Pearls

Exercise has been shown to significantly reduce depressive symptoms and decrease the chances of relapse.¹

If you’re having trouble getting a depressed patient for whom exercise is not contraindicated to take that first step on the road to fitness, the following motivational tips can help:

• Explain how exercise can decrease mild to moderate depressive symptoms and improve overall health.²
• Ask patients to document the time they spend watching television, sitting in traffic, or lying on the couch, and to compare this with time spent doing physical activity. By keeping this record, patients often discover they are not exercising nearly enough.
• Emphasize that yoga, t’ai chi, aerobics, and walking are all effective types of exercise. Patients often associate “exercise” with weightlifting or long-distance running and do not consider less-strenuous options.
• Tell unmotivated patients that getting started is the hardest part. The more a patient exercises, the more motivated he or she will feel.

Keys to safe exercise

Once the patient decides to begin exercising, tell him or her to:

• Start with a light-intensity workout and gradually increase the regimen’s intensity. Encourage the patient to start with at least a once-weekly routine and advise him or her that overexertion can lead to injury.

Have a physical therapist or exercise trainer devise the program. For older or medically ill patients, clearance from an internist or family physician may be necessary.

• Exercise where the patient feels most comfortable. For example, patients who are obese or are self-conscious in public settings may prefer to work out at home.
• Keep exercising regularly and in moderation to guard against exercise addiction, “burnout,” or overtraining. Warn patients that stopping regular exercise can lead to rebound depression, anxiety, and insomnia.³ These pitfalls—which could occur as early as 2 weeks after stopping—can derail a fitness regimen and obstruct future attempts at exercise.

Exercise has been shown to significantly reduce depressive symptoms and decrease the chances of relapse.¹

If you’re having trouble getting a depressed patient for whom exercise is not contraindicated to take that first step on the road to fitness, the following motivational tips can help:

• Explain how exercise can decrease mild to moderate depressive symptoms and improve overall health.²
• Ask patients to document the time they spend watching television, sitting in traffic, or lying on the couch, and to compare this with time spent doing physical activity. By keeping this record, patients often discover they are not exercising nearly enough.
• Emphasize that yoga, t’ai chi, aerobics, and walking are all effective types of exercise. Patients often associate “exercise” with weightlifting or long-distance running and do not consider less-strenuous options.
• Tell unmotivated patients that getting started is the hardest part. The more a patient exercises, the more motivated he or she will feel.

Keys to safe exercise

Once the patient decides to begin exercising, tell him or her to:

• Start with a light-intensity workout and gradually increase the regimen’s intensity. Encourage the patient to start with at least a once-weekly routine and advise him or her that overexertion can lead to injury.

Have a physical therapist or exercise trainer devise the program. For older or medically ill patients, clearance from an internist or family physician may be necessary.

• Exercise where the patient feels most comfortable. For example, patients who are obese or are self-conscious in public settings may prefer to work out at home.
• Keep exercising regularly and in moderation to guard against exercise addiction, “burnout,” or overtraining. Warn patients that stopping regular exercise can lead to rebound depression, anxiety, and insomnia.³ These pitfalls—which could occur as early as 2 weeks after stopping—can derail a fitness regimen and obstruct future attempts at exercise.

Exercise has been shown to significantly reduce depressive symptoms and decrease the chances of relapse.¹

If you’re having trouble getting a depressed patient for whom exercise is not contraindicated to take that first step on the road to fitness, the following motivational tips can help:

• Explain how exercise can decrease mild to moderate depressive symptoms and improve overall health.²
• Ask patients to document the time they spend watching television, sitting in traffic, or lying on the couch, and to compare this with time spent doing physical activity. By keeping this record, patients often discover they are not exercising nearly enough.
• Emphasize that yoga, t’ai chi, aerobics, and walking are all effective types of exercise. Patients often associate “exercise” with weightlifting or long-distance running and do not consider less-strenuous options.
• Tell unmotivated patients that getting started is the hardest part. The more a patient exercises, the more motivated he or she will feel.

Keys to safe exercise

Once the patient decides to begin exercising, tell him or her to:

• Start with a light-intensity workout and gradually increase the regimen’s intensity. Encourage the patient to start with at least a once-weekly routine and advise him or her that overexertion can lead to injury.

Have a physical therapist or exercise trainer devise the program. For older or medically ill patients, clearance from an internist or family physician may be necessary.

• Exercise where the patient feels most comfortable. For example, patients who are obese or are self-conscious in public settings may prefer to work out at home.
• Keep exercising regularly and in moderation to guard against exercise addiction, “burnout,” or overtraining. Warn patients that stopping regular exercise can lead to rebound depression, anxiety, and insomnia.³ These pitfalls—which could occur as early as 2 weeks after stopping—can derail a fitness regimen and obstruct future attempts at exercise.

Whether you’ve just completed your residency or have been in practice for years, attention to small details can make or break a practice.

The following five tips can help you start—or improve upon—a successful practice:

1. Spell out your billing procedures in writing. List specific fees (eg, consultation fee, 45-minute therapy visit, 15- to 20-minute medical evaluation) and payment schedules.
2. Obtain billing software, especially if you employ minimal office help. You’ll need to generate insurance-based invoices on paper and to episodically (weekly to monthly) print out patient bills in batches, depending on your practice’s size and caseload.
3. Return phone calls. This may seem basic, but patients expect their doctors to get back to them the same day.
4. Be nice to referral sources and to your staff. Niceness is a remarkably powerful tool that can help you forge valuable professional relationships and assist you clinically.
5. Provide consultation reports—typewritten and timely—to referral sources. Many doctors keep typed records of all office encounters. Thoroughly documenting the first meeting with a patient is particularly important to establish rapport with referral sources and to refresh your memory of the case when the patient reappears after a hiatus. These reports also help justify consultation fees.

Whether you’ve just completed your residency or have been in practice for years, attention to small details can make or break a practice.

The following five tips can help you start—or improve upon—a successful practice:

1. Spell out your billing procedures in writing. List specific fees (eg, consultation fee, 45-minute therapy visit, 15- to 20-minute medical evaluation) and payment schedules.
2. Obtain billing software, especially if you employ minimal office help. You’ll need to generate insurance-based invoices on paper and to episodically (weekly to monthly) print out patient bills in batches, depending on your practice’s size and caseload.
3. Return phone calls. This may seem basic, but patients expect their doctors to get back to them the same day.
4. Be nice to referral sources and to your staff. Niceness is a remarkably powerful tool that can help you forge valuable professional relationships and assist you clinically.
5. Provide consultation reports—typewritten and timely—to referral sources. Many doctors keep typed records of all office encounters. Thoroughly documenting the first meeting with a patient is particularly important to establish rapport with referral sources and to refresh your memory of the case when the patient reappears after a hiatus. These reports also help justify consultation fees.

Whether you’ve just completed your residency or have been in practice for years, attention to small details can make or break a practice.

The following five tips can help you start—or improve upon—a successful practice:

1. Spell out your billing procedures in writing. List specific fees (eg, consultation fee, 45-minute therapy visit, 15- to 20-minute medical evaluation) and payment schedules.
2. Obtain billing software, especially if you employ minimal office help. You’ll need to generate insurance-based invoices on paper and to episodically (weekly to monthly) print out patient bills in batches, depending on your practice’s size and caseload.
3. Return phone calls. This may seem basic, but patients expect their doctors to get back to them the same day.
4. Be nice to referral sources and to your staff. Niceness is a remarkably powerful tool that can help you forge valuable professional relationships and assist you clinically.
5. Provide consultation reports—typewritten and timely—to referral sources. Many doctors keep typed records of all office encounters. Thoroughly documenting the first meeting with a patient is particularly important to establish rapport with referral sources and to refresh your memory of the case when the patient reappears after a hiatus. These reports also help justify consultation fees.

You’re anxiously awaiting an important e-mail from a patient or colleague. You click into your in box, only to find a string of solicitations urging you to refinance your mortgage, buy cheap Viagra, or get rich quick.

Meanwhile, that important message may have been bounced back to the sender and lost.

This is just one way electronic junk mail, or spam, wreaks havoc on millions of e-mail users. If you’re tired of ‘spammers’ feeding you unwanted messages, read on.

Why spam is a problem

Mailing printed advertisements to 20 million people can cost tens of thousands of dollars in postage, mailing lists, and printing. By contrast, a spammer can reach that same audience for a fraction of the cost. Anyone with an Internet service provider (ISP) and a mass-mailing program can flood cyberspace with junk messages.

As a result, users waste precious time and money deleting junk messages by the score. Spam is especially costly to users who pay by the hour for dial-up Internet access.

What’s more, ISPs need to purchase additional processing servers to handle the increase in e-mail volume caused by excessive junk messages. This often leads to rate increases for subscribers with DSL, cable-modem, or other broadband connections.

Fighting back

Federal lawmakers have begun taking aim at unwanted e-mails. The Can Spam Act of 2003, which awaits a Senate vote, would outlaw misleading advertising and mandate a range of requirements on e-solicitors, from inclusion of unsubscribe options on messages to use of functional return e-mail addresses. Violators would face fines of as much as $1 million and/or 1 year in prison.¹ Several states, such as Minnesota, also have been considering fines for junk e-mail.²

In the meantime, users can take measures—common-sense and technological—against spam.

Follow these 4 steps

To keep your e-mail address out of spammers’ hands, do not:

1. Open spam messages. Just as traditional junk mail is immediately discarded, spam should be deleted without opening. By clicking anywhere in the body of the junk e-mail, the sender receives a return message that e-mail access is valid, subjecting you to more spam.
2. Click on the ‘unsubscribe’ link. “Spammers” will not honor this request but will instead store your e-mail address for future reference. For similar reasons, do not reply to the e-mail.
3. Post your e-mail address on a Web page. Many spammers use programs that “harvest” e-mail addresses. These programs are particularly attracted to Web pages with hyperlinked e-mail addresses.
4. Use an obvious address. Some spammers use “dictionary spamming” by combining common last names and initials to find new e-mail targets. Try to include unusual numeral and character combinations in your address.

Also, use “jsluo|at|email.com” instead of jsluo@email.com. Replacing @ with |at| prevents mass-mailing programs from automatically harvesting and using that address. However, some novice users may not realize they need to type |at| instead of @ to contact you.

Finally, use an alternate e-mail address for contests and newsletters if you suspect these will open the floodgates for spam.

Fighting spam with technology

Many free Web-based e-mail accounts such as Hotmail or Yahoo allow users to receive and delete e-mail in bulk by checking one box. Most providers also employ proprietary anti-spam software to protect their subscribers and servers.

E-mail clients such as Microsoft Outlook or Outlook Express allow you to set up rules to organize mail. Mail from certain users or with particular subjects can be automatically moved from the in box to designated folders. Messages containing terms such as ‘mortgage’ or ‘improve your sex life’ can be automatically deleted. Certain senders can be sent directly to the trash. Consult the “Help” section of these clients for directions.

Check your “deleted items” box to ensure that your rules are not sending important mail to the trash. Once you know that the rules work, you can automatically delete the files.

An anti-spam program can be added to your mail client (Table). These programs work via a combination of methods:

• The program checks a message’s subject content and source to see if the address matches with a list of known spammers. Most spam has a characteristic style, format and phrasing that programs can spot.
• Users can “teach” the program which e-mails to block by verifying wanted and unwanted messages. Some programs send an e-mail to the sender requesting verification. Once the sender replies, mail will go through automatically.

But be careful. If you set your filter to get rid of any subject with ‘urgent,’ the filter may block a patient’s urgent message.

Blowing the whistle

You can also report a spammer to his or her ISP, which in turn may rescind the spammer’s account or assess “cleanup fees.”

Programs such as SpamCop and the Network Abuse Clearinghouse offer reporting/filtering programs that electronically forward spam complaints to ISPs and, in some cases, get a spammer’s address blacklisted, meaning that the user can be denied Internet access through that ISP.

Senders who advertise fraudulent products can also be reported to the Federal Trade Commission. Those who advertise unapproved medical products can be reported to the Food and Drug Administration at (800) 532-4440.

Selected anti-spam programs

Related Resources

Spam safety tips. http://www.spamfilterreview.com/spam-saftey-tips.html

Spam Tips and Help. http://spam.abuse.net/userhelp/

Mark R. Senate panel overwhelmingly passes anti-spam bill. dc.internet.com June 19, 2003. Available at: http://dc.internet.com/news/article.php/2224681. Accessed Sept. 5, 2003

Sturdevant C. Can-Spam Act can’t. eWeek June 9, 2003. Available at: http://www.eweek.com/print_article/0,3668,a=43121,00.asp. Accessed Sept. 5, 2003

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

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’re anxiously awaiting an important e-mail from a patient or colleague. You click into your in box, only to find a string of solicitations urging you to refinance your mortgage, buy cheap Viagra, or get rich quick.

Meanwhile, that important message may have been bounced back to the sender and lost.

This is just one way electronic junk mail, or spam, wreaks havoc on millions of e-mail users. If you’re tired of ‘spammers’ feeding you unwanted messages, read on.

Why spam is a problem

Mailing printed advertisements to 20 million people can cost tens of thousands of dollars in postage, mailing lists, and printing. By contrast, a spammer can reach that same audience for a fraction of the cost. Anyone with an Internet service provider (ISP) and a mass-mailing program can flood cyberspace with junk messages.

As a result, users waste precious time and money deleting junk messages by the score. Spam is especially costly to users who pay by the hour for dial-up Internet access.

What’s more, ISPs need to purchase additional processing servers to handle the increase in e-mail volume caused by excessive junk messages. This often leads to rate increases for subscribers with DSL, cable-modem, or other broadband connections.

Fighting back

Federal lawmakers have begun taking aim at unwanted e-mails. The Can Spam Act of 2003, which awaits a Senate vote, would outlaw misleading advertising and mandate a range of requirements on e-solicitors, from inclusion of unsubscribe options on messages to use of functional return e-mail addresses. Violators would face fines of as much as $1 million and/or 1 year in prison.¹ Several states, such as Minnesota, also have been considering fines for junk e-mail.²

In the meantime, users can take measures—common-sense and technological—against spam.

Follow these 4 steps

To keep your e-mail address out of spammers’ hands, do not:

1. Open spam messages. Just as traditional junk mail is immediately discarded, spam should be deleted without opening. By clicking anywhere in the body of the junk e-mail, the sender receives a return message that e-mail access is valid, subjecting you to more spam.
2. Click on the ‘unsubscribe’ link. “Spammers” will not honor this request but will instead store your e-mail address for future reference. For similar reasons, do not reply to the e-mail.
3. Post your e-mail address on a Web page. Many spammers use programs that “harvest” e-mail addresses. These programs are particularly attracted to Web pages with hyperlinked e-mail addresses.
4. Use an obvious address. Some spammers use “dictionary spamming” by combining common last names and initials to find new e-mail targets. Try to include unusual numeral and character combinations in your address.

Also, use “jsluo|at|email.com” instead of jsluo@email.com. Replacing @ with |at| prevents mass-mailing programs from automatically harvesting and using that address. However, some novice users may not realize they need to type |at| instead of @ to contact you.

Finally, use an alternate e-mail address for contests and newsletters if you suspect these will open the floodgates for spam.

Fighting spam with technology

Many free Web-based e-mail accounts such as Hotmail or Yahoo allow users to receive and delete e-mail in bulk by checking one box. Most providers also employ proprietary anti-spam software to protect their subscribers and servers.

E-mail clients such as Microsoft Outlook or Outlook Express allow you to set up rules to organize mail. Mail from certain users or with particular subjects can be automatically moved from the in box to designated folders. Messages containing terms such as ‘mortgage’ or ‘improve your sex life’ can be automatically deleted. Certain senders can be sent directly to the trash. Consult the “Help” section of these clients for directions.

Check your “deleted items” box to ensure that your rules are not sending important mail to the trash. Once you know that the rules work, you can automatically delete the files.

An anti-spam program can be added to your mail client (Table). These programs work via a combination of methods:

• The program checks a message’s subject content and source to see if the address matches with a list of known spammers. Most spam has a characteristic style, format and phrasing that programs can spot.
• Users can “teach” the program which e-mails to block by verifying wanted and unwanted messages. Some programs send an e-mail to the sender requesting verification. Once the sender replies, mail will go through automatically.

But be careful. If you set your filter to get rid of any subject with ‘urgent,’ the filter may block a patient’s urgent message.

Blowing the whistle

You can also report a spammer to his or her ISP, which in turn may rescind the spammer’s account or assess “cleanup fees.”

Programs such as SpamCop and the Network Abuse Clearinghouse offer reporting/filtering programs that electronically forward spam complaints to ISPs and, in some cases, get a spammer’s address blacklisted, meaning that the user can be denied Internet access through that ISP.

Senders who advertise fraudulent products can also be reported to the Federal Trade Commission. Those who advertise unapproved medical products can be reported to the Food and Drug Administration at (800) 532-4440.

Selected anti-spam programs

Related Resources

Spam safety tips. http://www.spamfilterreview.com/spam-saftey-tips.html

Spam Tips and Help. http://spam.abuse.net/userhelp/

Mark R. Senate panel overwhelmingly passes anti-spam bill. dc.internet.com June 19, 2003. Available at: http://dc.internet.com/news/article.php/2224681. Accessed Sept. 5, 2003

Sturdevant C. Can-Spam Act can’t. eWeek June 9, 2003. Available at: http://www.eweek.com/print_article/0,3668,a=43121,00.asp. Accessed Sept. 5, 2003

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

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’re anxiously awaiting an important e-mail from a patient or colleague. You click into your in box, only to find a string of solicitations urging you to refinance your mortgage, buy cheap Viagra, or get rich quick.

Meanwhile, that important message may have been bounced back to the sender and lost.

This is just one way electronic junk mail, or spam, wreaks havoc on millions of e-mail users. If you’re tired of ‘spammers’ feeding you unwanted messages, read on.

Why spam is a problem

Mailing printed advertisements to 20 million people can cost tens of thousands of dollars in postage, mailing lists, and printing. By contrast, a spammer can reach that same audience for a fraction of the cost. Anyone with an Internet service provider (ISP) and a mass-mailing program can flood cyberspace with junk messages.

As a result, users waste precious time and money deleting junk messages by the score. Spam is especially costly to users who pay by the hour for dial-up Internet access.

What’s more, ISPs need to purchase additional processing servers to handle the increase in e-mail volume caused by excessive junk messages. This often leads to rate increases for subscribers with DSL, cable-modem, or other broadband connections.

Fighting back

Federal lawmakers have begun taking aim at unwanted e-mails. The Can Spam Act of 2003, which awaits a Senate vote, would outlaw misleading advertising and mandate a range of requirements on e-solicitors, from inclusion of unsubscribe options on messages to use of functional return e-mail addresses. Violators would face fines of as much as $1 million and/or 1 year in prison.¹ Several states, such as Minnesota, also have been considering fines for junk e-mail.²

In the meantime, users can take measures—common-sense and technological—against spam.

Follow these 4 steps

To keep your e-mail address out of spammers’ hands, do not:

1. Open spam messages. Just as traditional junk mail is immediately discarded, spam should be deleted without opening. By clicking anywhere in the body of the junk e-mail, the sender receives a return message that e-mail access is valid, subjecting you to more spam.
2. Click on the ‘unsubscribe’ link. “Spammers” will not honor this request but will instead store your e-mail address for future reference. For similar reasons, do not reply to the e-mail.
3. Post your e-mail address on a Web page. Many spammers use programs that “harvest” e-mail addresses. These programs are particularly attracted to Web pages with hyperlinked e-mail addresses.
4. Use an obvious address. Some spammers use “dictionary spamming” by combining common last names and initials to find new e-mail targets. Try to include unusual numeral and character combinations in your address.

Also, use “jsluo|at|email.com” instead of jsluo@email.com. Replacing @ with |at| prevents mass-mailing programs from automatically harvesting and using that address. However, some novice users may not realize they need to type |at| instead of @ to contact you.

Finally, use an alternate e-mail address for contests and newsletters if you suspect these will open the floodgates for spam.

Fighting spam with technology

Many free Web-based e-mail accounts such as Hotmail or Yahoo allow users to receive and delete e-mail in bulk by checking one box. Most providers also employ proprietary anti-spam software to protect their subscribers and servers.

E-mail clients such as Microsoft Outlook or Outlook Express allow you to set up rules to organize mail. Mail from certain users or with particular subjects can be automatically moved from the in box to designated folders. Messages containing terms such as ‘mortgage’ or ‘improve your sex life’ can be automatically deleted. Certain senders can be sent directly to the trash. Consult the “Help” section of these clients for directions.

Check your “deleted items” box to ensure that your rules are not sending important mail to the trash. Once you know that the rules work, you can automatically delete the files.

An anti-spam program can be added to your mail client (Table). These programs work via a combination of methods:

• The program checks a message’s subject content and source to see if the address matches with a list of known spammers. Most spam has a characteristic style, format and phrasing that programs can spot.
• Users can “teach” the program which e-mails to block by verifying wanted and unwanted messages. Some programs send an e-mail to the sender requesting verification. Once the sender replies, mail will go through automatically.

But be careful. If you set your filter to get rid of any subject with ‘urgent,’ the filter may block a patient’s urgent message.

Blowing the whistle

You can also report a spammer to his or her ISP, which in turn may rescind the spammer’s account or assess “cleanup fees.”

Programs such as SpamCop and the Network Abuse Clearinghouse offer reporting/filtering programs that electronically forward spam complaints to ISPs and, in some cases, get a spammer’s address blacklisted, meaning that the user can be denied Internet access through that ISP.

Senders who advertise fraudulent products can also be reported to the Federal Trade Commission. Those who advertise unapproved medical products can be reported to the Food and Drug Administration at (800) 532-4440.

Selected anti-spam programs

Related Resources

Spam safety tips. http://www.spamfilterreview.com/spam-saftey-tips.html

Spam Tips and Help. http://spam.abuse.net/userhelp/

Mark R. Senate panel overwhelmingly passes anti-spam bill. dc.internet.com June 19, 2003. Available at: http://dc.internet.com/news/article.php/2224681. Accessed Sept. 5, 2003

Sturdevant C. Can-Spam Act can’t. eWeek June 9, 2003. Available at: http://www.eweek.com/print_article/0,3668,a=43121,00.asp. Accessed Sept. 5, 2003

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

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.

Despite numerous drug treatment innovations, just about all patients with bipolar disorder that I have treated reported improvement after starting a lithium regimen.

In the 1970s, the clinical literature began highlighting numerous drug therapies for different bipolar symptoms. Before then, I had been taught to treat all “manic-depressive” patients with lithium—regardless of whether mood swings, bouts of anger, depression, or mania were the dominant symptoms.

So I experimented. I prescribed lithium to any potential bipolar patient who did not meet DSM criteria for another mental illness. I discovered the following:

1. A family history of any mental illness, especially alcohol abuse and depression, is a strong indicator of bipolar disorder and of potential positive response to lithium.
2. The existence of mood swings, especially without cause, confirms the diagnosis of bipolar disorder when paired with family history.
3. Lithium, 900 mg/d, works fine as acute or maintenance therapy. I would decrease the dosage for smaller people (eg, 600 mg/d for a patient weighing approximately 125 lbs). I would only increase the dosage—to 1,200 mg/d—for patients with severe mania.
4. Gauging lithium blood levels is a waste of time, assuming you have checked for kidney disease. Across 3 decades in practice, the only patient I have ever seen with an abnormally high lithium blood count also suffered renal failure.
5. Side effects I have seen most commonly with lithium are:
   • weight gain in women, in which case another medication should be prescribed
   • tremor, which should warrant a check of the patient’s caffeine intake.

Other side effects (such as diarrhea and GI upset) are usually mild and easy to control by adding other medications.

Despite numerous drug treatment innovations, just about all patients with bipolar disorder that I have treated reported improvement after starting a lithium regimen.

In the 1970s, the clinical literature began highlighting numerous drug therapies for different bipolar symptoms. Before then, I had been taught to treat all “manic-depressive” patients with lithium—regardless of whether mood swings, bouts of anger, depression, or mania were the dominant symptoms.

So I experimented. I prescribed lithium to any potential bipolar patient who did not meet DSM criteria for another mental illness. I discovered the following:

1. A family history of any mental illness, especially alcohol abuse and depression, is a strong indicator of bipolar disorder and of potential positive response to lithium.
2. The existence of mood swings, especially without cause, confirms the diagnosis of bipolar disorder when paired with family history.
3. Lithium, 900 mg/d, works fine as acute or maintenance therapy. I would decrease the dosage for smaller people (eg, 600 mg/d for a patient weighing approximately 125 lbs). I would only increase the dosage—to 1,200 mg/d—for patients with severe mania.
4. Gauging lithium blood levels is a waste of time, assuming you have checked for kidney disease. Across 3 decades in practice, the only patient I have ever seen with an abnormally high lithium blood count also suffered renal failure.
5. Side effects I have seen most commonly with lithium are:
   • weight gain in women, in which case another medication should be prescribed
   • tremor, which should warrant a check of the patient’s caffeine intake.

Other side effects (such as diarrhea and GI upset) are usually mild and easy to control by adding other medications.

Despite numerous drug treatment innovations, just about all patients with bipolar disorder that I have treated reported improvement after starting a lithium regimen.

In the 1970s, the clinical literature began highlighting numerous drug therapies for different bipolar symptoms. Before then, I had been taught to treat all “manic-depressive” patients with lithium—regardless of whether mood swings, bouts of anger, depression, or mania were the dominant symptoms.

So I experimented. I prescribed lithium to any potential bipolar patient who did not meet DSM criteria for another mental illness. I discovered the following:

1. A family history of any mental illness, especially alcohol abuse and depression, is a strong indicator of bipolar disorder and of potential positive response to lithium.
2. The existence of mood swings, especially without cause, confirms the diagnosis of bipolar disorder when paired with family history.
3. Lithium, 900 mg/d, works fine as acute or maintenance therapy. I would decrease the dosage for smaller people (eg, 600 mg/d for a patient weighing approximately 125 lbs). I would only increase the dosage—to 1,200 mg/d—for patients with severe mania.
4. Gauging lithium blood levels is a waste of time, assuming you have checked for kidney disease. Across 3 decades in practice, the only patient I have ever seen with an abnormally high lithium blood count also suffered renal failure.
5. Side effects I have seen most commonly with lithium are:
   • weight gain in women, in which case another medication should be prescribed
   • tremor, which should warrant a check of the patient’s caffeine intake.

Other side effects (such as diarrhea and GI upset) are usually mild and easy to control by adding other medications.

Psychotic disorders are difficult to detect in children and adolescents. Such disorders often masquerade as a general medical condition or as a substance abuse, anxiety, mood, or pervasive developmental disorder. On the other hand, some youths whose presentations meet no psychiatric syndrome criteria may complain of psychotic symptoms.¹

Consider these six issues when a youth presents with symptoms that may indicate psychosis.

1. Mood disorders. Psychotic symptoms in the young:
   • often point to major depression with psychotic features¹
   • are common in youths with bipolar disorder and may initially be misidentified as onset of schizophrenia.² Conversely, negative symptoms of schizophrenia may be mistaken for major depression.
2. Cluster of symptoms. Psychosis is characterized by positive and negative symptoms and by symptoms of disorganization such as thought disorder. Youths with schizophrenia present with a cluster of psychotic symptoms.^3,4
3. Age. Childhood-onset schizophrenia is rare; adolescent-onset schizophrenia is not.⁵ The younger the patient, the less likely he or she is psychotic.
4. Course. A careful retrospective assessment may confirm schizophrenia by uncovering premorbid difficulties with function and a prodrome that preceded more-extensive symptom expression.⁴
5. Family history. Genetics are an important risk factor for schizophrenia.⁶ A thorough family history may help assess for schizophrenia and schizophrenia-spectrum disorders (including cluster A personality disorders).
6. Multidimensionally impaired syndrome (MIS). Patients with MIS do not have schizophrenia per se. Their symptoms include mild hallucinations, mood instability, social skills deficits, neuropsychological impairments, or excessive preoccupations with fantasy or magical thinking that are developmentally inappropriate but not clearly delusional.⁷

Psychotic disorders are difficult to detect in children and adolescents. Such disorders often masquerade as a general medical condition or as a substance abuse, anxiety, mood, or pervasive developmental disorder. On the other hand, some youths whose presentations meet no psychiatric syndrome criteria may complain of psychotic symptoms.¹

Consider these six issues when a youth presents with symptoms that may indicate psychosis.

1. Mood disorders. Psychotic symptoms in the young:
   • often point to major depression with psychotic features¹
   • are common in youths with bipolar disorder and may initially be misidentified as onset of schizophrenia.² Conversely, negative symptoms of schizophrenia may be mistaken for major depression.
2. Cluster of symptoms. Psychosis is characterized by positive and negative symptoms and by symptoms of disorganization such as thought disorder. Youths with schizophrenia present with a cluster of psychotic symptoms.^3,4
3. Age. Childhood-onset schizophrenia is rare; adolescent-onset schizophrenia is not.⁵ The younger the patient, the less likely he or she is psychotic.
4. Course. A careful retrospective assessment may confirm schizophrenia by uncovering premorbid difficulties with function and a prodrome that preceded more-extensive symptom expression.⁴
5. Family history. Genetics are an important risk factor for schizophrenia.⁶ A thorough family history may help assess for schizophrenia and schizophrenia-spectrum disorders (including cluster A personality disorders).
6. Multidimensionally impaired syndrome (MIS). Patients with MIS do not have schizophrenia per se. Their symptoms include mild hallucinations, mood instability, social skills deficits, neuropsychological impairments, or excessive preoccupations with fantasy or magical thinking that are developmentally inappropriate but not clearly delusional.⁷

Psychotic disorders are difficult to detect in children and adolescents. Such disorders often masquerade as a general medical condition or as a substance abuse, anxiety, mood, or pervasive developmental disorder. On the other hand, some youths whose presentations meet no psychiatric syndrome criteria may complain of psychotic symptoms.¹

Consider these six issues when a youth presents with symptoms that may indicate psychosis.

1. Mood disorders. Psychotic symptoms in the young:
   • often point to major depression with psychotic features¹
   • are common in youths with bipolar disorder and may initially be misidentified as onset of schizophrenia.² Conversely, negative symptoms of schizophrenia may be mistaken for major depression.
2. Cluster of symptoms. Psychosis is characterized by positive and negative symptoms and by symptoms of disorganization such as thought disorder. Youths with schizophrenia present with a cluster of psychotic symptoms.^3,4
3. Age. Childhood-onset schizophrenia is rare; adolescent-onset schizophrenia is not.⁵ The younger the patient, the less likely he or she is psychotic.
4. Course. A careful retrospective assessment may confirm schizophrenia by uncovering premorbid difficulties with function and a prodrome that preceded more-extensive symptom expression.⁴
5. Family history. Genetics are an important risk factor for schizophrenia.⁶ A thorough family history may help assess for schizophrenia and schizophrenia-spectrum disorders (including cluster A personality disorders).
6. Multidimensionally impaired syndrome (MIS). Patients with MIS do not have schizophrenia per se. Their symptoms include mild hallucinations, mood instability, social skills deficits, neuropsychological impairments, or excessive preoccupations with fantasy or magical thinking that are developmentally inappropriate but not clearly delusional.⁷

Today’s physician needs to stay abreast of ever-changing prescribing information. Print and CD-ROM drug guides, long regarded as the gold standard in clinical reference, are constrained by press deadlines and start becoming outdated upon publication.

Electronic drug guides, available online or via handheld computers, are updated regularly and provide real-time developments about drug alerts, safety recalls, and changes in prescribing information.

Online drug guides

Benefits. Drug-drug interactions can be checked with a couple of clicks. By contrast, scanning printed lists of interactions for each medication could cost you valuable time.

Some electronic guides list the medication’s cost and formulary availability in addition to dosing, indication(s), drug mechanism, precautions, and adverse reactions.

Drawbacks. Depending on the type of subscription, access to an online drug reference may be restricted. Many institutions purchase access to online references, which are readily available at any terminal or computer in the hospital network. When attempting to access the resource from an outside computer, however, access is denied.

Some facilities circumvent this problem by providing a proxy server to relay access or use a virtual private network to connect to the hospital network. Individual subscriptions, which provide access via password, do not have this limitation.

The table lists benefits and drawbacks of individual programs.

Drug guides for handhelds

Drug guides for personal digital assistants are more accessible, but many handhelds lack sufficient memory for the guides’ databases and programs.

Some programs, such as the American Hospital Formulary Service guide and Physicians’ Desk Reference, can operate from external memory-such as secure digital or compact flash-thus preserving the limited main memory of most handhelds. In working this way, however, these programs’ databases often cannot be updated automatically and require user intervention.

The handheld’s small screen size is another potential drawback. The better handheld drug guides are designed to maximize limited screen space and promote easy navigation by utilizing hyperlinks to jump to related information or pop up windows to provide additional information. Ideally, content should be succinct yet offer sufficient detail.

How to choose a drug reference guide

Electronic drug reference guides vary greatly in their detail, organization of content, and ease of navigation and downloading. To decide which drug reference guide is right for you, try several demonstration versions:

• Compare different features. Look for sufficient content and intuitive navigation.
• Find out if pre-made patient education brochures are available for printing.
• For handheld guides, determine how much memory is required by the program and databases, how often they must be updated, and whether they can be stored on external memory.
• Ask if discounts are offered for purchases during trade shows or for a combination purchase of the guide’s online and handheld versions.

The following table, which lists quick reviews of reference guide demonstration products, can help you explore the options.

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to: Current.Psychiatry@dowdenhealth.com.

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.

Today’s physician needs to stay abreast of ever-changing prescribing information. Print and CD-ROM drug guides, long regarded as the gold standard in clinical reference, are constrained by press deadlines and start becoming outdated upon publication.

Electronic drug guides, available online or via handheld computers, are updated regularly and provide real-time developments about drug alerts, safety recalls, and changes in prescribing information.

Online drug guides

Benefits. Drug-drug interactions can be checked with a couple of clicks. By contrast, scanning printed lists of interactions for each medication could cost you valuable time.

Some electronic guides list the medication’s cost and formulary availability in addition to dosing, indication(s), drug mechanism, precautions, and adverse reactions.

Drawbacks. Depending on the type of subscription, access to an online drug reference may be restricted. Many institutions purchase access to online references, which are readily available at any terminal or computer in the hospital network. When attempting to access the resource from an outside computer, however, access is denied.

Some facilities circumvent this problem by providing a proxy server to relay access or use a virtual private network to connect to the hospital network. Individual subscriptions, which provide access via password, do not have this limitation.

The table lists benefits and drawbacks of individual programs.

Drug guides for handhelds

Drug guides for personal digital assistants are more accessible, but many handhelds lack sufficient memory for the guides’ databases and programs.

Some programs, such as the American Hospital Formulary Service guide and Physicians’ Desk Reference, can operate from external memory-such as secure digital or compact flash-thus preserving the limited main memory of most handhelds. In working this way, however, these programs’ databases often cannot be updated automatically and require user intervention.

The handheld’s small screen size is another potential drawback. The better handheld drug guides are designed to maximize limited screen space and promote easy navigation by utilizing hyperlinks to jump to related information or pop up windows to provide additional information. Ideally, content should be succinct yet offer sufficient detail.

How to choose a drug reference guide

Electronic drug reference guides vary greatly in their detail, organization of content, and ease of navigation and downloading. To decide which drug reference guide is right for you, try several demonstration versions:

• Compare different features. Look for sufficient content and intuitive navigation.
• Find out if pre-made patient education brochures are available for printing.
• For handheld guides, determine how much memory is required by the program and databases, how often they must be updated, and whether they can be stored on external memory.
• Ask if discounts are offered for purchases during trade shows or for a combination purchase of the guide’s online and handheld versions.

The following table, which lists quick reviews of reference guide demonstration products, can help you explore the options.

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to: Current.Psychiatry@dowdenhealth.com.

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.

Today’s physician needs to stay abreast of ever-changing prescribing information. Print and CD-ROM drug guides, long regarded as the gold standard in clinical reference, are constrained by press deadlines and start becoming outdated upon publication.

Electronic drug guides, available online or via handheld computers, are updated regularly and provide real-time developments about drug alerts, safety recalls, and changes in prescribing information.

Online drug guides

Benefits. Drug-drug interactions can be checked with a couple of clicks. By contrast, scanning printed lists of interactions for each medication could cost you valuable time.

Some electronic guides list the medication’s cost and formulary availability in addition to dosing, indication(s), drug mechanism, precautions, and adverse reactions.

Drawbacks. Depending on the type of subscription, access to an online drug reference may be restricted. Many institutions purchase access to online references, which are readily available at any terminal or computer in the hospital network. When attempting to access the resource from an outside computer, however, access is denied.

Some facilities circumvent this problem by providing a proxy server to relay access or use a virtual private network to connect to the hospital network. Individual subscriptions, which provide access via password, do not have this limitation.

The table lists benefits and drawbacks of individual programs.

Drug guides for handhelds

Drug guides for personal digital assistants are more accessible, but many handhelds lack sufficient memory for the guides’ databases and programs.

Some programs, such as the American Hospital Formulary Service guide and Physicians’ Desk Reference, can operate from external memory-such as secure digital or compact flash-thus preserving the limited main memory of most handhelds. In working this way, however, these programs’ databases often cannot be updated automatically and require user intervention.

The handheld’s small screen size is another potential drawback. The better handheld drug guides are designed to maximize limited screen space and promote easy navigation by utilizing hyperlinks to jump to related information or pop up windows to provide additional information. Ideally, content should be succinct yet offer sufficient detail.

How to choose a drug reference guide

Electronic drug reference guides vary greatly in their detail, organization of content, and ease of navigation and downloading. To decide which drug reference guide is right for you, try several demonstration versions:

• Compare different features. Look for sufficient content and intuitive navigation.
• Find out if pre-made patient education brochures are available for printing.
• For handheld guides, determine how much memory is required by the program and databases, how often they must be updated, and whether they can be stored on external memory.
• Ask if discounts are offered for purchases during trade shows or for a combination purchase of the guide’s online and handheld versions.

The following table, which lists quick reviews of reference guide demonstration products, can help you explore the options.

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to: Current.Psychiatry@dowdenhealth.com.

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.

Severely mentally ill patients often do not get the care they need for chronic medical conditions such as diabetes, hypertension, or hepatitis C. They may lack insurance, forget follow-up appointments, or fail to provide adequate or accurate history because of cognitive deficits. Some fear blood work or other tests, and many adhere poorly to treatment.

12 ways to expedite care

The following tips can help remove some of these roadblocks to proper care:

1. Review the patient’s records—psychiatric and medical—to obtain information the patient might not have provided.
   
2. Explain the medical problem in terms the patient understands. Describe why an evaluation or treatment is necessary.
   
3. Ask the patient’s case manager or program nurse to follow up with the patient.
   
4. Refer the patient to a family doctor or internist who participates in the patient’s insurance plan and with whom he or she is comfortable.
   
5. Remind the patient of his or her appointment, preferably that morning. If possible, have the case manager arrange transportation.
   
6. Have a family member or staff member accompany the patient on the visit if the patient expresses fear beforehand. Consider offering an anxiolytic to be taken the day of the visit as needed. Above all, be encouraging.
   
7. Write a note to the doctor about the reason for the referral. Include some history because the patient may not be able to give it, especially within a 15-minute office visit.
   
8. Order specific blood work to be drawn before the visit, if indicated. Have results sent to the doctor’s office.
   
9. Consider screening high-risk patients for hepatitis, including those with a history of IV drug use or multiple sexual partners. Do not automatically attribute liver enzyme elevations to divalproex.
   
10. Review your patient’s diet and exercise habits. Politely discourage excessive sugar and caffeine intake. I always keep some bottled water and raw vegetables on hand to model recommended habits. Many patients have limited incomes, so recommend affordable, healthy foods.
    
11. Monitor for side effects of psychotropics, such as white blood counts for patients on clozapine, liver function and platelet counts with valproate, renal and thyroid function with lithium, etc.
    
12. Don’t give up. If your patient has missed multiple doctors’ appointments, keeps insisting he or she is not sick, or repeatedly fails to comply with diet or medication, continue to be encouraging and advocate the need for proper care.
    

• Clozapine • Clozaril
  
• Divalproex • Depakote
  
• Lithium • Eskalith, Lithobid, others
  
• Valproate • Depacon
  

Severely mentally ill patients often do not get the care they need for chronic medical conditions such as diabetes, hypertension, or hepatitis C. They may lack insurance, forget follow-up appointments, or fail to provide adequate or accurate history because of cognitive deficits. Some fear blood work or other tests, and many adhere poorly to treatment.

12 ways to expedite care

The following tips can help remove some of these roadblocks to proper care:

1. Review the patient’s records—psychiatric and medical—to obtain information the patient might not have provided.
   
2. Explain the medical problem in terms the patient understands. Describe why an evaluation or treatment is necessary.
   
3. Ask the patient’s case manager or program nurse to follow up with the patient.
   
4. Refer the patient to a family doctor or internist who participates in the patient’s insurance plan and with whom he or she is comfortable.
   
5. Remind the patient of his or her appointment, preferably that morning. If possible, have the case manager arrange transportation.
   
6. Have a family member or staff member accompany the patient on the visit if the patient expresses fear beforehand. Consider offering an anxiolytic to be taken the day of the visit as needed. Above all, be encouraging.
   
7. Write a note to the doctor about the reason for the referral. Include some history because the patient may not be able to give it, especially within a 15-minute office visit.
   
8. Order specific blood work to be drawn before the visit, if indicated. Have results sent to the doctor’s office.
   
9. Consider screening high-risk patients for hepatitis, including those with a history of IV drug use or multiple sexual partners. Do not automatically attribute liver enzyme elevations to divalproex.
   
10. Review your patient’s diet and exercise habits. Politely discourage excessive sugar and caffeine intake. I always keep some bottled water and raw vegetables on hand to model recommended habits. Many patients have limited incomes, so recommend affordable, healthy foods.
    
11. Monitor for side effects of psychotropics, such as white blood counts for patients on clozapine, liver function and platelet counts with valproate, renal and thyroid function with lithium, etc.
    
12. Don’t give up. If your patient has missed multiple doctors’ appointments, keeps insisting he or she is not sick, or repeatedly fails to comply with diet or medication, continue to be encouraging and advocate the need for proper care.
    

• Clozapine • Clozaril
  
• Divalproex • Depakote
  
• Lithium • Eskalith, Lithobid, others
  
• Valproate • Depacon
  

Severely mentally ill patients often do not get the care they need for chronic medical conditions such as diabetes, hypertension, or hepatitis C. They may lack insurance, forget follow-up appointments, or fail to provide adequate or accurate history because of cognitive deficits. Some fear blood work or other tests, and many adhere poorly to treatment.

12 ways to expedite care

The following tips can help remove some of these roadblocks to proper care:

1. Review the patient’s records—psychiatric and medical—to obtain information the patient might not have provided.
   
2. Explain the medical problem in terms the patient understands. Describe why an evaluation or treatment is necessary.
   
3. Ask the patient’s case manager or program nurse to follow up with the patient.
   
4. Refer the patient to a family doctor or internist who participates in the patient’s insurance plan and with whom he or she is comfortable.
   
5. Remind the patient of his or her appointment, preferably that morning. If possible, have the case manager arrange transportation.
   
6. Have a family member or staff member accompany the patient on the visit if the patient expresses fear beforehand. Consider offering an anxiolytic to be taken the day of the visit as needed. Above all, be encouraging.
   
7. Write a note to the doctor about the reason for the referral. Include some history because the patient may not be able to give it, especially within a 15-minute office visit.
   
8. Order specific blood work to be drawn before the visit, if indicated. Have results sent to the doctor’s office.
   
9. Consider screening high-risk patients for hepatitis, including those with a history of IV drug use or multiple sexual partners. Do not automatically attribute liver enzyme elevations to divalproex.
   
10. Review your patient’s diet and exercise habits. Politely discourage excessive sugar and caffeine intake. I always keep some bottled water and raw vegetables on hand to model recommended habits. Many patients have limited incomes, so recommend affordable, healthy foods.
    
11. Monitor for side effects of psychotropics, such as white blood counts for patients on clozapine, liver function and platelet counts with valproate, renal and thyroid function with lithium, etc.
    
12. Don’t give up. If your patient has missed multiple doctors’ appointments, keeps insisting he or she is not sick, or repeatedly fails to comply with diet or medication, continue to be encouraging and advocate the need for proper care.
    

• Clozapine • Clozaril
  
• Divalproex • Depakote
  
• Lithium • Eskalith, Lithobid, others
  
• Valproate • Depacon
  

Psyber Psychiatry, February. A few voice command programs also are available for Pocket PC devices ARTrecognition, VoiceLookup, PDsay, and VoiceContact allow you to use voice commands to lookup information and launch tasks.

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

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.

Psyber Psychiatry, February. A few voice command programs also are available for Pocket PC devices ARTrecognition, VoiceLookup, PDsay, and VoiceContact allow you to use voice commands to lookup information and launch tasks.

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

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.

Psyber Psychiatry, February. A few voice command programs also are available for Pocket PC devices ARTrecognition, VoiceLookup, PDsay, and VoiceContact allow you to use voice commands to lookup information and launch tasks.

If you have any questions about these products or comments about Psyber Psychiatry, click here to contact Dr. Luo or send an e-mail to Current.Psychiatry@dowdenhealth.com.

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.

Long-acting intramuscular (IM) antipsychotics are necessary for patients who do not respond to—or comply with—oral medication regimens. We can make these injections less painful, provided that agitation does not complicate treatment.

In 25 years of practice, I’ve discovered the following ways to diminish the pain of injection:

• Inject into the deltoid’s posterior aspect. Nociceptive pain fibers may be less dense in the posterior versus the anterior deltoid. I try to inject latitudinally about 1 cm behind the deltoid midline and longitudinally about 5 cm below the acromioclavicular joint.
• Inject into the lateral gluteusto avoid stimulating the sciatic nerve that runs down the medial gluteus.
• Have the patient fold his or her arm across the lap.Muscles that are relaxed before injection are less likely to hurt afterward. The arm’s flexed position will help relax the deltoid.
• Massage the muscle area overlying the injection sitefor about 10 seconds before injecting. This further relaxes the muscle.
• Inject slowly—about 30 seconds per cc. A faster injection can increase pain.
• Inject air into the vial before withdrawing. Commonly used injectable psychiatric drugs are based in sesame oil. Withdrawing these viscous medications through the perforation site can be difficult if the vial is partially evacuated and the remaining fluid is under negative atmospheric pressure.

Some clinicians use the “Z technique” to prevent backflow when injecting IM antipsychotics. With this method, skin and subcutaneous tissue are retracted to avoid creating a straight-line needle tract that would allow the ready backflow of injected material.

I feel this method is unnecessary for decanoate preparations; they are viscous enough to prevent significant backflow provided the injection is slowly administered.

To IM or not to IM

Where possible, administering medications subcutaneously instead of intramuscularly can also reduce pain.

Contrary to popular belief, fluphenazine decanoate can be administered subcutaneously, using a 5/8-inch, 22-gauge needle for patients who fear long needles or are exquisitely sensitive to pain. IM administration is required for haloperidol decanoate, however.

50 vs. 100 mg/cc

Choice of preparation can also promote post-injection comfort. I have heard patients occasionally complain of lingering muscular discomfort after receiving the 100 mg/cc haloperidol decanoate preparation, but I have never heard such complaints after administering haloperidol, 50 mg/cc, or fluphenazine, 25 mg/cc.

Drug brand names

• Fluphenazine • Prolixin
• Haloperidol • Haldol

Long-acting intramuscular (IM) antipsychotics are necessary for patients who do not respond to—or comply with—oral medication regimens. We can make these injections less painful, provided that agitation does not complicate treatment.

In 25 years of practice, I’ve discovered the following ways to diminish the pain of injection:

• Inject into the deltoid’s posterior aspect. Nociceptive pain fibers may be less dense in the posterior versus the anterior deltoid. I try to inject latitudinally about 1 cm behind the deltoid midline and longitudinally about 5 cm below the acromioclavicular joint.
• Inject into the lateral gluteusto avoid stimulating the sciatic nerve that runs down the medial gluteus.
• Have the patient fold his or her arm across the lap.Muscles that are relaxed before injection are less likely to hurt afterward. The arm’s flexed position will help relax the deltoid.
• Massage the muscle area overlying the injection sitefor about 10 seconds before injecting. This further relaxes the muscle.
• Inject slowly—about 30 seconds per cc. A faster injection can increase pain.
• Inject air into the vial before withdrawing. Commonly used injectable psychiatric drugs are based in sesame oil. Withdrawing these viscous medications through the perforation site can be difficult if the vial is partially evacuated and the remaining fluid is under negative atmospheric pressure.

Some clinicians use the “Z technique” to prevent backflow when injecting IM antipsychotics. With this method, skin and subcutaneous tissue are retracted to avoid creating a straight-line needle tract that would allow the ready backflow of injected material.

I feel this method is unnecessary for decanoate preparations; they are viscous enough to prevent significant backflow provided the injection is slowly administered.

To IM or not to IM

Where possible, administering medications subcutaneously instead of intramuscularly can also reduce pain.

Contrary to popular belief, fluphenazine decanoate can be administered subcutaneously, using a 5/8-inch, 22-gauge needle for patients who fear long needles or are exquisitely sensitive to pain. IM administration is required for haloperidol decanoate, however.

50 vs. 100 mg/cc

Choice of preparation can also promote post-injection comfort. I have heard patients occasionally complain of lingering muscular discomfort after receiving the 100 mg/cc haloperidol decanoate preparation, but I have never heard such complaints after administering haloperidol, 50 mg/cc, or fluphenazine, 25 mg/cc.

Drug brand names

• Fluphenazine • Prolixin
• Haloperidol • Haldol

Long-acting intramuscular (IM) antipsychotics are necessary for patients who do not respond to—or comply with—oral medication regimens. We can make these injections less painful, provided that agitation does not complicate treatment.

In 25 years of practice, I’ve discovered the following ways to diminish the pain of injection:

• Inject into the deltoid’s posterior aspect. Nociceptive pain fibers may be less dense in the posterior versus the anterior deltoid. I try to inject latitudinally about 1 cm behind the deltoid midline and longitudinally about 5 cm below the acromioclavicular joint.
• Inject into the lateral gluteusto avoid stimulating the sciatic nerve that runs down the medial gluteus.
• Have the patient fold his or her arm across the lap.Muscles that are relaxed before injection are less likely to hurt afterward. The arm’s flexed position will help relax the deltoid.
• Massage the muscle area overlying the injection sitefor about 10 seconds before injecting. This further relaxes the muscle.
• Inject slowly—about 30 seconds per cc. A faster injection can increase pain.
• Inject air into the vial before withdrawing. Commonly used injectable psychiatric drugs are based in sesame oil. Withdrawing these viscous medications through the perforation site can be difficult if the vial is partially evacuated and the remaining fluid is under negative atmospheric pressure.

Some clinicians use the “Z technique” to prevent backflow when injecting IM antipsychotics. With this method, skin and subcutaneous tissue are retracted to avoid creating a straight-line needle tract that would allow the ready backflow of injected material.

I feel this method is unnecessary for decanoate preparations; they are viscous enough to prevent significant backflow provided the injection is slowly administered.

To IM or not to IM

Where possible, administering medications subcutaneously instead of intramuscularly can also reduce pain.

Contrary to popular belief, fluphenazine decanoate can be administered subcutaneously, using a 5/8-inch, 22-gauge needle for patients who fear long needles or are exquisitely sensitive to pain. IM administration is required for haloperidol decanoate, however.

50 vs. 100 mg/cc

Choice of preparation can also promote post-injection comfort. I have heard patients occasionally complain of lingering muscular discomfort after receiving the 100 mg/cc haloperidol decanoate preparation, but I have never heard such complaints after administering haloperidol, 50 mg/cc, or fluphenazine, 25 mg/cc.

Drug brand names

• Fluphenazine • Prolixin
• Haloperidol • Haldol