Jonathan Avery

Psychiatrists' Attitudes Toward Individuals With Substance Use Disorders and Serious Mental Illness

Objective: The attitudes of psychiatrists toward individuals with highly stigmatized conditions such as substance use disorders and serious mental illness may influence treatment effectiveness. These attitudes may be influenced by factors including previous specialty training and current practice patterns. This study examined the attitudes of addiction and community psychiatrists toward individuals with diagnosed schizophrenia, polysubstance dependence, comorbid schizophrenia and polysubstance dependence, and depression. Methods: A web-based survey link was sent to the electronic mailing lists of addiction and community psychiatry associations. Results: A total of 84 respondents identified themselves as either addiction (n = 54) or community (n = 30) psychiatrists. The majority were male (70% of addiction and 57% of community psychiatrists) with an average age of 56.0 (SD = 11.86) and 52.7 (SD = 11.8), respectively. Addiction psychiatrists had less stigmatizing attitudes than community psychiatrists for individuals with polysubstance dependence (p < .0001), while community psychiatrists had less stigmatizing attitudes than addiction psychiatrists for those with schizophrenia (p < .0001). Attitudes toward individuals with dual diagnosis did not vary significantly by psychiatrist group, but both addiction and community psychiatrists had more stigmatizing attitudes for individuals with dual diagnosis (p < .0001). Conclusions: These findings suggest that even psychiatrists working with highly stigmatized groups of individuals may continue to hold stigmatizing attitudes toward people with other diseases. Future work is needed to further assess stigmatizing attitudes among psychiatrists and the impact of these attitudes on quality of care, as well as interventions such as specialized education and training to reduce such stigma among psychiatrists.

Dignity Therapy for Major Depressive Disorder: A Case Report

Dear Editor: Dignity therapy is a psychotherapeutic intervention that has primarily been studied and used with terminally ill patients. In this therapy, clinicians help a patient generate a document that can be passed on to loved ones by recording a patient’s life story and then transcribing the patient’s words. The document created usually contains the details of a patient’s life, life lessons the patient has learned, and declarations of affection towards loved ones. We report the case of a 61-year-old woman with major depressive disorder who participated in dignity therapy while hospitalized for a major depressive episode. Mrs. S is a 61-year-old Caucasian female who was brought into the hospital by her family for four weeks of severe depression in the setting of losing her job. Mrs. S was placed on citalopram, and gradually her mood improved. She remained hopeless, however, and wondered how she could find meaning in her life without her job. She agreed to participate in dignity therapy in order to ‘‘gain a fresh perspective on things.’’ Mrs. S was interviewed using the Dignity Psychotherapy Question Protocol, and her answers were recorded and then transcribed. She then edited the document. The final product was a 10-page life history which focused more on her children and her volunteer projects than on her work life. Mrs. S was given ten copies of her story, which she distributed to her family and friends. She reported that dignity therapy had helped her ‘‘find hope’’ and further improved her mood. This is the first documented report of the use of dignity therapy with a patient with only major depressive disorder. Dignity therapy was used to help this patient face a major life event much in the way it helps those facing a terminal illness. In end-of-life care, dignity therapy has helped patients achieve a heightened sense of dignity, purpose, and meaning, and an increased will to live; it has also been shown to decrease suffering and depressive symptoms. In individuals with depression, one might expect similar gains, especially since therapies that focus on narrative have been effective for individuals with depression, as they can help repair a damaged sense of self and aide a patient in making sense of an altered life course. Further, just as dignity therapy has been shown to moderate the bereavement experience and decrease suffering and distress in the relatives of terminally ill patients, one might expect it to have similar positive effects on the relatives of individuals who are experiencing a mental illness, as mental illness impacts the whole family. Future work is needed to adapt dignity therapy for people with depression and other mental illnesses and to identify which patients would benefit from such an intervention.

Improvement in Drug-Induced Parkinsonism With Electroconvulsive Therapy

BACKGROUND Drug-induced parkinsonism is a common medication side effect. OBJECTIVE The present report describes the case of a depressed elderly woman who developed parkinsonism after receiving risperidone and who had improvement of her depression and parkinsonism after electroconvulsive therapy (ECT). CASE SUMMARY A 67-year-old white female was admitted to a psychiatry ward for a major depressive episode with psychotic features. The patient developed pronounced parkinsonian features after taking risperidone, which did not improve with discontinuation of the drug, or with benztropine and carbidopa/levodopa. A total score of 6 was achieved using Naranjos adverse drug reaction causality algorithm, suggesting risperidone was a probable cause of this adverse event. The patients depression and parkinsonian symptoms did not improve until after initiation of ECT. After 19 treatments, the patient had resolution of her depression and only mild bradykinesia remained. CONCLUSIONS This was a case of probable drug-induced parkinsonism in an elderly woman who had improvement of her depression and parkinsonism after receiving ECT.

Improving Psychiatrists’ Attitudes Towards Individuals with Psychotic Disorders and Co-Occurring Substance Use Disorders

Psychiatrists and trainees are often called upon to treat individuals who have a psychotic spectrum disorder and a substance use disorder (SUD). Hartz and colleagues found staggeringly high amounts of tobacco smoking (odds ratio, 4.6), heavy alcohol use (odds ratio, 3.5), heavy marijuana use (odds ratio, 3.5), and other drug use (odds ratio, 4.6) among individuals with severe psychotic disorders relative to the general population [1]. The prevalence of individuals with cooccurring disorders is dramatically elevated from a baseline of 3–4 % of people living in the community to 40–60 % in mental health treatment settings and 50–60 % in substance abuse treatment settings [2]. Among patients with cooccurring disorders, those with severe and persistent mental illness have a particularly high co-occurrence of SUDs, estimated to be as many as 4 million adults in the USA [3]. Individuals with psychotic spectrum disorders and SUDs often have worse outcomes and pose many challenges to clinicians [4]. Despite the common co-occurrence between psychotic spectrum disorders and SUDs, they are often underrecognized and under-treated, leading to poor treatment outcomes [4]. In comparison to patients with only a psychotic spectrum disorder or a SUD, patients with co-occurring psychotic disorders and a SUD have a poorer prognosis with greater severity of illness and a worse longitudinal course of illness in multiple domains; these domains include an increased risk for psychiatric and substance use relapses, higher rates of recidivism, higher levels of psychological distress, poorer psychosocial functioning, worse treatment retention, poor medication compliance, higher rates of institutionalization, violence, suicide, legal difficulties, medical problems, and family stress, as well as higher utilization of health care services such as emergency room and inpatient services [5–7]. We will discuss the current literature on the attitudes of psychiatrists towards individuals with psychotic disorders and comorbid SUDs and outline potential strategies to improve these attitudes.

Improving Psychiatry Residents' Attitudes Toward Individuals Diagnosed with Substance Use Disorders.

Special attention needs to be paid to the attitudes of psychiatry residents toward individuals diagnosed with substance use disorders. The attitudes of trainees may be worse toward these individuals than toward individuals with other diagnoses, and these attitudes may worsen over time. While psychiatry residencies are increasingly teaching residents about how to diagnosis and treat individuals diagnosed with substance use disorders, more attention needs to be paid to educating residents about common attitudes toward these individuals. We recommend that psychiatry residency programs start with basic educational didactics and reflection exercises on attitudes toward individuals diagnosed with substance use disorders and that programs try to form a positive “hidden curriculum” in their institutions.

An updated model for the first-time hospitalization of patients with borderline personality disorder: two illustrative case reports.

Patients with borderline personality disorder can be difficult to treat on psychiatric units, especially since long-stay units specializing in the treatment of patients with borderline personality disorder are now few and far between. With the shorter length of hospital stay today, clinicians must work hard to establish the diagnosis of borderline personality disorder, adjust medications, stabilize the patient, and then find the appropriate outpatient treatment plan. Future research is needed to figure out the best way to accomplish these tasks and to identify which patients with borderline personality disorder respond to which treatments.

Our job and their jobs: mental health clinicians and patients' work functioning.

The capacity to love and work is a timeless definition of a mentally healthy individual. Conservatively 23 million working-age Americans have chronic health and mental health problems that diminish their ability to work (Hoffman and Rice, 1996). Millions more are projected to experience employment problems by 2030 (Lerner et al., 2005). There is a reciprocal relationship between illness and work, with symptoms impairing functioning and poor functioning worsening recovery. Mental health clinicians have long recognized the importance of work in their patients’ lives and know how to assess and manage symptom reduction and interpersonal functioning. However, they may feel less confident in their ability to assess work functioning beyond basic issues of employment status. Moreover, clinicians may ignore employment aspirations and job performance because of an assumption that function will improve as symptoms improve (Lerner and Henke, 2008). An evolving literature has documented the degree to which mental health conditions impair work functioning and has indicated that symptom reduction alone does not improve job performance and satisfaction (Adler et al., 2006; Bacharach et al., 2010; Blum et al., 1993; Greenberg et al., 2003; Kessler et al., 2001; Lerner et al., 2004b; Stewart et al., 2003). Using the example of depressive disorders, this article will provide a case presentation and offer a framework for understanding the impact of mental health conditions on work performance. We present a methodology for systematic assessment and treatment of work functioning as part of routine patient care. Improving work performance should be a principle goal of treatment. Depression affects almost 5% of the US working-age population (Berndt et al., 1998; Broadhead et al., 1990; Goetzel et al., 2003; Kessler et al., 1999a), and like several other mental disorders, it has been found to be associated with job loss, job turnover, absenteeism, and reduced job performance (now known as presenteeism; Adler et al., 2006; Budetti et al., 2000; Dooley et al., 1996; Greenberg et al., 2003; Kessler et al., 2001; Lerner et al., 2004a, 2004b, 2010; Stewart et al., 2003) at an estimated productivity cost of

End-of-Life Care in Colombia and the United States: A Personal Perspective

44 billion annually (Greenberg et al., 2003). Studies reveal that depressed workers miss an average of 0.5 to 4.0 workdays per month (Kessler et al., 1999a). Poor work performance may be an even larger problem. Stewart et al. (2003) suggest that it is more costly than medical care, absences, and disability combined. Conti and Burton (1995) found that depressed workers were impaired on the job approximately 35% of the time on average in a 2-week period. Despite the availability of effective pharmacological and therapeutic interventions, optimal care has been hindered by underdiagnosis, limited use of evidence-based approaches, and adherence problems (Calkins et al., 1991; Eisenberg, 1992; Kessler et al., 1996; Schulberg et al., 1995). In essence, depression causes a partial work disability. A second critical observation has been the low correlation between symptom response to treatment and functional improvement. Adler et al. (2006) found that compared with healthy controls, a recovered group of previously depressed employees had persistently lower ability to function on the job. Depression symptom severity explains part of the variation in work outcomes. Depression treatment studies indicate that guideline-concordant care may only partially prevent depression’s negative impact on work. A study of depression treatment and employment achieved a reduction in depressive symptoms and absenteeism but not improved job performance (Wang et al., 2007). COMMENTARY

VIP Patients: An Unexpectedly Vulnerable Population

Ioften sit on a bench outside my New York City office and marvel at the Manhattan skyline. It is easy to be awed by all the glass and concrete. The United States is a beautiful place from New York City to Florida to California—and everywhere in between—and I have been fortunate enough to travel across my new country. Despite all of the beauty that I have seen in the United States, I still often long for my home country, Colombia. I miss the tropical weather, the green mountains of Bogotá, and the pristine beaches of San Andres Island. Perhaps most of all, I miss the food: pepperoni pizza and cheap sushi cannot compare to arepa, sancocho, ajiaco, and the bandeja paisa feast. Colombia can be a wonderful place to live, but it can also be a very lonely place to die. When I was a medical student in Colombia, one of my most memorable patients was a 46-yearold woman, Mrs. R., who was healthy until she was diagnosed with a brain tumor (glioblastoma multiforme). Mrs. R. was a widow with young children. The diagnosis left her depressed and her children hopeless. Despite several surgeries, radiation treatments, and chemotherapy, her condition worsened rapidly. She eventually decided to leave the hospital and spend her last days at home with her children. In Colombia, only the very wealthy can afford medical care in their homes. Mrs. R. did not have a lot of money and therefore did not receive further medical treatment. Through my connections at the hospital, I found her a psychiatrist who agreed to visit her at home free of charge. For her physical ailments, she turned to local remedies and prayer. Perhaps worst of all, Mrs. R. did not have any help at home. Her children had to quickly learn how to shop, cook, and manage finances, in addition to maintaining their schoolwork. During her final days, Mrs. R.’s children took care of almost all of her needs. When she passed away, her small family was left in chaos. There are many other people in Colombia just like Mrs. R., because many people die at home without adequate medical supervision and social support. My family is currently struggling to take care of my grandmother during her final days. They must constantly supervise my grandmother and are having difficulty understanding when to give her medications and how to properly tend to her needs. In New York City and other cities around the United States, I have learned about hospice, a unique organization that takes care of patients during the last 6 months of their lives. I have witnessed the good that hospice care can do for a patient, often without regard to a patient’s financial status. I know there are many different companies that provide hospice care or other forms of homecare services, and perhaps the wealthy still do receive better care at the end of their lives than do the poor here in the United States, but I have met countless doctors, nurses, and social workers who dedicate themselves to caring for all people during their final days. Such individuals are a rarity in Colombia. In the United States, I helped take care of one patient, Mr. W., who reminded me of Mrs. R. He was a widower dying of lung cancer, and even though his children were adults, they were still very dependent on him. Mr. W. qualified for hospice care and took full advantage of their services. Mr. W. had a nurse who visited him every day, a doctor who managed his medical needs, and a volunteer who shopped for him. The hospice also provided him with a social worker to help him organize his finances and answer the questions of his children. Mrs. R. and her family would have benefited from similar comprehensive care. My family would welcome the help of an organization such as a hospice. I have witnessed how the nurses and support staff of one hospice organization in New York City made sure the homes of their patients were set up to properly address their patients’ needs. And one of the primary goals of the hospice doctors and nurses is to make sure that the patient is on the right medications and that both the patient and his or her family understand how to administer the proper treatment at home. No matter where an individual is from—be it the East Village of Manhattan or the foothills of Eastern Cordillera in Bogotá— the end of an individual’s life can be a very difficult and stressful time. Organizations such as hospice, which provide people with both medical and social support, are so valuable. I wish everyone in Colombia had access to such resources. Finally, I am beginning to understand that living a good life involves more than just great food and breathtaking mountains—living a good life also means learning how to die with dignity.

Benzodiazepine Maintenance Treatment in Schizophrenia.

When very important people (VIPs) become patients, they are at risk for receiving substandard care. Obstacles in the way of ideal care for these individuals include challenges with maintaining privacy, the complex attitudes of health-care professionals toward VIP patients, and the expectations of the VIP patient and family. While more research is certainly needed on this topic, health-care professionals and institutions should have a plan in place for treating VIP patients in order to ensure that their care and the care of other patients are not compromised. This plan must attend to patient and provider attitudes and expectations, a complex web of family and caregivers, and the influence of the VIP patient on the health-care system as a whole.