User login
12 best Web sites for clinical needs
Nearly 1 in 4 Internet users has searched the Web for mental health information,1 but finding reliable sources is challenging. Wading through poorly organized, variable quality sites to find information you need can be time-consuming and frustrating.2 Also, without your guidance, patients may consult disreputable Web sites and follow advice that is contrary to standard psychiatric care.3
Because less is more when using the Internet, we recommend 1 good Web site for each of the following clinical needs. Each may be useful to you and to recommend to your patients.
Patient education
Medlineplus.gov from the National Library of Medicine and the National Institutes of Health (NIH) is an authoritative source for reliable, unbiased information on medications and illnesses. You will find valuable information on all psychotropic and nonpsychotropic medications and most common psychiatric disorders, including information in Spanish.
You can print out medication information and give it to patients, though we recommend asking patients to visit the Web site to introduce them to this resource. Most important, Medlineplus.gov provides links to other trusted medical Web pages. For consumers, this site provides a variety of information including an illustrated medical encyclopedia and a guide to finding reputable health information on the Web. Medlineplus.gov is an enormous site that alone could satisfy most of your patient education needs.
Formulary information
When prescribing, you often need to know if a patient’s insurance will cover the cost of the drug or if preauthorization is necessary. Fingertipformulary.com, a free and user-friendly site, allows you to select a medication, your patient’s state, and insurance plan to find out if the drug will be covered. This site also tells you authorization requirements, quantity limits, and the medication’s “tier” classification, which specifies the patient’s copayment level.
Patient assistance programs
Needymeds.org is a nonprofit resource center of patient assistance programs (PAP) administered by pharmaceutical companies for individuals who cannot afford their medications. The site links to these programs’ Web sites, application forms, and groups that can help patients fill out necessary paperwork. With this Web site, patients no longer have to request or retain PAP paperwork.
Drug interactions
Enter a drug name into the search box at Epocrates.com to learn about possible drug interactions as well as dosing information, contraindications, black-box warnings, and adverse effects. This free, continually updated Web site is invaluable when treating patients who take a large number of medications.
Clinical trials
When you want to know what clinical trials are being conducted on a particular medication or disorder, visit clinicaltrials.gov. All federally and privately supported clinical trials now must be registered with the NIH and posted at clinicaltrials.gov. The site lists ongoing and completed trials, allows you to search by medication, disorder, and geographic area, and indicates which trials are recruiting volunteers.
Information on drug abuse
The National Institute on Drug Abuse’s Drugabuse.gov provides information about substance abuse for clinicians, patients, parents, and teachers. In addition, the site features new research findings, information in Spanish, and links related to substance abuse. Click on the link for parents and teachers to access a searchable index of substance abuse treatment facilities, with information about insurance plans accepted, available treatments, and contact information.
Medication pricing
When you pull out your prescription pad, patients may ask how much a drug costs or if there is a cheaper way to buy the medication. Visit the pharmacy section of Costco.com to quickly check prices and out-of-pocket expenses, even if the patient does not buy medications from this retailer. Search by drug name to find out how much a formulation of a drug costs and if generic alternatives are available. Often this exercise will help you prescribe tablet strengths or formulations that can save the patient money.
Searching MEDLINE
You can search the National Library of Medicine’s MEDLINE bibliographic database for free by visiting Pubmed.gov. You can read abstracts of all journal articles in the database and full-text of some articles. The number of free full-text articles will increase because all articles based on research funded by the NIH must now be posted on Pubmed.gov.
Support groups
We recommend support groups to most of our psychiatric patients and their families. To find support groups in your area visit:
- Depression and Bipolar Support Alliance (dbsalliance.org) for patients with mood disorders
- Alcoholics Anonymous (aa.org) and Narcotics Anonymous (na.org) for patients with alcohol and other substance abuse problems
- National Alliance on Mental Illness (nami.org) for general support related to severe mental illness.
1. Fox S. Online health search 2006. Washington, DC: Pew Internet & American Life Project. Available at: http://www.pewinternet.org/pdfs/PIP_Online_Health_2006.pdf. Accessed July 29, 2008.
2. Christensen H, Griffiths K. The Internet and mental health practice. Evid Based Ment Health 2003;6(3):66-9.
3. Montgomery R. Are irreputable health sites hurting your patients? Current Psychiatry 2006;5(12):98-100
Nearly 1 in 4 Internet users has searched the Web for mental health information,1 but finding reliable sources is challenging. Wading through poorly organized, variable quality sites to find information you need can be time-consuming and frustrating.2 Also, without your guidance, patients may consult disreputable Web sites and follow advice that is contrary to standard psychiatric care.3
Because less is more when using the Internet, we recommend 1 good Web site for each of the following clinical needs. Each may be useful to you and to recommend to your patients.
Patient education
Medlineplus.gov from the National Library of Medicine and the National Institutes of Health (NIH) is an authoritative source for reliable, unbiased information on medications and illnesses. You will find valuable information on all psychotropic and nonpsychotropic medications and most common psychiatric disorders, including information in Spanish.
You can print out medication information and give it to patients, though we recommend asking patients to visit the Web site to introduce them to this resource. Most important, Medlineplus.gov provides links to other trusted medical Web pages. For consumers, this site provides a variety of information including an illustrated medical encyclopedia and a guide to finding reputable health information on the Web. Medlineplus.gov is an enormous site that alone could satisfy most of your patient education needs.
Formulary information
When prescribing, you often need to know if a patient’s insurance will cover the cost of the drug or if preauthorization is necessary. Fingertipformulary.com, a free and user-friendly site, allows you to select a medication, your patient’s state, and insurance plan to find out if the drug will be covered. This site also tells you authorization requirements, quantity limits, and the medication’s “tier” classification, which specifies the patient’s copayment level.
Patient assistance programs
Needymeds.org is a nonprofit resource center of patient assistance programs (PAP) administered by pharmaceutical companies for individuals who cannot afford their medications. The site links to these programs’ Web sites, application forms, and groups that can help patients fill out necessary paperwork. With this Web site, patients no longer have to request or retain PAP paperwork.
Drug interactions
Enter a drug name into the search box at Epocrates.com to learn about possible drug interactions as well as dosing information, contraindications, black-box warnings, and adverse effects. This free, continually updated Web site is invaluable when treating patients who take a large number of medications.
Clinical trials
When you want to know what clinical trials are being conducted on a particular medication or disorder, visit clinicaltrials.gov. All federally and privately supported clinical trials now must be registered with the NIH and posted at clinicaltrials.gov. The site lists ongoing and completed trials, allows you to search by medication, disorder, and geographic area, and indicates which trials are recruiting volunteers.
Information on drug abuse
The National Institute on Drug Abuse’s Drugabuse.gov provides information about substance abuse for clinicians, patients, parents, and teachers. In addition, the site features new research findings, information in Spanish, and links related to substance abuse. Click on the link for parents and teachers to access a searchable index of substance abuse treatment facilities, with information about insurance plans accepted, available treatments, and contact information.
Medication pricing
When you pull out your prescription pad, patients may ask how much a drug costs or if there is a cheaper way to buy the medication. Visit the pharmacy section of Costco.com to quickly check prices and out-of-pocket expenses, even if the patient does not buy medications from this retailer. Search by drug name to find out how much a formulation of a drug costs and if generic alternatives are available. Often this exercise will help you prescribe tablet strengths or formulations that can save the patient money.
Searching MEDLINE
You can search the National Library of Medicine’s MEDLINE bibliographic database for free by visiting Pubmed.gov. You can read abstracts of all journal articles in the database and full-text of some articles. The number of free full-text articles will increase because all articles based on research funded by the NIH must now be posted on Pubmed.gov.
Support groups
We recommend support groups to most of our psychiatric patients and their families. To find support groups in your area visit:
- Depression and Bipolar Support Alliance (dbsalliance.org) for patients with mood disorders
- Alcoholics Anonymous (aa.org) and Narcotics Anonymous (na.org) for patients with alcohol and other substance abuse problems
- National Alliance on Mental Illness (nami.org) for general support related to severe mental illness.
Nearly 1 in 4 Internet users has searched the Web for mental health information,1 but finding reliable sources is challenging. Wading through poorly organized, variable quality sites to find information you need can be time-consuming and frustrating.2 Also, without your guidance, patients may consult disreputable Web sites and follow advice that is contrary to standard psychiatric care.3
Because less is more when using the Internet, we recommend 1 good Web site for each of the following clinical needs. Each may be useful to you and to recommend to your patients.
Patient education
Medlineplus.gov from the National Library of Medicine and the National Institutes of Health (NIH) is an authoritative source for reliable, unbiased information on medications and illnesses. You will find valuable information on all psychotropic and nonpsychotropic medications and most common psychiatric disorders, including information in Spanish.
You can print out medication information and give it to patients, though we recommend asking patients to visit the Web site to introduce them to this resource. Most important, Medlineplus.gov provides links to other trusted medical Web pages. For consumers, this site provides a variety of information including an illustrated medical encyclopedia and a guide to finding reputable health information on the Web. Medlineplus.gov is an enormous site that alone could satisfy most of your patient education needs.
Formulary information
When prescribing, you often need to know if a patient’s insurance will cover the cost of the drug or if preauthorization is necessary. Fingertipformulary.com, a free and user-friendly site, allows you to select a medication, your patient’s state, and insurance plan to find out if the drug will be covered. This site also tells you authorization requirements, quantity limits, and the medication’s “tier” classification, which specifies the patient’s copayment level.
Patient assistance programs
Needymeds.org is a nonprofit resource center of patient assistance programs (PAP) administered by pharmaceutical companies for individuals who cannot afford their medications. The site links to these programs’ Web sites, application forms, and groups that can help patients fill out necessary paperwork. With this Web site, patients no longer have to request or retain PAP paperwork.
Drug interactions
Enter a drug name into the search box at Epocrates.com to learn about possible drug interactions as well as dosing information, contraindications, black-box warnings, and adverse effects. This free, continually updated Web site is invaluable when treating patients who take a large number of medications.
Clinical trials
When you want to know what clinical trials are being conducted on a particular medication or disorder, visit clinicaltrials.gov. All federally and privately supported clinical trials now must be registered with the NIH and posted at clinicaltrials.gov. The site lists ongoing and completed trials, allows you to search by medication, disorder, and geographic area, and indicates which trials are recruiting volunteers.
Information on drug abuse
The National Institute on Drug Abuse’s Drugabuse.gov provides information about substance abuse for clinicians, patients, parents, and teachers. In addition, the site features new research findings, information in Spanish, and links related to substance abuse. Click on the link for parents and teachers to access a searchable index of substance abuse treatment facilities, with information about insurance plans accepted, available treatments, and contact information.
Medication pricing
When you pull out your prescription pad, patients may ask how much a drug costs or if there is a cheaper way to buy the medication. Visit the pharmacy section of Costco.com to quickly check prices and out-of-pocket expenses, even if the patient does not buy medications from this retailer. Search by drug name to find out how much a formulation of a drug costs and if generic alternatives are available. Often this exercise will help you prescribe tablet strengths or formulations that can save the patient money.
Searching MEDLINE
You can search the National Library of Medicine’s MEDLINE bibliographic database for free by visiting Pubmed.gov. You can read abstracts of all journal articles in the database and full-text of some articles. The number of free full-text articles will increase because all articles based on research funded by the NIH must now be posted on Pubmed.gov.
Support groups
We recommend support groups to most of our psychiatric patients and their families. To find support groups in your area visit:
- Depression and Bipolar Support Alliance (dbsalliance.org) for patients with mood disorders
- Alcoholics Anonymous (aa.org) and Narcotics Anonymous (na.org) for patients with alcohol and other substance abuse problems
- National Alliance on Mental Illness (nami.org) for general support related to severe mental illness.
1. Fox S. Online health search 2006. Washington, DC: Pew Internet & American Life Project. Available at: http://www.pewinternet.org/pdfs/PIP_Online_Health_2006.pdf. Accessed July 29, 2008.
2. Christensen H, Griffiths K. The Internet and mental health practice. Evid Based Ment Health 2003;6(3):66-9.
3. Montgomery R. Are irreputable health sites hurting your patients? Current Psychiatry 2006;5(12):98-100
1. Fox S. Online health search 2006. Washington, DC: Pew Internet & American Life Project. Available at: http://www.pewinternet.org/pdfs/PIP_Online_Health_2006.pdf. Accessed July 29, 2008.
2. Christensen H, Griffiths K. The Internet and mental health practice. Evid Based Ment Health 2003;6(3):66-9.
3. Montgomery R. Are irreputable health sites hurting your patients? Current Psychiatry 2006;5(12):98-100
How to reduce overdose risk with ‘super benzodiazepine’ atypicals
A new pattern of morbidity and mortality in suicidal patients who overdose has emerged with the broader use of atypical antipsychotics.1 Although it is not known how often antipsychotics and benzodiazepines are combined in suicide attempts, clinicians need to prescribe atypicals carefully to prevent their use in self-poisoning.
We recently treated nonpsychotic patients whose most common clinical presentation after overdosing on some atypicals was near-fatal respiratory outcomes.
The FDA has warned of the risk of potentially fatal respiratory depression with concomitant administration of antipsychotics and benzodiazepines.2 Each atypical carries a different respiratory warning and precaution. This observation prompted us to review the package inserts of the 3 “super benzodiazepine” atypicals.
Clozapine is a dibenzodiazepine. Its black-box warning states, “Since collapse, respiratory arrest, and cardiac arrest during initial treatment has occurred in patients who were being administered benzodiazepines or other psychotropic drugs, caution is advised when clozapine is initiated in patients taking a benzodiazepine or any other psychotropic drug.”3
Olanzapine is a thienobenzodiazepine. Its precaution states, “co-administration of intramuscular lorazepam and intramuscular olanzapine for injection added to the somnolence observed with either drug alone. Concomitant administration of intramuscular olanzapine and parenteral benzodiazepine has not been studied and is therefore not recommended.”3
Quetiapine is a dibenzothiazepine. Its precaution states, “The mean oral clearance of lorazepam (2 mg, single dose) was reduced by 20% in the presence of quetiapine administered as 250 mg PO tid dosing.”3
Recommendations. Because psychiatric patients have higher respiratory mortality than the general population, monitor patients’ pulmonary status when administering these 3 atypicals as one might when prescribing benzodiazepines. Note:
- preexisting conditions that compromise respiratory function such as chronic obstructive pulmonary disease, sleep apnea, asthma, or pneumonia
- clinical indicators of changes in respiratory function, such as respiratory rate, dyspnea, hypoxemia, and acidosis.
Be cautious of adverse respiratory events when prescribing atypicals alone or with any traditional CNS depressants such as benzodiazepines, sedative/hypnotics, minor tranquilizers, sleep aids, opiates, methadone, and GABAminergic agents. Controlling the amount of antipsychotics dispensed could minimize the risk of overdose. Screen for depression before prescribing a combination of atypicals and CNS depressants. Consider prescribing other atypicals—not “super benzodiazepines”—to patients with possible suicide risk.
1. Viner MW, Chen Y, Bakshi I, et al. Low-dose risperidone augmentation of antidepressants in nonpsychotic depressive disorders with suicidal ideation. J Clin Psychopharmacol 2003;23:105-6.
2. Ativan prescribing information. April 2007. Available at: http://www.fda.gov/medwatch/SAFETY/2007/Apr_PI/Ativan_PI.pdf. Accessed September 7, 2007.
3. Physicians’ desk reference. 62nd ed. Montvale, NJ: Thomson Healthcare Inc.; 2007.
A new pattern of morbidity and mortality in suicidal patients who overdose has emerged with the broader use of atypical antipsychotics.1 Although it is not known how often antipsychotics and benzodiazepines are combined in suicide attempts, clinicians need to prescribe atypicals carefully to prevent their use in self-poisoning.
We recently treated nonpsychotic patients whose most common clinical presentation after overdosing on some atypicals was near-fatal respiratory outcomes.
The FDA has warned of the risk of potentially fatal respiratory depression with concomitant administration of antipsychotics and benzodiazepines.2 Each atypical carries a different respiratory warning and precaution. This observation prompted us to review the package inserts of the 3 “super benzodiazepine” atypicals.
Clozapine is a dibenzodiazepine. Its black-box warning states, “Since collapse, respiratory arrest, and cardiac arrest during initial treatment has occurred in patients who were being administered benzodiazepines or other psychotropic drugs, caution is advised when clozapine is initiated in patients taking a benzodiazepine or any other psychotropic drug.”3
Olanzapine is a thienobenzodiazepine. Its precaution states, “co-administration of intramuscular lorazepam and intramuscular olanzapine for injection added to the somnolence observed with either drug alone. Concomitant administration of intramuscular olanzapine and parenteral benzodiazepine has not been studied and is therefore not recommended.”3
Quetiapine is a dibenzothiazepine. Its precaution states, “The mean oral clearance of lorazepam (2 mg, single dose) was reduced by 20% in the presence of quetiapine administered as 250 mg PO tid dosing.”3
Recommendations. Because psychiatric patients have higher respiratory mortality than the general population, monitor patients’ pulmonary status when administering these 3 atypicals as one might when prescribing benzodiazepines. Note:
- preexisting conditions that compromise respiratory function such as chronic obstructive pulmonary disease, sleep apnea, asthma, or pneumonia
- clinical indicators of changes in respiratory function, such as respiratory rate, dyspnea, hypoxemia, and acidosis.
Be cautious of adverse respiratory events when prescribing atypicals alone or with any traditional CNS depressants such as benzodiazepines, sedative/hypnotics, minor tranquilizers, sleep aids, opiates, methadone, and GABAminergic agents. Controlling the amount of antipsychotics dispensed could minimize the risk of overdose. Screen for depression before prescribing a combination of atypicals and CNS depressants. Consider prescribing other atypicals—not “super benzodiazepines”—to patients with possible suicide risk.
A new pattern of morbidity and mortality in suicidal patients who overdose has emerged with the broader use of atypical antipsychotics.1 Although it is not known how often antipsychotics and benzodiazepines are combined in suicide attempts, clinicians need to prescribe atypicals carefully to prevent their use in self-poisoning.
We recently treated nonpsychotic patients whose most common clinical presentation after overdosing on some atypicals was near-fatal respiratory outcomes.
The FDA has warned of the risk of potentially fatal respiratory depression with concomitant administration of antipsychotics and benzodiazepines.2 Each atypical carries a different respiratory warning and precaution. This observation prompted us to review the package inserts of the 3 “super benzodiazepine” atypicals.
Clozapine is a dibenzodiazepine. Its black-box warning states, “Since collapse, respiratory arrest, and cardiac arrest during initial treatment has occurred in patients who were being administered benzodiazepines or other psychotropic drugs, caution is advised when clozapine is initiated in patients taking a benzodiazepine or any other psychotropic drug.”3
Olanzapine is a thienobenzodiazepine. Its precaution states, “co-administration of intramuscular lorazepam and intramuscular olanzapine for injection added to the somnolence observed with either drug alone. Concomitant administration of intramuscular olanzapine and parenteral benzodiazepine has not been studied and is therefore not recommended.”3
Quetiapine is a dibenzothiazepine. Its precaution states, “The mean oral clearance of lorazepam (2 mg, single dose) was reduced by 20% in the presence of quetiapine administered as 250 mg PO tid dosing.”3
Recommendations. Because psychiatric patients have higher respiratory mortality than the general population, monitor patients’ pulmonary status when administering these 3 atypicals as one might when prescribing benzodiazepines. Note:
- preexisting conditions that compromise respiratory function such as chronic obstructive pulmonary disease, sleep apnea, asthma, or pneumonia
- clinical indicators of changes in respiratory function, such as respiratory rate, dyspnea, hypoxemia, and acidosis.
Be cautious of adverse respiratory events when prescribing atypicals alone or with any traditional CNS depressants such as benzodiazepines, sedative/hypnotics, minor tranquilizers, sleep aids, opiates, methadone, and GABAminergic agents. Controlling the amount of antipsychotics dispensed could minimize the risk of overdose. Screen for depression before prescribing a combination of atypicals and CNS depressants. Consider prescribing other atypicals—not “super benzodiazepines”—to patients with possible suicide risk.
1. Viner MW, Chen Y, Bakshi I, et al. Low-dose risperidone augmentation of antidepressants in nonpsychotic depressive disorders with suicidal ideation. J Clin Psychopharmacol 2003;23:105-6.
2. Ativan prescribing information. April 2007. Available at: http://www.fda.gov/medwatch/SAFETY/2007/Apr_PI/Ativan_PI.pdf. Accessed September 7, 2007.
3. Physicians’ desk reference. 62nd ed. Montvale, NJ: Thomson Healthcare Inc.; 2007.
1. Viner MW, Chen Y, Bakshi I, et al. Low-dose risperidone augmentation of antidepressants in nonpsychotic depressive disorders with suicidal ideation. J Clin Psychopharmacol 2003;23:105-6.
2. Ativan prescribing information. April 2007. Available at: http://www.fda.gov/medwatch/SAFETY/2007/Apr_PI/Ativan_PI.pdf. Accessed September 7, 2007.
3. Physicians’ desk reference. 62nd ed. Montvale, NJ: Thomson Healthcare Inc.; 2007.
Know your patient’s mental health benefits
Many Americans do not have health care insurance, and those who have mental health benefits are subject to limits on inpatient days and outpatient visits during the policy period (Table). Accordingly, it is important to review a patient’s mental health benefits before you formulate a treatment plan. Otherwise, you and your patient may find yourselves in a predicament.
If, for example, a patient with a major mental disorder requires close follow-up and you have not inquired about his or her mental health coverage, the benefits may run out before the need for monitoring ends. Abrupt transfer to another provider who is willing to accept a lower reimbursement or to a different mental health system could result in clinical decompensation.
Table
Common limitations in mental health insurance
| Mental health benefit | Coverage limitation |
|---|---|
| Outpatient care | Plans typically limit the number of outpatient visits per year, including partial hospitalization and intensive outpatient programs; copayments or coinsurance costs may be prohibitive |
| Emergency department | Copayments may be prohibitive; some states limit these amounts |
| Inpatient care | Insurance plans often limit the number of inpatient days per year; concurrent reviews by managed care organizations pressure the provider/hospital to discharge patients as soon as they no longer represent an imminent risk of harm to themselves or others |
| Psychosocial and drug rehabilitation programs | Most mental health care plans do not cover these programs |
| Pharmacy | Copayments may be prohibitive, especially if the prescriber writes numerous prescriptions when titrating a new medication |
Employ a proactive approach and inquire about your patients’ benefits during the initial evaluation.1 This information can guide the treatment plan and enable a thoughtful use of the patient’s resources. Knowing that a patient has a limited number of outpatient visits, for example, allows time for creative scheduling. You might spread outpatient visits over a longer period of time by incorporating telephone check-ins between appointments.
Other suggestions for maximizing your patient’s benefits include:
- Review pharmacy benefits. Often the greatest barrier to a drug’s bioavailability is the patient’s inability to obtain a prescribed medication. When appropriate, consider prescribing generic formulations.
- If you work part-time at a community mental health center or agency that has a sliding payment scale, suggest that a patient begin treatment with you at this location.
1. Campbell WH, Rohrbaugh RM. The biopsychosocial formulation manual: a guide for mental health professionals. New York, NY: Routledge; 2006.
Many Americans do not have health care insurance, and those who have mental health benefits are subject to limits on inpatient days and outpatient visits during the policy period (Table). Accordingly, it is important to review a patient’s mental health benefits before you formulate a treatment plan. Otherwise, you and your patient may find yourselves in a predicament.
If, for example, a patient with a major mental disorder requires close follow-up and you have not inquired about his or her mental health coverage, the benefits may run out before the need for monitoring ends. Abrupt transfer to another provider who is willing to accept a lower reimbursement or to a different mental health system could result in clinical decompensation.
Table
Common limitations in mental health insurance
| Mental health benefit | Coverage limitation |
|---|---|
| Outpatient care | Plans typically limit the number of outpatient visits per year, including partial hospitalization and intensive outpatient programs; copayments or coinsurance costs may be prohibitive |
| Emergency department | Copayments may be prohibitive; some states limit these amounts |
| Inpatient care | Insurance plans often limit the number of inpatient days per year; concurrent reviews by managed care organizations pressure the provider/hospital to discharge patients as soon as they no longer represent an imminent risk of harm to themselves or others |
| Psychosocial and drug rehabilitation programs | Most mental health care plans do not cover these programs |
| Pharmacy | Copayments may be prohibitive, especially if the prescriber writes numerous prescriptions when titrating a new medication |
Employ a proactive approach and inquire about your patients’ benefits during the initial evaluation.1 This information can guide the treatment plan and enable a thoughtful use of the patient’s resources. Knowing that a patient has a limited number of outpatient visits, for example, allows time for creative scheduling. You might spread outpatient visits over a longer period of time by incorporating telephone check-ins between appointments.
Other suggestions for maximizing your patient’s benefits include:
- Review pharmacy benefits. Often the greatest barrier to a drug’s bioavailability is the patient’s inability to obtain a prescribed medication. When appropriate, consider prescribing generic formulations.
- If you work part-time at a community mental health center or agency that has a sliding payment scale, suggest that a patient begin treatment with you at this location.
Many Americans do not have health care insurance, and those who have mental health benefits are subject to limits on inpatient days and outpatient visits during the policy period (Table). Accordingly, it is important to review a patient’s mental health benefits before you formulate a treatment plan. Otherwise, you and your patient may find yourselves in a predicament.
If, for example, a patient with a major mental disorder requires close follow-up and you have not inquired about his or her mental health coverage, the benefits may run out before the need for monitoring ends. Abrupt transfer to another provider who is willing to accept a lower reimbursement or to a different mental health system could result in clinical decompensation.
Table
Common limitations in mental health insurance
| Mental health benefit | Coverage limitation |
|---|---|
| Outpatient care | Plans typically limit the number of outpatient visits per year, including partial hospitalization and intensive outpatient programs; copayments or coinsurance costs may be prohibitive |
| Emergency department | Copayments may be prohibitive; some states limit these amounts |
| Inpatient care | Insurance plans often limit the number of inpatient days per year; concurrent reviews by managed care organizations pressure the provider/hospital to discharge patients as soon as they no longer represent an imminent risk of harm to themselves or others |
| Psychosocial and drug rehabilitation programs | Most mental health care plans do not cover these programs |
| Pharmacy | Copayments may be prohibitive, especially if the prescriber writes numerous prescriptions when titrating a new medication |
Employ a proactive approach and inquire about your patients’ benefits during the initial evaluation.1 This information can guide the treatment plan and enable a thoughtful use of the patient’s resources. Knowing that a patient has a limited number of outpatient visits, for example, allows time for creative scheduling. You might spread outpatient visits over a longer period of time by incorporating telephone check-ins between appointments.
Other suggestions for maximizing your patient’s benefits include:
- Review pharmacy benefits. Often the greatest barrier to a drug’s bioavailability is the patient’s inability to obtain a prescribed medication. When appropriate, consider prescribing generic formulations.
- If you work part-time at a community mental health center or agency that has a sliding payment scale, suggest that a patient begin treatment with you at this location.
1. Campbell WH, Rohrbaugh RM. The biopsychosocial formulation manual: a guide for mental health professionals. New York, NY: Routledge; 2006.
1. Campbell WH, Rohrbaugh RM. The biopsychosocial formulation manual: a guide for mental health professionals. New York, NY: Routledge; 2006.
6 screening questions for military veterans
Of the >1.6 million military personnel deployed to Iraq and Afghanistan since 2001, an estimated 300,000 have experienced major depression or post-traumatic stress disorder.1 Consequently, psychiatrists and mental health providers outside the Veterans Administration (VA) and Department of Defense likely will encounter veterans with psychiatric symptoms related to military service.
These 6 questions can help you:
- take a thorough mental health history
- demonstrate a basic familiarity with common military terminology and issues when treating veterans or veterans’ family members.
1 Did you experience traumatic events while deployed?
War without front lines or a clearly identified opposing force is referred to as a “low intensity conflict on an asymmetric battlefield.” This description epitomizes military operations in Iraq and Afghanistan, where random warfare with improvised explosive devices, sporadic firefights, suicide bombings, and rocket attacks are the norm. This type of warfare can put every deployed individual—not just combat soldiers—in harm’s way.
2 What was your job in the military?
“Military occupational specialty” (MOS) refers to an individual’s job in the military. In the Army, for example, an 11B is an infantryman, 88M is a truck driver, 68W is a medic, and 60W is a psychiatrist. The code itself is unimportant, but recognizing the term MOS shows familiarity with the military and provides potentially valuable information. An infantryman who was assigned to security and engaged the enemy regularly while on patrol is more likely to have experienced traumatic events than a soldier supporting the fight from an air-conditioned office in a fairly secure area.
3 Were you stop-lossed?
Stop-loss—a program created by Congress after the Vietnam War—is the involuntary extension of a service member’s active duty to retain the individual beyond the initial expiration of term of service (ETS) date. At a certain time before a unit departs for deployment—usually 90 days—the roster is “locked-in.” If an individual is deemed essential and his or her ETS date occurs after the lock-in date, that person can be stop-lossed and required to deploy—an involuntary prolonging of military service.
Most military personnel accept this practice, but it can cause disenchantment, especially when individuals who were looking forward to leaving the military think they will get stop-lossed and begrudgingly choose to re-enlist to receive financial and/ or occupational perks.
4 Did you receive mental health care downrange?
The term “downrange” is commonly used in the military and is synonymous with “theater of operations,” “Iraq,” or “Afghanistan.” Mental health teams of psychiatrists, psychologists, social workers, nurse practitioners, and mental health technicians have been deployed with fighting forces since the conflicts began in Afghanistan and Iraq. These teams have a well-established doctrine, concepts of operation, and access to a formulary of somatic interventions to meet clinical demand.
Military personnel can seek mental health services from the “CSH” (pronounced “cash” and stands for combat support hospital); “CSC team” (combat stress control, which are mobile outreach services); or “the BHO” (brigade behavioral health officer). Interventions include but are not limited to:
- time-limited psychotherapies using supportive, expressive, cognitive-behavioral, or psychoeducational methods
- medications, such as low-dose selective serotonin reuptake inhibitors or brief trials of zolpidem or trazodone for sleep, anxiety, and mood symptoms.
5 How did you exit the military?
Generally, there are 4 ways to leave the military:
Retirement. Military personnel in good standing are eligible to retire after 20 years of service and must obtain a waiver to serve for more than 30 years. A retiree receives a pension, health care, and other benefits.
Completion of service obligation is commonly referred to as “meeting ETS.” When an individual signs a contract to enlist for a specific number of years and chooses to leave the military after completing those years, that person has “ETS’d.” These individuals may be eligible for VA services and military alumni programs, such as the Montgomery GI Bill, but they are not retirees and do not receive the same benefits.
Administrative separation. Following regulations,2 a commander can separate individuals from the military for a variety reasons such as unsatisfactory performance, misconduct, pregnancy, and—with comprehensive input from mental health professionals—personality disorder.
Medical evaluation board (MEB) is a medical retirement from the military. A service member can get a MEB for physical and/or psychiatric conditions. If a soldier can no longer function in the military because of injuries or mental health disorders sustained while on active duty as defined by regulation,3 an “MEB packet” summarizing the case is prepared and sent to a review board. The board returns a rating that grants a severance package or permanent disability retirement and determines the final day of military service, often called the “final-out.” An individual who receives a MEB also can apply for a disability rating from the VA, regardless of the military’s decision.
6 Have you enrolled in the VA?
Every service member receives information on VA services during outprocessing from the military. Most—if not all—are eligible for some VA services. The individual is responsible for negotiating the process, which begins with an administrative visit and review of all of military documents at a local VA medical facility.
1. Tanielian TL, Jaycox LH. Invisible wounds of war. Santa Monica, CA: RAND Corporation; 2008.
2. Army Regulation [AR] 635-200. Active duty enlisted administrative separations, (Headquarters, Department of the Army [HQDA], Washington, DC, 6 June 2005).
3. Army Regulation [AR] 40-501. Standards of medical fitness, (Headquarters, Department of the Army [HQDA], Washington, DC, 14 December 2007).
Of the >1.6 million military personnel deployed to Iraq and Afghanistan since 2001, an estimated 300,000 have experienced major depression or post-traumatic stress disorder.1 Consequently, psychiatrists and mental health providers outside the Veterans Administration (VA) and Department of Defense likely will encounter veterans with psychiatric symptoms related to military service.
These 6 questions can help you:
- take a thorough mental health history
- demonstrate a basic familiarity with common military terminology and issues when treating veterans or veterans’ family members.
1 Did you experience traumatic events while deployed?
War without front lines or a clearly identified opposing force is referred to as a “low intensity conflict on an asymmetric battlefield.” This description epitomizes military operations in Iraq and Afghanistan, where random warfare with improvised explosive devices, sporadic firefights, suicide bombings, and rocket attacks are the norm. This type of warfare can put every deployed individual—not just combat soldiers—in harm’s way.
2 What was your job in the military?
“Military occupational specialty” (MOS) refers to an individual’s job in the military. In the Army, for example, an 11B is an infantryman, 88M is a truck driver, 68W is a medic, and 60W is a psychiatrist. The code itself is unimportant, but recognizing the term MOS shows familiarity with the military and provides potentially valuable information. An infantryman who was assigned to security and engaged the enemy regularly while on patrol is more likely to have experienced traumatic events than a soldier supporting the fight from an air-conditioned office in a fairly secure area.
3 Were you stop-lossed?
Stop-loss—a program created by Congress after the Vietnam War—is the involuntary extension of a service member’s active duty to retain the individual beyond the initial expiration of term of service (ETS) date. At a certain time before a unit departs for deployment—usually 90 days—the roster is “locked-in.” If an individual is deemed essential and his or her ETS date occurs after the lock-in date, that person can be stop-lossed and required to deploy—an involuntary prolonging of military service.
Most military personnel accept this practice, but it can cause disenchantment, especially when individuals who were looking forward to leaving the military think they will get stop-lossed and begrudgingly choose to re-enlist to receive financial and/ or occupational perks.
4 Did you receive mental health care downrange?
The term “downrange” is commonly used in the military and is synonymous with “theater of operations,” “Iraq,” or “Afghanistan.” Mental health teams of psychiatrists, psychologists, social workers, nurse practitioners, and mental health technicians have been deployed with fighting forces since the conflicts began in Afghanistan and Iraq. These teams have a well-established doctrine, concepts of operation, and access to a formulary of somatic interventions to meet clinical demand.
Military personnel can seek mental health services from the “CSH” (pronounced “cash” and stands for combat support hospital); “CSC team” (combat stress control, which are mobile outreach services); or “the BHO” (brigade behavioral health officer). Interventions include but are not limited to:
- time-limited psychotherapies using supportive, expressive, cognitive-behavioral, or psychoeducational methods
- medications, such as low-dose selective serotonin reuptake inhibitors or brief trials of zolpidem or trazodone for sleep, anxiety, and mood symptoms.
5 How did you exit the military?
Generally, there are 4 ways to leave the military:
Retirement. Military personnel in good standing are eligible to retire after 20 years of service and must obtain a waiver to serve for more than 30 years. A retiree receives a pension, health care, and other benefits.
Completion of service obligation is commonly referred to as “meeting ETS.” When an individual signs a contract to enlist for a specific number of years and chooses to leave the military after completing those years, that person has “ETS’d.” These individuals may be eligible for VA services and military alumni programs, such as the Montgomery GI Bill, but they are not retirees and do not receive the same benefits.
Administrative separation. Following regulations,2 a commander can separate individuals from the military for a variety reasons such as unsatisfactory performance, misconduct, pregnancy, and—with comprehensive input from mental health professionals—personality disorder.
Medical evaluation board (MEB) is a medical retirement from the military. A service member can get a MEB for physical and/or psychiatric conditions. If a soldier can no longer function in the military because of injuries or mental health disorders sustained while on active duty as defined by regulation,3 an “MEB packet” summarizing the case is prepared and sent to a review board. The board returns a rating that grants a severance package or permanent disability retirement and determines the final day of military service, often called the “final-out.” An individual who receives a MEB also can apply for a disability rating from the VA, regardless of the military’s decision.
6 Have you enrolled in the VA?
Every service member receives information on VA services during outprocessing from the military. Most—if not all—are eligible for some VA services. The individual is responsible for negotiating the process, which begins with an administrative visit and review of all of military documents at a local VA medical facility.
Of the >1.6 million military personnel deployed to Iraq and Afghanistan since 2001, an estimated 300,000 have experienced major depression or post-traumatic stress disorder.1 Consequently, psychiatrists and mental health providers outside the Veterans Administration (VA) and Department of Defense likely will encounter veterans with psychiatric symptoms related to military service.
These 6 questions can help you:
- take a thorough mental health history
- demonstrate a basic familiarity with common military terminology and issues when treating veterans or veterans’ family members.
1 Did you experience traumatic events while deployed?
War without front lines or a clearly identified opposing force is referred to as a “low intensity conflict on an asymmetric battlefield.” This description epitomizes military operations in Iraq and Afghanistan, where random warfare with improvised explosive devices, sporadic firefights, suicide bombings, and rocket attacks are the norm. This type of warfare can put every deployed individual—not just combat soldiers—in harm’s way.
2 What was your job in the military?
“Military occupational specialty” (MOS) refers to an individual’s job in the military. In the Army, for example, an 11B is an infantryman, 88M is a truck driver, 68W is a medic, and 60W is a psychiatrist. The code itself is unimportant, but recognizing the term MOS shows familiarity with the military and provides potentially valuable information. An infantryman who was assigned to security and engaged the enemy regularly while on patrol is more likely to have experienced traumatic events than a soldier supporting the fight from an air-conditioned office in a fairly secure area.
3 Were you stop-lossed?
Stop-loss—a program created by Congress after the Vietnam War—is the involuntary extension of a service member’s active duty to retain the individual beyond the initial expiration of term of service (ETS) date. At a certain time before a unit departs for deployment—usually 90 days—the roster is “locked-in.” If an individual is deemed essential and his or her ETS date occurs after the lock-in date, that person can be stop-lossed and required to deploy—an involuntary prolonging of military service.
Most military personnel accept this practice, but it can cause disenchantment, especially when individuals who were looking forward to leaving the military think they will get stop-lossed and begrudgingly choose to re-enlist to receive financial and/ or occupational perks.
4 Did you receive mental health care downrange?
The term “downrange” is commonly used in the military and is synonymous with “theater of operations,” “Iraq,” or “Afghanistan.” Mental health teams of psychiatrists, psychologists, social workers, nurse practitioners, and mental health technicians have been deployed with fighting forces since the conflicts began in Afghanistan and Iraq. These teams have a well-established doctrine, concepts of operation, and access to a formulary of somatic interventions to meet clinical demand.
Military personnel can seek mental health services from the “CSH” (pronounced “cash” and stands for combat support hospital); “CSC team” (combat stress control, which are mobile outreach services); or “the BHO” (brigade behavioral health officer). Interventions include but are not limited to:
- time-limited psychotherapies using supportive, expressive, cognitive-behavioral, or psychoeducational methods
- medications, such as low-dose selective serotonin reuptake inhibitors or brief trials of zolpidem or trazodone for sleep, anxiety, and mood symptoms.
5 How did you exit the military?
Generally, there are 4 ways to leave the military:
Retirement. Military personnel in good standing are eligible to retire after 20 years of service and must obtain a waiver to serve for more than 30 years. A retiree receives a pension, health care, and other benefits.
Completion of service obligation is commonly referred to as “meeting ETS.” When an individual signs a contract to enlist for a specific number of years and chooses to leave the military after completing those years, that person has “ETS’d.” These individuals may be eligible for VA services and military alumni programs, such as the Montgomery GI Bill, but they are not retirees and do not receive the same benefits.
Administrative separation. Following regulations,2 a commander can separate individuals from the military for a variety reasons such as unsatisfactory performance, misconduct, pregnancy, and—with comprehensive input from mental health professionals—personality disorder.
Medical evaluation board (MEB) is a medical retirement from the military. A service member can get a MEB for physical and/or psychiatric conditions. If a soldier can no longer function in the military because of injuries or mental health disorders sustained while on active duty as defined by regulation,3 an “MEB packet” summarizing the case is prepared and sent to a review board. The board returns a rating that grants a severance package or permanent disability retirement and determines the final day of military service, often called the “final-out.” An individual who receives a MEB also can apply for a disability rating from the VA, regardless of the military’s decision.
6 Have you enrolled in the VA?
Every service member receives information on VA services during outprocessing from the military. Most—if not all—are eligible for some VA services. The individual is responsible for negotiating the process, which begins with an administrative visit and review of all of military documents at a local VA medical facility.
1. Tanielian TL, Jaycox LH. Invisible wounds of war. Santa Monica, CA: RAND Corporation; 2008.
2. Army Regulation [AR] 635-200. Active duty enlisted administrative separations, (Headquarters, Department of the Army [HQDA], Washington, DC, 6 June 2005).
3. Army Regulation [AR] 40-501. Standards of medical fitness, (Headquarters, Department of the Army [HQDA], Washington, DC, 14 December 2007).
1. Tanielian TL, Jaycox LH. Invisible wounds of war. Santa Monica, CA: RAND Corporation; 2008.
2. Army Regulation [AR] 635-200. Active duty enlisted administrative separations, (Headquarters, Department of the Army [HQDA], Washington, DC, 6 June 2005).
3. Army Regulation [AR] 40-501. Standards of medical fitness, (Headquarters, Department of the Army [HQDA], Washington, DC, 14 December 2007).
8 lifestyle fixes to help patients lose weight
Psychiatric patients are at high risk of becoming obese—with rates up to 63% in schizophrenia and 68% in bipolar disorder.1 Moreover, weight gain from psychotropics is associated with medication nonadherence.
Psychiatrists can suggest and encourage lifestyle changes that will help patients lose weight. The 8 behaviors described below can help patients become more active and take steps toward a healthier lifestyle.
Keep a food diary. Ask patients to keep a written record of everything they eat or drink in a day. Encourage them to learn about healthy foods and look up the calories of common foods using food packaging, pocket books listing calorie counts, and online sources.
Start walking. Pedometers could motivate patients to exercise regularly and reach goals of taking a certain number of steps each day. A physically healthy individual should walk approximately 10,000 steps per day. Scheduling daily walks also provides structure for your patients.
Plan meals and eat mindfully. Advise your patients to schedule meals and eat mindfully. This means keeping your full attention on eating by noticing the smell, taste, and texture of food. Encourage patients to eat slowly, enjoy every bite, and avoid eating while watching television or when occupied by another activity.
Have a healthy snack before a meal. Eating a serving of boiled vegetables or a piece of fruit such as an apple before a meal can satisfy hunger and reduce food intake.
Increase fluid intake. Feeling hungry might be a signal that the body needs more fluid. Advise patients to drink water, avoid beverages that contain sugar, and limit fruit juice to 4 to 8 ounces per day.
Obtain support from family and friends. Loved ones can reinforce a patient’s weight loss efforts by not eating high-calorie food in front of the patient and buying only healthy snacks such as fruits and vegetables.
Improve nutrition. Advise patients to:
- eat at least 3 meals and 2 to 3 healthy snacks per day
- choose lean meats and whole grains
- eat 5 servings of fruits and vegetables daily
- avoid eating after 7 Pm or 3 to 4 hours before bedtime.
Monitor weight regularly. Digital scales give more precise measurements, which can prompt patients to reduce food intake when they notice weight gain. Frequent feedback can help facilitate behavior changes necessary for weight loss.
Patients often need help setting appropriate weight loss goals because achieving their ideal weight may not be possible. Losing 10% of body weight usually is a realistic goal that can improve their health.
1. Kolotkin RL, Corey-Lisle PK, Crosby RD, et al. Impact of obesity on health-related quality of life in schizophrenia and bipolar disorder. Obesity (Silver Spring) 2008;16:749-54.
Psychiatric patients are at high risk of becoming obese—with rates up to 63% in schizophrenia and 68% in bipolar disorder.1 Moreover, weight gain from psychotropics is associated with medication nonadherence.
Psychiatrists can suggest and encourage lifestyle changes that will help patients lose weight. The 8 behaviors described below can help patients become more active and take steps toward a healthier lifestyle.
Keep a food diary. Ask patients to keep a written record of everything they eat or drink in a day. Encourage them to learn about healthy foods and look up the calories of common foods using food packaging, pocket books listing calorie counts, and online sources.
Start walking. Pedometers could motivate patients to exercise regularly and reach goals of taking a certain number of steps each day. A physically healthy individual should walk approximately 10,000 steps per day. Scheduling daily walks also provides structure for your patients.
Plan meals and eat mindfully. Advise your patients to schedule meals and eat mindfully. This means keeping your full attention on eating by noticing the smell, taste, and texture of food. Encourage patients to eat slowly, enjoy every bite, and avoid eating while watching television or when occupied by another activity.
Have a healthy snack before a meal. Eating a serving of boiled vegetables or a piece of fruit such as an apple before a meal can satisfy hunger and reduce food intake.
Increase fluid intake. Feeling hungry might be a signal that the body needs more fluid. Advise patients to drink water, avoid beverages that contain sugar, and limit fruit juice to 4 to 8 ounces per day.
Obtain support from family and friends. Loved ones can reinforce a patient’s weight loss efforts by not eating high-calorie food in front of the patient and buying only healthy snacks such as fruits and vegetables.
Improve nutrition. Advise patients to:
- eat at least 3 meals and 2 to 3 healthy snacks per day
- choose lean meats and whole grains
- eat 5 servings of fruits and vegetables daily
- avoid eating after 7 Pm or 3 to 4 hours before bedtime.
Monitor weight regularly. Digital scales give more precise measurements, which can prompt patients to reduce food intake when they notice weight gain. Frequent feedback can help facilitate behavior changes necessary for weight loss.
Patients often need help setting appropriate weight loss goals because achieving their ideal weight may not be possible. Losing 10% of body weight usually is a realistic goal that can improve their health.
Psychiatric patients are at high risk of becoming obese—with rates up to 63% in schizophrenia and 68% in bipolar disorder.1 Moreover, weight gain from psychotropics is associated with medication nonadherence.
Psychiatrists can suggest and encourage lifestyle changes that will help patients lose weight. The 8 behaviors described below can help patients become more active and take steps toward a healthier lifestyle.
Keep a food diary. Ask patients to keep a written record of everything they eat or drink in a day. Encourage them to learn about healthy foods and look up the calories of common foods using food packaging, pocket books listing calorie counts, and online sources.
Start walking. Pedometers could motivate patients to exercise regularly and reach goals of taking a certain number of steps each day. A physically healthy individual should walk approximately 10,000 steps per day. Scheduling daily walks also provides structure for your patients.
Plan meals and eat mindfully. Advise your patients to schedule meals and eat mindfully. This means keeping your full attention on eating by noticing the smell, taste, and texture of food. Encourage patients to eat slowly, enjoy every bite, and avoid eating while watching television or when occupied by another activity.
Have a healthy snack before a meal. Eating a serving of boiled vegetables or a piece of fruit such as an apple before a meal can satisfy hunger and reduce food intake.
Increase fluid intake. Feeling hungry might be a signal that the body needs more fluid. Advise patients to drink water, avoid beverages that contain sugar, and limit fruit juice to 4 to 8 ounces per day.
Obtain support from family and friends. Loved ones can reinforce a patient’s weight loss efforts by not eating high-calorie food in front of the patient and buying only healthy snacks such as fruits and vegetables.
Improve nutrition. Advise patients to:
- eat at least 3 meals and 2 to 3 healthy snacks per day
- choose lean meats and whole grains
- eat 5 servings of fruits and vegetables daily
- avoid eating after 7 Pm or 3 to 4 hours before bedtime.
Monitor weight regularly. Digital scales give more precise measurements, which can prompt patients to reduce food intake when they notice weight gain. Frequent feedback can help facilitate behavior changes necessary for weight loss.
Patients often need help setting appropriate weight loss goals because achieving their ideal weight may not be possible. Losing 10% of body weight usually is a realistic goal that can improve their health.
1. Kolotkin RL, Corey-Lisle PK, Crosby RD, et al. Impact of obesity on health-related quality of life in schizophrenia and bipolar disorder. Obesity (Silver Spring) 2008;16:749-54.
1. Kolotkin RL, Corey-Lisle PK, Crosby RD, et al. Impact of obesity on health-related quality of life in schizophrenia and bipolar disorder. Obesity (Silver Spring) 2008;16:749-54.
Dosing units help avoid medication errors
Many medications are available in numerous dosage forms, which increases the risk of medication errors. To reduce dosing errors and avoid unnecessarily complex dosing, I suggest employing a “clinical reference dosing unit” (CRDU)—a basic reference dose expressed in milligrams that covers the typical dose range if administered as 1 to 4 pills.
CRDUs can help you and your patients remember a typical starting dose (1 pill), a target dose (2 or 3 pills), a high dose (4 pills), and a safe dose to make changes (1 pill). CRDUs also can help you track your prescribing because you can easily spot doses outside the usual range. For example, 8 pills indicate an unusually high dosage and a half pill might be too low.
Implementing CRDUs
Develop a list of CRDUs for the psychotropics you frequently prescribe. Note that the appropriate CRDU for a medication might vary among different clinical populations (Table). For any given medication use only 1 formulation, such as immediate-release or extended-release.
Monitor dosing by asking patients how many pills they take and when they take them.
Table
Sample CRDU prescribing of risperidone
| Patient population | CRDU (1 pill) | Dose range (1 to 4 pills) |
|---|---|---|
| First-episode psychosis patients | 1 mg | 1 to 4 mg |
| Chronic patients | 2 mg | 2 to 8 mg |
| Geriatric patients | 0.5 mg | 0.5 to 2 mg |
| CRDU: clinical reference dosing unit | ||
Patient education
Instruct your patients to initiate or change doses based on the number of pills, with 1 pill corresponding to the medication’s CRDU. For example, you might tell your patient, “Start with 1 pill at night for 1 week, then go up to 2 pills at night until you see me again.” Patients are more likely to correctly implement changes when instructions are based on the number of pills rather than on milligrams. Change the dosing to reach desired efficacy or increase tolerability by in-creasing or decreasing the number of pills or shifting the timing of the dosage, such as going from 1 pill twice daily to 2 pills at night.
Although CRDUs can be used for many antipsychotics, antidepressants, and anxiolytics, this method is not appropriate for medications that:
- are administered based on plasma levels or body weight, such as lithium or valproate
- do not have linear pharmacokinetics, such as phenytoin
- require a slower titration, such as clozapine.
Many medications are available in numerous dosage forms, which increases the risk of medication errors. To reduce dosing errors and avoid unnecessarily complex dosing, I suggest employing a “clinical reference dosing unit” (CRDU)—a basic reference dose expressed in milligrams that covers the typical dose range if administered as 1 to 4 pills.
CRDUs can help you and your patients remember a typical starting dose (1 pill), a target dose (2 or 3 pills), a high dose (4 pills), and a safe dose to make changes (1 pill). CRDUs also can help you track your prescribing because you can easily spot doses outside the usual range. For example, 8 pills indicate an unusually high dosage and a half pill might be too low.
Implementing CRDUs
Develop a list of CRDUs for the psychotropics you frequently prescribe. Note that the appropriate CRDU for a medication might vary among different clinical populations (Table). For any given medication use only 1 formulation, such as immediate-release or extended-release.
Monitor dosing by asking patients how many pills they take and when they take them.
Table
Sample CRDU prescribing of risperidone
| Patient population | CRDU (1 pill) | Dose range (1 to 4 pills) |
|---|---|---|
| First-episode psychosis patients | 1 mg | 1 to 4 mg |
| Chronic patients | 2 mg | 2 to 8 mg |
| Geriatric patients | 0.5 mg | 0.5 to 2 mg |
| CRDU: clinical reference dosing unit | ||
Patient education
Instruct your patients to initiate or change doses based on the number of pills, with 1 pill corresponding to the medication’s CRDU. For example, you might tell your patient, “Start with 1 pill at night for 1 week, then go up to 2 pills at night until you see me again.” Patients are more likely to correctly implement changes when instructions are based on the number of pills rather than on milligrams. Change the dosing to reach desired efficacy or increase tolerability by in-creasing or decreasing the number of pills or shifting the timing of the dosage, such as going from 1 pill twice daily to 2 pills at night.
Although CRDUs can be used for many antipsychotics, antidepressants, and anxiolytics, this method is not appropriate for medications that:
- are administered based on plasma levels or body weight, such as lithium or valproate
- do not have linear pharmacokinetics, such as phenytoin
- require a slower titration, such as clozapine.
Many medications are available in numerous dosage forms, which increases the risk of medication errors. To reduce dosing errors and avoid unnecessarily complex dosing, I suggest employing a “clinical reference dosing unit” (CRDU)—a basic reference dose expressed in milligrams that covers the typical dose range if administered as 1 to 4 pills.
CRDUs can help you and your patients remember a typical starting dose (1 pill), a target dose (2 or 3 pills), a high dose (4 pills), and a safe dose to make changes (1 pill). CRDUs also can help you track your prescribing because you can easily spot doses outside the usual range. For example, 8 pills indicate an unusually high dosage and a half pill might be too low.
Implementing CRDUs
Develop a list of CRDUs for the psychotropics you frequently prescribe. Note that the appropriate CRDU for a medication might vary among different clinical populations (Table). For any given medication use only 1 formulation, such as immediate-release or extended-release.
Monitor dosing by asking patients how many pills they take and when they take them.
Table
Sample CRDU prescribing of risperidone
| Patient population | CRDU (1 pill) | Dose range (1 to 4 pills) |
|---|---|---|
| First-episode psychosis patients | 1 mg | 1 to 4 mg |
| Chronic patients | 2 mg | 2 to 8 mg |
| Geriatric patients | 0.5 mg | 0.5 to 2 mg |
| CRDU: clinical reference dosing unit | ||
Patient education
Instruct your patients to initiate or change doses based on the number of pills, with 1 pill corresponding to the medication’s CRDU. For example, you might tell your patient, “Start with 1 pill at night for 1 week, then go up to 2 pills at night until you see me again.” Patients are more likely to correctly implement changes when instructions are based on the number of pills rather than on milligrams. Change the dosing to reach desired efficacy or increase tolerability by in-creasing or decreasing the number of pills or shifting the timing of the dosage, such as going from 1 pill twice daily to 2 pills at night.
Although CRDUs can be used for many antipsychotics, antidepressants, and anxiolytics, this method is not appropriate for medications that:
- are administered based on plasma levels or body weight, such as lithium or valproate
- do not have linear pharmacokinetics, such as phenytoin
- require a slower titration, such as clozapine.
STAT: 7 tips for the psychiatric ER
Psychiatric emergency rooms (ERs) often are the first stop for patients experiencing severe psychiatric symptoms. Following these strategies can help as you assess and treat a variety of patients and create a modicum of calm out of the chaos.
‘Heal’ borderlines
Although patients diagnosed with borderline personality disorder often present treatment challenges, a supportive psychotherapeutic approach based on empathic listening often can be helpful. Allowing these patients to feel understood in the midst of an interpersonal crisis may be enough to help them navigate their predicament in a healthier way.
Beware of shift changes
Patients arriving during a staff shift change might not receive the time and attention necessary for a comprehensive psychiatric evaluation. Resist pressure to speed up the workflow, and do not leave patients waiting to be seen by the oncoming shift. Working only by the clock may result in a rushed and inadequate assessment and a suboptimal treatment plan.
Sleeping it off
Patients often arrive intoxicated and might not be able to adequately participate in a psychiatric assessment. Talk to intoxicated patients briefly, get an adequate medical history, ensure their safety and monitoring, and then let them sleep in the ER. Re-evaluation in the morning often yields dramatically different mental status findings.
Be familiar with social services
Although some ERs employ staff members who specialize in coordinating social services, be familiar with available homeless shelters, travelers’ aid societies, halfway houses, and safe homes. Armed with this information, you can refer to appropriate agencies patients with problems that are more social than psychiatric.
Know your staff
Psychiatric ERs are staffed by a variety of mental health professionals, and individual team members’ experience, training, and knowledge can vary greatly. It is your responsibility to be familiar with the strengths and weaknesses of these workers to guard against having to repeat tasks.
Feed your patients
Providing patients with food is a straight-forward way to demonstrate you care about their needs and want to help. Though it is important that patients do not view psychiatric ERs as places to come to get a hot meal, generously dispensing food often helps lay the groundwork for a therapeutic relationship.
Be generous with thiamine
Many ER patients are undernourished or abuse alcohol and therefore are at risk for thiamine deficiency. The sequelae of thiamine deficiency, including Wernicke’s encephalopathy and Korsakoff’s syndrome, are serious and in some cases irreversible.
Psychiatric emergency rooms (ERs) often are the first stop for patients experiencing severe psychiatric symptoms. Following these strategies can help as you assess and treat a variety of patients and create a modicum of calm out of the chaos.
‘Heal’ borderlines
Although patients diagnosed with borderline personality disorder often present treatment challenges, a supportive psychotherapeutic approach based on empathic listening often can be helpful. Allowing these patients to feel understood in the midst of an interpersonal crisis may be enough to help them navigate their predicament in a healthier way.
Beware of shift changes
Patients arriving during a staff shift change might not receive the time and attention necessary for a comprehensive psychiatric evaluation. Resist pressure to speed up the workflow, and do not leave patients waiting to be seen by the oncoming shift. Working only by the clock may result in a rushed and inadequate assessment and a suboptimal treatment plan.
Sleeping it off
Patients often arrive intoxicated and might not be able to adequately participate in a psychiatric assessment. Talk to intoxicated patients briefly, get an adequate medical history, ensure their safety and monitoring, and then let them sleep in the ER. Re-evaluation in the morning often yields dramatically different mental status findings.
Be familiar with social services
Although some ERs employ staff members who specialize in coordinating social services, be familiar with available homeless shelters, travelers’ aid societies, halfway houses, and safe homes. Armed with this information, you can refer to appropriate agencies patients with problems that are more social than psychiatric.
Know your staff
Psychiatric ERs are staffed by a variety of mental health professionals, and individual team members’ experience, training, and knowledge can vary greatly. It is your responsibility to be familiar with the strengths and weaknesses of these workers to guard against having to repeat tasks.
Feed your patients
Providing patients with food is a straight-forward way to demonstrate you care about their needs and want to help. Though it is important that patients do not view psychiatric ERs as places to come to get a hot meal, generously dispensing food often helps lay the groundwork for a therapeutic relationship.
Be generous with thiamine
Many ER patients are undernourished or abuse alcohol and therefore are at risk for thiamine deficiency. The sequelae of thiamine deficiency, including Wernicke’s encephalopathy and Korsakoff’s syndrome, are serious and in some cases irreversible.
Psychiatric emergency rooms (ERs) often are the first stop for patients experiencing severe psychiatric symptoms. Following these strategies can help as you assess and treat a variety of patients and create a modicum of calm out of the chaos.
‘Heal’ borderlines
Although patients diagnosed with borderline personality disorder often present treatment challenges, a supportive psychotherapeutic approach based on empathic listening often can be helpful. Allowing these patients to feel understood in the midst of an interpersonal crisis may be enough to help them navigate their predicament in a healthier way.
Beware of shift changes
Patients arriving during a staff shift change might not receive the time and attention necessary for a comprehensive psychiatric evaluation. Resist pressure to speed up the workflow, and do not leave patients waiting to be seen by the oncoming shift. Working only by the clock may result in a rushed and inadequate assessment and a suboptimal treatment plan.
Sleeping it off
Patients often arrive intoxicated and might not be able to adequately participate in a psychiatric assessment. Talk to intoxicated patients briefly, get an adequate medical history, ensure their safety and monitoring, and then let them sleep in the ER. Re-evaluation in the morning often yields dramatically different mental status findings.
Be familiar with social services
Although some ERs employ staff members who specialize in coordinating social services, be familiar with available homeless shelters, travelers’ aid societies, halfway houses, and safe homes. Armed with this information, you can refer to appropriate agencies patients with problems that are more social than psychiatric.
Know your staff
Psychiatric ERs are staffed by a variety of mental health professionals, and individual team members’ experience, training, and knowledge can vary greatly. It is your responsibility to be familiar with the strengths and weaknesses of these workers to guard against having to repeat tasks.
Feed your patients
Providing patients with food is a straight-forward way to demonstrate you care about their needs and want to help. Though it is important that patients do not view psychiatric ERs as places to come to get a hot meal, generously dispensing food often helps lay the groundwork for a therapeutic relationship.
Be generous with thiamine
Many ER patients are undernourished or abuse alcohol and therefore are at risk for thiamine deficiency. The sequelae of thiamine deficiency, including Wernicke’s encephalopathy and Korsakoff’s syndrome, are serious and in some cases irreversible.
Self-rating scales tell you more than the score
Rating scales give psychiatrists an objective benchmark on which to base critical treatment decisions, but not all clinicians use them because they view scales as time-consuming and offering little clinical yield. However, any depression self-rating scale (Table) can yield valuable clinical information if you pay attention to 3 areas.
Table
Commonly used depression self-rating scales
|
1. Total score
The total score supplies patients with objective feedback on their symptom severity, supports your treatment recommendations, and provides a benchmark for clinical decision-making. This information can help you determine when:
- the patient has shown no or insufficient improvement and treatment should be changed
- the patient has improved enough to stay the course
- antidepressant treatment would not be helpful because the baseline score is within the normal range.
2. Individual items
Note items that stand out because the patient rated them very high or endorsed items such as suicidality. An item-by-item analysis can help you focus on symptoms the patient considers problematic and which could be treatment targets, such as severe insomnia or fatigue. Often you can detect a pattern in the results, such as if a patient displays strong somatization or has mostly depressive cognitions.
3. Approach to the scale
Observe the patient while he or she fills out the scale. Obsessive patients might take a long time to complete the scale be-cause they cannot decide which answer is correct and will argue with you about individual items. They may want to answer “2.5” instead of having to choose between 2 or 3. Patients with cognitive problems also might need a long time to complete the questionnaire, but don’t forget about possible marginal literacy. Narcissistic patients might refuse to take the test because it is “below” them to fill out a scale that surely cannot capture their specialness.
Used in these 3 ways, scales are not a burden but an opportunity to engage your patient and to practice patient-centered medicine, even during brief clinical encounters.
Rating scales give psychiatrists an objective benchmark on which to base critical treatment decisions, but not all clinicians use them because they view scales as time-consuming and offering little clinical yield. However, any depression self-rating scale (Table) can yield valuable clinical information if you pay attention to 3 areas.
Table
Commonly used depression self-rating scales
|
1. Total score
The total score supplies patients with objective feedback on their symptom severity, supports your treatment recommendations, and provides a benchmark for clinical decision-making. This information can help you determine when:
- the patient has shown no or insufficient improvement and treatment should be changed
- the patient has improved enough to stay the course
- antidepressant treatment would not be helpful because the baseline score is within the normal range.
2. Individual items
Note items that stand out because the patient rated them very high or endorsed items such as suicidality. An item-by-item analysis can help you focus on symptoms the patient considers problematic and which could be treatment targets, such as severe insomnia or fatigue. Often you can detect a pattern in the results, such as if a patient displays strong somatization or has mostly depressive cognitions.
3. Approach to the scale
Observe the patient while he or she fills out the scale. Obsessive patients might take a long time to complete the scale be-cause they cannot decide which answer is correct and will argue with you about individual items. They may want to answer “2.5” instead of having to choose between 2 or 3. Patients with cognitive problems also might need a long time to complete the questionnaire, but don’t forget about possible marginal literacy. Narcissistic patients might refuse to take the test because it is “below” them to fill out a scale that surely cannot capture their specialness.
Used in these 3 ways, scales are not a burden but an opportunity to engage your patient and to practice patient-centered medicine, even during brief clinical encounters.
Rating scales give psychiatrists an objective benchmark on which to base critical treatment decisions, but not all clinicians use them because they view scales as time-consuming and offering little clinical yield. However, any depression self-rating scale (Table) can yield valuable clinical information if you pay attention to 3 areas.
Table
Commonly used depression self-rating scales
|
1. Total score
The total score supplies patients with objective feedback on their symptom severity, supports your treatment recommendations, and provides a benchmark for clinical decision-making. This information can help you determine when:
- the patient has shown no or insufficient improvement and treatment should be changed
- the patient has improved enough to stay the course
- antidepressant treatment would not be helpful because the baseline score is within the normal range.
2. Individual items
Note items that stand out because the patient rated them very high or endorsed items such as suicidality. An item-by-item analysis can help you focus on symptoms the patient considers problematic and which could be treatment targets, such as severe insomnia or fatigue. Often you can detect a pattern in the results, such as if a patient displays strong somatization or has mostly depressive cognitions.
3. Approach to the scale
Observe the patient while he or she fills out the scale. Obsessive patients might take a long time to complete the scale be-cause they cannot decide which answer is correct and will argue with you about individual items. They may want to answer “2.5” instead of having to choose between 2 or 3. Patients with cognitive problems also might need a long time to complete the questionnaire, but don’t forget about possible marginal literacy. Narcissistic patients might refuse to take the test because it is “below” them to fill out a scale that surely cannot capture their specialness.
Used in these 3 ways, scales are not a burden but an opportunity to engage your patient and to practice patient-centered medicine, even during brief clinical encounters.
Break the ice with wary adolescents
A teenager who doesn’t trust you can become resistant, leave the room, clam up, or become verbally hostile during a psychiatric interview.1 Our group has identified techniques that may help you develop rapport with teen athletes or other adolescents.
Be a Good Sport
The department of psychiatry at Cooper University Hospital in Camden, NJ, established a program at an urban high school to evaluate student athletes for stress, anxiety, depression, trauma, and substance abuse. The assessment takes place in the high school’s athletic department after an initial screening. Because the assessment program and psychiatrists were new to the school, many of the boys and girls were not forthcoming when talking with clinicians.
Our resident psychiatrists and medical students used Sports Illustrated covers and popular films to break the ice with these teenagers. This approach—which we used during group and individual psychotherapy— often puts teens at ease.
For example, the psychiatrist would bring to the session an issue of Sports Illustrated featuring a well-known athlete with a psychiatric disorder—such as substance abuse, depression, or steroid abuse. The teens quickly became more relaxed and talkative. They seemed interested in giving opinions about the athlete on the magazine cover and his or her issues.
The teens also responded to discussion of the popular sports movie Friday Night Lights, which portrays a small town’s obsession with winning another state football championship. Many of the film’s characters exhibit psychopathology, including the running back’s narcissistic traits, the fullback’s substance abuse, and the quarterback’s lingering effects of having a mentally ill mother. The plot raises questions about the stress and pressure of football; does it exacerbate the development of psychopathology, adequately prepare athletes for life’s uncertainties, or encourage an unrealistic view of society?
Psychiatrists with a sports background often could relate well to the students’ experiences. A therapist with a good understanding of the sport the teen plays can talk about shared experiences, such as dealing with winning or losing. This shared knowledge allows you and the athlete to speak the same language and helps the teen identify with you.
Dress the part
By wearing neat casual attire, you can put a student athlete at ease. A modest polo shirt with the school’s or hospital’s logo—rather than a suit—is appropriate for male and female psychiatrists when interviewing an adolescent athlete at high school. In our experience, teens begin to view psychiatrists as down-to-earth people to whom they can relate, as opposed to overly formal physicians who ask difficult questions.
1. Sadock V, Sadock B. Kaplan and Sadock’s synopsis of psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:1312.
Dr. Demark is a fourth-year psychiatry resident and Dr. Anderson is a first-year psychiatry resident, Cooper University Hospital, Camden, NJ. Dr. Newmark is chief of psychiatry at Cooper University Hospital, professor of psychiatry at Robert Wood Johnson Medical School, Camden, and secretary of the International Society of Sports Psychiatry.
A teenager who doesn’t trust you can become resistant, leave the room, clam up, or become verbally hostile during a psychiatric interview.1 Our group has identified techniques that may help you develop rapport with teen athletes or other adolescents.
Be a Good Sport
The department of psychiatry at Cooper University Hospital in Camden, NJ, established a program at an urban high school to evaluate student athletes for stress, anxiety, depression, trauma, and substance abuse. The assessment takes place in the high school’s athletic department after an initial screening. Because the assessment program and psychiatrists were new to the school, many of the boys and girls were not forthcoming when talking with clinicians.
Our resident psychiatrists and medical students used Sports Illustrated covers and popular films to break the ice with these teenagers. This approach—which we used during group and individual psychotherapy— often puts teens at ease.
For example, the psychiatrist would bring to the session an issue of Sports Illustrated featuring a well-known athlete with a psychiatric disorder—such as substance abuse, depression, or steroid abuse. The teens quickly became more relaxed and talkative. They seemed interested in giving opinions about the athlete on the magazine cover and his or her issues.
The teens also responded to discussion of the popular sports movie Friday Night Lights, which portrays a small town’s obsession with winning another state football championship. Many of the film’s characters exhibit psychopathology, including the running back’s narcissistic traits, the fullback’s substance abuse, and the quarterback’s lingering effects of having a mentally ill mother. The plot raises questions about the stress and pressure of football; does it exacerbate the development of psychopathology, adequately prepare athletes for life’s uncertainties, or encourage an unrealistic view of society?
Psychiatrists with a sports background often could relate well to the students’ experiences. A therapist with a good understanding of the sport the teen plays can talk about shared experiences, such as dealing with winning or losing. This shared knowledge allows you and the athlete to speak the same language and helps the teen identify with you.
Dress the part
By wearing neat casual attire, you can put a student athlete at ease. A modest polo shirt with the school’s or hospital’s logo—rather than a suit—is appropriate for male and female psychiatrists when interviewing an adolescent athlete at high school. In our experience, teens begin to view psychiatrists as down-to-earth people to whom they can relate, as opposed to overly formal physicians who ask difficult questions.
A teenager who doesn’t trust you can become resistant, leave the room, clam up, or become verbally hostile during a psychiatric interview.1 Our group has identified techniques that may help you develop rapport with teen athletes or other adolescents.
Be a Good Sport
The department of psychiatry at Cooper University Hospital in Camden, NJ, established a program at an urban high school to evaluate student athletes for stress, anxiety, depression, trauma, and substance abuse. The assessment takes place in the high school’s athletic department after an initial screening. Because the assessment program and psychiatrists were new to the school, many of the boys and girls were not forthcoming when talking with clinicians.
Our resident psychiatrists and medical students used Sports Illustrated covers and popular films to break the ice with these teenagers. This approach—which we used during group and individual psychotherapy— often puts teens at ease.
For example, the psychiatrist would bring to the session an issue of Sports Illustrated featuring a well-known athlete with a psychiatric disorder—such as substance abuse, depression, or steroid abuse. The teens quickly became more relaxed and talkative. They seemed interested in giving opinions about the athlete on the magazine cover and his or her issues.
The teens also responded to discussion of the popular sports movie Friday Night Lights, which portrays a small town’s obsession with winning another state football championship. Many of the film’s characters exhibit psychopathology, including the running back’s narcissistic traits, the fullback’s substance abuse, and the quarterback’s lingering effects of having a mentally ill mother. The plot raises questions about the stress and pressure of football; does it exacerbate the development of psychopathology, adequately prepare athletes for life’s uncertainties, or encourage an unrealistic view of society?
Psychiatrists with a sports background often could relate well to the students’ experiences. A therapist with a good understanding of the sport the teen plays can talk about shared experiences, such as dealing with winning or losing. This shared knowledge allows you and the athlete to speak the same language and helps the teen identify with you.
Dress the part
By wearing neat casual attire, you can put a student athlete at ease. A modest polo shirt with the school’s or hospital’s logo—rather than a suit—is appropriate for male and female psychiatrists when interviewing an adolescent athlete at high school. In our experience, teens begin to view psychiatrists as down-to-earth people to whom they can relate, as opposed to overly formal physicians who ask difficult questions.
1. Sadock V, Sadock B. Kaplan and Sadock’s synopsis of psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:1312.
Dr. Demark is a fourth-year psychiatry resident and Dr. Anderson is a first-year psychiatry resident, Cooper University Hospital, Camden, NJ. Dr. Newmark is chief of psychiatry at Cooper University Hospital, professor of psychiatry at Robert Wood Johnson Medical School, Camden, and secretary of the International Society of Sports Psychiatry.
1. Sadock V, Sadock B. Kaplan and Sadock’s synopsis of psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:1312.
Dr. Demark is a fourth-year psychiatry resident and Dr. Anderson is a first-year psychiatry resident, Cooper University Hospital, Camden, NJ. Dr. Newmark is chief of psychiatry at Cooper University Hospital, professor of psychiatry at Robert Wood Johnson Medical School, Camden, and secretary of the International Society of Sports Psychiatry.
LITHIUM: Using the comeback drug
Lithium is making a comeback for good reason. Aside from its tried and true efficacy for bipolar disorder, lithium has neuroprotective effects and antisuicide properties.1,2
Psychiatry residents who were taught to use divalproex and atypical antipsychotics to treat bipolar disorder are discovering lithium’s benefits. However, all psychiatrists might need a refresher—outlined by the mnemonic LITHIUM—on the fundamentals of this “old school” medication.
Levels between 0.6 and 1.0 mEq/L are sufficient to maintain most bipolar patients, although acute manic patients might require higher levels.2,3 Some patients who cannot tolerate lithium’s side effects might benefit from lower levels near 0.4 to 0.5 mEq/L. Remember, lithium levels are standardized in 12-hour trough plasma concentrations.
Interactions. Nonsteroidal anti-inflammatory drugs (except aspirin and sulindac), angiotensin-converting enzyme inhibitors, thiazide and loop diuretics, verapamil, and diltiazem can increase lithium concentration.4 Caffeine, theophylline, sodium bicarbonate, and dialysis could decrease lithium levels. Be careful when adding lithium to anticonvulsants or antipsychotics because of increased neurotoxicity risk.
Toxicity can lead to coma, seizures, cardiovascular collapse, and death, especially when serum concentrations exceed 3.5 mEq/L.2,4,5 Be alert to early toxicity symptoms such as drowsiness, confusion, coarse hand tremor, worsening gastrointestinal complaints, dysarthria, impaired consciousness, cogwheel rigidity, and ataxia. Lithium’s narrow therapeutic index requires prudent monitoring. Some patients could experience toxicity at low plasma concentrations, such as 1.0 to 1.5 mEq/L.
Half-life varies depending on the patient’s renal function. Steady state is usually reached within 5 days2 but can take up to 10 days because of prolonged half-life in elderly and renally impaired patients (Table). Drawing lithium levels too early could lead to lithium toxicity in these patients, who require modified dosing regimens and monitoring.
Table
Renal metabolism of lithium
| Renal function | Half-life (hours)4 | Steady state (days)* |
|---|---|---|
| Normal | 20 to 27 | 2.5 to 5.6 |
| Renally impaired or elderly patients | 36 to 50 | 4.5 to 10.4 |
| * Steady state is reached after 3 to 5 half-lives | ||
Indications. Lithium is FDA-approved for acute mania and bipolar maintenance, but it also has been used for bipolar depression, antidepressant augmentation, schizoaffective disorder, and mixed manic states.3 Consider combining lithium with an atypical antipsychotic for inpatients with severe bipolar mania with psychotic features. Also consider lithium therapy for patients with recurrent unipolar depression who have been successfully treated with antidepressants but then relapse.
Urinary excretion. Order creatinine measurements every 2 to 3 months for the first 6 months of therapy, then every 6 to 12 months. Although lithium is not a first-line mood-stabilizing drug for patients with renal impairment, it can be used safely in patients with hepatic dysfunction.2,4 Dehydration and a low-sodium diet can cause lithium accumulation, so evaluate patients’ sodium and water balance at the beginning of and throughout lithium therapy. Encourage patients to keep their sodium and water intake as consistent as possible to avoid fluctuations in lithium levels.
Managing side effects is essential to maximize lithium’s effectiveness. Consider switching to a slow-release preparation if your patient cannot tolerate various side effects of regular lithium. If the patient continues to have side effects, consider lowering the dose in 300-mg increments or as clinically indicated. Closely monitor the patient for improved side effects while aiming to maintain an appropriate therapeutic level. Also, moving the entire lithium dose to bedtime could minimize side effects. If these strategies are not adequate, consider adding:
- thyroid replacement to manage elevated thyroid stimulating hormone or frank hypothyroidism
- propranolol, 40 to 100 mg/d in divided doses, for tremor
- amiloride, 5 to 10 mg/d, for polyuria
- loperamide as needed for diarrhea.2,5
Educate your patients on potential side effects, and encourage them to report any unwanted effects. Developing a good patient-provider relationship is essential to maximizing treatment adherence.
1. Chuang DM. Neuroprotective and neurotrophic actions of the mood stabilizer lithium: can it be used to treat neurodegenerative diseases? Crit Rev Neurobiol 2004;16(1-2):83-90.
2. American Psychiatric Association Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry 2002;159 (suppl 4):1-50.
3. Schou M, Grof P. Lithium treatment: focus on long-term prophylaxis. In: Akiskal HS, Tohen M, eds. Bipolar psychopharmacotherapy: caring for the patient. West Sussex, England: John Wiley & Sons Ltd; 2006:9–26.
4. Antimanic agents In: McEvoy GK, ed. AHFS Drug Information. Bethesda, MD: American Society of Health-System Pharmacists, Inc.; 2007:2566–75.
5. Dunner DL. Optimizing lithium treatment. J Clin Psychiatry 2000;61(suppl 9):76-81.
Lithium is making a comeback for good reason. Aside from its tried and true efficacy for bipolar disorder, lithium has neuroprotective effects and antisuicide properties.1,2
Psychiatry residents who were taught to use divalproex and atypical antipsychotics to treat bipolar disorder are discovering lithium’s benefits. However, all psychiatrists might need a refresher—outlined by the mnemonic LITHIUM—on the fundamentals of this “old school” medication.
Levels between 0.6 and 1.0 mEq/L are sufficient to maintain most bipolar patients, although acute manic patients might require higher levels.2,3 Some patients who cannot tolerate lithium’s side effects might benefit from lower levels near 0.4 to 0.5 mEq/L. Remember, lithium levels are standardized in 12-hour trough plasma concentrations.
Interactions. Nonsteroidal anti-inflammatory drugs (except aspirin and sulindac), angiotensin-converting enzyme inhibitors, thiazide and loop diuretics, verapamil, and diltiazem can increase lithium concentration.4 Caffeine, theophylline, sodium bicarbonate, and dialysis could decrease lithium levels. Be careful when adding lithium to anticonvulsants or antipsychotics because of increased neurotoxicity risk.
Toxicity can lead to coma, seizures, cardiovascular collapse, and death, especially when serum concentrations exceed 3.5 mEq/L.2,4,5 Be alert to early toxicity symptoms such as drowsiness, confusion, coarse hand tremor, worsening gastrointestinal complaints, dysarthria, impaired consciousness, cogwheel rigidity, and ataxia. Lithium’s narrow therapeutic index requires prudent monitoring. Some patients could experience toxicity at low plasma concentrations, such as 1.0 to 1.5 mEq/L.
Half-life varies depending on the patient’s renal function. Steady state is usually reached within 5 days2 but can take up to 10 days because of prolonged half-life in elderly and renally impaired patients (Table). Drawing lithium levels too early could lead to lithium toxicity in these patients, who require modified dosing regimens and monitoring.
Table
Renal metabolism of lithium
| Renal function | Half-life (hours)4 | Steady state (days)* |
|---|---|---|
| Normal | 20 to 27 | 2.5 to 5.6 |
| Renally impaired or elderly patients | 36 to 50 | 4.5 to 10.4 |
| * Steady state is reached after 3 to 5 half-lives | ||
Indications. Lithium is FDA-approved for acute mania and bipolar maintenance, but it also has been used for bipolar depression, antidepressant augmentation, schizoaffective disorder, and mixed manic states.3 Consider combining lithium with an atypical antipsychotic for inpatients with severe bipolar mania with psychotic features. Also consider lithium therapy for patients with recurrent unipolar depression who have been successfully treated with antidepressants but then relapse.
Urinary excretion. Order creatinine measurements every 2 to 3 months for the first 6 months of therapy, then every 6 to 12 months. Although lithium is not a first-line mood-stabilizing drug for patients with renal impairment, it can be used safely in patients with hepatic dysfunction.2,4 Dehydration and a low-sodium diet can cause lithium accumulation, so evaluate patients’ sodium and water balance at the beginning of and throughout lithium therapy. Encourage patients to keep their sodium and water intake as consistent as possible to avoid fluctuations in lithium levels.
Managing side effects is essential to maximize lithium’s effectiveness. Consider switching to a slow-release preparation if your patient cannot tolerate various side effects of regular lithium. If the patient continues to have side effects, consider lowering the dose in 300-mg increments or as clinically indicated. Closely monitor the patient for improved side effects while aiming to maintain an appropriate therapeutic level. Also, moving the entire lithium dose to bedtime could minimize side effects. If these strategies are not adequate, consider adding:
- thyroid replacement to manage elevated thyroid stimulating hormone or frank hypothyroidism
- propranolol, 40 to 100 mg/d in divided doses, for tremor
- amiloride, 5 to 10 mg/d, for polyuria
- loperamide as needed for diarrhea.2,5
Educate your patients on potential side effects, and encourage them to report any unwanted effects. Developing a good patient-provider relationship is essential to maximizing treatment adherence.
Lithium is making a comeback for good reason. Aside from its tried and true efficacy for bipolar disorder, lithium has neuroprotective effects and antisuicide properties.1,2
Psychiatry residents who were taught to use divalproex and atypical antipsychotics to treat bipolar disorder are discovering lithium’s benefits. However, all psychiatrists might need a refresher—outlined by the mnemonic LITHIUM—on the fundamentals of this “old school” medication.
Levels between 0.6 and 1.0 mEq/L are sufficient to maintain most bipolar patients, although acute manic patients might require higher levels.2,3 Some patients who cannot tolerate lithium’s side effects might benefit from lower levels near 0.4 to 0.5 mEq/L. Remember, lithium levels are standardized in 12-hour trough plasma concentrations.
Interactions. Nonsteroidal anti-inflammatory drugs (except aspirin and sulindac), angiotensin-converting enzyme inhibitors, thiazide and loop diuretics, verapamil, and diltiazem can increase lithium concentration.4 Caffeine, theophylline, sodium bicarbonate, and dialysis could decrease lithium levels. Be careful when adding lithium to anticonvulsants or antipsychotics because of increased neurotoxicity risk.
Toxicity can lead to coma, seizures, cardiovascular collapse, and death, especially when serum concentrations exceed 3.5 mEq/L.2,4,5 Be alert to early toxicity symptoms such as drowsiness, confusion, coarse hand tremor, worsening gastrointestinal complaints, dysarthria, impaired consciousness, cogwheel rigidity, and ataxia. Lithium’s narrow therapeutic index requires prudent monitoring. Some patients could experience toxicity at low plasma concentrations, such as 1.0 to 1.5 mEq/L.
Half-life varies depending on the patient’s renal function. Steady state is usually reached within 5 days2 but can take up to 10 days because of prolonged half-life in elderly and renally impaired patients (Table). Drawing lithium levels too early could lead to lithium toxicity in these patients, who require modified dosing regimens and monitoring.
Table
Renal metabolism of lithium
| Renal function | Half-life (hours)4 | Steady state (days)* |
|---|---|---|
| Normal | 20 to 27 | 2.5 to 5.6 |
| Renally impaired or elderly patients | 36 to 50 | 4.5 to 10.4 |
| * Steady state is reached after 3 to 5 half-lives | ||
Indications. Lithium is FDA-approved for acute mania and bipolar maintenance, but it also has been used for bipolar depression, antidepressant augmentation, schizoaffective disorder, and mixed manic states.3 Consider combining lithium with an atypical antipsychotic for inpatients with severe bipolar mania with psychotic features. Also consider lithium therapy for patients with recurrent unipolar depression who have been successfully treated with antidepressants but then relapse.
Urinary excretion. Order creatinine measurements every 2 to 3 months for the first 6 months of therapy, then every 6 to 12 months. Although lithium is not a first-line mood-stabilizing drug for patients with renal impairment, it can be used safely in patients with hepatic dysfunction.2,4 Dehydration and a low-sodium diet can cause lithium accumulation, so evaluate patients’ sodium and water balance at the beginning of and throughout lithium therapy. Encourage patients to keep their sodium and water intake as consistent as possible to avoid fluctuations in lithium levels.
Managing side effects is essential to maximize lithium’s effectiveness. Consider switching to a slow-release preparation if your patient cannot tolerate various side effects of regular lithium. If the patient continues to have side effects, consider lowering the dose in 300-mg increments or as clinically indicated. Closely monitor the patient for improved side effects while aiming to maintain an appropriate therapeutic level. Also, moving the entire lithium dose to bedtime could minimize side effects. If these strategies are not adequate, consider adding:
- thyroid replacement to manage elevated thyroid stimulating hormone or frank hypothyroidism
- propranolol, 40 to 100 mg/d in divided doses, for tremor
- amiloride, 5 to 10 mg/d, for polyuria
- loperamide as needed for diarrhea.2,5
Educate your patients on potential side effects, and encourage them to report any unwanted effects. Developing a good patient-provider relationship is essential to maximizing treatment adherence.
1. Chuang DM. Neuroprotective and neurotrophic actions of the mood stabilizer lithium: can it be used to treat neurodegenerative diseases? Crit Rev Neurobiol 2004;16(1-2):83-90.
2. American Psychiatric Association Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry 2002;159 (suppl 4):1-50.
3. Schou M, Grof P. Lithium treatment: focus on long-term prophylaxis. In: Akiskal HS, Tohen M, eds. Bipolar psychopharmacotherapy: caring for the patient. West Sussex, England: John Wiley & Sons Ltd; 2006:9–26.
4. Antimanic agents In: McEvoy GK, ed. AHFS Drug Information. Bethesda, MD: American Society of Health-System Pharmacists, Inc.; 2007:2566–75.
5. Dunner DL. Optimizing lithium treatment. J Clin Psychiatry 2000;61(suppl 9):76-81.
1. Chuang DM. Neuroprotective and neurotrophic actions of the mood stabilizer lithium: can it be used to treat neurodegenerative diseases? Crit Rev Neurobiol 2004;16(1-2):83-90.
2. American Psychiatric Association Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry 2002;159 (suppl 4):1-50.
3. Schou M, Grof P. Lithium treatment: focus on long-term prophylaxis. In: Akiskal HS, Tohen M, eds. Bipolar psychopharmacotherapy: caring for the patient. West Sussex, England: John Wiley & Sons Ltd; 2006:9–26.
4. Antimanic agents In: McEvoy GK, ed. AHFS Drug Information. Bethesda, MD: American Society of Health-System Pharmacists, Inc.; 2007:2566–75.
5. Dunner DL. Optimizing lithium treatment. J Clin Psychiatry 2000;61(suppl 9):76-81.