EARN 1.

5 CATEGORY 1 CME
CME
CREDITS
Neuropsychiatric
Implications of Caffeine
THE COMPLICATED PATIENT
Polypharmacy
SPECIAL REPORT: PART 2
Neuropsychiatry

Peer-Reviewed • Practice-Oriented AUGUST 2019 • Vol. XXXVI, No. 8

PSYCHIATRISTS
The Luckiest
People on Earth? » Daniel Morehead, MD

P
sychiatric practice is not for the faint of heart. Every day,
psychiatrists face human misery, trauma, tragedy, sui-
cidality, and death. People outside of the field (and even
our own patients) frequently declare that they could not imag- For all its perils,
ine being psychiatrists, because they would be “too depressed psychiatry is filled with
listening to that all day.”
Our work requires us to enter deeply into the painful expe-
extraordinary moments of
riences of others and to be with people who may have trouble healing, honesty, insight,
being with anyone in a constructive way. CONTINUED ON PAGE 5 & human connection.

Hospital-Based Psychiatric ISSUE HIGHLIGHTS

Emergency Programs Debunking the Two
The Missing Link for Mental Health Systems “Chemical Imbalance”
Myths (Again)
» Scott Zeller, MD tals across the country. Typically, the
emergency physician has determined
Unfortunately, few regions have
enough inpatient psychiatric beds to
Ronald W. Pies, MD

B
oarding of psychiatric patients that the patient needs further psychi- meet the needs of a system predicated Children Who Ask to
in medical emergency depart- atric care. However, the sole option on admitting the majority of ED pa-
ments (EDs) for hours or even available is usually admission to an tients, especially since, in the past de-
Become Suicide
days is a serious issue plaguing hospi- inpatient psychiatric facility. cade, behavioral health patients have Bombers
risen to become one in every eight cases Lawrence H. Climo, MD
in EDs in the US.1 As a result, psychiat-
ric patients can end up confined indefi- Making Your Practice
nitely in small ED quarters with a sitter
Work for You
or security guard, or restrained to a gur-
ney in a back hallway, while they await Joseph R. Sanok, MS
admission. Many of these boarded pa-
tients receive little or no psychiatric
treatment beyond sedation. Thus, sadly,
the most highly acute patients in a
CONTINUED ON PAGE 31 COMPLETE CONTENTS, PAGE 6

VISIT US
ONLINE PsychiatricTimes.com
AUGUST 2019 PS YC H I ATRI C TI M E S 5
w w w. psychi atr i cti mes. com

Yes, they need medications, but real- with other people’s outsides.” As
The Luckiest People istically they can get medications psychiatrists, we have a rare view
Continued from cover
elsewhere. They want to talk to us. into the “insides” of countless peo-
They want to be heard, and they want ple. We enjoy the privilege of seeing
As we attempt to do so, we suffer impediments and harassments by various to learn from our knowledge and wis- that self-doubt, inadequacy, guilt,
bureaucracies, including dwindling reimbursements, decreased time with pa- dom. They actually believe (at least stress, and illness are a normal part
on some level) that time spent with us of individual and family life. Our
tients, increased record-keeping requirements, and burdensome demands of
will make their lives better. This is profession allows us to better accept
specialty and other oversight boards. In short, we regularly interact with bureau- extraordinary—after all, how many ourselves and our limitations, using
cratic systems that pressure us to value money over health, screen time over people in the rest of daily life ap- adverse experiences for our own
face time, and record-keeping over people-helping. proach us and offer us money for our growth and the benefit of others.
sage advice, or re-arrange their day
Yet there is a reason that we become psychiatrists, and a reason that we re-
just to hear what we have to say about Love
main in the field. For all its perils, psychiatry is filled with extraordinary moments their lives? Do family members wait I consider love to be the “L-word” of
of healing, honesty, insight, and human connection. With such a heady mix of each day with bated breath for our our profession. We don’t often use it
costs and benefits, psychiatrists will always run the danger of being swamped words of wisdom? And yet there are with patients, for obvious reasons.
people, every day, who commute, But psychiatrists create constructive
by the negative as they seek to cultivate the positive.
show up, sit, and wait just for the op- relationships as the fundamental ba-
As human beings, in fact as mammals, we are inherently prone to pay more portunity to talk to us, their psychia- sis of their work. We are formally
attention to the bad than the good, and to demonstrate a negativity bias in most trists. trained to do so, even with the most
aspects of life.1 Gottman and colleagues2 have asserted it takes five positive difficult patients. Though extreme
interactions for every negative one to keep a relationship stable and happy.
Intellectual levels of patience and skill are some-
engagement times required, achieving such good
Positive psychology has taught us that we need to actively cultivate appreciation As we know, the human brain is the and meaningful relationships is
for the goods of life—gratitude—by regular and conscious practice. most complex object in the physical among the greatest joys of life. Bet-
Conscious emphasis on the positive does not mean denial of the negative, as universe, bar none. Our job challenges ter than most other professionals,
us to understand the workings of the psychiatrists understand that rela-
if a naive Pollyanna-like attitude constitutes self-actualization. Rather, by empha-
human brain and the human person on tionships are central to the good life
sizing the good, we more accurately balance positive and negative in our emo- every level that we can, and to help and base their professional lives on
tional and intellectual lives. Or, more fundamentally, by focusing on the positive, people make use of this knowledge to nurturing such relationships.8
we help keep ourselves from sinking into an ocean of negativity. live better lives. We help people under- “Life is pain,” declares Dread Pi-
stand and seek integration and healing rate Roberts in The Princess Bride.
And so, in a spirit of gratitude, here are a few of the many extraordinary
on biological, psychological, social, “Anyone who tells you differently is
advantages of being a psychiatrist. and spiritual levels. Our patients teach selling something.” If that is true,
us, our colleagues teach us, and every then thank goodness for psychiatry.
day new studies will come out to illu- And thanks to those who practice it.
External goods role that is ultimately about doing minate this most exquisite of all crea- Because of them, human life is a lit-
US psychiatrists earn an average of good for our patients, their families, tions. We will never stop learning, and tle bit less painful.
$273,000 a year, placing them in the and our society, and we will see tan- we need never be bored.6
top 2% of wage earners in the US.3 gible results of our efforts in both the Dr Morehead is a psychiatrist in private
Regardless of their position in the sal- short and long term. By the end of a Self-improvement practice, and former Assistant
ary range, psychiatrists earn more psychiatric career (and in spite of As a psychiatrist, whatever I learn ap- Residency Director at the Karl
than enough to provide for them- mistakes and limitations), countless plies to me. Every day, our work Menninger School of Psychiatry. He is
selves and their families. We are people and their families will be bet- teaches us more about the human con- board certified in General Psychiatry
among the top 3% in educational at- ter off because of our work. dition. We have access to the inner, (ABPN) and Neuropsychiatry (UCNS),
tainment, with a doctorate and four intimate, and (generally) honest expe- maintaining interests in neurosci-
years (plus) of post-graduate training. Being needed riences of countless people, not the
ence, psychotherapy, spirituality, and
Nationally and worldwide, there is a advocacy for mental illness.
We also enjoy the tremendous pres- superficial Facebook-type self-adver-
tige of being a physician, with instant vast shortage of psychiatrists that tising that goes on in much of our cul- References
respect, credibility, and social status will not end in the foreseeable fu- ture. Thus, we have a source of knowl- 1. Rozin P, Royzman EB. Negativity bias, negativity
ture. Wherever we go, we will be dominance, and contagion. Personality Social Psy-
wherever we go. Of course, positive edge about the human condition that chol Rev. 2001;5:296-320.
psychology has confirmed that mon- needed and valued. We do not need no one can better. And we have a daily 2. Gottman JM, Coan J, Carrere S, Swanson C. Pre-
to worry about being able to find dicting marital happiness and stability from newly-
ey, possessions, and social status are motivator to practice our own self- wed interactions. J Marriage Family. 1998;60:5-22.
relatively superficial goods and are work and support ourselves. Better care, self-improvement, and growth. 3. Peckham C. Medscape Psychiatrist Compensa-
not the most important factors in hap- than that, as an individual psychia- tion Report 2018. Medscape. April 18, 2018. https://
As we understand our patients more www.medscape.com/slideshow/2018-compensa-
piness and well-being.4 So (being trist, I can contemplate the fact that deeply and help them, we simultane- tion-psychiatrist-6009671. Accessed June 6, 2019.
good psychiatrists) let us look more if I were not filling the need I now 4. Ryan RM, Deci EL. On happiness and human poten-
ously learn to understand and help tials: a review of research on hedonic and eudaimon-
deeply. fill, there would not be anyone else ourselves. ic well-being. Annu Rev Psychol. 2001;52:141-166.
to make up for it. 5. Peterson C, Park N, Seligman ME. Orientations to
Helping others Self-esteem happiness and life satisfaction: the full life versus
the empty life. J Happiness Studies. 2005;6:25-41.
A profound and inescapable aspect of Being significant People who spend large amounts of 6. Waterman AS. On the importance of distinguish-
Obviously, we matter as psychia- ing hedonia and eudaimonia when contemplating
a meaningful, happy life is the ability time on social media appear vulner- the hedonic treadmill. Am Psychol. 2007;62:612-
to contribute to the good of others. As trists. Yet how many of us have con- able to feelings of inferiority and 613.
sidered the strange fact that people 7. Appel H, Gerlach AL, Crusius J. The interplay be-
psychiatrists, helping others is the es- discouragement in the face of oth- tween Facebook use, social comparison, envy, and
sence of our jobs. This truth is so fa- rearrange their lives, schedules, and ers’ relentless success.7 As the old depression. Curr Opinion Psychol. 2016;9:44-49.
finances, all to receive the privilege of 8. Helliwell JF, Putnam RD. The social context of
miliar that it often feels trivial when it Alcoholics Anonymous saying has well–being. Philos Trans Royal Soc London. Series B:
is in fact profound.5 We enjoy a social sitting with us in a room and talking? it, “You are comparing your insides Biological Sciences. 2004;359:1435-1446. ❒
6 PSYC HIATR I C T I M ES AUG US T 2 0 1 9
w ww.psychiatr ictim e s. c o m

FROM THE EDITOR FROM THE GROUP FOR THE

ADVANCEMENT OF
The Passing of a PSYCHIATRY
The Disabled Employee’s Manager:

Matriarch A Common Complicating Factor of

Workplace Disability

John J. Miller, MD | Editor in Chief

Barbara Long, MD, PhD, Andrew O. Brown,
MD, Sean Sassano-Higgins, MD, and
8.2019 VOLUME 36 NUMBER 8 David “Daven” E. Morrison, MD, for the
Committee on Work and
Throughout my life I have found COVER STORIES Organizations, GAP
myself reflecting on the philosoph-
ical question of how my life would Psychiatrists: The Luckiest People RUMINATIONS OF A
be, or in fact would I be here at all, on Earth?
PSYCHIATRIST
if a single event in history had oc- Daniel Morehead, MD
curred differently. Impersonal Children Who Ask to Become
Hospital-Based Psychiatric Suicide Bombers—And Their
events like the extinction of the di- Emergency Programs: The Missing
nosaurs or a larger accretion of star- Approving Parents—A Joyless
Link for Mental Health Systems Meditation
dust resulting in the Earth orbiting
Scott Zeller, MD Lawrence H. Climo, MD
the sun at a greater distance, incom-
patible with life, are obvious major FROM THE EDITOR
events. However, it is the smaller THE COMPLICATED PATIENT
and more personal events that bring The Passing of a Matriarch Polypharmacy: A Challenge for
up strong emotions and relief when John J. Miller, MD Community Psychiatrists
I reflect on these. Amresh Shrivastava, MD, Avinash De
My mother died on July 14th at CATEGORY 1 CME Sousa, MD, and Pragya Lodha, MA
the age of 83. She died peacefully her best friend in attending the Sa-
after years of progressing medical lem Hospital School of Nursing, Caffeine: Neurobiological and PRACTICE MANAGEMENT
ailments. My father, my 4 siblings, where she discovered her passion Psychiatric Implications
and I were all with her, and she had for pediatrics, and she worked as a Sergi Ferré, MD, PhD
Making Your Practice Work for You
said her goodbyes to her extended pediatric nurse until she retired. She Joseph R. Sanok, MA, LLP, LPC, NCC
family and friends. She welcomed married my father and gave birth to SPECIAL REPORT
her passing with relief, ready to join 5 children over 10 years. NEWS BRIEF
her parents in the heaven that had In 1975, at the age of 39, my NEUROPSYCHIATRY: PART 2 Opioid Use in Pregnancy Affects
been such an important part of her mother received a diagnosis of a Offspring Throughout Childhood
life. It was during the ensuing days, rare cardiac anomaly that she was Recognizing and Treating Comorbid
Laurie Martin
with the telling of all the stories and unknowingly born with. A fistula Psychiatric Disorders in People With
remembrances of my mother’s life, connected her coronary sinus with Autism
that I found myself reflecting on the her left coronary artery, and it had Heidi C. Collins, MD and COLUMNS
Matthew S. Siegel, MD
unpredictable web of events and de- slowly grown in diameter to the
HISTORY OF PSYCHIATRY
cisions that easily could have elimi- width of a pencil, shunting the oxy- Clinical Characteristics of Chronic
nated me from this story. For brevi- genated blood away from her heart Traumatic Encephalopathy Before Personality: Character
ty, I will share three. muscle and back to her right atrium. Arman Fesharaki-Zadeh, MD, PhD Assessment and Its Troubled History
Although my grandmother’s due During her 30s, as her heart en- Greg Eghigian, PhD
date was Christmas Day, my mother larged, she became increasingly Psychopathology of Tinnitus
was born on Thanksgiving Day in short of breath with minor activity; Zeina Chemali, MD, MPH and POETRY OF THE TIMES
1935 during a blizzard in Salem, finally, a cardiologist made the cor- Romy Nehme, MD
MA. When my grandmother went rect diagnosis. The only treatment All the World’s Notes
into labor that day, my grandfather option was open heart surgery to COMMENTARY Richard M. Berlin, MD
called the doctor, who informed close the fistula, which was very Debunking the Two “Chemical
them it was likely “false” labor, and new medical technology at that Imbalance” Myths (Again)
he was unable to go to their home time. In 1975 she became one of the Ronald W. Pies, MD
due to the severe weather. This first open heart surgery patients at Let Us Hear
weather also served to trap them in the Massachusetts General Hospital FROM THE NATIONAL From You!
their home, unable to go to the hos- in Boston. Do you have opinions about issues raised
NETWORK OF DEPRESSION
pital. Later that day, in the family These are but three of hundreds, in any of the articles in this issue?
home, my great grandmother deliv- likely hundreds of thousands of CENTERS
Write to us at [email protected] or
ered my mother, who was then events and decisions that have had a The History and Value of Guidelines post your comments on our website.
COVER IMAGE: njǙǐǜǑǕ ǫǗnjǙǝǖǔǕ @STOCK.ADOBE.COM

placed in a drawer next to the wood direct impact on me in unknowable for Best Practices of Telemental
stove in the kitchen to keep her ways. And so, it is for each of us, Health
warm. She weighed 4.5 pounds and reminding us of our responsibility Robert Caudill, MD and
was healthy. to make each decision and choose Jay H. Shore, MD, MPH
My mother’s family was devout- each action wisely and thoughtfully,
ly Catholic, and after attending an but simultaneously accepting the © 2019 Multimedia Healthcare LLC All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical including by photocopy, recording, or information storage and retrieval without permission in writing from the publisher.
all girl’s Catholic high school my reality that an infinite web of events Authorization to photocopy items for internal/educational or personal use, or the internal/educational or personal use of specific clients is granted by
mother wanted to become a nun. have led us to this life, and this mo- Multimedia Healthcare LLC for libraries and other users registered with the Copyright Clearance Center, 222 Rosewood Dr. Danvers, MA 01923, 978-750-
8400 fax 978-646-8700 or visit http://www.copyright.com online. For uses beyond those listed above, please direct your written request to Permission
Wisely, my grandfather asked her to ment. Dept. fax 732-647-1104 or email: [email protected]
delay that commitment for a year, Mom, thank you for your choic- Psychiatric Times (ISSN 0893-2905) is published monthly by Multimedia Healthcare LLC, 325 W 1st St STE 300, Duluth, MN 55802.

and to attend some type of post high es and actions, and may you rest in Periodicals postage paid at Duluth MN 55806 and at additional mailing offices.

school education. My mother joined peace. ❒ POSTMASTER: Please send address changes to Psychiatric Times, Multimedia Healthcare LLC, PO Box 6000, Duluth, MN 55806-6000.
 FOR THE TREATMENT OF ADULTS
WITH TARDIVE DYSKINESIA (TD)

The only VMAT2 inhibitor that offers1

THE EASE OF TWO DOSING
ONE CAPSULE, OPTIONS THAT
ONCE DAILY WORK Not actual size

VMAT2, vesicular monoamine transporter 2.

• INGREZZA® (valbenazine) capsules is the most prescribed

FDA-approved TD treatment for adults2,*
• In clinical trials, INGREZZA 80 mg provided rapid and
significant reductions in TD severity at 6 weeks1,3
—Observed reductions seen as early as 2 weeks and
sustained results through 48 weeks with both the
40 mg and 80 mg doses1,3,4
• Generally well tolerated in clinical trials across a
broad range of adult TD patients1,3
—The most common adverse reaction (≥5% and
twice the rate of placebo) is somnolence1

*Data identified from Q2 2018 through Q1 2019. Not an actual patient

Get exclusive resources for the management of TD at INGREZZAHCP.com/register

Important Information
INDICATION & USAGE
INGREZZA® (valbenazine) capsules is indicated for the treatment of adults with tardive dyskinesia.
IMPORTANT SAFETY INFORMATION
CONTRAINDICATIONS
INGREZZA is contraindicated in patients with a history of hypersensitivity to valbenazine or any components of INGREZZA. Rash, urticaria,
and reactions consistent with angioedema (e.g., swelling of the face, lips, and mouth) have been reported.
WARNINGS & PRECAUTIONS
Somnolence
INGREZZA can cause somnolence. Patients should not perform activities requiring mental alertness such as operating a motor vehicle or
operating hazardous machinery until they know how they will be affected by INGREZZA.
QT Prolongation
INGREZZA may prolong the QT interval, although the degree of QT prolongation is not clinically significant at concentrations expected with
recommended dosing. INGREZZA should be avoided in patients with congenital long QT syndrome or with arrhythmias associated with a
prolonged QT interval. For patients at increased risk of a prolonged QT interval, assess the QT interval before increasing the dosage.
Parkinsonism
INGREZZA may cause parkinsonism in patients with tardive dyskinesia. Parkinsonism has also been observed with other VMAT2 inhibitors.
Reduce the dose or discontinue INGREZZA treatment in patients who develop clinically significant parkinson-like signs or symptoms.
ADVERSE REACTIONS
The most common adverse reaction (*5% and twice the rate of placebo) is somnolence. Other adverse reactions (*2% and >Placebo) include:
anticholinergic effects, balance disorders/falls, headache, akathisia, vomiting, nausea, and arthralgia.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit MedWatch at www.fda.gov/medwatch or call
1-800-FDA-1088.
Please see the adjacent page for brief summary of Prescribing Information and visit www.INGREZZAHCP.com/PI for full Prescribing Information.
References: 1. INGREZZA [package insert]. San Diego, CA: Neurocrine Biosciences, Inc; 2019. 2. Data on file. Neurocrine Biosciences, Inc. 3. Hauser RA, Factor SA, Marder SR, et al. KINECT
3: a phase 3 randomized, double-blind, placebo-controlled trial of valbenazine for tardive dyskinesia. Am J Psychiatry. 2017;174(5):476-484. 4. Factor SA, Remington G, Comella CL, et al.
The effects of valbenazine in participants with tardive dyskinesia: results of the 1-Year KINECT 3 extension study. J Clin Psychiatry. 2017;78(9):1344-1350.

©2019 Neurocrine Biosciences, Inc. All Rights Reserved. CP-VBZ-US-0287v7 08/19

 Other Adverse Reactions Observed During the Premarketing Evaluation of INGREZZA
for oral use Other adverse reactions of ≥1% incidence and greater than placebo are shown below. The following
list does not include adverse reactions: 1) already listed in previous tables or elsewhere in the
Brief Summary: for full Prescribing Information and Patient Information, labeling, 2) for which a drug cause was remote, 3) which were so general as to be uninformative,
refer to package insert. 4) which were not considered to have clinically significant implications, or 5) which occurred at a rate
equal to or less than placebo.
INDICATION AND USAGE Endocrine Disorders: blood glucose increased
INGREZZA® (valbenazine) capsules is indicated for the treatment of adults with tardive dyskinesia.
General Disorders: weight increased
CONTRAINDICATIONS Infectious Disorders: respiratory infections
INGREZZA is contraindicated in patients with a history of hypersensitivity to valbenazine or any Neurologic Disorders: drooling, dyskinesia, extrapyramidal symptoms (non-akathisia)
components of INGREZZA. Rash, urticaria, and reactions consistent with angioedema (e.g., swelling of Psychiatric Disorders: anxiety, insomnia
the face, lips, and mouth) have been reported.
During controlled trials, there was a dose-related increase in prolactin. Additionally, there was a dose-
WARNINGS AND PRECAUTIONS related increase in alkaline phosphatase and bilirubin, suggesting a potential risk for cholestasis.
Somnolence Postmarketing Experience
INGREZZA can cause somnolence. Patients should not perform activities requiring mental alertness The following adverse reactions have been identified during post-approval use of INGREZZA that are
such as operating a motor vehicle or operating hazardous machinery until they know how they will be not included in other sections of labeling. Because these reactions are reported voluntarily from a
affected by INGREZZA. population of uncertain size, it is not always possible to reliably estimate their frequency or establish
QT Prolongation a causal relationship to drug exposure.
INGREZZA may prolong the QT interval, although the degree of QT prolongation is not clinically Immune System Disorders: hypersensitivity reactions (including allergic dermatitis, angioedema,
significant at concentrations expected with recommended dosing. In patients taking a strong CYP2D6 pruritis, and urticaria)
or CYP3A4 inhibitor, or who are CYP2D6 poor metabolizers, INGREZZA concentrations may be higher Skin and Subcutaneous Tissue Disorders: rash
and QT prolongation clinically significant. For patients who are CYP2D6 poor metabolizers or are
taking a strong CYP2D6 inhibitor, dose reduction may be necessary. For patients taking a strong DRUG INTERACTIONS
CYP3A4 inhibitor, reduce the dose of INGREZZA to 40 mg once daily. INGREZZA should be avoided Drugs Having Clinically Important Interactions with INGREZZA
in patients with congenital long QT syndrome or with arrhythmias associated with a prolonged QT Table 2: Clinically Significant Drug Interactions with INGREZZA
interval. For patients at increased risk of a prolonged QT interval, assess the QT interval before
increasing the dosage. Monoamine Oxidase Inhibitors (MAOIs)
Parkinsonism Clinical Implication: Concomitant use of INGREZZA with MAOIs may increase the
INGREZZA may cause parkinsonism in patients with tardive dyskinesia. Parkinsonism has also concentration of monoamine neurotransmitters in synapses,
been observed with other VMAT2 inhibitors. In the 3 placebo-controlled clinical studies in patients potentially leading to increased risk of adverse reactions such as
with tardive dyskinesia, the incidence of parkinson-like adverse events was 3% of patients serotonin syndrome, or attenuated treatment effect of INGREZZA.
treated with INGREZZA and <1% of placebo-treated patients. Postmarketing safety reports have Prevention or Avoid concomitant use of INGREZZA with MAOIs.
described parkinson-like symptoms, some of which were severe and required hospitalization. In Management:
most cases, severe parkinsonism occurred within the first 2 weeks after starting or increasing the
dose of INGREZZA. Associated symptoms have included falls, gait disturbances, tremor, drooling, Examples: isocarboxazid, phenelzine, selegiline
and hypokinesia. In cases in which follow-up clinical information was available, parkinson-like Strong CYP3A4 Inhibitors
symptoms were reported to resolve following discontinuation of INGREZZA therapy. Reduce the dose
or discontinue INGREZZA treatment in patients who develop clinically significant parkinson-like signs Clinical Implication: Concomitant use of INGREZZA with strong CYP3A4 inhibitors
or symptoms. increased the exposure (Cmax and AUC) to valbenazine and its active
metabolite compared with the use of INGREZZA alone. Increased
ADVERSE REACTIONS exposure of valbenazine and its active metabolite may increase the
The following adverse reactions are discussed in more detail in other sections of the labeling: risk of exposure-related adverse reactions.
• Hypersensitivity Prevention or Reduce INGREZZA dose when INGREZZA is
• Somnolence Management: coadministered with a strong CYP3A4 inhibitor.
• QT Prolongation Examples: itraconazole, ketoconazole, clarithromycin
• Parkinsonism Strong CYP2D6 Inhibitors
Clinical Trials Experience Clinical Implication: Concomitant use of INGREZZA with strong CYP2D6 inhibitors
Because clinical trials are conducted under widely varying conditions, adverse reaction rates may increase the exposure (Cmax and AUC) to valbenazine’s active
observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of metabolite compared with the use of INGREZZA alone. Increased
another drug and may not reflect the rates observed in practice. exposure of active metabolite may increase the risk of exposure-
Variable and Fixed Dose Placebo-Controlled Trial Experience related adverse reactions.
The safety of INGREZZA was evaluated in 3 placebo-controlled studies, each 6 weeks in duration Prevention or Consider reducing INGREZZA dose based on tolerability when
(fixed dose, dose escalation, dose reduction), including 445 patients. Patients were 26 to 84 years Management: INGREZZA is coadministered with a strong CYP2D6 inhibitor.
of age with moderate to severe tardive dyskinesia and had concurrent diagnoses of mood disorder Examples: paroxetine, fluoxetine, quinidine
(27%) or schizophrenia/schizoaffective disorder (72%). The mean age was 56 years. Patients were
57% Caucasian, 39% African-American, and 4% other. With respect to ethnicity, 28% were Hispanic Strong CYP3A4 Inducers
or Latino. All subjects continued previous stable regimens of antipsychotics; 85% and 27% of Clinical Implication: Concomitant use of INGREZZA with a strong CYP3A4 inducer
subjects, respectively, were taking atypical and typical antipsychotic medications at study entry. decreased the exposure of valbenazine and its active metabolite
Adverse Reactions Leading to Discontinuation of Treatment compared to the use of INGREZZA alone. Reduced exposure of
A total of 3% of INGREZZA treated patients and 2% of placebo-treated patients discontinued because of valbenazine and its active metabolite may reduce efficacy.
adverse reactions. Prevention or Concomitant use of strong CYP3A4 inducers with INGREZZA is not
Common Adverse Reactions Management: recommended.
Adverse reactions that occurred in the 3 placebo-controlled studies at an incidence of ≥2% and Examples: rifampin, carbamazepine, phenytoin, St. John’s wort1
greater than placebo are presented in Table 1. Digoxin
Table 1: Adverse Reactions in 3 Placebo-Controlled Studies of 6-week Clinical Implication: Concomitant use of INGREZZA with digoxin increased digoxin levels
Treatment Duration Reported at ≥2% and >Placebo because of inhibition of intestinal P-glycoprotein (P-gp).
Adverse Reaction1 INGREZZA Placebo Prevention or Digoxin concentrations should be monitored when
(n=262) (%) (n=183) (%) Management: coadministering INGREZZA with digoxin. Increased digoxin exposure
may increase the risk of exposure-related adverse reactions. Dosage
General Disorders adjustment of digoxin may be necessary.
Somnolence (somnolence, fatigue, sedation) 10.9% 4.2% 1
The induction potency of St. John’s wort may vary widely based on preparation.
Nervous System Disorders
Drugs Having No Clinically Important Interactions with INGREZZA
Anticholinergic effects (dry mouth, constipation, 5.4% 4.9% Dosage adjustment for INGREZZA is not necessary when used in combination with substrates of
disturbance in attention, vision blurred, urinary retention) CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2E1, or CYP3A4/5 based on in vitro study results.
Balance disorders/fall (fall, gait disturbance, dizziness, 4.1% 2.2% OVERDOSAGE
balance disorder)
Human Experience
Headache 3.4% 2.7% The pre-marketing clinical trials involving INGREZZA in approximately 850 subjects do not provide
Akathisia (akathisia, restlessness) 2.7% 0.5% information regarding symptoms with overdose.
Gastrointestinal Disorders Management of Overdosage
No specific antidotes for INGREZZA are known. In managing overdose, provide supportive care,
Vomiting 2.6% 0.6%
including close medical supervision and monitoring, and consider the possibility of multiple drug
Nausea 2.3% 2.1% involvement. If an overdose occurs, consult a Certified Poison Control Center (1-800-222-1222 or
Musculoskeletal Disorders www.poison.org).
For further information on INGREZZA, call 84-INGREZZA (844-647-3992).
Arthralgia 2.3% 0.5%
Distributed by: INGREZZA is a registered trademark
1
Within each adverse reaction category, the observed adverse reactions are listed in order of decreasing frequency. Neurocrine Biosciences, Inc. of Neurocrine Biosciences, Inc.
San Diego, CA 92130 CP-VBZ-US-0203v4 07/19
AUGUST 2019 P S Y C H I AT R I C T I M E S 9
COMMENTARY w w w. p s y c h i a t r i c t i m e s . c o m

Debunking the Two “Chemical

Imbalance” Myths (Again!)
And Moving Toward a Bio-psycho-socio-cultural Model
of Major Depression
» Ronald W. Pies, MD “Psychiatry defending its guild in-
terests” (as if the purveyors of an-
the significance of serotonin was
considerably over-emphasized—ow-
this nature, anti-psychiatry groups
and bloggers believe they have
ti-psychiatry animus have no ing to what Roger S. McIntyre, MD demonstrated that “Psychiatry” has
A little learning is a dangerous thing.
self-serving motives). has facetiously called, “Psychiatry’s defended a bogus chemical imbal-
Alexander Pope1 Ironically, anti-psychiatry groups High School Crush.”7 ance theory. These critics are simply
are quite right in heaping scorn on the Furthermore, the SSRIs were ac- wrong. Decontextualized quotes

L
ike the legendary Count Dracula, chemical imbalance theory of mental corded a rock-star status as effective from a dozen—or even a hundred—
who could be killed only by driv- illness, but not for the reasons they antidepressants that they did not de- famous psychiatrists do not represent
ing a stake through his heart, usually give. (I hasten to add that de- serve. Most troubling from the stand- an official professional consensus,
some myths seem almost immortal. bunking the chemical imbalance theo- point of misleading the general pub- much less the views of over 30,000
For more than 8 years now, I have ry is not to deny that biological factors lic, pharmaceutical companies US psychiatrists.
tried to drive a stake through the heart play an important role in serious men- heavily promoted the “chemical im- Moreover, most of the quotes or
of two myths regarding the so-called tal illness, including but not limited to balance” trope in their direct-to-con- statements usually cited by psychia-
“chemical imbalance theory”—but major depression, bipolar disorder, sumer advertising. There was no con- try’s critics use the term “chemical
with only limited success, as a recent and schizophrenia). The fact is, there certed attempt by our profession to imbalance” in the specific context of
piece in the New Yorker brought could never have been a scientifically promote a causal or etiological theo- antidepressants and their putative
home to me.2-5 based, chemical imbalance theory of ry of mental illness in general, based mechanism of action. For example,
And, yes, there are really two mental illness, because a genuine the- solely on chemical imbalances. Nei- here is a quote from 2004:
myths to debunk. The first holds that ory requires an integrated network of ther did the originators of the biogen-
mental illnesses (psychiatric disor- well-supported, interlinked hypothe- ic amine hypothesis—psychiatrists Patients with neurotransmitter
ders) in general are caused by “a ses. And yes, the frequently ignored Joseph J. Schildkraut and Seymour dysregulation may have an im-
chemical imbalance” in the brain— distinction between a theory and a hy- S. Kety—promote such a view in the balance of serotonin and nor-
the so-called “chemical imbalance pothesis is crucial. It is the key to un- 1960s.8 Indeed, in 1965, Dr Schild- epinephrine… Antidepressant
theory.” The second myth holds that derstanding why claims by antipsy- kraut stated: medications that act as dual
“Psychiatry” as a profession en- chiatry bloggers regarding the serotonin-norepinephrine re-
dorsed the first myth, deliberately chemical imbalance theory nearly al- A rigorous extrapolation from uptake inhibitors [SNRIs] . . .
and knowingly lying to countless, ways crash and burn. pharmacological studies to may aid in correcting the imbal-
unsuspecting patients. Depending pathophysiology clearly cannot ance of serotonin and norepi-
on which anti-psychiatry group, The theory that never was be made. Clinical studies rele- nephrine neurotransmission in
blogger, or website you investigate, Scientifically speaking, there never vant to the catecholamine hy- the brain.10
you will find a number of corollaries was a network of validated hypothe- pothesis are limited and the
to the second myth; for example, ses capable of sustaining a full- findings are inconclusive. It is The writer was hypothesizing a
“Psychiatrists lied to patients in or- blown, global chemical imbalance not possible, therefore, to con- mechanism of action by which SN-
der to justify giving them medica- theory of mental illness. Moreover— firm definitively or to reject the RIs may be helpful for patients who
tion,” or “Psychiatrists were cor- and here we come back to Myth 2— catecholamine hypothesis on experience depression in the context
rupted by Big Pharma, and stood to psychiatry as a profession and medi- the basis of data currently of pain. He was certainly not pro-
make a lot of money by promoting cal specialty never endorsed such a available. pounding a causal chemical imbal-
the chemical imbalance theory” bogus “theory,” when judged by its ance theory of depression, much less
(Sidebar). Rebuttals of these claims professional organizations, its The closest thing we have to an of psychiatric disorders in general.
are almost always dismissed as, peer-reviewed publications, its stand- “official” position on the etiology of Note, as well, the careful use of the
ard textbooks, or its official pro- psychiatric disorders is this 1978 word “may.” Yes: with 20-20 hind-
nouncements. Furthermore, the statement from the American Psychi- sight, the imbalance claim has proved
By whatever biological whole notion of some looming, mon- atric Association, which was approved inaccurate and simplistic—but was
olithic “Psychiatry” is absurd on its by the APA Board of Trustees: “Psy- not demonstrably false or menda-
mechanisms, the face, as my colleague, George Daw- chiatric disorders result from the com- cious when stated in 2004. (Even to-
son has argued.6 plex interaction of physical, psy- day, we simply do not have the so-
clinical reality is that To be sure: what many psychia- cho-logical, and social factors and phisticated technology to verify or
antidepressants are trists in the 1980s and 1990s did pro-
mote was some version of the bio-
treatment may be directed toward any
or all three of these areas.”9
falsify, in real time, putative neuro-
transmitter “imbalances” in the hu-
effective in many genic amine (or catecholamine)
hypothesis of mood disorders, focus-
Critics of my thesis are inordi-
nately fond of citing a dozen or so
man brain, during a patient’s depres-
sive bout.) Indeed, with the benefit of
patients with severe, ing mainly on the neurotransmitters
norepinephrine and serotonin.
statements by various psychiatric lu-
minaries—including two former
further research, we now believe that
the likely mechanisms of action of
acute major (Schizophrenia was conventionally APA presidents—that do, indeed, antidepressants are much more com-
explained by the now outdated “do- invoke the phrase, “chemical imbal- plicated than merely altering levels
depression. pamine hypothesis.”) And, in truth, ance.” By cherry-picking quotes of of neurotransmitters.
10 P S Y C H I AT R I C T I M E S AUGUST 2019
w w w. p s y c h i a t r i c t i m e s . c o m

EDITORIAL BOARD ADVISORY BOARD

Awais Aftab, MD
Psychiatrists questioned the growing evidence that various nerve Editors in Chief Emeriti
John L. Schwartz, MD | Founder Noel Amaladoss, MD
chemical imbalance theory growth factors, such as BDNF Kristel Carrington, MD
Ronald Pies, MD Ralph de Similien, MD
By the early 2000s, psychiatrists (brain-derived neurotrophic factor) Emeritus Professor of Psychiatry, SUNY Upstate Medical Center, Jessica Gold, MD, MS
were poking holes in the chemical are involved in the etiology of de- Syracuse, and Tufts University School of Medicine
Desiree Shapiro, MD
imbalance trope and raising serious pression and the mechanism of ac- James L. Knoll IV, MD John Torous, MD

questions about the entire catecho- tion of some antidepressants.17 The Director of Forensic Psychiatry, Professor of Psychiatry,
SECTION EDITORS
SUNY Upstate Medical University, Syracuse
lamine hypothesis. Antipsychiatry rapid antidepressant effect of keta- Bipolar Disorder: Chris Aiken, MD; James Phelps, MD
Allan Tasman, MD
critics should read over the chapter mine has also raised the possibility Professor and Emeritus Chair, Department of Psychiatry and
Book Review: Howard L. Forman, MD
Digital Psychiatry: John Torous, MD
on mood disorders in The American that the NMDA receptor, and possi- Behavioral Sciences, University of Louisville School of Medicine
Ethics: Cynthia M. A. Geppert, MD, DPS
Psychiatric Publishing Textbook of bly, the opioid system, are involved Deputy Editor in Chief Emeritus Neuropsychiatry: Barbara Schildkrout, MD
Clinical Psychiatry.11 In ten pages in the biology of depression.18 Michelle B. Riba, MD, MS
Professor, Integrated Medicine and Psychiatric Services; Associate EDITORIAL
of text, the etiology of mood disor- One important caveat, however: Director, Comprehensive Depression Center; Director, Executive Editor .................................................Natalie Timoshin
ders is discussed in classic “bio-psy- the DSM-5 construct of MDD is so PsychOncology Program; Director, Psychosomatic Fellowship Digital Managing Editor ..........................................Laurie Martin
Program, University of Michigan Editor....................................................... Heidi Anne Duerr, MPH
cho-social” terms. No chemical im- broad and elastic, it almost certainly Editor....................................................................... Julie Bowen
balance theory is presented. As for encompasses a multitude of under- John J. Miller, MD | Editor in Chief
Medical Director, Brain Health, Exeter, NH MULTIMEDIA HEALTHCARE
the catecholamine hypothesis, “Ad- lying disease entities. As Dr Joel Staff Psychiatrist, Seacoast Mental Health Center President ....................................................... Thomas W. Ehardt
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hypothesis . . . [for example] deple- problems in classification and in Richard Balon, MD
Art Director ........................................................... Nicole Slocum
Professor of Psychiatry, Wayne State University
tion of serotonin can aggravate de- specificity of treatment.”19
pression that has been in remission, In the area of bipolar disorder, Robert J. Boland, MD READER’S GUIDE
Vice Chair for Education, Department of Psychiatry, Brigham
but it does not predictably cause Maletic and Raison20 have described HOW TO REACH US
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As for the bogus chemical imbalance theory Raymond Young-Jin Cho, MD

Associate Professor, Department of Psychiatry and Behavioral
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AUGUST 2019 P S Y C H I AT R I C T I M E S 11
COMMENTARY w w w. p s y c h i a t r i c t i m e s . c o m

debilitating depression with heavy 6. Dawson G. The Myth of Monolithic Psychiatry.

2015. http://real-psychiatry.blogspot.com/2015/06/
consequences on their level of daily the-myth-of-monolithic-psychiatry.html. Accessed
functioning.” May 9, 2019.
THE TERM “ANTIPSYCHIATRY” HAS A 7. Pies RW. Serotonin: how psychiatry got over its
Conclusion high school crush. Psychiatric Times. 2015;32(11):
VARIETY OF MEANINGS, as my colleague, Dr Nassir Ghaemi 28,35.
In the 1980s, the 1990s, and beyond, 8. Schildkraut JJ. The catecholamine hypothesis of
pharmaceutical companies heavily and I discuss in detail elsewhere.25 There are many responsible critics of
affective disorders: a review of supporting evidence.
promoted something resembling a psychiatric nosology and praxis who are not “anti-psychiatry”—several of Am J Psychiatry. 1965;122:509-522
chemical imbalance theory of mood 9. American Psychiatric Association. Position state-
whom are themselves prominent psychiatrists. When I use the term “anti-
ment on active treatment. Am J Psychiatry.
disorders directly to consumers—or,
psychiatry,” I am referring to persons or organizations that deny the 1979;136:753.
at least, used the “chemical imbal- 10. Trivedi MH. The link between depression and
ance” trope to explain how antide- fundamental legitimacy of psychiatry as a medical specialty; and who physical symptoms. J Clin Psychiatry. 2004;6(Suppl
pressants supposedly work. In recent consistently impute malignant motives and mendacious practices to 1):12-16.
years, as psychologist Dr John Gro- 11. Dubovsky SL, Davies R, Dubovsky AN. Mood dis-
psychiatrists (see Schramme26 for more information). orders. Hales RE, Yudofsky SC, Eds. The American
hol has pointed out, some non-pro- Psychiatric Publishing Textbook of Clinical Psychia-
fessional websites have provided
Antipsychiatry bloggers often respond to my position by asking, “If
try, 4th ed. Washington DC: American Psychiatric
misleading graphics that reinforce psychiatrists knew all along that the chemical imbalance theory was Publishing; 2003.
the “chemical imbalance” trope.24 It 12. Smith RC. The biopsychosocial revolution: inter-
bogus, why did they continue to tell patients that their emotional problems
viewing and provider-patient relationships becoming
is not surprising that the “Theory were due to a chemical imbalance that would be corrected by key issues for primary care. J Gen Intern Med.
That Never Was” has taken hold in 2002;17309-310.
the minds of so many. medication?” Characteristically, these critics cite no credible evidence that 13. Pies RW. Comments on “cyclical swings” by Pro-
While some prominent psychia- psychiatrists as a group misled their patients in this way. Almost always, fessor Hannah Decker: the underappreciated “solid
center” of psychiatry. History Psychol. 2016;19:60-
trists have used the term “chemical their “evidence” consists of anecdotal claims, such as, “I’ve had dozens of 65.
imbalance” in their public comments 14. American Psychiatric Association. What is De-
patients tell me that they were given the chemical imbalance” explanation
about antidepressants—and possibly pression? https://www.psychiatry.org/patients-fam-
in their clinical practices (Side- by their psychiatrist! ilies/depression/what-is-depression. Accessed May
bar)—there was never a unified, 9, 2019.
Like Dr Dawson,6 I have never seen any evidence that the psychiatrists 15. Miller AH, Maletic V, Raison CL. Inflammation and
concerted effort within American in question were contacted or interviewed to present their side of the story, its discontents: the role of cytokines in the patho-
psychiatry to promote a chemical im- physiology of major depression. Biol Psychiatry.
balance theory of mental illness. to review their chart notes for what was actually communicated, etc. Some 2009;65:732-741.
The original catecholamine hy- critics cite a study by Frances and colleagues,27 who reported that among 16. Köhler-Forsberg O, N Lydholm C, et al. Efficacy of
anti-inflammatory treatment on major depressive
pothesis of mood disorders was care- 237 psychology students, 46% had heard the chemical imbalance disorder or depressive symptoms: meta-analysis of
fully qualified by its originators in the clinical trials. Acta Psychiatr Scand. 2019;139:404-
explanation from a physician. Even if valid, this study hardly implicates
1960s, and has been recognized as 419.
significantly flawed and inadequate psychiatrists in a massive campaign of misinformation. 17. Hashimoto K. Brain-derived neurotrophic factor
as a biomarker for mood disorders: an historical
by US psychiatrists since at least It is noteworthy that the overwhelming majority of antidepressant overview and future directions. Psychiatry Clin Neu-
2003—and probably much earlier. prescriptions in the US are written by primary care physicians—relatively rosci. 2010;64:341-357.
The hypothesis has since been modi- 18. Williams NR, Heifets BD, Blasey C et al. Attenua-
fied and corrected to reflect more few depressed patients in the US are evaluated by a psychiatrist. In fact, tion of antidepressant effects of ketamine by opioid
complex biological mechanisms in “Primary care providers prescribe 79% of antidepressant medications and receptor antagonism. Am J Psychiatr y.
2018;175:1205-1215.
major mood disorders. These disor- see 60% of people being treated for depression in the United States.”28 19. Paris J. The mistreatment of major depressive
ders are best understood using a disorder. Can J Psychiatry. 2014;59:148-151.
There are no reliable data on how often the “chemical imbalance” trope
bio-psycho-sociocultural model, 20. Maletic V, Raison C. Integrated neurobiology of
which has been the mainstay of aca- has been communicated to patients, either in primary care or in psychiatry. bipolar disorder. Front Psychiatry. 2014;5:98.
21. Norhayati MN, Hazlina NH, Asrenee AR, et al.
demic psychiatry for over 30 years. Nor do we know how nuanced the psychiatrists’ communications were. Magnitude and risk factors for postpartum symp-
As with many other neuropsychi- There is a big difference between telling a patient, “Your depression is due toms: a literature review. J Affect Disord.
atric diseases, including Alzheimer 2015;175:34-52.
disease, the precise causes of major to a chemical imbalance and this medication will correct it;” and saying, 22. Opel N, Redlich R, Dohm K, et al. Mediation of the
“We believe depression may be caused by a combination of biochemical influence of childhood maltreatment on depression
mood disorders are still unknown.
relapse by cortical structure: a 2-year longitudinal
Almost certainly, there is a plethora abnormalities in the brain, psychological factors, and environmental observational study. Lancet Psychiatry. 2019;6:318-
of causal processes involved, de- 326.
stresses. This antidepressant may help address the biological issues, while
pending on the diagnostic criteria 23. Bailey RK, Mokonogho J, Kumar A. Racial and
and subtype of the illness (similar to “talk therapy” can be helpful for the other issues.” In my nearly 40 years in ethnic differences in depression: current perspec-
tives. Neuropsychiatr Dis Treat. 2019;15:603-609.
the subtyping of anemia). Fortunate- the profession, I have heard hundreds of psychiatrists articulate some 24. Grohol JM. The problem with Google’s health
ly, we have effective pharmacologic version of the latter view. I have not heard a single voice of the former. knowledge graphs. Psych Central. https://psychcen-
and psychosocial treatments for tral.com/blog/the-problem-with-googles-health-
mood disorders. As for the bogus knowledge-graphs/. Accessed May 9, 2019.
Emeritus of Psychiatric Times (2007 to 2. Pies RW. Psychiatry’s New Brain-Mind and the 25. Pies RW, Thommi S, Ghaemi SN. Getting it from
chemical imbalance theory and its Legend of “Chemical Imbalance.” http://www.psy-
2010). He reports no conflicts of inter- both sides: foundational and antifoundational cri-
misattribution to the profession of chiatrictimes.com/blogs/couch-crisis/psychia- tiques of psychiatry. Psychiatric Times.
psychiatry, it is time to drive the stake est concerning the subject matter of try-new-brain-mind-and-legend-chemical-imbal- 2011;28(7):1,2,4.
into its misbegotten heart. We must this article. ance. 2011. Accessed May 9, 2019. 26. Schramme T. The legacy of antipsychiatry.
3. Pies RW. Doctor, Is My Mood Disorder Due to A Schramme T, Thome J, Eds. Philosophy and Psychia-
focus on providing our patients great-
ACKNOWLEDGEMENT—My thanks to Dr Chemical Imbalance? http://psychcentral.com/blog/ try. Berlin: de Gruyter; 2004: 94-119.
er access to holistic, comprehensive archives/2011/08/04/doctor-is-my-mood-disorder- 27. Frances CM, Lysaker PH, Robinson RP. The
psychiatric care. George Dawson for commenting on an early draft due-to-a-chemical-imbalance/. 2011. Accessed May “chemical imbalance” explanation for depression:
of this essay. 9, 2019. origins, lay endorsement, and clinical implications.
Dr Pies is Professor of Psychiatry, SUNY 4. Pies RW. Nuances, Narratives, and the “Chemical Prof Psychol. 2007;38:411-420.
References Imbalance” Debate. http://www.medscape.com/ 28. Barkil-Oteo A. Collaborative care for depression
Upstate Medical University, Syracuse, 1. Pope A. A Little Learning. Poets’ Graves. https:// in primary care: how psychiatry could “troubleshoot”
viewarticle/823368. 2014. Accessed May 9, 2019.
NY and Tufts University School of www.poetsgraves.co.uk/Classic%20Poems/Pope/a_ 5. Aviv R. The challenge of going off psychiatric current treatments and practices. Yale J Biol Med.
Medicine, Boston. He is Editor in Chief little_learning.htm. Accessed May 9, 2019. drugs. New Yorker. April 1, 2019. 2013;86:139-146. ❒
 12 P S Y C H I AT R I C T I M E S AUGUST 2019
w w w. p s y c h i a t r i c t i m e s . c o m

FROM THE NATIONAL NETWORK OF DEPRESSION CENTERS

The History and Value of Guidelines
for Best Practices of Telemental Health
» Robert Caudill, MD and Current best practices for principles and practices that are less likely to
Jay H. Shore, MD, MPH videoconferencing-based telemental health be subject to obsolescence in the face of tech-
With suitable fanfare, the most recent version nological progress. Hopefully the stage has
of Best Practices in Videoconferencing-Based
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T
elepsychiatry has moved from an eso- Telemental Health was adopted by both the
teric curiosity to mainstream practice. It APA and the American Telemedicine Associ-
has been challenged along the way at ation (ATA) in the spring of 2018. The founda- VJGOQUVTGEGPVXGTUKQP
many turns. Some degree of scientific skepti- tional texts were updated, streamlined, and
cism is required when considering any health harmonized and culminated in this co-branded QH$GUV2TCEVKEGUKP
care innovation. While the utility of telepsy- document. While the chair of the APA telepsy-
chiatry seemed obvious to many, it was al- chiatry committee is a psychiatrist by defini- 8KFGQEQPHGTGPEKPI
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tance of this health care innovation and asso-
ciated technology. That task was achieved
either of the two key ATA offices. This fortui-
tous arrangement of office holders and the op-
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long ago.
An outgrowth of the supporting evidence
portunity to synchronize between the two or-
ganizations greatly facilitated the creation of
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has been the creation and adoption of guide- this document. #OGTKECP6GNGOGFKEKPG
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American Psychiatric Association (APA) was merging and updating of ATA works from When the time for an inevitable updating of
a slow adopter of telepsychiatry. To its credit, 2009 and 2013.3,4 A writing committee com- the document is required, perhaps a similar
over time it has moved from skepticism to posed of 11 thought leaders from both organi- representative group of professionals will
gradual embrace, to acceptance and enthusias- zations undertook an iterative writing process come together for that task as well.
tic promoter of telepsychiatry. that produced the new document. Support staff
Telepsychiatry has its origins in the 1950s. from both organizations also contributed to the Dr Caudill is Professor, Director, Psychiatry
However, the more modern incarnation grew success of the final product. Once a working Resident Training Program, and Director,
from Internet advances and the ubiquity of ad- draft was completed, it was distributed to larg- Telemedicine and Information Technology
equate bandwidth. As with any novel technol- er groups within the two organizations includ- Programs, Department of Psychiatry and
ogy or practice, mainstream acceptance could ing the Telemental Health Special Interest Behavioral Sciences, University of Louisville
only follow pilot projects and pioneering ef- Group (TMH SIG) of the ATA, the APA Com- School of Medicine, Louisville, KY; Dr Shore is
forts. Protocols and processes were created mittee on Telepsychiatry, the ATA Standards Chief Medical Officer, AccessCare (a company
from scratch for these initial programs. Those and Guidelines Committee, as well as both that provides telemental health services).
who are the first to put new tools into use do so ATA and APA staff. Feedback from this ex- Dr Caudill reports no conflicts of interest con-
without the benefit of established guidelines. tended review was incorporated into the final cerning the subject matter of this article);
However, it is only through such efforts that work, which has been received with wide- Dr Shore reports that he receives royalties from
the data and evidence can be collected and the spread acceptance within the field. American Psychiatric Association Publishing,
field refined to allow for the development of The final product serves as an example of and he serves on the Board of Directors of APA.
the standards that follow. high level collaboration between large organi-
In this regard, telepsychiatry is no different zations working toward a common goal. The
ACKNOWLEDGMENT—This article is contributed by National
from any other area of medicine where techni- document became available online on the
Network of Depression Centers (NNDC) Telehealth Interest
cal developments have moved from theory to websites of both APA and ATA and was re-
Group, of which Drs Caudill and Shore are the co-chairs. NNDC’s
established and routine practice. Activities, cently published in Telemedicine and e-Health,
goal is to foster collaborative research to advance scientific dis-
disciplines, and methods that are available to the leading journal of the telemedicine field.5
covery and drive forward improved care for patients with de-
identify, implement, and monitor the available The document itself stands as a succinct sum-
pression and mood disorders. NNDC is an American-based ini-
evidence in health care are called “best prac- mation of accepted best practices for deploy-
tiative and is a content partner of Psychiatric Times.
tices.”1 Such guiding principles must hold up ing telemedicine technology in the service of
to the scrutiny of those who are active in the mental health care.
field. Those protocols developed during the The process by which the document came References
1. Perleth, M, Jakubowski E, Busse R. What is “best practice” in
early adoption of a new technology must with- into existence, was refined, and ultimately health care? State of the art and perspectives in improving the
stand repeated challenges if they are to garner promulgated should also serve as an example. effectiveness and efficiency of the European health care systems.
wide acceptance and mainstream implementa- Other areas of the medical field where multi- Health Policy (Amsterdam). 2001;56:235-250.
tion. The evolution of telepsychiatry has fol- ple groups are working in an area with intrin- 2. American Psychiatric Association. Telemental Health Via Video-
conferencing; 1998.
lowed this process. Specific technical organi- sic and overlapping interests in the success and 3. Yellowlees P, Shore J, Roberts L. Practice guidelines for video-
zations formed and grew to support such growth of that initiative could benefit from conferencing-based telemental health: October 2009. Telemed
innovation. These groups then give back to the emulating this process. Writings on technolo- eHealth. 2010;16(:1074-1089.
field through the aggregation of data followed gy topics are prone to having relatively short 4. American Telemedicine Association. Practice Guidelines for Vid-
eo-Based Online Mental Health Services; 2013;19:722-730.
by thoughtful synthesis and promulgation of shelf-lives as the technologies themselves rap- 5. Shore JH, Yellowlees P, Caudill R, et al. Best Practices in Video-
this material to others who are prepared to fol- idly evolve. This concern was embraced by the conferencing-Based Telemental Health. Telemed e-Health. No-
low. writing group through a focus on outlining vember 2018; Epub ahead of print. ❒
AUGUST 2019 P S Y C H I AT R I C T I M E S 13
RUMINATIONS OF A PSYCHIATRIST w w w. p s y c h i a t r i c t i m e s . c o m

Children Who Ask to Become

Suicide Bombers
And Their Approving Parents: A Joyless Meditation
» Lawrence H. Climo, MD permanent state of mind, one from
which one never wakes up or grows
here, to a distinctly un-Western
version of “Born Again,” which,
wanting to die, to suicide, doesn’t
mean he or she is depressed, doesn’t

A 
while back I was asked, as a up and comes to one’s senses? It’s as creepy as it feels, sheds sobering rule out a motive of simply trying
psychiatrist, to weigh in on if, for some, there simply isn’t a self light on our task. In both cases— not to go mad, end pain, or not be a
the topic of Arab children to wake up—a self-awareness, an theirs and ours—we are talking burden. How many people have,
who ask to become suicide bomb- awareness of self-with-agency. And about religious people, determined while psychotic, killed others, not
ers, and their approving parents. I never was. It’s as if for some children to faithfully do God’s will by doing from hate or anger as the media au-
took a pass. I wasn’t ready to go who’ve never had support for pon- the right thing, unafraid to sacrifice tomatically assumes in their cover-
down that path, to set aside my dering and raising questions, only to make the world a better place. age, but from fear of harm and the
shield of labels, all variations of for doing and thinking as they were I’m reminded of the Bible story urge to protect, to save themselves,
“brainwashed,” “fanatic,” and told, obedience has been their con- of Eve in the Garden of Eden who or others. Or the world?
“crazy,” and put down my cleaver sistently reliable source for belong- bit into that apple even though she’d One can see where a would-be
that splits the me from them and ing, identity, appreciation, and love. been told she would die if she did. I bomber and the parents, having
the them from their humanity. made this decision, stand out among
Then, I remembered. If psychi- their peers in a new way, noticed
atrists can stand ready to help sur-
vivors of cults and kidnappings,
If psychiatrists can stand ready to help and affirmed. One can see where
this, for them, is a new experience,
and returning POWs, how is a child survivors of cults and kidnappings, and status, and identity that commands
suicide-bomber applicant with ap- attention and respect. They have
proving parents any different? I set returning POWs, how is a child stepped forward to stand apart and
aside my shield and put down my are now special. Might their orches-
cleaver and asked myself the fol- suicide-bomber applicant with approving trating and experiencing this new
lowing question: “Face-to-face status represent an instinctual pull
with such a child and the approv- parents any different? toward the completion of some-
ing parents, what would I say? thing that had been aborted years
Where might I begin?” What would it mean to such a child, don’t think she was thinking of dy- before, something that had never
For this I began pondering the fa- now a youth, to be told, “Just be ing back then, or even death. I don’t developed, that singular voice that
miliar experience of letting oneself yourself”? And if that doesn’t carry think she even knew what those no one would dare silence now?
get carried away by a destructive im- meaning might the absence of affir- words meant, nothing having ever Might this be a manifestation of a
pulse, remembering and reflecting mation of one’s individuality in early died in the Garden. How could she wholeness with agency, long de-
on those dares and double-dares of life account for that? Are we talking know? So, like Eve, maybe for pro- nied? Such a formulation would, of
childhood. I reflected on our readi- about a sense of Self that is not sim- spective child bombers and their course, be a reach, but it’s not that
ness to tear down goal-posts follow- ply dark, it’s absent? parents it’s not death they have in hard to imagine these children and
ing a victory on the gridiron in our For us in the West, of course, mind but a state akin to transforma- their parents trying, in this way, to
teens and our joining a march as submission to the will of a group is tion, of being “Born Again.” realize something, complete and
young adults and remaining even af- generally a conditional thing—tem- There’s this story we tell of the fulfill something. If not something
ter it morphed into a destructive riot. porary—whereas in the Arab world psychiatrist becoming frustrated in their lives, then something in the
A part of us knew there was more at it can be unconditional and perma- trying to talk his patient out of the lives of their People or in the world
risk than property; there was our nent. What we might call a depriva- delusional belief that he, the patient, of their Maker. Such behaviors, for
health, reputation, and career. But, at tion they might consider an asset is actually dead. “You’re alive!” the child and parent both, might not be
such moments these aren’t our prior- wherein hope for redemption, for a doctor finally begins shouting in ab- about anger, revenge, brainwash-
ities, are they? “I don’t know why I recovery of lost honor and dignity, ject frustration. “No. I’m dead!” the ing, or madness. They may simply
did that,” you hear yourself telling a if not in this life then in the next, is patient shouts back until, in desper- be about repair and redemption.
parent, teacher, or judge. Think of bona fide. Obviously, the mention ation, the doctor grabs a letter-open- I can imagine myself now
actor Mel Gibson who said as much of fulfillment and becoming whole er. “Do dead men bleed?” “No!” across the table from that child
following his drunken anti-Semitic can have different meanings. It’s not The psychiatrist stabs the patient’s who asks to be a suicide bomber.
rant after a traffic stop, or those so surprising, then, that people who arm and the patient, staring with His parents are with him. I am
youthful accusers during Salem’s approve of and sponsor suicide disbelief at his bleeding arm, mur- there as analyst, maybe designat-
witch trials in the 1690s and their bombings by children never seem to murs, “I was wrong. Dead men ed healer. Where do I begin? I be-
subsequent apologies. Think of Pi- use the word “death” in their justifi- bleed.” We laugh, of course, never gin where they are, where both of
nocchio. They all had one thing in cations, promotions, and celebra- thinking to ponder what such a pa- us are. Healers trying to make the
common; they came to their senses. tions, preferring instead words like tient might have meant by “dead” or world a better place.
They woke up, or grew up, as it were, being (eg, being a martyr, being in why his doctor never asked. Just
and felt and expressed remorse. Paradise) and becoming (eg, be- because we don’t use words in the Dr Climo is the author of Psychiatrist
So, the question becomes: where- coming a Hero), highlighting what same way, doesn’t mean we’re not, on the Road: Encounters in Healing
in does the state of being carried is gained, not lost. in some sense, on the same page. and Healthcare, an account of his
away by group-think become one’s We’re uncomfortably close, Just because someone speaks of Locum Tenens experience. ❒
14 P S Y C H I AT R I C T I M E S
w w w. p s y c h i a t r i c t i m e s . c o m SPECIAL REPORT AUGUST 2019

NEUROPSYCHIATRY
Recognizing and
Treating Comorbid
Psychiatric Disorders
in People With Autism

» Heidi C. Collins, MD, and Matthew S. Siegel, MD Assessment of comorbid psychiatric disorders
Screening instruments designed for psychiatric condi-
tions in the general population may not adequately differ- ALSO IN THIS

T
he Centers for Disease Control and Prevention es- entiate features of ASD and can result in overdiagnosis.
timates that autism affects 1 in every 59 children in However, there are several validated disorder-specific SPECIAL REPORT
the US.1 While the core features of autism impair tools that have been specifically developed to assess for
functioning, a significant source of further impairment comorbid disorders in children and adults with ASD (Ta-
is comorbid psychiatric disorders. People with autism ble 1). Features of ASD can appear to overlap with symp- Special Report Chairperson
spectrum disorder (ASD) are more likely than the gen- toms of other conditions making it difficult to distinguish Vivek Datta, MD, MPH
eral population to have comorbid psychiatric disorders. symptoms that relate to the core features of ASD versus
Although prevalence rates vary widely, converging evi- symptoms of other psychiatric disorders (Table 2).
dence suggests that anxiety disorders and ADHD are 20 Clinical Characteristics of
Chronic Traumatic
most prevalent. General considerations for assessing psychiatric
Numerous factors contribute to the increased risk for comorbidity in ASD Encephalopathy
comorbid psychiatric disorders. People with autism are Arman Fesharaki-Zadeh, MD, PhD
at higher risk of being bullied and are more likely to
experience adverse life events, which can increase stress
1 Establish a baseline. It is important to establish an
individual’s baseline for when he or she has
functioned best. For psychiatric conditions that are
22 Psychopathology of Tinnitus
and risk for depression and anxiety. Cognitive rigidity, episodic (eg, mood disorders) or those that appear Zeina Chemali, MD, MPH and
problems with emotion regulation, and intolerance of later in development (eg, OCD, psychosis), it is Romy Nehme, MD
uncertainty associated with ASD can predispose this important to distinguish baseline behaviors and
population to higher levels of anxiety and depression.2 functioning from distinct changes in symptoms that
Emotional regulation deficits may be a transdiagnostic are expected with the onset of a co-occurring
phenomenon that underlies features of ASD as well as psychiatric condition.
anxiety and other psychiatric comorbidities.3
The Autism Comorbidity Interview (ACI) is a
semi-structured interview that utilizes the Kiddie Sched-
ule for Affective Disorders and Schizophrenia (K-SADS)
2 Assess for medical comorbidity . Assess for medical
problems that can exacerbate emotional and
behavioral symptoms, particularly in less verbal people.
with adaptation to increase validity in the ASD popula-
tion. Additional screening questions and coding options
were added to the ACI to help distinguish core features of 3 Factor in genetics. Some genetic syndromes are
known to be associated with psychiatric
conditions and behavioral phenotypes. This can help
ASD from features of other psychiatric disorders.
The ACI was used to assess psychiatric comorbidity with more targeted screening (eg, fragile X syndrome
in 109 children with ASD aged 5 to 17 years.4 Findings has a higher prevalence of anxiety and ADHD,
indicate that 72% of the children had at least one addi- Williams syndrome has a higher prevalence of anxiety,
tional DSM-IV psychiatric diagnosis. Anxiety disorders and 22q11 deletion syndrome is associated with
were most common, followed by ADHD (Figure). higher prevalence of psychosis).
 AUGUST 2019 P S Y C H I AT R I C T I M E S 15
NEUROPSYCHIATRY w w w. p s y c h i a t r i c t i m e s . c o m

4 Consider symptoms in the context

of developmental level.
Comorbid conditions should be
Obsessive compulsive disorder. Re-
petitive behaviors and restricted in-
terests in ASD can be difficult to dis-
inference and the prevalence of OCD
was estimated at 8.2%.
port of mood symptoms such as feel-
ings of sadness, hopelessness, or
decreased self-esteem. Describing
considered if there are symptoms tinguish from the compulsions and Social anxiety. Diagnosis of social these internal states can be difficult
that are beyond what would be obsessions of OCD. In OCD, obses- anxiety in ASD requires that a person for many people with ASD, particu-
expected for an individual’s mental sions are recurrent, intrusive thoughts with ASD is avoiding social interac- larly those with limited verbal skills.
age and developmental level. that are distressing, and compulsive tion due to a fear of potential negative Magnuson and Constantino8 de-
behaviors in OCD are bothersome, outcome rather than just a lack of in- veloped a framework for assessment
Anxiety disorders unwanted, and serve the function of terest in social interaction, which is a of depression in ASD. For people
Using findings from their meta-anal- attempting to alleviate the obsession- common core feature of ASD. In old- with limited verbal skills or difficul-
ysis, vanSteensel and colleagues5 es- al content. er higher-functioning youth social ties verbalizing feelings, increased
timated that 40% of youth with ASD Repetitive behaviors in ASD (eg, anxiety can develop as awareness of self-injurious behavior, decreased
have a comorbid anxiety disorder. lining up objects, following the same differences from peers increases. self-care, labile moods, decreased in-
Risk factors for developing anxiety routine, watching the same video) are terest in special interests, and regres-
that are prevalent in ASD include so- generally a preferred or comforting Attention deficit-hyperactivity sion of skills were observable behav-
cial skill deficits, sensory sensitivity, activity, although they can lead to disorder iors associated with depression. For
cognitive rigidity, heightened physi- problematic behaviors or irritability ADHD is a common co-occurring verbal youth with ASD, insight into

SPECIALREPORT
ological arousal, and difficulties reg- when the person is interrupted or condition with ASD and as such ASD symptoms and their impact on
ulating stress. needs to stop. In addition, the most DSM-5 no longer prohibits ADHD to functioning, awareness of being
common forms of compulsions in be diagnosed with ASD. Diagnosis of teased or being different from peers,
Specific phobias. Specific phobia OCD: hand washing, cleaning, mak- co-occurring ADHD can be challeng- social rejection, and low self-efficacy
tends to have an onset in childhood. ing things “just right” are distinct ing because symptoms of inattention, were risk factors for depression.
In most cases the phenomenology of from the typical repetitive behaviors executive functioning problems, and
specific phobia in ASD tends to be of ASD, such as hand flapping, body social cognitive deficits are common Psychosis
similar to typically developing youth. rocking, and finger flicking. in both conditions. It is important to While their co-occurrence is uncom-
However, people with developmental People with ASD can have diffi- distinguish features of inattention and mon, autism and psychosis have
disabilities may also develop fears to culty articulating obsessive thoughts impulsivity that may be inherent in some symptom overlap, which can
unusual objects or situations, such as and describing whether a behavior is ASD, such as distractibility related to raise diagnostic questions. Pragmatic
elevators, vacuum cleaners, etc. aimed at reducing anxiety. The ACI a special interest, sensory seeking be- language deficits in ASD can include
Common phobias found in youth adapted the criteria for OCD to allow haviors, or processing problems, from abrupt changes in topic, failure to
with ASD include loud noises, nee- caregivers to infer the mental experi- those that warrant an additional diag- provide context, and tangential com-
dles, and crowds. Sensory sensitivi- ences of people who exhibit compul- nosis of ADHD in children with ASD. ments, which can contribute to what
ties can contribute to specific fears in sive behaviors. For example, caregiv- The hyperactive-impulsive subtype of appears to be a disorganized quality
autism, some of which may not rise ers could be asked if a compulsive ADHD can also manifest in people of language and thought process.
to the level of meeting criteria for behavior appeared to be aimed at re- with ASD and is best assessed in the When people with ASD are under
specific phobia but can contribute to ducing anxiety or linked to recurrent context of the youth’s developmental stress they can have more disorgan-
impairment. For example, anxiety thoughts. Using this criteria Leyfer age, expected activity level, and envi- ized and tangential speech, which is
about eating food due to food tex- and colleagues4 found that 37% of ronmental demands. typically attributable to anxiety,
tures, avoidance of clothing due to their sample met criteria of OCD. In problems with cognitive control, and
tactile sensitivity, or fear of loud ob- a different study by Simonoff and Depression pragmatic language deficits rather
jects such as vacuums and hairdryers colleagues,7 the assessment tool did Diagnosis of depression in neurotyp- than underlying psychosis.
due to noise sensitivity. not allow for caregivers to make this ical youth typically relies on self-re- CONTINUED ON PAGE 20

Generalized anxiety. Worry related to

intense preoccupations, schedules,
and environmental changes may be Lifetime prevalence of psychiatric disorders in children with autism2
atypical features of anxiety that are
important to recognize and ask pa- MDE (>1 episode) 10.1% 13.8%
tients about. Some of these features
are captured by Kerns’s6 summation Schizophrenia, other 0.0%
that they represent an “intolerance of
uncertainty,” which can mark atypi-
Social phobia 7.5% 3.2%
cal anxiety in ASD.
Anxiety can present as persevera-
tive questioning and reassurance Specific phobia 44.3%
seeking about an anticipated event or
other worry. Repetitive questions Generalized anxiety 2.4% 2.4%
used to obtain more information
about a restricted interest should be 37.2% 5.7%
OCD
distinguished from questions that are
triggered by anxiety. People with
ADHD 30.6% 24.7%
ASD can have difficulty verbalizing
[email protected]

internal states of anxiety or triggers

for anxiety. For those who are ODD 7.0% 4.6%
non-communicative, an anxiety dis-
order may have to be considered by 0% 10% 20% 30% 40% 50% 60%
inference based on observation, such
as persistent resistance to entering MDE, major depressive episode; ODD, oppositional defiant disorder. DSM-IV Subsyndromal
crowded rooms.
Adhansia XR is a central nervous system (CNS)
stimulant indicated for the treatment
of Attention Deficit Hyperactivity Disorder
(ADHD) in patients 6 years and older.1

ARE YOU TREATING YOUR PATIENT’S FULL DAY?

In adults, Adhansia XR significantly improved attention vs. placebo, as measured
by mean PERMP-T scores averaged across all time points up to 16 hours post-dose.1,2*
*Randomized, double-blind, placebo-controlled, crossover design, adult workplace environment (AWE) study of Adhansia XR
in 45 adults (18-58 years) with ADHD. Primary Endpoint: Mean PERMP-T scores of Adhansia XR vs. placebo, averaged across
all time points on the AWE days. PERMP-T=Permanent Product Measure of Performance Total score.1

Important Safety Information

WARNING: ABUSE AND DEPENDENCE

CNS stimulants, including Adhansia XR, other methylphenidate-containing products, and amphetamines, have a high potential
for abuse and dependence. Assess the risk of abuse prior to prescribing, and monitor for signs of abuse and dependence while
on therapy.

Please see Additional Important Safety Information on the following page.

Please read Brief Summary of Full Prescribing Information on the following pages, including Boxed Warning.
Important Safety Information (cont’d)
CONTRAINDICATIONS sequelae include digital ulceration and/or soft tissue breakdown. Effects
Adhansia XR is contraindicated in patients with a known hypersensitivity of peripheral vasculopathy, including Raynaud’s phenomenon, were
to methylphenidate or other components of Adhansia XR. Hypersensitivity observed in post-marketing reports at different times and at therapeutic
reactions such as angioedema and anaphylactic reactions have been doses in all age groups throughout the course of treatment. Signs and
reported in patients treated with other methylphenidate products. symptoms generally improve after reduction in dose or discontinuation of
Adhansia XR is also contraindicated in patients receiving concomitant drug. Careful observation for digital changes is necessary during treatment
treatment with monoamine oxidase inhibitors (MAOIs), and also within 14 with ADHD stimulants. Further clinical evaluation (e.g., rheumatology
days following discontinuation of treatment with a MAOI, because of the referral) may be appropriate for certain patients.
risk of hypertensive crisis. Long-Term Suppression of Growth
WARNINGS AND PRECAUTIONS CNS stimulants have been associated with weight loss and slowing of
Potential for Abuse and Dependence growth rate in pediatric patients.
CNS stimulants, including Adhansia XR, other methylphenidate-containing Careful follow-up of weight and height in pediatric patients ages 7 to 10
products, and amphetamines, have a high potential for abuse and years who were randomized to either methylphenidate or non-medication
dependence. Assess the risk of abuse prior to prescribing, and monitor treatment groups over 14 months, as well as in naturalistic subgroups of newly
for signs of abuse and dependence while on therapy. methylphenidate-treated and non-medication treated pediatric patients
Serious Cardiovascular Events over 36 months (to the ages of 10 to 13 years), suggests that consistently
Sudden death, stroke and myocardial infarction have occurred in medicated pediatric patients (i.e., treatment for 7 days per week throughout
adults treated with CNS stimulant treatment at recommended doses. the year) have a temporary slowing in growth rate (on average, a total of about
Sudden death has occurred in pediatric patients with structural cardiac 2 cm less growth in height and 2.7 kg less growth in weight over 3 years),
abnormalities and other serious cardiac problems taking CNS stimulants without evidence of growth rebound during this period of development.
at recommended doses for ADHD. Avoid use in patients with known Closely monitor growth (weight and height) in pediatric patients treated
structural cardiac abnormalities, cardiomyopathy, serious heart arrhythmia, with CNS stimulants, including Adhansia XR. Patients who are not
coronary artery disease, and other serious heart problems. Further evaluate growing or gaining height or weight as expected may need to have their
patients who develop exertional chest pain, unexplained syncope, or treatment interrupted.
arrhythmias during Adhansia XR treatment. Allergic-Type Reactions FD&C Yellow No. 5
Blood Pressure and Heart Rate Increases Adhansia XR 45 mg capsules contain FD&C Yellow No. 5 (tartrazine) which
CNS stimulants cause an increase in blood pressure (mean increase may cause allergic-type reactions (including bronchial asthma) in certain
approximately 2 to 4 mmHg) and heart rate (mean increase approximately susceptible persons. Although the overall incidence of FD&C Yellow No. 5
3 to 6 bpm). Individuals may have larger increases. Monitor all patients (tartrazine) sensitivity in the general population is low, it is frequently seen
for hypertension and tachycardia. in patients who also have aspirin hypersensitivity.
Psychiatric Adverse Reactions ADVERSE REACTIONS
CNS stimulants may exacerbate symptoms of behavior disturbance and The most common (≥5% and twice the rate of placebo) adverse reactions
thought disorder in patients with a pre-existing psychotic disorder. occurring with Adhansia XR in adults are insomnia, dry mouth, and
CNS stimulants may induce a manic or mixed episode in patients. Prior decreased appetite.
to initiating treatment, screen patients for risk factors for developing a The most common (≥5% and twice the rate of placebo) adverse reactions
manic episode (e.g., comorbid or history of depressive symptoms or a occurring with Adhansia XR in pediatric patients are decreased appetite,
family history of suicide, bipolar disorder, or depression). insomnia, and weight decreased.
CNS stimulants, at recommended doses, may cause psychotic or manic
PREGNANCY EXPOSURE REGISTRY
symptoms (e.g., hallucinations, delusional thinking, or mania) in patients
There is a pregnancy exposure registry that monitors pregnancy
without a prior history of psychotic illness or mania. If such symptoms
outcomes in women exposed to Adhansia XR during pregnancy.
occur, consider discontinuing Adhansia XR. In a pooled analysis of multiple
Healthcare providers are encouraged to register patients by calling
short-term, placebo-controlled studies of CNS stimulants, psychotic or
the National Pregnancy Registry for Psychostimulants at 1-866-961-2388.
manic symptoms occurred in approximately 0.1% of CNS stimulant-treated
patients, compared to 0% in placebo-treated patients. To report SUSPECTED ADVERSE REACTIONS, contact Purdue Pharma L.P.
Priapism at 1-888-726-7535 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch
Prolonged and painful erections, sometimes requiring surgical intervention,
Please read Brief Summary of Full Prescribing Information on the
have been reported with methylphenidate products, in both pediatric
following pages, including Boxed Warning.
and adult patients. Priapism was not reported with drug initiation but
developed after some time on the drug, often subsequent to an increase REFERENCES: 1. Adhansia XR™ (methylphenidate HCl) prescribing information. Stamford, CT. Purdue
Pharma L.P. 2. Wigal SB, Wigal T, Childress A, et al. The time course of effect of multilayer-release
in dose. Priapism has also appeared during a period of drug withdrawal
methylphenidate hydrochloride capsules: A randomized, double-blind study of adults with ADHD in
(drug holidays or during discontinuation). Patients who develop abnormally a simulated adult workplace environment [published online ahead of print October 1, 2016]. J Atten
sustained or frequent and painful erections should seek immediate Disord. doi: 10.1177/1087054716672335.
medical attention.
Peripheral Vasculopathy, including Raynaud’s Phenomenon For more information, visit AdhansiaXR-hcp.com
CNS stimulants, including Adhansia XR, used to treat ADHD are associated
with peripheral vasculopathy, including Raynaud’s phenomenon. Signs
and symptoms are usually intermittent and mild; however, very rare

© 2019 Adlon Therapeutics L.P. All Rights Reserved. Intended for residents of the United States only.
Adlon Therapeutics L.P. is a subsidiary of Purdue Pharma L.P. MR-05645
 including Raynaud’s phenomenon [see Warnings and Precautions (5.6)] • Long-term suppression of
growth [see Warnings and Precautions (5.7)] • Allergic Reactions FD&C Yellow No.5 [see Warnings
and Precautions (5.8)] 6.1. Clinical Trial Experience Because clinical trials are conducted under
widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot
be directly compared to rates in the clinical trials of another drug and may not reflect the rates
observed in clinical practice. Clinical Trials Experience with Other Methylphenidate Products in
Children, Adolescents, and Adults with ADHD Commonly reported (≥2% of the methylphenidate
BRIEF SUMMARY OF PRESCRIBING INFORMATION group and twice the rate of the placebo group) adverse reactions from placebo-controlled trials of
(For complete details, please see the Full Prescribing Information and Medication Guide.) methylphenidate products include: appetite decreased, weight decreased, nausea, abdominal pain,
dyspepsia, dry mouth, vomiting, insomnia, anxiety, nervousness, restlessness, affect lability, agitation,
irritability, dizziness, vertigo, tremor, blurred vision, blood pressure increased, heart rate increased,
WARNING: ABUSE AND DEPENDENCE
tachycardia, palpitations, hyperhidrosis, and pyrexia. Clinical Trials Experience with ADHANSIA XR
CNS stimulants, including ADHANSIA XR, other methylphenidate-containing products,
ADHANSIA XR was studied in adults (18 to 72 years) and pediatric patients (6 to 17 years) who met
and amphetamines, have a high potential for abuse and dependence. Assess the risk Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for ADHD. The
of abuse prior to prescribing, and monitor for signs of abuse and dependence while safety data for adults is based on two randomized, double-blind, placebo-controlled studies in
on therapy [see Warnings and Precautions (5.1), Drug Abuse and Dependence (9.2, 9.3)]. doses of 25 mg to 100 mg per day. The safety data for pediatric patients (6 to 17 years) is based
on randomized, double-blind, placebo-controlled studies in doses of 25 mg to 85 mg per day. The
total number of patients exposed to ADHANSIA XR during 1 to 4-week long, controlled treatment
4. CONTRAINDICATIONS ADHANSIA XR is contraindicated in patients: • With a known hypersensitivity periods is 883; this included 434 adult patients and 449 pediatric patients [156 (6 to 12 years); 293
to methylphenidate or other components of ADHANSIA XR. Hypersensitivity reactions such as (12 to 17 years)], from two clinical trials in adults, one in pediatric patients ages 12 to 17 years, and
angioedema and anaphylactic reactions have been reported in patients treated with other one in pediatric patients ages 6 to 12 years [see Clinical Studies (14)]. Adverse Reactions Leading
methylphenidate products [see Adverse Reactions (6.2)]. • Receiving concomitant treatment with to Discontinuation of Treatment In controlled adult trials for Study 1, 3% of both of ADHANSIA XR-
monoamine oxidase inhibitors (MAOIs), and also within 14 days following discontinuation of treated patients and placebo-treated patients discontinued due to adverse reactions. In an adult
treatment with a MAOI, because of the risk of hypertensive crisis [see Drug Interactions (7.1)]. workplace environment study (Study 2), 10% of ADHANSIA XR-treated patients discontinued due
5. WARNINGS AND PRECAUTIONS 5.1. Potential for Abuse and Dependence CNS stimulants, to adverse reactions compared to 0% of placebotreated patients. The following adverse reactions
including ADHANSIA XR, other methylphenidate-containing products, and amphetamines, have a led to discontinuation at a frequency of 2% of ADHANSIA XR-treated patients: nausea, bronchitis,
high potential for abuse and dependence. Assess the risk of abuse prior to prescribing, and monitor gastroenteritis viral, viral infection, blood pressure increased, and hypomania. In a controlled trial
for signs of abuse and dependence while on therapy [see Drug Abuse and Dependence (9.2, 9.3)]. (Study 3) in pediatric patients (12 to 17 years), 3% of ADHANSIA XR-treated patients discontinued
5.2. Serious Cardiovascular Events Sudden death, stroke and myocardial infarction have occurred due to adverse reactions compared to 0% of placebo-treated patients. The most frequent adverse
in adults treated with CNS stimulant treatment at recommended doses. Sudden death has occurred reactions leading to discontinuation in at least 1% of ADHANSIA XR-treated patients and at a rate
in pediatric patients with structural cardiac abnormalities and other serious cardiac problems taking greater that placebo was irritability (1%). Two patients taking ADHANSIA XR 70 or 85 mg had delirium
CNS stimulants at recommended doses for ADHD. Avoid use in patients with known structural cardiac leading to discontinuation. In a controlled trial (Study 4) in pediatric patients (6 to 12 years), 1% of
abnormalities, cardiomyopathy, serious heart arrhythmia, coronary artery disease, and other serious ADHANSIA XR-treated patients discontinued due to adverse reactions compared to 0% of placebo-
heart problems. Further evaluate patients who develop exertional chest pain, unexplained syncope, treated patients. Adult Patients with ADHD The most common adverse reactions (incidence of ≥5%
or arrhythmias during ADHANSIA XR treatment. 5.3. Blood Pressure and Heart Rate Increases CNS and at least twice placebo) of ADHANSIA XR occurring in controlled trials in adults were insomnia,
stimulants cause an increase in blood pressure (mean increase approximately 2 to 4 mmHg) and dry mouth, and decreased appetite. Table 1 lists the adverse reactions that occurred ≥2% of adult
heart rate (mean increase approximately 3 to 6 bpm). Individuals may have larger increases. Monitor patients and greater than placebo among ADHANSIA XR-treated adult patients.
all patients for hypertension and tachycardia. 5.4. Psychiatric Adverse Reactions Exacerbation of Pre- Table 1: Adverse Reactions Occurring in ≥ 2% of Adult Patients with ADHD on ADHANSIA XR and
Existing Psychosis CNS stimulants may exacerbate symptoms of behavior disturbance and thought Greater than Patients Taking Placebo in a 4-week Clinical Trial
disorder in patients with a pre-existing psychotic disorder. Induction of a Manic Episode in Patients
with Bipolar Disorder CNS stimulants may induce a manic or mixed episode in patients. Prior to All doses
initiating treatment, screen patients for risk factors for developing a manic episode (e.g., comorbid Adverse Reaction ADHANSIA XR Placebo
ADHANSIA XR
or history of depressive symptoms or a family history of suicide, bipolar disorder, or depression).
New Psychotic or Manic Symptoms CNS stimulants, at recommended doses, may cause psychotic 25 mg 45 mg 70 mg 100 mg
or manic symptoms (e.g., hallucinations, delusional thinking, or mania) in patients without a prior N=375 (N=77) (N=73) (N=73) (N=74) (N=297) (N=78)
history of psychotic illness or mania. If such symptoms occur, consider discontinuing ADHANSIA XR. Insomnia 4% 8% 6% 7% 6% 1%
In a pooled analysis of multiple short-term, placebo-controlled studies of CNS stimulants, psychotic
or manic symptoms occurred in approximately 0.1% of CNS stimulant-treated patients, compared to Initial Insomnia 17% 11% 16% 19% 16% 4%
0% in placebo-treated patients. 5.5. Priapism Prolonged and painful erections, sometimes requiring Dry mouth 8% 8% 7% 14% 9% 4%
surgical intervention, have been reported with methylphenidate products, in both pediatric and
adult patients. Priapism was not reported with drug initiation but developed after some time on Nausea 4% 6% 4% 11% 6% 3%
the drug, often subsequent to an increase in dose. Priapism has also appeared during a period Diarrhea 1% 3% 7% 5% 4% 1%
of drug withdrawal (drug holidays or during discontinuation). Patients who develop abnormally
Decreased appetite 4% 7% 15% 19% 11% 3%
sustained or frequent and painful erections should seek immediate medical attention. 5.6. Peripheral
Vasculopathy, including Raynaud’s Phenomenon CNS stimulants, including ADHANSIA XR, used Feeling jittery 1% 3% 8% 4% 4% 1%
to treat ADHD are associated with peripheral vasculopathy, including Raynaud’s phenomenon. Weight decreased 3% 4% 3% 5% 4% 1%
Signs and symptoms are usually intermittent and mild; however, very rare sequelae include digital
Upper respiratory tract
ulceration and/or soft tissue breakdown. Effects of peripheral vasculopathy, including Raynaud’s 0% 4% 3% 3% 2% 1%
infection
phenomenon, were observed in post-marketing reports at different times and at therapeutic doses
in all age groups throughout the course of treatment. Signs and symptoms generally improve after Pediatric Patients (12 to 17 years) with ADHD The most common (incidence ≥5% and at least twice
reduction in dose or discontinuation of drug. Careful observation for digital changes is necessary placebo) adverse reactions reported in pediatric patients (12 to 17 years) were decreased appetite,
during treatment with ADHD stimulants. Further clinical evaluation (e.g., rheumatology referral) may insomnia, and weight decreased. Table 2 lists the adverse reactions that occurred ≥2% of pediatric
be appropriate for certain patients. 5.7. Long-Term Suppression of Growth CNS stimulants have patients (12 to 17 years) and greater than placebo among ADHANSIA XR-treated pediatric patients
been associated with weight loss and slowing of growth rate in pediatric patients. Careful follow- (12 to 17 years).
up of weight and height in pediatric patients ages 7 to 10 years who were randomized to either
methylphenidate or non-medication treatment groups over 14 months, as well as in naturalistic Table 2: Adverse Reactions Occurring in ≥ 2% of Pediatric Patients
subgroups of newly methylphenidate-treated and non-medication treated pediatric patients over (12 to 17 years) with ADHD Taking ADHANSIA XR and Greater than Placebo
36 months (to the ages of 10 to 13 years), suggests that consistently medicated pediatric patients in a 4-week Clinical Trial
(i.e., treatment for 7 days per week throughout the year) have a temporary slowing in growth rate
(on average, a total of about 2 cm less growth in height and 2.7 kg less growth in weight over 3 All doses
Adverse Reaction ADHANSIA XR Placebo
years), without evidence of growth rebound during this period of development. Closely monitor ADHANSIA XR
growth (weight and height) in pediatric patients treated with CNS stimulants, including ADHANSIA 25 mg 45 mg 70 mg 100 mg
XR. Patients who are not growing or gaining height or weight as expected may need to have
(N=73) (N=72) (N=76) (N=72) (N=293) (N=74)
their treatment interrupted. 5.8. Allergic-Type Reactions: FD&C Yellow No. 5 ADHANSIA XR 45 mg
capsules contain FD&C Yellow No. 5 (tartrazine) which may cause allergic-type reactions (including Decreased appetite 7% 19% 28% 26% 20% 0%
bronchial asthma) in certain susceptible persons. Although the overall incidence of FD&C Yellow No. Insomnia 4% 0% 9% 13% 6% 1%
5 (tartrazine) sensitivity in the general population is low, it is frequently seen in patients who also
have aspirin hypersensitivity [see Contraindications (4)]. Initial Insomnia 4% 7% 5% 4% 5% 1%
Weight decreased 1% 3% 8% 13% 7% 0%
6. ADVERSE REACTIONS The following are discussed in more detail in other sections of the
labeling: • Known hypersensitivity to methylphenidate or other ingredients of ADHANSIA XR [see Abdominal pain
5% 1% 5% 4% 4% 1%
Contraindications (4)] • Hypertensive crisis when used concomitantly with monoamine oxidase upper
inhibitors [see Contraindications (4) and Drug Interactions (7.1)] • Drug dependence [see Boxed Nausea 3% 6% 7% 8% 6% 4%
Warning, Warnings and Precautions (5.1), and Drug Abuse and Dependence (9.2,9.3)] • Serious Dizziness 3% 0% 4% 4% 3% 0%
cardiovascular reactions [see Warnings and Precautions (5.2)] • Blood pressure and heart rate
increases [see Warnings and Precautions (5.3)] • Psychiatric adverse reactions [see Warnings Dry mouth 1% 0% 5% 4% 3% 1%
and Precautions (5.4)] • Priapism [see Warnings and Precautions (5.5)] • Peripheral vasculopathy, Vomiting 1% 1% 3% 6% 3% 0%
Pediatric Patients (6 to 12 years) with ADHD Study 4, conducted in pediatric patients 6 to 12 years of stimulants, including ADHANSIA XR. Pediatric patients who are not growing or gaining weight as
age, was comprised of a 6-week open-label doseoptimization phase in which all patients received expected may need to have their treatment interrupted [see Warnings and Precautions (5.7)]. Juvenile
ADHANSIA XR (n=156; mean dose 48 mg), followed by a 1-week, double-blind controlled phase Animal Toxicity Data Rats treated with methylphenidate early in the postnatal period through sexual
in which patients were randomized to continue ADHANSIA XR (n=75) or switch to placebo (n=73). maturation demonstrated a decrease in spontaneous locomotor activity in adulthood. A deficit
During the open-label ADHANSIA XR treatment phase, adverse reactions reported in > 5% of patients in acquisition of a specific learning task was observed in females only. The doses at which these
included: decreased appetite (35%), upper abdominal pain (15%), affect lability (13%), nausea or findings were observed are at least 3 times the maximum recommended human dose (MRHD) of 85
vomiting (13%), weight decreased (12%), insomnia (10%), irritability (10%), headache (10%), and heart mg/day given to children on a mg/m2 basis. In the study conducted in young rats, methylphenidate
rate increased (5%). Because of the trial design (6-week open-label active treatment phase followed was administered orally at doses of up to 100 mg/kg/day for 9 weeks, starting early in the postnatal
by a 1-week, randomized, double-blind, placebo-controlled withdrawal), the adverse reaction rates period (postnatal day 7) and continuing through sexual maturity (postnatal week 10). When these
described in the double-blind phase are lower than expected in clinical practice. No difference animals were tested as adults (postnatal weeks 13-14), decreased spontaneous locomotor activity
occurred in the incidence of adverse reactions between ADHANSIA XR and placebo during the was observed in males and females previously treated with 50 mg/kg/day (approximately 3 times the
1-week, double-blind, placebo-controlled treatment phase. MRHD of 85 mg/day given to children on a mg/m2 basis) or greater, and a deficit in the acquisition
of a specific learning task was observed in females exposed to the highest dose (6 times the MRHD
7.1. Clinically Important Drug Interactions Table 3 presents clinically important drug interactions given to children on a mg/m2 basis). The no effect level for juvenile neurobehavioral development in
with ADHANSIA XR. rats was 5 mg/kg/day (approximately 0.25 times the MRHD given to children on a mg/m2 basis). The
Table 3: Drugs Having Clinically Important Interactions with ADHANSIA XR clinical significance of the long-term behavioral effects observed in rats is unknown. 8.5. Geriatric
Use ADHANSIA XR has not been studied in the patients over the age of 72 years.
Monoamine Oxidase Inhibitors (MAOI) 9. DRUG ABUSE AND DEPENDENCE 9.1. Controlled Substance ADHANSIA XR contains
Concomitant use of MAOIs and CNS stimulants can cause hypertensive methylphenidate, a Schedule II controlled substance. 9.2. Abuse CNS stimulants including ADHANSIA
crisis. Potential outcomes include death, stroke, myocardial infarction, XR, other methylphenidate-containing products, and amphetamines have a high potential for abuse.
Clinical Impact: Abuse is the intentional non-therapeutic use of a drug, even once, to achieve a desired psychological
aortic dissection, ophthalmological complications, eclampsia, pulmonary
edema, and renal failure [see Contraindications (4)]. or physiological effect. Abuse is characterized by impaired control over drug use, compulsive use,
Do not administer ADHANSIA XR concomitantly with MAOIs or within continued use despite harm, and craving. Signs and symptoms of CNS stimulant abuse include
Intervention: increased heart rate, respiratory rate, blood pressure, and/or sweating, dilated pupils, hyperactivity,
14 days after discontinuing MAOI treatment.
selegiline, tranylcypromine, isocarboxazid, phenelzine, linezolid,
restlessness, insomnia, decreased appetite, loss of coordination, tremors, flushed skin, vomiting,
Examples: and/or abdominal pain. Anxiety, psychosis, hostility, aggression, suicidal or homicidal ideation have
methylene blue
also been observed. Abusers of CNS stimulants may chew, snort, inject, or use other unapproved
Gastric pH Modulators routes of administration which can result in overdose and death [see Overdosage (10)]. To reduce
May change the release, PK profiles and alter the pharmacodynamics the abuse of CNS stimulants including ADHANSIA XR, assess the risk of abuse prior to prescribing.
Clinical Impact: After prescribing, keep careful prescription records, educate patients and their families about abuse
of ADHANSIA XR.
Monitor patients for changes in clinical effect and use alternative therapy and on proper storage and disposal of CNS stimulants, monitor for signs of abuse while on therapy,
Intervention: and re-evaluate the need for ADHANSIA XR use. 9.3. Dependence Tolerance Tolerance (a state of
based on clinical response.
adaptation in which exposure to a drug results in a reduction of the drug’s desired and/or undesired
Examples: Omeprazole, esomeprazole, pantoprazole, famotidine, sodium bicarbonate effects over time) may occur during chronic therapy with CNS stimulants including ADHANSIA XR.
Dependence Physical dependence (a state of adaptation manifested by a withdrawal syndrome
8. USE IN SPECIFIC POPULATIONS 8.1. Pregnancy Pregnancy Exposure Registry There is a pregnancy produced by abrupt cessation, rapid dose reduction, or administration of an antagonist) can occur
exposure registry that monitors pregnancy outcomes in women exposed to ADHANSIA XR during in patients treated with CNS stimulants including ADHANSIA XR. Withdrawal symptoms after abrupt
pregnancy. Healthcare providers are encouraged to register patients by calling the National cessation following prolonged high-dosage administration of CNS stimulants include dysphoric
Pregnancy Registry for Psychostimulants at 1-866-961-2388. Risk Summary Published studies and mood; depression; fatigue; vivid, unpleasant dreams; insomnia or hypersomnia; increased appetite;
post-marketing reports on methylphenidate use during pregnancy are insufficient to identify a and psychomotor retardation or agitation.
drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes.
10. OVERDOSAGE 10.1. Signs and Symptoms Signs and symptoms of acute methylphenidate
There are risks to the fetus associated with the use of central nervous system (CNS) stimulants during
overdosage, resulting principally from overstimulation of the CNS and from excessive sympathomimetic
pregnancy (see Clinical Considerations). No effects on morphological development were observed
effects, may include the following: nausea, vomiting, diarrhea, restlessness, anxiety, agitation,
in embryo-fetal studies with oral administration of methylphenidate to pregnant rats and rabbits
tremors, hyperflexia, muscle twitching, convulsion (may be followed by coma), euphoria, confusion,
during organogenesis at doses up to 7 and 11 times, respectively, the maximum recommended
hallucinations, delirium, sweating, flushing, headache, hyperpyrexia, tachycardia, palpitations, cardiac
human dose (MRHD) of 85 mg/day given to adolescents on a mg/m2 basis. However, fetal spina
arrhythmias, hypertension, hypotension, tachypnea, mydriasis, dryness of mucous membranes, and
bifida was observed in rabbits at a dose 36 times the MRHD given to adolescents. A decrease in
rhabdomyolysis. 10.2. Management of Overdose Consult with a Certified Poison Control Center
pup body weight was observed in a pre- and post-natal development study with oral administration
(1-800-222-1222) for up-to-date guidance and advice on the management of overdosage with
of methylphenidate to rats throughout pregnancy and lactation at doses 4 times the MRHD given
methylphenidate. Provide supportive care, including close medical supervision and monitoring.
to adolescents [see Data]. The estimated background risk of major birth defects and miscarriage
Treatment should consist of general measures employed in the management of overdosage with any
for the indicated population is unknown. All pregnancies have a background risk of birth defect,
drug. Consider the possibility of multiple drug overdosage. Ensure an adequate airway, oxygenation,
loss, or other adverse outcomes. In the U.S. general population, the estimated background risk
and ventilation. Monitor cardiac rhythm and vital signs. Use supportive and symptomatic measures.
of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to
20%, respectively. Clinical Considerations Fetal/Neonatal Adverse Reactions CNS stimulants, such Healthcare professionals can telephone Adlon Therapeutics’ Medical Information Department
as ADHANSIA XR, can cause vasoconstriction and thereby decrease placental perfusion. No (1-888-827-0618) for information on this product.
fetal and/or neonatal adverse reactions have been reported with the use of therapeutic doses of
methylphenidate during pregnancy; however, premature delivery and low birth weight infants have Adlon Therapeutics L.P.
been reported in amphetamine-dependent mothers. Data Animal Data In embryo-fetal development 201 Tresser Boulevard
studies conducted in rats and rabbits, methylphenidate was administered orally at doses of Stamford, CT 06901-3431
up to 75 and 200 mg/kg/day, respectively, during the period of organogenesis. Malformations
(increased incidence of fetal spina bifida) were observed in rabbits at the highest dose. which is ©2019 Adlon Therapeutics L.P.
approximately 36 times the maximum recommended human dose (MRHD) of 85 mg/day given to U.S. Patent Numbers: 9,974,752 and 10,111,839
adolescents on a mg/m2 basis. The no effect level for embryo-fetal development in rabbits was This brief summary is based on Adhansia XR Prescribing Information, 07/2019
60 mg/kg/day (11 times the MRHD given to adolescents on a mg/m2 basis). There was no evidence of
morphological development effects in rats, although increased incidences of fetal skeletal variations
were seen at the highest dose level (7 times the MRHD given to adolescents on a mg/m2 basis), which
was also maternally toxic. The no effect level for embryo-fetal development in rats was 25 mg/kg/day.
(2 times the MRHD given to adolescents on a mg/m2 basis). When methylphenidate was administered
to rats throughout pregnancy and lactation at doses of up to 45 mg/kg/day, offspring body weight
gain was decreased at the highest dose (4 times the MRHD on a mg/m2 basis), but no other effects
on postnatal development were observed. The no effect level for pre- and postnatal development
in rats was 15 mg/kg/day (equivalent to the MRHD given to adolescents on a mg/m2 basis).
8.2. Lactation Risk Summary Limited published literature, based on breast milk sampling from five
mothers, reports that methylphenidate is present in human milk, which resulted in infant doses of
0.16% to 0.7% of the maternal weight-adjusted dosage and a milk/plasma ratio ranging between
1.1 and 2.7. There are no reports of adverse effects on the breastfed infant and no effects on milk
production. Long-term neurodevelopmental effects on infants from stimulant exposure are unknown.
The developmental and health benefits of breastfeeding should be considered along with the
mother’s clinical need for ADHANSIA XR and any potential adverse effects on the breastfed infant
from ADHANSIA XR or from the underlying maternal condition. Clinical Considerations Monitor
breastfeeding infants for adverse reactions, such as agitation, anorexia, and reduced weight gain.
8.4. Pediatric Use Safety and effectiveness of ADHANSIA XR in pediatric patients under the age
of 6 years have not been established. The safety and effectiveness of ADHANSIA XR have been
established in one adequate and wellcontrolled 6-week study in pediatric patients ages 6 to 12 years,
and in one adequate and well-controlled 4-week study in pediatric patients ages 12 to 17 years [see
Clinical Studies (14)]. The long-term efficacy of methylphenidate in pediatric patients has not been
established. Long Term Suppression of Growth Growth should be monitored during treatment with
 20 AUGUST 2019
P S Y C H I AT R I C T I M E S
w w w. p s y c h i a t r i c t i m e s . c o m NEUROPSYCHIATRY

Psychiatric Disorders in cause of not meeting the duration of

TABLE 1. Disorder-specific assessment tools for
symptoms requirement.
Autism psychiatric comorbidity in ASD
Continued from page 15
Catatonia ◗ Children’s Yale-Brown Obsessive Compulsive Scale (CY BOCS) – PDD
Catatonic symptoms can develop in
◗ Repetitive Behavior Interview
Moreover, people with ASD may people with ASD with age of onset
use idiosyncratic language or script- typically in adolescence.10 The oc- ◗ Repetitive Behavior Questionnaire
ed phrases from favorite movies or currence of catatonia in autism is ◗ Parent-Rated Anxiety Scale for Youth with Autism Spectrum Disorder
songs that appear out of context to rare, but it is important to recognize (PRAS-ASD)
the listener and therefore may sound given the benefit of early treatment ◗ ASD – Comorbidity for Adult Scale (ASD-CA)
disorganized or delusional. Strong and risk for life-threatening compli- ◗ Anxiety Scale for Children with ASD (ASC-ASD)
convictions and overvalued ideas cations in severe cases. Diagnosis of
◗ Anxiety Disorders Interview Schedule with Autism Spectrum Addendum
about their special interests may catatonia in ASD can be challenging
(ADIS-ASA)
seem delusional. Difficulties with because echolalia, mutism, and stere-
theory of mind and understanding the otypic movements are common in
intentions of others may lead to dis- both conditions. dren with ASD and anxiety disorders. Portland, ME; he is also Associate
trust and paranoia but are best under- Onset of catatonic symptoms in Effective modifications to traditional Professor of Psychiatry and Pediatrics,
Tufts University School of Medicine,
SPECIALREPORT

stood as the downstream effects of ASD may be gradual and in its early CBT for youth with ASD have includ-
ASD core deficits, rather than a stages can present with a regression ed increased parent involvement to Boston, MA. Dr Collins is a Child and
co-occurring psychosis. in self-care skills, reduction in promote generalization, incorporation Adolescent Psychiatrist,
There are currently no validated speech, and difficulties initiating of visual aids, making sessions highly Developmental Disorders Program,
measures for assessing psychosis in tasks. New onset of movement prob- structured and predictable, increased Sprint Harbor Hospital, Center for
ASD. Taking a detailed develop- lems such as getting stuck part way practice of skills, and explicit teaching Autism and Developmental Disorders,
mental history is key to distinguish- through an action, difficulty initiat- of social skills as part of the thera- Maine Behavioral Healthcare. The au-
ing features of these two conditions. ing movements, immobility, increase py.11,12 Use of the child’s restricted in- thors report no conflicts of interest
When psychosis occurs in ASD, the in repetitive behaviors, difficulty terests can make the therapy more sa- concerning the subject matter of this
onset of psychotic symptoms is typ- crossing thresholds, and holding pos- lient, help explain therapeutic article.
ically in adolescence or early adult- tures should raise suspicion for cata- concepts, create concrete metaphors,
hood and is associated with a change tonia. Repetitive behaviors such as and reinforce participation. References
1. Baio J, Wiggins L, Christensen DL, et al. Prevalence
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itive behaviors, tendency to disor- rate diagnosis of catatonia if they are and Social Skills Intervention (MAS- toring Network, 11 Sites, United States, 2014. MMWR
Surveill Summ. 2018;67:1-23.
ganized speech when under stress, consistent with an individual’s base- SI), Face Your Fears, and Behavioral 2. Cai R, Richdale A, Dissanayake C, Uljarevic, M.
self-talk, or magical thinking, which line symptoms of ASD. Interventions for Anxiety in Children Brief report: inter-relationship between emotion reg-
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of emotion regulation in autism specgtrum disorder.
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When baseline restricted interests modal approach with contributions 688.
become more morbid, illogical, and from caretaker education (applied Pharmacological interventions. There 4. Leyfer O, Folstein S, Bacalman S, et al. Comorbid
psychiatric disorders in children and adolescents
held with greater conviction with loss behavioral analysis); psychotherapy; are currently no medications for the with autism: interview development and rates of dis-
of reality testing, this may be more pharmacology; sensory, speech, and core symptoms of ASD. Pharmaco- orders. J Autism Dev Disord. 2006;36:849-861.
consistent delusional thought content, language interventions; and other logic interventions for comorbid psy- 5. vanSteensel F, Bogels S, Perrin S. Anxiety disorders
in children and adolescents with autism spectrum
which may warrant an additional psy- disciplines depending on the individ- chiatric conditions may help to alle- disorder: a meta-analysis. Psychol Rev. 2011;14:302-
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leagues9 found that when psychosis though a review of all of these mo- better engagement for the individual 6. Kerns C, Kendall P, Berry L, et al. Traditional and
atypical presentations of anxiety in youth with autism
co-occurs with ASD, the signs and dalities is beyond the scope of this in educational and psychosocial spectrum disorders. J Autism Dev Disord. 2014;44:
symptoms of psychosis tended to be article, some of the evidence and re- treatments. 2851-2861.
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disorders in children with autism spectrum disorders:
As a result, the researchers noted that py for psychiatric comorbidity in clude but are not limited to anxiety, prevalance, comorbidity, and associated factors in a
there tends to be a higher prevalence ASD follow. impulsivity, hyperactivity, sleep population-derived sample. J Am Acad Child Adolesc
of psychotic disorder NOS (from problems, mood instability, depres- Psychiatry. 2008;47:921-929.
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DSM IV) diagnoses compared with Cognitive behavioral therapy. CBT has sion, aggression, and self-injurious depression in children with autism spectrum disor-
schizophrenia diagnoses in part be- been shown to reduce anxiety in chil- behavior. The American Academy of der. J Devel Behav Pediat. 2011;32:332-340.
Child and Adolescent Psychiatry 9. Larson F, Wagner A, Jones P, et al. Psychosis in
autism: comparison of the features of both conditions
TABLE 2. Symptoms of ASD that overlap with symptoms (AACAP) Practice Parameter on in a dually affected cohort. Br J Psychiatry.
of other conditions ASD13 provides a summary of ran- 2017;210:269-275.
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disorder. Br J Psychiatry. 2000;176:357-362.
Symptoms of ASD Symptoms of other conditions tions to treat comorbid psychiatric 11. Johnco C, Storch E. Anxiety in youth with autism
conditions in ASD; the AACAP14 spectrum disorder: implications for treatment. Expert
Rev Neurother. 2015;15:1343-1352.
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approaches by symptom area and in children and adolescents with autism spectrum
Scripted phrases out of context Disorganized thoughts of psychosis guidelines for parent-provider dis- disorder. Clin Psychol Rev. 2009;29:216-229.
13. Volkmar F, Siegel M, Woodbury-Smith M, et al.
cussion. Both are available for free Practice parameter for the assessment and treat-
Lack of social motivation Social anxiety download at www.aacap.org. ment of children and adolescents with autism spec-
trum disorder. J Am Acad Child Adolesc Psychiatry.
Repetitive behaviors Compulsions 2014;53:237-257.
Dr Siegel is Vice President Medical 14. American Academy of Child and Adolescent Psy-
chiatry: Autism Parents’ Medication Guide Work
Restricted interests Obsessions Affairs, Developmental Disorders Group. Autism Spectrum Disorder: Parents’ Medica-
Service, Maine Behavioral Healthcare, tion Guide. 2016. ❒
AUGUST 2019 P S Y C H I AT R I C T I M E S 21
NEUROPSYCHIATRY w w w. p s y c h i a t r i c t i m e s . c o m

Clinical Characteristics of
Chronic Traumatic Encephalopathy
» Arman Fesharaki-Zadeh, MD, PhD Stern and colleagues.3 The researchers
looked at 36 male patients with patho-
Findings suggest an association
between cumulative repetitive head
light protein (NFL), which have been
reported to be elevated in both acute
logically confirmed CTE, who did not impacts and the development of neu- and chronic phase post TBI.10

C
hronic traumatic encephalopa- have any comorbid neurodegenerative ropsychiatric symptoms including Since most patients with mild TBI
thy (CTE) occurs as a result of diseases; histories were provided by depression, behavioral dysregula- are typically not assessed acutely in a
repetitive mild traumatic brain next of kin informants retrospectively. tion, executive functioning deficits, clinical setting, these assays could
injury (TBI) with a progressive neu- There were two distinct emergent and cognitive impairment in adult- offer significant diagnostic advantag-
rodegenerative pathology. CTE was clinical subgroups: the younger group hood.5 The age at the time of expo- es. This is especially applicable to
first identified as “punch drunk” syn- initially presented with behavioral/ sure to repetitive head impacts is an- football players, who suffer multiple
drome by Martland in 1928, who re- mood symptoms, while the older other distinct risk factor for concussive and subconcussive hits

SPECIALREPORT
ported severe neuropsychiatric group presented with mainly cogni- development of neurocognitive defi- during their playing season. These
symptoms in a group of boxers.1 tive symptoms. Cognitive deficits cits in later adulthood. markers could be used to gauge the
The disease process involves ac- eventually developed in the younger ability of athletes to resume play af-
cumulation of phosphorylated tau group, whereas there were significant- Mechanism of CTE pathogenesis ter an injury.
(p-tau) in the sulci and peri-vascular ly less mood and behavioral symp- Although there are no treatments for Although CTE’s clinical diagnos-
region, with accompanying gliosis. toms in the older group as time went CTE, preclinical studies provide a tic criterion is undergoing further re-
CTE neuropathological progression by. Furthermore, the younger group of promising avenue for studying the visions, there is an increasing under-
is described in four stages. In stage I, patients were significantly more phys- mechanism of CTE pathogenesis as standing of the clinical progression
there are few loci of p-tau in the sulci ically violent and behaviorally disin- well as exploring possible treatment of the disease. Patients with CTE are
of lateral frontal cortices. The ad- hibited. It is important to note that regimens under controlled laboratory typically in their 4th or 5th decade of
vancement of the disease involves approximately one-quarter of these conditions. The exact mechanism by life and can present with new-onset
areas of the brain including the tem- patients did not have memory symp- which repetitive head impacts lead to mood or anxiety symptoms, which
poral and parietal lobes as well as the toms. However, as the researchers not- CTE remains to be fully described, typically later involve memory and
insula. By stage 4, there is global ed, these two clinical subtypes may but one proposed mechanism is im- cognitive deficits. The patient’s his-
spread of p-tau, as well as phospho- tory is of paramount importance,
rylated 43 kDa TAR DNA binding since a typical patient would have
protein (TDP-43). suffered multiple prior concussive
The patient’s history is of paramount importance, and subconcussive hits occurring in a
Clinical characteristics variety of different settings including
Although there is no consensus on since a typical patient would have suffered playing sports or in a combat setting.
the clinical characteristics of CTE,
McKee and colleagues2 proposed a multiple prior concussive and subconcussive hits
set of clinical symptoms correspond- CASE VIGNETTE
ing to each of four neuropathological occurring in a variety of different settings.
stages. Bob is a 59-year-old with a history of
multiple concussions who has been
Stage 1. A typical CTE patient is ei- having a series of neurocognitive
ther clinically asymptomatic or may not be representative of the wider munoexcitotoxicity, during which symptoms for the past several years.
complain of mild short-term memory spectrum of all CTE patients. brain trauma leads to activation of He describes himself as an ex-foot-
deficits, or depressive symptoms. In a more extensive study, Mez microglia, the brain’s inflammatory ball player, who played in high school
Mild aggressive symptoms have also and colleagues4 examined 202 Amer- agents. After the initial priming, re- and college, and had more than 20
been reported. ican football players; 177 of these petitive head impacts lead to patho- concussions. He lost consciousness a
players had a confirmed CTE diag- logic conversion of these cells from a few times for unknown durations.
Stage 2.Mood and behavioral symp- nosis. The mean age at the time of non-destructive phenotype to a de- Significant memory and cognitive
toms are more severe and may in- death was 67 years; the mean number structive one.6,7 issues developed about 4 years ago.
clude explosive behavioral outbursts of years of playing football was 15.1. The development of new neuro- He experienced symptoms of depres-
and more severe depressive symp- Study subjects were divided into imaging techniques such as diffusion sion and began to drink excessively
toms. mild and severe neuropathology weighted magnetic resonance imag- to cope with work-related frustra-
groups. The vast majority from both ing (MRI), as well as positron emis- tions. His wife reports that there were
Stage 3. Patients typically display groups suffered from behavioral and sion tomography (PET) using tau li- a few episodes of noticeable behav-
more cognitive deficits, ranging from mood symptoms, as retrospectively gands are promising new modalities ioral changes, including unusual
memory loss to executive and visu- reported by next of kin (96% from of diagnosis and detecting neuronal emotional reactivity in certain every-
ospatial functioning deficits as well the mild CTE subgroup vs 89% from injury due to TBI.8 Other develop- day situations, such as a simple fam-
as symptoms of apathy. severe CTE subgroup). Similarly, ments include biomarkers, such as ily-related discussion. She started to
most of the patients in both groups phosphorylated tau (p-tau) and total notice that Bob was having difficul-
Stage 4. Patients have profound lan- had cognitive symptoms (85% in the tau (t-tau).9 One distinct advantage of ties following instructions, and re-
guage deficits, psychotic symptoms mild subgroup vs 95% in the severe the reported biomarkers was that they taining details from conversations.
such as paranoia as well as motor subgroup). Moreover, 33% of pa- showed a significant elevation of Bob continues to drive on a regular
deficits and parkinsonism. tients in the first group displayed p-tau and p-tau/t-tau ratio in patients basis, although he has had an epi-
signs of dementia compared with with chronic TBI. Other potential bi- sode of not being able to navigate.
Further attempts at clinical classifi- 85% of the second group who had omarkers are glial fibrillary acidic Bob’s wife has taken over the family
cation of CTE patients were made by signs of dementia. protein (GFAP) and neurofilament finances. She describes her husband
 22 AUGUST 2019
P S Y C H I AT R I C T I M E S
w w w. p s y c h i a t r i c t i m e s . c o m NEUROPSYCHIATRY

as previously being a sociable person FIGURE 1. FIGURE 2.

but now avoids public settings.
In addition, according to his wife,
Bob has become overly passive in
certain situations. He had been a
heavy drinker but stopped drinking
about 8 months earlier and has re-
mained sober. He manages his basic
activity of daily living without difficul-
ties, but at times he forgets to com-
plete various routine tasks and needs
reminders.
Bob’s medical history includes hy-
pertension and depression, for which
he takes 60-mg duloxetine daily. The
overall results of his laboratory tests
are normal although his gait is cau-
SPECIALREPORT

tious and slow with mild shuffling,

and he walks with a cane. His score
on the Montreal Cognitive Assess-
ment (MOCA) is 13/30 (normal score
≥26/30). Bob has significant deficits
in free recall, executive functioning,
attention, and abstraction.
Bob is well-groomed and dressed
appropriately. His mood is euthymic,
and his affect is reactive and congru-
ent to his mood. His thought process CSP Hippocampal atrophy
is mostly linear, coherent, and
goal-directed. He denies any suicidal/
homicidal ideations/intents/plans Conclusion diagnostic neuroimaging such as a University, New Haven, CT. He reports
and does not endorse any auditory or CTE is increasingly entering the pub- brain MRI or PET CT scan using per- no conflicts of interest concerning the
visual hallucinations. His insight and lic discourse via mass media. The tinent ligands such as tau ligands, if subject matter of this article.
judgment are limited to fair. increasing number of younger retired available.
Brain imaging indicates cavum athletes with CTE is especially References
1. Martland HS. Punch drunk. JAMA. 1928;91:1103-
septum pellucidum (CSP) involving alarming. Another population that is 1107.
the lateral ventricles (Figure 1). There
is also significant asymmetrical left
especially vulnerable to CTE are war
veterans. There is a great deal of
It is imperative to 2. McKee AC, Stern RA, Nowinski CJ, et al. The
spectrum of disease in chronic traumatic encepha-
hippocampal atrophy, 11th percentile
compared with his age-matched
complexity regarding the possible
etiology of CTE in this population.
exercise vigilance lopathy. Brain. 2013;136:43-64.
3. Andrikopoulos J, Montenigro PH, Stern RA. Clini-

controls (Figure 2). The rate of mild (m)TBI is exceed- given the degree of cal presentation of chronic traumatic encephalopa-
thy. Neurology. 2014;83:1991-1992.
ingly high, and it is highly comorbid 4. Mez J, Daneshvar DH, Kiernan PT, et al. Clinico-
with PTSD. Moreover, multiple symptom overlap pathological evaluation of chronic traumatic en-
cephalopathy in players of American football. JAMA.
Prevention mTBIs can increase the risk for
Based on the nature and popularity PTSD progression adding to the between affective 2017;318:360-370.
5. Montenigro PH, Alosco ML, Marin BM, et al. Cu-
of contact sports and the intrinsic
component of head collisions, pre-
complexity of their clinical interac-
tion.
symptoms of CTE and mulative head impact exposure predicts later-life
depression, apathy, executive dysfunction, and cog-
nitive impairment in former high school and college
vention of head trauma poses a par-
amount challenge and requires a
Omalu and colleagues11 reported a
case of an Iraqi war veteran with a
other neuropsychiatric football players. J Neurotrauma. 2017;34: 328-340.
6. Turner RC, Lucke-Wold BP, Robson MJ, et al. Re-
paradigm shift. Education of ath-
letes on safe techniques, such as safe
history of PTSD but no history TBI,
whose brain showed characteristic
disorders (eg, PTSD, petitive traumatic brain injury and development of
chronic traumatic encephalopathy: a potential role

tackling, could offer significant po- signs of CTE upon postmortem neu- behavioral variant for biomarkers in diagnosis, prognosis, and treat-
ment? Front Neurol. 2013;3:186.
tential benefits. ropathological examination. Howev- 7. Blaylock RL, Maroon J. Immunoexcitotoxicity as
Cultural changes must include the er, it is unclear whether PTSD alone frontotemporal a central mechanism in chronic traumatic enceph-
alopathy: a unifying hypothesis. Surg Neurol Int.
creation of a “stigma free” environ- is an independent risk factor for CTE
ment, in which athletes are encour- development. dementia). 2011;2:107.
8. Stern RA, Adler CH, Chen K, et al. Tau posi-
aged to responsibly report symptoms As the CTE clinical characteriza- tron-emission tomography in former National Foot-
to coaches, referees, and team physi- tion continues to evolve, it is impera- ball League players. N Engl J Med. 2019;380:1716-
1725.
cians. This in turn would create op- tive to exercise vigilance. This is ex- The collective awareness of this 9. Rubenstein R, Chang B, Yue JK, et al. Comparing
portunities for timely assessment, ceedingly important given the degree devastating neurodegenerative dis- plasma phospho tau, total tau, and phospho tau–to-
diagnosis, and symptom-based treat- of symptom overlap between affec- ease will likely result in intensifying tal tau ratio as acute and chronic traumatic brain
ment. It is imperative for team physi- tive symptoms of CTE and other neu- efforts to improve our understanding injury biomarkers. JAMA Neurol. 2017;74:1063-
1072.
cians to intervene in cases in which ropsychiatric disorders such as PTSD of disease pathology as well as ex- 10. Neselius S, Brisby H, Theodorsson A, et al.
athletes are prematurely encouraged or behavioral variant frontotemporal ploring potentially a promising ther- CSF-biomarkers in Olympic boxing: diagnosis and
to return to play in spite of persistent dementia. A thorough assessment apeutic regimen. effects of repetitive head trauma. PloS One.
neurocognitive deficits. Such athletes must consist of a comprehensive his- 2012;7:e33606.
11. Omalu B, Hammers JL, Bailes J, et al. Chronic
are especially vulnerable to repetitive tory, a detailed neuropsychiatric as- Dr Fesharaki-Zadeh is Instructor of traumatic encephalopathy in an Iraqi war veteran
head impacts and new onset chronic sessment including a full neurologi- Psychiatry and Neurology, Boyer with posttraumatic stress disorder who committed
neuropsychiatric symptoms. cal exam, as well as detailed Center of Molecular Medicine, Yale suicide. Neurosurg Focus. 2011;31:E3. ❒
AUGUST 2019 P S Y C H I AT R I C T I M E S 23
NEUROPSYCHIATRY w w w. p s y c h i a t r i c t i m e s . c o m

 ANXIETY DISORDER: along with

Psychopathology of Tinnitus depression, anxiety is more

prevalent among the tinnitus
clinical population4
» Zeina Chemali, MD, MPH, and ing a lack of restorative sleep due to
sleep apnea and a split shift work
from the cochlea is weakened, the au-
ditory system automatically compen-
 PERSONALITY DISORDERS: tinnitus
distress is associated with high
Romy Nehme, MD schedule, as well as a history of alco- sates the loss by augmenting its gain. neuroticism, low extraversion, high
hol use. The goal of the evaluation In such situations, tinnitus is com- stress reaction, higher alienation,

T
innitus is the perception of noise and management of this patient was pared to that of phantom limb pain. worse social closeness, worsened
in the absence of any correspond- to treat his comorbid conditions, de- Indeed, a strong positive correlation well-being, lower self-control,
ing sound source. Physicians and creasing his perception of tinnitus. It between the amount of cortical reor- lower psychological acceptance,
patients tend to immediately assume was recommended that he use ear ganization and the subjective strength type D personality, and
that this disorder is mainly localized at protection, wear sound cancellation of tinnitus was found in a study by externalized locus of control5
the level of the auditory system. In the devices, and taper off alcohol. He re- Muhlnickel and colleagues.1 Other
 PSYCHOSIS: patients with tinnitus
case of idiopathic tinnitus, patients are ceives mindfulness training and cog- theories have also been described that
have higher scores on paranoid
told that there is no treatment and they nitive behavioral therapy for dyslexia are non-adaptive in nature and con-
ideation, psychoticism, and
just need to “learn to live with it.” The and attentional difficulties. A low nect tinnitus to the somatosensory
hostility6

SPECIALREPORT
aim of this article is to show that tinni- dose of sertraline is started for anxi- system or the hypothalamic-pituitary
tus is secondary to an aberrant brain- ety and melatonin and continuous axis, specifically cortisol.  SOMATOFORM DISORDER: findings
ear circuitry affected by disorders positive airway pressure (CPAP) for Interestingly in tinnitus, many from the World Health Organization
such as mood, anxiety, and alcohol sleep regulation. brain areas are affected beyond the indicate that 42% of the patients
and substance abuse as well as execu- auditory system and pathway. In fact, with somatization disorder had
tive dysfunction, migraine, sleep and electrophysiological data show that tinnitus with autonomic arousal as
stress. By treating these comorbidi- Epidemiology various electroencephalogram (EEG) a common link7
ties, tinnitus tends to improve. Tinnitus is described as ringing, roar- abnormalities involving different  COGNITIVE IMPAIRMENT: tinnitus
ing, hissing, or pulsatile. It is classi- brain areas are associated with tinni- affects executive function and
fied as subjective and objective. Ob- tus. Particularly, quantitative EEG attention; patients also have
CASE VIGNETTE jective tinnitus is very rare and showed unilateral localized focus of slower cognitive processing
consists of a sound heard by both the high frequency activity over the tem- speed and longer reaction times
A 55-year old man (MR) presents patient and the physician such as ar- poral lobe auditory cortex in tinnitus on brain speed test8
with bilateral tinnitus and high-fre- terial bruits, venous hums, and pala- patients. Other areas involved in tin-
quency sensorineural hearing loss. tal and stapedial myoclonus. Subjec- nitus include the anterior cingulate  STRESS: emotional exhaustion is a
MR has a complex developmental tive tinnitus is the most common and cortex, dorsal lateral prefrontal cor- strong predictor of the severity of
history including global developmen- is only appreciated by the patient. It tex, insula, supplementary motor ar- tinnitus; exposure to high stress
tal delay, traumatic brain injury at the affects 50 million people in the US. ea, orbitofrontal cortex, parahip- has the same incidence of tinnitus
age of 5, and dyslexia diagnosed at About 0.5% to 2% of people request pocampus, posterior cingulate as exposure to occupational
age 16. MR works part-time as a train urgent medical assistance either for cortex, and the precuneus. noise9; some people report that
operator and is exposed to high levels acute unbearable tinnitus or for Imaging studies also showed in- their first awareness of tinnitus
of acoustic trauma. His brain MRI chronic tinnitus that worsened sud- volvement of certain regions including coincides with a stressful event
scan reveals an incidental finding of denly. The number one culprit of tin- auditory structures (auditory brain such as divorce, accident,
volume loss within the bilateral pari- nitus is hearing loss. stem, medial geniculate nucleus, pri- surgery, loss of employment, or
etal lobes. He denies any significant mary and secondary auditory cortex illness in the family
decline in cognitive functioning. How- Causes and differential diagnosis and temporo-parietal association are-  SLEEP: insomnia is a common
ever, in the context of a lan- of tinnitus as) as well as cortical and subcortical complaint in tinnitus patients, in
guage-based learning disability, he There is no standard diagnostic crite- areas found on positron emission to- particular difficulty falling asleep;
continues to struggle with several rion for tinnitus. Self-report is the mography (PET) scan and functional obstructive sleep apnea is a key
aspects of language, including prob- base for determining tinnitus pres- MRI (amygdala, hippocampus, anteri- factor to screen for during an
lems with articulation, reading, writ- ence. In a subset of psychiatric pa- or cingulate, and orbitofrontal cortex).2 evaluation for tinnitus10; achieving
ing, and spelling, consistent with his tients (eg, with schizophrenia) tinni- restorative sleep is a key element
baseline. tus may be confused with auditory Comorbid psychiatric symptoms of tinnitus management.
MR reports no difficulty carrying hallucinations. and syndromes
out his job responsibilities and is fully The causes of tinnitus could be pe- Alcohol consumption has been de- Impact on quality of life/level of
independent for all activities of daily ripheral or central. Peripheral causes scribed as a risk factor for tinnitus; distress
living. His mental status is consistent usually involve cochlear pathologies however, most results have not been The Tinnitus Handicap Inventory
with expectations for an individual associated with hearing loss (eg, significant. There is very limited lit- (THI) is a good tool to assess the im-
with a language-based learning dis- noise-induced hearing loss or Meniere erature on the relationship between pact of tinnitus on quality of life and
ability, including deficits across sev- disease), acoustic neuroma or vestibu- tinnitus and substance use, and most patients’ progress. Patients with tin-
eral aspects of language. He also lar nerve damage due to infection, an results are inconclusive. However, it nitus appear to have poorer quality of
exhibits select weakness in aspects autoimmune disorder, or diabetes. is still recommended that patients ab- life compared with people who do
of the executive domain that overlap Central causes of tinnitus include stain from substance use including not have tinnitus, notably in those
heavily with language functions, in- stroke, demyelinating lesions, trau- alcohol and tobacco because of their with disabling hearing loss. Reported
cluding sequencing, word generation, matic brain injury, and arteriovenous negative effects on overall health. consequences include anxiety, con-
and retrieval of unstructured verbal malformations. Other causes of tinni- centration difficulties, depression,
information. tus include the use of ototoxic drugs  AFFECTIVE DISORDERS: there is a and irritability.
The causes of his difficulties, al- and neck trauma. high prevalence of depressive Similarly, reducing tinnitus inten-
though likely neurodevelopmental, Pathophysiologically, tinnitus is disorder in tinnitus patients; in sity has a direct impact on the im-
were exacerbated by additional sa- understood as the result of an adaptive fact, a decrease in depression provement in patients’ quality of life.
lient factors, such as tinnitus that in mechanism to a diminished input: was associated with a decrease It is interesting to note that children’s
turn is directly related to and worsen- when the neural output stemming in tinnitus3 quality of life is affected less by tin-
 24 AUGUST 2019
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w w w. p s y c h i a t r i c t i m e s . c o m NEUROPSYCHIATRY

is no single treatment for tinnitus,

TABLE. Pharmacological treatment of tinnitus and the goal is to target associated
Medication class Effective; not effective Notes distress with CBT to decrease the
perception of tinnitus and improve
Benzodiazepines GABA-A such as alprazolam, midazolam, Risk of addiction, cognitive difficulties, gait the patient’s quality of life.
clonazepam decrease amplitude of tinnitus; disturbances; caution needed because
superior to placebo, GABA-B agonists such as cases of tinnitus were induced by off-label
baclofen have been suggested for animal and
Dr Chemali is Director, Neuropsychiatry
use of baclofen18 Clinics; Director, Behavioral
human models of severe chronic tinnitus19
Neurology-Neuropsychiatry
Antidepressants Nortriptyline, sertraline, duloxetine, tricyclics— Higher doses of TCAs and SSRIs appear Fellowship; Director, Global
used earlier—not much currently given high to work for tinnitus patients who also Implementation Program in
anticholinergic effect; bupropion worsens tinnitus; exhibit depression and anxiety or insomnia Neuropsychiatry, Behavioral and
mirtazapine increases perception of tinnitus
Social Sciences; Associate Professor,
Mood stabilizers/ Carbamazepine, valproic acid, gabapentin Used when tinnitus is comorbid to bipolar Harvard Medical School,
anticonvulsants disorder, seizure, or migraine Massachusetts General Hospital,
Boston, MA. Dr Nehme is Psychiatry
Acamprosate Anecdotal use with efficacy renders its trial Beware of use with underlying alcohol
Fellow, Consult-Liaison Psychiatry,
possible to consider; one double-blind study intake as it causes acute and severe
SPECIALREPORT

showed effectiveness over placebo20 changes in mental status including Cambridge Health Alliance,
hallucinations Cambridge, MA. The authors report no
conflicts of interest concerning the
Antipsychotics Sulpiride decreases perception of tinnitus Used as last resort unless comorbid subject matter of this article.
psychotic disorder

Note: all medications listed in the Table are used off-label for the treatment of tinnitus. References
1. Muhlnickel W, Elbert T, Taub E, et al. Reorganization
of auditory cortex in tinnitus. Proc Natl Acad Sci USA.
1998;95:10340-10343.
nitus. Although children experience chotics may also be used (Table). Other interventions. Patients who re- 2. Landgrebe M, Langguth B, Rosengarth K, et al.
tinnitus, they complain about it less Benzodiazepines such as alprazolam, ceived acupuncture treatments report- Structural brain changes in tinnitus: grey matter de-
frequently. It could be that children midazolam, and clonazepam are ef- ed benefit compared with the control crease in auditory and non-auditory brain areas.
Neuroimage. 2009;46:213-218.
adjust better and quicker to the tinni- fective treatments and decrease the group that received sham treatment 3. Hebert S, Canlon B, Hasson D. Emotional exhaus-
tus or that they consider tinnitus to be amplitude of tinnitus. This treatment with fake needles.15 When the tinnitus tion as a predictor of tinnitus. Psychother Psychosom.
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themselves with other activities, addiction, cognitive difficulties, and ing loss, especially if unilateral, coch- lence and characteristics of tinnitus among US
thereby ignoring it more easily. gait disturbances in the elderly popu- lear implantation may be indicated. adults. Am J Med. 2010;123:711-718.
5. Durai M, Searchfield G. Anxiety and depression,
lation. personality traits relevant to tinnitus: a scoping re-
Treatment strategies Antidepressants such as nortrip- Brain stimulation. Both low frequency view. Int J Audiol. 2016;55:605-615.
Ideally, the treatment of tinnitus con- tyline, sertraline, and duloxetine have and high frequency repetitive trans- 6. Belli S, Belli H, Bahcebasi T, et al. Assessment of
psychopathological aspects and psychiatric comor-
sists of treating the underlying etiol- been shown to be beneficial in stud- cranial magnetic stimulation to the bidities in patients affected by tinnitus. Eur Arch
ogy. This includes stopping an oto- ies.12 It is recommended that bupropi- auditory cortex was studied in pa- Otorhinolaryngol. 2008;265:279-285.
7. Hiller W, Janca A, Burke KC. Association between
toxic drug and treating arteriovenous on be avoided in patients because its tients with tinnitus and showed prom- tinnitus and somatoform disorders. J Psychosom
malformations or strokes. In the case activating dopaminergic effect could ising results. Other areas studied are Res. 1997;43:613-624.
of dysfunction of the cervical spine worsen the tinnitus. Mirtazapine the frontal and parietal regions, as 8. Das SK, Wineland A, Kallogjeri D, et al. Cognitive
speed as an objective measure of tinnitus. Laryngo-
or the temporomandibular joint, ma- should be avoided as it could increase well as the dorsal cochlear nucleus, scope. 2012;122:2533-2538.
nipulations, exercises, occlusion ad- tinnitus perception. the inferior colliculus, and the medial 9. Baigi A, Oden A, Almlid-Larsen V, et al. Tinnitus in the
general population with a focus on noise and stress: a
justments, and trigger point treatment Mood stabilizers and/or anticon- geniculate body of the thalamus.16 public health study. Ear Hear. 2011;32:787-789.
can improve tinnitus severity. If the vulsants have been investigated in the Epidural stimulation has been 10. Koo M, Hwang JH. Risk of tinnitus in patients with
tinnitus is caused by a tumor, stereo- treatment of tinnitus. Carbamaze- shown to be safe and effective in sleep apnea: A nationwide, population-based case
control study. Laryngoscope. 2017;127:2171-2175.
tactic radiosurgery or microscopic pine, valproic acid, and gabapentin small trials.17 Deep brain stimulation, 11. Drexler D, Lopez-Paullier M, Rodio S, et al. Impact
decompression may be needed. have shown some benefit.13 Mood although not used specifically for tin- of reduction of tinnitus intensity on patients’ quality
Most patients are affected by chron- stabilizers are mainly used when tin- nitus but rather for other approved of life. Int J Audiol. 2016;55:11-19.
12. Chang JP, Wu CC. Serotonin-norepinephrine re-
ic idiopathic tinnitus. In these cases, a nitus is comorbid with bipolar disor- indications (eg, movement disorders) uptake inhibitor treatment for tinnitus and depres-
comprehensive evaluation should be der, seizure disorder, or migraine. has shown benefit in patients who sion. J Clin Psychopharmacol. 2012;32:729.
13. Hoekstra CE, Rynja SP, van Zanten GA, et al. Anti-
conducted to identify comorbidities Antipsychotics should be used as have comorbid tinnitus.18 convulsants for tinnitus. Cochrane Database Syst
such as depression, anxiety, alcohol a last resort unless patients have a co- Rev. 2011;(7):CD007960.
and substance abuse as well as insom- morbid psychotic disorder. Antipsy- Conclusion 14. Hesser H, Weise C, Westin VZ, et al. A systematic
review and meta-analysis of randomized controlled
nia. By treating these comorbidities, chotics have been found helpful in We currently know that tinnitus is an trials of cognitive-behavioral therapy for tinnitus dis-
tinnitus severity might decrease. moderate to severe obsessive-com- aberrant brain-ear circuitry. The work- tress. Clin Psychol Rev. 2011;31:545-553.
15. Rogha M, Rezvani M, Khodami AR. The effects of
pulsive disorders worsening tinnitus up consists of a thorough history and acupuncture on the inner ear originated tinnitus. J
Auditory therapeutic measures. For tin- and for short-term treatment of physical exam including a cognitive Res Med Sci. 2011;16:1217-1223.
nitus associated with hearing loss or hyperacusis. assessment. Urgent referrals should 16. van Zwieten G, Smit JV, Jahanshahi A, Temel Y,
Stokroos RJ. Tinnitus: is there a place for brain stim-
deafness, hearing aids are used; a be made when tinnitus is pulsatile or ulation? Surg Neurol Int. 2016;7(Suppl 4):S125-S129.
cochlear implant may be indicated. Psychotherapy. Cognitive behavioral associated with neural deficits (facial 17. De Ridder D, Vanneste S, Menovsky T, et al. Sur-
Acoustic simulation during sleep has therapy (CBT) is the most studied weakness or paralysis), unexplained gical brain modulation for tinnitus: the past, present
and future. J Neurosurg Sci. 2012; 56:323-340.
also been shown to reduce tinnitus nonpharmacological treatment. It is sudden hearing loss, vestibular symp- 18. Auffret M, Rolland B, Deheul S, et al, for the
intensity and improve patients’ qual- the treatment of choice as it targets toms, or otalgia and drainage. CAMTEA team. Severe tinnitus induced by off-label
use baclofen. Ann Pharmacother. 2014;48:656-659.
ity of life.11 anxiety and improves patients’ qual- In the case of tinnitus without the 19. Smith PF, Zheng Y, Darlington CL. Revisiting ba-
ity of life.14 Mindfulness and medita- symptoms described above, other co- clofen for the treatment of severe chronic tinnitus.
Pharmacotherapy. Psychiatric medica- tion reduce the stress response state morbidities such as psychiatric Front Neurol. 2012;3:34.
20. Azevedo AA, Figueiredo RR. Tinnitu treatment
tions such as anxiolytics, antidepres- and in turn decrease the distress asso- symptoms, stress, sleep, and trauma with acamprosate: double-blind study. Braz J Otorhi-
sants, mood stabilizers, and antipsy- ciated with tinnitus. should be assessed and treated. There nolarygol. 2005;71:618-623. ❒
AUGUST 2019 P S Y C H I AT R I C T I M E S 25
THE COMPLICATED PATIENT w w w. p s y c h i a t r i c t i m e s . c o m

Polypharmacy: A Challenge CASE VIGNETTE

for Community Psychiatrists Mr VD, aged 40 years, has a diagno-

sis of schizophrenia. He is being
treated daily with 15-mg olanzapine
monotherapy often works and non- at high doses rather than clinical in divided doses, 30-mg mirtazapine
» Amresh Shrivastava, MD, drug therapies may be preferred op- practice scenario where multiple at night, and 300-mg clozapine at
Avinash De Sousa, MD, and tions. Psychosocial interventions drugs targeted at specific symptoms night. He also receives 10-mg zolp-
Pragya Lodha, MA are seldom used because they are are prescribed. idem because of sleep disturbances.
not easily accessible, and such limi- There is a need for polypharmacy He was treated in the past with
tations make it necessary to pre- that is rational and judicious. Despite risperidone and haloperidol, but the

T
he pharmacological manage- scribe more medication in a hope to its limitations and lack of consensus, drugs had to be withdrawn because
ment of psychiatric disorders obtain symptom remission. In the polypharmacy does improve overall of extrapyramidal reactions when he
has been revolutionized since presence of clear clinical evidence outcomes for patients.3 The National was initially started on these drugs.
chlorpromazine became available in of serious adverse effects due to Association of State Mental Health During his last relapse, Mr VD re-
1955. Newer psychotropics have multiple medications, one argument Programme Directors (NASMHPD) ceived clozapine during his inpatient
added years to the life of people suf- in decision making is the effective- provides classification of polyphar- stay. He had a 90% improvement in
fering with mental illness, and they ness of polypharmacy in improving macy (Table 1).4 symptoms with clozapine.
have enhanced the quality of life for the outcomes for patients.1 After drinking alcohol at a family
patients. Psychopharmacology is re- When using polypharmacy, it is Is there evidence to substantiate function, he became drowsy and
sponsible for the reduction in dura- important to address adherence is- polypharmacy? started convulsing. He was taken to a
tion of inpatient care, and it has sues and to educate patients and their One of the major fallacies of poly- nearby hospital and admitted in an
helped to provide recovery to mil- families. In doing so, medication pharmacy is the lack of randomized intensive care unit; he died later that
lions of patients discriminated dosages, the possible adverse effects controlled trials and an evidence night due to seizure-related compli-
against because of the stigma of of the medications, and drug-drug base that can help clinicians decide cations. The emergency physician
mental disorders. However, poly- interactions are explained. Despite what combinations and medications was unable to ascertain which medi-
pharmacy has been met with chal- all the difficulties and complexities will work for psychiatry. Many re- cation may have caused the seizures.
lenges because many practicing associated with polypharmacy, there views of polypharmacy look at drug The hospital did not have the facility
clinical guidelines and treatment has been an exponential rise in its combinations that are used in the for clozapine monitoring, and patient
algorithms prefer a monotherapy ap- use (based on clinical communica- treatment of schizophrenia and de- records were not available.
proach. tion and experience sharing with col- pression.5 Certain combinations are
The challenge of polypharmacy is leagues). The primary reason for this mentioned; however, none has been
not only in clinical practice but also is the advent of psychopharmacolo- found to be superior to another. This raises several questions about
in the evidence for its effects. Poly- gy that is receptor specific-based Moreover, because there are huge prescribing patterns. Despite strict
pharmacy in psychiatry is often a rather than a disorder-based medica- differences in prescribing styles guidelines about clozapine, its use re-
clinical need that reflects a clinician’s tion.2 among clinicians, there are many mains fairly complex in many coun-
frustration. The main indication of Although polypharmacy is often variations in the combinations of tries. Was clozapine alone responsible
polypharmacy remains nonresponse used in the management of psychiat- drugs prescribed. It is often con- for seizures or was this an additive
to monotherapy and persisting symp- ric disorders, there is very poor strued that polypharmacy is more effect of the various drugs prescribed
toms. These symptoms are seen in awareness of its efficacy. In some sit- calculated scientific guesswork than with clozapine? Would clozapine do
the domain of persistent positive, uations, polypharmacy also lacks re- evidence-based treatment.6 better as monotherapy of 300 to 400
negative, cognitive, affective, or anx- spect and acceptability. This arises It is important to remember that mg with a response of 60% to 70%
iety/phobias. out of the fact that most reputed text- each prescribed drug has clear indica- compared with polypharmacy that
The prescribing of polypharmacy books and clinical guidelines advo- tions, has well-defined therapeutic showed an improvement of 90% but
continues despite the evidence that cate monotherapy and a single drug goals, and as far as possible is evi- may have additively caused seizures?
dence based. Clinicians need to evalu- Emergency physicians may not be
ate whether polypharmacy enhances aware of the adverse effects of psychi-
clinical outcomes or whether it pro- atric drugs, and in this case no serum
TABLE 1. Types of psychiatric polypharmacy
motes adverse effects. This is even clozapine levels were checked to de-
more important when patients already termine whether clozapine toxicity
Same-class The use of more than one medication of the same class
polypharmacy (eg, using two different SSRIs to treat depression) on polypharmacy are shifted to a new resulted in the seizures. Polypharma-
combination of drugs and when pa- cy, while viable in improving the qual-
Multi-class The use of full therapeutic doses of more than one tients are shifted from mono- ity of life, may have additive adverse
polypharmacy medication from different classes for the same disorder therapy to polypharmacy.7 effects that may go undetected when
and/or symptom-cluster (eg, use of lithium and The STAR*D and CATIE trials the patient presents to the emergency
olanzapine for the treatment of mania) have focused on combination thera- department.
py but despite elaborate methodolo-
Adjunctive One medication is used to treat the adverse effects of gy and painstaking research, they Does polypharmacy enhance
polypharmacy another medication (eg, aripiprazole for amisulpride- have failed to elucidate what drug clinical outcomes?
induced hyperprolactinemia) combination works in either depres- Polypharmacy is paramount when
sion or schizophrenia.8,9 Most of the treating comorbid psychiatric disorders
Augmentation The use of one medication at lower dose with another
combinations used in polypharmacy (eg, depression and panic disorder;
polypharmacy medication at full dose (eg, low-dose haloperidol to
augment effects of full-dose risperidone)
are based on the clinical judgment ADHD and enuresis).10 In polyphar-
and experience of the treating psy- macy we may use multiple drugs pre-
Total The total number of medications used in a patient; also chiatrist and their experience with scribed at lower to normal doses rather
polypharmacy referred to as total drug load individual patients rather than clini- than one drug at a higher dose. Various
cal studies. CONTINUED ON PAGE 35
26 AUGUST 2019
P S Y C H I AT R I C T I M E S
w w w. p s y c h i a t r i c t i m e s . c o m HISTORY OF PSYCHIATRY

Before Personality: Character Assessment

and Its Troubled History
» Greg Eghigian, PhD sis on testing and quantitative meas-
ures and more on the observation and
ral, racial inequality separating groups
of human beings, one that penetrated
guished themselves from Europeans
by giving everyone in society a chance
interpretation of expressions of vir- deep into the body and mind. Here to realize their full potential, thus mak-

T
he 20th century introduced a tues, such as patience, independence, characterology intersected with the ing the US a more adaptable society.7
number of new concepts to psy- love of order, and calmness.2 toxic anti-Semitism of its time, hold- That said, despite contending that Jap-
chiatry and clinical psychology. ing to the view that Jews literally em- anese-Americans were essentially
One of the most influential has been How then did characterologists bodied this inequality, casting them as American in their make-up and con-
the notion of personality. Carl Jung, propose doing this? perpetual outsiders, but ones who dis- duct, she and her colleagues appear to
Gordon Allport, Abraham Maslow, One way was developed by psychia- guised their true selves.5 It therefore have done nothing to speak out or
Harry Stack Sullivan, and Carl Rog- trist Ernst Kretschmer (1888-1964), should come as no surprise that under campaign against the forced detention
ers are just a few of the early figures which he laid out in his influential book the Nazis characterology flourished. of Japanese-Americans during World
who, starting in the 1920s, developed Physique and Character in 1921. He It needs to be pointed out, howev- War II.8
theories and models designed to cap- argued that two types of constitu- er, that interest in character was not In Europe, after the war, character-
ture the inner core of human subjec- tions—a cyclothymic and a limited to Germany. During World ologists continued their work
tivity (or the “self,” as Rogers put it). schizothymic—are at the core of hu- War II, for instance, a number of throughout the 1950s and early
But while their names and ideas con- man character to varying degrees.
tinue to resonate, time has proven Moreover, human beings are born with
less kind to another psychological one of three basic body types: asthenic, /GCFCTIWGFHQTTGLGEVKPITCEKUV
project that played out at the same
time. This was characterology.
pyknic, and athletic, and these body
types are closely associated with con- GUUGPVKCNKUOUCDQWVITQWRUYJKNGCNUQ
Coined in 1867 by Julius Bahnsen,
a student of the philosopher Arthur
trasting pairs of character features. In-
dividuals of the pyknic variety, for in-
KPUKUVKPIQPVJGEQPUKUVGPE[QHEGTVCKP
Schopenhauer, characterology was
associated primarily with Germany.
stance, he believed, temperamentally
fluctuate between joviality and despair.
VTCKVUCOQPIGVJPKEEQOOWPKVKGU
It is there that it began to take hold Thus, if Kretschmer’s model was accu-
and thrive, with the founding of the rate, it was possible to read character American cultural anthropologists 1960s. But times were changing. As
field’s two major journals in the mid- features and predilections by simply volunteered their services and knowl- West German researchers and clini-
1920s: Jahrbuch für Charakterologie inspecting a subject’s physique.3 edge to aid in the war effort against cians increasingly turned to the US
(Yearbook for Characterology) and Psychologist Ludwig Klages Nazi Germany and Imperial Japan for inspiration, they found themselves
Zeitschrift für Menschenkunde (Jour- (1872-1956) offered another tech- (and they would go on to continue drawn to “trait-and-factor” methods
nal for Human Studies). nique: graphology. The notion that a this work during the early years of instead. The idea was no longer to un-
Characterology emerged as a type bodily movement like handwriting the Cold War). They engaged in what cover supposedly fixed character
of character analysis following along could provide direct insight into the was referred to as “studies of culture traits, but rather to identify the gener-
the lines of the clinical assessment of soul or character of a person was not at a distance,” a form of applied an- al aptitudes, adaptabilities, and inter-
functional disorders in the 19th centu- new, having been the subject of trea- thropology intended to serve the in- ests of a person.9 As a result, a more
ry. This was an assessment that in- tises dating back to at least the 17th terests of the US and framed as the dynamic and developmental concept
volved examining a patient for outward century. What Klages and others did study of national characteristics. Ja- of “personality” replaced “character”
signs indicating a psychopathology or by the early 20th century, however, pan, Germany, Russia, Britain, and in academic and professional circles.
at least a proclivity toward some patho- was to tie handwriting directly to Poland, all became subjects for these
logical state of mind. The approach neurology, understanding the activity kinds of analyses, which were subse- Dr Eghigian is Professor of History,
was beholden in no small measure to to be a form of expression that pro- quently criticized for simplifying Penn State University.
the work of the France-based psychia- jected facets of a person’s inner core.4 complex communities and relations.6
trist Bénédict Morel (1809-1873), Klages’s graphology was hardly an One of the most famous anthropol- References
whose theory of degeneration held that innocuous exercise. Instead, it was ogists engaged in this project was Mar- 1. Pick D. Faces of Degeneration: A European Disor-
most mental disorders were due to cor- bound up in the psychologist’s dark garet Mead (1901-1978). Among her der, c. 1848-c. 1918. Cambridge: Cambridge Univer-
sity Press; 1993.
rupt hereditary constitutions and that vision of the modern world. Like tasks was to collaborate on an initiative 2. Meskill D. Characterological psychology and the
these corruptions were reflected in ob- many of his reactionary contemporar- of the Council on Intercultural Affairs German political economy in the Weimar period
servable physical stigmata and behav- ies, Klages considered modernity to in New York City to study the “nation- (1919-1933). Hist Psychol. 2004;7:3-19.
3. Stanghellini G, Broome M, Raballo A, et al. The Ox-
ioral abnormalities.1 Characterology’s be dangerously superficial and chaotic al character” of Axis powers and, later ford Handbook of Phenomenological Psychopatholo-
innovation was to extend this kind of in a way that undermined the ability of on, the assimilation of minorities in the gy. New York; Oxford: Oxford University Press. 2019.
evaluation to populations beyond those human beings (and Germans in par- US along with “our American charac- 4. Schäfer A. Graphology in German psychiatry
(1870-1930). Hist Psychiatry. 2016;27:307-319.
deemed “abnormal,” in order to identi- ticular) to fully realize themselves. ter.” Publishing the results of her anal- 5. Lebovic N. The Philosophy of Life and Death: Lud-
fy those traits that drove an individual’s The world therefore needed a way to ysis in 1942 in the book And Keep Your wig Klages and the Rise of Nazi Biopolitics. New York:
will and conduct. differentiate between authenticity and Powder Dry, Mead argued for reject- Palgrave Macmillan; 2013.
6. Neiburg F, Goldman M. Anthropology and politics in
In Germany, characterology’s star falsehood, between genuine virtue ing racist essentialisms about groups, studies of national character. Cult Anthropol.
began rising in the 1920s and 1930s, and corrosive subterfuge. Character- while also insisting on the consistency 2998;13:56-81.
when industry and the public sector ology and graphology were therefore of certain traits among ethnic commu- 7. Hazard Jr, AQ. Wartime anthropology, nationalism,
and ‘race’ in Margaret Mead’s And Keep Your Powder
began seeing the value in applied psy- conceived as tools capable of breaking nities: environment and upbringing, Dry. J Anthropol Res. 2014;70:365-383.
chology. Both psychotechnics and through the veneer of a person and ex- not blood, were the formative elements 8. Mabee C. Margaret Mead and behavioral scientists
vocational counseling were benefi- posing his or her true nature. in national character. And while she in World War II: problems in responsibility, truth, and
effectiveness. J Hist Behav Sci. 1987;23:3-13.
ciaries of this growing interest. So too As historians Per Leo and Nitzan invariably invoked an idea of “white-
9. Meskill D. Psychological testing and the German
was characterology, whose practi- Lebovic have shown, Klages in par- ness” indebted to European prejudic- labor market, 1925 to 1965. Hist Psychol.
tioners at the time placed less empha- ticular argued for there being a natu- es, she held that Americans distin- 2015;18:353-366. ❒
 AUGUST 2019 P S Y C H I AT R I C T I M E S 27
w w w. p s y c h i a t r i c t i m e s . c o m

FROM THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY

The Disabled Employee’s Manager
A Common Complicating Factor of Workplace Disability
Long absences from work make it difficult
» Barbara Long, MD, PhD, Andrew O. well. Physicians are trained to be knowledgeable
and confident in their point of view, and a treat- to return to work, for a number of reasons:
Brown, MD, Sean Sassano-Higgins, MD, ment plan is the foundation of this training. Yet,  The anxiety associated with being accepted
and David “Daven” E. Morrison, MD, for the most psychiatrists are quickly out of synch with back into the group
Committee on Work and Organizations, the workplace as it relates to disability.
 The unconscious tendency of the group to
Group for the Advancement of Psychiatry Here is an abbreviated list of why
exclude fellow members during their
absence
psychiatrists can also feel incompetent:
 The concern about being able to perform

O 1
ne of the most perplexing challenges for They have not been trained to see the
psychiatrists who interact with the work- one’s duties at excellent levels
workplace from the managers’ point of view.
place is the competing forces for and  The effect of injury on one’s self-esteem
against mental health. As previously argued,
work is of paramount importance for the mental 2 They do not know how to analyze a system
like a workplace or a work environment that
can include interacting internationally or
during the period of “doing nothing and not
contributing”
health of any person, especially an adult.1-3 Build-
virtually, and to decide who is responsible for
ing off of what we have argued to this point, the There is a missing piece that can help the man-
what aspect of the work flow.
intersection of work, health, the patient, and the ager, the psychiatrist, and the employee find com-
doctor becomes decoupled as disability is con-
sidered. If returning to work is not thoughtfully 3 The terms toxic, stress, and even PTSD
are often used imprecisely in the
workplace without the discipline or clarity
mon ground: a pathway to returning to work while
managing mental illness and its sequelae. Our
planned for, the whole delicate web can fall apart. larger mission is to support both the managers at
We are a group of psychiatric professionals typically used in medical assessments and work as well as psychiatrists with their patients to
whose work varies. At times we are focused 100% treatment plans. understand the forces leading to mental health.6
on clinical, other times we are 100% focused on
the work environment, and much of the time we 4 Their allotted time with patients is
shrinking.
In the previous article in our series on disabil-
ity we highlighted the need to address the con-

5
are focused on the intersection. This Psychiatric The expertise on the Internet to pursue cept of functional assessment.3 It is important to
Times exploration of work and disability focuses disability is large and growing every day note, however, that because symptoms are sub-
on the challenges of the workplace manager, the creating an asymmetric knowledge for the jective, functional assessments don’t always pro-
employee with whom there is a conflict related to doctor compared with the employee. vide a true picture of the patient’s disability. If the

6
performance, and the psychiatrist who is tasked patient is being coached on how to respond to
Most psychiatrists do not understand
with the challenge to determine disability. assessments, the problems affecting the doc-
effective and ineffective performance
For many of the cases we see there is a great tor-patient and/or the employee-manager rela-
management systems or competent leaders
deal of ambiguity or gray space. There are some of healthy workplace cultures.
tionships are worsened. Psychiatrists must work
cases where there is clear evidence of the onset of with the patient to improve functioning gradual-
a mental illness independent of workplace dy- In our preliminary survey-based research, ly, paralleling the return to work plans that are
namics, yet in many others there is not. As in all “Psychiatry of Workplace Dysfunction—Tools regularly used by other medical practitioners (eg,
systems, there is a critical balance to find be- for Mental Health Professionals, Managers, and orthopedists). The goal is to avoid permanently
tween what is pathological and what is support- Employees,” the findings indicate that psychia- eliminating work from patients’ lives.
ing mental health. trists generally feel incompetent addressing com-
mon psychiatric challenges to the workplace, Dr Long is Committee Chair, Work and Disability
How might the psychiatrist support mental such as how to compose a thoughtful return to Consultant Private Industry, the Courts, and the
health at work? work plan.4 Moreover, the survey findings sug- Legal Profession; Dr Brown is Department
To the workplace organization, the mental health gest that residency training directors feel unpre- Psychiatrist, Boston Police Department,
system seems fraught with traps to undermine pro- pared to design curricula that cover these short- Consulting Psychiatrist, Boston Fire Department,
ductivity: decreased production, lost hours, and falls. Work and Disability Consultant, Private Industry
distracted and “on edge” supervisors all tracking In the end, the patient’s anxiety about return- and Government; Dr Sassano-Higgins is Adjunct
back to performance issues of employees. For ing to work combined with direction from fami- Professor, Department of Psychiatry, University
managers, the role becomes confusing and even ly, friends, or the Internet has the potential to of Southern California; Dr Morrison is Clinical
frustrating. They most likely do not know what cause the patient to single-mindedly pursue disa- Assistant Professor of Psychiatry and Behavioral
“toxic” means, much less how to handle “periods bility. The powerful emotional affects generated Sciences, Chicago Medical School.
of irritability, down moods,” or how to grant “oc- in the sessions about returning to work over-
casional time to be away from work.” whelm the treating doctor and the worker patient. References
Many managers are not trained in the various The compounding forces to pursue disability 1. Long B, Brown AO, Sassano-Higgins S, et al. A complicated case
of psychiatric disability. Psychiatric Times. 2019;36(4):26-27.
regulations such as the Family and Medical create demands on the patient and on the psychi- 2. Long B, Brown AO, Sassano-Higgins S, et al. Disability: overview
Leave Act (FMLA), and they can be particularly atrist. This combined with the distress of an over- of concepts psychiatrists need to know. Psychiatric Times.
2019;36(5):20, 26.
perplexed by options for dealing with employees whelmed manager leads to an adversarial and 3. Long B, Brown AO, Sassano-Higgins S, et al. Functional assess-
who are distressed to the point of distraction and misaligned system that rapidly escalates. Thus, ment for disability applications: tools for the psychiatrist. Psychiat-
deteriorating performance. In fact, although not ironically the employee, psychiatrist, and manag- ric Times. 2019;36(6):19-20.
4. Long B, Brown AO, Sassano-Higgins S, et al. The psychiatry of
always written explicitly, the manager feels in- er all play a role in the decline of the overall men- work: is residency training adequate? Psychiatric Times. December
competent because the psychiatrist or the plan tal health of patients. Specifically, it harms the 2014.
5. Group for the Advancement of Psychiatry. What Price Compensa-
generated by the Employee Assistance Program ability of the patient and the manager to learn tion? Committee on Psychiatry in Industry, Vol IX, Publication No. 99;
(EAP) carries with it many implicit requests “to how to resolve conflict. June 1977.
be a therapist.” This is not new. Our committee has explored 6. Committee on Work and Organizations, Group for the Advance-
ment of Psychiatry. Psychiatry of Workplace Dysfunction: Tools for
On the psychiatrist’s side of things, the doctor this dynamic for over 40 years with the original Mental Health Professionals, Managers, and Employees. New York:
is at risk of unspoken feelings of incompetence as position paper, “What Price Compensation.”5 Oxford University Press; 2018. ❒
28 AUGUST 2019
P S Y C H I AT R I C T I M E S
w w w. p s y c h i a t r i c t i m e s . c o m NEWS BRIEF

Opioid Use in Pregnancy

Affects Offspring Across All the
Their Lifespan World’s
» Laurie Martin creased risks of lack of expected physiological
development and conduct disorder/emotional
Notes
Richard M. Berlin, MD
C
hildren exposed to opioids in utero are at disturbance. For school-aged children, opioid
significant risk for health problems, includ- exposure was associated with a higher risk of
ing preterm birth, neurodevelopmental is- ADHD,” Dr Azuine reported to Psychiatric
sues in infancy, and psychological and medical Times.
At a performance of Ravel’s “Piano
issues in childhood, according to a study pub- Concerto for the Left Hand,”
lished in JAMA Network Open. Azuine and col- Insights for psychiatrists commissioned by Austrian pianist Paul

POETRY OF THE TIMES

leagues1 sought to determine risk factors for Although study authors do not make clinical rec-
women who used opioids in pregnancy and ommendations per se, Dr Azuine notes that psy- Wittgenstein who lost his right arm during
found significant short- and long-term health chiatrists play a critical role in the screening, World War I.
consequences that may include emotional issues diagnosis, and treatment of substance use disor-
as well as conduct disorder and ADHD. ders and addiction. He also states that the find-
To investigate the issue, researchers looked at ings have two key implications for psychiatrists. The moment the maestro flicks his baton,
8509 mother-newborn pairs from the Boston
Birth Cohort (BBC), a large sample of an urban, Scope: The magnitude of poor health outcomes an orchestra thunders and the pianist suffers
low-income population from its inception in associated with in utero opioid exposure under-
1998. The cohort followed 3153 children scores the need for psychiatrists to look out for a stroke. But everyone plays on while
throughout their lives until aged 21 years. Moth- women at risk for opioid exposure. “The short-
ers’ self-reports and/or electronic health records and long-term outcomes associated with opioid we watch his left hand glissando the keyboard
determined that 454 (5.3%) children had in utero exposure are too dire to ignore . . . We must act
opioid exposure or neonatal abstinence syn- now. All hands must be on deck, and psychiatrists
with so much force his thumb sprays blood.
drome (NAS). The researchers defined in utero can be the leaders on this.”
exposure as “opioid use or a clinical diagnosis of
neonatal abstinence syndrome for a child.”2 Screening and treatment: The consequences of I close my eyes to turn off the sight
opioid exposure cut across the life span of wom-
6JGOCIPKVWFGQH en and their children. “Screening and treatment
for opioid use disorder should be delivered with-
of his right hemiplegia, only to picture

RQQTJGCNVJQWVEQOGU in the context of the life course identifying and lesions on MRIs and clots busted with tPA.
treating women before they become pregnant,
CUUQEKCVGFYKVJKP when they are pregnant, and after they have had I crush my impulse to call 9-1-1 and lock in
their babies. Health care providers must use
WVGTQQRKQKFGZRQUWTG every window of opportunity to prevent the
to 88 keys stroked by five fingers, confused
WPFGTUEQTGUVJGPGGF harm of opioid use and exposure among mothers
and children.”
by the illusion I hear the thunder of ten.
HQTRU[EJKCVTKUVUVQNQQM The implications of the study as it relates to
QWVHQTYQOGPCVTKUM psychiatric treatment are to continue to provide
compassionate care within a safe environment.
And when I let myself look again,

HQTQRKQKFGZRQUWTG “We found that there were sociodemographic half a man nails the climax, then vaults
risk factors for opioid exposure. Psychiatrists
Lead author, Romuladus Azuine, DrPH, should consider these social and environmental to his feet, cuff stained crimson, both palms
MPH, RN, at the Health Resources and Services factors when they see pregnant mothers suspect-
Administration at the US Department of Health ed with opioid use disorders.”
held to his heart, the audience in tears,
and Human Services, noted the wide-ranging Future studies should consider other factors
effects of mother-child opioid use: “The federal outside the scope of this research that found pa-
government is making concerted efforts to iden- tients who abuse opioids may also gravitate to standing with “Bravos” for the soloist,
tify risk factors and improve prevention strate- other drugs (eg, marijuana, stimulants, alcohol,
gies to reduce health effects of opioids. This is tobacco). “This tells us that there is probably no for the thrust of Ravel’s impossible score,
the first study to understand the consequences of single substance of addiction,” said Dr Azuine.
maternal opioid use on physical health and de- and for Wittgenstein’s first proof
velopmental outcomes of children exposed to References
1. Azuine RE, Ji Y, Chang HY, Kim Y, et al. Prenatal Risk Factors and
opioids using 20 years of clinical data.” that a man can gather all the world’s notes
Perinatal and Postnatal Outcomes Associated With Maternal Opioid
The effects of maternal opioid abuse can be Exposure in an Urban, Low-Income, Multiethnic US Population. JAMA
found across the lifespan of their offspring: Netw Open. 2019;2:e196405.
2. Birth, Child Outcomes Associated With Moms Using Opioids During
in one hand and play them with the power of two.
“Opioid exposure was associated with higher
Pregnancy. JAMA Network [press release]. June 28, 2019. https://
risks of fetal growth restriction and preterm
media.jamanetwork.com/news-item/birth-child-outcomes-associ-
birth. For preschool-aged children, we found ated-with-moms-using-opioids-during-pregnancy. Accessed July 8,
Dr Berlin is Instructor in Psychiatry, University of
that opioid exposure was associated with in- 2019. ❒ Massachusetts Medical School, Worcester, MA. ❒
AUGUST 2019 P S Y C H I AT R I C T I M E S 29
PRACTICE MANAGEMENT w w w. p s y c h i a t r i c t i m e s . c o m

Making Your Practice Work for You

» Joseph R. Sanok, MA, LLP, LPC, NCC trists need to work crazy hours to
make a living and serve their patients.
Within the current model, that’s often
ASSUMPTIONS THAT 3 EXTERNAL SYSTEMS: What external
systems cause waste within the
practice? This could be insurance
MAY BE HOLDING companies that do not pay on time

I
have a virtual assistant in Cape true to make rent, if you’re the practice
or local regulators. Evaluate from
Town, South Africa. She helps with
my private practice, as well as mar-
owner, you need a specific level of
gross income. But what if there were
YOU BACK where most patients come for the
keting for my consulting business. other ways to generate income that greatest hourly return.
When I have an idea, I sketch it out, were not entirely based on your time?  There aren’t enough
take a picture and then by the next What if your skills could be replicated psychiatrists, I have to do it all In the book, The One Thing,1 au-
morning it is a beautiful blog post, beyond the face-to-face client time thors Gary Keller and Jay Papasan
 Patients need me to work
worksheet, or resource. “How would I that insurance covers? Might we learn crazy hours
repeat the question, “What’s the one
ever use a virtual assistant in my prac- something from other fields that are thing I can do such that by doing it
tice?” you might be thinking. I believe doing this well?  To pay the bills I have to see everything else will be easier or un-
that for you to pursue your highest The long-term mistake most peo- [fill in the ridiculous number necessary?”
calling and potential, you have to ple make is starting or joining a prac- here] patients every week Online productivity guru, Rory
work on only the tasks that you are tice and going with the current model  I don’t have anything to say to Vaden, has a tool he calls the Focus
excellent at doing. In fact, it’s proba- of modern medicine, which may not the world Funnel,2 in which he asks the ques-
bly most import to eliminate and del- work for them and their lifestyles. In tions:
egate, more than it is for you to actual- fact, usually it is not until a child is  I don’t have to do any  Can this task be eliminated?
ly create. born, a parent is sick, or there is some marketing, since psychiatrists
are in demand  Can I automate this task?
other life disruption that motivates cli-
 Can I delegate this task?
Private practice assumptions nicians to start to really evaluate how  I went into medicine, not
Private practice as we know it today is they are spending their time. business, learning about  Do I need to concentrate on this
not the result of a grand master plan, It is helpful to first design your life, marketing, business, and task or should I procrastinate on
carefully constructed. While research which will then inform your business technology won’t help me as purpose?
informs best practices for clinical deci- and practice. much as doing clinical work
sions, there is less guidance on best  I can do it best, so I should do Whether it’s an email, meeting, or
practices for running the practice. In- What would your perfect week denied insurance claim, tasks suck
stead, practice management is often the
result of trial and error, as practitioners
1 look like? How much time would
you have to work-out, meditate, and
almost everything
time and energy from you. Most of the
time it is unnecessary. Even worse, it
and society reacted to studies on best enjoy social activities? What time Examining strengths and stops you from putting time into the
practices, changes in laws, codes of would you start/end work to have productivity ideas that could genuinely have an im-
ethics, and rules and responding to so- the healthiest family and social life? Many psychiatrists get on the treadmill pact on the world, make your schedule
cioeconomic factors such as insurance How much sleep would you get? of seeing patients, keeping up with re- easier, and create space to innovate.
reforms. As a result, many clinicians What experiment could you do to cords, and putting out fires in their By asking, “What’s the very best use
struggle and grow frustrated.
To make a change and have your
2 test a change in your
assumptions? For example, could
practice. In doing so, it is easy to miss
the redundancies and inefficiencies in
of my time?” you can clearly identify
what you need to outsource to an as-
practice work for you, you first need you block out Thursday afternoons their practice. For example, if a front sistant or virtual assistant.
to evaluate practice assumptions. for golf, commit to being home for desk staff member needs to type a date
What’s the typical mindset? Why do dinner four out of five days, or drop of birth 15 times for an intake and three Better than a new best friend—
we believe this? Is that true? Next, off your kids at school every day? times for progress notes, that is a waste the virtual assistant
we move from the global discussion What if you tried it for a month or 3 of time. Even though it may be 2 min- What is a virtual assistant? A virtual
of private practice, into your individ- months? utes here and 3 minutes there, all of it assistant (VA) does not physically
ual decisions about what type of psy- adds up to lost time and money. Im- work in your office. This could be a
Then examine what fell apart
chiatrist you want to be. What do you
have to say? What issues interest 3 during the experiment? An
experiment like this will point out the
agine a patient is billed after the ap-
pointment, only to be sent five more
medical biller who lives in Houston, a
scheduler who answers live but lives
you? What change do you want to letters until he or she pays. There are in Florida, or a graphic designer in
see? Next, we need to question the systems and opportunities for numerous electronic health record pro- South Africa. So, why hire a virtual
best use of your time. Are you mov- change. For example, maybe you grams (EHRs) that allow a credit card assistant?
ing toward genuine impact in the need to schedule a different on-call to be billed when insurance is paid. The clearest reason to hire some-
field or are you just keeping the prac- routine. Or maybe an assistant These essentials will be unique to one virtually is that you save money.
tice going? How do you find time needs additional training on each practice, but there are several You don’t have to find a space for
when you’re seeing a billion pa- prescription refills. common categories that will assist them. VAs typically have their own
tients? What are others doing to scale your evaluation. tools, like a computer and phone. Al-
beyond their own time? Last, we Highly educated individuals often so, most VAs are paid by the project or
need to understand how to genuinely
grow outside of your time. In doing
this, we allow your passion, insights,
have a very concrete view of the
world. There may be an assumption
that if you start a new system, you will
1TECHNOLOGY: What systems can
automate each phase of the
practice from patient experience to
only for time when they work. So,
you’re not paying for someone to sit in
an office for 40 hours a week. Instead,
and ideas to impact the world around have to do it that way forever. But suc- clinical work to accounting? they may be in a shared workspace, a
you, while also growing your private cessful business people understand home office, or sitting at their dining
practice.
Many psychiatrists follow a very
that you can always change and adapt.
If, after a month, it is impossible to
2 ASSISTANTS: What tasks are
essential for a person? If they
cannot be automated through
room table. A typical private practice
might have a four office suite with a
traditional practice model (Table). have dinner with the family four technology, what will it take for an reception area. If this were automated,
For many this works. But this often nights a week, change the systems or individual to be competent in this the VA might answer phones, onboard
leads to the assumption that psychia- the experiment. task? new patients before their appointment,
30 AUGUST 2019
P S Y C H I AT R I C T I M E S
w w w. p s y c h i a t r i c t i m e s . c o m PRACTICE MANAGEMENT

and schedule additional appointments Taking it to the next level: growing tant through MoveForwardVirtualAs-
virtually. If that additional space is
used, that could save 20% to 30% on
beyond your practice
The opportunities for psychiatrists are
sistants.com and a medical billing
company to help manage patient calen-
GROWING
rent. Then add the productivity side as immense if you can challenge the typ- dars. Here’s what happens: OPPORTUNITIES
well and that 40-hour week may only ical model. For example, numerous
be 25 hours. private practices have worked to grow Each clinician does 8 individual BEYOND
Before we go too far down this
path, there are obvious objections:
billable services outside of the clini-
cian’s hours. Here are some questions
1 or family sessions per week with
an average reimbursement of $92
PATIENT CARE
 How do I know they are following that allow you to identify key opportu- per session: $1472 per week x 4
HIPAA? nities for your practice: weeks = $5888 Clay Cockrell is a great example
 What is the liability? Her new biller charges 5% of how to evaluate and challenge
 Is it legal?
1 What other services are your
patients already paying for (eg,
2 collected: $294.40 face-to-face patient time. Clay
has a thriving private practice in
 What does the code of ethics say Her new virtual assistant does
about this?
mental health counseling, massage,
acupuncture, health coaching)? 3 scheduling and is paid when
working. The cost is $395 per
New York City. His practice is on
the edge of Central Park. He
What lifestyle choices do you
I’m not an attorney and as a rule
you should never take legal advice
2 wish your patients would make
month through the company.
Dr Matthews optimizes her own
was one of the first mental health
counselors to coin the term

solely on one article you read. Each

state and city has its own laws, rules,
(eg, increased exercise, changes in
nutrition, improved sleep)? 4 office so that current space is
used for the sessions, that way they
“walk and talk counseling.” He
was on Good Morning America
What specialties could be and by all measures, his practice
and boards that may have a say in this,
so consult an attorney on your model 3 developed that are needed in
your community (eg, more focused
occur in the evenings or on
weekends, when she’s not in the
was going great. But, he knew
his money was tied to his time
and contracts. Legal best practices office. No additional rent.
abound for this. Something as simple work on trauma, EMDR, support doing therapy. He had to walk
as a Business Associate Agreement groups)? Dr Matthews makes an additional and talk to have an income. If he
can outline the limits of HIPAA, dis- By collaborating with an $5,888 gross minus the $689 adminis- was sick, on vacation, or out for
closure to patients, and methods to assistant, it is possible to grow and trative expenses to equal $5,199 per some reason, he didn’t make
ensure legal and ethical confidentiali- scale your practice beyond your month or $62,388 gross annually. She money. Clay had to decide,
ty. Assuming the legal and ethical side own time. The following example compensates that master-level clini- should he start a group practice,
has been covered, how do you start may be helpful. cians at 40%, which increases overall add staff, and scale that way, or
outsourcing to take tasks off your expenses by $24,955.20. This gives innovate something new. Clay
plate? Dr Matthews sees 50 patients per Dr Mathews an annual net profit of had been dabbling with tele-
In his book, Virtual Freedom,3 week. She focuses on teens with $37,432.80. health and found very few re-
Chris Ducker outlines an exercise that emerging mental health issues. How- In the start-up phase, Dr Matthews sources on the topic.
is helpful. Take out a sheet of paper ever, several of the parents have re- had additional costs such as her attor- In talking with Clay, I realized
and make three columns: quested to start seeing her. She has ney, accountant, and legal forms. As he has a natural curiosity, easily
 Don’t Like Doing noticed an increase of mental health well, there might be additional costs networks with people, and has a
 Can’t Do issues around anxiety and depression. such as a new EMR like Therapy Notes great radio voice. In seemed ide-
She knows she can’t see more people or additional phone lines or email. Dr al to marry these skills with his
 Shouldn’t Do
because she has designed her schedule Mathews also had to check state em- interest in telehealth. The first
In this activity, you identify tasks in to accommodate her personal life. ployment law to determine if the clini- step was to launch the Online
your day that you don’t like doing, However, she doesn’t want to miss cians should receive 1099 or W2 forms.
Counseling Podcast. In inter-
can’t do, or shouldn’t do. These are all this opportunity. But you get the point. This is one ex-
viewing others, not only did he
opportunities to outsource work to an- She asks her assistant to design a ample of how simply a practice can
entertain and educate his audi-
other individual. survey for each patient to complete begin to shift beyond the face-to-face
ence, but he also became more
What types of tasks are private while waiting for their appoints. The income earned by a psychiatrist.
of an expert on the topic of on-
practices outsourcing? Here is a list of survey has three main questions:
the most frequently outsourced tasks  What services are you currently Moving forward to endless line counselling.
in a private practice: using outside of our office that possibilities This podcast became a feed-
 In-coming phone calls, reminder support your mental health By releasing old assumptions and er for onlinecounseling.com,
calls, and scheduling (please include services you plan brainstorming, it is possible to break which is the first directory site
to use in the next 6 months such the old models of private practice and exclusively for online clinicians.
 Insurance billing
as mental health counseling, find new ways to be productive within Now more of his income comes
 Social media marketing from supporting clinicians than
massage, or other mental health your practice. The creativity and flex-
 Maintenance of electronic health support services)? ibility of virtual assistants and real from his own clinical work.
records assistants can help relieve burnout,
 What services do you wish we
 Website updates offered here? increase happiness and fulfillment,
and increase your income. Just im- is passionate about helping practice
 Delivery of office supplies, water,  How would your life be different if
agine what your practice might look owners to optimize their practices and
or beverages for patients we offered these services here?
like if you fully optimized your time launch big ideas, all within the context
 Monitoring and responding to Based on this survey Dr Mathews and thought about how to make an im- of designing their lifestyle. He offers
emails discovers that her current patients pact on the world beyond the walls of the one-week intensive for practice
 Resource and video editing would like to have mental health coun- your practice. owners, Slow Down School, and has
 Case management and ancillary seling and support groups to assist with numerous resources on his website. To
services psychiatric medication reviews. Over Mr Sanok is the Founder of Practice of schedule a time to talk with him go to
the next 6 months, Dr. Matthews hires the Practice. He is a TEDx speaker, busi- www.PracticeofthePractice.com/apply.
 Electronic prescription delivery
two Master-level clinicians to run ness consultant, and has the No. 1
 Accepting and processing groups and offer counseling 10 hours podcast for private practices, The Dr Sanok reports no conflicts of interest con-
payment immediately per week. She also hires a virtual assis- Practice of the Practice Podcast. Joe cerning the subject matter of this article. ❒
AUGUST 2019 PS YC H I ATRI C TI M E S 31
w w w. psychi atr i cti mes. com

Emergency Psychiatry Community crisis centers are most gency patients are also experiencing
Continued from cover commonly staffed by therapists and so- TABLE. Common urgent distress and deserve that same
cial workers trained to counsel individ- exclusion criteria for rapid approach.
mental health system are often ironical- uals while providing a safe and support- community crisis centers Initiating prompt emergency care is
ly the most underserved. ive environment. Psychiatrists or exactly what the psychiatric EDs do. This
Fortunately, we now have an psychiatric nurse practitioners may also ◗ Patients who are currently is also completely consistent with the
agitated/aggressive
evidence-based solution that can fill this be available, though their hours are federal Emergency Medical Treatment
glaring gap in the psychiatric care contin- usually limited. ◗ Patients with history of violence/ and Labor Act (EMTALA) governing
aggression
uum: hospital-based psychiatric EDs. Most community crisis center pa- hospitals that considers high-acuity psy-
These timely, compassionate, trauma-in- tients self-present or are escorted vol- ◗ Patients with profound symptoms chiatric emergencies to be equivalent le-
formed, and cost-effective programs untarily to the clinic by case managers, of psychosis/disorganization gally to medical emergencies, deserving
have the potential to not only dramatical- mobile crisis personnel, or police offi- ◗ Patients with severe suicidal the same immediate attempts to evaluate
ly improve treatment options, but also cers. Each patient typically receives a ideation or a serious suicide and stabilize. Meanwhile, patients who
attempt in the current episode
save behavioral health systems millions thorough psychosocial assessment and may benefit most from community crisis
of dollars annually by stabilizing patients referrals to follow-up care. Some clin- ◗ Patients with active substance/ centers might be unlikely to require the
in the emergency setting, and thus avoid- ics also provide overnight crisis stabili- alcohol intoxication high-acuity approach of the emergency
ing costly inpatient admissions. zation services.2 ◗ Patients in active substance/ psychiatry sites and would perhaps be
Hospital-based psychiatric EDs are Yet while community-based pro- alcohol withdrawal reluctant to go to hospital EDs in the first
also known as Psychiatric Emergency grams provide many benefits, they are ◗ Patients on involuntary status place—so these programs can optimally
Services (PESs), Comprehensive Psy- usually not equipped to care for patients ◗ Patients with active criminal work together in an almost completely
chiatric Emergency Programs (CPEPs), with serious or dangerous psychiatric charges complementary way, which would rarely
Clinical Decision Units (CDUs) or, conditions. These centers commonly ◗ Patients with glucose be redundant.
more recently, EmPATH Units (Emer- have a long list of exclusion criteria abnormalities/need for insulin One historic distinction has been the
gency Psychiatry Assessment, Treat- such as acute aggression, danger to self, ◗ Patients with vital signs idea that hospitals use the medical mod-
ment and Healing Units). Psychiatric involuntary status, or comorbid sub- abnormalities el while community crisis centers are
EDs have been shown to stabilize over stance abuse disorders (Table). Both ◗ Patients needing wound care more wellness and recovery focused,
75% of high-acuity psychiatric outpa- current and prospective patients who ◗ Patients with other pronounced
but this does not have to be the case
tients within 24 hours.2 These units pro- display these criteria are typically di- comorbid medical issues when a hospital-based psychiatric
vide far faster relief from distressing rected to hospital EDs or transported emergency program is part of the sys-
◗ Patients with serious
mental health symptoms than tradition- there by law enforcement or emergency developmental disabilities/ tem. Many psychiatric EDs—particu-
al treatment pathways while preserving medical services; indeed, many centers neurologic issues larly newer designs like EmPATH
inpatient psychiatric beds for patients have required treatment algorithms for ◗ Patients who have utilized the Units—blend the wellness and recov-
who truly have no alternative. high-acuity patients that clearly end in crisis program too frequently/ ery model with the medical model, hop-
This article, the first of a three-part “send to hospital emergency department recidivists ing to bring the best of both approaches,
series, describes how hospital-based or call 911.” ◗ Patients who refuse indicated where appropriate, to the unique chal-
psychiatric EDs differ from communi- It is worth noting that these types of medications lenges of high-acuity patients. The re-
ty-based crisis centers. Also explored is patients who would be excluded from sult is a supportive, calming, and home-
how these centers can serve as the miss- community crisis centers likely make like environment where patients can
ing link in comprehensive behavioral up a large percentage of the high-acuity share of patients who would be exclud- also receive the specialized medical at-
health systems while complementing individuals who end up boarding in ed from community crisis centers. But tention and intervention needed. There
both inpatient and community services. EDs awaiting inpatient care. So, while rather than board patients for admis- is thus potential for a seamless continu-
The second installment will highlight community crisis centers can do fantas- sion as would traditional medical EDs, ity of care philosophy connecting hos-
innovative psychiatric ED programs tic work, they might have a negligible hospital-based psychiatric EDs quickly pital-based psychiatric EDs and com-
around the nation and their impressive effect on ED utilization involving pa- assess and initiate prompt treatment, munity crisis clinics.
outcomes and metrics. And in the final tients with high-acuity psychiatric con- with a goal of stabilization in the emer- It is clear that to provide every pa-
installment, the perplexing reimburse- ditions. In fact, expecting these organi- gency setting, and discharge to home tient experiencing acute psychiatric
ment issues facing psychiatric EDs will zations to handle the most acute or other less-restrictive levels of care symptoms with timely, individualized,
be discussed with strategies to over- psychiatric patients would be like ex- rather than inpatient admission. And and an appropriate level of care, and to
come them suggested. pecting a private doctor’s office to treat indeed, across many different locations minimize ED boarding, mental health
heart attacks and severe car accidents. and care models—rural and urban, ac- systems should endeavor to support
Differentiating hospital-based Through no fault of their own, some ademic and municipal—psychiatric both community crisis centers and hos-
psychiatric EDs from community community crisis centers have become EDs have proved very effective. The pital-based psychiatric EDs.
crisis centers victims of unrealistic expectations. great majority of psychiatric ED pa-
Community-based crisis centers have State and county behavioral health tients in programs around the country, Dr Zeller is Vice President for Acute
burgeoned in recent years and have leaders might assume that by creating typically 70% to 80% or even higher, Psychiatry with the physician partnership
been a valuable addition to the spec- these centers they will dramatically re- successfully stabilize and return home Vituity and Assistant Clinical Professor of
trum of behavioral health services. Typ- duce the number of psychiatric patients or to outpatient dispositions in less Psychiatry, University of California,
ically basing their approach on a Well- presenting to EDs—and therefore put a than 24 hours.3 Riverside, CA. He is an Editorial Board
ness and Recovery model, they can dent in ED boarding. This is not only Treating high-acuity patients in psy- Member of Psychiatric Times.
help many people through difficult life unfair to the centers, it also sadly under- chiatric EDs rather than boarding them
events, stressful situations, and decom- estimates how serious, debilitating, in general EDs just makes sense. Psy- References
pensations of chronic psychiatric ill- life-threatening, and unpredictable the chiatric cases are the only class of pa- 1. Santillanes G, Lam CN, Axeen S, Menchine MD. 45
nesses. Also known as drop-in or walk- emergency symptoms of severe mental tients seen in EDs for whom the default trends in emergency department mental health visits
from 2009-2015. Annals Emerg Med. 2018;72:S21.
in services, crisis intervention or illness can be, and how these require an treatment plan has traditionally been
2. Zeller S, Calma N, Stone A. Effects of a dedicated
diversion, community subacute crisis elevated level of care. inpatient admission. An ED would not, regional psychiatric emergency service on boarding
stabilization units, and psychiatric ur- This is where hospital-based psy- for example, hold a patient having an of psychiatric patients in area emergency depart-
gent care, these welcoming facilities chiatric EDs fit in. Because emergency asthma attack for transfer to an “inpa- ments. West J Emerg Med. 2014;15:1-6.
3. National Council 2015 Crisis Services Survey.
are typically located away from hospi- psychiatry programs are designed to tient asthma bed”; instead, they would
https://www.thenationalcouncil.org/wp-content/up-
tals—often near public services and work with highly acute individuals, treat the patient’s breathing difficulties loads/2015/04/CrisisServices_SurveyResults.pdf.
mental health clinics. they can typically accept the lion’s as soon as possible. Psychiatric emer- Accessed July 8, 2019. ❒
 PREMIERE DATE: August 20, 2019
EXPIRATION DATE: February 20, 2021
This activity offers CE credits for:
1. Physicians (CME)
AUGUST 2019 2. Other
All other clinicians either will receive
a CME Attendance Certificate or
may choose any of the types of CE
credit being offered.

www.psychiatrictimes.com/cme EARN 30 FREE Category 1 CME Credits

Caffeine: Neurobiological and

Psychiatric Implications
Sergi Ferré, MD, PhD
molecules are remarkably similar in structure, and also have varying degrees of theophylline and theo-
Dr Ferré is Senior Scientist and Chief of the the non-caffeine members vary only in the place- bromine. The use of tea as a beverage is described
Integrative Neurobiology Section, National Institute ment of their two methyl groups (CH3). Caffeine as far back as 3000 BCE, and tea leaves are found
on Drug Abuse, Intramural Research Program, uniquely has a third methyl group and is metabo- throughout East Asia.1 The cocoa bean contains pri-
National Institutes of Health, Department of Health lized by the liver to varying percentages of the other marily theobromine, with some caffeine and virtu-
and Human Services, Baltimore, MD. three. All have psychostimulant properties but vary ally no theophylline. Cocoa bean residue has been
in other physiological effects. Theophylline also found in a Mayan pot dating back to 600 BCE.1

C
affeine requires no introduction as it is the functions as a bronchodilator, and, not surprisingly, Historically, it has been challenging to elucidate
most commonly consumed psychotropic is used in the treatment of asthma and chronic ob- the mechanism of action of caffeine as a CNS psy-
drug in the world. It is primarily used for its structive pulmonary disease. Theobromine has sig- chostimulant. Previous competing theories includ-
predictable psychostimulant properties on nificant diuretic properties in addition to its weak ed: increase in calcium release; inhibition of the
the CNS. As with many drugs found in nature, it psychostimulant effects. Paraxanthine does not enzyme phosphodiesterase that results in an in-
naturally occurs in select plant species located in exist naturally in any plants but is the most common crease in the secondary messenger cAMP; and in-
Africa, East Asia, and South America. For these metabolite of caffeine in humans. teraction with adenosine receptors. This third theo-
plants, it serves as an insecticide and a fungicide. It The coffee bean, which seems to have originated ry is now believed to be the primary mechanism by
is commonly found in the leaves, seeds, and/or nuts in Yemen, has only caffeine. It was first described which caffeine acts as a psychostimulant.
of coffee, tea, and cocoa plants. around 1450, at which time Sufi monks used the Caffeine, which is similar in structure to adenos-
Caffeine is a member of the molecular class coffee bean to make a beverage to help with wake- ine, is a competitive antagonist of adenosine A1 and
methylated xanthines, which also includes theoph- fulness while praying in their monasteries in A2A receptors (A1R and A2AR). The psychostim-
ylline, theobromine, and paraxanthine. All four Yemen.1 Tea leaves contain primarily caffeine, but ulant effects of caffeine can be neurobiologically

ACTIVITY GOAL through the joint providership of CME Outfitters, LLC, and Psychiatric Sergi Ferré, MD, PhD, has no disclosures to report.
The goal of this activity is to provide an understand- Times. CME Outfitters, LLC, is accredited by the ACCME to provide
Cyril Willson (peer/content reviewer), has no disclosures to report.
ing of the mechanisms involved in the innervating continuing medical education for physicians.
effects of caffeine and the impact that caffeine may John J. Miller, MD (peer/content reviewer), has no disclosures to
CME Outfitters designates this enduring material for a maximum
have on psychiatric disorders. report.
of 1.5 AMA PRA Category 1 Credit™. Physicians should claim only
LEARNING OBJECTIVES the credit commensurate with the extent of their participation in the Applicable Psychiatric Times staff and CME Outfitters staff have no
activity. disclosures to report.
At the end of this CE activity, participants should be able to:
• Discuss the pharmacokinetics of caffeine Note to Nurse Practitioners and Physician Assistants: AANPCP UNLABELED USE DISCLOSURE
and AAPA accept certificates of participation for educational activi- Faculty of this CME/CE activity may include discussion of products or
• Explain the adenosine-dependent modulation of striatal dopamine
ties certified for AMA PRA Category 1 Credit™. devices that are not currently labeled for use by the FDA. The faculty
and glutamate neurotransmission
have been informed of their responsibility to disclose to the audience
• Describe the adenosine-dependent modulation of glutamate neuro- DISCLOSURE DECLARATION if they will be discussing off-label or investigational uses (any uses
transmission in the amygdala It is the policy of CME Outfitters, LLC, to ensure independence, bal- not approved by the FDA) of products or devices. CME Outfitters, LLC,
• Recount the implications of caffeine on anxiety ance, objectivity, and scientific rigor and integrity in all of their CME/ and the faculty do not endorse the use of any product outside of the
CE activities. Faculty must disclose to the participants any relation- FDA-labeled indications. Medical professionals should not utilize the
TARGET AUDIENCE ships with commercial companies whose products or devices may be procedures, products, or diagnosis techniques discussed during this
This continuing medical education activity is intended for psychia- mentioned in faculty presentations, or with the commercial supporter activity without evaluation of their patient for contraindications or
trists, psychologists, primary care physicians, physician assistants, of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, dangers of use.
nurse practitioners, and other health care professionals who seek and attempted to resolve any potential conflicts of interest through a
to improve their care for patients with mental health disorders. rigorous content validation procedure, use of evidence-based data/ For content-related questions, email us at
research, and a multidisciplinary peer-review process. [email protected];
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AUGUST 2019 PSYCHIATRIC TIMES 33
CATEGORY 1
dissociated into psychomotor activation and in- behavioral activation in response to specific stimuli,
creased arousal. Both pharmacological properties more specifically, to reward-related stimuli (re-
Figure 1. Distribution of
are responsible for the wide use of caffeine. The in- wards, conditioned rewards, or discriminative stim- A2AR in the basal ganglia
creased arousal is related to the caffeine-mediated uli that signal the proximity of rewards). Psycho- of different mammalian
counteraction of the effect of adenosine on homeo- stimulants also have reinforcing properties—the species:
static sleep. Caffeine counteracts the adenosine-me- psychostimulant, itself, acts as a “reward” (ie, re- in situ hybridization shows a very
diated sleepiness induced by prolonged wakeful- warding stimulus or reinforcer), implying that it
ness, mostly by acting on A1R that control the elicits approach and work to obtain it.
high level of A2AR mRNA in the
activity of ascending arousal systems. On the other These properties of psychostimulants are similar different striatal areas, including the
hand, caffeine produces psychomotor activation by to those of dopamine in the brain and, particularly, caudate–putamen (C-P), the nucleus
acting preferentially on A2AR, by indirectly con- in the striatum, the brain area with the highest dopa- accumbens (NACC), and the olfactory
trolling striatal dopaminergic transmission. mine innervation and the highest density of dopa- tubercle (OT) in mouse (A), rat (B),
mine receptors. Thus, activation of the central dopa-
Pharmacokinetics of caffeine mine system is involved with increasing
dog (C), and human (D) brain as
After drinking a beverage containing caffeine, it responsiveness to reward-related stimuli—with ori- compared to other areas, such as
takes from 30 minutes to 2 hours to reach its maxi- enting and approaching responses to those stimuli— the cortex (CX).
mum serum concentration on average. Because of thus reward-oriented behavior. Concomitantly, do-
its property of solubility in both lipids and water, it pamine is directly involved with the learning
is rapidly distributed evenly in all tissues throughout (“stamping-in”) of stimulus-reward and reward-re-
the body. It readily crosses the blood-brain barrier, sponse associations that follows the receipt of re-
allowing rapid access to receptors in the brain. ward.
There are a number of factors that can affect the Stimulus-reward associations lead some stimuli
metabolism of caffeine in humans, and hence its to acquire discriminative properties that signal the
pharmacokinetics. The average half-life of caffeine proximity of the reward or even to acquire rewarding
in humans is 2 to 6 hours. Caffeine is metabolized by properties (ie, conditioned rewarding stimuli),
the liver in first pass metabolism through the cyto- which become themselves behavioral attractors. The
chrome P450 1A2 enzyme (CYP450 1A2). In addi- stamping-in of reward-response associations pro-
tion to being a substrate for CYP450 1A2, caffeine motes positive reinforcement, the learning of the
is also a moderate inhibitor of this enzyme.2,3 optimal sequential response—the action skill—that
These properties have significant consequences leads to the reward.
for how the metabolism of caffeine is affected by Dopamine cells increase their activity by the cues
some drugs, and how other drug metabolisms are that predict the occurrence of the reward (discrimi-
Adapted from Schiffmann et al.18
affected by caffeine. The most common drug-drug native/conditioned reward stimuli) and when the
interaction, which can have a clinical effect on how reward is better than expected (positive reward pre- nosine receptors to establish molecular interactions
much caffeine is required to achieve a psychostimu- diction error), in which case there is a phasic in- and inhibitory modulations of dopamine receptors.
lant effect, is related to smoke. It is well established crease in striatal dopamine. This dopamine increase Postsynaptic A2AR play the most significant role in
that smoke from any source (nicotine cigarettes or promotes activation of excitatory dopamine D1 re- the modulation of striatal dopamine neurotransmis-
cigars, cannabis cigarettes, lengthy and prolonged ceptors (D1R) and inhibitory dopamine D2 receptors sion.4,5
exposure to smoke from a wood fire) induces the (D2R), which have low and high affinity for dopa- Apart from the high expression of D2R, the stria-
liver’s CYP450 1A2 enzyme—gradually increasing mine, respectively. D1R and D2R are separately lo- topallidal neuron expresses the highest density of
the activity of this enzyme by continuous smoke ex- calized in the striatal cells that respectively consti- A2AR in the brain (Figure 1). Experimental data
posure over 2 weeks. This induction results in in- tute the “Go” (excitatory) and “No Go” (inhibitory) indicate that striatal A2AR constitute the main target
creased metabolism of caffeine by the CYP450 1A2 striatal efferent neuronal outputs. responsible for the psychomotor activating and re-
enzyme, requiring more caffeine to attain the same The respective activation and inhibition promote warding effects of caffeine (for recent review, see
blood level as would be required in a non-smoker.1,2 the elicitation and learning of positively reinforced Ferré4). Significantly, the predominant populations
Estradiol inhibits the metabolism of caffeine; behaviors (approach behaviors). But dopamine cells of both A2AR and D2R in the striatopallidal neuron
hence taking estradiol on a regular basis requires less also receive signals related to aversive stimuli and establish strong functional and intermolecular inter-
caffeine to achieve the same level as being off estra- increase their activity with cues that predict the suc- actions, forming A2AR-D2R heteromers (a receptor
diol. During pregnancy—a high estrogen state—the cessful avoidance of an aversive stimulus. Conse- complex of, at least, two different receptors). With a
half-life of caffeine can be increased up to 15 hours quently, there is elicitation and learning of negative- significant lower density, A2AR are also localized
in the third trimester. The SSRI fluvoxamine, FDA ly reinforced behaviors. presynaptically in corticostriatal glutamate termi-
approved to treat obsessive compulsive disorder, is a On the other hand, aversive stimuli (or cues that nals, where they form heteromers with A1R.4
potent inhibitor of CYP450 1A2 and has been shown predict a non-avoidable aversive stimulus) produce Recent studies have provided details about the
to increase caffeine’s half-life 10-fold.2,3 inhibition of dopamine cell activity, which leads to molecular structure and functional properties of
Moreover, caffeine can elevate blood levels of the loss of a tonic activation of the high affinity D2R A2AR-D2R and A1-A2A receptor heteromers. They
some medications that can have significant clinical by endogenous dopamine. The consequent increase constitute heterotetramers (with homodimers of
effects. Through its activity as a moderate inhibitor at in the activity (by release of the D2R-mediated neu- A2AR and D2R or A2AR and A1R) that form part of
the CYP450 1A2 enzyme, caffeine can increase the ronal inhibition) of the “No Go” neuronal output, large pre-coupled signaling complexes that include
serum levels of clozapine and warfarin. Patients who which is represented by the striatopallidal neurons, their cognate G proteins and the effector adenylyl
are taking clozapine can be challenging to maintain leads to freezing/withdrawal/escape behaviors.4,5 cyclase (Figure 2).5-7 The A2AR-D2R heterotetram-
at a steady serum level, as smoking cigarettes will Classic psychostimulants, such as cocaine, meth- er acts as an integrative molecular device that allows
decrease clozapine levels and drinking caffeinated ylphenidate, and amphetamine, activate the dopa- reciprocal antagonistic interactions between ade-
beverages will increase clozapine levels.2,3 mine system by increasing the concentration of ex- nosine and dopamine to facilitate a switch in the
tracellular dopamine. In contrast, caffeine A2AR-mediated activation versus D2R-mediated
Adenosine-dependent modulation of potentiates the effects of dopamine by counteracting inhibition of the striatopallidal neuron. In fact,
striatal dopamine and glutamate adenosine neurotransmission. Blockade of A1R and A2AR activation is responsible for the increase in
neurotransmission A2AR in the striatum by caffeine releases the brake the activity of the striatopallidal neuron and the con-
Psychomotor activation is a major pharmacological that endogenous adenosine exerts on dopamine ac- sequent freezing/withdrawal/escape behaviors in-
effect of psychostimulants and classically implies a tivation, which is related to the ability of both ade- duced by release of the D2R-mediated neuronal in-
34 PSYCHIATRIC TIMES AUGUST 2019

CATEGORY 1
hibition upon exposure to punishment-related form a neutral stimulus into an aversive conditioned behavioral response that avoids the interaction with
stimuli. Caffeine or selective A2AR antagonists, on stimulus. the aversive stimulus, requires the suppression of
the other hand, block these effects and potentiate the The central nucleus of the amygdala is the major fear conditioning. This system provides a significant
effects of endogenous dopamine on D2R-mediated amygdalar output. For instance, its projections to the additional mechanism by which dopamine pro-
neuronal inhibition, promoting an apparent psycho- periaqueductal gray are involved in conditioned motes negative reinforcement during the establish-
motor activation as a result of inhibition of freezing/ stimulus-induced freezing. Information from the ment of an avoidance behavior—the switch “from
withdrawal/escape from punishment-related stimu- lateral to the central nuclei is conveyed by the basal fear to safety.”
li.4,5 nucleus and the intercalated cell masses. The ade- Although still speculative, the anxiolytic effects
The striatal A1R-A2AR receptor heteromer con- nosine control of glutamate transmission onto the of low doses of caffeine could be mostly mediated
stitutes a molecular device to fine tune glutamate pyramidal neurons of the basal nucleus of the amyg- by blockade of striatal postsynaptic A2AR (in the
transmission. Low concentrations of adenosine acti- dala seems particularly critical. The A1R-mediated A2AR-D2R heteromers) and presynaptic A1R (in
vate A1R, which inhibits glutamate release, while inhibition or an A2AR-mediated activation of the the A1R-A2R heteromers) in the posterior-medial
higher concentrations also activate A2AR, which pyramidal cells of the basal nucleus leads to a re- shell of the NAc, which should be expected to poten-
causes the opposite effect. Since there is a predomi- spective decrease or increase in fear conditioning.8-10 tiate fear extinction. With higher doses of caffeine or
nant tonic activation of presynaptic A1 versus The opposite effects of A1R and A2AR blockade with an increased expression of A2AR, as in the
A2AR, caffeine acts mostly as a presynaptic A1R have been documented experimentally, with A1R presence of anxiety susceptibility A2AR gene poly-
antagonist and promotes a facilitation of striatal glu- antagonists facilitating, while A2AR antagonists de- morphisms, striatal presynaptic A2AR blockade (in
tamate transmission, which locally promotes dopa- crease fear conditioning.8-10 Therefore, adenos- the A1R-A2AR heterodimer) would promote anxi-
mine release from striatal dopamine terminals, ine-mediated modulation of glutamate transmission ety.
therefore adding to the postsynaptic potentiation of in the amygdala represents a potential mechanism
dopamine transmission mediated by the A2AR- for the documented effects of caffeine on anxiety. Conclusion
D2R heteromer in the striatopallidal neuron.4,7 Caffeine is a naturally occurring psychotropic drug
Caffeine and implications for anxiety that has been used for its psychostimulant effects by
Adenosine-dependent modulation of Anxiety disorders are common in psychiatry, and humans for thousands of years. It is legal and re-
glutamate neurotransmission in the anxiety is a common symptom in many other psy- quires no regulation, ubiquitous in most cultures,
amygdala chiatric disorders. It is generally known that low and used by all age groups. Although found natural-
The striatum is not the only localization of A1R and doses of caffeine can be anxiolytic and high doses ly in coffee beans, tea leaves, and cocoa beans, it is
A2AR in the brain; adenosine also controls gluta- can be anxiogenic, particularly in susceptible indi- added to many beverages that are consumed daily
mate neurotransmission in other brain areas, such as viduals. Several studies indicate that a common for its psychostimulant effects.
the amygdala, by segregated presynaptic A1R and block of polymorphisms of the A2AR gene (grouped Caffeine is also used in a variety of over-the-
postsynaptic A2AR (expressed with significantly by linkage disequilibrium) that is associated with an counter medications to treat various symptoms,
lower levels than in the striatum).8-10 The amygdala increased expression of A2AR in the brain, predis- ranging from headaches to somnolence. Further-
is the critical substrate of Pavlovian aversive condi- poses to panic attacks and to the anxiogenic effects more, caffeine has a wide array of other physiologi-
tioning, (ie, fear conditioning). The conditioned and of caffeine.11-13 Based on the role of amygdalar A1R cal effects that we continue to discover and charac-
unconditioned aversive stimuli converge in the later- and A2AR on fear conditioning, A1R blockade, and terize. There is now a solid body of research that
al nucleus, where a variety of cellular events trans- not A2AR blockade, should lead to anxiogenic ef- supports caffeine’s mechanism of action as a psy-
fects, making it difficult to explain the role of A2AR chostimulant resulting from it being a non-compet-
gene polymorphisms in anxiety and caffeine-in- itive antagonist on adenosine receptors, in part
Figure 2. The A2AR-D2R duced anxiety. But the involvement of A2AR local- through their ability to interact with dopamine re-
heterotetramer- ized in the most posterior and medial part of the ceptors.
ventral striatum, with its putative role in fear extinc- However, much work remains to be done, partic-
AC5complex.
tion—the suppression of fear (more appropriately ularly in relation to the psychiatric implications.
Schematic slice-representation, threat) conditioning—provides a possible way out Clinical studies are needed that specifically evaluate
viewed from the extracellular side, of of this conundrum. the role of caffeine and A2AR antagonists in persons
the minimal functional unit of the Apart from the dopamine neurons that respond with anxiety. In order to establish the therapeutic
A2AR-D2R heterotetramer in complex with a decrease in their activity upon presentation of versus anxiogenic doses of caffeine, studies should
an aversive and punishment-related stimulus, a spe- control for the role of anxiety susceptibility of A2AR
with Gs (more specifically Golf) and Gi
cific population of dopamine cells increases its ac- gene polymorphisms, as well as polymorphisms of
proteins (with GƠ and GơƢ subunits) tivity. In rodents, this neuronal subpopulation seems the gene for CYP450 1A2, which determine signif-
and adenyl cyclase (subtype AC5). to be mostly localized in the most medial and poste- icant individual pharmacokinetic differences of caf-
rior part of the ventral tegmental area (VTA), which feine.
specifically projects to the most posterior-medial However, this would still provide an incomplete
part of the ventral striatum, the posterior-medial picture because of the large variety of exogenous
shell of the nucleus accumbens (NAc).14,15 This area and endogenous factors, such as age, sex, hormonal
of the striatum is mostly innervated by the rodent status, diet, smoking, and exposure to drugs that in-
infralimbic cortex, equivalent to the rostral anterior fluence caffeine intake, absorption, metabolism and
cingulate cortex (ACC) in humans. pharmacological effects. An additional complica-
The infralimbic cortex innervates the intercon- tion is the recent discovery of the psychomotor ef-
nected posterior-medial portions of the VTA and fect of paraxanthine, the main metabolite of caffeine
shell of the NAc, the amygdala, and the insular cor- in humans, which is related to its additional specific
tex, and this circuit plays a key role in fear extinc- ability to inhibit a cGMP-preferring phosphodiester-
tion. Specifically, the amygdalar input from the in- ase.17
fralimbic cortex corresponds to the intercalated
masses. These correspond to GABAergic inhibitory
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Polypharmacy prescribing clozapine in combina- where monotherapy often provides Canada; Dr De Sousa is Consultant
Continued from page 25 tion with other drugs without blood insufficient symptom improvement. Psychiatrist, Desousa Foundation,
monitoring; other psychiatrists did The dilemma is the number of over- Mumbai, India; and Ms Lodha is
neurotransmitters are implicated in not use the drug, thus depriving pa- whelming drug possibilities availa- Research Assistant, Desousa
psychiatric disorders and polypharma- tients of possible better outcomes.13 ble and the need to be aware of the Foundation, Mumbai. The authors re-
cy can target several receptor sites al- There is a need for proper clinical right permutations and combina- port no conflicts of interest concern-
lowing multiple symptom recovery titration, sound treatment algo- tions. This perplexing decision is left ing the subject matter of this article.
and quicker improvement.11 rithms, and well-defined protocols to the clinician where rational pre-
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We offer an easily accessible location within a beautiful residential Bronx neighborhood,
We offer an easily accessible location within a beautiful residential Bronx neighborhood,
generous compensation package, as well as unparalleled health benefits, opportunities for generous compensation package, as well as unparalleled health benefits, opportunities for
advancement, retirement plan, malpractice, Sponsorship for H1 & J1 Visas, and much more! advancement, retirement plan, malpractice, Sponsorship for H1 & J1 Visas, and much more!
For immediate confidential consideration, please contact: Carmen Velez – Office of Physician For immediate confidential consideration, please contact: Carmen Velez – Office
Recruitment: [email protected] 646-494-7559 of Physician Recruitment: [email protected] 646-494-7559

www.pagny.org www.pagny.org
Physician Affiliate Group of New York [PAGNY] provides services to NYC Health + Hospitals Corporation (H + H), Physician Affiliate Group of New York [PAGNY] provides services to NYC Health + Hospitals Corporation (H + H),
the largest public healthcare system in the United States. EOE M/F/D/V the largest public healthcare system in the United States. EOE M/F/D/V

RECRUITINGFULLTIME&PERDIEMPSYCHIATRISTS
NEWYORKMETROAREAS
NorthwellHealth’sBehavioralHealthServiceLinestrivestoaddressthediversementalhealthneedsofthecommunitiesweservebyprovidinga
continuumofaccessible,highqualitypsychiatricandsubstanceabuseservicesincludingemergency,crisis,inpatient,andoutpatientprogramsforpeople
ofallages.Northwell’s clinicalprogramsarecomplementedbyarobusteducation,training,andresearchenterprise,includingtheworldrenowned
PsychiatryResearchDepartmentatTheZuckerHillsideHospital,whichhasledcuttingedgeinvestigationsthathavemeaningfully influencedmanylives.

TOBOLSTEROURNETWORKOFOUTSTANDINGCAREPROVIDERS,
WEARERECRUITINGBOARDELIGIBLE/BOARDCERTIFIEDPSYCHIATRISTSFORTHEFOLLOWINGPOSITIONS:

GERIATRICOUTPATIENTPSYCHIATRIST ADULTINPATIENTPSYCHIATRIST DIRECTOR,OUTPATIENTMENTAL TELEPSYCHIATRIST

TheZuckerHillside Hospital SouthOaksHospital HEALTHCLINIC GreenwichVillageHealthPlex
GlenOaks,NY Amityville,NY LenoxHillsideHospital(MEETH) GreenwichVillage,NY
Manhattan,NY
NorthernWestchester Hospital
CONSULTATIONLIAISONPSYCHIATRIST CONSULTATIONLIAISONPSYCHIATRIST
Mt.Kisco,NY
LIJMC ForestHillsHospital,NY PhelpsHospital
StatenIslandUniversityHospital,NY Mt.Kisco,NY
StatenIslandUniversityHospital
StatenIsland,NY

HuntingtonHospital
Huntington,NY
BenefitsatNorthwellHealthinclude:

9 Nationallycompetitivesalaries 9 Academicappointmentcommensuratewithexperience
9 Comprehensivebenefitspackage 9 Advancededucationopportunities
9 Fourweeks’vacationpluspaidconference/CMEtime 9 CollegeTuitionreimbursementfordependentchildren

QualifiedcandidatesshouldforwardtheirCVto LanMa:[email protected]
38 CLASSIFIEDS AUGUST 2019

Department of Psychiatry
With the continued growth of our Department of Psychiatry and our New General Psychiatry Residency Programs
at Ocean Medical Center and Jersey Shore University Medical Center our vision for Behavioral Health is Bright.

As the area’s premier provider of psychiatric services,

Hackensack Meridian Health is a leading not-
Hackensack Meridian Behavioral Health Services has
for-profit health care network in New Jersey offering
a complete range of medical services, innovative provided comprehensive mental health and substance abuse
research, and life enhancing care aiming to serve as services to the residents of Monmouth, Ocean, Middlesex,
a national model for changing and simplifying health and Bergen Counties for over forty years. Due to continued
care delivery through partnerships with innovative growth and expansion, we are currently accepting
companies and focusing on quality and safety. applications for Psychiatrists to join our Mental Health and
Through a partnership between Hackensack Addiction Interdisciplinary Teams in the following positions:
Meridian Health and Seton Hall University, the
School of Medicine will re-define graduate medical • Inpatient Attending: Child/Adolescent and Adult/Geriatric
education, research, and clinical practice; reverse –Carrier Clinic (Belle Mead, NJ)
the critical physician shortage in both the New York/
New Jersey metropolitan area and the nation; and • Consultation Liaison Psychiatrists: Riverview Medical
stimulate economic development in northern New Center (Red Bank, NJ) and Hackensack University Medical
Jersey.
Center (Hackensack, NJ)
The School of Medicine will be the anchor in the
development of a comprehensive health sciences • Staff Psychiatrist for Adult Inpatient Unit: Jersey Shore
campus that will also include research facilities and University Medical Center (Neptune, NJ) and Riverview
biotechnology endeavors – all in service of Medical Center (Red Bank, NJ) and Hackensack University
educating tomorrow’s doctors, discovering novel
Medical Center (Hackensack, NJ)
therapies, and facilitating compassionate and
effective healthcare that will meet the ever- • Outpatient Child& Adolescent Psychiatrist: Hackensack
changing needs of tomorrow’s patients.
University Medical Center (Hackensack, NJ)
The School of Medicine will be the cornerstone of a
dynamic venue for the exchange of ideas, the • Outpatient General Psychiatrist: Jersey Shore University
development of healthcare and research thought Medical Center (Neptune, NJ), Riverview Medical Center
leaders and practitioners, and the discovery of novel
(Red Bank, NJ), and Raritan Bay Medical Center (Perth
therapies to meet the medical challenges of the
future. Amboy, NJ)
“Ocean Medical Center’s psychiatry program will be • Medical Director of Adult Inpatient Unit Riverview (Red
a community-based program,’’ said Ramon Bank, NJ)
Solhkhah, M.D., program director for psychiatry as
well as founding Chair of Psychiatry & Behavioral • Geriatric Psychiatry: Hackensack University Medical
Health at the Hackensack Meridian School of Center (Hackensack, NJ)
Medicine at Seton Hall University. “Our new
psychiatry residency program will improve clinical [email protected] or
care and ultimately encourage future health care call: 732 751-3597
leaders to build practices in the Jersey Shore area,’’
HackensackMeridianHealth.org

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 AUGUST 2019
CLASSIFIEDS 39
NATIONWIDE For more information contact:
Mark Blakeney, Voice: 972-420-7473,
Fax: 972-420-8233;
email: [email protected]
EOE.

Outpatient Psychiatry Opportunity

Aligned Telehealth, Inc. – California CALIFORNIA San Joaquin County Behavioral Health
Our mission is to be the leader in Services is seeking to fill Outpatient Adult
innovative, high quality, accessible [General], and Sub-Specialty Psychiatry
behavioral health solutions. Explore (Child Psychiatry, Geriatric, Forensic,
opportunities in multiple states. Addiction and Psychosomatic Medicine)
Hiring MULTIPLE Psychiatrists for positions in a multidisciplinary, recovery-
Telemedicine and Onsite positions in oriented clinical setting. Services are
the following states provided either on-site or using a hybrid
Locum Psychiatrists needed model of on-site and tele-psychiatry
CA, TX, NV, AZ, FL, OR, and Ref/Sign Bonuses practice. The positions offer a very
Many other states. Full time and Part Time CA State Hospitals $275 to $280/hr competitive salary with a guaranteed base,
positions are available. $1/2 Million to ¾ Million plus/year. plus incentive opportunities, board certified
$185-$300/hr. Psychiatrists have the potential to easily earn
We offer competitive salaries and CA Counties, Prisons, DMH-LA, over 300K+ a year; comprehensive health
excellent benefits! Telepsychiatry, A+ Occurrence Insurance insurance; up to three retirement and pension
www.imperiallocum.com programs; 35 days of vacation and CME
Immediate Need for BC Psychiatrist FL Call: 559-799-8344 Fax: 888-712-2412
Medical license – Onsite time that increase with tenure. Signing and
Email: [email protected] moving bonuses are also available.
VERO BEACH, FL Interested J-1 and H-1B candidates are
SIGN ON BONUS- RELOCATION Outpatient Adult and Child Psychiatrists are welcome to apply.
PROVIDED. OUTSTANDING needed for Stanislaus County Behavioral Contact Khurram Durrani, MD at:
SALARYAND BENEFITS Health & Recovery Services, in the Central [email protected];
Valley less than two hours from San Fax CV to 209-468-2399. EOE.
Immediate Need for BC Psychiatrist Francisco and Yosemite.
with CA license for several outpatient
Psychiatrist Position
and inpatient sites Recovery-oriented treatment provided in a
multidisciplinary setting with friendly and J-1 Visa Opportunity in California
Contact Sandra Williams at 818-814-7790 dedicated staff members. Recently revised Imperial County Behavioral Health Services
or email me your current CV to rates with full malpractice coverage and is currently recruiting for a full time
[email protected] pension plan (PARS) as a Personal Service psychiatrist. Imperial County is located 90
To be considered for these contractor with an income potential of over miles by freeway to the city of San Diego to
great opportunities. $325 K per year for adult psychiatrist and the west, and 90 miles to Palm Springs to the
over $355 K per year for child psychiatrist north. Located in a rich farming area,
for F/T work. Imperial County has a population of 180,000
ALABAMA and borders with Yuma, Arizona and with the
P/T options and the opportunity to combine
cosmopolitan city of Mexicali, Mexico The doctors of TRADITIONS
Horizon Health seeks a Medical Director Tele-Psych with limited onsite work are also
population 1.2 million. San Diego State BEHAVIORAL HEALTH are the largest
for our Geriatric inpatient psychiatric available. Excellent work environment with
University maintains a satellite campus in provider of MD psychiatric services to adult
program at our client hospital, North NO Call Requirement, lower than average
Calexico and there are a number of private populations in institutional and community
Baldwin Infirmary, in Bay Minette, AL, case load and comprehensive nursing &
and public universities located in Mexicali, based programs in California. We provide
one hour north of the beautiful beaches in ancillary support makes this a very pleasant
the state capital of Baja California Norte. services to the seriously and persistently
Gulf Shores, AL. Excellent clinical team, and rewarding opportunity. J 1 applicants are
Imperial County’s location and diversity mentally ill and have openings in the San
attractive income, great marketing support welcome.
make it the perfect place for a psychiatrist to Francisco Bay Area, Santa Barbara, San
and outstanding resources from the nation’s relocate under the J-1 Visa program or for
Fax CV to Bernardo Mora, MD at Diego and Los Angeles. Overall we plan to
largest psychiatric contract management any reason.
(209) 558-4326 or Email: add 50 more Fulltime psychiatrists in
company.
[email protected] California to bring our medical staff team to
The position pays a highly competitive
400 psychiatrists. Our packages vary from
For more information contact: salary, including health benefits for you and
a minimum of $300,000 per year plus
Mark Blakeney, Voice: 972-420-7473, your family, and requires no hospital work
$10,000 in bonuses and a benefit package
Fax: 972-420-8233; and minimal after hours work freeing you up
valued at approximately $90,000, to up to
email: [email protected] for more leisurely activities.
$500,000, for the industrious physician.
EOE.
The successful candidate diagnoses and Our generous benefit package includes
Multidisciplinary treats patients with mental, emotional, and almost 7 weeks paid time off per year. If you
behavioral disorders. Qualified candidate are creative and think outside the box, if you
ARIZONA telemedicine medical group looking for
must have CA medical license or ability to value diversity and cultural competency, if
additional California licensed
Telepsychiatrists. obtain. you like innovative programs that are patient
Show Low, AZ!
Contact us at 661-840-9270 or inquire driven, using a rehabilitative, rather than
Horizon Health, in partnership with Send CV to Imperial County Behavioral
with CV at [email protected] illness model, if you want more time to work
Summit Healthcare Regional Medical Health Services, 202 North 8th Street,
Center in Show Low, AZ, is seeking a with patients, to get the best results, then TBH
El Centro, CA 92243. is the company for you. To learn more about
Medical Director for a new 12-bed geriatric
inpatient psychiatric program to open in J-1 applicants welcome. the specific job openings and salary and
December, 2019. Position will offer an Our competitive rates benefit packages, check out our Website at:
attractive Base Salary, Medical Director’s For additional information,
www.tbhcare.com or Email your letter of
Stipend and a full array of benefits! The
Medical Director will provide rounding and
can help you promote please contact:
interest and CV to our company President,
Kristen Smith (442)265-1606 Gary A. Hayes, Ph.D. at:
treatment on patients for the inpatient
program, as well as program administration
physician products and [email protected] [email protected]
and oversight services regarding service line TBH is an equal opportunity employer
policies, practice, development, compliance, services. www.psychiatrictimes.com
and performance improvement.

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 40 CLASSIFIEDS AUGUST 2019

FLORIDA
Chief of Psychiatry
BE or BC psychiatrist needed. Following Steward Health Care System
locations have immediate openings: Carney Hospital, Dorchester, MA

• Modesto/Ceres, CA: Schedule: 40hrs per Carney Hospital in Dorchester, MA, is seeking a Chief of Psychiatry to
week. Pay Rate: $291,200 - $364,000
• Oakland, CA: Schedule: 20 hours per
lead our comprehensive Psychiatry Program. This is a full-time position
week Pay Rate: $140 - $150 per hour which involves administrative oversight and direct patient care for patients
• Oakland, CA: Schedule: 8 hours per week admitted to Carney Hospital. The ideal candidate will be a team player with
Pay Rate: $166 - $187 per hour strong verbal and written communication skills, as well as a track record
(Contractor) of providing leadership and quality care. The ideal candidate will also
• Stockton, CA: Schedule: 16 hours per UNIVERSITY OF MIAMI, work closely with hospital administration in helping grow the behavioral
week Pay Rate: $182 - $205 per hour DEPARTMENT OF PSYCHIATRY health services at Carney Hospital. The Chief of Psychiatry will be part of
(Contractor) SYLVESTER COMPREHENSICE
• Anaheim, CA: Schedule: 30 hours per
an experienced and collegial team, and will be eligible for an academic
CANCER CENTER appointment at Tufts University School of Medicine.
week Pay Rate: $166 - $185 per hour
(Contractor); $128 - $144 per hour EXCEPTIONAL PSYCHIATRY
(Employee) with Benefits. OPPORTUNITY Carney Hospital, in the Dorchester neighborhood of Boston, MA, has a
• For additional listings, please visit: Consultation-Liaison Psychiatrist robust array of services, including a 20-bed adult unit for short-term crisis
www.telecarecorp.com/physician-jobs/ intervention, a 14-bed adolescent unit, and a 16-bed older adult/geriatric
The Department of Psychiatry at the unit. We also have partial hospitalization and outpatient programs.
You will work as part of a multidisciplinary University of Miami and The Sylvester
team. The staff is all very friendly and it is a Comprehensive Cancer Center announces a
supportive working environment. Carney Hospital is a member of Steward Health Care, the largest private,
search for an academic psychiatrist with
interest and experience in psychosomatic
physician-led health care network committed to providing the highest
Please email your resume to tlcrecruiting@ medicine and psycho-oncology. Applicants quality of care in the communities where patients live. Steward operates
telecarecorp.com can anticipate working collaboratively with 37 community hospitals across nine states and the country of Malta
fellow psycho-oncology providers including serving over 800 communities, with more than 42,000 employees.
EOE M/F/V/Disability five psychologists, a psychiatrist and a team
of oncology social workers. If you are interested in learning more, or would like to apply,
CONNECTICUT JOB DESCRIPTION
please contact:
Providing psychiatric consultation-liaison Kerry Ciejek, Senior Physician Recruitment Specialist
services in either inpatient, outpatient or Steward Health Care
both oncology settings across the oncology E: [email protected]
enterprise
Participation as a member of the Department $OOLQTXLULHVZLOOUHPDLQFRQ¿GHQWLDO
of Psychiatry and Behavioral Sciences Learn more about Steward at:
Natchaug Hospital seeks Adult Patient Participating in teaching activity for
Psychiatrist in Mansfield, CT to: provide www.stewardphysicians.org EOE
advanced trainees to ensure the highest level
psychiatric services to adult and older adult of educational excellence.
patients on inpatient units and in partial
CV and cover letter may be sent directly to
hospitalization programs and outpatient QUALIFICATIONS OF THE MASSACHUSETTS [email protected].
services as required by patient coverage PSYCHIATRIST
needs; perform diagnostic admission • Board certification in Psychiatry. CHA is an equal opportunity employer and
evaluations, psychotherapy, and • Board eligibility/certification in C-L all qualified applicants will receive
Psychiatrist Opportunities -
psychopharmacology, as appropriate; and Psychiatry would be preferred but consideration for employment without regard
Cambridge Health Alliance (CHA)
provide rotational coverage at Natchaug experience will be considered. to race, color, religion, sex, sexual orientation,
Hospital in Mansfield, CT, Windham CHA, a well-respected, nationally recognized gender identity, national origin, disability
Hospital in Willimantic, CT, and William W. COMPENSATION & BENEFITS and award-winning public healthcare system, status, protected veteran status, or any other
Backus Hospital in Norwich, CT during This dynamic position commands an is seeking full- and part-time Psychiatrists. characteristic protected by law.
days, nights, weekends, vacations and extremely competitive salary enhanced by We are comprised of three campuses and an
holidays. Minimum requirements: an attractive benefits package, including but integrated network of primary and specialty
possession of US M.D. degree or its foreign not limited to: outpatient care practices. Our competitive rates
equivalent; completion of four-year • Competitive compensation including
ACGME-accredited residency training bonus programs, vacation CHA offers inpatient and outpatient can help you promote
program in general psychiatry; eligibility for Psychiatry services for all ages. Psychiatrist
or possession of certification in psychiatry
• Comprehensive benefits include: health/
dental/vision, paid malpractice, 403(b) plan opportunities are available in our Adult, physician products and
by American Board of Psychiatry and Child/Adolescent, and Consultation-
Neurology; prior experience with adult Liaison services. services like these:
The University of Miami (UM) Miller School
inpatient and older adult patient evaluation of Medicine is an academic medical center
services and with multidisciplinary team with extensive clinical facilities including the
CHA offers a collaborative practice • Medical transcription
treatment model; eligibility for participation environment with an innovative clinical
in federal health programs as defined by 42
Sylvester Comprehensive Cancer Center model. As a teaching affiliate of Harvard • Practice management
(Sylvester). All Sylvester physicians are on Medical School; academic appointments are
USC § 1329-7b(f); eligibility for or the faculty of the Miller School of Medicine, • Internet Services
possession of Connecticut medical license, available commensurate with medical school
South Florida’s only academic medical criteria.
Drug Enforcement Administration license center. • Insurance
and Connecticut controlled substance
Ideal candidates will possess excellent
registration. CV’s and letter of interest can be directed to clinical/communication skills and a strong
• Legal services
Maria Rueda-Lara, MD commitment to and passion for our
Apply to: Pamela Lasser,
Physician Recruiter, at 389 John Downey
email: [email protected] multicultural, underserved patient population. For details call
Drive, New Britain, CT 06051, at
[email protected] or at (203) 523-7026 Please visit www.CHAproviders.org
to learn more and apply.
(203) 523-7026
www.hhchealth.org/careers

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 AUGUST 2019
CLASSIFIEDS
NORTH CAROLINA OHIO
Cleveland Area Medical Director

Horizon Health seeks a Medical Director

UMass Memorial Health Care and the University of Massachusetts Medical School
for our Geriatric inpatient psychiatric
currently have openings within the Department of Psychiatry.
We Want You to Join Our Behavioral program at our client hospital, Lake Health
The Department of Psychiatry is a national leader in public sector psychiatry, child and adolescent Health Team! – Tri-Point Medical Center, in Concord,
psychiatry, psychosocial rehabilitation, women’s mental health, and addiction psychiatry. We integrate OH, Employment or Independent
our clinical, research, teaching and community partnership activities to help individuals and families Cape Fear Valley Behavioral Health is one Contractor Models available with
transform their lives through recovery from mental illness and addiction. We are the largest provider of the largest comprehensive, multi-tiered Psychiatric Nurse Practitioners’ support for
of psychiatric services in central Massachusetts, with over 370 faculty members and 12 hospitals and behavioral health services in North call coverage. State of the art facility and
community mental health centers. Carolina. Behavioral Health Care’s mission beautiful new 20-bed geriatric inpatient
is to meet and respond to the mental health unit. Excellent clinical team, great
Our residency program trains 7 residents per year, including general psychiatry and specialty tracks
for combined adult and child psychiatry and combined neurology. We offer fellowships in Child and
needs of the community. We offer evidence- marketing support and outstanding
Adolescent Psychiatry, Addiction Psychiatry, Forensic Psychiatry, Neuropsychiatry, and Adult based, best practice treatments. Staffed by resources from the nation’s largest
Developmental Disabilities. psychiatrists, psychologists, clinical social psychiatric contract management company.
workers, psychiatric nurses, licensed
Interested candidates should send their curriculum vitae addressed to Dr. Sheldon Benjamin, MD. professional counselors, and other mental For more information contact:
health professionals, Cape Fear Valley Mark Blakeney, Voice: 972-420-7473,
School Positions Clinical Positions
Behavioral Health Care provides a team Fax: 972-420-8233;
Facility Medical Directors (Taunton State Chief Medical Officer (CHL, Worcester, approach to mental wellness. Behavioral
Hospital, Taunton, MA and Cape Cod and MA): Supervision of a large group of
email: [email protected]
Health Care is accredited by The Joint EOE.
Islands Mental Health Center, Pocasset, MA): professionals and participation in development Commission and licensed by the State of
Provides administrative and clinical oversight for efforts serving >22,000 individuals each year.
the DMH-operated and contracted state hospital
North Carolina.
The Health System is seeking providers for
and community support programs. Medical Director (Adult Outpatient
Psychiatry, Worcester, MA): the following due to regional volumes and
OREGON
Part-Time/Full-Time Psychiatrist (Cape Provides clinical operational effectiveness, commitment to expand services:
Cod and Islands Mental Health Center, quality of care, and serves as a liaison to the
Pocasset, MA): Work closely with two advance community of UMass Memorial Emergency Opportunity
practice psychiatric nurses, a consulting internist,
• Two BE/BC providers with experience
and a multidisciplinary team. Adult Attending Psychiatrist (CHL, Worcester,
MA): Outpatient clinic in Worcester serving a in ED or trained in ED/Psychiatry.
The Emergency Department maintains Physician-Scientist Staff Psychiatrist
diverse population with mental health and
substance use disorders. a Psychiatric Unit of 9 beds for patients
in crisis. Support team is specialty VA Portland Health Care System (in OR)
General Adult Outpatient Psychiatrist trained. Schedule consists of 16 hour is recruiting for a psychiatrist with
For additional information, please contact: (Worcester, Ma): expertise in clinical or health services
shifts, approximately 10 shifts per month.
Marie Hobart, MD, Vice Chair, Public Sector Outpatient services while providing behavioral research who can successfully compete for
Psychiatry healthcare services. research funding on topics relevant to
[email protected] Adult Outpatient Opportunity
Veterans including depression, suicide
Interested applicants should submit a letter • BE/BC provider with training/experience
Geoffrey Bottone
prevention, PTSD, chronic pain, substance
of interest and curriculum vitae addressed to in a variety of mental health treatment
[email protected]. Dr. Sheldon Benjamin, MD: use disorder, or schizophrenia. Research
conditions as well as Chemical
c/o: Jessica Saintelus, Physician Recruiter space, equipment, protected time and
Dependency and Substance Abuse.
Interested applicants should apply directly [email protected] other support to be negotiated. VA
at www.academicjobsonline.org http://jobs.jobvite.com/
Candidate
Portland is closely affiliated with Oregon
(J-1 and H-1B candidates are welcome to umassmemorialmedicalgroupphysicians/ with experience in treatment of Bipolar
Health & Science University (OHSU) and
apply) search?q=&d=Psychiatry Disorder, Borderline Personality Disorder,
the position includes an academic
and Mood Disorders is preferred. appointment at OHSU.
As the leading employer in the Worcester area, we seek talent and ideas from individuals of Additionally, ECT training and experience
varied backgrounds and viewpoints. is highly desirable. Well established Interested candidates should submit a
adult team is flexible and transparent for letter of inquiry and CV to Beau Edwards
either or both inpatient and outpatient
NEW JERSEY NEW YORK services. Clinic hours are Monday -
[email protected]. Applicants must
be US citizens and board certified/eligible
Friday with limited call in a psychiatry specialty.
Child Outpatient Opportunity
• BE/BC Child & Adolescent providers.
The current structure is for 90% outpatient
Monday through Friday work schedule.
If you are a board certified/eligible Child & We offer best in class compensation plus
Find What You’re
Adolescent Psychiatrist, who would enjoy
growing in a multidisciplinary practice, not Locum Psychiatrists needed
Ref/Sign Bonuses
generous benefits including Paid
Malpractice, CME Time and Allowance,
Looking For Now
dependent on managed care, we have a part-
time/full-time position available.
Responsibilities include: Psychiatric
$200-$250/hr.
Up to $1/2 Million plus/year.
Accrued Paid Time Off, 403(b) match and
457(b), Health, Dental, and other desirable Log on to:
State Hospitals/OMH NYC and Upstate benefits.
Evaluations, Medication Management and www.PsychiatricTimes.com/
Psychotherapy to an affluent, suburban All Locations, A+ Occurrence Insurance Please contact Suzy Cobb,
community, 30 miles from New York City. www.imperiallocum.com classifieds
Physician Recruiter for more details
Generous compensation and benefits are Call: 559-799-8344 Fax: 888-712-2412 at (910) 615-1889
available. Email: [email protected] or [email protected].
Send resumes to:
[email protected]
CALL FOR MORE INFORMATION
Find What You’re
Looking For Now (203) 523-7026
Qualify For A Free Subscription Online @ www.psychiatrictimes.com
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