Pearls

A patient with early-stage dementia may wish to write a will before diminishing memory and cognition void future legal transactions.¹You can help patients protect their heirs from posthumous legal struggles by:

• advising them to consult an attorney about drafting a will
  
• and explaining the basics of testamentary capacity.
  

Testamentary capacity is a person’s ability to understand his property ownership, rights to claiming that property, and the practical effects of executing his will. Determining whether a person has testamentary capacity rests with a judge or jury, but courts often ask psychiatrists—especially those who diagnose dementia—to help describe the deceased’s state of mind when he or she wrote a contested will.

When a will is in probate, a usual heir or some other person may challenge its validity. Lawsuits questioning whether an elderly person had the mental capacity to authorize a legal transaction often hinge on two possible claims:

• undue influence (the will writer was not capable of resisting pressure or manipulation by a person who wanted to influence property distribution)²
  
• insane delusion (the will writer had mistaken beliefs that were not based in reason and could only be explained by mental illness).
  

The mere presence of mental illnesses, even severe schizophrenia or dementia, does not automatically render a person incapable of creating a valid will.² In fact, the court requires a higher level of decision-making capacity for other legal transactions such as contracts. Will writing is an individual matter, whereas a valid contract involves an agreement between two or more persons and necessitates a higher level of functioning to understand.¹

When counselling patients and their families, explain the basics of testamentary capacity so they can get help navigating end-of-life legal decisions. Legal transactions are more likely to be upheld in court if they are made in the early stages of a dementing disorder, rather than after it progresses.

A patient with early-stage dementia may wish to write a will before diminishing memory and cognition void future legal transactions.¹You can help patients protect their heirs from posthumous legal struggles by:

• advising them to consult an attorney about drafting a will
  
• and explaining the basics of testamentary capacity.
  

Testamentary capacity is a person’s ability to understand his property ownership, rights to claiming that property, and the practical effects of executing his will. Determining whether a person has testamentary capacity rests with a judge or jury, but courts often ask psychiatrists—especially those who diagnose dementia—to help describe the deceased’s state of mind when he or she wrote a contested will.

When a will is in probate, a usual heir or some other person may challenge its validity. Lawsuits questioning whether an elderly person had the mental capacity to authorize a legal transaction often hinge on two possible claims:

• undue influence (the will writer was not capable of resisting pressure or manipulation by a person who wanted to influence property distribution)²
  
• insane delusion (the will writer had mistaken beliefs that were not based in reason and could only be explained by mental illness).
  

The mere presence of mental illnesses, even severe schizophrenia or dementia, does not automatically render a person incapable of creating a valid will.² In fact, the court requires a higher level of decision-making capacity for other legal transactions such as contracts. Will writing is an individual matter, whereas a valid contract involves an agreement between two or more persons and necessitates a higher level of functioning to understand.¹

When counselling patients and their families, explain the basics of testamentary capacity so they can get help navigating end-of-life legal decisions. Legal transactions are more likely to be upheld in court if they are made in the early stages of a dementing disorder, rather than after it progresses.

A patient with early-stage dementia may wish to write a will before diminishing memory and cognition void future legal transactions.¹You can help patients protect their heirs from posthumous legal struggles by:

• advising them to consult an attorney about drafting a will
  
• and explaining the basics of testamentary capacity.
  

Testamentary capacity is a person’s ability to understand his property ownership, rights to claiming that property, and the practical effects of executing his will. Determining whether a person has testamentary capacity rests with a judge or jury, but courts often ask psychiatrists—especially those who diagnose dementia—to help describe the deceased’s state of mind when he or she wrote a contested will.

When a will is in probate, a usual heir or some other person may challenge its validity. Lawsuits questioning whether an elderly person had the mental capacity to authorize a legal transaction often hinge on two possible claims:

• undue influence (the will writer was not capable of resisting pressure or manipulation by a person who wanted to influence property distribution)²
  
• insane delusion (the will writer had mistaken beliefs that were not based in reason and could only be explained by mental illness).
  

The mere presence of mental illnesses, even severe schizophrenia or dementia, does not automatically render a person incapable of creating a valid will.² In fact, the court requires a higher level of decision-making capacity for other legal transactions such as contracts. Will writing is an individual matter, whereas a valid contract involves an agreement between two or more persons and necessitates a higher level of functioning to understand.¹

When counselling patients and their families, explain the basics of testamentary capacity so they can get help navigating end-of-life legal decisions. Legal transactions are more likely to be upheld in court if they are made in the early stages of a dementing disorder, rather than after it progresses.

Collaborative (or split) treatment—when therapists provide primarily psychotherapy while psychiatrists manage medication¹—carries benefits and risks (Table).² Six simple steps can improve treatment quality for both patients and the treatment teams.

Obtain the therapist’s diagnostic evaluation before the patient’s first visit with you to learn why he or she sought help from a mental health professional.

Reduce liability risk by asking the collaborative therapist to share significant developments in the patient’s life such as suicide attempts, traumatic events, medication side effects, etc. Document that you had this discussion.

Read the therapist’s recent progress notes every time you see the patient to greatly reduce chances of “splitting,” a type of interference in which a patient sides with one person or faction that causes infighting within the team. If the collaborative therapist practices at a facility other than your own, ask the therapist to send you a summary of his or her notes periodically.

Encourage the therapist to discuss medication early. Even if the therapist does not expect medication to become necessary, suggest a discussion about the possibility of a medication trial with the patient early in treatment. This can avoid confusion about the psychiatrist’s and therapist’s roles later in therapy.

Discuss medications’ limitations to minimize therapists’ and patients’ impulse to change medication whenever the patient endures an emotional challenge or mild side effect.

Maximize communication with e-mail and phone calls. Schedule time for communicating with collaborative therapists. Above all, maintain mutual respect for different disciplines.

Table

Benefits and risks of collaborative treatment

Collaborative (or split) treatment—when therapists provide primarily psychotherapy while psychiatrists manage medication¹—carries benefits and risks (Table).² Six simple steps can improve treatment quality for both patients and the treatment teams.

Obtain the therapist’s diagnostic evaluation before the patient’s first visit with you to learn why he or she sought help from a mental health professional.

Reduce liability risk by asking the collaborative therapist to share significant developments in the patient’s life such as suicide attempts, traumatic events, medication side effects, etc. Document that you had this discussion.

Read the therapist’s recent progress notes every time you see the patient to greatly reduce chances of “splitting,” a type of interference in which a patient sides with one person or faction that causes infighting within the team. If the collaborative therapist practices at a facility other than your own, ask the therapist to send you a summary of his or her notes periodically.

Encourage the therapist to discuss medication early. Even if the therapist does not expect medication to become necessary, suggest a discussion about the possibility of a medication trial with the patient early in treatment. This can avoid confusion about the psychiatrist’s and therapist’s roles later in therapy.

Discuss medications’ limitations to minimize therapists’ and patients’ impulse to change medication whenever the patient endures an emotional challenge or mild side effect.

Maximize communication with e-mail and phone calls. Schedule time for communicating with collaborative therapists. Above all, maintain mutual respect for different disciplines.

Table

Benefits and risks of collaborative treatment

Collaborative (or split) treatment—when therapists provide primarily psychotherapy while psychiatrists manage medication¹—carries benefits and risks (Table).² Six simple steps can improve treatment quality for both patients and the treatment teams.

Obtain the therapist’s diagnostic evaluation before the patient’s first visit with you to learn why he or she sought help from a mental health professional.

Reduce liability risk by asking the collaborative therapist to share significant developments in the patient’s life such as suicide attempts, traumatic events, medication side effects, etc. Document that you had this discussion.

Read the therapist’s recent progress notes every time you see the patient to greatly reduce chances of “splitting,” a type of interference in which a patient sides with one person or faction that causes infighting within the team. If the collaborative therapist practices at a facility other than your own, ask the therapist to send you a summary of his or her notes periodically.

Encourage the therapist to discuss medication early. Even if the therapist does not expect medication to become necessary, suggest a discussion about the possibility of a medication trial with the patient early in treatment. This can avoid confusion about the psychiatrist’s and therapist’s roles later in therapy.

Discuss medications’ limitations to minimize therapists’ and patients’ impulse to change medication whenever the patient endures an emotional challenge or mild side effect.

Maximize communication with e-mail and phone calls. Schedule time for communicating with collaborative therapists. Above all, maintain mutual respect for different disciplines.

Table

Benefits and risks of collaborative treatment

Patient phone calls—if handled appropriately—can eliminate unnecessary office visits, prevent relapse, and help you monitor treatment adherence. We offer strategies for turning potential disruptions into opportunities.

Develop a protocol for handling distress calls (and communicate it to staff) to minimize frustration for you and patients who might struggle to reach you. Your protocol could include:

• instructions for patients on how to contact you
  
• a 24-hour answering service and/or voice mail option during business hours
  
• how and when staff should connect you to patients during clinic hours
  
• how staff verifies your office is authorized to communicate with family members who call
  
• how you or your staff verifies callers are your patients. (In some states you establish a doctor-patient relationship and assume responsibility for care simply by answering a call and identifying yourself as a doctor.)
  

Some psychiatrists give patients their cell or home phone numbers and/or e-mail addresses. They say most patients find this reassuring and rarely contact them. We recommend offering your personal information on a case-by-case basis.

For billing and medicolegal protection, purchase software that documents patient phone calls and messages and their outcomes and decisions.

‘911’. Train staff to triage phone calls from patients with dangerous intentions. Instruct staff to immediately notify you or a covering provider or refer the patient to the emergency room. Check your voice mail several times daily for such calls.

If a patient is in crisis and you are in an appointment, have staff page you a ‘911.’ Avoid talking with one patient in the presence of another.

Scheduled phone calls can help monitor treatment. Decide whether you or your patient will initiate planned calls. Aim to return all messages the same day or at least within 24 hours.

Although a patient providing callback information implies consent, use caution when identifying yourself or leaving messages, especially if patients give you their work numbers.

Patients with personality disorders tend to consume substantial mental health resources.¹ Scheduling phone calls with such patients, even if they are doing well, provides positive support. If you treat their frequent calls as disruptive, they may feel rejected and seek treatment elsewhere.

Prescribing. Use caution when patients—especially those with addiction problems and/or a history of nonadherence—call in prescription requests. Prescribe opioids and stimulants in person.

Patient phone calls—if handled appropriately—can eliminate unnecessary office visits, prevent relapse, and help you monitor treatment adherence. We offer strategies for turning potential disruptions into opportunities.

Develop a protocol for handling distress calls (and communicate it to staff) to minimize frustration for you and patients who might struggle to reach you. Your protocol could include:

• instructions for patients on how to contact you
  
• a 24-hour answering service and/or voice mail option during business hours
  
• how and when staff should connect you to patients during clinic hours
  
• how staff verifies your office is authorized to communicate with family members who call
  
• how you or your staff verifies callers are your patients. (In some states you establish a doctor-patient relationship and assume responsibility for care simply by answering a call and identifying yourself as a doctor.)
  

Some psychiatrists give patients their cell or home phone numbers and/or e-mail addresses. They say most patients find this reassuring and rarely contact them. We recommend offering your personal information on a case-by-case basis.

For billing and medicolegal protection, purchase software that documents patient phone calls and messages and their outcomes and decisions.

‘911’. Train staff to triage phone calls from patients with dangerous intentions. Instruct staff to immediately notify you or a covering provider or refer the patient to the emergency room. Check your voice mail several times daily for such calls.

If a patient is in crisis and you are in an appointment, have staff page you a ‘911.’ Avoid talking with one patient in the presence of another.

Scheduled phone calls can help monitor treatment. Decide whether you or your patient will initiate planned calls. Aim to return all messages the same day or at least within 24 hours.

Although a patient providing callback information implies consent, use caution when identifying yourself or leaving messages, especially if patients give you their work numbers.

Patients with personality disorders tend to consume substantial mental health resources.¹ Scheduling phone calls with such patients, even if they are doing well, provides positive support. If you treat their frequent calls as disruptive, they may feel rejected and seek treatment elsewhere.

Prescribing. Use caution when patients—especially those with addiction problems and/or a history of nonadherence—call in prescription requests. Prescribe opioids and stimulants in person.

Patient phone calls—if handled appropriately—can eliminate unnecessary office visits, prevent relapse, and help you monitor treatment adherence. We offer strategies for turning potential disruptions into opportunities.

Develop a protocol for handling distress calls (and communicate it to staff) to minimize frustration for you and patients who might struggle to reach you. Your protocol could include:

• instructions for patients on how to contact you
  
• a 24-hour answering service and/or voice mail option during business hours
  
• how and when staff should connect you to patients during clinic hours
  
• how staff verifies your office is authorized to communicate with family members who call
  
• how you or your staff verifies callers are your patients. (In some states you establish a doctor-patient relationship and assume responsibility for care simply by answering a call and identifying yourself as a doctor.)
  

Some psychiatrists give patients their cell or home phone numbers and/or e-mail addresses. They say most patients find this reassuring and rarely contact them. We recommend offering your personal information on a case-by-case basis.

For billing and medicolegal protection, purchase software that documents patient phone calls and messages and their outcomes and decisions.

‘911’. Train staff to triage phone calls from patients with dangerous intentions. Instruct staff to immediately notify you or a covering provider or refer the patient to the emergency room. Check your voice mail several times daily for such calls.

If a patient is in crisis and you are in an appointment, have staff page you a ‘911.’ Avoid talking with one patient in the presence of another.

Scheduled phone calls can help monitor treatment. Decide whether you or your patient will initiate planned calls. Aim to return all messages the same day or at least within 24 hours.

Although a patient providing callback information implies consent, use caution when identifying yourself or leaving messages, especially if patients give you their work numbers.

Patients with personality disorders tend to consume substantial mental health resources.¹ Scheduling phone calls with such patients, even if they are doing well, provides positive support. If you treat their frequent calls as disruptive, they may feel rejected and seek treatment elsewhere.

Prescribing. Use caution when patients—especially those with addiction problems and/or a history of nonadherence—call in prescription requests. Prescribe opioids and stimulants in person.

On October 4, Muslims begin the month-long Ramadan, during which they refrain from all food and drink (even water) in the daytime. Clinical concerns that may arise from fasting are:

• inability to take medications during the day
  
• dehydration and other somatic changes that necessitate dosing modification
  
• psychiatric symptom exacerbation.
  

Based on our experience, we offer these guidelines to address possible health risks in these patients.

Symptom risks. During Ramadan, even persons without mental disorders have reported irritability, decreased sleep, difficulty concentrating, and anxiety.¹ In patients with bipolar disorder, one study described a high rate (45%) of breakthrough manic or depressive episodes during Ramadan, despite stable lithium levels.² Fasting-related changes in circadian rhythms and insomnia are thought to contribute to psychiatric symptom exacerbation.

Religious sensitivity. The best way to identify a Muslim patient who intends to fast during Ramadan is to ask about religious or spiritual backgrounds as part of a thorough psychiatric intake. Ramadan serves as a reminder of the suffering of the poor and signifies an opportunity for self-restraint, prayer, and charity. Common interpretation of the Quran requires fasting unless it is medically harmful.¹

If you anticipate a clinical problem, inform your patient of the risks of fasting. For patients with severe mental illness, fasting may not be reasonable. Be aware, however, that patients may ignore your advice because of the stigma of mental illness coupled with family or community pressure to fast.

Do not underestimate the importance Muslims place on fasting. Although the consequences of psychiatric symptom exacerbation can be disastrous, your advice must be balanced by your patient’s religious beliefs. Patients may be reluctant to broach this topic, but discussing it will strengthen your therapeutic alliance.

Allay natural guilt by focusing on medical necessity. Consider increased psychotherapy as a transitional possibility during Ramadan.

Modifying pharmacotherapy. Fasting may cause dehydration and decrease glomerular filtration, which may increase serum levels of renally dependent psychotropics such as lithium.³ Fasting also changes gastric pH and phase II liver metabolism, altering the pharmacokinetics of valproic acid.⁴

For patients taking antidepressants and antipsychotics, watch for anticholinergic side effects—dry mouth, dehydration, and confusion—especially in the elderly. To avoid having patients alter their treatment regimens without consulting you, consider a temporary switch before Ramadan to longer-acting medications or medications with once- or twice-daily dosing. Increased monitoring may also be necessary during this period.

Substance abstinence. Fasting mandates abstinence from alcohol, caffeine, and tobacco. For users of these substances, discuss a tapering approach to preempt possible withdrawal symptoms. Changes in intake of caffeine and tobacco—inducers of cytochrome P-450 isoenzymes, especially 1A2—can alter (usually by increasing) drug levels of antidepressants and antipsychotics metabolized by this pathway.⁵

Disclaimer

The opinions expressed in this article are the authors’ and do not reflect those of the Department of Defense or the Department of Veterans Affairs.

Acknowledgments

The authors thank Hashib Faruque, MD, for his comments and suggestions.

On October 4, Muslims begin the month-long Ramadan, during which they refrain from all food and drink (even water) in the daytime. Clinical concerns that may arise from fasting are:

• inability to take medications during the day
  
• dehydration and other somatic changes that necessitate dosing modification
  
• psychiatric symptom exacerbation.
  

Based on our experience, we offer these guidelines to address possible health risks in these patients.

Symptom risks. During Ramadan, even persons without mental disorders have reported irritability, decreased sleep, difficulty concentrating, and anxiety.¹ In patients with bipolar disorder, one study described a high rate (45%) of breakthrough manic or depressive episodes during Ramadan, despite stable lithium levels.² Fasting-related changes in circadian rhythms and insomnia are thought to contribute to psychiatric symptom exacerbation.

Religious sensitivity. The best way to identify a Muslim patient who intends to fast during Ramadan is to ask about religious or spiritual backgrounds as part of a thorough psychiatric intake. Ramadan serves as a reminder of the suffering of the poor and signifies an opportunity for self-restraint, prayer, and charity. Common interpretation of the Quran requires fasting unless it is medically harmful.¹

If you anticipate a clinical problem, inform your patient of the risks of fasting. For patients with severe mental illness, fasting may not be reasonable. Be aware, however, that patients may ignore your advice because of the stigma of mental illness coupled with family or community pressure to fast.

Do not underestimate the importance Muslims place on fasting. Although the consequences of psychiatric symptom exacerbation can be disastrous, your advice must be balanced by your patient’s religious beliefs. Patients may be reluctant to broach this topic, but discussing it will strengthen your therapeutic alliance.

Allay natural guilt by focusing on medical necessity. Consider increased psychotherapy as a transitional possibility during Ramadan.

Modifying pharmacotherapy. Fasting may cause dehydration and decrease glomerular filtration, which may increase serum levels of renally dependent psychotropics such as lithium.³ Fasting also changes gastric pH and phase II liver metabolism, altering the pharmacokinetics of valproic acid.⁴

For patients taking antidepressants and antipsychotics, watch for anticholinergic side effects—dry mouth, dehydration, and confusion—especially in the elderly. To avoid having patients alter their treatment regimens without consulting you, consider a temporary switch before Ramadan to longer-acting medications or medications with once- or twice-daily dosing. Increased monitoring may also be necessary during this period.

Substance abstinence. Fasting mandates abstinence from alcohol, caffeine, and tobacco. For users of these substances, discuss a tapering approach to preempt possible withdrawal symptoms. Changes in intake of caffeine and tobacco—inducers of cytochrome P-450 isoenzymes, especially 1A2—can alter (usually by increasing) drug levels of antidepressants and antipsychotics metabolized by this pathway.⁵

Disclaimer

The opinions expressed in this article are the authors’ and do not reflect those of the Department of Defense or the Department of Veterans Affairs.

Acknowledgments

The authors thank Hashib Faruque, MD, for his comments and suggestions.

On October 4, Muslims begin the month-long Ramadan, during which they refrain from all food and drink (even water) in the daytime. Clinical concerns that may arise from fasting are:

• inability to take medications during the day
  
• dehydration and other somatic changes that necessitate dosing modification
  
• psychiatric symptom exacerbation.
  

Based on our experience, we offer these guidelines to address possible health risks in these patients.

Symptom risks. During Ramadan, even persons without mental disorders have reported irritability, decreased sleep, difficulty concentrating, and anxiety.¹ In patients with bipolar disorder, one study described a high rate (45%) of breakthrough manic or depressive episodes during Ramadan, despite stable lithium levels.² Fasting-related changes in circadian rhythms and insomnia are thought to contribute to psychiatric symptom exacerbation.

Religious sensitivity. The best way to identify a Muslim patient who intends to fast during Ramadan is to ask about religious or spiritual backgrounds as part of a thorough psychiatric intake. Ramadan serves as a reminder of the suffering of the poor and signifies an opportunity for self-restraint, prayer, and charity. Common interpretation of the Quran requires fasting unless it is medically harmful.¹

If you anticipate a clinical problem, inform your patient of the risks of fasting. For patients with severe mental illness, fasting may not be reasonable. Be aware, however, that patients may ignore your advice because of the stigma of mental illness coupled with family or community pressure to fast.

Do not underestimate the importance Muslims place on fasting. Although the consequences of psychiatric symptom exacerbation can be disastrous, your advice must be balanced by your patient’s religious beliefs. Patients may be reluctant to broach this topic, but discussing it will strengthen your therapeutic alliance.

Allay natural guilt by focusing on medical necessity. Consider increased psychotherapy as a transitional possibility during Ramadan.

Modifying pharmacotherapy. Fasting may cause dehydration and decrease glomerular filtration, which may increase serum levels of renally dependent psychotropics such as lithium.³ Fasting also changes gastric pH and phase II liver metabolism, altering the pharmacokinetics of valproic acid.⁴

For patients taking antidepressants and antipsychotics, watch for anticholinergic side effects—dry mouth, dehydration, and confusion—especially in the elderly. To avoid having patients alter their treatment regimens without consulting you, consider a temporary switch before Ramadan to longer-acting medications or medications with once- or twice-daily dosing. Increased monitoring may also be necessary during this period.

Substance abstinence. Fasting mandates abstinence from alcohol, caffeine, and tobacco. For users of these substances, discuss a tapering approach to preempt possible withdrawal symptoms. Changes in intake of caffeine and tobacco—inducers of cytochrome P-450 isoenzymes, especially 1A2—can alter (usually by increasing) drug levels of antidepressants and antipsychotics metabolized by this pathway.⁵

Disclaimer

The opinions expressed in this article are the authors’ and do not reflect those of the Department of Defense or the Department of Veterans Affairs.

Acknowledgments

The authors thank Hashib Faruque, MD, for his comments and suggestions.

One day we may be able to consistently choose medications that offer optimal benefit and minimal adverse events—without subjecting our patients to unsuccessful trials. Thanks to quantitative EEG (OEEG) testing and pharmacogenetic testing, that day may be coming closer.

How quantitative eeg works

QEEG adds modern computer and statistical analyses to traditional EEG recordings. The computer creates a graphic display on a schematic map of the head. The procedure is often called brain electrical activity mapping (BEAM) or simply “mapping.” ^{New tool: Genotyping makes prescribing safer, more effective, Current Psychiatry, September 2004.) Physicians can order any combination of gene tests, which cost about $150 to $200 each, or all available tests for a discounted price of approximately $600.}

Genelex and Signature Genetics can create individualized CYP-450 function reports to facilitate prescribing and customized reports that take into account the patient’s medication and diet regimen. Genelex also offers an Internet-based software tool, GeneMedRx, which allows doctors to customize medication regimens based on both potential drug-drug interactions and genomic information.

Signature Genetics offers a prospective assessment of drugs based on genetic test results. This assessment provides a comprehensive report of which medications are affected by the test results.

Genetic profiling can help psychiatrists improve the likelihood of treatment success and minimize potential drug-drug interactions and adverse reactions. Patients will be more satisfied, knowing that their medications fit their individual needs. Also, as more is learned about genetic analysis, genetic testing could one day reveal susceptibility to Alzheimer’s disease, heart attack risk, or other medical problems.

As with quantitative EEG, however, few insurance companies cover genetic testing. Also, patients found to have a higher likelihood of developing certain diseases could potentially be charged higher health insurance premiums.

Related resources

Indiana University School of Medicine. Drug interactions table. http://medicine.iupui.edu/flockhart/clinlist.htm

Luo J. Psyber Psychiatry. Prescribing Information: scroll with the changes (online, handheld resources on drug-drug interaction, medications’ effect on CYP-450 system. Current Psychiatry 2003;2(8 online edition). http://www.currentpsychiatry.com/article_pages.asp?AID=666&UID=8877

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

One day we may be able to consistently choose medications that offer optimal benefit and minimal adverse events—without subjecting our patients to unsuccessful trials. Thanks to quantitative EEG (OEEG) testing and pharmacogenetic testing, that day may be coming closer.

How quantitative eeg works

QEEG adds modern computer and statistical analyses to traditional EEG recordings. The computer creates a graphic display on a schematic map of the head. The procedure is often called brain electrical activity mapping (BEAM) or simply “mapping.” ^{New tool: Genotyping makes prescribing safer, more effective, Current Psychiatry, September 2004.) Physicians can order any combination of gene tests, which cost about $150 to $200 each, or all available tests for a discounted price of approximately $600.}

Genelex and Signature Genetics can create individualized CYP-450 function reports to facilitate prescribing and customized reports that take into account the patient’s medication and diet regimen. Genelex also offers an Internet-based software tool, GeneMedRx, which allows doctors to customize medication regimens based on both potential drug-drug interactions and genomic information.

Signature Genetics offers a prospective assessment of drugs based on genetic test results. This assessment provides a comprehensive report of which medications are affected by the test results.

Genetic profiling can help psychiatrists improve the likelihood of treatment success and minimize potential drug-drug interactions and adverse reactions. Patients will be more satisfied, knowing that their medications fit their individual needs. Also, as more is learned about genetic analysis, genetic testing could one day reveal susceptibility to Alzheimer’s disease, heart attack risk, or other medical problems.

As with quantitative EEG, however, few insurance companies cover genetic testing. Also, patients found to have a higher likelihood of developing certain diseases could potentially be charged higher health insurance premiums.

Related resources

Indiana University School of Medicine. Drug interactions table. http://medicine.iupui.edu/flockhart/clinlist.htm

Luo J. Psyber Psychiatry. Prescribing Information: scroll with the changes (online, handheld resources on drug-drug interaction, medications’ effect on CYP-450 system. Current Psychiatry 2003;2(8 online edition). http://www.currentpsychiatry.com/article_pages.asp?AID=666&UID=8877

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

One day we may be able to consistently choose medications that offer optimal benefit and minimal adverse events—without subjecting our patients to unsuccessful trials. Thanks to quantitative EEG (OEEG) testing and pharmacogenetic testing, that day may be coming closer.

How quantitative eeg works

QEEG adds modern computer and statistical analyses to traditional EEG recordings. The computer creates a graphic display on a schematic map of the head. The procedure is often called brain electrical activity mapping (BEAM) or simply “mapping.” ^{New tool: Genotyping makes prescribing safer, more effective, Current Psychiatry, September 2004.) Physicians can order any combination of gene tests, which cost about $150 to $200 each, or all available tests for a discounted price of approximately $600.}

Genelex and Signature Genetics can create individualized CYP-450 function reports to facilitate prescribing and customized reports that take into account the patient’s medication and diet regimen. Genelex also offers an Internet-based software tool, GeneMedRx, which allows doctors to customize medication regimens based on both potential drug-drug interactions and genomic information.

Signature Genetics offers a prospective assessment of drugs based on genetic test results. This assessment provides a comprehensive report of which medications are affected by the test results.

Genetic profiling can help psychiatrists improve the likelihood of treatment success and minimize potential drug-drug interactions and adverse reactions. Patients will be more satisfied, knowing that their medications fit their individual needs. Also, as more is learned about genetic analysis, genetic testing could one day reveal susceptibility to Alzheimer’s disease, heart attack risk, or other medical problems.

As with quantitative EEG, however, few insurance companies cover genetic testing. Also, patients found to have a higher likelihood of developing certain diseases could potentially be charged higher health insurance premiums.

Related resources

Indiana University School of Medicine. Drug interactions table. http://medicine.iupui.edu/flockhart/clinlist.htm

Luo J. Psyber Psychiatry. Prescribing Information: scroll with the changes (online, handheld resources on drug-drug interaction, medications’ effect on CYP-450 system. Current Psychiatry 2003;2(8 online edition). http://www.currentpsychiatry.com/article_pages.asp?AID=666&UID=8877

Disclosure

Dr. Luo reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Luo in this column are his own and do not necessarily reflect those of Current Psychiatry.

Almost one-half of patients prescribed psychotropics do not take recommended dosages, but interrogating them can make them defensive and compromise your therapeutic alliance. When a patient resists starting a psychotropic, targeted interventions tied to a medication-specific transtheoretical approach can help.

Stages of change

Willey et al¹ validated Prochaska and DiClemente’s stages of change² for patients prescribed medications. Their modification provides quick assessment of how ready a patient is to commit to taking medication.

If your patient does not start a psychotropic, acknowledge that some find it difficult to take medication as directed. After you determine the patient’s stage of change, I suggest that you tailor interventions to match that level (Table), then work toward the action stage: commitment to adherence.

With stage-specific interventions, patients feel empowered to make their own decisions, rather than coerced or pressured to take medications.

Table

Assessing readiness to start medication

Almost one-half of patients prescribed psychotropics do not take recommended dosages, but interrogating them can make them defensive and compromise your therapeutic alliance. When a patient resists starting a psychotropic, targeted interventions tied to a medication-specific transtheoretical approach can help.

Stages of change

Willey et al¹ validated Prochaska and DiClemente’s stages of change² for patients prescribed medications. Their modification provides quick assessment of how ready a patient is to commit to taking medication.

If your patient does not start a psychotropic, acknowledge that some find it difficult to take medication as directed. After you determine the patient’s stage of change, I suggest that you tailor interventions to match that level (Table), then work toward the action stage: commitment to adherence.

With stage-specific interventions, patients feel empowered to make their own decisions, rather than coerced or pressured to take medications.

Table

Assessing readiness to start medication

Almost one-half of patients prescribed psychotropics do not take recommended dosages, but interrogating them can make them defensive and compromise your therapeutic alliance. When a patient resists starting a psychotropic, targeted interventions tied to a medication-specific transtheoretical approach can help.

Stages of change

Willey et al¹ validated Prochaska and DiClemente’s stages of change² for patients prescribed medications. Their modification provides quick assessment of how ready a patient is to commit to taking medication.

If your patient does not start a psychotropic, acknowledge that some find it difficult to take medication as directed. After you determine the patient’s stage of change, I suggest that you tailor interventions to match that level (Table), then work toward the action stage: commitment to adherence.

With stage-specific interventions, patients feel empowered to make their own decisions, rather than coerced or pressured to take medications.

Table

Assessing readiness to start medication

Patients with anxiety disorders often struggle with in-session anxiety. Five simple steps can help you reduce their anxiety and teach them how to manage their fear within minutes.

Step 1: During a session, encourage patients to rate their current anxiety on a scale from 0 to 100 with 100 being the most intense.

Step 2: Ask patients to identify the score at which anxiety is too distressing or impairs functioning. Because patient perception distinguishes grades of anxiety, this activity helps differentiate between mild anxiety they can manage, moderate anxiety that needs immediate, non-pharmacologic intervention, and extreme anxiety that may require medication.

Step 3: Have patients identify which anxiety symptoms are most distressing:

• physiologic symptoms such as palpitations, tremors, and tachypnea
  
• affective symptoms (unpleasant feelings, anxious affect)
  
• cognitive symptoms (racing thoughts, impaired concentration, thoughts of impending doom, loss of control).
  

Knowing which symptoms are most bothersome helps you tailor your intervention. Patients also see how anxiety symptoms are not equally distressing.

Step 4: Choose one of two interventions depending on which symptoms predominate, and tell the patient you are teaching him or her a coping skill.

For cognitive symptoms, ask the patient to look around the room and describe in detail what he sees over the next 3 minutes. If time remains, ask him how he would make the room more presentable. Avoid eye contact during this time so that the patient stays focused on observing the room.

For physiologic and affective symptoms, try the “safe-place technique.” Ask the patient to close his eyes and recall a time when he felt safe and content. During the next 3 minutes, have him describe the situation, people, and positive feelings involved. Don’t let the patient get sidetracked by negative thoughts or attention to the present. Ask him to slowly open his eyes when finished.

Step 5: Ask the patient to rate anxiety symptoms again on the same 0-to-100 scale. This second score often is significantly reduced (usually between 10 and 60 points). If one technique is not effective, try the other if time permits.

These interventions also show patients that they can control their anxiousness. Encourage patients to try other anxiety- or stress-management techniques and rate their effectiveness using the 0-to-100 scale.¹ Have them record effective methods in a notebook so they can develop a personalized repertoire of calming activities and techniques.

Patients with anxiety disorders often struggle with in-session anxiety. Five simple steps can help you reduce their anxiety and teach them how to manage their fear within minutes.

Step 1: During a session, encourage patients to rate their current anxiety on a scale from 0 to 100 with 100 being the most intense.

Step 2: Ask patients to identify the score at which anxiety is too distressing or impairs functioning. Because patient perception distinguishes grades of anxiety, this activity helps differentiate between mild anxiety they can manage, moderate anxiety that needs immediate, non-pharmacologic intervention, and extreme anxiety that may require medication.

Step 3: Have patients identify which anxiety symptoms are most distressing:

• physiologic symptoms such as palpitations, tremors, and tachypnea
  
• affective symptoms (unpleasant feelings, anxious affect)
  
• cognitive symptoms (racing thoughts, impaired concentration, thoughts of impending doom, loss of control).
  

Knowing which symptoms are most bothersome helps you tailor your intervention. Patients also see how anxiety symptoms are not equally distressing.

Step 4: Choose one of two interventions depending on which symptoms predominate, and tell the patient you are teaching him or her a coping skill.

For cognitive symptoms, ask the patient to look around the room and describe in detail what he sees over the next 3 minutes. If time remains, ask him how he would make the room more presentable. Avoid eye contact during this time so that the patient stays focused on observing the room.

For physiologic and affective symptoms, try the “safe-place technique.” Ask the patient to close his eyes and recall a time when he felt safe and content. During the next 3 minutes, have him describe the situation, people, and positive feelings involved. Don’t let the patient get sidetracked by negative thoughts or attention to the present. Ask him to slowly open his eyes when finished.

Step 5: Ask the patient to rate anxiety symptoms again on the same 0-to-100 scale. This second score often is significantly reduced (usually between 10 and 60 points). If one technique is not effective, try the other if time permits.

These interventions also show patients that they can control their anxiousness. Encourage patients to try other anxiety- or stress-management techniques and rate their effectiveness using the 0-to-100 scale.¹ Have them record effective methods in a notebook so they can develop a personalized repertoire of calming activities and techniques.

Patients with anxiety disorders often struggle with in-session anxiety. Five simple steps can help you reduce their anxiety and teach them how to manage their fear within minutes.

Step 1: During a session, encourage patients to rate their current anxiety on a scale from 0 to 100 with 100 being the most intense.

Step 2: Ask patients to identify the score at which anxiety is too distressing or impairs functioning. Because patient perception distinguishes grades of anxiety, this activity helps differentiate between mild anxiety they can manage, moderate anxiety that needs immediate, non-pharmacologic intervention, and extreme anxiety that may require medication.

Step 3: Have patients identify which anxiety symptoms are most distressing:

• physiologic symptoms such as palpitations, tremors, and tachypnea
  
• affective symptoms (unpleasant feelings, anxious affect)
  
• cognitive symptoms (racing thoughts, impaired concentration, thoughts of impending doom, loss of control).
  

Knowing which symptoms are most bothersome helps you tailor your intervention. Patients also see how anxiety symptoms are not equally distressing.

Step 4: Choose one of two interventions depending on which symptoms predominate, and tell the patient you are teaching him or her a coping skill.

For cognitive symptoms, ask the patient to look around the room and describe in detail what he sees over the next 3 minutes. If time remains, ask him how he would make the room more presentable. Avoid eye contact during this time so that the patient stays focused on observing the room.

For physiologic and affective symptoms, try the “safe-place technique.” Ask the patient to close his eyes and recall a time when he felt safe and content. During the next 3 minutes, have him describe the situation, people, and positive feelings involved. Don’t let the patient get sidetracked by negative thoughts or attention to the present. Ask him to slowly open his eyes when finished.

Step 5: Ask the patient to rate anxiety symptoms again on the same 0-to-100 scale. This second score often is significantly reduced (usually between 10 and 60 points). If one technique is not effective, try the other if time permits.

These interventions also show patients that they can control their anxiousness. Encourage patients to try other anxiety- or stress-management techniques and rate their effectiveness using the 0-to-100 scale.¹ Have them record effective methods in a notebook so they can develop a personalized repertoire of calming activities and techniques.

Speech recognition technology—once too slow and inaccurate for clinical practice—is increasingly helping psychiatrists record patient notes, dictate letters and lengthy reports, and operate their computers.

Is speech recognition right for your practice? This article will help you decide by reviewing available programs and offering insights on choosing one for your practice.

Speaking of progress

Clinicians in radiology and pathology were among the first to use limited programs that employed voice commands and short phrases. Shortcuts that told the computer to type boilerplate passages have been available for more than 25 years. Early speech recognition programs required users to speak with a stilted voice and pauses between words.

By 1998, several “continuous speech” systems were available, but most were not suitable for a solo or small group psychiatric practice. Some included diagnosis-specific report templates that could be customized for initial assessment and progress notes.¹ These programs were useful for dictating short memos or e-mails but not for composing longer documents because of awkward editing and difficulties with punctuation, formatting, and on-screen navigation.²

Today’s programs recognize natural speech without pauses between words. As the clinician speaks into a microphone at a normal pace, text is typed at speeds approaching 160 words per minute with 90% to 98% accuracy. New versions of some programs save the dictation in audio files, allowing an assistant to listen to the dictation later and edit the transcription. These programs also eliminate superfluous utterances and perform macro commands, including handling e-mail.

Newer speech recognition products are much easier to use than older programs. They can be mastered within days and are cost-effective for solo or small group practices. Single-user programs range in cost from free (included with the Windows XP or newer Macintosh operating systems), to approximately $175 for ViaVoice Professional, to about $800 for the highly recommended Dragon Naturally Speaking Version 8.0.³

How to get started

Speech recognition programs require a powerful computer with processor (microchip) speed >1 gigahertz, random access memory (RAM) ≥ 512 megabytes, and a platform no older than Windows 2000 or Mac OS X Version 10.1.

After the software is installed, some clicking and keystroking may still be necessary. Learning when to talk or type can help users increase efficiency and prevent repetitive strain injury.

Critical factors for successful use include user motivation and training (or consultation with a reseller), a specialized vocabulary and language model, and a high-quality sound card and microphone (the most sophisticated hardware available is recommended, and this usually must be purchased separately).

Most speech recognition programs allow different users to train on the same computer. Users can dictate directly into word-processing applications, and some products allow dictation into other office programs.

What’s available

Dragon Naturally Speaking Professional Medical Solutions Version 8.0 (www.dragontalk.com/DNS_MED_ PRO.htm) is widely recognized for its performance, high accuracy, and easy user interface. Users can dictate directly into a PC for immediate transcription or into selected digital recorders or personal digital assistants for transcription later. A file of your recorded speech can be saved along with the computer-transcribed document for future proofreading.

The program can process previously completed reports to customize word-use patterns and build a personalized vocabulary. The optional but useful medical vocabulary includes many terms unique to psychiatry and psychology.

Dragon responds to voice commands and macros and features online training and user guides. It works in most Windows-based applications but is not available for Macintosh.⁴

IBM’s ViaVoice Release 10 (uk.scansoft.com/viavoice) is available in six languages and multiple levels and comes in versions for Windows and Macintosh platforms (also optimized for G4). Its manufacturer offers support for selected digital handheld recorders.

ViaVoice can analyze previous documents and save recorded dictation, is strong on voice navigation, and recognizes file names and tool bar buttons. Users can open a file by speaking its name or activate a command by saying it.

There are some drawbacks, however. Specialized medical vocabularies must be obtained from outside the company, creating additional technical obstacles or requiring developer assistance. Also, several reviewers do not consider ViaVoice as robust, accurate, or fast as Dragon for lengthy or medical dictation.⁵

Philips SpeechMagic. (www.speech.philips.com) Philips has developed sophisticated tools for document creation, transcription, and commands that integrate with larger information systems. The products are network-based and scalable, essentially designed for large groups or medical centers. The programs cannot be purchased from Philips but are installed by its distributors and software vendors.

Microsoft Office XP (http://office.microsoft.com) includes an alternative user input speech recognition feature within the operating system that offers dictation and voice command modes. It works with any office program and offers a “taste” of speech recognition, but with extremely limited function. It requires awkward switching between dictation and commands, does not filter out extraneous noises, and has no specialized medical vocabulary.

Apple Speech Recognition (www.apple.com/macosx/features/speech/), included in Mac OS X, is rudimentary and is appropriate primarily for controlling a computer by voice commands. It requires no training and can convert English text to spoken words.

The future

Speech recognition programs that can be integrated with telephones, wireless phones, and tablet screens are in development. Microsoft has released speech-control software for Pocket PC devices that run on Windows Mobile 2003 and recognition software for navigating the Web.

Before long, personal digital assistants with built-in speech-recognition technology may respond to spoken questions or commands with a computer-synthesized voice, thus making a clumsy stylus or keypad outdated.

Related resources

• Huang MP, Alessi NE. The Internet and the future of psychiatry. Am J Psychiatry 1996;153:861-9.
• Fulton S. Chart comparing features of Windows-based continuous speech programs. www.out-loud.com/features.html.
• Taintor Z. Computers, the patient, and the psychiatrist. In Dickstein LJ, Riba MB, Oldham JM. Review of psychiatry. Vol 16. Washington, DC: American Psychiatric Press; 1997.

Disclosure

Dr. Green reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Green are his and do not necessarily reflect those of Current Psychiatry.

Acknowledgment

The author thanks Dan Newman, author of several books and video guides on speech recognition, and Len Zullo, chief executive officer, Assistive Technologies Inc., for their help with researching this article and personal communication regarding current product features and comparisons.

Speech recognition technology—once too slow and inaccurate for clinical practice—is increasingly helping psychiatrists record patient notes, dictate letters and lengthy reports, and operate their computers.

Is speech recognition right for your practice? This article will help you decide by reviewing available programs and offering insights on choosing one for your practice.

Speaking of progress

Clinicians in radiology and pathology were among the first to use limited programs that employed voice commands and short phrases. Shortcuts that told the computer to type boilerplate passages have been available for more than 25 years. Early speech recognition programs required users to speak with a stilted voice and pauses between words.

By 1998, several “continuous speech” systems were available, but most were not suitable for a solo or small group psychiatric practice. Some included diagnosis-specific report templates that could be customized for initial assessment and progress notes.¹ These programs were useful for dictating short memos or e-mails but not for composing longer documents because of awkward editing and difficulties with punctuation, formatting, and on-screen navigation.²

Today’s programs recognize natural speech without pauses between words. As the clinician speaks into a microphone at a normal pace, text is typed at speeds approaching 160 words per minute with 90% to 98% accuracy. New versions of some programs save the dictation in audio files, allowing an assistant to listen to the dictation later and edit the transcription. These programs also eliminate superfluous utterances and perform macro commands, including handling e-mail.

Newer speech recognition products are much easier to use than older programs. They can be mastered within days and are cost-effective for solo or small group practices. Single-user programs range in cost from free (included with the Windows XP or newer Macintosh operating systems), to approximately $175 for ViaVoice Professional, to about $800 for the highly recommended Dragon Naturally Speaking Version 8.0.³

How to get started

Speech recognition programs require a powerful computer with processor (microchip) speed >1 gigahertz, random access memory (RAM) ≥ 512 megabytes, and a platform no older than Windows 2000 or Mac OS X Version 10.1.

After the software is installed, some clicking and keystroking may still be necessary. Learning when to talk or type can help users increase efficiency and prevent repetitive strain injury.

Critical factors for successful use include user motivation and training (or consultation with a reseller), a specialized vocabulary and language model, and a high-quality sound card and microphone (the most sophisticated hardware available is recommended, and this usually must be purchased separately).

Most speech recognition programs allow different users to train on the same computer. Users can dictate directly into word-processing applications, and some products allow dictation into other office programs.

What’s available

Dragon Naturally Speaking Professional Medical Solutions Version 8.0 (www.dragontalk.com/DNS_MED_ PRO.htm) is widely recognized for its performance, high accuracy, and easy user interface. Users can dictate directly into a PC for immediate transcription or into selected digital recorders or personal digital assistants for transcription later. A file of your recorded speech can be saved along with the computer-transcribed document for future proofreading.

The program can process previously completed reports to customize word-use patterns and build a personalized vocabulary. The optional but useful medical vocabulary includes many terms unique to psychiatry and psychology.

Dragon responds to voice commands and macros and features online training and user guides. It works in most Windows-based applications but is not available for Macintosh.⁴

IBM’s ViaVoice Release 10 (uk.scansoft.com/viavoice) is available in six languages and multiple levels and comes in versions for Windows and Macintosh platforms (also optimized for G4). Its manufacturer offers support for selected digital handheld recorders.

ViaVoice can analyze previous documents and save recorded dictation, is strong on voice navigation, and recognizes file names and tool bar buttons. Users can open a file by speaking its name or activate a command by saying it.

There are some drawbacks, however. Specialized medical vocabularies must be obtained from outside the company, creating additional technical obstacles or requiring developer assistance. Also, several reviewers do not consider ViaVoice as robust, accurate, or fast as Dragon for lengthy or medical dictation.⁵

Philips SpeechMagic. (www.speech.philips.com) Philips has developed sophisticated tools for document creation, transcription, and commands that integrate with larger information systems. The products are network-based and scalable, essentially designed for large groups or medical centers. The programs cannot be purchased from Philips but are installed by its distributors and software vendors.

Microsoft Office XP (http://office.microsoft.com) includes an alternative user input speech recognition feature within the operating system that offers dictation and voice command modes. It works with any office program and offers a “taste” of speech recognition, but with extremely limited function. It requires awkward switching between dictation and commands, does not filter out extraneous noises, and has no specialized medical vocabulary.

Apple Speech Recognition (www.apple.com/macosx/features/speech/), included in Mac OS X, is rudimentary and is appropriate primarily for controlling a computer by voice commands. It requires no training and can convert English text to spoken words.

The future

Speech recognition programs that can be integrated with telephones, wireless phones, and tablet screens are in development. Microsoft has released speech-control software for Pocket PC devices that run on Windows Mobile 2003 and recognition software for navigating the Web.

Before long, personal digital assistants with built-in speech-recognition technology may respond to spoken questions or commands with a computer-synthesized voice, thus making a clumsy stylus or keypad outdated.

Related resources

• Huang MP, Alessi NE. The Internet and the future of psychiatry. Am J Psychiatry 1996;153:861-9.
• Fulton S. Chart comparing features of Windows-based continuous speech programs. www.out-loud.com/features.html.
• Taintor Z. Computers, the patient, and the psychiatrist. In Dickstein LJ, Riba MB, Oldham JM. Review of psychiatry. Vol 16. Washington, DC: American Psychiatric Press; 1997.

Disclosure

Dr. Green reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Green are his and do not necessarily reflect those of Current Psychiatry.

Acknowledgment

The author thanks Dan Newman, author of several books and video guides on speech recognition, and Len Zullo, chief executive officer, Assistive Technologies Inc., for their help with researching this article and personal communication regarding current product features and comparisons.

Speech recognition technology—once too slow and inaccurate for clinical practice—is increasingly helping psychiatrists record patient notes, dictate letters and lengthy reports, and operate their computers.

Is speech recognition right for your practice? This article will help you decide by reviewing available programs and offering insights on choosing one for your practice.

Speaking of progress

Clinicians in radiology and pathology were among the first to use limited programs that employed voice commands and short phrases. Shortcuts that told the computer to type boilerplate passages have been available for more than 25 years. Early speech recognition programs required users to speak with a stilted voice and pauses between words.

By 1998, several “continuous speech” systems were available, but most were not suitable for a solo or small group psychiatric practice. Some included diagnosis-specific report templates that could be customized for initial assessment and progress notes.¹ These programs were useful for dictating short memos or e-mails but not for composing longer documents because of awkward editing and difficulties with punctuation, formatting, and on-screen navigation.²

Today’s programs recognize natural speech without pauses between words. As the clinician speaks into a microphone at a normal pace, text is typed at speeds approaching 160 words per minute with 90% to 98% accuracy. New versions of some programs save the dictation in audio files, allowing an assistant to listen to the dictation later and edit the transcription. These programs also eliminate superfluous utterances and perform macro commands, including handling e-mail.

Newer speech recognition products are much easier to use than older programs. They can be mastered within days and are cost-effective for solo or small group practices. Single-user programs range in cost from free (included with the Windows XP or newer Macintosh operating systems), to approximately $175 for ViaVoice Professional, to about $800 for the highly recommended Dragon Naturally Speaking Version 8.0.³

How to get started

Speech recognition programs require a powerful computer with processor (microchip) speed >1 gigahertz, random access memory (RAM) ≥ 512 megabytes, and a platform no older than Windows 2000 or Mac OS X Version 10.1.

After the software is installed, some clicking and keystroking may still be necessary. Learning when to talk or type can help users increase efficiency and prevent repetitive strain injury.

Critical factors for successful use include user motivation and training (or consultation with a reseller), a specialized vocabulary and language model, and a high-quality sound card and microphone (the most sophisticated hardware available is recommended, and this usually must be purchased separately).

Most speech recognition programs allow different users to train on the same computer. Users can dictate directly into word-processing applications, and some products allow dictation into other office programs.

What’s available

Dragon Naturally Speaking Professional Medical Solutions Version 8.0 (www.dragontalk.com/DNS_MED_ PRO.htm) is widely recognized for its performance, high accuracy, and easy user interface. Users can dictate directly into a PC for immediate transcription or into selected digital recorders or personal digital assistants for transcription later. A file of your recorded speech can be saved along with the computer-transcribed document for future proofreading.

The program can process previously completed reports to customize word-use patterns and build a personalized vocabulary. The optional but useful medical vocabulary includes many terms unique to psychiatry and psychology.

Dragon responds to voice commands and macros and features online training and user guides. It works in most Windows-based applications but is not available for Macintosh.⁴

IBM’s ViaVoice Release 10 (uk.scansoft.com/viavoice) is available in six languages and multiple levels and comes in versions for Windows and Macintosh platforms (also optimized for G4). Its manufacturer offers support for selected digital handheld recorders.

ViaVoice can analyze previous documents and save recorded dictation, is strong on voice navigation, and recognizes file names and tool bar buttons. Users can open a file by speaking its name or activate a command by saying it.

There are some drawbacks, however. Specialized medical vocabularies must be obtained from outside the company, creating additional technical obstacles or requiring developer assistance. Also, several reviewers do not consider ViaVoice as robust, accurate, or fast as Dragon for lengthy or medical dictation.⁵

Philips SpeechMagic. (www.speech.philips.com) Philips has developed sophisticated tools for document creation, transcription, and commands that integrate with larger information systems. The products are network-based and scalable, essentially designed for large groups or medical centers. The programs cannot be purchased from Philips but are installed by its distributors and software vendors.

Microsoft Office XP (http://office.microsoft.com) includes an alternative user input speech recognition feature within the operating system that offers dictation and voice command modes. It works with any office program and offers a “taste” of speech recognition, but with extremely limited function. It requires awkward switching between dictation and commands, does not filter out extraneous noises, and has no specialized medical vocabulary.

Apple Speech Recognition (www.apple.com/macosx/features/speech/), included in Mac OS X, is rudimentary and is appropriate primarily for controlling a computer by voice commands. It requires no training and can convert English text to spoken words.

The future

Speech recognition programs that can be integrated with telephones, wireless phones, and tablet screens are in development. Microsoft has released speech-control software for Pocket PC devices that run on Windows Mobile 2003 and recognition software for navigating the Web.

Before long, personal digital assistants with built-in speech-recognition technology may respond to spoken questions or commands with a computer-synthesized voice, thus making a clumsy stylus or keypad outdated.

Related resources

• Huang MP, Alessi NE. The Internet and the future of psychiatry. Am J Psychiatry 1996;153:861-9.
• Fulton S. Chart comparing features of Windows-based continuous speech programs. www.out-loud.com/features.html.
• Taintor Z. Computers, the patient, and the psychiatrist. In Dickstein LJ, Riba MB, Oldham JM. Review of psychiatry. Vol 16. Washington, DC: American Psychiatric Press; 1997.

Disclosure

Dr. Green reports no financial relationship with any company whose products are mentioned in this article. The opinions expressed by Dr. Green are his and do not necessarily reflect those of Current Psychiatry.

Acknowledgment

The author thanks Dan Newman, author of several books and video guides on speech recognition, and Len Zullo, chief executive officer, Assistive Technologies Inc., for their help with researching this article and personal communication regarding current product features and comparisons.

Neuroleptic malignant syndrome (NMS) is an uncommon but by no means rare side effect of antipsychotics and other dopamine-blocking agents. This life-threatening form of drug-induced hyperthermia can be disastrous if missed, as initial treatment is based squarely on discontinuing the offending agent (see Malpractice Verdicts).

The mnemonic FEVER can help identify clinical and laboratory NMS markers in patients who exhibit mental and neurologic deterioration while taking antipsychotics or dopaminergic antagonists.

Fever. Hyperthermia is often considered NMS’ hallmark and distinguishes it from other acute neuropsychiatric disorders. However, recent research suggests hyperthermia may be a late sign of NMS and predicts a fulminant state.¹ Although it is never too late to intervene, do not wait until fever develops to start treatment if you suspect an evolving NMS.

Encephalopathy. Patients may abruptly and unexpectedly become confused, obtunded, and disoriented during early or prodomal NMS stages. Such mental status changes likely result from multiple causative mechanisms in the brain that promote a clouding of consciousness.

Vital sign instability. Autonomic instability symptoms—such as tachycardia, tachypnea, and/or labile blood pressure readings—are common.

Enzyme elevation. Extreme creatinine phosphokinase (CPK) elevations because of rhabdomyolysis can indicate NMS. Serum CPKs can sometimes be as high as 2,000 times normal.¹ Rhabdomyolysis, caused by muscular rigidity (see below), can help distinguish NMS from other hyperthermic toxidromes such as serotonin syndrome and anticholinergic toxicity.

Rigidity. Generalized muscle rigidity—frequently described as “lead-pipe” in the literature—is an early and easily identified clinical sign.

Although no data clearly substantiate a temporal pattern of NMS, evidence suggests that symptoms progress sequentially. Mental status changes, muscle rigidity, and autonomic instability may appear first, with hyperthermia developing later.² Recognizing the syndrome early and promptly discontinuing the neuroleptic agent can avert a medical crisis.³

Neuroleptic malignant syndrome (NMS) is an uncommon but by no means rare side effect of antipsychotics and other dopamine-blocking agents. This life-threatening form of drug-induced hyperthermia can be disastrous if missed, as initial treatment is based squarely on discontinuing the offending agent (see Malpractice Verdicts).

The mnemonic FEVER can help identify clinical and laboratory NMS markers in patients who exhibit mental and neurologic deterioration while taking antipsychotics or dopaminergic antagonists.

Fever. Hyperthermia is often considered NMS’ hallmark and distinguishes it from other acute neuropsychiatric disorders. However, recent research suggests hyperthermia may be a late sign of NMS and predicts a fulminant state.¹ Although it is never too late to intervene, do not wait until fever develops to start treatment if you suspect an evolving NMS.

Encephalopathy. Patients may abruptly and unexpectedly become confused, obtunded, and disoriented during early or prodomal NMS stages. Such mental status changes likely result from multiple causative mechanisms in the brain that promote a clouding of consciousness.

Vital sign instability. Autonomic instability symptoms—such as tachycardia, tachypnea, and/or labile blood pressure readings—are common.

Enzyme elevation. Extreme creatinine phosphokinase (CPK) elevations because of rhabdomyolysis can indicate NMS. Serum CPKs can sometimes be as high as 2,000 times normal.¹ Rhabdomyolysis, caused by muscular rigidity (see below), can help distinguish NMS from other hyperthermic toxidromes such as serotonin syndrome and anticholinergic toxicity.

Rigidity. Generalized muscle rigidity—frequently described as “lead-pipe” in the literature—is an early and easily identified clinical sign.

Although no data clearly substantiate a temporal pattern of NMS, evidence suggests that symptoms progress sequentially. Mental status changes, muscle rigidity, and autonomic instability may appear first, with hyperthermia developing later.² Recognizing the syndrome early and promptly discontinuing the neuroleptic agent can avert a medical crisis.³

Neuroleptic malignant syndrome (NMS) is an uncommon but by no means rare side effect of antipsychotics and other dopamine-blocking agents. This life-threatening form of drug-induced hyperthermia can be disastrous if missed, as initial treatment is based squarely on discontinuing the offending agent (see Malpractice Verdicts).

The mnemonic FEVER can help identify clinical and laboratory NMS markers in patients who exhibit mental and neurologic deterioration while taking antipsychotics or dopaminergic antagonists.

Fever. Hyperthermia is often considered NMS’ hallmark and distinguishes it from other acute neuropsychiatric disorders. However, recent research suggests hyperthermia may be a late sign of NMS and predicts a fulminant state.¹ Although it is never too late to intervene, do not wait until fever develops to start treatment if you suspect an evolving NMS.

Encephalopathy. Patients may abruptly and unexpectedly become confused, obtunded, and disoriented during early or prodomal NMS stages. Such mental status changes likely result from multiple causative mechanisms in the brain that promote a clouding of consciousness.

Vital sign instability. Autonomic instability symptoms—such as tachycardia, tachypnea, and/or labile blood pressure readings—are common.

Enzyme elevation. Extreme creatinine phosphokinase (CPK) elevations because of rhabdomyolysis can indicate NMS. Serum CPKs can sometimes be as high as 2,000 times normal.¹ Rhabdomyolysis, caused by muscular rigidity (see below), can help distinguish NMS from other hyperthermic toxidromes such as serotonin syndrome and anticholinergic toxicity.

Rigidity. Generalized muscle rigidity—frequently described as “lead-pipe” in the literature—is an early and easily identified clinical sign.

Although no data clearly substantiate a temporal pattern of NMS, evidence suggests that symptoms progress sequentially. Mental status changes, muscle rigidity, and autonomic instability may appear first, with hyperthermia developing later.² Recognizing the syndrome early and promptly discontinuing the neuroleptic agent can avert a medical crisis.³