Deepak Prabhakar
Henry Ford Health System
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Academic Psychiatry | 2013
Deepak Prabhakar; Joan M. Anzia; Richard Balon; Glen O. Gabbard; Emily Gray; Nick Hatzis; Nicole M. Lanouette; James W. Lomax; Paul Puri; Sidney Zisook
Losingapatienttosuicideisone ofthemost taxing emotional issues psychiatrists, psychiatry trainees, and other mental health workers ever face. Balon (1) noted that “we find it emotionally more tolerable to see our patients dying of cancer than of suicide.” Some psychiatrists reported stress levels in the weeks after a patient’s suicide comparable to levels reported in people seeking treatment after the death of a parent (2). Younger, less-experienced clinicians are more affected by patient suicide than older clinicians (2), and the psychological impact of patient suicide may be especiallypronounced in trainees (3). The most junior psychiatry trainees often care for the most challenging patients in minimally-structured settings (3). Poor outcomes may have profound effects on the trainee’s developing sense of self and may trigger feelings of personal failure. Reactions such as shock and disbelief, self-appraisal, and working through to a resolution have been described (4), as have feelings of shame, guilt, isolation, anger, abandonment, and fear of litigation (5). Despite patients’ suicide being an “occupational risk” for anyone caring for severely ill psychiatric patients, most training programs provide relatively little educational attention on helping trainees learn about and cope with the completed suicide of one of their patients (4, 6–8). Furthermore, a national survey of chief residents of psychiatry residency programsidentified lack of audio or video teachingmaterials as common barriers to education on suicide care (9). In an effort to fill this important training gap, we have developed an interactive curriculum to help psychiatrists, psychiatry trainees, and training programs cope with patient suicide. We developed a DVD, “Collateral Damages,” that provides multimodalteachingmaterialstoeducate,inform,and,most important, stimulate discussion in the aftermath of patient suicide. The Collateral Damages DVD consists of 1) a video program that includes introductory comments; five brief vignettes (two from senior faculty, two from junior faculty, and one from a trainee) on patients who killed themselves and the clinicians’ immediate emotions, thoughts, and behaviors; a panel discussion of the five psychiatrists who have provided their narratives plus two training directors, that focuses on universal themes, processes, and procedures to follow after a patient suicide, principles of dealing with families, critical-incident review, risk-management, and the roles of counseling/support trainees and colleagues, and closingcomments;2)aPowerPointpresentationemphasizing suicide-related basic epidemiological facts, emotional reactions to patient suicide,and a brief overviewofresources available to grieving individuals; 3) a patient-based case learning exercise covering Accreditation Council for GraduateMedicalEducation(ACGME)competenciesasameans
The Primary Care Companion To The Journal of Clinical Psychiatry | 2013
Deepak Prabhakar
To the Editor: Use of hallucinogens among school-age children (grades 8, 10, and 12) has been declining.1 However, because hallucinogen use has a lifetime prevalence of 5% in this age group, hallucinogens continue to be a serious public health concern.1 Within the class of hallucinogens, the use of lysergic acid diethylamide (LSD) has declined compared to the other agents such as psilocybin.1 Even though the perceived risk of LSD has declined in recent years, the decline in its use may be partially attributable to its reduced availability.1 As with other drugs of abuse, reduced availability of LSD has prompted introduction of more potent, more dangerous, and cheaper alternatives. We report a suspected case of one such alternative, phenethylamine derivative 25I-NBOMe (2-(4-iodo-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine), commonly known as N-Bomb. To the dismay of public health advocates, 25I-NBOMe is reported to be gaining traction with adolescents and young adults.2 Although in this case the use of 25I-NBOMe was not confirmed with laboratory testing, the clinical presentation and an otherwise negative serum drug profile were highly suggestive of the use of this novel agent. Case report. Seventeen-year-old Mr A presented to the emergency department after ingesting “acid.” He described ingesting a blotter paper stained with the psychoactive agent after keeping it on his tongue “for a while.” After ingestion, he became acutely combative toward his friend, who called police, and the patient had to be restrained. The use of drugs prompted a call to emergency medical services, and emergency medical personnel found him to be diaphoretic, flushed, mydriatic, and combative. In the emergency department, he required multiple staff to restrain him for safety concerns. He continued to be diaphoretic and aggressive, screamed incoherently, reported active hallucinations, and thrashed his limbs. Baseline laboratory testing revealed an elevated serum creatine phosphokinase (CPK) level of 2,064 U/L; results of the rest of the tests were within normal limits. A urine drug screen was negative for the use of alcohol, amphetamine, barbiturates, benzodiazepines, cocaine, opiate, salicylates, and tetrahydrocannabinol. In the emergency department, the patient received a bolus of normal saline, haloperidol 5 mg, and lorazepam 2 mg intramuscularly. While on the medical floor, the patient received continuous intravenous hydration and tolerated oral intake. By second day of hospitalization, his serum CPK level dropped to 1,099 U/L, and the patient did not develop signs of acute renal failure. The clinical presentation was deemed to be inconsistent with the use of LSD, and, after a consultation with the toxicology service, it was determined that the patient ingested a synthetic phenethylamine, most likely 25I-NBOMe. Intoxication with synthetic phenethylamine derivatives such as 25I-NBOMe leads to mixed adrenergic and serotonergic symptoms. It is suggested that 25I-NBOMe may be a more potent serotonin-2A (5-HT2A) agonist than many of the previously available phenethylamine derivatives.3 Patients may present with anxiety, agitation, aggression, hallucinations, mydriasis, diaphoresis, hypertension, tachycardia, and serotonin syndrome.3 Patients have to be monitored for development of more serious effects such as tonic-clonic seizures and rhabdomyolysis leading to renal failure.3 As in this case, a high index of suspicion for newer, more dangerous synthetic hallucinogens is necessary to manage patients who present with atypical presentation of reported LSD use. Treatment options such as aggressive hydration to manage metabolic acidosis and developing renal failure, benzodiazepines, and external cooling for nonresponsive pyrexia may be considered depending upon unique clinical presentation. Serotonergic agents such as selective serotonin reuptake inhibitors should be prevented and withheld during the toxidrome, as these patients are at an elevated risk of developing serotonin syndrome due to the excessive serotonergic activity of synthetic phenethylamine derivatives. In cases of suspected toxicity, a clinical consultation from the toxicology service should be requested. Specific laboratory testing may also be considered for analytical confirmation.2,3 Finally, patients, families, first responders, and providers should be educated about the dangers of these novel compounds that may carry a risk of severe morbidity and mortality within a short time span after exposure.
Psychosomatics | 2018
Deepak Prabhakar; Edward L. Peterson; Yong Hu; Rebecca C. Rossom; Frances Lynch; Christine Y. Lu; Beth Waitzfelder; Ashli Owen-Smith; L. Keoki Williams; Arne Beck; Gregory E. Simon; Brian K. Ahmedani
BACKGROUND Patients diagnosed with skin conditions have a higher risk of comorbid psychiatric conditions and suicide-related outcomes such as suicidal ideations and behaviors. There is paucity of evidence in the US general population about the risk of suicide death in patients with dermatologic conditions. METHODS We conducted a retrospective case-control study to investigate the risk of suicide death in patients receiving care for dermatologic conditions. This study involved 8 US health systems. A total of 2674 individuals who died by suicide (cases) were matched with 267,400 general population control individuals. RESULTS After adjusting for age, sex, and any mental health or substance use condition, we did not find an association between death by suicide and any skin condition including conditions where clinicians are generally concerned about the risk such as acne (adjusted odds ratio [aOR] = 1.04, p = 0.814), atopic dermatitis (aOR = 0.77, p = 0.28), and psoriasis (aOR = 0.91, p = 0.64). CONCLUSION This case-control study provides no evidence of increased risk of death by suicide in individuals with major skin disorders in the US general population.
Academic Psychiatry | 2017
Mara Pheister; Susan Stagno; Robert O. Cotes; Deepak Prabhakar; Fauzia Mahr; Andrea Crowell; Ann C. Schwartz
The role and utility of simulated and standardized patients in medical education has evolved tremendously since its first introduction in 1963. The United States Medical Licensing Examination (USMLE) routinely uses standardized patients in the assessment of clinical skills to assess a candidate’s ability to elicit information, perform exams, and communicate clinically relevant findings. Psychiatry has been slower to adopt the use of simulated or standardized patients, partly due to the difficulty in creating scenarios depicting valid emotions [1, 2]. However, there are several areas of psychiatric education that lend themselves well to using a simulated patient or simulated scenario for learner assessment or for teaching. Here, we share examples from several programs where simulation has helped enhance teaching and assessment of residents. We address some of the practical issues in working with simulated patients. Finally, we briefly review the advantages and disadvantages of using simulation in psychiatric education. We do not intend this to be an exhaustive review of the use of simulated patients in psychiatry, but rather representative examples of ways simulated patients have been used successfully in residency training. To clarify our use of language related to this pedagogical method, we define “simulated patient” as any person who is not an actual patient and is being utilized to play the role of a patient in a learning or testing encounter; a “standardized patient” is a subset of simulated patients for which a person has been specially trained to act as a patient so that specific symptoms or signs can be demonstrated and/or feedback given to a learner.
The Primary Care Companion To The Journal of Clinical Psychiatry | 2016
Fady Henein; Deepak Prabhakar; Edward L. Peterson; L. Keoki Williams; Brian K. Ahmedani
Previous studies examining the link between antidepressant medication and suicidal ideation among youth have been inconclusive.1–3 Earlier studies demonstrated an association leading to the Food and Drug Administration’s black box warning,1 but more recent studies have suggested an inverse association, such that antidepressants may reduce suicide risk. Additionally, most studies among adults suggest that antidepressants decrease suicidal ideation during the immediate period following initiation.2 Nevertheless, little research has examined long-term suicidal ideation associated with continued antidepressant therapy. It is not known whether risk varies by level of adherence or by the class of antidepressant medication. The current study examined whether antidepressant adherence was associated with a heightened or lower likelihood of suicidal ideation among adults with depression.
The Primary Care Companion To The Journal of Clinical Psychiatry | 2014
Deepak Prabhakar
To the Editor: Tourette’s disorder is a chronic condition frequently causing functional and psychosocial impairment in young children. Typically, both vocal and motor tics begin at school age. Tic severity peaks around adolescence, often declining by adulthood.1 According to the Centers for Disease Control and Prevention (CDC), about 27% of children report moderate to severe symptoms.2 This finding would suggest that the majority of children with Tourette’s disorder have a milder symptomatic presentation. Despite psychopharmacologic advances, high-potency antipsychotics remain the mainstay of treatment. Even though these medications are effective in symptom reduction, they are rarely successful in eliminating tics altogether.1 Further, the side effects of medications such as haloperidol, risperidone, and pimozide may outweigh the benefits in young children with mild to moderate symptomatic presentation. Comprehensive Behavior Intervention for Tics (CBIT), a manualized behavioral treatment based on habit reversal training, offers a safer and effective psychotherapeutic alternative.1,3 However, its application is thus far limited due to the limited number of trained providers and challenges with insurance coverage.3 Further, in younger children who may not be able to comprehend premonitory sensations, the utilization of tic awareness—an important feature of CBIT—may not be possible. Though CBIT emphasizes the importance of tic awareness in habit reversal training, some have suggested that tic awareness may not be an essential element in reduction of tic severity.4,5 I describe a case of Tourette’s disorder in a 5-year-old child who benefited from the components of CBIT even though my colleagues and I were unable to establish awareness of premonitory signs associated with vocal and motor tics. Case report. A 5-year-old boy presented with complaints of worsening “tics.” According to his parents, symptoms consisted of frequent throat clearing, grunting, grimacing, and jaw stretching. His neurologist, who made the initial diagnosis of Tourette’s disorder, referred him for outpatient behavioral treatment. After detailed evaluation, a tic hierarchy was completed, and it was determined that frequent vocalizations were the most impairing tics. Both in school and at home, these tics frequently invited negative attention from peers, sibling, and parents. Caregivers often reprimanded him for making “embarrassing sounds,” whereas peers made fun by copying him. Over several sessions, psychoeducation was provided to parents and grandparents. The schoolteacher was also included by having parents share information and occasional phone consultations. Several themes emerged during these conversations: parents had difficulty believing that tics were involuntary since, in several instances, the patient was able to control them; similarly, grandparents viewed tics as “controlling” behaviors. Caregivers responded to psychoeducation and started conceptualizing tics as a neurologic manifestation. They also responded to parent management training emphasizing appropriate and consistent disciplining methods. Competing responses were discussed, demonstrated, and practiced during sessions and at home. At school, the child started sitting in the front of the classroom, thereby reducing negative attention by peers. When vocalizations emerged, his teacher directed him to a cup of water by a gentle touch on his shoulder without making it obvious to other students; the ingesting movement’s incompatibility with throat clearing and grunting acted as a vocal tic suppression strategy. The child responded to treatment, and the severity of his tics was reduced significantly, leading to increased participation in school activities and at home. My colleagues and I did not notice tic substitution or worsening. Tics may be debilitating for younger children and are generally worsened by environmental stressors. CBIT offers a safe and effective treatment option in children for tics with varying severity. In specific instances when a complete manualized approach might not be possible, individual strategies such as functional analysis and habit reversal may still be useful in reducing tic severity. In addition to this being a single case-based finding, one should also take into account that no objective measure of tic severity was utilized in assessing baseline or post treatment symptomatology. Nevertheless, clinical improvement was correlated with caregiver and teacher report of symptom reduction.
Archive | 2009
Deepak Prabhakar; Raquel Y. Qualls-Hampton; Rachael Jackson; Kathryn M. Cardarelli
To successfully move into the new millennium, President George W. Bush commissioned healthcare providers and advocates as well as policy makers to transform the current delivery of mental health services in the United States. This chapter addresses the need to assess the demographic characteristics of individuals who experience mental illness. We compiled available mental health data to describe the prevalence of mental illness in Dallas County and in Texas, with comparisons to national rates. This report presents mental health indicators for the United States, Texas, and Dallas County by age, race/ethnicity, education, and poverty level, where available. Because the methods for collecting the data were different, comparisons of state and local data with the national level data should be made with caution. This chapter is intended to assist researchers, policymakers, and service providers in employing consistent measure of mental health disorders that will allow comparisons at the local, state, and national levels. These efforts represent the beginning of a process of responding to mental health and illness in our community to better serve affected individuals and their families.
Psychiatric Services | 2018
Jennifer M. Boggs; Arne Beck; Samuel Hubley; Edward L. Peterson; Yong Hu; L. Keoki Williams; Deepak Prabhakar; Rebecca C. Rossom; Frances Lynch; Christine Y. Lu; Beth Waitzfelder; Ashli Owen-Smith; Gregory E. Simon; Brian K. Ahmedani
OBJECTIVE Mitigation of suicide risk by reducing access to lethal means, such as firearms and potentially lethal medications, is a highly recommended practice. To better understand groups of patients at risk of suicide in medical settings, the authors compared demographic and clinical risk factors between patients who died by suicide by using firearms or other means with matched patients who did not die by suicide (control group). METHODS In a case-control study in 2016 from eight health care systems within the Mental Health Research Network, 2,674 suicide cases from 2010-2013 were matched to a control group (N=267,400). The association between suicide by firearm or other means and medical record information on demographic characteristics, general medical disorders, and mental disorders was assessed. RESULTS The odds of having a mental disorder were higher among cases of suicide involving a method other than a firearm. Fourteen general medical disorders were associated with statistically significant (p<.001) greater odds of suicide by firearm, including traumatic brain injury (TBI) (odds ratio [OR]=23.53), epilepsy (OR=3.17), psychogenic pain (OR=2.82), migraine (OR=2.35), and stroke (OR=2.20). Fifteen general medical disorders were associated with statistically significant (p<.001) greater odds of suicide by other means, with particularly high odds for TBI (OR=7.74), epilepsy (OR=3.28), HIV/AIDS (OR=6.03), and migraine (OR=3.17). CONCLUSIONS Medical providers should consider targeting suicide risk screening for patients with any mental disorder, TBI, epilepsy, HIV, psychogenic pain, stroke, and migraine. When suicide risk is detected, counseling on reducing access to lethal means should include both firearms and other means for at-risk groups.
Hemodialysis International | 2018
Shehryar Khan; Lauren Wake; Kristina Glover; Pedro Bauza; Deepak Prabhakar; Esther Akinyemi
“Mr K” was a 65-year-old African American male, nursing home resident, with a past medical history of persistent schizophrenia, hemodialysis-dependent end-stage renal disease (HD-ESRD), hypertension, and type 2 diabetes mellitus. He had been refusing dialysis for around 6 months and was administered intramuscular psychotropic medications (5mg of haloperidol, 2mg of lorazepam, 50mg of diphenhydramine) prior to all hemodialysis sessions while he was living at his nursing home. He was admitted for catheter replacement, having pulled out his vascular access for the fourth time in the past 5 months. During the current admission, he demonstrated a general resistance to treatment; not only refusing replacement of the dialysis catheter but also resisting laboratory tests and vital signs. He had been without dialysis for 4 days at the time of interview. He, however, continued to compliant with all his medications and nursing care. A psychiatry consult was requested to evaluate for Mr K’s decision-making capacity and for recommendations if his long standing mental illness was playing a role in his refusal of treatment. Mr K was unable to provide most of his history. Court records revealed a 30 year history of severe mental illness which included numerous involuntary hospitalizations as well as a succession of court-appointed guardians, the first of which was appointed when the patient was just 26 years old. He remained legally incompetent with a legal guardian in place at the time of consultation. His most recent psychotic symptoms, as per report of the psychiatrist who had been seeing him at the nursing home, consisted of auditory hallucinations and paranoid delusions which responded to his current haloperidol dose of 10 mg. He was reported to be in adherence with his medication. His positive psychotic symptoms were stable with treatment. As per his outpatient psychiatrist, the patient at least had trials of quetiapine and risperidone in the past, started by different providers, at appropriate doses and with remission of positive symptoms. No further collateral information was available as there had been no family involvement in Mr K’s life for many years. Mr K had been consistent regarding his refusal of dialysis. Further questioning revealed that he understood neither the nature of his illness nor the ramifications of his continued refusal of treatment. He stated that he would continue to remove the catheter as he found it irritating; however, he denied any problems with his kidney function and stated that he would continue to live even without dialysis. At no point during the initial exam or subsequent follow-up visits was he observed to have Correspondence to: Shehryar Khan, M.D., Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, Michigan 48202, USA. E-mail: [email protected] Disclosures: The authors report no financial relationships with commercial interests. Conflict of Interest: None.
Depression and Anxiety | 2018
Florence J. Dallo; Deepak Prabhakar; Julie J. Ruterbusch; Kendra Schwartz; Edward L. Peterson; Bin Liu; Brian K. Ahmedani
The authors compared proportions and associations of depression screening, major depression, and follow‐up care of Arab Americans compared to non‐Hispanic whites, non‐Hispanic blacks, Asians, and Hispanics.