Pearls

Search engines are the express lanes of the Internet. Knowing how to navigate them can help you get exactly the information you need in seconds flat.

This article will address the differences between search engines, offer basic and advanced search methods, and discuss Web search technologies and alternatives.

How search engines work

Search engines employ different methods of finding Web pages and ranking them according to relevance of information requested.¹

Search engines such as Google and Altavista gather information by “crawling” or “spidering” through the Web. They check all the pages in a site and then proceed through pages linked to that site. As it progresses, it creates an indexed database of the content of each page it finds. Some search engines index more Web pages than others, while others update their indexes more often.

Many search engines pick up on how often and where the key word appears on a Web page.² Pages on which key words appear more frequently or near the top usually will be deemed more relevant.

Search engines garner additional listings by charging advertisers to list their Web sites (e.g., a pharmaceutical company’s site promoting a particular drug) among the search results. These listings vary from paid placement, where sites are guaranteed a high ranking, to paid inclusion, by which an advertisement might be listed in more search requests.³

Taken together, these methods can generate millions of search results for a user who enters a broad topic. For example, entering “depression” in the Google search field produces 5,420,000 links ranging from product sites, government agencies and academic departments, to advocacy organizations and patients’ blogs. Unless the page relevant to you happens to be among the top five search results, you will need to refine your search. Fortunately, there are many ways to do this.

Refining your search: Basic tips

Say you’re trying to find this article without a link or a URL. Just follow these simple key word tips.⁴

• First, try the obvious. Enter Psyber Psychiatry.
• Use words likely to appear on a site with the information you want (e.g., psychiatry, John Luo).
• Make key words as specific as possible-for example, Current Psychiatry Psyber vs. Psyber Psychiatry

Google and most search engines assume that you want to find pages with all the words you have entered. Other search engines, such as Teoma, usually generate pages containing all key words preceded by a + (e.g., +Current +Psychiatry will produce a link to this Web site).

If that search produces too many results, you can eliminate sites containing certain key words by inserting a - before the key word (e.g., +current +psychiatry -American -psychology). Your search still may be too broad, however, because the words “current” and “psychiatry” could appear anywhere on the site-including pages you’re trying to rule out. Placing key words within quotation marks (e.g., “Current Psychiatry” “Psyber Psychiatry”) can eliminate still more sites.

Advanced searches

If your search requires even more fine-tuning, consider the following:

Site search. Specifying a site in your query can uncover references to specific topics. For example, enter computers site: www.currentpsychiatry.com in Google to find all pages with computers mentioned on the Current Psychiatry Web site. Other sites such as AltaVista use the term host: instead of site:.

Title search. Every Web page has an HTML title, which is also searched by the spider programs. Because an HTML title usually is indicative of the site’s content, searching through these titles may point to relevant information. Use allintitle: or intitle: to find a site (e.g., intitle:currentpsychiatry).

URL search. Similar to a site and title search, you can also search for words in the URL of a Web page. For example, in Google try entering current inurl:psychiatry or inurl:currentpsychiatry.

Some search engines employ techniques such as “clustering” (prevents a search from finding too many results from the same site), “stemming” (searches for variations of a word), and “find similar” (seeks out other pages with similar information). Some sites offer “related searches” or “search again” options to help users zero in on the desired information.

Confused about which commands and search features work for which search engines? searchenginewatch.com offers a comprehensive list of basic and power search commands, search assistance features, customization and display features, and Boolean commands.

Because Google is the most popular search engine, many search tools have been developed based on the Google engine. Fagan Finder provides a Web-based interface to Google that lets users search by exact phrase, any/all words, subject, author, and many other ways. Visualization technologies such as Touchgraph and Anacubis, both of which are connected to Google, allow searchers to visually explore and navigate relationships between Web sites.

KartOO is a metasearch engine with visual display interfaces. A metasearch engine uses other search engines to find information. After you enter a search term, KartOO launches the query to a set of search engines, compiles the results, and presents them in a series of interactive maps through a proprietary algorithm. Users can narrow the search by clicking on one of the plus/minus icons and categories between the results.

When all else fails …

If you cannot be bothered with search engine tricks and tools, consider Ask Jeeves, a popular site that uses natural language processing to enter a search request. Users simply phrase and enter a query as it would be phrased in conversation-for example, “What are the side effects of lithium?” Using techniques such as tokenization, stemming, parsing, and semantic analysis, Ask Jeeves attempts to determine the information you desire, and then generates results via the Teoma search engine.

If you’re really strapped for time, you could pay someone to do the searching for you.⁵ For example, Google Answers allows users to submit a question for between $2.50 and $200. Google’s research team will provide an answer, usually within 24 hours.

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.

Related Resources

Sullivan D. Articles on searchenginewatch.com:

• Search engine math. http://www.searchenginewatch.com/facts/math.html
• Power searching for anyone. http://www.searchenginewatch.com/facts/powersearch.html
• Search assistance features. http://www.searchenginewatch.com/facts/assistance.html

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.

Search engines are the express lanes of the Internet. Knowing how to navigate them can help you get exactly the information you need in seconds flat.

This article will address the differences between search engines, offer basic and advanced search methods, and discuss Web search technologies and alternatives.

How search engines work

Search engines employ different methods of finding Web pages and ranking them according to relevance of information requested.¹

Search engines such as Google and Altavista gather information by “crawling” or “spidering” through the Web. They check all the pages in a site and then proceed through pages linked to that site. As it progresses, it creates an indexed database of the content of each page it finds. Some search engines index more Web pages than others, while others update their indexes more often.

Many search engines pick up on how often and where the key word appears on a Web page.² Pages on which key words appear more frequently or near the top usually will be deemed more relevant.

Search engines garner additional listings by charging advertisers to list their Web sites (e.g., a pharmaceutical company’s site promoting a particular drug) among the search results. These listings vary from paid placement, where sites are guaranteed a high ranking, to paid inclusion, by which an advertisement might be listed in more search requests.³

Taken together, these methods can generate millions of search results for a user who enters a broad topic. For example, entering “depression” in the Google search field produces 5,420,000 links ranging from product sites, government agencies and academic departments, to advocacy organizations and patients’ blogs. Unless the page relevant to you happens to be among the top five search results, you will need to refine your search. Fortunately, there are many ways to do this.

Refining your search: Basic tips

Say you’re trying to find this article without a link or a URL. Just follow these simple key word tips.⁴

• First, try the obvious. Enter Psyber Psychiatry.
• Use words likely to appear on a site with the information you want (e.g., psychiatry, John Luo).
• Make key words as specific as possible-for example, Current Psychiatry Psyber vs. Psyber Psychiatry

Google and most search engines assume that you want to find pages with all the words you have entered. Other search engines, such as Teoma, usually generate pages containing all key words preceded by a + (e.g., +Current +Psychiatry will produce a link to this Web site).

If that search produces too many results, you can eliminate sites containing certain key words by inserting a - before the key word (e.g., +current +psychiatry -American -psychology). Your search still may be too broad, however, because the words “current” and “psychiatry” could appear anywhere on the site-including pages you’re trying to rule out. Placing key words within quotation marks (e.g., “Current Psychiatry” “Psyber Psychiatry”) can eliminate still more sites.

Advanced searches

If your search requires even more fine-tuning, consider the following:

Site search. Specifying a site in your query can uncover references to specific topics. For example, enter computers site: www.currentpsychiatry.com in Google to find all pages with computers mentioned on the Current Psychiatry Web site. Other sites such as AltaVista use the term host: instead of site:.

Title search. Every Web page has an HTML title, which is also searched by the spider programs. Because an HTML title usually is indicative of the site’s content, searching through these titles may point to relevant information. Use allintitle: or intitle: to find a site (e.g., intitle:currentpsychiatry).

URL search. Similar to a site and title search, you can also search for words in the URL of a Web page. For example, in Google try entering current inurl:psychiatry or inurl:currentpsychiatry.

Some search engines employ techniques such as “clustering” (prevents a search from finding too many results from the same site), “stemming” (searches for variations of a word), and “find similar” (seeks out other pages with similar information). Some sites offer “related searches” or “search again” options to help users zero in on the desired information.

Confused about which commands and search features work for which search engines? searchenginewatch.com offers a comprehensive list of basic and power search commands, search assistance features, customization and display features, and Boolean commands.

Because Google is the most popular search engine, many search tools have been developed based on the Google engine. Fagan Finder provides a Web-based interface to Google that lets users search by exact phrase, any/all words, subject, author, and many other ways. Visualization technologies such as Touchgraph and Anacubis, both of which are connected to Google, allow searchers to visually explore and navigate relationships between Web sites.

KartOO is a metasearch engine with visual display interfaces. A metasearch engine uses other search engines to find information. After you enter a search term, KartOO launches the query to a set of search engines, compiles the results, and presents them in a series of interactive maps through a proprietary algorithm. Users can narrow the search by clicking on one of the plus/minus icons and categories between the results.

When all else fails …

If you cannot be bothered with search engine tricks and tools, consider Ask Jeeves, a popular site that uses natural language processing to enter a search request. Users simply phrase and enter a query as it would be phrased in conversation-for example, “What are the side effects of lithium?” Using techniques such as tokenization, stemming, parsing, and semantic analysis, Ask Jeeves attempts to determine the information you desire, and then generates results via the Teoma search engine.

If you’re really strapped for time, you could pay someone to do the searching for you.⁵ For example, Google Answers allows users to submit a question for between $2.50 and $200. Google’s research team will provide an answer, usually within 24 hours.

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.

Related Resources

Sullivan D. Articles on searchenginewatch.com:

• Search engine math. http://www.searchenginewatch.com/facts/math.html
• Power searching for anyone. http://www.searchenginewatch.com/facts/powersearch.html
• Search assistance features. http://www.searchenginewatch.com/facts/assistance.html

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.

Search engines are the express lanes of the Internet. Knowing how to navigate them can help you get exactly the information you need in seconds flat.

This article will address the differences between search engines, offer basic and advanced search methods, and discuss Web search technologies and alternatives.

How search engines work

Search engines employ different methods of finding Web pages and ranking them according to relevance of information requested.¹

Search engines such as Google and Altavista gather information by “crawling” or “spidering” through the Web. They check all the pages in a site and then proceed through pages linked to that site. As it progresses, it creates an indexed database of the content of each page it finds. Some search engines index more Web pages than others, while others update their indexes more often.

Many search engines pick up on how often and where the key word appears on a Web page.² Pages on which key words appear more frequently or near the top usually will be deemed more relevant.

Search engines garner additional listings by charging advertisers to list their Web sites (e.g., a pharmaceutical company’s site promoting a particular drug) among the search results. These listings vary from paid placement, where sites are guaranteed a high ranking, to paid inclusion, by which an advertisement might be listed in more search requests.³

Taken together, these methods can generate millions of search results for a user who enters a broad topic. For example, entering “depression” in the Google search field produces 5,420,000 links ranging from product sites, government agencies and academic departments, to advocacy organizations and patients’ blogs. Unless the page relevant to you happens to be among the top five search results, you will need to refine your search. Fortunately, there are many ways to do this.

Refining your search: Basic tips

Say you’re trying to find this article without a link or a URL. Just follow these simple key word tips.⁴

• First, try the obvious. Enter Psyber Psychiatry.
• Use words likely to appear on a site with the information you want (e.g., psychiatry, John Luo).
• Make key words as specific as possible-for example, Current Psychiatry Psyber vs. Psyber Psychiatry

Google and most search engines assume that you want to find pages with all the words you have entered. Other search engines, such as Teoma, usually generate pages containing all key words preceded by a + (e.g., +Current +Psychiatry will produce a link to this Web site).

If that search produces too many results, you can eliminate sites containing certain key words by inserting a - before the key word (e.g., +current +psychiatry -American -psychology). Your search still may be too broad, however, because the words “current” and “psychiatry” could appear anywhere on the site-including pages you’re trying to rule out. Placing key words within quotation marks (e.g., “Current Psychiatry” “Psyber Psychiatry”) can eliminate still more sites.

Advanced searches

If your search requires even more fine-tuning, consider the following:

Site search. Specifying a site in your query can uncover references to specific topics. For example, enter computers site: www.currentpsychiatry.com in Google to find all pages with computers mentioned on the Current Psychiatry Web site. Other sites such as AltaVista use the term host: instead of site:.

Title search. Every Web page has an HTML title, which is also searched by the spider programs. Because an HTML title usually is indicative of the site’s content, searching through these titles may point to relevant information. Use allintitle: or intitle: to find a site (e.g., intitle:currentpsychiatry).

URL search. Similar to a site and title search, you can also search for words in the URL of a Web page. For example, in Google try entering current inurl:psychiatry or inurl:currentpsychiatry.

Some search engines employ techniques such as “clustering” (prevents a search from finding too many results from the same site), “stemming” (searches for variations of a word), and “find similar” (seeks out other pages with similar information). Some sites offer “related searches” or “search again” options to help users zero in on the desired information.

Confused about which commands and search features work for which search engines? searchenginewatch.com offers a comprehensive list of basic and power search commands, search assistance features, customization and display features, and Boolean commands.

Because Google is the most popular search engine, many search tools have been developed based on the Google engine. Fagan Finder provides a Web-based interface to Google that lets users search by exact phrase, any/all words, subject, author, and many other ways. Visualization technologies such as Touchgraph and Anacubis, both of which are connected to Google, allow searchers to visually explore and navigate relationships between Web sites.

KartOO is a metasearch engine with visual display interfaces. A metasearch engine uses other search engines to find information. After you enter a search term, KartOO launches the query to a set of search engines, compiles the results, and presents them in a series of interactive maps through a proprietary algorithm. Users can narrow the search by clicking on one of the plus/minus icons and categories between the results.

When all else fails …

If you cannot be bothered with search engine tricks and tools, consider Ask Jeeves, a popular site that uses natural language processing to enter a search request. Users simply phrase and enter a query as it would be phrased in conversation-for example, “What are the side effects of lithium?” Using techniques such as tokenization, stemming, parsing, and semantic analysis, Ask Jeeves attempts to determine the information you desire, and then generates results via the Teoma search engine.

If you’re really strapped for time, you could pay someone to do the searching for you.⁵ For example, Google Answers allows users to submit a question for between $2.50 and $200. Google’s research team will provide an answer, usually within 24 hours.

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.

Related Resources

Sullivan D. Articles on searchenginewatch.com:

• Search engine math. http://www.searchenginewatch.com/facts/math.html
• Power searching for anyone. http://www.searchenginewatch.com/facts/powersearch.html
• Search assistance features. http://www.searchenginewatch.com/facts/assistance.html

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.

As this nation’s population becomes increasingly diverse, tailoring your practice to your area’s demographics is crucial to providing effective treatment.

Here’s how to improve your “cultural competence.”

1. Recognize that culture extends beyond skin color. Although darker-skinned persons are commonly identified as “black” or African-American, some identify themselves as Hispanic, Jamaican, or white. Others may identify with their religion, gender, sexual preference, age, geography, socioeconomic status, or occupation. For example, the “tough-it-out” ethos of firefighters can breed denial of depression or trauma that limits their desire to seek or stay in treatment.
2. Find out each patient’s cultural background. On your intake forms, include questions about race, ethnicity, language(s), religion, and age, or ask the patient to discuss his or her cultural background during the initial interview.
3. Determine your cultural effectiveness. A sample breakdown of your patients can help you analyze treatment, compliance, progress, and outcomes among cultural groups.
4. Make your patients feel “at home.” If possible, your staff should reflect your area’s cultural makeup.
5. Conduct culturally sensitive evaluations. Cultural identification often leads to misdiagnosis.¹ For example, African-American men tend to be over-diagnosed with paranoid schizophrenia or antisocial personality disorder.²
6. Elicit patient expectations and preferences. Some cultures distrust modern drug therapy, while some patients think medication should magically resolve their disorders. Still others think psychotherapy works only for whites.
7. Understand your cultural identity. Do a “cultural self-analysis” and see how your values apply to psychiatry. For example, if your culture values independence and individuality, you may underestimate the effectiveness of family therapy for patients whose cultures value interdependence.

As this nation’s population becomes increasingly diverse, tailoring your practice to your area’s demographics is crucial to providing effective treatment.

Here’s how to improve your “cultural competence.”

1. Recognize that culture extends beyond skin color. Although darker-skinned persons are commonly identified as “black” or African-American, some identify themselves as Hispanic, Jamaican, or white. Others may identify with their religion, gender, sexual preference, age, geography, socioeconomic status, or occupation. For example, the “tough-it-out” ethos of firefighters can breed denial of depression or trauma that limits their desire to seek or stay in treatment.
2. Find out each patient’s cultural background. On your intake forms, include questions about race, ethnicity, language(s), religion, and age, or ask the patient to discuss his or her cultural background during the initial interview.
3. Determine your cultural effectiveness. A sample breakdown of your patients can help you analyze treatment, compliance, progress, and outcomes among cultural groups.
4. Make your patients feel “at home.” If possible, your staff should reflect your area’s cultural makeup.
5. Conduct culturally sensitive evaluations. Cultural identification often leads to misdiagnosis.¹ For example, African-American men tend to be over-diagnosed with paranoid schizophrenia or antisocial personality disorder.²
6. Elicit patient expectations and preferences. Some cultures distrust modern drug therapy, while some patients think medication should magically resolve their disorders. Still others think psychotherapy works only for whites.
7. Understand your cultural identity. Do a “cultural self-analysis” and see how your values apply to psychiatry. For example, if your culture values independence and individuality, you may underestimate the effectiveness of family therapy for patients whose cultures value interdependence.

As this nation’s population becomes increasingly diverse, tailoring your practice to your area’s demographics is crucial to providing effective treatment.

Here’s how to improve your “cultural competence.”

1. Recognize that culture extends beyond skin color. Although darker-skinned persons are commonly identified as “black” or African-American, some identify themselves as Hispanic, Jamaican, or white. Others may identify with their religion, gender, sexual preference, age, geography, socioeconomic status, or occupation. For example, the “tough-it-out” ethos of firefighters can breed denial of depression or trauma that limits their desire to seek or stay in treatment.
2. Find out each patient’s cultural background. On your intake forms, include questions about race, ethnicity, language(s), religion, and age, or ask the patient to discuss his or her cultural background during the initial interview.
3. Determine your cultural effectiveness. A sample breakdown of your patients can help you analyze treatment, compliance, progress, and outcomes among cultural groups.
4. Make your patients feel “at home.” If possible, your staff should reflect your area’s cultural makeup.
5. Conduct culturally sensitive evaluations. Cultural identification often leads to misdiagnosis.¹ For example, African-American men tend to be over-diagnosed with paranoid schizophrenia or antisocial personality disorder.²
6. Elicit patient expectations and preferences. Some cultures distrust modern drug therapy, while some patients think medication should magically resolve their disorders. Still others think psychotherapy works only for whites.
7. Understand your cultural identity. Do a “cultural self-analysis” and see how your values apply to psychiatry. For example, if your culture values independence and individuality, you may underestimate the effectiveness of family therapy for patients whose cultures value interdependence.

When a patient revisits past trauma during psychotherapy, strong reactions may surface. There is no single best way to confront emotions such as anger or despair, nor does the patient warn you before an outburst happens. The emotional reaction could be part of the healing process or could signal the need for additional treatment. You must decide on the spot whether to move up the next session, check on the patient the next day, or hospitalize the patient for his or her protection.

Keys to assessment

Before gauging a distraught patient’s needs, consider:

• How well do you know the patient? An established patient can be appraised fairly quickly. Assessing a new patient with confidence may take more time, however.
• Can the patient set emotional boundaries? Can he or she make sound choices and consider their consequences?
• Does the patient have adequate support? Is the patient going home to an empty room, a loving family or significant other, or a situation between the two?
• What therapy model are you employing? For example, cognitive therapy might address the meaning a patient places on a situation or reaction.

Dealing with emotional reaction

When a patient becomes overwrought:

• Encourage the patient to talk about the issue. This allows the patient to problem-solve and gives you time to think and plan.
• Extend the therapy session, especially if you fear a prompt discharge would endanger the patient. Consider the patient’s cognitive and emotional state. If you are uneasy with his or her degree of self-control, don’t discharge that patient.
• Formulate a plan to address the trauma. You might say: “It seems clear that this is troubling you. How can we work together to ease the burden? Can you comfortably think it through so that we can work it out next week? Would writing down your feelings and thoughts help?”
• Move up the patient’s next appointment. If the patient typically reacts badly to a certain issue or cannot handle feeling distraught, bringing him or her back sooner can be reassuring.
• Call the patient that evening or the next day. A distraught patient who does not need immediate hospitalization may benefit from extra contact. Decide whether to call the patient at a set time or to arrange for the patient to contact you. These usually brief calls reassure you that the patient has gained some perspective toward the problem and convey to the patient that you care.

Arrange to admit the patient to the hospital until the acute situation is resolved or perspective restored. Consider a brief hospitalization:

• when a situation or issue seriously challenges the patient’s coping mechanisms
• for patients with a history of self-harm when stressed
• for a patient who is psychotic and whose response to the emotional state is unpredictable
• when drugs or alcohol cloud the patient’s sensorium
• for a patient who lives alone.

When a patient revisits past trauma during psychotherapy, strong reactions may surface. There is no single best way to confront emotions such as anger or despair, nor does the patient warn you before an outburst happens. The emotional reaction could be part of the healing process or could signal the need for additional treatment. You must decide on the spot whether to move up the next session, check on the patient the next day, or hospitalize the patient for his or her protection.

Keys to assessment

Before gauging a distraught patient’s needs, consider:

• How well do you know the patient? An established patient can be appraised fairly quickly. Assessing a new patient with confidence may take more time, however.
• Can the patient set emotional boundaries? Can he or she make sound choices and consider their consequences?
• Does the patient have adequate support? Is the patient going home to an empty room, a loving family or significant other, or a situation between the two?
• What therapy model are you employing? For example, cognitive therapy might address the meaning a patient places on a situation or reaction.

Dealing with emotional reaction

When a patient becomes overwrought:

• Encourage the patient to talk about the issue. This allows the patient to problem-solve and gives you time to think and plan.
• Extend the therapy session, especially if you fear a prompt discharge would endanger the patient. Consider the patient’s cognitive and emotional state. If you are uneasy with his or her degree of self-control, don’t discharge that patient.
• Formulate a plan to address the trauma. You might say: “It seems clear that this is troubling you. How can we work together to ease the burden? Can you comfortably think it through so that we can work it out next week? Would writing down your feelings and thoughts help?”
• Move up the patient’s next appointment. If the patient typically reacts badly to a certain issue or cannot handle feeling distraught, bringing him or her back sooner can be reassuring.
• Call the patient that evening or the next day. A distraught patient who does not need immediate hospitalization may benefit from extra contact. Decide whether to call the patient at a set time or to arrange for the patient to contact you. These usually brief calls reassure you that the patient has gained some perspective toward the problem and convey to the patient that you care.

Arrange to admit the patient to the hospital until the acute situation is resolved or perspective restored. Consider a brief hospitalization:

• when a situation or issue seriously challenges the patient’s coping mechanisms
• for patients with a history of self-harm when stressed
• for a patient who is psychotic and whose response to the emotional state is unpredictable
• when drugs or alcohol cloud the patient’s sensorium
• for a patient who lives alone.

When a patient revisits past trauma during psychotherapy, strong reactions may surface. There is no single best way to confront emotions such as anger or despair, nor does the patient warn you before an outburst happens. The emotional reaction could be part of the healing process or could signal the need for additional treatment. You must decide on the spot whether to move up the next session, check on the patient the next day, or hospitalize the patient for his or her protection.

Keys to assessment

Before gauging a distraught patient’s needs, consider:

• How well do you know the patient? An established patient can be appraised fairly quickly. Assessing a new patient with confidence may take more time, however.
• Can the patient set emotional boundaries? Can he or she make sound choices and consider their consequences?
• Does the patient have adequate support? Is the patient going home to an empty room, a loving family or significant other, or a situation between the two?
• What therapy model are you employing? For example, cognitive therapy might address the meaning a patient places on a situation or reaction.

Dealing with emotional reaction

When a patient becomes overwrought:

• Encourage the patient to talk about the issue. This allows the patient to problem-solve and gives you time to think and plan.
• Extend the therapy session, especially if you fear a prompt discharge would endanger the patient. Consider the patient’s cognitive and emotional state. If you are uneasy with his or her degree of self-control, don’t discharge that patient.
• Formulate a plan to address the trauma. You might say: “It seems clear that this is troubling you. How can we work together to ease the burden? Can you comfortably think it through so that we can work it out next week? Would writing down your feelings and thoughts help?”
• Move up the patient’s next appointment. If the patient typically reacts badly to a certain issue or cannot handle feeling distraught, bringing him or her back sooner can be reassuring.
• Call the patient that evening or the next day. A distraught patient who does not need immediate hospitalization may benefit from extra contact. Decide whether to call the patient at a set time or to arrange for the patient to contact you. These usually brief calls reassure you that the patient has gained some perspective toward the problem and convey to the patient that you care.

Arrange to admit the patient to the hospital until the acute situation is resolved or perspective restored. Consider a brief hospitalization:

• when a situation or issue seriously challenges the patient’s coping mechanisms
• for patients with a history of self-harm when stressed
• for a patient who is psychotic and whose response to the emotional state is unpredictable
• when drugs or alcohol cloud the patient’s sensorium
• for a patient who lives alone.

Discussing fees with your patients can be unpleasant, especially if you have had little or no business training. When patient-physician payment disputes turn nasty, they can dredge up feelings of fear, guilt, shame, responsibility, anger, and entitlement on both sides.

Some psychiatrists avoid discussing fees with patients, but this opens the door to unhappy surprises at billing time. An uninformed patient may feel used or betrayed after receiving your billing statement.

Presenting a written fee policy to new patients prior to treatment is one of the best ways to reduce payment misunderstandings. Taking a few minutes to discuss your fee schedule can improve your relationship with the patient, and he or she may appreciate knowing your policies up front.

What a fee policy includes

After listing regular charges for services, your fee policy also should address:

• charges for missed or canceled appointments. For example, how late can a patient cancel an appointment without being charged for it?
• penalties for bounced or returned checks.
• charges for psychotherapy sessions that extend beyond the allotted time, if applicable.
• fees for out-of-session contact. Spell out which scenarios are part of treatment and which will cost extra.
• late fees, including your grace period (e.g., 30 days from the date of the first billing) for on-time payment.
• charges for services not included with the office visit (e.g., report writing, communication with third parties, giving testimony at a trial).

Writing the fee policy

When you write your fee policy:

• Keep your policy to one single page. This way, the patient will not feel overwhelmed by the document’s length. Be concise, and adjust the fonts and margins as necessary.
• Have the policy reviewed by an attorney, preferably one who is familiar with your local health care laws.
• Review and update the policy at least once a year, particularly when unforeseen situations arise, such as new legislation or managed care policy changes.

Discussing your fees

Discuss your fees during the initial office visit, so that the patient clearly understands his or her responsibilities during treatment. Patients who need structure or have problems setting limits will especially benefit from knowing what they will owe up front. Where applicable, disclose anticipated charges when discussing informed consent.

Require a deposit for future visits. A patient who pays something at the start is more likely to remember your fee policies and less likely to contest them. He or she also will get a clearer picture of the overall cost of treatment.

The deposit, similar to an attorney’s retainer fee, should equal the cost of a missed visit or anticipated costs between appointments.

Sign the fee policy and have it signed. Make sure both you and the patient sign the policy immediately after discussing it. I’ve found that signing this document in front of the patient makes my dealings with him or her seem more interactive and personalized.

Discussing fees with your patients can be unpleasant, especially if you have had little or no business training. When patient-physician payment disputes turn nasty, they can dredge up feelings of fear, guilt, shame, responsibility, anger, and entitlement on both sides.

Some psychiatrists avoid discussing fees with patients, but this opens the door to unhappy surprises at billing time. An uninformed patient may feel used or betrayed after receiving your billing statement.

Presenting a written fee policy to new patients prior to treatment is one of the best ways to reduce payment misunderstandings. Taking a few minutes to discuss your fee schedule can improve your relationship with the patient, and he or she may appreciate knowing your policies up front.

What a fee policy includes

After listing regular charges for services, your fee policy also should address:

• charges for missed or canceled appointments. For example, how late can a patient cancel an appointment without being charged for it?
• penalties for bounced or returned checks.
• charges for psychotherapy sessions that extend beyond the allotted time, if applicable.
• fees for out-of-session contact. Spell out which scenarios are part of treatment and which will cost extra.
• late fees, including your grace period (e.g., 30 days from the date of the first billing) for on-time payment.
• charges for services not included with the office visit (e.g., report writing, communication with third parties, giving testimony at a trial).

Writing the fee policy

When you write your fee policy:

• Keep your policy to one single page. This way, the patient will not feel overwhelmed by the document’s length. Be concise, and adjust the fonts and margins as necessary.
• Have the policy reviewed by an attorney, preferably one who is familiar with your local health care laws.
• Review and update the policy at least once a year, particularly when unforeseen situations arise, such as new legislation or managed care policy changes.

Discussing your fees

Discuss your fees during the initial office visit, so that the patient clearly understands his or her responsibilities during treatment. Patients who need structure or have problems setting limits will especially benefit from knowing what they will owe up front. Where applicable, disclose anticipated charges when discussing informed consent.

Require a deposit for future visits. A patient who pays something at the start is more likely to remember your fee policies and less likely to contest them. He or she also will get a clearer picture of the overall cost of treatment.

The deposit, similar to an attorney’s retainer fee, should equal the cost of a missed visit or anticipated costs between appointments.

Sign the fee policy and have it signed. Make sure both you and the patient sign the policy immediately after discussing it. I’ve found that signing this document in front of the patient makes my dealings with him or her seem more interactive and personalized.

Discussing fees with your patients can be unpleasant, especially if you have had little or no business training. When patient-physician payment disputes turn nasty, they can dredge up feelings of fear, guilt, shame, responsibility, anger, and entitlement on both sides.

Some psychiatrists avoid discussing fees with patients, but this opens the door to unhappy surprises at billing time. An uninformed patient may feel used or betrayed after receiving your billing statement.

Presenting a written fee policy to new patients prior to treatment is one of the best ways to reduce payment misunderstandings. Taking a few minutes to discuss your fee schedule can improve your relationship with the patient, and he or she may appreciate knowing your policies up front.

What a fee policy includes

After listing regular charges for services, your fee policy also should address:

• charges for missed or canceled appointments. For example, how late can a patient cancel an appointment without being charged for it?
• penalties for bounced or returned checks.
• charges for psychotherapy sessions that extend beyond the allotted time, if applicable.
• fees for out-of-session contact. Spell out which scenarios are part of treatment and which will cost extra.
• late fees, including your grace period (e.g., 30 days from the date of the first billing) for on-time payment.
• charges for services not included with the office visit (e.g., report writing, communication with third parties, giving testimony at a trial).

Writing the fee policy

When you write your fee policy:

• Keep your policy to one single page. This way, the patient will not feel overwhelmed by the document’s length. Be concise, and adjust the fonts and margins as necessary.
• Have the policy reviewed by an attorney, preferably one who is familiar with your local health care laws.
• Review and update the policy at least once a year, particularly when unforeseen situations arise, such as new legislation or managed care policy changes.

Discussing your fees

Discuss your fees during the initial office visit, so that the patient clearly understands his or her responsibilities during treatment. Patients who need structure or have problems setting limits will especially benefit from knowing what they will owe up front. Where applicable, disclose anticipated charges when discussing informed consent.

Require a deposit for future visits. A patient who pays something at the start is more likely to remember your fee policies and less likely to contest them. He or she also will get a clearer picture of the overall cost of treatment.

The deposit, similar to an attorney’s retainer fee, should equal the cost of a missed visit or anticipated costs between appointments.

Sign the fee policy and have it signed. Make sure both you and the patient sign the policy immediately after discussing it. I’ve found that signing this document in front of the patient makes my dealings with him or her seem more interactive and personalized.

Achieving maximum efficacy with minimal side effects is never easy, but nausea and other associated GI effects can make use of the newer antidepressants difficult. Drug-induced nausea can compound the GI discomfort already felt in anxiety disorder. Patients often stop taking the medication.

Metoclopramide and prochlorperazine are used to treat nausea, but both carry a risk for extrapyramidal symptoms and—if used for extended periods—tardive dyskinesia or dystonia.

Over the past decade, I’ve found that use of ginger as an antiemetic has helped improve compliance—and outcomes—among my patients. Ginger is relatively devoid of side effects or drug interactions and can help ease antidepressant-related GI discomfort.

In an era when people tend to equate “natural” with “good,” I find that patients generally are receptive to trying ginger. What’s more, ginger supplements are inexpensive and available over the counter in most supermarkets, pharmacies, and vitamin and health-food stores.

What researchers say

As “alternative” and “new age” as it sounds, medical use of ginger is well supported in the clinical literature. Bone et al¹ compared powdered ginger root (1,000 mg orally) with metoclopramide (10 mg IV) and placebo 90 minutes before surgery in 60 gynecologic patients. Postsurgical nausea was reduced significantly in both active treatment groups compared with placebo.

Fisher-Rasmussen et al² noted a statistically significant drop in nausea after use of ginger, 250 mg qid, to treat hyperemesis gravidarum across 4 days vs. placebo. Ginger’s antiemetic efficacy has also been demonstrated in motion sickness.³

How it works

Ginger, long used as an herbal medicine and in food preparation, is a perennial that grows in India, China, and Jamaica. Gingerol and other biologically active aromatic compounds found in ginger are thought to be the source of its pharmacologic actions. Its GI protective effects are considered local rather than CNS phenomena and are probably related to ginger’s stimulation of GI motility, as is seen with metoclopramide and domperidone.

I typically have patients start by using the ginger as needed during antidepressant therapy. If nausea is persistent or pervasive—as it tends to be in the first few weeks of treatment—I will prescribe the ginger at 1,000 mg bid or tid.

Possible side effects include heartburn, increased risk of bleeding (diminished platelet aggregation), and uterine contractions at high doses. No fatalities have been reported due to ginger overdose to date, although CNS depression and arrhythmias are possible.⁴ No exact maximum dosage has been cited in the literature, but I would advise against exceeding 1,000 mg tid.

Ginger has not been reported to be teratogenic, but pregnant women should take no more than 500 mg in one dose and no more than 1,000 mg/d.

To date, none of my patients have reported any serious side effects. The worst complaint I have heard has been mild heartburn, which could have implications for individuals with gastroesophageal reflux disease.

Finally, ginger ale has been used over the years as a folk remedy for nausea. Ginger ale is not an effective antiemetic, however, because it contains only ginger flavoring, not real ginger.

Achieving maximum efficacy with minimal side effects is never easy, but nausea and other associated GI effects can make use of the newer antidepressants difficult. Drug-induced nausea can compound the GI discomfort already felt in anxiety disorder. Patients often stop taking the medication.

Metoclopramide and prochlorperazine are used to treat nausea, but both carry a risk for extrapyramidal symptoms and—if used for extended periods—tardive dyskinesia or dystonia.

Over the past decade, I’ve found that use of ginger as an antiemetic has helped improve compliance—and outcomes—among my patients. Ginger is relatively devoid of side effects or drug interactions and can help ease antidepressant-related GI discomfort.

In an era when people tend to equate “natural” with “good,” I find that patients generally are receptive to trying ginger. What’s more, ginger supplements are inexpensive and available over the counter in most supermarkets, pharmacies, and vitamin and health-food stores.

What researchers say

As “alternative” and “new age” as it sounds, medical use of ginger is well supported in the clinical literature. Bone et al¹ compared powdered ginger root (1,000 mg orally) with metoclopramide (10 mg IV) and placebo 90 minutes before surgery in 60 gynecologic patients. Postsurgical nausea was reduced significantly in both active treatment groups compared with placebo.

Fisher-Rasmussen et al² noted a statistically significant drop in nausea after use of ginger, 250 mg qid, to treat hyperemesis gravidarum across 4 days vs. placebo. Ginger’s antiemetic efficacy has also been demonstrated in motion sickness.³

How it works

Ginger, long used as an herbal medicine and in food preparation, is a perennial that grows in India, China, and Jamaica. Gingerol and other biologically active aromatic compounds found in ginger are thought to be the source of its pharmacologic actions. Its GI protective effects are considered local rather than CNS phenomena and are probably related to ginger’s stimulation of GI motility, as is seen with metoclopramide and domperidone.

I typically have patients start by using the ginger as needed during antidepressant therapy. If nausea is persistent or pervasive—as it tends to be in the first few weeks of treatment—I will prescribe the ginger at 1,000 mg bid or tid.

Possible side effects include heartburn, increased risk of bleeding (diminished platelet aggregation), and uterine contractions at high doses. No fatalities have been reported due to ginger overdose to date, although CNS depression and arrhythmias are possible.⁴ No exact maximum dosage has been cited in the literature, but I would advise against exceeding 1,000 mg tid.

Ginger has not been reported to be teratogenic, but pregnant women should take no more than 500 mg in one dose and no more than 1,000 mg/d.

To date, none of my patients have reported any serious side effects. The worst complaint I have heard has been mild heartburn, which could have implications for individuals with gastroesophageal reflux disease.

Finally, ginger ale has been used over the years as a folk remedy for nausea. Ginger ale is not an effective antiemetic, however, because it contains only ginger flavoring, not real ginger.

Achieving maximum efficacy with minimal side effects is never easy, but nausea and other associated GI effects can make use of the newer antidepressants difficult. Drug-induced nausea can compound the GI discomfort already felt in anxiety disorder. Patients often stop taking the medication.

Metoclopramide and prochlorperazine are used to treat nausea, but both carry a risk for extrapyramidal symptoms and—if used for extended periods—tardive dyskinesia or dystonia.

Over the past decade, I’ve found that use of ginger as an antiemetic has helped improve compliance—and outcomes—among my patients. Ginger is relatively devoid of side effects or drug interactions and can help ease antidepressant-related GI discomfort.

In an era when people tend to equate “natural” with “good,” I find that patients generally are receptive to trying ginger. What’s more, ginger supplements are inexpensive and available over the counter in most supermarkets, pharmacies, and vitamin and health-food stores.

What researchers say

As “alternative” and “new age” as it sounds, medical use of ginger is well supported in the clinical literature. Bone et al¹ compared powdered ginger root (1,000 mg orally) with metoclopramide (10 mg IV) and placebo 90 minutes before surgery in 60 gynecologic patients. Postsurgical nausea was reduced significantly in both active treatment groups compared with placebo.

Fisher-Rasmussen et al² noted a statistically significant drop in nausea after use of ginger, 250 mg qid, to treat hyperemesis gravidarum across 4 days vs. placebo. Ginger’s antiemetic efficacy has also been demonstrated in motion sickness.³

How it works

Ginger, long used as an herbal medicine and in food preparation, is a perennial that grows in India, China, and Jamaica. Gingerol and other biologically active aromatic compounds found in ginger are thought to be the source of its pharmacologic actions. Its GI protective effects are considered local rather than CNS phenomena and are probably related to ginger’s stimulation of GI motility, as is seen with metoclopramide and domperidone.

I typically have patients start by using the ginger as needed during antidepressant therapy. If nausea is persistent or pervasive—as it tends to be in the first few weeks of treatment—I will prescribe the ginger at 1,000 mg bid or tid.

Possible side effects include heartburn, increased risk of bleeding (diminished platelet aggregation), and uterine contractions at high doses. No fatalities have been reported due to ginger overdose to date, although CNS depression and arrhythmias are possible.⁴ No exact maximum dosage has been cited in the literature, but I would advise against exceeding 1,000 mg tid.

Ginger has not been reported to be teratogenic, but pregnant women should take no more than 500 mg in one dose and no more than 1,000 mg/d.

To date, none of my patients have reported any serious side effects. The worst complaint I have heard has been mild heartburn, which could have implications for individuals with gastroesophageal reflux disease.

Finally, ginger ale has been used over the years as a folk remedy for nausea. Ginger ale is not an effective antiemetic, however, because it contains only ginger flavoring, not real ginger.

Achieving maximum efficacy with minimal side effects is never easy, but nausea and other associated GI effects can make use of the newer antidepressants difficult. Drug-induced nausea can compound the GI discomfort already felt in anxiety disorder. Patients often stop taking the medication.

Metoclopramide and prochlorperazine are used to treat nausea, but both carry a risk for extrapyramidal symptoms and—if used for extended periods—tardive dyskinesia or dystonia.

Over the past decade, I’ve found that use of ginger as an antiemetic has helped improve compliance—and outcomes—among my patients. Ginger is relatively devoid of side effects or drug interactions and can help ease antidepressant-related GI discomfort.

In an era when people tend to equate “natural” with “good,” I find that patients generally are receptive to trying ginger. What’s more, ginger supplements are inexpensive and available over the counter in most supermarkets, pharmacies, and vitamin and health-food stores.

What researchers say

As “alternative” and “new age” as it sounds, medical use of ginger is well supported in the clinical literature. Bone et al¹ compared powdered ginger root (1,000 mg orally) with metoclopramide (10 mg IV) and placebo 90 minutes before surgery in 60 gynecologic patients. Postsurgical nausea was reduced significantly in both active treatment groups compared with placebo.

Fisher-Rasmussen et al² noted a statistically significant drop in nausea after use of ginger, 250 mg qid, to treat hyperemesis gravidarum across 4 days vs. placebo. Ginger’s antiemetic efficacy has also been demonstrated in motion sickness.³

How it works

Ginger, long used as an herbal medicine and in food preparation, is a perennial that grows in India, China, and Jamaica. Gingerol and other biologically active aromatic compounds found in ginger are thought to be the source of its pharmacologic actions. Its GI protective effects are considered local rather than CNS phenomena and are probably related to ginger’s stimulation of GI motility, as is seen with metoclopramide and domperidone.

I typically have patients start by using the ginger as needed during antidepressant therapy. If nausea is persistent or pervasive—as it tends to be in the first few weeks of treatment—I will prescribe the ginger at 1,000 mg bid or tid.

Possible side effects include heartburn, increased risk of bleeding (diminished platelet aggregation), and uterine contractions at high doses. No fatalities have been reported due to ginger overdose to date, although CNS depression and arrhythmias are possible.⁴ No exact maximum dosage has been cited in the literature, but I would advise against exceeding 1,000 mg tid.

Ginger has not been reported to be teratogenic, but pregnant women should take no more than 500 mg in one dose and no more than 1,000 mg/d.

To date, none of my patients have reported any serious side effects. The worst complaint I have heard has been mild heartburn, which could have implications for individuals with gastroesophageal reflux disease.

Finally, ginger ale has been used over the years as a folk remedy for nausea. Ginger ale is not an effective antiemetic, however, because it contains only ginger flavoring, not real ginger.

Achieving maximum efficacy with minimal side effects is never easy, but nausea and other associated GI effects can make use of the newer antidepressants difficult. Drug-induced nausea can compound the GI discomfort already felt in anxiety disorder. Patients often stop taking the medication.

Metoclopramide and prochlorperazine are used to treat nausea, but both carry a risk for extrapyramidal symptoms and—if used for extended periods—tardive dyskinesia or dystonia.

Over the past decade, I’ve found that use of ginger as an antiemetic has helped improve compliance—and outcomes—among my patients. Ginger is relatively devoid of side effects or drug interactions and can help ease antidepressant-related GI discomfort.

In an era when people tend to equate “natural” with “good,” I find that patients generally are receptive to trying ginger. What’s more, ginger supplements are inexpensive and available over the counter in most supermarkets, pharmacies, and vitamin and health-food stores.

What researchers say

As “alternative” and “new age” as it sounds, medical use of ginger is well supported in the clinical literature. Bone et al¹ compared powdered ginger root (1,000 mg orally) with metoclopramide (10 mg IV) and placebo 90 minutes before surgery in 60 gynecologic patients. Postsurgical nausea was reduced significantly in both active treatment groups compared with placebo.

Fisher-Rasmussen et al² noted a statistically significant drop in nausea after use of ginger, 250 mg qid, to treat hyperemesis gravidarum across 4 days vs. placebo. Ginger’s antiemetic efficacy has also been demonstrated in motion sickness.³

How it works

Ginger, long used as an herbal medicine and in food preparation, is a perennial that grows in India, China, and Jamaica. Gingerol and other biologically active aromatic compounds found in ginger are thought to be the source of its pharmacologic actions. Its GI protective effects are considered local rather than CNS phenomena and are probably related to ginger’s stimulation of GI motility, as is seen with metoclopramide and domperidone.

I typically have patients start by using the ginger as needed during antidepressant therapy. If nausea is persistent or pervasive—as it tends to be in the first few weeks of treatment—I will prescribe the ginger at 1,000 mg bid or tid.

Possible side effects include heartburn, increased risk of bleeding (diminished platelet aggregation), and uterine contractions at high doses. No fatalities have been reported due to ginger overdose to date, although CNS depression and arrhythmias are possible.⁴ No exact maximum dosage has been cited in the literature, but I would advise against exceeding 1,000 mg tid.

Ginger has not been reported to be teratogenic, but pregnant women should take no more than 500 mg in one dose and no more than 1,000 mg/d.

To date, none of my patients have reported any serious side effects. The worst complaint I have heard has been mild heartburn, which could have implications for individuals with gastroesophageal reflux disease.

Finally, ginger ale has been used over the years as a folk remedy for nausea. Ginger ale is not an effective antiemetic, however, because it contains only ginger flavoring, not real ginger.

Achieving maximum efficacy with minimal side effects is never easy, but nausea and other associated GI effects can make use of the newer antidepressants difficult. Drug-induced nausea can compound the GI discomfort already felt in anxiety disorder. Patients often stop taking the medication.

Metoclopramide and prochlorperazine are used to treat nausea, but both carry a risk for extrapyramidal symptoms and—if used for extended periods—tardive dyskinesia or dystonia.

Over the past decade, I’ve found that use of ginger as an antiemetic has helped improve compliance—and outcomes—among my patients. Ginger is relatively devoid of side effects or drug interactions and can help ease antidepressant-related GI discomfort.

In an era when people tend to equate “natural” with “good,” I find that patients generally are receptive to trying ginger. What’s more, ginger supplements are inexpensive and available over the counter in most supermarkets, pharmacies, and vitamin and health-food stores.

What researchers say

As “alternative” and “new age” as it sounds, medical use of ginger is well supported in the clinical literature. Bone et al¹ compared powdered ginger root (1,000 mg orally) with metoclopramide (10 mg IV) and placebo 90 minutes before surgery in 60 gynecologic patients. Postsurgical nausea was reduced significantly in both active treatment groups compared with placebo.

Fisher-Rasmussen et al² noted a statistically significant drop in nausea after use of ginger, 250 mg qid, to treat hyperemesis gravidarum across 4 days vs. placebo. Ginger’s antiemetic efficacy has also been demonstrated in motion sickness.³

How it works

Ginger, long used as an herbal medicine and in food preparation, is a perennial that grows in India, China, and Jamaica. Gingerol and other biologically active aromatic compounds found in ginger are thought to be the source of its pharmacologic actions. Its GI protective effects are considered local rather than CNS phenomena and are probably related to ginger’s stimulation of GI motility, as is seen with metoclopramide and domperidone.

I typically have patients start by using the ginger as needed during antidepressant therapy. If nausea is persistent or pervasive—as it tends to be in the first few weeks of treatment—I will prescribe the ginger at 1,000 mg bid or tid.

Possible side effects include heartburn, increased risk of bleeding (diminished platelet aggregation), and uterine contractions at high doses. No fatalities have been reported due to ginger overdose to date, although CNS depression and arrhythmias are possible.⁴ No exact maximum dosage has been cited in the literature, but I would advise against exceeding 1,000 mg tid.

Ginger has not been reported to be teratogenic, but pregnant women should take no more than 500 mg in one dose and no more than 1,000 mg/d.

To date, none of my patients have reported any serious side effects. The worst complaint I have heard has been mild heartburn, which could have implications for individuals with gastroesophageal reflux disease.

Finally, ginger ale has been used over the years as a folk remedy for nausea. Ginger ale is not an effective antiemetic, however, because it contains only ginger flavoring, not real ginger.

Persons who regularly record their thoughts are increasingly reaching for a mouse instead of a pen and paper.

Web logs, or “blogs,” are public online diaries that represent an emerging trend in self-expression and networking. Blogs cover everything from health care and current events to finding Mr. or Ms. Right, and the medium could become a powerful communication tool for mental health professionals and their patients as it becomes more mainstream.

Blogs are similar to personal home pages and newsletters, except that the content is updated more frequently-daily in many cases-and usually focuses on a single topic. The blog of Alex Chernavsky, a critic of psychiatry and the pharmaceutical industry, is one example.¹

The medium has emerged as part of the consumer empowerment trend that has characterized the Internet age, and is borne of a philosophy that embraces the exchange of information in cyberspace. Blogs have been employed most extensively in the news industry, where columnists use them to extend their communication with readers.² More companies today use blog software to collaborate on product development and post updates on market conditions, among other uses. Even the CIA is using Traction Software, an enterprise-based blog software package.³

Blogs are a hybrid form of communication, combining elements of individual and group psychotherapy with a public journal. Blogs not only are an outlet for the writer’s thoughts and feelings, but also provide a forum for ongoing discussion.

For example, one person with schizophrenia and bipolar disorder posts a blog at www.h13.com. Reading his poetry and reflections on his illness is bound to change one’s perspective on how a patient perceives his or her mental illness. The comments by visitors who provide support, find a shared experience, or describe their triumphs and setbacks are equally revealing.

In another blog (www.crazytracy.com), a registered nurse at a psychiatric hospital vents about her experiences in life and at work. Her outrageous rants and raves appear to have attracted a cult following.

A ‘blogring’- a group of blogs identified by a central theme, such as ‘depression’ or ‘self-loathing’-can also promote a sense of belonging for the user. When signing up for the ring, a specialized code on the user’s site will identify the viewer as belonging to that blogring and allow him or her to visit other blogs within the ring. Users select blogrings, visit each other’s blogs, and post comments,⁴ thus creating a community of support through Internet connectivity.

Many blogs also include specific links to the online diaries of friends or to other blogs or Web sites of interest. Technology such as blogLinker (www.bloglinker.com), myMediaList (www.mymedialist.com), and Blogrolling (www.blogrolling.com) facilitate this process.

Creating a blog once required knowledge of hypertext markup language (HTML), the code commonly used to create a Web page. Now, however, anyone with Netscape, Internet Explorer, or another Web browser can devise a blog using such services as Blog*Spot (www.blogspot.com), Xanga (www.xanga.com), or LiveJournal (www.livejournal.com).

Blog*Spot, Xanga, and CrimsonBlog (www.crimsonblog.com) provide free blog service, but may place ads on your site at their discretion. For users willing to pay for premium service, the ads are removed and additional features are available. The Developer’s Corner (http://fahim.razorsys.com/Blog.htm) is suitable for users who want to use their own site but need software.

Blogs in psychiatry

Blogs can be useful for patients who keep a journal. The patient and therapist can review an online diary and more quickly address issues outside of regular sessions. Postings can also be followed across a historical timeline-a function that e-mail does not offer. What’s more, each user can review comments from other viewers and post responses. For the patient who misses a group session, blogs can help him or her catch up on the current discussion.

Psychiatrists can also use blogs to exchange information with other members of a patient’s multidisciplinary care team. Such communication often is impeded, especially in hospitals that lack an electronic medical records system or do not have the central chart readily available. A blog on the hospital’s Intranet, however, can bridge the communication gap by providing links to articles and reports.

But use of blogs in psychiatry has its drawbacks, with potential lack of privacy the most obvious among them. Most blog software offers password protection, however: Either the entire site is blocked from public access or specific messages can be hidden.

Further, although blogs can be a useful adjunct to therapy, they are not a replacement. For fmany patients, the social interaction and non-verbal cues associated with traditional psychotherapy are crucial to treatment. Blogs may also frustrate therapy by allowing a patient to avoid direct ‘confrontation’ in an interpersonal setting.

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

Related Resources

• Dvorak JC. The blog phenomenon. PC Magazine Feb. 5, 2002. Available at: http://www.pcmag.com/article2/0,4149,81500,00.asp. Accessed Dec. 16, 2002.
• NetHistory.com. Media coverage of blogs. Available at: http://nethistory.urldir.com/blogs.php. Accessed Jan. 2, 2003.

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.

Persons who regularly record their thoughts are increasingly reaching for a mouse instead of a pen and paper.

Web logs, or “blogs,” are public online diaries that represent an emerging trend in self-expression and networking. Blogs cover everything from health care and current events to finding Mr. or Ms. Right, and the medium could become a powerful communication tool for mental health professionals and their patients as it becomes more mainstream.

Blogs are similar to personal home pages and newsletters, except that the content is updated more frequently-daily in many cases-and usually focuses on a single topic. The blog of Alex Chernavsky, a critic of psychiatry and the pharmaceutical industry, is one example.¹

The medium has emerged as part of the consumer empowerment trend that has characterized the Internet age, and is borne of a philosophy that embraces the exchange of information in cyberspace. Blogs have been employed most extensively in the news industry, where columnists use them to extend their communication with readers.² More companies today use blog software to collaborate on product development and post updates on market conditions, among other uses. Even the CIA is using Traction Software, an enterprise-based blog software package.³

Blogs are a hybrid form of communication, combining elements of individual and group psychotherapy with a public journal. Blogs not only are an outlet for the writer’s thoughts and feelings, but also provide a forum for ongoing discussion.

For example, one person with schizophrenia and bipolar disorder posts a blog at www.h13.com. Reading his poetry and reflections on his illness is bound to change one’s perspective on how a patient perceives his or her mental illness. The comments by visitors who provide support, find a shared experience, or describe their triumphs and setbacks are equally revealing.

In another blog (www.crazytracy.com), a registered nurse at a psychiatric hospital vents about her experiences in life and at work. Her outrageous rants and raves appear to have attracted a cult following.

A ‘blogring’- a group of blogs identified by a central theme, such as ‘depression’ or ‘self-loathing’-can also promote a sense of belonging for the user. When signing up for the ring, a specialized code on the user’s site will identify the viewer as belonging to that blogring and allow him or her to visit other blogs within the ring. Users select blogrings, visit each other’s blogs, and post comments,⁴ thus creating a community of support through Internet connectivity.

Many blogs also include specific links to the online diaries of friends or to other blogs or Web sites of interest. Technology such as blogLinker (www.bloglinker.com), myMediaList (www.mymedialist.com), and Blogrolling (www.blogrolling.com) facilitate this process.

Creating a blog once required knowledge of hypertext markup language (HTML), the code commonly used to create a Web page. Now, however, anyone with Netscape, Internet Explorer, or another Web browser can devise a blog using such services as Blog*Spot (www.blogspot.com), Xanga (www.xanga.com), or LiveJournal (www.livejournal.com).

Blog*Spot, Xanga, and CrimsonBlog (www.crimsonblog.com) provide free blog service, but may place ads on your site at their discretion. For users willing to pay for premium service, the ads are removed and additional features are available. The Developer’s Corner (http://fahim.razorsys.com/Blog.htm) is suitable for users who want to use their own site but need software.

Blogs in psychiatry

Blogs can be useful for patients who keep a journal. The patient and therapist can review an online diary and more quickly address issues outside of regular sessions. Postings can also be followed across a historical timeline-a function that e-mail does not offer. What’s more, each user can review comments from other viewers and post responses. For the patient who misses a group session, blogs can help him or her catch up on the current discussion.

Psychiatrists can also use blogs to exchange information with other members of a patient’s multidisciplinary care team. Such communication often is impeded, especially in hospitals that lack an electronic medical records system or do not have the central chart readily available. A blog on the hospital’s Intranet, however, can bridge the communication gap by providing links to articles and reports.

But use of blogs in psychiatry has its drawbacks, with potential lack of privacy the most obvious among them. Most blog software offers password protection, however: Either the entire site is blocked from public access or specific messages can be hidden.

Further, although blogs can be a useful adjunct to therapy, they are not a replacement. For fmany patients, the social interaction and non-verbal cues associated with traditional psychotherapy are crucial to treatment. Blogs may also frustrate therapy by allowing a patient to avoid direct ‘confrontation’ in an interpersonal setting.

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

Related Resources

• Dvorak JC. The blog phenomenon. PC Magazine Feb. 5, 2002. Available at: http://www.pcmag.com/article2/0,4149,81500,00.asp. Accessed Dec. 16, 2002.
• NetHistory.com. Media coverage of blogs. Available at: http://nethistory.urldir.com/blogs.php. Accessed Jan. 2, 2003.

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.

Persons who regularly record their thoughts are increasingly reaching for a mouse instead of a pen and paper.

Web logs, or “blogs,” are public online diaries that represent an emerging trend in self-expression and networking. Blogs cover everything from health care and current events to finding Mr. or Ms. Right, and the medium could become a powerful communication tool for mental health professionals and their patients as it becomes more mainstream.

Blogs are similar to personal home pages and newsletters, except that the content is updated more frequently-daily in many cases-and usually focuses on a single topic. The blog of Alex Chernavsky, a critic of psychiatry and the pharmaceutical industry, is one example.¹

The medium has emerged as part of the consumer empowerment trend that has characterized the Internet age, and is borne of a philosophy that embraces the exchange of information in cyberspace. Blogs have been employed most extensively in the news industry, where columnists use them to extend their communication with readers.² More companies today use blog software to collaborate on product development and post updates on market conditions, among other uses. Even the CIA is using Traction Software, an enterprise-based blog software package.³

Blogs are a hybrid form of communication, combining elements of individual and group psychotherapy with a public journal. Blogs not only are an outlet for the writer’s thoughts and feelings, but also provide a forum for ongoing discussion.

For example, one person with schizophrenia and bipolar disorder posts a blog at www.h13.com. Reading his poetry and reflections on his illness is bound to change one’s perspective on how a patient perceives his or her mental illness. The comments by visitors who provide support, find a shared experience, or describe their triumphs and setbacks are equally revealing.

In another blog (www.crazytracy.com), a registered nurse at a psychiatric hospital vents about her experiences in life and at work. Her outrageous rants and raves appear to have attracted a cult following.

A ‘blogring’- a group of blogs identified by a central theme, such as ‘depression’ or ‘self-loathing’-can also promote a sense of belonging for the user. When signing up for the ring, a specialized code on the user’s site will identify the viewer as belonging to that blogring and allow him or her to visit other blogs within the ring. Users select blogrings, visit each other’s blogs, and post comments,⁴ thus creating a community of support through Internet connectivity.

Many blogs also include specific links to the online diaries of friends or to other blogs or Web sites of interest. Technology such as blogLinker (www.bloglinker.com), myMediaList (www.mymedialist.com), and Blogrolling (www.blogrolling.com) facilitate this process.

Creating a blog once required knowledge of hypertext markup language (HTML), the code commonly used to create a Web page. Now, however, anyone with Netscape, Internet Explorer, or another Web browser can devise a blog using such services as Blog*Spot (www.blogspot.com), Xanga (www.xanga.com), or LiveJournal (www.livejournal.com).

Blog*Spot, Xanga, and CrimsonBlog (www.crimsonblog.com) provide free blog service, but may place ads on your site at their discretion. For users willing to pay for premium service, the ads are removed and additional features are available. The Developer’s Corner (http://fahim.razorsys.com/Blog.htm) is suitable for users who want to use their own site but need software.

Blogs in psychiatry

Blogs can be useful for patients who keep a journal. The patient and therapist can review an online diary and more quickly address issues outside of regular sessions. Postings can also be followed across a historical timeline-a function that e-mail does not offer. What’s more, each user can review comments from other viewers and post responses. For the patient who misses a group session, blogs can help him or her catch up on the current discussion.

Psychiatrists can also use blogs to exchange information with other members of a patient’s multidisciplinary care team. Such communication often is impeded, especially in hospitals that lack an electronic medical records system or do not have the central chart readily available. A blog on the hospital’s Intranet, however, can bridge the communication gap by providing links to articles and reports.

But use of blogs in psychiatry has its drawbacks, with potential lack of privacy the most obvious among them. Most blog software offers password protection, however: Either the entire site is blocked from public access or specific messages can be hidden.

Further, although blogs can be a useful adjunct to therapy, they are not a replacement. For fmany patients, the social interaction and non-verbal cues associated with traditional psychotherapy are crucial to treatment. Blogs may also frustrate therapy by allowing a patient to avoid direct ‘confrontation’ in an interpersonal setting.

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

Related Resources

• Dvorak JC. The blog phenomenon. PC Magazine Feb. 5, 2002. Available at: http://www.pcmag.com/article2/0,4149,81500,00.asp. Accessed Dec. 16, 2002.
• NetHistory.com. Media coverage of blogs. Available at: http://nethistory.urldir.com/blogs.php. Accessed Jan. 2, 2003.

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.

Schizophrenia is a lifelong disorder, but new-onset patients often do not see it that way. Many patients responding to an acute episode believe they need only a few days of medication—or none at all. Unfortunately, research has repeatedly shown that maintenance antipsychotics are needed to prevent or delay recurrence.

How do you get patients to accept long-term treatment? How do you prepare them for a lifetime of antipsychotic therapy, with its stigma, hassle, and side effects?

Basically, you don’t. Just as a reader will not commit to a 3-year magazine subscription without first receiving a couple of free issues, a therapeutic alliance with the newly diagnosed schizophrenia patient must be built over time. Honesty is paramount, but if you insist on the need for long-term antipsychotic medication right after an initial hospitalization, chances are you’ll turn the patient off to any treatment.

Breaking treatment down into shorter periods

I first ask the patient how long he or she plans to take the medication. If the answer is in days (or hours), I’ll try to convince the patient to agree to 1 month of antipsychotic therapy. I say, “I know you don’t think you need this medication. But you should know that based on experience with similar patients, I think this medication will help you stay out of the hospital. Just take it until your next appointment, then we’ll see what happens.” I have not mentioned long-term medication, but I haven’t lied either.

Simply telling the patient, “Not taking this medication could lead to a relapse,” will not work. The patient invariably will respond, “I’m the exception. Relapses happen to other patients, not me.”

Often patients realize by the next visit that the medication is helping them function better and continue taking it. Conversely, if the patient is adamant about stopping the regimen, we agree to disagree. I’ll say, “I still think you need this medication, but I’m not the one who’s taking it.” I do, however, urge the patient to taper over the next month to lessen the severity of a prospective psychotic episode.

Discussing life goals can convince some patients that adherence to an antipsychotic prescription is in their best interests. Let’s say that a young woman who has just suffered her first psychotic episode tells me she hopes to return to school, advance her career, or find a husband. I respond, “Your recent hospitalization was devastating, wasn’t it? The way I see it, another hospitalization would delay your reaching these goals or even jeopardize them, is that correct?”

I then explain, “Taking the medications, as unpleasant as they can be, will decrease your chances of another hospitalization and allow you to live your life.” I’m not changing the patient’s fundamental attitude toward psychiatric treatment, but I am extending care for a month or two. In the bargain, I’m strengthening our therapeutic alliance with the hope that the patient will call me if he or she decides to resume treatment later on.

Discussing a clozapine trial

This approach also is helpful when prescribing clozapine. For patients who have not responded to other antipsychotics, a clozapine regimen can be a particularly hard sell. The agent is effective, but the patient often is discouraged after learning of the need for weekly blood draws to check for agranulocytosis. It is frightening to commit to lifelong blood draws before you know if the medication will be helpful.

Rather than ask for a lifelong commitment to blood draws, I try to persuade the patient that a therapeutic trial of clozapine is worth the trouble. I say, “Just put up with 12 blood draws in the next 3 months. After that, you can stop the medication if you’d like.” When taking this tack, I’ve found that roughly one out of three patients who might otherwise have refused clozapine stay with the medication beyond the first 3 months.

Schizophrenia is a lifelong disorder, but new-onset patients often do not see it that way. Many patients responding to an acute episode believe they need only a few days of medication—or none at all. Unfortunately, research has repeatedly shown that maintenance antipsychotics are needed to prevent or delay recurrence.

How do you get patients to accept long-term treatment? How do you prepare them for a lifetime of antipsychotic therapy, with its stigma, hassle, and side effects?

Basically, you don’t. Just as a reader will not commit to a 3-year magazine subscription without first receiving a couple of free issues, a therapeutic alliance with the newly diagnosed schizophrenia patient must be built over time. Honesty is paramount, but if you insist on the need for long-term antipsychotic medication right after an initial hospitalization, chances are you’ll turn the patient off to any treatment.

Breaking treatment down into shorter periods

I first ask the patient how long he or she plans to take the medication. If the answer is in days (or hours), I’ll try to convince the patient to agree to 1 month of antipsychotic therapy. I say, “I know you don’t think you need this medication. But you should know that based on experience with similar patients, I think this medication will help you stay out of the hospital. Just take it until your next appointment, then we’ll see what happens.” I have not mentioned long-term medication, but I haven’t lied either.

Simply telling the patient, “Not taking this medication could lead to a relapse,” will not work. The patient invariably will respond, “I’m the exception. Relapses happen to other patients, not me.”

Often patients realize by the next visit that the medication is helping them function better and continue taking it. Conversely, if the patient is adamant about stopping the regimen, we agree to disagree. I’ll say, “I still think you need this medication, but I’m not the one who’s taking it.” I do, however, urge the patient to taper over the next month to lessen the severity of a prospective psychotic episode.

Discussing life goals can convince some patients that adherence to an antipsychotic prescription is in their best interests. Let’s say that a young woman who has just suffered her first psychotic episode tells me she hopes to return to school, advance her career, or find a husband. I respond, “Your recent hospitalization was devastating, wasn’t it? The way I see it, another hospitalization would delay your reaching these goals or even jeopardize them, is that correct?”

I then explain, “Taking the medications, as unpleasant as they can be, will decrease your chances of another hospitalization and allow you to live your life.” I’m not changing the patient’s fundamental attitude toward psychiatric treatment, but I am extending care for a month or two. In the bargain, I’m strengthening our therapeutic alliance with the hope that the patient will call me if he or she decides to resume treatment later on.

Discussing a clozapine trial

This approach also is helpful when prescribing clozapine. For patients who have not responded to other antipsychotics, a clozapine regimen can be a particularly hard sell. The agent is effective, but the patient often is discouraged after learning of the need for weekly blood draws to check for agranulocytosis. It is frightening to commit to lifelong blood draws before you know if the medication will be helpful.

Rather than ask for a lifelong commitment to blood draws, I try to persuade the patient that a therapeutic trial of clozapine is worth the trouble. I say, “Just put up with 12 blood draws in the next 3 months. After that, you can stop the medication if you’d like.” When taking this tack, I’ve found that roughly one out of three patients who might otherwise have refused clozapine stay with the medication beyond the first 3 months.

Schizophrenia is a lifelong disorder, but new-onset patients often do not see it that way. Many patients responding to an acute episode believe they need only a few days of medication—or none at all. Unfortunately, research has repeatedly shown that maintenance antipsychotics are needed to prevent or delay recurrence.

How do you get patients to accept long-term treatment? How do you prepare them for a lifetime of antipsychotic therapy, with its stigma, hassle, and side effects?

Basically, you don’t. Just as a reader will not commit to a 3-year magazine subscription without first receiving a couple of free issues, a therapeutic alliance with the newly diagnosed schizophrenia patient must be built over time. Honesty is paramount, but if you insist on the need for long-term antipsychotic medication right after an initial hospitalization, chances are you’ll turn the patient off to any treatment.

Breaking treatment down into shorter periods

I first ask the patient how long he or she plans to take the medication. If the answer is in days (or hours), I’ll try to convince the patient to agree to 1 month of antipsychotic therapy. I say, “I know you don’t think you need this medication. But you should know that based on experience with similar patients, I think this medication will help you stay out of the hospital. Just take it until your next appointment, then we’ll see what happens.” I have not mentioned long-term medication, but I haven’t lied either.

Simply telling the patient, “Not taking this medication could lead to a relapse,” will not work. The patient invariably will respond, “I’m the exception. Relapses happen to other patients, not me.”

Often patients realize by the next visit that the medication is helping them function better and continue taking it. Conversely, if the patient is adamant about stopping the regimen, we agree to disagree. I’ll say, “I still think you need this medication, but I’m not the one who’s taking it.” I do, however, urge the patient to taper over the next month to lessen the severity of a prospective psychotic episode.

Discussing life goals can convince some patients that adherence to an antipsychotic prescription is in their best interests. Let’s say that a young woman who has just suffered her first psychotic episode tells me she hopes to return to school, advance her career, or find a husband. I respond, “Your recent hospitalization was devastating, wasn’t it? The way I see it, another hospitalization would delay your reaching these goals or even jeopardize them, is that correct?”

I then explain, “Taking the medications, as unpleasant as they can be, will decrease your chances of another hospitalization and allow you to live your life.” I’m not changing the patient’s fundamental attitude toward psychiatric treatment, but I am extending care for a month or two. In the bargain, I’m strengthening our therapeutic alliance with the hope that the patient will call me if he or she decides to resume treatment later on.

Discussing a clozapine trial

This approach also is helpful when prescribing clozapine. For patients who have not responded to other antipsychotics, a clozapine regimen can be a particularly hard sell. The agent is effective, but the patient often is discouraged after learning of the need for weekly blood draws to check for agranulocytosis. It is frightening to commit to lifelong blood draws before you know if the medication will be helpful.

Rather than ask for a lifelong commitment to blood draws, I try to persuade the patient that a therapeutic trial of clozapine is worth the trouble. I say, “Just put up with 12 blood draws in the next 3 months. After that, you can stop the medication if you’d like.” When taking this tack, I’ve found that roughly one out of three patients who might otherwise have refused clozapine stay with the medication beyond the first 3 months.

Schizophrenia is a lifelong disorder, but new-onset patients often do not see it that way. Many patients responding to an acute episode believe they need only a few days of medication—or none at all. Unfortunately, research has repeatedly shown that maintenance antipsychotics are needed to prevent or delay recurrence.

How do you get patients to accept long-term treatment? How do you prepare them for a lifetime of antipsychotic therapy, with its stigma, hassle, and side effects?

Basically, you don’t. Just as a reader will not commit to a 3-year magazine subscription without first receiving a couple of free issues, a therapeutic alliance with the newly diagnosed schizophrenia patient must be built over time. Honesty is paramount, but if you insist on the need for long-term antipsychotic medication right after an initial hospitalization, chances are you’ll turn the patient off to any treatment.

Breaking treatment down into shorter periods

I first ask the patient how long he or she plans to take the medication. If the answer is in days (or hours), I’ll try to convince the patient to agree to 1 month of antipsychotic therapy. I say, “I know you don’t think you need this medication. But you should know that based on experience with similar patients, I think this medication will help you stay out of the hospital. Just take it until your next appointment, then we’ll see what happens.” I have not mentioned long-term medication, but I haven’t lied either.

Simply telling the patient, “Not taking this medication could lead to a relapse,” will not work. The patient invariably will respond, “I’m the exception. Relapses happen to other patients, not me.”

Often patients realize by the next visit that the medication is helping them function better and continue taking it. Conversely, if the patient is adamant about stopping the regimen, we agree to disagree. I’ll say, “I still think you need this medication, but I’m not the one who’s taking it.” I do, however, urge the patient to taper over the next month to lessen the severity of a prospective psychotic episode.

Discussing life goals can convince some patients that adherence to an antipsychotic prescription is in their best interests. Let’s say that a young woman who has just suffered her first psychotic episode tells me she hopes to return to school, advance her career, or find a husband. I respond, “Your recent hospitalization was devastating, wasn’t it? The way I see it, another hospitalization would delay your reaching these goals or even jeopardize them, is that correct?”

I then explain, “Taking the medications, as unpleasant as they can be, will decrease your chances of another hospitalization and allow you to live your life.” I’m not changing the patient’s fundamental attitude toward psychiatric treatment, but I am extending care for a month or two. In the bargain, I’m strengthening our therapeutic alliance with the hope that the patient will call me if he or she decides to resume treatment later on.

Discussing a clozapine trial

This approach also is helpful when prescribing clozapine. For patients who have not responded to other antipsychotics, a clozapine regimen can be a particularly hard sell. The agent is effective, but the patient often is discouraged after learning of the need for weekly blood draws to check for agranulocytosis. It is frightening to commit to lifelong blood draws before you know if the medication will be helpful.

Rather than ask for a lifelong commitment to blood draws, I try to persuade the patient that a therapeutic trial of clozapine is worth the trouble. I say, “Just put up with 12 blood draws in the next 3 months. After that, you can stop the medication if you’d like.” When taking this tack, I’ve found that roughly one out of three patients who might otherwise have refused clozapine stay with the medication beyond the first 3 months.

Schizophrenia is a lifelong disorder, but new-onset patients often do not see it that way. Many patients responding to an acute episode believe they need only a few days of medication—or none at all. Unfortunately, research has repeatedly shown that maintenance antipsychotics are needed to prevent or delay recurrence.

How do you get patients to accept long-term treatment? How do you prepare them for a lifetime of antipsychotic therapy, with its stigma, hassle, and side effects?

Basically, you don’t. Just as a reader will not commit to a 3-year magazine subscription without first receiving a couple of free issues, a therapeutic alliance with the newly diagnosed schizophrenia patient must be built over time. Honesty is paramount, but if you insist on the need for long-term antipsychotic medication right after an initial hospitalization, chances are you’ll turn the patient off to any treatment.

Breaking treatment down into shorter periods

I first ask the patient how long he or she plans to take the medication. If the answer is in days (or hours), I’ll try to convince the patient to agree to 1 month of antipsychotic therapy. I say, “I know you don’t think you need this medication. But you should know that based on experience with similar patients, I think this medication will help you stay out of the hospital. Just take it until your next appointment, then we’ll see what happens.” I have not mentioned long-term medication, but I haven’t lied either.

Simply telling the patient, “Not taking this medication could lead to a relapse,” will not work. The patient invariably will respond, “I’m the exception. Relapses happen to other patients, not me.”

Often patients realize by the next visit that the medication is helping them function better and continue taking it. Conversely, if the patient is adamant about stopping the regimen, we agree to disagree. I’ll say, “I still think you need this medication, but I’m not the one who’s taking it.” I do, however, urge the patient to taper over the next month to lessen the severity of a prospective psychotic episode.

Discussing life goals can convince some patients that adherence to an antipsychotic prescription is in their best interests. Let’s say that a young woman who has just suffered her first psychotic episode tells me she hopes to return to school, advance her career, or find a husband. I respond, “Your recent hospitalization was devastating, wasn’t it? The way I see it, another hospitalization would delay your reaching these goals or even jeopardize them, is that correct?”

I then explain, “Taking the medications, as unpleasant as they can be, will decrease your chances of another hospitalization and allow you to live your life.” I’m not changing the patient’s fundamental attitude toward psychiatric treatment, but I am extending care for a month or two. In the bargain, I’m strengthening our therapeutic alliance with the hope that the patient will call me if he or she decides to resume treatment later on.

Discussing a clozapine trial

This approach also is helpful when prescribing clozapine. For patients who have not responded to other antipsychotics, a clozapine regimen can be a particularly hard sell. The agent is effective, but the patient often is discouraged after learning of the need for weekly blood draws to check for agranulocytosis. It is frightening to commit to lifelong blood draws before you know if the medication will be helpful.

Rather than ask for a lifelong commitment to blood draws, I try to persuade the patient that a therapeutic trial of clozapine is worth the trouble. I say, “Just put up with 12 blood draws in the next 3 months. After that, you can stop the medication if you’d like.” When taking this tack, I’ve found that roughly one out of three patients who might otherwise have refused clozapine stay with the medication beyond the first 3 months.

Schizophrenia is a lifelong disorder, but new-onset patients often do not see it that way. Many patients responding to an acute episode believe they need only a few days of medication—or none at all. Unfortunately, research has repeatedly shown that maintenance antipsychotics are needed to prevent or delay recurrence.

How do you get patients to accept long-term treatment? How do you prepare them for a lifetime of antipsychotic therapy, with its stigma, hassle, and side effects?

Basically, you don’t. Just as a reader will not commit to a 3-year magazine subscription without first receiving a couple of free issues, a therapeutic alliance with the newly diagnosed schizophrenia patient must be built over time. Honesty is paramount, but if you insist on the need for long-term antipsychotic medication right after an initial hospitalization, chances are you’ll turn the patient off to any treatment.

Breaking treatment down into shorter periods

I first ask the patient how long he or she plans to take the medication. If the answer is in days (or hours), I’ll try to convince the patient to agree to 1 month of antipsychotic therapy. I say, “I know you don’t think you need this medication. But you should know that based on experience with similar patients, I think this medication will help you stay out of the hospital. Just take it until your next appointment, then we’ll see what happens.” I have not mentioned long-term medication, but I haven’t lied either.

Simply telling the patient, “Not taking this medication could lead to a relapse,” will not work. The patient invariably will respond, “I’m the exception. Relapses happen to other patients, not me.”

Often patients realize by the next visit that the medication is helping them function better and continue taking it. Conversely, if the patient is adamant about stopping the regimen, we agree to disagree. I’ll say, “I still think you need this medication, but I’m not the one who’s taking it.” I do, however, urge the patient to taper over the next month to lessen the severity of a prospective psychotic episode.

Discussing life goals can convince some patients that adherence to an antipsychotic prescription is in their best interests. Let’s say that a young woman who has just suffered her first psychotic episode tells me she hopes to return to school, advance her career, or find a husband. I respond, “Your recent hospitalization was devastating, wasn’t it? The way I see it, another hospitalization would delay your reaching these goals or even jeopardize them, is that correct?”

I then explain, “Taking the medications, as unpleasant as they can be, will decrease your chances of another hospitalization and allow you to live your life.” I’m not changing the patient’s fundamental attitude toward psychiatric treatment, but I am extending care for a month or two. In the bargain, I’m strengthening our therapeutic alliance with the hope that the patient will call me if he or she decides to resume treatment later on.

Discussing a clozapine trial

This approach also is helpful when prescribing clozapine. For patients who have not responded to other antipsychotics, a clozapine regimen can be a particularly hard sell. The agent is effective, but the patient often is discouraged after learning of the need for weekly blood draws to check for agranulocytosis. It is frightening to commit to lifelong blood draws before you know if the medication will be helpful.

Rather than ask for a lifelong commitment to blood draws, I try to persuade the patient that a therapeutic trial of clozapine is worth the trouble. I say, “Just put up with 12 blood draws in the next 3 months. After that, you can stop the medication if you’d like.” When taking this tack, I’ve found that roughly one out of three patients who might otherwise have refused clozapine stay with the medication beyond the first 3 months.