Geoffrey Neimark, MD

Some psychiatric patients report intolerable side effects with almost every psychotropic one reasonably could prescribe. Their psychiatric disorders remain undertreated as treatment-emergent side effects lead again and again to medication nonadherence. These patients often are frustrated by their lack of progress and in turn exasperate practitioners, creating strong transference and countertransference reactions.

To keep the therapeutic relationship on track, consider that your patient’s physiologic response to medication may be the result of genetic or psychodynamic factors you can overcome.

Start low and go slow

One option is to initiate medication far below the recommended starting dose. For example, try starting a patient on 1, 2, or 5 mg/d of fluoxetine instead of the typical 20 mg/d. These small doses can be achieved with a pill cutter or by using a liquid formulation with a measuring spoon that allows for 1-mg increments.

Some patients may report significant amelioration of symptoms even if they do not reach what is considered a therapeutic dose. These clinical observations have been confirmed by pharmacogenetic research that demonstrates metabolic variation across the population.¹ Improving patients’ well-being rather than arriving at a predetermined therapeutic dose should guide treatment.

Patients who experience multiple side effects may need extra time to acclimate to a new medication. Try initiating medication changes or increases at longer intervals, such as over months rather than weeks.

Examine psychodynamic factors

Seek to understand dynamic factors that contribute to your patient’s pattern of intolerable side effects. For example, patients’ disappointing early experiences with parents may result in angry feelings toward authority figures and a desire to frustrate them. In traumatized patients, internalized object relations consisting of pain-inflicting authority figures may be acted out through medication matters.

By understanding patients’ dynamics, we can better understand our own countertransference reactions and devise interventions that are more likely to help patients tolerate medication.

Accept patients’ sensitivity

I often tell patients, “You happen to be sensitive to side effects of medication. We might have to try a number of different medications before we find one that works and is tolerable. Furthermore, we need to start at a very low dose and take things very slowly.” This statement:

• recognizes and accepts patients’ sensitivity to psychotropics
  
• allows for externalization of some responsibility for troublesome side effects to the medication
  
• conveys a sense of therapeutic uncertainty
  
• allows patients to undertake treatment at a comfortable pace.
  

Some psychiatric patients report intolerable side effects with almost every psychotropic one reasonably could prescribe. Their psychiatric disorders remain undertreated as treatment-emergent side effects lead again and again to medication nonadherence. These patients often are frustrated by their lack of progress and in turn exasperate practitioners, creating strong transference and countertransference reactions.

To keep the therapeutic relationship on track, consider that your patient’s physiologic response to medication may be the result of genetic or psychodynamic factors you can overcome.

Start low and go slow

One option is to initiate medication far below the recommended starting dose. For example, try starting a patient on 1, 2, or 5 mg/d of fluoxetine instead of the typical 20 mg/d. These small doses can be achieved with a pill cutter or by using a liquid formulation with a measuring spoon that allows for 1-mg increments.

Some patients may report significant amelioration of symptoms even if they do not reach what is considered a therapeutic dose. These clinical observations have been confirmed by pharmacogenetic research that demonstrates metabolic variation across the population.¹ Improving patients’ well-being rather than arriving at a predetermined therapeutic dose should guide treatment.

Patients who experience multiple side effects may need extra time to acclimate to a new medication. Try initiating medication changes or increases at longer intervals, such as over months rather than weeks.

Examine psychodynamic factors

Seek to understand dynamic factors that contribute to your patient’s pattern of intolerable side effects. For example, patients’ disappointing early experiences with parents may result in angry feelings toward authority figures and a desire to frustrate them. In traumatized patients, internalized object relations consisting of pain-inflicting authority figures may be acted out through medication matters.

By understanding patients’ dynamics, we can better understand our own countertransference reactions and devise interventions that are more likely to help patients tolerate medication.

Accept patients’ sensitivity

I often tell patients, “You happen to be sensitive to side effects of medication. We might have to try a number of different medications before we find one that works and is tolerable. Furthermore, we need to start at a very low dose and take things very slowly.” This statement:

• recognizes and accepts patients’ sensitivity to psychotropics
  
• allows for externalization of some responsibility for troublesome side effects to the medication
  
• conveys a sense of therapeutic uncertainty
  
• allows patients to undertake treatment at a comfortable pace.
  

Some psychiatric patients report intolerable side effects with almost every psychotropic one reasonably could prescribe. Their psychiatric disorders remain undertreated as treatment-emergent side effects lead again and again to medication nonadherence. These patients often are frustrated by their lack of progress and in turn exasperate practitioners, creating strong transference and countertransference reactions.

To keep the therapeutic relationship on track, consider that your patient’s physiologic response to medication may be the result of genetic or psychodynamic factors you can overcome.

Start low and go slow

One option is to initiate medication far below the recommended starting dose. For example, try starting a patient on 1, 2, or 5 mg/d of fluoxetine instead of the typical 20 mg/d. These small doses can be achieved with a pill cutter or by using a liquid formulation with a measuring spoon that allows for 1-mg increments.

Some patients may report significant amelioration of symptoms even if they do not reach what is considered a therapeutic dose. These clinical observations have been confirmed by pharmacogenetic research that demonstrates metabolic variation across the population.¹ Improving patients’ well-being rather than arriving at a predetermined therapeutic dose should guide treatment.

Patients who experience multiple side effects may need extra time to acclimate to a new medication. Try initiating medication changes or increases at longer intervals, such as over months rather than weeks.

Examine psychodynamic factors

Seek to understand dynamic factors that contribute to your patient’s pattern of intolerable side effects. For example, patients’ disappointing early experiences with parents may result in angry feelings toward authority figures and a desire to frustrate them. In traumatized patients, internalized object relations consisting of pain-inflicting authority figures may be acted out through medication matters.

By understanding patients’ dynamics, we can better understand our own countertransference reactions and devise interventions that are more likely to help patients tolerate medication.

Accept patients’ sensitivity

I often tell patients, “You happen to be sensitive to side effects of medication. We might have to try a number of different medications before we find one that works and is tolerable. Furthermore, we need to start at a very low dose and take things very slowly.” This statement:

• recognizes and accepts patients’ sensitivity to psychotropics
  
• allows for externalization of some responsibility for troublesome side effects to the medication
  
• conveys a sense of therapeutic uncertainty
  
• allows patients to undertake treatment at a comfortable pace.
  

Psychiatric emergency rooms (ERs) often are the first stop for patients experiencing severe psychiatric symptoms. Following these strategies can help as you assess and treat a variety of patients and create a modicum of calm out of the chaos.

‘Heal’ borderlines

Although patients diagnosed with borderline personality disorder often present treatment challenges, a supportive psychotherapeutic approach based on empathic listening often can be helpful. Allowing these patients to feel understood in the midst of an interpersonal crisis may be enough to help them navigate their predicament in a healthier way.

Beware of shift changes

Patients arriving during a staff shift change might not receive the time and attention necessary for a comprehensive psychiatric evaluation. Resist pressure to speed up the workflow, and do not leave patients waiting to be seen by the oncoming shift. Working only by the clock may result in a rushed and inadequate assessment and a suboptimal treatment plan.

Sleeping it off

Patients often arrive intoxicated and might not be able to adequately participate in a psychiatric assessment. Talk to intoxicated patients briefly, get an adequate medical history, ensure their safety and monitoring, and then let them sleep in the ER. Re-evaluation in the morning often yields dramatically different mental status findings.

Be familiar with social services

Although some ERs employ staff members who specialize in coordinating social services, be familiar with available homeless shelters, travelers’ aid societies, halfway houses, and safe homes. Armed with this information, you can refer to appropriate agencies patients with problems that are more social than psychiatric.

Know your staff

Psychiatric ERs are staffed by a variety of mental health professionals, and individual team members’ experience, training, and knowledge can vary greatly. It is your responsibility to be familiar with the strengths and weaknesses of these workers to guard against having to repeat tasks.

Feed your patients

Providing patients with food is a straight-forward way to demonstrate you care about their needs and want to help. Though it is important that patients do not view psychiatric ERs as places to come to get a hot meal, generously dispensing food often helps lay the groundwork for a therapeutic relationship.

Be generous with thiamine

Many ER patients are undernourished or abuse alcohol and therefore are at risk for thiamine deficiency. The sequelae of thiamine deficiency, including Wernicke’s encephalopathy and Korsakoff’s syndrome, are serious and in some cases irreversible.

Psychiatric emergency rooms (ERs) often are the first stop for patients experiencing severe psychiatric symptoms. Following these strategies can help as you assess and treat a variety of patients and create a modicum of calm out of the chaos.

‘Heal’ borderlines

Although patients diagnosed with borderline personality disorder often present treatment challenges, a supportive psychotherapeutic approach based on empathic listening often can be helpful. Allowing these patients to feel understood in the midst of an interpersonal crisis may be enough to help them navigate their predicament in a healthier way.

Beware of shift changes

Patients arriving during a staff shift change might not receive the time and attention necessary for a comprehensive psychiatric evaluation. Resist pressure to speed up the workflow, and do not leave patients waiting to be seen by the oncoming shift. Working only by the clock may result in a rushed and inadequate assessment and a suboptimal treatment plan.

Sleeping it off

Patients often arrive intoxicated and might not be able to adequately participate in a psychiatric assessment. Talk to intoxicated patients briefly, get an adequate medical history, ensure their safety and monitoring, and then let them sleep in the ER. Re-evaluation in the morning often yields dramatically different mental status findings.

Be familiar with social services

Although some ERs employ staff members who specialize in coordinating social services, be familiar with available homeless shelters, travelers’ aid societies, halfway houses, and safe homes. Armed with this information, you can refer to appropriate agencies patients with problems that are more social than psychiatric.

Know your staff

Psychiatric ERs are staffed by a variety of mental health professionals, and individual team members’ experience, training, and knowledge can vary greatly. It is your responsibility to be familiar with the strengths and weaknesses of these workers to guard against having to repeat tasks.

Feed your patients

Providing patients with food is a straight-forward way to demonstrate you care about their needs and want to help. Though it is important that patients do not view psychiatric ERs as places to come to get a hot meal, generously dispensing food often helps lay the groundwork for a therapeutic relationship.

Be generous with thiamine

Many ER patients are undernourished or abuse alcohol and therefore are at risk for thiamine deficiency. The sequelae of thiamine deficiency, including Wernicke’s encephalopathy and Korsakoff’s syndrome, are serious and in some cases irreversible.

Psychiatric emergency rooms (ERs) often are the first stop for patients experiencing severe psychiatric symptoms. Following these strategies can help as you assess and treat a variety of patients and create a modicum of calm out of the chaos.

‘Heal’ borderlines

Although patients diagnosed with borderline personality disorder often present treatment challenges, a supportive psychotherapeutic approach based on empathic listening often can be helpful. Allowing these patients to feel understood in the midst of an interpersonal crisis may be enough to help them navigate their predicament in a healthier way.

Beware of shift changes

Patients arriving during a staff shift change might not receive the time and attention necessary for a comprehensive psychiatric evaluation. Resist pressure to speed up the workflow, and do not leave patients waiting to be seen by the oncoming shift. Working only by the clock may result in a rushed and inadequate assessment and a suboptimal treatment plan.

Sleeping it off

Patients often arrive intoxicated and might not be able to adequately participate in a psychiatric assessment. Talk to intoxicated patients briefly, get an adequate medical history, ensure their safety and monitoring, and then let them sleep in the ER. Re-evaluation in the morning often yields dramatically different mental status findings.

Be familiar with social services

Although some ERs employ staff members who specialize in coordinating social services, be familiar with available homeless shelters, travelers’ aid societies, halfway houses, and safe homes. Armed with this information, you can refer to appropriate agencies patients with problems that are more social than psychiatric.

Know your staff

Psychiatric ERs are staffed by a variety of mental health professionals, and individual team members’ experience, training, and knowledge can vary greatly. It is your responsibility to be familiar with the strengths and weaknesses of these workers to guard against having to repeat tasks.

Feed your patients

Providing patients with food is a straight-forward way to demonstrate you care about their needs and want to help. Though it is important that patients do not view psychiatric ERs as places to come to get a hot meal, generously dispensing food often helps lay the groundwork for a therapeutic relationship.

Be generous with thiamine

Many ER patients are undernourished or abuse alcohol and therefore are at risk for thiamine deficiency. The sequelae of thiamine deficiency, including Wernicke’s encephalopathy and Korsakoff’s syndrome, are serious and in some cases irreversible.

Your answering machine’s outgoing message contains a wealth of information that goes beyond “I’m not here right now.” Carefully consider these messages because they communicate to your patients important information about you and your treatment philosophy.

Three “C’s”—callbacks, contact, and crisis—can help you think about the nuances and implications of creating an appropriate outgoing answering machine message.

Callbacks. In their messages, some psychiatrists provide a timeframe within which they will return patients’ phone calls—such as within “1 business day”—whereas others intentionally omit any reference to time. What is said or omitted about call-backs speaks to your responsiveness and sets a precedent for how you will address patients’ time-related concerns.

Some patients may find comfort in knowing when they can expect a return call. This reassurance, however, also might perpetuate a patient’s unrealistic fantasies and expectations about you, such as that you always will immediately respond to the patient’s concerns.

Contact. Patients often are unsure about how to contact their doctors after office hours or during weekends. You can handle this concern by providing alternate phone numbers such as a mobile phone, answering service, or covering physician.

After-hours contact establishes your availability. Although no doctor can be available to every patient all the time, your patients’ perception of your availability is important, particularly to personality- disordered patients who have not achieved object constancy. For some clinicians, this means their answering machines contain reference to how they can be contacted after hours. Other clinicians, however, omit this information because they may believe patients need to learn how to self-soothe, and constant availability may hamper this process.

Crisis. How you will handle a crisis can bring up feelings of uncertainty and danger in patients. Statements such as “If you are having a psychiatric emergency, please call 911 or go to your nearest emergency room” might communicate to the patient that you are unable or unwilling to deal with emergencies. Subsequently, the patient might not be comfortable discussing some topics in treatment because of anxiety about whether you can handle intense therapeutic situations.

A more neutral statement that might be preferable would be: “If you are having an emergency and are unable to communicate with me in a timely manner, you may go to the nearest emergency room.” Stated in this way, you establish your willingness to deal with emergent situations and encourage rather than merely outsource or avoid contact.

Your answering machine’s outgoing message contains a wealth of information that goes beyond “I’m not here right now.” Carefully consider these messages because they communicate to your patients important information about you and your treatment philosophy.

Three “C’s”—callbacks, contact, and crisis—can help you think about the nuances and implications of creating an appropriate outgoing answering machine message.

Callbacks. In their messages, some psychiatrists provide a timeframe within which they will return patients’ phone calls—such as within “1 business day”—whereas others intentionally omit any reference to time. What is said or omitted about call-backs speaks to your responsiveness and sets a precedent for how you will address patients’ time-related concerns.

Some patients may find comfort in knowing when they can expect a return call. This reassurance, however, also might perpetuate a patient’s unrealistic fantasies and expectations about you, such as that you always will immediately respond to the patient’s concerns.

Contact. Patients often are unsure about how to contact their doctors after office hours or during weekends. You can handle this concern by providing alternate phone numbers such as a mobile phone, answering service, or covering physician.

After-hours contact establishes your availability. Although no doctor can be available to every patient all the time, your patients’ perception of your availability is important, particularly to personality- disordered patients who have not achieved object constancy. For some clinicians, this means their answering machines contain reference to how they can be contacted after hours. Other clinicians, however, omit this information because they may believe patients need to learn how to self-soothe, and constant availability may hamper this process.

Crisis. How you will handle a crisis can bring up feelings of uncertainty and danger in patients. Statements such as “If you are having a psychiatric emergency, please call 911 or go to your nearest emergency room” might communicate to the patient that you are unable or unwilling to deal with emergencies. Subsequently, the patient might not be comfortable discussing some topics in treatment because of anxiety about whether you can handle intense therapeutic situations.

A more neutral statement that might be preferable would be: “If you are having an emergency and are unable to communicate with me in a timely manner, you may go to the nearest emergency room.” Stated in this way, you establish your willingness to deal with emergent situations and encourage rather than merely outsource or avoid contact.

Your answering machine’s outgoing message contains a wealth of information that goes beyond “I’m not here right now.” Carefully consider these messages because they communicate to your patients important information about you and your treatment philosophy.

Three “C’s”—callbacks, contact, and crisis—can help you think about the nuances and implications of creating an appropriate outgoing answering machine message.

Callbacks. In their messages, some psychiatrists provide a timeframe within which they will return patients’ phone calls—such as within “1 business day”—whereas others intentionally omit any reference to time. What is said or omitted about call-backs speaks to your responsiveness and sets a precedent for how you will address patients’ time-related concerns.

Some patients may find comfort in knowing when they can expect a return call. This reassurance, however, also might perpetuate a patient’s unrealistic fantasies and expectations about you, such as that you always will immediately respond to the patient’s concerns.

Contact. Patients often are unsure about how to contact their doctors after office hours or during weekends. You can handle this concern by providing alternate phone numbers such as a mobile phone, answering service, or covering physician.

After-hours contact establishes your availability. Although no doctor can be available to every patient all the time, your patients’ perception of your availability is important, particularly to personality- disordered patients who have not achieved object constancy. For some clinicians, this means their answering machines contain reference to how they can be contacted after hours. Other clinicians, however, omit this information because they may believe patients need to learn how to self-soothe, and constant availability may hamper this process.

Crisis. How you will handle a crisis can bring up feelings of uncertainty and danger in patients. Statements such as “If you are having a psychiatric emergency, please call 911 or go to your nearest emergency room” might communicate to the patient that you are unable or unwilling to deal with emergencies. Subsequently, the patient might not be comfortable discussing some topics in treatment because of anxiety about whether you can handle intense therapeutic situations.

A more neutral statement that might be preferable would be: “If you are having an emergency and are unable to communicate with me in a timely manner, you may go to the nearest emergency room.” Stated in this way, you establish your willingness to deal with emergent situations and encourage rather than merely outsource or avoid contact.

Assessing suicide risk is a fundamental skill for all psychiatrists. Early in training we are taught to look for prior attempts, family history of suicide, related psychiatric diagnoses (such as depression, psychosis, or substance abuse), symptomatology, and medical comorbidities, as well as demographic risk factors such as age, race, marital status, and religion.

This tendency to focus on data, document risks factors, and differentiate between ideation, intent, and plan may cause us to overlook why a patient wants to commit suicide, however. And rapid-fire questioning—particularly about suicide—can compromise rapport and leave the patient feeling alienated.

Positive inquiry

I always end the suicide risk assessment component of the interview by asking, “What keeps you from killing yourself?” Patients’ responses to this question often reveal compelling reasons why they do not want to harm themselves, including meaningful relationships or religious beliefs.

Examining these so-called protective factors—or the lack thereof—in conjunction with the overall clinical picture often can help clarify the patient’s risk of suicide. When patients identify factors that prevent them from committing suicide, such as a relationship with a loving spouse or a religious conviction, I am inclined to use a more liberal treatment plan, such as immediate outpatient follow-up, rather than a more conservative approach, such as inpatient hospitalization.

Asking a supportive question helps to end difficult discussions on a positive note. After talking about ways a patient has thought about ending his or her life, for example, I can use a protective factor as the endpoint to the suicide risk evaluation before segueing into other questions.

Supportive interviewing embodies a framework of inquiry in which mental health clinicians can gather valuable information and at the same time build up the patient’s psychological defenses. This line of questioning does not guarantee a successful suicide-risk assessment. However, focusing on protective factors ensures that these difficult conversations—often undertaken when patients are under extreme stress—accomplish more than simply gathering data.

Assessing suicide risk is a fundamental skill for all psychiatrists. Early in training we are taught to look for prior attempts, family history of suicide, related psychiatric diagnoses (such as depression, psychosis, or substance abuse), symptomatology, and medical comorbidities, as well as demographic risk factors such as age, race, marital status, and religion.

This tendency to focus on data, document risks factors, and differentiate between ideation, intent, and plan may cause us to overlook why a patient wants to commit suicide, however. And rapid-fire questioning—particularly about suicide—can compromise rapport and leave the patient feeling alienated.

Positive inquiry

I always end the suicide risk assessment component of the interview by asking, “What keeps you from killing yourself?” Patients’ responses to this question often reveal compelling reasons why they do not want to harm themselves, including meaningful relationships or religious beliefs.

Examining these so-called protective factors—or the lack thereof—in conjunction with the overall clinical picture often can help clarify the patient’s risk of suicide. When patients identify factors that prevent them from committing suicide, such as a relationship with a loving spouse or a religious conviction, I am inclined to use a more liberal treatment plan, such as immediate outpatient follow-up, rather than a more conservative approach, such as inpatient hospitalization.

Asking a supportive question helps to end difficult discussions on a positive note. After talking about ways a patient has thought about ending his or her life, for example, I can use a protective factor as the endpoint to the suicide risk evaluation before segueing into other questions.

Supportive interviewing embodies a framework of inquiry in which mental health clinicians can gather valuable information and at the same time build up the patient’s psychological defenses. This line of questioning does not guarantee a successful suicide-risk assessment. However, focusing on protective factors ensures that these difficult conversations—often undertaken when patients are under extreme stress—accomplish more than simply gathering data.

Assessing suicide risk is a fundamental skill for all psychiatrists. Early in training we are taught to look for prior attempts, family history of suicide, related psychiatric diagnoses (such as depression, psychosis, or substance abuse), symptomatology, and medical comorbidities, as well as demographic risk factors such as age, race, marital status, and religion.

This tendency to focus on data, document risks factors, and differentiate between ideation, intent, and plan may cause us to overlook why a patient wants to commit suicide, however. And rapid-fire questioning—particularly about suicide—can compromise rapport and leave the patient feeling alienated.

Positive inquiry

I always end the suicide risk assessment component of the interview by asking, “What keeps you from killing yourself?” Patients’ responses to this question often reveal compelling reasons why they do not want to harm themselves, including meaningful relationships or religious beliefs.

Examining these so-called protective factors—or the lack thereof—in conjunction with the overall clinical picture often can help clarify the patient’s risk of suicide. When patients identify factors that prevent them from committing suicide, such as a relationship with a loving spouse or a religious conviction, I am inclined to use a more liberal treatment plan, such as immediate outpatient follow-up, rather than a more conservative approach, such as inpatient hospitalization.

Asking a supportive question helps to end difficult discussions on a positive note. After talking about ways a patient has thought about ending his or her life, for example, I can use a protective factor as the endpoint to the suicide risk evaluation before segueing into other questions.

Supportive interviewing embodies a framework of inquiry in which mental health clinicians can gather valuable information and at the same time build up the patient’s psychological defenses. This line of questioning does not guarantee a successful suicide-risk assessment. However, focusing on protective factors ensures that these difficult conversations—often undertaken when patients are under extreme stress—accomplish more than simply gathering data.