Pearls

Treating homeless mentally ill persons in a community-based setting—such as an inpatient medical or psychiatric unit, emergency department, or shelter clinic—requires special clinical adaptations. Four strategies can help achieve a successful intervention.

1. Engage patiently. Many homeless persons view the mental health care system with suspicion and apprehension. Meaningful engagement often develops slowly;¹ you could see a patient for weeks or months before he or she accepts treatment. Empathy and persuasion may be your most important therapeutic skills during initial encounters.

2. Assess needs broadly. During the initial evaluation ask about basic needs (safety, food, clothing, and emergency shelter) as well as psychiatric symptoms. Understandably, the homeless patient may place a much higher priority on food and shelter than on mental health services.²

Successful psychiatric treatment will be difficult if the person has no stable access to shelter. Make sure a workable strategy to obtain emergency, transitional, or permanent housing is in place.³ Work closely with the hospital’s social worker or the shelter’s case managers to facilitate this process.

3. Shape interventions pragmatically. To prevent the chaos of a shelter or the street from thwarting even a basic intervention:

• provide psychotropic samples rather than written prescriptions
  
• simplify dosing regimens to once-daily
  
• help the patient develop safe storage strategies for medications to prevent theft and exposure. For example, provide pill boxes or blister packs, or request that the shelter’s case manager store pills for the patient.
  

4. Retain arduously. Don’t expect perfect cooperation. Expect treatment nonadherence, lost or stolen medications, missed appointments, sporadic follow-through with other services, and inconsistency in abstaining from alcohol or other substances of abuse.

Set limits and establish consequences to keep a homeless person in treatment rather than to justify termination. For instance, if the patient repeatedly “loses” her medications, then provide just a few days’ supply at a time. This strategy encourages frequent follow-up and monitoring, which is more effective than discharging the patient for “noncompliance.”

Treating homeless mentally ill persons in a community-based setting—such as an inpatient medical or psychiatric unit, emergency department, or shelter clinic—requires special clinical adaptations. Four strategies can help achieve a successful intervention.

1. Engage patiently. Many homeless persons view the mental health care system with suspicion and apprehension. Meaningful engagement often develops slowly;¹ you could see a patient for weeks or months before he or she accepts treatment. Empathy and persuasion may be your most important therapeutic skills during initial encounters.

2. Assess needs broadly. During the initial evaluation ask about basic needs (safety, food, clothing, and emergency shelter) as well as psychiatric symptoms. Understandably, the homeless patient may place a much higher priority on food and shelter than on mental health services.²

Successful psychiatric treatment will be difficult if the person has no stable access to shelter. Make sure a workable strategy to obtain emergency, transitional, or permanent housing is in place.³ Work closely with the hospital’s social worker or the shelter’s case managers to facilitate this process.

3. Shape interventions pragmatically. To prevent the chaos of a shelter or the street from thwarting even a basic intervention:

• provide psychotropic samples rather than written prescriptions
  
• simplify dosing regimens to once-daily
  
• help the patient develop safe storage strategies for medications to prevent theft and exposure. For example, provide pill boxes or blister packs, or request that the shelter’s case manager store pills for the patient.
  

4. Retain arduously. Don’t expect perfect cooperation. Expect treatment nonadherence, lost or stolen medications, missed appointments, sporadic follow-through with other services, and inconsistency in abstaining from alcohol or other substances of abuse.

Set limits and establish consequences to keep a homeless person in treatment rather than to justify termination. For instance, if the patient repeatedly “loses” her medications, then provide just a few days’ supply at a time. This strategy encourages frequent follow-up and monitoring, which is more effective than discharging the patient for “noncompliance.”

Treating homeless mentally ill persons in a community-based setting—such as an inpatient medical or psychiatric unit, emergency department, or shelter clinic—requires special clinical adaptations. Four strategies can help achieve a successful intervention.

1. Engage patiently. Many homeless persons view the mental health care system with suspicion and apprehension. Meaningful engagement often develops slowly;¹ you could see a patient for weeks or months before he or she accepts treatment. Empathy and persuasion may be your most important therapeutic skills during initial encounters.

2. Assess needs broadly. During the initial evaluation ask about basic needs (safety, food, clothing, and emergency shelter) as well as psychiatric symptoms. Understandably, the homeless patient may place a much higher priority on food and shelter than on mental health services.²

Successful psychiatric treatment will be difficult if the person has no stable access to shelter. Make sure a workable strategy to obtain emergency, transitional, or permanent housing is in place.³ Work closely with the hospital’s social worker or the shelter’s case managers to facilitate this process.

3. Shape interventions pragmatically. To prevent the chaos of a shelter or the street from thwarting even a basic intervention:

• provide psychotropic samples rather than written prescriptions
  
• simplify dosing regimens to once-daily
  
• help the patient develop safe storage strategies for medications to prevent theft and exposure. For example, provide pill boxes or blister packs, or request that the shelter’s case manager store pills for the patient.
  

4. Retain arduously. Don’t expect perfect cooperation. Expect treatment nonadherence, lost or stolen medications, missed appointments, sporadic follow-through with other services, and inconsistency in abstaining from alcohol or other substances of abuse.

Set limits and establish consequences to keep a homeless person in treatment rather than to justify termination. For instance, if the patient repeatedly “loses” her medications, then provide just a few days’ supply at a time. This strategy encourages frequent follow-up and monitoring, which is more effective than discharging the patient for “noncompliance.”

We know backing up data is important yet few of us do it consistently, either because we don’t think of it or cannot spare the time. Also, because today’s computers are less expensive and more reliable than before, many doctors think a system crash “can’t happen to me.”

Don’t wait for a power surge or hard drive failure to obliterate your crucial files or documents. This article describes numerous ways to back up and store data, each with different features. Your needs will determine which method is best for you.

HARD DRIVE FAILURE

Hard drives, which store information on platters via electrical charges, are vulnerable. They are rated with a mean time between failure (MTBF),1 which indicates how long on average a hard drive will work before it fails. Although the average MTBF is 50 years, electrical discharges such as power surges or lightning storms can force failure much sooner.

Viruses—if programmed to do so—can also corrupt hard drives. Most viruses propagate to another computer, using your computer as a host.

Companies such as Dataleach can recover information from your hard drive, but recovery may take days.

BASIC BACKUP TOOLS

CD-ROM-burning programs such as Nero Burning ROM are one way to back up data. Most computers purchased within the last 2 years have a built-in CD-ROM burner—a device that reads and creates CD-ROMs—along with CD-burning software.

Keep in mind the size of the disk you are using. CD-ROMs have a maximum capacity of 700 megabytes, but file location information consumes about 10 megabytes. A DVD-ROM can hold 4.7 gigabytes, almost 7 times the capacity of a CD-ROM.

Also consider expense. Recordable CDs on average cost 25 cents per disk. Recordable DVDs are more expensive (between 50 cents and $1 per disk depending on quantity purchased) but could save you money if you’re storing several gigabytes of data. The average cost per 100 megabytes of backup is 3.6 cents with CDs and 1.5 cents with DVDs.

Avoid rewriteable CD and DVDs—disks that can be erased and used again. Although such a disk may minimize backup costs, another computer may be unable to read it.

Alternate storage devices offer varying speeds and capacities. For example, a portable USB flash drive may be useful for storing less than 2 gigabytes. If you need more capacity, external USB hard drives can store up to 80 gigabytes. You can download or store a file within seconds with either device if it has a USB 2.0 transfer speed rating.

Zip drives, which can hold 750 megabytes, were once popular but have become less useful because they lack speed. Tape backup systems are extremely fast and can hold 130 gigabytes, but these devices are expensive and used more for large-scale business server backup.

‘WHICH FILES SHOULD I BACK UP?’

Obviously, you should back up electronic medical and billing records as well as documents created in your Microsoft Office suite.

Don’t ignore other critical information sources, such as Web browser bookmarks and e-mails, but remember that your mail, address book, and account information may be stored in different places depending on your e-mail program.

If you use a recordable CD or DVD, you must determine one by one which directories and files to archive. Nero has an easy-to-use “wizard” that guides you through this process. Nero also lets you automate backup: You would no loner have to remember to do it. Backing up e-mail and browser-bookmarked sites will be difficult, however, unless you know where they are kept.

Products such as Genie Backup Home Manager and NovaBACKUP have built-in search/inventory capability and back up to CDs or DVDs. Also, once the first backup is created, these programs can determine if the files have changed. Thus, subsequent backups will duplicate only files or modifications created since the previous backup. Specialized back-up programs also encrypt information and compress data to conserve space.

SCHEDULING DATA BACKUP

If you don’t create a schedule for backup, chances are it will never get done.

Ideally, you should back up data daily at a set time, such as at noon or closing.

Many psychiatrists, however, probably need a longer interval depending on how long backup takes (anywhere from 5 to 20 minutes depending on volume of data) and whether the information is critical. Also, a file cannot be duplicated while in use, as two computer programs cannot share a file in order to protect the data.

STORING BACKUP

After creating your backup:

• keep the backup and the software used to create it at another location in case of fire or theft
• test with your staff the process of restoring the information to the original hard drive, so that you will learn how to do it and how long it takes to get your computers running.

ALTERNATIVE BACKUP METHODS

If you have broadband Internet access via DSL or cable modem, consider using online backup services offered by Connected or Xdrive. Your data will be safe once you’ve downloaded and installed their software, designated files, and determined backup frequency. These online services also store the data at a remote site in case of fire or theft. Some physicians, however, may feel uncomfortable keeping data on another server for security reasons.

The Mirra Personal Server, an alternative to off-site backup, can be connected to one computer or a network and can back up one or all computers. This server can also synchronize files between computers and allow access to them over the Internet.

For real-time backup, a RAID array2 (redundant array of inexpensive drives) is your only choice. With RAID level 1, two hard drives record simultaneously. When one drive fails, another continues to work and has the information. A RAID array requires a specialized drive controller card, which costs around $150, or specialized software.3 Controller cards are widely available on the Internet (use search terms “Mac Raid controller” or “PC raid controller”), and raid arrays are available for any platform.

THE FUTURE

As multimedia become integrated into medical records and software programs create more information, physicians will need more storage space. New storage technologies such as the HD-DVD and Blu-Ray4 offer up to 25 to 30 gigabytes per disc. Similar to the VHS-Betamax wars of the 1980s, manufacturers are vying to make these high-density storage devices the future storage standard. Also, perpendicular recording technology is increasing hard drive storage capacity.5

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.

We know backing up data is important yet few of us do it consistently, either because we don’t think of it or cannot spare the time. Also, because today’s computers are less expensive and more reliable than before, many doctors think a system crash “can’t happen to me.”

Don’t wait for a power surge or hard drive failure to obliterate your crucial files or documents. This article describes numerous ways to back up and store data, each with different features. Your needs will determine which method is best for you.

HARD DRIVE FAILURE

Hard drives, which store information on platters via electrical charges, are vulnerable. They are rated with a mean time between failure (MTBF),1 which indicates how long on average a hard drive will work before it fails. Although the average MTBF is 50 years, electrical discharges such as power surges or lightning storms can force failure much sooner.

Viruses—if programmed to do so—can also corrupt hard drives. Most viruses propagate to another computer, using your computer as a host.

Companies such as Dataleach can recover information from your hard drive, but recovery may take days.

BASIC BACKUP TOOLS

CD-ROM-burning programs such as Nero Burning ROM are one way to back up data. Most computers purchased within the last 2 years have a built-in CD-ROM burner—a device that reads and creates CD-ROMs—along with CD-burning software.

Keep in mind the size of the disk you are using. CD-ROMs have a maximum capacity of 700 megabytes, but file location information consumes about 10 megabytes. A DVD-ROM can hold 4.7 gigabytes, almost 7 times the capacity of a CD-ROM.

Also consider expense. Recordable CDs on average cost 25 cents per disk. Recordable DVDs are more expensive (between 50 cents and $1 per disk depending on quantity purchased) but could save you money if you’re storing several gigabytes of data. The average cost per 100 megabytes of backup is 3.6 cents with CDs and 1.5 cents with DVDs.

Avoid rewriteable CD and DVDs—disks that can be erased and used again. Although such a disk may minimize backup costs, another computer may be unable to read it.

Alternate storage devices offer varying speeds and capacities. For example, a portable USB flash drive may be useful for storing less than 2 gigabytes. If you need more capacity, external USB hard drives can store up to 80 gigabytes. You can download or store a file within seconds with either device if it has a USB 2.0 transfer speed rating.

Zip drives, which can hold 750 megabytes, were once popular but have become less useful because they lack speed. Tape backup systems are extremely fast and can hold 130 gigabytes, but these devices are expensive and used more for large-scale business server backup.

‘WHICH FILES SHOULD I BACK UP?’

Obviously, you should back up electronic medical and billing records as well as documents created in your Microsoft Office suite.

Don’t ignore other critical information sources, such as Web browser bookmarks and e-mails, but remember that your mail, address book, and account information may be stored in different places depending on your e-mail program.

If you use a recordable CD or DVD, you must determine one by one which directories and files to archive. Nero has an easy-to-use “wizard” that guides you through this process. Nero also lets you automate backup: You would no loner have to remember to do it. Backing up e-mail and browser-bookmarked sites will be difficult, however, unless you know where they are kept.

Products such as Genie Backup Home Manager and NovaBACKUP have built-in search/inventory capability and back up to CDs or DVDs. Also, once the first backup is created, these programs can determine if the files have changed. Thus, subsequent backups will duplicate only files or modifications created since the previous backup. Specialized back-up programs also encrypt information and compress data to conserve space.

SCHEDULING DATA BACKUP

If you don’t create a schedule for backup, chances are it will never get done.

Ideally, you should back up data daily at a set time, such as at noon or closing.

Many psychiatrists, however, probably need a longer interval depending on how long backup takes (anywhere from 5 to 20 minutes depending on volume of data) and whether the information is critical. Also, a file cannot be duplicated while in use, as two computer programs cannot share a file in order to protect the data.

STORING BACKUP

After creating your backup:

• keep the backup and the software used to create it at another location in case of fire or theft
• test with your staff the process of restoring the information to the original hard drive, so that you will learn how to do it and how long it takes to get your computers running.

ALTERNATIVE BACKUP METHODS

If you have broadband Internet access via DSL or cable modem, consider using online backup services offered by Connected or Xdrive. Your data will be safe once you’ve downloaded and installed their software, designated files, and determined backup frequency. These online services also store the data at a remote site in case of fire or theft. Some physicians, however, may feel uncomfortable keeping data on another server for security reasons.

The Mirra Personal Server, an alternative to off-site backup, can be connected to one computer or a network and can back up one or all computers. This server can also synchronize files between computers and allow access to them over the Internet.

For real-time backup, a RAID array2 (redundant array of inexpensive drives) is your only choice. With RAID level 1, two hard drives record simultaneously. When one drive fails, another continues to work and has the information. A RAID array requires a specialized drive controller card, which costs around $150, or specialized software.3 Controller cards are widely available on the Internet (use search terms “Mac Raid controller” or “PC raid controller”), and raid arrays are available for any platform.

THE FUTURE

As multimedia become integrated into medical records and software programs create more information, physicians will need more storage space. New storage technologies such as the HD-DVD and Blu-Ray4 offer up to 25 to 30 gigabytes per disc. Similar to the VHS-Betamax wars of the 1980s, manufacturers are vying to make these high-density storage devices the future storage standard. Also, perpendicular recording technology is increasing hard drive storage capacity.5

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.

We know backing up data is important yet few of us do it consistently, either because we don’t think of it or cannot spare the time. Also, because today’s computers are less expensive and more reliable than before, many doctors think a system crash “can’t happen to me.”

Don’t wait for a power surge or hard drive failure to obliterate your crucial files or documents. This article describes numerous ways to back up and store data, each with different features. Your needs will determine which method is best for you.

HARD DRIVE FAILURE

Hard drives, which store information on platters via electrical charges, are vulnerable. They are rated with a mean time between failure (MTBF),1 which indicates how long on average a hard drive will work before it fails. Although the average MTBF is 50 years, electrical discharges such as power surges or lightning storms can force failure much sooner.

Viruses—if programmed to do so—can also corrupt hard drives. Most viruses propagate to another computer, using your computer as a host.

Companies such as Dataleach can recover information from your hard drive, but recovery may take days.

BASIC BACKUP TOOLS

CD-ROM-burning programs such as Nero Burning ROM are one way to back up data. Most computers purchased within the last 2 years have a built-in CD-ROM burner—a device that reads and creates CD-ROMs—along with CD-burning software.

Keep in mind the size of the disk you are using. CD-ROMs have a maximum capacity of 700 megabytes, but file location information consumes about 10 megabytes. A DVD-ROM can hold 4.7 gigabytes, almost 7 times the capacity of a CD-ROM.

Also consider expense. Recordable CDs on average cost 25 cents per disk. Recordable DVDs are more expensive (between 50 cents and $1 per disk depending on quantity purchased) but could save you money if you’re storing several gigabytes of data. The average cost per 100 megabytes of backup is 3.6 cents with CDs and 1.5 cents with DVDs.

Avoid rewriteable CD and DVDs—disks that can be erased and used again. Although such a disk may minimize backup costs, another computer may be unable to read it.

Alternate storage devices offer varying speeds and capacities. For example, a portable USB flash drive may be useful for storing less than 2 gigabytes. If you need more capacity, external USB hard drives can store up to 80 gigabytes. You can download or store a file within seconds with either device if it has a USB 2.0 transfer speed rating.

Zip drives, which can hold 750 megabytes, were once popular but have become less useful because they lack speed. Tape backup systems are extremely fast and can hold 130 gigabytes, but these devices are expensive and used more for large-scale business server backup.

‘WHICH FILES SHOULD I BACK UP?’

Obviously, you should back up electronic medical and billing records as well as documents created in your Microsoft Office suite.

Don’t ignore other critical information sources, such as Web browser bookmarks and e-mails, but remember that your mail, address book, and account information may be stored in different places depending on your e-mail program.

If you use a recordable CD or DVD, you must determine one by one which directories and files to archive. Nero has an easy-to-use “wizard” that guides you through this process. Nero also lets you automate backup: You would no loner have to remember to do it. Backing up e-mail and browser-bookmarked sites will be difficult, however, unless you know where they are kept.

Products such as Genie Backup Home Manager and NovaBACKUP have built-in search/inventory capability and back up to CDs or DVDs. Also, once the first backup is created, these programs can determine if the files have changed. Thus, subsequent backups will duplicate only files or modifications created since the previous backup. Specialized back-up programs also encrypt information and compress data to conserve space.

SCHEDULING DATA BACKUP

If you don’t create a schedule for backup, chances are it will never get done.

Ideally, you should back up data daily at a set time, such as at noon or closing.

Many psychiatrists, however, probably need a longer interval depending on how long backup takes (anywhere from 5 to 20 minutes depending on volume of data) and whether the information is critical. Also, a file cannot be duplicated while in use, as two computer programs cannot share a file in order to protect the data.

STORING BACKUP

After creating your backup:

• keep the backup and the software used to create it at another location in case of fire or theft
• test with your staff the process of restoring the information to the original hard drive, so that you will learn how to do it and how long it takes to get your computers running.

ALTERNATIVE BACKUP METHODS

If you have broadband Internet access via DSL or cable modem, consider using online backup services offered by Connected or Xdrive. Your data will be safe once you’ve downloaded and installed their software, designated files, and determined backup frequency. These online services also store the data at a remote site in case of fire or theft. Some physicians, however, may feel uncomfortable keeping data on another server for security reasons.

The Mirra Personal Server, an alternative to off-site backup, can be connected to one computer or a network and can back up one or all computers. This server can also synchronize files between computers and allow access to them over the Internet.

For real-time backup, a RAID array2 (redundant array of inexpensive drives) is your only choice. With RAID level 1, two hard drives record simultaneously. When one drive fails, another continues to work and has the information. A RAID array requires a specialized drive controller card, which costs around $150, or specialized software.3 Controller cards are widely available on the Internet (use search terms “Mac Raid controller” or “PC raid controller”), and raid arrays are available for any platform.

THE FUTURE

As multimedia become integrated into medical records and software programs create more information, physicians will need more storage space. New storage technologies such as the HD-DVD and Blu-Ray4 offer up to 25 to 30 gigabytes per disc. Similar to the VHS-Betamax wars of the 1980s, manufacturers are vying to make these high-density storage devices the future storage standard. Also, perpendicular recording technology is increasing hard drive storage capacity.5

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.

When evaluating a patient diagnosed as having a “refractory” mental disorder, ask yourself:

• Is the working diagnosis correct?
  
• Could another undiagnosed condition be hindering response to treatment?
  
• Is the patient adhering to his or her prescribed treatment?
  
• Have prior medication trials used adequate dosages and durations?
  

For example, in a patient diagnosed with “refractory depression,” undiagnosed bipolar depression may explain the lack of response to antidepressant monotherapy. An undiagnosed general medical condition, such as hypothyroidism, would also explain the lack of response.

Also consider the effects of a comorbid psychiatric disorder. Anxiety, substance use, and personality disorders are common in patients with “refractory” depression.

Addressing nonadherence

Always suspect nonadherence—a frequent problem among patients with mental disorders—when assessing a “refractory” condition.^1,2 Collateral sources of information such as family, friends, and previous inpatient and outpatient psychiatrists can help clarify this issue when the patient’s account seems unreliable.

If the patient is not adhering to prescribed medication, re-evaluate your therapeutic alliance by considering these questions:

• Has the patient seemed comfortable and open during recent sessions?
  
• Has he or she been able to discuss emotionally laden material that might lead to shame or guilt?
  
• Did the patient maintain eye contact and respond appropriately to questions and observations?
  

If the patient has been following the treatment plan but complains of persistent symptoms, verify that an adequate dosage (often the maximum recommended) and duration (at least 4 to 6 weeks for major depression) of medication have been prescribed. Also assess the adequacy of any psychotherapy.³

When evaluating a patient diagnosed as having a “refractory” mental disorder, ask yourself:

• Is the working diagnosis correct?
  
• Could another undiagnosed condition be hindering response to treatment?
  
• Is the patient adhering to his or her prescribed treatment?
  
• Have prior medication trials used adequate dosages and durations?
  

For example, in a patient diagnosed with “refractory depression,” undiagnosed bipolar depression may explain the lack of response to antidepressant monotherapy. An undiagnosed general medical condition, such as hypothyroidism, would also explain the lack of response.

Also consider the effects of a comorbid psychiatric disorder. Anxiety, substance use, and personality disorders are common in patients with “refractory” depression.

Addressing nonadherence

Always suspect nonadherence—a frequent problem among patients with mental disorders—when assessing a “refractory” condition.^1,2 Collateral sources of information such as family, friends, and previous inpatient and outpatient psychiatrists can help clarify this issue when the patient’s account seems unreliable.

If the patient is not adhering to prescribed medication, re-evaluate your therapeutic alliance by considering these questions:

• Has the patient seemed comfortable and open during recent sessions?
  
• Has he or she been able to discuss emotionally laden material that might lead to shame or guilt?
  
• Did the patient maintain eye contact and respond appropriately to questions and observations?
  

If the patient has been following the treatment plan but complains of persistent symptoms, verify that an adequate dosage (often the maximum recommended) and duration (at least 4 to 6 weeks for major depression) of medication have been prescribed. Also assess the adequacy of any psychotherapy.³

When evaluating a patient diagnosed as having a “refractory” mental disorder, ask yourself:

• Is the working diagnosis correct?
  
• Could another undiagnosed condition be hindering response to treatment?
  
• Is the patient adhering to his or her prescribed treatment?
  
• Have prior medication trials used adequate dosages and durations?
  

For example, in a patient diagnosed with “refractory depression,” undiagnosed bipolar depression may explain the lack of response to antidepressant monotherapy. An undiagnosed general medical condition, such as hypothyroidism, would also explain the lack of response.

Also consider the effects of a comorbid psychiatric disorder. Anxiety, substance use, and personality disorders are common in patients with “refractory” depression.

Addressing nonadherence

Always suspect nonadherence—a frequent problem among patients with mental disorders—when assessing a “refractory” condition.^1,2 Collateral sources of information such as family, friends, and previous inpatient and outpatient psychiatrists can help clarify this issue when the patient’s account seems unreliable.

If the patient is not adhering to prescribed medication, re-evaluate your therapeutic alliance by considering these questions:

• Has the patient seemed comfortable and open during recent sessions?
  
• Has he or she been able to discuss emotionally laden material that might lead to shame or guilt?
  
• Did the patient maintain eye contact and respond appropriately to questions and observations?
  

If the patient has been following the treatment plan but complains of persistent symptoms, verify that an adequate dosage (often the maximum recommended) and duration (at least 4 to 6 weeks for major depression) of medication have been prescribed. Also assess the adequacy of any psychotherapy.³

Cognitive-behavioral therapy (CBT) can help patients cope with auditory hallucinations and reshape delusional beliefs to make the voices less frequent.¹ Use the following CBT methods alone or with medication.

1. Engage the patient by showing interest in the voices. Ask: “When did the voices start? Where are they coming from? Can you bring them on or stop them? Do they tell you to do things? What happens when you ignore them?”

2. Normalize the hallucination. List scientifically plausible “reasons for hearing voices,”² including sleep deprivation, isolation, dehydration and/or starvation, extreme stress, strong thoughts or emotions, fever and illness, and drug/alcohol use.

Ask which reasons might apply. Patients often agree with several explanations and begin questioning their delusional interpretations. Your list should include the possibility that the voices are real, but only if the patient initially believes this.

3. Suggest coping strategies, such as:

• humming or singing a song several times
• listening to music
• reading (forwards and backwards)
• talking with others
• exercise
• ignoring the voices
• medication (important to include).

Ask which methods worked previously and have patients build on that list, if possible.

If a patient hears command hallucinations, assess their acuity and decide whether he or she is likely to act on them before starting CBT.

4. Use in-session voices to teach coping strategies. Ask the patient to hum a song with you (“Happy Birthday” works well). If unsuccessful, try reading a paragraph together forwards or backwards. If the voices stop—even for 2 minutes—tell the patient that he or she has begun to control them.³ Have the patient practice these exercises at home and notice if the voices stop for longer periods.

5. Briefly explain the neurology behind the voices. PET scans have shown that auditory hallucinations activate brain areas that regulate hearing and speaking,⁴ suggesting that people talk or think to themselves while hearing voices.

When patients ask why they hear strange voices, explain that many voices are buried inside our memory. When people hear voices, the brain’s speech, hearing, and memory centers interact.⁵

That said, calling auditory hallucinations “voice-thoughts,” rather than “voices,” reduces stigma and reinforces an alternate explanation behind the delusion. As the patient begins to understand that hallucinations are related to dysfunctional thoughts, we can help correct them.

Cognitive-behavioral therapy (CBT) can help patients cope with auditory hallucinations and reshape delusional beliefs to make the voices less frequent.¹ Use the following CBT methods alone or with medication.

1. Engage the patient by showing interest in the voices. Ask: “When did the voices start? Where are they coming from? Can you bring them on or stop them? Do they tell you to do things? What happens when you ignore them?”

2. Normalize the hallucination. List scientifically plausible “reasons for hearing voices,”² including sleep deprivation, isolation, dehydration and/or starvation, extreme stress, strong thoughts or emotions, fever and illness, and drug/alcohol use.

Ask which reasons might apply. Patients often agree with several explanations and begin questioning their delusional interpretations. Your list should include the possibility that the voices are real, but only if the patient initially believes this.

3. Suggest coping strategies, such as:

• humming or singing a song several times
• listening to music
• reading (forwards and backwards)
• talking with others
• exercise
• ignoring the voices
• medication (important to include).

Ask which methods worked previously and have patients build on that list, if possible.

If a patient hears command hallucinations, assess their acuity and decide whether he or she is likely to act on them before starting CBT.

4. Use in-session voices to teach coping strategies. Ask the patient to hum a song with you (“Happy Birthday” works well). If unsuccessful, try reading a paragraph together forwards or backwards. If the voices stop—even for 2 minutes—tell the patient that he or she has begun to control them.³ Have the patient practice these exercises at home and notice if the voices stop for longer periods.

5. Briefly explain the neurology behind the voices. PET scans have shown that auditory hallucinations activate brain areas that regulate hearing and speaking,⁴ suggesting that people talk or think to themselves while hearing voices.

When patients ask why they hear strange voices, explain that many voices are buried inside our memory. When people hear voices, the brain’s speech, hearing, and memory centers interact.⁵

That said, calling auditory hallucinations “voice-thoughts,” rather than “voices,” reduces stigma and reinforces an alternate explanation behind the delusion. As the patient begins to understand that hallucinations are related to dysfunctional thoughts, we can help correct them.

Cognitive-behavioral therapy (CBT) can help patients cope with auditory hallucinations and reshape delusional beliefs to make the voices less frequent.¹ Use the following CBT methods alone or with medication.

1. Engage the patient by showing interest in the voices. Ask: “When did the voices start? Where are they coming from? Can you bring them on or stop them? Do they tell you to do things? What happens when you ignore them?”

2. Normalize the hallucination. List scientifically plausible “reasons for hearing voices,”² including sleep deprivation, isolation, dehydration and/or starvation, extreme stress, strong thoughts or emotions, fever and illness, and drug/alcohol use.

Ask which reasons might apply. Patients often agree with several explanations and begin questioning their delusional interpretations. Your list should include the possibility that the voices are real, but only if the patient initially believes this.

3. Suggest coping strategies, such as:

• humming or singing a song several times
• listening to music
• reading (forwards and backwards)
• talking with others
• exercise
• ignoring the voices
• medication (important to include).

Ask which methods worked previously and have patients build on that list, if possible.

If a patient hears command hallucinations, assess their acuity and decide whether he or she is likely to act on them before starting CBT.

4. Use in-session voices to teach coping strategies. Ask the patient to hum a song with you (“Happy Birthday” works well). If unsuccessful, try reading a paragraph together forwards or backwards. If the voices stop—even for 2 minutes—tell the patient that he or she has begun to control them.³ Have the patient practice these exercises at home and notice if the voices stop for longer periods.

5. Briefly explain the neurology behind the voices. PET scans have shown that auditory hallucinations activate brain areas that regulate hearing and speaking,⁴ suggesting that people talk or think to themselves while hearing voices.

When patients ask why they hear strange voices, explain that many voices are buried inside our memory. When people hear voices, the brain’s speech, hearing, and memory centers interact.⁵

That said, calling auditory hallucinations “voice-thoughts,” rather than “voices,” reduces stigma and reinforces an alternate explanation behind the delusion. As the patient begins to understand that hallucinations are related to dysfunctional thoughts, we can help correct them.

Pharmaceutical companies, through detailers and assistance programs, offer resources for helping our financially strapped patients.

Drug company representatives. Doctors may consider visits from drug reps a waste of time, but we can give the coupons and free drug samples they offer to indigent, disabled, or working-poor patients who often cannot afford the psychotropics they need.

To make meetings with detailers more productive:

• Be clear about your needs, expectations, and how much time you are willing to spend.
  
• Be frank about whether you want to hear about studies. Tell the detailer that you’ll accept information by request only.
  
• State specific dates and times you are available.
  
• Request coupons for patients whose medication samples are likely to be lost or stolen.
  

Patient assistance programs. Pharmaceutical companies’ assistance programs provide deeply discounted drugs to patients in need (Box). The paperwork to qualify takes minutes for clinician and patient to fill out, and many forms are available online or via fax.

Box

Pharmaceutical companies, through detailers and assistance programs, offer resources for helping our financially strapped patients.

Drug company representatives. Doctors may consider visits from drug reps a waste of time, but we can give the coupons and free drug samples they offer to indigent, disabled, or working-poor patients who often cannot afford the psychotropics they need.

To make meetings with detailers more productive:

• Be clear about your needs, expectations, and how much time you are willing to spend.
  
• Be frank about whether you want to hear about studies. Tell the detailer that you’ll accept information by request only.
  
• State specific dates and times you are available.
  
• Request coupons for patients whose medication samples are likely to be lost or stolen.
  

Patient assistance programs. Pharmaceutical companies’ assistance programs provide deeply discounted drugs to patients in need (Box). The paperwork to qualify takes minutes for clinician and patient to fill out, and many forms are available online or via fax.

Box

Pharmaceutical companies, through detailers and assistance programs, offer resources for helping our financially strapped patients.

Drug company representatives. Doctors may consider visits from drug reps a waste of time, but we can give the coupons and free drug samples they offer to indigent, disabled, or working-poor patients who often cannot afford the psychotropics they need.

To make meetings with detailers more productive:

• Be clear about your needs, expectations, and how much time you are willing to spend.
  
• Be frank about whether you want to hear about studies. Tell the detailer that you’ll accept information by request only.
  
• State specific dates and times you are available.
  
• Request coupons for patients whose medication samples are likely to be lost or stolen.
  

Patient assistance programs. Pharmaceutical companies’ assistance programs provide deeply discounted drugs to patients in need (Box). The paperwork to qualify takes minutes for clinician and patient to fill out, and many forms are available online or via fax.

Box

You need a printout now, but you’re at a meeting, in a hotel, or at the hospital. What do you do?

Printers have become more compact and versatile, and numerous remote printing solutions exist with more on the way. This article reviews the options to help you print anytime, anywhere.

Portable printers

HP and Canon make inkjet printers that weigh approximately 4 lbs but are portable and compatible with most systems. These printers can be connected to your notebook via a USB or parallel port cable, or wirelessly with Bluetooth or infrared. Built with high-resolution inkjet nozzles, portable printers provide sharp printouts and can even print photos (although this can quickly drain their small ink cartridges).

By contrast, the Psyber Psychiatry, December 2003). WiFi makes printing from your hotel room relatively easy.

Psyber Psychiatry, December 2004).

First, make sure the program you used to create the document is compatible with the business center’s computers. Because most business centers use the free Adobe document reader, your best bet is to convert the file to Adobe PDF, which maintains its format. Use PDFCreator or PrimoPDF to convert the file; both are free and work on Windows computers. Mac users can download the Mac-Net Freeware PDF file creator.

The future

Imagine a pocket-size device that prints onto a blank page as you move it across.

PrintDreams is developing such a device using its random-movement printing technology (RMPT). PrintDreams reports that the scanning device can print any document with 100% accuracy, though it seems best suited to text. The device is still a year or two from reaching the mainstream; PrintDreams is licensing its technology to other printer manufacturers.

Also, don’t be surprised if cellular phones one day have the capability to print e-mail attachments using Bluetooth or general packet radio service (GPRS), a very fast data transfer protocol on a GSM network.

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.

You need a printout now, but you’re at a meeting, in a hotel, or at the hospital. What do you do?

Printers have become more compact and versatile, and numerous remote printing solutions exist with more on the way. This article reviews the options to help you print anytime, anywhere.

Portable printers

HP and Canon make inkjet printers that weigh approximately 4 lbs but are portable and compatible with most systems. These printers can be connected to your notebook via a USB or parallel port cable, or wirelessly with Bluetooth or infrared. Built with high-resolution inkjet nozzles, portable printers provide sharp printouts and can even print photos (although this can quickly drain their small ink cartridges).

By contrast, the Psyber Psychiatry, December 2003). WiFi makes printing from your hotel room relatively easy.

Psyber Psychiatry, December 2004).

First, make sure the program you used to create the document is compatible with the business center’s computers. Because most business centers use the free Adobe document reader, your best bet is to convert the file to Adobe PDF, which maintains its format. Use PDFCreator or PrimoPDF to convert the file; both are free and work on Windows computers. Mac users can download the Mac-Net Freeware PDF file creator.

The future

Imagine a pocket-size device that prints onto a blank page as you move it across.

PrintDreams is developing such a device using its random-movement printing technology (RMPT). PrintDreams reports that the scanning device can print any document with 100% accuracy, though it seems best suited to text. The device is still a year or two from reaching the mainstream; PrintDreams is licensing its technology to other printer manufacturers.

Also, don’t be surprised if cellular phones one day have the capability to print e-mail attachments using Bluetooth or general packet radio service (GPRS), a very fast data transfer protocol on a GSM network.

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.

You need a printout now, but you’re at a meeting, in a hotel, or at the hospital. What do you do?

Printers have become more compact and versatile, and numerous remote printing solutions exist with more on the way. This article reviews the options to help you print anytime, anywhere.

Portable printers

HP and Canon make inkjet printers that weigh approximately 4 lbs but are portable and compatible with most systems. These printers can be connected to your notebook via a USB or parallel port cable, or wirelessly with Bluetooth or infrared. Built with high-resolution inkjet nozzles, portable printers provide sharp printouts and can even print photos (although this can quickly drain their small ink cartridges).

By contrast, the Psyber Psychiatry, December 2003). WiFi makes printing from your hotel room relatively easy.

Psyber Psychiatry, December 2004).

First, make sure the program you used to create the document is compatible with the business center’s computers. Because most business centers use the free Adobe document reader, your best bet is to convert the file to Adobe PDF, which maintains its format. Use PDFCreator or PrimoPDF to convert the file; both are free and work on Windows computers. Mac users can download the Mac-Net Freeware PDF file creator.

The future

Imagine a pocket-size device that prints onto a blank page as you move it across.

PrintDreams is developing such a device using its random-movement printing technology (RMPT). PrintDreams reports that the scanning device can print any document with 100% accuracy, though it seems best suited to text. The device is still a year or two from reaching the mainstream; PrintDreams is licensing its technology to other printer manufacturers.

Also, don’t be surprised if cellular phones one day have the capability to print e-mail attachments using Bluetooth or general packet radio service (GPRS), a very fast data transfer protocol on a GSM network.

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.

You need a printout now, but you’re at a meeting, in a hotel, or at the hospital. What do you do?

Printers have become more compact and versatile, and numerous remote printing solutions exist with more on the way. This article reviews the options to help you print anytime, anywhere.

Portable printers

HP and Canon make inkjet printers that weigh approximately 4 lbs but are portable and compatible with most systems. These printers can be connected to your notebook via a USB or parallel port cable, or wirelessly with Bluetooth or infrared. Built with high-resolution inkjet nozzles, portable printers provide sharp printouts and can even print photos (although this can quickly drain their small ink cartridges).

By contrast, the Psyber Psychiatry, December 2003). WiFi makes printing from your hotel room relatively easy.

Psyber Psychiatry, December 2004).

First, make sure the program you used to create the document is compatible with the business center’s computers. Because most business centers use the free Adobe document reader, your best bet is to convert the file to Adobe PDF, which maintains its format. Use PDFCreator or PrimoPDF to convert the file; both are free and work on Windows computers. Mac users can download the Mac-Net Freeware PDF file creator.

The future

Imagine a pocket-size device that prints onto a blank page as you move it across.

PrintDreams is developing such a device using its random-movement printing technology (RMPT). PrintDreams reports that the scanning device can print any document with 100% accuracy, though it seems best suited to text. The device is still a year or two from reaching the mainstream; PrintDreams is licensing its technology to other printer manufacturers.

Also, don’t be surprised if cellular phones one day have the capability to print e-mail attachments using Bluetooth or general packet radio service (GPRS), a very fast data transfer protocol on a GSM network.

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.

You need a printout now, but you’re at a meeting, in a hotel, or at the hospital. What do you do?

Printers have become more compact and versatile, and numerous remote printing solutions exist with more on the way. This article reviews the options to help you print anytime, anywhere.

Portable printers

HP and Canon make inkjet printers that weigh approximately 4 lbs but are portable and compatible with most systems. These printers can be connected to your notebook via a USB or parallel port cable, or wirelessly with Bluetooth or infrared. Built with high-resolution inkjet nozzles, portable printers provide sharp printouts and can even print photos (although this can quickly drain their small ink cartridges).

By contrast, the Psyber Psychiatry, December 2003). WiFi makes printing from your hotel room relatively easy.

Psyber Psychiatry, December 2004).

First, make sure the program you used to create the document is compatible with the business center’s computers. Because most business centers use the free Adobe document reader, your best bet is to convert the file to Adobe PDF, which maintains its format. Use PDFCreator or PrimoPDF to convert the file; both are free and work on Windows computers. Mac users can download the Mac-Net Freeware PDF file creator.

The future

Imagine a pocket-size device that prints onto a blank page as you move it across.

PrintDreams is developing such a device using its random-movement printing technology (RMPT). PrintDreams reports that the scanning device can print any document with 100% accuracy, though it seems best suited to text. The device is still a year or two from reaching the mainstream; PrintDreams is licensing its technology to other printer manufacturers.

Also, don’t be surprised if cellular phones one day have the capability to print e-mail attachments using Bluetooth or general packet radio service (GPRS), a very fast data transfer protocol on a GSM network.

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.

You need a printout now, but you’re at a meeting, in a hotel, or at the hospital. What do you do?

Printers have become more compact and versatile, and numerous remote printing solutions exist with more on the way. This article reviews the options to help you print anytime, anywhere.

Portable printers

HP and Canon make inkjet printers that weigh approximately 4 lbs but are portable and compatible with most systems. These printers can be connected to your notebook via a USB or parallel port cable, or wirelessly with Bluetooth or infrared. Built with high-resolution inkjet nozzles, portable printers provide sharp printouts and can even print photos (although this can quickly drain their small ink cartridges).

By contrast, the Psyber Psychiatry, December 2003). WiFi makes printing from your hotel room relatively easy.

Psyber Psychiatry, December 2004).

First, make sure the program you used to create the document is compatible with the business center’s computers. Because most business centers use the free Adobe document reader, your best bet is to convert the file to Adobe PDF, which maintains its format. Use PDFCreator or PrimoPDF to convert the file; both are free and work on Windows computers. Mac users can download the Mac-Net Freeware PDF file creator.

The future

Imagine a pocket-size device that prints onto a blank page as you move it across.

PrintDreams is developing such a device using its random-movement printing technology (RMPT). PrintDreams reports that the scanning device can print any document with 100% accuracy, though it seems best suited to text. The device is still a year or two from reaching the mainstream; PrintDreams is licensing its technology to other printer manufacturers.

Also, don’t be surprised if cellular phones one day have the capability to print e-mail attachments using Bluetooth or general packet radio service (GPRS), a very fast data transfer protocol on a GSM network.

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.

Wernicke’s encephalopathy is often missed in clinical practice.¹ Left untreated, the alcohol-induced amnestic disorder can progress to Korsakoff’s syndrome, a form of permanent short-term memory loss from which four out of five patients do not recover.²

Why Wernicke’s is missed

Lesions in the medial dorsal nucleus of the thalamus, hippocampus, and mammillary bodies cause signs and symptoms of Wernicke’s. Associated psychotic symptoms—including delusions, confusion, agitation, blunted to apathetic affect, and confabulation—may incorrectly suggest delirium tremens, alcohol-induced psychosis, delusional disorder, or dementia.

Key features of Wernicke’s are remembered with the acronym CANON:

Clouded consciousness with impaired orientation and inability to sustain attention to environmental stimuli.

Ataxia, primarily affecting gait

Nystagmus, mainly horizontal

Ophthalmoplegia accompanied by lateral orbital palsy and gaze palsy, which is usually bilateral. Anisocoria and a sluggish reaction to light also are present.

Neuropathy, mainly peripheral.

Early recognition and treatment is essential as early-stage Wernicke’s responds rapidly to parenteral thiamine, 100 mg/d for 5 to 7 days. Oral thiamine, 100 mg two to three times daily, is then given for 1 to 2 weeks.

Wernicke’s encephalopathy is often missed in clinical practice.¹ Left untreated, the alcohol-induced amnestic disorder can progress to Korsakoff’s syndrome, a form of permanent short-term memory loss from which four out of five patients do not recover.²

Why Wernicke’s is missed

Lesions in the medial dorsal nucleus of the thalamus, hippocampus, and mammillary bodies cause signs and symptoms of Wernicke’s. Associated psychotic symptoms—including delusions, confusion, agitation, blunted to apathetic affect, and confabulation—may incorrectly suggest delirium tremens, alcohol-induced psychosis, delusional disorder, or dementia.

Key features of Wernicke’s are remembered with the acronym CANON:

Clouded consciousness with impaired orientation and inability to sustain attention to environmental stimuli.

Ataxia, primarily affecting gait

Nystagmus, mainly horizontal

Ophthalmoplegia accompanied by lateral orbital palsy and gaze palsy, which is usually bilateral. Anisocoria and a sluggish reaction to light also are present.

Neuropathy, mainly peripheral.

Early recognition and treatment is essential as early-stage Wernicke’s responds rapidly to parenteral thiamine, 100 mg/d for 5 to 7 days. Oral thiamine, 100 mg two to three times daily, is then given for 1 to 2 weeks.

Wernicke’s encephalopathy is often missed in clinical practice.¹ Left untreated, the alcohol-induced amnestic disorder can progress to Korsakoff’s syndrome, a form of permanent short-term memory loss from which four out of five patients do not recover.²

Why Wernicke’s is missed

Lesions in the medial dorsal nucleus of the thalamus, hippocampus, and mammillary bodies cause signs and symptoms of Wernicke’s. Associated psychotic symptoms—including delusions, confusion, agitation, blunted to apathetic affect, and confabulation—may incorrectly suggest delirium tremens, alcohol-induced psychosis, delusional disorder, or dementia.

Key features of Wernicke’s are remembered with the acronym CANON:

Clouded consciousness with impaired orientation and inability to sustain attention to environmental stimuli.

Ataxia, primarily affecting gait

Nystagmus, mainly horizontal

Ophthalmoplegia accompanied by lateral orbital palsy and gaze palsy, which is usually bilateral. Anisocoria and a sluggish reaction to light also are present.

Neuropathy, mainly peripheral.

Early recognition and treatment is essential as early-stage Wernicke’s responds rapidly to parenteral thiamine, 100 mg/d for 5 to 7 days. Oral thiamine, 100 mg two to three times daily, is then given for 1 to 2 weeks.

A treatment-resistant patient’s medication history alone may not explain why trial after trial has failed. To help such patients, also evaluate their psychotherapy histories.

CASE: TWO DECADES OF DEPRESSION

Mrs. H, age 48, had battled depression for more than 20 years and had tried numerous antidepressants, including several tricyclics and one monoamine oxidase inhibitor. She was not working and resisted social interaction because of a persistent belief that she was inferior.

When Mrs. H consulted with me, she was seeing a psychiatrist once a month for medication management. She was taking fluoxetine, 80 mg/d, and methylphenidate, 10 mg tid, but remained hopeless and demoralized.

While taking her history, I learned that Mrs. H had been a successful art historian. She seemed surprised when I asked about this; she said her previous psychiatrist had never asked about her work.

I also learned that Mrs. H was relatively euthymic for nearly 7 years in her early 30s. During that time she married, found a challenging job, and received therapy from a psychologist who “really listened and took me seriously.”

I recommended weekly psychotherapy and medication management, both of which I would perform. The first sessions were rocky as several medication augmentation strategies led to side effects and little else. Finally, I left her medications alone and listened to her story.

After 2 years of psychotherapy, Mrs. H is optimistic despite multiple stressors. She is an involved wife and mother, works at a respected academic institution, and has a growing network of friends.

Four history lessons

My experience with Mrs. H and other patients taught me four key lessons about evaluating psychiatric treatment histories:

• Ask about all past and current therapy contacts. Get details on each type of therapy performed, frequency and duration, and patient response to the therapist and therapy.
  
• Look for clues that suggest the patient is open to psychotherapy. Does the patient seem interested in his/her inner life? Does he/she show insight into his/her role in certain situations, especially those involving interpersonal interactions? Can he/she process analogy or metaphor?¹
  
• Don’t be afraid to try psychotherapy with a medication-resistant patient. A round of intensive psychotherapy may calm residual depression or anxiety symptoms.
  
• When possible, perform the psychotherapy yourself to become more familiar with your patients—especially if you are prescribing medication.
  

A treatment-resistant patient’s medication history alone may not explain why trial after trial has failed. To help such patients, also evaluate their psychotherapy histories.

CASE: TWO DECADES OF DEPRESSION

Mrs. H, age 48, had battled depression for more than 20 years and had tried numerous antidepressants, including several tricyclics and one monoamine oxidase inhibitor. She was not working and resisted social interaction because of a persistent belief that she was inferior.

When Mrs. H consulted with me, she was seeing a psychiatrist once a month for medication management. She was taking fluoxetine, 80 mg/d, and methylphenidate, 10 mg tid, but remained hopeless and demoralized.

While taking her history, I learned that Mrs. H had been a successful art historian. She seemed surprised when I asked about this; she said her previous psychiatrist had never asked about her work.

I also learned that Mrs. H was relatively euthymic for nearly 7 years in her early 30s. During that time she married, found a challenging job, and received therapy from a psychologist who “really listened and took me seriously.”

I recommended weekly psychotherapy and medication management, both of which I would perform. The first sessions were rocky as several medication augmentation strategies led to side effects and little else. Finally, I left her medications alone and listened to her story.

After 2 years of psychotherapy, Mrs. H is optimistic despite multiple stressors. She is an involved wife and mother, works at a respected academic institution, and has a growing network of friends.

Four history lessons

My experience with Mrs. H and other patients taught me four key lessons about evaluating psychiatric treatment histories:

• Ask about all past and current therapy contacts. Get details on each type of therapy performed, frequency and duration, and patient response to the therapist and therapy.
  
• Look for clues that suggest the patient is open to psychotherapy. Does the patient seem interested in his/her inner life? Does he/she show insight into his/her role in certain situations, especially those involving interpersonal interactions? Can he/she process analogy or metaphor?¹
  
• Don’t be afraid to try psychotherapy with a medication-resistant patient. A round of intensive psychotherapy may calm residual depression or anxiety symptoms.
  
• When possible, perform the psychotherapy yourself to become more familiar with your patients—especially if you are prescribing medication.
  

A treatment-resistant patient’s medication history alone may not explain why trial after trial has failed. To help such patients, also evaluate their psychotherapy histories.

CASE: TWO DECADES OF DEPRESSION

Mrs. H, age 48, had battled depression for more than 20 years and had tried numerous antidepressants, including several tricyclics and one monoamine oxidase inhibitor. She was not working and resisted social interaction because of a persistent belief that she was inferior.

When Mrs. H consulted with me, she was seeing a psychiatrist once a month for medication management. She was taking fluoxetine, 80 mg/d, and methylphenidate, 10 mg tid, but remained hopeless and demoralized.

While taking her history, I learned that Mrs. H had been a successful art historian. She seemed surprised when I asked about this; she said her previous psychiatrist had never asked about her work.

I also learned that Mrs. H was relatively euthymic for nearly 7 years in her early 30s. During that time she married, found a challenging job, and received therapy from a psychologist who “really listened and took me seriously.”

I recommended weekly psychotherapy and medication management, both of which I would perform. The first sessions were rocky as several medication augmentation strategies led to side effects and little else. Finally, I left her medications alone and listened to her story.

After 2 years of psychotherapy, Mrs. H is optimistic despite multiple stressors. She is an involved wife and mother, works at a respected academic institution, and has a growing network of friends.

Four history lessons

My experience with Mrs. H and other patients taught me four key lessons about evaluating psychiatric treatment histories:

• Ask about all past and current therapy contacts. Get details on each type of therapy performed, frequency and duration, and patient response to the therapist and therapy.
  
• Look for clues that suggest the patient is open to psychotherapy. Does the patient seem interested in his/her inner life? Does he/she show insight into his/her role in certain situations, especially those involving interpersonal interactions? Can he/she process analogy or metaphor?¹
  
• Don’t be afraid to try psychotherapy with a medication-resistant patient. A round of intensive psychotherapy may calm residual depression or anxiety symptoms.
  
• When possible, perform the psychotherapy yourself to become more familiar with your patients—especially if you are prescribing medication.