Residents' Voices

"Ramadan will be depressing this year,” a patient told me as I entered the room for an evaluation. This is one of many similar reactions my patients expressed in March, when mosques began to close and social distancing parameters were put in place to limit the spread of coronavirus disease 2019 (COVID-19). Muslims began to adjust to new social norms, such as replacing warm hugs with waving hands from 6 feet away. They were suddenly advised to avoid century-long cultural practices, such as spending time with extended family, visiting the sick and the elderly, and meeting for Jummah (Friday) prayer at mosque. With increasing anxiety and uncertainty in the air, I began thinking about how the pandemic would psychologically affect Islamic spirituality, especially during Ramadan (the Islamic month of fasting) this year.

As a Muslim psychiatry resident working on an inpatient psychiatric unit and in a psychiatry consultation service during the COVID-19 pandemic, I often explore spirituality and faith with my patients as a way of providing supportive therapy for anxiety. Many of my Christian patients endorsed anxiety about how Easter would be “terrible” this year because they could not attend church. Upon hearing this, I realized that I could not picture a Ramadan during which I was not permitted to go to mosque. How was I supposed to provide supportive therapy for my patients when I also felt so uncertain? These concerns led me to take a step back and remind myself of what I frequently tell my patients when they feel hopeless: “With every difficulty, there comes an opportunity to gain a new perspective.”

A time for spirituality

When Ramadan began in April, many people who are Muslim and were working from home told me that it felt strange to have so much time during the day to pray, reflect, and read the Quran. Others mentioned that they enjoyed the peace of Iftar (breaking fast) at home, because they could avoid the hustle and bustle of this at mosque. Halfway through Ramadan, a Muslim patient I was treating reported that her “coronavirus anxiety” had improved as she began focusing her energy on Allah, rather than spending hours watching the news and obsessing over death tolls.

Due to the pandemic, many more opportunities for donating to those in need arose, which led my religious community to perform Zakat (providing charity) and send supplies to food banks in our area. Because of social distancing, Muslim families were able to spend more time preparing meals, learning together, and supporting each other. Although mosques were closed due to the pandemic, it seemed as though each home became its own gathering place for spirituality, gratitude, and self-reflection. By the end of Ramadan, the values of self-discipline, empathy, and patience became self-evident.

Increased attention to mental health among Muslims

Psychologically, I believe resilience has grown stronger among Muslims worldwide during this pandemic. Along with adopting a positive mindset, Muslims have committed to creating their own routines to combat anxiety during this stressful time. The Salat (praying 5 times a day) and Taharat (cleanliness) that Islam emphasizes have been helpful in creating structure to offset the uncertainty and fear that is associated with COVID-19.

The discussion of mental illness, which previously has been regarded as a culturally stigmatized topic, has been gaining significant recognition within Islamic communities. Depression, anxiety, and self-care are now emphasized during virtual sermons, and contact information for mental health hotlines and professionals are being rapidly disseminated. There is now a greater sense of encouragement for people of Islamic faith to seek psychiatric help when needed.

Although COVID-19 has limited some social and physical religious practices, this pandemic has helped to strengthen faith and spirituality not only among Muslims, but also people of other faiths. During periods of stress, change, and uncertainty, it is important to remember that “With every difficulty, there comes an opportunity to gain a new perspective.” Although mosques and churches continue to stay closed and anxiety persists, I can now confidently reassure my patients that through this experience we are becoming resilient and learning to value patience, gratitude, and empathy more than ever.

"Ramadan will be depressing this year,” a patient told me as I entered the room for an evaluation. This is one of many similar reactions my patients expressed in March, when mosques began to close and social distancing parameters were put in place to limit the spread of coronavirus disease 2019 (COVID-19). Muslims began to adjust to new social norms, such as replacing warm hugs with waving hands from 6 feet away. They were suddenly advised to avoid century-long cultural practices, such as spending time with extended family, visiting the sick and the elderly, and meeting for Jummah (Friday) prayer at mosque. With increasing anxiety and uncertainty in the air, I began thinking about how the pandemic would psychologically affect Islamic spirituality, especially during Ramadan (the Islamic month of fasting) this year.

As a Muslim psychiatry resident working on an inpatient psychiatric unit and in a psychiatry consultation service during the COVID-19 pandemic, I often explore spirituality and faith with my patients as a way of providing supportive therapy for anxiety. Many of my Christian patients endorsed anxiety about how Easter would be “terrible” this year because they could not attend church. Upon hearing this, I realized that I could not picture a Ramadan during which I was not permitted to go to mosque. How was I supposed to provide supportive therapy for my patients when I also felt so uncertain? These concerns led me to take a step back and remind myself of what I frequently tell my patients when they feel hopeless: “With every difficulty, there comes an opportunity to gain a new perspective.”

A time for spirituality

When Ramadan began in April, many people who are Muslim and were working from home told me that it felt strange to have so much time during the day to pray, reflect, and read the Quran. Others mentioned that they enjoyed the peace of Iftar (breaking fast) at home, because they could avoid the hustle and bustle of this at mosque. Halfway through Ramadan, a Muslim patient I was treating reported that her “coronavirus anxiety” had improved as she began focusing her energy on Allah, rather than spending hours watching the news and obsessing over death tolls.

Due to the pandemic, many more opportunities for donating to those in need arose, which led my religious community to perform Zakat (providing charity) and send supplies to food banks in our area. Because of social distancing, Muslim families were able to spend more time preparing meals, learning together, and supporting each other. Although mosques were closed due to the pandemic, it seemed as though each home became its own gathering place for spirituality, gratitude, and self-reflection. By the end of Ramadan, the values of self-discipline, empathy, and patience became self-evident.

Increased attention to mental health among Muslims

Psychologically, I believe resilience has grown stronger among Muslims worldwide during this pandemic. Along with adopting a positive mindset, Muslims have committed to creating their own routines to combat anxiety during this stressful time. The Salat (praying 5 times a day) and Taharat (cleanliness) that Islam emphasizes have been helpful in creating structure to offset the uncertainty and fear that is associated with COVID-19.

The discussion of mental illness, which previously has been regarded as a culturally stigmatized topic, has been gaining significant recognition within Islamic communities. Depression, anxiety, and self-care are now emphasized during virtual sermons, and contact information for mental health hotlines and professionals are being rapidly disseminated. There is now a greater sense of encouragement for people of Islamic faith to seek psychiatric help when needed.

Although COVID-19 has limited some social and physical religious practices, this pandemic has helped to strengthen faith and spirituality not only among Muslims, but also people of other faiths. During periods of stress, change, and uncertainty, it is important to remember that “With every difficulty, there comes an opportunity to gain a new perspective.” Although mosques and churches continue to stay closed and anxiety persists, I can now confidently reassure my patients that through this experience we are becoming resilient and learning to value patience, gratitude, and empathy more than ever.

"Ramadan will be depressing this year,” a patient told me as I entered the room for an evaluation. This is one of many similar reactions my patients expressed in March, when mosques began to close and social distancing parameters were put in place to limit the spread of coronavirus disease 2019 (COVID-19). Muslims began to adjust to new social norms, such as replacing warm hugs with waving hands from 6 feet away. They were suddenly advised to avoid century-long cultural practices, such as spending time with extended family, visiting the sick and the elderly, and meeting for Jummah (Friday) prayer at mosque. With increasing anxiety and uncertainty in the air, I began thinking about how the pandemic would psychologically affect Islamic spirituality, especially during Ramadan (the Islamic month of fasting) this year.

As a Muslim psychiatry resident working on an inpatient psychiatric unit and in a psychiatry consultation service during the COVID-19 pandemic, I often explore spirituality and faith with my patients as a way of providing supportive therapy for anxiety. Many of my Christian patients endorsed anxiety about how Easter would be “terrible” this year because they could not attend church. Upon hearing this, I realized that I could not picture a Ramadan during which I was not permitted to go to mosque. How was I supposed to provide supportive therapy for my patients when I also felt so uncertain? These concerns led me to take a step back and remind myself of what I frequently tell my patients when they feel hopeless: “With every difficulty, there comes an opportunity to gain a new perspective.”

A time for spirituality

When Ramadan began in April, many people who are Muslim and were working from home told me that it felt strange to have so much time during the day to pray, reflect, and read the Quran. Others mentioned that they enjoyed the peace of Iftar (breaking fast) at home, because they could avoid the hustle and bustle of this at mosque. Halfway through Ramadan, a Muslim patient I was treating reported that her “coronavirus anxiety” had improved as she began focusing her energy on Allah, rather than spending hours watching the news and obsessing over death tolls.

Due to the pandemic, many more opportunities for donating to those in need arose, which led my religious community to perform Zakat (providing charity) and send supplies to food banks in our area. Because of social distancing, Muslim families were able to spend more time preparing meals, learning together, and supporting each other. Although mosques were closed due to the pandemic, it seemed as though each home became its own gathering place for spirituality, gratitude, and self-reflection. By the end of Ramadan, the values of self-discipline, empathy, and patience became self-evident.

Increased attention to mental health among Muslims

Psychologically, I believe resilience has grown stronger among Muslims worldwide during this pandemic. Along with adopting a positive mindset, Muslims have committed to creating their own routines to combat anxiety during this stressful time. The Salat (praying 5 times a day) and Taharat (cleanliness) that Islam emphasizes have been helpful in creating structure to offset the uncertainty and fear that is associated with COVID-19.

The discussion of mental illness, which previously has been regarded as a culturally stigmatized topic, has been gaining significant recognition within Islamic communities. Depression, anxiety, and self-care are now emphasized during virtual sermons, and contact information for mental health hotlines and professionals are being rapidly disseminated. There is now a greater sense of encouragement for people of Islamic faith to seek psychiatric help when needed.

Although COVID-19 has limited some social and physical religious practices, this pandemic has helped to strengthen faith and spirituality not only among Muslims, but also people of other faiths. During periods of stress, change, and uncertainty, it is important to remember that “With every difficulty, there comes an opportunity to gain a new perspective.” Although mosques and churches continue to stay closed and anxiety persists, I can now confidently reassure my patients that through this experience we are becoming resilient and learning to value patience, gratitude, and empathy more than ever.

After graduating from medical school in India, where I was born and raised, I came to the United States in 2009 to expand my medical knowledge. At that time, I completed my clinical skills exam and soon after began a volunteer rotation at New York-Presbyterian Queens Hospital. In those early days, as I made my rounds through the emergency department (ED) of the hospital, I would introduce myself as Dr. Siva, which is my first name; this is how the doctors back home in India would introduce themselves to patients. Little did I know that the same name convention was not necessarily used here in the United States. Nonetheless, in those formative days, I learned a great deal from listening to the unique stories of how my patients had ended up in the ED, and I quickly felt right at home getting to know them.

When I first came to the United States, I had limited knowledge of psychiatry because I had only had a few months of psychiatry rotations during medical school. But in 2012, while I served as a volunteer in a research and observership program at Beth Israel Medical Center, one of my colleagues who was a psychiatry resident piqued my interest in the specialty and motivated me to explore and learn more about the various treatment modalities, strategies, and nuances this new modern world of psychiatry had to offer.

So I began by attending training sessions and evening seminars at the New York Psychoanalytic Society & Institute, where I became interested in Sigmund Freud’s work on the development of psychoanalysis. From there, my appetite for knowledge only continued to grow, and I took every opportunity to participate in various learning exercises, present at poster sessions, and give lectures at national conferences. I read and absorbed significant theories and texts and interacted with and learned from colleagues and mentors as I strived to sculpt my mind, with the aim of becoming a well-rounded psychiatrist.

Overcoming challenges

As I worked to further my understanding of psychiatry and understand the different treatment modalities—my goals becoming more clear with each step of my journey—I faced a significant setback. I was unable to secure a residency position to officially enter the specialty. I was devastated in my pursuit to realize the American Dream. At that point, I had been in the United States for 4 years with the financial and emotional support of my parents back home in India. I continued to struggle; another 2 years passed, and I was still coming up empty in my search for a residency position.

In the meantime, I kept moving forward, with my sights firmly on learning more about psychiatry. This time, I sought out several projects, including one where I served as a research assistant (volunteer) for nonpharmacologic clinical trials in patients with bipolar disorder, and another where I served as a research assistant (volunteer) at a substance use disorder clinic at Columbia University. I was also accepted into the “Prelude to Training” program at the Psychoanalytic Association of New York, which is affiliated with the NYU Grossman School of Medicine. Through that program, I was introduced to psychodynamic thinking and practice, which gave me the valuable foundation of thinking beyond oneself.

Grit and determination

To further my education, I studied clinical and translational sciences at Creighton University in Omaha. I was given opportunities to discuss topics related to the historical aspects of and recent advances in psychoanalysis through my involvement with the Professional Reading Alliance on Psychoanalysis at The Circle for the Lacanian Orientation of Omaha. Then came the moment when all my dreams came to fruition—I was accepted into the psychiatry residency program at Creighton University.

Those 4 years of residency passed by in a flash! Recently, I began a neuromodulation fellowship at the University of Florida in Gainesville. Here, my journey continues, as I search for tools to help the disenfranchised and those in need of mental health support. After the neuromodulation fellowship, I plan to pursue a pain medicine fellowship.

Continue to: Through the years...

Through the years, I have grown both professionally and personally. I have also overcome the instinctual urge to introduce myself to patients by my first name and have adapted to the American style of using my last name, and now introduce myself as Dr. Koppolu.

My educational journey in a place far from home has impacted me in ways I never knew possible, and I believe my strength to continue the pursuit is rooted in my passion and ambition to become a psychiatrist. I never gave up working toward that dream—a dream that is slowly becoming a reality.

After graduating from medical school in India, where I was born and raised, I came to the United States in 2009 to expand my medical knowledge. At that time, I completed my clinical skills exam and soon after began a volunteer rotation at New York-Presbyterian Queens Hospital. In those early days, as I made my rounds through the emergency department (ED) of the hospital, I would introduce myself as Dr. Siva, which is my first name; this is how the doctors back home in India would introduce themselves to patients. Little did I know that the same name convention was not necessarily used here in the United States. Nonetheless, in those formative days, I learned a great deal from listening to the unique stories of how my patients had ended up in the ED, and I quickly felt right at home getting to know them.

When I first came to the United States, I had limited knowledge of psychiatry because I had only had a few months of psychiatry rotations during medical school. But in 2012, while I served as a volunteer in a research and observership program at Beth Israel Medical Center, one of my colleagues who was a psychiatry resident piqued my interest in the specialty and motivated me to explore and learn more about the various treatment modalities, strategies, and nuances this new modern world of psychiatry had to offer.

So I began by attending training sessions and evening seminars at the New York Psychoanalytic Society & Institute, where I became interested in Sigmund Freud’s work on the development of psychoanalysis. From there, my appetite for knowledge only continued to grow, and I took every opportunity to participate in various learning exercises, present at poster sessions, and give lectures at national conferences. I read and absorbed significant theories and texts and interacted with and learned from colleagues and mentors as I strived to sculpt my mind, with the aim of becoming a well-rounded psychiatrist.

Overcoming challenges

As I worked to further my understanding of psychiatry and understand the different treatment modalities—my goals becoming more clear with each step of my journey—I faced a significant setback. I was unable to secure a residency position to officially enter the specialty. I was devastated in my pursuit to realize the American Dream. At that point, I had been in the United States for 4 years with the financial and emotional support of my parents back home in India. I continued to struggle; another 2 years passed, and I was still coming up empty in my search for a residency position.

In the meantime, I kept moving forward, with my sights firmly on learning more about psychiatry. This time, I sought out several projects, including one where I served as a research assistant (volunteer) for nonpharmacologic clinical trials in patients with bipolar disorder, and another where I served as a research assistant (volunteer) at a substance use disorder clinic at Columbia University. I was also accepted into the “Prelude to Training” program at the Psychoanalytic Association of New York, which is affiliated with the NYU Grossman School of Medicine. Through that program, I was introduced to psychodynamic thinking and practice, which gave me the valuable foundation of thinking beyond oneself.

Grit and determination

To further my education, I studied clinical and translational sciences at Creighton University in Omaha. I was given opportunities to discuss topics related to the historical aspects of and recent advances in psychoanalysis through my involvement with the Professional Reading Alliance on Psychoanalysis at The Circle for the Lacanian Orientation of Omaha. Then came the moment when all my dreams came to fruition—I was accepted into the psychiatry residency program at Creighton University.

Those 4 years of residency passed by in a flash! Recently, I began a neuromodulation fellowship at the University of Florida in Gainesville. Here, my journey continues, as I search for tools to help the disenfranchised and those in need of mental health support. After the neuromodulation fellowship, I plan to pursue a pain medicine fellowship.

Continue to: Through the years...

Through the years, I have grown both professionally and personally. I have also overcome the instinctual urge to introduce myself to patients by my first name and have adapted to the American style of using my last name, and now introduce myself as Dr. Koppolu.

My educational journey in a place far from home has impacted me in ways I never knew possible, and I believe my strength to continue the pursuit is rooted in my passion and ambition to become a psychiatrist. I never gave up working toward that dream—a dream that is slowly becoming a reality.

After graduating from medical school in India, where I was born and raised, I came to the United States in 2009 to expand my medical knowledge. At that time, I completed my clinical skills exam and soon after began a volunteer rotation at New York-Presbyterian Queens Hospital. In those early days, as I made my rounds through the emergency department (ED) of the hospital, I would introduce myself as Dr. Siva, which is my first name; this is how the doctors back home in India would introduce themselves to patients. Little did I know that the same name convention was not necessarily used here in the United States. Nonetheless, in those formative days, I learned a great deal from listening to the unique stories of how my patients had ended up in the ED, and I quickly felt right at home getting to know them.

When I first came to the United States, I had limited knowledge of psychiatry because I had only had a few months of psychiatry rotations during medical school. But in 2012, while I served as a volunteer in a research and observership program at Beth Israel Medical Center, one of my colleagues who was a psychiatry resident piqued my interest in the specialty and motivated me to explore and learn more about the various treatment modalities, strategies, and nuances this new modern world of psychiatry had to offer.

So I began by attending training sessions and evening seminars at the New York Psychoanalytic Society & Institute, where I became interested in Sigmund Freud’s work on the development of psychoanalysis. From there, my appetite for knowledge only continued to grow, and I took every opportunity to participate in various learning exercises, present at poster sessions, and give lectures at national conferences. I read and absorbed significant theories and texts and interacted with and learned from colleagues and mentors as I strived to sculpt my mind, with the aim of becoming a well-rounded psychiatrist.

Overcoming challenges

As I worked to further my understanding of psychiatry and understand the different treatment modalities—my goals becoming more clear with each step of my journey—I faced a significant setback. I was unable to secure a residency position to officially enter the specialty. I was devastated in my pursuit to realize the American Dream. At that point, I had been in the United States for 4 years with the financial and emotional support of my parents back home in India. I continued to struggle; another 2 years passed, and I was still coming up empty in my search for a residency position.

In the meantime, I kept moving forward, with my sights firmly on learning more about psychiatry. This time, I sought out several projects, including one where I served as a research assistant (volunteer) for nonpharmacologic clinical trials in patients with bipolar disorder, and another where I served as a research assistant (volunteer) at a substance use disorder clinic at Columbia University. I was also accepted into the “Prelude to Training” program at the Psychoanalytic Association of New York, which is affiliated with the NYU Grossman School of Medicine. Through that program, I was introduced to psychodynamic thinking and practice, which gave me the valuable foundation of thinking beyond oneself.

Grit and determination

To further my education, I studied clinical and translational sciences at Creighton University in Omaha. I was given opportunities to discuss topics related to the historical aspects of and recent advances in psychoanalysis through my involvement with the Professional Reading Alliance on Psychoanalysis at The Circle for the Lacanian Orientation of Omaha. Then came the moment when all my dreams came to fruition—I was accepted into the psychiatry residency program at Creighton University.

Those 4 years of residency passed by in a flash! Recently, I began a neuromodulation fellowship at the University of Florida in Gainesville. Here, my journey continues, as I search for tools to help the disenfranchised and those in need of mental health support. After the neuromodulation fellowship, I plan to pursue a pain medicine fellowship.

Continue to: Through the years...

Through the years, I have grown both professionally and personally. I have also overcome the instinctual urge to introduce myself to patients by my first name and have adapted to the American style of using my last name, and now introduce myself as Dr. Koppolu.

My educational journey in a place far from home has impacted me in ways I never knew possible, and I believe my strength to continue the pursuit is rooted in my passion and ambition to become a psychiatrist. I never gave up working toward that dream—a dream that is slowly becoming a reality.

Medical and surgical inpatient teams often consult psychiatrists to help assess a patient’s decision-making capacity (DMC). Completing a DMC assessment can be a source of stress and frustration for psychiatry residents; however, the process can be significantly improved by following a consistent and focused psychiatric interview. In our institution, the most frequently used tool for assessing DMC is the Aid to Capacity Evaluation (ACE).¹ The American Academy of Family Physicians offers a printer-friendly adaptation² of the ACE assessment.

Reasons for a DMC consultation

When accepting a DMC consultation, make sure to specify for which medical decision the primary team would like the patient to be evaluated so that the consultation can be most helpful and specific to primary team’s concerns.³ The 4 most common reasons for a DMC consultation are:

Acute changes in mental status. These changes may be due to hypoxia, infection, medication, metabolic disturbances, or other medical conditions. Often, the diagnosis is delirium due to a medical condition, and assessing for DMC is deferred until the delirium resolves.

Refusal of a recommended treatment. One of the most frequent reasons for a DMC consultation is when a patient declines the primary team’s treatment recommendations. These recommendations may include medications, interventions (procedural or surgical), or discharge planning (such as transfer to a rehabilitation facility or skilled nursing care facility).

Consenting to a risky or invasive treatment too hastily. This occurs less often than the other 3 scenarios, most likely because capacity is rarely questioned when a patient’s decision aligns with the physicians’ recommendations.

Having risk factors for impaired decision-making. One of the most common reasons for involving psychiatry in a DMC consultation is when the patient has a risk factor that may impair his/her decision-making.

These risk factors include:

• a chronic psychiatric or neurologic condition
• a significant cultural or language barrier
• a low or unknown education level
• anxiety or discomfort with institutional health care settings
• age <18 or >85.

Continue to: When should you put off a DMC consultation?

There are situations in which a DMC consultation should be declined or postponed. A DMC consultation is not appropriate for patients who have a court-appointed legal guardian because these patients are considered legally incapacitated. Although such patients may still choose to participate in shared decision-making with the treatment team and communicate those decisions to their legal guardian, all treatment decisions are made by their legal guardian.

Consider delaying DMC consultations for patients with acute changes in mental status, including delirium, or those who are sedated or intubated. On the other hand, patients not excluded from a DMC assessment include those with mild or major neurocognitive disorders (such as Alzheimer’s disease or other types of dementia), intellectual disabilities, a durable power of attorney (DPOA), or legal charges. It is important to note that a diagnosis of a neurocognitive disorder does not preclude capacity, and capacity may therefore vary based on the complexity of medical decision.

Prepare for the interview

Prior to meeting the patient, familiarize yourself with his/her reason for admission, diagnosis, medical workup, treatment provided thus far, and proposed future treatment. If possible, attempt to gather the patient’s medical and psychiatric history from chart review, which may be obtained from outside medical records or inferred from the patient’s current medication list. Review the chart for any signs that the patient is in a delirious state, including the use of psychotropic medications for agitation, restraints, or a sitter at bedside. Finally, speak with the patient’s nurse before entering the patient’s room. This may provide valuable information regarding the patient’s willingness to participate (including any hostility or aggression toward clinicians), any barriers to the interview (such as hearing or language difficulties), and if any family or friends are present at the bedside.

During the interview

The structure of a decision-making capacity evaluation has been well documented elsewhere^1,2 and, if completed, is sufficient for determining DMC. Asking the patient about additional psychiatric histories, including hospitalizations, suicide attempts, or a family history of psychiatric illness, may be counterproductive and frustrating for the patient, especially if the interview has already been lengthy and emotionally exhausting. Therefore, it is often appropriate to shorten the psychiatric interview to assess for symptoms of anxiety and depression, perform a brief suicide risk assessment, and assess for the presence of auditory or visual hallucinations, or delusions. This allows for a complete mental status exam while still focusing the interview on determining DMC. If time allows and the patient is willing to participate, it can be helpful to perform a Montreal Cognitive Assessment (MoCA) or Mini-Mental State Exam, although a score that indicates some level of cognitive impairment (<26 on MoCA⁴) does not necessarily preclude patient from having capacity for certain medical decisions. Additionally, if the patient does not understand a question, explain it and return to it later to check for comprehension.

Making a recommendation

Patients are presumed to be capable; therefore, if the determination is not clear, err on the side of capacity. Additional information may be helpful from the patient’s family, friends, DPOA, or guardian, especially as it pertains to the patient’s past wishes and medical decisions made in similar situations. If available and pertinent, review the patient’s advance health care directive.

Communicate your recommendations to the primary team clearly and concisely, including if the evaluation is incomplete, and if the patient will be seen again by the consult team, because this may determine disposition planning. Finally, if the patient is deemed to not have DMC, the primary team must then establish a surrogate decision maker on the patient’s behalf. Because the protocol and hierarchy of next-of-kin varies by state law and institution policy, it is essential to involve social work and case management

Medical and surgical inpatient teams often consult psychiatrists to help assess a patient’s decision-making capacity (DMC). Completing a DMC assessment can be a source of stress and frustration for psychiatry residents; however, the process can be significantly improved by following a consistent and focused psychiatric interview. In our institution, the most frequently used tool for assessing DMC is the Aid to Capacity Evaluation (ACE).¹ The American Academy of Family Physicians offers a printer-friendly adaptation² of the ACE assessment.

Reasons for a DMC consultation

When accepting a DMC consultation, make sure to specify for which medical decision the primary team would like the patient to be evaluated so that the consultation can be most helpful and specific to primary team’s concerns.³ The 4 most common reasons for a DMC consultation are:

Acute changes in mental status. These changes may be due to hypoxia, infection, medication, metabolic disturbances, or other medical conditions. Often, the diagnosis is delirium due to a medical condition, and assessing for DMC is deferred until the delirium resolves.

Refusal of a recommended treatment. One of the most frequent reasons for a DMC consultation is when a patient declines the primary team’s treatment recommendations. These recommendations may include medications, interventions (procedural or surgical), or discharge planning (such as transfer to a rehabilitation facility or skilled nursing care facility).

Consenting to a risky or invasive treatment too hastily. This occurs less often than the other 3 scenarios, most likely because capacity is rarely questioned when a patient’s decision aligns with the physicians’ recommendations.

Having risk factors for impaired decision-making. One of the most common reasons for involving psychiatry in a DMC consultation is when the patient has a risk factor that may impair his/her decision-making.

These risk factors include:

• a chronic psychiatric or neurologic condition
• a significant cultural or language barrier
• a low or unknown education level
• anxiety or discomfort with institutional health care settings
• age <18 or >85.

Continue to: When should you put off a DMC consultation?

There are situations in which a DMC consultation should be declined or postponed. A DMC consultation is not appropriate for patients who have a court-appointed legal guardian because these patients are considered legally incapacitated. Although such patients may still choose to participate in shared decision-making with the treatment team and communicate those decisions to their legal guardian, all treatment decisions are made by their legal guardian.

Consider delaying DMC consultations for patients with acute changes in mental status, including delirium, or those who are sedated or intubated. On the other hand, patients not excluded from a DMC assessment include those with mild or major neurocognitive disorders (such as Alzheimer’s disease or other types of dementia), intellectual disabilities, a durable power of attorney (DPOA), or legal charges. It is important to note that a diagnosis of a neurocognitive disorder does not preclude capacity, and capacity may therefore vary based on the complexity of medical decision.

Prepare for the interview

Prior to meeting the patient, familiarize yourself with his/her reason for admission, diagnosis, medical workup, treatment provided thus far, and proposed future treatment. If possible, attempt to gather the patient’s medical and psychiatric history from chart review, which may be obtained from outside medical records or inferred from the patient’s current medication list. Review the chart for any signs that the patient is in a delirious state, including the use of psychotropic medications for agitation, restraints, or a sitter at bedside. Finally, speak with the patient’s nurse before entering the patient’s room. This may provide valuable information regarding the patient’s willingness to participate (including any hostility or aggression toward clinicians), any barriers to the interview (such as hearing or language difficulties), and if any family or friends are present at the bedside.

During the interview

The structure of a decision-making capacity evaluation has been well documented elsewhere^1,2 and, if completed, is sufficient for determining DMC. Asking the patient about additional psychiatric histories, including hospitalizations, suicide attempts, or a family history of psychiatric illness, may be counterproductive and frustrating for the patient, especially if the interview has already been lengthy and emotionally exhausting. Therefore, it is often appropriate to shorten the psychiatric interview to assess for symptoms of anxiety and depression, perform a brief suicide risk assessment, and assess for the presence of auditory or visual hallucinations, or delusions. This allows for a complete mental status exam while still focusing the interview on determining DMC. If time allows and the patient is willing to participate, it can be helpful to perform a Montreal Cognitive Assessment (MoCA) or Mini-Mental State Exam, although a score that indicates some level of cognitive impairment (<26 on MoCA⁴) does not necessarily preclude patient from having capacity for certain medical decisions. Additionally, if the patient does not understand a question, explain it and return to it later to check for comprehension.

Making a recommendation

Patients are presumed to be capable; therefore, if the determination is not clear, err on the side of capacity. Additional information may be helpful from the patient’s family, friends, DPOA, or guardian, especially as it pertains to the patient’s past wishes and medical decisions made in similar situations. If available and pertinent, review the patient’s advance health care directive.

Communicate your recommendations to the primary team clearly and concisely, including if the evaluation is incomplete, and if the patient will be seen again by the consult team, because this may determine disposition planning. Finally, if the patient is deemed to not have DMC, the primary team must then establish a surrogate decision maker on the patient’s behalf. Because the protocol and hierarchy of next-of-kin varies by state law and institution policy, it is essential to involve social work and case management

Medical and surgical inpatient teams often consult psychiatrists to help assess a patient’s decision-making capacity (DMC). Completing a DMC assessment can be a source of stress and frustration for psychiatry residents; however, the process can be significantly improved by following a consistent and focused psychiatric interview. In our institution, the most frequently used tool for assessing DMC is the Aid to Capacity Evaluation (ACE).¹ The American Academy of Family Physicians offers a printer-friendly adaptation² of the ACE assessment.

Reasons for a DMC consultation

When accepting a DMC consultation, make sure to specify for which medical decision the primary team would like the patient to be evaluated so that the consultation can be most helpful and specific to primary team’s concerns.³ The 4 most common reasons for a DMC consultation are:

Acute changes in mental status. These changes may be due to hypoxia, infection, medication, metabolic disturbances, or other medical conditions. Often, the diagnosis is delirium due to a medical condition, and assessing for DMC is deferred until the delirium resolves.

Refusal of a recommended treatment. One of the most frequent reasons for a DMC consultation is when a patient declines the primary team’s treatment recommendations. These recommendations may include medications, interventions (procedural or surgical), or discharge planning (such as transfer to a rehabilitation facility or skilled nursing care facility).

Consenting to a risky or invasive treatment too hastily. This occurs less often than the other 3 scenarios, most likely because capacity is rarely questioned when a patient’s decision aligns with the physicians’ recommendations.

Having risk factors for impaired decision-making. One of the most common reasons for involving psychiatry in a DMC consultation is when the patient has a risk factor that may impair his/her decision-making.

These risk factors include:

• a chronic psychiatric or neurologic condition
• a significant cultural or language barrier
• a low or unknown education level
• anxiety or discomfort with institutional health care settings
• age <18 or >85.

Continue to: When should you put off a DMC consultation?

There are situations in which a DMC consultation should be declined or postponed. A DMC consultation is not appropriate for patients who have a court-appointed legal guardian because these patients are considered legally incapacitated. Although such patients may still choose to participate in shared decision-making with the treatment team and communicate those decisions to their legal guardian, all treatment decisions are made by their legal guardian.

Consider delaying DMC consultations for patients with acute changes in mental status, including delirium, or those who are sedated or intubated. On the other hand, patients not excluded from a DMC assessment include those with mild or major neurocognitive disorders (such as Alzheimer’s disease or other types of dementia), intellectual disabilities, a durable power of attorney (DPOA), or legal charges. It is important to note that a diagnosis of a neurocognitive disorder does not preclude capacity, and capacity may therefore vary based on the complexity of medical decision.

Prepare for the interview

Prior to meeting the patient, familiarize yourself with his/her reason for admission, diagnosis, medical workup, treatment provided thus far, and proposed future treatment. If possible, attempt to gather the patient’s medical and psychiatric history from chart review, which may be obtained from outside medical records or inferred from the patient’s current medication list. Review the chart for any signs that the patient is in a delirious state, including the use of psychotropic medications for agitation, restraints, or a sitter at bedside. Finally, speak with the patient’s nurse before entering the patient’s room. This may provide valuable information regarding the patient’s willingness to participate (including any hostility or aggression toward clinicians), any barriers to the interview (such as hearing or language difficulties), and if any family or friends are present at the bedside.

During the interview

The structure of a decision-making capacity evaluation has been well documented elsewhere^1,2 and, if completed, is sufficient for determining DMC. Asking the patient about additional psychiatric histories, including hospitalizations, suicide attempts, or a family history of psychiatric illness, may be counterproductive and frustrating for the patient, especially if the interview has already been lengthy and emotionally exhausting. Therefore, it is often appropriate to shorten the psychiatric interview to assess for symptoms of anxiety and depression, perform a brief suicide risk assessment, and assess for the presence of auditory or visual hallucinations, or delusions. This allows for a complete mental status exam while still focusing the interview on determining DMC. If time allows and the patient is willing to participate, it can be helpful to perform a Montreal Cognitive Assessment (MoCA) or Mini-Mental State Exam, although a score that indicates some level of cognitive impairment (<26 on MoCA⁴) does not necessarily preclude patient from having capacity for certain medical decisions. Additionally, if the patient does not understand a question, explain it and return to it later to check for comprehension.

Making a recommendation

Patients are presumed to be capable; therefore, if the determination is not clear, err on the side of capacity. Additional information may be helpful from the patient’s family, friends, DPOA, or guardian, especially as it pertains to the patient’s past wishes and medical decisions made in similar situations. If available and pertinent, review the patient’s advance health care directive.

Communicate your recommendations to the primary team clearly and concisely, including if the evaluation is incomplete, and if the patient will be seen again by the consult team, because this may determine disposition planning. Finally, if the patient is deemed to not have DMC, the primary team must then establish a surrogate decision maker on the patient’s behalf. Because the protocol and hierarchy of next-of-kin varies by state law and institution policy, it is essential to involve social work and case management

I arrived at the inpatient psychiatry unit to begin my last overnight call shift as an intern. When I received sign-out from the day-shift resident, Dr. A (all names have been changed to protect anonymity), I was surprised to learn that the medical student assigned for call that day, G, did not present for his shift. In my residency program, a third-year medical student was assigned to accompany an intern during call shifts. While this assignment was for the medical student’s “learning purposes,” the presence of a medical student was vital for the intern. The high volume of patients who needed to be seen while on call was difficult to manage, and the help of a medical student certainly lessened that burden.

During her shift, Dr. A had texted G regarding his missed shift, but he replied that he was busy with a research project and did not intend to attend his call shift. Dr. A and I agreed that G’s behavior was unusual, especially because we had both worked with him before and had found him to be highly motivated and competent. Dr. A said that she was going to follow up with the clerkship director about G’s missed shift. While I was initially angry about having to work the call shift alone, I was quickly overcome with patient care. I labored through the night, and then spent the next day sleeping and recovering.

The following morning, I was back on the inpatient unit to start the work week. I was performing my usual morning pre-rounding when I received shocking news: a medical student had completed suicide on the school’s campus. After processing this news, I asked for the name of the student. It was G.

I sat in disbelief. How could a medical student who was supposed to work with me just 2 days ago have completed suicide? How could such a bright and well-presenting student decide to end his life? I voiced these thoughts to my colleague, who responded, “He must have been preparing to do it instead of coming to your call shift.” This statement hit me like a ton of bricks. Should I have done more to reach out to him? If I had spoken with him, could I have intervened and arrested his planning?

Later, I found out that G had been diagnosed with bipolar disorder. He had shared his diagnosis with some of his classmates and his psychiatry attending. G had wanted to share his success story as someone with mental illness who could have a career in medicine. However, because mental illness carries stigma, the attending had warned G about possible negative consequences in professional settings if he chose to share his diagnosis openly. G expressed disappointment with this advice. Subsequently, he had appeared more withdrawn during his clerkship engagements.

As psychiatrists, we expect to have conversations with our patients about thoughts of suicide, but such discussions with our physician colleagues are far from the norm. We know that the rate of suicide in physicians is higher than in the general population¹—particularly in women²—but stigma often prevents those who work in medicine from seeking treatment.³ Unfortunately, professional requirements and attitudes perpetuate barriers to accessing mental health care.⁴ As long as licensure concerns or other negative professional consequences persist, physicians will avoid seeking potentially life-saving treatment.

I felt guilty for having been angry at G for missing my call shift. I knew that the sequence of events could not be changed, but that did not stop me from wondering, “What if?” What if I had reached out? What if Dr. A had corresponded differently? If we want to prevent tragic outcomes like G’s, then we need to fix our flawed system. We need to allow physicians to seek treatment and share their experience without punitive professional consequences, because suicide is permanent, and there is no undoing.

I arrived at the inpatient psychiatry unit to begin my last overnight call shift as an intern. When I received sign-out from the day-shift resident, Dr. A (all names have been changed to protect anonymity), I was surprised to learn that the medical student assigned for call that day, G, did not present for his shift. In my residency program, a third-year medical student was assigned to accompany an intern during call shifts. While this assignment was for the medical student’s “learning purposes,” the presence of a medical student was vital for the intern. The high volume of patients who needed to be seen while on call was difficult to manage, and the help of a medical student certainly lessened that burden.

During her shift, Dr. A had texted G regarding his missed shift, but he replied that he was busy with a research project and did not intend to attend his call shift. Dr. A and I agreed that G’s behavior was unusual, especially because we had both worked with him before and had found him to be highly motivated and competent. Dr. A said that she was going to follow up with the clerkship director about G’s missed shift. While I was initially angry about having to work the call shift alone, I was quickly overcome with patient care. I labored through the night, and then spent the next day sleeping and recovering.

The following morning, I was back on the inpatient unit to start the work week. I was performing my usual morning pre-rounding when I received shocking news: a medical student had completed suicide on the school’s campus. After processing this news, I asked for the name of the student. It was G.

I sat in disbelief. How could a medical student who was supposed to work with me just 2 days ago have completed suicide? How could such a bright and well-presenting student decide to end his life? I voiced these thoughts to my colleague, who responded, “He must have been preparing to do it instead of coming to your call shift.” This statement hit me like a ton of bricks. Should I have done more to reach out to him? If I had spoken with him, could I have intervened and arrested his planning?

Later, I found out that G had been diagnosed with bipolar disorder. He had shared his diagnosis with some of his classmates and his psychiatry attending. G had wanted to share his success story as someone with mental illness who could have a career in medicine. However, because mental illness carries stigma, the attending had warned G about possible negative consequences in professional settings if he chose to share his diagnosis openly. G expressed disappointment with this advice. Subsequently, he had appeared more withdrawn during his clerkship engagements.

As psychiatrists, we expect to have conversations with our patients about thoughts of suicide, but such discussions with our physician colleagues are far from the norm. We know that the rate of suicide in physicians is higher than in the general population¹—particularly in women²—but stigma often prevents those who work in medicine from seeking treatment.³ Unfortunately, professional requirements and attitudes perpetuate barriers to accessing mental health care.⁴ As long as licensure concerns or other negative professional consequences persist, physicians will avoid seeking potentially life-saving treatment.

I felt guilty for having been angry at G for missing my call shift. I knew that the sequence of events could not be changed, but that did not stop me from wondering, “What if?” What if I had reached out? What if Dr. A had corresponded differently? If we want to prevent tragic outcomes like G’s, then we need to fix our flawed system. We need to allow physicians to seek treatment and share their experience without punitive professional consequences, because suicide is permanent, and there is no undoing.

I arrived at the inpatient psychiatry unit to begin my last overnight call shift as an intern. When I received sign-out from the day-shift resident, Dr. A (all names have been changed to protect anonymity), I was surprised to learn that the medical student assigned for call that day, G, did not present for his shift. In my residency program, a third-year medical student was assigned to accompany an intern during call shifts. While this assignment was for the medical student’s “learning purposes,” the presence of a medical student was vital for the intern. The high volume of patients who needed to be seen while on call was difficult to manage, and the help of a medical student certainly lessened that burden.

During her shift, Dr. A had texted G regarding his missed shift, but he replied that he was busy with a research project and did not intend to attend his call shift. Dr. A and I agreed that G’s behavior was unusual, especially because we had both worked with him before and had found him to be highly motivated and competent. Dr. A said that she was going to follow up with the clerkship director about G’s missed shift. While I was initially angry about having to work the call shift alone, I was quickly overcome with patient care. I labored through the night, and then spent the next day sleeping and recovering.

The following morning, I was back on the inpatient unit to start the work week. I was performing my usual morning pre-rounding when I received shocking news: a medical student had completed suicide on the school’s campus. After processing this news, I asked for the name of the student. It was G.

I sat in disbelief. How could a medical student who was supposed to work with me just 2 days ago have completed suicide? How could such a bright and well-presenting student decide to end his life? I voiced these thoughts to my colleague, who responded, “He must have been preparing to do it instead of coming to your call shift.” This statement hit me like a ton of bricks. Should I have done more to reach out to him? If I had spoken with him, could I have intervened and arrested his planning?

Later, I found out that G had been diagnosed with bipolar disorder. He had shared his diagnosis with some of his classmates and his psychiatry attending. G had wanted to share his success story as someone with mental illness who could have a career in medicine. However, because mental illness carries stigma, the attending had warned G about possible negative consequences in professional settings if he chose to share his diagnosis openly. G expressed disappointment with this advice. Subsequently, he had appeared more withdrawn during his clerkship engagements.

As psychiatrists, we expect to have conversations with our patients about thoughts of suicide, but such discussions with our physician colleagues are far from the norm. We know that the rate of suicide in physicians is higher than in the general population¹—particularly in women²—but stigma often prevents those who work in medicine from seeking treatment.³ Unfortunately, professional requirements and attitudes perpetuate barriers to accessing mental health care.⁴ As long as licensure concerns or other negative professional consequences persist, physicians will avoid seeking potentially life-saving treatment.

I felt guilty for having been angry at G for missing my call shift. I knew that the sequence of events could not be changed, but that did not stop me from wondering, “What if?” What if I had reached out? What if Dr. A had corresponded differently? If we want to prevent tragic outcomes like G’s, then we need to fix our flawed system. We need to allow physicians to seek treatment and share their experience without punitive professional consequences, because suicide is permanent, and there is no undoing.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.

An underappreciated problem

Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.¹ Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.²

While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.³ In a survey at one institution, 60% of medical students reported burnout.⁴ It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?

A recent study found burnout among medical students peaks during the third year of medical school.⁵ This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.

How residents can help

Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.

The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.⁶ Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.⁷ A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”

So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.

Continue to: It's as important to be proactive...

It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.

It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.

Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.

An underappreciated problem

Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.¹ Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.²

While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.³ In a survey at one institution, 60% of medical students reported burnout.⁴ It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?

A recent study found burnout among medical students peaks during the third year of medical school.⁵ This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.

How residents can help

Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.

The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.⁶ Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.⁷ A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”

So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.

Continue to: It's as important to be proactive...

It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.

It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.

Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.

An underappreciated problem

Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.¹ Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.²

While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.³ In a survey at one institution, 60% of medical students reported burnout.⁴ It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?

A recent study found burnout among medical students peaks during the third year of medical school.⁵ This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.

How residents can help

Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.

The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.⁶ Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.⁷ A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”

So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.

Continue to: It's as important to be proactive...

It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.

It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.