Pearls

Nonsuicidal self-injury (NSSI) is the direct and deliberate destruction of body tissue without intent to die.¹ Cutting is the most common form of NSSI; other methods include burning, scraping/scratching skin, interfering with wound healing, hitting, biting, self-poisoning, and purposeful non-recreational risk-taking.^2,3 Although most individuals who engage in NSSI have no intention to die, suicidal ideation often precedes the initial engagement in NSSI,⁴ and a history of repeated NSSI is a risk factor for suicide attempts.⁴ In a systematic review, Cipriano et al⁵ found that NSSI is most common among adolescents and young adults, with onset most often occurring between age 12 and 14. Prevalence rates of NSSI are 7.5% to 46.5% in adolescents, 38.9% in university students, and 4% to 23% in adults.⁵

Although no medications have consistently shown efficacy for treating NSSI, research suggests cognitive-behavioral therapy and dialectical behavioral therapy may be helpful. Unfortunately, these therapies are often not available during a patient’s acute crisis.³ Because a thorough review of the treatment options for NSSI is beyond the scope of this article, here I offer tips for caring for adults who engage in NSSI. Although there are slight differences in managing NSSI in adolescents (eg, the need for parental monitoring and reducing risk of contagion), these tips also can be used with adolescents.

Explore why your patient engages in NSSI. Identifying the reasons for our patients’ NSSI makes it easier for us to empathize with them, and puts us in a better position to treat them.³ The most widely reported reasons for NSSI are to cope with distress/anguish and to exert influence on others.⁶ In a systematic review, self-reported reasons for NSSI also included punishing oneself for having positive feelings, punishing others, managing dissociation (ie, active pursuit of numbness), sensation-seeking (ie, to generate excitement or exhilaration), averting suicide (ie, warding off suicidal thoughts), maintaining or exploring boundaries, and expressing or coping with sexuality.⁶ When exploring your patient’s reasons for NSSI, determine if the behavior is based on a true suicidal desire. Because NSSI is associated with mood disorders, anxiety disorders, personality disorders, and other disorders, also assess for any underlying psychiatric conditions, and treat them accordingly because mental health treatment has been empirically proven to reduce suicide rates.^2,7

Conduct a suicide risk assessment. Regardless of your patient’s reasons for NSSI, an individualized and thorough suicide risk assessment is needed to identify modifiable, non-modifiable, and protective factors that you can consider when developing a treatment plan. Key components of such assessments include (but are not limited to) current and past urges to engage in NSSI, past NSSI and suicide attempts, access to lethal means, and ability to follow a safety plan.

Avoid exaggerating the danger and importance of NSSI. Treating a patient who engages in NSSI who is motivated by a true suicidal desire and/or has underlying psychiatric conditions may prompt you to consider hospitalization and/or prescribing psychotropic medications.³ However, because most NSSI is not due to a true suicidal desire, overreacting may unwittingly communicate to the patient that self-harm is a way to sustain someone’s attention, thus reinforcing that such behaviors can help them obtain support when distressed.³ Further, overreacting will not help patients comprehend and better cope with the reasons for their self-injurious behaviors.³

Restrict your patient’s access to lethal means. Restricting access to items such as firearms, sharp objects (eg, knives and razors), medications, implements for suffocation/hanging (eg, belts), and household poisons has been empirically proven to reduce suicide rates.⁷ Such restrictions can also potentially reduce the likelihood of NSSI. It is important to repeatedly ask your patient if they have acquired any new means, and to listen for information that indicates they possess means that they did not previously disclose. It is also important to ask if the patient has moved existing means to an area for easier access to use them.

Create a safety plan. Written safety plans can include a list of warning signs (thoughts, images, mood, situations, behaviors) that a crisis is developing, coping strategies (eg, going for a walk, exercising, engaging in a hobby, socializing with friends or family), and contact information for 24-hour crisis hotlines, emergency rooms, and mental health clinicians.⁸ The Suicide Prevention Resource Center offers a safety plan template at www.sprc.org/sites/default/files/resource-program/Brown_StanleySafetyPlanTemplate.pdf.⁸ 

Offer empathy. Individuals who engage in NSSI are making a desperate call for help that requires concerned and supportive responses.³ One such response is to provide empathy. In addition to expressing concern and compassion, empathy involves recognizing and sharing your patients’ emotions. Empathy also can help you avoid any resistance during the visit by considering what is appropriate to say to patients.

Manage countertransference. You may have negative feelings toward a patient who engages in NSSI, or may even view self-harm as a willful act designed to gain attention. However, such feelings could lead you to minimize or dismiss the importance of your patient’s behaviors, which may push them to engage in more dangerous self-harm.³ Acknowledging any feelings of derision for a patient who engages in NSSI and understanding why you have these emotions will help you better understand your patient, improve rapport, and ensure that you are not impeding the delivery of appropriate clinical care.

Nonsuicidal self-injury (NSSI) is the direct and deliberate destruction of body tissue without intent to die.¹ Cutting is the most common form of NSSI; other methods include burning, scraping/scratching skin, interfering with wound healing, hitting, biting, self-poisoning, and purposeful non-recreational risk-taking.^2,3 Although most individuals who engage in NSSI have no intention to die, suicidal ideation often precedes the initial engagement in NSSI,⁴ and a history of repeated NSSI is a risk factor for suicide attempts.⁴ In a systematic review, Cipriano et al⁵ found that NSSI is most common among adolescents and young adults, with onset most often occurring between age 12 and 14. Prevalence rates of NSSI are 7.5% to 46.5% in adolescents, 38.9% in university students, and 4% to 23% in adults.⁵

Although no medications have consistently shown efficacy for treating NSSI, research suggests cognitive-behavioral therapy and dialectical behavioral therapy may be helpful. Unfortunately, these therapies are often not available during a patient’s acute crisis.³ Because a thorough review of the treatment options for NSSI is beyond the scope of this article, here I offer tips for caring for adults who engage in NSSI. Although there are slight differences in managing NSSI in adolescents (eg, the need for parental monitoring and reducing risk of contagion), these tips also can be used with adolescents.

Explore why your patient engages in NSSI. Identifying the reasons for our patients’ NSSI makes it easier for us to empathize with them, and puts us in a better position to treat them.³ The most widely reported reasons for NSSI are to cope with distress/anguish and to exert influence on others.⁶ In a systematic review, self-reported reasons for NSSI also included punishing oneself for having positive feelings, punishing others, managing dissociation (ie, active pursuit of numbness), sensation-seeking (ie, to generate excitement or exhilaration), averting suicide (ie, warding off suicidal thoughts), maintaining or exploring boundaries, and expressing or coping with sexuality.⁶ When exploring your patient’s reasons for NSSI, determine if the behavior is based on a true suicidal desire. Because NSSI is associated with mood disorders, anxiety disorders, personality disorders, and other disorders, also assess for any underlying psychiatric conditions, and treat them accordingly because mental health treatment has been empirically proven to reduce suicide rates.^2,7

Conduct a suicide risk assessment. Regardless of your patient’s reasons for NSSI, an individualized and thorough suicide risk assessment is needed to identify modifiable, non-modifiable, and protective factors that you can consider when developing a treatment plan. Key components of such assessments include (but are not limited to) current and past urges to engage in NSSI, past NSSI and suicide attempts, access to lethal means, and ability to follow a safety plan.

Avoid exaggerating the danger and importance of NSSI. Treating a patient who engages in NSSI who is motivated by a true suicidal desire and/or has underlying psychiatric conditions may prompt you to consider hospitalization and/or prescribing psychotropic medications.³ However, because most NSSI is not due to a true suicidal desire, overreacting may unwittingly communicate to the patient that self-harm is a way to sustain someone’s attention, thus reinforcing that such behaviors can help them obtain support when distressed.³ Further, overreacting will not help patients comprehend and better cope with the reasons for their self-injurious behaviors.³

Restrict your patient’s access to lethal means. Restricting access to items such as firearms, sharp objects (eg, knives and razors), medications, implements for suffocation/hanging (eg, belts), and household poisons has been empirically proven to reduce suicide rates.⁷ Such restrictions can also potentially reduce the likelihood of NSSI. It is important to repeatedly ask your patient if they have acquired any new means, and to listen for information that indicates they possess means that they did not previously disclose. It is also important to ask if the patient has moved existing means to an area for easier access to use them.

Create a safety plan. Written safety plans can include a list of warning signs (thoughts, images, mood, situations, behaviors) that a crisis is developing, coping strategies (eg, going for a walk, exercising, engaging in a hobby, socializing with friends or family), and contact information for 24-hour crisis hotlines, emergency rooms, and mental health clinicians.⁸ The Suicide Prevention Resource Center offers a safety plan template at www.sprc.org/sites/default/files/resource-program/Brown_StanleySafetyPlanTemplate.pdf.⁸ 

Offer empathy. Individuals who engage in NSSI are making a desperate call for help that requires concerned and supportive responses.³ One such response is to provide empathy. In addition to expressing concern and compassion, empathy involves recognizing and sharing your patients’ emotions. Empathy also can help you avoid any resistance during the visit by considering what is appropriate to say to patients.

Manage countertransference. You may have negative feelings toward a patient who engages in NSSI, or may even view self-harm as a willful act designed to gain attention. However, such feelings could lead you to minimize or dismiss the importance of your patient’s behaviors, which may push them to engage in more dangerous self-harm.³ Acknowledging any feelings of derision for a patient who engages in NSSI and understanding why you have these emotions will help you better understand your patient, improve rapport, and ensure that you are not impeding the delivery of appropriate clinical care.

Nonsuicidal self-injury (NSSI) is the direct and deliberate destruction of body tissue without intent to die.¹ Cutting is the most common form of NSSI; other methods include burning, scraping/scratching skin, interfering with wound healing, hitting, biting, self-poisoning, and purposeful non-recreational risk-taking.^2,3 Although most individuals who engage in NSSI have no intention to die, suicidal ideation often precedes the initial engagement in NSSI,⁴ and a history of repeated NSSI is a risk factor for suicide attempts.⁴ In a systematic review, Cipriano et al⁵ found that NSSI is most common among adolescents and young adults, with onset most often occurring between age 12 and 14. Prevalence rates of NSSI are 7.5% to 46.5% in adolescents, 38.9% in university students, and 4% to 23% in adults.⁵

Although no medications have consistently shown efficacy for treating NSSI, research suggests cognitive-behavioral therapy and dialectical behavioral therapy may be helpful. Unfortunately, these therapies are often not available during a patient’s acute crisis.³ Because a thorough review of the treatment options for NSSI is beyond the scope of this article, here I offer tips for caring for adults who engage in NSSI. Although there are slight differences in managing NSSI in adolescents (eg, the need for parental monitoring and reducing risk of contagion), these tips also can be used with adolescents.

Explore why your patient engages in NSSI. Identifying the reasons for our patients’ NSSI makes it easier for us to empathize with them, and puts us in a better position to treat them.³ The most widely reported reasons for NSSI are to cope with distress/anguish and to exert influence on others.⁶ In a systematic review, self-reported reasons for NSSI also included punishing oneself for having positive feelings, punishing others, managing dissociation (ie, active pursuit of numbness), sensation-seeking (ie, to generate excitement or exhilaration), averting suicide (ie, warding off suicidal thoughts), maintaining or exploring boundaries, and expressing or coping with sexuality.⁶ When exploring your patient’s reasons for NSSI, determine if the behavior is based on a true suicidal desire. Because NSSI is associated with mood disorders, anxiety disorders, personality disorders, and other disorders, also assess for any underlying psychiatric conditions, and treat them accordingly because mental health treatment has been empirically proven to reduce suicide rates.^2,7

Conduct a suicide risk assessment. Regardless of your patient’s reasons for NSSI, an individualized and thorough suicide risk assessment is needed to identify modifiable, non-modifiable, and protective factors that you can consider when developing a treatment plan. Key components of such assessments include (but are not limited to) current and past urges to engage in NSSI, past NSSI and suicide attempts, access to lethal means, and ability to follow a safety plan.

Avoid exaggerating the danger and importance of NSSI. Treating a patient who engages in NSSI who is motivated by a true suicidal desire and/or has underlying psychiatric conditions may prompt you to consider hospitalization and/or prescribing psychotropic medications.³ However, because most NSSI is not due to a true suicidal desire, overreacting may unwittingly communicate to the patient that self-harm is a way to sustain someone’s attention, thus reinforcing that such behaviors can help them obtain support when distressed.³ Further, overreacting will not help patients comprehend and better cope with the reasons for their self-injurious behaviors.³

Restrict your patient’s access to lethal means. Restricting access to items such as firearms, sharp objects (eg, knives and razors), medications, implements for suffocation/hanging (eg, belts), and household poisons has been empirically proven to reduce suicide rates.⁷ Such restrictions can also potentially reduce the likelihood of NSSI. It is important to repeatedly ask your patient if they have acquired any new means, and to listen for information that indicates they possess means that they did not previously disclose. It is also important to ask if the patient has moved existing means to an area for easier access to use them.

Create a safety plan. Written safety plans can include a list of warning signs (thoughts, images, mood, situations, behaviors) that a crisis is developing, coping strategies (eg, going for a walk, exercising, engaging in a hobby, socializing with friends or family), and contact information for 24-hour crisis hotlines, emergency rooms, and mental health clinicians.⁸ The Suicide Prevention Resource Center offers a safety plan template at www.sprc.org/sites/default/files/resource-program/Brown_StanleySafetyPlanTemplate.pdf.⁸ 

Offer empathy. Individuals who engage in NSSI are making a desperate call for help that requires concerned and supportive responses.³ One such response is to provide empathy. In addition to expressing concern and compassion, empathy involves recognizing and sharing your patients’ emotions. Empathy also can help you avoid any resistance during the visit by considering what is appropriate to say to patients.

Manage countertransference. You may have negative feelings toward a patient who engages in NSSI, or may even view self-harm as a willful act designed to gain attention. However, such feelings could lead you to minimize or dismiss the importance of your patient’s behaviors, which may push them to engage in more dangerous self-harm.³ Acknowledging any feelings of derision for a patient who engages in NSSI and understanding why you have these emotions will help you better understand your patient, improve rapport, and ensure that you are not impeding the delivery of appropriate clinical care.

Alcohol withdrawal syndrome (AWS) occurs when an individual who is alcohol-dependent suddenly stops or significantly reduces his/her alcohol intake.¹ Symptoms of AWS, which can be fatal, include anxiety, restlessness, seizures, confusion, and delirium.¹ Because benzodiazepines have been proven effective in improving symptoms of AWS, they are considered the first-line treatment, but they also carry the risk of abuse, psychomotor sedation, cognitive impairment, and interactions with alcohol.¹

Non-benzodiazepine anticonvulsants (NBACs) such as valproic acid (VPA) and carbamazepine may offer benefit as alternatives or adjuncts to benzodiazepines.¹ Many NBACs affect the functioning of glutamate and gamma-aminobutyric acid (GABA) neurotransmitters,² which are particularly dysregulated in patients with AWS. Because NBACs help stabilize this imbalance, they may be useful for managing AWS and preventing relapse without the risks associated with benzodiazepines.²

Valproic acid: A better choice than carbamazepine

Compared with other NBACs, VPA and carbamazepine have been studied more extensively for treating patients with AWS, and their clinical effectiveness has been well documented.¹ For mild-to-moderate AWS, VPA and carbamazepine may be as effective as benzodiazepines in reducing the severity of symptoms, and more potent for preventing withdrawal seizures.¹

Increasing data suggests that compared with VPA, adjunctive treatment with carbamazepine for AWS may be more frequently associated with intolerable adverse effects such as ataxia, orthostatic hypotension, vertigo, nausea, and vomiting.¹ The rapid onset of AWS requires rapid-acting pharmacotherapy.¹ In attempting to rapidly achieve the desired plasma concentrations of carbamazepine, clinicians may risk inducing adverse effects. Compared with carbamazepine, VPA is associated with faster symptom resolution, a shorter duration of pharmacologic treatment, fewer transfers to the ICU, fewer withdrawal seizures, and a more favorable adverse effect profile.¹ Likely due to its shorter half-life, VPA delivers its therapeutic effects without producing significant adverse effects.¹

Early and aggressive treatment of AWS is needed to block kindling,³ which is characterized by the worsening of withdrawal symptoms each time an individual attempts to quit drinking alcohol. Compared with carbamazepine, VPA may be more helpful for blocking kindling.³

More data is needed

Due to ethical concerns, few studies have compared anticonvulsant medications with placebo for treating AWS.² Most studies examining NBACs for AWS have either used the anticonvulsant as an adjunct to a benzodiazepine to examine improvement in withdrawal symptoms, or compared the anticonvulsant with placebo or another intervention to assess the amount of a benzodiazepine required for safe detoxification.^2,4 Additionally, most studies examining NBACs have been short, and few followed patients after the active medication period, which limits our knowledge of the long-term effectiveness of NBACs.² Before NBACs can replace benzodiazepines for managing AWS, further evidence from clinical trials is needed to assess their efficiency as a stand-alone treatment.

Alcohol withdrawal syndrome (AWS) occurs when an individual who is alcohol-dependent suddenly stops or significantly reduces his/her alcohol intake.¹ Symptoms of AWS, which can be fatal, include anxiety, restlessness, seizures, confusion, and delirium.¹ Because benzodiazepines have been proven effective in improving symptoms of AWS, they are considered the first-line treatment, but they also carry the risk of abuse, psychomotor sedation, cognitive impairment, and interactions with alcohol.¹

Non-benzodiazepine anticonvulsants (NBACs) such as valproic acid (VPA) and carbamazepine may offer benefit as alternatives or adjuncts to benzodiazepines.¹ Many NBACs affect the functioning of glutamate and gamma-aminobutyric acid (GABA) neurotransmitters,² which are particularly dysregulated in patients with AWS. Because NBACs help stabilize this imbalance, they may be useful for managing AWS and preventing relapse without the risks associated with benzodiazepines.²

Valproic acid: A better choice than carbamazepine

Compared with other NBACs, VPA and carbamazepine have been studied more extensively for treating patients with AWS, and their clinical effectiveness has been well documented.¹ For mild-to-moderate AWS, VPA and carbamazepine may be as effective as benzodiazepines in reducing the severity of symptoms, and more potent for preventing withdrawal seizures.¹

Increasing data suggests that compared with VPA, adjunctive treatment with carbamazepine for AWS may be more frequently associated with intolerable adverse effects such as ataxia, orthostatic hypotension, vertigo, nausea, and vomiting.¹ The rapid onset of AWS requires rapid-acting pharmacotherapy.¹ In attempting to rapidly achieve the desired plasma concentrations of carbamazepine, clinicians may risk inducing adverse effects. Compared with carbamazepine, VPA is associated with faster symptom resolution, a shorter duration of pharmacologic treatment, fewer transfers to the ICU, fewer withdrawal seizures, and a more favorable adverse effect profile.¹ Likely due to its shorter half-life, VPA delivers its therapeutic effects without producing significant adverse effects.¹

Early and aggressive treatment of AWS is needed to block kindling,³ which is characterized by the worsening of withdrawal symptoms each time an individual attempts to quit drinking alcohol. Compared with carbamazepine, VPA may be more helpful for blocking kindling.³

More data is needed

Due to ethical concerns, few studies have compared anticonvulsant medications with placebo for treating AWS.² Most studies examining NBACs for AWS have either used the anticonvulsant as an adjunct to a benzodiazepine to examine improvement in withdrawal symptoms, or compared the anticonvulsant with placebo or another intervention to assess the amount of a benzodiazepine required for safe detoxification.^2,4 Additionally, most studies examining NBACs have been short, and few followed patients after the active medication period, which limits our knowledge of the long-term effectiveness of NBACs.² Before NBACs can replace benzodiazepines for managing AWS, further evidence from clinical trials is needed to assess their efficiency as a stand-alone treatment.

Alcohol withdrawal syndrome (AWS) occurs when an individual who is alcohol-dependent suddenly stops or significantly reduces his/her alcohol intake.¹ Symptoms of AWS, which can be fatal, include anxiety, restlessness, seizures, confusion, and delirium.¹ Because benzodiazepines have been proven effective in improving symptoms of AWS, they are considered the first-line treatment, but they also carry the risk of abuse, psychomotor sedation, cognitive impairment, and interactions with alcohol.¹

Non-benzodiazepine anticonvulsants (NBACs) such as valproic acid (VPA) and carbamazepine may offer benefit as alternatives or adjuncts to benzodiazepines.¹ Many NBACs affect the functioning of glutamate and gamma-aminobutyric acid (GABA) neurotransmitters,² which are particularly dysregulated in patients with AWS. Because NBACs help stabilize this imbalance, they may be useful for managing AWS and preventing relapse without the risks associated with benzodiazepines.²

Valproic acid: A better choice than carbamazepine

Compared with other NBACs, VPA and carbamazepine have been studied more extensively for treating patients with AWS, and their clinical effectiveness has been well documented.¹ For mild-to-moderate AWS, VPA and carbamazepine may be as effective as benzodiazepines in reducing the severity of symptoms, and more potent for preventing withdrawal seizures.¹

Increasing data suggests that compared with VPA, adjunctive treatment with carbamazepine for AWS may be more frequently associated with intolerable adverse effects such as ataxia, orthostatic hypotension, vertigo, nausea, and vomiting.¹ The rapid onset of AWS requires rapid-acting pharmacotherapy.¹ In attempting to rapidly achieve the desired plasma concentrations of carbamazepine, clinicians may risk inducing adverse effects. Compared with carbamazepine, VPA is associated with faster symptom resolution, a shorter duration of pharmacologic treatment, fewer transfers to the ICU, fewer withdrawal seizures, and a more favorable adverse effect profile.¹ Likely due to its shorter half-life, VPA delivers its therapeutic effects without producing significant adverse effects.¹

Early and aggressive treatment of AWS is needed to block kindling,³ which is characterized by the worsening of withdrawal symptoms each time an individual attempts to quit drinking alcohol. Compared with carbamazepine, VPA may be more helpful for blocking kindling.³

More data is needed

Due to ethical concerns, few studies have compared anticonvulsant medications with placebo for treating AWS.² Most studies examining NBACs for AWS have either used the anticonvulsant as an adjunct to a benzodiazepine to examine improvement in withdrawal symptoms, or compared the anticonvulsant with placebo or another intervention to assess the amount of a benzodiazepine required for safe detoxification.^2,4 Additionally, most studies examining NBACs have been short, and few followed patients after the active medication period, which limits our knowledge of the long-term effectiveness of NBACs.² Before NBACs can replace benzodiazepines for managing AWS, further evidence from clinical trials is needed to assess their efficiency as a stand-alone treatment.

Autism spectrum disorder (ASD) is characterized by impairments in communication and social interactions, along with repetitive and perseverant behaviors.¹ It has a prevalence of 0.75% to 1.1% among the general population.¹ The presentation of ASD can vary, and patients may have a wide range of comorbidities, such as attention-deficit/hyperactivity disorder (ADHD), neurologic disorders, and genetic disorders.¹ Therefore, a comprehensive evaluation needs to include a multidisciplinary assessment by clinicians from several specialties, including primary care, psychiatry, psychology, and neurology. Here I offer psychiatrists 3 Ps and the mnemonic SONG to describe a multidisciplinary approach to assessing a patient with suspected or confirmed ASD.

Primary care evaluation of patients with ASD is important for the diagnosis and treatment of any co-existing medical conditions. Primary care physicians are often the source of referrals to psychiatry, although the reason for the referral may not always be suspicion of autism. In my clinical practice, almost all referrals from primary care involve a chief complaint of anger or behavioral problems, or even obsessive-compulsive behaviors.

Psychiatric evaluation should include obtaining a detailed history of the patient’s conception, birth, development, and social life, and his/her family history of genetic conditions. In my practice, ADHD and elimination disorders are common comorbidities in patients with ASD. Consider communicating with daycare staff or teachers and auxiliary staff, such as guidance counselors, because doing so can help elucidate the diagnosis. Also, ask adult family members, preferably a parent, for collateral information to help establish an accurate diagnosis in your adult patients.

Psychological evaluation should include testing to rule out intellectual disability and learning disorders, which are common in patients with ASD.² Tests commonly used for evaluation of ASD include the Autism Diagnostic Observation Schedule (ADOS), Childhood Autism Rating Scale (CARS), and Autism Diagnostic Interview-Revised (ADI-R).

Speech evaluation. Deficits in language and communication are commonly observed in patients with ASD, especially in younger patients.³ A study of the relationship between early language skills (age of first word production) and later functioning in children with ASD indicated that earlier age of first word acquisition was associated with higher cognitive ability and adaptive skills when measured later in childhood.³ Therefore, timely intervention following speech evaluation can result in favorable outcomes.

Occupational evaluation. Approximately 69% to 93% of children and adults with ASD exhibit sensory symptoms (hyperresponsive, hyporesponsive, and sensory-seeking behaviors).⁴ Patients with sensory symptoms often experience limitations in multiple areas of their life. Early intervention by an occupational therapist can help improve long-term outcomes.⁴

Neurologic evaluation is important because ASD is a neurodevelopmental disorder. Patients with ASD often have comorbid seizure disorders.¹ The estimated prevalence of epilepsy in these patients ranges from 2.7% to 44.4%.¹ A baseline EEG and neuroimaging can help improve your understanding of the relationship between ASD and seizure disorders, and guide treatment.

Genetic testing. Between 10% to 15% of individuals with ASD have a medical condition, such as cytogenetic or single-gene disorder, that causes ASD.⁵ Fragile X syndrome, tuberous sclerosis, and Prader-Willi syndrome are a few common examples of genetic disorders associated with ASD.⁵ Autism spectrum disorder has also been known to have a strong genetic basis with high probability of heritability in families.⁵ Genetic testing can help to detect any underlying genetic disorders in your patients as well as their family members. Chromosomal microarray analysis has become more accessible due to improved insurance coverage, and is convenient to perform by collection of a buccal mucosa sample in the office setting.

Autism spectrum disorder (ASD) is characterized by impairments in communication and social interactions, along with repetitive and perseverant behaviors.¹ It has a prevalence of 0.75% to 1.1% among the general population.¹ The presentation of ASD can vary, and patients may have a wide range of comorbidities, such as attention-deficit/hyperactivity disorder (ADHD), neurologic disorders, and genetic disorders.¹ Therefore, a comprehensive evaluation needs to include a multidisciplinary assessment by clinicians from several specialties, including primary care, psychiatry, psychology, and neurology. Here I offer psychiatrists 3 Ps and the mnemonic SONG to describe a multidisciplinary approach to assessing a patient with suspected or confirmed ASD.

Primary care evaluation of patients with ASD is important for the diagnosis and treatment of any co-existing medical conditions. Primary care physicians are often the source of referrals to psychiatry, although the reason for the referral may not always be suspicion of autism. In my clinical practice, almost all referrals from primary care involve a chief complaint of anger or behavioral problems, or even obsessive-compulsive behaviors.

Psychiatric evaluation should include obtaining a detailed history of the patient’s conception, birth, development, and social life, and his/her family history of genetic conditions. In my practice, ADHD and elimination disorders are common comorbidities in patients with ASD. Consider communicating with daycare staff or teachers and auxiliary staff, such as guidance counselors, because doing so can help elucidate the diagnosis. Also, ask adult family members, preferably a parent, for collateral information to help establish an accurate diagnosis in your adult patients.

Psychological evaluation should include testing to rule out intellectual disability and learning disorders, which are common in patients with ASD.² Tests commonly used for evaluation of ASD include the Autism Diagnostic Observation Schedule (ADOS), Childhood Autism Rating Scale (CARS), and Autism Diagnostic Interview-Revised (ADI-R).

Speech evaluation. Deficits in language and communication are commonly observed in patients with ASD, especially in younger patients.³ A study of the relationship between early language skills (age of first word production) and later functioning in children with ASD indicated that earlier age of first word acquisition was associated with higher cognitive ability and adaptive skills when measured later in childhood.³ Therefore, timely intervention following speech evaluation can result in favorable outcomes.

Occupational evaluation. Approximately 69% to 93% of children and adults with ASD exhibit sensory symptoms (hyperresponsive, hyporesponsive, and sensory-seeking behaviors).⁴ Patients with sensory symptoms often experience limitations in multiple areas of their life. Early intervention by an occupational therapist can help improve long-term outcomes.⁴

Neurologic evaluation is important because ASD is a neurodevelopmental disorder. Patients with ASD often have comorbid seizure disorders.¹ The estimated prevalence of epilepsy in these patients ranges from 2.7% to 44.4%.¹ A baseline EEG and neuroimaging can help improve your understanding of the relationship between ASD and seizure disorders, and guide treatment.

Genetic testing. Between 10% to 15% of individuals with ASD have a medical condition, such as cytogenetic or single-gene disorder, that causes ASD.⁵ Fragile X syndrome, tuberous sclerosis, and Prader-Willi syndrome are a few common examples of genetic disorders associated with ASD.⁵ Autism spectrum disorder has also been known to have a strong genetic basis with high probability of heritability in families.⁵ Genetic testing can help to detect any underlying genetic disorders in your patients as well as their family members. Chromosomal microarray analysis has become more accessible due to improved insurance coverage, and is convenient to perform by collection of a buccal mucosa sample in the office setting.

Autism spectrum disorder (ASD) is characterized by impairments in communication and social interactions, along with repetitive and perseverant behaviors.¹ It has a prevalence of 0.75% to 1.1% among the general population.¹ The presentation of ASD can vary, and patients may have a wide range of comorbidities, such as attention-deficit/hyperactivity disorder (ADHD), neurologic disorders, and genetic disorders.¹ Therefore, a comprehensive evaluation needs to include a multidisciplinary assessment by clinicians from several specialties, including primary care, psychiatry, psychology, and neurology. Here I offer psychiatrists 3 Ps and the mnemonic SONG to describe a multidisciplinary approach to assessing a patient with suspected or confirmed ASD.

Primary care evaluation of patients with ASD is important for the diagnosis and treatment of any co-existing medical conditions. Primary care physicians are often the source of referrals to psychiatry, although the reason for the referral may not always be suspicion of autism. In my clinical practice, almost all referrals from primary care involve a chief complaint of anger or behavioral problems, or even obsessive-compulsive behaviors.

Psychiatric evaluation should include obtaining a detailed history of the patient’s conception, birth, development, and social life, and his/her family history of genetic conditions. In my practice, ADHD and elimination disorders are common comorbidities in patients with ASD. Consider communicating with daycare staff or teachers and auxiliary staff, such as guidance counselors, because doing so can help elucidate the diagnosis. Also, ask adult family members, preferably a parent, for collateral information to help establish an accurate diagnosis in your adult patients.

Psychological evaluation should include testing to rule out intellectual disability and learning disorders, which are common in patients with ASD.² Tests commonly used for evaluation of ASD include the Autism Diagnostic Observation Schedule (ADOS), Childhood Autism Rating Scale (CARS), and Autism Diagnostic Interview-Revised (ADI-R).

Speech evaluation. Deficits in language and communication are commonly observed in patients with ASD, especially in younger patients.³ A study of the relationship between early language skills (age of first word production) and later functioning in children with ASD indicated that earlier age of first word acquisition was associated with higher cognitive ability and adaptive skills when measured later in childhood.³ Therefore, timely intervention following speech evaluation can result in favorable outcomes.

Occupational evaluation. Approximately 69% to 93% of children and adults with ASD exhibit sensory symptoms (hyperresponsive, hyporesponsive, and sensory-seeking behaviors).⁴ Patients with sensory symptoms often experience limitations in multiple areas of their life. Early intervention by an occupational therapist can help improve long-term outcomes.⁴

Neurologic evaluation is important because ASD is a neurodevelopmental disorder. Patients with ASD often have comorbid seizure disorders.¹ The estimated prevalence of epilepsy in these patients ranges from 2.7% to 44.4%.¹ A baseline EEG and neuroimaging can help improve your understanding of the relationship between ASD and seizure disorders, and guide treatment.

Genetic testing. Between 10% to 15% of individuals with ASD have a medical condition, such as cytogenetic or single-gene disorder, that causes ASD.⁵ Fragile X syndrome, tuberous sclerosis, and Prader-Willi syndrome are a few common examples of genetic disorders associated with ASD.⁵ Autism spectrum disorder has also been known to have a strong genetic basis with high probability of heritability in families.⁵ Genetic testing can help to detect any underlying genetic disorders in your patients as well as their family members. Chromosomal microarray analysis has become more accessible due to improved insurance coverage, and is convenient to perform by collection of a buccal mucosa sample in the office setting.

Online reviews have become a popular method for patients to rate their psychiatrists. Patients’ online reviews can help other patients make more informed decisions about pursuing treatment, offer us valuable feedback on our performance, and help improve standards of care.¹ However, during the course of our careers, we may receive negative online reviews. These reviews may range from mild dissatisfaction to abusive comments, and they could have adverse personal and professional consequences.² For example, online discussions might make current patients question your practices or consider ending their treatment with you.² Also, potential patients might decide to not inquire about your services.² Here I offer suggestions for approaching negative online reviews, and point out some potential pitfalls of responding to them.

Remain professional. You might become upset or frazzled after reading online criticisms about your performance, particularly if the information is erroneous or deceptive. As much as you would like to immediately respond, a public tit-for-tat could prolong or fuel a conflict, or make you come across as angry.²

There may be occasions, however, when it would be appropriate to respond. If you choose to respond to a negative online review, you need to have a methodical plan. Avoid reacting in a knee-jerk manner because this is usually unproductive. In addition, ensure that your response is professional and polite, because an intemperate response could undermine the public’s confidence in our profession.²

Maintain patient confidentiality. Although patients are free to post anything they desire, psychiatrists must maintain confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) applies to online reviews, which prevents us from disclosing information about patients without their permission, including even acknowledging that someone is our patient.³ Your patients’ disclosures are not permission to disclose their health information. Potential patients might avoid us or existing patients may end their treatment with us if they believe their personal information could be disclosed online without their consent. To avoid such concerns, reply to online reviews with generic comments about your practice’s general policies without violating confidentiality. Also, to avoid violating HIPAA rules, you may want to contact your malpractice carrier or your facility’s legal department before replying.¹

Invite patients to discuss their grievances. If your patients identify themselves in a review, or if you are able to identify them, consider inviting them to discuss their concerns with you (over the phone, face-to-face, or via video conferencing). During such conversations, thank the patient for their review, and do not ask them to delete it.² Focus on addressing their concerns and resolving any problems they experienced during treatment; doing so can help improve your practice. This approach also might lead a patient to remove their negative review or to write a review that lets other patients know that you are listening to them.

Even if you choose not to invite your patients to air their concerns, do not entirely dismiss negative reviews. Instead, try to step back from your emotions and take an objective look at such reviews so you can determine what steps to take to improve your practices. Improving your communication with patients could decrease the likelihood that they will write negative reviews in the first place.

Take action on fake reviews. If a negative review is fake (not written by one of your patients) or blatantly untrue, contact the web site administrator and provide evidence to support having the review deleted, especially if it violates the site’s terms of service.¹ However, this approach may not be fruitful. Web sites can be manipulated, and many do not require users to authenticate that they are actual patients.¹ Although most web sites would not want their reputation damaged by users posting fake reviews, more dramatic reviews could help lead to increased traffic, which lowers an administrator’s incentive to remove negative reviews.¹

Continue to: Consider legal repercussions

Consider legal repercussions. Stay up-to-date with online reviews about you by conducting internet searches once every 3 months.¹ Consider notifying your malpractice carrier or facility’s legal department if a review suggests a patient or family might initiate legal action against you or the facility.¹ You might consider pursuing legal action if an online review is defamatory, but such claims often are difficult to prove in court.¹ Even if you win, such a case could later be repeatedly mentioned in articles and journals, thus creating a permanent record of the negative review in the literature.¹

Enlist help with your online image. If financially feasible, hire a professional service to help improve your online image or assist in responding to negative reviews.¹ Build your profile on review web sites to help frame your online image, and include information that mentions the pertinent steps you are taking to address any legitimate concerns your patients raise in their reviews. Encourage your patients to post reviews because that could produce a more equitable sample and paint a more accurate picture of your practice.

Lobby professional medical organizations to take action to protect psychiatrists from negative online reviews by creating legislation that holds web sites accountable for their content.¹

Stay positive. Unfounded or not, negative online reviews are an inevitable part of a psychiatrist’s professional life.² One negative review (or even several) is not going to destroy your reputation or career. Do not feel alone if you receive a negative review. Seek advice from colleagues who have received negative reviews; in addition to offering advice, they can also provide a listening ear.²

Online reviews have become a popular method for patients to rate their psychiatrists. Patients’ online reviews can help other patients make more informed decisions about pursuing treatment, offer us valuable feedback on our performance, and help improve standards of care.¹ However, during the course of our careers, we may receive negative online reviews. These reviews may range from mild dissatisfaction to abusive comments, and they could have adverse personal and professional consequences.² For example, online discussions might make current patients question your practices or consider ending their treatment with you.² Also, potential patients might decide to not inquire about your services.² Here I offer suggestions for approaching negative online reviews, and point out some potential pitfalls of responding to them.

Remain professional. You might become upset or frazzled after reading online criticisms about your performance, particularly if the information is erroneous or deceptive. As much as you would like to immediately respond, a public tit-for-tat could prolong or fuel a conflict, or make you come across as angry.²

There may be occasions, however, when it would be appropriate to respond. If you choose to respond to a negative online review, you need to have a methodical plan. Avoid reacting in a knee-jerk manner because this is usually unproductive. In addition, ensure that your response is professional and polite, because an intemperate response could undermine the public’s confidence in our profession.²

Maintain patient confidentiality. Although patients are free to post anything they desire, psychiatrists must maintain confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) applies to online reviews, which prevents us from disclosing information about patients without their permission, including even acknowledging that someone is our patient.³ Your patients’ disclosures are not permission to disclose their health information. Potential patients might avoid us or existing patients may end their treatment with us if they believe their personal information could be disclosed online without their consent. To avoid such concerns, reply to online reviews with generic comments about your practice’s general policies without violating confidentiality. Also, to avoid violating HIPAA rules, you may want to contact your malpractice carrier or your facility’s legal department before replying.¹

Invite patients to discuss their grievances. If your patients identify themselves in a review, or if you are able to identify them, consider inviting them to discuss their concerns with you (over the phone, face-to-face, or via video conferencing). During such conversations, thank the patient for their review, and do not ask them to delete it.² Focus on addressing their concerns and resolving any problems they experienced during treatment; doing so can help improve your practice. This approach also might lead a patient to remove their negative review or to write a review that lets other patients know that you are listening to them.

Even if you choose not to invite your patients to air their concerns, do not entirely dismiss negative reviews. Instead, try to step back from your emotions and take an objective look at such reviews so you can determine what steps to take to improve your practices. Improving your communication with patients could decrease the likelihood that they will write negative reviews in the first place.

Take action on fake reviews. If a negative review is fake (not written by one of your patients) or blatantly untrue, contact the web site administrator and provide evidence to support having the review deleted, especially if it violates the site’s terms of service.¹ However, this approach may not be fruitful. Web sites can be manipulated, and many do not require users to authenticate that they are actual patients.¹ Although most web sites would not want their reputation damaged by users posting fake reviews, more dramatic reviews could help lead to increased traffic, which lowers an administrator’s incentive to remove negative reviews.¹

Continue to: Consider legal repercussions

Consider legal repercussions. Stay up-to-date with online reviews about you by conducting internet searches once every 3 months.¹ Consider notifying your malpractice carrier or facility’s legal department if a review suggests a patient or family might initiate legal action against you or the facility.¹ You might consider pursuing legal action if an online review is defamatory, but such claims often are difficult to prove in court.¹ Even if you win, such a case could later be repeatedly mentioned in articles and journals, thus creating a permanent record of the negative review in the literature.¹

Enlist help with your online image. If financially feasible, hire a professional service to help improve your online image or assist in responding to negative reviews.¹ Build your profile on review web sites to help frame your online image, and include information that mentions the pertinent steps you are taking to address any legitimate concerns your patients raise in their reviews. Encourage your patients to post reviews because that could produce a more equitable sample and paint a more accurate picture of your practice.

Lobby professional medical organizations to take action to protect psychiatrists from negative online reviews by creating legislation that holds web sites accountable for their content.¹

Stay positive. Unfounded or not, negative online reviews are an inevitable part of a psychiatrist’s professional life.² One negative review (or even several) is not going to destroy your reputation or career. Do not feel alone if you receive a negative review. Seek advice from colleagues who have received negative reviews; in addition to offering advice, they can also provide a listening ear.²

Online reviews have become a popular method for patients to rate their psychiatrists. Patients’ online reviews can help other patients make more informed decisions about pursuing treatment, offer us valuable feedback on our performance, and help improve standards of care.¹ However, during the course of our careers, we may receive negative online reviews. These reviews may range from mild dissatisfaction to abusive comments, and they could have adverse personal and professional consequences.² For example, online discussions might make current patients question your practices or consider ending their treatment with you.² Also, potential patients might decide to not inquire about your services.² Here I offer suggestions for approaching negative online reviews, and point out some potential pitfalls of responding to them.

Remain professional. You might become upset or frazzled after reading online criticisms about your performance, particularly if the information is erroneous or deceptive. As much as you would like to immediately respond, a public tit-for-tat could prolong or fuel a conflict, or make you come across as angry.²

There may be occasions, however, when it would be appropriate to respond. If you choose to respond to a negative online review, you need to have a methodical plan. Avoid reacting in a knee-jerk manner because this is usually unproductive. In addition, ensure that your response is professional and polite, because an intemperate response could undermine the public’s confidence in our profession.²

Maintain patient confidentiality. Although patients are free to post anything they desire, psychiatrists must maintain confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) applies to online reviews, which prevents us from disclosing information about patients without their permission, including even acknowledging that someone is our patient.³ Your patients’ disclosures are not permission to disclose their health information. Potential patients might avoid us or existing patients may end their treatment with us if they believe their personal information could be disclosed online without their consent. To avoid such concerns, reply to online reviews with generic comments about your practice’s general policies without violating confidentiality. Also, to avoid violating HIPAA rules, you may want to contact your malpractice carrier or your facility’s legal department before replying.¹

Invite patients to discuss their grievances. If your patients identify themselves in a review, or if you are able to identify them, consider inviting them to discuss their concerns with you (over the phone, face-to-face, or via video conferencing). During such conversations, thank the patient for their review, and do not ask them to delete it.² Focus on addressing their concerns and resolving any problems they experienced during treatment; doing so can help improve your practice. This approach also might lead a patient to remove their negative review or to write a review that lets other patients know that you are listening to them.

Even if you choose not to invite your patients to air their concerns, do not entirely dismiss negative reviews. Instead, try to step back from your emotions and take an objective look at such reviews so you can determine what steps to take to improve your practices. Improving your communication with patients could decrease the likelihood that they will write negative reviews in the first place.

Take action on fake reviews. If a negative review is fake (not written by one of your patients) or blatantly untrue, contact the web site administrator and provide evidence to support having the review deleted, especially if it violates the site’s terms of service.¹ However, this approach may not be fruitful. Web sites can be manipulated, and many do not require users to authenticate that they are actual patients.¹ Although most web sites would not want their reputation damaged by users posting fake reviews, more dramatic reviews could help lead to increased traffic, which lowers an administrator’s incentive to remove negative reviews.¹

Continue to: Consider legal repercussions

Consider legal repercussions. Stay up-to-date with online reviews about you by conducting internet searches once every 3 months.¹ Consider notifying your malpractice carrier or facility’s legal department if a review suggests a patient or family might initiate legal action against you or the facility.¹ You might consider pursuing legal action if an online review is defamatory, but such claims often are difficult to prove in court.¹ Even if you win, such a case could later be repeatedly mentioned in articles and journals, thus creating a permanent record of the negative review in the literature.¹

Enlist help with your online image. If financially feasible, hire a professional service to help improve your online image or assist in responding to negative reviews.¹ Build your profile on review web sites to help frame your online image, and include information that mentions the pertinent steps you are taking to address any legitimate concerns your patients raise in their reviews. Encourage your patients to post reviews because that could produce a more equitable sample and paint a more accurate picture of your practice.

Lobby professional medical organizations to take action to protect psychiatrists from negative online reviews by creating legislation that holds web sites accountable for their content.¹

Stay positive. Unfounded or not, negative online reviews are an inevitable part of a psychiatrist’s professional life.² One negative review (or even several) is not going to destroy your reputation or career. Do not feel alone if you receive a negative review. Seek advice from colleagues who have received negative reviews; in addition to offering advice, they can also provide a listening ear.²

When selecting a psychotropic medication for a patient with a challenging illness, you may want to consider ordering pharmacogenetic testing. By characterizing how a patient’s genetic profile affects their medication metabolism, pharmacogenetic testing can potentially help improve medication adherence, reduce “trial-and-error” prescribing, and target an effective treatment. Here we address 5 important questions about using pharmacogenetic testing.

1. What can pharmacogenetic testing tell you? Pharmacogenetic testing looks for variants in genes that can affect how a patient metabolizes specific medications. While the results will not inform you about a specific medication’s effectiveness, they can describe the patient’s tolerability of that medication based on his/her metabolism. Most psychotropic medications are biotransformed in the liver by cytochrome P450 (CYP) through pathway enzymes such as 2D6, 2C19, and 3A4. For example, fluoxetine and paroxetine exert their inhibition on CYP2D6, while other psychotropic medications, such as lurasidone, are metabolized at CYP3A4 and are contraindicated with potent CYP3A4 inhibitors (eg, grapefruit juice).¹

In addition to CYP450 enzymes, pharmacogenetic testing can assess for the serotonin transporter gene, SLC6A4, and its sequence promoter variant, 5-HTTLPR. This sequence variation influences response to selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tertiary amine tricyclic antidepressants.² Pharmacogenetic testing also looks for genes related to Stevens-Johnson syndrome, such as HLA-B*1502, which is associated with adverse effects of carbamazepine and lamotrigine.³ Additional testing of methyl­enetetrahydrofolate reductase (MTHFR) can inform you of the patient’s metabolism of folic acid, which is useful for creating augmentation strategies with fluoxetine.⁴

2. When should you order pharmacogenetic testing? Not all patients require pharma­cogenetic testing. Anxious patients who have had multiple unsuccessful medication trials may be good candidates for testing. Consider testing for patients with a history of sensitivity to medications, or whose family members have experienced unusual drug responses.²

3. What steps should you take before ordering pharmacogenetic testing? First, obtain your patient’s informed consent, because clinical testing reveals personal genetic information. Make sure your patient understands that such testing is voluntary and that he/she can opt out. Also, explain that the information obtained from pharmacogenetic testing is confidential and will become part of the patient’s medical record.

Second, choose the best test for your patient’s needs. Pharmacogenetic tests can assess for single genes encoded for selected CYP450 enzymes based on pharmacokinetics (metabolism), or for multiple genes based on pharmacodynamic (mechanism of action) factors.⁵ In a recent randomized controlled trial, Bradley et al⁶ found that testing for multiple genes improved response and remission rates in patients with depression and/or anxiety.

Third, confirm that your patient’s insurance covers pharmacogenetic testing, because this testing can be expensive, although some genetic testing companies may offer patients financial assistance.

Continue to: How are samples taken?

4. How are samples taken? Several methods are used for obtaining samples, including saliva, buccal swab, and peripheral blood. Your patient should not smoke, eat, or drink for at least 30 minutes before providing a saliva sample. For a buccal swab, a cotton swab is rubbed in a circular motion along the oral lining inside each of the patient’s cheeks. The most invasive method is peripheral blood obtained via venipuncture. The sample is sent through expedited mail to an accredited genetic processing laboratory for analysis.

5. How do you interpret the results? Pharmacogenetic testing results are provided in a confidential report. A single gene report allows you to choose psychotropic agents based on pharmacokinetics.⁵ Some laboratories assess multiple genes in a single report, and create categories of medications (such as “use as directed” or “use with caution”) based on the pharmacodynamic factors of each agent.^5,6 Certain laboratories offer dosing guidelines for types of medications that you should use with caution.^1,5,6

When interpreting such testing results, it is critical to use your clinical judgment, because pharmacogenetic testing alone does not assess whether a medication will help improve the patient’s symptoms. It is of utmost importance that you have an understanding of pharmacodynamics, knowledge of the patient’s diet and age, and a caring doctor–patient relationship.

When selecting a psychotropic medication for a patient with a challenging illness, you may want to consider ordering pharmacogenetic testing. By characterizing how a patient’s genetic profile affects their medication metabolism, pharmacogenetic testing can potentially help improve medication adherence, reduce “trial-and-error” prescribing, and target an effective treatment. Here we address 5 important questions about using pharmacogenetic testing.

1. What can pharmacogenetic testing tell you? Pharmacogenetic testing looks for variants in genes that can affect how a patient metabolizes specific medications. While the results will not inform you about a specific medication’s effectiveness, they can describe the patient’s tolerability of that medication based on his/her metabolism. Most psychotropic medications are biotransformed in the liver by cytochrome P450 (CYP) through pathway enzymes such as 2D6, 2C19, and 3A4. For example, fluoxetine and paroxetine exert their inhibition on CYP2D6, while other psychotropic medications, such as lurasidone, are metabolized at CYP3A4 and are contraindicated with potent CYP3A4 inhibitors (eg, grapefruit juice).¹

In addition to CYP450 enzymes, pharmacogenetic testing can assess for the serotonin transporter gene, SLC6A4, and its sequence promoter variant, 5-HTTLPR. This sequence variation influences response to selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tertiary amine tricyclic antidepressants.² Pharmacogenetic testing also looks for genes related to Stevens-Johnson syndrome, such as HLA-B*1502, which is associated with adverse effects of carbamazepine and lamotrigine.³ Additional testing of methyl­enetetrahydrofolate reductase (MTHFR) can inform you of the patient’s metabolism of folic acid, which is useful for creating augmentation strategies with fluoxetine.⁴

2. When should you order pharmacogenetic testing? Not all patients require pharma­cogenetic testing. Anxious patients who have had multiple unsuccessful medication trials may be good candidates for testing. Consider testing for patients with a history of sensitivity to medications, or whose family members have experienced unusual drug responses.²

3. What steps should you take before ordering pharmacogenetic testing? First, obtain your patient’s informed consent, because clinical testing reveals personal genetic information. Make sure your patient understands that such testing is voluntary and that he/she can opt out. Also, explain that the information obtained from pharmacogenetic testing is confidential and will become part of the patient’s medical record.

Second, choose the best test for your patient’s needs. Pharmacogenetic tests can assess for single genes encoded for selected CYP450 enzymes based on pharmacokinetics (metabolism), or for multiple genes based on pharmacodynamic (mechanism of action) factors.⁵ In a recent randomized controlled trial, Bradley et al⁶ found that testing for multiple genes improved response and remission rates in patients with depression and/or anxiety.

Third, confirm that your patient’s insurance covers pharmacogenetic testing, because this testing can be expensive, although some genetic testing companies may offer patients financial assistance.

Continue to: How are samples taken?

4. How are samples taken? Several methods are used for obtaining samples, including saliva, buccal swab, and peripheral blood. Your patient should not smoke, eat, or drink for at least 30 minutes before providing a saliva sample. For a buccal swab, a cotton swab is rubbed in a circular motion along the oral lining inside each of the patient’s cheeks. The most invasive method is peripheral blood obtained via venipuncture. The sample is sent through expedited mail to an accredited genetic processing laboratory for analysis.

5. How do you interpret the results? Pharmacogenetic testing results are provided in a confidential report. A single gene report allows you to choose psychotropic agents based on pharmacokinetics.⁵ Some laboratories assess multiple genes in a single report, and create categories of medications (such as “use as directed” or “use with caution”) based on the pharmacodynamic factors of each agent.^5,6 Certain laboratories offer dosing guidelines for types of medications that you should use with caution.^1,5,6

When interpreting such testing results, it is critical to use your clinical judgment, because pharmacogenetic testing alone does not assess whether a medication will help improve the patient’s symptoms. It is of utmost importance that you have an understanding of pharmacodynamics, knowledge of the patient’s diet and age, and a caring doctor–patient relationship.

When selecting a psychotropic medication for a patient with a challenging illness, you may want to consider ordering pharmacogenetic testing. By characterizing how a patient’s genetic profile affects their medication metabolism, pharmacogenetic testing can potentially help improve medication adherence, reduce “trial-and-error” prescribing, and target an effective treatment. Here we address 5 important questions about using pharmacogenetic testing.

1. What can pharmacogenetic testing tell you? Pharmacogenetic testing looks for variants in genes that can affect how a patient metabolizes specific medications. While the results will not inform you about a specific medication’s effectiveness, they can describe the patient’s tolerability of that medication based on his/her metabolism. Most psychotropic medications are biotransformed in the liver by cytochrome P450 (CYP) through pathway enzymes such as 2D6, 2C19, and 3A4. For example, fluoxetine and paroxetine exert their inhibition on CYP2D6, while other psychotropic medications, such as lurasidone, are metabolized at CYP3A4 and are contraindicated with potent CYP3A4 inhibitors (eg, grapefruit juice).¹

In addition to CYP450 enzymes, pharmacogenetic testing can assess for the serotonin transporter gene, SLC6A4, and its sequence promoter variant, 5-HTTLPR. This sequence variation influences response to selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tertiary amine tricyclic antidepressants.² Pharmacogenetic testing also looks for genes related to Stevens-Johnson syndrome, such as HLA-B*1502, which is associated with adverse effects of carbamazepine and lamotrigine.³ Additional testing of methyl­enetetrahydrofolate reductase (MTHFR) can inform you of the patient’s metabolism of folic acid, which is useful for creating augmentation strategies with fluoxetine.⁴

2. When should you order pharmacogenetic testing? Not all patients require pharma­cogenetic testing. Anxious patients who have had multiple unsuccessful medication trials may be good candidates for testing. Consider testing for patients with a history of sensitivity to medications, or whose family members have experienced unusual drug responses.²

3. What steps should you take before ordering pharmacogenetic testing? First, obtain your patient’s informed consent, because clinical testing reveals personal genetic information. Make sure your patient understands that such testing is voluntary and that he/she can opt out. Also, explain that the information obtained from pharmacogenetic testing is confidential and will become part of the patient’s medical record.

Second, choose the best test for your patient’s needs. Pharmacogenetic tests can assess for single genes encoded for selected CYP450 enzymes based on pharmacokinetics (metabolism), or for multiple genes based on pharmacodynamic (mechanism of action) factors.⁵ In a recent randomized controlled trial, Bradley et al⁶ found that testing for multiple genes improved response and remission rates in patients with depression and/or anxiety.

Third, confirm that your patient’s insurance covers pharmacogenetic testing, because this testing can be expensive, although some genetic testing companies may offer patients financial assistance.

Continue to: How are samples taken?

4. How are samples taken? Several methods are used for obtaining samples, including saliva, buccal swab, and peripheral blood. Your patient should not smoke, eat, or drink for at least 30 minutes before providing a saliva sample. For a buccal swab, a cotton swab is rubbed in a circular motion along the oral lining inside each of the patient’s cheeks. The most invasive method is peripheral blood obtained via venipuncture. The sample is sent through expedited mail to an accredited genetic processing laboratory for analysis.

5. How do you interpret the results? Pharmacogenetic testing results are provided in a confidential report. A single gene report allows you to choose psychotropic agents based on pharmacokinetics.⁵ Some laboratories assess multiple genes in a single report, and create categories of medications (such as “use as directed” or “use with caution”) based on the pharmacodynamic factors of each agent.^5,6 Certain laboratories offer dosing guidelines for types of medications that you should use with caution.^1,5,6

When interpreting such testing results, it is critical to use your clinical judgment, because pharmacogenetic testing alone does not assess whether a medication will help improve the patient’s symptoms. It is of utmost importance that you have an understanding of pharmacodynamics, knowledge of the patient’s diet and age, and a caring doctor–patient relationship.

Most psychiatrists will care for at least one patient who dies by suicide. Many clinicians consider this to be one of the most stressful and formative events of their careers, prompting strong emotions, logistical questions, and legal concerns. Because the aftermath of a patient suicide can be difficult, we offer guidance on how to cope with such events, and specifically how to address the legal concerns. 

Attend to self-care. “At a cardiac arrest, the first procedure is to take your own pulse.” This advice, from Samuel Shem’s The House of God, highlights the importance of self-awareness during highly stressful events.¹ When facing the aftermath of a patient suicide, be sure to attend to your own needs, such as eating, staying hydrated, and getting enough sleep. Identify and reach out to your support systems, such as friends and family. Your colleagues can be a source of support, both formally or informally. Reaching out to other psychiatrists, who likely have their own experience with patient suicide, can help process the event. A support group consisting of other psychiatrists also may be beneficial. Finally, avoid blaming yourself. Although you might perceive your patient’s suicide as a personal failing, suicide is notoriously difficult to predict and an unfortunate reality of working in this specialty.

Report the event. Follow your institution’s guidelines for reporting adverse events. You may be required to inform your supervisor, the risk management department, legal services, your malpractice provider, and/or the police. Your risk management department and malpractice provider may have their own regulations and recommendations.

Review the case. Institutions often have established processes for reviewing adverse events and, if applicable, suggesting constructive feedback or general quality improvements. A review process may provide an opportunity to look for potential negligence that could be an issue if there is a malpractice suit. Ideally, such processes are constructive and a time for reflection, rather than punitive or blaming. Trainees may find their supervisors’ presence and guidance to be particularly helpful during this review process. 

Assess malpractice risk. Although psychiatrists have a relatively low risk of being sued for malpractice, many lawsuits against psychiatrists occur after a completed patient suicide.² In a successful malpractice suit, the plaintiff needs to establish all 4 “Ds” of medical malpractice:

1) Duty, or an established physician–patient relationship

2) Damages from an adverse event

3) Dereliction of duty (negligence) 

4) Direct causality between the deviation and the damages.

In the event of a patient suicide, both a doctor–patient relationship (duty) and an adverse outcome (damages) exist.³ Establishing dereliction of duty and direct causality rests on the plaintiff to prove. Good documentation can serve as evidence against accusations of negligence.³ 

Typically, a patient’s medical record will be used as evidence in a malpractice suit. After a suicide, do not alter this record, such as by editing your past assessments of the patient. If an addendum must be made, such as to document a conversation with suicide survivors (family and friends of the deceased), be sure to label it as such with the current date. An addendum should contain only facts; avoid adding information that attempts to explain your patient’s suicide, justifying or apologizing for past treatment decisions, or otherwise editorializing. 

Continue to: Consider reaching out to suicide survivors

Consider reaching out to suicide survivors. The Health Insurance Portability and Accountability Act permits clinicians to use their best judgment when identifying individuals to contact and deciding what information to share after a patient’s death.⁴ Some states and practice settings have stricter confidentiality laws. Consider seeking legal counsel before interacting with suicide survivors.

Suicide survivors may experience feelings such as guilt, shame, and anger, and these feelings may lead suicide survivors to file a malpractice suit.³ Speaking with suicide survivors can help to address these feelings and potentially decrease the likelihood of them pursuing a malpractice suit. In addition, suicide survivors are at high risk for developing mental health issues, including suicidality. Contacting them can be an opportunity to encourage them to seek mental health treatment. It is important to clarify that any recommendations you provide in such situations do not constitute a doctor–patient relationship. 

Should you offer an apology? Consider seeking legal counsel if you wish to apologize. Some states have “apology laws” that render a clinician’s apologetic statements inadmissible if a malpractice suit should occur.⁵ These laws might include empathic statements (“I’m sorry for your loss”) or disclosures of error (“I’m sorry for causing your loss”).⁵ It is unclear whether these laws affect the likelihood and/or outcome of malpractice suits.⁵

Focus on empathy. Experiencing a patient suicide can be one of the most challenging events in a psychiatrist’s career. Empathy is crucial, both towards the suicide survivors and to oneself.  

Most psychiatrists will care for at least one patient who dies by suicide. Many clinicians consider this to be one of the most stressful and formative events of their careers, prompting strong emotions, logistical questions, and legal concerns. Because the aftermath of a patient suicide can be difficult, we offer guidance on how to cope with such events, and specifically how to address the legal concerns. 

Attend to self-care. “At a cardiac arrest, the first procedure is to take your own pulse.” This advice, from Samuel Shem’s The House of God, highlights the importance of self-awareness during highly stressful events.¹ When facing the aftermath of a patient suicide, be sure to attend to your own needs, such as eating, staying hydrated, and getting enough sleep. Identify and reach out to your support systems, such as friends and family. Your colleagues can be a source of support, both formally or informally. Reaching out to other psychiatrists, who likely have their own experience with patient suicide, can help process the event. A support group consisting of other psychiatrists also may be beneficial. Finally, avoid blaming yourself. Although you might perceive your patient’s suicide as a personal failing, suicide is notoriously difficult to predict and an unfortunate reality of working in this specialty.

Report the event. Follow your institution’s guidelines for reporting adverse events. You may be required to inform your supervisor, the risk management department, legal services, your malpractice provider, and/or the police. Your risk management department and malpractice provider may have their own regulations and recommendations.

Review the case. Institutions often have established processes for reviewing adverse events and, if applicable, suggesting constructive feedback or general quality improvements. A review process may provide an opportunity to look for potential negligence that could be an issue if there is a malpractice suit. Ideally, such processes are constructive and a time for reflection, rather than punitive or blaming. Trainees may find their supervisors’ presence and guidance to be particularly helpful during this review process. 

Assess malpractice risk. Although psychiatrists have a relatively low risk of being sued for malpractice, many lawsuits against psychiatrists occur after a completed patient suicide.² In a successful malpractice suit, the plaintiff needs to establish all 4 “Ds” of medical malpractice:

1) Duty, or an established physician–patient relationship

2) Damages from an adverse event

3) Dereliction of duty (negligence) 

4) Direct causality between the deviation and the damages.

In the event of a patient suicide, both a doctor–patient relationship (duty) and an adverse outcome (damages) exist.³ Establishing dereliction of duty and direct causality rests on the plaintiff to prove. Good documentation can serve as evidence against accusations of negligence.³ 

Typically, a patient’s medical record will be used as evidence in a malpractice suit. After a suicide, do not alter this record, such as by editing your past assessments of the patient. If an addendum must be made, such as to document a conversation with suicide survivors (family and friends of the deceased), be sure to label it as such with the current date. An addendum should contain only facts; avoid adding information that attempts to explain your patient’s suicide, justifying or apologizing for past treatment decisions, or otherwise editorializing. 

Continue to: Consider reaching out to suicide survivors

Consider reaching out to suicide survivors. The Health Insurance Portability and Accountability Act permits clinicians to use their best judgment when identifying individuals to contact and deciding what information to share after a patient’s death.⁴ Some states and practice settings have stricter confidentiality laws. Consider seeking legal counsel before interacting with suicide survivors.

Suicide survivors may experience feelings such as guilt, shame, and anger, and these feelings may lead suicide survivors to file a malpractice suit.³ Speaking with suicide survivors can help to address these feelings and potentially decrease the likelihood of them pursuing a malpractice suit. In addition, suicide survivors are at high risk for developing mental health issues, including suicidality. Contacting them can be an opportunity to encourage them to seek mental health treatment. It is important to clarify that any recommendations you provide in such situations do not constitute a doctor–patient relationship. 

Should you offer an apology? Consider seeking legal counsel if you wish to apologize. Some states have “apology laws” that render a clinician’s apologetic statements inadmissible if a malpractice suit should occur.⁵ These laws might include empathic statements (“I’m sorry for your loss”) or disclosures of error (“I’m sorry for causing your loss”).⁵ It is unclear whether these laws affect the likelihood and/or outcome of malpractice suits.⁵

Focus on empathy. Experiencing a patient suicide can be one of the most challenging events in a psychiatrist’s career. Empathy is crucial, both towards the suicide survivors and to oneself.  

Most psychiatrists will care for at least one patient who dies by suicide. Many clinicians consider this to be one of the most stressful and formative events of their careers, prompting strong emotions, logistical questions, and legal concerns. Because the aftermath of a patient suicide can be difficult, we offer guidance on how to cope with such events, and specifically how to address the legal concerns. 

Attend to self-care. “At a cardiac arrest, the first procedure is to take your own pulse.” This advice, from Samuel Shem’s The House of God, highlights the importance of self-awareness during highly stressful events.¹ When facing the aftermath of a patient suicide, be sure to attend to your own needs, such as eating, staying hydrated, and getting enough sleep. Identify and reach out to your support systems, such as friends and family. Your colleagues can be a source of support, both formally or informally. Reaching out to other psychiatrists, who likely have their own experience with patient suicide, can help process the event. A support group consisting of other psychiatrists also may be beneficial. Finally, avoid blaming yourself. Although you might perceive your patient’s suicide as a personal failing, suicide is notoriously difficult to predict and an unfortunate reality of working in this specialty.

Report the event. Follow your institution’s guidelines for reporting adverse events. You may be required to inform your supervisor, the risk management department, legal services, your malpractice provider, and/or the police. Your risk management department and malpractice provider may have their own regulations and recommendations.

Review the case. Institutions often have established processes for reviewing adverse events and, if applicable, suggesting constructive feedback or general quality improvements. A review process may provide an opportunity to look for potential negligence that could be an issue if there is a malpractice suit. Ideally, such processes are constructive and a time for reflection, rather than punitive or blaming. Trainees may find their supervisors’ presence and guidance to be particularly helpful during this review process. 

Assess malpractice risk. Although psychiatrists have a relatively low risk of being sued for malpractice, many lawsuits against psychiatrists occur after a completed patient suicide.² In a successful malpractice suit, the plaintiff needs to establish all 4 “Ds” of medical malpractice:

1) Duty, or an established physician–patient relationship

2) Damages from an adverse event

3) Dereliction of duty (negligence) 

4) Direct causality between the deviation and the damages.

In the event of a patient suicide, both a doctor–patient relationship (duty) and an adverse outcome (damages) exist.³ Establishing dereliction of duty and direct causality rests on the plaintiff to prove. Good documentation can serve as evidence against accusations of negligence.³ 

Typically, a patient’s medical record will be used as evidence in a malpractice suit. After a suicide, do not alter this record, such as by editing your past assessments of the patient. If an addendum must be made, such as to document a conversation with suicide survivors (family and friends of the deceased), be sure to label it as such with the current date. An addendum should contain only facts; avoid adding information that attempts to explain your patient’s suicide, justifying or apologizing for past treatment decisions, or otherwise editorializing. 

Continue to: Consider reaching out to suicide survivors

Consider reaching out to suicide survivors. The Health Insurance Portability and Accountability Act permits clinicians to use their best judgment when identifying individuals to contact and deciding what information to share after a patient’s death.⁴ Some states and practice settings have stricter confidentiality laws. Consider seeking legal counsel before interacting with suicide survivors.

Suicide survivors may experience feelings such as guilt, shame, and anger, and these feelings may lead suicide survivors to file a malpractice suit.³ Speaking with suicide survivors can help to address these feelings and potentially decrease the likelihood of them pursuing a malpractice suit. In addition, suicide survivors are at high risk for developing mental health issues, including suicidality. Contacting them can be an opportunity to encourage them to seek mental health treatment. It is important to clarify that any recommendations you provide in such situations do not constitute a doctor–patient relationship. 

Should you offer an apology? Consider seeking legal counsel if you wish to apologize. Some states have “apology laws” that render a clinician’s apologetic statements inadmissible if a malpractice suit should occur.⁵ These laws might include empathic statements (“I’m sorry for your loss”) or disclosures of error (“I’m sorry for causing your loss”).⁵ It is unclear whether these laws affect the likelihood and/or outcome of malpractice suits.⁵

Focus on empathy. Experiencing a patient suicide can be one of the most challenging events in a psychiatrist’s career. Empathy is crucial, both towards the suicide survivors and to oneself.  

Cannabis-derived compounds, such as cannabidiol (CBD), are popping up like weeds (so to speak) in retail and online stores, and are being marketed for a wide range of purported health benefits, most of which are unsubstantiated. Cannabidiol—a chemical component of the Cannabis sativa plant (marijuana)—does not produce intoxication or euphoria (ie, the “high”) that comes from delta-9-tetrahydrocannabinol (THC), which is the psychoactive component of marijuana.¹ Cannabidiol has become popular partly due to increased cultural acceptance of marijuana. In a 2019 Pew Research Center survey, 67% of Americans supported marijuana legalization.²

In addition, changing laws have increased the interest in and availability of CBD. The Agricultural Improvement Act of 2018 legalized hemp, which is defined as cannabis and cannabis-derived compounds with significantly low concentrations of THC (<0.3% on a dry weight basis).^1,3 However, this act also preserved the FDA’s authority to regulate products containing cannabis and cannabis-derived compounds.¹

With the recent emphasis on CBD, it is easy to forget that the FDA has approved a few medications that are derived from or related to cannabis. In this article, I review the current FDA-approved cannabis-related treatments and their indications, and concerns regarding CBD products.

FDA-approved treatments

To date, the FDA has not approved cannabis for the treatment of any medical or psychiatric condition. However, the FDA has approved 1 cannabis-derived medication (CBD) and 2 cannabis-related medications (dronabinol and nabilone) for specific indications (these medications are available by prescription only):

Cannabidiol (brand name: Epidiolex) is approved for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients age ≥2, and for the treatment of seizures associated with tuberous sclerosis complex in patients age ≥1.^1,4 There are no other FDA-approved medications that contain CBD.

Dronabinol (brand names: Marinol and Syndros) is an antiemetic agent that contains synthetic THC. It is approved for treating or preventing nausea and vomiting caused by cancer medications and for increasing the appetite of individuals with AIDS.¹

Nabilone (brand name: Cesamet) is a synthetic compound that is structurally similar to THC. It is approved for treating or preventing nausea and vomiting caused by cancer medications.¹

Continue to: Questionable claims about CBD

Some manufacturers market CBD products as having a variety of health benefits for both humans and pets, but most of these claims are unsubstantiated.¹ The FDA has issued warning letters to several manufacturers who have marketed CBD products as producing therapeutic effects.⁵

Under the Federal Food, Drug, and Cosmetic Act, any products intended to have a therapeutic effect are considered drugs, and unapproved drugs cannot be distributed or sold in interstate commerce.¹ Cannabidiol products cannot be sold as dietary supplements.¹ In addition, food products containing CBD cannot be introduced or delivered for introduction into interstate commerce.¹ Many CBD products do not contain the amount of CBD advertised, and some contain contaminants such as pesticides and heavy metals.¹ Also, CBD products can affect the therapeutic effectiveness of prescription medications.

Discuss CBD with your patients

Ask your patients if they use CBD and, if so, find out which product(s), the quantity and frequency of use, and any effects they have experienced from using them. Patients can report any adverse effects from CBD products to the FDA’s MedWatch program (www.accessdata.fda.gov/scripts/medwatch/). Tell your patients that there is limited or inconclusive evidence regarding the therapeutic efficacy of over-the-counter CBD products for any medical or psychiatric condition. Encourage your patients to be open with you about using these products, so you can make appropriate treatment decisions.

Cannabis-derived compounds, such as cannabidiol (CBD), are popping up like weeds (so to speak) in retail and online stores, and are being marketed for a wide range of purported health benefits, most of which are unsubstantiated. Cannabidiol—a chemical component of the Cannabis sativa plant (marijuana)—does not produce intoxication or euphoria (ie, the “high”) that comes from delta-9-tetrahydrocannabinol (THC), which is the psychoactive component of marijuana.¹ Cannabidiol has become popular partly due to increased cultural acceptance of marijuana. In a 2019 Pew Research Center survey, 67% of Americans supported marijuana legalization.²

In addition, changing laws have increased the interest in and availability of CBD. The Agricultural Improvement Act of 2018 legalized hemp, which is defined as cannabis and cannabis-derived compounds with significantly low concentrations of THC (<0.3% on a dry weight basis).^1,3 However, this act also preserved the FDA’s authority to regulate products containing cannabis and cannabis-derived compounds.¹

With the recent emphasis on CBD, it is easy to forget that the FDA has approved a few medications that are derived from or related to cannabis. In this article, I review the current FDA-approved cannabis-related treatments and their indications, and concerns regarding CBD products.

FDA-approved treatments

To date, the FDA has not approved cannabis for the treatment of any medical or psychiatric condition. However, the FDA has approved 1 cannabis-derived medication (CBD) and 2 cannabis-related medications (dronabinol and nabilone) for specific indications (these medications are available by prescription only):

Cannabidiol (brand name: Epidiolex) is approved for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients age ≥2, and for the treatment of seizures associated with tuberous sclerosis complex in patients age ≥1.^1,4 There are no other FDA-approved medications that contain CBD.

Dronabinol (brand names: Marinol and Syndros) is an antiemetic agent that contains synthetic THC. It is approved for treating or preventing nausea and vomiting caused by cancer medications and for increasing the appetite of individuals with AIDS.¹

Nabilone (brand name: Cesamet) is a synthetic compound that is structurally similar to THC. It is approved for treating or preventing nausea and vomiting caused by cancer medications.¹

Continue to: Questionable claims about CBD

Some manufacturers market CBD products as having a variety of health benefits for both humans and pets, but most of these claims are unsubstantiated.¹ The FDA has issued warning letters to several manufacturers who have marketed CBD products as producing therapeutic effects.⁵

Under the Federal Food, Drug, and Cosmetic Act, any products intended to have a therapeutic effect are considered drugs, and unapproved drugs cannot be distributed or sold in interstate commerce.¹ Cannabidiol products cannot be sold as dietary supplements.¹ In addition, food products containing CBD cannot be introduced or delivered for introduction into interstate commerce.¹ Many CBD products do not contain the amount of CBD advertised, and some contain contaminants such as pesticides and heavy metals.¹ Also, CBD products can affect the therapeutic effectiveness of prescription medications.

Discuss CBD with your patients

Ask your patients if they use CBD and, if so, find out which product(s), the quantity and frequency of use, and any effects they have experienced from using them. Patients can report any adverse effects from CBD products to the FDA’s MedWatch program (www.accessdata.fda.gov/scripts/medwatch/). Tell your patients that there is limited or inconclusive evidence regarding the therapeutic efficacy of over-the-counter CBD products for any medical or psychiatric condition. Encourage your patients to be open with you about using these products, so you can make appropriate treatment decisions.

Cannabis-derived compounds, such as cannabidiol (CBD), are popping up like weeds (so to speak) in retail and online stores, and are being marketed for a wide range of purported health benefits, most of which are unsubstantiated. Cannabidiol—a chemical component of the Cannabis sativa plant (marijuana)—does not produce intoxication or euphoria (ie, the “high”) that comes from delta-9-tetrahydrocannabinol (THC), which is the psychoactive component of marijuana.¹ Cannabidiol has become popular partly due to increased cultural acceptance of marijuana. In a 2019 Pew Research Center survey, 67% of Americans supported marijuana legalization.²

In addition, changing laws have increased the interest in and availability of CBD. The Agricultural Improvement Act of 2018 legalized hemp, which is defined as cannabis and cannabis-derived compounds with significantly low concentrations of THC (<0.3% on a dry weight basis).^1,3 However, this act also preserved the FDA’s authority to regulate products containing cannabis and cannabis-derived compounds.¹

With the recent emphasis on CBD, it is easy to forget that the FDA has approved a few medications that are derived from or related to cannabis. In this article, I review the current FDA-approved cannabis-related treatments and their indications, and concerns regarding CBD products.

FDA-approved treatments

To date, the FDA has not approved cannabis for the treatment of any medical or psychiatric condition. However, the FDA has approved 1 cannabis-derived medication (CBD) and 2 cannabis-related medications (dronabinol and nabilone) for specific indications (these medications are available by prescription only):

Cannabidiol (brand name: Epidiolex) is approved for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients age ≥2, and for the treatment of seizures associated with tuberous sclerosis complex in patients age ≥1.^1,4 There are no other FDA-approved medications that contain CBD.

Dronabinol (brand names: Marinol and Syndros) is an antiemetic agent that contains synthetic THC. It is approved for treating or preventing nausea and vomiting caused by cancer medications and for increasing the appetite of individuals with AIDS.¹

Nabilone (brand name: Cesamet) is a synthetic compound that is structurally similar to THC. It is approved for treating or preventing nausea and vomiting caused by cancer medications.¹

Continue to: Questionable claims about CBD

Some manufacturers market CBD products as having a variety of health benefits for both humans and pets, but most of these claims are unsubstantiated.¹ The FDA has issued warning letters to several manufacturers who have marketed CBD products as producing therapeutic effects.⁵

Under the Federal Food, Drug, and Cosmetic Act, any products intended to have a therapeutic effect are considered drugs, and unapproved drugs cannot be distributed or sold in interstate commerce.¹ Cannabidiol products cannot be sold as dietary supplements.¹ In addition, food products containing CBD cannot be introduced or delivered for introduction into interstate commerce.¹ Many CBD products do not contain the amount of CBD advertised, and some contain contaminants such as pesticides and heavy metals.¹ Also, CBD products can affect the therapeutic effectiveness of prescription medications.

Discuss CBD with your patients

Ask your patients if they use CBD and, if so, find out which product(s), the quantity and frequency of use, and any effects they have experienced from using them. Patients can report any adverse effects from CBD products to the FDA’s MedWatch program (www.accessdata.fda.gov/scripts/medwatch/). Tell your patients that there is limited or inconclusive evidence regarding the therapeutic efficacy of over-the-counter CBD products for any medical or psychiatric condition. Encourage your patients to be open with you about using these products, so you can make appropriate treatment decisions.