Practicing psychiatry via Skype: Medicolegal considerations

Helen M. Farrell, MD 

Dr. Farrell is an instructor at Harvard Medical School and a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston, MA

Douglas Mossman, MD 

Dr. Mossman is administrative director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, and Adjunct Professor of Clinical Psychiatry and Training Director for the University of Cincinnati Forensic Psychiatry Fellowship, Cincinnati, OH 

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Dear Dr. Mossman:
I practice in a region with few psychiatrists and very little public transportation. For many patients, coming to my office is inconvenient, expensive, or time-consuming. Sometimes, their emotional problems make it hard for them to travel, and sometimes, bad weather makes travel difficult. I am considering providing remote treatment via Skype. Is this a reasonable idea? What are the risks of using this technology in my practice?—Submitted by “Dr. A”

Diagnosing and treating patients without a face-to-face encounter is not new. Doctors have provided “remote treatment” since shortly after telephones were invented. Until recently, however, forensic psychiatrists advised colleagues not to diagnose patients or start treatment based on phone contact alone.

The Internet has revolutionized our attitudes about many things. Communication technologies that seemed miraculous a generation ago have become commonplace and have transformed standards for ordinary and “acceptable” human contact. A quick Internet search of “telephone psychotherapy” turns up hundreds of mental health professionals who offer remote treatment services to patients via computers and Web cams.

Physicians in many specialties practice telemedicine, often with the support and encouragement of state governments and third-party payers. To decide whether to include telepsychiatry in your psychiatric practice, you should know:

• what “telemedicine” means and includes
• the possible advantages of offering remote health care
• potential risks and ambiguity about legal matters.
  
  
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Opioid use disorder during pregnancy

Shannon C. Miller, MD, FASAM, FAPA, Medical Director, Integrated Dual Diagnosis and Outpatient Addiction Psychiatry/Medicine, Program Director, VA Advanced Fellowship in Addiction Medicine/Research, Veterans Affairs Medical Center, Cincinnati, Associate Professor of Clinical Psychiatry, Associate Director of Education, Training, and Dissemination, Center for Treatment, Research, and Education in Addictive Disorders (CeTREAD),Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH

Lisa Fernandez, MD, Addiction Psychiatry Fellow, University Hospital/University of Cincinnati, CeTREAD, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH

Roberto Soria, MD, Medical Director, Opiate Addiction Recovery Services, Assistant Professor of Clinical Psychiatry, Co-Director, Clinical Services, CeTREAD, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH

Early identification of opioid use disorder (OUD) in pregnant women can be challenging. Self-reports underestimate use and shame, fear of prosecution or involvement of child welfare services, and guilt can further erode self-report. Women with OUD may have irregular menses and might not be aware of their pregnancy until several months after conception. Also, women with OUD who are maintained on opioid agonist therapies may misinterpret early signs of pregnancy—such as fatigue, nausea, vomiting, headaches, and cramps—as withdrawal symptoms and may respond by increasing their opioid dosing, thus exposing their fetus to increased drug levels. Finally, many women with OUD experience amenorrhea as a result of their stressful, unhealthy lifestyle, which may preclude pregnancy despite sexual activity. When these women later enroll in an opioid maintenance program, their endocrine function may return to normal, leading to unexpected pregnancy.

Screening for OUD in pregnant patients has not been well studied. An interviewer’s nonjudgmental, empathic attitude may be more important than the specific questions he or she asks. It may be best to begin with less threatening questions and proceed to more specific questions after developing a therapeutic alliance.

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How anxiety presents differently in older adults

Nazem Bassil, MD, Assistant Professor of Medicine/Geriatrics, Faculty of Medicine, Balamand University, St. George Hospital Medical Center, Beirut, Lebanon

Abdalraouf Ghandour, MD, Fellow, Division of Geriatric Medicine, University of Missouri, Columbia Columbia, MO

George T. Grossberg, MD, Samuel W. Fordyce Professor, Director of Geriatric Psychiatry, Department of Neurology and Psychiatry, St. Louis University School of Medicine, St. Louis, MO

Although anxiety disorders are common at all ages, there is a misconception that their prevalence drastically declines with age. For this reason anxiety disorders often are underdiagnosed and undertreated in geriatric patients, especially when the clinical presentation of these disorders in older patients differs from that seen in younger adults.

In older persons, anxiety symptoms often overlap with medical conditions such as hyperthyroidism and geriatric patients tend to express anxiety symptoms as medical or somatic problems such as pain rather than as psychological distress. As a result, older adults often seek treatment for depressive or anxiety symptoms from their primary care physician instead of a psychiatrist. Unfortunately, primary care physicians often miss psychiatric illness, including anxiety disorders, in geriatric patients.

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Adapting dialectical behavior therapy to help suicidal adolescents

Nicholas L. Salsman, PhD , Assistant Professor, Department of Psychology, Xavier University, Cincinnati, OH

Robin Arthur, PsyD, Chief of Psychology, Lindner Center of HOPE, Assistant Professor, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH

Treating suicidal adolescents is fraught with challenges. Antidepressants may be associated with increased suicidal ideation in adolescents, although some data suggest that increased adolescent suicide rates are correlated with decreases in antidepressant prescribing. Adolescents hospitalized after a suicide attempt are likely to attempt suicide again after they are discharged. Such patients might not attend outpatient psychotherapy; a study of 167 adolescents discharged after a suicide attempt found that 26% never attended follow-up appointments and 11% went once.

Emerging research supports the effectiveness of dialectical behavior therapy (DBT) for suicidal adolescents. DBT is a form of cognitive-behavioral therapy that combines individual therapy, skills training, and telephone coaching and is implemented by a therapist consultation team that meets weekly. This article reviews evidence supporting the efficacy of DBT for suicidal adolescents and describes principles of outpatient DBT for these patients as developed by Miller et al.

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Folie en masse! It’s so tempting to drink the Kool-Aid

Henry A. Nasrallah, MD

Editor-in-Chief

Psychiatrists occasionally encounter a case of folie à deux, where 2 persons share the same false belief. Paradoxically, it is more common for a large number of people to share a false belief (folie en masse) and uphold it as fact because the idea appears enticingly valid as an “explanation” for a problem or event.

“Conspiracy theories” abound in our society and yet conspiracy theory advocates would express shock and disdain at the infamous event when 918 followers of Jim Jones drank cyanide-laced Kool-Aid because they believed their leader’s irrational ideas. Apart from recognizable cults—some of whom claim to have their own “solutions” for mental illness—many ordinary people uphold beliefs that are not supported by evidence but widely “accepted” as true:

Persons with psychosis are dangerous. This incorrect belief was prevalent before the tragic events at Virginia Tech and Tucson, AZ (remember the “Son of Sam” in New York?) and was reinforced by them. Clinicians know that, similar to the general population, only a small proportion of persons suffering from a psychotic illness exhibit violent behavior. In fact, their illness renders them more likely to be victims than perpetrators of crime.

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Not all mood swings are bipolar disorder

Robert A. Kowatch, MD, PhD, Professor of Psychiatry and Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Erin Monroe, CNS, Clinical Nurse Specialist, Division of Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Sergio V. Delgado, MD, Associate Professor of Psychiatry and Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Mood swings is a popular term that is nonspecific and not part of DSM-IV-TR diagnostic criteria for BD. The complaint of “mood swings” may reflect severe mood lability of pediatric patients with BD. This mood lability is best described by the Kiddie-Mania Rating Scale (K-MRS) developed by Axelson and colleagues as “rapid mood variation with several mood states within a brief period of time which appears internally driven without regard to the circumstance.” On K-MRS mood lability items, children with mania typically score:

• Moderate—many mood changes throughout the day, can vary from elevated mood to anger to sadness within a few hours; changes in mood are clearly out of proportion to circumstances and cause impairment in functioning

• Severe—rapid mood swings nearly all of the time, with mood intensity greatly out of proportion to circumstances

• Extreme—constant, explosive variability in mood, several mood changes occurring within minutes, difficult to identify a particular mood, changes in mood radically out of proportion to circumstances.

Patients with BD typically exhibit what is best described as a “mood cycle”—a pronounced shift in mood and energy from 1 extreme to another. An example of this would be a child who wakes up with extreme silliness, high energy, and intrusive behavior that persists for several hours and then later in the day becomes sad, depressed, and suicidal with no precipitant for either mood cycle. BD patients also will exhibit other symptoms of mania during these mood cycling periods.

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Psychiatry behind bars: Practicing in jails and prisons

Kathryn A. Burns, MD, MPH, Adjunct Clinical Assistant Professor of Psychiatry, Ohio State University, Columbus, OH, Assistant Clinical Professor of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH

Over the last 2 decades mandatory prison sentences, longer prison terms, and more restrictive release policies have lead to a dramatic increase in the number of persons in jails and prisons. Currently, more than 2 million individuals are incarcerated in the United States. Psychiatric illness is over-represented in correctional populations compared with the general population—more than half of all inmates have a mental health diagnosis. Correctional facilities are legally obligated to address the medical and mental health needs of the persons committed to them. As a result, more psychiatrists are practicing in jails and prisons.

This article explains correctional facilities’ obligation to provide for inmates’ mental health needs and describes correctional mental health processes and how psychiatrists can play a role in screening, evaluation, and suicide prevention.

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Two vastly underutilized interventions can improve schizophrenia outcomes

Henry A. Nasrallah, MD

Editor-in-Chief

Many psychiatrists would agree that schizophrenia is the most devastating psychiatric brain disease. Its disabling effects result in stigma, unemployment, poverty, loneliness, homelessness, victimization, incarceration, malnutrition, infections, social isolation, ostracism, discrimination, suicide, poor health, medical neglect, and early death

The consequences of schizophrenia are in many ways more malignant than those of cancer, where sympathy, prompt medical care, and preservation of friends and employment are assured. Also, unlike schizophrenia patients, persons with cancer are never hauled to jail, even when a slow-growing brain tumor causes erratic or violent behavior.

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Bariatric procedures: Managing patients after surgery

David B. Sarwer, PhD, Associate Professor of Psychology, Departments of Psychiatry and Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA

Lucy F. Faulconbridge, PhD, Assistant Professor of Psychology, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA

Kristine J. Steffen, PharmD, PhD, Research Scientist, Neuropsychiatric Research Institute, Fargo, ND

James L. Roerig, PharmD, BCPP, Associate Professor, Department of Clinical, Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, ND

James E. Mitchell, MD, President and Scientific Director, Neuropsychiatric Research Institute, Christoferson Professor and Chair, Department of Clinical Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, ND

Bariatric surgery is the most effective treatment for obesity (defined as a body mass index [BMI] >30 kg/m²) and is recommended for extremely obese individuals (BMI >40 kg/m²) age >18. Most patients experience significant weight loss accompanied by improvements in mood, physical comorbidities, and quality of life. Despite these favorable outcomes, several aspects of postoperative care—such as management of mental health issues—remain unclear. Bariatric surgery candidates show high rates of preoperative psychopathology, particularly depression and dysphoria. Little is known about how bariatric surgery affects absorption of psychiatric medications, leaving prescribing clinicians with minimal guidance when a postoperative patient reports changes in mood symptoms.

This article discusses the psychosocial status of bariatric surgery candidates and presents a rationale for increased medication monitoring after surgery.

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Atypical antipsychotics for delirium: A reasonable alternative to haloperidol?

David R. Spiegel, MD, Associate Professor of Clinical Psychiatry and Behavioral Sciences, Director of Consultation-Liaison Services, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

David Ahlers, MD, Psychiatry Resident, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

Grant Yoder, DO, Psychiatry Resident, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

Nabeel Qureshi, MD, Psychiatry Resident, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

Ms. B, age 48, is admitted to our hospital after overdosing on unknown amounts of amitriptyline, diphenhydramine, and laxatives. Three days after admission, the psychiatry service is consulted to assess her for “bipolar disorder.” Although Ms. B does not have a psychiatric history, her internist believes her pressured speech and psychomotor agitation warrant investigation.

During the initial psychiatric interview, Ms. B is disoriented, with fluctuating alertness and cognition. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is positive for delirium. We perform a delirium workup while we start Ms. B on olanzapine, 5 mg/d orally and 5 mg intramuscular (IM) every 8 hours as needed.

Ms. B’s laboratory results (complete blood count, complete metabolic profile, urinalysis, chest roentgenogram, vitamin B12 level, blood alcohol level, urine drug screen, arterial blood gas, and head CT) are unremarkable except for her amitriptyline/nortriptyline level, which is in the toxic range. On physical examination, Ms. B’s heart rate and temperature are elevated, her pupils are dilated and sluggish, and her skin is hot and dry. Based on these findings, we determine that Ms. B’s delirium most likely is an anticholinergic syndrome from amitriptyline/diphenhydramine toxicity. We discontinue olanzapine after only 2 doses because of its potential anticholinergic effects.

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Shattering dogmas

Henry A. Nasrallah, MD
Editor-in-Chief

Like all other medical specialties, psychiatry has its share of dogmas that are perpetuated via the clinical apprenticeship model from one generation of physicians to the next, despite the lack of hard evidence. They become “articles of faith” that go unchallenged by trainees who acquire them from their supervisors. A dogma masquerades as a truism and eventually becomes a sacred feature of the “clinical lore.”

Sooner or later, however, the bright light of scientific evidence will reveal the ersatz nature of a dogma and it will come crashing down. Similar to a revolution to depose a dictator, the demise of a dogma will have a salutary effect on medical practice and a liberating effect on practitioners.

Here are examples of psychiatric dogmas that were part of my training but have been/or are in the process of being taken to the slaughterhouse of obsolete tenets:

Psychiatrists should not touch their patients. Really! How can we be practicing physicians if we don’t? This dogma arbitrarily sexualized the physical exam, including drawing blood, measuring blood pressure or waist circumference, assessing neuroleptic-induced cogwheeling, or checking the body for a drug-induced rash. This dogma is the antithesis of good medical care for psychiatric patients, who frequently suffer from serious physical ailments and often do not have a primary care provider. It was created during the primordial phase of psychiatry (aka psychoanalysis) and is irrelevant in modern-era psychiatry.

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Antiepileptics for psychiatric illness: Find the right match

Theresa M. Gerst, PharmD, Clinical Assistant Professor, Division of Pharmacy Practice, College of Pharmacy, The University of Texas at Austin, Austin, TX

Tawny L. Smith, PharmD, BCPP, Clinical Pharmacy Specialist, Psychiatry, Seton Family of Hospitals, Austin, TX, Assistant Professor, Department of Psychiatry, University of Texas Southwestern Medical School, Dallas, TX

Nick C. Patel, PharmD, PhD, BCPP, Clinical Pharmacist, LifeSynch, Inc. Las Colinas, TX, Clinical Assistant Professor, Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta, GA

Although antiepileptic drugs (AEDs) are used to treat a spectrum of psychiatric disorders, in some instances they are prescribed without clear evidence of clinical benefit or safety. When considering prescribing an AED, ask yourself:

• Does the evidence show the drug is efficacious for my patient’s disorder or symptoms?

• Which adverse effects are associated with this medication?

• What are the advantages of monitoring the patient’s serum drug concentration?

This review provides an evidence-based framework regarding the safe and effective use of AEDs in psychiatric patients.

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How do SSRIs cause sexual dysfunction?

Deepak Prabhakar, MD, MPH, Chief Resident, Outpatient Department, Department of Psychiatry and Behavioral, Neurosciences, Wayne State University, Detroit, MI

Richard Balon, MD, Professor, Department of Psychiatry and Behavioral, Neurosciences, Wayne State University, Detroit, MI

Although selective serotonin reuptake inhibitors (SSRIs) are frequently prescribed and are better tolerated than older antidepressants, side effects such as sexual dysfunction limit patient acceptance of these medications. DSM-IV-TR categorizes medication-induced sexual dysfunction as a type of substance-induced sexual dysfunction. These dysfunctions are characterized by impairment of various sexual response phases.

Estimating the true incidence and prevalence of SSRI-related sexual dysfunction can be difficult. Zimmerman et al compared psychiatrists’ clinical assessments of depressed patients receiving ongoing treatment with results of a standardized side effects questionnaire and found that even though psychiatrists regularly inquired about sexual side effects, on the questionnaire patients reported higher rates of almost all sexual dysfunctions. The incidence of SSRI-induced sexual dysfunction also can be difficult to ascertain because some sexual dysfunctions frequently accompany a primary psychiatric disorder or physical illness. Balon suggested that the incidence of SSRI-associated sexual dysfunction is 30% to 50%, although others have reported higher incidences.

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Recognizing the unheralded heroes of psychiatry

Henry A. Nasrallah, MD
Editor-in-Chief

A large number of individuals contribute in many ways to the process of discovering, applying, and disseminating new psychiatric knowledge. I am, of course, referring to researchers, clinicians, teachers, and advocates who touch the lives of millions of persons who suffer from mental illness every year. This editorial is dedicated to singing the praises of those who quietly contribute to advancing psychiatry.

Patients. Tens of thousands of psychiatric patients sign an informed consent form and volunteer to participate in clinical trials to test new drugs in double-blind, placebo-controlled studies that could lead to FDA approval. Without these volunteers, it would be almost impossible to develop new medications.Research assistants. They are an army of skilled technical workers who do the heavy lifting in animal or human research and put in long hours to collect data or conduct tests. Yet they are rarely recognized for their critical contributions to science and clinical practice.


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Therapeutic neuromodulation

Philip G. Janicak, MD, Professor, Department of Psychiatry, Rush University Medical Center, Chicago, IL

Sheila M. Dowd, PhD, Assistant Professor, Department of Psychiatry, Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL

Jeffrey T. Rado, MD, Assistant Professor, Department of Psychiatry and Medicine, Rush University Medical Center, Chicago, IL

Mary Jane Welch, DNP, APRN, BC, CIP, Assistant Professor, College of Nursing, Director, Human Subjects Protection, Rush University Medical Center, Chicago, IL

The brain is an electrochemical organ, and its activity can be modulated for therapeutic purposes by electrical, pharmacologic, or combined approaches. In general, neuromodulation induces electrical current in peripheral or central nervous tissue, which is accomplished by various techniques, including:

• electroconvulsive therapy (ECT)
• vagus nerve stimulation (VNS)
• transcranial magnetic stimulation (TMS)
• deep brain stimulation (DBS).

It is thought that therapeutic benefit occurs by regulating functional disturbances in relevant distributed neural circuits. Depending on the stimulation method, the frequencies chosen may excite or inhibit different or the same areas of the brain in varying patterns. Unlike medication, neuromodulation impacts the brain episodically, which may mitigate adaptation to the therapy’s beneficial effects and avoid systemic adverse effects.

Neuromodulation techniques are categorized based on their risk level as invasive or noninvasive and seizurogenic or nonseizurogenic. Although these and other approaches are being considered for various neuropsychiatric disorders, the most common application is for severe, treatment-resistant depression. Therefore, this article focuses on FDA-approved neuromodulation treatments for depression, with limited discussion of other indications.

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Parricide: Characteristics of sons and daughters who kill their parents

Sara G. West, MD, Assistant Professor of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH

Mendel Feldsher, MD, Consulting Forensic Psychiatrist, Patton State Hospital, Patton, CA

Parricide—killing one’s parents—once was referred to as “the schizophrenic crime,” but is now recognized as being more complex. In the United States, parricides accounted for 2% of all homicides from 1976 to 1998, which is consistent with studies from France and the United Kingdom. Parricide’s scandalous nature has long attracted the public’s fascination.

This article primarily focuses on the interplay of the diagnostic and demographic factors seen in adults who kill their biological parents but briefly notes differences seen in juvenile perpetrators and those who kill their stepparents. Knowledge of these characteristics can help clinicians identify and more safely manage patients who may be at risk of harming their parents.

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Depression treatment for women with breast cancer

Prachi Agarwala, MD, Psychiatry Resident, PGY-V, Department of Psychiatry, University of Michigan, Ann Arbor, MI

Michelle B. Riba, MD, MS, Clinical Professor, Department of Psychiatry, University of Michigan, Ann Arbor, MI

Psychological distress among patients with breast cancer is common and is linked to worse clinical outcomes. Depressive and anxiety symptoms affect up to 40% of breast cancer patients, and depression is associated with a higher relative risk of mortality in individuals with breast cancer. Psychotropic medications and psychotherapy used to treat depression in patients without carcinoma also are appropriate and effective for breast cancer patients. However, some patients present distinct challenges to standard treatment. For example, growing evidence suggests that some selective serotonin reuptake inhibitors (SSRIs) may reduce the effectiveness of tamoxifen, a chemotherapeutic agent. This article discusses challenges in diagnosing and treating depression in breast cancer patients and reviews evidence supporting appropriate psychiatric care.

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Are some nonpsychotic psychiatric disorders actually psychotic?

Henry A. Nasrallah, MD
Editor-in-Chief

One of the basic psychiatric principles accepted by all practicing psychiatrists is that a delusion is a fundamental symptom of psychosis.

A delusion is defined as “a fixed false belief not commensurate with the person’s educational and cultural background” and is almost universally associated with schizophrenia and other psychotic disorders. But if we apply the notion that a fixed false belief is delusional, then several “nonpsychotic” psychiatric disorders would qualify as psychoses based on their core clinical symptoms, including major depressive disorder, obsessive-compulsive disorder, anxiety disorders, and others.

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CAM for your anxious patient: What the evidence says

Diana J. Antonacci, MD, Associate professor and director of residency training, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC
Ervin Davis, PhD, Assistant professor, Department of psychology, Adjunct assistant professor of psychiatry, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC
Richard M. Bloch, PhD, Professor and director of research, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC
Crystal Manuel, MD, Assistant professor, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC
Sy Atezaz Saeed, MD, Professor and chair, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

The number of people with psychiatric disorders who use complementary and alternative medicine (CAM) is on the rise. In surveys of patients seeking psychiatric care, estimates of CAM use range from 8% to 57%; the most frequent uses are for depression and anxiety disorders. A population-based study in the United States found that 9% of respondents had anxiety attacks and 57% of these individuals had used CAM. Similarly, in a Finnish population-based study (N=5,987) 35% of subjects reported some form of CAM use in the previous year; those with comorbid anxiety and depressive disorders used CAM most frequently.

Unfortunately, a MEDLINE search shows that the number of studies examining psychotropic medications dwarfs the number of studies on even the most common CAM treatments used for psychiatric disorders. Far more patients with diagnosed mental disorders are studied in trials of standard treatments than CAM treatments. Because very few studies evaluate the cost-effectiveness of CAM treatments for psychiatric disorders, the risk-to-benefit ratio is difficult to calculate. Although several CAM treatments for depressive disorders have enough support to be considered options, CAM options for anxiety disorders are fewer and have less evidence of efficacy.

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