Current Psychiatry

With the diagnosis of attention-deficit/hyperactivity disorder (ADHD) on the rise¹ and a surge in prescriptions to treat the disorder leading to stimulant shortages,² ensuring that patients are appropriately evaluated for ADHD is more critical than ever. ADHD is a clinical diagnosis that can be established by clinical interview, although the results of neuropsychological testing and collateral information from family members are helpful. Assessing adults for ADHD can be challenging when they appear to want to convince the clinician that they have the disorder. In this article, I provide tips to help you accurately diagnose ADHD in adult patients.

Use an ADHD symptom scale

An ADHD symptom checklist, such as the Adult ADHD Self-Report Scale, is an effective tool to establish the presence of ADHD symptoms. A patient can complete this self-assessment tool before their visit, and you can use the results as a springboard to ask them about ADHD symptoms. It is important to elicit specific examples of the ADHD symptoms the patient reports, and to understand how these symptoms affect their functioning and quality of life.

Review the prescription drug monitoring program

Review your state’s prescription drug monitoring program to explore the patient’s prior and current prescriptions of stimulants and other controlled substances. Discern if, when, and by whom a patient was previously treated for ADHD, and rule out the rare possibility that the patient has obtained multiple prescriptions for controlled substances from multiple clinicians, which suggests the patient may have a substance use disorder.

Begin the assessment at your initial contact with the patient

How patients present on an initial screening call or how they compose emails can reveal clues about their level of organization and overall executive functioning. The way patients complete intake forms (eg, using a concise vs a meandering writing style) as well as their punctuality when presenting to appointments can also be telling.

Conduct a mental status examination

Patients can have difficulty focusing and completing tasks for reasons other than having ADHD. A mental status examination can sometimes provide objective clues that an individual has ADHD. A digressive thought process, visible physical restlessness, and instances of a patient interrupting the evaluator are suggestive of ADHD, although all these symptoms can be present in other conditions (eg, mania). However, signs of ADHD in the mental status examination do not confirm an ADHD diagnosis, nor does their absence rule it out.

Maintain an appropriate diagnostic threshold

Per DSM-5, an ADHD diagnosis requires that the symptoms cause a significant impairment in functioning.³ It is up to the clinician to determine if this threshold is met. It is imperative to thoughtfully consider this because stimulants are first-line treatment for ADHD and are commonly misused. Psychiatrists are usually motivated to please their patients in order to maintain them as patients and develop a positive therapeutic relationship, which improves outcomes.⁴ However, it is important to demonstrate integrity, provide an accurate diagnosis, and not be unduly swayed by a patient’s wish to receive an ADHD diagnosis. If you sense that a prospective patient is hoping they will receive an ADHD diagnosis and be prescribed a stimulant, it may be prudent to emphasize that the patient will be assessed for multiple mental health conditions, including ADHD, and that treatment will depend on the outcome of the evaluation.

With the diagnosis of attention-deficit/hyperactivity disorder (ADHD) on the rise¹ and a surge in prescriptions to treat the disorder leading to stimulant shortages,² ensuring that patients are appropriately evaluated for ADHD is more critical than ever. ADHD is a clinical diagnosis that can be established by clinical interview, although the results of neuropsychological testing and collateral information from family members are helpful. Assessing adults for ADHD can be challenging when they appear to want to convince the clinician that they have the disorder. In this article, I provide tips to help you accurately diagnose ADHD in adult patients.

Use an ADHD symptom scale

An ADHD symptom checklist, such as the Adult ADHD Self-Report Scale, is an effective tool to establish the presence of ADHD symptoms. A patient can complete this self-assessment tool before their visit, and you can use the results as a springboard to ask them about ADHD symptoms. It is important to elicit specific examples of the ADHD symptoms the patient reports, and to understand how these symptoms affect their functioning and quality of life.

Review the prescription drug monitoring program

Review your state’s prescription drug monitoring program to explore the patient’s prior and current prescriptions of stimulants and other controlled substances. Discern if, when, and by whom a patient was previously treated for ADHD, and rule out the rare possibility that the patient has obtained multiple prescriptions for controlled substances from multiple clinicians, which suggests the patient may have a substance use disorder.

Begin the assessment at your initial contact with the patient

How patients present on an initial screening call or how they compose emails can reveal clues about their level of organization and overall executive functioning. The way patients complete intake forms (eg, using a concise vs a meandering writing style) as well as their punctuality when presenting to appointments can also be telling.

Conduct a mental status examination

Patients can have difficulty focusing and completing tasks for reasons other than having ADHD. A mental status examination can sometimes provide objective clues that an individual has ADHD. A digressive thought process, visible physical restlessness, and instances of a patient interrupting the evaluator are suggestive of ADHD, although all these symptoms can be present in other conditions (eg, mania). However, signs of ADHD in the mental status examination do not confirm an ADHD diagnosis, nor does their absence rule it out.

Maintain an appropriate diagnostic threshold

Per DSM-5, an ADHD diagnosis requires that the symptoms cause a significant impairment in functioning.³ It is up to the clinician to determine if this threshold is met. It is imperative to thoughtfully consider this because stimulants are first-line treatment for ADHD and are commonly misused. Psychiatrists are usually motivated to please their patients in order to maintain them as patients and develop a positive therapeutic relationship, which improves outcomes.⁴ However, it is important to demonstrate integrity, provide an accurate diagnosis, and not be unduly swayed by a patient’s wish to receive an ADHD diagnosis. If you sense that a prospective patient is hoping they will receive an ADHD diagnosis and be prescribed a stimulant, it may be prudent to emphasize that the patient will be assessed for multiple mental health conditions, including ADHD, and that treatment will depend on the outcome of the evaluation.

With the diagnosis of attention-deficit/hyperactivity disorder (ADHD) on the rise¹ and a surge in prescriptions to treat the disorder leading to stimulant shortages,² ensuring that patients are appropriately evaluated for ADHD is more critical than ever. ADHD is a clinical diagnosis that can be established by clinical interview, although the results of neuropsychological testing and collateral information from family members are helpful. Assessing adults for ADHD can be challenging when they appear to want to convince the clinician that they have the disorder. In this article, I provide tips to help you accurately diagnose ADHD in adult patients.

Use an ADHD symptom scale

An ADHD symptom checklist, such as the Adult ADHD Self-Report Scale, is an effective tool to establish the presence of ADHD symptoms. A patient can complete this self-assessment tool before their visit, and you can use the results as a springboard to ask them about ADHD symptoms. It is important to elicit specific examples of the ADHD symptoms the patient reports, and to understand how these symptoms affect their functioning and quality of life.

Review the prescription drug monitoring program

Review your state’s prescription drug monitoring program to explore the patient’s prior and current prescriptions of stimulants and other controlled substances. Discern if, when, and by whom a patient was previously treated for ADHD, and rule out the rare possibility that the patient has obtained multiple prescriptions for controlled substances from multiple clinicians, which suggests the patient may have a substance use disorder.

Begin the assessment at your initial contact with the patient

How patients present on an initial screening call or how they compose emails can reveal clues about their level of organization and overall executive functioning. The way patients complete intake forms (eg, using a concise vs a meandering writing style) as well as their punctuality when presenting to appointments can also be telling.

Conduct a mental status examination

Patients can have difficulty focusing and completing tasks for reasons other than having ADHD. A mental status examination can sometimes provide objective clues that an individual has ADHD. A digressive thought process, visible physical restlessness, and instances of a patient interrupting the evaluator are suggestive of ADHD, although all these symptoms can be present in other conditions (eg, mania). However, signs of ADHD in the mental status examination do not confirm an ADHD diagnosis, nor does their absence rule it out.

Maintain an appropriate diagnostic threshold

Per DSM-5, an ADHD diagnosis requires that the symptoms cause a significant impairment in functioning.³ It is up to the clinician to determine if this threshold is met. It is imperative to thoughtfully consider this because stimulants are first-line treatment for ADHD and are commonly misused. Psychiatrists are usually motivated to please their patients in order to maintain them as patients and develop a positive therapeutic relationship, which improves outcomes.⁴ However, it is important to demonstrate integrity, provide an accurate diagnosis, and not be unduly swayed by a patient’s wish to receive an ADHD diagnosis. If you sense that a prospective patient is hoping they will receive an ADHD diagnosis and be prescribed a stimulant, it may be prudent to emphasize that the patient will be assessed for multiple mental health conditions, including ADHD, and that treatment will depend on the outcome of the evaluation.

Childbirth-related posttraumatic stress disorder (CB-PTSD) is a form of PTSD that can develop related to trauma surrounding the events of giving birth. It affects approximately 5% of women after any birth, which is similar to the rate of PTSD after experiencing a natural disaster.¹ Up to 17% of women may have posttraumatic symptoms in the postpartum period.¹ Despite the high prevalence of CB-PTSD, many psychiatric clinicians have not incorporated screening for and management of CB-PTSD into their practice.

This is partly because childbirth has been conceptualized as a “stressful but positive life event.”² Historically, childbirth was not recognized as a traumatic event; for example, in DSM-III-R, the criteria for trauma in PTSD required an event outside the range of usual human experience, and childbirth was implicitly excluded as being too common to be traumatic. In the past decade, this clinical phenomenon has been more formally recognized and studied.²

CP02212055_t1.png

CB-PTSD presents with symptoms similar to those of other forms of PTSD, with some nuances, as outlined in Table 1.³ Avoidance can be the predominant symptom; this can affect mothers’ engagement in postnatal care and is a major risk factor for postpartum depression.³

Many risk factors in the peripartum period can impact the development of CB-PTSD (Table 2³). The most significant risk factor is whether the patient views the delivery of their baby as a subjectively negative experience, regardless of the presence or lack of peripartum complications.¹ However, parents of infants who require treatment in a neonatal intensive care unit and women who require emergency medical treatment following delivery are at higher risk.

CP02212055_t2.png

Screening and treatment

Ideally, every woman should be screened for CB-PTSD by their psychiatrist or obstetrician during a postpartum visit at least 1 month after delivery. In particular, high-risk populations and women with subjectively negative birth experiences should be screened, as well as women with postpartum depression that may have been precipitated or perpetuated by a traumatic experience. The City Birth Trauma Scale is a free 31-item self-report scale that can be used for such screening. It addresses both general and birth-related symptoms and is validated in multiple languages.⁴

Selective serotonin reuptake inhibitors and prazosin may be helpful for symptomatic treatment of CB-PTSD. Ongoing research studying the efficacy of cognitive-behavioral therapy and eye movement desensitization and reprocessing for CB-PTSD has yielded promising results but is limited in its generalizability.

Many women who develop CB-PTSD choose to get pregnant again. Psychiatrists can apply the principles of trauma-informed care and collaborate with obstetric and pediatric physicians to reduce the risk of retraumatization. It is critical to identify at-risk women and educate and prepare them for their next delivery experience. By focusing on communication, informed consent, and emotional support, we can do our best to prevent the recurrence of CB-PTSD.

Childbirth-related posttraumatic stress disorder (CB-PTSD) is a form of PTSD that can develop related to trauma surrounding the events of giving birth. It affects approximately 5% of women after any birth, which is similar to the rate of PTSD after experiencing a natural disaster.¹ Up to 17% of women may have posttraumatic symptoms in the postpartum period.¹ Despite the high prevalence of CB-PTSD, many psychiatric clinicians have not incorporated screening for and management of CB-PTSD into their practice.

This is partly because childbirth has been conceptualized as a “stressful but positive life event.”² Historically, childbirth was not recognized as a traumatic event; for example, in DSM-III-R, the criteria for trauma in PTSD required an event outside the range of usual human experience, and childbirth was implicitly excluded as being too common to be traumatic. In the past decade, this clinical phenomenon has been more formally recognized and studied.²

CP02212055_t1.png

CB-PTSD presents with symptoms similar to those of other forms of PTSD, with some nuances, as outlined in Table 1.³ Avoidance can be the predominant symptom; this can affect mothers’ engagement in postnatal care and is a major risk factor for postpartum depression.³

Many risk factors in the peripartum period can impact the development of CB-PTSD (Table 2³). The most significant risk factor is whether the patient views the delivery of their baby as a subjectively negative experience, regardless of the presence or lack of peripartum complications.¹ However, parents of infants who require treatment in a neonatal intensive care unit and women who require emergency medical treatment following delivery are at higher risk.

CP02212055_t2.png

Screening and treatment

Ideally, every woman should be screened for CB-PTSD by their psychiatrist or obstetrician during a postpartum visit at least 1 month after delivery. In particular, high-risk populations and women with subjectively negative birth experiences should be screened, as well as women with postpartum depression that may have been precipitated or perpetuated by a traumatic experience. The City Birth Trauma Scale is a free 31-item self-report scale that can be used for such screening. It addresses both general and birth-related symptoms and is validated in multiple languages.⁴

Selective serotonin reuptake inhibitors and prazosin may be helpful for symptomatic treatment of CB-PTSD. Ongoing research studying the efficacy of cognitive-behavioral therapy and eye movement desensitization and reprocessing for CB-PTSD has yielded promising results but is limited in its generalizability.

Many women who develop CB-PTSD choose to get pregnant again. Psychiatrists can apply the principles of trauma-informed care and collaborate with obstetric and pediatric physicians to reduce the risk of retraumatization. It is critical to identify at-risk women and educate and prepare them for their next delivery experience. By focusing on communication, informed consent, and emotional support, we can do our best to prevent the recurrence of CB-PTSD.

Childbirth-related posttraumatic stress disorder (CB-PTSD) is a form of PTSD that can develop related to trauma surrounding the events of giving birth. It affects approximately 5% of women after any birth, which is similar to the rate of PTSD after experiencing a natural disaster.¹ Up to 17% of women may have posttraumatic symptoms in the postpartum period.¹ Despite the high prevalence of CB-PTSD, many psychiatric clinicians have not incorporated screening for and management of CB-PTSD into their practice.

This is partly because childbirth has been conceptualized as a “stressful but positive life event.”² Historically, childbirth was not recognized as a traumatic event; for example, in DSM-III-R, the criteria for trauma in PTSD required an event outside the range of usual human experience, and childbirth was implicitly excluded as being too common to be traumatic. In the past decade, this clinical phenomenon has been more formally recognized and studied.²

CP02212055_t1.png

CB-PTSD presents with symptoms similar to those of other forms of PTSD, with some nuances, as outlined in Table 1.³ Avoidance can be the predominant symptom; this can affect mothers’ engagement in postnatal care and is a major risk factor for postpartum depression.³

Many risk factors in the peripartum period can impact the development of CB-PTSD (Table 2³). The most significant risk factor is whether the patient views the delivery of their baby as a subjectively negative experience, regardless of the presence or lack of peripartum complications.¹ However, parents of infants who require treatment in a neonatal intensive care unit and women who require emergency medical treatment following delivery are at higher risk.

CP02212055_t2.png

Screening and treatment

Ideally, every woman should be screened for CB-PTSD by their psychiatrist or obstetrician during a postpartum visit at least 1 month after delivery. In particular, high-risk populations and women with subjectively negative birth experiences should be screened, as well as women with postpartum depression that may have been precipitated or perpetuated by a traumatic experience. The City Birth Trauma Scale is a free 31-item self-report scale that can be used for such screening. It addresses both general and birth-related symptoms and is validated in multiple languages.⁴

Selective serotonin reuptake inhibitors and prazosin may be helpful for symptomatic treatment of CB-PTSD. Ongoing research studying the efficacy of cognitive-behavioral therapy and eye movement desensitization and reprocessing for CB-PTSD has yielded promising results but is limited in its generalizability.

Many women who develop CB-PTSD choose to get pregnant again. Psychiatrists can apply the principles of trauma-informed care and collaborate with obstetric and pediatric physicians to reduce the risk of retraumatization. It is critical to identify at-risk women and educate and prepare them for their next delivery experience. By focusing on communication, informed consent, and emotional support, we can do our best to prevent the recurrence of CB-PTSD.

Perinatal psychiatry focuses on the evaluation, diagnosis, and treatment of mental health disorders during the preconception, pregnancy, and postpartum periods. Mood disorders, anxiety disorders, and posttraumatic stress disorder are the most common mental health conditions that arise during the perinatal period.¹ Mediating factors include hormone fluctuations, sleep deprivation, trauma exposure, financial stress, having a history of psychiatric illness, and factors related to newborn care.

During the perinatal period, a comprehensive psychiatric interview is crucial. Effective screening and identification of maternal mental health conditions necessitate more than merely checking off boxes on a questionnaire. It requires compassionate, informed, and individualized conversations between physicians and their patients.

In addition to asking about pertinent positive and negative psychiatric symptoms, the following screening questions could be asked during a structured interview to identify perinatal issues during pregnancy and the postpartum period.

During pregnancy

• How do you feel about your pregnancy?
• Was this pregnancy planned or unplanned, desired or not?
• Was fertility treatment needed or used?
• Did you think about stopping the pregnancy? If so, was your decision influenced by laws that restrict abortion in your state?
• Do you feel connected to the fetus?
• Do you have a room or crib at home for the baby? A car seat? Clothing? Baby supplies?
• Are you planning on breastfeeding?
• Do you have thoughts on future desired fertility and/or contraception?
• Who is your support system at home?
• How is your relationship with the baby’s father?
• How is the baby’s father’s mental well-being?
• Have you been subject to any abuse, intimate partner violence, or neglect?
• Are your other children being taken care of properly? What is the plan for them during delivery days at the hospital?

During the postpartum period

• Was your baby born prematurely?
• Did you have a vaginal or cesarean delivery?
• Did you encounter any delivery complications?
• Did you see the baby after the delivery?
• Do you feel connected to or able to bond with the baby?
• Do you have access to maternity leave from work?
• Have you had scary or upsetting thoughts about hurting your baby?
• Do you have any concerns about your treatment plan, such as medication use?
• In case of an emergency, are you aware of perinatal psychiatry resources in your area or the national maternal mental health hotline (833-852-6262)?

The American College of Obstetricians and Gynecologists clinical practice guidelines recommend that clinicians conduct depression and anxiety screening at least once during the perinatal period by using a standardized, validated tool.² Psychiatry residents should receive adequate guidance and education about perinatal psychiatric evaluation, risk assessment, and treatment counseling. Early detection of mental health symptoms allows for early referral, close surveillance during episodes of vulnerability, and better access to mental health care during the perinatal period.

Perinatal psychiatry focuses on the evaluation, diagnosis, and treatment of mental health disorders during the preconception, pregnancy, and postpartum periods. Mood disorders, anxiety disorders, and posttraumatic stress disorder are the most common mental health conditions that arise during the perinatal period.¹ Mediating factors include hormone fluctuations, sleep deprivation, trauma exposure, financial stress, having a history of psychiatric illness, and factors related to newborn care.

During the perinatal period, a comprehensive psychiatric interview is crucial. Effective screening and identification of maternal mental health conditions necessitate more than merely checking off boxes on a questionnaire. It requires compassionate, informed, and individualized conversations between physicians and their patients.

In addition to asking about pertinent positive and negative psychiatric symptoms, the following screening questions could be asked during a structured interview to identify perinatal issues during pregnancy and the postpartum period.

During pregnancy

• How do you feel about your pregnancy?
• Was this pregnancy planned or unplanned, desired or not?
• Was fertility treatment needed or used?
• Did you think about stopping the pregnancy? If so, was your decision influenced by laws that restrict abortion in your state?
• Do you feel connected to the fetus?
• Do you have a room or crib at home for the baby? A car seat? Clothing? Baby supplies?
• Are you planning on breastfeeding?
• Do you have thoughts on future desired fertility and/or contraception?
• Who is your support system at home?
• How is your relationship with the baby’s father?
• How is the baby’s father’s mental well-being?
• Have you been subject to any abuse, intimate partner violence, or neglect?
• Are your other children being taken care of properly? What is the plan for them during delivery days at the hospital?

During the postpartum period

• Was your baby born prematurely?
• Did you have a vaginal or cesarean delivery?
• Did you encounter any delivery complications?
• Did you see the baby after the delivery?
• Do you feel connected to or able to bond with the baby?
• Do you have access to maternity leave from work?
• Have you had scary or upsetting thoughts about hurting your baby?
• Do you have any concerns about your treatment plan, such as medication use?
• In case of an emergency, are you aware of perinatal psychiatry resources in your area or the national maternal mental health hotline (833-852-6262)?

The American College of Obstetricians and Gynecologists clinical practice guidelines recommend that clinicians conduct depression and anxiety screening at least once during the perinatal period by using a standardized, validated tool.² Psychiatry residents should receive adequate guidance and education about perinatal psychiatric evaluation, risk assessment, and treatment counseling. Early detection of mental health symptoms allows for early referral, close surveillance during episodes of vulnerability, and better access to mental health care during the perinatal period.

Perinatal psychiatry focuses on the evaluation, diagnosis, and treatment of mental health disorders during the preconception, pregnancy, and postpartum periods. Mood disorders, anxiety disorders, and posttraumatic stress disorder are the most common mental health conditions that arise during the perinatal period.¹ Mediating factors include hormone fluctuations, sleep deprivation, trauma exposure, financial stress, having a history of psychiatric illness, and factors related to newborn care.

During the perinatal period, a comprehensive psychiatric interview is crucial. Effective screening and identification of maternal mental health conditions necessitate more than merely checking off boxes on a questionnaire. It requires compassionate, informed, and individualized conversations between physicians and their patients.

In addition to asking about pertinent positive and negative psychiatric symptoms, the following screening questions could be asked during a structured interview to identify perinatal issues during pregnancy and the postpartum period.

During pregnancy

• How do you feel about your pregnancy?
• Was this pregnancy planned or unplanned, desired or not?
• Was fertility treatment needed or used?
• Did you think about stopping the pregnancy? If so, was your decision influenced by laws that restrict abortion in your state?
• Do you feel connected to the fetus?
• Do you have a room or crib at home for the baby? A car seat? Clothing? Baby supplies?
• Are you planning on breastfeeding?
• Do you have thoughts on future desired fertility and/or contraception?
• Who is your support system at home?
• How is your relationship with the baby’s father?
• How is the baby’s father’s mental well-being?
• Have you been subject to any abuse, intimate partner violence, or neglect?
• Are your other children being taken care of properly? What is the plan for them during delivery days at the hospital?

During the postpartum period

• Was your baby born prematurely?
• Did you have a vaginal or cesarean delivery?
• Did you encounter any delivery complications?
• Did you see the baby after the delivery?
• Do you feel connected to or able to bond with the baby?
• Do you have access to maternity leave from work?
• Have you had scary or upsetting thoughts about hurting your baby?
• Do you have any concerns about your treatment plan, such as medication use?
• In case of an emergency, are you aware of perinatal psychiatry resources in your area or the national maternal mental health hotline (833-852-6262)?

The American College of Obstetricians and Gynecologists clinical practice guidelines recommend that clinicians conduct depression and anxiety screening at least once during the perinatal period by using a standardized, validated tool.² Psychiatry residents should receive adequate guidance and education about perinatal psychiatric evaluation, risk assessment, and treatment counseling. Early detection of mental health symptoms allows for early referral, close surveillance during episodes of vulnerability, and better access to mental health care during the perinatal period.

My colleagues and I entered the realm of outpatient psychiatry during residency at a logistically and dynamically interesting time. At the beginning of our third year in training (July 2022), almost all of the outpatients we were treating were still being seen virtually. For much of the year, they remained that way. However, with the reinstatement of the Ryan Haight Act in May 2023, I began to meet patients in person for the first time—the same patients whom I had known only virtually for the first 10 months of our therapeutic relationship. I observed vast changes in the dynamic of the room; many of these patients opened up more in their first in-person session than they had all year over Zoom.

Once in-person sessions resumed, patients who during virtual visits had assured me for almost a year that their home situation was optimized had a plethora of new things to share about their seemingly straightforward living situations. Relationships that appeared stable had more layers to reveal once the half of the relationship I was treating was now comfortably seated within the walls of my office. Problems that had previously seemed biologically based suddenly had complex sociocultural elements that were divulged for the first time. Some patients felt freer to be unrestricted in their affect, in contrast to the logistical (and metaphorical) buttoned-up virtual environment. Emotions ranged from cathartic (“It’s so great to see you in person!”) to bemused (“You’re taller/shorter, older/younger than I thought!”). The screen was gone, and the tangibility of it all breathed a different air into the room.

Virtual vs in-person: Crabs on a beach

The virtual treatment space could be envisioned as crabs in shells scattered on a beach, in which 2 crabs situated in their own shells, not necessarily adjacent to each other, could communicate. This certainly had benefits, such as the convenience of not having to move to another shell, as well as the brief but telling opportunity to gaze into their home shell environment. However, sometimes there would be disadvantages, such as interference with the connection due to static in the sand; at other times, there was the potential for other crabs to overhear and inadvertently learn of each other’s presence, thus affecting the openness of the communication. In this analogy, perhaps the equivalent of an in-person meeting would be 1 crab meandering over and the 2 crabs cohabiting a conch for the first time—it’s spacious (enough), all-enveloping, and within the harkened privacy of a shared sacred space.

A unique training experience

My co-residents and I are uniquely positioned to observe this novel phenomenon due to the timing of having entered our outpatient psychiatry training during the COVID-19 pandemic. Previous generations of residents—as well as practicing psychiatrists who had initially met their patients in person and were forced to switch to virtual sessions during the pandemic—had certain perspectives and challenges of their own, but they had a known dynamic of in-person interactions at baseline. Accordingly, residents who practiced peak- and mid-pandemic and graduated without being required to treat patients face-to-face (the classes of 2022 and 2023) might have spent entire therapeutic relationships having never met their patients in person. My class (2024) was situated in this time- and situation-bound frame in which we started virtually, and by requirements of the law, later met our patients in person. Being not only an observer but an active participant in a treatment dyad within the context of this phenomenon taught me astutely about transference, countertransference, and the holding environment. Training in psychodynamic psychotherapy has taught me about the act of listening deeply and qualities of therapeutic communication. Having the opportunity to enact these principles in such a dichotomy of treatment settings has been invaluable in my education, in getting to know different facets of my patients, and in understanding the nuances of the human experience.

My colleagues and I entered the realm of outpatient psychiatry during residency at a logistically and dynamically interesting time. At the beginning of our third year in training (July 2022), almost all of the outpatients we were treating were still being seen virtually. For much of the year, they remained that way. However, with the reinstatement of the Ryan Haight Act in May 2023, I began to meet patients in person for the first time—the same patients whom I had known only virtually for the first 10 months of our therapeutic relationship. I observed vast changes in the dynamic of the room; many of these patients opened up more in their first in-person session than they had all year over Zoom.

Once in-person sessions resumed, patients who during virtual visits had assured me for almost a year that their home situation was optimized had a plethora of new things to share about their seemingly straightforward living situations. Relationships that appeared stable had more layers to reveal once the half of the relationship I was treating was now comfortably seated within the walls of my office. Problems that had previously seemed biologically based suddenly had complex sociocultural elements that were divulged for the first time. Some patients felt freer to be unrestricted in their affect, in contrast to the logistical (and metaphorical) buttoned-up virtual environment. Emotions ranged from cathartic (“It’s so great to see you in person!”) to bemused (“You’re taller/shorter, older/younger than I thought!”). The screen was gone, and the tangibility of it all breathed a different air into the room.

Virtual vs in-person: Crabs on a beach

The virtual treatment space could be envisioned as crabs in shells scattered on a beach, in which 2 crabs situated in their own shells, not necessarily adjacent to each other, could communicate. This certainly had benefits, such as the convenience of not having to move to another shell, as well as the brief but telling opportunity to gaze into their home shell environment. However, sometimes there would be disadvantages, such as interference with the connection due to static in the sand; at other times, there was the potential for other crabs to overhear and inadvertently learn of each other’s presence, thus affecting the openness of the communication. In this analogy, perhaps the equivalent of an in-person meeting would be 1 crab meandering over and the 2 crabs cohabiting a conch for the first time—it’s spacious (enough), all-enveloping, and within the harkened privacy of a shared sacred space.

A unique training experience

My co-residents and I are uniquely positioned to observe this novel phenomenon due to the timing of having entered our outpatient psychiatry training during the COVID-19 pandemic. Previous generations of residents—as well as practicing psychiatrists who had initially met their patients in person and were forced to switch to virtual sessions during the pandemic—had certain perspectives and challenges of their own, but they had a known dynamic of in-person interactions at baseline. Accordingly, residents who practiced peak- and mid-pandemic and graduated without being required to treat patients face-to-face (the classes of 2022 and 2023) might have spent entire therapeutic relationships having never met their patients in person. My class (2024) was situated in this time- and situation-bound frame in which we started virtually, and by requirements of the law, later met our patients in person. Being not only an observer but an active participant in a treatment dyad within the context of this phenomenon taught me astutely about transference, countertransference, and the holding environment. Training in psychodynamic psychotherapy has taught me about the act of listening deeply and qualities of therapeutic communication. Having the opportunity to enact these principles in such a dichotomy of treatment settings has been invaluable in my education, in getting to know different facets of my patients, and in understanding the nuances of the human experience.

My colleagues and I entered the realm of outpatient psychiatry during residency at a logistically and dynamically interesting time. At the beginning of our third year in training (July 2022), almost all of the outpatients we were treating were still being seen virtually. For much of the year, they remained that way. However, with the reinstatement of the Ryan Haight Act in May 2023, I began to meet patients in person for the first time—the same patients whom I had known only virtually for the first 10 months of our therapeutic relationship. I observed vast changes in the dynamic of the room; many of these patients opened up more in their first in-person session than they had all year over Zoom.

Once in-person sessions resumed, patients who during virtual visits had assured me for almost a year that their home situation was optimized had a plethora of new things to share about their seemingly straightforward living situations. Relationships that appeared stable had more layers to reveal once the half of the relationship I was treating was now comfortably seated within the walls of my office. Problems that had previously seemed biologically based suddenly had complex sociocultural elements that were divulged for the first time. Some patients felt freer to be unrestricted in their affect, in contrast to the logistical (and metaphorical) buttoned-up virtual environment. Emotions ranged from cathartic (“It’s so great to see you in person!”) to bemused (“You’re taller/shorter, older/younger than I thought!”). The screen was gone, and the tangibility of it all breathed a different air into the room.

Virtual vs in-person: Crabs on a beach

The virtual treatment space could be envisioned as crabs in shells scattered on a beach, in which 2 crabs situated in their own shells, not necessarily adjacent to each other, could communicate. This certainly had benefits, such as the convenience of not having to move to another shell, as well as the brief but telling opportunity to gaze into their home shell environment. However, sometimes there would be disadvantages, such as interference with the connection due to static in the sand; at other times, there was the potential for other crabs to overhear and inadvertently learn of each other’s presence, thus affecting the openness of the communication. In this analogy, perhaps the equivalent of an in-person meeting would be 1 crab meandering over and the 2 crabs cohabiting a conch for the first time—it’s spacious (enough), all-enveloping, and within the harkened privacy of a shared sacred space.

A unique training experience

My co-residents and I are uniquely positioned to observe this novel phenomenon due to the timing of having entered our outpatient psychiatry training during the COVID-19 pandemic. Previous generations of residents—as well as practicing psychiatrists who had initially met their patients in person and were forced to switch to virtual sessions during the pandemic—had certain perspectives and challenges of their own, but they had a known dynamic of in-person interactions at baseline. Accordingly, residents who practiced peak- and mid-pandemic and graduated without being required to treat patients face-to-face (the classes of 2022 and 2023) might have spent entire therapeutic relationships having never met their patients in person. My class (2024) was situated in this time- and situation-bound frame in which we started virtually, and by requirements of the law, later met our patients in person. Being not only an observer but an active participant in a treatment dyad within the context of this phenomenon taught me astutely about transference, countertransference, and the holding environment. Training in psychodynamic psychotherapy has taught me about the act of listening deeply and qualities of therapeutic communication. Having the opportunity to enact these principles in such a dichotomy of treatment settings has been invaluable in my education, in getting to know different facets of my patients, and in understanding the nuances of the human experience.

As a 2020 graduate, my medical school experience was largely untouched by the coronavirus. However, when I transitioned to residency, the world was 4 months into the COVID-19 pandemic, and I was required to wear an N95 mask. Just as I started calling myself Dr. Petteruti, I stopped seeing my patients’ entire face, and they stopped seeing mine. In this article, I share my reflections on wearing a mask during residency.

Even after 3 years of daily practice, I have found that wearing a mask brings an acute awareness of my face. As a community physician, the spheres of personal and public life intersect as I treat patients. Learning to navigate this is an important and shared experience across many community-based residency programs. However, during the first few years of residency, I have been able to shop at a local grocery store or eat at a nearby restaurant without any concerns of being recognized by a patient. Until recently, my patients had never seen my face. That has now changed.

For a new intern, a mask can be a savior. It can hide most of what is on your face from your patient. It is remarkable how the brain fills in the gaps of the visage and, by extension, aspects of the person. Many times, I was thankful to have my morning yawn or facial expression covered during provoking conversations with patients. Furthermore, masks gave me an opportunity to examine my own reactions, emotions, affect, and countertransference of each interaction on my own time.

The mask mandate also protected some features that illustrated my youth. For the patient, a mask can add a dry, clinical distance to the physician, often emitting a professional interpretation to the encounter. For the physician, the mask serves as a concrete barrier to the otherwise effortless acts of observation. Early in my career, I had to set reminders to have patients who were taking antipsychotic medications remove their masks to assess for tardive dyskinesia. Sometimes this surprised the patient, who was hesitant to expose themselves physically and psychologically. Alternatively, mask wearing has proved to be an additional data point on some patients, such as those with disorganized behavior. If the mask is located on the patient’s head, chin, or eyes, or is otherwise inappropriately placed, this provides the clinician with supplemental information.

After spending most of my third year of residency in an outpatient office diligently learning how to build a sturdy therapeutic patient alliance, the mask mandate was lifted. Patients’ transference began to change right before my newly bared face. People often relate age to wisdom and experience, so my lack of age—and thus, possible perceived lack of knowledge—became glaringly apparent. During our initial encounters without masks, patients I had known for most of the year began discussing their symptoms and treatments with more hesitancy. My established patients suddenly had a noticeable change in the intensity of their eye contact. Some even asked if I had cut my hair or what had changed about my appearance since our previous visit. This change in affect and behavior offers a unique experience for the resident; renovating the patient-doctor relationship based on the physician’s appearance.

As psychiatrists, we would generally assume mask wearing has an undesirable effect on the therapeutic alliance and increases skewed inferences in our evaluations. This held true for my experience in residency. In psychotherapy, we work to help patients remove their own metaphorical “masks” of defense and security in self-exploration. However, as young physicians, rather than creating barriers between us and our patients, the mask mandate seemed to have created a sense of credibility in our practice and trustworthiness in our decisions.

Some questions remain. As clinicians, what are we missing when we can only see our patient’s eyes and forehead? How will the COVID-19 pandemic affect my training and career as a psychiatrist? These may remain unanswered for my generation of trainees for some time, as society will look back and contemplate this period for decades. Though we entered our career in uncertain times, with an increased risk of morbidity and death and high demand for proper personal protective equipment, we were and still are thankful for our masks and for the limited infection exposure afforded by the nature of our specialty.

As a 2020 graduate, my medical school experience was largely untouched by the coronavirus. However, when I transitioned to residency, the world was 4 months into the COVID-19 pandemic, and I was required to wear an N95 mask. Just as I started calling myself Dr. Petteruti, I stopped seeing my patients’ entire face, and they stopped seeing mine. In this article, I share my reflections on wearing a mask during residency.

Even after 3 years of daily practice, I have found that wearing a mask brings an acute awareness of my face. As a community physician, the spheres of personal and public life intersect as I treat patients. Learning to navigate this is an important and shared experience across many community-based residency programs. However, during the first few years of residency, I have been able to shop at a local grocery store or eat at a nearby restaurant without any concerns of being recognized by a patient. Until recently, my patients had never seen my face. That has now changed.

For a new intern, a mask can be a savior. It can hide most of what is on your face from your patient. It is remarkable how the brain fills in the gaps of the visage and, by extension, aspects of the person. Many times, I was thankful to have my morning yawn or facial expression covered during provoking conversations with patients. Furthermore, masks gave me an opportunity to examine my own reactions, emotions, affect, and countertransference of each interaction on my own time.

The mask mandate also protected some features that illustrated my youth. For the patient, a mask can add a dry, clinical distance to the physician, often emitting a professional interpretation to the encounter. For the physician, the mask serves as a concrete barrier to the otherwise effortless acts of observation. Early in my career, I had to set reminders to have patients who were taking antipsychotic medications remove their masks to assess for tardive dyskinesia. Sometimes this surprised the patient, who was hesitant to expose themselves physically and psychologically. Alternatively, mask wearing has proved to be an additional data point on some patients, such as those with disorganized behavior. If the mask is located on the patient’s head, chin, or eyes, or is otherwise inappropriately placed, this provides the clinician with supplemental information.

After spending most of my third year of residency in an outpatient office diligently learning how to build a sturdy therapeutic patient alliance, the mask mandate was lifted. Patients’ transference began to change right before my newly bared face. People often relate age to wisdom and experience, so my lack of age—and thus, possible perceived lack of knowledge—became glaringly apparent. During our initial encounters without masks, patients I had known for most of the year began discussing their symptoms and treatments with more hesitancy. My established patients suddenly had a noticeable change in the intensity of their eye contact. Some even asked if I had cut my hair or what had changed about my appearance since our previous visit. This change in affect and behavior offers a unique experience for the resident; renovating the patient-doctor relationship based on the physician’s appearance.

As psychiatrists, we would generally assume mask wearing has an undesirable effect on the therapeutic alliance and increases skewed inferences in our evaluations. This held true for my experience in residency. In psychotherapy, we work to help patients remove their own metaphorical “masks” of defense and security in self-exploration. However, as young physicians, rather than creating barriers between us and our patients, the mask mandate seemed to have created a sense of credibility in our practice and trustworthiness in our decisions.

Some questions remain. As clinicians, what are we missing when we can only see our patient’s eyes and forehead? How will the COVID-19 pandemic affect my training and career as a psychiatrist? These may remain unanswered for my generation of trainees for some time, as society will look back and contemplate this period for decades. Though we entered our career in uncertain times, with an increased risk of morbidity and death and high demand for proper personal protective equipment, we were and still are thankful for our masks and for the limited infection exposure afforded by the nature of our specialty.

As a 2020 graduate, my medical school experience was largely untouched by the coronavirus. However, when I transitioned to residency, the world was 4 months into the COVID-19 pandemic, and I was required to wear an N95 mask. Just as I started calling myself Dr. Petteruti, I stopped seeing my patients’ entire face, and they stopped seeing mine. In this article, I share my reflections on wearing a mask during residency.

Even after 3 years of daily practice, I have found that wearing a mask brings an acute awareness of my face. As a community physician, the spheres of personal and public life intersect as I treat patients. Learning to navigate this is an important and shared experience across many community-based residency programs. However, during the first few years of residency, I have been able to shop at a local grocery store or eat at a nearby restaurant without any concerns of being recognized by a patient. Until recently, my patients had never seen my face. That has now changed.

For a new intern, a mask can be a savior. It can hide most of what is on your face from your patient. It is remarkable how the brain fills in the gaps of the visage and, by extension, aspects of the person. Many times, I was thankful to have my morning yawn or facial expression covered during provoking conversations with patients. Furthermore, masks gave me an opportunity to examine my own reactions, emotions, affect, and countertransference of each interaction on my own time.

The mask mandate also protected some features that illustrated my youth. For the patient, a mask can add a dry, clinical distance to the physician, often emitting a professional interpretation to the encounter. For the physician, the mask serves as a concrete barrier to the otherwise effortless acts of observation. Early in my career, I had to set reminders to have patients who were taking antipsychotic medications remove their masks to assess for tardive dyskinesia. Sometimes this surprised the patient, who was hesitant to expose themselves physically and psychologically. Alternatively, mask wearing has proved to be an additional data point on some patients, such as those with disorganized behavior. If the mask is located on the patient’s head, chin, or eyes, or is otherwise inappropriately placed, this provides the clinician with supplemental information.

After spending most of my third year of residency in an outpatient office diligently learning how to build a sturdy therapeutic patient alliance, the mask mandate was lifted. Patients’ transference began to change right before my newly bared face. People often relate age to wisdom and experience, so my lack of age—and thus, possible perceived lack of knowledge—became glaringly apparent. During our initial encounters without masks, patients I had known for most of the year began discussing their symptoms and treatments with more hesitancy. My established patients suddenly had a noticeable change in the intensity of their eye contact. Some even asked if I had cut my hair or what had changed about my appearance since our previous visit. This change in affect and behavior offers a unique experience for the resident; renovating the patient-doctor relationship based on the physician’s appearance.

As psychiatrists, we would generally assume mask wearing has an undesirable effect on the therapeutic alliance and increases skewed inferences in our evaluations. This held true for my experience in residency. In psychotherapy, we work to help patients remove their own metaphorical “masks” of defense and security in self-exploration. However, as young physicians, rather than creating barriers between us and our patients, the mask mandate seemed to have created a sense of credibility in our practice and trustworthiness in our decisions.

Some questions remain. As clinicians, what are we missing when we can only see our patient’s eyes and forehead? How will the COVID-19 pandemic affect my training and career as a psychiatrist? These may remain unanswered for my generation of trainees for some time, as society will look back and contemplate this period for decades. Though we entered our career in uncertain times, with an increased risk of morbidity and death and high demand for proper personal protective equipment, we were and still are thankful for our masks and for the limited infection exposure afforded by the nature of our specialty.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

The second-generation antipsychotic quetiapine is commonly used to treat several psychiatric disorders, including bipolar disorder (BD) and insomnia. In this case report, we discuss a patient with a history of unipolar depression and initial signs of mania who experienced an exacerbation of manic symptoms following administration of low-dose quetiapine. This case underscores the need for careful monitoring of patients receiving quetiapine, especially at lower doses, and the potential limitations of its efficacy in controlling manic symptoms.

Depressed with racing thoughts

Mr. X, age 58, is an Army veteran who lives with his wife of 29 years and works as a contractor. He has a history of depression and a suicide attempt 10 years ago by self-inflicted gunshot wound to the head, which left him with a bullet lodged in his sinus cavity and residual dysarthria after tongue surgery. After the suicide attempt, Mr. X was medically hospitalized, but not psychiatrically hospitalized. Shortly after, he self-discontinued all psychotropic medications and follow-up.

Mr. X has no other medical history and takes no other medications or supplements. His family history includes a mother with schizoaffective disorder, 1 brother with BD, and another brother with developmental delay.

Mr. X remained euthymic until his brother died. Soon after, he began to experience low mood, heightened anxiety, racing thoughts, tearfulness, and mild insomnia. He was prescribed quetiapine 25 mg/d at bedtime and instructed to titrate up to 50 mg/d.

Ten days later, Mr. X was brought to the hospital by his wife, who reported that after starting quetiapine, her husband began to act erratically. He had disorganized and racing thoughts, loose associations, labile affect, hyperactivity/restlessness, and was not sleeping. In the morning before presenting to the hospital, Mr. X had gone to work, laid down on the floor, began mumbling to himself, and would not respond to coworkers. Upon evaluation, Mr. X was noted to have pressured speech, disorganized speech, delusions, anxiety, and hallucinations. A CT scan of his head was normal, and a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, B12, folate, and hemoglobin A1c were within normal limits. Mr. X’s vitamin D level was low at 22 ng/mL, and a syphilis screen was negative.

Mr. X was admitted to the hospital for his safety. The treatment team discontinued quetiapine and started risperidone 3 mg twice a day for psychotic symptoms and mood stabilization. At the time of discharge 7 days later, Mr. X was no longer experiencing any hallucinations or delusions, his thought process was linear and goal-directed, his mood was stable, and his insomnia had improved. Based on the temporal relationship between the initiation of quetiapine and the onset of Mr. X’s manic symptoms, along with an absence of organic causes, the treatment team suspected Mr. X had experienced a worsening of manic symptoms induced by quetiapine. Before starting quetiapine, he had presented with an initial manic symptom of racing thoughts.

At his next outpatient appointment, Mr. X exhibited significant akathisia. The treatment team initiated propranolol 20 mg twice a day but Mr. X did not experience much improvement. Risperidone was reduced to 1 mg twice a day and Mr. X was started on clonazepam 0.5 mg twice a day. The akathisia resolved. The treatment team decided to discontinue all medications and observe Mr. X for any recurrence of symptoms. One year after his manic episode. Mr. X remained euthymic. He was able to resume full-time work and began psychotherapy to process the grief over the loss of his brother.

Quetiapine’s unique profile

This case sheds light on the potential limitations of quetiapine, especially at lower doses, for managing manic symptoms. Quetiapine exhibits antidepressant effects, even at doses as low as 50 mg/d.¹ At higher doses, quetiapine acts as an antagonist at serotonin (5-HT1A and 5-HT2A), dopamine (D1 and D2), histamine H1, and adrenergic receptors.² At doses <300 mg/d, there is an absence of dopamine receptor blockade and a higher affinity for 5-HT2A receptors, which could explain why higher doses are generally necessary for treating mania and psychotic symptoms.^3-5 High 5-HT2A antagonism may disinhibit the dopaminergic system and paradoxically increase dopaminergic activity, which could be the mechanism responsible for lack of control of manic symptoms with low doses of quetiapine.² Another possible explanation is that the metabolite of quetiapine, N-desalkylquetiapine, acts as a norepine­phrine reuptake blocker and partial 5-HT1Aantagonist, which acts as an antidepressant, and antidepressants are known to induce mania in vulnerable patients.⁴

The antimanic property of most antipsychotics (except possibly clozapine) is attributed to their D2 antagonistic potency. Because quetiapine is among the weaker D2 antagonists, its inability to prevent the progression of mania, especially at 50 mg/d, is not unexpected. Mr. X’s subsequent need for a stronger D2 antagonist—risperidone—at a significant dose further supports this observation. A common misconception is that quetiapine’s sedating effects make it effective for treating mania, but that is not the case. Clinicians should be cautious when prescribing quetiapine, especially at lower doses, to patients who exhibit signs of mania. Given the potential risk, clinicians should consider alternative treatments before resorting to low-dose quetiapine for insomnia. Regular monitoring for manic symptoms is crucial for all patients receiving quetiapine. If patients present with signs of mania or hypomania, a therapeutic dose range of 600 to 800 mg/d is recommended.⁶

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

The second-generation antipsychotic quetiapine is commonly used to treat several psychiatric disorders, including bipolar disorder (BD) and insomnia. In this case report, we discuss a patient with a history of unipolar depression and initial signs of mania who experienced an exacerbation of manic symptoms following administration of low-dose quetiapine. This case underscores the need for careful monitoring of patients receiving quetiapine, especially at lower doses, and the potential limitations of its efficacy in controlling manic symptoms.

Depressed with racing thoughts

Mr. X, age 58, is an Army veteran who lives with his wife of 29 years and works as a contractor. He has a history of depression and a suicide attempt 10 years ago by self-inflicted gunshot wound to the head, which left him with a bullet lodged in his sinus cavity and residual dysarthria after tongue surgery. After the suicide attempt, Mr. X was medically hospitalized, but not psychiatrically hospitalized. Shortly after, he self-discontinued all psychotropic medications and follow-up.

Mr. X has no other medical history and takes no other medications or supplements. His family history includes a mother with schizoaffective disorder, 1 brother with BD, and another brother with developmental delay.

Mr. X remained euthymic until his brother died. Soon after, he began to experience low mood, heightened anxiety, racing thoughts, tearfulness, and mild insomnia. He was prescribed quetiapine 25 mg/d at bedtime and instructed to titrate up to 50 mg/d.

Ten days later, Mr. X was brought to the hospital by his wife, who reported that after starting quetiapine, her husband began to act erratically. He had disorganized and racing thoughts, loose associations, labile affect, hyperactivity/restlessness, and was not sleeping. In the morning before presenting to the hospital, Mr. X had gone to work, laid down on the floor, began mumbling to himself, and would not respond to coworkers. Upon evaluation, Mr. X was noted to have pressured speech, disorganized speech, delusions, anxiety, and hallucinations. A CT scan of his head was normal, and a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, B12, folate, and hemoglobin A1c were within normal limits. Mr. X’s vitamin D level was low at 22 ng/mL, and a syphilis screen was negative.

Mr. X was admitted to the hospital for his safety. The treatment team discontinued quetiapine and started risperidone 3 mg twice a day for psychotic symptoms and mood stabilization. At the time of discharge 7 days later, Mr. X was no longer experiencing any hallucinations or delusions, his thought process was linear and goal-directed, his mood was stable, and his insomnia had improved. Based on the temporal relationship between the initiation of quetiapine and the onset of Mr. X’s manic symptoms, along with an absence of organic causes, the treatment team suspected Mr. X had experienced a worsening of manic symptoms induced by quetiapine. Before starting quetiapine, he had presented with an initial manic symptom of racing thoughts.

At his next outpatient appointment, Mr. X exhibited significant akathisia. The treatment team initiated propranolol 20 mg twice a day but Mr. X did not experience much improvement. Risperidone was reduced to 1 mg twice a day and Mr. X was started on clonazepam 0.5 mg twice a day. The akathisia resolved. The treatment team decided to discontinue all medications and observe Mr. X for any recurrence of symptoms. One year after his manic episode. Mr. X remained euthymic. He was able to resume full-time work and began psychotherapy to process the grief over the loss of his brother.

Quetiapine’s unique profile

This case sheds light on the potential limitations of quetiapine, especially at lower doses, for managing manic symptoms. Quetiapine exhibits antidepressant effects, even at doses as low as 50 mg/d.¹ At higher doses, quetiapine acts as an antagonist at serotonin (5-HT1A and 5-HT2A), dopamine (D1 and D2), histamine H1, and adrenergic receptors.² At doses <300 mg/d, there is an absence of dopamine receptor blockade and a higher affinity for 5-HT2A receptors, which could explain why higher doses are generally necessary for treating mania and psychotic symptoms.^3-5 High 5-HT2A antagonism may disinhibit the dopaminergic system and paradoxically increase dopaminergic activity, which could be the mechanism responsible for lack of control of manic symptoms with low doses of quetiapine.² Another possible explanation is that the metabolite of quetiapine, N-desalkylquetiapine, acts as a norepine­phrine reuptake blocker and partial 5-HT1Aantagonist, which acts as an antidepressant, and antidepressants are known to induce mania in vulnerable patients.⁴

The antimanic property of most antipsychotics (except possibly clozapine) is attributed to their D2 antagonistic potency. Because quetiapine is among the weaker D2 antagonists, its inability to prevent the progression of mania, especially at 50 mg/d, is not unexpected. Mr. X’s subsequent need for a stronger D2 antagonist—risperidone—at a significant dose further supports this observation. A common misconception is that quetiapine’s sedating effects make it effective for treating mania, but that is not the case. Clinicians should be cautious when prescribing quetiapine, especially at lower doses, to patients who exhibit signs of mania. Given the potential risk, clinicians should consider alternative treatments before resorting to low-dose quetiapine for insomnia. Regular monitoring for manic symptoms is crucial for all patients receiving quetiapine. If patients present with signs of mania or hypomania, a therapeutic dose range of 600 to 800 mg/d is recommended.⁶

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

The second-generation antipsychotic quetiapine is commonly used to treat several psychiatric disorders, including bipolar disorder (BD) and insomnia. In this case report, we discuss a patient with a history of unipolar depression and initial signs of mania who experienced an exacerbation of manic symptoms following administration of low-dose quetiapine. This case underscores the need for careful monitoring of patients receiving quetiapine, especially at lower doses, and the potential limitations of its efficacy in controlling manic symptoms.

Depressed with racing thoughts

Mr. X, age 58, is an Army veteran who lives with his wife of 29 years and works as a contractor. He has a history of depression and a suicide attempt 10 years ago by self-inflicted gunshot wound to the head, which left him with a bullet lodged in his sinus cavity and residual dysarthria after tongue surgery. After the suicide attempt, Mr. X was medically hospitalized, but not psychiatrically hospitalized. Shortly after, he self-discontinued all psychotropic medications and follow-up.

Mr. X has no other medical history and takes no other medications or supplements. His family history includes a mother with schizoaffective disorder, 1 brother with BD, and another brother with developmental delay.

Mr. X remained euthymic until his brother died. Soon after, he began to experience low mood, heightened anxiety, racing thoughts, tearfulness, and mild insomnia. He was prescribed quetiapine 25 mg/d at bedtime and instructed to titrate up to 50 mg/d.

Ten days later, Mr. X was brought to the hospital by his wife, who reported that after starting quetiapine, her husband began to act erratically. He had disorganized and racing thoughts, loose associations, labile affect, hyperactivity/restlessness, and was not sleeping. In the morning before presenting to the hospital, Mr. X had gone to work, laid down on the floor, began mumbling to himself, and would not respond to coworkers. Upon evaluation, Mr. X was noted to have pressured speech, disorganized speech, delusions, anxiety, and hallucinations. A CT scan of his head was normal, and a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, B12, folate, and hemoglobin A1c were within normal limits. Mr. X’s vitamin D level was low at 22 ng/mL, and a syphilis screen was negative.

Mr. X was admitted to the hospital for his safety. The treatment team discontinued quetiapine and started risperidone 3 mg twice a day for psychotic symptoms and mood stabilization. At the time of discharge 7 days later, Mr. X was no longer experiencing any hallucinations or delusions, his thought process was linear and goal-directed, his mood was stable, and his insomnia had improved. Based on the temporal relationship between the initiation of quetiapine and the onset of Mr. X’s manic symptoms, along with an absence of organic causes, the treatment team suspected Mr. X had experienced a worsening of manic symptoms induced by quetiapine. Before starting quetiapine, he had presented with an initial manic symptom of racing thoughts.

At his next outpatient appointment, Mr. X exhibited significant akathisia. The treatment team initiated propranolol 20 mg twice a day but Mr. X did not experience much improvement. Risperidone was reduced to 1 mg twice a day and Mr. X was started on clonazepam 0.5 mg twice a day. The akathisia resolved. The treatment team decided to discontinue all medications and observe Mr. X for any recurrence of symptoms. One year after his manic episode. Mr. X remained euthymic. He was able to resume full-time work and began psychotherapy to process the grief over the loss of his brother.

Quetiapine’s unique profile

This case sheds light on the potential limitations of quetiapine, especially at lower doses, for managing manic symptoms. Quetiapine exhibits antidepressant effects, even at doses as low as 50 mg/d.¹ At higher doses, quetiapine acts as an antagonist at serotonin (5-HT1A and 5-HT2A), dopamine (D1 and D2), histamine H1, and adrenergic receptors.² At doses <300 mg/d, there is an absence of dopamine receptor blockade and a higher affinity for 5-HT2A receptors, which could explain why higher doses are generally necessary for treating mania and psychotic symptoms.^3-5 High 5-HT2A antagonism may disinhibit the dopaminergic system and paradoxically increase dopaminergic activity, which could be the mechanism responsible for lack of control of manic symptoms with low doses of quetiapine.² Another possible explanation is that the metabolite of quetiapine, N-desalkylquetiapine, acts as a norepine­phrine reuptake blocker and partial 5-HT1Aantagonist, which acts as an antidepressant, and antidepressants are known to induce mania in vulnerable patients.⁴

The antimanic property of most antipsychotics (except possibly clozapine) is attributed to their D2 antagonistic potency. Because quetiapine is among the weaker D2 antagonists, its inability to prevent the progression of mania, especially at 50 mg/d, is not unexpected. Mr. X’s subsequent need for a stronger D2 antagonist—risperidone—at a significant dose further supports this observation. A common misconception is that quetiapine’s sedating effects make it effective for treating mania, but that is not the case. Clinicians should be cautious when prescribing quetiapine, especially at lower doses, to patients who exhibit signs of mania. Given the potential risk, clinicians should consider alternative treatments before resorting to low-dose quetiapine for insomnia. Regular monitoring for manic symptoms is crucial for all patients receiving quetiapine. If patients present with signs of mania or hypomania, a therapeutic dose range of 600 to 800 mg/d is recommended.⁶

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

Working closely with individuals with substance use disorders (SUDs), we’ve observed a worrisome trend of patients leaving the hospital against medical advice (AMA). This issue is not only prevalent in psychiatric settings, but also in emergency departments, medical and surgical floors, and even intensive care units.¹

Compared to individuals without such disorders, individuals with SUDs—particularly those with opioid use disorders—are up to 3 times more likely to leave the hospital AMA.^1,2 Leaving AMA can lead to multiple complications, including an increased risk of readmission, suboptimal treatment outcomes, and an increased use of health care resources.^1-3

It is critical to understand why patients elect to leave a hospital AMA. In a qualitative study, Simon et al¹ found that individuals with SUDs often leave AMA due to uncontrolled withdrawal symptoms and pain, perceived stigma and discrimination, and dissatisfaction with care. Predictors of patients leaving the hospital AMA include the severity of their drug dependence and previous negative treatment experiences.⁴ A systematic review found housing instability and a lack of social support influence an individual’s decision to leave AMA.⁵

Recommendations for managing patients who leave AMA

Enhancing your understanding of withdrawal symptoms may allow you to offer patients more effective symptom control, possibly with methadone or buprenorphine.² Injectable opioid agonist treatment may also help to retain a patient in care. In a case report, a 47-year-old man with a severe opioid use disorder who had left the hospital AMA due to uncontrolled opioid withdrawal was readmitted, treated with IV hydromorphone, and enrolled in ongoing community injectable opioid agonist treatment.⁶

Clinicians must address the stigma and discrimination patients with SUDs often face in health care institutions. Additional training for clinicians to improve their understanding of these disorders and foster a more compassionate and nonjudgmental approach to care may be beneficial.

Like most medicolegal conflicts, leaving AMA is often a clinical and interpersonal problem disguised as a legal one. When assessing these patients’ decision-making capacity, we often find they are angry and dissatisfied with the care they have (or have not) received. The most useful intervention may be to restore communication between the patient and their treatment team.

Even after a patient leaves AMA, the treatment team may experience countertransference issues, such as heightened emotional reactions or biases, that could compromise their clinical judgment. Addressing these dynamics may require team debriefings, supervision, or further training in managing transference and countertransference, particularly since patients who leave AMA may return for subsequent care.⁷

Integrated care models, which feature close collaboration between clinicians from different specialties, can help ensure that a patient’s diverse health needs are met and reduce the likelihood of them leaving AMA. Integrated care models may be particularly effective for patients with co-occurring conditions such as HIV and SUDs.⁸

Implementing these recommendations can be challenging. Barriers to addressing AMA departures span several domains, including patient-specific barriers (eg, stigma and discrimination), clinical barriers (eg, lack of resources and training for clinicians), institutional hurdles (eg, systemic inefficiencies), and broader social barriers (eg, housing instability and inadequate social support). Overcoming these barriers requires a multifaceted approach involving clinicians, policymakers, and the community that considers medical, psychological, and social factors.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

Working closely with individuals with substance use disorders (SUDs), we’ve observed a worrisome trend of patients leaving the hospital against medical advice (AMA). This issue is not only prevalent in psychiatric settings, but also in emergency departments, medical and surgical floors, and even intensive care units.¹

Compared to individuals without such disorders, individuals with SUDs—particularly those with opioid use disorders—are up to 3 times more likely to leave the hospital AMA.^1,2 Leaving AMA can lead to multiple complications, including an increased risk of readmission, suboptimal treatment outcomes, and an increased use of health care resources.^1-3

It is critical to understand why patients elect to leave a hospital AMA. In a qualitative study, Simon et al¹ found that individuals with SUDs often leave AMA due to uncontrolled withdrawal symptoms and pain, perceived stigma and discrimination, and dissatisfaction with care. Predictors of patients leaving the hospital AMA include the severity of their drug dependence and previous negative treatment experiences.⁴ A systematic review found housing instability and a lack of social support influence an individual’s decision to leave AMA.⁵

Recommendations for managing patients who leave AMA

Enhancing your understanding of withdrawal symptoms may allow you to offer patients more effective symptom control, possibly with methadone or buprenorphine.² Injectable opioid agonist treatment may also help to retain a patient in care. In a case report, a 47-year-old man with a severe opioid use disorder who had left the hospital AMA due to uncontrolled opioid withdrawal was readmitted, treated with IV hydromorphone, and enrolled in ongoing community injectable opioid agonist treatment.⁶

Clinicians must address the stigma and discrimination patients with SUDs often face in health care institutions. Additional training for clinicians to improve their understanding of these disorders and foster a more compassionate and nonjudgmental approach to care may be beneficial.

Like most medicolegal conflicts, leaving AMA is often a clinical and interpersonal problem disguised as a legal one. When assessing these patients’ decision-making capacity, we often find they are angry and dissatisfied with the care they have (or have not) received. The most useful intervention may be to restore communication between the patient and their treatment team.

Even after a patient leaves AMA, the treatment team may experience countertransference issues, such as heightened emotional reactions or biases, that could compromise their clinical judgment. Addressing these dynamics may require team debriefings, supervision, or further training in managing transference and countertransference, particularly since patients who leave AMA may return for subsequent care.⁷

Integrated care models, which feature close collaboration between clinicians from different specialties, can help ensure that a patient’s diverse health needs are met and reduce the likelihood of them leaving AMA. Integrated care models may be particularly effective for patients with co-occurring conditions such as HIV and SUDs.⁸

Implementing these recommendations can be challenging. Barriers to addressing AMA departures span several domains, including patient-specific barriers (eg, stigma and discrimination), clinical barriers (eg, lack of resources and training for clinicians), institutional hurdles (eg, systemic inefficiencies), and broader social barriers (eg, housing instability and inadequate social support). Overcoming these barriers requires a multifaceted approach involving clinicians, policymakers, and the community that considers medical, psychological, and social factors.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style.

Working closely with individuals with substance use disorders (SUDs), we’ve observed a worrisome trend of patients leaving the hospital against medical advice (AMA). This issue is not only prevalent in psychiatric settings, but also in emergency departments, medical and surgical floors, and even intensive care units.¹

Compared to individuals without such disorders, individuals with SUDs—particularly those with opioid use disorders—are up to 3 times more likely to leave the hospital AMA.^1,2 Leaving AMA can lead to multiple complications, including an increased risk of readmission, suboptimal treatment outcomes, and an increased use of health care resources.^1-3

It is critical to understand why patients elect to leave a hospital AMA. In a qualitative study, Simon et al¹ found that individuals with SUDs often leave AMA due to uncontrolled withdrawal symptoms and pain, perceived stigma and discrimination, and dissatisfaction with care. Predictors of patients leaving the hospital AMA include the severity of their drug dependence and previous negative treatment experiences.⁴ A systematic review found housing instability and a lack of social support influence an individual’s decision to leave AMA.⁵

Recommendations for managing patients who leave AMA

Enhancing your understanding of withdrawal symptoms may allow you to offer patients more effective symptom control, possibly with methadone or buprenorphine.² Injectable opioid agonist treatment may also help to retain a patient in care. In a case report, a 47-year-old man with a severe opioid use disorder who had left the hospital AMA due to uncontrolled opioid withdrawal was readmitted, treated with IV hydromorphone, and enrolled in ongoing community injectable opioid agonist treatment.⁶

Clinicians must address the stigma and discrimination patients with SUDs often face in health care institutions. Additional training for clinicians to improve their understanding of these disorders and foster a more compassionate and nonjudgmental approach to care may be beneficial.

Like most medicolegal conflicts, leaving AMA is often a clinical and interpersonal problem disguised as a legal one. When assessing these patients’ decision-making capacity, we often find they are angry and dissatisfied with the care they have (or have not) received. The most useful intervention may be to restore communication between the patient and their treatment team.

Even after a patient leaves AMA, the treatment team may experience countertransference issues, such as heightened emotional reactions or biases, that could compromise their clinical judgment. Addressing these dynamics may require team debriefings, supervision, or further training in managing transference and countertransference, particularly since patients who leave AMA may return for subsequent care.⁷

Integrated care models, which feature close collaboration between clinicians from different specialties, can help ensure that a patient’s diverse health needs are met and reduce the likelihood of them leaving AMA. Integrated care models may be particularly effective for patients with co-occurring conditions such as HIV and SUDs.⁸

Implementing these recommendations can be challenging. Barriers to addressing AMA departures span several domains, including patient-specific barriers (eg, stigma and discrimination), clinical barriers (eg, lack of resources and training for clinicians), institutional hurdles (eg, systemic inefficiencies), and broader social barriers (eg, housing instability and inadequate social support). Overcoming these barriers requires a multifaceted approach involving clinicians, policymakers, and the community that considers medical, psychological, and social factors.

In a recent editorial, “Is the contemporary mental health crisis among youth due to DMN disruption?” (Current Psychiatry, June 2023, p. 10-11,21, doi:10.12788/cp.0372), Dr. Nasrallah argued that “[Default mode network] DMN deactivation by excessive use of social media may explain the mental health decline in youth.” He proposed that focused attention tasks such as “smartphones, video games, and social media” disrupt the activation of the DMN: “When another brain network, the attention network ... is activated … DMN activity declines.” Dr. Nasrallah then suggested that reduced DMN activity—resulting from focused attention tasks like social media—is associated with mental health problems. Increased DMN activity, on the other hand, is positive, and results from “exercise, daydreaming, and sleep,” activities that “have declined drastically with the widespread use of smartphones, video games, and social media.” Finally, Dr. Nasrallah suggested that DMN activity can be increased via interventions such as meditation and psychedelics. The proposed causal model can therefore be summarized as: focused attention tasks like social media → increased attention network → reduced DMN → mental health problems in youth. This theory is implausible, for 4 reasons.

First, Dr. Nasrallah referred to the well-cited review by Whitfield-Gabrieli et al¹ regarding the relationship between DMN activation and mental health problems. However, this review shows that in mental health problems like “schizophrenia and depression, the DMN is often found to be hyperactivated and hyperconnected.” This stands in contradiction with the theory of decreased DMN activity in youth with mental health problems, and would, according to Dr. Nasrallah’s theory, call for more, not less, social media use.

Second, Dr. Nasrallah’s theory implies a substantial relationship between social media use and mental health problems. The latest umbrella review on the topic included 25 reviews, of which the majority found either “inconsistent” results or only “weak evidence” for a relationship.² Additionally, a study of 355,358 adolescents found that digital technology use explains only 0.4% of the variance of well-being.³

Third, there are many focused attention tasks other than video games and social media, such as reading, doing math homework, and playing chess. Dr. Nasrallah’s theory suggests that the World Health Organization should refrain from global efforts to get more kids into schools, given that this would increase the amount of focused attention tasks, reduce DMN activation, and increase the amount of mental health problems.

Fourth, youth mental health problems are multifactorial. Identified predictors include “female gender, low socioeconomic status, higher stress reactivity, conduct issues, substance misuse, and problems in peer and parental relationships.”⁴ Given that these factors are unrelated to the DMN, under-activation of the DMN cannot “explain” the youth mental health crisis, as the editorial suggested.

[embed:render:related:node:263193]

In a recent editorial, “Is the contemporary mental health crisis among youth due to DMN disruption?” (Current Psychiatry, June 2023, p. 10-11,21, doi:10.12788/cp.0372), Dr. Nasrallah argued that “[Default mode network] DMN deactivation by excessive use of social media may explain the mental health decline in youth.” He proposed that focused attention tasks such as “smartphones, video games, and social media” disrupt the activation of the DMN: “When another brain network, the attention network ... is activated … DMN activity declines.” Dr. Nasrallah then suggested that reduced DMN activity—resulting from focused attention tasks like social media—is associated with mental health problems. Increased DMN activity, on the other hand, is positive, and results from “exercise, daydreaming, and sleep,” activities that “have declined drastically with the widespread use of smartphones, video games, and social media.” Finally, Dr. Nasrallah suggested that DMN activity can be increased via interventions such as meditation and psychedelics. The proposed causal model can therefore be summarized as: focused attention tasks like social media → increased attention network → reduced DMN → mental health problems in youth. This theory is implausible, for 4 reasons.

First, Dr. Nasrallah referred to the well-cited review by Whitfield-Gabrieli et al¹ regarding the relationship between DMN activation and mental health problems. However, this review shows that in mental health problems like “schizophrenia and depression, the DMN is often found to be hyperactivated and hyperconnected.” This stands in contradiction with the theory of decreased DMN activity in youth with mental health problems, and would, according to Dr. Nasrallah’s theory, call for more, not less, social media use.

Second, Dr. Nasrallah’s theory implies a substantial relationship between social media use and mental health problems. The latest umbrella review on the topic included 25 reviews, of which the majority found either “inconsistent” results or only “weak evidence” for a relationship.² Additionally, a study of 355,358 adolescents found that digital technology use explains only 0.4% of the variance of well-being.³

Third, there are many focused attention tasks other than video games and social media, such as reading, doing math homework, and playing chess. Dr. Nasrallah’s theory suggests that the World Health Organization should refrain from global efforts to get more kids into schools, given that this would increase the amount of focused attention tasks, reduce DMN activation, and increase the amount of mental health problems.

Fourth, youth mental health problems are multifactorial. Identified predictors include “female gender, low socioeconomic status, higher stress reactivity, conduct issues, substance misuse, and problems in peer and parental relationships.”⁴ Given that these factors are unrelated to the DMN, under-activation of the DMN cannot “explain” the youth mental health crisis, as the editorial suggested.

[embed:render:related:node:263193]

In a recent editorial, “Is the contemporary mental health crisis among youth due to DMN disruption?” (Current Psychiatry, June 2023, p. 10-11,21, doi:10.12788/cp.0372), Dr. Nasrallah argued that “[Default mode network] DMN deactivation by excessive use of social media may explain the mental health decline in youth.” He proposed that focused attention tasks such as “smartphones, video games, and social media” disrupt the activation of the DMN: “When another brain network, the attention network ... is activated … DMN activity declines.” Dr. Nasrallah then suggested that reduced DMN activity—resulting from focused attention tasks like social media—is associated with mental health problems. Increased DMN activity, on the other hand, is positive, and results from “exercise, daydreaming, and sleep,” activities that “have declined drastically with the widespread use of smartphones, video games, and social media.” Finally, Dr. Nasrallah suggested that DMN activity can be increased via interventions such as meditation and psychedelics. The proposed causal model can therefore be summarized as: focused attention tasks like social media → increased attention network → reduced DMN → mental health problems in youth. This theory is implausible, for 4 reasons.

First, Dr. Nasrallah referred to the well-cited review by Whitfield-Gabrieli et al¹ regarding the relationship between DMN activation and mental health problems. However, this review shows that in mental health problems like “schizophrenia and depression, the DMN is often found to be hyperactivated and hyperconnected.” This stands in contradiction with the theory of decreased DMN activity in youth with mental health problems, and would, according to Dr. Nasrallah’s theory, call for more, not less, social media use.

Second, Dr. Nasrallah’s theory implies a substantial relationship between social media use and mental health problems. The latest umbrella review on the topic included 25 reviews, of which the majority found either “inconsistent” results or only “weak evidence” for a relationship.² Additionally, a study of 355,358 adolescents found that digital technology use explains only 0.4% of the variance of well-being.³

Third, there are many focused attention tasks other than video games and social media, such as reading, doing math homework, and playing chess. Dr. Nasrallah’s theory suggests that the World Health Organization should refrain from global efforts to get more kids into schools, given that this would increase the amount of focused attention tasks, reduce DMN activation, and increase the amount of mental health problems.

Fourth, youth mental health problems are multifactorial. Identified predictors include “female gender, low socioeconomic status, higher stress reactivity, conduct issues, substance misuse, and problems in peer and parental relationships.”⁴ Given that these factors are unrelated to the DMN, under-activation of the DMN cannot “explain” the youth mental health crisis, as the editorial suggested.

[embed:render:related:node:263193]

Mr. B, age 23, is admitted to an inpatient psychiatric unit for depression. During his hospitalization, Mr. B becomes fixated on obtaining specific medications, including controlled substances. He is treated by Dr. M, a psychiatrist early in her training. In a difficult conversation, Dr. M tells Mr. B he will not be prescribed the medications he is requesting and explains why. Mr. B responds by jumping across a table and repeatedly punching Dr. M. Unit staff restrains Mr. B, and Dr. M leaves to seek medical care.

Assaults perpetrated against employees on inpatient psychiatric units are common.¹ Assaults on physicians can occur at any level of training, including during residency.² This is not a new phenomenon: concerns about patients assaulting psychiatrists and other inpatient staff have been reported for decades.^3-5 Most research surrounding this topic has focused on risk factors for violence and prevention.⁶ Research regarding the aftermath of a patient assault and what services an employee requires have primarily centered on nurses.^7,8

Practical guidance for a psychiatrist who has been assaulted and wants to return to work is difficult to find. This article provides strategies to help psychiatrists (and their colleagues) transition back to work after being the victim of a patient assault. While the recommendations we provide can be applied to trainees as well as attending physicians, there are some considerations specific to residents who have been assaulted (Box^9,10).

Box

Having a plan for after an assault

The aftereffects of a patient assault can take a significant toll on the individual who is assaulted. A 2021 article about psychiatric mental health nurses by Dean et al⁸ identified multiple potential repercussions of unaddressed workplace violence, including role confusion, job dissatisfaction, decreased resiliency traits, poor coping methods, increased attrition rate, and increased expenditures related to assault injuries. Providing appropriate services and having a plan for how best to support an assaulted psychiatrist are likely to mitigate these effects. This can be grouped into 4 categories: 1) seeking immediate care, 2) removing the patient from your care, 3) easing back into the environment, and 4) finding long-term support.

1. Seeking immediate care

“Round or be rounded on” is a phrase that encapsulates many physicians’ attitude regarding their own health care and may contribute to their refusal of medical care following acute trauma such as an assault. Feelings of shock, guilt, and shame may also lead to a psychiatrist’s initial hesitation to seek treatment. However, it is important for the victim of an assault to be promptly evaluated and treated.

Elevated adrenaline in the aftermath of a physical engagement may mask the perception of injuries, and there is a risk for exposure to blood-borne pathogens. Regardless of the severity of injuries, seeking medical care establishes documentation of any injuries that can later serve as a record for workers’ compensation claims or if legal action is taken.

In addition to medical needs, immediate psychological support should be considered. Compulsory participation in crisis intervention stress debriefing, particularly when performed by untrained individuals, is not recommended due to questions about its demonstrated efficacy and potential to increase the risk of posttraumatic stress disorder (PTSD) in the long term.^11,12 However, research has established the need for immediate support that does not necessarily involve a discussion of the traumatic event. One option is psychological first aid (PFA), an intervention supported by the World Health Organization. Originally developed for victims of mass crisis events, PFA easily translates to the hospital setting.^12,13 PFA focuses on the immediate, basic needs of the victim to reduce distress and anxiety and encourage adaptive coping. Table 1^12,13 summarizes key components of PFA.

CP02211020_t1.png

Continue to: PFA can be compared...

PFA can be compared to medical first aid in the field prior to reaching the hospital. In the case of Dr. M, other residents collaborated to transport her to the hospital, keep attendings and program directors apprised of the situation, and bring her snacks and comfort items to the hospital. Dr. M also received support from attending physicians at a neighboring hospital who helped coordinate her care. Essentially, she received a de facto version of PFA. However, given the evidence behind PFA and the unfortunate rate of violence against health care staff, institutions and organizations may offer training in PFA to ensure this level of support for all victims.

Multiple groups may take the lead to support a physician following an injury, including human resources, employee health, or other offices within the institution. The principles of PFA can be used to guide these employees in assisting the victim. Even if such employees are not trained in PFA, they can align with these principles by ensuring access to counseling and medical care, assisting with time off and accommodations, and helping the victim of an assault navigate the legal and administrative processes. Workers’ compensation can be a challenging process, and an institution’s human resources department should be available to assist the assaulted individual in navigating resources both within and outside of what they are able to offer.

2. Removing the patient from the psychiatrist’s care

During her recovery, Dr. M heard from a few peers that what happened was an occupational hazard. On some level, they were correct. While the public does not perceive a career in medicine to be physically dangerous, violence is a rampant problem in health care. Research shows that health care professionals are up to 16 times more likely to experience violence than other occupations; the odds for nurses are even higher.⁸

The frequency and pervasiveness of violence against health care professionals create an environment in which it can become an expected, and even accepted, phenomenon. However, violence cannot and should not be viewed as a normal part of workplace culture. A 2016 study by Moylan et al⁷ found that many nurses believe violence is part of their role, and therefore do not recognize the need to report such incidents or seek the necessary support. In other studies, only 30% of nurses reported violence, and the rate of reporting by physicians was 26%.¹⁴ This underreporting likely represents the role confusion surrounding whether caring for self or caring for the patient takes precedent, as well as normative expectations surrounding violence in the workplace.

It must be made clear to the victim that their safety is a priority and violence will not be tolerated. An institution’s administration can achieve this by immediately removing the patient from the victim’s care. In many cases, discharge of the patient from the clinic or facility may be warranted. A psychiatrist should not be expected to continue as the primary physician for a patient who has assaulted them; transfer to another psychiatrist is necessary if discharge is not an appropriate option. In a scenario in which a psychiatrist must maintain the treating relationship with a patient who assaulted them until the patient can be placed with another clinician (eg, as might occur on a unit with severely limited resources), staff chaperones can be considered when interacting with the patient.

Continue to: An institution's adminstration... 

An institution’s administration should provide support if the psychiatrist chooses to press charges. At the core of our ethos as physicians is “do no harm,” and for some, the prospect of filing charges may be a difficult decision. However, health care professionals do not have an ethical obligation to put themselves in danger of serious bodily harm.¹⁵ While there is no one-size-fits-all answer to the question of whether or not to press charges against a patient who has committed an assault, the Occupational Safety and Health Administration considers the perception that violence is tolerated and victims are unable to report to law enforcement an organizational risk factor for workplace violence.¹⁶

As leaders in the workplace, physicians should set the precedent that violence will not be tolerated by reporting incidents to police and filing charges when appropriate. In the case of Dr. M, she received full support from her institution’s administration in filing charges against Mr. B due to the specific details of the assault.

3. Easing back into the environment

Despite assurances from her superiors that she could take time off, Dr. M wanted to return to work as soon as possible. She considered the balance between her physical injuries and desire to return to work and ultimately returned to work 5 days after the assault. She did well with supportive measures from administration and other staff, including the use of technician escorts on the unit, peer support, and frequent communication with and check-ins from management.

The decision on how quickly to return to work should always lie with the individual who was assaulted. The administration should offer time off without hesitation. Victims of an assault may feel overwhelmed by 2 diverging paths on how to return to a traumatic environment: avoid the location at all costs, or try to “face their fears” and return as quickly as possible. Research from outside medicine indicates that the timing of returning to work after a traumatic injury may not be nearly as important as the method of returning, and who makes this decision.¹⁷ Predictors of return to work after an assault include not only the severity of the trauma and amount of distress symptoms, but also any actual or perceived injustice on the part of the victim.¹⁷ Although this study was not specific to health care employees, it suggests that overall, an employee who does not feel a sense of control over their choice to return to work could perceive that as an injustice on the part of administration, leading to decreased job satisfaction.¹⁷

A study by Lamothe et al¹⁸ that was specific to health care professionals found that despite the importance of self-efficacy for the assault victim, perceived organizational support had an even greater protective effect following patient violence.Additionally, monitoring for signs of distress among victims after an episode of violence could prevent further violence by reducing the risk for subsequent victimization.¹⁸ This highlights the need for leadership of an inpatient unit to be keenly aware of how an assault on a psychiatrist or other health care professional may change the work environment and create a need to help staff navigate the new normal they may face on the unit.

Continue to: Finding long-term support

Longitudinal support is key in the initial transition back to work, as well as in the following weeks and months. Studies assessing the impacts of patient assault on mental health nurses indicate that while most individuals exposed to a traumatic event do not develop PTSD, many reported continued somatic symptoms, and more still reported ongoing psychological effects such as recurring thoughts of the assault, fear, generalized anger, and feeling a loss of control.⁸ Peer support is a common method employed by physicians and nurses alike, but administrative support is also essential.⁸

Regardless which form of psychotherapy, medication treatment, or peer support is utilized, access to the tools the psychiatrist finds most helpful is crucial to making them feel safe and comfortable returning to their role. Table 2 details practical steps administrators and peers can take to facilitate longitudinal support in these situations. In the case of Dr. M, administration was not only supportive in encouraging time off, but also in allowing protected time for therapy when she endorsed distress over the event. The combination of immediate responses and more long-term support greatly helped Dr. M continue her role as a psychiatrist and remain satisfied with her work.

CP02211020_t2.png

Bottom Line

Being assaulted by a patient can make a psychiatrist reluctant to return to work. Strategies to ease this transition include seeking immediate care, removing the patient from the care of the psychiatrist who was assaulted, easing back into the environment, and finding long-term support.

Related Resources

• Lapic S, Joshi KG. What to do after a patient assaults you. Current Psychiatry. 2017;16(10):53-54.
• Joshi KG. Workplace violence: enhance your safety in outpatient settings. Current Psychiatry. 2021;20(8):37-38. doi:10.12788/cp.0163
• Su D. Harassment of health care workers: a survey. Current Psychiatry. 2021;20(6):48-50. doi:10.12788/cp.0135
• Rozel JS, Wiles C, Amin P. Too close for comfort: when the psychiatrist is stalked. Current Psychiatry. 2022;21(1): 23-28. doi:10.12788/cp.0209

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Mr. B, age 23, is admitted to an inpatient psychiatric unit for depression. During his hospitalization, Mr. B becomes fixated on obtaining specific medications, including controlled substances. He is treated by Dr. M, a psychiatrist early in her training. In a difficult conversation, Dr. M tells Mr. B he will not be prescribed the medications he is requesting and explains why. Mr. B responds by jumping across a table and repeatedly punching Dr. M. Unit staff restrains Mr. B, and Dr. M leaves to seek medical care.

Assaults perpetrated against employees on inpatient psychiatric units are common.¹ Assaults on physicians can occur at any level of training, including during residency.² This is not a new phenomenon: concerns about patients assaulting psychiatrists and other inpatient staff have been reported for decades.^3-5 Most research surrounding this topic has focused on risk factors for violence and prevention.⁶ Research regarding the aftermath of a patient assault and what services an employee requires have primarily centered on nurses.^7,8

Practical guidance for a psychiatrist who has been assaulted and wants to return to work is difficult to find. This article provides strategies to help psychiatrists (and their colleagues) transition back to work after being the victim of a patient assault. While the recommendations we provide can be applied to trainees as well as attending physicians, there are some considerations specific to residents who have been assaulted (Box^9,10).

Box

Having a plan for after an assault

The aftereffects of a patient assault can take a significant toll on the individual who is assaulted. A 2021 article about psychiatric mental health nurses by Dean et al⁸ identified multiple potential repercussions of unaddressed workplace violence, including role confusion, job dissatisfaction, decreased resiliency traits, poor coping methods, increased attrition rate, and increased expenditures related to assault injuries. Providing appropriate services and having a plan for how best to support an assaulted psychiatrist are likely to mitigate these effects. This can be grouped into 4 categories: 1) seeking immediate care, 2) removing the patient from your care, 3) easing back into the environment, and 4) finding long-term support.

1. Seeking immediate care

“Round or be rounded on” is a phrase that encapsulates many physicians’ attitude regarding their own health care and may contribute to their refusal of medical care following acute trauma such as an assault. Feelings of shock, guilt, and shame may also lead to a psychiatrist’s initial hesitation to seek treatment. However, it is important for the victim of an assault to be promptly evaluated and treated.

Elevated adrenaline in the aftermath of a physical engagement may mask the perception of injuries, and there is a risk for exposure to blood-borne pathogens. Regardless of the severity of injuries, seeking medical care establishes documentation of any injuries that can later serve as a record for workers’ compensation claims or if legal action is taken.

In addition to medical needs, immediate psychological support should be considered. Compulsory participation in crisis intervention stress debriefing, particularly when performed by untrained individuals, is not recommended due to questions about its demonstrated efficacy and potential to increase the risk of posttraumatic stress disorder (PTSD) in the long term.^11,12 However, research has established the need for immediate support that does not necessarily involve a discussion of the traumatic event. One option is psychological first aid (PFA), an intervention supported by the World Health Organization. Originally developed for victims of mass crisis events, PFA easily translates to the hospital setting.^12,13 PFA focuses on the immediate, basic needs of the victim to reduce distress and anxiety and encourage adaptive coping. Table 1^12,13 summarizes key components of PFA.

CP02211020_t1.png

Continue to: PFA can be compared...

PFA can be compared to medical first aid in the field prior to reaching the hospital. In the case of Dr. M, other residents collaborated to transport her to the hospital, keep attendings and program directors apprised of the situation, and bring her snacks and comfort items to the hospital. Dr. M also received support from attending physicians at a neighboring hospital who helped coordinate her care. Essentially, she received a de facto version of PFA. However, given the evidence behind PFA and the unfortunate rate of violence against health care staff, institutions and organizations may offer training in PFA to ensure this level of support for all victims.

Multiple groups may take the lead to support a physician following an injury, including human resources, employee health, or other offices within the institution. The principles of PFA can be used to guide these employees in assisting the victim. Even if such employees are not trained in PFA, they can align with these principles by ensuring access to counseling and medical care, assisting with time off and accommodations, and helping the victim of an assault navigate the legal and administrative processes. Workers’ compensation can be a challenging process, and an institution’s human resources department should be available to assist the assaulted individual in navigating resources both within and outside of what they are able to offer.

2. Removing the patient from the psychiatrist’s care

During her recovery, Dr. M heard from a few peers that what happened was an occupational hazard. On some level, they were correct. While the public does not perceive a career in medicine to be physically dangerous, violence is a rampant problem in health care. Research shows that health care professionals are up to 16 times more likely to experience violence than other occupations; the odds for nurses are even higher.⁸

The frequency and pervasiveness of violence against health care professionals create an environment in which it can become an expected, and even accepted, phenomenon. However, violence cannot and should not be viewed as a normal part of workplace culture. A 2016 study by Moylan et al⁷ found that many nurses believe violence is part of their role, and therefore do not recognize the need to report such incidents or seek the necessary support. In other studies, only 30% of nurses reported violence, and the rate of reporting by physicians was 26%.¹⁴ This underreporting likely represents the role confusion surrounding whether caring for self or caring for the patient takes precedent, as well as normative expectations surrounding violence in the workplace.

It must be made clear to the victim that their safety is a priority and violence will not be tolerated. An institution’s administration can achieve this by immediately removing the patient from the victim’s care. In many cases, discharge of the patient from the clinic or facility may be warranted. A psychiatrist should not be expected to continue as the primary physician for a patient who has assaulted them; transfer to another psychiatrist is necessary if discharge is not an appropriate option. In a scenario in which a psychiatrist must maintain the treating relationship with a patient who assaulted them until the patient can be placed with another clinician (eg, as might occur on a unit with severely limited resources), staff chaperones can be considered when interacting with the patient.

Continue to: An institution's adminstration... 

An institution’s administration should provide support if the psychiatrist chooses to press charges. At the core of our ethos as physicians is “do no harm,” and for some, the prospect of filing charges may be a difficult decision. However, health care professionals do not have an ethical obligation to put themselves in danger of serious bodily harm.¹⁵ While there is no one-size-fits-all answer to the question of whether or not to press charges against a patient who has committed an assault, the Occupational Safety and Health Administration considers the perception that violence is tolerated and victims are unable to report to law enforcement an organizational risk factor for workplace violence.¹⁶

As leaders in the workplace, physicians should set the precedent that violence will not be tolerated by reporting incidents to police and filing charges when appropriate. In the case of Dr. M, she received full support from her institution’s administration in filing charges against Mr. B due to the specific details of the assault.

3. Easing back into the environment

Despite assurances from her superiors that she could take time off, Dr. M wanted to return to work as soon as possible. She considered the balance between her physical injuries and desire to return to work and ultimately returned to work 5 days after the assault. She did well with supportive measures from administration and other staff, including the use of technician escorts on the unit, peer support, and frequent communication with and check-ins from management.

The decision on how quickly to return to work should always lie with the individual who was assaulted. The administration should offer time off without hesitation. Victims of an assault may feel overwhelmed by 2 diverging paths on how to return to a traumatic environment: avoid the location at all costs, or try to “face their fears” and return as quickly as possible. Research from outside medicine indicates that the timing of returning to work after a traumatic injury may not be nearly as important as the method of returning, and who makes this decision.¹⁷ Predictors of return to work after an assault include not only the severity of the trauma and amount of distress symptoms, but also any actual or perceived injustice on the part of the victim.¹⁷ Although this study was not specific to health care employees, it suggests that overall, an employee who does not feel a sense of control over their choice to return to work could perceive that as an injustice on the part of administration, leading to decreased job satisfaction.¹⁷

A study by Lamothe et al¹⁸ that was specific to health care professionals found that despite the importance of self-efficacy for the assault victim, perceived organizational support had an even greater protective effect following patient violence.Additionally, monitoring for signs of distress among victims after an episode of violence could prevent further violence by reducing the risk for subsequent victimization.¹⁸ This highlights the need for leadership of an inpatient unit to be keenly aware of how an assault on a psychiatrist or other health care professional may change the work environment and create a need to help staff navigate the new normal they may face on the unit.

Continue to: Finding long-term support

Longitudinal support is key in the initial transition back to work, as well as in the following weeks and months. Studies assessing the impacts of patient assault on mental health nurses indicate that while most individuals exposed to a traumatic event do not develop PTSD, many reported continued somatic symptoms, and more still reported ongoing psychological effects such as recurring thoughts of the assault, fear, generalized anger, and feeling a loss of control.⁸ Peer support is a common method employed by physicians and nurses alike, but administrative support is also essential.⁸

Regardless which form of psychotherapy, medication treatment, or peer support is utilized, access to the tools the psychiatrist finds most helpful is crucial to making them feel safe and comfortable returning to their role. Table 2 details practical steps administrators and peers can take to facilitate longitudinal support in these situations. In the case of Dr. M, administration was not only supportive in encouraging time off, but also in allowing protected time for therapy when she endorsed distress over the event. The combination of immediate responses and more long-term support greatly helped Dr. M continue her role as a psychiatrist and remain satisfied with her work.

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Bottom Line

Being assaulted by a patient can make a psychiatrist reluctant to return to work. Strategies to ease this transition include seeking immediate care, removing the patient from the care of the psychiatrist who was assaulted, easing back into the environment, and finding long-term support.

Related Resources

• Lapic S, Joshi KG. What to do after a patient assaults you. Current Psychiatry. 2017;16(10):53-54.
• Joshi KG. Workplace violence: enhance your safety in outpatient settings. Current Psychiatry. 2021;20(8):37-38. doi:10.12788/cp.0163
• Su D. Harassment of health care workers: a survey. Current Psychiatry. 2021;20(6):48-50. doi:10.12788/cp.0135
• Rozel JS, Wiles C, Amin P. Too close for comfort: when the psychiatrist is stalked. Current Psychiatry. 2022;21(1): 23-28. doi:10.12788/cp.0209

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Mr. B, age 23, is admitted to an inpatient psychiatric unit for depression. During his hospitalization, Mr. B becomes fixated on obtaining specific medications, including controlled substances. He is treated by Dr. M, a psychiatrist early in her training. In a difficult conversation, Dr. M tells Mr. B he will not be prescribed the medications he is requesting and explains why. Mr. B responds by jumping across a table and repeatedly punching Dr. M. Unit staff restrains Mr. B, and Dr. M leaves to seek medical care.

Assaults perpetrated against employees on inpatient psychiatric units are common.¹ Assaults on physicians can occur at any level of training, including during residency.² This is not a new phenomenon: concerns about patients assaulting psychiatrists and other inpatient staff have been reported for decades.^3-5 Most research surrounding this topic has focused on risk factors for violence and prevention.⁶ Research regarding the aftermath of a patient assault and what services an employee requires have primarily centered on nurses.^7,8

Practical guidance for a psychiatrist who has been assaulted and wants to return to work is difficult to find. This article provides strategies to help psychiatrists (and their colleagues) transition back to work after being the victim of a patient assault. While the recommendations we provide can be applied to trainees as well as attending physicians, there are some considerations specific to residents who have been assaulted (Box^9,10).

Box

Having a plan for after an assault

The aftereffects of a patient assault can take a significant toll on the individual who is assaulted. A 2021 article about psychiatric mental health nurses by Dean et al⁸ identified multiple potential repercussions of unaddressed workplace violence, including role confusion, job dissatisfaction, decreased resiliency traits, poor coping methods, increased attrition rate, and increased expenditures related to assault injuries. Providing appropriate services and having a plan for how best to support an assaulted psychiatrist are likely to mitigate these effects. This can be grouped into 4 categories: 1) seeking immediate care, 2) removing the patient from your care, 3) easing back into the environment, and 4) finding long-term support.

1. Seeking immediate care

“Round or be rounded on” is a phrase that encapsulates many physicians’ attitude regarding their own health care and may contribute to their refusal of medical care following acute trauma such as an assault. Feelings of shock, guilt, and shame may also lead to a psychiatrist’s initial hesitation to seek treatment. However, it is important for the victim of an assault to be promptly evaluated and treated.

Elevated adrenaline in the aftermath of a physical engagement may mask the perception of injuries, and there is a risk for exposure to blood-borne pathogens. Regardless of the severity of injuries, seeking medical care establishes documentation of any injuries that can later serve as a record for workers’ compensation claims or if legal action is taken.

In addition to medical needs, immediate psychological support should be considered. Compulsory participation in crisis intervention stress debriefing, particularly when performed by untrained individuals, is not recommended due to questions about its demonstrated efficacy and potential to increase the risk of posttraumatic stress disorder (PTSD) in the long term.^11,12 However, research has established the need for immediate support that does not necessarily involve a discussion of the traumatic event. One option is psychological first aid (PFA), an intervention supported by the World Health Organization. Originally developed for victims of mass crisis events, PFA easily translates to the hospital setting.^12,13 PFA focuses on the immediate, basic needs of the victim to reduce distress and anxiety and encourage adaptive coping. Table 1^12,13 summarizes key components of PFA.

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Continue to: PFA can be compared...

PFA can be compared to medical first aid in the field prior to reaching the hospital. In the case of Dr. M, other residents collaborated to transport her to the hospital, keep attendings and program directors apprised of the situation, and bring her snacks and comfort items to the hospital. Dr. M also received support from attending physicians at a neighboring hospital who helped coordinate her care. Essentially, she received a de facto version of PFA. However, given the evidence behind PFA and the unfortunate rate of violence against health care staff, institutions and organizations may offer training in PFA to ensure this level of support for all victims.

Multiple groups may take the lead to support a physician following an injury, including human resources, employee health, or other offices within the institution. The principles of PFA can be used to guide these employees in assisting the victim. Even if such employees are not trained in PFA, they can align with these principles by ensuring access to counseling and medical care, assisting with time off and accommodations, and helping the victim of an assault navigate the legal and administrative processes. Workers’ compensation can be a challenging process, and an institution’s human resources department should be available to assist the assaulted individual in navigating resources both within and outside of what they are able to offer.

2. Removing the patient from the psychiatrist’s care

During her recovery, Dr. M heard from a few peers that what happened was an occupational hazard. On some level, they were correct. While the public does not perceive a career in medicine to be physically dangerous, violence is a rampant problem in health care. Research shows that health care professionals are up to 16 times more likely to experience violence than other occupations; the odds for nurses are even higher.⁸

The frequency and pervasiveness of violence against health care professionals create an environment in which it can become an expected, and even accepted, phenomenon. However, violence cannot and should not be viewed as a normal part of workplace culture. A 2016 study by Moylan et al⁷ found that many nurses believe violence is part of their role, and therefore do not recognize the need to report such incidents or seek the necessary support. In other studies, only 30% of nurses reported violence, and the rate of reporting by physicians was 26%.¹⁴ This underreporting likely represents the role confusion surrounding whether caring for self or caring for the patient takes precedent, as well as normative expectations surrounding violence in the workplace.

It must be made clear to the victim that their safety is a priority and violence will not be tolerated. An institution’s administration can achieve this by immediately removing the patient from the victim’s care. In many cases, discharge of the patient from the clinic or facility may be warranted. A psychiatrist should not be expected to continue as the primary physician for a patient who has assaulted them; transfer to another psychiatrist is necessary if discharge is not an appropriate option. In a scenario in which a psychiatrist must maintain the treating relationship with a patient who assaulted them until the patient can be placed with another clinician (eg, as might occur on a unit with severely limited resources), staff chaperones can be considered when interacting with the patient.

Continue to: An institution's adminstration... 

An institution’s administration should provide support if the psychiatrist chooses to press charges. At the core of our ethos as physicians is “do no harm,” and for some, the prospect of filing charges may be a difficult decision. However, health care professionals do not have an ethical obligation to put themselves in danger of serious bodily harm.¹⁵ While there is no one-size-fits-all answer to the question of whether or not to press charges against a patient who has committed an assault, the Occupational Safety and Health Administration considers the perception that violence is tolerated and victims are unable to report to law enforcement an organizational risk factor for workplace violence.¹⁶

As leaders in the workplace, physicians should set the precedent that violence will not be tolerated by reporting incidents to police and filing charges when appropriate. In the case of Dr. M, she received full support from her institution’s administration in filing charges against Mr. B due to the specific details of the assault.

3. Easing back into the environment

Despite assurances from her superiors that she could take time off, Dr. M wanted to return to work as soon as possible. She considered the balance between her physical injuries and desire to return to work and ultimately returned to work 5 days after the assault. She did well with supportive measures from administration and other staff, including the use of technician escorts on the unit, peer support, and frequent communication with and check-ins from management.

The decision on how quickly to return to work should always lie with the individual who was assaulted. The administration should offer time off without hesitation. Victims of an assault may feel overwhelmed by 2 diverging paths on how to return to a traumatic environment: avoid the location at all costs, or try to “face their fears” and return as quickly as possible. Research from outside medicine indicates that the timing of returning to work after a traumatic injury may not be nearly as important as the method of returning, and who makes this decision.¹⁷ Predictors of return to work after an assault include not only the severity of the trauma and amount of distress symptoms, but also any actual or perceived injustice on the part of the victim.¹⁷ Although this study was not specific to health care employees, it suggests that overall, an employee who does not feel a sense of control over their choice to return to work could perceive that as an injustice on the part of administration, leading to decreased job satisfaction.¹⁷

A study by Lamothe et al¹⁸ that was specific to health care professionals found that despite the importance of self-efficacy for the assault victim, perceived organizational support had an even greater protective effect following patient violence.Additionally, monitoring for signs of distress among victims after an episode of violence could prevent further violence by reducing the risk for subsequent victimization.¹⁸ This highlights the need for leadership of an inpatient unit to be keenly aware of how an assault on a psychiatrist or other health care professional may change the work environment and create a need to help staff navigate the new normal they may face on the unit.

Continue to: Finding long-term support

Longitudinal support is key in the initial transition back to work, as well as in the following weeks and months. Studies assessing the impacts of patient assault on mental health nurses indicate that while most individuals exposed to a traumatic event do not develop PTSD, many reported continued somatic symptoms, and more still reported ongoing psychological effects such as recurring thoughts of the assault, fear, generalized anger, and feeling a loss of control.⁸ Peer support is a common method employed by physicians and nurses alike, but administrative support is also essential.⁸

Regardless which form of psychotherapy, medication treatment, or peer support is utilized, access to the tools the psychiatrist finds most helpful is crucial to making them feel safe and comfortable returning to their role. Table 2 details practical steps administrators and peers can take to facilitate longitudinal support in these situations. In the case of Dr. M, administration was not only supportive in encouraging time off, but also in allowing protected time for therapy when she endorsed distress over the event. The combination of immediate responses and more long-term support greatly helped Dr. M continue her role as a psychiatrist and remain satisfied with her work.

CP02211020_t2.png

Bottom Line

Being assaulted by a patient can make a psychiatrist reluctant to return to work. Strategies to ease this transition include seeking immediate care, removing the patient from the care of the psychiatrist who was assaulted, easing back into the environment, and finding long-term support.

Related Resources

• Lapic S, Joshi KG. What to do after a patient assaults you. Current Psychiatry. 2017;16(10):53-54.
• Joshi KG. Workplace violence: enhance your safety in outpatient settings. Current Psychiatry. 2021;20(8):37-38. doi:10.12788/cp.0163
• Su D. Harassment of health care workers: a survey. Current Psychiatry. 2021;20(6):48-50. doi:10.12788/cp.0135
• Rozel JS, Wiles C, Amin P. Too close for comfort: when the psychiatrist is stalked. Current Psychiatry. 2022;21(1): 23-28. doi:10.12788/cp.0209

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