Pearls

As Internet use grows, so has patient demand for e-mail access to their physicians. Using e-mail in psychiatric practice has many advantages but also some unique drawbacks.

Advantages

For you, e-mail’s advantages include:

• decreased “phone tag” with patients
  
• ability to respond to requests at your convenience
  
• an automatically generated medical record¹
  
• easy distribution of handouts and references to patients, eliminating the need to store paper copies.
  

Using e-mail also could facilitate patient understanding and adherence. For example, consider e-mailing appointment reminders or medication instructions or asking cognitive-behavioral therapy patients to send in daily homework.

E-mail’s advantages for patients include:

• increased satisfaction and participation in care
  
• convenience
  
• better understanding of instructions that can be reread vs verbal information that might not be recalled.
  

Some patients may be more comfortable discussing sensitive topics via e-mail than in person.¹ In my practice, I’ve found this to be the case with university students, particularly those with anxiety disorders.

For example, a patient of mine with a history of trauma dropped out of treatment after revealing aspects of the trauma early in therapy. He did not respond to my phone calls, but after several weeks he unexpectedly e-mailed me. After an e-mail exchange about what happened, he returned to therapy and came weekly for several years. I feel this positive outcome occurred because he could contact me in a way that provided him a sense of distance, control, and safety.

E-mail guidelines

Potential risk of malpractice is a drawback of using e-mail in clinical practice. Malpractice by definition requires 2 elements:

• a patient-physician relationship—which unsolicited e-mail likely can establish if a physician gives advice that the patient takes²
  
• a breach of duty that results in harm to the patient.
  

The American Medical Association’s extensive guidelines suggest how physicians who use e-mail can reduce their malpractice risk (Table).³ In addition, individual states may have rules governing the use of e-mail in clinical practice.

Don’t diagnose or treat by e-mail

Diagnosis and treatment via e-mail could be considered substandard care. Patients might not be forthcoming about symptoms in an e-mail, either because of concerns about how symptoms might be perceived or poor insight. The lack of auditory and visual cues makes proper assessment difficult and can increase the risk of misdiagnosis and inappropriate treatment.² This is especially true in psychiatry, where diagnosis can rely heavily on analyzing a patient’s physical presentation, including psychomotor behavior, affect, and speech patterns.

For example, if a patient you are treating with a selective serotonin reuptake inhibitor for a depressive episode e-mails you about feeling anxiety in the presence of others, it may be tempting to diagnose a comorbid anxiety disorder. However, anxious feelings also can be caused by paranoia related to an evolving first lifetime episode of mania with psychotic features. Clues to this diagnosis—such as expansive affect, pressured speech, and psychomotor agitation—might be detected during an in-person assessment but missed in an e-mail.

For this reason, avoid making new diagnostic assessments or changing a treatment plan based on an e-mail exchange. If you are tempted to do so, call the patient to discuss the issue or ask him or her to come in for an office visit.

Set e-mail boundaries

Using e-mail in clinical practice could be time-consuming, adding extra work to already packed days. A subset of patients—such as those with personality disorders—might e-mail excessively, bring up subjects that are inappropriate for e-mail, or try to build permeable boundaries into the patient-physician relationship. Minimize these concerns by clearly outlining which topics are and are not appropriate for e-mail.³

Table

6 strategies to minimize liability when using e-mail

Protect patient confidentiality, especially when e-mail contains sensitive mental health information. E-mail easily can be misaddressed or read by other people
Avoid establishing new patient-physician relationships via e-mail
Use an informed consent procedure. Detail confidentiality risks, how often e-mail is checked and by whom, and how long before patients generally can expect a reply. State clearly that e-mail never should be used for urgent concerns or in an emergency
Add a footer to outgoing e-mails that summarizes your e-mail policy. Also include office and emergency contact information
Use an ‘Auto Reply’ message that includes this footer that will be sent in response to every message you receive
Include e-mail in the medical record
Source: Reference 3

For example, you could use e-mail only for appointment scheduling, medication refill requests, and providing instructions, handouts, and references, all of which could increase practice efficiency. Some psychiatrists may be comfortable discussing some therapeutic issues via e-mail or allowing patients to communicate thoughts and concerns during the week—without expecting a reply—to be addressed during their next session. You could decline to provide your e-mail address to patients who might abuse the privilege and instruct them to call the office instead.

 

Inappropriate use of e-mail can be addressed during a session as you would any other transference-countertransference or boundary issue, potentially yielding important therapeutic gains.

As Internet use grows, so has patient demand for e-mail access to their physicians. Using e-mail in psychiatric practice has many advantages but also some unique drawbacks.

Advantages

For you, e-mail’s advantages include:

• decreased “phone tag” with patients
  
• ability to respond to requests at your convenience
  
• an automatically generated medical record¹
  
• easy distribution of handouts and references to patients, eliminating the need to store paper copies.
  

Using e-mail also could facilitate patient understanding and adherence. For example, consider e-mailing appointment reminders or medication instructions or asking cognitive-behavioral therapy patients to send in daily homework.

E-mail’s advantages for patients include:

• increased satisfaction and participation in care
  
• convenience
  
• better understanding of instructions that can be reread vs verbal information that might not be recalled.
  

Some patients may be more comfortable discussing sensitive topics via e-mail than in person.¹ In my practice, I’ve found this to be the case with university students, particularly those with anxiety disorders.

For example, a patient of mine with a history of trauma dropped out of treatment after revealing aspects of the trauma early in therapy. He did not respond to my phone calls, but after several weeks he unexpectedly e-mailed me. After an e-mail exchange about what happened, he returned to therapy and came weekly for several years. I feel this positive outcome occurred because he could contact me in a way that provided him a sense of distance, control, and safety.

E-mail guidelines

Potential risk of malpractice is a drawback of using e-mail in clinical practice. Malpractice by definition requires 2 elements:

• a patient-physician relationship—which unsolicited e-mail likely can establish if a physician gives advice that the patient takes²
  
• a breach of duty that results in harm to the patient.
  

The American Medical Association’s extensive guidelines suggest how physicians who use e-mail can reduce their malpractice risk (Table).³ In addition, individual states may have rules governing the use of e-mail in clinical practice.

Don’t diagnose or treat by e-mail

Diagnosis and treatment via e-mail could be considered substandard care. Patients might not be forthcoming about symptoms in an e-mail, either because of concerns about how symptoms might be perceived or poor insight. The lack of auditory and visual cues makes proper assessment difficult and can increase the risk of misdiagnosis and inappropriate treatment.² This is especially true in psychiatry, where diagnosis can rely heavily on analyzing a patient’s physical presentation, including psychomotor behavior, affect, and speech patterns.

For example, if a patient you are treating with a selective serotonin reuptake inhibitor for a depressive episode e-mails you about feeling anxiety in the presence of others, it may be tempting to diagnose a comorbid anxiety disorder. However, anxious feelings also can be caused by paranoia related to an evolving first lifetime episode of mania with psychotic features. Clues to this diagnosis—such as expansive affect, pressured speech, and psychomotor agitation—might be detected during an in-person assessment but missed in an e-mail.

For this reason, avoid making new diagnostic assessments or changing a treatment plan based on an e-mail exchange. If you are tempted to do so, call the patient to discuss the issue or ask him or her to come in for an office visit.

Set e-mail boundaries

Using e-mail in clinical practice could be time-consuming, adding extra work to already packed days. A subset of patients—such as those with personality disorders—might e-mail excessively, bring up subjects that are inappropriate for e-mail, or try to build permeable boundaries into the patient-physician relationship. Minimize these concerns by clearly outlining which topics are and are not appropriate for e-mail.³

Table

6 strategies to minimize liability when using e-mail

Protect patient confidentiality, especially when e-mail contains sensitive mental health information. E-mail easily can be misaddressed or read by other people
Avoid establishing new patient-physician relationships via e-mail
Use an informed consent procedure. Detail confidentiality risks, how often e-mail is checked and by whom, and how long before patients generally can expect a reply. State clearly that e-mail never should be used for urgent concerns or in an emergency
Add a footer to outgoing e-mails that summarizes your e-mail policy. Also include office and emergency contact information
Use an ‘Auto Reply’ message that includes this footer that will be sent in response to every message you receive
Include e-mail in the medical record
Source: Reference 3

For example, you could use e-mail only for appointment scheduling, medication refill requests, and providing instructions, handouts, and references, all of which could increase practice efficiency. Some psychiatrists may be comfortable discussing some therapeutic issues via e-mail or allowing patients to communicate thoughts and concerns during the week—without expecting a reply—to be addressed during their next session. You could decline to provide your e-mail address to patients who might abuse the privilege and instruct them to call the office instead.

 

Inappropriate use of e-mail can be addressed during a session as you would any other transference-countertransference or boundary issue, potentially yielding important therapeutic gains.

As Internet use grows, so has patient demand for e-mail access to their physicians. Using e-mail in psychiatric practice has many advantages but also some unique drawbacks.

Advantages

For you, e-mail’s advantages include:

• decreased “phone tag” with patients
  
• ability to respond to requests at your convenience
  
• an automatically generated medical record¹
  
• easy distribution of handouts and references to patients, eliminating the need to store paper copies.
  

Using e-mail also could facilitate patient understanding and adherence. For example, consider e-mailing appointment reminders or medication instructions or asking cognitive-behavioral therapy patients to send in daily homework.

E-mail’s advantages for patients include:

• increased satisfaction and participation in care
  
• convenience
  
• better understanding of instructions that can be reread vs verbal information that might not be recalled.
  

Some patients may be more comfortable discussing sensitive topics via e-mail than in person.¹ In my practice, I’ve found this to be the case with university students, particularly those with anxiety disorders.

For example, a patient of mine with a history of trauma dropped out of treatment after revealing aspects of the trauma early in therapy. He did not respond to my phone calls, but after several weeks he unexpectedly e-mailed me. After an e-mail exchange about what happened, he returned to therapy and came weekly for several years. I feel this positive outcome occurred because he could contact me in a way that provided him a sense of distance, control, and safety.

E-mail guidelines

Potential risk of malpractice is a drawback of using e-mail in clinical practice. Malpractice by definition requires 2 elements:

• a patient-physician relationship—which unsolicited e-mail likely can establish if a physician gives advice that the patient takes²
  
• a breach of duty that results in harm to the patient.
  

The American Medical Association’s extensive guidelines suggest how physicians who use e-mail can reduce their malpractice risk (Table).³ In addition, individual states may have rules governing the use of e-mail in clinical practice.

Don’t diagnose or treat by e-mail

Diagnosis and treatment via e-mail could be considered substandard care. Patients might not be forthcoming about symptoms in an e-mail, either because of concerns about how symptoms might be perceived or poor insight. The lack of auditory and visual cues makes proper assessment difficult and can increase the risk of misdiagnosis and inappropriate treatment.² This is especially true in psychiatry, where diagnosis can rely heavily on analyzing a patient’s physical presentation, including psychomotor behavior, affect, and speech patterns.

For example, if a patient you are treating with a selective serotonin reuptake inhibitor for a depressive episode e-mails you about feeling anxiety in the presence of others, it may be tempting to diagnose a comorbid anxiety disorder. However, anxious feelings also can be caused by paranoia related to an evolving first lifetime episode of mania with psychotic features. Clues to this diagnosis—such as expansive affect, pressured speech, and psychomotor agitation—might be detected during an in-person assessment but missed in an e-mail.

For this reason, avoid making new diagnostic assessments or changing a treatment plan based on an e-mail exchange. If you are tempted to do so, call the patient to discuss the issue or ask him or her to come in for an office visit.

Set e-mail boundaries

Using e-mail in clinical practice could be time-consuming, adding extra work to already packed days. A subset of patients—such as those with personality disorders—might e-mail excessively, bring up subjects that are inappropriate for e-mail, or try to build permeable boundaries into the patient-physician relationship. Minimize these concerns by clearly outlining which topics are and are not appropriate for e-mail.³

Table

6 strategies to minimize liability when using e-mail

Protect patient confidentiality, especially when e-mail contains sensitive mental health information. E-mail easily can be misaddressed or read by other people
Avoid establishing new patient-physician relationships via e-mail
Use an informed consent procedure. Detail confidentiality risks, how often e-mail is checked and by whom, and how long before patients generally can expect a reply. State clearly that e-mail never should be used for urgent concerns or in an emergency
Add a footer to outgoing e-mails that summarizes your e-mail policy. Also include office and emergency contact information
Use an ‘Auto Reply’ message that includes this footer that will be sent in response to every message you receive
Include e-mail in the medical record
Source: Reference 3

For example, you could use e-mail only for appointment scheduling, medication refill requests, and providing instructions, handouts, and references, all of which could increase practice efficiency. Some psychiatrists may be comfortable discussing some therapeutic issues via e-mail or allowing patients to communicate thoughts and concerns during the week—without expecting a reply—to be addressed during their next session. You could decline to provide your e-mail address to patients who might abuse the privilege and instruct them to call the office instead.

 

Inappropriate use of e-mail can be addressed during a session as you would any other transference-countertransference or boundary issue, potentially yielding important therapeutic gains.

Diagnostic criteria for schizophrenia emphasize positive and negative symptoms at the expense of other domains, such as cognition or affective states. For a comprehensive, cross-sectional diagnostic assessment, I suggest looking for 6 symptom clusters—motor symptoms, disorganization, delusions and hallucinations, negative symptoms, cognitive symptoms, and affective symptoms—when treating patients with psychotic disorders.

Depicting these 6 symptom clusters graphically—in your mind or on paper—allows you to appreciate your patient’s problems and target interventions appropriately. View the diagram of a sample schizophrenia patient’s symptom clusters. A graph drawn on a blackboard or a piece of paper also is a good tool to educate patients and their friends, families, and caregivers about key aspects of schizophrenia beyond psychosis.

1 Motor symptoms

Note symptoms associated with antipsychotics (ie, iatrogenic morbidity), such as the restlessness with akathisia, tremor and bradykinesia with pseudoparkinsonism, and irregular abnormal movements with tardive dyskinesia. Consider catatonia if you see paucity of movement or peculiar motor behaviors.

2 Disorganization

Note speech, thinking, appearance, and behaviors that suggest disorganization. Symptoms in this cluster often make patients look “psychiatric.”

3 Delusions and hallucinations

For some patients with schizophrenia, symptoms in this cluster prevent treatment engagement (such as impairing paranoia) or pose a risk to the patient or the community (such as command hallucinations). Delusions and hallucinations often remit or are functionally irrelevant in patients who are treated successfully.

4 Negative symptoms

This symptom cluster, often associated with functional impairment, includes the 2 observable symptoms of blunted affect and alogia.

5 Cognitive symptoms

Executive dysfunction and verbal memory impairment also are associated with functional impairment but may not be apparent during the clinical encounter. To screen for typical problems in this cluster, I include tests of verbal fluency and word list recall during the interview.

6 Affective symptoms

Depression, anxiety, demoralization, and suicidality can affect your patient’s quality of life. Also look on the opposite pole for maniform or “mania-like” presentations, such as lack of inhibition, excitability, and irritability.

Diagnostic criteria for schizophrenia emphasize positive and negative symptoms at the expense of other domains, such as cognition or affective states. For a comprehensive, cross-sectional diagnostic assessment, I suggest looking for 6 symptom clusters—motor symptoms, disorganization, delusions and hallucinations, negative symptoms, cognitive symptoms, and affective symptoms—when treating patients with psychotic disorders.

Depicting these 6 symptom clusters graphically—in your mind or on paper—allows you to appreciate your patient’s problems and target interventions appropriately. View the diagram of a sample schizophrenia patient’s symptom clusters. A graph drawn on a blackboard or a piece of paper also is a good tool to educate patients and their friends, families, and caregivers about key aspects of schizophrenia beyond psychosis.

1 Motor symptoms

Note symptoms associated with antipsychotics (ie, iatrogenic morbidity), such as the restlessness with akathisia, tremor and bradykinesia with pseudoparkinsonism, and irregular abnormal movements with tardive dyskinesia. Consider catatonia if you see paucity of movement or peculiar motor behaviors.

2 Disorganization

Note speech, thinking, appearance, and behaviors that suggest disorganization. Symptoms in this cluster often make patients look “psychiatric.”

3 Delusions and hallucinations

For some patients with schizophrenia, symptoms in this cluster prevent treatment engagement (such as impairing paranoia) or pose a risk to the patient or the community (such as command hallucinations). Delusions and hallucinations often remit or are functionally irrelevant in patients who are treated successfully.

4 Negative symptoms

This symptom cluster, often associated with functional impairment, includes the 2 observable symptoms of blunted affect and alogia.

5 Cognitive symptoms

Executive dysfunction and verbal memory impairment also are associated with functional impairment but may not be apparent during the clinical encounter. To screen for typical problems in this cluster, I include tests of verbal fluency and word list recall during the interview.

6 Affective symptoms

Depression, anxiety, demoralization, and suicidality can affect your patient’s quality of life. Also look on the opposite pole for maniform or “mania-like” presentations, such as lack of inhibition, excitability, and irritability.

Diagnostic criteria for schizophrenia emphasize positive and negative symptoms at the expense of other domains, such as cognition or affective states. For a comprehensive, cross-sectional diagnostic assessment, I suggest looking for 6 symptom clusters—motor symptoms, disorganization, delusions and hallucinations, negative symptoms, cognitive symptoms, and affective symptoms—when treating patients with psychotic disorders.

Depicting these 6 symptom clusters graphically—in your mind or on paper—allows you to appreciate your patient’s problems and target interventions appropriately. View the diagram of a sample schizophrenia patient’s symptom clusters. A graph drawn on a blackboard or a piece of paper also is a good tool to educate patients and their friends, families, and caregivers about key aspects of schizophrenia beyond psychosis.

1 Motor symptoms

Note symptoms associated with antipsychotics (ie, iatrogenic morbidity), such as the restlessness with akathisia, tremor and bradykinesia with pseudoparkinsonism, and irregular abnormal movements with tardive dyskinesia. Consider catatonia if you see paucity of movement or peculiar motor behaviors.

2 Disorganization

Note speech, thinking, appearance, and behaviors that suggest disorganization. Symptoms in this cluster often make patients look “psychiatric.”

3 Delusions and hallucinations

For some patients with schizophrenia, symptoms in this cluster prevent treatment engagement (such as impairing paranoia) or pose a risk to the patient or the community (such as command hallucinations). Delusions and hallucinations often remit or are functionally irrelevant in patients who are treated successfully.

4 Negative symptoms

This symptom cluster, often associated with functional impairment, includes the 2 observable symptoms of blunted affect and alogia.

5 Cognitive symptoms

Executive dysfunction and verbal memory impairment also are associated with functional impairment but may not be apparent during the clinical encounter. To screen for typical problems in this cluster, I include tests of verbal fluency and word list recall during the interview.

6 Affective symptoms

Depression, anxiety, demoralization, and suicidality can affect your patient’s quality of life. Also look on the opposite pole for maniform or “mania-like” presentations, such as lack of inhibition, excitability, and irritability.

Substance dependence is defined by physiologic and behavioral symptoms, and substance abuse is described in terms of adverse social consequences of substance use. Dependence involves physiologic processes whereas abuse reflects a complex interaction between the individual, the abused substance, and society.

Diagnostic criteria for substance use disorders allow clinicians to:

• plan treatment and monitor progress
  
• provide patients access to health insurance coverage.
  

Following the mnemonic DRiNK TWO 6 PACK can help you determine if your patient’s symptoms meet diagnostic criteria for substance abuse or substance dependence, which then allows you develop an appropriate treatment plan. The mnemonic suggests alcohol abuse and dependence, but it can be applied to any substance.

Substance abuse

DSM-IV-TR¹ defines substance abuse as a maladaptive pattern of use leading to clinically significant impairment or distress as evidenced by ≥1 of 4 symptom criteria within a 12-month period. The mnemonic DRiNK aids recall of the 4 symptoms:

• Dangerously driving a vehicle or machine when impaired by substances
  
• Ri: Role failure in home, school, or work because of recurrent substance use
  
• No respect for the law, leading to legal problems
  
• Keeps using a substance despite persistent or recurrent social or interpersonal problems.
  

Finally, the patient must not have met criteria for substance dependence. Although a substance abuse diagnosis is more likely in individuals who recently started using the substance,² some individuals can have substance-related adverse social consequences for a long time without developing dependence.

Substance dependence

Physiologic dependence is development of tolerance leading to withdrawal symptoms. According to DSM-IV-TR, substance dependence is a maladaptive pattern of substance use leading to clinically significant impairment or distress identified by ≥3 of the 7 symptoms at any time in the same 12-month period. These symptoms can be recalled with the mnemonic TWO 6 PACK:

• Tolerance
  
• Withdrawal
  
• Occupational, social, or recreational activities given up or reduced
  
• 6
  
• Persistent desire or unsuccessful efforts to cut down or control substance use
  
• Amount of use is excessive
  
• Continues substance use despite having persistent or recurrent physical or psychological problems
  
• Keeps spending a lot of time in search, use, or recovery from the substance.
  

Substance dependence is defined by physiologic and behavioral symptoms, and substance abuse is described in terms of adverse social consequences of substance use. Dependence involves physiologic processes whereas abuse reflects a complex interaction between the individual, the abused substance, and society.

Diagnostic criteria for substance use disorders allow clinicians to:

• plan treatment and monitor progress
  
• provide patients access to health insurance coverage.
  

Following the mnemonic DRiNK TWO 6 PACK can help you determine if your patient’s symptoms meet diagnostic criteria for substance abuse or substance dependence, which then allows you develop an appropriate treatment plan. The mnemonic suggests alcohol abuse and dependence, but it can be applied to any substance.

Substance abuse

DSM-IV-TR¹ defines substance abuse as a maladaptive pattern of use leading to clinically significant impairment or distress as evidenced by ≥1 of 4 symptom criteria within a 12-month period. The mnemonic DRiNK aids recall of the 4 symptoms:

• Dangerously driving a vehicle or machine when impaired by substances
  
• Ri: Role failure in home, school, or work because of recurrent substance use
  
• No respect for the law, leading to legal problems
  
• Keeps using a substance despite persistent or recurrent social or interpersonal problems.
  

Finally, the patient must not have met criteria for substance dependence. Although a substance abuse diagnosis is more likely in individuals who recently started using the substance,² some individuals can have substance-related adverse social consequences for a long time without developing dependence.

Substance dependence

Physiologic dependence is development of tolerance leading to withdrawal symptoms. According to DSM-IV-TR, substance dependence is a maladaptive pattern of substance use leading to clinically significant impairment or distress identified by ≥3 of the 7 symptoms at any time in the same 12-month period. These symptoms can be recalled with the mnemonic TWO 6 PACK:

• Tolerance
  
• Withdrawal
  
• Occupational, social, or recreational activities given up or reduced
  
• 6
  
• Persistent desire or unsuccessful efforts to cut down or control substance use
  
• Amount of use is excessive
  
• Continues substance use despite having persistent or recurrent physical or psychological problems
  
• Keeps spending a lot of time in search, use, or recovery from the substance.
  

Substance dependence is defined by physiologic and behavioral symptoms, and substance abuse is described in terms of adverse social consequences of substance use. Dependence involves physiologic processes whereas abuse reflects a complex interaction between the individual, the abused substance, and society.

Diagnostic criteria for substance use disorders allow clinicians to:

• plan treatment and monitor progress
  
• provide patients access to health insurance coverage.
  

Following the mnemonic DRiNK TWO 6 PACK can help you determine if your patient’s symptoms meet diagnostic criteria for substance abuse or substance dependence, which then allows you develop an appropriate treatment plan. The mnemonic suggests alcohol abuse and dependence, but it can be applied to any substance.

Substance abuse

DSM-IV-TR¹ defines substance abuse as a maladaptive pattern of use leading to clinically significant impairment or distress as evidenced by ≥1 of 4 symptom criteria within a 12-month period. The mnemonic DRiNK aids recall of the 4 symptoms:

• Dangerously driving a vehicle or machine when impaired by substances
  
• Ri: Role failure in home, school, or work because of recurrent substance use
  
• No respect for the law, leading to legal problems
  
• Keeps using a substance despite persistent or recurrent social or interpersonal problems.
  

Finally, the patient must not have met criteria for substance dependence. Although a substance abuse diagnosis is more likely in individuals who recently started using the substance,² some individuals can have substance-related adverse social consequences for a long time without developing dependence.

Substance dependence

Physiologic dependence is development of tolerance leading to withdrawal symptoms. According to DSM-IV-TR, substance dependence is a maladaptive pattern of substance use leading to clinically significant impairment or distress identified by ≥3 of the 7 symptoms at any time in the same 12-month period. These symptoms can be recalled with the mnemonic TWO 6 PACK:

• Tolerance
  
• Withdrawal
  
• Occupational, social, or recreational activities given up or reduced
  
• 6
  
• Persistent desire or unsuccessful efforts to cut down or control substance use
  
• Amount of use is excessive
  
• Continues substance use despite having persistent or recurrent physical or psychological problems
  
• Keeps spending a lot of time in search, use, or recovery from the substance.
  

Cognitive-behavioral therapy for insomnia (CBT-I) can be effective, regardless of whether chronic insomnia is primary or secondary to psychiatric, substance dependence, or psychophysiologic causes.¹ In fact, with a response rate of 70% to 80%,² CBT-I can be as effective as medication in the short term and even more effective in the long term.³

Delivered in 4 to 10 sessions, CBT-I typically includes assessment and monitoring of insomnia and sleep patterns, sleep restriction, stimulus control, sleep hygiene education, relaxation training, cognitive therapy, and relapse prevention. Goals are to:

• decrease the time spent awake in bed, thereby increasing sleep efficiency
  
• strengthen the association between the bedroom and sleep
  
• address maladaptive sleep habits and lifestyle factors that affect sleep
  
• remove extraneous stimuli from the bedroom.
  

Group therapy with CBT-I

At our clinic, we have modified standard CBT-I techniques into a group format that includes patients with other sleep disorders, medical conditions, or psychiatric diagnoses. Also, CBT-I can benefit mentally ill out-patients with persistent secondary insomnia despite adequate hypnotic dosages.

Challenges to a CBT-I format include: member dropout, inconsistent attendance, disparate psychiatric diagnoses, and different forms of insomnia. In addition, motivating patients to change poor sleep habits that have been in place for decades can be difficult. Finally, CBT-I—although simple in concept—can be difficult to employ, particularly the behavioral components of stimulus control and sleep restriction. Many patients resist these behavioral interventions because they do not experience relief in the short term. Because improved sleep quality frequently is experienced toward the end of treatment, patient motivation and consistency are crucial for success.

For optimal results when leading group CBT-I, be consistent when teaching skills, checking homework, and gaining treatment compliance. Educate patients about CBT-I principles, and help them understand the rationale for what may seem like counterintuitive treatments, such as decreasing time spent in bed. Inform patients that they must practice these skills consistently and stick with the protocol until treatment ends. When patients know the treatment is time-limited and see others in the group begin to benefit, this commitment can seem less daunting.

Cognitive-behavioral therapy for insomnia (CBT-I) can be effective, regardless of whether chronic insomnia is primary or secondary to psychiatric, substance dependence, or psychophysiologic causes.¹ In fact, with a response rate of 70% to 80%,² CBT-I can be as effective as medication in the short term and even more effective in the long term.³

Delivered in 4 to 10 sessions, CBT-I typically includes assessment and monitoring of insomnia and sleep patterns, sleep restriction, stimulus control, sleep hygiene education, relaxation training, cognitive therapy, and relapse prevention. Goals are to:

• decrease the time spent awake in bed, thereby increasing sleep efficiency
  
• strengthen the association between the bedroom and sleep
  
• address maladaptive sleep habits and lifestyle factors that affect sleep
  
• remove extraneous stimuli from the bedroom.
  

Group therapy with CBT-I

At our clinic, we have modified standard CBT-I techniques into a group format that includes patients with other sleep disorders, medical conditions, or psychiatric diagnoses. Also, CBT-I can benefit mentally ill out-patients with persistent secondary insomnia despite adequate hypnotic dosages.

Challenges to a CBT-I format include: member dropout, inconsistent attendance, disparate psychiatric diagnoses, and different forms of insomnia. In addition, motivating patients to change poor sleep habits that have been in place for decades can be difficult. Finally, CBT-I—although simple in concept—can be difficult to employ, particularly the behavioral components of stimulus control and sleep restriction. Many patients resist these behavioral interventions because they do not experience relief in the short term. Because improved sleep quality frequently is experienced toward the end of treatment, patient motivation and consistency are crucial for success.

For optimal results when leading group CBT-I, be consistent when teaching skills, checking homework, and gaining treatment compliance. Educate patients about CBT-I principles, and help them understand the rationale for what may seem like counterintuitive treatments, such as decreasing time spent in bed. Inform patients that they must practice these skills consistently and stick with the protocol until treatment ends. When patients know the treatment is time-limited and see others in the group begin to benefit, this commitment can seem less daunting.

Cognitive-behavioral therapy for insomnia (CBT-I) can be effective, regardless of whether chronic insomnia is primary or secondary to psychiatric, substance dependence, or psychophysiologic causes.¹ In fact, with a response rate of 70% to 80%,² CBT-I can be as effective as medication in the short term and even more effective in the long term.³

Delivered in 4 to 10 sessions, CBT-I typically includes assessment and monitoring of insomnia and sleep patterns, sleep restriction, stimulus control, sleep hygiene education, relaxation training, cognitive therapy, and relapse prevention. Goals are to:

• decrease the time spent awake in bed, thereby increasing sleep efficiency
  
• strengthen the association between the bedroom and sleep
  
• address maladaptive sleep habits and lifestyle factors that affect sleep
  
• remove extraneous stimuli from the bedroom.
  

Group therapy with CBT-I

At our clinic, we have modified standard CBT-I techniques into a group format that includes patients with other sleep disorders, medical conditions, or psychiatric diagnoses. Also, CBT-I can benefit mentally ill out-patients with persistent secondary insomnia despite adequate hypnotic dosages.

Challenges to a CBT-I format include: member dropout, inconsistent attendance, disparate psychiatric diagnoses, and different forms of insomnia. In addition, motivating patients to change poor sleep habits that have been in place for decades can be difficult. Finally, CBT-I—although simple in concept—can be difficult to employ, particularly the behavioral components of stimulus control and sleep restriction. Many patients resist these behavioral interventions because they do not experience relief in the short term. Because improved sleep quality frequently is experienced toward the end of treatment, patient motivation and consistency are crucial for success.

For optimal results when leading group CBT-I, be consistent when teaching skills, checking homework, and gaining treatment compliance. Educate patients about CBT-I principles, and help them understand the rationale for what may seem like counterintuitive treatments, such as decreasing time spent in bed. Inform patients that they must practice these skills consistently and stick with the protocol until treatment ends. When patients know the treatment is time-limited and see others in the group begin to benefit, this commitment can seem less daunting.

Finding the best clozapine dosage for your psychotic patient can be challenging because any given dose of the drug yields highly variable clozapine serum levels. This interindividual variability reflects clozapine’s complex metabolism.

Obtaining serum levels will help you determine if your patient remains psychotic because of insufficient dosing or if your asymptomatic patient can safely receive a lower dose to minimize side effects without risking psychotic relapse. Following these guidelines will help you make the ban use of clozapine drug levels.

Obtaining clozapine levels

Measure clozapine as steady-state trough levels. I usually draw them 12 hours after the last dose (such as in the morning after the nightly dose) and several days after treatment begins.

When you order a clozapine level, most laboratories report 3 numbers: clozapine, norclozapine, and their sum. The literature addresses only the clinical use of clozapine levels and ignores the much less active metabolite, norclozapine.

Interpreting clozapine levels

Although there is no simple relationship among clozapine levels, therapeutic efficacy, and toxicity, a randomized clinical trial of patients with chronic schizophrenia¹ compared 3 non-overlapping ranges and found:

• “medium” range (200 to 300 ng/mL) is a good initial target
• low range (50 to 150 ng/mL) is not as effective as medium or high levels
• high range (350 to 450 ng/mL) can be tried if clinical response is insufficient, although the high range was no more effective than the medium range
• overy high levels (ie >1,000 ng/mL combined clozapine and norclozapine levels) have no proven benefit and increase seizure risk.

These guidelines are based on bid or tid dosing. If your patient receives clozapine only at night, take into account the higher morning level compared with the same dose administered on a split schedule.

Adjusting clozapine dose

Now that you have an accurate drug level, take advantage of clozapine’s linear pharmacokinetics. If you double the dose, you double the level; if you halve the dose, you halve the level.

For example, consider the case of a schizophrenia patient who remains psychotic despite a clozapine dose of 200 mg bid (400 mg/d). His clozapine level is 100 ng/mL (ie, low range) and his norclozapine level is 50 ng/mL. This patient would need double his dose (800 mg/d) to achieve a clozapine level at the low end of the medium range (200 ng/mL). Note that the norclozapine level is ignored for this calculation.

Finding the best clozapine dosage for your psychotic patient can be challenging because any given dose of the drug yields highly variable clozapine serum levels. This interindividual variability reflects clozapine’s complex metabolism.

Obtaining serum levels will help you determine if your patient remains psychotic because of insufficient dosing or if your asymptomatic patient can safely receive a lower dose to minimize side effects without risking psychotic relapse. Following these guidelines will help you make the ban use of clozapine drug levels.

Obtaining clozapine levels

Measure clozapine as steady-state trough levels. I usually draw them 12 hours after the last dose (such as in the morning after the nightly dose) and several days after treatment begins.

When you order a clozapine level, most laboratories report 3 numbers: clozapine, norclozapine, and their sum. The literature addresses only the clinical use of clozapine levels and ignores the much less active metabolite, norclozapine.

Interpreting clozapine levels

Although there is no simple relationship among clozapine levels, therapeutic efficacy, and toxicity, a randomized clinical trial of patients with chronic schizophrenia¹ compared 3 non-overlapping ranges and found:

• “medium” range (200 to 300 ng/mL) is a good initial target
• low range (50 to 150 ng/mL) is not as effective as medium or high levels
• high range (350 to 450 ng/mL) can be tried if clinical response is insufficient, although the high range was no more effective than the medium range
• overy high levels (ie >1,000 ng/mL combined clozapine and norclozapine levels) have no proven benefit and increase seizure risk.

These guidelines are based on bid or tid dosing. If your patient receives clozapine only at night, take into account the higher morning level compared with the same dose administered on a split schedule.

Adjusting clozapine dose

Now that you have an accurate drug level, take advantage of clozapine’s linear pharmacokinetics. If you double the dose, you double the level; if you halve the dose, you halve the level.

For example, consider the case of a schizophrenia patient who remains psychotic despite a clozapine dose of 200 mg bid (400 mg/d). His clozapine level is 100 ng/mL (ie, low range) and his norclozapine level is 50 ng/mL. This patient would need double his dose (800 mg/d) to achieve a clozapine level at the low end of the medium range (200 ng/mL). Note that the norclozapine level is ignored for this calculation.

Finding the best clozapine dosage for your psychotic patient can be challenging because any given dose of the drug yields highly variable clozapine serum levels. This interindividual variability reflects clozapine’s complex metabolism.

Obtaining serum levels will help you determine if your patient remains psychotic because of insufficient dosing or if your asymptomatic patient can safely receive a lower dose to minimize side effects without risking psychotic relapse. Following these guidelines will help you make the ban use of clozapine drug levels.

Obtaining clozapine levels

Measure clozapine as steady-state trough levels. I usually draw them 12 hours after the last dose (such as in the morning after the nightly dose) and several days after treatment begins.

When you order a clozapine level, most laboratories report 3 numbers: clozapine, norclozapine, and their sum. The literature addresses only the clinical use of clozapine levels and ignores the much less active metabolite, norclozapine.

Interpreting clozapine levels

Although there is no simple relationship among clozapine levels, therapeutic efficacy, and toxicity, a randomized clinical trial of patients with chronic schizophrenia¹ compared 3 non-overlapping ranges and found:

• “medium” range (200 to 300 ng/mL) is a good initial target
• low range (50 to 150 ng/mL) is not as effective as medium or high levels
• high range (350 to 450 ng/mL) can be tried if clinical response is insufficient, although the high range was no more effective than the medium range
• overy high levels (ie >1,000 ng/mL combined clozapine and norclozapine levels) have no proven benefit and increase seizure risk.

These guidelines are based on bid or tid dosing. If your patient receives clozapine only at night, take into account the higher morning level compared with the same dose administered on a split schedule.

Adjusting clozapine dose

Now that you have an accurate drug level, take advantage of clozapine’s linear pharmacokinetics. If you double the dose, you double the level; if you halve the dose, you halve the level.

For example, consider the case of a schizophrenia patient who remains psychotic despite a clozapine dose of 200 mg bid (400 mg/d). His clozapine level is 100 ng/mL (ie, low range) and his norclozapine level is 50 ng/mL. This patient would need double his dose (800 mg/d) to achieve a clozapine level at the low end of the medium range (200 ng/mL). Note that the norclozapine level is ignored for this calculation.

Psychological testing can help you clear up questions about psychiatric differential diagnosis and treatment planning, but only if your patients make and keep appointments for the tests you recommend.

Based on my observations as a psychologist who administers these tests, factors that undermine patient follow-through include patient or family resistance, prohibitive managed care policies, and limited availability of psychologists who perform testing. I suggest 7 practices that may enhance your patients’ adherence.

Familiarize yourself with best practices in psychological testing—including indications and contraindications—by consulting standard references,¹ taking a continuing education overview course, or attending in-service training with local psychologists.

Encourage your patient to find out if his health insurance covers the recommended testing. For example, few—if any—managed care plans cover testing for learning disorders, and some will not reimburse for testing when the primary rule-out diagnosis is attention-deficit/hyperactivity disorder. Plans may be more likely to cover testing when you frame the referral in terms of a differential diagnosis or need for clarity regarding treatment planning.

Maintain an updated list of well-regarded, established clinicians experienced in psychological testing. Children and adolescents should be evaluated by psychologists specializing in pediatric patients, and elderly adults should be seen by clinicians with experience in geriatric neuropsychology.

Educate patients about your reasons for the referral. Refer to earlier discussions when you and the patient were in broad agreement. You might say, for example, “You have wondered whether your forgetfulness is related to depression. Testing can help clarify this issue for us and move treatment forward.”

Remain empathic to characterologic resistance to psychological consultation. Patients with borderline personality disorder might experience a recommendation for testing as abandonment or coerced separation, narcissistic patients may fear humiliation or shame, and obsessive patients may become anxious about failing to “measure up” to some idealized standard of test performance.

Consult with the testing psychologist when you have questions about the clinical value of a formal referral or insurance coverage. Facilitate patient compliance by calling or forwarding the referral to the testing psychologist, who then can write a letter reminding the patient about the referral.

Provide reading materials about psychological testing in your waiting room to help demystify these procedures and encourage patient interest and adherence.

Psychological testing can help you clear up questions about psychiatric differential diagnosis and treatment planning, but only if your patients make and keep appointments for the tests you recommend.

Based on my observations as a psychologist who administers these tests, factors that undermine patient follow-through include patient or family resistance, prohibitive managed care policies, and limited availability of psychologists who perform testing. I suggest 7 practices that may enhance your patients’ adherence.

Familiarize yourself with best practices in psychological testing—including indications and contraindications—by consulting standard references,¹ taking a continuing education overview course, or attending in-service training with local psychologists.

Encourage your patient to find out if his health insurance covers the recommended testing. For example, few—if any—managed care plans cover testing for learning disorders, and some will not reimburse for testing when the primary rule-out diagnosis is attention-deficit/hyperactivity disorder. Plans may be more likely to cover testing when you frame the referral in terms of a differential diagnosis or need for clarity regarding treatment planning.

Maintain an updated list of well-regarded, established clinicians experienced in psychological testing. Children and adolescents should be evaluated by psychologists specializing in pediatric patients, and elderly adults should be seen by clinicians with experience in geriatric neuropsychology.

Educate patients about your reasons for the referral. Refer to earlier discussions when you and the patient were in broad agreement. You might say, for example, “You have wondered whether your forgetfulness is related to depression. Testing can help clarify this issue for us and move treatment forward.”

Remain empathic to characterologic resistance to psychological consultation. Patients with borderline personality disorder might experience a recommendation for testing as abandonment or coerced separation, narcissistic patients may fear humiliation or shame, and obsessive patients may become anxious about failing to “measure up” to some idealized standard of test performance.

Consult with the testing psychologist when you have questions about the clinical value of a formal referral or insurance coverage. Facilitate patient compliance by calling or forwarding the referral to the testing psychologist, who then can write a letter reminding the patient about the referral.

Provide reading materials about psychological testing in your waiting room to help demystify these procedures and encourage patient interest and adherence.

Psychological testing can help you clear up questions about psychiatric differential diagnosis and treatment planning, but only if your patients make and keep appointments for the tests you recommend.

Based on my observations as a psychologist who administers these tests, factors that undermine patient follow-through include patient or family resistance, prohibitive managed care policies, and limited availability of psychologists who perform testing. I suggest 7 practices that may enhance your patients’ adherence.

Familiarize yourself with best practices in psychological testing—including indications and contraindications—by consulting standard references,¹ taking a continuing education overview course, or attending in-service training with local psychologists.

Encourage your patient to find out if his health insurance covers the recommended testing. For example, few—if any—managed care plans cover testing for learning disorders, and some will not reimburse for testing when the primary rule-out diagnosis is attention-deficit/hyperactivity disorder. Plans may be more likely to cover testing when you frame the referral in terms of a differential diagnosis or need for clarity regarding treatment planning.

Maintain an updated list of well-regarded, established clinicians experienced in psychological testing. Children and adolescents should be evaluated by psychologists specializing in pediatric patients, and elderly adults should be seen by clinicians with experience in geriatric neuropsychology.

Educate patients about your reasons for the referral. Refer to earlier discussions when you and the patient were in broad agreement. You might say, for example, “You have wondered whether your forgetfulness is related to depression. Testing can help clarify this issue for us and move treatment forward.”

Remain empathic to characterologic resistance to psychological consultation. Patients with borderline personality disorder might experience a recommendation for testing as abandonment or coerced separation, narcissistic patients may fear humiliation or shame, and obsessive patients may become anxious about failing to “measure up” to some idealized standard of test performance.

Consult with the testing psychologist when you have questions about the clinical value of a formal referral or insurance coverage. Facilitate patient compliance by calling or forwarding the referral to the testing psychologist, who then can write a letter reminding the patient about the referral.

Provide reading materials about psychological testing in your waiting room to help demystify these procedures and encourage patient interest and adherence.

A psychiatrist named in a malpractice suit may doubt the need to attend the deposition of the plaintiff and his hired experts. In a time when many psychiatrists are handling busy private practices, you may be tempted to skip the plaintiff’s deposition because often the law does not require you to attend.

However, based on our forensic psychiatry, expert witness, and risk management experience, we highly recommend that psychiatrists involved in a malpractice lawsuit attend plaintiff’s depositions for several reasons.

Counteract countertransference

One of the most often encountered ingredients of a malpractice lawsuit is negative transference toward the defendant psychiatrist and/or negative countertransference by the psychiatrist toward the plaintiff.¹ Attending the deposition gives you the opportunity to identify and analyze these reactions, consider how they could impair your objectivity, and allow you and your attorney to put together the best defense.²

Identify errors

Listening to depositions lets you identify errors, misunderstandings, misinterpretations, or distortions of facts in the plaintiff’s allegations or his experts’ testimony and supply your attorney fuel for an effective cross-examination.^2–4

Make your presence known

Sometimes your physical presence during the deposition might prevent any misstatements or false allegations.

Assess your case

Attending a plaintiff’s deposition is an excellent opportunity to see and assess the case as a whole while deepening your and your attorney’s understanding of the malpractice lawsuit.^2,5

Discuss your decision to attend the deposition with your attorney. If you choose not to attend, be sure to carefully read the transcripts of all depositions and use this information when preparing for your deposition.

Although attending the plaintiff’s deposition is optional, your presence during a malpractice trial is mandatory. Your expertise is most valuable when your attorney cross-examines witnesses. Your presence in the courtroom is necessary to establish your credibility, professionalism, and personality. In most trials jurors will assess the defendant psychiatrist, and not showing up could damage your case.

A psychiatrist named in a malpractice suit may doubt the need to attend the deposition of the plaintiff and his hired experts. In a time when many psychiatrists are handling busy private practices, you may be tempted to skip the plaintiff’s deposition because often the law does not require you to attend.

However, based on our forensic psychiatry, expert witness, and risk management experience, we highly recommend that psychiatrists involved in a malpractice lawsuit attend plaintiff’s depositions for several reasons.

Counteract countertransference

One of the most often encountered ingredients of a malpractice lawsuit is negative transference toward the defendant psychiatrist and/or negative countertransference by the psychiatrist toward the plaintiff.¹ Attending the deposition gives you the opportunity to identify and analyze these reactions, consider how they could impair your objectivity, and allow you and your attorney to put together the best defense.²

Identify errors

Listening to depositions lets you identify errors, misunderstandings, misinterpretations, or distortions of facts in the plaintiff’s allegations or his experts’ testimony and supply your attorney fuel for an effective cross-examination.^2–4

Make your presence known

Sometimes your physical presence during the deposition might prevent any misstatements or false allegations.

Assess your case

Attending a plaintiff’s deposition is an excellent opportunity to see and assess the case as a whole while deepening your and your attorney’s understanding of the malpractice lawsuit.^2,5

Discuss your decision to attend the deposition with your attorney. If you choose not to attend, be sure to carefully read the transcripts of all depositions and use this information when preparing for your deposition.

Although attending the plaintiff’s deposition is optional, your presence during a malpractice trial is mandatory. Your expertise is most valuable when your attorney cross-examines witnesses. Your presence in the courtroom is necessary to establish your credibility, professionalism, and personality. In most trials jurors will assess the defendant psychiatrist, and not showing up could damage your case.

A psychiatrist named in a malpractice suit may doubt the need to attend the deposition of the plaintiff and his hired experts. In a time when many psychiatrists are handling busy private practices, you may be tempted to skip the plaintiff’s deposition because often the law does not require you to attend.

However, based on our forensic psychiatry, expert witness, and risk management experience, we highly recommend that psychiatrists involved in a malpractice lawsuit attend plaintiff’s depositions for several reasons.

Counteract countertransference

One of the most often encountered ingredients of a malpractice lawsuit is negative transference toward the defendant psychiatrist and/or negative countertransference by the psychiatrist toward the plaintiff.¹ Attending the deposition gives you the opportunity to identify and analyze these reactions, consider how they could impair your objectivity, and allow you and your attorney to put together the best defense.²

Identify errors

Listening to depositions lets you identify errors, misunderstandings, misinterpretations, or distortions of facts in the plaintiff’s allegations or his experts’ testimony and supply your attorney fuel for an effective cross-examination.^2–4

Make your presence known

Sometimes your physical presence during the deposition might prevent any misstatements or false allegations.

Assess your case

Attending a plaintiff’s deposition is an excellent opportunity to see and assess the case as a whole while deepening your and your attorney’s understanding of the malpractice lawsuit.^2,5

Discuss your decision to attend the deposition with your attorney. If you choose not to attend, be sure to carefully read the transcripts of all depositions and use this information when preparing for your deposition.

Although attending the plaintiff’s deposition is optional, your presence during a malpractice trial is mandatory. Your expertise is most valuable when your attorney cross-examines witnesses. Your presence in the courtroom is necessary to establish your credibility, professionalism, and personality. In most trials jurors will assess the defendant psychiatrist, and not showing up could damage your case.

Psychiatrists often are consulted when patients are struggling with the slings and arrows of outrageous medical fortune, to paraphrase Shakespeare. The goal of coping is to bring about relief, reward, quiescence, and equilibrium.¹ This definition focuses on the process and does not assume that all of life’s problems can be solved. If your patient seems to be coping poorly, you can help by first identifying the patient’s main coping mode and then increasing his or her repertoire of coping skills.

Emotion-based coping

Are painful psychological experiences such as anxiety or despair interfering with your patient’s ability to cope? Managing emotions with medications, cognitive therapy, or relaxation does not directly address the causes of distress, but it can mitigate psychological paralysis, prevent secondary problems such as alcoholism or demoralization, and allow patients to use executive brain function.

Humor can be effective for managing emotions, but be careful because not all patients can find humor in a painful situation.

Problem-based coping

How well is your patient dealing with the practical aspects of treatment such as keeping doctors’ appointments or going to work when fatigued from chemotherapy? Thinking rationally is difficult when one is overwhelmed by lack of social support or uncontrolled emotions. Ask what your patient sees as the main problem so you can discuss specific, tangible interventions such as child care, transportation, financial assistance, support groups, or informational materials.

Attitudinal-based coping

Adopting an attitude of accepting unavoidable circumstances—which is not the same as passivity—can come from wrestling with the ideas of secular and religious philosophers or spiritual leaders. Show great sensitivity when recommending bibliotherapy or bringing up philosophical ideas, however, so you don’t make your patient feel inadequate or poorly educated. Emotional growth in times of crisis cannot be accelerated. Determine if your patient can find meaning in the illness by asking “Has this illness taught you anything or changed you?”

Successful adaptation to medical adversity and disability requires that a patient use various coping strategies, shifting flexibly between them. Although these 3 coping modes are not necessarily hierarchical, patients who show only emotion-based coping might benefit from being nudged toward problem-based coping. Start by this process by examining practical implications of the illness.

Psychiatrists often are consulted when patients are struggling with the slings and arrows of outrageous medical fortune, to paraphrase Shakespeare. The goal of coping is to bring about relief, reward, quiescence, and equilibrium.¹ This definition focuses on the process and does not assume that all of life’s problems can be solved. If your patient seems to be coping poorly, you can help by first identifying the patient’s main coping mode and then increasing his or her repertoire of coping skills.

Emotion-based coping

Are painful psychological experiences such as anxiety or despair interfering with your patient’s ability to cope? Managing emotions with medications, cognitive therapy, or relaxation does not directly address the causes of distress, but it can mitigate psychological paralysis, prevent secondary problems such as alcoholism or demoralization, and allow patients to use executive brain function.

Humor can be effective for managing emotions, but be careful because not all patients can find humor in a painful situation.

Problem-based coping

How well is your patient dealing with the practical aspects of treatment such as keeping doctors’ appointments or going to work when fatigued from chemotherapy? Thinking rationally is difficult when one is overwhelmed by lack of social support or uncontrolled emotions. Ask what your patient sees as the main problem so you can discuss specific, tangible interventions such as child care, transportation, financial assistance, support groups, or informational materials.

Attitudinal-based coping

Adopting an attitude of accepting unavoidable circumstances—which is not the same as passivity—can come from wrestling with the ideas of secular and religious philosophers or spiritual leaders. Show great sensitivity when recommending bibliotherapy or bringing up philosophical ideas, however, so you don’t make your patient feel inadequate or poorly educated. Emotional growth in times of crisis cannot be accelerated. Determine if your patient can find meaning in the illness by asking “Has this illness taught you anything or changed you?”

Successful adaptation to medical adversity and disability requires that a patient use various coping strategies, shifting flexibly between them. Although these 3 coping modes are not necessarily hierarchical, patients who show only emotion-based coping might benefit from being nudged toward problem-based coping. Start by this process by examining practical implications of the illness.

Psychiatrists often are consulted when patients are struggling with the slings and arrows of outrageous medical fortune, to paraphrase Shakespeare. The goal of coping is to bring about relief, reward, quiescence, and equilibrium.¹ This definition focuses on the process and does not assume that all of life’s problems can be solved. If your patient seems to be coping poorly, you can help by first identifying the patient’s main coping mode and then increasing his or her repertoire of coping skills.

Emotion-based coping

Are painful psychological experiences such as anxiety or despair interfering with your patient’s ability to cope? Managing emotions with medications, cognitive therapy, or relaxation does not directly address the causes of distress, but it can mitigate psychological paralysis, prevent secondary problems such as alcoholism or demoralization, and allow patients to use executive brain function.

Humor can be effective for managing emotions, but be careful because not all patients can find humor in a painful situation.

Problem-based coping

How well is your patient dealing with the practical aspects of treatment such as keeping doctors’ appointments or going to work when fatigued from chemotherapy? Thinking rationally is difficult when one is overwhelmed by lack of social support or uncontrolled emotions. Ask what your patient sees as the main problem so you can discuss specific, tangible interventions such as child care, transportation, financial assistance, support groups, or informational materials.

Attitudinal-based coping

Adopting an attitude of accepting unavoidable circumstances—which is not the same as passivity—can come from wrestling with the ideas of secular and religious philosophers or spiritual leaders. Show great sensitivity when recommending bibliotherapy or bringing up philosophical ideas, however, so you don’t make your patient feel inadequate or poorly educated. Emotional growth in times of crisis cannot be accelerated. Determine if your patient can find meaning in the illness by asking “Has this illness taught you anything or changed you?”

Successful adaptation to medical adversity and disability requires that a patient use various coping strategies, shifting flexibly between them. Although these 3 coping modes are not necessarily hierarchical, patients who show only emotion-based coping might benefit from being nudged toward problem-based coping. Start by this process by examining practical implications of the illness.

Medication nonadherence challenges psychiatrists in most clinical settings.¹ Supportive psychotherapy techniques—outlined in the mnemonic PROGRESS—can improve adherence and strengthen the therapeutic relationship. They also can help restore adaptive living skills, promote patient autonomy, minimize relapse, and improve attitudes toward treatment.

Praise. Reinforce positive behavior with genuine praise. Build an inventory of phrases to congratulate patients when they meet their goals or demonstrate a new effort. Follow praise with a question that elicits feedback from patients about their behavior.

Reassure. Because patients may lose faith in medications’ efficacy, use reassurance to explain the time frame for drugs to reach therapeutic levels. Instill hope and remind patients that psychiatric illnesses can improve. Point out that although medications have limitations they do help reduce symptoms.

Optimize regimens. Find an appropriate dosing and frequency that minimizes side effects and facilitates a daily routine of taking medication.² This will help alleviate patients’ anxiety and support confidence in managing their medications.

Guide. Provide verbal and written guidance about what patients can expect from their medications. Include information about side effects and explore supplemental treatment options such as healthy eating, psychotherapy, community rehabilitation programs, and refraining from substances. If patients are unsure about why they take medication, help identify their goals and point out how pharmacotherapy might improve their symptoms.

Remind. Brainstorm with patients about how they can set up ambient cues to help them remember to take medications. Environmental associations promote autonomous behavior that can become second nature. For example, patients may learn to associate breakfast with taking medications. If patients place their medications on the table where they eat their meals, this may reinforce breakfast as a cue to take their medications.

Encourage patients to complete tasks that could help them achieve their goals. This includes taking medications as prescribed and communicating with mental healthcare providers to report side effects or during times of crisis.

Solidify strengths. Build on patients’ adaptive skills and strengths. Identifying efforts to improve their illnesses may turn roadblocks into opportunities to build rapport.

Support self-efficacy. Commend patients, for example, when they can explain and break down into steps the complexities of refilling and taking their medications.

Medication nonadherence challenges psychiatrists in most clinical settings.¹ Supportive psychotherapy techniques—outlined in the mnemonic PROGRESS—can improve adherence and strengthen the therapeutic relationship. They also can help restore adaptive living skills, promote patient autonomy, minimize relapse, and improve attitudes toward treatment.

Praise. Reinforce positive behavior with genuine praise. Build an inventory of phrases to congratulate patients when they meet their goals or demonstrate a new effort. Follow praise with a question that elicits feedback from patients about their behavior.

Reassure. Because patients may lose faith in medications’ efficacy, use reassurance to explain the time frame for drugs to reach therapeutic levels. Instill hope and remind patients that psychiatric illnesses can improve. Point out that although medications have limitations they do help reduce symptoms.

Optimize regimens. Find an appropriate dosing and frequency that minimizes side effects and facilitates a daily routine of taking medication.² This will help alleviate patients’ anxiety and support confidence in managing their medications.

Guide. Provide verbal and written guidance about what patients can expect from their medications. Include information about side effects and explore supplemental treatment options such as healthy eating, psychotherapy, community rehabilitation programs, and refraining from substances. If patients are unsure about why they take medication, help identify their goals and point out how pharmacotherapy might improve their symptoms.

Remind. Brainstorm with patients about how they can set up ambient cues to help them remember to take medications. Environmental associations promote autonomous behavior that can become second nature. For example, patients may learn to associate breakfast with taking medications. If patients place their medications on the table where they eat their meals, this may reinforce breakfast as a cue to take their medications.

Encourage patients to complete tasks that could help them achieve their goals. This includes taking medications as prescribed and communicating with mental healthcare providers to report side effects or during times of crisis.

Solidify strengths. Build on patients’ adaptive skills and strengths. Identifying efforts to improve their illnesses may turn roadblocks into opportunities to build rapport.

Support self-efficacy. Commend patients, for example, when they can explain and break down into steps the complexities of refilling and taking their medications.

Medication nonadherence challenges psychiatrists in most clinical settings.¹ Supportive psychotherapy techniques—outlined in the mnemonic PROGRESS—can improve adherence and strengthen the therapeutic relationship. They also can help restore adaptive living skills, promote patient autonomy, minimize relapse, and improve attitudes toward treatment.

Praise. Reinforce positive behavior with genuine praise. Build an inventory of phrases to congratulate patients when they meet their goals or demonstrate a new effort. Follow praise with a question that elicits feedback from patients about their behavior.

Reassure. Because patients may lose faith in medications’ efficacy, use reassurance to explain the time frame for drugs to reach therapeutic levels. Instill hope and remind patients that psychiatric illnesses can improve. Point out that although medications have limitations they do help reduce symptoms.

Optimize regimens. Find an appropriate dosing and frequency that minimizes side effects and facilitates a daily routine of taking medication.² This will help alleviate patients’ anxiety and support confidence in managing their medications.

Guide. Provide verbal and written guidance about what patients can expect from their medications. Include information about side effects and explore supplemental treatment options such as healthy eating, psychotherapy, community rehabilitation programs, and refraining from substances. If patients are unsure about why they take medication, help identify their goals and point out how pharmacotherapy might improve their symptoms.

Remind. Brainstorm with patients about how they can set up ambient cues to help them remember to take medications. Environmental associations promote autonomous behavior that can become second nature. For example, patients may learn to associate breakfast with taking medications. If patients place their medications on the table where they eat their meals, this may reinforce breakfast as a cue to take their medications.

Encourage patients to complete tasks that could help them achieve their goals. This includes taking medications as prescribed and communicating with mental healthcare providers to report side effects or during times of crisis.

Solidify strengths. Build on patients’ adaptive skills and strengths. Identifying efforts to improve their illnesses may turn roadblocks into opportunities to build rapport.

Support self-efficacy. Commend patients, for example, when they can explain and break down into steps the complexities of refilling and taking their medications.

When planning your outpatient, office-based practice, you might have overlooked the design of your waiting room while you negotiated a lease, ensured Health Insurance Portability and Accountability Act (HIPAA) compliance, and procured adequate liability insurance. The waiting room is important, however, because it provides a patient’s first impression of you. Aim to make your waiting room as comfortable as possible while avoiding unintended negative meanings.

Privacy

Maintaining privacy and confidentiality is many patients’ primary concern when they see a psychiatrist, given the sensitive nature of their presenting problems and the lingering stigma surrounding mental illness.

Some outpatient psychiatrists provide separate entrances and exits to ensure that successive patients will not see one another. Although this setup depends on the office’s layout, it may be an important factor to consider, especially when choosing new space.

Design

Whether you are a minimalist or favor a more eclectic style, give thought to the waiting room décor. Many physicians decorate their waiting rooms—as they do their offices—with personal works of art. Avoid overly personal pieces, however, such as family pictures, or provocative works of art, such as those with explicit sexual or aggressive content.

Providing magazines on an array of topics is a simple but thoughtful way to make your patient feel at ease. Choose comfortable furniture arranged to ensure adequate personal space and avoid crowding. Some physicians allow pharmaceutical representatives to leave literature in the waiting room, whereas others believe such advertisements are inappropriate.

Etiquette

A busy or shared waiting room can exacerbate the anxiety a patient may feel when meeting you for the first session. One way to maintain confidentiality when you meet a patient is to identify yourself and ask who in the room is waiting to meet with you.

Although some doctors wonder whether to use a patient’s first or last name, we initially refer to patients as Mr., Ms., or Mrs. Inside the office, we ask the patient how he or she would like to be addressed to establish openness and avoid awkwardness.

Body language

Establish eye contact when meeting the patient. A smile and maintaining 1 to 2 arm-lengths of personal space indicates appropriate intimacy without appearing threatening.

Even extending your hand may seem too forward or uncomfortable to some patients. Because some may refuse to shake hands out of religious or cultural observance, wait a moment when in doubt to see if the patient offers his or her hand first.

When planning your outpatient, office-based practice, you might have overlooked the design of your waiting room while you negotiated a lease, ensured Health Insurance Portability and Accountability Act (HIPAA) compliance, and procured adequate liability insurance. The waiting room is important, however, because it provides a patient’s first impression of you. Aim to make your waiting room as comfortable as possible while avoiding unintended negative meanings.

Privacy

Maintaining privacy and confidentiality is many patients’ primary concern when they see a psychiatrist, given the sensitive nature of their presenting problems and the lingering stigma surrounding mental illness.

Some outpatient psychiatrists provide separate entrances and exits to ensure that successive patients will not see one another. Although this setup depends on the office’s layout, it may be an important factor to consider, especially when choosing new space.

Design

Whether you are a minimalist or favor a more eclectic style, give thought to the waiting room décor. Many physicians decorate their waiting rooms—as they do their offices—with personal works of art. Avoid overly personal pieces, however, such as family pictures, or provocative works of art, such as those with explicit sexual or aggressive content.

Providing magazines on an array of topics is a simple but thoughtful way to make your patient feel at ease. Choose comfortable furniture arranged to ensure adequate personal space and avoid crowding. Some physicians allow pharmaceutical representatives to leave literature in the waiting room, whereas others believe such advertisements are inappropriate.

Etiquette

A busy or shared waiting room can exacerbate the anxiety a patient may feel when meeting you for the first session. One way to maintain confidentiality when you meet a patient is to identify yourself and ask who in the room is waiting to meet with you.

Although some doctors wonder whether to use a patient’s first or last name, we initially refer to patients as Mr., Ms., or Mrs. Inside the office, we ask the patient how he or she would like to be addressed to establish openness and avoid awkwardness.

Body language

Establish eye contact when meeting the patient. A smile and maintaining 1 to 2 arm-lengths of personal space indicates appropriate intimacy without appearing threatening.

Even extending your hand may seem too forward or uncomfortable to some patients. Because some may refuse to shake hands out of religious or cultural observance, wait a moment when in doubt to see if the patient offers his or her hand first.

When planning your outpatient, office-based practice, you might have overlooked the design of your waiting room while you negotiated a lease, ensured Health Insurance Portability and Accountability Act (HIPAA) compliance, and procured adequate liability insurance. The waiting room is important, however, because it provides a patient’s first impression of you. Aim to make your waiting room as comfortable as possible while avoiding unintended negative meanings.

Privacy

Maintaining privacy and confidentiality is many patients’ primary concern when they see a psychiatrist, given the sensitive nature of their presenting problems and the lingering stigma surrounding mental illness.

Some outpatient psychiatrists provide separate entrances and exits to ensure that successive patients will not see one another. Although this setup depends on the office’s layout, it may be an important factor to consider, especially when choosing new space.

Design

Whether you are a minimalist or favor a more eclectic style, give thought to the waiting room décor. Many physicians decorate their waiting rooms—as they do their offices—with personal works of art. Avoid overly personal pieces, however, such as family pictures, or provocative works of art, such as those with explicit sexual or aggressive content.

Providing magazines on an array of topics is a simple but thoughtful way to make your patient feel at ease. Choose comfortable furniture arranged to ensure adequate personal space and avoid crowding. Some physicians allow pharmaceutical representatives to leave literature in the waiting room, whereas others believe such advertisements are inappropriate.

Etiquette

A busy or shared waiting room can exacerbate the anxiety a patient may feel when meeting you for the first session. One way to maintain confidentiality when you meet a patient is to identify yourself and ask who in the room is waiting to meet with you.

Although some doctors wonder whether to use a patient’s first or last name, we initially refer to patients as Mr., Ms., or Mrs. Inside the office, we ask the patient how he or she would like to be addressed to establish openness and avoid awkwardness.

Body language

Establish eye contact when meeting the patient. A smile and maintaining 1 to 2 arm-lengths of personal space indicates appropriate intimacy without appearing threatening.

Even extending your hand may seem too forward or uncomfortable to some patients. Because some may refuse to shake hands out of religious or cultural observance, wait a moment when in doubt to see if the patient offers his or her hand first.