level, and milk-to-plasma ratio (M:P).

Daily infant dosage can be calculated by multiplying the average concentration of the drug in breast milk (mg/mL) by the average volume of milk the baby ingests in 24 hours (usually 150 mL).¹ The rela­tive infant dosage can be calculated as the percentage maternal dosage, which is the daily infant dosage (mg/kg/d) ÷ maternal dosage (mg/kg/d) × 100.¹

According to the American Academy of Pediatrics, ≤10% of the maternal dos­age is compatible with breast-feeding.¹ Most psychotropics studied fall below this threshold. Keep in mind that all published research is for breast-feeding a full-term infant; exercise caution with premature or low birth weight infants. Infants born to mothers taking a psychotropic should be monitored for withdrawal symptoms, which might be associated with antide­pressants and benzodiazepines, but other­wise are rare.

Lithium
Breast-feeding during lithium treatment has been considered contraindicated based on early reports that lithium was highly excreted in breast milk.² A 2003 study² of 11 women found that lithium was excreted in breast milk in amounts between zero and 30% of maternal dosage (mean, 12.2% ± 8.5%; median, 11.2%; 95% CI, 6.3% to 18.0%). Researchers measured serum con­centrations in 2 infants and found that 1 received 17% to 20% of the maternal dos­age, and the other showed 50%. None of the infants experienced adverse events. In a study of 10 mother-infant pairs, breast milk lithium concentration averaged 0.35 mEq/L (standard deviation [SD] = 0.10, range 0.19 to 0.48 mEq/L), with paired infant serum concentrations of 0.16 mEq/L (SD = 0.06, range 0.09 to 0.25 mEq/L).³ Some transient abnormali­ties were found in infant serum concen­trations of thyroid-stimulating hormone (TSH), blood urea nitrogen, and creatinine; there were no adverse effects on develop­ment. The authors recommend monitoring for TSH abnormalities in infants.

Olanzapine
Olanzapine prescribing information cites a study reporting that 1.8% of the maternal dosage is transferred to breast milk.⁴ Yet the olanzapine prescribing information states, “It is recommended that women receiv­ing olanzapine should not breast-feed.” Olanzapine use during breast-feeding has been studied more than many medications, in part because of a database maintained by the manufacturer. In a study using the man­ufacturer’s database (N = 102) adverse reac­tions were reported in 15.6% of the infants, with the most common being somnolence (3.9%), irritability (2%), tremor (2%), and insomnia (2%).⁵

Other second-generation antipsychotics
Aripiprazole. The only case report of aripip­razole excretion in human breast milk found a concentration of approximately 20% of the maternal plasma level and an M:P ratio of 0.18:0.2.⁶

Asenapine. According to asenapine pre­scribing information⁷ and a literature search, it is not known whether asenapine is excreted in breast milk of humans, although it is found in the milk of lactating rats.

Lurasidone. According to the lurasidone prescribing information⁸ and a literature search, it is not known whether lurasidone is excreted in human breast milk, although it is found in the milk of lactating rats.

Quetiapine. An initial study reported that 0.09% to 0.43% of the maternal dosage of quetiapine was excreted in breast milk.⁹ Further studies found excretion to be 0.09% of maternal dosage, with infant plasma levels reaching 6% of the maternal dos­age.¹⁰ A case series found that one-third of babies exposed to quetiapine during breast-feeding showed some neurodevelopmental delay, although these mothers also were taking other psychotropics.¹¹

Risperidone. A 2000 study¹² of risperidone in lactation reported that 0.84% weight-adjusted maternal risperidone dosage and 3.46% of its metabolite 9-hydroxyrisperi­done is transferred to the infant. A later study showed 2.3% to 4.7% of the mater­nal dosage is transferred, with no adverse events reported in infants.¹³ A case study reported no adverse events and normal neu­rodevelopment in a the child of a mother taking risperidone.¹⁴

Ziprasidone. According to the ziprasidone prescribing information¹⁵ and a literature search, is not known whether ziprasidone is excreted in human breast milk.

See the Table^{4,6-10,12,13,15} for a summary of the evidence levels of second-generation antipsychotics that are excreted in breast milk.

Valproic acid. Because of its high plasma protein binding, valproic acid does not pass readily into the breast milk. Newborns receive approximately 1.4% to 1.7% of the maternal dosage.¹⁶ Caution is advised, however, because of some reported adverse events. One case reported thrombocytopenic purpura and anemia in an infant.¹⁹ Valproic acid is considered to be compatible with breast-feeding with proper monitoring.

Benzodiazepines
Benzodiazepines can be helpful adjunctive medications to aid sleep, which is essen­tial for the mother’s and infant’s health. In a prospectively recruited, retrospec­tively assessed cohort study that evaluated 124 women taking benzodiazepines while breast-feeding, adverse effects, specifically sedation, were noted in 1.6% of infants.²⁰

Future developments in prescribing information
Under a 2008 FDA recommendation, the “Nursing Mothers” section of prescribing information would be replaced with a sec­tion entitled “Lactation.” This new head­ing would include the sub-headings Risk Summary, Clinical Considerations, and Data.¹ It is expected that this new format will be more practical and will help clini­cians and patients make informed deci­sions. The prescribing changes will be in effect on June 30, 2015.²¹

Related Resources
• Massachusetts General Hospital Center for Women’s Mental Health. www.womensmentalhealth.org.
• LactMed. http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm.
• MOTHERISK. www.motherisk.org/women/ breastfeeding.jsp.

Drug Brand Names
Aripiprazole • Abilify                    Olanzapine • Zyprexa
Asenapine • Saphris                    Quetiapine • Seroquel
Carbamazepine • Tegretol           Risperidone • Risperdal
Lamotrigine • Lamictal                 Valproic acid • Depakene
Lithium • Eskalith, Lithobid           Ziprasidone • Geodon
Lurasidone • Latuda

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Physicians hardly need the Health Insurance Portability and Accountability Act (HIPAA) to remind them how important it is to safe­guard their patients’ records. Physicians understand that patient information is sen­sitive and it would be disastrous if their files became public or fell into the wrong hands. However, the use of health infor­mation technology to record patient infor­mation, although beneficial for medical professionals and patients, poses risks to patient privacy.¹

HIPAA requires clinicians and health care systems to protect patient information, whether it is maintained in an electronic health records system, stored on a mobile device, or transmitted via e-mail to another physician. The U.S. Department of Health and Human Services will increase HIPAA audits this year to make sure that medical practices have taken measures to protect their patients’ health information. Physicians and other clinicians can take advantage of cloud-based file-sharing services, such as Dropbox, without running afoul of HIPAA.

Mobile computing, the cloud, and patient information: A risky combination
Although mobile computing and cloud-based file-sharing sites such as Dropbox and Google Drive allow physicians to take notes on a tablet, annotate those notes on a laptop, and share them with a physician who views them on his (her) desktop, this free flow of information makes it more dif­ficult to stay compliant with HIPAA.

Dropbox and other file-sharing services encrypt documents while they’re stored in the cloud but the files are unprotected when downloaded to a device. E-mail, which isn’t as versatile or useful as these services, also is not HIPAA-compliant unless the files are encrypted.

Often, small psychiatric practices use these online services and e-mail even if they’re aware of the risks because they don’t have time to research a better solu­tion. Or they might resort to faxing or even snail-mailing documents, losing out on the increased productivity that the cloud can provide.

Secure technologies satisfy auditors
A number of tools exist to help physicians seamlessly integrate the encryption nec­essary to keep their patients’ records safe and meet HIPAA security requirements. Here’s a look at 3 options.

Sookasa (plus Dropbox). One option is to invest in a software product designed to encrypt documents shared through cloud-based services. This type of soft­ware creates a compliance “shield” around files stored on the cloud, converting files into HIPAA safe havens. The files are encrypted when synced to new devices or shared with other users, meaning they’re protected no matter where they reside.²

Sookasa is an online service that encrypts files shared and stored in Dropbox. The company plans to extend its support to other popular cloud services such as Google Drive and Microsoft OneDrive. Sookasa also audits and controls access to encrypted files, so that patient data can be blocked even if a device is lost or sto­ len. Sookasa users also can share files via e-mail with added encryption and authen­tication to make sure only the authorized receiver gets the documents.²

TigerText. Regular SMS text messages on your mobile phone aren’t compliant with HIPAA, but TigerText replicates the tex­ting experience in a secure way. Instead of being stored on your mobile phone, mes­sages sent through TigerText are stored on the company’s servers. Messages sent through the application can’t be saved, copied, or forwarded to other recipients. TigerText messages also are deleted, either after a set time period or after they’ve been read. Because the messages aren’t stored on phones, a lost or stolen phone won’t result in a data breach and a HIPAA violation.3

Secure text messaging won’t help physi­cians store and manage large amounts of patient files, but it’s a must-have if they use texting to communicate about patient care.

DataMotion SecureMail provides e-mail encryption services to health care orga­nizations and other enterprises. Using a decryption key, authorized users can open and read the encrypted e-mails, which are HIPAA-compliant.⁴ This method is supe­rior to other services that encrypt e-mails on the server. Several providers, such as Google’s e-mail encryption service Postini, ensure that e-mails are encrypted when they are stored on the server; however, the body text and attachments included in specific e-mails are not encrypted on the senders’ and receivers’ devices. If you lose a connected device, you would still be at risk of a HIPAA breach.

DataMotion’s SecureMail provides detailed tracking and logging of e-mails, which is necessary for auditing purposes. The product also works on mobile devices.

E-mail is a helpful tool for quickly shar­ing files and an e-mail encryption product such as SecureMail makes it possible to do so securely. Other e-mail encryption prod­ucts do not securely store and back up all files in a centralized way.

DisclosureDr. Cidon is CEO and Co-founder of Sookasa.

Physicians hardly need the Health Insurance Portability and Accountability Act (HIPAA) to remind them how important it is to safe­guard their patients’ records. Physicians understand that patient information is sen­sitive and it would be disastrous if their files became public or fell into the wrong hands. However, the use of health infor­mation technology to record patient infor­mation, although beneficial for medical professionals and patients, poses risks to patient privacy.¹

HIPAA requires clinicians and health care systems to protect patient information, whether it is maintained in an electronic health records system, stored on a mobile device, or transmitted via e-mail to another physician. The U.S. Department of Health and Human Services will increase HIPAA audits this year to make sure that medical practices have taken measures to protect their patients’ health information. Physicians and other clinicians can take advantage of cloud-based file-sharing services, such as Dropbox, without running afoul of HIPAA.

Mobile computing, the cloud, and patient information: A risky combination
Although mobile computing and cloud-based file-sharing sites such as Dropbox and Google Drive allow physicians to take notes on a tablet, annotate those notes on a laptop, and share them with a physician who views them on his (her) desktop, this free flow of information makes it more dif­ficult to stay compliant with HIPAA.

Dropbox and other file-sharing services encrypt documents while they’re stored in the cloud but the files are unprotected when downloaded to a device. E-mail, which isn’t as versatile or useful as these services, also is not HIPAA-compliant unless the files are encrypted.

Often, small psychiatric practices use these online services and e-mail even if they’re aware of the risks because they don’t have time to research a better solu­tion. Or they might resort to faxing or even snail-mailing documents, losing out on the increased productivity that the cloud can provide.

Secure technologies satisfy auditors
A number of tools exist to help physicians seamlessly integrate the encryption nec­essary to keep their patients’ records safe and meet HIPAA security requirements. Here’s a look at 3 options.

Sookasa (plus Dropbox). One option is to invest in a software product designed to encrypt documents shared through cloud-based services. This type of soft­ware creates a compliance “shield” around files stored on the cloud, converting files into HIPAA safe havens. The files are encrypted when synced to new devices or shared with other users, meaning they’re protected no matter where they reside.²

Sookasa is an online service that encrypts files shared and stored in Dropbox. The company plans to extend its support to other popular cloud services such as Google Drive and Microsoft OneDrive. Sookasa also audits and controls access to encrypted files, so that patient data can be blocked even if a device is lost or sto­ len. Sookasa users also can share files via e-mail with added encryption and authen­tication to make sure only the authorized receiver gets the documents.²

TigerText. Regular SMS text messages on your mobile phone aren’t compliant with HIPAA, but TigerText replicates the tex­ting experience in a secure way. Instead of being stored on your mobile phone, mes­sages sent through TigerText are stored on the company’s servers. Messages sent through the application can’t be saved, copied, or forwarded to other recipients. TigerText messages also are deleted, either after a set time period or after they’ve been read. Because the messages aren’t stored on phones, a lost or stolen phone won’t result in a data breach and a HIPAA violation.3

Secure text messaging won’t help physi­cians store and manage large amounts of patient files, but it’s a must-have if they use texting to communicate about patient care.

DataMotion SecureMail provides e-mail encryption services to health care orga­nizations and other enterprises. Using a decryption key, authorized users can open and read the encrypted e-mails, which are HIPAA-compliant.⁴ This method is supe­rior to other services that encrypt e-mails on the server. Several providers, such as Google’s e-mail encryption service Postini, ensure that e-mails are encrypted when they are stored on the server; however, the body text and attachments included in specific e-mails are not encrypted on the senders’ and receivers’ devices. If you lose a connected device, you would still be at risk of a HIPAA breach.

DataMotion’s SecureMail provides detailed tracking and logging of e-mails, which is necessary for auditing purposes. The product also works on mobile devices.

E-mail is a helpful tool for quickly shar­ing files and an e-mail encryption product such as SecureMail makes it possible to do so securely. Other e-mail encryption prod­ucts do not securely store and back up all files in a centralized way.

DisclosureDr. Cidon is CEO and Co-founder of Sookasa.

Physicians hardly need the Health Insurance Portability and Accountability Act (HIPAA) to remind them how important it is to safe­guard their patients’ records. Physicians understand that patient information is sen­sitive and it would be disastrous if their files became public or fell into the wrong hands. However, the use of health infor­mation technology to record patient infor­mation, although beneficial for medical professionals and patients, poses risks to patient privacy.¹

HIPAA requires clinicians and health care systems to protect patient information, whether it is maintained in an electronic health records system, stored on a mobile device, or transmitted via e-mail to another physician. The U.S. Department of Health and Human Services will increase HIPAA audits this year to make sure that medical practices have taken measures to protect their patients’ health information. Physicians and other clinicians can take advantage of cloud-based file-sharing services, such as Dropbox, without running afoul of HIPAA.

Mobile computing, the cloud, and patient information: A risky combination
Although mobile computing and cloud-based file-sharing sites such as Dropbox and Google Drive allow physicians to take notes on a tablet, annotate those notes on a laptop, and share them with a physician who views them on his (her) desktop, this free flow of information makes it more dif­ficult to stay compliant with HIPAA.

Dropbox and other file-sharing services encrypt documents while they’re stored in the cloud but the files are unprotected when downloaded to a device. E-mail, which isn’t as versatile or useful as these services, also is not HIPAA-compliant unless the files are encrypted.

Often, small psychiatric practices use these online services and e-mail even if they’re aware of the risks because they don’t have time to research a better solu­tion. Or they might resort to faxing or even snail-mailing documents, losing out on the increased productivity that the cloud can provide.

Secure technologies satisfy auditors
A number of tools exist to help physicians seamlessly integrate the encryption nec­essary to keep their patients’ records safe and meet HIPAA security requirements. Here’s a look at 3 options.

Sookasa (plus Dropbox). One option is to invest in a software product designed to encrypt documents shared through cloud-based services. This type of soft­ware creates a compliance “shield” around files stored on the cloud, converting files into HIPAA safe havens. The files are encrypted when synced to new devices or shared with other users, meaning they’re protected no matter where they reside.²

Sookasa is an online service that encrypts files shared and stored in Dropbox. The company plans to extend its support to other popular cloud services such as Google Drive and Microsoft OneDrive. Sookasa also audits and controls access to encrypted files, so that patient data can be blocked even if a device is lost or sto­ len. Sookasa users also can share files via e-mail with added encryption and authen­tication to make sure only the authorized receiver gets the documents.²

TigerText. Regular SMS text messages on your mobile phone aren’t compliant with HIPAA, but TigerText replicates the tex­ting experience in a secure way. Instead of being stored on your mobile phone, mes­sages sent through TigerText are stored on the company’s servers. Messages sent through the application can’t be saved, copied, or forwarded to other recipients. TigerText messages also are deleted, either after a set time period or after they’ve been read. Because the messages aren’t stored on phones, a lost or stolen phone won’t result in a data breach and a HIPAA violation.3

Secure text messaging won’t help physi­cians store and manage large amounts of patient files, but it’s a must-have if they use texting to communicate about patient care.

DataMotion SecureMail provides e-mail encryption services to health care orga­nizations and other enterprises. Using a decryption key, authorized users can open and read the encrypted e-mails, which are HIPAA-compliant.⁴ This method is supe­rior to other services that encrypt e-mails on the server. Several providers, such as Google’s e-mail encryption service Postini, ensure that e-mails are encrypted when they are stored on the server; however, the body text and attachments included in specific e-mails are not encrypted on the senders’ and receivers’ devices. If you lose a connected device, you would still be at risk of a HIPAA breach.

DataMotion’s SecureMail provides detailed tracking and logging of e-mails, which is necessary for auditing purposes. The product also works on mobile devices.

E-mail is a helpful tool for quickly shar­ing files and an e-mail encryption product such as SecureMail makes it possible to do so securely. Other e-mail encryption prod­ucts do not securely store and back up all files in a centralized way.

DisclosureDr. Cidon is CEO and Co-founder of Sookasa.

3/24/15, Day 3 at SGS

Many topics, many learning opportunities   

The morning’s focus topics at SGS were divided up in small-group academic roundtables, with 15 experts in the field providing authoritative know-how and guidance to attendees. Topics ranged from tips for in-bag tissue extraction, endometriosis surgery, surviving health care transformation, cost-effectiveness, and single-site surgery to innovative treatments for fecal incontinence.

In the main hall, the fourth scientific session included oral presentations and videos that focused on anatomic landmarks and variations and included data presentation from an interesting prospective randomized trial in which the authors found bladder support is reduced by pregnancy, regardless of delivery method.

The highlight of the morning was certainly the debate over "power" morcellation. Dr. Cheryl Iglesia moderated in her charming and comical manner. Dr. Andrew Sokol and Dr. Jubilee Brown argued that power morcellation still should be available to a select group of appropriately chosen, low-risk women, and backed their arguments up with solid data. Dr. Eric Sokol, Andrew’s twin (and better looking, per him) brother, and Dr. Carl Zimmerman argued against the use of power morcellation, instead urging everyone in the audience to perform more vaginal hysterectomies. Though spirited and based largely on sound medical evidence, the debate did not have a clear winner. The overall consensus seemed to be that this controversial topic needed further evaluation and more data to support either claim.

"Sesame street graduates” and andragogy

We were then honored to have Vice President for Education, American College of Obstetricians and Gynecologists Dr. Sandra Carson as the esteemed TeLinde Lecturer. Her talk, “Teaching Medicine and Surgery to Sesame Street Graduates,” outlined the challenges in teaching surgery to a new generation of ObGyn residents as well as identified opportunities for improvement. She restated what seems to be the running theme at SGS this year: young faculty and residents are losing the skill for vaginal hysterectomy.

Dr. Carson introduced members of the audience to the adult theory of learning called andragogy. Adults like active learning, which is problem centered, rather than content oriented; linking new concepts to prior experience; and learning what is relevant to them, she noted. Then she shared ACOG’s strategies for applying these learning principles in resident education. She discussed ACOG’s recently formed Vaginal Hysterectomy Teaching Taskforce, which has put together a simulation consortium online toolkit and a surgical skills module to help educate residents on vaginal hysterectomy techniques. This toolkit and module can be accessed by doing a quick search after signing into the ACOG Web site.

Dr. Carson, a reproductive endocrinologist formerly at Brown University, is also now an honorary member of SGS.

Wise words from a wise physician

In his presidential address Dr. Stephen Metz acknowledged that all physicians are subject to even subtle “conflicts of interest,” reminding us to treat our patients as people not as a disease or a procedure.

“What does my patient really want from me? She wants me to get to know her to develop the right recommendations for her,” he said. His career has spanned multiple decades, and his service to the field of gynecology is outstanding. He received a well-deserved standing ovation at the end of his address.

Sport and socialization a necessity in sunny Florida!

The afternoon adjourned after the business meeting, and members were able to play golf, tennis, paddleboard in Winter Park, or just relax at the resort. Congratulations to the winners of the golf tournament (Drs. Hopkins, Rasmussen, Hurd, and Flora) and the tennis tournament (Dr. Ted Lee)!

Everyone convened at the outside terrace for the evening “Mojito Night in the Caribbean” reception, sharing good times, cocktails, and hors d’oeuvres. Proceeds from each ticket sold helped support Surgeons Helping Advance Research and Education (SHARE).

Tomorrow looks to be an excellent conclusion to a well-planned and very well-executed meeting. Kudos, and large thanks, to the SGS leadership.

3/23/15, Day 2 at SGS

Surgeons from 17 countries converge

The first day of the SGS scientific sessions was another energetic and interactive day. Sixteen new SGS members were recognized and welcomed in the main conference hall. Dr. Charles Rardin presented a brief overview and some basic statistics related to this year’s meeting—the largest ever in the history of SGS. A total of 401 attendees representing 17 countries are here in Orlando for SGS 2015! 

In the first scientific session, oral presentations touched on the subjects of preoperative dexamethasone use, vaginal packing, surgical site infections, and a new treatment modality for fecal incontinence. An excellent technique video on laparoscopic ureterolysis by Dr. Cara King then followed, in which she demonstrated excellent surgical skills with amazingly clear anatomy. Her video was recognized later in the day with a well-deserved award—congratulations! 

A short break in the exhibit hall allowed for mingling with other attendees, many of whom have been active on social media surrounding the meeting, and for visiting the booths of the industry sponsors. The second scientific session then picked up where the first left off, with more scientifically sound research presented on such topics as mechanical bowel preparation use in laparoscopy and pelvic floor disorders in women with gynecologic malignancies.

No room for fads in gyn surgery

Dr. David Grimes, a true leader in our field, provided an exceptional keynote address, “Is Teaching Evidence-Based Surgery Possible?" He shared his expertise of evidence-based medicine, and described (in sometimes very comical but always stimulating and provocative terms) the need for incorporating evidence-based surgery in gynecology. He urged us to strive to do best by our patients by applying evidenced-based practices rather than following fads and gizmos.

Gyn surgery training: Have we reached a “perfect storm”?

The afternoon brought with it a panel discussion on "Teaching the Next Generation of GYN Surgeons," with Dr. Hal Lawrence moderating and Dr. Mark Walters and Dr. Dee Fenner serving as panelists. They discussed the future of ObGyn residency training in great detail: increasing subspecialization, a stable birth rate, declining hysterectomy rates, increasing safety and quality monitoring, and increased access to data and informed consumers. All of these trends were highlighted as reasons for a perfect storm in gynecologic surgery training. In addition, the panel presented some surprising statistics: 

• The majority of hysterectomies in the United States are being done by surgeons who perform less than 1 per month.
• The higher volume surgeons provide higher value and tend to utilize more minimally invasive approaches.

Videofest!

The scientific day concluded with a videofest that included complex robotic, laparoscopic, hysteroscopic, cystoscopic, and vaginal surgeries, demonstrating the surgical talents and ingenuity of SGS members.

Simultaneously, the Fellows’ Pelvic Research Network (FPRN) met to update their ongoing projects and to review new proposals. The meeting sought to unite FPRMS and MIS fellows to conduct multicenter studies. This was an enlightening and engaging session, which should give everyone great hope to see the creativity and energy of the next generation of researchers.

A grounder for attendees

All in attendance were treated to a unique, eye-opening, motivational, and very moving talk by Professor (and Sir) Ajay Rane, MD, PhD from Australia on female genital mutilation. He stressed the importance of respecting women for who they are, not what they do.

“My idea of feminism is applauding a woman who gives birth. Celebrate women for who they are," he said. He highlighted the work being done by his team in Australia and India, and urged everyone in attendance to become more aware of the staggering statistics and reality of female genital mutilation.

The jam-packed day wrapped with the awards ceremony in the main hall. Lifelong mentors were honored by their mentees and SGS President Dr. Stephen Metz and Scientific Program Chair Dr. Charles Rardin presented various awards to those who had submitted and presented novel and groundbreaking research.

One last surprise

The President’s Reception in the exhibit hall was lively, with meeting sponsors, colleagues, and friends in attendance. And, of course, a visit from special guest! (Thanks to SGS Fellow Christina Saad, MD @XtinaSaad for the pic!)

See you all tomorrow for another educational, enlightening, and spirited day at #SGS2015! 

3/22/15. DAY 1 AT SGS

A focus on evidence-based medicine

Strong analytic skills (of your own research as well as the published literature) translates to better patient care, was the underlying theme of the opening postgraduate course here in Orlando, Florida, for day 1 of the 41st annual meeting of the Society of Gynecologic Surgeons.

Building on the success of last year’s course on evidence-based medicine (EBM), Dr. Vivian Sung and Dr. Ike Rahn put together an amazing team to review and apply the principles of so-called EBM, a workshop that was in part sponsored by ABOG.

A quick introduction to EBM principles by Dr. Thomas Wheeler was followed by small break-out groups, where attendees used the PICO-DD model to define a Population, Intervention, Comparator, Outcomes, Duration, and study Design. Further talks focused on the benefits and caveats of randomized controlled trials (RCTs), surrogate and intermediate outcomes, and systematic reviews and meta-analyses.

Dr. Ethan Balk cautioned us to consider the costly and underpowered RCT, and lack of generalizability needed to define rigorous study inclusion and outcome criteria. Dr. Sung then pointed out that, while the perfect surrogate outcome would allow us to shorten study lengths (and save money), the seduction of association and causation can lead to some questionable conclusions.

When using a clinical practice guideline, Dr. Miles Murphy indicated that a systematic review needs to be included, although a meta-analysis is not always required. The poor quality and paucity of RCTs for most patient populations is what limits us.

Dr. Rahn gave an excellent presentation on subgroup analysis, recommending to attendees that they perform these analyses cautiously, describe which groups are analyzed, and have statistical back-up for power and P value calculations.

Dr. Kristen Matteson then spoke about interpreting the literature on screening and diagnostic tests, giving a thorough but understandable review of the basics of statistics. Dr. John Wong rounded out the course, suggesting that because RCTs are expensive and comprise less than 5% of published studies, the analysis of observational studies as RCTs would allow us to better inform our patients and our colleagues on the best treatments, using patient-centered outcomes, efficacy data, and multiple providers. He urged us all to be more skeptical and ask critical questions when dealing with evidence in medicine.

Sharpening ultrasonography skills

Simultaneously, others attended a hands-on learning course on comprehensive pelvic floor ultrasonography, including transperineal, endovaginal, and endoanal imaging, organized by Dr. Abbas Shobeiri.

Tips for the difficult hysterectomy

Dr. Ted Lee (with help from Drs. Arnold P. Advincula, Rosanne Kho, and Matthew Seidhoff) prepared a surgical tutorial on laparoscopic, robotic, and vaginal strategies and techniques for approaching the difficult hysterectomy. The course was phenomenal, as described by many of the members fortunate enough to learn some of the tips and tricks demonstrated by the master surgeons.

Training for the NIH application process

Following the postgraduate courses, Dr. Katherine Hartmann led an “NIH Application Training Camp,” an offering supported by SGS research donations and a generous donation from Dr. Holly Richter. Dr. Hartmann provided in-depth insight into the world of NIH grant funding and provided background prep for a K or R award application. A mock NIH application study section, in which two actual applications were reviewed, demystified the process of grant review (and rejection). 

A social end to day 1

To end the first day, a welcome reception was held where residents, fellows, and attendings from different fields of ObGyn mingled and shared drinks, stories, and good laughs.

The "social" activities continue on social media for the rest of the conference. Follow #SGS2015, @gynsurgery, @obgmanagement, and @sukrantmehta for more!

3/24/15, Day 3 at SGS

Many topics, many learning opportunities   

The morning’s focus topics at SGS were divided up in small-group academic roundtables, with 15 experts in the field providing authoritative know-how and guidance to attendees. Topics ranged from tips for in-bag tissue extraction, endometriosis surgery, surviving health care transformation, cost-effectiveness, and single-site surgery to innovative treatments for fecal incontinence.

In the main hall, the fourth scientific session included oral presentations and videos that focused on anatomic landmarks and variations and included data presentation from an interesting prospective randomized trial in which the authors found bladder support is reduced by pregnancy, regardless of delivery method.

The highlight of the morning was certainly the debate over "power" morcellation. Dr. Cheryl Iglesia moderated in her charming and comical manner. Dr. Andrew Sokol and Dr. Jubilee Brown argued that power morcellation still should be available to a select group of appropriately chosen, low-risk women, and backed their arguments up with solid data. Dr. Eric Sokol, Andrew’s twin (and better looking, per him) brother, and Dr. Carl Zimmerman argued against the use of power morcellation, instead urging everyone in the audience to perform more vaginal hysterectomies. Though spirited and based largely on sound medical evidence, the debate did not have a clear winner. The overall consensus seemed to be that this controversial topic needed further evaluation and more data to support either claim.

"Sesame street graduates” and andragogy

We were then honored to have Vice President for Education, American College of Obstetricians and Gynecologists Dr. Sandra Carson as the esteemed TeLinde Lecturer. Her talk, “Teaching Medicine and Surgery to Sesame Street Graduates,” outlined the challenges in teaching surgery to a new generation of ObGyn residents as well as identified opportunities for improvement. She restated what seems to be the running theme at SGS this year: young faculty and residents are losing the skill for vaginal hysterectomy.

Dr. Carson introduced members of the audience to the adult theory of learning called andragogy. Adults like active learning, which is problem centered, rather than content oriented; linking new concepts to prior experience; and learning what is relevant to them, she noted. Then she shared ACOG’s strategies for applying these learning principles in resident education. She discussed ACOG’s recently formed Vaginal Hysterectomy Teaching Taskforce, which has put together a simulation consortium online toolkit and a surgical skills module to help educate residents on vaginal hysterectomy techniques. This toolkit and module can be accessed by doing a quick search after signing into the ACOG Web site.

Dr. Carson, a reproductive endocrinologist formerly at Brown University, is also now an honorary member of SGS.

Wise words from a wise physician

In his presidential address Dr. Stephen Metz acknowledged that all physicians are subject to even subtle “conflicts of interest,” reminding us to treat our patients as people not as a disease or a procedure.

“What does my patient really want from me? She wants me to get to know her to develop the right recommendations for her,” he said. His career has spanned multiple decades, and his service to the field of gynecology is outstanding. He received a well-deserved standing ovation at the end of his address.

Sport and socialization a necessity in sunny Florida!

The afternoon adjourned after the business meeting, and members were able to play golf, tennis, paddleboard in Winter Park, or just relax at the resort. Congratulations to the winners of the golf tournament (Drs. Hopkins, Rasmussen, Hurd, and Flora) and the tennis tournament (Dr. Ted Lee)!

Everyone convened at the outside terrace for the evening “Mojito Night in the Caribbean” reception, sharing good times, cocktails, and hors d’oeuvres. Proceeds from each ticket sold helped support Surgeons Helping Advance Research and Education (SHARE).

Tomorrow looks to be an excellent conclusion to a well-planned and very well-executed meeting. Kudos, and large thanks, to the SGS leadership.

3/23/15, Day 2 at SGS

Surgeons from 17 countries converge

The first day of the SGS scientific sessions was another energetic and interactive day. Sixteen new SGS members were recognized and welcomed in the main conference hall. Dr. Charles Rardin presented a brief overview and some basic statistics related to this year’s meeting—the largest ever in the history of SGS. A total of 401 attendees representing 17 countries are here in Orlando for SGS 2015! 

In the first scientific session, oral presentations touched on the subjects of preoperative dexamethasone use, vaginal packing, surgical site infections, and a new treatment modality for fecal incontinence. An excellent technique video on laparoscopic ureterolysis by Dr. Cara King then followed, in which she demonstrated excellent surgical skills with amazingly clear anatomy. Her video was recognized later in the day with a well-deserved award—congratulations! 

A short break in the exhibit hall allowed for mingling with other attendees, many of whom have been active on social media surrounding the meeting, and for visiting the booths of the industry sponsors. The second scientific session then picked up where the first left off, with more scientifically sound research presented on such topics as mechanical bowel preparation use in laparoscopy and pelvic floor disorders in women with gynecologic malignancies.

No room for fads in gyn surgery

Dr. David Grimes, a true leader in our field, provided an exceptional keynote address, “Is Teaching Evidence-Based Surgery Possible?" He shared his expertise of evidence-based medicine, and described (in sometimes very comical but always stimulating and provocative terms) the need for incorporating evidence-based surgery in gynecology. He urged us to strive to do best by our patients by applying evidenced-based practices rather than following fads and gizmos.

Gyn surgery training: Have we reached a “perfect storm”?

The afternoon brought with it a panel discussion on "Teaching the Next Generation of GYN Surgeons," with Dr. Hal Lawrence moderating and Dr. Mark Walters and Dr. Dee Fenner serving as panelists. They discussed the future of ObGyn residency training in great detail: increasing subspecialization, a stable birth rate, declining hysterectomy rates, increasing safety and quality monitoring, and increased access to data and informed consumers. All of these trends were highlighted as reasons for a perfect storm in gynecologic surgery training. In addition, the panel presented some surprising statistics: 

• The majority of hysterectomies in the United States are being done by surgeons who perform less than 1 per month.
• The higher volume surgeons provide higher value and tend to utilize more minimally invasive approaches.

Videofest!

The scientific day concluded with a videofest that included complex robotic, laparoscopic, hysteroscopic, cystoscopic, and vaginal surgeries, demonstrating the surgical talents and ingenuity of SGS members.

Simultaneously, the Fellows’ Pelvic Research Network (FPRN) met to update their ongoing projects and to review new proposals. The meeting sought to unite FPRMS and MIS fellows to conduct multicenter studies. This was an enlightening and engaging session, which should give everyone great hope to see the creativity and energy of the next generation of researchers.

A grounder for attendees

All in attendance were treated to a unique, eye-opening, motivational, and very moving talk by Professor (and Sir) Ajay Rane, MD, PhD from Australia on female genital mutilation. He stressed the importance of respecting women for who they are, not what they do.

“My idea of feminism is applauding a woman who gives birth. Celebrate women for who they are," he said. He highlighted the work being done by his team in Australia and India, and urged everyone in attendance to become more aware of the staggering statistics and reality of female genital mutilation.

The jam-packed day wrapped with the awards ceremony in the main hall. Lifelong mentors were honored by their mentees and SGS President Dr. Stephen Metz and Scientific Program Chair Dr. Charles Rardin presented various awards to those who had submitted and presented novel and groundbreaking research.

One last surprise

The President’s Reception in the exhibit hall was lively, with meeting sponsors, colleagues, and friends in attendance. And, of course, a visit from special guest! (Thanks to SGS Fellow Christina Saad, MD @XtinaSaad for the pic!)

See you all tomorrow for another educational, enlightening, and spirited day at #SGS2015! 

3/22/15. DAY 1 AT SGS

A focus on evidence-based medicine

Strong analytic skills (of your own research as well as the published literature) translates to better patient care, was the underlying theme of the opening postgraduate course here in Orlando, Florida, for day 1 of the 41st annual meeting of the Society of Gynecologic Surgeons.

Building on the success of last year’s course on evidence-based medicine (EBM), Dr. Vivian Sung and Dr. Ike Rahn put together an amazing team to review and apply the principles of so-called EBM, a workshop that was in part sponsored by ABOG.

A quick introduction to EBM principles by Dr. Thomas Wheeler was followed by small break-out groups, where attendees used the PICO-DD model to define a Population, Intervention, Comparator, Outcomes, Duration, and study Design. Further talks focused on the benefits and caveats of randomized controlled trials (RCTs), surrogate and intermediate outcomes, and systematic reviews and meta-analyses.

Dr. Ethan Balk cautioned us to consider the costly and underpowered RCT, and lack of generalizability needed to define rigorous study inclusion and outcome criteria. Dr. Sung then pointed out that, while the perfect surrogate outcome would allow us to shorten study lengths (and save money), the seduction of association and causation can lead to some questionable conclusions.

When using a clinical practice guideline, Dr. Miles Murphy indicated that a systematic review needs to be included, although a meta-analysis is not always required. The poor quality and paucity of RCTs for most patient populations is what limits us.

Dr. Rahn gave an excellent presentation on subgroup analysis, recommending to attendees that they perform these analyses cautiously, describe which groups are analyzed, and have statistical back-up for power and P value calculations.

Dr. Kristen Matteson then spoke about interpreting the literature on screening and diagnostic tests, giving a thorough but understandable review of the basics of statistics. Dr. John Wong rounded out the course, suggesting that because RCTs are expensive and comprise less than 5% of published studies, the analysis of observational studies as RCTs would allow us to better inform our patients and our colleagues on the best treatments, using patient-centered outcomes, efficacy data, and multiple providers. He urged us all to be more skeptical and ask critical questions when dealing with evidence in medicine.

Sharpening ultrasonography skills

Simultaneously, others attended a hands-on learning course on comprehensive pelvic floor ultrasonography, including transperineal, endovaginal, and endoanal imaging, organized by Dr. Abbas Shobeiri.

Tips for the difficult hysterectomy

Dr. Ted Lee (with help from Drs. Arnold P. Advincula, Rosanne Kho, and Matthew Seidhoff) prepared a surgical tutorial on laparoscopic, robotic, and vaginal strategies and techniques for approaching the difficult hysterectomy. The course was phenomenal, as described by many of the members fortunate enough to learn some of the tips and tricks demonstrated by the master surgeons.

Training for the NIH application process

Following the postgraduate courses, Dr. Katherine Hartmann led an “NIH Application Training Camp,” an offering supported by SGS research donations and a generous donation from Dr. Holly Richter. Dr. Hartmann provided in-depth insight into the world of NIH grant funding and provided background prep for a K or R award application. A mock NIH application study section, in which two actual applications were reviewed, demystified the process of grant review (and rejection). 

A social end to day 1

To end the first day, a welcome reception was held where residents, fellows, and attendings from different fields of ObGyn mingled and shared drinks, stories, and good laughs.

The "social" activities continue on social media for the rest of the conference. Follow #SGS2015, @gynsurgery, @obgmanagement, and @sukrantmehta for more!

3/24/15, Day 3 at SGS

Many topics, many learning opportunities   

The morning’s focus topics at SGS were divided up in small-group academic roundtables, with 15 experts in the field providing authoritative know-how and guidance to attendees. Topics ranged from tips for in-bag tissue extraction, endometriosis surgery, surviving health care transformation, cost-effectiveness, and single-site surgery to innovative treatments for fecal incontinence.

In the main hall, the fourth scientific session included oral presentations and videos that focused on anatomic landmarks and variations and included data presentation from an interesting prospective randomized trial in which the authors found bladder support is reduced by pregnancy, regardless of delivery method.

The highlight of the morning was certainly the debate over "power" morcellation. Dr. Cheryl Iglesia moderated in her charming and comical manner. Dr. Andrew Sokol and Dr. Jubilee Brown argued that power morcellation still should be available to a select group of appropriately chosen, low-risk women, and backed their arguments up with solid data. Dr. Eric Sokol, Andrew’s twin (and better looking, per him) brother, and Dr. Carl Zimmerman argued against the use of power morcellation, instead urging everyone in the audience to perform more vaginal hysterectomies. Though spirited and based largely on sound medical evidence, the debate did not have a clear winner. The overall consensus seemed to be that this controversial topic needed further evaluation and more data to support either claim.

"Sesame street graduates” and andragogy

We were then honored to have Vice President for Education, American College of Obstetricians and Gynecologists Dr. Sandra Carson as the esteemed TeLinde Lecturer. Her talk, “Teaching Medicine and Surgery to Sesame Street Graduates,” outlined the challenges in teaching surgery to a new generation of ObGyn residents as well as identified opportunities for improvement. She restated what seems to be the running theme at SGS this year: young faculty and residents are losing the skill for vaginal hysterectomy.

Dr. Carson introduced members of the audience to the adult theory of learning called andragogy. Adults like active learning, which is problem centered, rather than content oriented; linking new concepts to prior experience; and learning what is relevant to them, she noted. Then she shared ACOG’s strategies for applying these learning principles in resident education. She discussed ACOG’s recently formed Vaginal Hysterectomy Teaching Taskforce, which has put together a simulation consortium online toolkit and a surgical skills module to help educate residents on vaginal hysterectomy techniques. This toolkit and module can be accessed by doing a quick search after signing into the ACOG Web site.

Dr. Carson, a reproductive endocrinologist formerly at Brown University, is also now an honorary member of SGS.

Wise words from a wise physician

In his presidential address Dr. Stephen Metz acknowledged that all physicians are subject to even subtle “conflicts of interest,” reminding us to treat our patients as people not as a disease or a procedure.

“What does my patient really want from me? She wants me to get to know her to develop the right recommendations for her,” he said. His career has spanned multiple decades, and his service to the field of gynecology is outstanding. He received a well-deserved standing ovation at the end of his address.

Sport and socialization a necessity in sunny Florida!

The afternoon adjourned after the business meeting, and members were able to play golf, tennis, paddleboard in Winter Park, or just relax at the resort. Congratulations to the winners of the golf tournament (Drs. Hopkins, Rasmussen, Hurd, and Flora) and the tennis tournament (Dr. Ted Lee)!

Everyone convened at the outside terrace for the evening “Mojito Night in the Caribbean” reception, sharing good times, cocktails, and hors d’oeuvres. Proceeds from each ticket sold helped support Surgeons Helping Advance Research and Education (SHARE).

Tomorrow looks to be an excellent conclusion to a well-planned and very well-executed meeting. Kudos, and large thanks, to the SGS leadership.

3/23/15, Day 2 at SGS

Surgeons from 17 countries converge

The first day of the SGS scientific sessions was another energetic and interactive day. Sixteen new SGS members were recognized and welcomed in the main conference hall. Dr. Charles Rardin presented a brief overview and some basic statistics related to this year’s meeting—the largest ever in the history of SGS. A total of 401 attendees representing 17 countries are here in Orlando for SGS 2015! 

In the first scientific session, oral presentations touched on the subjects of preoperative dexamethasone use, vaginal packing, surgical site infections, and a new treatment modality for fecal incontinence. An excellent technique video on laparoscopic ureterolysis by Dr. Cara King then followed, in which she demonstrated excellent surgical skills with amazingly clear anatomy. Her video was recognized later in the day with a well-deserved award—congratulations! 

A short break in the exhibit hall allowed for mingling with other attendees, many of whom have been active on social media surrounding the meeting, and for visiting the booths of the industry sponsors. The second scientific session then picked up where the first left off, with more scientifically sound research presented on such topics as mechanical bowel preparation use in laparoscopy and pelvic floor disorders in women with gynecologic malignancies.

No room for fads in gyn surgery

Dr. David Grimes, a true leader in our field, provided an exceptional keynote address, “Is Teaching Evidence-Based Surgery Possible?" He shared his expertise of evidence-based medicine, and described (in sometimes very comical but always stimulating and provocative terms) the need for incorporating evidence-based surgery in gynecology. He urged us to strive to do best by our patients by applying evidenced-based practices rather than following fads and gizmos.

Gyn surgery training: Have we reached a “perfect storm”?

The afternoon brought with it a panel discussion on "Teaching the Next Generation of GYN Surgeons," with Dr. Hal Lawrence moderating and Dr. Mark Walters and Dr. Dee Fenner serving as panelists. They discussed the future of ObGyn residency training in great detail: increasing subspecialization, a stable birth rate, declining hysterectomy rates, increasing safety and quality monitoring, and increased access to data and informed consumers. All of these trends were highlighted as reasons for a perfect storm in gynecologic surgery training. In addition, the panel presented some surprising statistics: 

• The majority of hysterectomies in the United States are being done by surgeons who perform less than 1 per month.
• The higher volume surgeons provide higher value and tend to utilize more minimally invasive approaches.

Videofest!

The scientific day concluded with a videofest that included complex robotic, laparoscopic, hysteroscopic, cystoscopic, and vaginal surgeries, demonstrating the surgical talents and ingenuity of SGS members.

Simultaneously, the Fellows’ Pelvic Research Network (FPRN) met to update their ongoing projects and to review new proposals. The meeting sought to unite FPRMS and MIS fellows to conduct multicenter studies. This was an enlightening and engaging session, which should give everyone great hope to see the creativity and energy of the next generation of researchers.

A grounder for attendees

All in attendance were treated to a unique, eye-opening, motivational, and very moving talk by Professor (and Sir) Ajay Rane, MD, PhD from Australia on female genital mutilation. He stressed the importance of respecting women for who they are, not what they do.

“My idea of feminism is applauding a woman who gives birth. Celebrate women for who they are," he said. He highlighted the work being done by his team in Australia and India, and urged everyone in attendance to become more aware of the staggering statistics and reality of female genital mutilation.

The jam-packed day wrapped with the awards ceremony in the main hall. Lifelong mentors were honored by their mentees and SGS President Dr. Stephen Metz and Scientific Program Chair Dr. Charles Rardin presented various awards to those who had submitted and presented novel and groundbreaking research.

One last surprise

The President’s Reception in the exhibit hall was lively, with meeting sponsors, colleagues, and friends in attendance. And, of course, a visit from special guest! (Thanks to SGS Fellow Christina Saad, MD @XtinaSaad for the pic!)

See you all tomorrow for another educational, enlightening, and spirited day at #SGS2015! 

3/22/15. DAY 1 AT SGS

A focus on evidence-based medicine

Strong analytic skills (of your own research as well as the published literature) translates to better patient care, was the underlying theme of the opening postgraduate course here in Orlando, Florida, for day 1 of the 41st annual meeting of the Society of Gynecologic Surgeons.

Building on the success of last year’s course on evidence-based medicine (EBM), Dr. Vivian Sung and Dr. Ike Rahn put together an amazing team to review and apply the principles of so-called EBM, a workshop that was in part sponsored by ABOG.

A quick introduction to EBM principles by Dr. Thomas Wheeler was followed by small break-out groups, where attendees used the PICO-DD model to define a Population, Intervention, Comparator, Outcomes, Duration, and study Design. Further talks focused on the benefits and caveats of randomized controlled trials (RCTs), surrogate and intermediate outcomes, and systematic reviews and meta-analyses.

Dr. Ethan Balk cautioned us to consider the costly and underpowered RCT, and lack of generalizability needed to define rigorous study inclusion and outcome criteria. Dr. Sung then pointed out that, while the perfect surrogate outcome would allow us to shorten study lengths (and save money), the seduction of association and causation can lead to some questionable conclusions.

When using a clinical practice guideline, Dr. Miles Murphy indicated that a systematic review needs to be included, although a meta-analysis is not always required. The poor quality and paucity of RCTs for most patient populations is what limits us.

Dr. Rahn gave an excellent presentation on subgroup analysis, recommending to attendees that they perform these analyses cautiously, describe which groups are analyzed, and have statistical back-up for power and P value calculations.

Dr. Kristen Matteson then spoke about interpreting the literature on screening and diagnostic tests, giving a thorough but understandable review of the basics of statistics. Dr. John Wong rounded out the course, suggesting that because RCTs are expensive and comprise less than 5% of published studies, the analysis of observational studies as RCTs would allow us to better inform our patients and our colleagues on the best treatments, using patient-centered outcomes, efficacy data, and multiple providers. He urged us all to be more skeptical and ask critical questions when dealing with evidence in medicine.

Sharpening ultrasonography skills

Simultaneously, others attended a hands-on learning course on comprehensive pelvic floor ultrasonography, including transperineal, endovaginal, and endoanal imaging, organized by Dr. Abbas Shobeiri.

Tips for the difficult hysterectomy

Dr. Ted Lee (with help from Drs. Arnold P. Advincula, Rosanne Kho, and Matthew Seidhoff) prepared a surgical tutorial on laparoscopic, robotic, and vaginal strategies and techniques for approaching the difficult hysterectomy. The course was phenomenal, as described by many of the members fortunate enough to learn some of the tips and tricks demonstrated by the master surgeons.

Training for the NIH application process

Following the postgraduate courses, Dr. Katherine Hartmann led an “NIH Application Training Camp,” an offering supported by SGS research donations and a generous donation from Dr. Holly Richter. Dr. Hartmann provided in-depth insight into the world of NIH grant funding and provided background prep for a K or R award application. A mock NIH application study section, in which two actual applications were reviewed, demystified the process of grant review (and rejection). 

A social end to day 1

To end the first day, a welcome reception was held where residents, fellows, and attendings from different fields of ObGyn mingled and shared drinks, stories, and good laughs.

The "social" activities continue on social media for the rest of the conference. Follow #SGS2015, @gynsurgery, @obgmanagement, and @sukrantmehta for more!

Over the past several years, there has been increasing amounts of research documenting the caregiving challenges that accompany the day-to-day parenting of a child with special health needs and/or chronic medical conditions. Children who are diagnosed with emotional and behavioral problems (ranging from attention-deficit/hyperactivity disorder (ADHD) to autism – which also can be considered chronic conditions), can pose parenting challenges for even the most healthy, supportive, and committed parents. From the point of receiving a diagnosis to daily management of the range of symptoms and attempting to coordinate care with various providers, the emotional stress experienced by caregivers can be quite burdensome and may affect the functioning of the entire family. In an effort to achieve successful treatment outcomes for the child, it’s important to be mindful of this emotional stress and provide parents with tools to foster their own wellness and mental health while mitigating the risk for them developing their own health concerns.

Case summary

Bridget is a 10-year-old girl who presents with her single mother for a psychiatric consultation. Since early childhood, Bridget has demonstrated an array of behaviors that have affected her ability to engage with others socially; she was thought to be a temperamentally shy and sensitive toddler, and in elementary school, her mother describes the emergence of odd mental status changes and accompanying motor movements that were later diagnosed as complex-partial epilepsy. Since this diagnosis at the age of 6 years, despite receiving various antiepileptic treatment, Bridget has continued to present with an intractable seizure disorder. She is now prescribed a combination of benzodiazepines, cannabinoids, and other antiepileptic agents, but still has marked functional impairments. Behaviorally, it appears that Bridget has experienced some regression over the years and has been recently tested to have low-average intelligence and a neurocognitive profile characterized by attentional difficulties, executive impairments, and significant processing deficits.

Because of her complicated presentation, Bridget has been unable to attend school-based academic instruction, and her escalating levels of generalized worry have limited her ability to reliably interact with individuals outside of the family. These challenges also have posed difficulties for providers to perform thorough evaluations and provide Bridget with psychosocial interventions to address her anxiety and self-regulatory deficits. All in all, Bridget is a diagnostically complicated young girl. Her mother wishes to “figure things out,” and acknowledges having trouble managing her daughter’s increasingly defiant and unpredictable behaviors. In the past, setting limits and placing stress on Bridget have been thought to be etiologically related to seizure onset. Additionally, Bridget’s mother has been unable to find her own employment while providing care for her daughter and reports that financially, she isn’t sure how she can make ends meet while providing Bridget with medical marijuana. Bridget’s mother’s composure during the evaluation is applauded (particularly when her daughter’s defiant actions are readily appreciated), but she admits to feeling “exhausted.”

Discussion

Bridget’s case illustrates not only the complexities in attempting to understand and diagnose multifaceted neuropsychiatric phenomena, but also the struggles experienced by families who are challenged economically, socially, psychologically, and emotionally as a result of their child’s difficulties. Although caregiving and parenting is rife with rewarding opportunities for many family members, the provision of such nurturance can undoubtedly place parents at risk for significant hardships. Studies have demonstrated that caregiving demands are associated with poor health outcomes in adult caregivers (Ann. Behav. Med. 1997;19:110-6), and maternal cortisol levels in mothers of older children with autism were found to be significantly lower than normal and the hormonal dysregulation was associated with their child’s behavioral profile. Such findings are similar to those recognized in combat soldiers and others who experience enduring psychological distress (J. Autism Dev. Disord. 2010; 40:457-69).

Upon meeting with Bridget, it became clear that her mother required additional support and services to help care for her daughter’s difficult needs. Through seeking a diagnosis for her daughter, Bridget’s mother also was pursuing an understanding of her daughter’s strengths and struggles, and looking to partner with a provider who might be able to help her navigate the often complicated system of care. By gathering a comprehensive family history (assessing what mom’s vulnerabilities may be for developing her own mental health issues) and thoroughly assessing her current functioning with the Adult Self-Report and the Parenting Stress Index, as a provider, I was better informed to offer family-based treatment recommendations. Through self-reporting, Bridget’s mother endorsed her own mood complaints, occasional substance use, and a constellation of anxiety-based difficulties. We had a thoughtful discussion pertaining to elements of grief, fears, and guilt, which helped to lay the foundation for later exploring how Bridget may best be cared for in the future (such as residential placement). Bridget’s mother shared that she initially felt like a failure for seeking help and not “being able to parent” her daughter; supportive techniques were used to provide her with reassurance and validation.

Using Bridget’s mother’s strengths (resiliency, being a strong advocate for her daughter), other recommendations also were offered to help her to more effectively parent her child and avoid burnout. Not inclusive of suggestions directed towards Bridget individually, these recommendations included:

• Having mom seek her own psychotherapeutic and psychiatric care. Goals of her treatment would be to support her own wellness (through exercise, mindfulness, engagement in positive activities) and focus on developing healthy relationships. By getting her own anxiety under control, assessing her own parenting and coping styles, and additionally obtaining psychoeducation about anxiety disorders in children, mom is primed to develop more successful ways to address Bridget’s defiance and avoid enabling her daughter’s excessive worry while encouraging her to be more socially active.

• Finding respite providers for Bridget. Then mom has more opportunities to seek employment and participate in other out-of-the-home activities.

• Developing a relationship with the school district. This way mom can obtain appropriate supports and accommodations for Bridget to be educated outside the home.

• Exploring community resources through local agencies. This would help mom plan for the future, examine possible sources of financial support, and perhaps most importantly, obtain a treatment team leader and care coordinator.

• Enhancing social supports. This can be done via connections to local support groups.

Clinical pearl

It’s not surprising that parents of children with special needs experience high levels of stress. Be aware of how such stress can affect a parent’s ability to care for their child, and be mindful that a child’s wellness can be significantly mediated by parental wellness and health. When designing treatment plans, routinely assess family caregivers’ stress levels (including that of siblings and fathers) and evaluate other indicators of stress (such as sleep disturbances, weight change, apathy, and expression of negative emotion). Advocate for programs and systems of care that can address both parental and child mental health issues in a coordinated manner that also enhances family cohesion, reduces social isolation, and decreases parental marginalization.

Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont, Burlington. He is the director of the university’s autism diagnostic clinic. Contact Dr. Dickerson at [email protected].

Over the past several years, there has been increasing amounts of research documenting the caregiving challenges that accompany the day-to-day parenting of a child with special health needs and/or chronic medical conditions. Children who are diagnosed with emotional and behavioral problems (ranging from attention-deficit/hyperactivity disorder (ADHD) to autism – which also can be considered chronic conditions), can pose parenting challenges for even the most healthy, supportive, and committed parents. From the point of receiving a diagnosis to daily management of the range of symptoms and attempting to coordinate care with various providers, the emotional stress experienced by caregivers can be quite burdensome and may affect the functioning of the entire family. In an effort to achieve successful treatment outcomes for the child, it’s important to be mindful of this emotional stress and provide parents with tools to foster their own wellness and mental health while mitigating the risk for them developing their own health concerns.

Case summary

Bridget is a 10-year-old girl who presents with her single mother for a psychiatric consultation. Since early childhood, Bridget has demonstrated an array of behaviors that have affected her ability to engage with others socially; she was thought to be a temperamentally shy and sensitive toddler, and in elementary school, her mother describes the emergence of odd mental status changes and accompanying motor movements that were later diagnosed as complex-partial epilepsy. Since this diagnosis at the age of 6 years, despite receiving various antiepileptic treatment, Bridget has continued to present with an intractable seizure disorder. She is now prescribed a combination of benzodiazepines, cannabinoids, and other antiepileptic agents, but still has marked functional impairments. Behaviorally, it appears that Bridget has experienced some regression over the years and has been recently tested to have low-average intelligence and a neurocognitive profile characterized by attentional difficulties, executive impairments, and significant processing deficits.

Because of her complicated presentation, Bridget has been unable to attend school-based academic instruction, and her escalating levels of generalized worry have limited her ability to reliably interact with individuals outside of the family. These challenges also have posed difficulties for providers to perform thorough evaluations and provide Bridget with psychosocial interventions to address her anxiety and self-regulatory deficits. All in all, Bridget is a diagnostically complicated young girl. Her mother wishes to “figure things out,” and acknowledges having trouble managing her daughter’s increasingly defiant and unpredictable behaviors. In the past, setting limits and placing stress on Bridget have been thought to be etiologically related to seizure onset. Additionally, Bridget’s mother has been unable to find her own employment while providing care for her daughter and reports that financially, she isn’t sure how she can make ends meet while providing Bridget with medical marijuana. Bridget’s mother’s composure during the evaluation is applauded (particularly when her daughter’s defiant actions are readily appreciated), but she admits to feeling “exhausted.”

Discussion

Bridget’s case illustrates not only the complexities in attempting to understand and diagnose multifaceted neuropsychiatric phenomena, but also the struggles experienced by families who are challenged economically, socially, psychologically, and emotionally as a result of their child’s difficulties. Although caregiving and parenting is rife with rewarding opportunities for many family members, the provision of such nurturance can undoubtedly place parents at risk for significant hardships. Studies have demonstrated that caregiving demands are associated with poor health outcomes in adult caregivers (Ann. Behav. Med. 1997;19:110-6), and maternal cortisol levels in mothers of older children with autism were found to be significantly lower than normal and the hormonal dysregulation was associated with their child’s behavioral profile. Such findings are similar to those recognized in combat soldiers and others who experience enduring psychological distress (J. Autism Dev. Disord. 2010; 40:457-69).

Upon meeting with Bridget, it became clear that her mother required additional support and services to help care for her daughter’s difficult needs. Through seeking a diagnosis for her daughter, Bridget’s mother also was pursuing an understanding of her daughter’s strengths and struggles, and looking to partner with a provider who might be able to help her navigate the often complicated system of care. By gathering a comprehensive family history (assessing what mom’s vulnerabilities may be for developing her own mental health issues) and thoroughly assessing her current functioning with the Adult Self-Report and the Parenting Stress Index, as a provider, I was better informed to offer family-based treatment recommendations. Through self-reporting, Bridget’s mother endorsed her own mood complaints, occasional substance use, and a constellation of anxiety-based difficulties. We had a thoughtful discussion pertaining to elements of grief, fears, and guilt, which helped to lay the foundation for later exploring how Bridget may best be cared for in the future (such as residential placement). Bridget’s mother shared that she initially felt like a failure for seeking help and not “being able to parent” her daughter; supportive techniques were used to provide her with reassurance and validation.

Using Bridget’s mother’s strengths (resiliency, being a strong advocate for her daughter), other recommendations also were offered to help her to more effectively parent her child and avoid burnout. Not inclusive of suggestions directed towards Bridget individually, these recommendations included:

• Having mom seek her own psychotherapeutic and psychiatric care. Goals of her treatment would be to support her own wellness (through exercise, mindfulness, engagement in positive activities) and focus on developing healthy relationships. By getting her own anxiety under control, assessing her own parenting and coping styles, and additionally obtaining psychoeducation about anxiety disorders in children, mom is primed to develop more successful ways to address Bridget’s defiance and avoid enabling her daughter’s excessive worry while encouraging her to be more socially active.

• Finding respite providers for Bridget. Then mom has more opportunities to seek employment and participate in other out-of-the-home activities.

• Developing a relationship with the school district. This way mom can obtain appropriate supports and accommodations for Bridget to be educated outside the home.

• Exploring community resources through local agencies. This would help mom plan for the future, examine possible sources of financial support, and perhaps most importantly, obtain a treatment team leader and care coordinator.

• Enhancing social supports. This can be done via connections to local support groups.

Clinical pearl

It’s not surprising that parents of children with special needs experience high levels of stress. Be aware of how such stress can affect a parent’s ability to care for their child, and be mindful that a child’s wellness can be significantly mediated by parental wellness and health. When designing treatment plans, routinely assess family caregivers’ stress levels (including that of siblings and fathers) and evaluate other indicators of stress (such as sleep disturbances, weight change, apathy, and expression of negative emotion). Advocate for programs and systems of care that can address both parental and child mental health issues in a coordinated manner that also enhances family cohesion, reduces social isolation, and decreases parental marginalization.

Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont, Burlington. He is the director of the university’s autism diagnostic clinic. Contact Dr. Dickerson at [email protected].

Over the past several years, there has been increasing amounts of research documenting the caregiving challenges that accompany the day-to-day parenting of a child with special health needs and/or chronic medical conditions. Children who are diagnosed with emotional and behavioral problems (ranging from attention-deficit/hyperactivity disorder (ADHD) to autism – which also can be considered chronic conditions), can pose parenting challenges for even the most healthy, supportive, and committed parents. From the point of receiving a diagnosis to daily management of the range of symptoms and attempting to coordinate care with various providers, the emotional stress experienced by caregivers can be quite burdensome and may affect the functioning of the entire family. In an effort to achieve successful treatment outcomes for the child, it’s important to be mindful of this emotional stress and provide parents with tools to foster their own wellness and mental health while mitigating the risk for them developing their own health concerns.

Case summary

Bridget is a 10-year-old girl who presents with her single mother for a psychiatric consultation. Since early childhood, Bridget has demonstrated an array of behaviors that have affected her ability to engage with others socially; she was thought to be a temperamentally shy and sensitive toddler, and in elementary school, her mother describes the emergence of odd mental status changes and accompanying motor movements that were later diagnosed as complex-partial epilepsy. Since this diagnosis at the age of 6 years, despite receiving various antiepileptic treatment, Bridget has continued to present with an intractable seizure disorder. She is now prescribed a combination of benzodiazepines, cannabinoids, and other antiepileptic agents, but still has marked functional impairments. Behaviorally, it appears that Bridget has experienced some regression over the years and has been recently tested to have low-average intelligence and a neurocognitive profile characterized by attentional difficulties, executive impairments, and significant processing deficits.

Because of her complicated presentation, Bridget has been unable to attend school-based academic instruction, and her escalating levels of generalized worry have limited her ability to reliably interact with individuals outside of the family. These challenges also have posed difficulties for providers to perform thorough evaluations and provide Bridget with psychosocial interventions to address her anxiety and self-regulatory deficits. All in all, Bridget is a diagnostically complicated young girl. Her mother wishes to “figure things out,” and acknowledges having trouble managing her daughter’s increasingly defiant and unpredictable behaviors. In the past, setting limits and placing stress on Bridget have been thought to be etiologically related to seizure onset. Additionally, Bridget’s mother has been unable to find her own employment while providing care for her daughter and reports that financially, she isn’t sure how she can make ends meet while providing Bridget with medical marijuana. Bridget’s mother’s composure during the evaluation is applauded (particularly when her daughter’s defiant actions are readily appreciated), but she admits to feeling “exhausted.”

Discussion

Bridget’s case illustrates not only the complexities in attempting to understand and diagnose multifaceted neuropsychiatric phenomena, but also the struggles experienced by families who are challenged economically, socially, psychologically, and emotionally as a result of their child’s difficulties. Although caregiving and parenting is rife with rewarding opportunities for many family members, the provision of such nurturance can undoubtedly place parents at risk for significant hardships. Studies have demonstrated that caregiving demands are associated with poor health outcomes in adult caregivers (Ann. Behav. Med. 1997;19:110-6), and maternal cortisol levels in mothers of older children with autism were found to be significantly lower than normal and the hormonal dysregulation was associated with their child’s behavioral profile. Such findings are similar to those recognized in combat soldiers and others who experience enduring psychological distress (J. Autism Dev. Disord. 2010; 40:457-69).

Upon meeting with Bridget, it became clear that her mother required additional support and services to help care for her daughter’s difficult needs. Through seeking a diagnosis for her daughter, Bridget’s mother also was pursuing an understanding of her daughter’s strengths and struggles, and looking to partner with a provider who might be able to help her navigate the often complicated system of care. By gathering a comprehensive family history (assessing what mom’s vulnerabilities may be for developing her own mental health issues) and thoroughly assessing her current functioning with the Adult Self-Report and the Parenting Stress Index, as a provider, I was better informed to offer family-based treatment recommendations. Through self-reporting, Bridget’s mother endorsed her own mood complaints, occasional substance use, and a constellation of anxiety-based difficulties. We had a thoughtful discussion pertaining to elements of grief, fears, and guilt, which helped to lay the foundation for later exploring how Bridget may best be cared for in the future (such as residential placement). Bridget’s mother shared that she initially felt like a failure for seeking help and not “being able to parent” her daughter; supportive techniques were used to provide her with reassurance and validation.

Using Bridget’s mother’s strengths (resiliency, being a strong advocate for her daughter), other recommendations also were offered to help her to more effectively parent her child and avoid burnout. Not inclusive of suggestions directed towards Bridget individually, these recommendations included:

• Having mom seek her own psychotherapeutic and psychiatric care. Goals of her treatment would be to support her own wellness (through exercise, mindfulness, engagement in positive activities) and focus on developing healthy relationships. By getting her own anxiety under control, assessing her own parenting and coping styles, and additionally obtaining psychoeducation about anxiety disorders in children, mom is primed to develop more successful ways to address Bridget’s defiance and avoid enabling her daughter’s excessive worry while encouraging her to be more socially active.

• Finding respite providers for Bridget. Then mom has more opportunities to seek employment and participate in other out-of-the-home activities.

• Developing a relationship with the school district. This way mom can obtain appropriate supports and accommodations for Bridget to be educated outside the home.

• Exploring community resources through local agencies. This would help mom plan for the future, examine possible sources of financial support, and perhaps most importantly, obtain a treatment team leader and care coordinator.

• Enhancing social supports. This can be done via connections to local support groups.

Clinical pearl

It’s not surprising that parents of children with special needs experience high levels of stress. Be aware of how such stress can affect a parent’s ability to care for their child, and be mindful that a child’s wellness can be significantly mediated by parental wellness and health. When designing treatment plans, routinely assess family caregivers’ stress levels (including that of siblings and fathers) and evaluate other indicators of stress (such as sleep disturbances, weight change, apathy, and expression of negative emotion). Advocate for programs and systems of care that can address both parental and child mental health issues in a coordinated manner that also enhances family cohesion, reduces social isolation, and decreases parental marginalization.

Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont, Burlington. He is the director of the university’s autism diagnostic clinic. Contact Dr. Dickerson at [email protected].