Oliver Freudenreich, MD

Many medications are available in numerous dosage forms, which increases the risk of medication errors. To reduce dosing errors and avoid unnecessarily complex dosing, I suggest employing a “clinical reference dosing unit” (CRDU)—a basic reference dose expressed in milligrams that covers the typical dose range if administered as 1 to 4 pills.

CRDUs can help you and your patients remember a typical starting dose (1 pill), a target dose (2 or 3 pills), a high dose (4 pills), and a safe dose to make changes (1 pill). CRDUs also can help you track your prescribing because you can easily spot doses outside the usual range. For example, 8 pills indicate an unusually high dosage and a half pill might be too low.

Implementing CRDUs

Develop a list of CRDUs for the psychotropics you frequently prescribe. Note that the appropriate CRDU for a medication might vary among different clinical populations (Table). For any given medication use only 1 formulation, such as immediate-release or extended-release.

Monitor dosing by asking patients how many pills they take and when they take them.

Table

Sample CRDU prescribing of risperidone

Patient education

Instruct your patients to initiate or change doses based on the number of pills, with 1 pill corresponding to the medication’s CRDU. For example, you might tell your patient, “Start with 1 pill at night for 1 week, then go up to 2 pills at night until you see me again.” Patients are more likely to correctly implement changes when instructions are based on the number of pills rather than on milligrams. Change the dosing to reach desired efficacy or increase tolerability by in-creasing or decreasing the number of pills or shifting the timing of the dosage, such as going from 1 pill twice daily to 2 pills at night.

Although CRDUs can be used for many antipsychotics, antidepressants, and anxiolytics, this method is not appropriate for medications that:

• are administered based on plasma levels or body weight, such as lithium or valproate
  
• do not have linear pharmacokinetics, such as phenytoin
  
• require a slower titration, such as clozapine.
  

Many medications are available in numerous dosage forms, which increases the risk of medication errors. To reduce dosing errors and avoid unnecessarily complex dosing, I suggest employing a “clinical reference dosing unit” (CRDU)—a basic reference dose expressed in milligrams that covers the typical dose range if administered as 1 to 4 pills.

CRDUs can help you and your patients remember a typical starting dose (1 pill), a target dose (2 or 3 pills), a high dose (4 pills), and a safe dose to make changes (1 pill). CRDUs also can help you track your prescribing because you can easily spot doses outside the usual range. For example, 8 pills indicate an unusually high dosage and a half pill might be too low.

Implementing CRDUs

Develop a list of CRDUs for the psychotropics you frequently prescribe. Note that the appropriate CRDU for a medication might vary among different clinical populations (Table). For any given medication use only 1 formulation, such as immediate-release or extended-release.

Monitor dosing by asking patients how many pills they take and when they take them.

Table

Sample CRDU prescribing of risperidone

Patient education

Instruct your patients to initiate or change doses based on the number of pills, with 1 pill corresponding to the medication’s CRDU. For example, you might tell your patient, “Start with 1 pill at night for 1 week, then go up to 2 pills at night until you see me again.” Patients are more likely to correctly implement changes when instructions are based on the number of pills rather than on milligrams. Change the dosing to reach desired efficacy or increase tolerability by in-creasing or decreasing the number of pills or shifting the timing of the dosage, such as going from 1 pill twice daily to 2 pills at night.

Although CRDUs can be used for many antipsychotics, antidepressants, and anxiolytics, this method is not appropriate for medications that:

• are administered based on plasma levels or body weight, such as lithium or valproate
  
• do not have linear pharmacokinetics, such as phenytoin
  
• require a slower titration, such as clozapine.
  

Many medications are available in numerous dosage forms, which increases the risk of medication errors. To reduce dosing errors and avoid unnecessarily complex dosing, I suggest employing a “clinical reference dosing unit” (CRDU)—a basic reference dose expressed in milligrams that covers the typical dose range if administered as 1 to 4 pills.

CRDUs can help you and your patients remember a typical starting dose (1 pill), a target dose (2 or 3 pills), a high dose (4 pills), and a safe dose to make changes (1 pill). CRDUs also can help you track your prescribing because you can easily spot doses outside the usual range. For example, 8 pills indicate an unusually high dosage and a half pill might be too low.

Implementing CRDUs

Develop a list of CRDUs for the psychotropics you frequently prescribe. Note that the appropriate CRDU for a medication might vary among different clinical populations (Table). For any given medication use only 1 formulation, such as immediate-release or extended-release.

Monitor dosing by asking patients how many pills they take and when they take them.

Table

Sample CRDU prescribing of risperidone

Patient education

Instruct your patients to initiate or change doses based on the number of pills, with 1 pill corresponding to the medication’s CRDU. For example, you might tell your patient, “Start with 1 pill at night for 1 week, then go up to 2 pills at night until you see me again.” Patients are more likely to correctly implement changes when instructions are based on the number of pills rather than on milligrams. Change the dosing to reach desired efficacy or increase tolerability by in-creasing or decreasing the number of pills or shifting the timing of the dosage, such as going from 1 pill twice daily to 2 pills at night.

Although CRDUs can be used for many antipsychotics, antidepressants, and anxiolytics, this method is not appropriate for medications that:

• are administered based on plasma levels or body weight, such as lithium or valproate
  
• do not have linear pharmacokinetics, such as phenytoin
  
• require a slower titration, such as clozapine.
  

Rating scales give psychiatrists an objective benchmark on which to base critical treatment decisions, but not all clinicians use them because they view scales as time-consuming and offering little clinical yield. However, any depression self-rating scale (Table) can yield valuable clinical information if you pay attention to 3 areas.

Table

Commonly used depression self-rating scales

1. Total score

The total score supplies patients with objective feedback on their symptom severity, supports your treatment recommendations, and provides a benchmark for clinical decision-making. This information can help you determine when:

• the patient has shown no or insufficient improvement and treatment should be changed
  
• the patient has improved enough to stay the course
  
• antidepressant treatment would not be helpful because the baseline score is within the normal range.
  

2. Individual items

Note items that stand out because the patient rated them very high or endorsed items such as suicidality. An item-by-item analysis can help you focus on symptoms the patient considers problematic and which could be treatment targets, such as severe insomnia or fatigue. Often you can detect a pattern in the results, such as if a patient displays strong somatization or has mostly depressive cognitions.

3. Approach to the scale

Observe the patient while he or she fills out the scale. Obsessive patients might take a long time to complete the scale be-cause they cannot decide which answer is correct and will argue with you about individual items. They may want to answer “2.5” instead of having to choose between 2 or 3. Patients with cognitive problems also might need a long time to complete the questionnaire, but don’t forget about possible marginal literacy. Narcissistic patients might refuse to take the test because it is “below” them to fill out a scale that surely cannot capture their specialness.

Used in these 3 ways, scales are not a burden but an opportunity to engage your patient and to practice patient-centered medicine, even during brief clinical encounters.

Rating scales give psychiatrists an objective benchmark on which to base critical treatment decisions, but not all clinicians use them because they view scales as time-consuming and offering little clinical yield. However, any depression self-rating scale (Table) can yield valuable clinical information if you pay attention to 3 areas.

Table

Commonly used depression self-rating scales

1. Total score

The total score supplies patients with objective feedback on their symptom severity, supports your treatment recommendations, and provides a benchmark for clinical decision-making. This information can help you determine when:

• the patient has shown no or insufficient improvement and treatment should be changed
  
• the patient has improved enough to stay the course
  
• antidepressant treatment would not be helpful because the baseline score is within the normal range.
  

2. Individual items

Note items that stand out because the patient rated them very high or endorsed items such as suicidality. An item-by-item analysis can help you focus on symptoms the patient considers problematic and which could be treatment targets, such as severe insomnia or fatigue. Often you can detect a pattern in the results, such as if a patient displays strong somatization or has mostly depressive cognitions.

3. Approach to the scale

Observe the patient while he or she fills out the scale. Obsessive patients might take a long time to complete the scale be-cause they cannot decide which answer is correct and will argue with you about individual items. They may want to answer “2.5” instead of having to choose between 2 or 3. Patients with cognitive problems also might need a long time to complete the questionnaire, but don’t forget about possible marginal literacy. Narcissistic patients might refuse to take the test because it is “below” them to fill out a scale that surely cannot capture their specialness.

Used in these 3 ways, scales are not a burden but an opportunity to engage your patient and to practice patient-centered medicine, even during brief clinical encounters.

Rating scales give psychiatrists an objective benchmark on which to base critical treatment decisions, but not all clinicians use them because they view scales as time-consuming and offering little clinical yield. However, any depression self-rating scale (Table) can yield valuable clinical information if you pay attention to 3 areas.

Table

Commonly used depression self-rating scales

1. Total score

The total score supplies patients with objective feedback on their symptom severity, supports your treatment recommendations, and provides a benchmark for clinical decision-making. This information can help you determine when:

• the patient has shown no or insufficient improvement and treatment should be changed
  
• the patient has improved enough to stay the course
  
• antidepressant treatment would not be helpful because the baseline score is within the normal range.
  

2. Individual items

Note items that stand out because the patient rated them very high or endorsed items such as suicidality. An item-by-item analysis can help you focus on symptoms the patient considers problematic and which could be treatment targets, such as severe insomnia or fatigue. Often you can detect a pattern in the results, such as if a patient displays strong somatization or has mostly depressive cognitions.

3. Approach to the scale

Observe the patient while he or she fills out the scale. Obsessive patients might take a long time to complete the scale be-cause they cannot decide which answer is correct and will argue with you about individual items. They may want to answer “2.5” instead of having to choose between 2 or 3. Patients with cognitive problems also might need a long time to complete the questionnaire, but don’t forget about possible marginal literacy. Narcissistic patients might refuse to take the test because it is “below” them to fill out a scale that surely cannot capture their specialness.

Used in these 3 ways, scales are not a burden but an opportunity to engage your patient and to practice patient-centered medicine, even during brief clinical encounters.

In our experience, psychiatry residents often are encouraged to present rich psychodynamic or biopsychosocial formulations,¹ while diagnostic assessments are relegated to robotic statements about whether patients meet DSM-IV-TR criteria. This practice can lead to “checklist psychiatry.”²

However, thoughtfully invoking DSM criteria can enhance clinical acumen if the following conclusions are chosen and justified during patient assessments.

“This person meets diagnostic criteria, and I believe this is the correct diagnosis.”

Ask the resident to back up his or her conclusion that symptoms are “not due to another condition” and cause “significant distress or impairment” as required by DSM. Emphasize differential diagnosis and understanding illness impact and illness behaviors. Also ask the resident to explain why the patient is considered a reliable reporter of his or her experience.

“This person seems to meet criteria, but I do not believe the diagnosis is correct.”

Seeming to meet criteria is not the same as “having” a psychiatric diagnosis. Ask the resident to discuss alternate diagnoses and confounding factors in the patient’s presentation. Some patients overreport psychological distress to pursue secondary gain or because of idiosyncratic ways of experiencing distress. Likewise, some clinicians interpret too narrowly patients’ endorsements of symptoms and assume that patients share their definitions of terms such as depression and panic.³

“This person does not meet criteria, but I believe the disorder is present.”

This scenario often leads to a rapid “not otherwise specified” (NOS) diagnosis. However, if a patient has an incomplete yet longitudinally consistent and sufficiently severe version of a known syndrome, an NOS diagnosis is not clinically useful (research settings are a different story). Encourage the trainee to justify the diagnosis that he or she plans to treat.

“This person does not meet criteria, and I believe no disorder is present.”

Some people are not mentally ill; in fact, most are not. Yet most residents we supervise cannot recall the last time they diagnosed “no mental illness” or saw a supervisor do so. Adopt this practice, and give trainees overt permission to make this assessment.

In our experience, psychiatry residents often are encouraged to present rich psychodynamic or biopsychosocial formulations,¹ while diagnostic assessments are relegated to robotic statements about whether patients meet DSM-IV-TR criteria. This practice can lead to “checklist psychiatry.”²

However, thoughtfully invoking DSM criteria can enhance clinical acumen if the following conclusions are chosen and justified during patient assessments.

“This person meets diagnostic criteria, and I believe this is the correct diagnosis.”

Ask the resident to back up his or her conclusion that symptoms are “not due to another condition” and cause “significant distress or impairment” as required by DSM. Emphasize differential diagnosis and understanding illness impact and illness behaviors. Also ask the resident to explain why the patient is considered a reliable reporter of his or her experience.

“This person seems to meet criteria, but I do not believe the diagnosis is correct.”

Seeming to meet criteria is not the same as “having” a psychiatric diagnosis. Ask the resident to discuss alternate diagnoses and confounding factors in the patient’s presentation. Some patients overreport psychological distress to pursue secondary gain or because of idiosyncratic ways of experiencing distress. Likewise, some clinicians interpret too narrowly patients’ endorsements of symptoms and assume that patients share their definitions of terms such as depression and panic.³

“This person does not meet criteria, but I believe the disorder is present.”

This scenario often leads to a rapid “not otherwise specified” (NOS) diagnosis. However, if a patient has an incomplete yet longitudinally consistent and sufficiently severe version of a known syndrome, an NOS diagnosis is not clinically useful (research settings are a different story). Encourage the trainee to justify the diagnosis that he or she plans to treat.

“This person does not meet criteria, and I believe no disorder is present.”

Some people are not mentally ill; in fact, most are not. Yet most residents we supervise cannot recall the last time they diagnosed “no mental illness” or saw a supervisor do so. Adopt this practice, and give trainees overt permission to make this assessment.

In our experience, psychiatry residents often are encouraged to present rich psychodynamic or biopsychosocial formulations,¹ while diagnostic assessments are relegated to robotic statements about whether patients meet DSM-IV-TR criteria. This practice can lead to “checklist psychiatry.”²

However, thoughtfully invoking DSM criteria can enhance clinical acumen if the following conclusions are chosen and justified during patient assessments.

“This person meets diagnostic criteria, and I believe this is the correct diagnosis.”

Ask the resident to back up his or her conclusion that symptoms are “not due to another condition” and cause “significant distress or impairment” as required by DSM. Emphasize differential diagnosis and understanding illness impact and illness behaviors. Also ask the resident to explain why the patient is considered a reliable reporter of his or her experience.

“This person seems to meet criteria, but I do not believe the diagnosis is correct.”

Seeming to meet criteria is not the same as “having” a psychiatric diagnosis. Ask the resident to discuss alternate diagnoses and confounding factors in the patient’s presentation. Some patients overreport psychological distress to pursue secondary gain or because of idiosyncratic ways of experiencing distress. Likewise, some clinicians interpret too narrowly patients’ endorsements of symptoms and assume that patients share their definitions of terms such as depression and panic.³

“This person does not meet criteria, but I believe the disorder is present.”

This scenario often leads to a rapid “not otherwise specified” (NOS) diagnosis. However, if a patient has an incomplete yet longitudinally consistent and sufficiently severe version of a known syndrome, an NOS diagnosis is not clinically useful (research settings are a different story). Encourage the trainee to justify the diagnosis that he or she plans to treat.

“This person does not meet criteria, and I believe no disorder is present.”

Some people are not mentally ill; in fact, most are not. Yet most residents we supervise cannot recall the last time they diagnosed “no mental illness” or saw a supervisor do so. Adopt this practice, and give trainees overt permission to make this assessment.

Keeping track of outpatients with psychosis can be challenging when multiple clinicians provide care and social services are disjointed. To ensure continuity of care and achieve optimal functional outcome, answer these five questions periodically during long-term treatment.

1. Are you acquainted with the patient’s primary care physician? If not, introduce yourself by e-mail, letter, or telephone.

For some patients, you are the primary physician by default, so know some medical monitoring guidelines such as the Mount Sinai Consensus Conference Recommendations for Physical Health Monitoring in Schizophrenia.¹ Also encourage the patient to exercise, stop smoking, and lose weight, if necessary.²

2. When did you last request a written consultation from a specialist? Documenting consultations helps other clinicians follow the steps you took to care for the patient. Requesting and preparing the written consultation also forces you and the consultant to think about the exact nature of the patient’s problem.

3. How strong is the patient’s social network? To identify who can help with the patient’s care, draw a schematic of his or her family tree. Determine who lives with the patient or lives nearby and regularly sees him or her. Repeat this exercise every year because family networks change.

4. Do you have data regarding the patient’s complaints? Get as much information as possible to determine a cause. For example, if the patient has:

• Insomnia—Have the patient or caregiver complete a sleep log and count the number of caffeinated drinks and cigarettes the patient consumes daily.
  
• Overweight/obesity—Weigh the patient at each visit and suggest that the patient or caregiver keep a food diary.
  
• Worsening psychosis—Use a psychopathology rating scale such as the Brief Psychiatric Rating Scale. Count pills, and order antipsychotic blood levels and urine drug screens if necessary to test for medication non-adherence or unrecognized drug use.
  
• Possible cognitive problems—Order neuropsychological tests, particularly to assess memory, attention, and executive function.
  

5. How much progress can you expect in 1 year? To help you set feasible rehabilitation goals, make a schedule of a typical week in the patient’s life. This schedule will suggest how to engage the patient in work, family, and the community. Have the patient bring in a resume or work history as a starting point for discussion. Repeat this exercise annually.

Keeping track of outpatients with psychosis can be challenging when multiple clinicians provide care and social services are disjointed. To ensure continuity of care and achieve optimal functional outcome, answer these five questions periodically during long-term treatment.

1. Are you acquainted with the patient’s primary care physician? If not, introduce yourself by e-mail, letter, or telephone.

For some patients, you are the primary physician by default, so know some medical monitoring guidelines such as the Mount Sinai Consensus Conference Recommendations for Physical Health Monitoring in Schizophrenia.¹ Also encourage the patient to exercise, stop smoking, and lose weight, if necessary.²

2. When did you last request a written consultation from a specialist? Documenting consultations helps other clinicians follow the steps you took to care for the patient. Requesting and preparing the written consultation also forces you and the consultant to think about the exact nature of the patient’s problem.

3. How strong is the patient’s social network? To identify who can help with the patient’s care, draw a schematic of his or her family tree. Determine who lives with the patient or lives nearby and regularly sees him or her. Repeat this exercise every year because family networks change.

4. Do you have data regarding the patient’s complaints? Get as much information as possible to determine a cause. For example, if the patient has:

• Insomnia—Have the patient or caregiver complete a sleep log and count the number of caffeinated drinks and cigarettes the patient consumes daily.
  
• Overweight/obesity—Weigh the patient at each visit and suggest that the patient or caregiver keep a food diary.
  
• Worsening psychosis—Use a psychopathology rating scale such as the Brief Psychiatric Rating Scale. Count pills, and order antipsychotic blood levels and urine drug screens if necessary to test for medication non-adherence or unrecognized drug use.
  
• Possible cognitive problems—Order neuropsychological tests, particularly to assess memory, attention, and executive function.
  

5. How much progress can you expect in 1 year? To help you set feasible rehabilitation goals, make a schedule of a typical week in the patient’s life. This schedule will suggest how to engage the patient in work, family, and the community. Have the patient bring in a resume or work history as a starting point for discussion. Repeat this exercise annually.

Keeping track of outpatients with psychosis can be challenging when multiple clinicians provide care and social services are disjointed. To ensure continuity of care and achieve optimal functional outcome, answer these five questions periodically during long-term treatment.

1. Are you acquainted with the patient’s primary care physician? If not, introduce yourself by e-mail, letter, or telephone.

For some patients, you are the primary physician by default, so know some medical monitoring guidelines such as the Mount Sinai Consensus Conference Recommendations for Physical Health Monitoring in Schizophrenia.¹ Also encourage the patient to exercise, stop smoking, and lose weight, if necessary.²

2. When did you last request a written consultation from a specialist? Documenting consultations helps other clinicians follow the steps you took to care for the patient. Requesting and preparing the written consultation also forces you and the consultant to think about the exact nature of the patient’s problem.

3. How strong is the patient’s social network? To identify who can help with the patient’s care, draw a schematic of his or her family tree. Determine who lives with the patient or lives nearby and regularly sees him or her. Repeat this exercise every year because family networks change.

4. Do you have data regarding the patient’s complaints? Get as much information as possible to determine a cause. For example, if the patient has:

• Insomnia—Have the patient or caregiver complete a sleep log and count the number of caffeinated drinks and cigarettes the patient consumes daily.
  
• Overweight/obesity—Weigh the patient at each visit and suggest that the patient or caregiver keep a food diary.
  
• Worsening psychosis—Use a psychopathology rating scale such as the Brief Psychiatric Rating Scale. Count pills, and order antipsychotic blood levels and urine drug screens if necessary to test for medication non-adherence or unrecognized drug use.
  
• Possible cognitive problems—Order neuropsychological tests, particularly to assess memory, attention, and executive function.
  

5. How much progress can you expect in 1 year? To help you set feasible rehabilitation goals, make a schedule of a typical week in the patient’s life. This schedule will suggest how to engage the patient in work, family, and the community. Have the patient bring in a resume or work history as a starting point for discussion. Repeat this exercise annually.