Pearls

Benzodiazepines are one of the most commonly prescribed medication classes worldwide.¹ Patients prescribed benzodiazepines who have no history of abuse or misuse may want to reduce or discontinue using these agents for various reasons, including adverse effects or wanting to reduce the number of medications they take. In this article, we offer strategies for creating an individualized taper plan, and describe additional nonpharmacologic interventions to help ensure that the taper is successful.

Formulating a taper plan

There is no gold-standard algorithm for tapering benzodiazepines.^1,2 Even with a carefully designed plan, tapering can be challenging because approximately one-third of patients will experience difficulties such as withdrawal symptoms.¹ Prior to creating a plan, carefully assess the patient’s history, including the type of benzodiazepine prescribed (short- or long-acting); the dose, dosing frequency, and duration of use; comorbid medical and psychiatric conditions; any previous experience with withdrawal symptoms; and psychosocial factors (eg, lifestyle and personality). Consider whether the patient can be safely tapered in an outpatient setting or will require hospitalization. Tapering designed to take place over several weeks or months tends to be more successful; however, patient-specific circumstances play a role in determining the duration of the taper.^1,2

For the greatest chance of success, a benzodiazepine should not be reduced faster than 25% of the total daily dose per week.¹ Consider which of the following pharmacologic approaches to benzodiazepine tapering might work best for your patient:

• Reduce the daily dose by one-eighth to one-tenth every 1 to 2 weeks over a 2- to 12-month period for patients with a physiological dependence.¹
• Reduce the benzodiazepine dose by 10% to 25% every 2 weeks over a 4- to 8-week period.²
• Some guidelines have suggested converting the prescribed benzodiazepine to an equivalent dose of diazepam because of its long half-life, and then reducing the diazepam dose by one-eighth every 2 weeks.³

There is uncertainty in the medical literature about using a long-acting benzodiazepine to taper off a short-acting benzodiazepine, although this practice is generally clinically accepted.^1,2 Similarly, there is no definitive evidence that supports using adjuvant medications to facilitate tapering.^1,2

Nonpharmacologic interventions

Patients are more likely to have a successful taper if nonpharmacologic interventions are part of a comprehensive treatment plan.¹

To help your patients through the challenges of a benzodiazepine taper:

• Validate their concerns, reassure them that you will support them throughout the taper, and provide information on additional resources for support.
• Provide education about the process of tapering and symptoms of withdrawal.
• Recommend therapies, such as cognitive-behavioral therapy or motivational interventions, that develop or enhance coping skills.
• Enlist the help of the patient’s family and friends for support and encouragement.

Despite some clinicians’ trepidation, 70% to 90% of patients can be successfully tapered off benzodiazepines by using an individualized approach that includes tailored tapering and nonpharmacologic interventions that provide benefits that persist after the patient completes the taper.¹

Benzodiazepines are one of the most commonly prescribed medication classes worldwide.¹ Patients prescribed benzodiazepines who have no history of abuse or misuse may want to reduce or discontinue using these agents for various reasons, including adverse effects or wanting to reduce the number of medications they take. In this article, we offer strategies for creating an individualized taper plan, and describe additional nonpharmacologic interventions to help ensure that the taper is successful.

Formulating a taper plan

There is no gold-standard algorithm for tapering benzodiazepines.^1,2 Even with a carefully designed plan, tapering can be challenging because approximately one-third of patients will experience difficulties such as withdrawal symptoms.¹ Prior to creating a plan, carefully assess the patient’s history, including the type of benzodiazepine prescribed (short- or long-acting); the dose, dosing frequency, and duration of use; comorbid medical and psychiatric conditions; any previous experience with withdrawal symptoms; and psychosocial factors (eg, lifestyle and personality). Consider whether the patient can be safely tapered in an outpatient setting or will require hospitalization. Tapering designed to take place over several weeks or months tends to be more successful; however, patient-specific circumstances play a role in determining the duration of the taper.^1,2

For the greatest chance of success, a benzodiazepine should not be reduced faster than 25% of the total daily dose per week.¹ Consider which of the following pharmacologic approaches to benzodiazepine tapering might work best for your patient:

• Reduce the daily dose by one-eighth to one-tenth every 1 to 2 weeks over a 2- to 12-month period for patients with a physiological dependence.¹
• Reduce the benzodiazepine dose by 10% to 25% every 2 weeks over a 4- to 8-week period.²
• Some guidelines have suggested converting the prescribed benzodiazepine to an equivalent dose of diazepam because of its long half-life, and then reducing the diazepam dose by one-eighth every 2 weeks.³

There is uncertainty in the medical literature about using a long-acting benzodiazepine to taper off a short-acting benzodiazepine, although this practice is generally clinically accepted.^1,2 Similarly, there is no definitive evidence that supports using adjuvant medications to facilitate tapering.^1,2

Nonpharmacologic interventions

Patients are more likely to have a successful taper if nonpharmacologic interventions are part of a comprehensive treatment plan.¹

To help your patients through the challenges of a benzodiazepine taper:

• Validate their concerns, reassure them that you will support them throughout the taper, and provide information on additional resources for support.
• Provide education about the process of tapering and symptoms of withdrawal.
• Recommend therapies, such as cognitive-behavioral therapy or motivational interventions, that develop or enhance coping skills.
• Enlist the help of the patient’s family and friends for support and encouragement.

Despite some clinicians’ trepidation, 70% to 90% of patients can be successfully tapered off benzodiazepines by using an individualized approach that includes tailored tapering and nonpharmacologic interventions that provide benefits that persist after the patient completes the taper.¹

Benzodiazepines are one of the most commonly prescribed medication classes worldwide.¹ Patients prescribed benzodiazepines who have no history of abuse or misuse may want to reduce or discontinue using these agents for various reasons, including adverse effects or wanting to reduce the number of medications they take. In this article, we offer strategies for creating an individualized taper plan, and describe additional nonpharmacologic interventions to help ensure that the taper is successful.

Formulating a taper plan

There is no gold-standard algorithm for tapering benzodiazepines.^1,2 Even with a carefully designed plan, tapering can be challenging because approximately one-third of patients will experience difficulties such as withdrawal symptoms.¹ Prior to creating a plan, carefully assess the patient’s history, including the type of benzodiazepine prescribed (short- or long-acting); the dose, dosing frequency, and duration of use; comorbid medical and psychiatric conditions; any previous experience with withdrawal symptoms; and psychosocial factors (eg, lifestyle and personality). Consider whether the patient can be safely tapered in an outpatient setting or will require hospitalization. Tapering designed to take place over several weeks or months tends to be more successful; however, patient-specific circumstances play a role in determining the duration of the taper.^1,2

For the greatest chance of success, a benzodiazepine should not be reduced faster than 25% of the total daily dose per week.¹ Consider which of the following pharmacologic approaches to benzodiazepine tapering might work best for your patient:

• Reduce the daily dose by one-eighth to one-tenth every 1 to 2 weeks over a 2- to 12-month period for patients with a physiological dependence.¹
• Reduce the benzodiazepine dose by 10% to 25% every 2 weeks over a 4- to 8-week period.²
• Some guidelines have suggested converting the prescribed benzodiazepine to an equivalent dose of diazepam because of its long half-life, and then reducing the diazepam dose by one-eighth every 2 weeks.³

There is uncertainty in the medical literature about using a long-acting benzodiazepine to taper off a short-acting benzodiazepine, although this practice is generally clinically accepted.^1,2 Similarly, there is no definitive evidence that supports using adjuvant medications to facilitate tapering.^1,2

Nonpharmacologic interventions

Patients are more likely to have a successful taper if nonpharmacologic interventions are part of a comprehensive treatment plan.¹

To help your patients through the challenges of a benzodiazepine taper:

• Validate their concerns, reassure them that you will support them throughout the taper, and provide information on additional resources for support.
• Provide education about the process of tapering and symptoms of withdrawal.
• Recommend therapies, such as cognitive-behavioral therapy or motivational interventions, that develop or enhance coping skills.
• Enlist the help of the patient’s family and friends for support and encouragement.

Despite some clinicians’ trepidation, 70% to 90% of patients can be successfully tapered off benzodiazepines by using an individualized approach that includes tailored tapering and nonpharmacologic interventions that provide benefits that persist after the patient completes the taper.¹

Several psychiatric disorders, including depression, schizophrenia, bipolar disorder, Alzheimer’s disease, traumatic brain injury, autism, and posttraumatic stress disorder, are associated with a dysregulated immune response and elevated levels of inflammatory biomarkers. Inflammation has long been associated with an increased risk of aggressive behavior.^1,2 By taming immune system dysregulation, we might be able to more effectively reduce inflammation, and thus reduce aggression, in patients with psychiatric illness.

Inflammation and psychiatric symptoms

An overactivated immune response has been empirically correlated to the development of psychiatric symptoms. Inducing systemic inflammation has adverse effects on cognition and behavior, whereas suppressing inflammation can dramatically improve sensorium and mood. Brain regions involved in arousal and alarm are particularly susceptible to inflammation. Subcortical areas, such as the basal ganglia, and cortical circuits, such as the amygdala and anterior insula, are affected by neuroinflammation. Several modifiable factors, including a diet rich in high glycemic food, improper sleep hygiene, tobacco use, a sedentary lifestyle, obesity, and excess psychosocial stressors, can contribute to systemic inflammation and the development of psychiatric symptoms. Oral diseases, such as tooth decay, periodontitis, and gingivitis, also contribute significantly to overall inflammation.

Anti-inflammatory agents

Using nonsteroidal anti-inflammatory drugs as augmentation to standard treatments has shown promise in several psychiatric illnesses. For example, low-dose aspirin, 81 mg/d, has demonstrated reliable results as an adjunctive treatment for depression.³ Research also has shown that the use of ibuprofen may reduce the chances of individuals seeking psychiatric care.³

Individuals who are at high risk for psychosis and schizophrenia have measurable increases in inflammatory microglial activity.⁴ The severity of psychotic symptoms corresponds to the magnitude of the immune response; this suggests that neuroinflammation is a risk factor for psychosis, and that anti-inflammatory treatments might help prevent or ameliorate psychosis.

In a double-blind, placebo-controlled study, 70 patients diagnosed with schizophrenia who were taking an antipsychotic were randomized to adjunctive aspirin, 1,000 mg/d, or placebo.⁵ Participants who received aspirin had significant improvement as measured by changes in Positive and Negative Syndrome Scale total score.⁵

Targeting C-reactive protein

Inflammation has long been associated with impulsive aggression. C-reactive protein (CRP) is a biomarker produced in the liver in response to inflammatory triggers. In a study of 213 inpatients with schizophrenia, researchers compared 57 patients with higher levels of CRP (>1 mg/dL) with 156 patients with normal levels (<1 mg/dL).² Compared with patients with normal CRP levels, those with higher levels displayed increased aggressive behavior. Researchers found that the chance of being physically restrained during hospitalization was almost 2.5 times greater for patients with elevated CRP levels on admission compared with those with normal CRP levels.

Statins have long been used to reduce C-reactive peptides in patients with cardiovascular conditions. The use of simvastatin has been shown to significantly reduce negative symptoms in patients with schizophrenia.⁶

Continue to: Vitamin C also can effectively...

Vitamin C also can effectively lower CRP levels. In a 2-month study, 396 participants with elevated CRP levels received vitamin C, 1,000 mg/d, vitamin E, 800 IU/d, or placebo.⁷ Although vitamin E didn’t reduce CRP levels, vitamin C reduced CRP by 25.3% compared with placebo. Vitamin C is as effective as statins in controlling this biomarker.

Several nonpharmacologic measures also can help reduce the immune system’s activation of CRP, including increased physical activity, increased intake of low glycemic food and supplemental omega-3 fatty acids, improved dental hygiene, and enhanced sleep.

Using a relatively simple and inexpensive laboratory test for measuring CRP might help predict or stratify the risk of aggressive behavior among psychiatric inpatients. For psychiatric patients with elevated inflammatory markers, the interventions described here may be useful as adjunctive treatments to help reduce aggression and injury in an inpatient setting.

Several psychiatric disorders, including depression, schizophrenia, bipolar disorder, Alzheimer’s disease, traumatic brain injury, autism, and posttraumatic stress disorder, are associated with a dysregulated immune response and elevated levels of inflammatory biomarkers. Inflammation has long been associated with an increased risk of aggressive behavior.^1,2 By taming immune system dysregulation, we might be able to more effectively reduce inflammation, and thus reduce aggression, in patients with psychiatric illness.

Inflammation and psychiatric symptoms

An overactivated immune response has been empirically correlated to the development of psychiatric symptoms. Inducing systemic inflammation has adverse effects on cognition and behavior, whereas suppressing inflammation can dramatically improve sensorium and mood. Brain regions involved in arousal and alarm are particularly susceptible to inflammation. Subcortical areas, such as the basal ganglia, and cortical circuits, such as the amygdala and anterior insula, are affected by neuroinflammation. Several modifiable factors, including a diet rich in high glycemic food, improper sleep hygiene, tobacco use, a sedentary lifestyle, obesity, and excess psychosocial stressors, can contribute to systemic inflammation and the development of psychiatric symptoms. Oral diseases, such as tooth decay, periodontitis, and gingivitis, also contribute significantly to overall inflammation.

Anti-inflammatory agents

Using nonsteroidal anti-inflammatory drugs as augmentation to standard treatments has shown promise in several psychiatric illnesses. For example, low-dose aspirin, 81 mg/d, has demonstrated reliable results as an adjunctive treatment for depression.³ Research also has shown that the use of ibuprofen may reduce the chances of individuals seeking psychiatric care.³

Individuals who are at high risk for psychosis and schizophrenia have measurable increases in inflammatory microglial activity.⁴ The severity of psychotic symptoms corresponds to the magnitude of the immune response; this suggests that neuroinflammation is a risk factor for psychosis, and that anti-inflammatory treatments might help prevent or ameliorate psychosis.

In a double-blind, placebo-controlled study, 70 patients diagnosed with schizophrenia who were taking an antipsychotic were randomized to adjunctive aspirin, 1,000 mg/d, or placebo.⁵ Participants who received aspirin had significant improvement as measured by changes in Positive and Negative Syndrome Scale total score.⁵

Targeting C-reactive protein

Inflammation has long been associated with impulsive aggression. C-reactive protein (CRP) is a biomarker produced in the liver in response to inflammatory triggers. In a study of 213 inpatients with schizophrenia, researchers compared 57 patients with higher levels of CRP (>1 mg/dL) with 156 patients with normal levels (<1 mg/dL).² Compared with patients with normal CRP levels, those with higher levels displayed increased aggressive behavior. Researchers found that the chance of being physically restrained during hospitalization was almost 2.5 times greater for patients with elevated CRP levels on admission compared with those with normal CRP levels.

Statins have long been used to reduce C-reactive peptides in patients with cardiovascular conditions. The use of simvastatin has been shown to significantly reduce negative symptoms in patients with schizophrenia.⁶

Continue to: Vitamin C also can effectively...

Vitamin C also can effectively lower CRP levels. In a 2-month study, 396 participants with elevated CRP levels received vitamin C, 1,000 mg/d, vitamin E, 800 IU/d, or placebo.⁷ Although vitamin E didn’t reduce CRP levels, vitamin C reduced CRP by 25.3% compared with placebo. Vitamin C is as effective as statins in controlling this biomarker.

Several nonpharmacologic measures also can help reduce the immune system’s activation of CRP, including increased physical activity, increased intake of low glycemic food and supplemental omega-3 fatty acids, improved dental hygiene, and enhanced sleep.

Using a relatively simple and inexpensive laboratory test for measuring CRP might help predict or stratify the risk of aggressive behavior among psychiatric inpatients. For psychiatric patients with elevated inflammatory markers, the interventions described here may be useful as adjunctive treatments to help reduce aggression and injury in an inpatient setting.

Several psychiatric disorders, including depression, schizophrenia, bipolar disorder, Alzheimer’s disease, traumatic brain injury, autism, and posttraumatic stress disorder, are associated with a dysregulated immune response and elevated levels of inflammatory biomarkers. Inflammation has long been associated with an increased risk of aggressive behavior.^1,2 By taming immune system dysregulation, we might be able to more effectively reduce inflammation, and thus reduce aggression, in patients with psychiatric illness.

Inflammation and psychiatric symptoms

An overactivated immune response has been empirically correlated to the development of psychiatric symptoms. Inducing systemic inflammation has adverse effects on cognition and behavior, whereas suppressing inflammation can dramatically improve sensorium and mood. Brain regions involved in arousal and alarm are particularly susceptible to inflammation. Subcortical areas, such as the basal ganglia, and cortical circuits, such as the amygdala and anterior insula, are affected by neuroinflammation. Several modifiable factors, including a diet rich in high glycemic food, improper sleep hygiene, tobacco use, a sedentary lifestyle, obesity, and excess psychosocial stressors, can contribute to systemic inflammation and the development of psychiatric symptoms. Oral diseases, such as tooth decay, periodontitis, and gingivitis, also contribute significantly to overall inflammation.

Anti-inflammatory agents

Using nonsteroidal anti-inflammatory drugs as augmentation to standard treatments has shown promise in several psychiatric illnesses. For example, low-dose aspirin, 81 mg/d, has demonstrated reliable results as an adjunctive treatment for depression.³ Research also has shown that the use of ibuprofen may reduce the chances of individuals seeking psychiatric care.³

Individuals who are at high risk for psychosis and schizophrenia have measurable increases in inflammatory microglial activity.⁴ The severity of psychotic symptoms corresponds to the magnitude of the immune response; this suggests that neuroinflammation is a risk factor for psychosis, and that anti-inflammatory treatments might help prevent or ameliorate psychosis.

In a double-blind, placebo-controlled study, 70 patients diagnosed with schizophrenia who were taking an antipsychotic were randomized to adjunctive aspirin, 1,000 mg/d, or placebo.⁵ Participants who received aspirin had significant improvement as measured by changes in Positive and Negative Syndrome Scale total score.⁵

Targeting C-reactive protein

Inflammation has long been associated with impulsive aggression. C-reactive protein (CRP) is a biomarker produced in the liver in response to inflammatory triggers. In a study of 213 inpatients with schizophrenia, researchers compared 57 patients with higher levels of CRP (>1 mg/dL) with 156 patients with normal levels (<1 mg/dL).² Compared with patients with normal CRP levels, those with higher levels displayed increased aggressive behavior. Researchers found that the chance of being physically restrained during hospitalization was almost 2.5 times greater for patients with elevated CRP levels on admission compared with those with normal CRP levels.

Statins have long been used to reduce C-reactive peptides in patients with cardiovascular conditions. The use of simvastatin has been shown to significantly reduce negative symptoms in patients with schizophrenia.⁶

Continue to: Vitamin C also can effectively...

Vitamin C also can effectively lower CRP levels. In a 2-month study, 396 participants with elevated CRP levels received vitamin C, 1,000 mg/d, vitamin E, 800 IU/d, or placebo.⁷ Although vitamin E didn’t reduce CRP levels, vitamin C reduced CRP by 25.3% compared with placebo. Vitamin C is as effective as statins in controlling this biomarker.

Several nonpharmacologic measures also can help reduce the immune system’s activation of CRP, including increased physical activity, increased intake of low glycemic food and supplemental omega-3 fatty acids, improved dental hygiene, and enhanced sleep.

Using a relatively simple and inexpensive laboratory test for measuring CRP might help predict or stratify the risk of aggressive behavior among psychiatric inpatients. For psychiatric patients with elevated inflammatory markers, the interventions described here may be useful as adjunctive treatments to help reduce aggression and injury in an inpatient setting.

Our 24-hour society has made night shift work essential to people in many professions, including medical specialties. Working nights disrupts homeostatic and circadian rhythms, which leads to an accumulation of sleep debt (ie, the cumulative effect of not getting enough sleep).¹ This debt can affect performance by impairing processing speed, concentration, mood, and physical health.¹ Night shift work takes place during the period of the sleep-wake cycle that is programmed for sleep; after the shift, workers need to sleep during the period that is least conducive to sleep.¹ Research indicates that a night shift worker’s sleep can be improved by scheduling light exposure and optimizing the timing of when they start their shifts.² However, this may not be practical because night shifts usually are scheduled at particular intervals and cannot be tailored to the individual worker’s preference. Additionally, in the short term, full circadian adaptation to night shifts is impossible.¹

Because sleep and performance are complex phenomena that are difficult to control, there is no single solution to maximizing these factors when one works nights.¹ The most effective approach to combating the effects of night shift work is individualized and multimodal.¹ However, whether you are working a night shift or are caring for a patient who does, the following nonpharmacologic strategies can help improve sleep and performance until the body naturally adapts to working this type of schedule^1,3:

Minimize sleep debt before starting aseries of night shifts by not setting an alarm on the morning before the first night shift and by napping in the afternoon for approximately 45 minutes.

Take a nap during a work break (if work demands allow you to do so). However, nap for <30 minutes to avoid slow-wave sleep and subsequent grogginess when awakening.

Expose yourself to bright light immediately upon waking and for 15 minutes 2 or 3 times during a shift to promote alertness.

Drink caffeinated beverages before and during the shift to help improve concentration and reasoning (if there is no medical contraindication to consuming caffeine). However, avoid caffeine for at least 3 hours prior to going to sleep.

Add additional checks to critical tasks, such as ordering medications, during the shift, especially during the physiological nadir in the early hours of the morning.

Continue to: Create a cool, dark, quiet environment for sleep...

Create a cool, dark, quiet environment for sleep using a comfortable mattress and pillow, blackout blinds, ear plugs, and a noise machine. Also, avoid using your smartphone or tablet while trying to go to sleep. Minimize exposure to bright light on the drive home, and stick to a routine (eg, for meals and exercise).

Avoid working too many consecutive night shifts (if possible) because this can increase sleep deprivation. Also, limiting the number of night shifts and scheduling days off can speed recovery from sleep deprivation.

Our 24-hour society has made night shift work essential to people in many professions, including medical specialties. Working nights disrupts homeostatic and circadian rhythms, which leads to an accumulation of sleep debt (ie, the cumulative effect of not getting enough sleep).¹ This debt can affect performance by impairing processing speed, concentration, mood, and physical health.¹ Night shift work takes place during the period of the sleep-wake cycle that is programmed for sleep; after the shift, workers need to sleep during the period that is least conducive to sleep.¹ Research indicates that a night shift worker’s sleep can be improved by scheduling light exposure and optimizing the timing of when they start their shifts.² However, this may not be practical because night shifts usually are scheduled at particular intervals and cannot be tailored to the individual worker’s preference. Additionally, in the short term, full circadian adaptation to night shifts is impossible.¹

Because sleep and performance are complex phenomena that are difficult to control, there is no single solution to maximizing these factors when one works nights.¹ The most effective approach to combating the effects of night shift work is individualized and multimodal.¹ However, whether you are working a night shift or are caring for a patient who does, the following nonpharmacologic strategies can help improve sleep and performance until the body naturally adapts to working this type of schedule^1,3:

Minimize sleep debt before starting aseries of night shifts by not setting an alarm on the morning before the first night shift and by napping in the afternoon for approximately 45 minutes.

Take a nap during a work break (if work demands allow you to do so). However, nap for <30 minutes to avoid slow-wave sleep and subsequent grogginess when awakening.

Expose yourself to bright light immediately upon waking and for 15 minutes 2 or 3 times during a shift to promote alertness.

Drink caffeinated beverages before and during the shift to help improve concentration and reasoning (if there is no medical contraindication to consuming caffeine). However, avoid caffeine for at least 3 hours prior to going to sleep.

Add additional checks to critical tasks, such as ordering medications, during the shift, especially during the physiological nadir in the early hours of the morning.

Continue to: Create a cool, dark, quiet environment for sleep...

Create a cool, dark, quiet environment for sleep using a comfortable mattress and pillow, blackout blinds, ear plugs, and a noise machine. Also, avoid using your smartphone or tablet while trying to go to sleep. Minimize exposure to bright light on the drive home, and stick to a routine (eg, for meals and exercise).

Avoid working too many consecutive night shifts (if possible) because this can increase sleep deprivation. Also, limiting the number of night shifts and scheduling days off can speed recovery from sleep deprivation.

Our 24-hour society has made night shift work essential to people in many professions, including medical specialties. Working nights disrupts homeostatic and circadian rhythms, which leads to an accumulation of sleep debt (ie, the cumulative effect of not getting enough sleep).¹ This debt can affect performance by impairing processing speed, concentration, mood, and physical health.¹ Night shift work takes place during the period of the sleep-wake cycle that is programmed for sleep; after the shift, workers need to sleep during the period that is least conducive to sleep.¹ Research indicates that a night shift worker’s sleep can be improved by scheduling light exposure and optimizing the timing of when they start their shifts.² However, this may not be practical because night shifts usually are scheduled at particular intervals and cannot be tailored to the individual worker’s preference. Additionally, in the short term, full circadian adaptation to night shifts is impossible.¹

Because sleep and performance are complex phenomena that are difficult to control, there is no single solution to maximizing these factors when one works nights.¹ The most effective approach to combating the effects of night shift work is individualized and multimodal.¹ However, whether you are working a night shift or are caring for a patient who does, the following nonpharmacologic strategies can help improve sleep and performance until the body naturally adapts to working this type of schedule^1,3:

Minimize sleep debt before starting aseries of night shifts by not setting an alarm on the morning before the first night shift and by napping in the afternoon for approximately 45 minutes.

Take a nap during a work break (if work demands allow you to do so). However, nap for <30 minutes to avoid slow-wave sleep and subsequent grogginess when awakening.

Expose yourself to bright light immediately upon waking and for 15 minutes 2 or 3 times during a shift to promote alertness.

Drink caffeinated beverages before and during the shift to help improve concentration and reasoning (if there is no medical contraindication to consuming caffeine). However, avoid caffeine for at least 3 hours prior to going to sleep.

Add additional checks to critical tasks, such as ordering medications, during the shift, especially during the physiological nadir in the early hours of the morning.

Continue to: Create a cool, dark, quiet environment for sleep...

Create a cool, dark, quiet environment for sleep using a comfortable mattress and pillow, blackout blinds, ear plugs, and a noise machine. Also, avoid using your smartphone or tablet while trying to go to sleep. Minimize exposure to bright light on the drive home, and stick to a routine (eg, for meals and exercise).

Avoid working too many consecutive night shifts (if possible) because this can increase sleep deprivation. Also, limiting the number of night shifts and scheduling days off can speed recovery from sleep deprivation.

CASE

Mr. C, a veteran in his 60s who has posttraumatic stress disorder (PTSD), presents to your clinic for a 45-minute follow-up visit. He has a remote history of depression and a 20-year history of substance use disorder (SUD); he uses heroin, at least 3 bags a day by insufflation. You review his response to his currently prescribed PTSD treatment regimen, ask if he is experiencing any adverse effects, and perform a mental status exam and a review of systems. You offer Mr. C detoxification and rehabilitation treatment for his heroin use, but he refuses. With 15 minutes left in the appointment, you consider conducting motivational interviewing (MI) to help him reconsider getting treatment for his SUD.

Even when delivered as a brief, one-time intervention, MI can be effective in getting patients to change their behavior.¹ First created in part by psychologists William Miller, PhD, and Stephen Rollnick, PhD,² MI is based on the premise that a patient’s ambivalence to change is normal and that all patients vary in their readiness to change. MI can be brief, and can be more helpful than providing only proscriptive advice, which sometimes can be counterproductitive.³

To effectively implement MI during a brief visit, it is helpful to keep in mind 3 mnemonics: RULE, PACE, and OARS.

RULE

RULE can be used to remember the core principles of MI.⁴ First, Resist the righting reflex, which means we should resist giving suggestions to our patients for their problems. While we may mean well, offering suggestions might actually make the patient less likely to make a positive change. Understand the patient’s motivation by being a curious listener and attempting to elicit the patient’s own underlying motivation for change. Listen with a patient-centered, empathic approach. Lastly, Empower the patient. He must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change.

PACE

PACE is the “spirit” or mindset that clinicians should have when conducting MI.^4,5 Always work in Partnership with the patient; this allows the patient and clinician to collaborate on the same level. While the physician is a clinical expert, the patient is an expert in prior efforts at trying to change his or her circumstances for the better. Make the therapeutic environment as positive as possible so that your patient will find it comfortable to discuss change. The patient should see the clinician as a guide who offers information about paths the patient may choose, not someone who decides the destination.⁵ While as physicians we must continue to educate our patients about the harms of behaviors such as excessive drinking or substance use, we recognize that ultimately the decision is the patient’s. Make every effort to draw from the patients’ goals and values, so that the patient, and not the clinician, can argue for why change is needed. This Acceptance helps foster an attitude that we are on the patient’s side and that his past choices in life do not negatively affect our perception of him. The patient should be accepted for who he is, and not met with disapproval over any personal decisions that he made.⁵ Exercise Compassion towards the patient’s struggles and experiences,⁵ and never be punitive. Make every attempt to have discussions that can be Evocative for the patient. Strong feelings and memories can be particularly salient to discuss, especially if they could help change the patient’s attitude towards maladaptive behaviors.

OARS

OARS can be used to help remember core skills of MI.⁵ These include asking Open-ended questions to get the patient to think before responding, providing frequent Affirmations of the patient’s positive traits, using Reflective listening techniques while your patient talks about his disorder, and providing succinct Summaries of the experiences expressed by your patient throughout the encounter to invite continued exploration of his behaviors.

Getting patients to talk about change

Use RULE, PACE, and OARS to elicit “change talk,”⁴ so that your patient makes his own arguments for change. Here ambivalence is good, in that an ambivalent patient may be open to discuss reasons for making changes. It is important to remember not to use the righting reflex to give suggestions to change.

Continue to: CASE...

You use the last 15 minutes of Mr. C’s visit to conduct MI and acknowledge his ambivalence to change. Mr. C reveals that his motivation for change centers on how he perceives himself as a disappointment to his daughter because of his continuous drug use. At the end of the encounter, Mr. C is in tears but has a renewed motivation to stop using heroin. He agrees to enter substance abuse treatment.

CASE

Mr. C, a veteran in his 60s who has posttraumatic stress disorder (PTSD), presents to your clinic for a 45-minute follow-up visit. He has a remote history of depression and a 20-year history of substance use disorder (SUD); he uses heroin, at least 3 bags a day by insufflation. You review his response to his currently prescribed PTSD treatment regimen, ask if he is experiencing any adverse effects, and perform a mental status exam and a review of systems. You offer Mr. C detoxification and rehabilitation treatment for his heroin use, but he refuses. With 15 minutes left in the appointment, you consider conducting motivational interviewing (MI) to help him reconsider getting treatment for his SUD.

Even when delivered as a brief, one-time intervention, MI can be effective in getting patients to change their behavior.¹ First created in part by psychologists William Miller, PhD, and Stephen Rollnick, PhD,² MI is based on the premise that a patient’s ambivalence to change is normal and that all patients vary in their readiness to change. MI can be brief, and can be more helpful than providing only proscriptive advice, which sometimes can be counterproductitive.³

To effectively implement MI during a brief visit, it is helpful to keep in mind 3 mnemonics: RULE, PACE, and OARS.

RULE

RULE can be used to remember the core principles of MI.⁴ First, Resist the righting reflex, which means we should resist giving suggestions to our patients for their problems. While we may mean well, offering suggestions might actually make the patient less likely to make a positive change. Understand the patient’s motivation by being a curious listener and attempting to elicit the patient’s own underlying motivation for change. Listen with a patient-centered, empathic approach. Lastly, Empower the patient. He must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change.

PACE

PACE is the “spirit” or mindset that clinicians should have when conducting MI.^4,5 Always work in Partnership with the patient; this allows the patient and clinician to collaborate on the same level. While the physician is a clinical expert, the patient is an expert in prior efforts at trying to change his or her circumstances for the better. Make the therapeutic environment as positive as possible so that your patient will find it comfortable to discuss change. The patient should see the clinician as a guide who offers information about paths the patient may choose, not someone who decides the destination.⁵ While as physicians we must continue to educate our patients about the harms of behaviors such as excessive drinking or substance use, we recognize that ultimately the decision is the patient’s. Make every effort to draw from the patients’ goals and values, so that the patient, and not the clinician, can argue for why change is needed. This Acceptance helps foster an attitude that we are on the patient’s side and that his past choices in life do not negatively affect our perception of him. The patient should be accepted for who he is, and not met with disapproval over any personal decisions that he made.⁵ Exercise Compassion towards the patient’s struggles and experiences,⁵ and never be punitive. Make every attempt to have discussions that can be Evocative for the patient. Strong feelings and memories can be particularly salient to discuss, especially if they could help change the patient’s attitude towards maladaptive behaviors.

OARS

OARS can be used to help remember core skills of MI.⁵ These include asking Open-ended questions to get the patient to think before responding, providing frequent Affirmations of the patient’s positive traits, using Reflective listening techniques while your patient talks about his disorder, and providing succinct Summaries of the experiences expressed by your patient throughout the encounter to invite continued exploration of his behaviors.

Getting patients to talk about change

Use RULE, PACE, and OARS to elicit “change talk,”⁴ so that your patient makes his own arguments for change. Here ambivalence is good, in that an ambivalent patient may be open to discuss reasons for making changes. It is important to remember not to use the righting reflex to give suggestions to change.

Continue to: CASE...

You use the last 15 minutes of Mr. C’s visit to conduct MI and acknowledge his ambivalence to change. Mr. C reveals that his motivation for change centers on how he perceives himself as a disappointment to his daughter because of his continuous drug use. At the end of the encounter, Mr. C is in tears but has a renewed motivation to stop using heroin. He agrees to enter substance abuse treatment.

CASE

Mr. C, a veteran in his 60s who has posttraumatic stress disorder (PTSD), presents to your clinic for a 45-minute follow-up visit. He has a remote history of depression and a 20-year history of substance use disorder (SUD); he uses heroin, at least 3 bags a day by insufflation. You review his response to his currently prescribed PTSD treatment regimen, ask if he is experiencing any adverse effects, and perform a mental status exam and a review of systems. You offer Mr. C detoxification and rehabilitation treatment for his heroin use, but he refuses. With 15 minutes left in the appointment, you consider conducting motivational interviewing (MI) to help him reconsider getting treatment for his SUD.

Even when delivered as a brief, one-time intervention, MI can be effective in getting patients to change their behavior.¹ First created in part by psychologists William Miller, PhD, and Stephen Rollnick, PhD,² MI is based on the premise that a patient’s ambivalence to change is normal and that all patients vary in their readiness to change. MI can be brief, and can be more helpful than providing only proscriptive advice, which sometimes can be counterproductitive.³

To effectively implement MI during a brief visit, it is helpful to keep in mind 3 mnemonics: RULE, PACE, and OARS.

RULE

RULE can be used to remember the core principles of MI.⁴ First, Resist the righting reflex, which means we should resist giving suggestions to our patients for their problems. While we may mean well, offering suggestions might actually make the patient less likely to make a positive change. Understand the patient’s motivation by being a curious listener and attempting to elicit the patient’s own underlying motivation for change. Listen with a patient-centered, empathic approach. Lastly, Empower the patient. He must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change.

PACE

PACE is the “spirit” or mindset that clinicians should have when conducting MI.^4,5 Always work in Partnership with the patient; this allows the patient and clinician to collaborate on the same level. While the physician is a clinical expert, the patient is an expert in prior efforts at trying to change his or her circumstances for the better. Make the therapeutic environment as positive as possible so that your patient will find it comfortable to discuss change. The patient should see the clinician as a guide who offers information about paths the patient may choose, not someone who decides the destination.⁵ While as physicians we must continue to educate our patients about the harms of behaviors such as excessive drinking or substance use, we recognize that ultimately the decision is the patient’s. Make every effort to draw from the patients’ goals and values, so that the patient, and not the clinician, can argue for why change is needed. This Acceptance helps foster an attitude that we are on the patient’s side and that his past choices in life do not negatively affect our perception of him. The patient should be accepted for who he is, and not met with disapproval over any personal decisions that he made.⁵ Exercise Compassion towards the patient’s struggles and experiences,⁵ and never be punitive. Make every attempt to have discussions that can be Evocative for the patient. Strong feelings and memories can be particularly salient to discuss, especially if they could help change the patient’s attitude towards maladaptive behaviors.

OARS

OARS can be used to help remember core skills of MI.⁵ These include asking Open-ended questions to get the patient to think before responding, providing frequent Affirmations of the patient’s positive traits, using Reflective listening techniques while your patient talks about his disorder, and providing succinct Summaries of the experiences expressed by your patient throughout the encounter to invite continued exploration of his behaviors.

Getting patients to talk about change

Use RULE, PACE, and OARS to elicit “change talk,”⁴ so that your patient makes his own arguments for change. Here ambivalence is good, in that an ambivalent patient may be open to discuss reasons for making changes. It is important to remember not to use the righting reflex to give suggestions to change.

Continue to: CASE...

You use the last 15 minutes of Mr. C’s visit to conduct MI and acknowledge his ambivalence to change. Mr. C reveals that his motivation for change centers on how he perceives himself as a disappointment to his daughter because of his continuous drug use. At the end of the encounter, Mr. C is in tears but has a renewed motivation to stop using heroin. He agrees to enter substance abuse treatment.

Although urine drug screens (UDS) are most commonly used to screen job applicants, some clinicians have started to use them as a tool for improving their patients’ clinical outcomes.¹ Recently, some clinicians have begun using UDS to help patients who experience chronic pain and dependency (mainly on opioids) and for those who use diverted drugs to relieve these conditions. Many psychiatrists are concerned about the high cost of drug diversion, as well as the possibility of diversion-related patient mortality. Clinicians should therefore consider using UDS as a tool to help address these challenges.

Consider individualized UDS monitoring

The standard 5-substance UDS test panel consists of tetrahydrocannabinol, opiates, amphetamines, cocaine, and phencyclidine. Although this panel was sufficient for an employment screening-related UDS, the American Society of Addiction Medicine (ASAM) has rejected its use for patients with substance abuse. As part of its emphasis on the importance of incorporating preventative procedures, diagnostics, and surveillance protocols, the ASAM advocates using a rotating test panel in conjunction with a patient-specific UDS.² This type of patient-specific regimen would take into account the dynamic nature of a patient’s health profile factors, including comorbid and psychosocial status, subjective pain features, and diverted drug use. Furthermore, the ASAM recommends evaluating patients for the concurrent use of other substances and agents, such as benzodiazepines, sleep-inducing medications, stimulants, and alcohol, because these can interact with opioids.

Consider extending individualized monitoring by implementing standard “cutoff” values for each drug; patients whose levels of a specific substance are above the established cutoff value are categorized as testing positive for the use of that substance. The Substance Abuse Mental Health Services Administration favors adjusting UDS cutoffs, specifically the use of decreased cutoffs, to improve patient compliance.³ However, standardized drug concentration cutoff values may not be applicable for each patient; therefore, such values may need to be carefully tailored to each patient.

Additional drug monitoring techniques

Existing UDS practices, such as medication adherence and compliance, can be supplemented or alternately used with UDS panels that are modified to account for a patient’s fluctuating clinical conditions and concurrent medications. Point-of-care immunoassays, which provide accurate screening for medication compliance and adherence and possible drug diversion, should be used for routine monitoring. Using DNA-authenticated UDS also adds further control in monitoring a patient’s use of different drugs.^4,5

In addition to being helpful for monitoring opioid use, a DNA-verified UDS can be used to evaluate for the presence of synthetic urine substitutes.^6-8 Diversion remains a growing epidemiologic concern, and the number of cases is vastly underreported in the literature. The DNA-authenticated UDS can give clinicians greater precision in identifying synthetic and substituted urine among patient-provided samples.⁴

Using a combination of the methods described here can help expand a clinician’s ability to perform individualized drug monitoring, and verify whether a patient is adhering to his or her treatment regimen.

Although urine drug screens (UDS) are most commonly used to screen job applicants, some clinicians have started to use them as a tool for improving their patients’ clinical outcomes.¹ Recently, some clinicians have begun using UDS to help patients who experience chronic pain and dependency (mainly on opioids) and for those who use diverted drugs to relieve these conditions. Many psychiatrists are concerned about the high cost of drug diversion, as well as the possibility of diversion-related patient mortality. Clinicians should therefore consider using UDS as a tool to help address these challenges.

Consider individualized UDS monitoring

The standard 5-substance UDS test panel consists of tetrahydrocannabinol, opiates, amphetamines, cocaine, and phencyclidine. Although this panel was sufficient for an employment screening-related UDS, the American Society of Addiction Medicine (ASAM) has rejected its use for patients with substance abuse. As part of its emphasis on the importance of incorporating preventative procedures, diagnostics, and surveillance protocols, the ASAM advocates using a rotating test panel in conjunction with a patient-specific UDS.² This type of patient-specific regimen would take into account the dynamic nature of a patient’s health profile factors, including comorbid and psychosocial status, subjective pain features, and diverted drug use. Furthermore, the ASAM recommends evaluating patients for the concurrent use of other substances and agents, such as benzodiazepines, sleep-inducing medications, stimulants, and alcohol, because these can interact with opioids.

Consider extending individualized monitoring by implementing standard “cutoff” values for each drug; patients whose levels of a specific substance are above the established cutoff value are categorized as testing positive for the use of that substance. The Substance Abuse Mental Health Services Administration favors adjusting UDS cutoffs, specifically the use of decreased cutoffs, to improve patient compliance.³ However, standardized drug concentration cutoff values may not be applicable for each patient; therefore, such values may need to be carefully tailored to each patient.

Additional drug monitoring techniques

Existing UDS practices, such as medication adherence and compliance, can be supplemented or alternately used with UDS panels that are modified to account for a patient’s fluctuating clinical conditions and concurrent medications. Point-of-care immunoassays, which provide accurate screening for medication compliance and adherence and possible drug diversion, should be used for routine monitoring. Using DNA-authenticated UDS also adds further control in monitoring a patient’s use of different drugs.^4,5

In addition to being helpful for monitoring opioid use, a DNA-verified UDS can be used to evaluate for the presence of synthetic urine substitutes.^6-8 Diversion remains a growing epidemiologic concern, and the number of cases is vastly underreported in the literature. The DNA-authenticated UDS can give clinicians greater precision in identifying synthetic and substituted urine among patient-provided samples.⁴

Using a combination of the methods described here can help expand a clinician’s ability to perform individualized drug monitoring, and verify whether a patient is adhering to his or her treatment regimen.

Although urine drug screens (UDS) are most commonly used to screen job applicants, some clinicians have started to use them as a tool for improving their patients’ clinical outcomes.¹ Recently, some clinicians have begun using UDS to help patients who experience chronic pain and dependency (mainly on opioids) and for those who use diverted drugs to relieve these conditions. Many psychiatrists are concerned about the high cost of drug diversion, as well as the possibility of diversion-related patient mortality. Clinicians should therefore consider using UDS as a tool to help address these challenges.

Consider individualized UDS monitoring

The standard 5-substance UDS test panel consists of tetrahydrocannabinol, opiates, amphetamines, cocaine, and phencyclidine. Although this panel was sufficient for an employment screening-related UDS, the American Society of Addiction Medicine (ASAM) has rejected its use for patients with substance abuse. As part of its emphasis on the importance of incorporating preventative procedures, diagnostics, and surveillance protocols, the ASAM advocates using a rotating test panel in conjunction with a patient-specific UDS.² This type of patient-specific regimen would take into account the dynamic nature of a patient’s health profile factors, including comorbid and psychosocial status, subjective pain features, and diverted drug use. Furthermore, the ASAM recommends evaluating patients for the concurrent use of other substances and agents, such as benzodiazepines, sleep-inducing medications, stimulants, and alcohol, because these can interact with opioids.

Consider extending individualized monitoring by implementing standard “cutoff” values for each drug; patients whose levels of a specific substance are above the established cutoff value are categorized as testing positive for the use of that substance. The Substance Abuse Mental Health Services Administration favors adjusting UDS cutoffs, specifically the use of decreased cutoffs, to improve patient compliance.³ However, standardized drug concentration cutoff values may not be applicable for each patient; therefore, such values may need to be carefully tailored to each patient.

Additional drug monitoring techniques

Existing UDS practices, such as medication adherence and compliance, can be supplemented or alternately used with UDS panels that are modified to account for a patient’s fluctuating clinical conditions and concurrent medications. Point-of-care immunoassays, which provide accurate screening for medication compliance and adherence and possible drug diversion, should be used for routine monitoring. Using DNA-authenticated UDS also adds further control in monitoring a patient’s use of different drugs.^4,5

In addition to being helpful for monitoring opioid use, a DNA-verified UDS can be used to evaluate for the presence of synthetic urine substitutes.^6-8 Diversion remains a growing epidemiologic concern, and the number of cases is vastly underreported in the literature. The DNA-authenticated UDS can give clinicians greater precision in identifying synthetic and substituted urine among patient-provided samples.⁴

Using a combination of the methods described here can help expand a clinician’s ability to perform individualized drug monitoring, and verify whether a patient is adhering to his or her treatment regimen.

Clinical errors are common during shift changes in a hospital setting.^1-3 Clinicians on the outgoing shift may forget to communicate important details, such as medication dosages, critical laboratory orders, or other interventions, to the clinicians in the next shift. To help myself formally structure the sign-out process for each patient during a shift change in a psychiatric emergency room, I came up with the acronym COMPRESS for key questions to ask the outgoing provider:

Communicate. Did you communicate with this patient in any way at any time during your shift?

Orders. Did you write any orders for this patient? If not, had another clinician already written orders for this patient?

Medications. Did you review and reconcile the medication list for this patient? If not, had another clinician already reviewed and reconciled the medication list for this patient?

PRogrESs. Did you write a progress note for this patient? If not, had the attending clinician written a progress note for this patient within the last 24 hours?

Sign. Did you sign all of your orders and progress notes for this patient?

In my experience in the psychiatric emergency room, COMPRESS has helped me efficiently structure the outgoing clinicians’ reports about my patients by having them provide vital clinical sign-out information before they leave. I hope that other clinicians working in this setting also find these questions useful.

Clinical errors are common during shift changes in a hospital setting.^1-3 Clinicians on the outgoing shift may forget to communicate important details, such as medication dosages, critical laboratory orders, or other interventions, to the clinicians in the next shift. To help myself formally structure the sign-out process for each patient during a shift change in a psychiatric emergency room, I came up with the acronym COMPRESS for key questions to ask the outgoing provider:

Communicate. Did you communicate with this patient in any way at any time during your shift?

Orders. Did you write any orders for this patient? If not, had another clinician already written orders for this patient?

Medications. Did you review and reconcile the medication list for this patient? If not, had another clinician already reviewed and reconciled the medication list for this patient?

PRogrESs. Did you write a progress note for this patient? If not, had the attending clinician written a progress note for this patient within the last 24 hours?

Sign. Did you sign all of your orders and progress notes for this patient?

In my experience in the psychiatric emergency room, COMPRESS has helped me efficiently structure the outgoing clinicians’ reports about my patients by having them provide vital clinical sign-out information before they leave. I hope that other clinicians working in this setting also find these questions useful.

Clinical errors are common during shift changes in a hospital setting.^1-3 Clinicians on the outgoing shift may forget to communicate important details, such as medication dosages, critical laboratory orders, or other interventions, to the clinicians in the next shift. To help myself formally structure the sign-out process for each patient during a shift change in a psychiatric emergency room, I came up with the acronym COMPRESS for key questions to ask the outgoing provider:

Communicate. Did you communicate with this patient in any way at any time during your shift?

Orders. Did you write any orders for this patient? If not, had another clinician already written orders for this patient?

Medications. Did you review and reconcile the medication list for this patient? If not, had another clinician already reviewed and reconciled the medication list for this patient?

PRogrESs. Did you write a progress note for this patient? If not, had the attending clinician written a progress note for this patient within the last 24 hours?

Sign. Did you sign all of your orders and progress notes for this patient?

In my experience in the psychiatric emergency room, COMPRESS has helped me efficiently structure the outgoing clinicians’ reports about my patients by having them provide vital clinical sign-out information before they leave. I hope that other clinicians working in this setting also find these questions useful.

Searching for someone on the Internet and viewing his or her social media profile is an effective way to obtain information about people, including patients. Following our patients’ “digital footprint” may help us understand the context of their lives, reconcile discrepancies in what they have told us, or allow us to confront denial and address incomplete reporting.¹ However, perusing our patients’ online profiles could negatively impact treatment and adherence. Consider these factors before looking up your patients’ online profiles^1-3:

Inaccurate information. Information on the Internet, especially what you can find on user-generated forums, is largely unregulated; as a result, the veracity of that information cannot be guaranteed.¹ Patients may choose to portray themselves inaccurately on their online profiles, and their identities often cannot be confirmed. Even if some information is accurate, you might discover things that you did not expect to learn about your patients, including important information that they did not share, or even something they lied about. This can create the conundrums of what to do with such information and how to discuss it at the next visit.

Impact on treatment. Despite patients’ online activities being displayed for the world to see, many patients do not expect their clinicians to access their online information. They might perceive such perusal as a breach of trust, which might lead some to view the doctor–patient relationship as adversarial. Accessing this information also could create a more intimate relationship than intended. Even if a clinician acquires consent to perform a search, patients may still feel coerced into allowing it because they might feel that declining to grant permission would make the clinician suspect that they have something to hide, or that the clinician would search without consent.²

In addition, if patients are aware that their psychiatrists are monitoring them, they might change their behavior. For example, they may delete certain data, add additional information that may not be accurate, or censor future social media posts. Knowing that their clinicians could be paying attention to them around the clock also might motivate certain patients to act out more or become withdrawn.

Possible medicolegal repercussions. If clinicians are able to access their patients’ electronic profiles, are they then legally obligated to monitor them? For example, if a patient who posts a picture with a noose around his neck later completes suicide, does the clinician who intermittently monitored this patient’s online profile face legal ramifications for not seeing the post? Do clinicians have to call 911 for vaguely suicidal tweets? What responsibilities does a clinician have at the first sign of an innocuous “sad” emoji? The sheer volume of online content that patients can create over different outlets is staggering. It can be overwhelming and ineffective to attempt to monitor patients’ online activities in addition to attending to one’s usual clinical duties, and the medicolegal repercussions of doing so are largely unknown.

Before searching the Internet to learn more about your patients, first consider the ramifications of doing so. While such searches could be helpful, they may lead to poor adherence, a lack of trust, or legal quagmires.

Searching for someone on the Internet and viewing his or her social media profile is an effective way to obtain information about people, including patients. Following our patients’ “digital footprint” may help us understand the context of their lives, reconcile discrepancies in what they have told us, or allow us to confront denial and address incomplete reporting.¹ However, perusing our patients’ online profiles could negatively impact treatment and adherence. Consider these factors before looking up your patients’ online profiles^1-3:

Inaccurate information. Information on the Internet, especially what you can find on user-generated forums, is largely unregulated; as a result, the veracity of that information cannot be guaranteed.¹ Patients may choose to portray themselves inaccurately on their online profiles, and their identities often cannot be confirmed. Even if some information is accurate, you might discover things that you did not expect to learn about your patients, including important information that they did not share, or even something they lied about. This can create the conundrums of what to do with such information and how to discuss it at the next visit.

Impact on treatment. Despite patients’ online activities being displayed for the world to see, many patients do not expect their clinicians to access their online information. They might perceive such perusal as a breach of trust, which might lead some to view the doctor–patient relationship as adversarial. Accessing this information also could create a more intimate relationship than intended. Even if a clinician acquires consent to perform a search, patients may still feel coerced into allowing it because they might feel that declining to grant permission would make the clinician suspect that they have something to hide, or that the clinician would search without consent.²

In addition, if patients are aware that their psychiatrists are monitoring them, they might change their behavior. For example, they may delete certain data, add additional information that may not be accurate, or censor future social media posts. Knowing that their clinicians could be paying attention to them around the clock also might motivate certain patients to act out more or become withdrawn.

Possible medicolegal repercussions. If clinicians are able to access their patients’ electronic profiles, are they then legally obligated to monitor them? For example, if a patient who posts a picture with a noose around his neck later completes suicide, does the clinician who intermittently monitored this patient’s online profile face legal ramifications for not seeing the post? Do clinicians have to call 911 for vaguely suicidal tweets? What responsibilities does a clinician have at the first sign of an innocuous “sad” emoji? The sheer volume of online content that patients can create over different outlets is staggering. It can be overwhelming and ineffective to attempt to monitor patients’ online activities in addition to attending to one’s usual clinical duties, and the medicolegal repercussions of doing so are largely unknown.

Before searching the Internet to learn more about your patients, first consider the ramifications of doing so. While such searches could be helpful, they may lead to poor adherence, a lack of trust, or legal quagmires.

Searching for someone on the Internet and viewing his or her social media profile is an effective way to obtain information about people, including patients. Following our patients’ “digital footprint” may help us understand the context of their lives, reconcile discrepancies in what they have told us, or allow us to confront denial and address incomplete reporting.¹ However, perusing our patients’ online profiles could negatively impact treatment and adherence. Consider these factors before looking up your patients’ online profiles^1-3:

Inaccurate information. Information on the Internet, especially what you can find on user-generated forums, is largely unregulated; as a result, the veracity of that information cannot be guaranteed.¹ Patients may choose to portray themselves inaccurately on their online profiles, and their identities often cannot be confirmed. Even if some information is accurate, you might discover things that you did not expect to learn about your patients, including important information that they did not share, or even something they lied about. This can create the conundrums of what to do with such information and how to discuss it at the next visit.

Impact on treatment. Despite patients’ online activities being displayed for the world to see, many patients do not expect their clinicians to access their online information. They might perceive such perusal as a breach of trust, which might lead some to view the doctor–patient relationship as adversarial. Accessing this information also could create a more intimate relationship than intended. Even if a clinician acquires consent to perform a search, patients may still feel coerced into allowing it because they might feel that declining to grant permission would make the clinician suspect that they have something to hide, or that the clinician would search without consent.²

In addition, if patients are aware that their psychiatrists are monitoring them, they might change their behavior. For example, they may delete certain data, add additional information that may not be accurate, or censor future social media posts. Knowing that their clinicians could be paying attention to them around the clock also might motivate certain patients to act out more or become withdrawn.

Possible medicolegal repercussions. If clinicians are able to access their patients’ electronic profiles, are they then legally obligated to monitor them? For example, if a patient who posts a picture with a noose around his neck later completes suicide, does the clinician who intermittently monitored this patient’s online profile face legal ramifications for not seeing the post? Do clinicians have to call 911 for vaguely suicidal tweets? What responsibilities does a clinician have at the first sign of an innocuous “sad” emoji? The sheer volume of online content that patients can create over different outlets is staggering. It can be overwhelming and ineffective to attempt to monitor patients’ online activities in addition to attending to one’s usual clinical duties, and the medicolegal repercussions of doing so are largely unknown.

Before searching the Internet to learn more about your patients, first consider the ramifications of doing so. While such searches could be helpful, they may lead to poor adherence, a lack of trust, or legal quagmires.