Pearls

E-mail is fast becoming a key medium for addressing interpersonal and other therapeutic needs. E-therapy delivered via e-mail and other media offers convenience and a sense of privacy that can break down barriers to treatment for persons grappling with the stigma of mental illness or an emotional problem.

E-therapy is not a substitute for psychotherapy or psychological counseling, nor should it be confused with those modalities. By helping the patient resolve life and relationship issues under the guidance of a qualified professional, however, e-therapy can be a worthwhile adjunct to psychiatric treatment. E-therapy is best for significant but not critical issues that result in adjustment disorders, such as frustration over not receiving a promotion or job offer.

In additional to counseling via e-mail, e-therapy also takes the form of telemedicine; “ask-the-expert” Web sites; office-based therapy supplemented with e-mail, instant messaging or private chat programs; and online group treatment.

Benefits and drawbacks

Convenience is a major advantage of e-therapy. For people with limited mobility or who are leery of entering a mental health facility, e-therapy provides access to psychological services that would otherwise be unavailable. For patients with anxiety disorders such as social phobia, e-therapy abolishes the initial barrier to treatment.

When asynchronous communication such as e-mail is employed, e-therapy provides time for reflection on issues raised in the previous message. While traditional therapy offers a more free-form process, e-therapy allows the user to organize and carefully examine his or her thoughts and feelings.

Since the need for social interaction and nonverbal cues is eliminated, the salient issues may be addressed quickly and without distraction. Also, links to educational material can easily be embedded within messages, providing immediate access to information not available in traditional face-to-face therapy.

Depending on which e-mail program is used, e-therapy is also potentially more confidential and can be performed more anonymously than traditional therapy.¹ For example, a patient can use a Hushmail (www.hushmail.com) account, which provides secure e-mail messaging.

But many of these benefits double as major drawbacks. For one, most e-mail programs/services are not secure, subjecting patients to possible breach of confidentiality as evidenced by Carnivore, a program that enables the FBI to intercept electronic communications without detection.² Use of a virtual private network allows users to establish a two-way encrypted channel of communication and reduce the chances of intrusion.

The asynchronous nature of text-based communication can also be detrimental. A miscommunication cannot be immediately clarified and can leave the patient feeling more rejected or isolated than before.

Also, the social and nonverbal cues that may facilitate the communication’s context are not available. Without these cues, emergencies such as suicidal ideation may go undetected. For that reason, patients who are suicidal should be advised against e-therapy. Also, since the therapist is not “present,” e-therapy should not be used to address issues that raise intense feelings.

More research needed

Information on the efficacy of e-therapy is limited. According to preliminary data on Metanoia-an online mental health consumer guide (www.metanoia.org)-60% of 450 patients who have tried e-therapy found it very helpful, 32% found it somewhat helpful, and 8% found it not helpful.³

Stephen Biggs, MA, a doctoral candidate in clinical psychology at York University in Toronto, is conducting a more formal assessment of the consumer’s experience with online mental health services.⁴

Helping patients choose an e-therapist

E-therapists-mostly psychologists, marriage and family therapists, and licensed clinical social workers-are fairly easy to find on the Web. Interestingly, a recent Web search using the term “e-therapy” turned up only one psychiatrist from among 30 names, although more MDs may offer online therapy as the modality gains acceptance.

Because most state laws governing licensing do not address e-therapy, a patient dissatisfied with his or her e-therapist has no legal recourse. Therefore, advise patients to proceed carefully. John Grohol, Psy.D, founding president of the International Society for Mental Health Online (ISMHO), recommends that patients sign or consent to a counseling agreement and a privacy statement, which clearly delineate responsibilities and operating procedures.⁵

Online resources such as Metanoia and ISMHO (www.ismho.org) offer advice on choosing a qualified e-therapist. Metanoia, for example, offers a directory of e-therapists⁶ and explains what to look for-and avoid-in a therapist. Site creator Martha Ainsworth notes that Metanoia only lists therapists who have credentials, a degree, and/or a license to provide therapy. ISMHO’s Suggested Principles for the Online Provision of Mental Health Services⁷ also spells out what services patients should expect from an e-therapist.

Finally, although cyberspace has a global reach, advise patients to choose an e-therapist who lives within driving distance if possible. That way, the patient can consult the therapist in person if a crisis arises.

Related resources

• Hsiung RC (ed). E-therapy: case studies, guiding principles, and the clinical potential of the Internet. New York: W.W. Norton & Co., 2002.
• Fink J. How to use computers and cyberspace in the clinical practice of psychotherapy. Northvale, NJ: Jason Aronson Inc., 1999.

Disclosure

The author reports no affiliation or financial relationship with any of the companies whose products are mentioned in this article.

E-mail is fast becoming a key medium for addressing interpersonal and other therapeutic needs. E-therapy delivered via e-mail and other media offers convenience and a sense of privacy that can break down barriers to treatment for persons grappling with the stigma of mental illness or an emotional problem.

E-therapy is not a substitute for psychotherapy or psychological counseling, nor should it be confused with those modalities. By helping the patient resolve life and relationship issues under the guidance of a qualified professional, however, e-therapy can be a worthwhile adjunct to psychiatric treatment. E-therapy is best for significant but not critical issues that result in adjustment disorders, such as frustration over not receiving a promotion or job offer.

In additional to counseling via e-mail, e-therapy also takes the form of telemedicine; “ask-the-expert” Web sites; office-based therapy supplemented with e-mail, instant messaging or private chat programs; and online group treatment.

Benefits and drawbacks

Convenience is a major advantage of e-therapy. For people with limited mobility or who are leery of entering a mental health facility, e-therapy provides access to psychological services that would otherwise be unavailable. For patients with anxiety disorders such as social phobia, e-therapy abolishes the initial barrier to treatment.

When asynchronous communication such as e-mail is employed, e-therapy provides time for reflection on issues raised in the previous message. While traditional therapy offers a more free-form process, e-therapy allows the user to organize and carefully examine his or her thoughts and feelings.

Since the need for social interaction and nonverbal cues is eliminated, the salient issues may be addressed quickly and without distraction. Also, links to educational material can easily be embedded within messages, providing immediate access to information not available in traditional face-to-face therapy.

Depending on which e-mail program is used, e-therapy is also potentially more confidential and can be performed more anonymously than traditional therapy.¹ For example, a patient can use a Hushmail (www.hushmail.com) account, which provides secure e-mail messaging.

But many of these benefits double as major drawbacks. For one, most e-mail programs/services are not secure, subjecting patients to possible breach of confidentiality as evidenced by Carnivore, a program that enables the FBI to intercept electronic communications without detection.² Use of a virtual private network allows users to establish a two-way encrypted channel of communication and reduce the chances of intrusion.

The asynchronous nature of text-based communication can also be detrimental. A miscommunication cannot be immediately clarified and can leave the patient feeling more rejected or isolated than before.

Also, the social and nonverbal cues that may facilitate the communication’s context are not available. Without these cues, emergencies such as suicidal ideation may go undetected. For that reason, patients who are suicidal should be advised against e-therapy. Also, since the therapist is not “present,” e-therapy should not be used to address issues that raise intense feelings.

More research needed

Information on the efficacy of e-therapy is limited. According to preliminary data on Metanoia-an online mental health consumer guide (www.metanoia.org)-60% of 450 patients who have tried e-therapy found it very helpful, 32% found it somewhat helpful, and 8% found it not helpful.³

Stephen Biggs, MA, a doctoral candidate in clinical psychology at York University in Toronto, is conducting a more formal assessment of the consumer’s experience with online mental health services.⁴

Helping patients choose an e-therapist

E-therapists-mostly psychologists, marriage and family therapists, and licensed clinical social workers-are fairly easy to find on the Web. Interestingly, a recent Web search using the term “e-therapy” turned up only one psychiatrist from among 30 names, although more MDs may offer online therapy as the modality gains acceptance.

Because most state laws governing licensing do not address e-therapy, a patient dissatisfied with his or her e-therapist has no legal recourse. Therefore, advise patients to proceed carefully. John Grohol, Psy.D, founding president of the International Society for Mental Health Online (ISMHO), recommends that patients sign or consent to a counseling agreement and a privacy statement, which clearly delineate responsibilities and operating procedures.⁵

Online resources such as Metanoia and ISMHO (www.ismho.org) offer advice on choosing a qualified e-therapist. Metanoia, for example, offers a directory of e-therapists⁶ and explains what to look for-and avoid-in a therapist. Site creator Martha Ainsworth notes that Metanoia only lists therapists who have credentials, a degree, and/or a license to provide therapy. ISMHO’s Suggested Principles for the Online Provision of Mental Health Services⁷ also spells out what services patients should expect from an e-therapist.

Finally, although cyberspace has a global reach, advise patients to choose an e-therapist who lives within driving distance if possible. That way, the patient can consult the therapist in person if a crisis arises.

Related resources

• Hsiung RC (ed). E-therapy: case studies, guiding principles, and the clinical potential of the Internet. New York: W.W. Norton & Co., 2002.
• Fink J. How to use computers and cyberspace in the clinical practice of psychotherapy. Northvale, NJ: Jason Aronson Inc., 1999.

Disclosure

The author reports no affiliation or financial relationship with any of the companies whose products are mentioned in this article.

E-mail is fast becoming a key medium for addressing interpersonal and other therapeutic needs. E-therapy delivered via e-mail and other media offers convenience and a sense of privacy that can break down barriers to treatment for persons grappling with the stigma of mental illness or an emotional problem.

E-therapy is not a substitute for psychotherapy or psychological counseling, nor should it be confused with those modalities. By helping the patient resolve life and relationship issues under the guidance of a qualified professional, however, e-therapy can be a worthwhile adjunct to psychiatric treatment. E-therapy is best for significant but not critical issues that result in adjustment disorders, such as frustration over not receiving a promotion or job offer.

In additional to counseling via e-mail, e-therapy also takes the form of telemedicine; “ask-the-expert” Web sites; office-based therapy supplemented with e-mail, instant messaging or private chat programs; and online group treatment.

Benefits and drawbacks

Convenience is a major advantage of e-therapy. For people with limited mobility or who are leery of entering a mental health facility, e-therapy provides access to psychological services that would otherwise be unavailable. For patients with anxiety disorders such as social phobia, e-therapy abolishes the initial barrier to treatment.

When asynchronous communication such as e-mail is employed, e-therapy provides time for reflection on issues raised in the previous message. While traditional therapy offers a more free-form process, e-therapy allows the user to organize and carefully examine his or her thoughts and feelings.

Since the need for social interaction and nonverbal cues is eliminated, the salient issues may be addressed quickly and without distraction. Also, links to educational material can easily be embedded within messages, providing immediate access to information not available in traditional face-to-face therapy.

Depending on which e-mail program is used, e-therapy is also potentially more confidential and can be performed more anonymously than traditional therapy.¹ For example, a patient can use a Hushmail (www.hushmail.com) account, which provides secure e-mail messaging.

But many of these benefits double as major drawbacks. For one, most e-mail programs/services are not secure, subjecting patients to possible breach of confidentiality as evidenced by Carnivore, a program that enables the FBI to intercept electronic communications without detection.² Use of a virtual private network allows users to establish a two-way encrypted channel of communication and reduce the chances of intrusion.

The asynchronous nature of text-based communication can also be detrimental. A miscommunication cannot be immediately clarified and can leave the patient feeling more rejected or isolated than before.

Also, the social and nonverbal cues that may facilitate the communication’s context are not available. Without these cues, emergencies such as suicidal ideation may go undetected. For that reason, patients who are suicidal should be advised against e-therapy. Also, since the therapist is not “present,” e-therapy should not be used to address issues that raise intense feelings.

More research needed

Information on the efficacy of e-therapy is limited. According to preliminary data on Metanoia-an online mental health consumer guide (www.metanoia.org)-60% of 450 patients who have tried e-therapy found it very helpful, 32% found it somewhat helpful, and 8% found it not helpful.³

Stephen Biggs, MA, a doctoral candidate in clinical psychology at York University in Toronto, is conducting a more formal assessment of the consumer’s experience with online mental health services.⁴

Helping patients choose an e-therapist

E-therapists-mostly psychologists, marriage and family therapists, and licensed clinical social workers-are fairly easy to find on the Web. Interestingly, a recent Web search using the term “e-therapy” turned up only one psychiatrist from among 30 names, although more MDs may offer online therapy as the modality gains acceptance.

Because most state laws governing licensing do not address e-therapy, a patient dissatisfied with his or her e-therapist has no legal recourse. Therefore, advise patients to proceed carefully. John Grohol, Psy.D, founding president of the International Society for Mental Health Online (ISMHO), recommends that patients sign or consent to a counseling agreement and a privacy statement, which clearly delineate responsibilities and operating procedures.⁵

Online resources such as Metanoia and ISMHO (www.ismho.org) offer advice on choosing a qualified e-therapist. Metanoia, for example, offers a directory of e-therapists⁶ and explains what to look for-and avoid-in a therapist. Site creator Martha Ainsworth notes that Metanoia only lists therapists who have credentials, a degree, and/or a license to provide therapy. ISMHO’s Suggested Principles for the Online Provision of Mental Health Services⁷ also spells out what services patients should expect from an e-therapist.

Finally, although cyberspace has a global reach, advise patients to choose an e-therapist who lives within driving distance if possible. That way, the patient can consult the therapist in person if a crisis arises.

Related resources

• Hsiung RC (ed). E-therapy: case studies, guiding principles, and the clinical potential of the Internet. New York: W.W. Norton & Co., 2002.
• Fink J. How to use computers and cyberspace in the clinical practice of psychotherapy. Northvale, NJ: Jason Aronson Inc., 1999.

Disclosure

The author reports no affiliation or financial relationship with any of the companies whose products are mentioned in this article.

For psychiatrists who often cannot find time to do standard neurologic examinations, a 2-minute face-hand test (FHT) can quickly help distinguish primary (idiopathic) from secondary (organic) psychiatric disorders and schizophrenia from other psychotic disorders.

FHT results are:

• frequently and markedly abnormal in dementia and mental retardation
• less frequently and less severely abnormal in (though still indicative of) schizophrenia
• rarely abnormal in other psychiatric patients.

The FHT is an extension of the (symmetric) double simultaneous stimulation test method, in which clinicians routinely apply light simultaneous touches to the same location bilaterally (both hands, both cheeks) to screen for touch sensation deficits. The FHT merely extends this to incorporate asymmetric double simultaneous stimuli (one hand, one cheek). Both approaches are more sensitive than applying single stimuli.

How the test is performed

• I tell the patient, “I want to test your sense of touch. While your eyes are closed, I’m going to touch one or the other hand, one or the other side of your face, or some combination. All you need to do is tell me where you felt touched.” Specific instructions can affect the performance of this test, so I stick to this script.
• I then lightly and briefly touch the left hand and right cheek as simultaneously as possible, then wait for the patient to clearly indicate where any touch was felt. If only the face stimulus is reported, I ask “Anywhere else?” I only use this prompt once, after the first trial. I then touch the right hand and left cheek, the left hand and left cheek, the right hand and right cheek, both hands, and both cheeks.
• If the patient does not report touches to the hand in at least three of the first four asymmetric trials, I continue after the two symmetric trials with four more asymmetric trials (one of each face-hand combination).
• I count failure to correctly localize any touch as an error. Neglect (“extinction”) of the hand stimulus when the face is also being touched accounts for most errors, although various other errors can occur. Once patients begin to perceive the hand stimulus, they rarely make additional errors.

Experience with the FHT improves performance, so repeated testing may obscure the results. Specific instructions given to the patient can also affect the results. Emphasing dual stimuli (e.g., “I’m going to be touching you on the face and on the hand”) reduces both sensitivity and the chance for error. Not mentioning dual stimuli (e.g., “Tell me where you feel a touch”) increases the chance for error and reduces specificity.

Using the FHT as described, I’ve found that about 20% of patients with first-episode schizophrenia extinguish at least one hand stimulus (usually on the first trial), but first-episode patients with other idiopathic psychotic disorders almost never make errors.

In a separate sample taken with a different testing approach, patients with schizophrenia had more hand extinctions than did those with other psychiatric disorders.¹ I feel a positive FHT supports a diagnosis of schizophrenia in a cognitively intact patient with psychosis.

Patients with significant cognitive impairment (e.g., dementia, delirium, or mental retardation) typically extinguish several hand stimuli; continuing to extinguish hand stimuli even after correctly completing the test’s symmetric portion suggests a cognitive disorder. Persistent neglect of one side, particularly during symmetric double-simultaneous stimulation, also indicates localized sensory disturbance.

For psychiatrists who often cannot find time to do standard neurologic examinations, a 2-minute face-hand test (FHT) can quickly help distinguish primary (idiopathic) from secondary (organic) psychiatric disorders and schizophrenia from other psychotic disorders.

FHT results are:

• frequently and markedly abnormal in dementia and mental retardation
• less frequently and less severely abnormal in (though still indicative of) schizophrenia
• rarely abnormal in other psychiatric patients.

The FHT is an extension of the (symmetric) double simultaneous stimulation test method, in which clinicians routinely apply light simultaneous touches to the same location bilaterally (both hands, both cheeks) to screen for touch sensation deficits. The FHT merely extends this to incorporate asymmetric double simultaneous stimuli (one hand, one cheek). Both approaches are more sensitive than applying single stimuli.

How the test is performed

• I tell the patient, “I want to test your sense of touch. While your eyes are closed, I’m going to touch one or the other hand, one or the other side of your face, or some combination. All you need to do is tell me where you felt touched.” Specific instructions can affect the performance of this test, so I stick to this script.
• I then lightly and briefly touch the left hand and right cheek as simultaneously as possible, then wait for the patient to clearly indicate where any touch was felt. If only the face stimulus is reported, I ask “Anywhere else?” I only use this prompt once, after the first trial. I then touch the right hand and left cheek, the left hand and left cheek, the right hand and right cheek, both hands, and both cheeks.
• If the patient does not report touches to the hand in at least three of the first four asymmetric trials, I continue after the two symmetric trials with four more asymmetric trials (one of each face-hand combination).
• I count failure to correctly localize any touch as an error. Neglect (“extinction”) of the hand stimulus when the face is also being touched accounts for most errors, although various other errors can occur. Once patients begin to perceive the hand stimulus, they rarely make additional errors.

Experience with the FHT improves performance, so repeated testing may obscure the results. Specific instructions given to the patient can also affect the results. Emphasing dual stimuli (e.g., “I’m going to be touching you on the face and on the hand”) reduces both sensitivity and the chance for error. Not mentioning dual stimuli (e.g., “Tell me where you feel a touch”) increases the chance for error and reduces specificity.

Using the FHT as described, I’ve found that about 20% of patients with first-episode schizophrenia extinguish at least one hand stimulus (usually on the first trial), but first-episode patients with other idiopathic psychotic disorders almost never make errors.

In a separate sample taken with a different testing approach, patients with schizophrenia had more hand extinctions than did those with other psychiatric disorders.¹ I feel a positive FHT supports a diagnosis of schizophrenia in a cognitively intact patient with psychosis.

Patients with significant cognitive impairment (e.g., dementia, delirium, or mental retardation) typically extinguish several hand stimuli; continuing to extinguish hand stimuli even after correctly completing the test’s symmetric portion suggests a cognitive disorder. Persistent neglect of one side, particularly during symmetric double-simultaneous stimulation, also indicates localized sensory disturbance.

For psychiatrists who often cannot find time to do standard neurologic examinations, a 2-minute face-hand test (FHT) can quickly help distinguish primary (idiopathic) from secondary (organic) psychiatric disorders and schizophrenia from other psychotic disorders.

FHT results are:

• frequently and markedly abnormal in dementia and mental retardation
• less frequently and less severely abnormal in (though still indicative of) schizophrenia
• rarely abnormal in other psychiatric patients.

The FHT is an extension of the (symmetric) double simultaneous stimulation test method, in which clinicians routinely apply light simultaneous touches to the same location bilaterally (both hands, both cheeks) to screen for touch sensation deficits. The FHT merely extends this to incorporate asymmetric double simultaneous stimuli (one hand, one cheek). Both approaches are more sensitive than applying single stimuli.

How the test is performed

• I tell the patient, “I want to test your sense of touch. While your eyes are closed, I’m going to touch one or the other hand, one or the other side of your face, or some combination. All you need to do is tell me where you felt touched.” Specific instructions can affect the performance of this test, so I stick to this script.
• I then lightly and briefly touch the left hand and right cheek as simultaneously as possible, then wait for the patient to clearly indicate where any touch was felt. If only the face stimulus is reported, I ask “Anywhere else?” I only use this prompt once, after the first trial. I then touch the right hand and left cheek, the left hand and left cheek, the right hand and right cheek, both hands, and both cheeks.
• If the patient does not report touches to the hand in at least three of the first four asymmetric trials, I continue after the two symmetric trials with four more asymmetric trials (one of each face-hand combination).
• I count failure to correctly localize any touch as an error. Neglect (“extinction”) of the hand stimulus when the face is also being touched accounts for most errors, although various other errors can occur. Once patients begin to perceive the hand stimulus, they rarely make additional errors.

Experience with the FHT improves performance, so repeated testing may obscure the results. Specific instructions given to the patient can also affect the results. Emphasing dual stimuli (e.g., “I’m going to be touching you on the face and on the hand”) reduces both sensitivity and the chance for error. Not mentioning dual stimuli (e.g., “Tell me where you feel a touch”) increases the chance for error and reduces specificity.

Using the FHT as described, I’ve found that about 20% of patients with first-episode schizophrenia extinguish at least one hand stimulus (usually on the first trial), but first-episode patients with other idiopathic psychotic disorders almost never make errors.

In a separate sample taken with a different testing approach, patients with schizophrenia had more hand extinctions than did those with other psychiatric disorders.¹ I feel a positive FHT supports a diagnosis of schizophrenia in a cognitively intact patient with psychosis.

Patients with significant cognitive impairment (e.g., dementia, delirium, or mental retardation) typically extinguish several hand stimuli; continuing to extinguish hand stimuli even after correctly completing the test’s symmetric portion suggests a cognitive disorder. Persistent neglect of one side, particularly during symmetric double-simultaneous stimulation, also indicates localized sensory disturbance.

For psychiatrists who often cannot find time to do standard neurologic examinations, a 2-minute face-hand test (FHT) can quickly help distinguish primary (idiopathic) from secondary (organic) psychiatric disorders and schizophrenia from other psychotic disorders.

FHT results are:

• frequently and markedly abnormal in dementia and mental retardation
• less frequently and less severely abnormal in (though still indicative of) schizophrenia
• rarely abnormal in other psychiatric patients.

The FHT is an extension of the (symmetric) double simultaneous stimulation test method, in which clinicians routinely apply light simultaneous touches to the same location bilaterally (both hands, both cheeks) to screen for touch sensation deficits. The FHT merely extends this to incorporate asymmetric double simultaneous stimuli (one hand, one cheek). Both approaches are more sensitive than applying single stimuli.

How the test is performed

• I tell the patient, “I want to test your sense of touch. While your eyes are closed, I’m going to touch one or the other hand, one or the other side of your face, or some combination. All you need to do is tell me where you felt touched.” Specific instructions can affect the performance of this test, so I stick to this script.
• I then lightly and briefly touch the left hand and right cheek as simultaneously as possible, then wait for the patient to clearly indicate where any touch was felt. If only the face stimulus is reported, I ask “Anywhere else?” I only use this prompt once, after the first trial. I then touch the right hand and left cheek, the left hand and left cheek, the right hand and right cheek, both hands, and both cheeks.
• If the patient does not report touches to the hand in at least three of the first four asymmetric trials, I continue after the two symmetric trials with four more asymmetric trials (one of each face-hand combination).
• I count failure to correctly localize any touch as an error. Neglect (“extinction”) of the hand stimulus when the face is also being touched accounts for most errors, although various other errors can occur. Once patients begin to perceive the hand stimulus, they rarely make additional errors.

Experience with the FHT improves performance, so repeated testing may obscure the results. Specific instructions given to the patient can also affect the results. Emphasing dual stimuli (e.g., “I’m going to be touching you on the face and on the hand”) reduces both sensitivity and the chance for error. Not mentioning dual stimuli (e.g., “Tell me where you feel a touch”) increases the chance for error and reduces specificity.

Using the FHT as described, I’ve found that about 20% of patients with first-episode schizophrenia extinguish at least one hand stimulus (usually on the first trial), but first-episode patients with other idiopathic psychotic disorders almost never make errors.

In a separate sample taken with a different testing approach, patients with schizophrenia had more hand extinctions than did those with other psychiatric disorders.¹ I feel a positive FHT supports a diagnosis of schizophrenia in a cognitively intact patient with psychosis.

Patients with significant cognitive impairment (e.g., dementia, delirium, or mental retardation) typically extinguish several hand stimuli; continuing to extinguish hand stimuli even after correctly completing the test’s symmetric portion suggests a cognitive disorder. Persistent neglect of one side, particularly during symmetric double-simultaneous stimulation, also indicates localized sensory disturbance.

For psychiatrists who often cannot find time to do standard neurologic examinations, a 2-minute face-hand test (FHT) can quickly help distinguish primary (idiopathic) from secondary (organic) psychiatric disorders and schizophrenia from other psychotic disorders.

FHT results are:

• frequently and markedly abnormal in dementia and mental retardation
• less frequently and less severely abnormal in (though still indicative of) schizophrenia
• rarely abnormal in other psychiatric patients.

The FHT is an extension of the (symmetric) double simultaneous stimulation test method, in which clinicians routinely apply light simultaneous touches to the same location bilaterally (both hands, both cheeks) to screen for touch sensation deficits. The FHT merely extends this to incorporate asymmetric double simultaneous stimuli (one hand, one cheek). Both approaches are more sensitive than applying single stimuli.

How the test is performed

• I tell the patient, “I want to test your sense of touch. While your eyes are closed, I’m going to touch one or the other hand, one or the other side of your face, or some combination. All you need to do is tell me where you felt touched.” Specific instructions can affect the performance of this test, so I stick to this script.
• I then lightly and briefly touch the left hand and right cheek as simultaneously as possible, then wait for the patient to clearly indicate where any touch was felt. If only the face stimulus is reported, I ask “Anywhere else?” I only use this prompt once, after the first trial. I then touch the right hand and left cheek, the left hand and left cheek, the right hand and right cheek, both hands, and both cheeks.
• If the patient does not report touches to the hand in at least three of the first four asymmetric trials, I continue after the two symmetric trials with four more asymmetric trials (one of each face-hand combination).
• I count failure to correctly localize any touch as an error. Neglect (“extinction”) of the hand stimulus when the face is also being touched accounts for most errors, although various other errors can occur. Once patients begin to perceive the hand stimulus, they rarely make additional errors.

Experience with the FHT improves performance, so repeated testing may obscure the results. Specific instructions given to the patient can also affect the results. Emphasing dual stimuli (e.g., “I’m going to be touching you on the face and on the hand”) reduces both sensitivity and the chance for error. Not mentioning dual stimuli (e.g., “Tell me where you feel a touch”) increases the chance for error and reduces specificity.

Using the FHT as described, I’ve found that about 20% of patients with first-episode schizophrenia extinguish at least one hand stimulus (usually on the first trial), but first-episode patients with other idiopathic psychotic disorders almost never make errors.

In a separate sample taken with a different testing approach, patients with schizophrenia had more hand extinctions than did those with other psychiatric disorders.¹ I feel a positive FHT supports a diagnosis of schizophrenia in a cognitively intact patient with psychosis.

Patients with significant cognitive impairment (e.g., dementia, delirium, or mental retardation) typically extinguish several hand stimuli; continuing to extinguish hand stimuli even after correctly completing the test’s symmetric portion suggests a cognitive disorder. Persistent neglect of one side, particularly during symmetric double-simultaneous stimulation, also indicates localized sensory disturbance.

For psychiatrists who often cannot find time to do standard neurologic examinations, a 2-minute face-hand test (FHT) can quickly help distinguish primary (idiopathic) from secondary (organic) psychiatric disorders and schizophrenia from other psychotic disorders.

FHT results are:

• frequently and markedly abnormal in dementia and mental retardation
• less frequently and less severely abnormal in (though still indicative of) schizophrenia
• rarely abnormal in other psychiatric patients.

The FHT is an extension of the (symmetric) double simultaneous stimulation test method, in which clinicians routinely apply light simultaneous touches to the same location bilaterally (both hands, both cheeks) to screen for touch sensation deficits. The FHT merely extends this to incorporate asymmetric double simultaneous stimuli (one hand, one cheek). Both approaches are more sensitive than applying single stimuli.

How the test is performed

• I tell the patient, “I want to test your sense of touch. While your eyes are closed, I’m going to touch one or the other hand, one or the other side of your face, or some combination. All you need to do is tell me where you felt touched.” Specific instructions can affect the performance of this test, so I stick to this script.
• I then lightly and briefly touch the left hand and right cheek as simultaneously as possible, then wait for the patient to clearly indicate where any touch was felt. If only the face stimulus is reported, I ask “Anywhere else?” I only use this prompt once, after the first trial. I then touch the right hand and left cheek, the left hand and left cheek, the right hand and right cheek, both hands, and both cheeks.
• If the patient does not report touches to the hand in at least three of the first four asymmetric trials, I continue after the two symmetric trials with four more asymmetric trials (one of each face-hand combination).
• I count failure to correctly localize any touch as an error. Neglect (“extinction”) of the hand stimulus when the face is also being touched accounts for most errors, although various other errors can occur. Once patients begin to perceive the hand stimulus, they rarely make additional errors.

Experience with the FHT improves performance, so repeated testing may obscure the results. Specific instructions given to the patient can also affect the results. Emphasing dual stimuli (e.g., “I’m going to be touching you on the face and on the hand”) reduces both sensitivity and the chance for error. Not mentioning dual stimuli (e.g., “Tell me where you feel a touch”) increases the chance for error and reduces specificity.

Using the FHT as described, I’ve found that about 20% of patients with first-episode schizophrenia extinguish at least one hand stimulus (usually on the first trial), but first-episode patients with other idiopathic psychotic disorders almost never make errors.

In a separate sample taken with a different testing approach, patients with schizophrenia had more hand extinctions than did those with other psychiatric disorders.¹ I feel a positive FHT supports a diagnosis of schizophrenia in a cognitively intact patient with psychosis.

Patients with significant cognitive impairment (e.g., dementia, delirium, or mental retardation) typically extinguish several hand stimuli; continuing to extinguish hand stimuli even after correctly completing the test’s symmetric portion suggests a cognitive disorder. Persistent neglect of one side, particularly during symmetric double-simultaneous stimulation, also indicates localized sensory disturbance.

The days of lugging a portable projector and a laptop to your clinical or other presentations may soon fade to black.

Many psychiatrists use personal digital assistants (PDAs, or handheld computers) to organize their schedules, access medical texts, and check for drug-drug interactions. These pocket-size devices are also quite adept at editing and displaying PowerPoint presentations. For an investment anywhere between $100 and $250, you can turn your PDA into a valuable audio-visual tool.

To display and edit your presentation, you will need:

• software that converts PowerPoint slides into a PDA-compatible format
• hardware that connects the PDA to the LCD projector.

I have used the Margi Presenter-to-Go (www.margi.com) for the Handspring Visor Edge PDA (Palm operating system), which comes with both the software and hardware adapter (Table 1). For the Pocket PC operating system, I have used a Toshiba e740 device with the Toshiba expansion module (hardware), which works with IA Presenter software (included).

Using Palm

The conversion software for Margi Presenter-to-Go must be installed onto your desktop computer from the CD-ROM-just click on the “install” icon when the CD-ROM starts.

The software is also easy to use: simply choose the Presenter-to-Go “Virtual Printer” on your computer, then “print” your presentation to the Presenter-to-Go conversion program. This action initiates the conversion process and takes several minutes. To load the converted presentation onto the PDA requires only a “HotSync” (synchronization of information from desktop to handheld); this should take 5 to 10 minutes depending on the size of your presentation.

If you wish to include Web pages and Microsoft Word documents in your presentation, Margi Presenter-to-Go can convert them as well.

As you prepare to speak, you will need an extra power outlet near the LCD projector in order to power the Margi presentation module. Connect the LCD projector to the module’s VGA cable and point the PDA infrared port towards you. Using the infrared remote that is included with the presentation module, you can move through the slides from about 6 feet away.

You can reorganize your slides on the PDA and hide or show selected slides. The PDA can store more than one presentation, and multiple users can load a presentation onto their devices. The slides are also quite sharp at 1,024 by 768 pixels and 8-bit color depth.

The capacity of Presenter-to-Go slides, however, is limited by the PDA’s main memory, usually between 8 and 16 mb for Palm OS PDAs. Presentations on the desktop computer typically will be compressed when converted for the PDA, but presentations with many embedded images will be about the same size when on the PDA. I suggest using QuickPoint software and Pitch presentation module to minimize the size limitation. Still, with any Palm OS product you will lose all available “movement,” such as animation and slide transitions.

Using Pocket PC

While solutions for Palm OS are less expensive, hardware and software options for Pocket PC offer more power and variety (Table 2). Converting PowerPoint presentations for Pocket PC also are a minute or two faster than conversion for Palm OS because less processing is needed. For example, after installing IA Presenter from the Toshiba CD-ROM, simply “drag and drop” your presentation into the “Pocket PC My Documents” folder on your desktop. Connect the expansion module to the handheld and the LCD panel, and you’re in business.

The resolution in Pocket PC is also good at 1,024 by 768 pixels and 16-bit color depth. Standard features include speaker notes, ability to hide slides, slide sorting, and presentation beaming. You also can maintain slide transitions and progressive display sequencing of individual bulleted items, graphics, photo shapes, and objects.

Because current Pocket PC devices offer more main memory than current Palm OS devices (32 or 64 mb for Pocket PC versus 8 to 16 mb for Palm), PowerPoint presentation size is less limited. The presentations also can be stored in external memory such as compact flash cards. The main drawback to the Pocket PC solution is its significantly shorter battery life (several hours with intense use). I strongly recommend using an AC adapter with your Pocket PC to avoid a potential blackout-even if your presentation is only an hour long.

THIS MONTH’S WEB PICKS

Medical hardware accessories for your PDA

• ActiveECG (www.activecenter.com)
• Snap (www.viasyshealthcare.com/products/snap/snap.asp)
• Pocketview ECG (www.micromed.com.au/08_products/20_pocketview/)
• Magic Marker (www.eeg-persyst.com/web/MagicMarker-Look.html) EEG remote monitor for Pocket

The days of lugging a portable projector and a laptop to your clinical or other presentations may soon fade to black.

Many psychiatrists use personal digital assistants (PDAs, or handheld computers) to organize their schedules, access medical texts, and check for drug-drug interactions. These pocket-size devices are also quite adept at editing and displaying PowerPoint presentations. For an investment anywhere between $100 and $250, you can turn your PDA into a valuable audio-visual tool.

To display and edit your presentation, you will need:

• software that converts PowerPoint slides into a PDA-compatible format
• hardware that connects the PDA to the LCD projector.

I have used the Margi Presenter-to-Go (www.margi.com) for the Handspring Visor Edge PDA (Palm operating system), which comes with both the software and hardware adapter (Table 1). For the Pocket PC operating system, I have used a Toshiba e740 device with the Toshiba expansion module (hardware), which works with IA Presenter software (included).

Using Palm

The conversion software for Margi Presenter-to-Go must be installed onto your desktop computer from the CD-ROM-just click on the “install” icon when the CD-ROM starts.

The software is also easy to use: simply choose the Presenter-to-Go “Virtual Printer” on your computer, then “print” your presentation to the Presenter-to-Go conversion program. This action initiates the conversion process and takes several minutes. To load the converted presentation onto the PDA requires only a “HotSync” (synchronization of information from desktop to handheld); this should take 5 to 10 minutes depending on the size of your presentation.

If you wish to include Web pages and Microsoft Word documents in your presentation, Margi Presenter-to-Go can convert them as well.

As you prepare to speak, you will need an extra power outlet near the LCD projector in order to power the Margi presentation module. Connect the LCD projector to the module’s VGA cable and point the PDA infrared port towards you. Using the infrared remote that is included with the presentation module, you can move through the slides from about 6 feet away.

You can reorganize your slides on the PDA and hide or show selected slides. The PDA can store more than one presentation, and multiple users can load a presentation onto their devices. The slides are also quite sharp at 1,024 by 768 pixels and 8-bit color depth.

The capacity of Presenter-to-Go slides, however, is limited by the PDA’s main memory, usually between 8 and 16 mb for Palm OS PDAs. Presentations on the desktop computer typically will be compressed when converted for the PDA, but presentations with many embedded images will be about the same size when on the PDA. I suggest using QuickPoint software and Pitch presentation module to minimize the size limitation. Still, with any Palm OS product you will lose all available “movement,” such as animation and slide transitions.

Using Pocket PC

While solutions for Palm OS are less expensive, hardware and software options for Pocket PC offer more power and variety (Table 2). Converting PowerPoint presentations for Pocket PC also are a minute or two faster than conversion for Palm OS because less processing is needed. For example, after installing IA Presenter from the Toshiba CD-ROM, simply “drag and drop” your presentation into the “Pocket PC My Documents” folder on your desktop. Connect the expansion module to the handheld and the LCD panel, and you’re in business.

The resolution in Pocket PC is also good at 1,024 by 768 pixels and 16-bit color depth. Standard features include speaker notes, ability to hide slides, slide sorting, and presentation beaming. You also can maintain slide transitions and progressive display sequencing of individual bulleted items, graphics, photo shapes, and objects.

Because current Pocket PC devices offer more main memory than current Palm OS devices (32 or 64 mb for Pocket PC versus 8 to 16 mb for Palm), PowerPoint presentation size is less limited. The presentations also can be stored in external memory such as compact flash cards. The main drawback to the Pocket PC solution is its significantly shorter battery life (several hours with intense use). I strongly recommend using an AC adapter with your Pocket PC to avoid a potential blackout-even if your presentation is only an hour long.

THIS MONTH’S WEB PICKS

Medical hardware accessories for your PDA

• ActiveECG (www.activecenter.com)
• Snap (www.viasyshealthcare.com/products/snap/snap.asp)
• Pocketview ECG (www.micromed.com.au/08_products/20_pocketview/)
• Magic Marker (www.eeg-persyst.com/web/MagicMarker-Look.html) EEG remote monitor for Pocket

The days of lugging a portable projector and a laptop to your clinical or other presentations may soon fade to black.

Many psychiatrists use personal digital assistants (PDAs, or handheld computers) to organize their schedules, access medical texts, and check for drug-drug interactions. These pocket-size devices are also quite adept at editing and displaying PowerPoint presentations. For an investment anywhere between $100 and $250, you can turn your PDA into a valuable audio-visual tool.

To display and edit your presentation, you will need:

• software that converts PowerPoint slides into a PDA-compatible format
• hardware that connects the PDA to the LCD projector.

I have used the Margi Presenter-to-Go (www.margi.com) for the Handspring Visor Edge PDA (Palm operating system), which comes with both the software and hardware adapter (Table 1). For the Pocket PC operating system, I have used a Toshiba e740 device with the Toshiba expansion module (hardware), which works with IA Presenter software (included).

Using Palm

The conversion software for Margi Presenter-to-Go must be installed onto your desktop computer from the CD-ROM-just click on the “install” icon when the CD-ROM starts.

The software is also easy to use: simply choose the Presenter-to-Go “Virtual Printer” on your computer, then “print” your presentation to the Presenter-to-Go conversion program. This action initiates the conversion process and takes several minutes. To load the converted presentation onto the PDA requires only a “HotSync” (synchronization of information from desktop to handheld); this should take 5 to 10 minutes depending on the size of your presentation.

If you wish to include Web pages and Microsoft Word documents in your presentation, Margi Presenter-to-Go can convert them as well.

As you prepare to speak, you will need an extra power outlet near the LCD projector in order to power the Margi presentation module. Connect the LCD projector to the module’s VGA cable and point the PDA infrared port towards you. Using the infrared remote that is included with the presentation module, you can move through the slides from about 6 feet away.

You can reorganize your slides on the PDA and hide or show selected slides. The PDA can store more than one presentation, and multiple users can load a presentation onto their devices. The slides are also quite sharp at 1,024 by 768 pixels and 8-bit color depth.

The capacity of Presenter-to-Go slides, however, is limited by the PDA’s main memory, usually between 8 and 16 mb for Palm OS PDAs. Presentations on the desktop computer typically will be compressed when converted for the PDA, but presentations with many embedded images will be about the same size when on the PDA. I suggest using QuickPoint software and Pitch presentation module to minimize the size limitation. Still, with any Palm OS product you will lose all available “movement,” such as animation and slide transitions.

Using Pocket PC

While solutions for Palm OS are less expensive, hardware and software options for Pocket PC offer more power and variety (Table 2). Converting PowerPoint presentations for Pocket PC also are a minute or two faster than conversion for Palm OS because less processing is needed. For example, after installing IA Presenter from the Toshiba CD-ROM, simply “drag and drop” your presentation into the “Pocket PC My Documents” folder on your desktop. Connect the expansion module to the handheld and the LCD panel, and you’re in business.

The resolution in Pocket PC is also good at 1,024 by 768 pixels and 16-bit color depth. Standard features include speaker notes, ability to hide slides, slide sorting, and presentation beaming. You also can maintain slide transitions and progressive display sequencing of individual bulleted items, graphics, photo shapes, and objects.

Because current Pocket PC devices offer more main memory than current Palm OS devices (32 or 64 mb for Pocket PC versus 8 to 16 mb for Palm), PowerPoint presentation size is less limited. The presentations also can be stored in external memory such as compact flash cards. The main drawback to the Pocket PC solution is its significantly shorter battery life (several hours with intense use). I strongly recommend using an AC adapter with your Pocket PC to avoid a potential blackout-even if your presentation is only an hour long.

THIS MONTH’S WEB PICKS

Medical hardware accessories for your PDA

• ActiveECG (www.activecenter.com)
• Snap (www.viasyshealthcare.com/products/snap/snap.asp)
• Pocketview ECG (www.micromed.com.au/08_products/20_pocketview/)
• Magic Marker (www.eeg-persyst.com/web/MagicMarker-Look.html) EEG remote monitor for Pocket

Addiction and prescription abuse are potential dangers with some medications that psychiatrists prescribe for long-term use. Benzodiazepines for chronic anxiety and stimulants prescribed for narcolepsy and attention-deficit/hyperactivity disorder are among the agents most commonly abused by psychiatric patients. Here are some telltale signs that point to prescription abuse:

• The patient frequently loses the prescription or medication. Accidents will happen, and any patient can misplace a prescription medication or experience a mishap (e.g., “I knocked my pills in the toilet”). Give the patient the benefit of the doubt if it happens once, but a second report of lost or accidentally discarded medication should raise a red flag.

• The patient’s dosage of a potentially addictive medication has steadily increased in recent months. This is especially telling if the dosage had been static for years.

• The patient often exhausts the medication early.

• The patient asks you to send the prescription to a different pharmacy with each renewal. A patient with accounts at several pharmacies might try to forge copies of a legitimate prescription and get it filled simultaneously at multiple pharmacies.

• The police call your office to check on a prescription you wrote. This is an obvious red flag: The patient may be trying to forge a bogus prescription in your name.

Tips on preventing prescription fraud

The following steps can reduce the potential for prescription fraud:

• Keep copious patient records. I can’t stress enough the importance of documenting every visit, every interaction, every prescription, every refill. When several doctors cover the same office, detailed documentation ensures that the covering physician can make informed decisions about refills

• Make sure stable patients are seen at least once a year. This helps you stay on top of any medical status changes and ascertain whether a change in medication or dosage is needed.

• Mail prescriptions directly to the pharmacy. This is especially useful if the patient is stable and is on a long-term prescription.

Forwarding prescriptions for some agents via fax may be an option, depending on the laws in your state. For example, some states allow faxed prescriptions for benzodiazepines, but federal law requires original written prescriptions for most stimulants.

• Require 2 weeks’ notice before refilling a prescription. This allows you to keep tighter controls on the prescription and will ensure that the medication will be mailed before it runs out. This is prudent when prescribing Schedule II agents (legal but highly addictive prescription medications).

• Stipulate that the patient must have prescriptions and refills authorized by a single provider, be it you or the primary care physician. Be explicit and unyielding in this demand. If you find that the patient is getting the medication you’ve prescribed from at least one other physician, discontinue the prescription.

If you suspect the patient is abusing a prescribed medication, you must confront that patient. Be scrupulously honest; tell the patient, “I’m concerned about your steadily increasing use of this medication. It is important that you trust me and follow my directions, or else I cannot help you.”

Consider referring the patient to a substance abuse specialist if prescription abuse is suspected. I’ve also known some clinicians to administer urine tests to check for medication abuse.

Addiction and prescription abuse are potential dangers with some medications that psychiatrists prescribe for long-term use. Benzodiazepines for chronic anxiety and stimulants prescribed for narcolepsy and attention-deficit/hyperactivity disorder are among the agents most commonly abused by psychiatric patients. Here are some telltale signs that point to prescription abuse:

• The patient frequently loses the prescription or medication. Accidents will happen, and any patient can misplace a prescription medication or experience a mishap (e.g., “I knocked my pills in the toilet”). Give the patient the benefit of the doubt if it happens once, but a second report of lost or accidentally discarded medication should raise a red flag.

• The patient’s dosage of a potentially addictive medication has steadily increased in recent months. This is especially telling if the dosage had been static for years.

• The patient often exhausts the medication early.

• The patient asks you to send the prescription to a different pharmacy with each renewal. A patient with accounts at several pharmacies might try to forge copies of a legitimate prescription and get it filled simultaneously at multiple pharmacies.

• The police call your office to check on a prescription you wrote. This is an obvious red flag: The patient may be trying to forge a bogus prescription in your name.

Tips on preventing prescription fraud

The following steps can reduce the potential for prescription fraud:

• Keep copious patient records. I can’t stress enough the importance of documenting every visit, every interaction, every prescription, every refill. When several doctors cover the same office, detailed documentation ensures that the covering physician can make informed decisions about refills

• Make sure stable patients are seen at least once a year. This helps you stay on top of any medical status changes and ascertain whether a change in medication or dosage is needed.

• Mail prescriptions directly to the pharmacy. This is especially useful if the patient is stable and is on a long-term prescription.

Forwarding prescriptions for some agents via fax may be an option, depending on the laws in your state. For example, some states allow faxed prescriptions for benzodiazepines, but federal law requires original written prescriptions for most stimulants.

• Require 2 weeks’ notice before refilling a prescription. This allows you to keep tighter controls on the prescription and will ensure that the medication will be mailed before it runs out. This is prudent when prescribing Schedule II agents (legal but highly addictive prescription medications).

• Stipulate that the patient must have prescriptions and refills authorized by a single provider, be it you or the primary care physician. Be explicit and unyielding in this demand. If you find that the patient is getting the medication you’ve prescribed from at least one other physician, discontinue the prescription.

If you suspect the patient is abusing a prescribed medication, you must confront that patient. Be scrupulously honest; tell the patient, “I’m concerned about your steadily increasing use of this medication. It is important that you trust me and follow my directions, or else I cannot help you.”

Consider referring the patient to a substance abuse specialist if prescription abuse is suspected. I’ve also known some clinicians to administer urine tests to check for medication abuse.

Addiction and prescription abuse are potential dangers with some medications that psychiatrists prescribe for long-term use. Benzodiazepines for chronic anxiety and stimulants prescribed for narcolepsy and attention-deficit/hyperactivity disorder are among the agents most commonly abused by psychiatric patients. Here are some telltale signs that point to prescription abuse:

• The patient frequently loses the prescription or medication. Accidents will happen, and any patient can misplace a prescription medication or experience a mishap (e.g., “I knocked my pills in the toilet”). Give the patient the benefit of the doubt if it happens once, but a second report of lost or accidentally discarded medication should raise a red flag.

• The patient’s dosage of a potentially addictive medication has steadily increased in recent months. This is especially telling if the dosage had been static for years.

• The patient often exhausts the medication early.

• The patient asks you to send the prescription to a different pharmacy with each renewal. A patient with accounts at several pharmacies might try to forge copies of a legitimate prescription and get it filled simultaneously at multiple pharmacies.

• The police call your office to check on a prescription you wrote. This is an obvious red flag: The patient may be trying to forge a bogus prescription in your name.

Tips on preventing prescription fraud

The following steps can reduce the potential for prescription fraud:

• Keep copious patient records. I can’t stress enough the importance of documenting every visit, every interaction, every prescription, every refill. When several doctors cover the same office, detailed documentation ensures that the covering physician can make informed decisions about refills

• Make sure stable patients are seen at least once a year. This helps you stay on top of any medical status changes and ascertain whether a change in medication or dosage is needed.

• Mail prescriptions directly to the pharmacy. This is especially useful if the patient is stable and is on a long-term prescription.

Forwarding prescriptions for some agents via fax may be an option, depending on the laws in your state. For example, some states allow faxed prescriptions for benzodiazepines, but federal law requires original written prescriptions for most stimulants.

• Require 2 weeks’ notice before refilling a prescription. This allows you to keep tighter controls on the prescription and will ensure that the medication will be mailed before it runs out. This is prudent when prescribing Schedule II agents (legal but highly addictive prescription medications).

• Stipulate that the patient must have prescriptions and refills authorized by a single provider, be it you or the primary care physician. Be explicit and unyielding in this demand. If you find that the patient is getting the medication you’ve prescribed from at least one other physician, discontinue the prescription.

If you suspect the patient is abusing a prescribed medication, you must confront that patient. Be scrupulously honest; tell the patient, “I’m concerned about your steadily increasing use of this medication. It is important that you trust me and follow my directions, or else I cannot help you.”

Consider referring the patient to a substance abuse specialist if prescription abuse is suspected. I’ve also known some clinicians to administer urine tests to check for medication abuse.

Addiction and prescription abuse are potential dangers with some medications that psychiatrists prescribe for long-term use. Benzodiazepines for chronic anxiety and stimulants prescribed for narcolepsy and attention-deficit/hyperactivity disorder are among the agents most commonly abused by psychiatric patients. Here are some telltale signs that point to prescription abuse:

• The patient frequently loses the prescription or medication. Accidents will happen, and any patient can misplace a prescription medication or experience a mishap (e.g., “I knocked my pills in the toilet”). Give the patient the benefit of the doubt if it happens once, but a second report of lost or accidentally discarded medication should raise a red flag.

• The patient’s dosage of a potentially addictive medication has steadily increased in recent months. This is especially telling if the dosage had been static for years.

• The patient often exhausts the medication early.

• The patient asks you to send the prescription to a different pharmacy with each renewal. A patient with accounts at several pharmacies might try to forge copies of a legitimate prescription and get it filled simultaneously at multiple pharmacies.

• The police call your office to check on a prescription you wrote. This is an obvious red flag: The patient may be trying to forge a bogus prescription in your name.

Tips on preventing prescription fraud

The following steps can reduce the potential for prescription fraud:

• Keep copious patient records. I can’t stress enough the importance of documenting every visit, every interaction, every prescription, every refill. When several doctors cover the same office, detailed documentation ensures that the covering physician can make informed decisions about refills

• Make sure stable patients are seen at least once a year. This helps you stay on top of any medical status changes and ascertain whether a change in medication or dosage is needed.

• Mail prescriptions directly to the pharmacy. This is especially useful if the patient is stable and is on a long-term prescription.

Forwarding prescriptions for some agents via fax may be an option, depending on the laws in your state. For example, some states allow faxed prescriptions for benzodiazepines, but federal law requires original written prescriptions for most stimulants.

• Require 2 weeks’ notice before refilling a prescription. This allows you to keep tighter controls on the prescription and will ensure that the medication will be mailed before it runs out. This is prudent when prescribing Schedule II agents (legal but highly addictive prescription medications).

• Stipulate that the patient must have prescriptions and refills authorized by a single provider, be it you or the primary care physician. Be explicit and unyielding in this demand. If you find that the patient is getting the medication you’ve prescribed from at least one other physician, discontinue the prescription.

If you suspect the patient is abusing a prescribed medication, you must confront that patient. Be scrupulously honest; tell the patient, “I’m concerned about your steadily increasing use of this medication. It is important that you trust me and follow my directions, or else I cannot help you.”

Consider referring the patient to a substance abuse specialist if prescription abuse is suspected. I’ve also known some clinicians to administer urine tests to check for medication abuse.

Addiction and prescription abuse are potential dangers with some medications that psychiatrists prescribe for long-term use. Benzodiazepines for chronic anxiety and stimulants prescribed for narcolepsy and attention-deficit/hyperactivity disorder are among the agents most commonly abused by psychiatric patients. Here are some telltale signs that point to prescription abuse:

• The patient frequently loses the prescription or medication. Accidents will happen, and any patient can misplace a prescription medication or experience a mishap (e.g., “I knocked my pills in the toilet”). Give the patient the benefit of the doubt if it happens once, but a second report of lost or accidentally discarded medication should raise a red flag.

• The patient’s dosage of a potentially addictive medication has steadily increased in recent months. This is especially telling if the dosage had been static for years.

• The patient often exhausts the medication early.

• The patient asks you to send the prescription to a different pharmacy with each renewal. A patient with accounts at several pharmacies might try to forge copies of a legitimate prescription and get it filled simultaneously at multiple pharmacies.

• The police call your office to check on a prescription you wrote. This is an obvious red flag: The patient may be trying to forge a bogus prescription in your name.

Tips on preventing prescription fraud

The following steps can reduce the potential for prescription fraud:

• Keep copious patient records. I can’t stress enough the importance of documenting every visit, every interaction, every prescription, every refill. When several doctors cover the same office, detailed documentation ensures that the covering physician can make informed decisions about refills

• Make sure stable patients are seen at least once a year. This helps you stay on top of any medical status changes and ascertain whether a change in medication or dosage is needed.

• Mail prescriptions directly to the pharmacy. This is especially useful if the patient is stable and is on a long-term prescription.

Forwarding prescriptions for some agents via fax may be an option, depending on the laws in your state. For example, some states allow faxed prescriptions for benzodiazepines, but federal law requires original written prescriptions for most stimulants.

• Require 2 weeks’ notice before refilling a prescription. This allows you to keep tighter controls on the prescription and will ensure that the medication will be mailed before it runs out. This is prudent when prescribing Schedule II agents (legal but highly addictive prescription medications).

• Stipulate that the patient must have prescriptions and refills authorized by a single provider, be it you or the primary care physician. Be explicit and unyielding in this demand. If you find that the patient is getting the medication you’ve prescribed from at least one other physician, discontinue the prescription.

If you suspect the patient is abusing a prescribed medication, you must confront that patient. Be scrupulously honest; tell the patient, “I’m concerned about your steadily increasing use of this medication. It is important that you trust me and follow my directions, or else I cannot help you.”

Consider referring the patient to a substance abuse specialist if prescription abuse is suspected. I’ve also known some clinicians to administer urine tests to check for medication abuse.

Addiction and prescription abuse are potential dangers with some medications that psychiatrists prescribe for long-term use. Benzodiazepines for chronic anxiety and stimulants prescribed for narcolepsy and attention-deficit/hyperactivity disorder are among the agents most commonly abused by psychiatric patients. Here are some telltale signs that point to prescription abuse:

• The patient frequently loses the prescription or medication. Accidents will happen, and any patient can misplace a prescription medication or experience a mishap (e.g., “I knocked my pills in the toilet”). Give the patient the benefit of the doubt if it happens once, but a second report of lost or accidentally discarded medication should raise a red flag.

• The patient’s dosage of a potentially addictive medication has steadily increased in recent months. This is especially telling if the dosage had been static for years.

• The patient often exhausts the medication early.

• The patient asks you to send the prescription to a different pharmacy with each renewal. A patient with accounts at several pharmacies might try to forge copies of a legitimate prescription and get it filled simultaneously at multiple pharmacies.

• The police call your office to check on a prescription you wrote. This is an obvious red flag: The patient may be trying to forge a bogus prescription in your name.

Tips on preventing prescription fraud

The following steps can reduce the potential for prescription fraud:

• Keep copious patient records. I can’t stress enough the importance of documenting every visit, every interaction, every prescription, every refill. When several doctors cover the same office, detailed documentation ensures that the covering physician can make informed decisions about refills

• Make sure stable patients are seen at least once a year. This helps you stay on top of any medical status changes and ascertain whether a change in medication or dosage is needed.

• Mail prescriptions directly to the pharmacy. This is especially useful if the patient is stable and is on a long-term prescription.

Forwarding prescriptions for some agents via fax may be an option, depending on the laws in your state. For example, some states allow faxed prescriptions for benzodiazepines, but federal law requires original written prescriptions for most stimulants.

• Require 2 weeks’ notice before refilling a prescription. This allows you to keep tighter controls on the prescription and will ensure that the medication will be mailed before it runs out. This is prudent when prescribing Schedule II agents (legal but highly addictive prescription medications).

• Stipulate that the patient must have prescriptions and refills authorized by a single provider, be it you or the primary care physician. Be explicit and unyielding in this demand. If you find that the patient is getting the medication you’ve prescribed from at least one other physician, discontinue the prescription.

If you suspect the patient is abusing a prescribed medication, you must confront that patient. Be scrupulously honest; tell the patient, “I’m concerned about your steadily increasing use of this medication. It is important that you trust me and follow my directions, or else I cannot help you.”

Consider referring the patient to a substance abuse specialist if prescription abuse is suspected. I’ve also known some clinicians to administer urine tests to check for medication abuse.

Many of us—and our patients—enjoy computer games, and at first glance computer gaming and psychiatry appear to have little in common. Yet computer gaming has spurred the growth of cyber technology by demanding high-level capabilities in computer hardware and software. Games initially were developed and played in two dimensions, but—with improved graphic cards and software rendering engines—they can now be three-dimensional. Some games are realistic enough to stimulate nausea and vertigo.

Overexposure to especially graphic computer games has been blamed for causing violent behavior in some individuals.¹ Jeanne B. Funk, PhD, of the University of Toledo department of psychology, testified before the U.S. Senate Commerce Committee regarding the impact of interactive violence on children.²

Avatar psychotherapy. Some computer games also have therapeutic properties, however. John Suler, PhD, of the psychology department at Rider University (Lawrenceville, NJ), writes about “Avatar psychotherapy,” in which an avatar—a personal manifestation in a virtual world—can be used to facilitate psychotherapy.³ Such an environment can permit role-playing, enable fantasies, and allow psychiatrists to explore transference and countertransference issues.

“The Sims,” a popular people simulator game (http://thesims.ea.com/), has also been considered useful for therapy as a “technology of self.”⁴ One resident physician at the UC Davis psychiatry department uses this game in therapy with adolescents to facilitate expression of family dynamics. Although this technology does not replace traditional psychotherapy, it clearly augments and provides unique benefits.

Virtual fears. In 1995, members of the Georgia Tech computer science department and Emory University department of psychiatry in Atlanta created the Graphics Visualization & Usability Center,⁵ a project using virtual reality and exposure therapy. Patients wear a head-mounted display and other devices to track their movements in the virtual world. With virtual reality technology, patients can be exposed to a feared stimulus in a safe, computer-generated environment.

This technology has been used to treat acrophobia, fear of flying, and posttraumatic stress disorder. Its benefits include cost effectiveness, high patient acceptance, and effective therapy for patients with imagination deficits.

The developers of virtrual reality therapy have now formed a company called Virtually Better to provide this technology to other therapists.⁶ Although the technology currently is not applicable to the individual psychiatrist, this tool is expected to be widely available in the coming years with ever-improving and more affordable computing power.

Telemedicine. Virtual reality is also being used to link providers and patients through telemedicine or video conferencing. In clinical practice, telemedicine offers many advantages, such as the ability to reach patients in wide geographic areas, cost effectiveness, and linking of specialists to primary providers.⁷

Patients appreciate traveling less and are quite satisfied with their virtual visits. In fact, patients with schizophrenia prefer telemedicine to real office visits.⁸

One of telemedicine’s downsides has been its expense, requiring dedicated ISDN lines and specialized equipment. Other issues include licensing, confidentiality, reimbursement, and adherence to practice guidelines.⁹ For readers interested in this technology, the American Telemedicine Association Web site (www.americantelemed.org) is a good starting point. As high-speed Internet access becomes more widely available, telemedicine is poised to overtake e-mail as the next communication tool.

Summary. These virtual methods are still considered quite novel and are not yet part of mainstream psychiatry. The technology is not quite mature but is rapidly improving with new hardware and software developments. Its cost, although a barrier today, is diminishing fast. Patient acceptance is likely to grow over time among our increasingly technology-savvy public. With Internet connectivity and improved visual and audio capabilities of computers at affordable prices, virtual reality could soon play a significant new role in psychiatric care.

Many of us—and our patients—enjoy computer games, and at first glance computer gaming and psychiatry appear to have little in common. Yet computer gaming has spurred the growth of cyber technology by demanding high-level capabilities in computer hardware and software. Games initially were developed and played in two dimensions, but—with improved graphic cards and software rendering engines—they can now be three-dimensional. Some games are realistic enough to stimulate nausea and vertigo.

Overexposure to especially graphic computer games has been blamed for causing violent behavior in some individuals.¹ Jeanne B. Funk, PhD, of the University of Toledo department of psychology, testified before the U.S. Senate Commerce Committee regarding the impact of interactive violence on children.²

Avatar psychotherapy. Some computer games also have therapeutic properties, however. John Suler, PhD, of the psychology department at Rider University (Lawrenceville, NJ), writes about “Avatar psychotherapy,” in which an avatar—a personal manifestation in a virtual world—can be used to facilitate psychotherapy.³ Such an environment can permit role-playing, enable fantasies, and allow psychiatrists to explore transference and countertransference issues.

“The Sims,” a popular people simulator game (http://thesims.ea.com/), has also been considered useful for therapy as a “technology of self.”⁴ One resident physician at the UC Davis psychiatry department uses this game in therapy with adolescents to facilitate expression of family dynamics. Although this technology does not replace traditional psychotherapy, it clearly augments and provides unique benefits.

Virtual fears. In 1995, members of the Georgia Tech computer science department and Emory University department of psychiatry in Atlanta created the Graphics Visualization & Usability Center,⁵ a project using virtual reality and exposure therapy. Patients wear a head-mounted display and other devices to track their movements in the virtual world. With virtual reality technology, patients can be exposed to a feared stimulus in a safe, computer-generated environment.

This technology has been used to treat acrophobia, fear of flying, and posttraumatic stress disorder. Its benefits include cost effectiveness, high patient acceptance, and effective therapy for patients with imagination deficits.

The developers of virtrual reality therapy have now formed a company called Virtually Better to provide this technology to other therapists.⁶ Although the technology currently is not applicable to the individual psychiatrist, this tool is expected to be widely available in the coming years with ever-improving and more affordable computing power.

Telemedicine. Virtual reality is also being used to link providers and patients through telemedicine or video conferencing. In clinical practice, telemedicine offers many advantages, such as the ability to reach patients in wide geographic areas, cost effectiveness, and linking of specialists to primary providers.⁷

Patients appreciate traveling less and are quite satisfied with their virtual visits. In fact, patients with schizophrenia prefer telemedicine to real office visits.⁸

One of telemedicine’s downsides has been its expense, requiring dedicated ISDN lines and specialized equipment. Other issues include licensing, confidentiality, reimbursement, and adherence to practice guidelines.⁹ For readers interested in this technology, the American Telemedicine Association Web site (www.americantelemed.org) is a good starting point. As high-speed Internet access becomes more widely available, telemedicine is poised to overtake e-mail as the next communication tool.

Summary. These virtual methods are still considered quite novel and are not yet part of mainstream psychiatry. The technology is not quite mature but is rapidly improving with new hardware and software developments. Its cost, although a barrier today, is diminishing fast. Patient acceptance is likely to grow over time among our increasingly technology-savvy public. With Internet connectivity and improved visual and audio capabilities of computers at affordable prices, virtual reality could soon play a significant new role in psychiatric care.

Many of us—and our patients—enjoy computer games, and at first glance computer gaming and psychiatry appear to have little in common. Yet computer gaming has spurred the growth of cyber technology by demanding high-level capabilities in computer hardware and software. Games initially were developed and played in two dimensions, but—with improved graphic cards and software rendering engines—they can now be three-dimensional. Some games are realistic enough to stimulate nausea and vertigo.

Overexposure to especially graphic computer games has been blamed for causing violent behavior in some individuals.¹ Jeanne B. Funk, PhD, of the University of Toledo department of psychology, testified before the U.S. Senate Commerce Committee regarding the impact of interactive violence on children.²

Avatar psychotherapy. Some computer games also have therapeutic properties, however. John Suler, PhD, of the psychology department at Rider University (Lawrenceville, NJ), writes about “Avatar psychotherapy,” in which an avatar—a personal manifestation in a virtual world—can be used to facilitate psychotherapy.³ Such an environment can permit role-playing, enable fantasies, and allow psychiatrists to explore transference and countertransference issues.

“The Sims,” a popular people simulator game (http://thesims.ea.com/), has also been considered useful for therapy as a “technology of self.”⁴ One resident physician at the UC Davis psychiatry department uses this game in therapy with adolescents to facilitate expression of family dynamics. Although this technology does not replace traditional psychotherapy, it clearly augments and provides unique benefits.

Virtual fears. In 1995, members of the Georgia Tech computer science department and Emory University department of psychiatry in Atlanta created the Graphics Visualization & Usability Center,⁵ a project using virtual reality and exposure therapy. Patients wear a head-mounted display and other devices to track their movements in the virtual world. With virtual reality technology, patients can be exposed to a feared stimulus in a safe, computer-generated environment.

This technology has been used to treat acrophobia, fear of flying, and posttraumatic stress disorder. Its benefits include cost effectiveness, high patient acceptance, and effective therapy for patients with imagination deficits.

The developers of virtrual reality therapy have now formed a company called Virtually Better to provide this technology to other therapists.⁶ Although the technology currently is not applicable to the individual psychiatrist, this tool is expected to be widely available in the coming years with ever-improving and more affordable computing power.

Telemedicine. Virtual reality is also being used to link providers and patients through telemedicine or video conferencing. In clinical practice, telemedicine offers many advantages, such as the ability to reach patients in wide geographic areas, cost effectiveness, and linking of specialists to primary providers.⁷

Patients appreciate traveling less and are quite satisfied with their virtual visits. In fact, patients with schizophrenia prefer telemedicine to real office visits.⁸

One of telemedicine’s downsides has been its expense, requiring dedicated ISDN lines and specialized equipment. Other issues include licensing, confidentiality, reimbursement, and adherence to practice guidelines.⁹ For readers interested in this technology, the American Telemedicine Association Web site (www.americantelemed.org) is a good starting point. As high-speed Internet access becomes more widely available, telemedicine is poised to overtake e-mail as the next communication tool.

Summary. These virtual methods are still considered quite novel and are not yet part of mainstream psychiatry. The technology is not quite mature but is rapidly improving with new hardware and software developments. Its cost, although a barrier today, is diminishing fast. Patient acceptance is likely to grow over time among our increasingly technology-savvy public. With Internet connectivity and improved visual and audio capabilities of computers at affordable prices, virtual reality could soon play a significant new role in psychiatric care.

Some of the problems we face and solutions we employ in clinical practice run contrary to what we were taught in psychiatry rotations. I’ve found this to be particularly true regarding depression diagnosis and treatment.

Throughout my career, I’ve seen many truisms concerning depression that were passed on in medical training and later contradicted through clinical experience. Witness the following seven “myths” about depression therapy:

1. Early morning awakening and suppressed appetite with weight loss are cardinal symptoms of major depression. Sleep and appetite disturbances remain core DSM-IV symptoms of major depression, but depressed patients seldom present with “classic” terminal insomnia and significant anorexia. So-called “atypical” neurovegetative changes involving hyperphagia and hypersomnia or initial/middle insomnia are common in outpatients.
2. Patients with major depression face a 15% lifetime suicide risk. The American Foundation of Suicide Prevention says that “30% of all depressed patients attempt suicide and half of them succeed.”¹ More recent data have shown the lifetime suicide risk in depression to be only 2 to 6%.²
3. The risk of suicide increases when response to antidepressant therapy begins. The assumption is that patients in the initial stages of response to medication experience a preferential increase in energy and motivation with persistence of hopelessness, helplessness, or worthlessness. This supposedly predisposes them to follow through with a suicide plan they did not have the energy to complete before starting antidepressant treatment.
4. Patients with dysthymic disorder respond poorly to antidepressants. Many patients with low-grade, longstanding depression or dysthymic disorder respond well to appropriate antidepressant medication. There is no valid evidence that patients with acute depressive disorders respond more favorably to chemotherapy than do those with dysthymia.³
5. A patient’s subjective response to antidepressants lags behind more noticeable improvements. No research has borne this out. In the course of response to antidepressants, patients typically realize improvements in subjectively experienced symptoms (e.g., hopelessness, dysphoria, and amotivation) that tend to parallel, not lag behind, more observable somatic and interpersonal improvements (e.g., in sleep and social interaction).
6. A slim adolescent female typically requires a lower antidepressant dose than a burly adult male does. Many complex factors determine response to and tolerability of antidepressant medications. But age, gender, and body type do not appear to be consistent determinants. Male endomorphic adults can be highly sensitive to low doses of medications, while petite younger females may require and tolerate relatively high doses—and vice versa.
7. A patient’s response to one SRI predicts his or her response to another. Responses to different medications in the same class are highly individual and unpredictable. A patient may have identical responses to several SRIs, or may tolerate them similarly. More commonly, individual patients experience varying types and degrees of side effects and disparate responses to different agents.

Some of the problems we face and solutions we employ in clinical practice run contrary to what we were taught in psychiatry rotations. I’ve found this to be particularly true regarding depression diagnosis and treatment.

Throughout my career, I’ve seen many truisms concerning depression that were passed on in medical training and later contradicted through clinical experience. Witness the following seven “myths” about depression therapy:

1. Early morning awakening and suppressed appetite with weight loss are cardinal symptoms of major depression. Sleep and appetite disturbances remain core DSM-IV symptoms of major depression, but depressed patients seldom present with “classic” terminal insomnia and significant anorexia. So-called “atypical” neurovegetative changes involving hyperphagia and hypersomnia or initial/middle insomnia are common in outpatients.
2. Patients with major depression face a 15% lifetime suicide risk. The American Foundation of Suicide Prevention says that “30% of all depressed patients attempt suicide and half of them succeed.”¹ More recent data have shown the lifetime suicide risk in depression to be only 2 to 6%.²
3. The risk of suicide increases when response to antidepressant therapy begins. The assumption is that patients in the initial stages of response to medication experience a preferential increase in energy and motivation with persistence of hopelessness, helplessness, or worthlessness. This supposedly predisposes them to follow through with a suicide plan they did not have the energy to complete before starting antidepressant treatment.
4. Patients with dysthymic disorder respond poorly to antidepressants. Many patients with low-grade, longstanding depression or dysthymic disorder respond well to appropriate antidepressant medication. There is no valid evidence that patients with acute depressive disorders respond more favorably to chemotherapy than do those with dysthymia.³
5. A patient’s subjective response to antidepressants lags behind more noticeable improvements. No research has borne this out. In the course of response to antidepressants, patients typically realize improvements in subjectively experienced symptoms (e.g., hopelessness, dysphoria, and amotivation) that tend to parallel, not lag behind, more observable somatic and interpersonal improvements (e.g., in sleep and social interaction).
6. A slim adolescent female typically requires a lower antidepressant dose than a burly adult male does. Many complex factors determine response to and tolerability of antidepressant medications. But age, gender, and body type do not appear to be consistent determinants. Male endomorphic adults can be highly sensitive to low doses of medications, while petite younger females may require and tolerate relatively high doses—and vice versa.
7. A patient’s response to one SRI predicts his or her response to another. Responses to different medications in the same class are highly individual and unpredictable. A patient may have identical responses to several SRIs, or may tolerate them similarly. More commonly, individual patients experience varying types and degrees of side effects and disparate responses to different agents.

Some of the problems we face and solutions we employ in clinical practice run contrary to what we were taught in psychiatry rotations. I’ve found this to be particularly true regarding depression diagnosis and treatment.

Throughout my career, I’ve seen many truisms concerning depression that were passed on in medical training and later contradicted through clinical experience. Witness the following seven “myths” about depression therapy:

1. Early morning awakening and suppressed appetite with weight loss are cardinal symptoms of major depression. Sleep and appetite disturbances remain core DSM-IV symptoms of major depression, but depressed patients seldom present with “classic” terminal insomnia and significant anorexia. So-called “atypical” neurovegetative changes involving hyperphagia and hypersomnia or initial/middle insomnia are common in outpatients.
2. Patients with major depression face a 15% lifetime suicide risk. The American Foundation of Suicide Prevention says that “30% of all depressed patients attempt suicide and half of them succeed.”¹ More recent data have shown the lifetime suicide risk in depression to be only 2 to 6%.²
3. The risk of suicide increases when response to antidepressant therapy begins. The assumption is that patients in the initial stages of response to medication experience a preferential increase in energy and motivation with persistence of hopelessness, helplessness, or worthlessness. This supposedly predisposes them to follow through with a suicide plan they did not have the energy to complete before starting antidepressant treatment.
4. Patients with dysthymic disorder respond poorly to antidepressants. Many patients with low-grade, longstanding depression or dysthymic disorder respond well to appropriate antidepressant medication. There is no valid evidence that patients with acute depressive disorders respond more favorably to chemotherapy than do those with dysthymia.³
5. A patient’s subjective response to antidepressants lags behind more noticeable improvements. No research has borne this out. In the course of response to antidepressants, patients typically realize improvements in subjectively experienced symptoms (e.g., hopelessness, dysphoria, and amotivation) that tend to parallel, not lag behind, more observable somatic and interpersonal improvements (e.g., in sleep and social interaction).
6. A slim adolescent female typically requires a lower antidepressant dose than a burly adult male does. Many complex factors determine response to and tolerability of antidepressant medications. But age, gender, and body type do not appear to be consistent determinants. Male endomorphic adults can be highly sensitive to low doses of medications, while petite younger females may require and tolerate relatively high doses—and vice versa.
7. A patient’s response to one SRI predicts his or her response to another. Responses to different medications in the same class are highly individual and unpredictable. A patient may have identical responses to several SRIs, or may tolerate them similarly. More commonly, individual patients experience varying types and degrees of side effects and disparate responses to different agents.

Depression, in its most severe forms, carries the risk of suicide or even homicide. But sorting life-or-death cases from less serious ones becomes complicated when your patient base covers a large geographical region or several thousand persons. In a large practice, many patients may be relatively unfamiliar to you, and you have limited time to make critical triage decisions.

As a psychiatrist with experience following a large outpatient practice and managing an inpatient unit, I believe the following advice can help you identify which cases require emergency treatment.

Pay attention to immediate signals from the first-time patient. Psychiatrists working with large patient bases often receive new patients, and the feelings, circumstances, and symptoms surrounding initial visits warrant special attention. Check for signals that the patient is at risk for homicide or suicide and for signs of acute depression, including obvious psychomotor retardation, physical agitation, and preoccupation with nihilistic themes or death.

Your suspicion threshold should be high when patients are involuntarily brought in by concerned friends or relatives. In such cases, it is often prudent to interpret the situation as an emergency.

Remember that symptoms of serious mental health problems can be deceiving. Acutely depressed patients often exhibit slow movement and speech, but what looks like lack of cooperation may signal conceptual disorganization, paranoia, or catatonia—all severe symptoms that carry a high risk of suicide and warrant hospitalization.

If a patient insists he or she will be OK, proceed with caution. Your toughest cases will be patients who acknowledge that they feel suicidal but assure you they can remain stable as outpatients. Ask targeted questions to sort out whether their reluctance to accept inpatient care could lead to an emergency. For example, does the patient have a recent history of making suicidal plans, or do any of the risk factors listed below apply?

Keep in mind that most patients will not disclose a concrete suicide plan if they do not wish to be hospitalized. You may need to rely on information from those who brought the patient to you. When a patient is unfamiliar to you, no “safety contract” between you and the patient is sufficiently secure.

Of course, things are different in an outpatient, nonemergency scenario. In “cooperative” triage situations, many patients can be believed when they say they are not acutely suicidal. The easiest clinical decisions are made when patients come to you with the expectation that you will help them.

Watch for risk factors in familiar patients. Some established patients may become highly depressed but do not exhibit signs of an impending emergency. Be aware of the usual risk factors:

• previous psychiatric hospitalization(s)
  
• current emotional instability
  
• comorbid personality disorder
  
• history of substance abuse
  
• lack of adequate support from family and friends
  
• presence of psychosis
  
• family history of suicide
  
• gender (women make more frequent suicide attempts, but men are more likely to succeed).¹
  

Finally, even if you’ve never met the patient before, you can negotiate varying levels of contact, such as daily office visits or telephone conversations. You can also encourage family and friends to monitor the patient’s behavior and provide emotional support, as long as you are careful not to draft them into caregiver responsibilities they may not be equipped to handle.

Depression, in its most severe forms, carries the risk of suicide or even homicide. But sorting life-or-death cases from less serious ones becomes complicated when your patient base covers a large geographical region or several thousand persons. In a large practice, many patients may be relatively unfamiliar to you, and you have limited time to make critical triage decisions.

As a psychiatrist with experience following a large outpatient practice and managing an inpatient unit, I believe the following advice can help you identify which cases require emergency treatment.

Pay attention to immediate signals from the first-time patient. Psychiatrists working with large patient bases often receive new patients, and the feelings, circumstances, and symptoms surrounding initial visits warrant special attention. Check for signals that the patient is at risk for homicide or suicide and for signs of acute depression, including obvious psychomotor retardation, physical agitation, and preoccupation with nihilistic themes or death.

Your suspicion threshold should be high when patients are involuntarily brought in by concerned friends or relatives. In such cases, it is often prudent to interpret the situation as an emergency.

Remember that symptoms of serious mental health problems can be deceiving. Acutely depressed patients often exhibit slow movement and speech, but what looks like lack of cooperation may signal conceptual disorganization, paranoia, or catatonia—all severe symptoms that carry a high risk of suicide and warrant hospitalization.

If a patient insists he or she will be OK, proceed with caution. Your toughest cases will be patients who acknowledge that they feel suicidal but assure you they can remain stable as outpatients. Ask targeted questions to sort out whether their reluctance to accept inpatient care could lead to an emergency. For example, does the patient have a recent history of making suicidal plans, or do any of the risk factors listed below apply?

Keep in mind that most patients will not disclose a concrete suicide plan if they do not wish to be hospitalized. You may need to rely on information from those who brought the patient to you. When a patient is unfamiliar to you, no “safety contract” between you and the patient is sufficiently secure.

Of course, things are different in an outpatient, nonemergency scenario. In “cooperative” triage situations, many patients can be believed when they say they are not acutely suicidal. The easiest clinical decisions are made when patients come to you with the expectation that you will help them.

Watch for risk factors in familiar patients. Some established patients may become highly depressed but do not exhibit signs of an impending emergency. Be aware of the usual risk factors:

• previous psychiatric hospitalization(s)
  
• current emotional instability
  
• comorbid personality disorder
  
• history of substance abuse
  
• lack of adequate support from family and friends
  
• presence of psychosis
  
• family history of suicide
  
• gender (women make more frequent suicide attempts, but men are more likely to succeed).¹
  

Finally, even if you’ve never met the patient before, you can negotiate varying levels of contact, such as daily office visits or telephone conversations. You can also encourage family and friends to monitor the patient’s behavior and provide emotional support, as long as you are careful not to draft them into caregiver responsibilities they may not be equipped to handle.

Depression, in its most severe forms, carries the risk of suicide or even homicide. But sorting life-or-death cases from less serious ones becomes complicated when your patient base covers a large geographical region or several thousand persons. In a large practice, many patients may be relatively unfamiliar to you, and you have limited time to make critical triage decisions.

As a psychiatrist with experience following a large outpatient practice and managing an inpatient unit, I believe the following advice can help you identify which cases require emergency treatment.

Pay attention to immediate signals from the first-time patient. Psychiatrists working with large patient bases often receive new patients, and the feelings, circumstances, and symptoms surrounding initial visits warrant special attention. Check for signals that the patient is at risk for homicide or suicide and for signs of acute depression, including obvious psychomotor retardation, physical agitation, and preoccupation with nihilistic themes or death.

Your suspicion threshold should be high when patients are involuntarily brought in by concerned friends or relatives. In such cases, it is often prudent to interpret the situation as an emergency.

Remember that symptoms of serious mental health problems can be deceiving. Acutely depressed patients often exhibit slow movement and speech, but what looks like lack of cooperation may signal conceptual disorganization, paranoia, or catatonia—all severe symptoms that carry a high risk of suicide and warrant hospitalization.

If a patient insists he or she will be OK, proceed with caution. Your toughest cases will be patients who acknowledge that they feel suicidal but assure you they can remain stable as outpatients. Ask targeted questions to sort out whether their reluctance to accept inpatient care could lead to an emergency. For example, does the patient have a recent history of making suicidal plans, or do any of the risk factors listed below apply?

Keep in mind that most patients will not disclose a concrete suicide plan if they do not wish to be hospitalized. You may need to rely on information from those who brought the patient to you. When a patient is unfamiliar to you, no “safety contract” between you and the patient is sufficiently secure.

Of course, things are different in an outpatient, nonemergency scenario. In “cooperative” triage situations, many patients can be believed when they say they are not acutely suicidal. The easiest clinical decisions are made when patients come to you with the expectation that you will help them.

Watch for risk factors in familiar patients. Some established patients may become highly depressed but do not exhibit signs of an impending emergency. Be aware of the usual risk factors:

• previous psychiatric hospitalization(s)
  
• current emotional instability
  
• comorbid personality disorder
  
• history of substance abuse
  
• lack of adequate support from family and friends
  
• presence of psychosis
  
• family history of suicide
  
• gender (women make more frequent suicide attempts, but men are more likely to succeed).¹
  

Finally, even if you’ve never met the patient before, you can negotiate varying levels of contact, such as daily office visits or telephone conversations. You can also encourage family and friends to monitor the patient’s behavior and provide emotional support, as long as you are careful not to draft them into caregiver responsibilities they may not be equipped to handle.

Depression, in its most severe forms, carries the risk of suicide or even homicide. But sorting life-or-death cases from less serious ones becomes complicated when your patient base covers a large geographical region or several thousand persons. In a large practice, many patients may be relatively unfamiliar to you, and you have limited time to make critical triage decisions.

As a psychiatrist with experience following a large outpatient practice and managing an inpatient unit, I believe the following advice can help you identify which cases require emergency treatment.

Pay attention to immediate signals from the first-time patient. Psychiatrists working with large patient bases often receive new patients, and the feelings, circumstances, and symptoms surrounding initial visits warrant special attention. Check for signals that the patient is at risk for homicide or suicide and for signs of acute depression, including obvious psychomotor retardation, physical agitation, and preoccupation with nihilistic themes or death.

Your suspicion threshold should be high when patients are involuntarily brought in by concerned friends or relatives. In such cases, it is often prudent to interpret the situation as an emergency.

Remember that symptoms of serious mental health problems can be deceiving. Acutely depressed patients often exhibit slow movement and speech, but what looks like lack of cooperation may signal conceptual disorganization, paranoia, or catatonia—all severe symptoms that carry a high risk of suicide and warrant hospitalization.

If a patient insists he or she will be OK, proceed with caution. Your toughest cases will be patients who acknowledge that they feel suicidal but assure you they can remain stable as outpatients. Ask targeted questions to sort out whether their reluctance to accept inpatient care could lead to an emergency. For example, does the patient have a recent history of making suicidal plans, or do any of the risk factors listed below apply?

Keep in mind that most patients will not disclose a concrete suicide plan if they do not wish to be hospitalized. You may need to rely on information from those who brought the patient to you. When a patient is unfamiliar to you, no “safety contract” between you and the patient is sufficiently secure.

Of course, things are different in an outpatient, nonemergency scenario. In “cooperative” triage situations, many patients can be believed when they say they are not acutely suicidal. The easiest clinical decisions are made when patients come to you with the expectation that you will help them.

Watch for risk factors in familiar patients. Some established patients may become highly depressed but do not exhibit signs of an impending emergency. Be aware of the usual risk factors:

• previous psychiatric hospitalization(s)
  
• current emotional instability
  
• comorbid personality disorder
  
• history of substance abuse
  
• lack of adequate support from family and friends
  
• presence of psychosis
  
• family history of suicide
  
• gender (women make more frequent suicide attempts, but men are more likely to succeed).¹
  

Finally, even if you’ve never met the patient before, you can negotiate varying levels of contact, such as daily office visits or telephone conversations. You can also encourage family and friends to monitor the patient’s behavior and provide emotional support, as long as you are careful not to draft them into caregiver responsibilities they may not be equipped to handle.

Depression, in its most severe forms, carries the risk of suicide or even homicide. But sorting life-or-death cases from less serious ones becomes complicated when your patient base covers a large geographical region or several thousand persons. In a large practice, many patients may be relatively unfamiliar to you, and you have limited time to make critical triage decisions.

As a psychiatrist with experience following a large outpatient practice and managing an inpatient unit, I believe the following advice can help you identify which cases require emergency treatment.

Pay attention to immediate signals from the first-time patient. Psychiatrists working with large patient bases often receive new patients, and the feelings, circumstances, and symptoms surrounding initial visits warrant special attention. Check for signals that the patient is at risk for homicide or suicide and for signs of acute depression, including obvious psychomotor retardation, physical agitation, and preoccupation with nihilistic themes or death.

Your suspicion threshold should be high when patients are involuntarily brought in by concerned friends or relatives. In such cases, it is often prudent to interpret the situation as an emergency.

Remember that symptoms of serious mental health problems can be deceiving. Acutely depressed patients often exhibit slow movement and speech, but what looks like lack of cooperation may signal conceptual disorganization, paranoia, or catatonia—all severe symptoms that carry a high risk of suicide and warrant hospitalization.

If a patient insists he or she will be OK, proceed with caution. Your toughest cases will be patients who acknowledge that they feel suicidal but assure you they can remain stable as outpatients. Ask targeted questions to sort out whether their reluctance to accept inpatient care could lead to an emergency. For example, does the patient have a recent history of making suicidal plans, or do any of the risk factors listed below apply?

Keep in mind that most patients will not disclose a concrete suicide plan if they do not wish to be hospitalized. You may need to rely on information from those who brought the patient to you. When a patient is unfamiliar to you, no “safety contract” between you and the patient is sufficiently secure.

Of course, things are different in an outpatient, nonemergency scenario. In “cooperative” triage situations, many patients can be believed when they say they are not acutely suicidal. The easiest clinical decisions are made when patients come to you with the expectation that you will help them.

Watch for risk factors in familiar patients. Some established patients may become highly depressed but do not exhibit signs of an impending emergency. Be aware of the usual risk factors:

• previous psychiatric hospitalization(s)
  
• current emotional instability
  
• comorbid personality disorder
  
• history of substance abuse
  
• lack of adequate support from family and friends
  
• presence of psychosis
  
• family history of suicide
  
• gender (women make more frequent suicide attempts, but men are more likely to succeed).¹
  

Finally, even if you’ve never met the patient before, you can negotiate varying levels of contact, such as daily office visits or telephone conversations. You can also encourage family and friends to monitor the patient’s behavior and provide emotional support, as long as you are careful not to draft them into caregiver responsibilities they may not be equipped to handle.

Depression, in its most severe forms, carries the risk of suicide or even homicide. But sorting life-or-death cases from less serious ones becomes complicated when your patient base covers a large geographical region or several thousand persons. In a large practice, many patients may be relatively unfamiliar to you, and you have limited time to make critical triage decisions.

As a psychiatrist with experience following a large outpatient practice and managing an inpatient unit, I believe the following advice can help you identify which cases require emergency treatment.

Pay attention to immediate signals from the first-time patient. Psychiatrists working with large patient bases often receive new patients, and the feelings, circumstances, and symptoms surrounding initial visits warrant special attention. Check for signals that the patient is at risk for homicide or suicide and for signs of acute depression, including obvious psychomotor retardation, physical agitation, and preoccupation with nihilistic themes or death.

Your suspicion threshold should be high when patients are involuntarily brought in by concerned friends or relatives. In such cases, it is often prudent to interpret the situation as an emergency.

Remember that symptoms of serious mental health problems can be deceiving. Acutely depressed patients often exhibit slow movement and speech, but what looks like lack of cooperation may signal conceptual disorganization, paranoia, or catatonia—all severe symptoms that carry a high risk of suicide and warrant hospitalization.

If a patient insists he or she will be OK, proceed with caution. Your toughest cases will be patients who acknowledge that they feel suicidal but assure you they can remain stable as outpatients. Ask targeted questions to sort out whether their reluctance to accept inpatient care could lead to an emergency. For example, does the patient have a recent history of making suicidal plans, or do any of the risk factors listed below apply?

Keep in mind that most patients will not disclose a concrete suicide plan if they do not wish to be hospitalized. You may need to rely on information from those who brought the patient to you. When a patient is unfamiliar to you, no “safety contract” between you and the patient is sufficiently secure.

Of course, things are different in an outpatient, nonemergency scenario. In “cooperative” triage situations, many patients can be believed when they say they are not acutely suicidal. The easiest clinical decisions are made when patients come to you with the expectation that you will help them.

Watch for risk factors in familiar patients. Some established patients may become highly depressed but do not exhibit signs of an impending emergency. Be aware of the usual risk factors:

• previous psychiatric hospitalization(s)
  
• current emotional instability
  
• comorbid personality disorder
  
• history of substance abuse
  
• lack of adequate support from family and friends
  
• presence of psychosis
  
• family history of suicide
  
• gender (women make more frequent suicide attempts, but men are more likely to succeed).¹
  

Finally, even if you’ve never met the patient before, you can negotiate varying levels of contact, such as daily office visits or telephone conversations. You can also encourage family and friends to monitor the patient’s behavior and provide emotional support, as long as you are careful not to draft them into caregiver responsibilities they may not be equipped to handle.