THE AMERICAN JOURNAL OF PSYCHIATRY RESIDENTS’ JOURNAL

January 2015 Volume 10 Issue 1

Inside In This Issue 2 The Pharmacologic and Nonpharmacologic Treatment of Opioid Use Disorder Rohit Aiyer, M.D. 5 A Case of New-Onset Schizophrenia With Gilbert’s Syndrome Cody Armstrong, M.D. 7 Pain, Depression, and Delirium: Evaluation of the Complex Consultation-Liaison Patient Joanna Koutros, M.D. 9 Revisiting the Guidelines for Violence Risk Assessment of Patients in the Psychiatric Emergency or Inpatient Setting Swapnil Rath, M.D. This month’s issue of the Residents’ Journal focuses on a variety of topics. Rohit Aiyer, M.D., examines the pharmacologic and nonpharmacologic treatment of opioid use Toward Forging a National 11 disorder and provides discussion of diagnostic criteria, withdrawal symptoms and Policy for Police Mental Health monitoring, relapse prevention, and overdose. In a case report, Cody Armstrong, M.D., Training explores the link between schizophrenia with Gilbert’s syndrome in a patient with Rehan Puri, M.D., M.P.H. changing bilirubin levels. In another case report, Joanna Koutros, M.D., emphasizes 12 Marijuana and Madness, 2nd the effect of depression on a patient’s somatic complaints and the importance of rec- Edition ognizing symptom clusters. Swapnil Rath, M.D., outlines and explains the guidelines Review by Tony Pham, B.A. for violence risk assessment in the psychiatric emergency or inpatient setting. Rehan Puri, M.D., M.P.H., comments on a national policy for police mental health training. 15 Residents’ Resources Lastly, Tony Pham, B.A., reviews the second edition of Marijuana and Madness.

Editor-in-Chief Associate Editors Editors Emeriti Misty Richards, M.D., M.S. Ijeoma Chukwu, M.D., M.P.H. Sarah B. Johnson, M.D. Kathleen Mary Patchan, M.D. Molly McVoy, M.D. Senior Deputy Editor Joseph M. Cerimele, M.D. Rajiv Radhakrishnan, M.B.B.S., M.D. Media Editor Holly S. Peek, M.D., M.P.H. Sarah M. Fayad, M.D. Deputy Editor Staff Editor Monifa Seawell, M.D. Tobias Wasser, M.D. Angela Moore Arshya Vahabzadeh, M.D. The Pharmacologic and Nonpharmacologic Treatment of Opioid Use Disorder

Rohit Aiyer, M.D.

Opioid prescription analgesics are re- Treatment ally assessed and should not be >10 mg sponsible for more deaths than the Methadone is a synthetic, long-acting every few days (8). The literature shows combined number of deaths from both opioid with pharmacologic actions similar that there are several methods to calcu- suicide and motor vehicle accidents (1). to morphine (see Table 1). It is primar- late and convert, and Weschules and Bain In addition, opioid use disorder has a ily a full-receptor agonist and simulates (9) reviewed several of these methods and serious economic impact in the United the action of endogenous opioids and af- concluded that there is no superiority in States, with total costs of prescription fects the release of the neurotransmitters any one conversion protocol. opioid abuse estimated at $55.7 billion glutamate, norepinephrine, dopamine, Buprenorphine maintenance treatment in 2007. Workplace costs accounted for acetylcholine, and serotonin. Methadone doses studied for opioid addiction treat- $25.6 billion (46%), health care costs also competitively inhibits N-methyl-D- ment have ranged from 1 mg–2 mg to 16 accounted for $25.0 billion (45%), and aspartate (4). According to World Health mg–32 mg, depending upon the formu- criminal justice costs accounted for $5.1 Organization (WHO) guidelines, for pa- lation (solution versus tablet), with the billion (9%) (2). Opioid use disorder is an tients using street opioids, such as heroin, duration of treatment lasting from a few epidemic issue in the United States that methadone doses of 20 mg/day will typi- weeks to years. There are three phases in needs to be addressed and taken very seri- cally be adequate to relieve withdrawal buprenorphine maintenance treatment ously by American health care providers, symptoms and retain patients in treat- that should be addressed. The first is the particularly psychiatrists. ment. When it is established that the induction phase, which involves helping initial dose is well tolerated, the metha- Opioid Use Disorder the patient to initiate the process. The done dose should be gradually increased second phase is the stabilization phase, Diagnostic Criteria until the patient is comfortable and not which lasts 1–2 months and is started using heroin or other illicit opioids (5). when the patient is not experiencing In DSM-IV, there were two separate di- Buprenorphine, a partial mu-agonist and withdrawal symptoms. The third phase agnoses: substance abuse and substance antagonist at the kappa opioid receptor, is maintenance, which can last for an in- dependence. In DSM-5, the abuse and has been shown to be effective and safe as definite period and focuses on prevention dependence criteria have been combined a treatment for withdrawal symptoms (see of relapse (10). into one disorder, and the diagnosis has Table 1). Buprenorphine combined with been renamed “substance use disorder.” naloxone is the variation preferred for Buprenorphine/naloxone comprises the DSM-5 states that a patient is considered withdrawal therapy in opioid use disorder partial mu-opioid receptor agonist bu- to have an opioid use disorder if he or she patients (6). Detoxification can also be prenorphine in combination with the has a problematic pattern of opioid use accomplished by symptomatic treatment opioid antagonist naloxone in a 4:1 ratio, leading to clinically significant impair- of opioid withdrawal using medications respectively. When buprenorphine/nal- ment or distress, as manifested by two of such as clonidine (for autonomic hyper- oxone is taken sublingually as prescribed, 11 criteria, which are clustered into the activity), nonsteroidal anti-inflammatory the naloxone exerts no clinically signifi- following four groups: impaired control, drugs (for malaise and myalgias), antidi- cant effect, leaving the opioid agonist social impairment, risky use, and pharma- arrheals and antispasmodics (for diarrhea effects of buprenorphine to predominate. cologic dependence (3). and abdominal cramps), and ondansetron Less frequent dispensing of buprenor- (for nausea) (7). phine/naloxone (e.g., three times per Opioid Withdrawal week) is a major advantage of this in- Maintenance Treatment of tervention and therefore can improve Symptoms and Monitoring Opioid Use Disorder patient satisfaction (11). Opioid withdrawal can be monitored using scales such as the Clinical Opiate For methadone maintenance treatment, Pharmacologic Treatment of Withdrawal Scale. The withdrawal syn- WHO guidelines state that doses in the Opioid Use Disorder drome usually includes symptoms and range of 60 mg–109 mg are the most signs of CNS hyperactivity, such as lac- effective (5). There are many proposed Relapse Prevention rimation, agitation, nausea, rhinorrhea, ratios to convert dosages from mor- Relapse involves use of a substance, such increased respiration rate, insomnia, and phine to methadone, ranging from 4:1 as heroin, following a week or more of ab- stomach cramps (4). to 40:1 (oral morphine:oral methadone). stinence, or one day of heavy use during a The rate of increase should be individu- time when the patient has been drug-free

The Residents’ Journal 2 TABLE 1. Pharmacologic Treatments for Opioid Use Disordera Drug Dosage Pharmacokinetics Pharmacodynamics Side Effects Drug-Drug Interactions

Methadone 60 mg–110 Rapidly absorbed from Mu-agonist and N-methyl-d- Dizziness, There are additive CNS depres- mg the gastrointestinal tract aspartate antagonist. drowsiness, sive effects. Can potentiate the and can be detected in the nausea, deleterious effects of alcohol. blood within 30 minutes. vomiting, and There is also strong evidence sweating. for QTc prolongation. Buprenorphine 8 mg–32 mg Broken down into A partial agonist at the Headache, CYP3A4 Inhibitors and induc- norbuprenorphine and mu-opioid receptor and an nausea, insom- ers. glucuronidation. antagonist at the kappa- nia, abdomi- opioid receptor. nal pain, and sweating. Buprenorphine 8 mg plus Broken down into Buprenorphine is a partial Headache, Benzodiazepine, erythromycin, plus naloxone 2 mg–16 mg norbuprenorphine and agonist at the mu-opioid pain, insom- itraconazole, an HIV protease plus 4 mg glucuronidation. receptor and an antagonist nia, constipa- inhibitor, rifampin, phenytoin, at the kappa-opioid recep- tion, sweating, carbamazepine, and a barbitu- tor. Naloxone is a potent and nausea. rate such as phenobarbital. antagonist at mu-opioid receptors. Naltrexone 50 mg Subject to significant first- Pure opioid antagonist (mu Blurred vision, Safety is unknown, and the pass metabolism. receptor). tachycardia, concomitant use of two are hallucinations, potentially hepatotoxic medica- nausea, stom- tions. ach pain, and lower fever. Naloxone 0.02 mg, Rapidly distributed in the Pure opioid antagonist (mu Chest pain, Large dosages are required to 0.4 mg, and body. receptor). tachycardia, antagonize buprenorphine. 1.0 mg per mL dry cough, sweating, nausea, headache, and seizures. a Data were obtained from the RxList (http://www.rxlist.com).

and is attempting to maintain abstinence. Overdose change in behavior (15). CBT interven- To counter relapse and prevent future Naloxone is a nonselective short-acting tion has been proposed by researchers episodes, Marlatt and Donovan (12) sug- opioid receptor antagonist and is pres- to have great potential, particularly in gested six strategies to help clinicians: ently considered a safe drug for the prison settings where CBT programs are remain nonjudgmental with clients; en- treatment of acute intoxication (see Table less costly to implement, because it re- courage patients to return to treatment 1). Naloxone is typically administered quires fewer demands and less space to quickly after relapse; limit the harm as- intravenously at a dosage of 0.4 mg (al- conduct compared with other therapeu- sociated with relapse episodes; educate ternative routes include intramuscular tic interventions, such as a therapeutic clients on prevention and management and subcutaneous injections) to rap- community approach. A meta-analysis of overdose; discuss less harmful ways to idly reverse unconsciousness and apnea. of 69 studies examining the effective- use drugs; and examine use of drugs other Patients treated for opioid acute intoxica- ness of CBT, conducted by Pearson et al. than opioids. tion should be hospitalized and observed (16), found that such treatment was gen- Naltrexone is an opioid antagonist that for at least 24 hours (14). erally superior to standard correctional programming in reducing recidivism; competitively blocks opioid receptors Nonpharmacologic Treatment (see Table 1). The blockade depends however, this meta-analysis was limited on the concentration of agonists to an- of Opioid Use Disorder with regard to the quality of the studies tagonists and their affinity for opioid included (17). receptors. Pharmacologically, naltrexone Cognitive-Behavioral Therapy (CBT) Contingency Management is an effective treatment for heroin relapse CBT primarily aims to change addic- Contingency management treatments in- prevention (6). Naltrexone is also available tive behavior through changes in faulty volve three basic principles: 1) frequently in an extended sustainable release form. thoughts and cognitions that serve to monitoring for change in the behavior However, psychiatrists should be aware of maintain the behavior or through posi- desired, 2) reinforce the desired behav- the liver dysfunction it can cause (13). tive cognitions or motivation to promote ior each time it occurs, and 3) withhold

The Residents’ Journal 3 positive reinforcers when the desired References tocol (TIP) Series, No 40. Rockville, Md, behavior does not occur (18). Petry and Substance Abuse and Mental Health Ser- Carroll (19) examined the addition of 1. Manchikanti, Helm S, Fellows B, et al: vices Administration, 2005 Opioid epidemic in the United States. contingency management as an adjunct 11. Toombs J, Kral L: Methadone treatment Pain Physician 2012; 15:ES9–ES38 to standard community-based treatment for pain states. Am Fam Physician 2005; (methadone maintenance and monthly 2. Birnbaum HG, White AG, Schiller M, et 71:1353–1358 al: Societal costs of prescription opioid individual counseling) for opioid-depen- 12. Marlatt A, Donovan D: Relapse Preven- abuse, dependence and misuse in the dent patients. Patients in the contingency tion: Maintenance Strategies in the Treat- United States. Pain Med 2011; ment of Addictive Behaviors. New York, management intervention achieved lon- 12:657–667 ger durations of abstinence throughout Guilford Press, 2005, pp 151–153 3. Hilaire ML, Woods TM: Opioid abuse a 6-month follow-up period compared 13. Taylor R Jr, Raffa RB, Pergolizzi JV: Nal- and dependence: treatment review and fu- with those who did not receive contin- trexone extended-release injection: an op- ture options. Formulary 2010; 45:284–291 gency management. tion for the management of opioid abuse. 4. Merk: Opioids: The Merck Manual Pro- Subst Abuse Rehabil 2011; 2:219–226 fessional Edition. Whitehouse Station, Conclusions 14. Krupitsky E, Zvartau E, Woody G: Use of NJ, Merck Sharp and Dohme Corp, 2013 naltrexone to treat opioid addiction in a A variety of treatment options for opioid 5. World Health Organization: Guidelines country in which methadone and bu- use disorder are available, and it is essen- for the Psychosocially Assisted Pharma- prenorphine are not available. Curr Psy- tial for physicians in this field to know cological Treatment of Opioid Depen- chiatry Rep 2010; 12:448–453 dence. Geneva, World Health how to optimize the treatment of opi- 15. Ebrahimi S, Ghasemian D, Khosravi M: Organization, 2009 oid use disorder for patient care. There is Effects of a period CBT on mental health a growing burden of opioid use disorder, 6. American Society for Addiction Medi- of homeless women in recovery phase of and these interventions will continue to cine: Public Policy Statement on Bu- narcotics addict. J Nov Appl Sci 2014; make significant impact in psychiatry pri- prenorphine for Opioid Dependence and 3:362–366 Withdrawal. Chevy Chase, Md, Ameri- vate practices with regard to patient care. 16. Pearson FS, Lipton DS, Cleland CM, et can Society of Addiction Medicine, 2006 While general psychiatrists can utilize a al: The effects of behavioral/cognitive-be- variety of treatments, they should also be 7. Smithedajkul PY, Cullen MW: Managing havioral programs on recidivism. Crime comfortable in referring to addiction psy- acute opiate withdrawal in hospitalized Delinquen 2002; 48:476–496 patients. ACP Hospitalist, Oct 2009 chiatrists when it is clinically warranted 17. Bennett L: New Topics in Substance for the patient. 8. Volkow N: America’s addiction to opioids: Abuse Treatment. Halifax, Nova Scotia, Dr. Aiyer is a first-year resident in the De- heroin and prescription drug abuse. Canada, Nova Science Publishers, 2006, p Bethesda, Md, National Institute on Drug 85 partment of Psychiatry, North Shore-LIJ Abuse, 2014 Health System-Staten Island University 18. McHugh K, Hearon BA, Otto MW: Hospital, Staten Island, N.Y. 9. Weschules DJ, Bain KT: A systematic re- Cognitive-behavioral therapy for sub- view of opioid conversion ratios used with stance use disorders. Psychiatr Clin North The author thanks Harshal Kirane, M.D, methadone for the treatment of pain. Pain Am 2010; 33:511–525 Med 2008; 5:595–612 Director of Addiction Services at North 19. Petry NM, Carroll KM: Contingency Shore-LIJ Health System-Staten Island 10. Center for Substance Abuse Treatment: management is efficacious in opioid-de- University Hospital. Clinical Guidelines for the Use of Bu- pendent outpatients not maintained on prenorphine in the Treatment of Opioid agonist pharmacotherapy. Psychol Addict Addiction–Treatment Improvement Pro- Behav 2013; 27:1036–1043

The American Journal of Psychiatry Residents’ Journal Let us Know Your Thoughts Please complete our survey at https://www.surveymonkey.com/s/ZRNGTJH þþþ The Residents’ Journal 4 Case Report A Case of New-Onset Schizophrenia With Gilbert’s Syndrome

Cody Armstrong, M.D.

There have been few studies showing an the United States, his examination only dose of aripiprazole was increased to 15 association between schizophrenia and revealed mild concreteness. He under- mg, and a diagnosis of schizophreniform Gilbert’s syndrome, with existing studies went psychological testing, including the disorder was given at discharge. Also on reporting a 20% prevalence of Gilbert’s Millon Clinical Multiaxial Inventory, the this admission, it was noticed that his syndrome in persons with schizophre- Personality Assessment Inventory, and bilirubin level was elevated slightly, to nia, compared with 3%–7% in the adult the Structured Inventory of Malingered 1.6 mg/dL. Upon record review, it was population (1). Most of the research Symptomatology, none of which revealed discovered that his bilirubin level had around this phenomenon has dealt with any abnormalities. At this point, it was been mildly elevated at each of his four theories related to hyperbilirubinemia as decided that the patient should remain presentations, mainly consisting of un- a causal factor, differences in severity of in the local area in a limited duty status conjugated bilirubin, with resolution by symptoms between individuals with and so that he could be observed if another the time of discharge (see Figure 1). The without hyperbilirubinemia, and changes episode occurred. About 1 month later, elevation in unconjugated bilirubin was on brain imaging, with most subjects he was once again seen in the emergency consistent with a diagnosis of Gilbert’s having established schizophrenia (2–4). department with stomach pain and dis- syndrome, a typically benign syndrome. The present case is of a young man with organized thoughts and behaviors and changes in bilirubin observed in four was admitted. This was the first time that Discussion hospitalizations. he saw a psychiatrist while he was expe- There are few studies of the connection riencing symptoms, and he was observed between schizophrenia and hyperbiliru- Case to be concrete but to have difficulty with binemia (1, 5). These studies mainly show memory. He was evaluated for acute inter- “Mr. T” is a 25-year-old single, active- an increased prevalence of unconjugated mittent porphyria, with negative results, duty service member in the U.S. Navy, hyperbilirubinemia among persons with and he was discharged on aripiprazole 5 with 4 years of continuous service. On schizophrenia and suggest a connection mg daily. One month later, he returned his first admission to the hospital, he was with chronic hyperbilirubinemia and for his fourth admission, brought in by medically evacuated from Italy due to neuronal damage as one possible etiology police from the airport because he at- disorganized behavior and thought pro- for schizophrenia (4). Most of these stud- tempted to board a plane without a ticket cesses after presenting to the emergency ies have been performed with patients and used his tattoos with his name on department with stomach pains in the presenting much later in the clinical them as identification. He did not have context of a restricted 500 kcal diet for course. In the above case, the patient any official identification, and his super- several weeks. By the time he had arrived appeared without detectable psychotic visor had not approved vacation leave. On back in the United States to see a psychi- processes in-between events and was able this admission, he appeared more disor- atrist, mental status examination revealed to function at a high level. His supervisor ganized than he did previously. While mild concreteness of thought. The noted good performance at work, with on the ward, he punched out the glass patient’s laboratory work-up, which in- minimal supervision (e.g., showing up on inside the exit door in an attempt to es- cluded complete blood count, chemistry time, always getting the job done), and cape. He had not shown any aggressive panels, liver function tests, rapid plasma he was able to obtain an apartment and or agitated behavior while in the United reagin test, thyroid-stimulating hormone a car without assistance. Additionally, it is States in the psychiatric unit prior to this measurement, urinalysis, and urine drug interesting that for almost 2 months dur- admission, although there were reports of screen for “spice” and “bath salts,” was un- ing this period, the patient was not taking some mild agitation while he was in Italy. remarkable. At that time, he was returned any medication, and for the remainder of On this admission, he received an MRI to Italy, with the thought that his presen- the time, he was only receiving aripipra- scan, which did not show any pathology. tation could have been delirium that had zole 5 mg/day, discontinuing treatment 1 He also underwent a Rorschach test after cleared. After 1 week back in Italy, he pre- week prior to his fourth admission. Also his psychosis had cleared, but the test did sented in the same way to the emergency intriguing is that psychological testing not indicate any evidence of an overtly department, with disorganized behavior done in-between episodes did not in- psychotic thought process. On this ad- and thought processes, as well as gastro- dicate any pathology, and the patient’s mission, his presentation was much more intestinal complaints. Once again, by the acute symptoms coincided perfectly with convincing for psychosis, and his daily time he was evacuated and sent back to elevated unconjugated bilirubin and reso-

The Residents’ Journal 5 FIGURE 1. Levels of Conjugated and known Gilbert’s syndrome and a history Health of the Department of Mental Health, Unconjugated Bilirubin in a Patient of psychosis by restricting calories when Naval Medical Center, for guidance in the Presenting With Disorganized they are not experiencing psychosis to see formulation of this article. Thoughts and Gastrointestinal whether they then became psychotic. An- a Complaints other method would be to perform serial References 2 liver function tests in these patients to see Conj 1. Miyaoka T, Seno H, Itoga M, et al: 1.8 how fluctuations in unconjugated biliru- Unconj Schizophrenia-associated idiopathic un- 1.6 bin match up with psychotic symptoms. Total conjugated hyperbilirubinemia (Gilbert’s 1.4 One study found that elevations in un- syndrome). J Clin Psychiatry 2000; 1.2 conjugated bilirubin levels were only seen 61:868–871 1 2. Wake R, Miyaoka T, Tsuchie K, et al: Ab- 0.8 in patients with acute and transient psy- chotic disorder, based on ICD-10 criteria, normalities in MRI signal intensity in 0.6 schizophrenia associated with idiopathic 0.4 which is partially equivalent to brief psy- chotic disorder, and not schizophrenia, unconjugated hyperbilirubinemia. Aust N 0.2 Z J Psychiatry 2009; 43:1057–1069 0 in DSM-5 (6). This study also suggested 16- 17- 18- 19- 20- 21- 22- 23- 3. Yasukawa R, Miyaoka T, Mizuno S, et al: Jun Jun Jun Jun Jun Jun Jun Jun that the increase in unconjugated biliru- bin may not be due to Gilbert’s syndrome Proton magnetic resonance spectroscopy of the anterior cingulate gyrus, insular 2 / / because some of the participants with Conj cortex and thalamus in schizophrenia as- 1.8 / / unconjugated hyperbilirubinemia associ- Unconj sociated with idiopathic unconjugated hy- 1.6 / / ated with psychosis lacked the UGT gene Total perbilirubinemia (Gilbert’s syndrome). J 1.4 / / mutation of Gilbert’s syndrome. Ad- Psychiatry Neurosci 2005; 30:416–422 1.2 / / ditionally, it would be interesting to see 4. Brites D, Fernandes A, Falcao AS, et al: 1 / / whether levels of bilirubin differed in pa- Biological risks for neurological abnor- 0.8 / / tients with acute and transient psychotic malities associated with hyperbilirubine- 0.6 / / disorder that occurred once compared mia. J Perinatology 2009; 0.4 / / with several times as in our patient. 29(suppl):S8–S13 0.2 / / Another element to test would be to de- 5. Radhakrishnan R, Kanigere M, Menon J, 0 / / 18- 19- 20- 21- 22- 23- 24- 25- 16- termine whether preventing the rises in et al: Association between unconjugated Jul Jul Jul Jul Jul Jul Jul Jul Sep bilirubin could alter the course of the bilirubin and schizophrenia. Psychiatry Res 2011; 189:480–482 2 disease. Several suggestions for control- Conj 1.8 ling bilirubin have come from research 6. Bach DR, Kindler J, Strik WK: Elevated Unconj 1.6 on the treatment of Crigler-Najjar syn- bilirubin in acute and transient psychotic Total 1.4 drome. Suggested treatments for control disorder. Pharmacopsychiatry 2010; 43:12–16 1.2 of unconjugated bilirubin include cal- 1 cium phosphate, orlistat, corticosteroids, 7. Van Der Veere CN, Schoemaker B, Bak- 0.8 avoiding low-calorie diets, and avoiding ker C, et al: Influence of dietary calcium 0.6 stress (7–10). phosphate on the disposition of bilirubin 0.4 in rats with unconjugated hyperbilirubi- nemia. Hepatology 1996; 24:620 0.2 Conclusions 0 8. Ohkubo H, Okuda K, Iida S: Effects of 22-Oct 24-Oct 26-Oct 28-Oct 30-Oct There is a well-documented but not so corticosteroids on bilirubin metabolism in well understood connection between patients with Gilbert’s syndrome. Hepa- a Conj=conjugated; Unconj=unconjugated. schizophrenia and Gilbert’s syndrome. tology 1981; 1:168 Although as many as 20% of persons 9. Hafkamp AM, Nelisse-Haak R, Sinaas- with schizophrenia have Gilbert’s syn- appel M, et al: Orlistat treatment of un- lution coincided perfectly with a return to drome, there is not much research on this conjugated hyperbilirubinemia in normal values. connection. More studies on this topic Crigler-Najjar disease: a randomized con- This raises the question as to which should be conducted, since this could be trolled trial. Pediatr Res 2007; 62:725 comes first. Are the psychotic symptoms an endophenotype of schizophrenia. 10. Hafkamp AM, Havinga R, Sinaasappel somehow brought on by the increase in Dr. Armstrong is a third-year resident in M, et al: Effective oral treatment of un- unconjugated bilirubin, or is the elevated conjugated hyperbilirubinemia in Gunn the Department of Mental Health, Naval bilirubin level a response to psychotic rats. Hepatology 2005; 41:526 Medical Center, San Diego. symptoms? One method that could be used to determine this would be to in- The author thanks his mentor, Dr. Ashbrook, duce hyperbilirubinemia in patients with Division Officer for Inpatient Mental

The Residents’ Journal 6 Case Report Pain, Depression, and Delirium: Evaluation of the Complex Consultation-Liaison Patient

Joanna Koutros, M.D.

Somatic pain has been shown to nega- however, the primary team was adamant are four times more likely to develop anx- tively affect the recognition of depression, that she was alert, oriented, cooperative, iety or depressive disorders than patients as well as treatment (1). The present case and capable of being interviewed. It was who are pain-free (2). In addition, so- is of a middle-aged woman who experi- discovered that in the time since the ini- matic pain has been shown to negatively enced abdominal pain likely affected by tial consult, her ill daughter had passed affect the recognition and treatment of her history of major depressive disorder. away—on the same day as the 1-year an- depression (1). The above case is a prime niversary of her son’s death. Furthermore, example of this effect. The primary team Case she had stopped taking her antidepres- was so focused on the patient’s frequent sants after the most recent hospital complaints of pain and requests for pain “Ms. M” is a 59-year-old divorced Afri- discharge because her insurance would medication that they were unable to rec- can American woman with a history of not cover the prescription for dulox- ognize its connection to her underlying major depressive disorder and multiple etine. Evaluation of the patient’s mental depression. Furthermore, there is a strong medical comorbidities. She was admit- status in the intensive care unit revealed correlation between pain and suicide (2). ted to the inpatient medicine service with disorientation, inability to process and One particular study demonstrated that abdominal pain consistent with prior epi- register questions, decreased production the prevalence of suicidality (passive and sodes of pancreatitis. However, laboratory of speech with frequent staring, inatten- active ideation, as well as attempts) was testing and diagnostic imaging did not tion, and memory impairment. She did two to three times greater in subjects with support a diagnosis of acute pancreatitis. not exhibit any hallucinations, delusions, chronic abdominal pain compared with The psychiatry consultation liaison team or agitation, making her symptoms con- those without pain (3). was consulted for a psychosomatic evalu- sistent with hypoactive delirium. ation of the patient because the primary Although it is impossible to specify team felt that her complaints of pain were Discussion why this patient attempted suicide, the out of proportion with her physical ex- discontinuation of her antidepressant amination. Upon interview, she discussed This case illustrates several missed op- treatment during an already difficult and various psychosocial stressors, including portunities on the part of the treating stressful time was a likely contributor. her daughter who had been admitted to physicians that could have resulted in There have been many epidemiological the intensive care unit and the upcom- better patient care. First, at the time of studies worldwide that have shown a re- ing 1-year anniversary of her son’s death. the patient’s initial presentation, the duction in suicide rates in regions with It became clear that she was suffering primary team did not recognize the sig- increased antidepressant prescription from a recurrent moderate major depres- nificance and impact of depression on her (4–6). Moreover, autopsy studies have sive episode, without suicidal ideation or subjective experience of abdominal pain. shown that only 8%–20% of patients di- psychosis. She felt that citalopram, which Second, while the psychiatry consultation agnosed with depression who completed she had been taking for the last 15 years, liaison team chose a reasonable agent, suicide were found to be positive for an- was no longer working. Consequently, they did not ensure insurance coverage of tidepressants on postmortem toxicology the psychiatry consultation liaison team her new prescription or closer outpatient testing (7, 8). These findings suggest that recommended switching to duloxetine follow-up. Lastly, upon her readmission, antidepressants have a protective effect for the dual purpose of treating her de- the intensive care unit team did not iden- on suicidality, and lack of antidepressant pression and pain. She was also advised tify her cluster of symptoms as delirium treatment has a negative effect. Another to follow up at her previously scheduled because she lacked more of the striking study demonstrated that antidepressant outpatient appointment in 2–3 weeks. features of hyperactive delirium. initiation, dose changes, and discontinu- ation all specifically increased risk for Two weeks later, the consultation liai- The literature shows that there is a clear suicide attempt (9). This is of particular son team was consulted again regarding link between pain and depression. One relevance to the case presented above the patient, who was readmitted into the study showed that 75%–80% of patients in which the patient attempted suicide intensive care unit following a suicide fulfilling the criteria for depression re- shortly after initiation and discontinua- attempt by overdose. The consultation ported painful somatic symptoms, such as tion of a new antidepressant. liaison team was initially concerned that headache, abdominal pain, neck and back she would be unable to tolerate evalua- pain, and nonspecific generalized pain (1). As a consequence of this patient’s sui- tion due to her medical complications; Conversely, patients with somatic pain cide attempt, she suffered several medical The Residents’ Journal 7 complications, including hypoxia, met- of reasoning may account for why the United States, 1985–1999. J Clin Psychia- abolic derangements, and aspiration symptoms of the patient in the above case try 2004; 65:1456–1162 pneumonia, which all likely contrib- were not identified as delirium initially. 5. Carlsten A, Waern M, Ekedahl A, et al: uted to her delirium. Phenomenological Antidepressant medication and suicide in studies have classified delirium, based Conclusions Sweden. Pharmacoepidemiol Drug Saf on symptoms, into three motoric sub- 2001; 10:525–530 It is important to learn from the missed types: hyperactive, hypoactive, and mixed 6. Barbui C, Campomori A, D’Avanzo B, et opportunities of this case. Underestimat- (10). Hyperactive delirium classically al: Antidepressant drug use in Italy since ing the impact of depression on various manifests as restlessness, agitation, and the introduction of SSRIs: national trends, somatic complaints may lead to the under- hyperalertness, and patients frequently regional differences and impact on suicide treatment of depression in some patients. display hallucinations and delusions. rates. Soc Psychiatry Psychiatr Epidemiol When considering treatment options, 1999; 34:152–156 On the other hand, hypoactive delir- psychiatrists should consider nonclini- ium manifests with lethargy, drowsiness, 7. Yerevanian BI, Koek RJ, Feusner JD, et al: cal factors, such as the affordability and and sedation. Patients typically respond Antidepressants and suicidal behaviour in accessibility of medications, in order to slowly to questions and have a paucity of unipolar depression. Psychiatr Scand increase the likelihood of compliance, 2004; 110:452–458 spontaneous movements. Patients with thereby decreasing the likelihood of the mixed delirium display symptoms of both 8. Isacsson G, Bergman U, Rich CL: Anti- possibly lethal consequences of discon- hyperactive and hypoactive subtypes (11). depressants, depression and suicide: an tinuation. Finally, clinicians need to be The diagnosis of delirium is very com- analysis of the San Diego Study. J Affect vigilant for hypoactive signs of delirium Disord 1994; 32:277–286 mon in the intensive care unit, with a in order to ensure that patients are accu- prevalence rate over 70% in patients older 9. Valuck RJ, Orton,HD, Libby AM: Anti- rately diagnosed and underlying medical than 65 years old and greater than 55% depressant discontinuation and risk of causes are appropriately treated. in patients younger than 65 years old (12, suicide attempt: a retrospective, nested case-control study. J Clin Psychiatry 2009; At the time this article was accepted for 13). One study found that in the intensive 70:1069–1077 care unit setting, mixed delirium had the publication, Dr. Koutros was a fourth-year highest prevalence (54.9%), followed by resident in the Department of Psychiatry, 10. Meagher DJ, O’Hanlon D, O’Mahony E, et al: Relationship between symptoms and hypoactive delirium (43.5%), and hyper- University Hospitals of Cleveland. motoric sybtype of delirium. J Neuropsy- active delirium (1.6%) (12). Furthermore, The author thanks Jeanne Lackamp, M.D., chiatry Clin Neurosci 2000; 12:51–56 geriatric patients in the intensive care for her guidance in preparation of this article. unit experienced a higher rate of hypo- 11. Liptzin B, Levkoff SE: An empirical study of delirium subtypes. Br J Psychiatry 1992; active delirium compared with younger References 161:843–845 patients (41.0% versus 21.6%) and were never diagnosed with hyperactive delir- 1. Kirmayer LJ, Robbins JM, Dworkind M, 12. Peterson JF, Pun BT, Dittus RS, et al: De- ium (12). The diagnosis of delirium can et al: Somatization and the recognition of lirium and its motoric subtypes: a study of depression and anxiety in primary care. 614 critically ill patients. J Am Geriatr be missed for various reasons. One study Am J Psychiatry 1993; 150:734–741 Soc 2006; 54:479–484 demonstrated that hypoactive delirium was one of four independent risk factors 2. Lépine JP, Briley M: The epidemiology of 13. McNicoll L, Pisani MA, Zhang Y, et al: for the under-recognition of delirium by pain in depression. Hum Psychopharma- Delirium in the intensive care unit: occur- col Clin Exp 2004; 19:S3–S7 rence and clinical course in older patients. clinicians (14). As explained in the article, J Am Geriatr Soc 2003; 51:591–598 “Nurses tended to use patient behavior as 3. Magni G, Rigatti-Luchini S, Fracca F, et an indication of cognitive function, and al: Suicidality in chronic abdominal pain: 14. Inouye SK, Foreman MD, Mion LC, et al: an analysis of the Hispanic Health and Nurses’ recognition of delirium and its they mistook compliance as an indica- Nutrition Examination Survey symptoms: comparison of nurse and re- tion of intact cognition. Thus, cooperative (HHANES). Pain 1998; 76:137–144 searcher ratings. Arch Intern Med 2001; patients with hypoactive delirium were 161:2467–2473 consistently not identified” (14). This line 4. Grunebaum MF, Ellis SP, Li S, et al: An- tidepressants and suicide risk in the

The Residents’ Journal 8 Special Article Revisiting the Guidelines for Violence Risk Assessment of Patients in the Psychiatric Emergency or Inpatient Setting

Swapnil Rath, M.D.

On July 24, 2014, Richard Plotts shot and Guidelines to Perform a victim(s), which can serve as a pre- killed his case worker at Mercy Fitzgerald Violence Risk Assessment dictor of future violence (4, 5). Hospital in Yeadon, Pa. After the crime, 7. Identify where the patient is on the it was reported that Mr. Plotts had re- 1. It would be preferable for patients to continuum of violence. What is la- ceived psychiatric care, which renewed be searched and disarmed if they are beled “homicidal” on an intake sheet the debate in local newspapers about the carrying weapons on arrival to psy- may range from globally aggressive association between violence and mental chiatric facilities (5). thoughts to a specific lethal plan with illness. This debate contributes to nega- 2. When interviewing a patient in a means to carry out the plan. Using a tive public attitudes toward persons with closed room, clinicians should be good clinical interview, assess for the serious mental illnesses (1). Although closer to the door in case an emer- presence of violent ideation, degree severe mental illness does not indepen- gency arises. On the other hand, of planning, intent, and available dently predict future violent behavior, some patients may feel “trapped” in means (4, 5). there are other factors that, if present a room, resulting in worsening para- in a psychiatric patient, can increase the 8. Assess for the presence of psychopa- noia and aggression. Hence, ideally, risk for violence (2). These risk factors thology. Loss of reality is a risk factor, the clinician and patient should be include certain demographic characteris- as are paranoid delusions and com- equidistant from the door, without tics such as younger age, male sex, lower mand hallucinations. Poor impulse either acting as a barrier to the other educational level, financial hardship, control in disorders such as mania, person’s egress (6). The presence of unemployment, and homelessness (3). delirium, intoxication, and certain a panic button or switch in rooms Hence, there is need to conduct a vio- personality disorders are additional where patient encounters occur lence risk assessment in this population, risk factors (4, 5). would also be helpful in crisis situ- which can be performed using actuarial 9. Alcohol or illicit drug use can ations (5). methods, clinical methods, or structured increase risk of violence through in- clinical judgment (4). Actuarial methods 3. There are rating scales, such as the toxication, withdrawal, or cognitive use structured instruments to predict the Overt Aggression Scale (which mea- deficits related to chronic use (4, 5). risk of violence in the long-term. Clini- sures aggressive behaviors in adults Substance misuse has been consis- cal methods help to evaluate the risk of and children) (7) and the Violence tently shown to be a significant risk violence in the short-term, which is use- and Suicide Assessment Scale (which factor for violence (9). ful to clinicians in evaluating patients in covers 10 areas related to suicide and 10. Look for factors reducing the like- the psychiatric emergency or inpatient violence for use in the emergency de- lihood for homicidal behavior. setting. Structured clinical judgment is a partment) (8). Religious beliefs, fear of legal con- third approach, which is a synthesis of the 4. Assess for risk factors that increase sequences, or a capacity for empathy first two approaches and utilizes violence risk for violence, including younger can be protective factors (5). risk assessment tools, such as the His- age, male sex, lower educational level, 11. Avoid “no-homicide contracts” on torical Clinical Risk Management-20, to financial hardship, unemployment, discharge. They fail to meet defined help inform and guide clinical decision and homelessness (4). making. standards of legal contracts and 5. Try to understand if there are any falsely reassure the clinician that a Below is a compilation of guidelines stressors behind a patient’s violent risk has disappeared (5). and principles to inform mental health intentions. Patients who are con- 12. Do not hesitate to ask for a second clinicians in performing violence risk cerned about their own safety may opinion. This may have multiple assessments (based on a review of the lit- lash out as a form of self-defense (5). erature [4, 5]) benefits, such as reducing the risk of 6. Obtain a detailed history of any past litigation, increasing or decreasing acts of violence through medical re- concern about disposition, and help- cords, police records, family reports, ing the clinician to gain perspective and information from any intended The Residents’ Journal 9 on his or her own countertransfer- violence. The above guidelines may help Clin North Am 1997; 20:323–335 ence (5). to guide mental health clinicians in de- 4. Tardiff K: Clinical risk assessment of vio- 13. Document the dispositional decision termining those patients with the greatest lence, in Textbook of Violence Assess- and its rationale. This will help the propensity for violence. These guidelines ment and Management. Edited by Simmon RI, Tardiff K. Washington, DC, receiving clinician assess the patient’s are by no means exhaustive or all-inclusive, and further research is needed in this area. American Psychiatric Publishing, 2008, continuing homicidal risk. The dis- pp 3–16 position should include what to do Dr. Rath is a fourth-year resident in the if the patient experiences homicidal Department of Psychiatry, St. Mary Mercy 5. Thienhaus OJ, Piasecki M: Assessment of psychiatric patient’s risk of violence to- thoughts again (4, 5). Hospital, Livonia, Mich. wards others. Psychiatr Serv 1998; 14. Remember legal duties: the duty to The author thanks William Cardasis, M.D, 49:1129–1147 protect a patient’s intended victim(s), for his comments during the preparation of 6. Beck JC: Outpatient settings, in Textbook which may include notifying the po- this article. The author also thanks Tobias of Violence Assessment and Manage- lice and/or hospitalizing the patient. Wasser, M.D., for editorial advice. ment. Edited by Simmon RI, Tardiff K. Most cases of violence toward others Washington, DC, American Psychiatric would include legal or criminal pen- References Publishing, 2008, pp 237–258 alties (4, 5). Legal duties vary by each 1. McGinty EE, Webster DW, Jarlenski M, 7. Yudofsky SC, Silver JM, Jackson W, et al: state, and thus clinicians should con- et al: News media framing of serious men- The Overt Aggression Scale for the objec- sult their individual state statutes to tal illness and gun violence in the United tive rating of verbal and physical aggres- guide decision making (5). States, 1997–2012. Am J Public Health sion. Am J Psychiatry 1986; 143:35–39 15. Do not forget to perform a suicide 2014; 104:406–413 8. Feinstein R, Plutchik R: Violence and sui- cide risk assessment in the psychiatric risk assessment. Patients present- 2. Elbogen EB, Johnson SC: The intricate link between violence and mental disor- emergency room. Compr Psychiatry 1990; ing with homicidal ideations are at 21:337–343 greater risk of hurting themselves (5). der: results from the National Epidemio- logic Survey on Alcohol and Related 9. Soyka M: Substance misuse, psychiatric Conclusions Conditions. Arch Gen Psychiatry 2009; disorder and violent and disturbed behav- 66:152–61 ior. Br J Psychiatry 2000; 176:345–350 As residents, we are on the “frontline” 3. Hasting EJ, Hamberger LK: Sociodemo- when assessing patients for their risk of graphic predictors of violence. Psychiatr

The American Journal of Psychiatry Residents’ Journal: How to Get Involved

Residents, fellows, and students are invited to attend the 2015 American Journal of Psychiatry Residents’ Journal workshop, to take place at the American Psychiatric Association Annual Meeting in Toronto, Canada.

n Bring your thoughts and ideas about the Residents’ Journal n Hear a brief presentation about the Journal’s new developments n Meet with Residents’ Journal editors and editorial staff n Meet the American Journal of Psychiatry Editor-in-Chief Robert Freedman, M.D.

Sunday, May 17, 2015 12:30 p.m. to 2:00 p.m. Toronto Convention Centre–North Level 200, Rooms 202 C/D

For further information please contact [email protected].

The Residents’ Journal Web: www.appi.org ajp.psychiatryonline.org Phone: 1-800-368-5777 Email: [email protected] AH150910 Commentary Toward Forging a National Policy for Police Mental Health Training

Rehan Puri, M.D., M.P.H.

Concern over the interactions be- A national agenda consistent as well. For example, Georgia tween law enforcement agencies and has a statewide crisis intervention team the mentally ill has been documented in on police mental initiative, whereas Alabama does not. In American history as early as 1825 (1). certain U.S. cities, such as Elgin, Illinois, Thus, programs to educate law enforce- health education in police officers receive two tiers of crisis ment officers in dealing with the mentally intervention team training, whereas cit- ill have long existed in the United States. the United States ies in the state of Arkansas do not have The most notable of these models is the such programs. We should work toward crisis intervention team model, which has remains lacking. a national policy on police mental health been shown in the literature to result in training that not only identifies national decreased morbidity, mortality, and in- gaps in training but rectifies them as well. carceration of the mentally ill upon its Dr. Puri is a third-year resident in the De- implementation in police departments conducting an unparalleled systematic partment of Psychiatry, Bergen Regional (2). However, such programs are the re- and scientific review of both local Ca- Medical Center, Paramus, N.J. sult of local grass roots initiatives and are nadian and international police mental scattered inconsistently across the coun- health education programs. The result has The author thanks Srikanth Reddy, M.D., try, as well as within individual states been the forging of an effective Canadian Attending Supervisor, and Taimur Mian, (3). A national agenda on police mental national strategy for law enforcement M.D., a research fellow at Bergen Regional health education in the United States re- mental health education: The TEMPO Medical Center. mains lacking. (Training and Education about Mental References In 2005, it was reported that in the Illness for Police Organizations) model. United States, >30% of primary refer- The TEMPO model does not replace ex- 1. Torrey EF: Out of the Shadows: Con- rals to psychiatric hospitals were made isting mental health education programs fronting America’s Mental Illness Crisis. by law enforcement personnel (2). It is in Canada, but it identifies core com- New York, John Wiley, 1997 estimated that about 92% of mentally ill petencies needed in programs, such as 2. Vermette H, Pinals D, Appelbaum P: persons currently not hospitalized would recognizing mental illness and de-esca- Mental health training for law enforce- have met criteria for hospitalization just lation techniques. Apart from providing ment professionals. J Am Acad Psychiatry Law 2005; 33:42–46 a few decades ago (1). Consistent with a framework for mental health education the literature, numerous law enforcement programs, the Mental Health Commis- 3. Oliva J, Compton M: A statewide crisis personnel across the country are speaking sion of Canada provides didactic mental intervention team (CIT) initiative: evolu- out in the media, stating that they have health training support to police depart- tion of the Georgia CIT program. J Am Acad Psychiatry Law 2008; 36:38–46 been attempting to manage this segment ments in local municipalities (5). of the nonhospitalized mentally ill popu- Unlike Canada, in the United States, 4. Bouscaren D: As run-ins rise, police train lation. However, not all law enforcement there is no cohesive national policy like to deal with those who have mental ill- personnel across the nation are trained the TEMPO model, nor is there a na- nesses. http://www.npr.org/2014/09/23/ 349098691/as-run-ins-rise-police-take- equally in handling encounters with tional agenda to ensure that encounters crash-courses-on-handling-mentally-ill mentally ill individuals (4). between the mentally ill and police are 5. Coleman T, Cotton D: TEMPO: A con- The growing number of encounters be- safeguarded. Crisis intervention team programs in the United States are initi- temporary model for police education and tween law enforcement and the mentally training about mental illness. Int J Law ill is an epidemic not only in the United ated mainly by advocacy groups, such as Psychiatry 2014; 37:325–333 States but internationally as well. The the National Alliance for the Mentally Mental Health Commission of Canada Ill, in areas where people feel the need has set an international precedent by for such programs. State policies are in-

The Residents’ Journal 11 Book Forum Marijuana and Madness, 2nd Edition Book Review Edited by David Castle, Robin M. Murray, and Deepak Cyril D’Souza. New York, Cambridge University Press, 2011, 252 pp., $99.99.

Review by Tony Pham, B.A.

Perhaps one of the most topical medi- in ways that may increase access in light cal and social issues today is marijuana. of the current research. It would behoove psychiatrists to know One criticism is that while the book ad- as much as possible about this substance, dresses the relationship between public not only as it relates to abuse and depen- policy and marijuana, the editors devote dence but also as it relates to established only one chapter to this matter. Moreover, mental illnesses such as schizophrenia. If while the authors mention reform poli- psychiatrists wish for an update on the cies and the effect of these policies on the many intriguing questions about canna- liberalization of marijuana, they refrain bis use, I would highly suggest the timely from mentioning any relevant history and highly relevant text Marijuana and that might help persons who are less up- Madness. to-date. These generalities are in contrast Edited by David Castle, Robin Murray, to the more detail-heavy molecular biol- and, as of the second edition, Deepak ogy chapters. Given the changing health D’Souza, the book brings together 26 policies currently under way, I hope and linked chapters, all of which include expect that the editors will devote more well-researched academic articles. Each of the third edition to the legal aspects chapter is thematically organized and of cannabis. logically progresses from one aspect of Overall, I would recommend this book psychiatry and marijuana to the next. The fects. Also unique to the second edition is not only to psychiatrists but to all mental first few chapters deal with cannabinoids health professionals because the mate- and their various mechanisms of action. a chapter concerning the policy implica- tions of marijuana and psychosis. rial deserves to be widely circulated and Following the discussion on molecular digested among those who wish to take biology, most of the book is devoted to In contrast to the simplistic claims an active stance on the public policies the clinically focused interrelationship made by popular media, Marijuana and surrounding marijuana. While clinicians between the drug and mental disorders. Madness makes it clear that this issue is and researchers who are interested in The book concludes with more treat- anything but simple. Chapters success- substance use disorders will benefit most ment-oriented chapters. fully go beyond discussion of the direct from this book, understanding the impact Those who have read the first edition (13 psychomimetic effects of cannabis and of consumption on the evolving course chapters) should not discount the second, touch on controversial topics such as of mental illness will be beneficial to any since most of the original chapters have “amotivational syndrome” and “cannabi- mental health worker. noid psychosis.” Most controversial is the been replaced with more up-to-date lit- Tony Pham is a fourth-year medical student erature. In addition, the second edition chapter on the policy implications of the evidence on cannabis and psychosis. The at Tulane University School of Medicine, expands on the discussion of molecular New Orleans. biology with the inclusion of chapters bottom line from the authors seems to be that deal with neurodevelopment and the that it is complicated. Overall, they advo- neural basis of cannabis and its acute ef- cate caution in liberalizing cannabis laws

The Residents’ Journal 12 SENIOR DEPUTY EDITOR DEPUTY EDITOR POSITION ASSOCIATE EDITOR POSITION 2015 2015 POSITIONS 2015

Job Description/Responsibilities Job Description/Responsibilities *Two positions available • Frequent correspondence with AJP-Res- • Frequent correspondence with Residents’ Job Description/Responsibilities idents’ Journal Editorial Board and AJP Journal Editorial Board and AJP profes- • Peer review manuscripts on a weekly basis. professional editorial staff. sional editorial staff. • Make decisions regarding manuscript • Frequent correspondence with authors. • Frequent correspondence with authors. acceptance. • Peer review manuscripts on a weekly basis. • Peer review manuscripts on a weekly basis. • Manage the Test Your Knowledge ques- • Make decisions regarding manuscript • Make decisions regarding manuscript tions on Facebook and work closely with acceptance. acceptance. authors in developing Board-style review questions for the Test Your Knowledge • Work with AJP editorial staff to prepare • Work with AJP editorial staff to prepare section. accepted manuscripts for publication to accepted manuscripts for publication to ensure clarity, conciseness, and conformity ensure clarity, conciseness, and conformity • Collaborate with the Senior Deputy Edi- with AJP style guidelines. with AJP style guidelines. tor, Deputy Editor, and Editor-in-Chief to develop innovative ideas for the Journal. • Collaborate with others as necessary to de- • Collaborate with others as necessary to de- velop innovative ideas. velop innovative ideas. • Attend and present at the APA Annual Meeting. • Coordinate selection of book review au- • Prepare a monthly Residents’ Resources thors and distribution of books with AJP section for the Journal that highlights up- • Commitment averages 5 hours per week. professional editorial staff. coming national opportunities for medical students and trainees. Requirements • Collaborate with the Editor-in-Chief in selecting the 2016 Senior Deputy Editor, • Collaborate with the Editor-in-Chief in • Must be an APA resident-fellow member Deputy Editor, and Associate Editors. selecting the 2016 Senior Deputy Editor, • Must be a PGY-2, PGY-3, or PGY-4 Deputy Editor, and Associate Editors. • Attend and present at the APA Annual resident in July 2015, or a fellow in an Meeting. • Attend and present at the APA Annual ACGME fellowship in July 2015 Meeting. • Commitment averages 10–15 hours per • Must be in a U.S. residency program or week. • Commitment averages 10 hours per week. fellowship This is a 1-year position only, with no auto- Requirements Requirements matic advancement to the Deputy Editor or • Must be an APA resident-fellow member. • Must be an APA resident-fellow member. Senior Deputy Editor position in 2016. If the selected candidate is interested in serving as • Must be a PGY-3 in July 2015, or a • Must be a PGY-2, PGY-3, or PGY-4 Deputy Editor or Senior Deputy Editor in PGY-4 in July 2015 with plans to enter an resident in July 2015, or a fellow in an 2016, he or she would need to formally apply ACGME fellowship in July 2016. ACGME fellowship in July 2015. for the position at that time. • Must be in a U.S. residency program. • Must be in a U.S. residency program or Applicants should e-mail a CV and personal fellowship. Selected candidate will be considered for a statement of up to 750 words describing 2-year position, including advancement to This is a 1-year position only, with no auto- their professional interests, qualifications, Editor-in-Chief. Applicants should e-mail matic advancement to the Senior Deputy and reasons for applying for the position, as a CV and personal statement of up to 750 Editor position in 2016. If the selected candi- well as ideas for journal development to rajiv. words describing their professional interests, date is interested in serving as Senior Deputy [email protected]. The deadline for qualifications, and reasons for applying for the Editor in 2016, he or she would need to for- applications is February 15th, 2015. position, as well as ideas for journal develop- mally apply for the position at that time. ment to [email protected]. The Applicants should e-mail a CV and personal deadline for applications is February 15th, statement of up to 750 words describing 2015. their professional interests, qualifications, and reasons for applying for the position, as well as ideas for journal development to rajiv. [email protected]. The deadline for applications is February 15th, 2015.

The Residents’ Journal 13

Test Your Knowledge Has Moved

Our Test Your Knowledge feature, in preparation for the PRITE and ABPN Board examinations, has moved to our Twitter (www.twitter.com/AJP_ResJournal) and Facebook (www.facebook.com/AJPResidentsJournal) pages.

We are currently seeking residents who are interested in submitting Board- style questions to appear in the Test Your Knowledge feature. Selected resi- dents will receive acknowledgment for their questions. Submissions should include the following: 1. Two to three Board review-style questions with four to five answer choices. 2. Answers should be complete and include detailed explanations with ref- erences from pertinent peer-reviewed journals, textbooks, or reference manuals.

*Please direct all inquiries to Rajiv Radhakrishnan, M.B.B.S., M.D., Senior Deputy Editor ([email protected]).

American Psychiatric Publishing has enhanced our JOURNALS with bold new looks and engaging features!

GABBARD | NUMBER 1 | VOLUME 172 2015 JANUARY • Each issue’s Table of Contents will include quick takeaways for each article to help readers The American Journal of quickly determine items to turn to or mark for later reading.

Psychiatry • Journal homepages will push the latest articles front and center as soon as they are published so that cutting-edge research articles are immediately discoverable.

• Symbols on the Table of Contents page and on the articles themselves will help readers navigate to content that addresses the Core Competencies as defined by the Accreditation Council of Graduate Medical Education (ACGME) and the

A Randomized Trial of Collaborative Depression Care in Obstetrics and American Board of Medical Specialties (ABMS). Gynecology Clinics: Socioeconomic Disadvantage and Treatment Response Treatment-Resistant Bipolar Depression: A Randomized Controlled Trial of Electroconvulsive Therapy vs. Algorithm-Based Pharmacological Treatment ElectroconvulsiveSchizophrenia: Therapy Augmentation A Prospective, in Clozapine-Resistant Randomized Study • More video content! Journal editors discuss the decisions that led them to Cross-Disorder Genome-Wide Analyses Suggest a Complex Genetic Relationship Between Tourette’s Syndrome and OCD tion accepting various research papers and also highlight the clinical significance

ajp.psychiatryonline.org Official Journal of the American Psychiatric Associa of content contained in each issue. We are excited to be bringing these enhancements to you and look forward to telling you about upcoming innovations designed to ensure we continue to offer the definitive resource for the psychiatric knowledge base.

www.psychiatryonline.org American Psychiatric Publishing • www.appi.org The Residents’ Journal Phone: 1-800-368-5777 • Email: [email protected] AH1508 14 Residents’ Resources We would like to welcome all our readers to this new feature of the Journal! Here we hope to highlight upcoming national oppor- tunities for medical students and trainees to be recognized for their hard work, dedication, and scholarship. *To contribute to the Residents’ Resources feature, contact Tobias Wasser, M.D., Deputy Editor ([email protected]). February Deadlines

Fellowship/Award Organization Brief Description Eligibility Contact Website and Deadline

APA Resident Recogni- APA Selection Criteria: Each institution may select Nancy Delanoche, http://www.psychiatry. tion Awards • Compassion, as evidenced by one resident or fellow for M.S., American Psy- org/residents/fellowships- exemplary patient care, and/or this award annually. chiatric Association awards/apa-resident- Deadline: compassion toward colleagues and in The trainee must be a Office of Graduate recognition-awards February 28, 2015 the workplace; member of the APA and Undergraduate • Leadership in the field of psychiatry Education as evidenced by holding leadership 1000 Wilson Blvd, roles in individual residency pro- Suite 1825 grams, at the district branch level of Arlington, VA 22209 the APA and/or at the national level; • Community service at the local or national level; • Political action on behalf of patients, the profession, and/or the community; and • Clinical excellence as evidenced by exemplary patient care.

American American All qualified applicants receive a Psychiatry applicants must None listed http://www.apsa.org/ Psychoanalytic Psychoanalytic psychoanalyst mentor with whom at the time of the applica- Association Association they meet to discuss their interest in tion be full-time general or Fellowship psychoanalysis, a free subscription to child psychiatry residents, the newsletter of the Association, and PGY-2 or higher, or fellows, Deadline: complimentary registration at the bian- or psychiatrists who have February 2015 nual meetings of the Association. become Board eligible (specific date TBD) within the previous 3 years. March Deadlines

Alexandra and Martin The Associa- The goal of this award is to increase Psychiatry resident; Frances Roton Bell http://associationofwom- Symonds Foundation tion of Women the exposure of female psychiatric AWP member e-mail: enpsychiatrists.com/ Fellowship Psychiatrists residents to scientific endeavors that womenpsych@aol. (AWP) will enhance residents’ understanding com Deadline: and commitment to the advancement March 1, 2015 of women’s mental health and the Phone: exploration of the impact of gender 972-613-0985 related issues on the lives of both men and women. The fellowship will award a $1,500 stipend for travel and participation in the AWP/APA Annual Meetings.

AWP Fellowship AWP Annual fellowship for outstanding Psychiatry resident; Frances Roton Bell http://associationofwom- female psychiatry residents who have AWP member e-mail: enpsychiatrists.com/ Deadline: demonstrated significant potential womenpsych@aol. awards.aspx March 1, 2015 for leadership and contribution in com women’s health. The fellowship will award a $1,500 stipend for travel Phone: and participation in the AWP/APA 972-613-0985 Annual Meetings.

Leah J. Dickstein, M.D., AWP Recognizes a female medical student Female medical students Frances Roton Bell http://associationofwom- Award who best exemplifies the spirit of who have demonstrated e-mail: enpsychiatrists.com/ creativity, energy, and leadership that superior academic achieve- womenpsych@aol. awards.aspx Deadline: Dr. Dickstein herself epitomizes and ment, creativity, and com March 1, 2015 seeks to foster in others. The recipient leadership. will be expected to attend the Annual Phone: Meeting (in conjunction with the APA 972-613-0985 Annual Meeting) in May.

The Residents’ Journal 15 Author Information for The Residents’ Journal Submissions

Editor-in-Chief Senior Deputy Editor Deputy Editor Misty Richards, M.D., M.S. Rajiv Radhakrishnan, M.B.B.S., M.D. Tobias Wasser, M.D. (UCLA) (Yale) (Yale) The Residents’ Journal accepts manuscripts authored by medical students, resident physicians, and fellows; manuscripts authored by members of faculty cannot be accepted. To submit a manuscript, please visit http://mc.manuscriptcentral.com/appi-ajp, and select “Residents” in the manuscript type field. 1. Commentary: Generally includes descriptions of recent events, opinion pieces, or narratives. Limited to 500 words and five references.

2. Treatment in Psychiatry: This article type begins with a brief, common clinical vignette and involves a description of the evaluation and management of a clinical scenario that house officers frequently encounter. This article type should also include 2-4 multiple choice questions based on the article’s content. Limited to 1,500 words, 15 references, and one figure.

3. Clinical Case Conference: A presentation and discussion of an unusual clinical event. Limited to 1,250 words, 10 references, and one figure.

4. Original Research: Reports of novel observations and research. Limited to 1,250 words, 10 references, and two figures.

5. Review Article: A clinically relevant review focused on educating the resident physician. Limited to 1,500 words, 20 references, and one figure.

6. Letters to the Editor: Limited to 250 words (including 3 references) and three authors. Comments on articles published in The Residents’ Journal will be considered for publication if received within 1 month of publication of the original article.

7. Book Review: Limited to 500 words and 3 references.

Abstracts: Articles should not include an abstract. Upcoming Themes

Please note that we will consider articles outside of the theme. Advances in Antidepressant Therapy Childhood Trauma and Psychopathology If you have a submission related to this If you have a submission related to this theme, contact the Section Editor, theme, contact the Section Editor, Samuel Wilkinson, M.D. Katherine Pier, M.D. ([email protected]). ([email protected]).

Personality Disorders If you have a submission related to this theme, contact the Editor-in-Chief Misty Richards, M.D., M.S. ([email protected]).

*If you are interested in serving as a Guest Section Editor for the Residents’ Journal, please send your CV, and include your ideas for topics, to Misty Richards, M.D., M.S., Editor-in-Chief ([email protected]).

The Residents’ Journal 16